THE DIABETES COMMUNITY EXERCISE PROGRAMME - SUPPORTING MARGINALISED PEOPLE WITH HIGH HBA1C, MULTIMORBIDITY AND POLYPHARMACY TO ENGAGE IN EXERCISE

C. Higgs¹, L. Hale¹, A. Gray², J. Mann³, R. Mani¹, T. Sullivan⁴, D. Keen¹, T. Stokes⁵

¹University of Otago, School of Physiotherapy, Dunedin, New Zealand, ²University of Otago, Biostatistics Centre, Dunedin, New Zealand, ³University of Otago, Otago Medical School, Dunedin, New Zealand, ⁴University of Otago, Department of Preventive and Social Medicine, Dunedin, New Zealand, ⁵University of Otago, Department of General Practice and Rural Health, Dunedin, New Zealand

Background: Type 2 diabetes (T2D), a highly prevalent non-communicable disease (NCD), significantly impacts health and quality of life. Additionally, people with T2D frequently present with multimorbidity. T2D non-pharmaceutical management includes evidenced-based guidelines around lifestyle changes focusing on healthy eating, exercise engagement, education and support. Despite such guidelines health inequities remain in New Zealand (NZ) with high prevalence of T2D amongst Māori (7.9%) and Pacific (13.6%) people. Needed are studies evaluating culturally appropriate programmes including long-term exercise engagement.

Purpose: The Diabetes Community Exercise Programme (DCEP) was developed with particular attention towards equitable access and supporting Māori and Pacific people and those from deprived circumstances to attend. DCEP is an interprofessional primary care rehabilitation programme, led by a physiotherapist and nurse, to support people with T2D and associated multimorbidity to engage with exercise and education in a safe and welcoming environment. Here we report whether DCEP (plus usual care) was more effective than usual care in improving 1-year glycaemic control and discuss the relevance of the findings to physiotherapy.

Methods: The design was a randomised, two-arm, parallel, open-label trial with blinding of outcome assessor and data analyst. Participants (age +35years) with T2D were recruited from two NZ communities and randomised to DCEP or usual care. DCEP participants attended two-hour sessions of exercise and education over 12-weeks twice-weekly, and then a twice-weekly maintenance exercise class for a further 12-months. The primary outcome was between-group differences in mean changes of glycated haemoglobin (HbA1c) from baseline to 1-year follow-up with intention-to treat analysis.

Results: Of 294 people screened, 165 (mean age 63.8, SD16.2 years, 56% female, 78.5% European, 14% Māori, 6% Pacific, 27% most deprived) were baseline evaluated, randomised, and analysed at study end (DCEP = 83, control = 82). Multimorbidity (≥2 long-term conditions) and polypharmacy (≥5 medications) were high (82%, 69%). Adherence of the 12-week programme was good (41% attended >80% available sessions) and no adverse events reported. No statistically significant between-groups differences in HbA1c (mmol/mol) change at 15 months (mean 3% higher in DCEP, 95% CI 2% lower to 8% higher, p =0.23) were found.

Conclusions: DCEP was not effective in improving glycaemic control, possibly due to insufficient exercise intensity. This study specifically focussed on equity, enabling attendance of those that experience inequities in health delivery and poor health outcomes. We reached ethnic representation in our Southern NZ region (Māori 10.8%, Pacific peoples 2.3%) and over a quarter of our cohort were living in the most deprived areas. DCEP, led by a physiotherapist and nurse, might support engagement in exercise of marginalised people with high Hb1Ac levels, multimorbidity, and polypharmacy.

Implications: For NCD’s such as T2D, people need access to an affordable intervention that they are comfortable to engage with lifelong. Perhaps for populations where equity and cultural accessibility are important, lifestyle interventions for T2D (such as exercise, diet, mental health) should first focus on wellbeing indicators and include outcomes of wellbeing, measures of confidence to take control of their own health and an indicator of long-term programme engagement.

Funding acknowledgements: This research project was funded by the Health Research Council of New Zealand.

Keywords:
Type 2 Diabetes
Health Equity
Exercise

Topics:
Non-communicable diseases (NCDs) & risk factors
Primary health care
Health promotion & wellbeing/healthy ageing/physical activity

Did this work require ethics approval? Yes

Institution: New Zealand Government, Ministry of Health

Committee: New Zealand Health and Disability Ethics Committee.

Ethics number: (17/CEN/241)