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

Jodi BarnettTime 2 ACT Project ManagerTime 2 ACT Project ManagerUniversity of DundeeUniversity of Dundee

Dr. Alison KirkSports Biomedicine Lecturer Sports Biomedicine Lecturer Time 2 ACT Principal InvestigatorTime 2 ACT Principal InvestigatorUniversity of DundeeUniversity of Dundee

OverviewOverview Type 2 diabetesType 2 diabetes Benefits of physical activity in type 2 Benefits of physical activity in type 2

diabetesdiabetes Promoting physical activity in type 2 Promoting physical activity in type 2

diabetesdiabetes Time 2 Act StudyTime 2 Act Study

What is type 2 What is type 2 diabetes?diabetes?

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

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

Two causes:1. Insulin produced doesn’t work properly ‘insulin

resistance’2. The body does not make enough insulin

Features of the “metabolic syndrome” (~25% of adults)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 Natural history of type 2 diabetestype 2 diabetes

Type 2 diabetes care: The role of insulin-sensitizing agents and practical implications for cardiovascular disease prevention. Am J

Med, 105(1A):20S-26S, 1998.

Type 2 diabetesType 2 diabetes

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

Mortality associated with diabetes has increased over the past twodecades, in contrast to declining associations with cardiovasculardisease 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)

Prevalence of type 2 Prevalence of type 2 diabetesdiabetes

Country Prevalence

Number of people 

England 3.60% 1,891,000NorthernIreland

3.06% 55,000

Scotland 3.40% 165,000Wales 4.10% 127,000

The known diagnosed

population in the UK is

2.2 million people

2006 in the UK  

UK average=3.54

%The global prevalence of type 2 diabetes is projected to

increase to >300 million by 2025Diabetes UK: Reports and Statistics. Diabetes Prevalence 2006. Published annually as part of the

QOF.

Type 2 diabetes & Type 2 diabetes & cardiovascular diseasecardiovascular 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 People with diabetes have up to a fivefoldfivefold increased risk of increased risk of CVDCVD

>65% of people with diabetes die from heart disease/stroke >65% of people with diabetes die from heart disease/stroke CHD is the CHD is the principal causeprincipal cause of premature mortality in type 2 of premature mortality in type 2

diabetesdiabetes

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

Type 2 diabetes Type 2 diabetes complicationscomplicationsMicrovascular complicationsMicrovascular complications Retinopathy ~80%Retinopathy ~80% Peripheral neuropathy ~60%Peripheral neuropathy ~60% Nephropathy ~30%Nephropathy ~30% Foot Ulcers ~5%Foot Ulcers ~5%

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

the lower the risk of complications”the lower the risk of complications”

A 1% drop in HBA1c, can reduce the risk of microvascularA 1% drop in HBA1c, can reduce the risk of microvascularcomplications by up to 40% (UKPDS, 2000 complications by up to 40% (UKPDS, 2000 Brit Med JBrit Med J))

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

Type 2 diabetes Type 2 diabetes treatmentstreatmentsLifestyle treatmentsLifestyle treatments DietDiet Physical Activity Weight control if overweight or obeseWeight control if overweight or obese

Pharmacological treatmentsPharmacological treatments Oral anti-diabetic agentsOral anti-diabetic agents InsulinInsulin Anti-hypertensives, statins, etc….Anti-hypertensives, statins, etc….

Benefits of physical Benefits of physical activityactivityPhysical activity has been shown to have favourable effects on allcomponents 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.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 Benefits of physical activityactivity

Better blood glucose controlBetter blood glucose control

1. Improved insulin sensitivity1. Improved insulin sensitivity2. Blood glucose lowering effect2. Blood glucose lowering effect

Exercise alone - decrease of 0.66% in HbAExercise alone - decrease of 0.66% in HbA1c1c - - (ex.)(ex.) 8-9% improvement8-9% improvement to ideal level of to ideal level of <7.0%<7.0%

Diet + Exercise - decrease of 0.76% in HbADiet + Exercise - decrease of 0.76% in HbA1c 1c

- - (ex.)(ex.) 9-10% improvement9-10% improvement to ideal level of <7.0% 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 Association 286(10):1218-1227

Benefits of physical Benefits of physical activityactivityAcute Benefits: Immediate improvements in blood glucose

levelsChronic Benefits: Improves cardio-respiratory fitness, body Composition,,HbA1c, lipid profiles and insulin sensitivity

““Walking is the best medicine for diabetes”Walking is the best medicine for diabetes”Frank B. Hu – 2003Frank 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%- 34% lower risk of cardiovascular mortality - 39%- 39% lower risk of all cause mortality

Gregg et al. (2003) Relationship of walking to mortality among US adults with diabetes. Arch. Intern. Med 163: 1440-1447

“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

Prevention of type 2 Prevention of type 2 diabetesdiabetes

Diabetes Prevention Programme Research Group (2002) Reduction in the incidence of type 2 diabetes with lifestyle intervention or metformin. N Engl J Med 346:393-403

0 1 2 3 4

0

10

20

30

40 Placebo (n=1082)Metformin (n=1073, p<0.001 vs. Plac)Lifestyle (n=1079, p<0.001 vs. Met , p<0.001 vs. Plac )

Percent developing diabetes

All participants

All participants

Years from randomization

Cum

ulat

ive

inci

denc

e (%

)

Placebo (n=1082)Metformin (n=1073, p<0.001 vs. Placebo)Lifestyle (n=1079, p<0.001 vs. Metformin , p<0.001 vs. Placebo)

Incidence of DiabetesIncidence of Diabetes

Risk reductionRisk reduction31% by metformin31% by metformin58% by lifestyle58% by lifestyle

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

Physical activity behaviourPhysical activity behaviour80% 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

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

Factors associated with poor physical activityFactors associated with poor physical activitybehaviour in Type 2 diabetesbehaviour in Type 2 diabetes

Lower self-efficacy for physical activity than other aspects Lower self-efficacy for physical activity than other aspects of diabetes managementof diabetes management

Lower belief in the effectiveness of physical activity than Lower belief in the effectiveness of physical activity than other aspects of diabetes careother aspects of diabetes care

Low motivation and increased perceived barriers to Low motivation and increased perceived barriers to participate in physical activityparticipate in physical activity

Less social support for engaging in physical activity than Less social support for engaging in physical activity than other aspects of diabetes careother aspects of diabetes care

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

Diabetic Medicine, 24, 809-816.Diabetic Medicine, 24, 809-816.

Physical activity Physical activity behaviourbehaviour

The Challenge of The Challenge of InactivityInactivity

We knowWe know A lot about the NEED to increase activity in people A lot about the NEED to increase activity in people

with or at risk of Type 2 diabeteswith or at risk of Type 2 diabetes That only a minority achieve current physical activity That only a minority achieve current physical activity

guidelines for improving/maintaining healthguidelines for improving/maintaining health In general there is limited resources (time, staff, In general there is limited resources (time, staff,

money) for physical activity promotion in diabetes money) for physical activity promotion in diabetes carecare

We don’t knowWe don’t know How to increase physical activity in people with Type 2 How to increase physical activity in people with Type 2

diabetesdiabetes Limited research/guidelines indicating best methods to Limited research/guidelines indicating best methods to

useuse

Physical activity Physical activity consultationconsultationEffective interventions use cognitive Effective interventions use cognitive behavioural strategies rather than behavioural strategies rather than health education, exercise prescriptions, health education, exercise prescriptions, or instruction aloneor instruction alone

One Approach: Physical Activity One Approach: Physical Activity ConsultationConsultation

A 20-30 minute one-to-one discussion with an individualA 20-30 minute one-to-one discussion with an individual Often incorporates evidence based strategies to promote Often incorporates evidence based strategies to promote

and maintain physical activityand maintain physical activity Semi-structured approach that encourages patients to Semi-structured approach that encourages patients to

take responsibility for changing their behaviourtake responsibility for changing their behaviour

Physical Activity Physical Activity ConsultationConsultation

Pre-contemplationNot active, no intentions

ContemplationNot active, intentions

PreparationSome activity, not enough

ActionJust started last 6 months

MaintenanceActive longer 6 months

ProgressRelapse

(Prochaska, 1983)(Prochaska, 1983)

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

STAGES OF CHANGE

Physical activity Physical activity consultationconsultationTranstheoretical Model

Pre-contemplation

Contemplation

Preparation

Action

Maintenance

10 Processes of Change

Decisional Balance

Self-efficacy

STAGES OF CHANGE

HOW WE CHANGE

Kirk A, Barnett J, Mutrie N (2007). Physical activity consultation for people with Type 2 diabetes. Evidence and guidelines. Diabetic Medicine 24: 809-816

Transtheoretical ModelTranstheoretical Model

Pre-contemplationNot active, no intentions

ContemplationNot active, intentions

PreparationSome activity, not enough

ActionJust started last 6 months

MaintenanceActive longer 6 months

Relapse Prevention Alternative activities

Information on the risks/benefits of activity

Appropriate StrategiesAppropriate Strategies

Decisional Balance Discuss/overcome barriers

Develop realistic goals Establish support

Revisit successful attempts Re-emphasize benefits Overcome potential barriers

Physical activity Physical activity consultationconsultation

Content of a consultationContent of a consultation1. Assess Stage of Change1. Assess Stage of Change2. Physical activity recommendations2. Physical activity recommendations3. Why be more active?3. Why be more active?4. Decisional Balance4. Decisional Balance5. Overcoming barriers5. Overcoming barriers6. Assess current physical activity level6. Assess current physical activity level7. Identify opportunities & goal setting7. Identify opportunities & goal setting8. Planning8. Planning9. Finding Support9. Finding Support10. Relapse Prevention10. Relapse PreventionKirk A, Barnett J, Mutrie N (2007). Physical activity consultation for people with Type 2 diabetes: Evidence and

guidelines.Diabetic Medicine 24: 809-816

Semi-Semi-StructuredStructured

Adapted to Adapted to needs of needs of the the individualindividual

Delivered Delivered by any by any member of member of a diabetes a diabetes care teamcare team

↓↓

Physical activity Physical activity consultation in type 2 consultation in type 2 diabetesdiabetesDi Loreto et al. 2003

RCT

N=340 2 yr

•30 min PA consultation by GP•support calls &15min outpatient appointments every 3 mon•Control group received standard-care appointment every 3 mon

↑ PA levels↓ HBA1c↓ BMI

Chun-Ja et al.2004

RCT

N=453 mon

•60 to 90 minute physical activity consultation delivered by a researcher•Support calls 2x per week

↑ PA levels↓ HBA1c↑ Stage

Kirk et al. 2004

RCT

N=701 yr

•30min PA consultation delivered by researcher at start & 6 mon•support calls at 1 and 3 months after consultation •control group received standard exercise leaflet

↑ PA levels↓ HBA1c↓ Sys BP↓ Chol↑ Stage

Current Research-Current Research-Time2ActTime2Act

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 aimTo evaluate the resultant effect on physiological, biochemical & quality of life variables

Additional analysis The cost effectiveness of each intervention

6 month assessmentRepeat all outcome measure

134 participants

Outcome measures Physical activity behaviour: Physical activity levels (accelerometer), components of TTM, 7-day physical activity recall interview, Environmental questionnairePhysiological: Blood pressure, BMI, waist & hip ratio, exercise capacityPsychological: SF-12, Well being & Subjective vitality questionnaires, Positive and Negative Affect ScheduleBiochemical: HbA1c, lipid profile, medication

2) Written self instructional intervention

3) Standard exercise information

1) Person delivered intervention

12 month assessmentRepeat all outcome measures

2) Written self instructional intervention

3) Standard exercise information

1) Person delivered intervention

Baseline Baseline Tailored to Tailored to contemplation contemplation & preparation & preparation stage of stage of changechange

6 months6 months Stage matched Stage matched to those who to those who progressed or progressed or stayed the stayed the same/relapsedsame/relapsed

Current Research-Current Research-Time2ActTime2Act

↓↓

Also includes:Also includes: *Pedometer*Pedometer *Walking plan*Walking plan *Diabetes information*Diabetes information *Local PA opportunities*Local PA opportunities

Initial data fromInitial data fromqualitative analysisqualitative analysis

Gannon M, Kirk AGannon M, Kirk ASupported by Supported by Nuffield FoundationNuffield Foundation

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

ACT intervention materialACT intervention material

Methods:Methods: 4 focus groups & 6 interviews (n=28) 4 focus groups & 6 interviews (n=28) Discussion guided by topic guides Discussion guided by topic guides Transcribed, coded and analysedTranscribed, coded and analysed Conducted by independent researchersConducted by independent researchers

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 helpfulSupport phone calls helpful“It reminded you that you had to do it”

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

tailoredtailored prescription & greater supportiveprescription & 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”

Thank you for your attentionThank you for your attention