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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. Type 2 diabetes

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

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  1. 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

  2. Overview • Type 2 diabetes • Benefits of physical activity in type 2 diabetes • Promoting physical activity in type 2 diabetes • Time 2 Act Study

  3. 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

  4. Natural history of type 2 diabetes

  5. 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)

  6. Prevalence of type 2 diabetes

  7. 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”

  8. 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.

  9. 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….

  10. 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

  11. 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

  12. 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

  13. 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

  14. 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

  15. 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

  16. 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.

  17. 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

  18. 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

  19. 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)

  20. 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

  21. 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

  22. 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

  23. Physical activity consultation in type 2 diabetes

  24. 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

  25. 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

  26. 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

  27. 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

  28. 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”

  29. Thank you for your attention

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