# Exercise as it relates to Disease/Exercise and its essential role in long-term health – How 30 minutes of walking every day is the perfect ‘first step’ to improve health outcomes of individuals with type II diabetes

This is an analysis and evaluation of the research paper by Catrine Tudor-Locke et al; Tudor-Locke C, Bell RC, Myers AM, Harris SB, Ecclestone NA, Lauzon N, Rodger NW. Controlled outcome evaluation of the First Step Program: a daily physical activity intervention for individuals with type II diabetes. International journal of obesity. 2004 Jan 1:113-9

## Research background

Type II diabetes mellitus is a disorder characterised by high blood glucose levels, primarily developed due to a sedentary lifestyle with little or no physical activity (PA). The onset of type II diabetes can increase the chances of further health complications. These may include but not restricted to coronary heart disease, stroke, atherosclerosis, and diabetic neuropathy. The purpose of this study was to assess if the implementation of a First Step Program (FSP) is effective in improving walking behaviour with individuals suffering from type II diabetes.
While there is no cure for type II diabetes, regular PA has been a widely acknowledged solution for the management and prevention of the disease. Despite this however, a significant percentage of this population are still physically inactive. A national survey found that 66% of individuals with diabetes reported non-regular leisure-time PA. Additionally, another study found almost 55% of those with type II diabetes reported no weekly PA via walking. As a result, low cardiovascular fitness and physical inactivity are the largest individual causes for mortality for men with type II diabetes.

## Research origin

The leading author of the study, Catrine Tudor-Locke, is a recognised world leader in objective PA assessment and promotion, and walking behaviour researcher. At the time of the study being published, she was working at Arizona State University East in the Department of Exercise and Wellness. She was also employed at the Canadian Centre for Activity and Aging. The research article was published by the International Journal of Obesity in October 2003. The intervention for this study was a behaviour modification program utilising goal setting, self-monitoring, and feedback, with the primary measurement of PA was steps/day using a pedometer. Given her specialty in pedometer and accelerometer-determined ambulatory activity captured as steps/day across the lifespan, Tudor-Locke was the correct person to lead the study. The findings of the article are very likely to remain accurate today, however the results presented may not be as significant if a larger population sample was used.

## Research type

The study was conducted in the form of a randomised controlled trial. This is a form of scientific experiment used in many studies to try and eliminate any sources of bias towards the effectiveness of an intervention, by randomly assigning a population sample to two or more groups. These groups are treated differently but are compared to the same measurements of the study. In this case, a randomised trial was appropriate as it determined whether a First Step Program improved walking behaviour amongst patients with type II diabetes. However, given the strict criteria used for the study, this intervention may not be effective for all diabetes patients. For example, patients under the age of 40 or those who were already part of an exercise program may not benefit from this intervention. Additionally, a longitudinal study including more groups of diabetic patients that match a less strict criteria would be more suitable to assess the validity of the intervention and how it affects patients complying to higher volume and intensity programs later on in their treatment.

## Research methodology

Patients from a diabetes education centre in Ontario, Canada were invited to take part in the part if they followed the following criteria: aged 40–60 y; minimum 3 months postdiagnosis of type II diabetes; treated by diet alone or by oral hypoglycaemic medications (not insulin); no PA limitations or documented heart conditions; not currently in an exercise program; and walked less than 8800 steps/day. At the conclusion of the experiment, 47 participants (male n= 26, female n= 21; mean age=52.9yrs) were assessed at both baseline and at the end of the intervention at 16 weeks. Five assessments were conducted on every patient, including PA using a pedometer, anthropometric measurements, resting heart rate and blood pressure, an oral glucose tolerance test, and blood samples for determination of insulin, haemoglobin A1c (HbA1c) and plasma lipid profiles. Smoking and educational status was also noted in the study.
A limitation to this study was that due to the strict criteria for the population sample, the intervention is not likely to be an effective strategy for the entire type II diabetic population. In a real-world context, the findings of the article may not be as significant as initially suggested.

## Basic results

The study hypothesised that a First Step Program would be effective in increasing levels of PA and improving blood pressure and waist girth. The results partially matched the presented hypothesis, as there was no evidence that the intervention significantly improved blood pressure. However, the program was successful in improving walking behaviour, consequently adding approximately 31 minutes of walking every day, and decreasing waist girth. As mentioned earlier, this intervention may only be effective for this sample selection, considering that type II diabetes is such a prominent disease. Furthermore, as stated in the paper, increasing PA volume and/or intensity would be necessary to improve long-term health outcomes in these patients. Future programs following these benchmarks may likely drastically lower the compliance to them amongst patients.
Mean physical activity, waist girth and blood pressure at baseline and after 16 weeks of intervention (FSP group n=24, control group n=23) :
| | FSP baseline | FSP week 16 | Control baseline | Control week 16 |
| Physical activity (steps/day) | 5723 | 9123 | 4965 | 5622 |
| Waist girth (cm) | 107.3 | 105.5 | 103.2 | 102.8 |
| Resting systolic | 133.2 | 135.7 | 131.4 | 130.7 |
| Resting diastolic | 81.5 | 81.1 | 78.9 | 78.1 |
The findings published in this research matches with similar studies. The utilisation of a pedometer-based intervention has previously worked in a population known to have little interest and high drop out rates in exercise programs. Regardless, PA is essential in the treatment and prevention of type II diabetes.

## Research conclusions

The study determined that a First Step Program was successful in increasing PA levels and lowering waist girth by improving the walking behaviour of patients. In accordance to the results, this type of change is very important to improve long-term health outcomes, making the intervention a perfect tool to start adopting a more physically active lifestyle and increase exercise volume and intensity later in treatment. Further research is important to determine realistic and responsive health outcomes for this population. Adjustments to the methodology may be necessary to validate these findings.

## Practical advice

A physically active lifestyle is one of the key factors in managing type II diabetes and minimising the risk of other health complications. Diabetic patients should try to engage in physical activity, even if it is only 30 minutes of extra walking. A First Step Program has shown to improve walking behaviour amongst a sample of the type II diabetic population, consequently increasing PA. Improvements to body composition, blood lipid profiles, hypertension and glycaemia control are all benefits to engaging in regular PA. However, exercise should be cautiously proceeded with professional assistance to ensure it can be performed safely.

## Further information/resources
#### Background information on type II diabetes

https://www.healthdirect.gov.au/type-2-diabetes
https://www.diabetesaustralia.com.au/type-2-diabetes

#### In depth article discussing pedometers and physical activity

https://files.eric.ed.gov/fulltext/ED470689.pdf

#### See also

Type I diabetes- https://www.diabetesaustralia.com.au/type-1-diabetes
Gestational diabetes- https://www.diabetesaustralia.com.au/gestational-diabetes
Obesity and overweight- https://www.who.int/news-room/fact-sheets/detail/obesity-and-overweight
List of diabetes complications- https://www.mayoclinic.org/diseases-conditions/diabetes/symptoms-causes/syc-20371444

## References

* ↑ Health Direct, (2019), Health Direct
* ↑ National Diabetes Data Group (US), National Institute of Diabetes, Digestive, Kidney Diseases (US). Diabetes in America. National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases; 1995
* ↑ Herman WH. Leisure-time physical activity patterns in the US diabetic population. Diabetes care. 1995;18(1):27-33
* ↑ Hays LM, Clark DO. Correlates of physical activity in a sample of older adults with type 2 diabetes. Diabetes care. 1999 May 1;22(5):706-12
* ↑ Wei M, Gibbons LW, Kampert JB, Nichaman MZ, Blair SN. Low cardiorespiratory fitness and physical inactivity as predictors of mortality in men with type 2 diabetes. Annals of internal medicine. 2000 Apr 18;132(8):605-11
* 1 2 Tudor-Locke C, Bell RC, Myers AM, Harris SB, Ecclestone NA, Lauzon N, Rodger NW. Controlled outcome evaluation of the First Step Program: a daily physical activity intervention for individuals with type II diabetes. International journal of obesity. 2004 Jan;28(1):113-9
* ↑ Tudor-Locke C. Taking steps toward increased physical activity: Using pedometers to measure and motivate. President's Council on Physical Fitness and Sports Research Digest. 2002 Jun
* 1 2 Tudor-Locke CE, Bell RC, Myers AM. Revisiting the role of physical activity and exercise in the treatment of type 2 diabetes. Canadian Journal of applied physiology. 2000 Dec 1;25(6):466-91
* ↑ Searle M, Ready E. Survey of exercise and dietary knowledge and behaviour in persons with type II diabetes. Canadian Journal of Public Health. 1991;82(5):344-8
1. Health Direct, (2019), Health Direct
2. National Diabetes Data Group (US), National Institute of Diabetes, Digestive, Kidney Diseases (US). Diabetes in America. National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases; 1995
3. Herman WH. Leisure-time physical activity patterns in the US diabetic population. Diabetes care. 1995;18(1):27-33
4. Hays LM, Clark DO. Correlates of physical activity in a sample of older adults with type 2 diabetes. Diabetes care. 1999 May 1;22(5):706-12
5. Wei M, Gibbons LW, Kampert JB, Nichaman MZ, Blair SN. Low cardiorespiratory fitness and physical inactivity as predictors of mortality in men with type 2 diabetes. Annals of internal medicine. 2000 Apr 18;132(8):605-11
6. Tudor-Locke C, Bell RC, Myers AM, Harris SB, Ecclestone NA, Lauzon N, Rodger NW. Controlled outcome evaluation of the First Step Program: a daily physical activity intervention for individuals with type II diabetes. International journal of obesity. 2004 Jan;28(1):113-9
7. Tudor-Locke C. Taking steps toward increased physical activity: Using pedometers to measure and motivate. President's Council on Physical Fitness and Sports Research Digest. 2002 Jun
8. Tudor-Locke CE, Bell RC, Myers AM. Revisiting the role of physical activity and exercise in the treatment of type 2 diabetes. Canadian Journal of applied physiology. 2000 Dec 1;25(6):466-91
9. Searle M, Ready E. Survey of exercise and dietary knowledge and behaviour in persons with type II diabetes. Canadian Journal of Public Health. 1991;82(5):344-8