Increasing exercise levels in patients with Type 2 diabetes: the how and the why.

Dr Rob Andrews Consultant Senior lecturer

University of Bristol / Taunton NHS trust

NHSTaunton and Somerset NHS foundation trust

Current suggested pathway

At diagnosis: Metformin + lifestyle

Lifestyle+ metformin

+ basal insulin

Step 1

Lifestyle+ metformin

+ Sulph

Lifestyle+ metformin

+ Pio

Step 2

Lifestyle+ metformin

+ GLP-1 agonist

Step 3

Lifestyle+ metformin

+ intensive insulin

Lifestyle+ metformin

+ Pio+ Sulp

Lifestyle+ metformin+bas insulin

Well validated Less validated

Number of people on glucose lowering agents

None

One

Two

three

207 41529 1

237 (36%)

Average time taken to start tablets

Metformin Gliclizide Glitizone

Weeks

fro

m D

iag

nosi

s 66% people had tablet started Within week of diagnosis

Overview

• Why lifestyle advice?

• What do clinical trials show us can be

achieved?

• What can we do?

• How do we encourage activity?

• How do we encourage lifestyle change?

• Where do drugs and surgery come in?

Physiologically makes sense

ExerciseMetabolic rate

Food EnvironmentGenes

Makes sense

135 125 115 105 95 85 75

0

500

1000

1500

2000

2500

3000

Weight (Kg)

Cal

orie

s

Calories to lose weight

Calories needed

Calories lost in urine

Fitness predicts outcomes

• Predicts risk of CVD1

• Is associated with complication. The less fit you are the greater the risk2

1Seyoum et al. Diab Vasc Dis Res.2006; 3: 197-202Estacio R et al Diabetes Care. 1998 Feb;21(2):291-

5

Activity of patients

% people reaching Guidelines

Morrato et al 2003

ACTID Senior Doctors

Junior Doctors

0102030405060708090

What do clinical trials say is possible?

“Running a red light does not count.You still need to get more exercise.”

Structured exercise programs

Umpierre, D. et al. JAMA 2011;305:1790-1799Copyright restrictions may apply.

-0.73

-0.57

-0.51

Physical activity advice

Umpierre, D. et al. JAMA 2011;305:1790-1799Copyright restrictions may apply.

-0.58

-0.16

Summary 1

Diet + ActivityDiet + ActivityDiet + ActivityDiet + ActivityDiet + ActivityDiet + ActivityDiet + Activity

What can we do in clinic?

Healthcare workers

• Agree what you are

going to target

• Use material

already shown to

be of benefit – DPP

• Give consistent

message

• Use all time

available

Motivational interviewing

• Shown to be very effective at increasing activity.– 4 RCTs – 1 of which had 340 patients

T2DM*

• After training , relatively inexpensive

• As effective as more intense therapies

*Di Loreto C et al, Diabetes Care 2003; 26: 404–408.

Identifying patients

One question• What is your

walking speed?

Two questions* • Job• Activity

*Taylor-piliae et al Am J Epidemiol. 2006 Sep 15;164(6):598-606

Brief Physical Activity questionnaire

F G H I J

A Inactive Light Moderate High Very high

B Light Light Moderate High Very high

C Light Light Moderate High Very high

D Moderate Moderate High High Very high

E High High Very high Very high Very high

Job

Act

ivit

y

Leisure Activity

Taylor-piliae et al Am J Epidemiol. 2006 Sep 15;164(6):598-606

Who to target - Stage of change

Do you exercise regularly?• Yes, I have been for MORE than 6 months.

• Yes, I have been for LESS than 6 months.

• No, but I intend to in the next 30 days.

• No, but I intend to in the next 6 months.

• No, and I do NOT intend to in the next 6 months.

✔

✔

✔✔

✖

✖✖

Comparison of different technique to increase activity

0

4

8

12

16

Gym based Supervisedwalking

Advice and info

Net

% in

crease

In p

eop

le g

oin

g >

15

0 m

in/w

k

943 patientsImprovement seen in:

- BP- Lipid profile- Wellbeing- Muscle strength

Isaac AJ et al Health Technol Assess. 2007 Mar;11(10):1-165, iii-iv.

How do we do it? - exercise

What fits your busy schedule better, exercising one hour per day or being dead 24 hours a day

Motivate

Benefits of exercise

Comprehension – understand the benefit to them

Help patients design the program

• Should set small targets that they can achieve

• Increase by 500-1000 steps per week

• 64% of targets set are too demanding

Pleasurable exercise

Ensure support in place

• The more contact more active the patient will become.

• Exercising in group or with family member more likely to be successful

Help patient overcome barriers

“You’ll probably find this considerably more Strenuous than other treadmill tests you’ve taken”

Record activity

Activity across the study

0 6 12 Months

Min

ute

s of

modera

te a

ctiv

ity

Usual

Diet

Diet + act

-4

-2

0

2

4

6

8

10

12

Alternative – target sitting time

1 2 3 498

100

102

104

106

108

110

112

Wais

t ci

rcu

mfe

ren

ce

Quartiles of sedentary time (least to most)

How - exercise

• Motivation – explain benefits of exercise

• Comprehension – ensure understands benefits

• Self-efficacy – help patient design program

• Pleasure – identify pleasurable exercises

• Support – groups or family

• Lack of impediments – help overcome barriers

• Diary – ask patient to record activity

How do we do it? - diet

“I think diabetes is affecting my eyesight I have trouble seeing the consequences of

poor food choices”

Desmond Intervention Control P value

HbA1c -1.49 -1.21 0.52

Wt (kg) -2.98 -1.86 0.027*

Cholesterol -0.95 -0.94 0.70

Waist circum

-2.85 -2.79 0.61

Systolic BP -6.12 -6.24 0.93

Diastolic BP

-4.17 -3.43 0.85

Smoking -3 0 0.03*

Davies et al BMJ. 2008 Feb 14; [Epub ahead of print]

Look ahead study

5,145 randomised(56.9% of those screened)

2,570 Intensive lifestyle intervention

Weekly behavioral groupCalorie controlled diet with meal replacement

Home based exercise programmeOrlistat after 6/12 if needed

2463 DM support & education

3 group sessions in year

Look ahead. Diabetes Care. 2007 Jun;30(6):1374-83

Weight loss

0 0.5 1 1.5 2 2.5 3 3.5 4-10

-9

-8

-7

-6

-5

-4

-3

-2

-1

0

ILIDSE

Time (years)

Perc

en

tag

e W

eig

ht

loss

Wing RR, Arch Intern Med. 2010 Sep 27;170(17):1566-75.

P<0.001

Weight loss

>5% >0% >0% >5% >7% >10% > 15%0

10

20

30

40

50

60

70

80

ILIDSE

Perc

enta

ge

Weight gain Weight loss

Wing RR, Arch Intern Med. 2010 Sep 27;170(17):1566-75.

Predictors of weight loss - contactN

um

ber

of

conta

cts

per

year

Chang in weight

>10 % loss 5-9.9% loss 0-4.9% loss Gained0

5

10

15

20

25

30

Wadden TA et al, Obesity. 2011 Oct;19(10):1987-98

Predictors of weight loss - calories

>10 % loss 5-9.9% loss 0-4.9% loss Gained 0

200

400

600

800

1000

1200

1400

1600

1800

2000

Num

ber

of

calo

ries

per

day

Wadden TA et al, Obesity. 2011 Oct;19(10):1987-98

Results: changes to nutrients

Men (blue) reduced energy by 218±332kcal (p<0.001)

Women (pink) reduced energy by 123±270kcal (p<0.001)

Changes in mean energy intakes from food groups: men (n=175)

England et al 2013 in press

Changes in mean energy intakes from food groups: women (n=87)

England et al 2013 in press

Changes in weight across study

0 6 12 Months

Ch

an

ge in

weig

ht

(kg

)

Usual

Diet

Diet + act

-3

-2.5

-2

-1.5

-1

-0.5

0

0.5

Top tips for losing WT

• Aim for 200 calorie reduction –

picking something they will change

• Eat regularly – in particular breakfast

• Reduce take away food

• Weigh self at least 2 times per week

• Increase activity levels

How - diet

• Education – needs to understand

• Motivation – explain benefits of improving diet

• Comprehension – ensure understands benefits

• Self-efficacy – help patient choose changes

• Support –family need to buy into changes

• Lack of impediments – help overcome barriers

• Diary – ask patient to record food intake and weigh

regularly

Role of lifestyle in other interventions

Treatments

Treatment 27-29.9 30-34.9 35-39.9 >40

Diet, Exercise, Behavior Tx + + + +

Pharmaco-therapy + + +

SurgeryWith co-

morbidities +

BMI Category (kg/m2)

Drug therapy

Wadden TA et al N Engl J Med 353 (2005), pp. 2111

Bariatric surgery

0

20

40

60

80

100

>5 %gain

0-5%gain

0-5%loss

5-10%loss

>10%loss

% p

eop

le r

each

ing

70

%

Loss

of

exc

ess

bod

y w

eig

ht

Still CD et al Arch Surg 2007:142 (10);994

Why lifestyle advice?

Diet and Exercise

Drugs

Surgery

At the moment there is no miracle

Diabetes control

0 6 12 Months

Chan

ge in

HbA

1c

%

Usual

Diet

Diet + act

-0.2

-0.1

0

0.1

0.2

6 months Difference P value

D vs D + A -0.05 0.56

D vs U -0.28 0.002

D + A vs U -0.33 <0.0001

12 months Difference P value

D vs D +A -0.08 0.6

D vs U -0.26 0.005

D +A vs U -0.33 <0.0001

Changes in diabetes medication

0 6 12 Months

% c

han

ge in

DM

med

icati

on

Usual

Diet

Diet + act

-2

0

2

4

6

8

10

12