Diabetes and the trouble with healthier lifestyles

At the end of January, the Ontario Ministry of Health and Long-Term Care (MOHLTC) announced almost $10 million in new funding to address type 2 diabetes, with a focus on screening and the ‘promotion of healthier lifestyles.’ There is a lot to celebrate in this announcement, particularly community-based screening initiatives. And who could complain about the promotion of healthier lifestyles? I would like to. Here’s why.

From 2009 – 2013, I worked in community health in a Toronto neighbourhood. The area had several diabetes-focused nurses, dietitians and outreach workers who ran community-based screening clinics and offered one-on-one appointments, healthy cooking classes, nutrition workshops and many other positive interventions.

At the same time, the area had one of the city’s highest concentrations of people over the age of 65 and lower household incomes than the city average. Parts of it were also notoriously difficult to navigate by public transit or on foot. Finally, the neighbourhood had little access to lower cost, healthy food.

Many community health workers – inspired by community residents, who volunteered and advocated around issues like access to healthy food – attempted to bridge these gaps. Unfortunately, health care ‘silos’ did not allow most the flexibility to sustainably support interventions like SHOP, which relies on local capacity to distribute free produce to targeted neighbourhoods. Health care workers also could not ensure people had access to regular healthy meals, stable and decent housing, recreation opportunities – even medications and blood sugar testing supplies – and other factors necessary to prevent or manage diabetes.

Today, I work at a research institute, and wonder what kind of evidence would compel governments to invest in chronic disease strategies targeting the social determinants of health in the same way they invest in chronic disease strategies targeting lifestyle change. In the neighbourhood I worked in, it would be interesting to see a randomized controlled trial of elders with diabetes who are offered regular drop-offs of washed, prepared and culturally appropriate fruit, vegetables and grains. Plus welcoming, no-cost fitness and social programs with interpretation if needed and transportation covered if walking is not a possibility. Include the offer of visits from a friendly community worker who can help with some cooking, share the first fitness class or simply talk, and my hypothesis: health improves.

Even better, what about a neighbourhood-based study that asks elders living with diabetes to describe the barriers they encounter as they try to make healthy choices? I’m guessing our study would demonstrate that interconnected factors like racism, unlivably low income supports, unstable housing, lack of access to transportation, punitive new rules for immigrants and refugees and isolation play key roles in hampering the management of diabetes, and likely other diseases on top of that – in Ontario, about 70 per cent of people over 45 who are chronically ill are living with more than one condition.

But we don’t need to do these imaginary studies. Not really. A recent report from the Wellesley Institute makes the clear case that lifestyle advice alone will not address diabetes in Ontario. More generally, there is already a compelling body of evidence linking  factors like income to a broad array of health issues from problems in pregnancy to, yes, diabetes. And, as a new study from the Centre for Research on Inner City Health and several partners demonstrates, the majority of Ontario residents have a clear understanding of the link between income and health. So do Ontario doctors, who have been making passionate arguments for livable minimum wages and broad policy interventions. The evidence demonstrates – and people in Ontario understand – that lifestyle advice addresses only the tip of the iceberg.

So, what can the Ontario government do to create the conditions to dramatically reduce the burden of diabetes and other chronic diseases? First – give health care and social service workers the flexibility and resources they need to collaborate with community residents on programs and advocacy initiatives that respond directly to neighbourhoods. (And it’s possible that this new round of funding will do just that.) Next – give government Ministries the flexibility they need to collaborate with each other to improve population health. Begin looking at investments in quality affordable housing, livable income supports and transportation as health care – in other words, adopt a ‘Health in All Policies’ approach. Finally – and I will admit that I believe this is something that will not come from polite policy recommendations, but rather as a result of long-term, grassroots action – begin addressing the ‘causes of the causes,’ the injustice and exploitation at the root of so much preventable ill health.

In the meantime, promoting healthy lifestyles is important, and will help some people. But, as many researchers passionately emphasize, it won’t transform the prevalence and management of diabetes and other chronic diseases in Ontario. And the evidence shows us clearly what will.