Including Physical Activity Exercise in Diabetes Management: Diabetes Educators' Perceptions of Their Own Abilities the Abilities of Their Patients

Lifestyle Patterns in Patients with Type 2 Diabetes

Modern lifestyles have led to sedentary behavior, lower participation in active movement and physical activities during leisure time, unhealthy diets, and increased exposure to stress. It is important to examine the interaction of several lifestyle risk factors instead of focusing on one alone. The purpose of this study was to identify lifestyle patterns in a group of patients with type 2 diabetes and the associations of its components with certain metabolic parameters. Using principal component analysis, we identified three dietary patterns: the prudent pattern (fat, oil, cereals, potatoes, vegetables, fish, nuts, seeds and fruits), the Western pattern (meat and meat products, eggs and soft drinks) and the traditional pattern (milk and its derivatives, soups and sauces, with a low intake of sugar/snacks). In addition, using the same method of analysis, we identified two lifestyle patterns: the inadequate lifestyle pattern (Western dietary pattern, increased hours of sleep and lower levels of stress) and the traditional lifestyle pattern (traditional dietary pattern, increased physical activity (PA) and non-smoking status). The inadequate lifestyle pattern was associated with younger age, hypertension and diabetic neuropathy. The traditional lifestyle pattern was related to lower postprandial blood glucose levels. Sedentary individuals were more likely to be over 65 years old and to have higher glycated hemoglobin (HbA1c). Smokers were also more likely to have inadequate glycemic and lipid profile control.

Level of physical activity and barriers to exercise in adults with type 2 diabetes

Introduction

Physical activity (PA) is an important element in type 2 diabetes mellitus (T2DM) management. The aims of this study were to assess the percentage of adults with T2DM who perform PA, according to the intensity level and to describe barriers to exercise and the association between metabolic control and other clinical variables.

Methods

Multicenter, observational, cross-sectional study. Data were collected through the International PA Questionnaire (IPAQ) and the PA Barrier Questionnaire. Adults (18–65 years old) with T2DM from 17 Argentine diabetes centers were included, from May to July 2018.

Results

A total of 270 men (54.9 ± 9.8 years) and 225 women (55.3 ± 9.6 years) were included. Duration of diabetes: 8.2 ± 6.3 years. The BMI in men was 32 ± 10.6 kg/m², whereas that in women was 32.5 ± 7.2 kg/m². The last two HbA1c values were 7.6 ± 1.7% and 7.5 ± 1.6. Results also showed that 12.7% had clinical heart disease, 13.7% had nephropathy, 20.8% had neuropathy, 6.1% had diabetic foot and 14.1% had retinopathy. The level of PA was low in 52.3% of the patients studied and moderate in 30.5%. The most frequent barriers were: “lack of will” (59.6%) and “lack of energy” (37.2%). The low level of PA was associated with age (OR: 1.05 per year of age; p < 0.001), HbA1c (OR: 1.16 per 1%; p < 0.05), BMI (OR: 1.06 per kg/m²; p < 0.001) and sex (OR: 1.69 for women; p < 0.01).

Conclusions

PA in a cornerstone in management T2DM. Nevertheless, in this study, 52.3% of T2DM adults showed low level of PA. The main barriers reported were related to low personal motivation. These factors should be taken into account to implement programs to promote physical activity.

Exercise is Medicine Canada workshop training improves physical activity practices of physicians across Canada, independent of initial confidence level

BACKGROUND

Educational workshops help physicians (MDs) include physical activity and exercise (PAE) content in more patient appointments. It is unclear if MDs with varying degrees of confidence discussing PAE with their patients equally benefit from such training. We evaluated whether MDs' initial confidence affects the impact of an educational PAE workshop.

METHODS

MDs (n = 63) across Canada completed self-reflection questionnaires initially and 3-months following a PAE workshop. MDs were divided into low-confidence [confidence score (out of 100%): <40%; n = 21], medium-confidence (40-60%; n = 19) and high-confidence (>60%; n = 23).

RESULTS

PAE counselling confidence increased in all groups (relative increase: Low=~40%, Medium=~20%, High=~10%). Training increased the low-confidence group's knowledge, awareness of guidance/resources and perception of their patients' interest in lifestyle management (~30% change; all p < 0.001). Compared to baseline, a greater proportion (all p < 0.001) of MDs reported prescribing exercise at 3-month follow-up in each of the low-confidence (10% to 62%) medium-confidence (16% to 89%) and high-confidence (57% to 87%) groups.

CONCLUSION

PAE training favorably improved MDs' confidence, perceived impact of many barriers and the proportion of MDs prescribing exercise, at each level of confidence. An educational workshop particularly assisted MDs with low-confidence (i.e., those who needed it the most) integrate PAE into their practice.

Perceptions and Practices of Providing Physical Activity Counselling and Exercise Prescriptions among Physiotherapists in Nova Scotia

Purpose: We assessed the perceptions and practices of physical activity counselling and exercise prescription of physiotherapists in Nova Scotia. Method: A total of 146 physiotherapists in Nova Scotia completed an online self-reflection survey regarding their current practice of, confidence in, barriers to, and facilitators of providing physical activity and exercise (PAE) counselling to their patients. Results: Physiotherapists included physical activity counselling and exercise content in 85% of patient counselling appointments. They reported a high level of confidence (> 90%) in providing PAE information and answering patients' PAE questions and moderate confidence in their patients' abilities to maintain PAE over the long term (73%) and to follow through on their PAE recommendations (66%). Patients' interest in PAE was the greatest barrier to providing PAE counselling. The physiotherapists reported being most comfortable when prescribing exercise for patients with musculoskeletal conditions and least comfortable with patients with cancer, insulin-dependent diabetes, and respiratory conditions. Most physiotherapists (71%) reported being interested in pursuing further education or training in PAE counselling and prescription. Conclusions: The physiotherapists frequently recommended PAE to their patients, had moderate confidence in their patients' ability to follow through on their advice, and experienced patients' disinterest in PAE as the greatest barrier to providing PAE counselling. The results of this study suggest a desire by physiotherapists for educational training opportunities, which we recommend be focused on providing behavioural strategies and further information to help overcome patient-focused barriers; this will help patients adopt and maintain physically active lifestyles.

Core competencies for diabetes educators: A scoping review

AIMS

Diabetes educators (DEs) play a major role in diabetes education and management. The aims of this scoping review were to compile the currently identified core competencies for DEs and, to review the currently used criteria to assess DEs' core competencies.

METHODS

A scoping review was conducted using the methodology of the Joanna Briggs Institute. Five databases (Ovid, CINAHL, Scopus, Web of Science and PubMed) were searched. Keywords as well as inclusion and exclusion criteria were identified as search strategies and study selection for this review.

RESULTS

A total of (n = 22) publications comprising sixteen peer-reviewed studies and six professional-organisations (grey literature) were selected for review, as they listed the core competencies of DEs. The most common core competencies were related to knowledge and skills in diabetes self-management education, knowledge of pathophysiology and epidemiology, teaching skills, clinical skills and cultural competency. Evidently, an appropriate tool for assessing DEs' competencies is currently unavailable.

CONCLUSIONS

Given the importance of diabetes education in the care of people living with diabetes, it is imperative that DEs possess competencies in diabetes education and management. The review also identified the need to develop a globally applicable core competency assessment tool for DEs.

Exercise is Medicine Canada physical activity counselling and exercise prescription training improves counselling, prescription, and referral practices among physicians across Canada

Exercise is Medicine Canada (EIMC) is an initiative that promotes physical activity (PA) counselling and exercise prescription within health care. The purpose of this study was to compare physicians' perceptions and practices around PA counselling and exercise prescription following EIMC training. Physicians (n = 46) from 7 different provinces completed questionnaires initially and 3 months following an EIMC workshop. Three months after intervention, physicians reported greater confidence compared with baseline for providing physical activity and exercise (PAE) information to patients (79% vs 55%; p < 0.001), assessing patients' PAE (69% vs 44%, p = 0.005), answering patients' PAE questions (78% vs 54%, p < 0.001), providing PAE advice (71% vs 43%, p < 0.001), and identifying which patients would benefit from referral to qualified exercise professionals (77% vs 52%, p = 0.002). At follow-up, physicians reported PA prescription barriers as less impactful (out of 4; all p < 0.05), including perceived patients' lack of interest (2.75 to 2.25), lack of available resources (2.59 to 2.00), and lack of time (2.41 to 2.14). The proportion of physicians providing written exercise prescriptions increased from 20% to 74%. This study suggests that the completion of a 1-day EIMC workshop increases physicians' confidence, knowledge, and counselling behaviours of physicians in prescribing PAE.

Building Competency and Capacity for Promotion of Effective Physical Activity in Diabetes Care in Canada

OBJECTIVES

The purpose of the present study was to examine the impact of the Canadian Diabetes Association's (CDA) resource titled Building Competency in Diabetes Education: Physical Activity and Exercise and associated workshops, on diabetes care providers' (DCPs) confidence and practices regarding physical-activity promotion 8 to 12 months after attending a workshop.

METHODS

In this action research study, 2 separate cross-sectional samples of DCPs were recruited. DCPs at baseline (N=462) completed a questionnaire assessing their current physical-activity promotion practices, intended changes in practice and intended implementation of the toolkit. At follow up, DCPs (n=132) completed an online questionnaire assessing their physical-activity counselling practices, confidence in their physical-activity counselling, use of the specific CDA resources as well as changes to practice and ongoing challenges.

RESULTS

At baseline, 58% of DCPs incorporated physical-activity content in the majority of their sessions; however, 66% of DCPs discussed physical activity in >50% of their sessions following the launch of the training initiative. Following the training, DCPs reported increased confidence across all 6 aspects of physical-activity counselling that were examined. Improvements were most frequently found in providing advice regarding the benefits of activity (86%) and providing instruction regarding resistance training (86%). DCPs most often changed their practices by discussing physical activity more frequently and confidently (27%); however, lack of time was frequently reported (37%) as an ongoing challenge to providing physical-activity counselling.

CONCLUSIONS

This evaluation highlights the impact of this national initiative and suggests that the resource is effective in improving physical-activity promotion in diabetes care.

Health care provider confidence and exercise prescription practices of Exercise is Medicine Canada workshop attendees

The Exercise is Medicine Canada (EIMC) initiative promotes physical activity counselling and exercise prescription within health care. The purpose of this study was to evaluate perceptions and practices around physical activity counselling and exercise prescription in health care professionals before and after EIMC training. Prior to and directly following EIMC workshops, 209 participants (physicians (n = 113); allied health professionals (AHPs) (n = 54), including primarily nurses (n = 36) and others; and exercise professionals (EPs) (n = 23), including kinesiologists (n = 16), physiotherapists (n = 5), and personal trainers (n = 2)) from 7 provinces completed self-reflection questionnaires. Compared with AHPs, physicians saw more patients (78% > 15 patients/day vs 93% < 15 patients/day; p < 0.001) and reported lower frequencies of exercise counselling during routine client encounters (48% vs 72% in most sessions; p < 0.001). EPs had higher confidence providing physical activity information (92 ± 11%) compared with both physicians (52 ± 25%; p < 0.001) and AHPs (56 ± 24%; p < 0.001). Physicians indicated that they experienced greater difficulty including physical activity and exercise counselling into sessions (2.74 ± 0.71, out of 5) compared with AHPs (2.17 ± 0.94; p = 0.001) and EPs (1.43 ± 0.66; p < 0.001). Physicians rated the most impactful barriers to exercise prescription as lack of patient interest (2.77 ± 0.85 out of 4), resources (2.65 ± 0.82 out of 4), and time (2.62 ± 0.71 out of 4). The majority of physicians (85%) provided a written prescription for exercise in <10% of appointments. Following the workshop, 87% of physician attendees proposed at least one change to practice; 47% intended on changing their practice by prescribing exercise routinely, and 33% planned on increasing physical activity and exercise counselling, measured through open-ended responses.

The connection between the primary care and the physical activity sector: professionals' perceptions

BACKGROUND

To stimulate physical activity (PA) and guide primary care patients towards local PA facilities, Care Sport Connectors (CSC), to whom a broker role has been ascribed, were introduced in 2012 in the Netherlands. The aim of this study is to assess perceptions of primary care, welfare, and sport professionals towards the CSC role and the connection between the primary care and the PA sector.

METHODS

Nine focus groups were held with primary care, welfare and sport professionals within the CSC network. In these focus groups the CSC role and the connection between the sectors were discussed. Both top-down and bottom-up codes were used to analyse the focus groups.

RESULTS

Professionals ascribed three roles to the CSC: 1) broker role, 2) referral, 3) facilitator. Professionals were enthusiastic about how the current connection was established. However, barriers relating to their own sector were currently hindering the connection: primary care professionals' lack of time, money and knowledge, and the lack of suitable PA activities and instructors for the target group.

CONCLUSIONS

This study provides further insight into the CSC role and the connection between the sectors from the point of view of primary care, welfare, and sport professionals. Professionals found the CSC role promising, but barriers are currently hindering the collaboration between both sectors. More time for the CSC and changes in the way the primary care and PA sector are organized seem to be necessary to overcome the identified barriers and to make a success of the connection.

TRIAL REGISTRATION

Dutch Trial register NTR4986 . Registered 14 December 2014.

Systematic review of interventions to increase the delivery of preventive care by primary care nurses and allied health clinicians

Background

Primary care nurses and allied health clinicians are potential providers of opportunistic preventive care. This systematic review aimed to summarise evidence for the effectiveness of practice change interventions in increasing nurse or allied health professional provision of any of five preventive care elements (ask, assess, advise, assist, and/or arrange) for any of four behavioural risks (smoking, inadequate nutrition, alcohol overconsumption, physical inactivity) within a primary care setting.

Methods

A search of Medline, Embase, PsycInfo, and CINAHL databases was undertaken to locate controlled intervention trials published between 1992 and May 2014 that provided practice change interventions to primary care nurses and/or allied health professionals to increase preventive care. The effect of interventions aimed at increasing the provision of any of the five care elements for any of the four behavioural risks was examined. A narrative synthesis was utilised.

Results

From 8109 articles, seven trials met the inclusion criteria. All trials bar one, assessed multi-strategic practice change interventions (three to five strategies) focused on care by nurses (six trials) or mixed nursing/allied health clinicians. One trial examined care provision for all four risks, five trials examined care for smoking only, and one trial examined care for alcohol consumption only. For the six trials reporting significance testing (excludes one smoking care trial), significant effects favouring the intervention group were reported in at least one trial for smoking risk assessment (2/4 trials reported an effect for at least one analysis of an assessment outcome), brief advice (2/3), assistance (2/2), and arranging referral (2/3); alcohol risk assessment (1/2) and brief advice (1/2); inadequate nutrition risk assessment (1/1); and physical inactivity risk assessment and brief advice (1/1). When the number of analyses undertaken within trials focusing on smoking care was considered, the results were less promising (e.g. of the 15 analyses conducted on brief advice variables across three trials, four showed a positive effect).

Conclusions

Evidence for the effect of practice change interventions on preventive care by primary care nurses or allied health providers is inconclusive given the small number of trials and inconsistency of results between and within trials.

Systematic review registration number

None

Electronic supplementary material

The online version of this article (doi:10.1186/s13012-016-0409-3) contains supplementary material, which is available to authorized users.

Contextualizing the Proven Effectiveness of a Lifestyle Intervention for Type 2 Diabetes in Primary Care: A Qualitative Assessment Based on the RE-AIM Framework

OBJECTIVE

The Healthy Eating and Active Living for Diabetes in Primary Care Networks (HEALD) intervention proved effective in increasing daily physical activity among people with type 2 diabetes in 4 community-based primary care networks (PCNs) in Alberta. Here, we contextualize its effectiveness by describing implementation fidelity and PCN staff's perceptions of its success in improving diabetes management.

METHODS

We used the Reach, Effectiveness, Adoption, Implementation and Maintenance (RE-AIM) framework to evaluate the HEALD intervention. Qualitative methods used to collect data related to the RE-AIM dimensions of implementation and effectiveness included interviews with PCN staff (n=24), research team reflections (n=4) and systematic documentation. We used content analysis, and data were imported into and managed using Nvivo 10.

RESULTS

HEALD was implemented as intended with adequate fidelity across all 4 PCNs. Identified implementation facilitators included appropriate human resources, the training provided, ongoing support, the provision of space and the simplicity of the intervention. However, PCN staff reported varying opinions regarding its potential for improving diabetes management among patients. Rationales for their views included intervention "dose" inadequacy; that the quality of usual care for people with diabetes was already good; patients were already managing their diabetes well; and the potential for cointervention. Recommended improvements to HEALD included increasing the dose of the intervention, expanding it to other modes of exercise and incorporating a medical clearance process.

CONCLUSIONS

Based on the high degree of fidelity, the demonstrated effectiveness of HEALD in improving physical activity among patients was a result of sound implementation of an efficacious intervention. Increasing the dose of HEALD could result in additional improvements for patients.

Increasing diabetes educators' confidence in physical activity and exercise counselling: the effectiveness of the "physical activity and exercise toolkit" training intervention

OBJECTIVE

The objective of this action research was to examine the effectiveness of a comprehensive intervention (the toolkit) in improving diabetes educators' (DEs') perceptions of their abilities and their patients' abilities related to physical activity as part of regular diabetes self-management.

METHODS

Two separate studies were conducted. Participants completed measures assessing confidence, attitudes and perceived difficulty. In study 1, a quasi-experimental design was used to examine the impact of the training intervention at 6 months. Cross-sectional sampling at baseline and 12 months then was used to assess the longer-term impact of the intervention. In study 2, a pre-post design was used to test the impact of the intervention at 12-months in a separate sample.

RESULTS

The primary finding was a consistent increase in DEs' confidence in their ability to provide physical activity and exercise counselling with increases of up to 20% after the training intervention. Furthermore, DEs reported greater knowledge about physical activity (p<0.03) yet perceived physical activity counselling to be more difficult after receiving the training (p<0.05). In study 2, the DEs reported increases in perceived patient knowledge and confidence in their patients (p<0.03) after the intervention. Secondary analyses showed that frequently referring to the toolkit was associated with higher counselling efficacy and lower perceived difficulty (p<0.03).

CONCLUSIONS

These findings suggest that the toolkit is an effective resource to improve DEs' confidence in the area of physical activity counselling. As a result of this work, the toolkit has been adopted as standard diabetes care across Nova Scotia and as a foundational resource for DEs across Canada.

Increasing preventive care by primary care nursing and allied health clinicians: a non-randomized controlled trial

BACKGROUND

Although primary care nurse and allied health clinician consultations represent key opportunities for the provision of preventive care, it is provided suboptimally.

PURPOSE

To assess the effectiveness of a practice change intervention in increasing primary care nursing and allied health clinician provision of preventive care for four health risks.

DESIGN

Two-group (intervention versus control), non-randomized controlled study assessing the effectiveness of the intervention in increasing clinician provision of preventive care.

SETTING/PARTICIPANTS

Randomly selected clients from 17 primary healthcare facilities participated in telephone surveys that assessed their receipt of preventive care prior to (September 2009-2010, n=876) and following intervention (October 2011-2012, n=1,113).

INTERVENTION

The intervention involved local leadership and consensus processes, electronic medical record system modification, educational meetings and outreach, provision of practice change resources and support, and performance monitoring and feedback.

MAIN OUTCOME MEASURES

The primary outcome was differential change in client-reported receipt of three elements of preventive care (assessment, brief advice, referral/follow-up) for each of four behavioral risks individually (smoking, inadequate fruit and vegetable consumption, alcohol overconsumption, physical inactivity) and combined. Logistic regression assessed intervention effectiveness.

RESULTS

Analyses conducted in 2013 indicated significant improvements in preventive care delivery in the intervention compared to the control group from baseline to follow-up for assessment of fruit and vegetable consumption (+23.8% vs -1.5%); physical activity (+11.1% vs -0.3%); all four risks combined (+16.9% vs -1.0%) and for brief advice for inadequate fruit and vegetable consumption (+19.3% vs -2.0%); alcohol overconsumption (+14.5% vs -8.9%); and all four risks combined (+14.3% vs +2.2%). The intervention was ineffective in increasing the provision of the remaining forms of preventive care.

CONCLUSIONS

The intervention's impact on the provision of preventive care varied by both care element and risk type. Further intervention is required to increase the consistent provision of preventive care, particularly referral/follow-up.

Clinician assessment, advice and referral for multiple health risk behaviors: prevalence and predictors of delivery by primary health care nurses and allied health professionals

OBJECTIVE

Primary care clinicians have considerable potential to provide preventive care. This study describes their preventive care delivery.

METHODS

A survey of 384 community health nurses and allied health clinicians from in New South Wales, Australia was undertaken (2010-11) to examine the assessment of client risk, provision of brief advice and referral/follow-up regarding smoking inadequate fruit and vegetable consumption, alcohol misuse, and physical inactivity; the existence of preventive care support strategies; and the association between supports and preventive care provision.

RESULTS

Preventive care to 80% or more clients was least often provided for referral/follow-up (24.7-45.6% of clinicians for individual risks, and 24.2% for all risks) and most often for assessment (34.4-69.3% of clinicians for individual risks, and 24.4% for all risks). Approximately 75% reported having 9 or fewer of 17 supports. Provision of care was associated with: availability of a paper screening tool; training; GP referral letter; and number of supports.

CONCLUSION

The delivery of preventive care was limited, and varied according to type of care and risk. Supports were variably associated with elements of preventive care.

PRACTICE IMPLICATIONS

Further research is required to increase routine preventive care delivery and the availability of supports.

Improving patients' adherence to physical activity in diabetes mellitus: a review

Regular physical activity (PA) is a key element in the prevention and management of type 2 diabetes mellitus (T2DM). Participation in regular PA improves blood glucose control and can prevent or delay T2DM and its complications, along with positively affecting lipids, blood pressure, cardiovascular events, mortality, and quality of life. However, most people with T2DM are not active and show poor adherence. This paper reviews the possible barriers to PA and strategies to improve the adherence to PA. Based on the currently available literature, it is concluded that self-efficacy and social support from family, friends, and health care providers play the important role in adoption and maintenance of regular PA. Here we also highlight some new modern and innovative interventions that facilitate exercise participation and improve the adherence.