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Promoting physical activity in type 2 diabetes: Time 2 Act Study. Dr. Alison Kirk Sports Biomedicine Lecturer Time 2 ACT Principal Investigator University of Dundee. Jodi Barnett Time 2 ACT Project Manager University of Dundee. Overview. Type 2 diabetes

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promoting physical activity in type 2 diabetes time 2 act study

Promoting physical activity in type 2 diabetes:Time 2 Act Study

Dr. Alison Kirk

Sports Biomedicine Lecturer

Time 2 ACT Principal Investigator

University of Dundee

Jodi Barnett

Time 2 ACT Project Manager

University of Dundee

overview
Overview
  • Type 2 diabetes
  • Benefits of physical activity in type 2 diabetes
  • Promoting physical activity in type 2 diabetes
  • Time 2 Act Study
what is type 2 diabetes
What is type 2 diabetes?

“A condition where the amount of glucose (sugar) in the

blood is too high because the body cannot use it properly"

Two causes:

    • Insulin produced doesn’t work properly ‘insulin resistance’
    • The body does not make enough insulin

Features of the “metabolic syndrome” (~25% of adults)

  • Central obesity
  • Atherogenic dyslipidemia (high trigs, low HDL-C, high LDL-C)
  • Elevated blood pressure
  • Insulin resistance or glucose intolerance
  • Prothrombotic state
type 2 diabetes
Type 2 diabetes

“Accounts for between 85% to 95% of all people with diabetes”

Risk Factors

  • Overweight/Obesity (present in>75% of cases)
  • Increasing age
  • A first degree relative with type 2 diabetes
  • Ethnicity

Emerging earlier in life, magnifying the prospect of long term

complications

Mortality associated with diabetes has increased over the past two

decades, in contrast to declining associations with cardiovascular

disease and stroke

McKinlay J, Marceau L. US public health and the 21st century: diabetes mellitus. The Lancet, 356, 757-761.

National Centre for Health Statistics: National Vital Statistics Reports (1980-2006)

type 2 diabetes cardiovascular disease
Type 2 diabetes & cardiovascular disease

“People with Type 2 diabetes, without prior myocardial infarction (MI), have as high a risk of a MI as a non-diabetic person who has already had an MI” (Haffner 1998)

  • People with diabetes have up to a fivefold increased risk of CVD
  • >65% of people with diabetes die from heart disease/stroke
  • CHD is the principal cause of premature mortality in type 2 diabetes

American Diabetes Association (web): “Complication of Diabetes in the United States”

type 2 diabetes complications
Type 2 diabetes complications

Microvascular complications

  • Retinopathy ~80%
  • Peripheral neuropathy ~60%
  • Nephropathy ~30%
  • Foot Ulcers ~5%

Common Link -- “The better the blood glucose control,

the lower the risk of complications”

A 1% drop in HBA1c, can reduce the risk of microvascular

complications by up to 40% (UKPDS, 2000 Brit Med J)

Type 2 Diabetes in Practice. 2nd Edition. A.J.Krentz, C.J.Bailey. The Royal Society of Medicine Press.

type 2 diabetes treatments
Type 2 diabetes treatments

Lifestyle treatments

  • Diet
  • Physical Activity
  • Weight control if overweight or obese

Pharmacological treatments

  • Oral anti-diabetic agents
  • Insulin
  • Anti-hypertensives, statins, etc….
benefits of physical activity
Benefits of physical activity

Physical activity has been shown to have favourable effects on all

components of the metabolic syndrome

  • Reduce adiposity
  • Improve lipid profile (↑ HDL, ↓ LDL)
  • Reduce blood pressure
  • Increase muscle mass
  • Improved insulin sensitivity (up to 25%)

Reduce morbidity/mortality

  • Stroke
  • Osteoporosis
  • Cancer
  • All cause mortality
  • Cardiovascular disease

Parliamentary Office of Science and Technology. Health Benefits of physical activity, 2001, Number 162.

Around 40% of CHD deaths are associated with inadequate physical activity

benefits of physical activity1
Benefits of physical activity

Better blood glucose control

1. Improved insulin sensitivity

2. Blood glucose lowering effect

Exercise alone - decrease of 0.66% in HbA1c

- (ex.)8-9% improvement to ideal level of <7.0%

Diet + Exercise - decrease of 0.76% in HbA1c

- (ex.)9-10% improvement to ideal level of <7.0%

Boulé et al. (2001) Effects of exercise on glycaemic control and body mass in type 2 diabetes mellitus; A meta-analysis of controlled clinical trials. American Medical Association286(10):1218-1227

benefits of physical activity2
Benefits of physical activity

Acute Benefits:Immediate improvements in blood glucose levels

Chronic Benefits: Improves cardio-respiratory fitness, body

Composition,,HbA1c, lipid profiles and insulin sensitivity

“Walking is the best medicine for diabetes”

Frank B. Hu – 2003

Walking Reduces Mortality

  • Prospective cohort study
  • People with Type 1 & Type 2 diabetes (n=2,896)
  • People who walk at least 2 hours/week at self selected pace:

- 34%lower risk of cardiovascular mortality

- 39%lower risk of all cause mortality

Gregg et al. (2003) Relationship of walking to mortality among US adults with diabetes. Arch. Intern. Med163: 1440-1447

prevention of type 2 diabetes
Prevention of type 2 diabetes

“Physical activity identified as important factor in preventing/delaying development of Type 2 diabetes”

Two multi-centre trials (Finland & USA)

  • People with Impaired Glucose Tolerance (IGT)
  • Participants in a lifestyle intervention group or control group
  • Followed for an average of about 3 years

Results: Progression to Type 2 diabetes was 58% lower in the lifestyle intervention group, compared to control group

Diabetes Prevention Programme Research Group (2002) Reduction in the incidence of type 2 diabetes with lifestyle intervention or metformin. N Engl J Med346:393-403

slide14

Incidence of Diabetes

Placebo (n=1082)

Metformin (n=1073, p<0.001 vs. Placebo)

Lifestyle (n=1079, p<0.001 vs. Metformin ,

p<0.001 vs. Placebo)

Risk reduction

31% by metformin

58% by lifestyle

The DPP Research Group, NEJM 346:393-403, 2002

physical activity behaviour
80% people with type 2 diabetes

remain inactive

Greater proportion than general population

More attempts to exercise but greater frequency of exercise relapse

Barriers

Physical discomfort, too overweight, lack of support, fear of having a hypo, complications of diabetes

Physical activity behaviour

The majority of cited barriers to physical activity can be overcome with appropriate guidance

physical activity behaviour1
Physical activity behaviour

Factors associated with poor physical activity

behaviour in Type 2 diabetes

  • Lower self-efficacy for physical activity than other aspects of diabetes management
  • Lower belief in the effectiveness of physical activity than other aspects of diabetes care
  • Low motivation and increased perceived barriers to participate in physical activity
  • Less social support for engaging in physical activity than other aspects of diabetes care

Kirk, A.F., Barnett, J., Mutrie, N. (2007) Physical activity consultation for people with Type 2 diabetes. Evidence and guidelines.

Diabetic Medicine, 24, 809-816.

the challenge of inactivity
The Challenge of Inactivity

We know

  • A lot about the NEED to increase activity in people with or at risk of Type 2 diabetes
  • That only a minority achieve current physical activity guidelines for improving/maintaining health
  • In general there is limited resources (time, staff, money) for physical activity promotion in diabetes care

We don’t know

  • How to increase physical activity in people with Type 2 diabetes
  • Limited research/guidelines indicating best methods to use
physical activity consultation
Physical activity consultation

Effective interventions use cognitive

behavioural strategies rather than

health education, exercise prescriptions,

or instruction alone

One Approach: Physical Activity Consultation

  • A 20-30 minute one-to-one discussion with an individual
  • Often incorporates evidence based strategies to promote and maintain physical activity
  • Semi-structured approach that encourages patients to take responsibility for changing their behaviour
physical activity consultation1

Pre-contemplation

Not active, no intentions

Contemplation

Not active, intentions

Preparation

Some activity, not enough

Relapse

Progress

Action

Just started last 6 months

Maintenance

Active longer 6 months

Physical Activity Consultation

Often based on the Transtheoretical Model of behaviour change, which has strong support for its application in physical activity promotion

STAGES OF CHANGE

(Prochaska, 1983)

physical activity consultation2

STAGES OF CHANGE

Pre-contemplation

Contemplation

Preparation

Action

Maintenance

HOW WE CHANGE

10 Processes of Change

Decisional Balance

Self-efficacy

Physical activity consultation

Transtheoretical Model

Kirk A, Barnett J, Mutrie N (2007). Physical activity consultation for people with Type 2 diabetes. Evidence and guidelines. Diabetic Medicine24: 809-816

slide22

Transtheoretical Model

Appropriate Strategies

Pre-contemplation

Not active, no intentions

  • Information on the

risks/benefits of activity

  • Decisional Balance
  • Discuss/overcome barriers

Contemplation

Not active, intentions

Preparation

Some activity, not enough

  • Develop realistic goals
  • Establish support
  • Revisit successful attempts
  • Re-emphasize benefits
  • Overcome potential barriers

Action

Just started last 6 months

Maintenance

Active longer 6 months

  • Relapse Prevention
  • Alternative activities
physical activity consultation3
Physical activity consultation

Semi-Structured

Content of a consultation

1. Assess Stage of Change

2. Physical activity recommendations

3. Why be more active?

4. Decisional Balance

5. Overcoming barriers

6. Assess current physical activity level

7. Identify opportunities & goal setting

8. Planning

9. Finding Support

10. Relapse Prevention

Kirk A, Barnett J, Mutrie N (2007). Physical activity consultation for people with Type 2 diabetes: Evidence and guidelines.

Diabetic Medicine24: 809-816

Adapted to needs of the individual

Delivered by any member of a diabetes care team

current research time2act
Current Research-Time2Act

Randomised controlled trial (Kirk et al 2003, 2004, 2004)

  • Primary aim
    • Investigate the effectiveness of a person and written delivered intervention, based on the transtheoretical model, to promote physical activity over 6 & 12 months
  • Secondary aim
    • To evaluate the resultant effect on physiological, biochemical & quality of life variables
  • Additional analysis
  • The cost effectiveness of each intervention
slide26

1) Person delivered intervention

2) Written self instructional intervention

3) Standard exercise information

134 participants

Outcome measures

Physical activity behaviour: Physical activity levels (accelerometer), components of TTM, 7-day physical activity recall interview, Environmental questionnaire

Physiological: Blood pressure, BMI, waist & hip ratio, exercise capacity

Psychological: SF-12, Well being & Subjective vitality questionnaires, Positive and Negative Affect Schedule

Biochemical: HbA1c, lipid profile, medication

6 month assessment

Repeat all outcome measure

1) Person delivered intervention

2) Written self instructional intervention

3) Standard exercise information

12 month assessment

Repeat all outcome measures

current research time2act1
Current Research-Time2Act

Baseline

Tailored to contemplation & preparation stage of change

Also includes:

*Pedometer

*Walking plan

*Diabetes information

*Local PA opportunities

6 monthsStage matched to those who progressed or stayed the same/relapsed

initial data from qualitative analysis
Initial data fromqualitative analysis

Gannon M, Kirk A

Supported by Nuffield Foundation

Aim:To investigate study participant’s view of the Time 2

ACT intervention material

Methods:

  • 4 focus groups & 6 interviews (n=28)
  • Discussion guided by topic guides
  • Transcribed, coded and analysed
  • Conducted by independent researchers
key findings so far
Key findings so far…
  • Previous advice on physical activity was limited

“I was given a lot of info about diet, but none on exercise”

  • Intervention components
    • Pedometers & workbooks useful

“I found the pedometer very useful because some days I thought I’d had a really busy day you know with the housework and gardening and I’d only clocked up about 1000 steps. And that actually shocked me”

“I did go over it quite a few times and then I found the more I got into it, I enjoyed filling out the sheets and so on and I felt that helped me”

    • Support phone calls helpful

“It reminded you that you had to do it”

  • Intervention delivery
    • Majority felt person delivered intervention allowed for clarification, tailored

prescription & greater supportive

“I keep hearing Jodi\'s voice ‘keep going, keep going it’s the only way it’s going to get better’ and it has, it’s improved dramatically”

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