Exercise and physical activity are one of the first and primary strategies advised for patients either at risk or newly diagnosed with type 2 diabetes. In combination with diet and behavior modification, exercise is a critical component of virtually every treatment or program aimed at diabetes, obesity prevention, and lifestyle intervention (Kirwan, Sacks and Nieuwoudt, 2017). Education and intervention programs attempt to focus on lifestyle changes, particularly physical activity because it is a powerful tool at prevention, managing, and sometimes reversing type-2 diabetes. In 53-study meta-analysis, Coppola et al. (2015) found that physical activity promotion program reduces the incidence of type-2 diabetes by 41%.
The modern medical approach to type-2 diabetes or pre-diabetes patients is to concentrate on symptom control and targeting glycosylated hemoglobin (HbA1C) levels. Lifestyle change and weight loss through interventions such as physical activity is important for managing glycaemia, dyslipidemia and hypertension after the diabetes diagnosis. Taheri et al. (2018) found improvement in glycemia associated with weight loss and a diabetes remission occurring in 11.5% of participants. This was further supported by Pan et al. (2018) which saw that supervised aerobic, combined, and resistance exercises showed up to 0.30% lower reductions in HbA1c compared to no exercise with also benefits to total cholesterol, triacylglycerol, and improvements in systolic blood pressure alongside weight loss due to physical activity. Targeted interventions which encompass dietary guidance alongside physical activity such as resistance training and increase to overall physical activity over a one year maintentance period demonstrate effective results at decreasing multiple risk factors for diabetes such as body weight, dietary and saturated fat, and dietary fiber (Lindstrom et al., 2003). There is also the added benefit of saving costs for medication for treatment of diabetes, as Kikuti‐Koyama et al. (2019) found that increased physical activity improves the status of diabetes mellitus through lower body weight and HbA1c levels, thus reducing medication expenses.
Al-Thani et al. (2018) suggests that regular physical activity has a protective effect on the risk of non-communicable diseases such as diabetes which is the major cause of morbidity and mortality in the Gulf region. Unfortunately, his studies found that for majority of youth, one of the least at-risk populations but represents the future of Qatar, do not receive the minimum requirement of 60 minutes of physical activity per day. More than 85% of females and 75% of males do not engage in sufficient amount of daily activity.
As mentioned earlier, physical activity is universally one of the primary lifestyle changes recommended by medical professionals for prevention of type-2 diabetes as well as a range of other health conditions. Physical inactivity can inherently increase the risk of stroke, heart disease, cancers, and remains one of the leading risk factors for mortality around the globe and in the Gulf region especially (Chrismas, Majed and Kneffel, 2019). Outside of highly unique or specific cases, there is no evidence to suggest that there are detrimental effects to physical activity in the management of diabetes. There was no research found which found negative or even neutral effects. Universally, all studies found some sort of positive effect of both short-term and long-term exercise for management of type-2 diabetes, either through weight loss or decreasing HbA1c levels. These studies, medical professionals, and health organizations worldwide include physical activity as a primary recommendation for the prevention and management of type-2 diabetes.
Policy
This paper will seek to examine policy approaches at the national level in Qatar regarding management of type-2 diabetes using physical activity and other related measures. The Gulf region is seeing increasingly high levels of obesity, cardiovascular disease, and type-2 diabetes. In 2017, a WHO study found that 72% of Qatari adults are overweight, 34% are obese. As known, obesity is directly linked with prevalence and risk factors for type-2 diabetes. 90% of diabetes diagnosed cases in Qatar are type-2 diabetes. Currently the prevalence rate for type-2 diabetes in Qatar is at approximately 17%, expected to increase to 24% by 2050 and accounting for 32% of national health expenditure if drastic measures are not taken (Awad et al., 2018). The WHO recommends a global action plan for prevention and control of noncommunicable diseases, diabetes being one of the primary targets. It is recommended that by 2025, national health targets seek to achieve a 25% reduction in premature mortality and reduce the prevalence of the primary behavioral risk factors which for diabetes are unhealthy diet (by 30%) and physical inactivity (by 10%) (Awad et al., 2019).
In 2016, Qatar launched its National Diabetes Strategy which is a comprehensive national plan targeted at prevention and treatment of diabetes. The focus is on providing access to correct information and tools to make healthy lifestyle choices alongside the proper services, research, and infrastructure which is aimed improving quality of life and diabetes service provision for citizens of Qatar (Ministry of Public Health, 2020). While a comprehensive and structured plan with long-term objectives is both beneficial and necessary, it is necessary to address critical preventive measures through education and stimulation of physical activity among the population. A 2012 survey found that 44% of young adults in Qatar had insufficient levels of physical activity, statistics that have likely increased by current year due to prevalence of technologies and stay-at home culture. For majority of these young adults, family health values as well as Islam played a role. Unfortunately, religion, culture, and family give priority to work and academic achievement as well as largely promote male physical activity rather than for females (Alijayyousi et al., 2019). This is indicative that a large sociocultural shift needs to occur over time which promotes equitable influence for physical activity through families as well as various institutions such as government, education, and places of work.
A proposed policy will take on a dual approach of educating the population and introducing government-run and funded initiatives that will popularize and motivate physical activity at the mass level, particularly in younger populations where diabetes prevention is both critical but also easier. In order to be successful at the national level, the initiative has to be universally implemented at all levels of population (urban and rural), governance, and levels of care including primary and secondary care. The centralized nature of Qatar’s government, the outreach of the ministries, and culture benefits a comprehensive national approach.
The first part of the initiative is a large public awareness campaign regarding obesity and type-2 diabetes. The key is to associate the two factors together alongside other health-related issues. The population should be aware of the origins and basic risks of type-2 diabetes development. However, the key is to create an informational but optimistic messaging which promotes solutions for addressing the health issue and incorporate citizens into the physical activity programs discussed below. Large scale studies demonstrate that professionally developed campaign advertisements for health can increase search for additional information regarding the health topic by as much as 50% in those exposed to the campaign (Yom-Tov). Educational and psychosocial interventions can improve diabetes management. With culturally appropriate and targeted interventions on diabetes health education, both knowledge regarding the disease as well as glycemic control via lifestyle changes and public attitudes improve (Nazar et al., 2016).
The public education program can be rolled out with the Ministry of Health at the leadership, creating all the necessary materials ranging from advertisements to billboards, posters, and brochures. There can be cooperation with the Government Communications Office as well as the Ministry of Education to roll out the program massively. The roll-out should focus on cooperation with government, health and education institutions which will promote the information campaign amongst its staff and students. A specific focus on targeting education institutions should be made with a promotion of healthier lifestyles and physical activity.
The second part of policy should aim at increasing physical activity through 1) infrastructure and 2) initiatives. Qatar is a unique position of hosting the FIFA World Cup in 2020, so there is a rapid construction boom of large sports facilities ongoing around the country. The government should take advantage of this to promote athleticism and physical activity. These facilities are world-class and consist of not only large stadiums but multiple training infrastructure. This can be utilized to the advantage of Qatar leading up to and after the World Cup, to adapt the infrastructure towards use by citizens. This should be done in combination of investment in localized sports infrastructure as well, including community gyms, outdoor parks, and other active recreational areas, all of which should be promoted and created with appeal to the female population as well. It includes investment into athletic facilities for local community centers and schools, ensuring that schools and universities offer comprehensive physical education. A number of public health research studies indicate that communities should offer a healthy physical and social environment for physical activity to thrive. This includes providing transportation networks for greater activity such as sidewalks, parks, and bicycle lanes as well as modifying residential and commercial facilities which offer appropriate resources to facilitate physical activity (MacKenzie et al., 2015).
Targeted government-sponsored initiatives can be undertaken to boost physical activity. National campaigns such as the Move Your Way launched in the U.S. a decade ago targets all populations and offers both resources and guidelines to increase physical activity. In the prominence of digital culture of the modern world, a smartphone app can be developed that promotes activity, offers tutorials and guided workouts, and perhaps creates competition both locally and nationally for prizes. Another initiative which can be adopted in Qatar in urban areas and had significant success in Singapore, is users of the Apple Watch product could get paid up to $380 dollars during the two year participation for consistently using the health application and conducting health activities such as walks, yoga, and swimming (Elegant, 2020). Financial incentive to maximize long-term participation in activity can be highly effective. Overall, policy should aim at publicly promoting and popularizing physical activity amongst all layers of the population while providing the necessary information, infrastructure, and potential rewards for citizens to utilize when they make the necessary adjustments to lifestyle.
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