Pictured above: Right to left, Dr. Greg Linton, President and Chair, Pacific Northwest Division of Family Practice, Physician Co-Lead, CHANGE BC, MaryLou McKay, Nisga'a Elder and CHANGE BC Advisor, Dr. Robert Boushel, Professor and Director, UBC School of Kinesiology, and Laurie Flood, President, Metabolic Syndrome Canada.
A program developed by family physicians and offered through Primary Care Networks (PCNs) in British Columbia’s Pacific Northwest has successfully contributed to reducing and reversing risk factors for metabolic syndrome and type 2 diabetes.
CHANGE BC is a collaborative, team-based, and culturally sensitive program that focuses on lifestyle medicine, emphasizing physical and culinary literacy.
Launched in 2018, the CHANGE BC pilot program arose from concerns by physicians, who found that 40% of their adult patients in the Pacific Northwest were living with type 2 diabetes or associated metabolic syndrome risk factors.
The program offered patients year-round individualized healthy nutrition and exercise plans, leading to a 32.4% reversal of one or more conditions related to metabolic syndrome within the community. This initiative, led by family physicians in collaboration with registered dietitians and kinesiologists, achieved one of the highest success rates in Canada in addressing these challenging risk factors, such as high blood pressure, cholesterol, triglycerides, and blood sugars.
Family practice health care providers serve as the primary link in this year-long initiative aimed at enhancing patient health.
Dr Greg Linton, a family physician lead for CHANGE BC in Terrace and president of the Pacific Northwest Division of Family Practice Board, described Change BC as a “highly proactive program.”
“People struggle with complex risk factors that can escalate into hypertension, high blood sugars, and issues with cholesterol and triglycerides, leading to higher risks for diabetes and cardiovascular problems. By emphasizing lifestyle medicine, we are proactively helping patients lead longer, healthier, and more active lives.”
CHANGE BC functions as a community of practice dedicated to the ongoing development, advancement, and implementation of the program throughout BC, in partnership with other provincial CHANGE groups, the University of British Columbia (UBC), and Metabolic Syndrome Canada, a national charitable organization.
By employing wellness strategies, CHANGE BC actively supports patients in living healthier lives and has seen substantial success in managing and reversing the risk factors related to metabolic syndrome and type 2 diabetes.
Initially funded by a $66,000 grant from Metabolic Syndrome Canada, CHANGE BC's success led to its endorsement by the Ministry of Health as a key innovative model within three Primary Care Networks: Bulkley Valley Witset PCN, Coast Mountain PCN, and Nisga’a Valley PCN. The initiative has since continued to expand provincially. The Surrey-North Delta Division of Family Practice recently implemented the program in its local Primary Care Network.
Based on extensive research on nutrition and exercise, the CHANGE BC program aims for lasting improvements in overall well-being while addressing health issues that often progress to high blood pressure, heart disease, stroke, and diabetes, thus decreasing reliance on medications.
Patients are referred by a family physician or nurse practitioner to their CHANGE BC team of registered dietitians and clinical exercise physiologist (CEP) kinesiologists, who tailor individual nutrition and exercise plans. Initially, the team will coach patients weekly for the first three months. Ongoing support, both culturally sensitive and culturally safe, continues over a 12-month period, supporting patients as they implement enduring, lifelong wellness strategies.
Colleen Enns, executive director of the Pacific Northwest Division of Family Practice, emphasizes that “CHANGE BC exemplifies the best of team-based care. Through this innovative, excellent program envisioned by family physicians, teams provide customized supports that greatly enhance patient care and reduces risk factors.”
The CHANGE program is continually evolving across British Columbia, with UBC recognized as a key partner, and implementing CHANGE BC as the premier example of team-based care at the new Gateway Clinic in Vancouver. Plans are also underway to establish a CHANGE BC Centre of Excellence in the Pacific Northwest region.
Every Friday at 7:30 a.m., around 50 community partners, including Nisga’a Elder Mary Lou McKay, convene via Zoom to advance the initiative. The Division has also collaborated with UBC to secure funding for a project manager to assist family practices and communities interested in adopting CHANGE BC’s frameworks.
In partnership with UBC, a CHANGE BC focused dental van visits communities in the Pacific Northwest, offering free oral health services, as dental issues can make it difficult to manage blood sugars. The Division also received support from the Health Data Coalition of British Columbia to create a CHANGE BC dashboard, which will aid in gathering anonymized data for quality improvement and measuring the program's impact region-wide.
“These resources originated in the Pacific Northwest and are now shared across the province,” Enns says, highlighting the accolades received by family physicians spearheading this initiative. “CHANGE BC has been recognized by Healthcare Excellence Canada as a top 20 Promising Practice for Strengthening Primary Care nation-wide. Together, we are improving access to safe, including culturally safe, team-based primary care.”
The initiative has also scored high in patient satisfaction surveys. The program’s success stems from its commitment to strong collaborative partnerships and evidence-based practices. CHANGE BC prioritizes continuity of support, recognizing that shorter lifestyle programs, often limited to three months, typically struggle with maintaining long-term success. In contrast, CHANGE BC's year-long approach demonstrates that health improvements can last, with benefits persisting years after program completion.
The program emphasizes that healthy eating and regular exercise yield significant health benefits regardless of weight changes.
Cultural considerations are integrated into the program, including land-based exercises such as fishing and food gathering, which strengthen connections to traditional foods like eulachon, a smelt significant to the region's Indigenous communities. In the Nisga’a Valley, line dancing has emerged as a favourite exercise among participants, showcasing the program’s focus on local culture and engagement.
Divisions of Family Practice collaborate closely with local health authorities, Doctors of BC, the Family Practice Services Committee (FPSC), BC's Ministry of Health, the First Nations Health Authority, and local First Nations to identify patient care gaps and co-create tailored solutions.
FPSC coaches have played a vital role in developing CHANGE BC by working with family physicians and nurse practitioners to create electronic medical records (EMR) dashboards. These tools help identify potential participants for CHANGE BC and track patient and care panel improvements.
FPSC offers personalized, hands-on support to help family physicians enhance efficiency, reduce administrative burdens, and focus on proactive patient care.
Physicians and nurse practitioners can access real-time patient reports through the CHANGE EMR dashboard, enabling them to monitor health outcomes effectively. Primary care providers regularly meet with the CHANGE BC team to discuss updates on their patients, addressing barriers or milestones encountered in the program. This team-based approach alleviates primary care provider workload while ensuring patients receive necessary care.
The benefits following the CHANGE BC initiative are apparent not only for patients and healthcare providers but also for the broader community.
“Loneliness is often overlooked in our society,” Dr Linton notes. “Encouraging people to participate in group activities through the CHANGE BC program can significantly improve social engagement, reduce feelings of isolation and provide numerous social benefits.”
He also highlights the potential financial advantages for the healthcare system. “Given the successes we've achieved, we hope to see widespread adoption of this program across the province,” he says.
For communities interested in establishing their own CHANGE BC initiatives, the program invites inquiries via email at participate@changeprogram.ca.
About CHANGE BC:
CHANGE BC comprises a network of health experts from various sectors—practicing family physicians, medical researchers, academics, dietitians, and kinesiologists—aligned with the Pacific Northwest Divisions of Family Practice, University of British Columbia, Northern Health, Nisga’a Valley Health Authority, Kitsumkalum First Nation, Kitselas First Nation, Doctors of BC, and Metabolic Syndrome Canada. With a commitment to innovative, team-based healthcare, CHANGE BC is paving the way for healthier communities throughout British Columbia.