Development, implementation and evaluation of a daily physical activity intervention for individuals with Type 2 diabetes

Abstract

The ultimate aim of this project was to develop an effective and acceptable physical activity intervention for individuals with Type 2 diabetes that was also feasible for diabetes educators to deliver. A program theory, formulated from published literature and in collaboration with diabetes educators and individuals with Type 2 diabetes, was used to drive the program design as well as the evaluation of this pilot intervention.

The primary confusion in the literature is a result of: 1) the misuse and/or preferential uses of the terms exercise or physical activity; and, 2) the difficulty in measuring physical activity. Physical activity can be a complex pattern of behaviour reflecting both the daily demands of unique individual life situations and intentional, or elective, activities. At its most complex levels, dimensions of physical activity volume include frequency, intensity, duration and type. Guidelines for increasing physical activity in general populations and in individuals with Type 2 diabetes are a reflection of this confusion and diabetes educators are frustrated about how to best counsel their clients. Individuals with Type 2 diabetes re typically sedentary and have difficulty adhering to structured exercise guidelines. The demands of diabetes self-management preclude such a complex prescriptive approach to increasing physical activity. Individuals with Type 2 diabetes want an acceptable and effective program.

The First Step Program is an 8-week program designed to incrementally increase physical activity levels in sedentary individuals with Type 2 diabetes. The program is divided into two distinct phases directed at adoption and adherence, respectively. The adoption phase consists of four weekly education and counseling meetings (in a group or face-to-face setting), combined with individual goal-setting and self-monitoring using a pedometer for feedback. The adherence phase occurs over a subsequent 4-week period with continued individual self-monitoring using a pedometer and reduced professional contact.

The formative evaluation (including qualitative methods) of the pilot program supported the acceptability of the First Step Program (to both educators and clients), especially with regards to self-monitoring using a pedometer in combination with an activity calendar. In contrast, follow-up contact via telephone was inefficient and unacceptable (to both stakeholder groups). The primary recruitment issue that emerged was determining who was sedentary. A number of self-report methods were evaluated and discarded as unacceptable. Recommendations for using baseline pedometer results to classify sedentarism, although not practiced in the pilot program, is currently being evaluated in a randomised controlled trial of the First Step Program.

In terms of the primary intended outcome (physical activity defined as steps/day), the summative, or impact evaluation showed dramatic results over four months. The pilot sample consisted of 9 sedentary individuals (3 males, 6 females; average age 53+-6 years) with Type 2 diabetes. Physical activity increased significantly from baseline (T1) and remained elevated for the duration of the study period (p<0.05). At T1, subjects averaged (+-SD) 6,342+-2,244 steps/day. After one month of programming (T2), subjects significantly increased their steps/day: 10,115+-3407. After a second month of individual daily activity (T3), activity levels did not differ from T2 but remained elevated from T1 (8,939+-2760). At 2 months post-intervention (T4), daily physical activity remained elevated from T1 (8,830+-2772) and did not differ from the other time points. This increase from baseline translates into an extra 22.6 minutes of walking a day for this population. Improvements in other outcomes (blood pressure, waist girth, cardiorespiratory fitness) support a valid change in physical activity. Although preliminary, these promising results provide support for further evaluation directed towards dissemination.