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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


  • Natural history of type 2 diabetes
    Natural history of type 2 diabetes


    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


    Promoting physical activity in type 2 diabetes time 2 act study

    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


    Promoting physical activity in type 2 diabetes time 2 act study

    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


    Promoting physical activity in type 2 diabetes time 2 act study

    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”