Special Report: Walkable Streets

WHO Diabetes Report Calls for Active Transportation Infrastructure

The solution to this crisis is not to tell people to be more careful but rather to combine education and policy to create an environment in which a healthy lifestyle becomes the default rather than a defiant act of will.

By Ryan McGreal
Published April 07, 2016

The World Health Organization has published a new Global Report on Diabetes [PDF], the metabolic disease in which the body progressively loses the ability to manage blood sugar levels.

The myriad and often devastating effects and complications of this chronic disease include nausea, seizures, coma, cardiovascular disease, poor circulation, foot ulcers, nerve damage, blindness, kidney disease, cognitive decline, and mortality.

Type 1 diabetes - sometimes called "juvenile diabetes" because it manifests in children - is an inability of the pancreas to produce insulin, the hormone that regulates blood sugar by helping cells absorb sugar for energy. Treatment for type 1 diabetes generally involves administering insulin, since the body cannot produce it.

Type 2 diabetes, in contrast, is an acquired disease in which the body's cells become insulin-resistant: they become progressively less responsive to the presence of insulin by absorbing blood sugar for energy. As a result, cells become starved for energy and blood sugar levels do not drop.

The pancreas responds by producing more insulin, but as the condition worsens it can no longer produce enough insulin to counteract the insulin resistance.

Lifestyle Disease

The underlying cause of type 1 diabetes is not yet clear and it is not known how to prevent it.

Type 2, on the other hand, is very much a lifestyle-related disease. While there are some genetic predispositions, the onset of type 2 diabetes can be prevented or delayed by a lifestyle that incorporates a healthy diet and regular physical activity.

Unfortunately, the standard Western lifestyle of highly processed food and low physical activity have created a perfect storm of chronic disease pathogenesis - a perfect storm that is spreading around the planet.

As a result, the incidence of type 2 diabetes has been rising rapidly in developed countries but also increasingly in developing middle-income countries.

According to the WHO report, approximately 422 million people worldwide had diabetes in 2014. The incidence of diabetes among adults rose from 4.7 percent in 1980 to 8.5 percent in 2014, and continues to rise.

In fact, type 2 diabetes - formerly called "adult-onset" to contrast with juvenile diabetes - is increasingly showing up in children.

Create Conditions for Health

The report argues forcefully that the solution to this crisis is not to tell people to be more careful but rather to combine education and policy to create an environment in which a healthy lifestyle becomes the default rather than a defiant act of will.

Effective approaches are available to prevent type 2 diabetes and to prevent the complications and premature death that can result from all types of diabetes. These include policies and practices across whole populations and within specific settings (school, home, workplace) that contribute to good health for everyone, regardless of whether they have diabetes, such as exercising regularly, eating healthily, avoiding smoking, and controlling blood pressure and lipids.

Taking a life-course perspective is essential for preventing type 2 diabetes, as it is for many health conditions. Early in life, when eating and physical activity habits are formed and when the long-term regulation of energy balance may be programmed, there is a critical window for intervention to mitigate the risk of obesity and type 2 diabetes later in life.

No single policy or intervention can ensure this happens. It calls for a whole-of-government and whole-of-society approach, in which all sectors systematically consider the health impact of policies in trade, agriculture, finance, transport, education and urban planning – recognizing that health is enhanced or obstructed as a result of policies in these and other areas.

It's not enough to say that people can make up their own minds and the state should not be trying to shape behaviour. The state is already shaping behaviour through policy decisions on how our streets and buildings are designed, decisions that make it difficult or impossible for people to choose active transportation.

Built Environment

The report is abundantly clear on the vital role of municipalities in creating a disease-resistant built environment that designs regular physical activity back into our lives:

The physical or built environment plays an important role in facilitating physical activity for many people. Urban planning and active transport policies can ensure that walking, cycling and other forms of non-motorized transport are accessible and safe for all.

The physical environment can also provide sports, recreation and leisure facilities, and ensure there are adequate safe spaces for active living for both children and adults.

The poorest groups in society, especially women, may have less time and fewer resources to participate in leisure-time activity, making policy interventions that target active transport and incidental physical activity throughout the day much more important.

This was borne out a few years ago in Toronto in a cohort study which found that the incidence of new cases of type 2 diabetes was signifciantly higher in less walkable neighbourhoods than in more walkable neighbourhoods, even after controlling for other contributing factors.

Another study, published in 2014, came to the same conclusion with respect to neighbourhood walkability and rates of obesity, which is an independent risk factor for diabetes.

Best Place to Raise Blood Sugar

Now, in a city that aspires to be "the best place in Canada to raise a child," this message has special significance.

Does Hamilton's urban planning policy support disease-preventing lifestyles with healthy eating and regular physical activity? Are individual projects and designs evaluated against this standard?

The conclusions of the report including the following recommendation:

Prioritize actions to prevent people becoming overweight and obese, beginning before birth and in early childhood. Implement policies and programmes to promote breastfeeding and the consumption of healthy foods and to discourage the consumption of unhealthy foods, such as sugary sodas. Create supportive built and social environments for physical activity. A combination of fiscal policies, legislation, changes to the environment and raising awareness of health risks works best for promoting healthier diets and physical activity at the necessary scale.

Will Hamilton be the best place to raise a child or the best place to raise blood sugar levels?

(h/t to Carlton Reid at Bike Biz for picking up on the WHO report.)

Ryan McGreal, the editor of Raise the Hammer, lives in Hamilton with his family and works as a programmer, writer and consultant. Ryan volunteers with Hamilton Light Rail, a citizen group dedicated to bringing light rail transit to Hamilton. Ryan writes a city affairs column in Hamilton Magazine, and several of his articles have been published in the Hamilton Spectator. He also maintains a personal website and has been known to post passing thoughts on Twitter @RyanMcGreal. Recently, he took the plunge and finally joined Facebook.

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By KevinLove (registered) | Posted April 07, 2016 at 10:55:30

An excellent article about a timely issue. For those interested in this topic, I highly recommend the Healthy Toronto by Design Report, Road to Health. This was produced by Toronto's Public Health Department.

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By Ted Mitchell (registered) | Posted April 07, 2016 at 11:18:53

To understand why physical activity is so important, you need to look at the graph from Dr. Steven Blair published in the BMJ. It is a statistical regression of the attributable fraction of various risk factors causing death.

Bottom line: stop thinking that checking your cholesterol makes much difference. Walk or bike to the doctors office, school, and work instead.

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By Ryan (registered) - website | Posted April 07, 2016 at 11:45:26 in reply to Comment 117509

That's quite remarkable! For reference, here are the charts:

Chart 1: Attributable fractions (%) for all-cause deaths in 40 842 (3333 deaths) men and 12 943 (491 deaths) women in the Aerobics Center Longitudinal Study. The attributable fractions are adjusted for age and each other item in the figure. *Cardiorespiratory fitness determined by a maximal exercise test on a treadmill.

Chart 1: Attributable fractions (%) for all-cause deaths in 40 842 (3333 deaths) men and 12 943 (491 deaths) women in the Aerobics Center Longitudinal Study. The attributable fractions are adjusted for age and each other item in the figure. *Cardiorespiratory fitness determined by a maximal exercise test on a treadmill.

Chart 2: Risk of cardiovascular disease mortality by cardiorespiratory fitness and body mass index categories, 2316 men with type 2 diabetes at baseline, 179 deaths. Risk ratios are adjusted for age and examination year. Black bars = low cardiorespiratory fitness, white bars = moderate cardiorespiratory fitness (in the obese category, the white bar includes both moderate and high cardiorespiratory fitness, and the grey bar = high cardiorespiratory fitness).

Chart 2: Risk of cardiovascular disease mortality by cardiorespiratory fitness and body mass index categories, 2316 men with type 2 diabetes at baseline, 179 deaths. Risk ratios are adjusted for age and examination year. Black bars = low cardiorespiratory fitness, white bars = moderate cardiorespiratory fitness (in the obese category, the white bar includes both moderate and high cardiorespiratory fitness, and the grey bar = high cardiorespiratory fitness).

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By JasonL (registered) | Posted April 07, 2016 at 15:17:55

Raise the hammer and sickle, WHO. Bunch of commies who clearly have an agenda

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By KevinLove (registered) | Posted April 07, 2016 at 21:46:26 in reply to Comment 117516

The communist agenda is quite clear. People who live long, healthy lives have the time to foment world revolution and the dictatorship of the proletariat!

Or maybe they will just live long, healthy lives.

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By Jenfitness (anonymous) | Posted April 07, 2016 at 21:46:44

Interesting data, but what we really need is education for those who are at risk on how to prevent diabetes and how sufferers can manage their disease. For more info on how to defeat diabetes check out my review jendoesfitness.com/defeatingdiabetes/ The key is reducing refined sugar intake, but that is just the first step.

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By Ted Mitchell (registered) | Posted April 13, 2016 at 19:46:39 in reply to Comment 117519

There is definitely something to the sugar and carbs thing, high amounts of carbs and increasingly simple sugars are in processed foods. But it depends who you are and when you consume them.

For an active athlete, carbs are fuel, in the right amount and the right time.

For an inactive person, especially obese and metabolically unhealthy eg. type 2 diabetes, carbs are poison, especially in a large dinner meal followed by TV and couch.

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By highasageorgiapine (registered) | Posted April 08, 2016 at 10:19:21 in reply to Comment 117519

education as a solution has limits and is inefficient. it relies on individuals enacting health promoting decisions that may not be easy for them based on socioeconomic and education attainment status. it also relies on having individuals presenting consistent, evidenced based information which is fairly resource intensive and a poor deployment of limited resources.

by developing infrastructure that facilitates active lifestyles as the most efficient option, we can reduce the need for more cost-intensive and less effective secondary interventions like health teaching.

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