Dr Motivator

Exercise is a key part of a healthy lifestyle, but it’s notoriously hard to instil as a behaviour change. Here’s the latest on how to succeed… 

We know that exercise can improve quality of life and outcomes for people with diabetes, and help to prevent progression from prediabetes, but questions remain on the most effective interventions.

Speaking at special session on exercise at the American Diabetes Association’s Scientific Sessions last month, Dr Matt Cocks, lecturer in muscle biochemistry at Liverpool John Moores University, began his talk on home-based exercise and other strategies to remove barriers to physical activity by highlighting a recent meta-analysis. This showed that supervised, structured exercise was as effective as non-insulin anti-diabetic drugs for reducing HbA1c.

The problem, however, is that that approach can be unfeasible in healthcare settings. Whilst it may be replaced with advice on exercise, evidence for efficacy is weak. Frequency and intensity of exercise are very important for reducing HbA1c: the more frequent and the higher the intensity, the more effective it is – but these factors may be lower when people are left to their own devices.

Physical activity on prescription (Physical Activity Referral Service or PARS) is also used – health screening and advice with access to exercise sessions led by qualified exercise professionals. Evidence here is also weak, probably due to poor uptake and adherence.

Home-based exercise programmes are another option. Dr Cocks reported on research he and his team have conducted looking at whether a HIIT (high-intensity interval training) programme at home can be an effective intervention. HIIT needs no equipment, it’s short in duration and requires little space. When studying the efficacy, they looked at adherence (whether the patient completed an exercise session) and compliance (whether they achieved the prescribed duration and intensity).

Using a progressive HIIT programme that they developed, they carried out feasibility studies – one on people with obesity and elevated cardiovascular risk and another on people with type 1 diabetes. Adherence and compliance were good and fitness increased.

To establish the effectiveness within a healthcare setting, they conducted a trial in which participants with elevated cardiovascular risk were offered either a traditional PARS prescription or the home-based HIIT programme. Patients could self-select and 56% of people chose the home-based programme because of the convenience, time-saving and flexible nature. Both groups were asked to do the session three times a week.

Heart-rate monitors were used to monitor their compliance and adherence. The percentage of recorded sessions meeting prescription was around 80% in both groups, showing that people can exercise unsupervised at home. In both groups, despite poor adherence, they saw clinically relevant improvements in cardiorespiratory fitness – 21% in the PARS group and 16% in the home-based group, and this was maintained in the three-month follow up, showing that home-based HIIT is a viable option for inclusion within PARS to increase patient choice.

The next stage of research was to establish whether mHealth technologies could influence adherence. The World Health Organisation (WHO) has defined mHealth as the ‘use of mobile and wireless technologies to support the achievement of health objectives’.

Participants were offered mHealth-supported counselling or online exercise resources. Those who had counselling/mHealth technology were given a Smartwatch that gave them instruction on when and how hard to exercise, feedback and monitored activity. Those in the online group were provided with a progressive online programme with written info and videos.

The mHealth group exercised more than they were asked to and Dr Cocks commented that he’d never seen this before in the literature. Compliance was higher in the mHealth group and, of sessions recorded, 90% were done according to prescription in the mHealth group compared with 70% in the online resources group. The data therefore suggests that mHealth can be used to support home-based interventions.

Their current work is looking at efficacy in patients with type 2 diabetes in a 6-month intervention.

The ingredients of success: self-monitoring and motivational interviewing

A presentation from Mary Jung, associate professor in the School of Health and Exercise Sciences at the University of British Columbia, tied in nicely with the above. Her talk was titled How Can We Get Everyone Active? Stop Telling, Start Listening.

She has a special interest in reducing risk of developing type 2 diabetes. While 80% of type 2 diabetes is preventable by adopting a healthy lifestyle, we don’t need to look far into the literature to see that many behavioural interventions fail. Why? Often because we fail to acknowledge the complexity of human volitional behaviour, said Professor Jung, and exercise is prescribed with no tailored support.

So how can we succeed? The most effective behaviour-change technique identified in the literature is self-monitoring, leading to the most potent changes and maintenance of weight loss.

Self-monitoring as a behaviour-change technique (BCT) has changed a lot in recent years with the advent of mHealth technologies – they cut down on paperwork and AI can be used to interact with patients.

As an example, she highlighted a pilot study looking at continuous glucose monitoring (CGM) to see if it could help people self-monitor and increase exercise frequency. The control group had a standard conversation about exercise and healthy lifestyle, but the intervention group wore a CGM device and were taught about the importance of self-monitoring and their glucose and exercise levels. The intervention group engaged in more exercise and their future exercise engagement was much higher.

Professor Jung and team deliver a programme called Small Steps for Big Changes and she discussed this in detail to demonstrate that mode of delivery matters. It comprises:

• Six brief, one-to-one counselling sessions over three weeks
• One-, six- and 12-month follow-ups
• Evidence-based diet and exercise information
• Evidence-based BCTs
• Motivational interviewing

They use an mHealth app to track diet and exercise, as it boosts self-monitoring and goal-setting feedback and a dietary component can be added in.

In counselling sessions, they use motivational interviewing (MI). This is a collaborative conversation that empowers the patient and strengthens their motivation and commitment to change, rather than the clinician telling them what they should be doing. It’s about arranging conversations so that people talk themselves into change based on their own values and interests.

Dr Jung commented that healthcare professionals (HCPs) often feel they don’t have the time to develop a new counselling technique or time in appointments to use MI. However, using it actually takes much less time than using a prescriptive approach. When an HCP prescribes, they’re often met with reluctance and questioning but when they use questions such as, ‘what’s going to work for you?’, the patient moves quickly from ambivalence to thinking for themselves and becomes motivated to meet their own goals.

In just six sessions of their programme, they see a high rate of success: 95% completion rate, 8 lb weight loss and maintenance at six months, 41 m increase in six-minute walk test at six months, 4/2 mmHg lower blood pressure at six months, increased vegetable consumption, decrease in sweets and white, refined carbs consumption, and an increase in self-reported exercise.

“Always act with compassion and empathy,” Professor Jung concluded. “If you’ve ever found it hard to stick to an exercise programme, imagine how hard it might be for the patient.”