In this study describing the self-reported self-management behaviors in a nationally representative sample of adult Canadians living with type 2 diabetes, we observed that lifestyle behavior change (in particular dietary change, exercise and weight control) appeared to be prevalent following a diagnosis, especially among patients who receive self-management advice from a health professional. However, smoking cessation may represent a challenge; only 31% of those who reported having smoked after diagnosis reported having successfully quit. Among persons who ever engaged in lifestyle behaviors for self-management, persons living with diabetes for over 6 years were more likely to not sustain the behaviors.
The finding that persons who do not receive health professional advice for behavior change are less likely to engage in diabetes self-management behaviors is consistent with previous findings [17, 18]. Individuals with type 2 diabetes who receive self-management support from physicians, nurses, pharmacists, dieticians or other health professionals on the management of their diet , exercise and weight management  or combinations thereof  are generally more likely to make such changes. In a randomized control trial of patients with type 2 diabetes , a brief intervention to increase dialogue between patients and health care providers about lifestyle behavior modification for diabetes self-management significantly improved the level of recommended physical activity and weight loss. Our findings highlight the importance of health care provider communication, either through the provision of information or participatory decision-making, in patients’ behaviors for diabetes self-management. Better healthcare provider communication may lead to better diabetes self-management and, in turn, improve health outcomes, including higher levels of patient satisfaction [21–23]. Nonetheless, it is important to also note that substantial numbers of individuals who reported not receiving advice from health professional for change in diet, exercise or weight still engaged in self-management behaviors, and may have accessed support services or programs independent of health professional advice. Whether these individuals were already living healthy lifestyles and are less likely to receive health professional advice could not be addressed with these data and therefore remains to be studied.
The prevalence of smoking among adults with type 2 diabetes in this study is comparable to previous reports in adult Canadians living with diabetes  and it is interesting that no difference was observed in the proportion of respondents who ever engaged in smoking cessation in our multivariate analyses. The null effect of healthcare provider dialogue on smoking cessation observed in this study highlights the need for a more rigorous smoking cessation program for diabetes care, apart from standard or usual care self-management education in persons with diabetes [24, 25]. The American Diabetes Association, for instance, recommends healthcare providers to utilize more intensive interventions for smoking cessation as a priority of care for diabetic smokers . Because smoking exacerbates the risk of developing both macrovascular and microvascular complications in patients with diabetes , the Canadian Diabetes Association Clinical Practice Guidelines asserts that “the first priority” in the prevention of diabetes complications should be the reduction in the risk for cardiovascular disease through a multifaceted, multi-factorial, approach, including smoking cessation .
Persons with lower household income were more likely to report never changing their diet or not engaging in exercise for self-management of type 2 diabetes. Socio-economic status (SES) is an important determinant of diabetes self-management behaviors, particularly diet and exercise. Socioeconomic disadvantage is associated with a wide range of risk behaviors, which in turn have a negative consequence on health . It is possible that this relationship is mediated by poor adherence to diabetes self-management recommendations, which is related to low accessibility to healthy foods and health promotion facilities. Elimination of disparities in health, through policies and interventions to improve access and quality of care in patients with type 2 diabetes should be prioritized.
We observed that persons living with diagnosed type 2 diabetes for more than 6 years are more likely to not sustain lifestyle behavior changes for diabetes self-management. In another Canadian study , self-management education was shown to have a significant impact in healthy eating among diabetes patients, and was sustained at 2 years. The study did not, however, capture the self-management behavior sustenance for more than 2 years. Our results indicate that persons living with type 2 diabetes for more than 6 years may need specific attention to maintain behavior change. Further studies are necessary to understand barriers to sustained self-management behavior change among patients living with the disease for longer durations.
The Survey on Living with Chronic Diseases in Canada is a population-based cross-sectional survey designed to provide information on chronic disease management among Canadians living with chronic diseases. Several limitations are noted. First, the survey was insufficiently powered to assess the effect of ethnicity on engagement in lifestyle behaviors. Because multiple ethnic populations known to be culturally and epidemiologically heterogeneous  were combined as a single category, differences in diabetes self-management behavior among these populations may have been masked. Second, it is acknowledged that self-reported adherence to recommended lifestyle behaviors can be overestimated in self-reported surveys due to social desirability. Our findings nevertheless provide an important profile of the relative prevalence of self-reported lifestyle behaviors for managing type 2 diabetes. Likewise, participants may not accurately remember the healthcare services they received from their healthcare providers; research has shown that a patient’s ability to retain information from health professionals is often limited, with 40-80% of information forgotten immediately [30, 31].
Third, the survey explores a limited range of determinants of lifestyle behaviors, and did not capture specific measures of lifestyle behavior change, e.g. patients’ self-reported engagement in physical activity was captured, without reference to the exercise intensity. The use of direct measures of physical activity (such as accelerometry), which would provide a more accurate estimate of physical activity levels including the intensity, was not feasible for this large national survey. On another note, never engaging and not sustaining lifestyle behaviors were described according to whether the respondent reported having received advice for the behavior from a health care professional. It is certainly possible that some patients changed their lifestyle behaviors on their own, with the use of self help books, internet, or other sources without having received specific advice from a health care professional .
This study may have some implications for action. First, although there is a high prevalence of diabetes self-management behavior modification among people living with type 2 diabetes in Canada, the findings suggest a need for more action. Receipt of advice from health care professionals is strongly associated with self-reported engagement in self-management behaviors. Of note, however, is the limited effect of dialogue on smoking cessation among patients with type 2 diabetes that smoke. This, perhaps, indicates a need for more aggressive smoking cessation interventions. Finally, the study notes that SES-dependent disparities in healthy lifestyle behaviors are observed among Canadians living with type 2 diabetes.