Diabetes: Lifestyle Changes to Eating Behavior and Physical Activity

Outline

Lifestyles Changes to Eating Behavior, Physical Activity, and Eating Behavior have been widely cited as major factors in the development of diabetes and other health-related complication. Lifestyle factors related to obesity, eating behavior, and physical activity, therefore, play a major role in the prevention and treatment of diabetes (Zachary, 2004). The development of behavioral strategies to modify these lifestyle behaviors has been tremendous (Sallis et al., 2006). This paper will discuss diabetes in relation to lifestyles Changes. Healthy eating habits and regular physical activities are important steps in the control and Prevention of diabetes. However, conventional wisdom states that not all physical activities can be suitable for all the age groups across the board, likewise to food types. It is therefore important to segment the age groups in order to have a clear and relevant prevention and control mechanism. Finally, the paper highlights the past studies and barriers to the prevention and treatment of diabetes, and concludes that despite all the barriers, diabetes can be effectively treated and prevented with a proper multifaceted or integrated approach to its management is implemented.

Introduction

Diabetes has become one of the most serious public health challenges of the 21st century. Over 150 million adults are affected worldwide, with the number expected to double in the next 25 years. Lifestyle factors related to obesity, eating behavior, and physical activity plays a major role in the prevention and treatment of diabetes (Zachary, 2004). The developments of behavioral strategies to modify these lifestyle behaviors have been remarkable in recent years (Sallis et al., 2006). This paper will discuss the following topics as they related to diabetes: Lifestyles Changes: (a) etiology of eating and physical activity; (b) environmental factors; (c) behavior changes; and (d) maintaining a healthful eating program and weight. Finally, it discusses prior research and identifies barriers to progress.

Literature Review

There has been progressing in the development of behavioral strategies to modify these lifestyle behaviors (Nichols, 2009). Further research is however needed, “because the rates of obesity in our country are escalating, and changing behavior for the long term has proven to be very difficult” (Tricker, Sherman, Armatas & Maschette, 1998). Our society faces the need of developing and implementing programs to promote a healthy diet and physical activity, the major modifiable lifestyle factors in the struggle against obesity, diabetes, and other chronic diseases (United States Department of Agriculture, 2005). However, eating healthfully and being physically active are challenging and involve many barriers (USDA, 2005).

Behavioral theories can be useful to explain and change lifestyle behaviors (Nichols 2009). The past program mainly focused on the individual level factors (e.g., knowledge, attitudes, and skills), “but recent research highlights the importance of environmental factors and the need for multifaceted approaches” (Sallis et al., 2006). The multifaceted approach regrettably does not have sufficient literature to count on, other than the disjointed information about diabetes prevention and treatment.

Etiology of eating and physical activity

The change in eating habits of people has been associated with the increased cases of diabetes. Some scholars have described it as an eating disorder and associating the problem with the adolescent lifestyle, citing the emerging evidence which indicated that it is evident in the prepubescent age range. In a study to investigate the prevalence and factors associated with eating/ dieting, physical activity, and body image among a nonclinical, naturalistically derived sample of preadolescents of ages between 10 and 11, Tricker, Sherman, Armatas & Maschette (1998) found an interesting scenario. They found out that the longitudinal assessment of body image [3 measures over 9 months] indicated signs of stability of actual assessments of body image for males, but marked changes for females who preferred to be ideally “chunkier” in stature over time. The “chunkiness” increased the diabetic risks in this group. On the other hand, strong evidence from different researches indicates that diabetes in itself should not be associated with a particular age group, but should be looked at in a more multifaceted view. For example, Nichols (2009) examined the association of dietary habits and other factors with diabetes prevalence in the adult lifestyle. In his find9ninds, it was revealed that good dietary habits reduced diabetes by a significant 31%, non-smokers had a further 23% reduced risk, light/moderate alcohol use had a 34% reduced risk, low body mass index (BMI) had a 45% reduced risk, and low waist circumference had a 46% reduced risk. These findings are for sure a clear indicator that eating habits affect the old just as it affects the young, and most probably has no limit to the age groups.

The connection between physical activity, dietary habits, and diabetes prevalence have been of concern for ages. Numerous studies have justified that good dietary habit connected with a routine- based physical activity is a sure way of reducing diabetes among the high-risk individuals. The same study by Nichols revealed that participants in the research whose eating habits were considered good, with regular physical activity had a lower risk of up to 82% of diabetes incidence compared to their counterparts. Furthermore, there is also significant evidence that lifestyle modifications through alteration in diet and improvement in exercise can delay or even prevent type 2 diabetes. This was evident in a large diabetes screening campaign in Swiss community pharmacies that detected 6.9% of persons with suspicion for diabetes, and 71.5% had more than two 2% risk factors (45 years and above, overweight of BMI, body index, more than 25 kg/m2, low physical activity, family history of diabetes, delivery of a baby 4 kg and above, and hypertension) (Botomino, Bruppacher, Krahenbuhl & Hersberger, 2008). The findings were crucial since they provided an opportunity to initiate targeted counseling regarding the importance of physical activity and nutrition for these risk-prone individuals.

Prevention and control

Healthy eating habits and regular physical activities are important steps in the control and Prevention of diabetes. However, conventional wisdom states that not all physical activities can be suitable for all the age groups across the board, likewise to food types. It is therefore important to segment the age groups in order to have a clear and relevant prevention and control mechanism.

Elderly group

Even though researchers agree that it is not necessarily direct lifestyle modification that would reduce diabetes prevalence, a recent study shows that lifestyle factors are nonetheless strongly associated with new-onset diabetes among the elderly. In fact, the revelation that a whopping 90% of new cases of diabetes could be as a result of lifestyle factors is really astonishing. To date, biological parameters are the main focus for diabetes prediction. A typical example can be illustrated by data from the Framingham Offspring study which found out that a risk score using age, sex, parental history of diabetes, and simple clinical variables (fasting glucose, BMI, HDL cholesterol, and triglycerides) could produce an area under the curve of 0.88 (Wilson, Meigs , Sullivan, Fox, Nathan, 2007). It is said that among the elderly people who are currently practicing low-risk lifestyles could have been doing so regularly for much of their lives (Tuomilehto, Eriksson, Valle, et al., 2001). It is therefore prudent to say that there are significant benefits to low-risk lifestyles that if consistently practiced, may extend well into adulthood.

According to Hornick & Aron (2008), a person’s risk of developing type 2 diabetes increases with obesity, lack of physical activity, and loss of muscle mass- factors that are more likely to develop as a result of aging. Regular exercise has been cited as being of particular importance in the improvement of insulin sensitivity and reducing cardiac risk in people with diabetes (Sigal, Kenny, Wasserman, et al., 2006). Heath & Stuart (2002) also states that weight loss can also improve pancreatic endocrine function and insulin sensitivity in obese older adults and more importantly provides numerous benefits to older adults. Such benefits are; increased strength and balance, reduced falls, decreased pain from osteoarthritis, improvement in depressive symptoms, and enhanced quality of life. Heath & Stuart says that if well-practiced, the results can be observed within a relatively short time frame.

Generally walking is often regarded as the most feasible and more importantly, a popular form of aerobic exercise for older adults (CDA, 2008). Additionally, resistance training has an important therapeutic benefit, thus should also be used to supplement general aerobic activities (Dunstan, Daly, Owen, et al., 2002). Other than the elderly group, patients too have mobility problems. They should therefore be advised of the effects of exercise on blood sugar levels and clear strategies should be used to avoid hypoglycemia (e.g. consuming extra carbohydrates or medication adjustments). Patients should also go through an assessment by the use of an exercise stress test before beginning exercise routine activity. This is to ensure that patients who may have significant comorbidities are detected. In case of such an incident, professionals advise that referral to a specialized program (e.g. a cardiac rehabilitation center) would emerge as the best alternative

Modifying lifestyle presents a relatively better and more effective way of preventing diabetes mellitus in those at high risk of developing the disease (DPPRG, 2002). According to the research done by the Diabetes Prevention Program Research Group (2002), the Diabetes Prevention Program trial, lifestyle changes, including modest weight reduction, a healthy low-fat, low-calorie diet, and regular physical activity, reduced the incidence of type 2 diabetes by 58% in persons with impaired fasting glucose or impaired glucose tolerance. The study further revealed even a greater effect among the subgroup of individuals over 60 years of age as compared to metformin treatment.

Principally, many older adults with diabetes are obese, a scenario that is rare in middle-aged people with diabetes (Hornick & Aron, 2008). Hornick & Aron say that lean people who are diabetic in old age also have reduced insulin secretion, responding to glucose load with comparatively less insulin resistance and that this group of persons may even be underweight and/or undernourished. They, therefore, advise that a less restricted diet for this population to improve quality of life with minimal adverse effects on glycemic control. Most importantly, all the circumstances would require referral to a dietician as the best starting point. In general, experts advise that optimal care of patients with diabetes should be based on a multifaceted approach that requires a multidisciplinary team of health care professionals, especially among older adults, to get the desired result (CD A, 2008).

Young adults and children Vs Obesity

Diabetes is one of the most common chronic diseases in young adults and children, with approximately 151, 000 people in America below the age of 20 said to be living with diabetes through to their adulthood (CDC, 2008). It is routinely assumed that type 1 diabetes is the sole type of diabetes that affects children, an assumption that is disputed by the recent studies that have proved otherwise. The U.S children and adolescents have been proved to be prone to type 2 diabetes in the last two decades like never before. Studies in European countries also reveal that there is an increase in the frequency of type 1 diabetes in young adults and children.

What causes diabetes in children and adolescents? According to CDC’s study on Epidemiology of Type 1 and Type 2 Diabetes Mellitus Among North American Children and Adolescents, conducted in 2008, “The epidemics of obesity and the low level of physical activity among young people, as well as exposure to diabetes in utero, may be major contributors to the increase in type 2 diabetes during childhood and adolescence”. The obesity prevalence, with body mass index exceeding 95th percentile among the children in the U.S and adolescents between the age of 6 and 19 has been spontaneously increasing over the last years, with the highest (15.5%) in the last decade being in 1999 and 2000 (Zachary, 2004). A cross-sectional survey of children aged 9–12 years in Hong Kong revealed that 38% of girls and 57% of boys were overweight, with both sexes showing higher systolic blood pressure, triglyceride, and insulin, and lower HDL cholesterol than the normal weight (Zachary, 2004). It is thus logical to conclude that reducing obesity in children is a relatively easy way to prevent diabetes prevalence in children and young adults. However, according to a government task force that investigated the healthcare professional’s ability to handle obesity cases, it was revealed that many healthcare providers negatively view obesity, an attitude that is seen to impair prevention and treatment of children with diabetes. An equally disturbing finding by this task force is that there is insufficient evidence that can be used to recommend to the health care providers that would enable them to sufficiently screen overweight children and adolescents (U.S. Preventive Services Task Force, 2005).

A national survey on the management of childhood and adolescent obesity found out that 939 health care providers (pediatricians, pediatric nurse practitioners, and registered dietitians), have self-perceived low skill levels in their ability to counsel patients with obesity in the areas of behavior management strategies, parenting techniques, and family conflicts (Story et al., 2005). Story et al. (2005), however, states that most practitioners showed concern on childhood obesity and favored treatment and most importantly showed interest in acquiring education on obesity.

Even though health care practitioners have had some basic information on the evaluation and treatment of obesity in children, integration of the available concepts for use has not been an advanced level to support primary care practice. But still, there is substantial hope that these barriers would be overcome such that treatment and prevention procedures would be leveraged, considering numerous researches going on, despite the present scenarios where neither caregivers nor children perceive overweight as a problem (Barlow & Dietz, 1998). This perceived attitude could lead to a lack of motivation to change unhealthy lifestyle behaviors like poor diet, associated with the disease prevalence among the children and the youth.

The task force advises that all sectors of the community, from medical fraternity to business community and religious organizations should come together to solve the childhood obesity epidemic. The report singles out clinicians and dieticians to play a central role in ensuring that there is a developed reverse tend to the rising obesity cases, emphasizing that it is this group that has an unmatched influence on the social perception of obesity and other behavioral diseases.

Environmental factors

The current environmental factors have been linked with the increased diabetes cases in the past. This is largely due to the increasing obesity epidemic that has long been associated with diabetes. According to Hill & Peters (1998), obesity epidemic prevalence today is largely caused by excessive junk food intake lack of physical activity promoted by the present environmental setting. They say that despite the fact that, physiologically, humans have developed an excellent body system that has significantly improved the defense ability of the body to lose weight, they have a weaker physiological mechanism to fight weight gain especially when abundant food is consumed (Hill & Peters, 1998). Regular physical activity, food consumption control, low-fat diet consumption are very significant steps in the control of weight gain but have proved very difficult to control in the present environmental setting.

Then what causes obesity? As stated earlier, the past two decades have seen an unprecedented increase in diabetes prevalence, concurrent with the increase in the number of obese individuals in American. World Health Organization estimated that 54% of Americans were overweight in 1998, while 22% were obese (Hill & Peters, 1998). Many have linked the increase in obesity and subsequently to diabetes to the molecular genetic factors that are said to determine an individual’s susceptibility to these pandemics. But critical findings have revealed that there have not been changed in the human genetic makeup in the past two decades while the behavioral nutrition problems keep on soaring yearly. Many experts and observers alike have concurred that it is the environment that promotes the lifestyle behavior that leads to obesity and consequently diabetes.

Obesity arises as a result of higher energy intake than the body needs expenditure. The environment has provided a highly convenient food supply, which is relatively inexpensive, highly palatable, and much in energy with low-physical activity hence the body ends up with a high energy reserve (Hill & Peters, 1998). Hill, Pagliassotti & Peters (1993) revealed that the weight and composition of an individual are largely dependent on the interactions between the environment and genetics. They, therefore, say that environmental impact on obesity should be analyzed in terms of its ability to increase the frequency of behaviors that increase the influence on behavioral change and that obesity should be viewed as a natural response to modifications in the environment and not as defensive physiology of the body.

So what environmental factors promote over eating? Hill & Peters (1998) highlights the following environmental factors to be the major contributor to overeating habit:

• Food availability and portion size; the current environment provides more opportunities to consume large quantities of food. The ready-made junk foods are available everywhere in places popularly known as “fast foods” restaurants, at relatively cheaper costs
• Diets high in fats; a study conducted by Chang, et al. (1990) found out that diet composition can influence the development of obesity and consequently lead to diabetes. When they used animal models to establish the difference between animals exposed to a low-fat diet Vs once fed on a high-fat composition diet, in the same locality, the former experienced low obesity cases than the latter. However, the prevalence of obesity increased more in some animals than others, even though they were all fed in an amount of fat level at the same level, a scenario associated with the difference in the environment. Numerous studies also reveal a higher prevalence of obesity in humans who consume higher fat content than those who consume less fat content.

There are underlined measures that can be taken to control obesity that would consequently control diabetes. Studies have shown that the creation of a healthier environment is a critical step for controlling the pandemic as it worsens daily. DPPRG, (2002) study stated that decreasing the average American diet by a mere 100 kcal/day or increasing energy expenditure by a similar amount could reverse the current alarming trend in rising rates of obesity (Knowler et al., 2002). However, the challenge has never been on the ability of these research findings but the implementation process. This is largely because the majority of the people in America and most likely around the globe have little knowledge of the control mechanism.

Some of the factors that have limited the obesity management by primary care clinicians can be overcome if some elements of modifications are done to our environment to eliminate environmental barriers such as fast food, sugary soft drinks, unhealthy school food, and inadequate physical activity (Tricker, Sherman, Armatas & Maschette, 1998). Such modifications may include improved fast food, control of media advertising to children, and increased community involvement (Hill & Peters, 1998). Hill & Peters (1998) therefore suggests an Obesity-related education effort for physicians and other health care professionals to be expanded at the office-based level.

Behavior changes

Cigarette smoking remains one of the leading causes of preventable morbidity and mortality. Smoking increase the risk of ischemic heart diseases, hypertension, chronic obstructive pulmonary disease, stroke and lung cancer, and more worrying is the fact that it can reduce the life expectancy of an individual by approximately eight years(Botelho, 2002). However, the most astonishing impact is on diabetic individuals, where studies indicate that this group is more susceptible to the adverse impact of this disease in that an individual may develop a wide range of micro and macrovascular complications (Zachary, 2004). The associated complications include retinopathy, nephropathy, and cardiovascular disease (CVD). Several clinical studies reveal the risks of developing the CVD increases two-fold for smoker more than non-smokers or the general population. A two to three-fold increase in the risk of developing CVD had been reported for the diabetic patients as compared to their non-smoking counterparts (Canadian tobacco use monitoring survey, 2003). The Canadian tobacco use monitoring survey (2003) revealed that 21% of the general population at the age of 15 years and above are currently smokers.

In this same study, physical activity revealed a strikingly behavioral factor in the process. The diabetic group of individuals who were reportedly engaged in more physical activities was less likely to smoke. Furthermore, type 1 physically active individuals were more likely to have quit smoking. It may be concluded that smokers just can’t keep up with the physical nature of these exercises due to problems arising from smoking-related activities and that there is a possibility that those who participate in physical activities are less likely to initiate smoking habits.

The above evidence clearly illustrates the behavioral habit of the population in terms of increasing diabetes prevalence. Even though many medical experts recommend the therapeutic approach to diabetic management, dieticians, however, believe that behavioral change is one very significant way of controlling the disease. The findings support the idea of a healthy lifestyle and that the linkages between healthy behaviors indicate that physical activity can act as both a preventive approach as well a cessation strategy.

How can behavior change be affected? Many kinds of research indicate that educating diabetic victims has a possibility of improving the self-management conscience of an individual, which consequently improves glycemic control and health status of such individuals. This is despite the fact that no empirical evidence has linked a specific type of education to a specific type of patient to produce a specific type desired of the result. However, initial findings may be used to generate a more multifaceted guideline to offer education to specific groups of individual patients, either segmented sex-wise or age-wise (age and sex are important factors in diabetes prevalence).

Readiness to behavior change

Many dieticians and observers alike agree that one of the most challenging aspects of controlling diabetes is a change of behavior among diabetic patients. Patients respond to self-management tasks differently, depending on the nature of the task. For example, a parent’s adherence to one task such as diet is not a sure way of predicting adherence to another task like glucose monitoring. It is therefore not advisable to segment patients as either compliant or non-compliant but to work on the adherence to one behavior at a time (Botelho, 2002)

If in any case, a patient is not ready to start such a behavioral change program, the physician main goal should be to move them toward that next stage of change (Botelho, 2002)

Table 1: stages of lifestyle change (Rollnick, Mason & Butler, 1999, and Prochaska & DiClemente, 1984)

NOTE: Relapse–patients often slide backward through these stages and most attempt major lifestyle changes numerous times before succeeding (Rollnick, Mason & Butler, 1999).

The U.S guideline for managing diabetes states that these “patients are better served through case management that addresses their immediate needs and ultimately improves the likelihood of treatment adherence” (VHA/DoD, 1999).

Motivation components

The components of motivation that the provider should have in mind when offering primary healthcare services for diabetes patients are conviction and confidence, since these two components have practical use in such a setting (Rollnick, Mason & Butler, 1999). If the assessments indicate that the patient is not ready for change, the physician may ask the patients such questions as, “How important is it for you to eat healthier food?” to assess the conviction, and “how confident are you in your ability to succeed in eating healthier food?” to assess confidence (Whitlock, Orleans, Pender & Allan, 2002). Alternatively rating the components on a scale of 1-10 by the patients could be used by the physician (Keller, Kemp-White, 1997). This approach of analyzing confidence and conviction is helpful to both physician and the patients since they are able to move together in all stages of change (Whitlock, Orleans, Pender & Allan, 2002).

Enhancing conviction and change

The low conviction will need the physician to emphasize the autonomy of the patient while very low conviction will require the physician to change the tactic and provide new information (Keller & Kemp-White, 1997). The physician should therefore try and focus on the limited conviction and ask the patient why he or she did not achieve or come closer to achieving the target (Whitlock & Orleans, 2002).

It is very crucial and important for the physician to identify the ambivalence that is, avoiding the confrontational approach, which is likely to provoke the patient to defend the failed effort rather than focus on the improvement (Glasgow et al., 1999). Ambivalence identification is also important since it helps the patients to have confidence in you by believing that you are looking at the issue from his or her perspective, therefore enhancing acceptance (Whitlock & Orleans, 2002). By this, it would be easy for the physician to identify barriers to the plan and consider changes if necessary, for example, the patient’s view of what makes her or him relax, in order of preference, and the possibility of integrating physical fitness activity into that which patients prefer (Whitlock & Orleans, 2002).

Enhancing confidence

Analysis of the previous success in change is very important in this case since it will provide the launching pad for the next step, and help navigate the obstacles experienced in the initial steps. Such questions as “Have you tried this before? How long did you continue that effort? What helped you succeed for that long? What do you think will work out for you at present? What obstacles did you experience?” and many more may be asked (Rubin & Peyrot, 2001). This will give the opportunity to expand on the limited confidence exposed by the patient.

Brainstorming stage; the solutions should be critically analyzed and patients should be geared towards a selection of “small and easy steps, based on his or her past previous experiences as well as preferences” (Rubin & Peyrot, 2001). Brainstorming will aid the shift from success or failure to stage model (Whitlock & Orleans, 2002).

Maintaining a healthful eating program and weight

One of the most challenging diabetes-related behaviors is healthful diet adherence (Ary, Toobert, Wilson, & Glasgow, 1986). Maintaining a healthy eating program coupled with regular exercise is a very important aspect of diabetes management and control since they have the potential of delaying or even preventing diabetes and its related complications, a fact supported by numerous strong evidence (Pan et al., 1997, Tuomilehto et al., 2001 and Knowler et al., 2002). After intensive multiyear treatment of adult “prediabetics,” with a focus on diet and increased physical activity, large multisite studies in three countries by Pan et al. (1997) revealed that the development of overt diabetes decreased by 32 to 58 percent, compared with usual care in the randomized control trial.

Table 2: specific Outcome Goals & Short-Term Behavior Targets of Diabetes Prevention RCTs (Pan et al., 1997, Tuomilehto et al., 2001, Knowler et al., 2002, and Eriksson et al., 1999)

Note: RCT = randomized controlled trial; BMI = body mass index.

Knowler, et al., (2002) revealed that intensive lifestyle intervention was more effective than metformin in reducing the incidence of type 2 diabetes. The other study by Tuomilehto, (2001) found out that “intervention for about three years, focused on a diet together with increased physical activity reduced diabetes incidence by a significant 11 percent, compared with an incidence of 23 percent among control subjects” (Tuomilehto, 2001). The Da Qing Impaired Glucose Tolerance and Diabetes Study (pan et al., 1997) demonstrated that lifestyle change lowered diabetes incidence in lean and overweight participants. In another study of nonrandomized groups, followed by a 12-year follow-up, Eriksson et al. (1998) found that lifestyle change lowered the mortality rate of participants with impaired glucose tolerance almost to the rate of normal control patients.

There is a unanimous agreement that specific measures that can reduce the fat content of the diet in the general population would be a useful step to preventing or delaying the development process of chronic diseases such as diabetes (National Research Council, 1989). However, the challenge is to public health policy and the general stakeholder lies in which method should be used to encourage lower-fat use by the general population.

The strategic environmental intervention approach to reduce the prevalence of population to high-fat food consumption presently focuses on basic consumer knowledge, emphasizing healthy eating habits through mass media, school-based, and point-of-education purchase (CDC, 2003). CDC acknowledges that even though such interventions have had some positive effects on the general nutrition knowledge among the population, food-choice behaviors have been experienced in small impact, inconsistent, and short-lived. As observed earlier, the availability of these high-fat foodstuffs has a greater influence on consumer habits. Unfortunately, environmental strategies designed to influence food choice through mechanisms of availability and cost rather than nutrition education have received less research attention. A recent cafeteria-based study by Knowler, et al., (2002) examined pricing and availability influences on food choice provided important information that can be used to improve healthy eating habits. The study revealed that when prices of fruit and salad were reduced by 50%, and the number of fruit and salad items available was increased, the purchase of these food items increased threefold within the three-week study period (Knowler, et al., 2002). Considering the level of effect manifested in this study, there would be the necessity to increase exploratory research on the feasibility and efficacy of the environmental intervention, to either justify or improve on the interventions.

Criteria for designing plans for diabetes treatment

Most dietitians recommend an individually tailored design for the treatment and control of diabetes. This is because different individuals have different body needs that require specialized treatments to focus on weight reduction through exercise and good eating habits (CDC, 2003). The individually tailored effort looks at the short-term behavioral habits of these individuals, more matching their progress (Gonder-Redenick, Cox & Ritterband, 2002).

(a) Narrowing down on the goals;

Whitlock & Orleans (2002) observe that many patients are faced with the dilemma of handling the desire to achieve the long-term goals and the short-term goals. There is normally confusion in separating the desired results step by step. It is advisable to phase these steps in small plans (Whitlock & Orleans, 2002). For example, when it comes to physical activities, the patients are advised to start with maybe one hour per week then increasing the number of hours gradually, and specifically dwelling on the patient’s most enjoyable game (Gonder-Redenick, Cox & Ritterband, 2002). Gradual improvement helps the patient build confidence in these steps, and each step is expected to improve with a lasting success (Ruggiero et al, 1999). Small steps can also give the physicians

(b) Stepped Care

Experts advise that the best technique for diabetes treatment and management is to start with simple steps, then progressing to more complex steps only if necessary (Whitlock & Orleans, 2002). In case the selected self-monitoring on self-selected dietary changes gives a positive result in terms of weight loss, the patient can shift his or her focus on the maintenance of such methods (Gonder-Redenick, Cox & Ritterband, 2002). (Ruggiero et al (1999) advise that in case the patient efforts through the plan do not give any positive change, then they can be advised to shift or improve the efforts on the dietary component. The physician must monitor and understand the reason why the patient did not follow the designed plans just in case the patients fail to do that.

(c) Long-term goal for assistance

Experts agree that the achievement of success in terms of permanent physical activity patterns is a long-term project that should focus on yearly progress rather than a monthly focus. “The longer the period of intervention, the more likely improvements in weight loss and physical activity will be maintained.” (Ruggiero et al., 1999). In a particular study of patients who had impaired glucose tolerance, the intensity of the interventions was observed to have declined from six to twelve months (Ruggiero et al., 1999). It is therefore recommended that healthcare providers visit after every six months.

(d) Self-monitoring by an individual for long term goal

Since long-term monitoring is required for the patients to realize success in the self-management process, the patients are required to have control of their own behaviors to ensure sustainability. The physician is therefore at liberty to provide a simple system that the patients can follow, encourage them to follow the steps, and do follow up (Ruggiero et al, 1999). One important approach in the prevention program needs the patients to have records and follow up all the activities and food eaten, thus giving them self-management skills for the sustainable result (Story et al., 20025). If a physician assigns the patient homework, a progress note should accompany the assignment to have the starting point in the next visit (Story et al., 20025), thus giving the physician track the countable progress. The physician should mostly emphasize the strong positive points that would help praise the strong achievements. The physician should be limiting the number of suggestions for the next visit, beginning with the simplest steps.

(e) The choices in the provision

The healthcare providers are advised to provide varied choices in the methods of achieving the goals. It is therefore the responsibility of the provider to advise the patient to either choose physical activity or a weight loss program. Later advice may involve options for the patient to count calories or just follow a simple meal plan. Some of the self-help materials like guide books and DVDs are efficient necessities to help the patients.

(f) Patients’ empowerment

It is noted that most physicians use an education approach to problem-solving like the doctor-talk, patiently listen to approach (Gonder-Redenick, Cox & Ritterband, 2002). But historically, not all problems related to diabetes treatment are sufficiently served by information dissemination

(g) Developing skill

The patients have been noted to lack basic skills in the management of diabetes. The general healthcare providers have little skill in terms of a multifaceted approach to the management and treatment of diabetes. Such barriers are hampering the success of diabetes treatment. It is therefore advisable to develop these skills effectively to help manage the pandemic since it would be both cost-effective and sustainable.

Early researches barriers to progress

Several efforts have been made to increase diabetes management and treatment, especially on the research front. However, just like any other research, diabetes management and treatment face numerous challenges as concerns the research limitations and implementation of the findings

Several documented studies connect physiological factors and diabetes. For instance, the high prevalence rate (15-20%) of depression in diabetic persons is basically associated with less self-care behavioral adherence and the decreased glycemic control (Gonder-Redenick, Cox & Ritterband, 2002). Glasgow et al. (1999) conducted an interventions study and the result showed that treatment with antidepressants or behavior therapy improves depression and glycemic control, a revelation justified by Delamater et al. (2001). Patients who are poor experience financial difficulty, lack of jobs and unsafe environment have little motivation to address complex long-term lifestyle issues, thus little adherence (Pan et al, 1997). Such patients can be helped better through case management to address their immediate needs and subsequently improve the likelihood of treatment adherence, a process that seems costly and may need support from all sectors of the community, especially the government (VHA/DoD, 1999).

Ruggiero et al. (1999) conducted a study on the stages of change for smokers with either type-1 or type-2 diabetes. The study found the following overall distribution of stages: 15.8% in the pre-contemplation stage, 9.6% in the contemplation stage, 2% in the preparation stage, 3.2% in the action stage, and 69.4% in the maintenance stage (Ruggiero et al., 1999). Specifically, of “those who ever smoked, more people with type 2 diabetes were in the maintenance stage (72.5% vs. 44.5%) and there were no differences in stage across a type of diabetes for those who were current smokers” (Ruggiero et al.,1999). Across groups, 57.8% of current smokers were in the pre-contemplation stage, 35.1% were in the contemplation stage, and 7.1% were in the preparation stage (Ruggiero et al.,1999).

These results portray a worrying trend, indicating that people with diabetes who smoke are less ready to change than the general population, for which the distribution of stages has been 40% pre-contemplation, 40% contemplation, and 20% preparation (Ruggiero et al., 1999). Furthermore, individuals who reportedly received provider advice (e.g. from doctors and/ or nurses, and dieticians) “regarding quitting smoking were further along on the stages of change” (Ruggiero et al.,1999). More than 85% of those who reportedly had not received provider advice about smoking were in the pre-contemplation stage (Dunstan, Daly, Owen, et al. 2002). This is a clear emphasis on the usefulness of provider advice in promoting smoking cessation together with other healthy behaviors such as regular exercise and low-fat food consumption among the general public. A national survey on the management of childhood and adolescent obesity found out that 939 health care providers (pediatricians, pediatric nurse practitioners, and registered dietitians), have self-perceived low skill levels in their ability to counsel patients with obesity in the areas of behavior management strategies, parenting techniques, and family conflicts (Story et al., 20025). Such findings could be postulated to the ability of healthcare providers to support diabetes management and treatment since as earlier stated, obesity and diabetes are directly connected. Further complications rely on the fact that there is relatively little information on what types of education produce what particular benefits for which types of patients. Moreover, the benefits of various forms of education (for selected groups) relative costs analysis are not yet established (Botelho, 2002).

The recent surge in type-2 diabetes in children has presented a worrying trend in general diabetic management and treatment (Botelho, 2002). However, it is hard to detect type 2 diabetes in children because it can go undiagnosed for a long time; because children may have no symptoms or mild symptoms; and because blood tests are needed for diagnosis (CDC, 2008). CDC also acknowledges that it is difficult to be sure if it is type-2 or type-1 because criteria for differentiating the two types in children are still not established; that is, children with type 2 can develop ketoacidosis (acid build-up in the blood); children with type 1 can be overweight; and because the overall prevalence of the disease may still be low (CDC, 2008). It, therefore, follows that for more representative data, scientists will have to sample a very large population of children in order to find a stable estimate of prevalence for a more viable result (Gonder-Redenick, Cox & Ritterband, 2002).

Conclusion

As elaborated in this paper through the highlighted studies, it is evident that diabetes can be prevented and effectively. This is because of the growing baseline knowledge on all facets of the disease (i.e. biological, physiological and social aspects). For example, the strategic environmental intervention approach to reduce the prevalence of population to high-fat food consumption presently focuses on basic consumer knowledge, emphasizing healthy eating habits through mass media, school-based, and point-of-education purchase (CDC, 2003) have shown some generally good trends. It is acknowledged that such interventions’ some positive effects on the general nutrition knowledge among the population are negatively affected by food-choice behaviors that seem inconsistent and short-lived. Likewise, the lack of physical exercise is said to magnify the disease prevalence like never before. This has been intensified by the environmental factors that seem to encourage bad eating habits and lack of regular exercise. It is said that type of work in the modern economy that does not give room for regular exercise is even making the whole process of managing diabetes more difficult. Again, as observed earlier, availability of these high-fat foodstuffs have a greater influence on the consumer habit.

This information is likely to open further prevention opportunities that have never been experienced before. The task ahead of the entire stakeholders (victims and relatives, dietitians, medical professionals, government, NGOs, and society in general) is how to leverage all these approaches to enhance benefits of the intervention efforts such as promoting healthy eating and weight loss, physical activity, and appropriate use of medications to prevent diabetes; and how to reduce or eliminate environmental factors that trigger the disease prevalence.

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