Robert Powell, PhD, CDE, CEP Assistant Professor- Exercise Science Director- Diabetes Exercise Center Marshall University Huntington, WV Conflict of Interest (COI) and Financial Relationship Disclosures: NONE CAN DIABETES EDUCATORS PROVIDE EFFECTIVE EXERCISE COUNSELING? EXAMINING CURRENT CHALLENGES FOR FUTURE OPPORTUNITIES Optimal Therapy TRIAD Comparison of the Reductions in HbAc levels with Different Modes of Treatment Non- Insulin Pharmacotherapy Drug Classification Average HbAc reduction₁ Biguinides/ TZDs - to -2% Sulfonylureas/ meglitinides -0.5 to -2.0% DPP-4 inhibitors -0.4 to -0.6% GLP- -0.5 to -% Physical Activity Mode of Exercise Average HbAc reduction₂,₃ Aerobic Exercise Resistance Exercise -0.67 to -0.89% -0.64%. The Art and Science of Diabetes Self-Management Education Desk Reference, 2nd Edition. American Association of Diabetes Educators. 2. Boule, N.G., et al., Effects of exercise on glycemic control and body mass in type 2 diabetes mellitus: a meta-analysis of controlled clinical trials. JAMA, 200. 286(0): p. 28-27. 3. Umpierre, D., et al., Volume of supervised exercise training impacts glycaemiccontrol in patients with type 2 diabetes: a systematic review with meta-regression analysis. Diabetologia. 56(2): p. 242-5. Reduces the incidence of heart disease and high blood pressure by approximately 40%. Lowers the risk of stroke by 27%. *Lowers the risk of developing type II diabetes by 58% *Can be twice as effective in treating type II diabetes than the standard insulin prescription and can save $2,250 per person per year when compared to the cost of standard drug treatment. Adults with greater muscle strength have a 20% lower risk of mortality than adults with low muscle strength. *A low level of fitness is a bigger risk factor for mortality than mild-moderate obesity. It is better to be fit and overweight than unfit with a lower percentage of body fat. Can decrease depression as effectively as Prozac or behavioral therapy. AADE 7 Self Care Behaviors Monitoring Taking Medications Healthy Eating Being Active Reducing Risks Problem Solving Healthy Coping Being Active Address knowledge: Type, duration, intensity safety precautions Address skills: Develop appropriate plan Balance with nutrition and medication Address barriers: Physical, environmental, psychological Time Fear Measure and assess outcomes and provide ongoing support Mulcahy, K., et al., Diabetes self-management education core outcomes measures. Diabetes Educ, 2003. 29(5):
Physical Activity Guidelines for U.S. Adults Aerobic Activity: A minimum of 50 minutes of moderate intensity aerobic activity per week 75 minutes of vigorous intensity aerobic activity per week An equivalent combination of the two per week Resistance Training: A minimum of 2 days per week of resistance training Underlying Message: Some is better than none, more is better than some Physical Activity Guidelines for Americans. Department of Health and Human Services. 2008. Available from: http://www.health.gov/paguidelines/guidelines/default.aspx#toc. Statement of the Problem Receive less support, education and encouragement for physical activity compared to other aspects of DSME/S Only 39% are considered regularly active Ages 60 years and older are 2-3x more likely to report inability to walk ¼ mile, climb stairs, or do housework Morrato, E.H., et al., Physical activity in U.S. adults with diabetes and at risk for developing diabetes, 2003. Diabetes Care, 2007. 30(2): p. 203-9. Kirk, A., et al., Increasing physical activity in people with type 2 diabetes. Diabetes Care, 2003. 26(4): p. 86-92. Diabetes Educators AADE 204 Membership Information 53% are Nurses (now 6%) 29% are Dietitians (now 25%) 9% pharmacists (now %) 3% other (same) < % exercise physiologists 45 of the 7,876 CDEs 63% are CDE and or BC-ADM (now 62%) Objective To identify factors that may influence the diabetes educator s ability to counseling on physical activity (PA) during DSME/S AADE member statistics, 204 Study Aims Primary Aims Time dedicated to PA counseling Importance placed on PA as a treatment Knowledge of the current PA guidelines for Adults Level of Confidence for PA counseling Barriers toward PA counseling Personal Practice based Exploratory Aims Level of Education Education Background Practice Setting Possession of the CDE Personal Exercise behaviors Recruitment and Sample Population Diabetes Educators attending the AADE, 3 rd Annual PA State Diabetes Conference Eligibility Criteria: Currently practicing Diabetes Educators Providing DSME/S to adults (8 years and older) Survey distribution: Unique Identifier Approved by AADE State Coordinating Body and Pitt IRB Incentives: Raffle for $60 Diabetes and Exercise Resource Exercise and Diabetes: A Clinician's Guide to Prescribing Physical Activity written by Sheri Colberg, PhD 2
Demographics Table : Demographic characteristicsof the Diabetes Educators who responded to the survey at the 204Pennsylvania State Diabetes Conference Variables Categories Mean + St. Dev. or % (N) Total (N) 5.9 ±0.7 9 Age (Years) Gender (% Female) 95.8% (4) 9 Race Caucasian 94.% (2) 9 Black or African American 3.4% (4) Native Hawaiian or Pacific Islander.8% () Asian.8% () Other.8% () Ethnicity Hispanic (% Yes) 2.5% (3) 9 Educational Discipline Nursing 60.5% (72) 9 Nutrition 28.6% (34) Pharmacy 5.9% (7) Health Education 2.5% (3) Doctor.7% (2) Other (Exercise Physiologist).8% () Level of Education Associate s Degree.8% (4) 9 Bachelor s Degree 50.4% (60) Master s Degree 23.5% (28) Doctoral Degree 5.0% (6) Other Degree 9.2% () CDE (% Yes) 73.9 (88) 9 Demographics (Cont.) Table 2: Delivery of Diabetes Self-Management and Support Variables Categories Mean + Standard Deviation or % (N) DSME/S Format: DSME/S Setting: Practice Setting: Group Individual Inpatient Outpatient Outpatient Hospital Primary Care Inpatient Hospital Pharmacy Home Health Other 2.6% (24) 78.4% (87) 22.8% (26) 77.2% (88) 5.7% (60).2% (3) 9.0% (22).9% ().7% (2) 5.5% (8) Sample (N) with valid data Performing DSME/S: (Years) 3 ±8.62 5 4 6 Time Counseling on Physical Activity Percent (%) 50 45 40 35 30 25 20 5 0 Figure : Percent of Time Spent Addressing the 4 Common Content areas of DSME/S 36.5 28.8 23.4 7.7 Importance of Physical Activity Counseling Table 3: Level of Importance Placed on the 4 Common Content Areas of Diabetes Self-Management Education and Support Variables Median Rank (Least Important) HealthyEating 3 20.4% (22) TakingMedications 2 3.8% (34) PhysicalActivity 3 2.5% (23) Ranking % (N) 2 3 4 (Most Important) 8.55 8.7% 27.% (29) 22.2% (24) 2.5% (23) 3.8% (34) 38.9% (42) 28% (30) 9.6% (2) 5 0 Blood Glucose Monitoring 2 26.2% (28) 35.5% (38) 24.3% (26) 4% (5) Healthy Eating Taking Medications Blood Glucose Monitoring Physical Activity 4 Common Content Areas Physical Activity Guidelines Knowledge Table 4: Knowledge of Current PA Guidelines for Adults Variable Established Guidelines [% Yes(N)] PercentStating Correct Guidelines (N) Range MAPA ----- 74 (88) 50-300 min VAPA 40.2 (45) 5% (23) 75-300 min RT 64 (72) 98.6 (7) 2-5 days MAPA= Moderate Intensity Aerobic Physical Activity VAPA=Vigorous Intensity Aerobic Physical Activity RT= Resistance Training Most likely to report the correct amounts of MAPA: Those with Nutrition Degree (p<0.0) Those with CDE (p< 0.00) Most likely to report the correct amounts of RT: Those with Nutrition Degree (p<0.047) Counseling Confidence Table 5: Level of Confidence for Delivering PA Counseling as a Treatment (N=7) Very Confident %(N) Somewhat Confident %(N) Not Confident at All %(N) 54.7 (64) 4 (48) 4.3 (5) Those working in the outpatient hospital setting had a significantly greater level of confidence compared to the inpatient hospital setting (mean ranks= 65.73 versus 43.70, respectively) (p=.08). Those who engage in regular physical activity (over past 6 months) perceive more confidence compared to their inactive counterparts (p=.02) 3
Personal Barriers Table 6: Ranking of Personal Barriers toward Physical Activity Counseling (N=07) Practice Based Barriers Table 7: Ranking of Practice Based Barriers toward Physical Activity Counseling (N=00) Barriers Assuring safe physical activity plans for patients with co-morbidities (HTN, CVD, etc.) Inability to engage patients in physical activity (i.e. motivation, interest, etc.) Limited knowledge of physical activity s effects on diabetes control Limited knowledge of proper physical activity counseling Ranking %(n) Median 2 3 4 Least Challenging Most Challenging 3 7.8% 6.8% 3.8% 33.6% (9) (8) (34) (36) 3 2.% 23.4% 27.% 37.4% (3) (25) (29) (40) 50.5% 24.3% 7.8% 7.5% (54) (26) (9) (8) 2 20.6% 35.5% 22.4% 2.5% (22) (38) (24) (23) Those without the CDE were more likely to rank limited Knowledge of physical activities effects on diabetes control as a greater challenge compared to those with the CDE (p=.02) Barriers Median Least Challenging Time allotted for DSME/ S visits 5 8% (8) Limited physician support and/ or 4 6% guidance for physical activity (6) counseling Lack of physical activity resources (i.e. handouts) No reimbursement for physical activity counseling Not sure which exercise professionals to refer to Limited availability for individual visits 3 9% (9) 3 6% (6) 3 3% (3) 3 8% (8) Ranking % (n) 2 3 4 5 6 2% (2) 2% (2) 20% 5% (5) 24% (24) 7% (7) 9% (9) 5% (5) 7% (7) 25% (25) 6% (6) 8% (8) 9% (9) 7% (7) 20% 8% (8) 27% (27) 7% (7) 7% (7) 2% (2) 4% (4) 20% 3% 26% (3) (26) Most Challenging 35% (35) 9% (9) 0% (0) 5% (5) 3% (3) 8% (8) Summary of Findings Diabetes educators spend the least amount of time addressing physical activity (Aim ) Diabetes educators ranked physical activity as the 3 rd most important treatment strategy (Aim 2) Physical Activity Guidelines (Aim 3): 25% did not report at least 50 minutes per week of MPA 80% did not report at least 75 minutes per week of VPA 37% did not report at least 2 days per week of RT 55% felt very confident counseling on physical activity (Aim 4) Barriers (Aim 5): Greatest personal barrier was assuring safe physical activity plans for diabetes patients Greatest practice barrier was time to discuss physical activity Who is Responsible for PA Counseling?? 30% of DEs stated they are not responsible for counseling on PA 60% CEP 4% not sure % MD 8% Personal Trainer We are reaching a point where NOT prescribing or counseling on physical activity should be considered patient neglect? KEEP CALM AND COUNSEL ON EXERCISE 4
Address Physical Activity?? Common physical activity counseling approaches Start Moving More! ARE THEY ABLE TO PRODUCE SUSTAINABLE HEALTH BENEFITS??? Park Farther Away from your Destination! Take The Stairs! AADE 7 Self Care Behaviors Monitoring Taking Medications Healthy Eating Being Active Reducing Risks Problem Solving Healthy Coping Being Active Address knowledge: Type, duration, intensity safety precautions Address skills: Develop appropriate plan Balance with nutrition and medication Address barriers: Physical, environmental, psychological Time Fear Measure and assess outcomes and provide ongoing support The role for Physical Activity in Clinical Settings are expanding The Healthcare sector is the nation s largest industry Healthcare professionals are INCREASINGLY called upon to initiate physical activity counseling Change in policies = change in deliveries DEs can expand our worth by becoming a stronger resource for engaging patients in effective physical activity regimens through a number of avenues Mulcahy, K., et al., Diabetes self-management education core outcomes measures. Diabetes Educ, 2003. 29(5): Physical activity Resources (for patient and provider) Continuing Education ADA, ACSM, AADE Webinars Online Learning Certification (ACSM, ACE, NSCA, NASM, etc.) WEB SOURCES http://www.health.gov/paguidelines/guidelines/ www.acsm.org www.exerciseismedicine.org www.acefitness.org www.webexercises.com http://www.diabetesmotion.com/ Activity Trackers/ Apps My Fitness Pal Map My Fitness Fitbit What happened to written logs????? BOOKS Coordinated Care 5
Physical Activity Resources: REFERRALS Clinical Exercise Centers Medical/ Clinical Exercise Centers Cardiac Rehabilitation Physical Therapy Diabetes Exercise Centers MARSHALL UNIVERSITY Diabetes Exercise Center Effects of the Cardiac Rehab Setting on Diabetes Patients Economic Domain Medical System Utilization Variable Pre Post* N Medication 7.94 7.36 37 ER visits.68.78 33 Hospital Admissions.08.27 33 Physician visits 8.39 3.3 3 *p<0.0 Diabetes Patients with CVD Enrolled in a Diabetes Exercise Program (4 year results) Ac (%) 8 7 6 5 4 3 2 0 7.4 Quarterly Changes [42 months] Progression with N=30 2 Years 3 6.0 Marley, WP et al. J Cardiopulm Rehab. 2006; 26:262. Marley, WP et al. 200 Diabetes Patients with CVD Enrolled in a Diabetes Exercise Program (4 year results) Mg/dl 80 60 40 20 00 80 60 40 20 0 4 year Change of Fasting Blood Glucose (mg/dl) 66 Pre p=.02 26 Post Physical Activity Resources: REFERRALS Fitness Centers Community Fitness Centers YMCA LA Fitness SNAP Fitness Wellness Centers Marley, WP et al. 200 6
General Recommendations for Chronic Disease Management and Prevention: 50 minutes of moderate aerobic exercise per week OR 75 minutes of vigorous aerobic exercise per week OR Equivalent combination of moderate to vigorous aerobic exercise per week PLUS: 2 days per week resistance training MY CHALLENGE TO YOU TRAIN YOUR WEAKNESSES: Expand YOUR: Medical home resources Referrals, measuring/ demonstration tools Physical activity knowledge Physical Activity counseling strategies University of Pittsburgh Linda Siminerio, PhD, RN, CDE John Jakicic, PhD Andrea Kriska, PhD Amy Rickman, PhD, RD Peg Thearle, BSN, CDE Patty Johnson, RN, CDE Thank You Acknowledgments AADE Members Physical Activity Community of Interest Marshall University William Marley, PhD Lois Adkins, MS Karri Britt, MS References. Haas. et al. National Standards for Diabetes Self-Management Education and Support. The Diabetes Educator. 202. 38:69. 2. Mulcahy, K., et al., Diabetes self-management education core outcomes measures. Diabetes Educ, 2003. 29(5): 3. Physical Activity Guidelines for Americans. Department of Health and Human Services. 2008. Available from: http://www.health.gov/paguidelines/guidelines/default.aspx#toc. 4. Morrato, E.H., et al., Physical activity in U.S. adults with diabetes and at risk for developing diabetes, 2003. Diabetes Care, 2007. 30(2): p. 203-9. 5. Kirk, A., et al., Increasing physical activity in people with type 2 diabetes. Diabetes Care, 2003. 26(4): p. 86-92. 6. Marsh LA, Armstrong JB, Marley WP. Impact of cardiac rehabilitation on the economic domain. J Cardiopulm Rehabil. 2006; 26: 262 (Abstract). 7. Marley, WP et al. The Effects of a Long-term Intensive Multifactorial Cardiac Rehabilitation Program on Hemoglobin AC. Journal of Cardiopulmonary Rehabilitation and Prevention. 200; 30:277.200 8. Robert Powell, Andrea Kriska, Amy Richman, Linda Siminerio, John Jakicic. Exploring Factors that Influence Diabetes Educator s Physical Activity Counseling during Diabetes Self-Management Education and Support. University of Pittsburgh. December st, 204. (Dissertation). 7