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Implementing lifestyle changes in diabetes

Karen Jones
Locality Lead
Diabetes Specialist Nurse
Northumbria Healthcare Trust

Type 2 diabetes accounts for 90% of the 2.5 million people in the UK diagnosed with the condition, and 80% of people with this type of diabetes are overweight.1

The treatment for type 2 diabetes follows a stepwise approach. Patients should be offered three months of lifestyle changes before commencing oral medication for their diabetes (unless very symptomatic at diagnosis). Changes such as introducing a balanced diet and exercise should be explored before each step to ensure that the person is continuing with this before adding to or increasing medication for diabetes.

Two studies have shown that increasing physical activity can even prevent diabetes from occurring in people with impaired glucose tolerance by 58% so it is an effective treatment.2,3

In one study, increased physical activity was more effective than metformin in preventing diabetes (58% vs 31%).3

Therefore, physical activity should be used as a treatment for impaired glucose tolerance to prevent diabetes from occurring rather than being introduced when the person is first diagnosed. This requires screening people for impaired glucose tolerance rather than diabetes.

A systematic review of studies that involved structured exercise interventions in clinical trials with people with type 2 diabetes showed that HbA1c was significantly lower in the exercise groups compared to the control groups with a mean difference of 7.65 vs 8.31% HbA1c.4 This reduction in HbA1c was independent of any effect on body weight. No mention was made of dietary changes in these studies, so the evidence was purely on activity increase. If dietary changes had also been investigated there may have been more of an impact on reduction in body weight.

The UK government recommends that adults undertake 30 minutes of moderate intensity physical activity, five days a week (this activity can be divided into three lots of 10 minutes), but it has been reported that only a third of men and a quarter of women are achieving this.1 In the USA, only 20–40% of the general adult population achieve this, and less people with diabetes achieve this (although a figure was not quoted). Only 23% of older adults with diabetes undertake more than 60 minutes of activity per week, which is less than that recommended by the British government.5 Moderate-level activity is any form of activity that raises your pulse and makes you slightly short of breath – if you are walking and can hold a conversation without catching your breath between words, your activity level is not great enough. Some examples of activity that equate to 30 minutes of moderate activity can be seen in Box 1.

[[Box 1 diabetes2]]

Reasons for not exercising
So why don't people undertake exercise? One study highlighted that people with diabetes gave several reasons for not undertaking activity: 67.3% cited symptoms; 50.8% cited lack of motivation; but the majority cited the environment (82.7%).5 This seems to indicate that supporting patients and providing a safe environment would enable the majority of people to undertake activity.

Walking groups and exercise on prescription are two examples of programmes that may help people feel better able to undertake activity in a safe, controlled environment. When encouraging people to increase their activity, explore options such as these with them; do you know of a local walking group or could you start one?

It is important to know what is available in your area. Rather than just suggesting walking, if you are able to point people in the direction of a walking group, they may be more likely to take up the activity. If you have personal experience of the group to reassure them that it is safe, in an enjoyable environment, this will also encourage people.

Social support is important and it is worth exploring whether the person has a family member or friend whom they could undertake the activity with. Sometimes, undertaking activity with someone else is a great motivator as you feel that you are going to let the other person down if you do not attend the activity.

Educating patients about the effects of activity and how it will help lower blood glucose levels, which, in turn, will reduce the number of symptoms they experience from hyperglycaemia, will also encourage people to undertake activity more frequently.

Patients should be informed that being symptomatic of raised blood glucose levels does not necessarily prohibit them from commencing gentle activity. As long as the patient feels well, has no urinary ketones (unlikely to occur in type 2 diabetes) and is not dehydrated, they are able to undertake activity. In any structured education programme for people with type 2 diabetes, the importance and benefits of activity should be emphasised.

Motivation to undertake activity
Before discussing activity with the patient, it is important to understand which stage of behaviour change the person is at. See Figure 1, as described by Prochaska and DiClemente.6

If the person is in the precontemplative stage, they will not even be considering activity and will not consider changing their lifestyle as important. In cases such as these, you can give the patient information about the importance of lifestyle changes; however, planning activities would be of no use as the person needs to move stages before they will start any activity.

[[Figure 1 diab]]

If you have a patient who is at this stage, it is important to revisit the conversation at each appointment until they move stages. Regular discussions about the importance of lifestyle changes may eventually prompt the person to move from the precontemplative stage. Although it may be disheartening continuously talking to someone about lifestyle changes who seems disinterested it is important to continue to reiterate its importance.

If the person is in the contemplative stage, they are considering increasing their activity. At this point, it is important to discuss the benefits and also start to discuss options they may take. This is the time that having knowledge of groups or exercise on prescription is useful to give the person options to consider. This will then lead to the preparation stage, where the person has decided they will undertake activity and will prepare for it. It is really important to encourage and support the patient to build a plan and set a date to start it, to help them move into the action stage. At the preparation stage goal setting becomes important. These goals should be SMART:

  • Specific.
  • Measurable.
  • Attainable.
  • Realistic.
  • Timely.

Setting achievable goals will increase the person's motivation to continue with the changes that they have made. It is useful to explore how important the goal is and how confident the person feels about achieving it on a scale of 1 to 10. Usually, the person will achieve their goal if both scores are 7 or above. If the goal is unachievable for that person they will become discouraged when they fail and will relapse and stop the lifestyle changes. An example of a simple goal-setting action plan can be seen in Figure 2 – although this only scores confidence and not importance.7

[[Figure 2 diab]]

It is important to really focus on what the individual can achieve. If they have not been physically active for many years and are very overweight, a goal of walking for 15 minutes a day or to a specific place, such as the local shops, will be achievable, in contrast to completing a 5 km run. Goals should have a time limit at which to be reviewed and new goals may then be set. For example, the person who achieves their goal of walking for 15 minutes may increase that to a 30-minute walk, before going on to undertake an exercise on prescription assessment.

I had one obese patient who set his goal to walk to the first bench in the park; he then increased the goal at each review to the next bench, and now he walks the length of the park and back before resting. His body mass index (BMI) has gone down from 40 to 31 in this time and he is delighted with his achievement. He would have given up at the first attempt if his original goal had been to walk through the park and back, as that would have been physically impossible for him.

Once the person is continuing with their increased activity they have then moved into the maintenance stage of the cycle. At this point, feedback on the improvements they are making to their health is essential to ensure that they remain in the maintenance stage of the cycle and do not relapse. Feedback can consist of measuring the person's waist circumference for fat loss, reduction in HbA1c, and blood glucose readings or blood pressure, and time should be agreed to review these markers on a regular basis. Regular goal reviewing and setting is equally as important in this stage of the cycle.

It is important that patients are aware of the potential to relapse from their goals. It may be beneficial to explain that this can occur but does not mean that the person has failed. If the patient contacts you as soon as it occurs, their goals can be reviewed and you can support them to recommence and return to the maintenance part of the cycle as soon as possible.

Conclusion
The person with diabetes should be told why lifestyle changes are a vital part of improving their diabetes health and to expel the myth that it is not possible to undertake activity if their blood glucose levels are high. This education should be revisited at every consultation.

It is important to identify where the person is in the Cycle of Change model. If the person is in the right stage of the cycle, they are ready to make changes and this is when supporting them to write their own realistic, achievable goals can help them to manage their diabetes more effectively.

References
1. Diabetes UK. Key statistics on diabetes. London: Diabetes UK; 2009.
2. Tuomilehto J, Lindström J, Eriksson JG et al. Prevention of type 2 diabetes mellitus by changes in lifestyle amongst subjects with impaired glucose tolerance. New Engl J Med 2001;344:1343-50.
3. Knowler WC, Barrett-Connor E, Fowler SE et al. Reduction in the incidence of type 2 diabetes with lifestyle intervention or metformin. New Engl J Med 2002;346:393-403.
4. Boulé NG, Haddad E, Kenny GP, Wells GA, Sigal RJ. Effects of exercise on glycemic control and body mass in type 2 diabetes mellitus: a meta-analysis of controlled clinical trials. JAMA 2001;286:1218–27.
5. Hays LM, Clark DO. Correlates of physical activity in a sample of older adults with type 2 diabetes. Diabetes Care 1999;22(5):706–12.
6. Prochaska JO, DiClemente CC, Miller WR, Rollnic S. Changing for Good. New York: Avon Books; 1995.
7. Bodenheimer et al. Helping patients adopt healthier behaviors. Clinical Diabetes 2007;25(2):66-70.