Preliminary outcome evaluation of the First Step Program: a daily physical activity intervention for individuals with type 2 diabetes

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Abstract

The First Step Program uses simple and inexpensive pedometers to incrementally increase walking behaviors in sedentary individuals with type 2 diabetes. The pilot sample consisted of nine individuals (six women, three men; group mean age 53±6; group mean body mass index=32.9±3.4 kg/m2). A timed self-paced walk while wearing the pedometer allowed for the conversion of changes in pedometer steps per day to time in minutes per day. There was an immediate and dramatic increase in walking behavior (an average of 34.3 min of walking a day) that was sustained even 2 months post-intervention and after withdrawal of contact (an average of 22.6 min of walking a day). Improvements in other outcomes (systolic blood pressure and waist girth) support a valid change in behavior. Although preliminary, these results warrant further investigation of such approaches.

Introduction

Exercise has long been heralded as a cornerstone in the treatment of type 2 diabetes. Regardless, a large proportion of this target group is still sedentary [1], [2]. Although most believe they should get more exercise, many individuals with type 2 diabetes are not interested in joining formal, structured exercise programs [3], and long-term adherence is poor for those who do [4], [5], [6]. Individuals with type 2 diabetes desire specific instructions that are individualized according to ability and can be readily incorporated into daily life [7]. A targeted behavioral intervention aimed at incrementally increasing and sustaining an elevated pattern of daily physical activity holds the most promise for modifying characteristically sedentary behavior.

The American Diabetes Association [8] has endorsed the US Surgeon General’s recommendation [9] that all adults should accumulate 30 min or more of moderate intensity physical activity (equivalent to brisk walking) on most, if not all days of the week. To date, however, only two studies have empirically examined physical activity interventions with individuals with type 2 diabetes that approximate this recommendation. Yamanouchi et al. [10] used a pedometer to increase and monitor 6–8 weeks of accumulated daily walking in a hospital-based population (instructing patients to aim for 10,000 steps per day), and reported substantial improvements in body weight and insulin sensitivity. Walker et al., meanwhile, instructed participants to walk continuously for 60 min bouts, 5 days each week for 12 weeks [11]. These researchers reported improvements in fasting glucose levels, body composition, and blood lipid profiles. While these results are encouraging, neither study provided sufficient detail to guide clinical application. Furthermore, both interventions prescribed a universal goal or milestone (10,000 steps; 60 min walks) in contrast to the typical clinical practice of individual goal-setting.

The First Step Program was developed to meet the need for a lifestyle physical activity intervention that would be appropriate, acceptable, easy to deliver, and inexpensive. The program was developed in collaboration with diabetes educators and clients [7], based on the theoretical framework of social cognitive theory, especially the constructs of self-efficacy and social support. A summary of the critical elements of the underlying program theory (explaining what happens in the program and why) has been published [12] and is not the focus of this report. The program description (organization and delivery) has also been published [13] and is summarized here. Briefly, the First Step Program has two distinct phases (each lasting 1 month) aimed at adoption and adherence, respectively. The first phase consists of four facilitated group meetings. Following orientation, each session follows an iterative agenda: individual progress reports; a brief group walk (10 min the first night, 20 min the second night, and 30 min the last two sessions); group discussion to plan strategies; and individual goal-setting for the upcoming week. Inexpensive, accurate [14] electronic pedometers (Yamax Digiwalker SW-200; $20.00 US) are used as both the intervention and monitoring tool [15], [16]. Between group sessions, participants are encouraged to wear their pedometers during waking hours, to record accumulated steps per day on their personal calendars, and to reset the pedometer to zero each day. This process is called individual practice. The second phase, over the subsequent 4 weeks, consists of continued individual practice with minimal professional telephone contact.

Formative evaluation was conducted to determine the feasibility and acceptability of the First Step Program, and to guide modifications prior to full-scale implementation and wider dissemination [13]. Educators and clients both agreed that the program was simple and straightforward. The pedometer was perceived as a novel and highly useful motivator, a direct source of feedback, and a readily available memory prompt and reminder [13].

While a program must be feasible to deliver and appealing to participants, it is equally important to document effectiveness [17]. This article presents the findings of a preliminary outcome evaluation conducted concurrently with the formative evaluation. Given that the purpose of the First Step Program was to increase and sustain physical activity, the primary outcome indicator was change in physical activity, described herein as increased time spent walking. Secondary indicators included physical fitness and cardiovascular disease risk factors as corroborating measures of program effectiveness. Other outcomes of interest for this population (e.g. glucose, insulin, etc.) were not the focus of this pilot study focused on evaluating the effectiveness of this novel program with regards to the intended behavior change.

Section snippets

Participants

A convenience sample of nine individuals (six women, three men; group mean age 53±6; group mean body mass index=32.9±3.4 kg/m2) with recently diagnosed type 2 diabetes (8.7±3.7 month) were recruited on a voluntary basis (first come, first serve) from the Lawson Diabetes Center to participate in the pilot program. All had attended education programs in diabetes self-management which included such topics as: nutrition, blood glucose monitoring, medications, and exercise. Five were being treated

Results

Time spent walking (based on the average of 2198±282 steps taken during the self-paced 20 min group walk during the program) increased significantly from baseline (mid-point Δ=34.3 min per day) and remained elevated without weekly group meetings (post-intervention Δ=23.6 min per day), even into the follow-up period after pedometers had been returned and all contact was terminated (follow-up Δ=22.6 min per day). The calculated effect size was 1.1. Fig. 1 displays a composite of the four blinded

Discussion

The pilot First Step Program succeeded in elevating the daily physical activity levels of this obese and sedentary group of individuals with type 2 diabetes and led to sustained levels over a 2-month post-intervention follow-up period. Corroborating evidence (improvements in systolic BP and waist girth) supports a valid increase in physical activity and further documents the effectiveness of this novel approach. Moreover, the First Step Program is appealing to the target audience and is simple

Practice implications

Motion sensors, including pedometers and accelerometers, are considered to be objective assessments of physical activity [38], [39]. Pedometers are the less expensive ($10–50) option and their output correlates very well (r=0.80–0.93) with more expensive ($50–400 plus requisite hardware and software) accelerometers [40], [41]. Pedometers represent an acceptable and feasible way of objectively and continuously monitoring physical activity patterns, or adherence to daily physical activity goals,

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