A study underway at UCHealth University of Colorado Hospital is addressing a question that has proven stubbornly difficult to answer: how to help patients with Type 2 diabetes increase their physical activity.
On the surface, both the problem and the solution are straightforward. Research shows that exercising or walking or simply moving around more can help people manage their Type 2 diabetes, which interferes with the body’s ability to use insulin to break down blood sugar. Doing so could help to not only improve lives but put a dent in the estimated $176 billion annual price tag for treating the disease.
“Physical activity is a cornerstone of treatment for Type 2 diabetes, along with diet and medicine,” said Amy Huebschmann, MD, an internist with the University of Colorado School of Medicine who practices at UCH. She noted that activity, even just 10 minutes’ worth, can help to lower blood sugar levels meaningfully, especially after a meal. Patients may not recognize that, however, Huebschmann added.
“An important message is that any movement is better than nothing,” she said. “We try to tell patients, ‘Do what you can.’”
But making that happen turns out to be a difficult challenge for many who are inactive, Huebschmann added. It’s not enough for providers to tell patients “just do it” and expect them to spring from couch to calisthenics. Aside from weight issues, many Type 2 diabetes patients suffer from conditions that discourage activity, including nerve pain (neuropathy) and arthritis.
The barriers may also be more subtle. For example, Huebschmann was the corresponding author for a study that demonstrated physiological reasons that exercise feels more difficult for middle-aged women with Type 2 diabetes than those without it. Another in which she played a lead role suggested that patients with diabetes fear injury from exercise more than those who don’t have the disease.
Now Huebschmann is leading a four-year, National Institutes of Health-funded study designed to identify and implement strategies for clinicians to help their patients surmount these and other barriers to physical activity.
It’s a multi-pronged effort. In one phase, explained in a study recently published in the journal Translational Behavior Medicine, the research team (see box) reviewed more than three decades of findings from evidence-based physical activity interventions with Type 2 diabetes patients that were implemented in clinical settings.
Huebschmann and her fellow researchers did not discount the importance of community-based programs that help Type 2 diabetes patients increase physical activity. However, she pointed to the importance of having physicians and advanced care providers as a “trusted source of information” in addressing health care questions and issues patients face.
“That’s very important for a complicated disease,” she noted, which frequently includes complications, such as eye, foot and heart problems.
The researchers were also intent on finding programs that have proven to be most successful in the real world and therefore the best bets for adoption by clinicians. They used an analytical tool called PRECIS-2 to assess each intervention’s feasibility for adoption in the clinical setting. The factors included flexibility, follow-up, adherence, reimbursement and others. They also evaluated the success of the interventions in increasing physical activity and lowering blood sugar levels.
The researchers analyzed 46 interventions that included more than 13,000 patients. Of the 16 judged the most feasible, or “pragmatic,” four successfully increased patients’ physical activity; two of those four improved both physical activity and HbA1C levels. The programs that were “both effective and pragmatic” for implementation in clinical settings “should be tested for dissemination using implementation trial designs,” the researchers concluded.
What distinguishes these approaches? In broad terms, Huebschmann said, the most successful programs recognize that one-size-fits-all approaches – rigid prescriptions for a daily exercise regimen, for example – rarely work for type 2 diabetes patients. Rather, a patient who moves very little might improve by starting to do a bit of walking during television commercial breaks. People with a fear of falling could work in the pool or on a stationary bike.
In turn, managing a complicated disease successfully requires an ongoing commitment from both providers and patients, Huebschmann said.
“Patients have to work on physical activity on an ongoing basis,” she said. “A one-time conversation is not typically effective. It’s much stronger to have an ongoing conversation because people’s challenges will change.”
Successful programs also invite patients to engage in managing their own health by tracking their progress, getting feedback from providers and identifying their personal reasons for being physically active, Huebschmann said.
Put me in, coach
The team at UCH is now continuing their work with a pilot coaching program that has thus far enrolled 19 Type 2 diabetes patients from the Internal Medicine practices at Anschutz and Lowry. Patients have a total of six visits over 12 weeks. The first visit and two follow-ups are with a primary care provider who assesses their risk for harm with increasing physical activity. The providers also help to guard patients who are taking certain medications, such as insulin, from hypoglycemia and other problems that can occur with increased physical activity.
The second phase involves six phone encounters with coaches from the Ambulatory Health Promotion program, which is a collaborative effort of UCHealth and CU Medicine to improve preventive care and chronic disease management for all primary care patients. For the Type 2 diabetes pilot, patients get a notebook with information about their disease and the importance of physical activity in controlling it; detailed examples of exercises to improve flexibility, stamina and strength; and logs to track their daily activities and blood glucose levels. Patients also get a Fitbit for the duration of the study to help with monitoring and recording their step counts and calories burned.
The coaches speak with the patients about their successes and challenges and help them to identify their personal motivations for getting more active. The overall idea, Huebschmann said, is to tailor plans to each patient’s needs and abilities. The coaches also play an important role in helping to explain the benefits of physical activity, she added.
“Not all patients recognize that,” she said. “And they may not realize that physical activity can be meaningful even in small doses. Throughout a given day, doing 10 minutes of walking, 10 minutes of gardening, and 10 minutes of playing outside with your children or grandchildren is just as effective as one 30-minute walk, in terms of health benefits.”
Small steps equal big changes
David Newbrough of Denver concurs. Newbrough, 70, was diagnosed with Type 2 diabetes in 2002. A Vietnam War veteran, Newbrough got a referral from the VA Medical Center to the Anschutz Internal Medicine Clinic last year and began care with nurse practitioner Deb Gothard, FNP. He enrolled in the pilot program last November and recently completed it.
Newbrough said he weighed about 240 pounds – down from 260 – when he got into the program, and is now at 220, a more reasonable figure for his 6’ 2” frame. When he started, 10 minutes on the treadmill pushed his heart rate to 140; he said he recently went seven minutes longer without getting to that level. The biggest reason: understanding that he didn’t need intense exercise to improve his physical condition.
“I didn’t think getting out and walking slow with the dog would do much good,” Newbrough said. “I’ve stuck with it and now my heart is much more efficient.” He said he’s had numbness in his feet and hands caused by diabetes-related neuropathy since 2004, but he refuses to blame it for his inactivity.
“It’s just an excuse not to do it,” he said. With help from the program, he added, physical activity and close attention to diet – he steers clear of starches in favor of chicken, fish and vegetables – are now part of his daily routine.
“I’m in the habit now of walking, knowing which foods to eat and knowing how to stretch,” Newbrough said. He also continues to manage his condition with Metformin, which he supplements with a dose of insulin at night. The result: blood sugar levels that are holding steady at or near the target of 100 mg/dL. He said his HbA1C readings, which had been over eight, are now below seven, the goal recommended by the American Diabetes Association.
“These are the things you want,” Newbrough said. “I’m so glad I was in the program. Before it, I couldn’t get enough understanding of my diabetes.”
Important as individual successes like Newbrough’s are, Huebschmann sees the pilot program as part of a larger change in health care delivery, one that elevates the importance of coordinated care delivered through patient centered medical homes. As part of the Comprehensive Primary Care Plus initiative launched early this year, UCHealth primary care practices receive support and reimbursement for services that aim to improve and maintain patients’ health and reduce unnecessary emergency department visits and hospital admissions. That’s in addition to fee-for-service payments.
“The patient centered medical home model is growing,” Huebschmann said. “We’re moving toward increasing the value of medical care. We want to stay ahead of the curve and promote patient engagement in improving their health.”
Lead authors of the published article in the journal Translational Behavior Medicine:
- Ian Leavitt, MS, co-first author
- Kelsey A. Luoma, MD, co-first author
- Amy Huebschmann, MD, MS, senior author