Prescribing Wellness: The Evolution of Chronic Disease Management

Verna MacKinnon 00:01
Research fuels our curiosity, which ultimately, is what keeps humanity moving forward.

Jonathon Fowles 00:09
Whenever we do, you know, a new research study, I always uncover something that I wasn’t planning on uncovering, and it just expands and broadens our perspective to look at things from different perspectives than the one direction that we’re thinking of.

Joy Chiekwe 00:23
Research is important. It just informs implementation, and it moves the community forward.

Stephanie Reid 00:37
Welcome to Beyond Research. I’m your host Stephanie Reid. In this episode, we explore a critical issue, the alarming rates of chronic diseases presenting challenges for both individuals and our broader healthcare system. Join us as we discuss how research becomes the catalyst for the evolution of healthcare practices, transforming our perspective on preventative medicine and chronic disease management.

Jonathon Fowles 01:08
Hi, I’m Dr. Jonathan Fowles. I’m a professor at Acadia University and also the Director of the Centre of Lifestyle Studies there.

Stephanie Reid 01:15
Since Dr. Fowles started at Acadia in the School of Kinesiology, he has built an internationally recognized health research program that explores how to prevent, manage and treat chronic diseases.

Verna MacKinnon 01:28
Hi, everyone, I’m Verna Mackinnon and I am an Operations Consultant with a focus on physical activity for Nova Scotia Health. I work for our primary health care and chronic disease management provincial network.

Stephanie Reid 01:41
In this role, Verna coordinates education resources, creates positions for exercise professionals within Nova Scotia Health, and leads the implementation of a physical activity practice support program. Her work aligns with the primary recommendations from the 2018 Exercise is Medicine Nova Scotia report, supported by Dr. Fowles’s research.

Joy Chiekwe 02:03
Hi, my name is Joy Chiekwe. I am the General Manager of Health Management at the John W. Lindsay YMCA here in Halifax and the provincial lead for the LiveWell YMCA program.

Stephanie Reid 02:11
Joy is a clinical exercise physiologist. She is a former student of Dr. Fowles’s and completed her master’s at Dalhousie University, where she studied cancer exercise. As provincial lead for the YMCA LiveWell program, she implements findings and recommendations from Dr. Fowles’s research. Well, thank you guys all for taking the time to join us here. I know you’re all very busy, so we really appreciate you taking the time to chat with us this morning on this sunny Tuesday morning. And so, to start, Jonathon, how many Nova Scotians suffer from chronic illness?

Jonathon Fowles 02:50
In Nova Scotia, we have one of the highest rates of chronic disease in Canada, anywhere between 45 and 65% of Nova Scotians, depending on what age demographic you look at, you know, adults 45% will have one chronic condition. If you look at people over the age of 65, the average is at least one and over the age of 65, two thirds of people have two or more chronic conditions. And diabetes is one of the most prevalent ones, it’s been doubling every 10 years for the last 30 or 40 years, the prevalence rates. And that’s partly because we also have in Nova Scotia an aging population. And we know that diabetes prevalence rates increase exponentially with age. And, you know, those kinds of factors relating to that, you know, and then there’s the clustering of comorbidities that kind of come along with metabolic disease.

Stephanie Reid 03:41
Right, and can you tell us a little bit, because a lot of the work and research that you’ve done over the last several years has been focused on those living with chronic disease, specifically, your first clinical trial centered around those with diabetes.

Jonathon Fowles 03:54
Yeah.

Stephanie Reid 03:55
Can you tell us a little bit about that?

Jonathon Fowles 03:56
Yeah. So, when we, this will be about 2005. And this was when the evidence was emerging that exercise was, you know, a potent thing to treat and manage many chronic conditions and diabetes being one of them. So we wanted to do an intervention in the valley, in conjunction with a local hospital and utilizing their cardiac rehab facilities and program. And so we basically adapted it for diabetes, and we enrolled diabetes patients and we had, you know, incredible outcomes as we would expect, and, and so from that work, you know, we, we knew that exercise works, but the key thing that came out of that was if exercise works so well, why aren’t so many people with diabetes, able to do it?

Stephanie Reid 04:43
As we’ve discussed, everyone knows exercise is good for them. Eating well is good for them. How do you make those with or without chronic disease adopt that or do something about that? So can you just describe a day in the life of a trial participant?

Jonathon Fowles 04:59
Yeah, so they were recruited through their normal diabetes appointments. And were given the option to participate in the exercise study that was going to go on and the exercise study was two one hour exercise classes of a combination of aerobic, like a warm up, aerobic activity and resistance activity done twice a week supervised by a clinical exercise physiologist. So somebody like Joy or Verna, they are clinical exercise physiologists who can manage exercise for people with chronic conditions, they have specialized training to understand the different conditions and things like that. Basically, the trial participants would be given this option. So that’s one of the things is that it’s voluntary participation, so that we recruited people from that diabetes centre that was at the hospital, as well as a few adjacent diabetes centres that were given the option. And so we enrolled, I think it was 30 people with diabetes into the trial. So it wasn’t a controlled trial, it was just a basically a pre-post intervention, where much like a cardiac rehab program, where they come a couple times a week, they’re monitored, there’s also education piece along with it. And then you look at the outcomes pre to post and we aligned it with normal diabetes care practice where they would have bloodwork done, they would have their A1Cs done, their blood pressure done at pre and then again, at the end of the intervention period, along with some of the questionnaires that we had about how do you feel about physical activity? What’s your confidence level, both for the patients, as well as the diabetes educators? You know, what is their interaction with the patients? And like, for example, one of the interesting findings that we had from that, was that when we surveyed diabetes educators about what is your confidence level in your patients’ ability to do physical activity? And how well do you think they will carry through on the recommendations that you get, so they rated their patients at about a 40 to 35% level in their confidence and to do it, and they rated their attitudes as about a two-and-a-half out of five. But then when we actually surveyed the patients, they rated their confidence level at about a 65%. So 25, or 30%, higher than what the diabetes educators were thinking their confidence was. And their attitudes were rated at a six out of seven towards physical activity. So what we, by doing that research, we recognize that there’s this huge chasm between the expectations and the, the understandings of where that person with diabetes is coming from. So understanding where they’re coming from that they may be very motivated to do something, but they just don’t know what to do. And if you don’t talk about it in your appointment, then they won’t know what to do. And so therefore, it’s not necessarily the fault of the diabetes patient for not following through on recommendations that they don’t understand and haven’t had any help with. So that was that education intervention was to explain to the diabetes educators that you need to understand where they’re coming from that they may be motivated, but they need help. And that has been a theme throughout all of the work that we’ve done with health care professionals to help the diabetes patients through that process. Well, why are we keeping it just to diabetes? Like, couldn’t this help all chronic conditions and in primary care? And so that’s when Exercise is Medicine and that whole development of those workshops that we developed through diabetes care, we just adapted it to primary care in all conditions.

Stephanie Reid 08:29
And Verna, I know you’re very involved with Exercise is Medicine, and specifically the three recommendations within that program. Can you tell us a little bit about Exercise is Medicine, Nova Scotia, and your work within?

Verna MacKinnon 08:44
The research that Dr. Fowles is talking about, his Exercise is Medicine work, informs the work that we’re using to implement these strategies in Nova Scotia Health. So the three main parts of my work is to one to build capacity of our primary health care providers to be able to speak to their patients around physical activity. We’ve developed what we call our physical activity Practice Support Program. Within primary health care we have our Practice Support Program is a place where we host resources and education for our providers to learn about a number of different things. And our physical activity one includes some self-directed education models so that we can build their knowledge around physical activity and then give them some strategies about how they can speak to their patients about physical activity. And we’ve actually implemented some physical activity specialists, Kinesiologists within our healthcare system to be built to also provide the service so that our providers have a place that they can refer their patients to to get this service. And all of our, a big part of our primary health care education strategy is embedded in behaviour change counseling, so we kind of take that foundation of behaviour change counseling and add that physical activity piece to it to educate our providers on how they can take behaviour change counseling and apply it to physical activity counseling.

Stephanie Reid 10:01
And so we talked a little bit about some of the barriers between this education and the physicians themselves and seeing exercise as almost something that should be written on that little notepad. How much progress has been made? And have you seen kind of that needle move a bit?

Jonathon Fowles 10:21
From the work that we started with the diabetes program of Nova Scotia to the national campaign, it was like 1/3 of diabetes educators were talking about physical activity, most of their appointments. And then five years later, on a national sample, more than 2/3 were talking about it in most of their appointments. So that’s 100% change in practice. Then with the physicians, we found similar things. But some of the barriers that we uncovered is that the physicians had the same improvements in confidence when we provide them with the education and resources and it changes practice two months and six months later, for the individuals, but what we identified for the physicians is there, the they needed more people, places and programs to refer, they didn’t want to be talking about physical activity in a vacuum. And that this team collaborative approach, that they wanted to engage the patient say, you know, you should be physically active. But they also have the limits of time and expertise that they wanted to refer to an exercise professional to take the ball rolling, and/or refer to a community program that could help that patient make that behaviour change over time.

Joy Chiekwe 11:28
Like Jonathon mentioned, we’re trying to find more people and places for people to go once they refer to, not putting all the pressure on the healthcare providers to figure those things out. So I am a clinical exercise specialist by trade. But now my new position at the Y as General Manager of Health Management is really to improve our programming we can offer to improve the quality of life of all Nova Scotians across the YMCAs wherever we are, not stopping at diabetes, going to cancer go and other chronic health conditions and making sure that we, they know of us where to go and knowing that they are in good hands with credible exercise specialists who are taking care of them and making sure that we’re improving their quality of life over time and then implementing that behaviour change that Verna mentioned as well.

Jonathon Fowles 12:07
Yeah, and that picks up on some of the research that we’ve done, where the number one barrier that older adults, particularly with a chronic condition have about exercise is fears about their health condition and exercise. And so having people, places, and programs to refer to support them and empower them to be active in a safe place with clinical exercise physiologists that can support that. That was also something that was identified but just about every single health care provider that we surveyed in our Exercise is Medicine Nova Scotia report.

Stephanie Reid 12:41
So Verna, I just wanted to ask you if we have more people engaged in physical activity and exercise, what impact as a whole, and I know this is a big question, does that have on Nova Scotia’s healthcare system?

Verna MacKinnon 12:54
Well, I think the main idea behind it would be you know, Dr. Fowles has talked a lot about the impact that physical activity can have not only on the prevention of some of these chronic diseases, but also on the management. So we can get, if we have, as he mentioned, all these people in Nova Scotia, we have these high rates of chronic disease, if we can get people here moving more, get them managing, and then maybe even preventing the onset of some of these diseases, then maybe the need for them to be in the healthcare system would become less. And we know that here in Nova Scotia, our health care system is strained. And what we need to do is we need to increase access; we need to get people more access to primary care. And there’s a number of ways that we can do that. And the way physical activity can do it is by reducing the amount of people that use it. So that that makes room for the people that do need it at the time. And then we kind of, we end up getting a balance of self-management and then access to primary care.

Stephanie Reid 13:49
Joy, what have you seen on the front lines like have you seen a shift?

Joy Chiekwe 13:55
Definitely. So coming from a student of Dr. Fowles back in the day to working in a hospital setting to now in the community, seeing it all transpire and kind of work together has been really interesting to see. So just the referrals we’re seeing within the YMCAs and the community across Nova Scotia from different health care providers has been really amazing over the last year from physicians to dieticians, to nurses to social workers and physiotherapist are now understanding that we are here and we need to get people active and they don’t have to do it themselves and we are here to help. So like Verna said, more people moving is going to mean less people in that primary care setting because it is strained. And so it’s been really, I’ve been just really great to see from a university student like I don’t know if this is really going to work to actually being in it and seeing your work every single day has just been amazing.

Stephanie Reid 14:43
And I bet you’ve, you know, it’s quite rewarding because you probably work with these patients or individuals for a longer period of time. Like what kind of changes have you seen in people?

Joy Chiekwe 14:55
So many it’s definitely a rewarding job to have and seeing the spark light up in everyone’s eyes saying, Oh, I can do this, I can manage my health, I don’t need to depend on my doctor to tell me exactly what to do, I can get those resources and tools within the community has just been just I don’t know how to put into words, and then also the accountability and the community that’s building and seeing the YMCAs be that source in community because we’re all about the power of belonging and making sure people understand we’re here to help in many different ways. And so seeing people come in and just asking the right questions, and getting the help and the tools and seeing how much more they can progress and manage their own health is, is just a great feeling for me, but I know for them, they’re getting way more out of it than I am. So it’s a great program to have to continue to have. And we’re just so happy to be part of it and see people grow and be part of different lives and how we’re changing everyone’s quality of life.

Jonathon Fowles 15:49
The one last story I want to tell was the very first one that we had with that diabetes program, which was we had one person who an older lady, you know, 68 years old, very immobile, came in with a walker needed help to get down the stairs, there was five or six stairs to get down to the exercise thing. And, you know, somebody asked her at the end of the 12 weeks, you know, how has this program affected you and she said, it’s completely changed my life. She said, I used to need this thing. And she pointed to her walker, I used to need this thing everywhere I went, and she goes, now look at me, she takes the walker puts it over her shoulder and hikes up the stairs. And she goes, that’s what’s changed. And we see that so much with these programs. And but it’s because they’ve been supported in that process in a safe, progressive, you know, overload kind of environment that meets them where they’re at, but then builds them up and builds them up not only physically, but also mentally and psychologically as well.

Stephanie Reid 16:51
You’re giving them confidence and independence.

Jonathon Fowles 16:53
Right, and that’s the whole goal is to develop that self-management that Verna talks about, that when people have that confidence and can manage those things on their own with their own physical activity, sleep, nutrition, those kinds of things, there’s going to be less of them, you know, seeing a primary care doctor and that’s what we get feedback from our doctors that we work with, like we have three clinical exercise physiologists embedded in, in three collaborative family practices in the valley. And they all say the same thing that the physicians, once they see those patients that have seen the CEPs and done the exercise programs, that their medications are lower, their moods better, you know, and so that’s when the referrals just kind of keep coming.

Stephanie Reid 17:34
I was just gonna say they’re probably more likely to refer. And that’s great. And Jonathon mentioned, Verna, you’re working to get kind of these tools and resources into more communities into more patients’ hands, can you speak to kind of next steps moving forward, long term goals for Nova Scotia Health and what you would like to see in the future?

Verna MacKinnon 17:54
I think kind of where we’re at right now is we need to build the relationship between the healthcare system and the community partners and do a scan of Nova Scotia currently and say, you know, what’s available now? And how can we all work together to one, give more Nova Scotians access to the resources that are available? Make sure we’re not duplicating work, decide, you know, what is everybody’s role in the process of physical activity? And how can we take those roles and responsibilities and work together so that we can get these, get people more access to these exercise programs that are available. We’re kind of in the early stages of the build a relationship and as Dr. Fowles had mentioned, we need to bridge that gap between the healthcare system, the community, we need to start to, we need to learn what’s out there and learn what we have and then identify where those gaps are, and then see what we can do to kind of build that to kind of spread and scale it so that more Nova Scotians have access to those programs within the community. My favorite thing about just getting to do this kind of work is to get to have this awareness and realization that it is that kind of top to bottom and bottom to top, side to side and getting to kind of transition from being the Kinesiologist on the ground that is working with people now up into this kind of leadership role. And getting to be here in Nova Scotia Health to create these opportunities for Kinesiologist and create these opportunities for people to get active. And then I hope that in the future, we can do this work, I hope that Nova Scotia is going to be the province where they say Nova Scotia has the highest levels of activity rather than the highest levels of chronic disease. And we can kind of change our profile here in Nova Scotia and ultimately reduce the amount of people that we have that deal with these chronic diseases and reduce the strain on our healthcare system. So big goals.

Stephanie Reid 19:47
Can you tell us a bit about some of the key outcomes from the research, not just the ongoing outcomes, but some of the other unexpected maybe outcomes of the research?

Jonathon Fowles 19:56
Well, one of the things that we’ve done in our quality assurance evaluations especially with the funding that we get from the province is to show the worth of clinical exercise physiologists in practice. And so we have done cost savings analysis with the number of patients that we have in our programs. And we look at some simple outcomes such as, you know, aerobic fitness score, blood pressure, muscle strength with a grip strength, a sit to stand as an indication of lower body strength and independence and single leg balance tests. And you can use those numbers to infer what cost savings would be. And we’ve done analysis that shows that our community group exercise programs are at least cost savings to the cost of the CEP running those programs and they’re more likely like saving two to three times the cost in reductions in not only just health care utilization, because people are healthier. If you take somebody from being somewhat active to active you save about $350 a year in just health care costs, on average. If you take someone from inactive to somewhat active, it’s about $600 a year in savings just in reduced health care utilization. Specifically, when you’re doing exercise, and you’re improving their strength and balance, the reducing the risk of falls, you only need 11 older adults exercising for a year to reduce their risk of falls by about 40%. Which means that 11 older adults, you’re going to save one serious fall a year, which 50% of which end up in a hospitalization and 25% of those end up in surgery, or worse. And so if you have 100 older adults exercising for a year, which is at least what we have in the valley, through our programs, you’re saving 10 serious falls a year of which you know, 50% of those are going to be hospitalization or otherwise, which costs 25 to 30,000. So, the cost savings of those CEP positions can be the projections are anywhere between two and 10 fold savings of the cost of the position and

Stephanie Reid 22:08
you can easily justify that.

Jonathon Fowles 22:09
Yeah, so you can easily justify those in-cost savings.

Stephanie Reid 22:12
Well, thank you all for the work you’re doing in this space and continue to do in the space and Joy, Verna, Jonathon, thank you so much again for taking the time to chat with us today. And we look forward to keeping on top of what comes next for your team and the research overall.

Joy Chiekwe 22:28
Thank you.

Verna MacKinnon 22:29
Thanks.

Jonathon Fowles 22:20
Pleasure to be here.

Stephanie Reid 22:33
During this conversation, we’ve explored potential for transformative impact of research on healthcare practices. Our guest Dr. Jonathon Fowles, Verna MacKinnon, and Joy Chiekwe have painted a vivid picture of purpose-led collaborative research, extending far beyond the lab. We’ve explored some of the challenges faced by patients and healthcare providers witnessing the collaborative approach that bridges research, healthcare and community.

Stephanie Reid 23:12
We hope you enjoyed today’s episode, be sure to hit the subscribe button and leave us five stars. You can also follow us on social @beyondresearchpodcast and let us know what research topics you would like to hear on the podcast. Thank you for listening, and we’ll see you next time.