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AustralasianMedicalJournal[AMJ2012,5,8, 429-435]

429

REVIEW

Pleasecitethispaperas:SukalaWR,PageRA,RowlandsDS,

LysI,KrebsJD,LeikisMJ,CheemaBS.Exerciseinterventionin

NewZealandPolynesianpeopleswithtype2diabetes:cultural

considerationsandclinicaltrialrecommendations.AMJ2012,

5,8,429-435.http//dx.doi.org/10.4066/AMJ.2012.1311.

Abstract

TheMaoriandPacificIslandspeoplesofNewZealandsuffera

greater burden of type 2 diabetes mellitus (T2DM) and

associated comorbidities than their European counterparts.

Empiricalevidencesupportstheclinicalapplicationofaerobic

and resistance training for effective diabetes management

andpotentialremission,butfewstudieshaveinvestigatedthe

effectivenessoftheseinterventionsinspecificethniccohorts.

Werecentlyconductedthefirsttrialtoinvestigatetheeffect

of prescribed exercise training in Polynesian people with

T2DM. This article presents the cultural considerations

undertakentosuccessfullyimplementthestudy.Theresearch

procedureswereaccepted andapproved bycultural liaisons

and potential participants. The approved methodology

involveda trialevaluatingandcomparingthe effectsof two,

16-week exercise regimens (i.e. aerobic training and

resistance training) on glycosylated haemoglobin (HbA1c),

relateddiabetesmarkers(i.e. insulinresistance,blood lipids,

relevant cytokines and anthropometric and hemodynamicindices) and health-related quality of life. Future exercise-

related researchor implementationstrategies in this cohort

shouldfocusonculturalawarenessandtechniquesto

enhanceparticipationandcompliance.Ourapproachto

cultural consultationcouldbe consideredby researchers

undertaking trials in this and other ethnic populations

suffering an extreme burden of T2DM, including

indigenousAustraliansandAmericans.

KeyWords

Resistance, Aerobic, Obesity, Maori, Pacific Islands,

Polynesia,Ethnic,High-Risk

Background

Significantdisparities inhealth status exist between the

indigenous people and non-indigenous people of

countries colonised by Great Britain.1-3 InNew Zealand,

this disparity has been highlighted in a recent national

healthsurveyinwhichthereportedprevalenceoftype2

diabetesmellitus (T2DM)was significantlyhigher among

Maori and Pacific Islands (Polynesian) peoples (8.2%)

compared to their European counterparts (3.1%).4 The

actualprevalenceintheindigenouscohortislikelymuch

higher asmany cases remain undiagnosed.5 Polynesian

people also suffer a higher burden of diabetes-related

comorbidities6andlowerlifeexpectancy.

7

Therift inhealthstatusbetweenPolynesianpeopleand

thoseofEuropeandescentmaybepartiallyexplainedby

the phenotypic expression of a formerly protective

thriftygenotype.8Thatis,fat-storinggenes,historically

selectedfor inPolynesianpeoplesdueto environmental

demands, now constitute a health liability. This

hypothesis remains controversial;9 however, recent

studieshaveindeedshownthatdiabetes-relatedmarkers,

includingfastinginsulin,insulinsensitivity,-cellfunction,

and glucoregulation differ by ethnicity, even aftercontrolling for variables such as age and adiposity.

10

Mechanistic factors, such as fat distribution patterns,

havealsobeenshowntovarybetweenPolynesianpeople

ExerciseinterventioninNewZealandPolynesianpeopleswithtype2diabetes:

Culturalconsiderationsandclinicaltrialrecommendations

WilliamR.Sukala1,2,RachelA.Page1,DavidS.Rowlands3,IsabelleLys4,JeremyD.Krebs5,MurrayJ.Leikis6,

and

BirinderS.Cheema7

1.InstituteofFood,Nutrition&HumanHealth,MasseyUniversity,Wellington,NewZealand

2.SchoolofHealthandHumanSciences,SouthernCrossUniversity,Lismore,Australia

3.SchoolofSportandExercise,MasseyUniversity,Wellington,NewZealand

4.FacultyofEngineering,Health,ScienceandtheEnvironment,CharlesDarwinUniversity,Australia

5.FacultyofMedicine,UniversityofOtago,Wellington,NewZealand

6.WellingtonHospital,CapitalandCoastDistrictHealthBoard,Wellington,NewZealand

7.SchoolofScienceandHealth,UniversityofWesternSydney,Campbelltown,Australia

CorrespondingAuthor:

BirinderS.Cheema,PhD

SchoolofScienceandHealth,UniversityofWestern

Sydney,LockedBag1797,PenrithSouthDC,NSW

1797,Australia

Email:[email protected]

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andotherethnicities.11

There is clear evidence that Polynesian health has been

significantly compromised by colonisation.12-14

Ubiquitous

processed foods and extreme physical inactivity, the lasting

effectsofcolonisation(i.e.westernisation),tendtounmaska

propensity towards cardiometabolic diseases in this

population. Additional insidious contributorsto thedeclines

in health status since colonisation include inequalities in

income, education, employment, housing15 as well as

interpersonal and institutional racism and discrimination.16

These factors impact upon the ability to improve diet and

physicalactivitybehaviours.

Exercise is essential for the prevention and remission of

T2DM. Numerous meta-analyses and review papers

underscore the value of progressive resistance training and

aerobictraining,prescribedindependentlyorincombination,

forimprovedglycaemiacontrolinindividualsdiagnosedwith

T2DM.17-23

However,themajorityoftrialsusedtoformulate

currentexerciseguidelineshaveinvolvedprimarilyCaucasian

patients, or the ethnicity was not reported. This is notable

given that certainethniccohorts aremore severely affected

bythisdiseasethanothers.Findingsofourrecentsystematic

review suggest a need to investigate theeffectsof exercise

traininginPolynesianpeoplewithT2DMandotherhigh-risk

cohorts.24

Our research group recently conducted the first trial toevaluate the effects of prescribed exercise training in

Polynesianadultswith T2DM.25,26

Thepurposeofthisstudy

was to determine if exercise could improve glycosylated

haemoglobin(HbA1c),relatedcardio-metabolicmarkers,and

quality oflife inthiscohort. Inorder toconduct this study,

thereweremanyculturalconsiderationsthathadtobetaken

into account. The study design itself involved extensive

consultationwithreligiousandcommunityleaders,aswellas

potentialparticipants.Documentationoftheseconsiderations

may prove beneficial for the development and guidance of

future exercise intervention trials in this and other distinct

ethnicpopulations.Therefore,thepurposeofthispaperisto

describe our research methodology within the overarching

culturalmilieupertinenttoestablishingaclinicalexercisetrial

acceptable to Maori and Pacif ic Islands people in New

Zealand.Recommendationswillbeprovidedtoguideexercise

scientists, healthcare professionals and researchers in

undertakingfutureexercisestudiesortreatmentinitiativesin

thiscohortandotherhigh-riskethnicpopulations.

CulturalconsultationandethicsMaoriandPacificresearchinNewZealandmustbeconducted

inaculturallysensitivemanner.Inconceptualisingourstudy,

we consulted with indigenous community and healthcare

leadersthroughoutthePoriruaandWellingtonregionsfor

nearly18monthspriortoenrollingthefirstparticipant.A

schematic of the consultation process is presented in

Figure1.

Figure1:Culturalconsultationschematic

Cultural consultation consisted of meetings with, and

presentations to, Maori and Pacific community leaders

andhealthcareliaisons.Proposedresearchprotocolsand

participant literature (e.g. information sheets, consent

forms,questionnaires)receivedongoingreviewtoensure

acceptanceandbenefittothePolynesiancommunitiesat

large.Organisationalsupportandguidancewerereceived

from the National Heart Foundations Pacific Heartbeat

liaison, Capitaland Coast District HealthBoard,OraToa

HealthServices,andPacificHealthServicesinWellington.

The consultation process revealed that potential

participants considered randomisation to a non-exercise

control group unethical. This issuewas also noted in a

previous lifestyle intervention trial enrolling Polynesian

participants.27 Our study design was therefore modified

from a randomisedcontrolled trial comparing resistancetraining tousual care (no exercise) to a trialevaluating

and comparing the effect of resistance and aerobic

training.

All feedback was integrated into our researchproposal,

which received approval from cultural and religious

liaisonspriortobeingsubmittedto,andapprovedby,the

Central Regional Ethics Committee (Approval Number;

CEN/07/08/054). Final ethics approval was obtained

within four months, while the first participants were

recruitedfivemonthsthereafter.

Recruitmentprocess

Healthcare professionals with the various agencies

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initially providedour recruitmentflyer topotentiallyeligible

individuals, however this strategy enrolled few participants.

Weaddressed thisissueby havinggeneralpractitioners and

practice nurses forward the names and contact telephone

numbers, with permission, of interested and potentially

eligibleparticipants.Wetheninitiatedfirstcontact.Thefirst

waveofparticipantsreferredfriends,family,co-workers,and

fellow church congregants to the study similar to the

snowball effect previously described by Murphy et al.27

Several potential participants also contacted the lead

investigatorafterreadingarticlesaboutthestudyinregional

andnationalprintmediaorafterviewingreportsdeliveredvia

thetelevisednationalnews.

Medicalreview

Individuals were selected for participation in the exercise

study if they met the following criteria: 1) self-identified

Polynesian (Maori or Pacific Islands) descent; 2) a clinical

diagnosis of T2DM; 3) visceral obesity (i.e. waist

circumferenceof>88cmforwomenand>102cmformen);4)

physically inactive for> 6months;5)no change indiabetes

medications for previous two months; and 6) no acute or

chronic medical conditions for which exercise would be

contraindicatedasoutlinedbytheAmericanCollegeofSports

Medicine.28 All protocols and safety procedures were

developedinpartnershipwithaconsultantdiabetesspecialist

andwereinaccordancewithestablishedinternationalsafety

guidelines set forth by the American Diabetes Association29

andtheAmericanCollegeofSportsMedicine.

28

After initial medical screening, potential participants were

invited, along with supportive family and/or friends for a

private consultation tolearn more about the studyand ask

questions,priortoprovidinginformedconsent.Theprincipal

investigatoralsomadehomeandofficevisitstoaccommodate

busyworkandfamilyschedules.Approvalwasalsoobtained

fromtherespectivephysicianand/orendocrinologist.

Exercisevenue

The trial was conducted at a commercial health and fitness

facility(CityFitness)inPorirua,NewZealand,approximately

20 minutes drive north of Wellington. The population of

Porirua is approximately 48,546 people and 46.5% are of

Polynesian descent, which ismuch higher than thenational

average of 19.6%.30 Accordingly, City Fitness has a high

Maori, Pacific, andmixed Polynesian/Europeanmembership

base. Ourparticipants, most ofwhich hadneverpreviously

exercised,receivedfreemembershipsforthedurationofthe

interventionperiod(16weeks). Managementalsoallocatedstaffandofficespacetofacilitatestudyprocedures.Exercise

trainingsessionswereconductedinthecircuitfitnessareaof

thegym,whichofferedadegreeofprivacytoourparticipants.

Exerciseleaders

Qualified exercisephysiologists ledallexercise sessions.

Four advanced Exercise Science students from Massey

Universityandthreequalifiedpersonaltrainersfrom City

Fitnessprovidedone-on-onesupervisiontoparticipants

which helped ensure both safety and compliance to

trainingprocedures.FoliakiandPearce31havenotedthat

behaviour modification interventions in Polynesian

people aremore likely to succeedwith theinvolvement

and support of family and community members. It is

notablethatfourofthesevenexercisephysiologistswere

ofMaoriand/orPacificheritage.SeveralMaoriandPacific

Island community leaders involved in the initial cultural

consultationwerealsopayingmembersofthefacilityand

periodically provided on-site encouragement to

participants. Participantswerealsoencouragedtobring

family and friends towatch, participate in the training,

and/or support their efforts. A level of camaraderie

developed amongst participants, as they spoke freely

abouttheirhealthissues,andofferedencouragementto

oneanother.Manyexchangedphonenumbersandemails

to maintain contact outside study hours and some

carpooledtotheexercisesessions.

Exercisesessions

Participants were randomised to either an aerobic

training group or a resistance training group. The twogroups exercised in parallel three sessions per week

(Monday,Wednesday,Friday)for16weeks.Theduration

of each session ranged from 40 to 60 minutes. The

exercise regimens were developed in accordance with

guidelines published by the American College of Sports

Medicine.32 Pre- and post-exercise heart rate, blood

pressure, and blood glucose (via Accu-Chek Performa

glucometer, Roche Diagnostics, Auckland, New Zealand)

weremonitoredandrecordedateachsession.Thelead

exercisephysiologistwas delegated tomaintain ongoing

communicationwiththediabetesmanagementteam(e.g.

endocrinologist, general practitioner, diabetes nurse

specialist)ofeachparticipant,whichinvolvedreportingof

untowardsignsorsymptoms,ifexperienced.

Resistance Training: after a five-minute warm-up,

participants performed eight machine-based resistance

exercisesinacircuitformatdesignedtotargetallmajor

muscle groups: seated leg press, knee extension, knee

flexion,chestpress,latpull-down,overheadpress,biceps

curls, triceps extension (Cybex International, Medway,MA). Dueto thelevelof physical deconditioning inour

cohort,wewereconcernedabouttheseverityofdelayed

onsetmuscle soreness(DOMS)thatcould beelicited by

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intervention33andtheimpactitmighthaveonattrition.We

therefore employed a graduated periodised regimen.

Participants performed six to eight repetitions with one

minute of rest provided between sets. Workloads were

increased by 35% when participants could perform 10

repetitions. Weeks 4, 8, and 12 were designated active

recoveryweeks inwhichparticipants performed one set of

eachexerciseataweight10%lessthanthepreviousweeks

peakworkload.Participantswereencouragedtoexerciseata

perceivedexertionofveryhardontheBorgscale.34Thehigh

stafftoparticipantratioassuredcompliancewithprotocols.

Aerobic Training: participants performed a graduated

progressive cycle ergometry (Life Fitness, Schiller Park, IL)

protocol.Thisprotocolwasspecificallyemployedtofacilitate

cardiovascularconditioningandpromotefatloss.Participants

were familiarised with the equipment and gradually

progressed from 65 to 85% of their calculated heart rate

reserve28 andencouraged to sustaina perceived exertionof

veryhard.34Heartrateandbloodpressureweremonitored

andrecordedatpeaksteadystateworkloads.Cycleresistance

andthedurationatpeakintensitywereincreasedby35%to

accommodateimprovedfitnesslevelsovertime.

Assessmentsofoutcomes

Outcome measures were collected before and after the

exercise intervention period. The primary endpoint was

HbA1candsecondaryendpointsincluded:insulinresistance,blood lipids, relevant cytokines (C-reactive protein,

adiponectin),andanthropometricandhaemodynamicindices.

Health history assessment and specific questionnaires,

including Medical Outcomes Trust Short-Form 36 (SF-36)

qualityoflifesurvey35werecompletedatCityFitness,while

medical procedures were completed at Kenepuru Hospital,

also located inPorirua. The hospital is a trusted healthcare

institution within the community, with multilingual signage

andculturallydiversestaff.Researchstaffgreetedparticipants

upon arrival at the hospital and guided them to the exam

rooms. Hospital staff performed fasting blood draws, while

researchstaffconductedanthropometricandhaemodynamic

assessments. Skeletal muscle biopsieswere taken from the

vastus lateralis muscle and were conducted by a trained

medic with extensive experience in the procedure.

Participantswereprovidedwithanopportunitytospeakwith

theattendingphysician,askquestionspriortotheprocedure,

and reserved the right to refuse the procedure. A separate

written informed consent was provided for the biopsy

procedureonly,asrecommendedbytheculturalconsultation

process.

Acceptabilitytoparticipants

CityFitnessinPoriruaprovidedawelcomingandsupportive

groupatmosphereanecdotallyreportedtobeacceptable

by participants. Participants often spoke their own

language with staff, club members, and fellow

participants. Participants occasionally attendedexercise

sessions dressed in traditional clothing, and sometimes

engaged in prayer together. Exercise staff and research

team members maintained a high-level of cultural

awareness and made every effort to accommodate

participants. For example, exercise sessions were

providedoutsideusualclasstimes,ifneeded,toallowfor

participants to meet pre-existing family, religious, or

employmentcommitments.Manyparticipantsexpressed

their satisfaction with the exercise program, but

acknowledged that it would be difficult to maintain

without ongoing support and encouragement. City

Fitness provided discounted memberships to

participants upon completion of the intervention. A

number of participants carried on atCity Fitness while

otherspurchasedmembershipsatotherfitnesscentresor

recreationfacilitiesinthevicinity.

Participantattrition

Eighteen of 26 randomised participants completed the

study. The most common reasons for dropping out

included:work-relatedcommitments(n=4),livingtoofar

fromtrainingvenue(n=1),andnewpregnancy(n=1).Two

participants provided no reason for discontinuation.

Attendancebecameanissueforseveralparticipantsthateventuallycompletedthestudy.Elevenof18participants

completed at least 32 of 48 (66.7%) available sessions.

The main reasons given for missed sessions included:

work, family, flu, funerals, and pre-existing obligations

plannedpriortojoiningthestudy.

Recommendations

A number of recommendations can be provided to

researchers conducting exercise intervention trials with

Maori andPacific Islands people. Extensive consultation

and a thorough awareness and sensitivity to important

cultural underpinnings should be integrated into the

study. Although this is a requirement of New Zealand

ethics committees, it is also imperative for establishing

trust with Polynesian communities and potential

participantsassomemembersofthiscommunityappear

sceptical of research, and are unaware of the need to

create wider dissemination of research outcomes.

Virtually all participants joined the study because they

wererecruitedthroughpeopletheyknewandtrusted.

The training venuemustpreserve andreinforce cultural

andethnicidentities.Anideallocationwouldperhapsbe

theMarae (i.e. sacredMaorimeetingplacefor religious

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and social gatherings) or the Pacific church, but this might

prove unfeasible without the necessary exercise equipment

andspace.Ourstudydemonstratedthatacommercialfitness

centrewithinaPolynesiancommunitywasanacceptableand

feasiblealternative.

Participant attrition and less than optimal attendance were

identifiedproblems,butthereasonsprovidedwerenotunlike

those reported in other clinical trials of exercise training.

Future exercise studies should place greater emphasis on

maintainingrecruitmentandmotivation.Financialincentives

and an extrinsic rewards system (e.g. vouchers, gifts) may

enhancecomplianceoverthelong-term.Theinvolvementof

abehaviouralpsychologistmayalsoenhanceadherencewith

greateremphasisbeingplacedontheidentificationofintrinsic

motivators and the determination and facilitation of

behaviouralchangeaselucidatedbyProchaskaandVelicer.36

Further,interventionsthataremorepracticable,thatinvolve

whole families or groups, may prove more beneficial for

participant retention. It has been suggested that behaviour

modification in Polynesian people ismore likely to succeed

withthe involvement andsupportof familyandcommunity

members.31 Traditional forms of exercise (e.g. paddling and

dance)maybemostacceptedanddesirable.

Our initial intent to carry out a randomised control trial

comparing a resistance training group to a non-exercising

controlgroupproveduntenable.Preliminarydiscussionswithpotential participants indicated that few would accept

random allocation to a non-exercise group. Future cultural

consultations could perhaps be directed toward ensuring

more rigorous scientific study designs. For example, if non-

exercising control group remains unacceptable, unequated

training regimens could be compared (e.g. aerobic training

versusaerobicplusresistancetraining).Wait-listorcross-over

study designs could also be employed. Future studies

involving focus groups and qualitative methods may be

requiredtodeterminewhichtypesofresearchmethodologies

aremostfeasibleanddesirable.

We attempted tomaintain recordsof confounding variables

including physical activity and diet. However, we identified

ongoing problemswith incomplete ormissing responses on

questionnaires. In particular, many participants stated the

InternationalPhysicalActivityQuestionnaire(IPAQ)37wastoo

daunting and confusing. The three-day dietary food record

wasparticularlydifficulttoadministerduetodifficultieswith

servingsizeestimationandrecallofmeals.

TheMedicalOutcomesTrustShort-Form36(SF-36)qualityof

lifesurveyhasbeenvalidatedintheNewZealandpopulation,

butahighnumberofmissingresponsesinPacificpeoplehas

alsobeen reported.38 In the present studywedid note

missing responses primarily due to item oversight.

Administrationof SF-36alternativessuchas theSF-12or

SF-8 might be more feasible in future studies. Future

investigations should strive to choose ordevelophealth

questionnaires that are simple, use minimal scientific

jargon,arevisuallyuncluttered,andeasytoadminister.

In summary, Maori and Pacific Islands people suffer

disproportionately from T2DM and associated

cardiometabolicaberrationscomparedtoNewZealanders

of European descent. A significant body of evidence

supports the use of resistance training and aerobic

exercise as potent therapeutic modalities for enhanced

T2DM management in predominantly Caucasian-

European participants. Both exercise modalities still

remain largely under prescribed and underutilised in

clinicalpractice,especiallyinindigenouspopulationswith

T2DM. Ample opportunity existswithin New Zealand to

extend the benefits of exercise to high risk Maori and

Pacific Islands people. The successful development and

implementationofthepresentstudydemonstratesthata

structured exercise intervention is both feasible and

acceptabletoPolynesianNewZealanderswithT2DM,and

efforts are indeed required to target the diabetes

epidemicinthisspecificethnicpopulation.Ourapproach

to cultural consultation could be implemented in trials

enrolling other ethnic populations highly afflicted withdiabetesincludingindigenousAustraliansandindigenous

Americans.

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ACKNOWLEDGEMENTS

Wewish tothank all studyparticipantsfor theirhardwork

anddedicationandwithoutwhomthisstudywouldnothave

been possible. We wish to thank Dominic Rogerson with

PoriruaCityFitnessforprovidingthehostvenueandongoing

staff and resource support for the study, Capital and Coast

DistrictHealthBoardforprovidingphysicalhospitalresources

andclinicalstaffsupport,andRocheDiagnosticsforproviding

Accu-chek blood glucose meters. We are also grateful to

KitionaTauira,PastorTeremoanaTauira,PastorsKenandTai

Roach,ReverendTavitaFilemoni,NationalHeartFoundation,

Pacific Health Services, Pacific Diabetes Society, Ora ToaHealth Services, Waitangirua Pharmacy, Waitangirua Health

Centre, Maraeroa Health Clinic, Whitby Doctors, Titahi Bay

Doctors,andNewlandsMedicalCentrefortheirguidanceand

supportfromstarttofinish.Thankyoutoouron-siteexercise

leaders Amy Doyle, Steve French, Moana Jarden-Osborne,

Bevan Kahui, ShellyMather,Mike Ritete,andMike ToeToe

fortheirdiligentsupervisionandassistance.

PEERREVIEW

Notcommissioned.Externallypeerreviewed.

CONFLICTSOFINTEREST

Theauthorsdeclarethattheyhavenocompetinginterests.

FUNDING

ThisprojectwassupportedbytheMasseyUniversityResearch

FundandtheWellingtonMedicalResearchFund.

ETHICSCOMMITTEEAPPROVAL

CentralRegionalEthicsCommittee(ApprovalNumber;

CEN/07/08/054).

amj-05-429.pdf

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