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


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

Promoting physical activity in type 2
diabetesTime 2 Act Study
  • Jodi Barnett
  • Time 2 ACT Project Manager
  • University of Dundee

Dr. Alison Kirk Sports Biomedicine Lecturer
Time 2 ACT Principal Investigator University of
  • 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?
  • A condition where the amount of glucose (sugar)
    in the
  • blood is too high because the body cannot use it
  • Two causes
  • Insulin produced doesnt work properly insulin
  • The body does not make enough insulin
  • Features of the metabolic syndrome (25 of
  • 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

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 diabetes
  • Accounts for between 85 to 95 of all people
    with diabetes
  • Risk Factors
  • Overweight/Obesity (present ingt75 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,
  • National Centre for Health Statistics National
    Vital Statistics Reports (1980-2006)

Prevalence of type 2 diabetes
2006 in the UK  
Country Prevalence Number of people 
England 3.60 1,891,000
Northern Ireland 3.06 55,000
Scotland 3.40 165,000
Wales 4.10 127,000
The known diagnosed population in the UK is 2.2 million people
UK average3.54
The global prevalence of type 2 diabetes is projected to increase to gt300 million by 2025
Diabetes UK Reports and Statistics. Diabetes Prevalence 2006. Published annually as part of the QOF.
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
  • gt65 of people with diabetes die from heart
  • 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
  • Microvascular complications
  • Retinopathy 80
  • Peripheral neuropathy 60
  • Nephropathy 30
  • Foot Ulcers 5
  • Common Link -- The better the blood glucose
  • the lower the risk of complications
  • A 1 drop in HBA1c, can reduce the risk of
  • complications by up to 40 (UKPDS, 2000 Brit Med
  • Type 2 Diabetes in Practice. 2nd Edition.
    A.J.Krentz, C.J.Bailey. The Royal Society of
    Medicine Press.

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
  • 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 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 lt7.0
  • Diet Exercise - decrease of 0.76 in HbA1c
  • - (ex.) 9-10 improvement to ideal level of

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
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
  • Walking is the best medicine for diabetes
  • Frank B. Hu 2003
  • Walking Reduces Mortality
  • Prospective cohort study
  • People with Type 1 Type 2 diabetes (n2,896)
  • 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. Med 163 1440-1447
Prevention of type 2 diabetes
  • Physical activity identified as important factor
    in preventing/delaying development of Type 2
  • 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 Med 346393-403
Incidence of Diabetes
Placebo (n1082)
Metformin (n1073, plt0.001 vs. Placebo)
Lifestyle (n1079, plt0.001 vs. Metformin ,
plt0.001 vs. Placebo)
Risk reduction 31 by metformin 58 by lifestyle
The DPP Research Group, NEJM 346393-403, 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

The majority of cited barriers to physical
activity can be overcome with appropriate guidance
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
  • 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
  • In general there is limited resources (time,
    staff, money) for physical activity promotion in
    diabetes care
  • We dont know
  • How to increase physical activity in people with
    Type 2 diabetes
  • Limited research/guidelines indicating best
    methods to use

(No Transcript)
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
  • Often incorporates evidence based strategies to
    promote and maintain physical activity
  • Semi-structured approach that encourages patients
    to take responsibility for changing their

Physical Activity Consultation
Often based on the Transtheoretical Model of
behaviour change, which has strong support for
its application in physical activity promotion
(Prochaska, 1983)
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
Medicine 24 809-816
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 consultation
  • 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 Medicine 24 809-816

Adapted to needs of the individual
Delivered by any member of a diabetes care team
Physical activity consultation in type 2 diabetes
Di Loreto et al. 2003 RCT N340 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 N45 3 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 N70 1 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-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
134 participants
Outcome measures Physical activity behaviour
Physical activity levels (accelerometer),
components of TTM, 7-day physical activity recall
interview, Environmental questionnaire Physiologic
al 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
2) Written self instructional intervention
3) Standard exercise information
1) Person delivered intervention
12 month assessment Repeat all outcome measures
Current Research-Time2Act
Baseline Tailored to contemplation
preparation stage of change
Also includes Pedometer Walking plan
Diabetes information Local PA opportunities
6 months Stage matched to those who progressed or
stayed the same/relapsed
Initial data fromqualitative analysis
  • Gannon M, Kirk A
  • Supported by Nuffield Foundation
  • Aim To investigate study participants view of
    the Time 2
  • ACT intervention material
  • Methods
  • 4 focus groups 6 interviews (n28)
  • Discussion guided by topic guides
  • Transcribed, coded and analysed
  • Conducted 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 Id had a really busy day you know
    with the housework and gardening and Id 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
  • 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 its the only way its going to get better
    and it has, its improved dramatically

  • Thank you for your attention