Effective education for diabetes self-management

Effect of a Behavioral Intervention Strategy on Sustained Change in Physical Activity and Sedentary Behavior in Patients With Type 2 Diabetes.

The IDES_2 Randomized Clinical Trial


Stefano Balducci, MD; Valeria D’Errico, MD; Jonida Haxhi, MD, PhD et al.

JAMA. 2019; 321(9): 880-890. doi:10.1001/jama.2019.0922

 

Abstract

Importance: There is no definitive evidence that changes in physical activity/sedentary behavior can be maintained long term in individuals with type 2 diabetes.

Objective: To investigate whether a behavioral intervention strategy can produce a sustained increase in physical activity and reduction in sedentary time among individuals with type 2 diabetes.

Design, setting and participants: The Italian Diabetes and Exercise Study 2 was an open-label, assessor blinded, randomized clinical superiority trial, with recruitment from October 2012 to February 2014 and follow-up until February 2017. In 3 outpatient diabetes clinics in Rome, 300 physically inactive and sedentary patients with type 2 diabetes were randomized 1:1 (stratified by center, age, and diabetes treatment) to receive a behavioral intervention or standard care for 3 years.

InterventionsAll participants received usual care targeted to meet American Diabetes Association guideline recommendations. Participants in the behavioral intervention group (n = 150) received 1 individual theoretical counseling session and 8 individual biweekly theoretical and practical counseling sessions each year. Participants in the standard care group (n = 150) received only general physician recommendations.

Main outcomes and measures: Co-primary end pointswere sustained change in physical activity volume, time spent in light-intensity and moderate- to vigorous-intensity physical activity, and sedentary time, measured by an accelerometer. 

Results: Of the 300 randomized participants (mean [SD] age, 61.6 [8.5] years; 116 women [38.7%]), 267 completed the study (133 in the behavioral intervention group and 134 in the standard care group). Median follow-up was 3.0 years. Participants in the behavioral intervention and standard care groups accumulated, respectively, 13.8 vs 10.5 metabolic equivalent-h/wk of physical activity volume (difference, 3.3 [95%CI, 2.2-4.4]; P < .001), 18.9 vs 12.5 min/d of moderate- to vigorous-intensity physical activity (difference, 6.4 [95%CI, 5.0-7.8]; P < .001), 4.6 vs 3.8 h/d of light-intensity physical activity (difference, 0.8 [95%CI, 0.5-1.1]; P < .001), and 10.9 vs 11.7 h/d of sedentary time (difference, −0.8 [95%CI, −1.0 to −0.5]; P < .001). Significant between-group differences were maintained throughout the study, but the between-group difference in moderate- to vigorous-intensity physical activity decreased during the third year from 6.5 to 3.6 min/d. There were 41 adverse events in the behavioral intervention group and 59 in the standard care group outside of the sessions; participants in the behavioral intervention group experienced 30 adverse events during the sessions (most commonly musculoskeletal injury/discomfort and mild hypoglycemia).

Conclusions and relevance: Among patients with type 2 diabetes at 3 diabetes clinics in Rome who were followed up for 3 years, a behavioral intervention strategy compared with standard care resulted in a sustained increase in physical activity and decrease in sedentary time. Further research is needed to assess the generalizability of these findings.        

Review Article: A practical framework for encouraging and supporting positive behaviour change in diabetes

Fisher L, Polonsky WH, Hessler D, and Potter MB.

Diabet. Med. 34, 1658–1666 (2017)

 

Abstract

A wide range of diabetes-directed interventions – including novel medications, devices and comprehensive education programmes – have been shown to be effective in clinical trials. But in the real world of diabetes care their efficacy is often dependent upon on how well a clinician is able to support personal engagement and motivation of the person with diabetes to use these new tools and knowledge consistently, and as directed. Although many person-centred motivational and behavioural strategies have been developed, for example, action planning, motivational interviewing and empowerment-based communication, the sheer number and apparent lack of clear differences among them have led to considerable confusion. The primary goal of this review, therefore, is to provide a practical framework that organizes and structures these programmes to enhance their more systematic use in clinical care. Its purpose is to enhance clinician efforts to respectfully encourage and support engagement and motivation for behaviour change in people with diabetes. The three-step framework for organizing and describing the specific clinical processes involved is based on self-determination theory and includes: clinician preparation for a different type of clinical encounter, clinician/person with diabetes relationship building, and clinician utilization of specific behavioural tools. We conclude with practical considerations for application of this framework to the real world of clinical care.        

Original Article: An innovative school-based intervention to promote healthy lifestyles

Natalia Piana, Claudia Ranucci, Livia Buratta, et al.

Health Education Journal, 1-10. (2017)

 

Abstract

Objective: To describe an innovative school-based intervention to promote a healthy lifestyle. To evaluate its effects on children’s food habits and to highlight the key components which contribute most to the beneficial effects obtained from children’s, teachers’ and parents’ perspectives.

Design: An educational tool to improve personal awareness, promote healthy food choices and increase children’s levels of physical activity was developed and evaluated. The tool used a community-based approach and included family members, schools, university, families, sports societies, farms, mass media and municipalities. Setting: a total of 11 primary school classes in five schools in Spoleto, Umbria.

Methods: The tool dealt with healthy food choices, lifestyle and physical activities and is structured in four phases (4 months). The Kidmed test (a validated index based on principles sustaining Mediterranean dietary patterns as well as those that undermine them) and open-ended questionnaires (to highlight the key components which contributed most to the beneficial effects) were used to assess the effectiveness of the intervention. Kidmed scores were evaluated both before and after intervention (T0–T1) and the written answers collected (from teachers, parents and children) were subjected to content analysis using a form of grounded theory.

Results: Data point to a significant before/after increase on Kidmed scores (t = −3.88; p = .000), revealing an increase in children’s adherence to the Mediterranean Diet, healthy habit changes, greater parental awareness of their educational responsibilities regarding food choices as well as physical activity, and a new school-family alliance as a result of the educational intervention. 

Conclusion: Project findings reveal positive effects on children’s food habits and highlight key components necessary to enhance the effectiveness of a school-based educational intervention. 

Multidisciplinary lifestyle intervention in the obese: Its impact on patients’ perception of the disease, food and physical exercise

N. Piana, D. Battistini, L. Urbani, et al.

Nutrition, Metabolism & Cardiovascular Diseases (2012), doi:10.1016/j.numecd.2011.12.008

 

Abstract

Background and aims: To be successful, lifestyle intervention in obesity must take into account patients’ views. The aim of the present study, conducted using a narrative autobiographical approach, was to report on the perception of disease, food and physical exercise in a group of 80 obese patients during a structured multidisciplinary lifestyle intervention.

Methods and Results: Patients underwent lifestyle intervention, of three months’ duration, structured in the following steps: 1) an initial medical examination; 2) an interview by a psychologist; 3) an assessment by a dietician, 4) a physical examination by a specialist in sports medicine; 5) an individualized program consisting of 24 sessions (two per week) of structured indoor exercise 6) eight sessions of group therapeutic education; 7) Nordic walking activity combined with walking excursions during weekends. All the narrative autobiographic texts obtained during the lifestyle intervention were submitted for content analysis; data were analysed according to the ‘‘grounded theory’’ method. According to patients’ descriptions at the end of the intervention, lifestyle intervention resulted in enhanced self-efficacy and a reduction in their dependency on food and people; their fear of change was also diminished because, by undergoing intervention, they had experienced change.

Conclusion: The findings made in the present qualitative analysis suggest that whenever multidisciplinary lifestyle intervention is planned for patients with obesity, it is of the utmost importance to tailor the approach while taking the following key aspects into account: motivation, barriers and/or facilitators in lifestyle change, patients’ perceptions of obesity and relationship with food, diet and exercise.