Preparazione efficace all'autogestione del diabete mellito.

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  


Messaggi chiave: 
I pazienti con diabete di tipo 2 di tre centri ambulatoriali di diabetologia sottoposti a un intervento comportamentale durato 3 anni hanno aumentato il volume di attività fisica e il tempo trascorso in attività di intensità leggera e moderata-intensa, inoltre hanno ridotto il comportamento sedentario. Il miglioramento si è mantenuto nel tempo, a parte che per il tempo trascorso in attività moderata-intensa, per cui si è osservata una flessione negativa al terzo anno.

Descrizione dello studio: Lo studio Italian Diabetes and Exercise Study 2 (IDES_2) ha arruolato, presso 3 centri ambulatoriali di diabetologia di Roma, 300 pazienti (età 40-80 anni) con diabete di tipo 2, che non raggiungevano i livelli di attività fisica minimi raccomandati e passavano più di 8 ore seduti o sdraiati. I pazienti sono stati randomizzati (1:1; stratificazione per: centro, età, terapia antidiabete): un gruppo ha ricevuto l’intervento comportamentale, l’altro gruppo le cure standard, per 3 anni.
I partecipanti del gruppo di intervento hanno ricevuto una sessione teorica di counseling individuale iniziale e 8 sessioni bisettimanali teoriche e pratiche di counseling individuale ogni anno. I co-endpoint primari erano le variazioni in: volume di attività fisica, tempo speso in attività fisica leggera e moderata-intensa, sedentarietà (misurati con un accelerometro). Il valutatore non era a conoscenza del gruppo a cui apparteneva il paziente. Fonte di finanziamento: Metabolic Fitness Association, Monterotondo (Roma).

Risultati principali: Hanno completato lo studio 267 pazienti (133 nel gruppo di intervento e 134 nel gruppo controllo). I partecipanti del gruppo di intervento hanno migliorato significativamente tutti i parametri:
- volume di attività fisica: 13,8 contro 10,5 equivalenti metabolici ore/settimana (+3,3; IC95% 2,2-4,4; P<0,001);
- attività fisica moderata-intensa: 18,9 contro 12,5 minuti/giorno (+6,4; 5,0-7,8; P<0,001); 
- attività fisica leggera: 4,6 contro 3,8 ore/giorno (+0,8; 0,5-1,1; P<0,001); 

- tempo sedentario: 10,9 contro 11,7 ore/giorno (-0,8; da -1,0 a -0,5; P<0,001).
Le differenze sono state mantenute nel tempo, anche se nel terzo anno la variazione nell’attività fisica di intensità moderata-intensa è scesa a 3,6 minuti/giorno. Al di fuori delle sessioni di counseling si sono verificati eventi avversi in 41 pazienti del gruppo di intervento e in 59 pazienti del gruppo controllo. Durante le sessioni di counseling si sono verificati eventi avversi in 30 pazienti (principalmente danni muscoloscheletrici/malessere e lieve ipoglicemia).

Limiti dello studio: I risultati potrebbero non essere generalizzabili; lo studio non ha preso in analisi l’alimentazione.

Perché è importante: I pazienti con diabete di tipo 2 spesso non raggiungono il livello di attività fisica minimo raccomandato e sono sedentari. La maggior parte degli studi basati sul counseling disponibili erano durati al massimo 12 mesi e si basavano su misure auto-dichiarate. Questo intervento comportamentale ha avuto successo nell’aumentare l’attività fisica e nel promuovere il passaggio dalla sedentarietà all’attività fisica leggera e, in misura minore, a quella moderata-intensa.        

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.