Science & Research

Prescription for prevention

A Winnipeg doctor is leading a program of research that could have significant implications for the health of Manitobans

BY HOLLI MONCRIEFF
Winnipeg Health Region
Wave, January / February 2014

An ounce of prevention is said to be worth a pound of cure.

And that would certainly be the case in Manitoba if Dr. Alan Katz and his seven-member research team have their way.

The group has recently embarked on a major program of research in the field of primary prevention, one that could have important implications for the health of Manitobans.

Essentially, Katz and his team are working to identify the best ways to help people stay healthy. In doing so, they hope to help Manitobans stave off chronic conditions such as diabetes, cancer and heart disease.

The effort follows the publication of a major report in 2010 entitled Making the Case for Primary Prevention: An Economic Analysis of Risk Factors in Manitoba.

It estimated that more than 55 per cent of Manitobans are overweight or obese, 45 per cent are inactive and 27 per cent smoke. These behaviours, the report notes, are known risk factors for chronic diseases such as heart disease, stroke, cancer, diabetes, kidney and lung diseases. And treating these conditions costs Manitobans about $492 million in direct annual health-care costs and $1.12 billion in indirect costs per year.

Given the numbers, a bit of primary prevention - the term used to describe a wide range of efforts aimed at preventing people from becoming sick - could make a big difference.

If the prevalence of risk factors were reduced, according to the report, some of the more significant health benefits would include: a 50 per cent drop in deadly cancers of the mouth, throat and lungs; an 80 per cent reduction in cases of Type 2 diabetes; and an estimated 50 per cent decrease in the number of heart disease cases.

In response to the report, the Manitoba Health Research Council is working with the Heart and Stroke Foundation of Manitoba to take action. They created the province's first Research Chair in Primary Prevention, with funding of $500,000 over five years to support research into primary prevention. And they named Katz its first recipient. 

A long-time family physician, Katz is an ideal choice for the job. In addition to being Director of Research in the Department of Family Medicine at the University of Manitoba's Faculty of Medicine, he is also Associate Director of Research at the Manitoba Centre for Health Policy. He has spent years studying and writing about issues associated with wellness and disease prevention.

Of course, Katz is the first to acknowledge that finding ways to shore up disease prevention will not be easy.

Most primary prevention efforts are usually aimed at achieving one of two things: changing the behaviour of the individual or changing the policies and regulations that influence the behaviour of the population as a whole.

An advertising campaign that warns about the dangers of smoking is designed to encourage individuals to quit smoking. A law that prohibits smoking in public places is an example of a population-based effort to curb smoking.

Then there are the social determinants of health - housing, education, poverty. It's one thing to come up with a plan to encourage people to eat more vegetables. But what do you do to improve the health of those who may not be able to afford to eat a healthy diet?

Katz says he believes that a broad, multi-platform effort that tackles public policy issues, encourages individuals to change their ways, and addresses the social determinants of health is needed in order to make the kind of progress required.

"We know what we need to do," says Katz. "But making those changes and affecting public policy is challenging. Changing people's behaviour is very difficult."

As Primary Prevention Chair, Katz has assembled a seven-member team to help him launch a series of research projects that will be carried out in the years ahead.

The first step involves having members of the team carry out "scoping reviews." This essentially amounts to wading through the research that has already been done on primary prevention to see what works and what doesn't.

Katz says this fundamental groundwork will take about a year as the team studies existing literature, compiles their findings from six to eight electronic databases, extracts the right studies, categorizes them and summarizes the appropriate ones.

"We'll see what comes out of these scoping reviews and see how we might be able to use (them) for other interventions to bring about change," Katz says. "If you haven't done your homework well, you run the risk of repetition. We'd waste time and money redoing the things that people have done before," he explains. "If we have good quality information about what we do know, we can find out what we don't know. We can ask questions - what do we already know about what really works?"

Katz and his team are delving into three specific areas: tobacco dependency, physical activity, and mental health.

"Smoking, physical activity and obesity are the three primary risk factors for behaviour that we know influence all kinds of diseases - cancer and cardiovascular diseases in particular - so those are what I saw as being critical areas to approach," says Katz.

Mental health is a little more complicated. Some mental health issues, such as schizophrenia are treatable, but not preventable. But people can reduce their risk of developing stress and anxiety. "Stress is the major issue. And there is something called resilience, which leads to people's ability to cope with stress better." 

While the team is working collaboratively on the research project, members are focusing on specific areas. Researchers Annette Schultz, an associate professor in the Faculty of Nursing at the University of Manitoba and investigator at St. Boniface Hospital Research, and Gayle Halas, for example, are looking into the area of tobacco dependence treatment.

As Schultz explains, tobacco use does seem to be a factor in almost every chronic disease that is on the rise. So it stands to reason that getting people to stop using tobacco, or perhaps more importantly, to never start using tobacco, is a key health issue. 

As part of their research, Schultz and Halas are reviewing the literature to see what has worked elsewhere. Areas to be analyzed include the effectiveness of clean air bylaws, tobacco taxes, and efforts to counter the promotion of tobacco products, new and old.

As Schultz explains, studies have shown that price can affect consumption of tobacco, especially among young people, so that is an area to explore. But there are other important issues to consider when tackling the use of tobacco.

The use of chewing tobacco is a case in point. Schultz notes that recent studies have shown an uptake in the use of chewing tobacco among young athletes, including junior hockey players, who might not ever consider smoking cigarettes.

"One of the things we are seeing right now is chewing tobacco and the other alternative forms that youth are really beginning to take up," says Schultz. "And what they are beginning to find out is that the youth who use chew tobacco are not always the same youth who use cigarette products."

The challenge for health officials, says Schultz, is to learn how to create programs and campaigns that speak to different groups of youth who may consume tobacco in different forms. "The types of programs you are going to put in place and how you are going to language the reasons not to (consume the particular tobacco product) will have to be different."

The research into mental health is, perhaps, the most challenging. "This is not an easy topic to look at in terms of primary care prevention," explains Kelly Carpick, who has been charged with carrying out the scoping review on the subject. "It's not as straightforward as you are exercising or you are not, you are smoking or you are not."

But the connections between anxiety, depression, stress and overall health are clear. "A lot of (people with mental health issues) are not exercising, a lot of them are smoking, so it all goes hand in hand," she says. If the team can identify methods to help people deal with stress, depression and anxiety, that may, in turn, enable them to deal with other health issues, such as smoking.      

Katz and researcher Leah Goertzen are focusing on physical activity.
While many groups in society are likely to suffer from the effects of obesity, Katz says it is children who are most at risk.

"Smoking rates are going down a little bit, but one thing that is going up is obesity in children. This is the first generation of children that will not live longer than their parents, due to changing eating habits and changing levels of exercise," says Katz. "Childhood today is all about screen time - time in front of the television, computer, and video games," he says. "Our diets have changed, not only in quality but also in quantity. We're taking in more energy with less movement. It's a simple equation."

Katz acknowledges that getting young people to make changes when it comes to diet can be particularly tricky. Winnipeg's obsession with Slurpees is an example of the type of behaviourial change that needs to take place to improve the rates of obesity.

"Winnipeg is the Slurpee capital of the world, and aren't we proud of that? Slurpees are full of sugar. They have a huge impact on the health of our children," he says. "How do you change that - do you ban Slurpees? That's very controversial. Do we need to ban extra-large, sugary-drinks, which are a significant cause of obesity in children?"

Learning more about what can be done to make people more active is also high on the list of priorities.  

"How do you help people make the right choices? If they have cheap, regular access to places for exercise, people are much more likely to use them, so what do we know about encouraging exercise in an extreme winter climate?"

And then there are the environmental barriers that prevent people from making healthy choices.

For example, Katz cites suburbs that don't have local stores nearby, which force people who live there to drive rather than cycle or walk to the store. He's also found that our transit service doesn't penetrate well into the city's residential areas. When policy-makers understand the impact of some of these obstacles, making improvements like bike lanes and safe roads for cyclists becomes an easy decision to make, he says.

"If we could influence the way planning is done in new developments so that it is more friendly towards physical activity and public transportation, those kinds of things are going to influence how people live their lives," he says.

Recommendations on how to deal with these kinds of issues won't be made until after the scoping studies are completed and further research is done, a process that will take several years.

In addition to programs and initiatives, Katz is also looking for ways to engage physicians and their patients in discussions around primary prevention.

"As a family physician, a big part of my role is helping people stay healthy," explains Katz. "Part of my focus is to help health-care providers work with patients to help them make the right decisions. We need to learn how to help health-care providers interact with their patients in a way that addresses the underlying causes of their health issues. If you have a patient complaining of knee pain, rather than just treating the pain, there is a need to resolve the cause of the pain itself."

To that end, Katz is pushing forward with an idea he started developing several years ago. It involves creating a computerized questionnaire that is loaded onto a tablet computer and filled out by patients while they are waiting to see their family doctor.

The questionnaire, officially known as the Risk Factor Identification Tool (RFIT), touches on a number of topics in detail, including how much exercise a person gets, what they eat, how much they drink or whether they smoke.

The queries are designed to gain some insight into the patient's attitude towards particular health issues. So, for example, a person might be asked "Do you smoke?" If they answered yes, the next question might be "Have you ever tried to quit?"

Once the questionnaire is completed, the computer program would generate a report, which could then be used by a health-care provider as the basis for a conversation about health risks and the importance of making healthy lifestyle choices, according to Halas, who has worked on the project with Katz for several years.   
 
"It (the report) would flag not only the behaviours that could be increased, like physical activity, or decreased, like smoking, but it would also ask how difficult would it be for you to change that, and sort of establish a bit of readiness for change," says Halas.

Katz says an RFIT report could help kick-start discussions between doctor and patient about activity levels and diet - things that are important to a person's long-term health, but may not be coming up in conversation. 

"That's a problem in family medicine. So much of your time is taken up with disease management. Ask what's the level of cholesterol they (physicians) want their patients to be at, and they'll know that number. But how many minutes of vigorous exercise, how many times a week? That's a little bit less certain."

It is possible that doctors who collect this kind of information could use it as a basis to refer their patient to a dietitian or a kinesiologist who could then work with the individual on dietary and physical activity issues.

The RFIT concept has already undergone some field testing involving small samples of patients. Katz has applied for funding to move forward with a larger project to test the effectiveness of the tool. "RFIT is new, so we're not going to find anything (in the literature) that is going to confirm its value. It's a new concept, a new idea, so we're trying to institute that to see what the effect is," he says, adding the study could take three years to complete.

Holli Moncrieff is a Winnipeg writer.

Sponsored by the Manitoba Health Research Council

Wave: January / February 2014

About Wave

Wave is published six times a year by the Winnipeg Health Region in cooperation with the Winnipeg Free Press. It is available at newsstands, hospitals and clinics throughout Winnipeg, as well as McNally Robinson Books.

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