Colon cancer and liver mets

OBJECTIVE -- There is enough evidence that physical activity is an effective therapeutic tool in the management of type 2 diabetes. The present study was designed to validate a counseling strategy that could be used by physicians in their daily outpatient practice to promote the adoption and maintenance of physical activity by type 2 diabetic subjects.

RESEARCH DESIGN AND METHODS -- The long-term (2-year) efficacy of the behavioral approach (n = 182) was compared with usual care treatment (n = 158) in two matched, randomized groups of patients with type 2 diabetes who had been referred to our Outpatient Diabetes Center. The outcome of the intervention was consistent patient achievement of an energy expenditure of >10 metabolic equivalents (METs)-h/week through voluntary physical activity.

RESULTS -- After 2 years, 69% of the patients in the intervention group (27.1 [+ or -] 2.0 METs X h/week) and 18% of the control group (4.1 [+ or -] 0.8 METs X h/week) achieved the target (P < 0.001) with significant (P < 0.001) improvements in BMI (intervention group 28.9 [+ or -] 0.2 versus control group 30.4 [+ or -] 0.3 kg/[m.sup.2]) and [HbA.sub.1c] (intervention group 7.0 [+ or -] 0.1 versus control group 7.6 [+ or -] 0.1%).

CONCLUSIONS - This randomized, controlled study shows that physicians can motivate most patients with type 2 diabetes to exercise long-term and emphasizes the value of individual behavioral approaches in daily practice.

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Many studies have shown that regular physical activity reduces the risk of coronary heart disease, stroke, colon cancer, and mortality from all causes (1,2). It is particularly advantageous in type 2 diabetes, and indeed, intervention trials have recently shown that diet plus exercise programs reduce the risk of developing diabetes by -60% in subjects with impaired glucose tolerance (3,4). In subjects with overt type 2 diabetes, diet and exercise are associated with more weight loss and less use of hypoglycemic medications than diet alone (5).

Despite this, many physicians do not spend time making an effort to convince type 2 diabetic subjects to exercise, probably because older adults comply poorly with their recommendations. In fact, adults with diabetes are less likely to engage in regular physical activity than the general adult population (6), and only 23% of older adults with type 2 diabetes reported >60 mm of weekly physical activity (7). The fact that people with diabetes have greater concerns with exercise than the general public might explain these negative figures, signifying the importance of proper education.

Regular physical exercise requires more time and effort than modifications to diet and taking medications, and patients often perceive it as a significant and difficult change in their lifestyle. For this reason, there is the need for reproducible interventions that can be used in daily ambulatory practice to motivate diabetic patients to regularly practice physical activity. In 1996, the U.S. Department of Health and Human Services reviewed all the interventions facilitating participation in physical activity (8), and consequently, we designed individualized counseling strategies based on the approaches that this panel of experts showed to be most effective.

To validate the long-term (2-year) efficacy of our intervention, we compared two groups of patients with type 2 diabetes who had been referred to our Outpatient Diabetes Center: a control group (n 158), treated with the usual care, and the intervention group (n = 182). The intervention aimed at a consistent patient achievement of an energy expenditure of >10 metabolic equivalents (METs)-h/week through voluntary physical activity. This target roughly corresponds to recommendations from the Centers for Disease Control and Prevention (CDC) and the American College of Sports Medicine (ACSM) (9), which both advise at least 30 mm of moderately intense physical activity most days and preferably every day. The results of the study have been analyzed as intention-to-treat.

RESEARCH DESIGN AND METHODS -- Eligibility criteria included type 2 diabetes diagnosed at least 2 years previously and age of 40 years or older. Patients who had illnesses that could seriously reduce their life expectancy and/or cardiac, liver, or renal failure were excluded from the study. All consecutive eligible patients attending our Outpatient Diabetes Clinic over a period of 2 months were randomized to the intervention group or the control group. Table 1 shows the clinical features of diabetic subjects and control subjects, which, at baseline, did not differ for age, sex, BMI, duration of diabetes, [HbA.sub.1c], type of therapy, and energy expenditure through voluntary physical activity.

All patients were seen by a physician in our Outpatient Diabetes Clinic. In accordance with our usual care criteria, in a 30-mm session, control subjects underwent a clinical examination and received counseling for diet and physical activity and the therapeutic prescription. The intervention group, in addition to the usual visit, received an additional 30 min of structured counseling recommending physical activity. During the first counseling session, the physician consecutively discussed with the patient the seven points listed below, which are summarized in the checklist (Table 2). The physician conducted the counseling using the checklist to strictly follow the protocol.

1. Motivation. The physician explained the benefits of exercise as reported by scientific literature for the general population and, specifically, for diabetic subjects, stressing those appealing most to the individual patient. Our efforts were designed 1) to convince the patient that regular physical exercise is the preeminent cure for type 2 diabetes and is beneficial for people in general, including physicians, and 2) to understand what positive expectations the individual patients held from this change in behavior.

2. Self-efficacy. Self-efficacy was promoted by patient collaboration in designing an individualized program of physical activity, based on age and physical state, they were confident they could positively perform. The program started with simple tasks (e.g., a 20-min walk daily) that were increased at weekly intervals, setting realistic personal goals.

3. Pleasure. We asked about the patient's previous experience of exercise. Several interchangeable indoor and outdoor aerobic activities (at least two to three different types) were proposed to identify those that were more appealing and to rule out those the patients perceived as boring.

4. Support. Approximately 70% of patients were accompanied to the initial counseling session by a partner. Partners were invited to share the sessions of physical activity with the patients. When patients came alone, we suggested they exercise with family members or friends. Although we did not offer any structured indoor or outdoor activity, we favored group walking by suggesting, especially to urban patients, the meeting points of known groups of walkers.

5. Comprehension. The physician listened to the patients to be sure that they had really understood the valuable advantages of the behavioral change. After the exercise program had been established, the physician posed a few questions to determine whether the patients had a really positive attitude toward the behavioral change. Enough time was spent listening to patients to recognize their uncertainties and perceived impediments to physical activity.

6. Lack of impediments. The physician helped the patient overcome potential obstacles to regular exercise. Instead of simply suggesting a solution, we invited the patients to solve the problem and their proposal was supplemented with our advice on time management strategies.

7. Diary. The patient was asked to record daily the type and time of physical activity they performed. On the subsequent visits (every 3 months), the diary was used to record the amount of physical activity, to encourage patients' self-efficacy, to increase the time or frequency of the exercise sessions, to overcome the practical problems related to exercise, and when required, to modify the treatment.

In the intervention group, the initial counseling session was followed, 1 month later, by a telephone call at home and, every 3 months, by an appointment of ~15 mm in the Outpatient Diabetes Clinic. The telephone call was made by the same physician who conducted the initial counseling to determine whether the patient was performing the physical activity as programmed. If the patient referred to problems or obstacles to physical activity, the phone call was prolonged to ~15 mm to reinforce the points discussed in the initial counseling session.