- Email: [email protected]
A Diabetes Intervention Program of Physical Activity carried out at primary care settings in Mexico
Diabetes Research and Clinical Practice 68 (2005) 135–140 www.elsevier.com/locate/diabres
A Diabetes Intervention Program of Physical Activity carried out at primary care settings in Mexico M. Bacardı´-Gasco´na, P. Rosales Garaya, A. Jime´nez-Cruza,b,* a
Calzada Tecnolo´gico 14418, Mesa de Otay, CP 22390, Unidad Universitaria Tijuana, B.C., Me´xico b Medical School, Universidad Auto´noma de Baja California, Mexico Received 2 July 2004; received in revised form 3 September 2004; accepted 6 September 2004 Available online 11 November 2004
Abstract Objective: The aim of this study was to document physical activity (PA) of migrant Mexican women with type 2 diabetes who have participated in diabetes intervention programs at a primary care level. Methods: One hundred out of 133 women of seven diabetes education groups from different Mexican institutions located in the city of Tijuana were invited to participate in the study. A PA history questionnaire was completed weekly. Metabolic Equivalents (METs) were used to calculate physical activity level (PAL). Results: Forty percent were classified as overweight and 31% as obese. Six percent of the women performed more than 150 min of moderate/vigorous weekly PA, while more than 80 min of weekly PA was reported by 73% of the population. There was no difference in frequency and intensity of PA between the participants from both institutions. The main indoor activities were cooking, dish washing, clothes washing and cleaning, and the main outdoor activities were walking, semi-active exercise and running. Conclusions: The majority of these migrant women who participated in the diabetes intervention program seem to engage in the minimum recommended levels of PA. In a country like Mexico, where its public health care system is facing huge economic constraints, PA counseling done in a primary health care practice may be a cost-effective approach. # 2004 Elsevier Ireland Ltd. All rights reserved. Keywords: Diabetes intervention programs; Type 2 diabetes; Mexican diabetics; Physical activity
1. Introduction The importance of physical activity (PA) has been emphasized for healthy individuals and for people with diabetes mellitus [1–3]. The American Diabetes * Corresponding author. E-mail address: [email protected] (A. Jime´nez-Cruz).
Association (ADA) concluded that physical activity should be regarded as a high priority in the management of type 2 diabetes [2]. The 2000 Dietary Guidelines for Americans recommends that adults participate in at least 30 min of moderate physical activity most days of the week, preferably daily [4]. The Mexican Ministry of Health recommends that people with diabetes should perform at least 20 min of
0168-8227/$ – see front matter # 2004 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.diabres.2004.09.003
136
M. Bacardı´-Gasco´n et al. / Diabetes Research and Clinical Practice 68 (2005) 135–140
PA most days of the week [3]. Guidelines can be considered effective if they lead to improved patient care [4]. However, a survey of clinical practice guidelines (CPGs) concluded that there is little evidence that CPGs improve patient outcome in primary care [5,6]. Nelson et al. [7] analyzed exercise practices among adults with type 2 diabetes from the third National Health and Nutrition Examination (NHANES III): 68, 78 and 72% of White, African-American and Mexican-American, respectively, reported no regular physical activity or less than recommended levels of physical activity. In addition, lower income and increasing age were associated with physical inactivity. Another study shows that the majority of Americans, including those with diabetes, are not meeting PA goals [8]. Several studies have shown that individualized intervention increased PA and improved glycemic control in people with type 2 diabetes [9,10]. However, to our knowledge, there has not been a study that explores the effect of diabetes intervention programs on physical activity among migrant Mexican women with type 2 diabetes. The purpose of this study was to document physical activity of migrant Mexican women with type 2 diabetes who have participated in diabetes intervention programs in primary care.
2. Methods 2.1. Setting In Mexico, the health care system has been segmented into three main compartments: (1) those protected by social security, which are also segmented into several institutions (IMSS, ISSSTE, ISSSTECALI, etc.), which amount in the state of Baja California to nearly 48%; (2) those that do not have a formal labor situation, are covered by the Instituto de Servicios de Salud (ISESALUD) in each state, which amounts to 20–40% of the total population. In addition, an estimated 10–30% attend private practices. People eligible for IMSS (48% of the total population) are all those that work for an employer and those who enrol by choice and pay for themselves. The ISSSTE and ISSSTECALI (10%) in Baja California are the social security institutions for state employees
[11]. In addition, non-government and non-profit organizations, as well as university clinics usually offer primary health care and prevention programs to the underprivileged. Therefore, the lowest income participants were those from the university clinic and ISESALUD. Although all the institutions have their own programs for the prevention and control of diabetes, the health ministry established the clinical practice guidelines for the control and prevention of diabetes, which include the recommendation of PA for 20–40 min most days of the week [3]. Baja California is the northwestern Mexican state that borders the US state of California, and Tijuana is the northwesternmost Mexican city that borders the city of San Diego, California. 2.2. Participants All women of seven diabetes education groups from different Mexican institutions located in Tijuana were invited to participate in the study. One hundred and eleven out of the 133 approached agreed to participate in the interviews. Three groups from IMSS, one group from ISSTECALI, two groups from ISESALUD and one from a diabetes program at the university clinic participated [12]. Women with type 2 diabetes, 30–80 years old who were enrolled in an education program for 2 months in the past 12 months participated in the study. Participants from the university clinic and ISESALUD are usually considered to be of low socio-economic status, with an income of less than two minimum wages. In Baja California, 26.6% of the population has less than one minimum wage. The IMSS and ISSSTECALI participants usually have less than five minimum wages. In Baja California, 74.3% of the total population has less than five minimum wages. The average minimum wage during 2002 was 16 dollars daily [11]. Participants were grouped into insured (IMSS, ISSTECALI) and uninsured (ISESALUD and university clinic). 2.3. Physical activity intervention The exercise involved a 60-min group discussion with a physical trainer assistant and was carried out following Mexican guidelines [13]. Participants were given exercise information by leaflets and PA
M. Bacardı´-Gasco´ n et al. / Diabetes Research and Clinical Practice 68 (2005) 135–140
counseling, which included 30 min of a group meeting exercise. This routine included strength training, flexibility exercises and aerobic exercise. At each meeting the diabetes educator or a research assistant encouraged patients to perform at least 20 min of moderate PA most days of the week. There was no difference in the PA program among the institutions. At the health institutions a Mexican food pyramid was used as a communicating graph, while the Apple of Health was used at the university clinic [13]. 2.4. Data collection All patients were interviewed by a physician (PRG) in the clinic where they usually attend. The questionnaire included current and past PA, indoors and outdoors PA, weekly frequency and duration in minutes.
137
Table 1 Population characteristics n
Data (mean S.D. or %) 53 12 98 98 29 7
Age (year) Years of residence in Tijuana Duration of diabetes (year) BMI (kg/m2)
100 90 100 100
Place of birth Tijuana or Baja California Other states
10 90
10 90
BMI (kg/m2) <25 25–29.9 >30.0
29 40 31
29 40 31
Fasting glucose (mmol/l) Cholesterol (mmol/l) Triglycerides (mmol/l)
100 100 100
8.7 4.4 3.88 3.18 1.26 1.33
The study was reviewed and approved by the Nutrition Subjects Program Review Board and written consent was obtained from the participants.
terms of METs, with an allowance for the postexercise increase in energy expenditure induced by physical activities and the thermic effect of the food that needs to be consumed to cover the overall cost of these activities [15,18].
2.6. Pilot study
2.8. Statistical Analysis
A weekly PA history questionnaire was completed twice (2 weeks interval) by 20 women with type 2 diabetes. PA at home and outside was assessed. Test-retest reproducibility was assessed by Spearman correlation. Test-retest was 0.55 (p = 0.05) for resting during the previous week, for PA during the previous week was 0.74 (p = 0.004) and for PA and resting was 0.64 (p = 0.02) during the previous week.
Analyses were conducted using the Statistical Program for Social Sciences (SPSS) computer package for personal computers, for Windows version 11.5. To calculate differences of activities between groups the Mann–Whitney test was used. Chi-square was used to explore the association of daily and weekly activity time among insured and uninsured groups.
2.5. Consent approval
2.7. Metabolic Equivalent (MET) 3. Results One MET is defined as 1 kcal/kg/min and is roughly equivalent to the energy cost of sitting quietly [14,15]. METs were used to score PA questionnaires. Physical activity level (PAL) is defined as the ratio of total energy expenditure to basal energy expenditure. To evaluate PAL based on the daily activities reported in the questionnaire, the number of minutes from each participant’s activity was multiplied by the DPAL coefficients. These coefficients are based on rates of energy expenditure during exercise reported in
One hundred and eleven agreed to participate in the questionnaire and 100 questionnaires were adequately answered. Table 1 displays the population characteristics. Table 2 shows the weekly physical activities among uninsured and insured groups according to the Mexican Ministry of Health recommendations, and Table 3 shows weekly PA at different levels of intensity.
M. Bacardı´-Gasco´ n et al. / Diabetes Research and Clinical Practice 68 (2005) 135–140
138
Table 2 Weekly physical activity (Mexican Ministry of Health recommendations) Institution
<80 min
N
Percentage
N
Percentage
63 37
18 9
28 24
45 28
71 76
100
27
27
73
73
IMSS/ISSTECALI (insured) ISESALUD/University clinic (uninsured) Total
>80 min
N
Chi-square test, p = 0.4.
Table 3 Indoor and outdoor weekly physical activity Institution
N
<150 min
>150 min
Light N IMSS/ISSTECALI (insured) ISESALUD/University clinic (uninsured) Total
MV
Light
MV
Percentage
N
Percentage
N
Percentage
N
Percentage
63 37
9 5
14 14
60 34
95 92
54 32
86 86
3 3
5 8
100
13
14
94
94
86
86
6
6
MV: moderate or vigorous PA.
In general, no significant differences were found between the uninsured and insured participants in daily outdoor activity (0.55 h versus 0.82 h, p = 0.3), and in daily indoor activity (5.55 h versus 5.82 h, p = 0.7). However, as indicated in Table 4, the uninsured spent more time (0.98 h/day) in moderate indoors activities (3.0–6.0 METs) than insured (0.77 h/day, p = 0.049) (Table 4). The average daily physical activity level was 1.56 0.04 for the uninsured and 1.53 0.03 for the insured subjects (p = 0.5). The main indoor activities were cooking (11.0 h/week), dish washing and clothes washing (3.2 h/week), cleaning (3.1 h/week), shopping (1.9 h/week), and the main outdoor physical activities were walking (3.1 h/week), semi-active exercise and stretching (1.26 h/week), running (0.23 h/week) and bicycling (0.18 h/week). The main resting activities
were sleeping (49.16 h/week), watching television (11.3 h/week), resting in bed (2 h/week), driving or sitting in a car (1.5 h/week) and sitting at home (1.38 h/ week).
4. Discussion This study shows that the majority of Mexicans with diabetes who are willing to follow the diabetes education at the primary health care clinics from government institutions for insured and uninsured people, engage in more than 20 min of PA most days of the week, as recommended by the Mexican Ministry of Health [3]. However, only 6% engaged in more than 150 min of PA weekly (Table 3). More than 70% of the
Table 4 Time expended (min/day) (mean S.E.M.) in outdoor and indoor activities by level of intensity Light activity (<3.0 METs)
Moderate METs)
activity
(3.0–6.0
Vigorous METs)
activity
(>6.0
Insured
Uninsured
Insured
Uninsured
Insured
Uninsured
Outdoors Indoors
26 3.5 300 17.3
40 8.5 264 20.2
4 1.1 46 6
42 59 6.8*
31 1 0.3
5 1.4 0.4 0.2
Total
326 18.4
304 22.6
50 5.9
63 7.3
4 1.1
5.5 1.5
*
Mann–Whitney test, p = 0.049 (within moderate activity indoors vs. outdoors).
M. Bacardı´-Gasco´ n et al. / Diabetes Research and Clinical Practice 68 (2005) 135–140
insured and uninsured subjects engaged in more than 80 min of weekly PA (Table 2). The majority (71%) of this population were overweight or obese and were migrants from other Mexican states (90%) (Table 1). Although our results are better than the USA and Mexican national data for adults with type 2 diabetes [7,8,16], the groups we studied were especially motivated subjects looking for improved metabolic control through their active participation in diabetes education groups. Light, moderate and vigorous activity was not different among insured and uninsured people, except that uninsured subjects reported more indoor moderate activity than insured subjects (Table 4). This population, of low socio-economic status, usually confront major environmental economic barriers to accessing safe recreational areas or fitness facilities. Tijuana, although one of the most affluent and growing cities in Mexico, is in the lowest percentile of urban infrastructure, including safe recreational areas and parks, among cities larger than 100,000 inhabitants. In Mexico, physical activity has not been promoted widely by government institutions, health care institutions or health care personnel. Additionally, role models, at home and community levels, such as parents and leaders of the community, are usually overweight. Among the Mexican-American in Starr County of Texas, women with a higher migration score exhibited poorer exercise habits [17]. However, our results suggest that promoting PA to Mexican people with diabetes who are eager to participate in education groups, even with economic restraints and inadequate environment for PA, is a worthwhile strategy that should be supported. The PA reported by this Mexican population with type 2 diabetes is higher than those reported by national data in the USA in both healthy MexicanAmericans and adults with type 2 diabetes [7,8,19,20]. In a study conducted by Crespo et al., from the results of NHANES III, Mexican-Americans have the largest prevalence of physical inactivity during leisure time than non-Hispanic Whites [20]. In addition, from NHANES III, leisure-time inactivity was highest among older persons, those with less than 12 year of education, and those who earned less than $20,000 per year, Mexican-American women had a higher prevalence of physical inactivity than MexicanAmerican men, men and women born in Mexico had a higher prevalence of physical inactivity and
139
those born in Mexico and living in the US less than 5 years were more likely to be inactive during leisure time [19,20]. Our results are consistent with Macintyre et al. [21] and Lowther et al. [22]. Macintyre examined United Kingdom surveys on PA and showed that higher social class adults engage in more formal sports activities. They are less likely to engage in sports and active play, while lower social class children are more likely to engage in sports [21]. The 12-month control trial fitness conducted in Scotland by Lowther et al. showed that those in socially and economically deprived communities respond well to PA interventions [22]. In the National Health Interview Survey, only onethird of people with diabetes reported exercising regularly [8]. On the other hand, Nelson et al. analyze from the results of NHANES III, exercise among adults with type 2 diabetes [7] and found that 21% reported no regular PA and another 38% (totalling 59%) reported less than recommended levels of PA. In addition, only 28% of Mexican-American reported recommended levels of PA (five or more episodes of moderate PA/week or three or more episodes of vigorous activity per week [7]). The main limitation of our study is that it was conducted on people with diabetes who are willing to participate in a diabetes educational group. In addition, we did not measure the actual duration of PA. Intervention studies have shown that PA plays an important role in glucose tolerance, insulin sensitivity and glycemic control [23–26]; additionally, a metaanalysis of clinical trials found that moderate-intensity PA can reduce HbA1c by 0.6% in individuals with type 2 diabetes [26]. Norris et al., in a systematic review of randomized controlled trials, also found that interventions actively involving patient participation can change exercise and diet [27]. In Italy [10] and Mexico [12] positive effects have been shown after different strategies to promote PA. At the US–Mexico border, a binational culturally sensitive tool, as part of a comprehensive self-empowerment program has also been shown in Mexican individuals with diabetes to have a positive effect on metabolic control [12]. Therefore, at the current health care practice at the primary care level of Mexican institutions, within a public health care system which cannot afford to provide diagnostic procedures and drug treatment for more than 40% of the population [28], more emphasis
140
M. Bacardı´-Gasco´ n et al. / Diabetes Research and Clinical Practice 68 (2005) 135–140
should be made on promoting PA. This is a costeffective approach for a health care system facing huge economic constraints.
References [1] WHO Technical Report Series, Diet, Nutrition and the Prevention of Chronic Diseases, WHO, Geneva 2003, pp. 1–149. [2] ADA, Physical activity, exercise and diabetes mellitus, Diabetes Care 26 (Suppl. 1) (2003) S7–S77. [3] Secretaria de Salud: Norma Oficial Mexicana para la prevencio´ n, tratamiento y control de la diabetes mellitus en la atencio´ n primaria a la salud. NOM-015-SSA2-1994, Mexico, DF, 2000. [4] USDA/DHHS, Dietary Guidelines for Americans, 5th ed., Home and Gauden Bulletin No. 232, Washington, 2000. [5] G. Worrall, P. Chaulk, D. Freake, The effects of clinical practice on patient outcomes in primary care: a systematic review, Can. Med. Assoc. J. 156 (1997) 1705–1712. [6] S.B. Harris, S.M. Webster-Bogaert, Evidence-based clinical practice guidelines, in: Gerstein, Haynes (Eds.), Evidencebased Diabetes Care, Hamilton, BC Decker Inc., 2001. [7] K.M. Nelson, G. Reiber, E.J. Boyko, Diet and exercise among adults with type 2 diabetes, Diabetes Care 25 (2002) 1722– 1728. [8] E.S. Ford, W.H. Herman, Leisure-time physical activity patterns in the US diabetic population: findings from the 1990 National Health Interview Survey-Health Promotion and Diseases Prevention Supplement, Diabetes Care 18 (1995) 27–33. [9] A. Kirk, N. Mutrie, P. MacIntryre, M. Fisher, Increasing physical activity in people with type 2 diabetes, Diabetes Care 26 (2003) 1186–1192. [10] C. Di Loreto, C. Fanelli, P. Lucidi, G. Murdolo, A. De Cicco, N. Parlanti, et al. Validation of a counseling strategy to promote the adoption and the maintenance of physical activity by type 2 diabetic subjects, Diabetes Care 26 (2003) 404–408. [11] INEGI, Retrieved (6/23/2003) from the www: http://bc.inegi. gob.mx/sociodem/espanol/salud/sal_04.html. [12] M. Bacardı´-Gasco´ n, P. Rosales-Garay, A. Jime´ nez-Cruz, Effect of Diabetes Intervention Programs on physical activity among migrant Mexican women with type 2 diabetes, Diabetes Care 27 (2004) 1213–1215. [13] A. Jimenez-Cruz, M. Bacardı´-Gasco´ n, P. Rosales-Garay, J. Herrera-Espinoza, O.W. Willis, A culturally sensitive tool for Mexican people with diabetes: La Manzana de la Salud, Rev. Biomed. 14 (2003) 51–59. [14] B.E. Ainsworth , The Compendium of Physical Activities Tracking Guide, Prevention Research Center, Norman J. Arnold School of Public Health, University of South Carolina, Retrieved (3/6/03) from the World Wide Web: http://prevention.sph.sc.edu/tools/compendium_tracking.pdf.
[15] B.E. Ainsworth, W.L. Haskell, A.S. Leon, D.R. Jacobs Jr., H.J. Montoye, J.F. Sallis, et al. Compendium of physical activities: classification of energy costs of human physical activities, Med. Sci. Sport Exerc. 25 (1993) 71–80. [16] Ribera J., Villalpando S., Shamah T., Encuesta Nacional de Nutricio´ n 1999, Instituto Nacional de Salud Publica, Cuernavaca, 2001. [17] N. Abate, M. Chandalia, The impact of ethnicity on type 2 diabetes, J. Diabetes Complications 17 (2003) 39–58. [18] Food Nutrition Board, Institute of Medicine, Dietary Reference Intakes For Energy, Carbohydrate, Fiber, Fat, Fatty Acids, Cholesterol, Protein and Aminoacids, The National Academies Press, Washington, DC, 2002. [19] B.M. Charkraborty, W.H. Mueller, R. Reeves, W.S. Poston, D.M. Hoscher, B. Quill, et al. Migration history, health behaviors, and cardiovascular disease risk factors in overweight Mexican-American women, Ethn. Dis. 13 (2003) 94–108. [20] C.J. Crespo, S.H.J. Keteyian, G.W. Heath, S.T. Sempos, Prevalence of leisure-time physical activity among US adults, results from the Third National Health and Nutrition Examination Survey, Arch. Intern. Med. 156 (1996) 93–98. [21] S. Macintyre, N. Mutrie, Socio-economic differences in cardiovascular disease and physical activity: stereotypes and reality, J. R. Soc. Health 124 (2004) 66–69. [22] M. Lowther, N. Mutrie, E.M. Scott, Promoting physical activity in a socially and economically deprived comm– unity: a 12 month randomized control trial of fitness assessment and exercise consultation, J. Sport Sci. 20 (2003) 577–588. [23] C.J. Crespo, E. Smit, O. Carter-Pokras, R. Andersen, Acculturation and leisure-time physical inactivity in Mexican-American adults: results from NHANES III 1988–1994, Am. J. Public Health 91 (2001) 1254–1257. [24] D.O. Clark, Physical activity efficacy and effectiveness among older adults and minorities, Diabetes Care 20 (1997) 1176– 1182. [25] D.W. Dunstan, R.M. Daly, N. Owen, D. Jolley, M. De Courten, J. Shaw, et al. High-intensity resistance training improves glycemic control in older patients with type 2 diabetes, Diabetes Care 25 (2002) 1729–1736. [26] N.G. Boule, E. Haddad, G.P. Kenny, G.A. Wells, R.J. Sigal, Effects of exercise on glycemic control and body mass in type 2 diabetes mellitus: a meta-analysis of controlled clinical trials, J. Am. Med. Asoc. 286 (2001) 1218– 1227. [27] E. Norris, M.M. Enelgau, K.M. Vnkat Narayan, Effectiveness of self-management training in type 2 diabetes: a systematic review of randomized controlled trials, Diabetes Care 24 (2001) 561–587. [28] A. Jimenez-Cruz, M. Bacardı´-Gasco´ n, The fattening burden of type 2 diabetes on Mexicans, Diabetes Care 27 (2004) 1213– 1215.
A Diabetes Intervention Program of Physical Activity carried out at primary care settings in Mexico M. Bacardı´-Gasco´na, P. Rosales Garaya, A. Jime´nez-Cruza,b,* a
Calzada Tecnolo´gico 14418, Mesa de Otay, CP 22390, Unidad Universitaria Tijuana, B.C., Me´xico b Medical School, Universidad Auto´noma de Baja California, Mexico Received 2 July 2004; received in revised form 3 September 2004; accepted 6 September 2004 Available online 11 November 2004
Abstract Objective: The aim of this study was to document physical activity (PA) of migrant Mexican women with type 2 diabetes who have participated in diabetes intervention programs at a primary care level. Methods: One hundred out of 133 women of seven diabetes education groups from different Mexican institutions located in the city of Tijuana were invited to participate in the study. A PA history questionnaire was completed weekly. Metabolic Equivalents (METs) were used to calculate physical activity level (PAL). Results: Forty percent were classified as overweight and 31% as obese. Six percent of the women performed more than 150 min of moderate/vigorous weekly PA, while more than 80 min of weekly PA was reported by 73% of the population. There was no difference in frequency and intensity of PA between the participants from both institutions. The main indoor activities were cooking, dish washing, clothes washing and cleaning, and the main outdoor activities were walking, semi-active exercise and running. Conclusions: The majority of these migrant women who participated in the diabetes intervention program seem to engage in the minimum recommended levels of PA. In a country like Mexico, where its public health care system is facing huge economic constraints, PA counseling done in a primary health care practice may be a cost-effective approach. # 2004 Elsevier Ireland Ltd. All rights reserved. Keywords: Diabetes intervention programs; Type 2 diabetes; Mexican diabetics; Physical activity
1. Introduction The importance of physical activity (PA) has been emphasized for healthy individuals and for people with diabetes mellitus [1–3]. The American Diabetes * Corresponding author. E-mail address: [email protected] (A. Jime´nez-Cruz).
Association (ADA) concluded that physical activity should be regarded as a high priority in the management of type 2 diabetes [2]. The 2000 Dietary Guidelines for Americans recommends that adults participate in at least 30 min of moderate physical activity most days of the week, preferably daily [4]. The Mexican Ministry of Health recommends that people with diabetes should perform at least 20 min of
0168-8227/$ – see front matter # 2004 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.diabres.2004.09.003
136
M. Bacardı´-Gasco´n et al. / Diabetes Research and Clinical Practice 68 (2005) 135–140
PA most days of the week [3]. Guidelines can be considered effective if they lead to improved patient care [4]. However, a survey of clinical practice guidelines (CPGs) concluded that there is little evidence that CPGs improve patient outcome in primary care [5,6]. Nelson et al. [7] analyzed exercise practices among adults with type 2 diabetes from the third National Health and Nutrition Examination (NHANES III): 68, 78 and 72% of White, African-American and Mexican-American, respectively, reported no regular physical activity or less than recommended levels of physical activity. In addition, lower income and increasing age were associated with physical inactivity. Another study shows that the majority of Americans, including those with diabetes, are not meeting PA goals [8]. Several studies have shown that individualized intervention increased PA and improved glycemic control in people with type 2 diabetes [9,10]. However, to our knowledge, there has not been a study that explores the effect of diabetes intervention programs on physical activity among migrant Mexican women with type 2 diabetes. The purpose of this study was to document physical activity of migrant Mexican women with type 2 diabetes who have participated in diabetes intervention programs in primary care.
2. Methods 2.1. Setting In Mexico, the health care system has been segmented into three main compartments: (1) those protected by social security, which are also segmented into several institutions (IMSS, ISSSTE, ISSSTECALI, etc.), which amount in the state of Baja California to nearly 48%; (2) those that do not have a formal labor situation, are covered by the Instituto de Servicios de Salud (ISESALUD) in each state, which amounts to 20–40% of the total population. In addition, an estimated 10–30% attend private practices. People eligible for IMSS (48% of the total population) are all those that work for an employer and those who enrol by choice and pay for themselves. The ISSSTE and ISSSTECALI (10%) in Baja California are the social security institutions for state employees
[11]. In addition, non-government and non-profit organizations, as well as university clinics usually offer primary health care and prevention programs to the underprivileged. Therefore, the lowest income participants were those from the university clinic and ISESALUD. Although all the institutions have their own programs for the prevention and control of diabetes, the health ministry established the clinical practice guidelines for the control and prevention of diabetes, which include the recommendation of PA for 20–40 min most days of the week [3]. Baja California is the northwestern Mexican state that borders the US state of California, and Tijuana is the northwesternmost Mexican city that borders the city of San Diego, California. 2.2. Participants All women of seven diabetes education groups from different Mexican institutions located in Tijuana were invited to participate in the study. One hundred and eleven out of the 133 approached agreed to participate in the interviews. Three groups from IMSS, one group from ISSTECALI, two groups from ISESALUD and one from a diabetes program at the university clinic participated [12]. Women with type 2 diabetes, 30–80 years old who were enrolled in an education program for 2 months in the past 12 months participated in the study. Participants from the university clinic and ISESALUD are usually considered to be of low socio-economic status, with an income of less than two minimum wages. In Baja California, 26.6% of the population has less than one minimum wage. The IMSS and ISSSTECALI participants usually have less than five minimum wages. In Baja California, 74.3% of the total population has less than five minimum wages. The average minimum wage during 2002 was 16 dollars daily [11]. Participants were grouped into insured (IMSS, ISSTECALI) and uninsured (ISESALUD and university clinic). 2.3. Physical activity intervention The exercise involved a 60-min group discussion with a physical trainer assistant and was carried out following Mexican guidelines [13]. Participants were given exercise information by leaflets and PA
M. Bacardı´-Gasco´ n et al. / Diabetes Research and Clinical Practice 68 (2005) 135–140
counseling, which included 30 min of a group meeting exercise. This routine included strength training, flexibility exercises and aerobic exercise. At each meeting the diabetes educator or a research assistant encouraged patients to perform at least 20 min of moderate PA most days of the week. There was no difference in the PA program among the institutions. At the health institutions a Mexican food pyramid was used as a communicating graph, while the Apple of Health was used at the university clinic [13]. 2.4. Data collection All patients were interviewed by a physician (PRG) in the clinic where they usually attend. The questionnaire included current and past PA, indoors and outdoors PA, weekly frequency and duration in minutes.
137
Table 1 Population characteristics n
Data (mean S.D. or %) 53 12 98 98 29 7
Age (year) Years of residence in Tijuana Duration of diabetes (year) BMI (kg/m2)
100 90 100 100
Place of birth Tijuana or Baja California Other states
10 90
10 90
BMI (kg/m2) <25 25–29.9 >30.0
29 40 31
29 40 31
Fasting glucose (mmol/l) Cholesterol (mmol/l) Triglycerides (mmol/l)
100 100 100
8.7 4.4 3.88 3.18 1.26 1.33
The study was reviewed and approved by the Nutrition Subjects Program Review Board and written consent was obtained from the participants.
terms of METs, with an allowance for the postexercise increase in energy expenditure induced by physical activities and the thermic effect of the food that needs to be consumed to cover the overall cost of these activities [15,18].
2.6. Pilot study
2.8. Statistical Analysis
A weekly PA history questionnaire was completed twice (2 weeks interval) by 20 women with type 2 diabetes. PA at home and outside was assessed. Test-retest reproducibility was assessed by Spearman correlation. Test-retest was 0.55 (p = 0.05) for resting during the previous week, for PA during the previous week was 0.74 (p = 0.004) and for PA and resting was 0.64 (p = 0.02) during the previous week.
Analyses were conducted using the Statistical Program for Social Sciences (SPSS) computer package for personal computers, for Windows version 11.5. To calculate differences of activities between groups the Mann–Whitney test was used. Chi-square was used to explore the association of daily and weekly activity time among insured and uninsured groups.
2.5. Consent approval
2.7. Metabolic Equivalent (MET) 3. Results One MET is defined as 1 kcal/kg/min and is roughly equivalent to the energy cost of sitting quietly [14,15]. METs were used to score PA questionnaires. Physical activity level (PAL) is defined as the ratio of total energy expenditure to basal energy expenditure. To evaluate PAL based on the daily activities reported in the questionnaire, the number of minutes from each participant’s activity was multiplied by the DPAL coefficients. These coefficients are based on rates of energy expenditure during exercise reported in
One hundred and eleven agreed to participate in the questionnaire and 100 questionnaires were adequately answered. Table 1 displays the population characteristics. Table 2 shows the weekly physical activities among uninsured and insured groups according to the Mexican Ministry of Health recommendations, and Table 3 shows weekly PA at different levels of intensity.
M. Bacardı´-Gasco´ n et al. / Diabetes Research and Clinical Practice 68 (2005) 135–140
138
Table 2 Weekly physical activity (Mexican Ministry of Health recommendations) Institution
<80 min
N
Percentage
N
Percentage
63 37
18 9
28 24
45 28
71 76
100
27
27
73
73
IMSS/ISSTECALI (insured) ISESALUD/University clinic (uninsured) Total
>80 min
N
Chi-square test, p = 0.4.
Table 3 Indoor and outdoor weekly physical activity Institution
N
<150 min
>150 min
Light N IMSS/ISSTECALI (insured) ISESALUD/University clinic (uninsured) Total
MV
Light
MV
Percentage
N
Percentage
N
Percentage
N
Percentage
63 37
9 5
14 14
60 34
95 92
54 32
86 86
3 3
5 8
100
13
14
94
94
86
86
6
6
MV: moderate or vigorous PA.
In general, no significant differences were found between the uninsured and insured participants in daily outdoor activity (0.55 h versus 0.82 h, p = 0.3), and in daily indoor activity (5.55 h versus 5.82 h, p = 0.7). However, as indicated in Table 4, the uninsured spent more time (0.98 h/day) in moderate indoors activities (3.0–6.0 METs) than insured (0.77 h/day, p = 0.049) (Table 4). The average daily physical activity level was 1.56 0.04 for the uninsured and 1.53 0.03 for the insured subjects (p = 0.5). The main indoor activities were cooking (11.0 h/week), dish washing and clothes washing (3.2 h/week), cleaning (3.1 h/week), shopping (1.9 h/week), and the main outdoor physical activities were walking (3.1 h/week), semi-active exercise and stretching (1.26 h/week), running (0.23 h/week) and bicycling (0.18 h/week). The main resting activities
were sleeping (49.16 h/week), watching television (11.3 h/week), resting in bed (2 h/week), driving or sitting in a car (1.5 h/week) and sitting at home (1.38 h/ week).
4. Discussion This study shows that the majority of Mexicans with diabetes who are willing to follow the diabetes education at the primary health care clinics from government institutions for insured and uninsured people, engage in more than 20 min of PA most days of the week, as recommended by the Mexican Ministry of Health [3]. However, only 6% engaged in more than 150 min of PA weekly (Table 3). More than 70% of the
Table 4 Time expended (min/day) (mean S.E.M.) in outdoor and indoor activities by level of intensity Light activity (<3.0 METs)
Moderate METs)
activity
(3.0–6.0
Vigorous METs)
activity
(>6.0
Insured
Uninsured
Insured
Uninsured
Insured
Uninsured
Outdoors Indoors
26 3.5 300 17.3
40 8.5 264 20.2
4 1.1 46 6
42 59 6.8*
31 1 0.3
5 1.4 0.4 0.2
Total
326 18.4
304 22.6
50 5.9
63 7.3
4 1.1
5.5 1.5
*
Mann–Whitney test, p = 0.049 (within moderate activity indoors vs. outdoors).
M. Bacardı´-Gasco´ n et al. / Diabetes Research and Clinical Practice 68 (2005) 135–140
insured and uninsured subjects engaged in more than 80 min of weekly PA (Table 2). The majority (71%) of this population were overweight or obese and were migrants from other Mexican states (90%) (Table 1). Although our results are better than the USA and Mexican national data for adults with type 2 diabetes [7,8,16], the groups we studied were especially motivated subjects looking for improved metabolic control through their active participation in diabetes education groups. Light, moderate and vigorous activity was not different among insured and uninsured people, except that uninsured subjects reported more indoor moderate activity than insured subjects (Table 4). This population, of low socio-economic status, usually confront major environmental economic barriers to accessing safe recreational areas or fitness facilities. Tijuana, although one of the most affluent and growing cities in Mexico, is in the lowest percentile of urban infrastructure, including safe recreational areas and parks, among cities larger than 100,000 inhabitants. In Mexico, physical activity has not been promoted widely by government institutions, health care institutions or health care personnel. Additionally, role models, at home and community levels, such as parents and leaders of the community, are usually overweight. Among the Mexican-American in Starr County of Texas, women with a higher migration score exhibited poorer exercise habits [17]. However, our results suggest that promoting PA to Mexican people with diabetes who are eager to participate in education groups, even with economic restraints and inadequate environment for PA, is a worthwhile strategy that should be supported. The PA reported by this Mexican population with type 2 diabetes is higher than those reported by national data in the USA in both healthy MexicanAmericans and adults with type 2 diabetes [7,8,19,20]. In a study conducted by Crespo et al., from the results of NHANES III, Mexican-Americans have the largest prevalence of physical inactivity during leisure time than non-Hispanic Whites [20]. In addition, from NHANES III, leisure-time inactivity was highest among older persons, those with less than 12 year of education, and those who earned less than $20,000 per year, Mexican-American women had a higher prevalence of physical inactivity than MexicanAmerican men, men and women born in Mexico had a higher prevalence of physical inactivity and
139
those born in Mexico and living in the US less than 5 years were more likely to be inactive during leisure time [19,20]. Our results are consistent with Macintyre et al. [21] and Lowther et al. [22]. Macintyre examined United Kingdom surveys on PA and showed that higher social class adults engage in more formal sports activities. They are less likely to engage in sports and active play, while lower social class children are more likely to engage in sports [21]. The 12-month control trial fitness conducted in Scotland by Lowther et al. showed that those in socially and economically deprived communities respond well to PA interventions [22]. In the National Health Interview Survey, only onethird of people with diabetes reported exercising regularly [8]. On the other hand, Nelson et al. analyze from the results of NHANES III, exercise among adults with type 2 diabetes [7] and found that 21% reported no regular PA and another 38% (totalling 59%) reported less than recommended levels of PA. In addition, only 28% of Mexican-American reported recommended levels of PA (five or more episodes of moderate PA/week or three or more episodes of vigorous activity per week [7]). The main limitation of our study is that it was conducted on people with diabetes who are willing to participate in a diabetes educational group. In addition, we did not measure the actual duration of PA. Intervention studies have shown that PA plays an important role in glucose tolerance, insulin sensitivity and glycemic control [23–26]; additionally, a metaanalysis of clinical trials found that moderate-intensity PA can reduce HbA1c by 0.6% in individuals with type 2 diabetes [26]. Norris et al., in a systematic review of randomized controlled trials, also found that interventions actively involving patient participation can change exercise and diet [27]. In Italy [10] and Mexico [12] positive effects have been shown after different strategies to promote PA. At the US–Mexico border, a binational culturally sensitive tool, as part of a comprehensive self-empowerment program has also been shown in Mexican individuals with diabetes to have a positive effect on metabolic control [12]. Therefore, at the current health care practice at the primary care level of Mexican institutions, within a public health care system which cannot afford to provide diagnostic procedures and drug treatment for more than 40% of the population [28], more emphasis
140
M. Bacardı´-Gasco´ n et al. / Diabetes Research and Clinical Practice 68 (2005) 135–140
should be made on promoting PA. This is a costeffective approach for a health care system facing huge economic constraints.
References [1] WHO Technical Report Series, Diet, Nutrition and the Prevention of Chronic Diseases, WHO, Geneva 2003, pp. 1–149. [2] ADA, Physical activity, exercise and diabetes mellitus, Diabetes Care 26 (Suppl. 1) (2003) S7–S77. [3] Secretaria de Salud: Norma Oficial Mexicana para la prevencio´ n, tratamiento y control de la diabetes mellitus en la atencio´ n primaria a la salud. NOM-015-SSA2-1994, Mexico, DF, 2000. [4] USDA/DHHS, Dietary Guidelines for Americans, 5th ed., Home and Gauden Bulletin No. 232, Washington, 2000. [5] G. Worrall, P. Chaulk, D. Freake, The effects of clinical practice on patient outcomes in primary care: a systematic review, Can. Med. Assoc. J. 156 (1997) 1705–1712. [6] S.B. Harris, S.M. Webster-Bogaert, Evidence-based clinical practice guidelines, in: Gerstein, Haynes (Eds.), Evidencebased Diabetes Care, Hamilton, BC Decker Inc., 2001. [7] K.M. Nelson, G. Reiber, E.J. Boyko, Diet and exercise among adults with type 2 diabetes, Diabetes Care 25 (2002) 1722– 1728. [8] E.S. Ford, W.H. Herman, Leisure-time physical activity patterns in the US diabetic population: findings from the 1990 National Health Interview Survey-Health Promotion and Diseases Prevention Supplement, Diabetes Care 18 (1995) 27–33. [9] A. Kirk, N. Mutrie, P. MacIntryre, M. Fisher, Increasing physical activity in people with type 2 diabetes, Diabetes Care 26 (2003) 1186–1192. [10] C. Di Loreto, C. Fanelli, P. Lucidi, G. Murdolo, A. De Cicco, N. Parlanti, et al. Validation of a counseling strategy to promote the adoption and the maintenance of physical activity by type 2 diabetic subjects, Diabetes Care 26 (2003) 404–408. [11] INEGI, Retrieved (6/23/2003) from the www: http://bc.inegi. gob.mx/sociodem/espanol/salud/sal_04.html. [12] M. Bacardı´-Gasco´ n, P. Rosales-Garay, A. Jime´ nez-Cruz, Effect of Diabetes Intervention Programs on physical activity among migrant Mexican women with type 2 diabetes, Diabetes Care 27 (2004) 1213–1215. [13] A. Jimenez-Cruz, M. Bacardı´-Gasco´ n, P. Rosales-Garay, J. Herrera-Espinoza, O.W. Willis, A culturally sensitive tool for Mexican people with diabetes: La Manzana de la Salud, Rev. Biomed. 14 (2003) 51–59. [14] B.E. Ainsworth , The Compendium of Physical Activities Tracking Guide, Prevention Research Center, Norman J. Arnold School of Public Health, University of South Carolina, Retrieved (3/6/03) from the World Wide Web: http://prevention.sph.sc.edu/tools/compendium_tracking.pdf.
[15] B.E. Ainsworth, W.L. Haskell, A.S. Leon, D.R. Jacobs Jr., H.J. Montoye, J.F. Sallis, et al. Compendium of physical activities: classification of energy costs of human physical activities, Med. Sci. Sport Exerc. 25 (1993) 71–80. [16] Ribera J., Villalpando S., Shamah T., Encuesta Nacional de Nutricio´ n 1999, Instituto Nacional de Salud Publica, Cuernavaca, 2001. [17] N. Abate, M. Chandalia, The impact of ethnicity on type 2 diabetes, J. Diabetes Complications 17 (2003) 39–58. [18] Food Nutrition Board, Institute of Medicine, Dietary Reference Intakes For Energy, Carbohydrate, Fiber, Fat, Fatty Acids, Cholesterol, Protein and Aminoacids, The National Academies Press, Washington, DC, 2002. [19] B.M. Charkraborty, W.H. Mueller, R. Reeves, W.S. Poston, D.M. Hoscher, B. Quill, et al. Migration history, health behaviors, and cardiovascular disease risk factors in overweight Mexican-American women, Ethn. Dis. 13 (2003) 94–108. [20] C.J. Crespo, S.H.J. Keteyian, G.W. Heath, S.T. Sempos, Prevalence of leisure-time physical activity among US adults, results from the Third National Health and Nutrition Examination Survey, Arch. Intern. Med. 156 (1996) 93–98. [21] S. Macintyre, N. Mutrie, Socio-economic differences in cardiovascular disease and physical activity: stereotypes and reality, J. R. Soc. Health 124 (2004) 66–69. [22] M. Lowther, N. Mutrie, E.M. Scott, Promoting physical activity in a socially and economically deprived comm– unity: a 12 month randomized control trial of fitness assessment and exercise consultation, J. Sport Sci. 20 (2003) 577–588. [23] C.J. Crespo, E. Smit, O. Carter-Pokras, R. Andersen, Acculturation and leisure-time physical inactivity in Mexican-American adults: results from NHANES III 1988–1994, Am. J. Public Health 91 (2001) 1254–1257. [24] D.O. Clark, Physical activity efficacy and effectiveness among older adults and minorities, Diabetes Care 20 (1997) 1176– 1182. [25] D.W. Dunstan, R.M. Daly, N. Owen, D. Jolley, M. De Courten, J. Shaw, et al. High-intensity resistance training improves glycemic control in older patients with type 2 diabetes, Diabetes Care 25 (2002) 1729–1736. [26] N.G. Boule, E. Haddad, G.P. Kenny, G.A. Wells, R.J. Sigal, Effects of exercise on glycemic control and body mass in type 2 diabetes mellitus: a meta-analysis of controlled clinical trials, J. Am. Med. Asoc. 286 (2001) 1218– 1227. [27] E. Norris, M.M. Enelgau, K.M. Vnkat Narayan, Effectiveness of self-management training in type 2 diabetes: a systematic review of randomized controlled trials, Diabetes Care 24 (2001) 561–587. [28] A. Jimenez-Cruz, M. Bacardı´-Gasco´ n, The fattening burden of type 2 diabetes on Mexicans, Diabetes Care 27 (2004) 1213– 1215.