A supervised exercise programme for people with diabetes – Exercise Programmes
1 Most patients with diabetes do not take enough exercise.
2 Health professionals are o en poor at giving advice on exercise.
3 Supervised exercise programmes provide both encouragement and education.
4 The diabetes team, with help from a fitness professional, can set up a successful programme.
5 Patients who attend the programme can expect to see many health benefits.
* Exercise programme
* Health benefits
* Glycaemic control
Many clinical trials have demonstrated that exercise can be of great benefit to patients with diabetes. This article describes a supervised exercise programme that was set up to encourage patients with diabetes to become more active — a notoriously difficult task. An experienced exercise instructor provided the exercise component of the programme and the diabetes team provided education and advice. Patients who completed the 12-week course showed improvements in wellbeing, long-term glycaemic control and body physique.
Physicians as early as the 18th century recognised the therapeutic usefulness of exercise in the treatment of diabetes (Rollo, 1798). People with diabetes who exercise live longer and have reduced mortality from all diseases compared with those who do not (Blair, 1993).
In both type I and type 2 diabetes, regular exercise has been shown to reduce blood pressure, improve insulin sensitivity and reduce the risk of developing coronary heart disease (Agurs-Collins et al 1997; American Diabetes Association, 1997). In patients with type 2 diabetes, further benefits from regular exercise include improved glycaemic control, reduced triglyceride levels, weight reduction and improvement in the HDL:LDL (high-density lipoprotein: low-density lipoprotein) cholesterol ratio (American Diabetes Association, 1997; Halle et al, 1999; Walker et al, 1999).
Encouraging patients with diabetes to take regular activity is notoriously difficult. Before changes are seen, three steps need to be taken:
1. Individuals must be convinced that regular activity will benefit them.
2. They must then be educated about how to manage their diabetes so that they can exercise safely.
3. They must be given regular encouragement to maintain these changes.
At present the multidisciplinary team that cares for people with diabetes comprises doctors, diabetes specialist nurses (DSNs), dietitians and chiropodists. Surprisingly, there is no team member to provide motivation and expertise for increasing activity — a cornerstone of diabetes management.
A novel approach
In the latter part of 1998 we sought professional advice on how to encourage our patients to become more active. Jillian Furness, an EXTEND exercise instructor was approached. EXTEND is an exercise system developed by Mary Bagot Stack, which aims to encourage individuals with health problems to become more active (for more details see www.extend.org.uk). Together with the then lead diabetes consultant (Dr Burns-Cox) we set about deciding how best to approach this difficult task.
A supervised exercise programme seemed to be the best approach. An experienced exercise instructor would provide the exercise component, and the diabetes team would provide education and advice.
On 5 February 1999 we started our first exercise programme. This initial programme lasted 6 months and was successful in terms of patient satisfaction, and improving wellbeing and many cardiovascular risk factors (Holland et al, 2001). The programme has since been reduced to 3 months duration, and to date 119 people have completed it.
Patients are referred to the programme from a variety of sources — GPs, practice nurses and hospital clinics – and by direct patient self-referral. No exclusion criteria are applied, as one of the aims of the programme is to set up an activity course that is suitable for anyone to attend (Figure I). Participants do, however, have to be motivated to make changes, and are made aware that regular attendance is very important.
No physical screening is carried out before enrolment, but if participants self-refer, their GPs are contacted to ensure suitability for inclusion. Places are offered on a first come, first served basis.
The programme is run by a DSN, a specialist diabetes dietitian, a podiatrist, and a doctor. An EXTEND exercise therapist, employed from external sources, is responsible for organising and delivering individually tailored activity in a group setting.
The DSN and exercise therapist are the only two team members who attend each session; the other members are involved in one or more sessions during the course as required (see below).
Each course accommodates 20 people, who attend one morning a week for 12 weeks. Each session is made up of one hour of activity followed by half an hour of education.
The activity used in this programme is based on the EXTEND movement to music principles. At the start of the programme each individual is assessed by the exercise therapist for physical ability or limitations and the classes are tailored as much as possible to their needs. The intensity and duration of the activity increase during the course as participants’ confidence and ability improve, culminating in an activity session lasting about one hour.
Diabetes-related educational topics are covered during a 30-minute education session at the end of each week’s activity. Topics covered include hypoglycaemia and exercise, healthy eating, foot care, eye care and exercising safely (Diabetes UK, 2002).
Participation in the programme is voluntary, and peer group support is strongly encouraged. The team are very aware that, in order to achieve this, they must make every effort to put participants at their ease as many will have been inactive for a long time, and are likely to be very overweight or have physical disabilities. The non-competitive nature of the programme is constantly stressed, and the environment is kept informal, friendly and non-threatening. All participants are offered individual consultations with the DSN and dietitian if it is thought necessary.
Pre- and post-course, [HbA.sub.1c], total cholesterol, waist circumference and body mass index (BMI) are measured and a wellbeing questionnaire is administered (Bradley, 1996) to enable the team to assess the physical and psychological value of the programme.
At present, this programme is funded from the local diabetes charitable fund. The local primary care trust has been approached for further funding to continue the programme. The running cost for the 12-week programme works out at [pounds sterling]50 per participant.
Results are expressed as mean +/- standard error. Measurements before and after were compared by Wilcoxon matched pairs test.
To date, 145 individuals have been referred and 142 have taken up places when offered. Of these 119 (84%) have completed the 3-month course, with 23 (16%) dropping out before programme completion.
Of those who completed the programme, 45 (38%) were male and 74 (62%) female. Mean age was 61 years (range 31-75; Figure 2) and the majority of participants had type 2 diabetes (87%; Figure 3). Ninety-nine (83%) had known macrovascular complications and 39 (33%) microvascular complications.
The majority of participants felt much better at the end of the programme. In keeping with this, their wellbeing score improved significantly (21 [+ or -] 1 vs 26 + 1, p<0.000000001 (Figure 4).
Cardiovascular risk factors
The supervised activity programme significantly improved [HbA.sub.1c] (9.1 [+ or -] 0.9 vs 7.9 [+ or -] 0.2%, P<0.05), BMI (33.5 [+ or -] 0.6 vs 32.7 [+ or -] 0.7, P<0.05) and waist circumference (108 [+ or -] 2 vs 105 [+ or -] 2 cm; P<0.00000001), but had no effect on total cholesterol (5.1 [+ or -] 0.1 vs 5.0 [+ or -] 0.1, P=0.2) (Figure 4).
We have shown that it is possible to set up and run a successful supervised exercise programme. Individuals who complete the 12-week programme can expect to see an improvement in wellbeing, long-term glycaemic control ([HbA.sub.1c]) and body physique, with a reduction in both BMI and waist circumference. These findings show that the benefits previously demonstrated in clinical trials can be replicated in clinical practice.
Previous studies of exercise in patients with diabetes (Schneider et al, 1984; Wing, 1985; Schneider et al, 1992) have focused on individuals who are younger, more able and less obese than the majority of patients we see in our clinics. These studies showed that regular exercise improves insulin sensitivity and glycaemic control, and aids weight loss. Whether these benefits would translate to a population that was more representative of patients with diabetes remains to be seen. The mean age of patients attending our exercise programme was 61 years (range 31-75), the average BMI was 34 kg/[m.sup.2] (range 20-53) and many of the patients had not exercised for many years and had numerous disabilities. These individuals showed similar improvements to those seen in previous trials, indicating that exercise can be of benefit to the majority of individuals attending our clinics.
Government guidelines (DoH, 1992), based on previous trials, recommend that a minimum of 30 minutes exercise five times a week should be taken. Many individuals with diabetes feel that this target is simply impossible to reach, and are put off doing any exercise. The data from our exercise programme indicates that one session of activity for one hour a week can have substantial benefits for the health and wellbeing of patients with diabetes, suggesting perhaps that these guidelines may need to be revised for people with diabetes.
Many groups have suggested that patients with diabetes should be screened before undertaking exercise (Horton, 1996; Schneider and Guleria, 2000). Some have even said that patients with retinopathy and neuropathy should not exercise (Horton, 1996).
We do not screen the participants in our programme, in spite of the fact that many of them are known to have macrovascular and/or microvascular disease. We believe that activity is safe for everyone, provided that it begins at low intensity and builds up gradually. In the 3 years that the programme has been running, there have been no injuries during the activity classes. Furthermore, at follow-up meetings (patient are seen at 3-monthly intervals after leaving the course), no-one has mentioned an escalation in any of their symptoms.
Setting up a supervised exercise programme is one way of encouraging patients with diabetes to become more active. Individuals who attend such programmes should notice an improvement in their overall wellbeing as well as a reduction in their [HbA.sub.1c], BMI and waist circumference. Whether these individuals continue to exercise once they have completed the course remains to be determined.
[FIGURE 2 OMITTED]
[FIGURE 4 OMITTED]
Type of diabetes in the 119 individuals who have attended the 3-month
exercise programme so far.
Type 1 diabetes 12
Type 2 diabetes 104
Obesity alone 3
Total participants = 119
Note: Table made from pie chart
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Julie Holland is Diabetes Specialist Nurse at Frenchay Hospital, Bristol; Jillian Furness is EXTEND Exercise Therapist working in the Southwest (Bath and Bristol); Sally Griffiths is Senior Dietitian at Frenchay Hospital, Bristol; and Robert Andrews is Lecturer in Medicine at the University of Bristol.
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