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From PEKN 1P93 Winter 2014: Group 05: Disease Prevention, Diabetes
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Diabetes mellitus, more commonly know as diabetes, is a condition that is characterized by high blood glucose levels. It develops when an individual's metabolism does not react appropriately to insulin, a hormone that controls blood glucose levels, or the hormone is unable to be secreted by the pancreas. Ultimately, this causes an imbalance in the body and forces it to adapt to the new glucose levels in the blood, which results in diabetes. Since the body has adapted to this new level of glucose and cannot be "reset", diabetes results. Currently,it cannot be cured; it can, however, be efficiently managed. In Canada today, diabetes is the sixth leading cause of death, accounting for 2.9% of all deaths in 2009 (StatsCan, 2013). Furthermore, 2.4 million Canadians are living with diabetes, with an additional 20% of undocumented cases according to a report released by the Public Health Agency of Canada (PHAC)(2011).
 Type 1 Diabetes
Type 1 diabetes mellitus (T1DM), formerly called insulin dependent diabetes, is defined by the destruction of insulin producing beta-cells as the result of an autoimmune deficiency (Canadian Diabetes Association, n.d.). In contrast to type 2 diabetes, it appears at a young age, most frequently between ages 10 and 15. It appears more prevalent in males than females and is most present in Caucasian individuals. The causes of T1DM is mainly genetic inheritance however there are also many environmental factors causing the deficiency of beta cells (Levy, 2011). Some of these factors include nutrition deficiency, diseases such as the mumps and even geographic environment. The frequency of type one diabetes is increasing 3-5 percent a year and is becoming increasingly frequent in youths under 5 year of age. Main symptoms are lack of glycemic control causing large amounts of urine, fatigue, nausea and blurred vision. T1DM is arguably the most serious form of diabetes because of the bodies inability to synthesize insulin (Casey, 2012).
 Type 2 Diabetes
Type 2 diabetes is distinguished by progressive beta-cell dysfunction. This is why individuals usually need insulin replacement therapy. Type 2 diabetes is one of the main causes of cardiovascular disorders, blindness, end-stage renal failure, amputations and hospitalizations. It is also linked to a higher risk of cancer, serious psychiatric illness, cognitive decline, chronic liver disease, accelerated arthritis, as well as other disabling or deadly conditions (Inzucchi et al., 2012). 90-95% of all diagnosed cases of diabetes in adults are type 2 diabetes (National Diabetes Education Program, n.d.). Since type 2 diabetes can be prevented, the prevalence of diabetes could be drastically reduced if children were more active and had healthier diets.
Before someone is diagnosed with type 2 diabetes they almost always show signs of prediabetes. It is a good indicator that an individual has a serious risk of developing type 2 diabetes. It is characterized by blood glucose levels that are higher than normal but not enough to be considered type 2 diabetes (Canadian Diabetes Association, 2014). At this point it is highly recommended that serious steps be taken in order to delay the onset of prevent the development of type 2 diabetes.
 Gestational Diabetes
Gestational diabetes mellitus (GDM) is an interesting form of diabetes that arises in pregnant women. Essentially, now that it is supporting a growing baby, the body cannot produce enough insulin to effectively control blood glucose levels. Coupled with the hormonal changes that accompany pregnancy, blood glucose levels will rise to higher, unnatural levels that may impose complications upon the mother and child.
If GDM is left untreated, there is an increased likelihood that the baby's birth weight will exceed 4 kilograms (9 lbs), which will ultimately cause complications during delivery. Moreover, it can significantly increase the risk of the newborn child of developing type 2 diabetes and becoming overweight. For the mother, blood glucose levels should return to normal after the pregnancy. Despite this, experiencing GDM in the first pregnancy puts the mother at greater risk of experiencing it again during her second pregnancy. She, too, is also more likely to develop type 2 diabetes (Canadian Diabetes Association, 2014).
Today, about 3-20% of women develop GDM during pregnancy depending on a few risk factors. Experts encourage women to be screened for GDM within the first 28 weeks of becoming pregnant (Canadian Diabetes Association, 2014).
 How can physical activity help?
The management and prevention of diabetes is directly linked to physical activity, but is still not widely used as a therapeutic strategy (Kirk, Barnett & Mutrie, 2007). Glucose stored in the blood at elevated levels must be used up in order to bring the body back into a homeostatic state. It is then ideal to know that glucose is the primary fuel source in cellular respiration, a metabolic process that creates energy for the cells within the body. By engaging in physical activity, whether it is mild, moderate, or extreme, the body increases the uptake of glucose in order to sufficiently nurture all the cells at work. This in turn reduces the levels of glucose stored in the blood and reduces the risk of developing diabetes and other cardiovascular related maladies. Nutrition will also play an important role in managing and preventing diabetes, which will be described in detail in later sections. Fuelling the body appropriately, coupled with regular exercise, provides the body with an outlet for fuel (glucose) and serves as a maintenance system for overall health.
 HistoryThe link between diabetes and physical inactivity is unmistakeable.
These statistics may seem superficial; people who are obese will obviously be more likely to suffer from a metabolic disease such as diabetes. However, more information exists to connect the increase of recorded cases of diabetes to physical inactivity. The PHAC reported in 2011 that individuals of low socio-economic status are more likely to develop type 2 diabetes. Coincidently, people of low socio-economic status are also less likely to engage in physical activity (Canadian Fitness & Lifestyle Institue, 2008). Being on the lower tier of the hierarchy, people of low socio-economic class may not have the time or the funds to commit to regular scheduled physical activity or healthy diet. This correlation leads the PHAC to conclude that physical activity is vital in the management and prevention of diabetes (Public Health Agency, 2011).
These statistical affiliations clearly supports the connection between diabetes and physical activity. Appropriately regulating diet and committing to a regular schedule of physical activity will undoubtedly aid in the management of diabetes. It will also decrease the likelihood that an individual will develop the disorder. Despite these facts, the situation seems to be growing grimmer. With 200,000 new cases of diabetes recorded in 2008/09 alone, experts fear that the number of Canadians living with diabetes will reach 3.7 million by 2018/19. If steps are not taken to promote factors that will reduce the frequency of the disorder, the mortality rate associated with diabetes will definitely increase.
 Target Audience
The information presented in the article will be focused on youth, specifically aged 5-21. As society begins to shift focus to the wellness and education of the mind, the promotion of physical activity for youth has gotten lost under the importance of being book smart and "getting the grade". Coupled with advancements in video game technology and the ongoing battle in the fast food industry, physical activity falls into the backs of everyone's mind. This is supported by the growing trend of childhood obesity (CBC News, 2014). Furthermore, the increase in teen pregnancies promotes the development of GDM, which presents complications as described previously.
With these growing trends, the likelihood that a child will develop some form of diabetes increases dramatically. In fact, the PHAC reported in 2011 that the prevalence of diabetes in youth has increased substantially, with some 3000 new cases being documented in 2009. Thus, it is important for youth to understand the risks and dangers associated with physical inactivity and a poor diet and how it may lead to diabetes. Moreover, if they already are dealing with some form of diabetes, this article will provide them with the information they need to manage their ailment efficiently.
Parents, too, should utilize this article as an effective way to promote a healthy lifestyle in their children. As some children are not old enough to access the internet or understand some of the information, it is up to the parents educate their children about the benefits of physical activity. By doing so, they can play a significant role in maintaining their child's health.
 Management and Prevention
 Physical ActivityAs stated previously, the PHAC concluded that physical activity is directly linked to the management and prevention of diabetes (2011).
Obviously, diabetes is associated with a number of environmental, or lifestyle, factors. Changing specific behaviour and monitoring a few things will undoubtedly aid in the management of the disease, but it will also prevent it if they are valued at a young age. Youth today are constantly sitting in front of televisions and other screens absorbed in various types of media. Studies show that limiting screen time to less than 60 minutes per day will aid in the prevention, as well as management, of diabetes (McGavock, Sellers & Dean, 2007). Nutrition, too, is very important to the management and prevention of diabetes, which will be explained in a later section. These two lifestyle factors, coupled with regular physical activity, will aid in the control of weight; reducing the chances of becoming overweight significantly decreases the chance of developing diabetes, as mentioned previously.
Ultimately, getting active and controlling weight will significantly impact the likelihood of adolescents developing diabetes while being an effective management method for those with the disease. If this is not a large enough incentive, implementing these changes will also significantly decrease the risk of developing other ailments associated with diabetes, such as cardiovascular disease (McGavock, Sellers & Dean, 2007). Thus, it is quite apparent that the incorporation of physical activity is important in maintaining individual health and well being for those of all ages.
Diet is an important factor in managing diabetes. What the body intakes, stores and uses for fuel has a significant effect on it’s daily functioning. Diabetics need to pay special attention to food that will affect their blood glucose levels. The component of ones diet that has the greatest influence on blood glucose is carbohydrates (Nancy Sheard, 2009).
Diabetics should always count their carbohydrate intake before each meal. Carbohydrates break down into glucose, which is then stored in the blood. This is what leads to elevated blood sugar levels. It is important to note, however, that diabetics cannot completely cut carbohydrates out of their diets. Carbohydrates are an essential macronutrient, providing most of the energy the body needs. Whole grain carbohydrates, such as whole grain bread and brown rice are the best choice for diabetics. When empty carbohydrates and foods high in sugar content are eaten, it forces the body to produce insulin in order to metabolize the sugars (Chek Institute, 2012). Limiting how often the body has to metabolize sugar leads to lower blood sugar levels. Eating a healthy, well balanced diet will help diabetics manage their diabetes.
 Existing Physical Activity Programs
1. KIN Kids
KIN Kids is a guided physical activity program for youth ages 5 to 12 years old. Children and program leaders participate in fun, non-competitive physical activities. The aim of these activities is to teach children the benefits of regular physical activity, as well as to increase self-esteem and self-confidence. This is done by creating a positive and comfortable environment where the focus is on making everyone feel included, regardless of skill level and ability. The leaders of the program are enthusiastic Kinesiology students from the University of New Brunswick who want to help children develop a positive relationship with physical activity. KIN Kids attributes the success of the program to their energetic leaders who are passionate about what they teach (University of New Brunswick, 2014).
Since diabetes can be prevented and managed with physical activity, it is imperative that children develop a positive relationship with physical activity at an early age. Numerous youth have low self-esteem, low self-confidence and body image issues. Youth may avoid participating in physical activities, where they feel others are evaluating their bodies and skill levels. KIN Kids not only provides opportunities for physical activities, but also works on increasing children’s self-esteem and confidence. Mental attitude toward physical activity is a key component in the success of a child’s participation (University of New Brunswick, 2014).
More information on KIN Kids can be found here: http://www.unb.ca/fredericton/kinesiology/outreach/kinkids.html
2. Family Guide to Physical Activity for Children
The “Family Guide to Physical Activity for Children” was created by The Public Health Agency of Canada, the Canadian Society for Exercise Physiology, provincial partners and children and youth organizations. This guide aims to educate families, teachers, and anyone with children in their lives on how to get Canadian children more active. The guide includes a specific program, with the goal being to increase the amount of physical activity children do every month, until they do a minimum of 90 minutes more per day. The program works by increasing the amount of time children spend being physically active, starting with 30 minutes more per day. The 30 minutes can be broken up into shorter increments and accumulated throughout the day. The amount of time children are not physically active (ex. watching television or playing video games) is decreased, starting with 30 minutes less per day. The increased physical activity time and decreased non-active time are increased by 15 minutes per month, for five months. By the fifth month of the program, children will be doing 90 more minutes of physical activity and 90 less minutes of sedentary activities (Canada’s Physical Activity Guide, n.d.).
Physical activity needs to be part of a child’s daily life, as it can decrease the risk for type 2 diabetes. It can also help children with diabetes to manage their diabetes. This program can be easily adapted to suit a child’s individual abilities and current activity levels. The end goal of 90 minutes can be altered to a more appropriate number if needed (Canada’s Physical Activity Guide, n.d.).
The full guide can be found here: http://www.effectivepractice.org/site/ywd_effectivepractice/assets/pdf/5bbb_kidsguide.pdf
3. The Canadian Diabetes Association: Resistance Training Program
The Canadian Diabetes Association created resistance training exercises to strengthen various areas of the body. There are a wide variety of exercises that target areas such as the shoulders, back, abdominals, and legs. These exercises use resistance bands, weights and the individual’s own body weight. Many of the exercises are done sitting on a chair, which is great for individuals with mobility difficulties. These exercises are not recommended for children but are appropriate for older youth (Canadian Diabetes Association, 2014).
The Canadian Diabetes Association developed a chart for individuals to follow to gradually increase the repetitions and sets of exercises they do as well as the resistance used in the exercises. There are three stages of the program; the initial stage lasts for 4 weeks, the improvement stage lasts for 5 to 24 weeks and the maintenance stage starts at the 25th week and can be continued for as long as the individual chooses. Resistance training can both improve the management of diabetes and prevent diabetes (Canadian Diabetes Association, 2014).
Resources for the program can be found at: http://www.diabetes.ca/diabetes-and-you/healthy-living-resources/exercise/resistance-exercises-plan
4. Aerobic Dances For Kids
“Aerobic Dances For Kids” is a physical activity program created by Henry Glass and Rosemary Hallum. It is a series of dances, including a warm-up and cool down. The program can be used by schools, recreation facilities and individuals. The dances are appropriate for children of all ages and the steps are kept simple so children can participate and enjoy the dances regardless of their skill level. Suggestions and variations are also included for the dances to help teachers communicate concepts effectively or tailor moves suit to different levels. Suggestions are also given for ways to integrate the dances with concepts taught in other classes such as science, art, language and social studies. Many of the songs include lyrics, which children can learn and sing. Recorded voice cues are included to assist in learning or teaching the dances (Glass & Hallum, 2004).
Since children are spending more time being sedentary using electronics, it is important to get them active. Physical activity can reduce the likelihood of a child becoming diabetic, and can help diabetic children manage their diabetes. Children spend the majority of their time in school, where physical activity is usually not the focus. It is important to have physical activity in schools, and create a positive relationship between children and physical activity. “Aerobic Dances for Kids” is a wonderful program to use in schools because it provides suggestions for how to integrate physical activity with other school subjects. This will not only benefit teachers who may be wary of losing time needed to teach curriculum, but also allow students to learn about the ways physical activity transfers to all aspects of their lives. The program can also be used in recreational facilities as an opportunity for youth to be more active. Parents can use the program at home as a fun way to be active with their children (Glass & Hallum, 2004).
The full program can be found at: https://www.edact.com/files/lyrics/CD93.pdf
5. CANFIT’s ACTIVE8
CANFIT (2014) addresses that the risk of developing type 2 diabetes can be decreased with regular physical activity. CANFIT’s program “ACTIVATE8” is an 8-step guide that outlines fun, inclusive opportunities for physical activity. The program encourages participation from teachers, parents and other adults in addition to children. The program explains how to incorporate physical activity in daily life, what kind of physical activities are appropriate and how to ensure youth enjoy physical activity in a positive environment. The program gives instructions for a wide variety of physical activities including those that can be done indoors and outdoors. There are also several games from different cultures, which encourages inclusion and diversity. They can also be used by teachers in conjunction with other school subjects or by parents to help teach children about geography and different cultures. “ACTIVATE8” includes templates and instructions on how to create a personalized physical activity program. This is a valuable resource for parents or educators because they can learn step-by-step what to include and how to teach activities (CANFIT, 2014).
The full program can be found here: http://canfit.org/our_work/physical_activity/
 Best Practice Activity Suggestions
Dance is a great form of aerobic exercise because it has so much variation. There are numerous styles to choose from such as jazz, hip-hop, ballet, samba and waltz. These styles can all be done at different levels to suit any individual. According to Alpert (2011), some of the benefits of dance are increasing flexibility, muscle strength and tone, endurance, balance and spatial awareness. Alpert also addresses that dancing provides a feeling of well-being. Dancing is so fun to do that people forget they are exercising. This is helpful for children that do not like to exercise or that lack motivation. It is also a great activity for families to do together.
More research can be found here: http://hhc.sagepub.com/content/23/2/155.extract#
2. Resistance training
According to Eves and Plotnikoff (2006), resistance training improves insulin sensitivity, and can increase muscle strength, lean muscle mass and bone mineral density. Eves and Plotnikoff also state that resistance training is a good alternative for obese individuals, who may have a hard time performing aerobic exercises. Resistance training is not recommended for young children, however adolescents and teenagers can perform resistance exercises at an appropriate level.
More research can be found here: http://care.diabetesjournals.org/content/29/8/1933.full
Walking is a simple yet effective form of exercise. Children can walk to school, walk around the neighbourhood with family or friends and even go on a nature walk in a park or forest. According to Thompson et al. (2003), walking increases exercise capacity, endurance and skeletal muscle strength. Thompson et al. also states that walking can lessen the risk of type 2 diabetes.
More research can be found here: http://circ.ahajournals.org/content/107/24/3109.long#content-block
4. Muscular Endurance & Yoga
Muscular endurance exercise very often is recommended with aerobic exercise. A very good method of this is yoga. Aside from its flexibility and holistic benefits yoga greatly increases muscular endurance (Elevarasi, V., Gopinath, R. 2012). Muscular endurance increases the ability to burn calories which in turn increases weight management and develops a greater control over a diabetics glucose levels (Canadian Diabetes Association, 2014).
Adults over the age of 18 are recommended to have at least 75 minutes of intense aerobic training a week (American Diabetes Association, 2013). A common form of this is interval training. Interval training includes periods of intense aerobic activity with periods of active rest between each period (Weil, 2013). Active rest periods are when the level of aerobic activity is at a normal or moderate level, whereas intense activities raise the heart rate to about 90% capacity. This reduces heart rates at higher levels of intense activity (Weil, 2013). Lower heart rates decrease the risk for various cardiovascular disease and increases glycemic control, benefiting an individual with diabetes (Canadian Diabetes Association, 2014).
More information can be found here: http://www.medicinenet.com/aerobic_exercise/article.htm
 Future Directions
A slogan from the Canadian Diabetes Association really identifies the direction in which diabetes management is going, “Helping people live healthy lives while we work to find a cure.” This statement puts direct emphasis on the healthy living being the main divisive factor between preventing and managing diabetes and being diabetic. Although it may not be the cure it is the next best thing. Canadian Diabetes association recommends 150 minutes of aerobic exercise along with 3 sessions of resistance training each week in order to maintain glucose levels in the blood and decrease risk of other diseases(2014). Various programs are being run to assist with physical activity levels, however many people do not realize the true benefits of this physical activity. Some researchers even endorse the prescription of physical activity by medical professionals.
The World Diabetes Foundation addresses this issue in one of its eight focus areas. “The coming generation,” is a focus area that emphasizes education in order to create further success in preventing and managing diabetes. Currently in Mexico, where diabetes is the leading cause of death, schools are introducing programs that promote healthy behaviours and inform the children of the benefits of physical activity (World Diabetes Foundation, n.d.). Results of this program are uncertain however a ban on soft-drinks being sold in schools in currently being implemented. Changes such as this can only be a result of proper knowledge on the effect unhealthy food has on the body.
The promotion of a healthy lifestyle and programs addressing the growing trend of a sedentary lifestyle must be addressed further. In fact, the American Diabetes Association acknowledges the importance of diabetes self management education (2013). If the population can be thoroughly educated and made aware that being active can be more than just fun, then perhaps the trend can be reversed. However, the devastating effects of this inactive lifestyle must be presented and supported scientifically, otherwise the population may not adhere. Medical professionals as well as governments should take on the initiative to explain the benefits of an active lifestyle; ultimately, it will end up saving them money in healthcare (PHAC, 2011)
 External Links
 Physical Activity
Canadian Diabetes Association: http://www.diabetes.ca/
World Diabetes Foundation: http://www.worlddiabetesfoundation.org/
Public Health Agency Full Report on Diabetes: http://www.phac-aspc.gc.ca/cd-mc/diabetes-diabete/index-eng.php
Tackling Diabetes with Physical Activity: https://www.youtube.com/watch?v=ZGMVZWOm994
Physical Activity and Diabetes: https://www.youtube.com/watch?v=VnaA_gQBtnI
Physiotherapists Can Help!: https://www.youtube.com/watch?v=_nxCAh9B834
A Doctor's take: https://www.youtube.com/watch?v=WKUDXjddQbc
Carb Counting: https://www.youtube.com/watch?v=7M8pMkeHseY
 Notes and References
Alpert, P. (2011). "The health benefits of dance." Home Health Care Management & Practice, 23(155-157). Retrieved from http://hhc.sagepub.com/content/23/2/155.extract#
American Diabetes Association, (2013). "Standards of Medical Care in Diabetes." American Diabetes Association. http://care.diabetesjournals.org/content/36/Supplement_1/S11.full. Accessed March 23, 2014.
Canadian Diabetes Association, (2014). "Living with gestational diabetes." Retrieved from http://www.diabetes.ca/diabetes-and-you/living-with-gestational-diabetes
Canadian Diabetes Association, (2014). "Living with Prediabetes." Retrieved from http://www.diabetes.ca/diabetes-and-you/living-with-prediabetes
Canadian Diabetes Association, (n.d.). "Programs and Support Services." Retrieved from http://www.diabetes.ca/in-your-community/programs-support-services (accessed March 14, 2014).
Canadian Diabetes Association, (2014). "Resistance exercises & plan." Retrieved from http://www.diabetes.ca/diabetes-and-you/healthy-living-resources/exercise/resistance-exercises-plan
Canadian Fitness & Lifestyle Research Institute. (Producer). (2008). "2008 Physical Activity Monitor"[Web Graphic]. Retrieved from http://188.8.131.52/media/node/82/charts/Bulletin 2 PhysicalActivityLevelsCharts.pdf
Canada’s Physical Activity Guide. (n.d.). "Family guide to physical activity for children." Retrieved from http://www.effectivepractice.org/site/ywd_effectivepractice/assets/pdf/5bbb_kidsguide.pdf
CANFIT. (2014). "CANFIT’S ACTIVE8." Retrieved from http://canfit.org/our_work/programs/ACTIVE8/
Casey, G. (2012). "Type 1 diabetes and insulin therapy." Kai Tiaki; Nursing New Zealand, 18(3).
CBC News. (2014, March 3). "Canada's obesity rates triple in less than 30 years." Retrieved from http://www.cbc.ca/news/health/canada-s-obesity-rates-triple-in-less-than-30-years-1.2558365
Colberg, S. R., Sigal, R. J., Fernhall, B., Regensteiner, J. G., Blissmer, B. J., Rubin, R. R., Chasan-Taber, L., Albright, A. L., Braun, B. (2010). "Exercise and type 2 diabetes." Diabetes Care, 33(147-167). Retrieved from care.diabetesjournals.org/content/33/12/e147.full
Elevarasi, V., Gopinath, R. (2012). "Effect of yogic practices and physical exercise on muscular endurance and vital capacity among working women." International Journal of Sports Sciences and Fitness. 2(1), 50-56.
Eves, N. & Plotnikoff, R. (2006). "Resistance training and type 2 diabetes." Diabetes Care, 29(1933-1941). Retrieved from http://care.diabetesjournals.org/content/29/8/1933.full
Forga, L., Goni, M., Cambra, K., Ibanez, B., Mozas, D., Chueca, M. (2013) "Influence of age at diagnosis on glycaemic control evolution in patients with type 1 diabetes." Diabetes and Metabolism, 39. 519-523.
Glass, H., & Hallum, R. (2004). "Aerobic dances for kids." Retrieved from https://www.edact.com/files/lyrics/CD93.pdf
International Diabetes Federation, (Producer), (2014). "Diabetes Blue Circle" [Web Graphic]. Retrieved from http://www.diabetesbluecircle.org/
Inzucchi, S. E., Bergenstal, R. M., Buse, J. B., Diamant, M., Ferrannini, E., Nauck, M., Peters, A. L., Tsapas, A., Wender, R. & Matthews, D. R. (2012). "Management of hyperglycemia in type 2 diabetes: a patient-centered approach." Diabetes Care, 35(1364-1379). Retrieved from care.diabetesjournals.org/content/35/6/1364.full
Jenkins, D. J. A., Kendall, C. W. C., Marchie, A., Jenkins, A. L., Augustin, L. S. A., Ludwig, D. S., Barnard, N. D. & Anderson, J. W. (2003). "Type 2 diabetes and the vegetarian diet." The American Journal of Clinical Nutrition, 78(610S-616S). Retrieved from ajcn.nutrition.org/content/78/3/610S.full.pdf+html
Kirk, A. F., Barnett, J., & Mutrie, N. (2007). "Physical activity consultation for people with Type 2 diabetes: evidence and guidelines." Diabetic Medicine, 24(8), 809-816.
Levy, D., (2011). "Type 1 diabetes." Oxford diabetes library. Oxford University: Oxford University Press
McGavock, J., Sellers, E., & Dean, H. (2007). “Physical activity for the prevention and management of youth-onset type 2 diabetes mellitus: focus on cardiovascular complications." Diabetes & Vascular Disease Research: Official Journal of the International Society Of Diabetes And Vascular Disease, 4(4), 305-310.
Michaliszyn, S. F., Shaibi. G. Q., Quinn, L., Frischi, C., & Faulkner, M. S. (2009). "Physical Fitness, Dietary Intake and Metabolic Control in Adolescents with Type 1 Diabetes.” Pediatric Diabetes, 10.389-394.
National Diabetes Education Program. (n.d.). "The facts about diabetes: a leading cause of death in the U.S." Retrieved from http://ndep.nih.gov/diabetes-facts/#type
Public Health Agency of Canada & Canadian Institute of Health Information, (2011). "Obesity in canada." Retrieved from website: https://secure.cihi.ca/free_products/Obesity_in_canada_2011_en.pdf
Statistics Canada, (2012). "Health indicator profile, annual estimates, by age group and sex, Canada, provinces, territories, health regions (2011 boundaries) and peer group" (CANSIM table 105-0501). Ottawa: Statistics Canada.
Thompson, P., Buchner, D., Piña, I., Balady, G., Williams, M., Marcus, B., . . . Wenger, N. (2003). "Exercise and physical activity in the prevention and treatment of atherosclerotic cardiovascular disease." Circulation, 107(3109-3116). Retrieved from http://circ.ahajournals.org/content/107/24/3109.long#content-block
University of New Brunswick. (2014). "KIN Kids physical activity program." Retrieved from http://www.unb.ca/fredericton/kinesiology/outreach/kinkids.html
Weil, R. (2013). "Aerobic Exercise." http://www.medicinenet.com/aerobic_exercise/page7.htm#what_are_some_aerobic_training_workouts_and_routines. Accessed March 23, 2014.
World Diabetes Foundation, (n.d.). Retrieved from http://www.worlddiabetesfoundation.org/ (accessed March 14, 2014).