1 Physical Activity and Inactivity in Individuals with Pre-Diabetes Andrea M. Kriska, PhD AADE15 New Orleans, LA August 5 - 8, 2015 Physical Activity/Nutrition/Sedentary Time Physical Activity/Nutrition/Sedentary Time Effect of Westernization on Health; Falling Out of Balance Total Activity Sedentary Moderate/ Vigorous Light + The Activity Spectrum Two people with similar amounts of moderate/vigorous activity but vary by time spent in light and sedentary Person A Light Sedentary Person B Moderate/Vigorous Light Sedentary Moderate/Vigorous Type 2 diabetes The BURDEN of a not being physically active is extensive: Coronary heart disease (CVD) Certain types of cancer Gallbladder disease Bone health Mental health Osteoarthritis Quality of life Weight management
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Physical Activity and Inactivity in Individuals with Pre-Diabetes
Andrea M. Kriska, PhD
AADE15New Orleans, LAAugust 5 - 8, 2015
Physical Activity/Nutrition/Sedentary TimePhysical Activity/Nutrition/Sedentary Time
Effect of Westernization on Health; Falling Out of Balance Total Activity Sedentary
Moderate/ Vigorous
Light+
The Activity Spectrum
Two people with similar amounts of
moderate/vigorous activity but vary by
time spent in light and sedentary Person A
Light
Sedentary
Person B
Moderate/Vigorous
Light
Sedentary
Moderate/Vigorous
Type 2 diabetes
The BURDEN of a not being physically active is extensive:
Coronary heart disease (CVD)
Certain types of cancer
Gallbladder disease
Bone health
Mental health
Osteoarthritis
Quality of life
Weight management
2
CLINIC PROCEDURES:
♦ Oral Glucose Tolerance Test
♦ Weight and Height (BMI)
♦ Waist-to-Thigh Ratio
♦ Physical Activity Questionnaire
Diabetes Incidence Rates by Total Physical Activity Levels(Follow-up of 1728 Pima Indians, without Diabetes at Baseline)
0
20
40
60
80
100
15-24 25-35 35-44 45-up
Low High
Age Groups (yr)
Incid
en
ce
/10
00
pe
rso
n y
ea
rs
Women (p=0.01)
Kriska, AJE, 2003
Diabetes Prevention Program
The Evidence Behind the Translation Efforts
The Landmark Study that DemonstratedLifestyle Intervention Prevented Type 2 Diabetes
DiverseAge
Ethnic/Racial
Geographic
• 3,234 individuals at unhealthy higher weights and with pre-diabetes from across 27 US sites
• Randomly assigned to one of 3 arms: lifestyle, drug (metformin), or placebo.
3
rogram Goals� Lose 7% of body weight
� Do 150 minutes (2½ hours) of moderate intensity physical activity per week
(These were minimum goals)
PPhysical Activity
RecommendationsPhysical Activity
Recommendations
“Every US adult should accumulate 30minutes or more of moderate-
intensity physical activity on most,preferably all, days of the week.”JAMA, 1995
A recommendation from theCenters for Disease Control and Prevention and the American College of Sports Medicine
Diabetes Prevention Program Results:
Mean Change in Leisure Physical Activity
*NEJM, Feb 2002
0
2
4
6
8
0 1 2 3 4
PlaceboMetformin
Lifestyle
Years from Randomization
ME
T H
ou
rs/W
ee
k
revention
� 58% decrease in diabetes incidence in the lifestyle vs. placebo groups
� Worked across all subgroups, including age, sex, baseline BMI and ethnicity/race
P
Diabetes Incidence Rates by EthnicityDiabetes Incidence Rates by Ethnicity
0
4
8
12
Caucasian(n=1768)
AfricanAmerican
(n=645)
Hispanic(n=508)
AmericanIndian (n=171)
Asian (n=142)
Ca
ses/
10
0 p
ers
on
-yr
Lifestyle Metformin Placebo
The DPP Research Group, NEJM 346:393-403, 2002
0
4
8
12
25-44 (n=1000) 45-59 (n=1586) > 60 (n=648)
Ca
ses/
10
0 p
ers
on
-yr
Lifestyle Metformin Placebo
Diabetes Incidence Rates by AgeDiabetes Incidence Rates by Age
Age (years)
The DPP Research Group, NEJM 346:393-403, 2002
4
The DPP Research Group, NEJM 346:393-403, 2002
0
4
8
12
Male (n=1043) Female (n=2191)
Cas
es/
100
per
son
-yr
Lifestyle
Metformin
Placebo
Diabetes Incidence Rates by SexMetabolic Syndrome
National Cholesterol Education Program (NCEP) Adult Treatment Panel III:
• Clustering of abdominal obesity, atherogenicdyslipidemia, hypertension, and insulin resistance
• Defined as any 3 of the following risk factors
– Waist circumference >40" (men) or >35" (women)
– TG ≥150 mg/dL
– HDL-C <40 mg/dL (men); <50 mg/dL (women)
– BP ≥130/≥85 mm Hg
– FPG ≥100 mg/dLTreatment of High Blood Cholesterol in Adults. JAMA. 2001;285:2486/ NHLBI/AHA 2005
Reduced Cumulative Incidence of the Metabolic Syndrome
0 1 2 3 4
Year from randomization
0.00
0.15
0.30
0.45
0.60
0.75
Cum
ula
tive incid
ence o
f
meta
bolic
syn
dro
me (%
)
Lifestyle
Placebo
Metformin
Risk reduction:Lifestyle vs. Placebo 41%#
Metformin vs. Placebo 17%*Lifestyle vs. Metformin 29%#
* p < 0.05; # p < 0.001
Orchard, et al., Ann Int Med ,142(8) 611-619, 2005
In the DPP, an investigation was done to examine
the impact of change in weight and activity on risk of developing diabetes among lifestyle participants.*
• Weight change significantly predicted the reduction in diabetes incidence (for every kg of weight, there was a 16% reduction in risk).
• Achieving the PA goal but not weight loss goal resulted in a 46% reduction in diabetes. PA was also important for weight loss.
*Hamman et al; Diabetes Care, 2006
DPP to DPPOS
June 1996 9
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DPP
Recruitment
Began
DPP
Enrollment
Complete
DPP
Results
DPPOS
BeganDPPOS
Midpoint
Results
DPPOS
Visits
End
DPPOS
Accelerometer
Ancillary
Study Begins
� January - June 2002; all participants were offered a group version of the DPP Lifestyle Intervention Program
� September 2002-present; the DPPOS study began
(N = 3251; 88% of all original DPP groups)
� June 2010 – July 2012; the DPPOS Accelerometer
Ancillary Study was conducted
•2766 DPP participants joined DPPOS(88% of all original DPP groups)
•DPPOS Goals:
•Diabetes delay or prevention
•Prevention of diabetes complications such as kidney, eye and nerve problems, and heart disease
DPP Outcomes Study(DPPOS)
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DPPOS Incidence of Diabetes
0 1 2 3 4 5 6 7 8 9 10
010
20
30
40
50
60
Year since DPP Randomization
Cu
mula
tive
Inc
ide
nce
(%
)
PlaceboMetformin
Lifestyle
Lancet 2009. 374(9702): p. 1677-1686.
DPPOS AccelerometerAncillary Study
• Designed to incorporate an objective measure of physical activity and sedentary time as part of the Diabetes Prevention Program Outcomes Study (DPPOS)
• Conducted at 23 of 26 DPP sites
• Open to all DPPOS participants who were not confined to a wheelchair, able to walk, and without significant cognitive impairment (per clinic staff)
Grant: NIDDK 5R01DK081345-03
Accelerometer
• Measures all intensities of movement throughout the day:–Inactivity – Sitting time–Light Activity–Moderate Activity–Vigorous Activity
• Best at capturing activities that resemble walking (and running)
Worn on a belt around the waist
Ph
ysi
cal
Act
ivit
y I
nte
nsi
ty
Measurement Tools
Low
Moderate
High
Sedentary
A. Kriska
Physical Activity Spectrum
So what do we know….
• We can prevent diabetes with lifestyle intervention
• Physical activity is a critical component of this intervention effort
So how about translation?
• Can we take this behavioral lifestyle intervention into the community and get successful results?
Met DPPCriteria
NHANESIII
Men & Women
Age > 24
BMI > 24
Impaired Glucose
Tolerance
EXPECTATIONS AS WE MOVE IN TO THE COMMUNITY
Kriska et al. MSSE, 2006
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Percent of women from the DPP and from
NHANES III reporting being physically inactive
over the past month
0
5
10
15
20
25
30
< 45 45-59 59+
NHANES III
DPP
Age Group
% I
nac
tiv
e
--0
2
4
6
8
10
12
14
16
18
20
< 45 45-59 59+
NHANES III
DPP
Age Group
% In
acti
ve
--
Percent of men from the DPP and from NHANES
III reporting being physically inactive over the
past month
Who is the group we are most interested in targeting?
Who is the group we are most interested in targeting?
Low Moderate High
Change in Activity from BaselineChange in Activity from Baseline
The Diabetes Prevention Support CenterUniversity of Pittsburgh
The DPSC guides community translation efforts thru facilitating all aspects of delivery of a modified DPP lifestyle intervention program, the Group Lifestyle Balance ™.
• Up-to-date one-year curriculum
• Curriculum approved by CDC Diabetes Prevention Recognition Program
• DVD version of core curriculum available
• Training and ongoing support for lifestyle coaches
Group Lifestyle Balance Translation Research Project
– University of Pittsburgh translational research study funded by NIH (Kriska, PI)
– Purpose: To formally evaluate delivery of the GLB lifestyle intervention research program in three very different community settings:
• Community Senior Centers
• Worksite
• Military
DPP-GLB Program EvaluationParticipant Eligibility
• ≥18 years of age
• No reported history of diabetes
• BMI ≥24kg/m2 (≥22kg/m2 for Asians)
• Pre-diabetes and/or the metabolic syndrome
• Pre-diabetes:
• Fasting glucose 100 mg/dL - 125 mg/dL and/or
• Hemoglobin A1c 5.7% - 6.4%
• Metabolic Syndrome (at least 3 of the following):
• Waist ≥35 (F) /≥40 (M) inches
• Blood Pressure ≥130 and/or ≥85 mm Hg (or on treatment)
• HDL Cholesterol <50 (F) / <40 (M) mg/dL
• Triglycerides ≥ 150 mg/dL)
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DPSC Translation Efforts:Group Lifestyle Balance Program
• One-year group program adapted and updated from the DPP Lifestyle Balance curriculum
• 82% report how PA was assessed (predominantly self-report, subjective measures)
• 60% report PA-related outcomes (most often percent of participants meeting goal)
Eaglehouse et. al., Preventive Medicine, 2015
Do 150 minutes (2½ hours) of moderate intensive physical activity
per week
Do 150 minutes (2½ hours) of moderate intensive physical activity
per week
♦♦ Aerobic activity (similar to a brisk walk) is the foundation activity
♦♦ Try to spread out over at least 3 days a week
♦♦ Do for at least 10 minutes at a time
♦♦ Intensity should be similar to a brisk walk
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What Impact Does Season/Weather Have on Physical Activity
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2
4
6
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10
12
14
16
18
ME
T h
r-w
k
Ap
r
Ma
y
Jun
Jul
Au
g
Sep
t
Oct
No
v
Dec
Jan
Feb
Ma
r
Ap
r
Ma
y
Jun
Jul
Au
g
Sep
t
Oct
2002 2003
Past Week MAQ at Baseline Clinic Visit (n=500)
Newman; MSSE 2009
Delayed Participants (N=71) PA Levels Prior to Intervention
0
5
10
15
20
Randomization End of Delay
ME
T-h
ou
rs p
er w
eek
of
PA
fro
m t
he
MA
Q
Winter
Summer
Winter to Summer p-change<0.0001; MAQ=Modifiable Activity Questionnaire
Lessons Learned
• Both efficacy trials, including the DPP, and effectiveness trials (like our GLB efforts in the community) suggest that we can increase participants’ PA levels
• DPP and GLB provide evidence that this improvement in PA levels may have a significant impact on health outcomes.
US Physical Activity Guidelines for Adults
1995 ACSM & CDC
recommendation (Pate et al.)
≥ 30 minutes of moderate-vigorous intensity activity on
most, preferably all days; equivalent to 150 minutes/week
≥ 30 minutes of moderate-vigorous intensity activity on
most, preferably all days; equivalent to 150 minutes/week
1996 Surgeon General’s Report on Physical Activity & Health
US Physical Activity Guidelines for Adults (cont.)
2007 ACSM & AHA recommendation (Haskell et al.)
≥ 30 minutes of moderate intensity activity on ≥ 5 days;
equivalent to 150 minutes/week
≥ 20 minutes of vigorous intensity activity on ≥ 3 days;
equivalent to 60 minutes/week
(OR) (AND)Muscle
strengthening exercises
≥ 150 minutes of moderate intensity
activity/week
≥ 75 minutes of vigorous intensity
activity/ week
Muscle strengthening
exercises
(OR) (AND)
2008 CDC Physical Activity Guidelines for Americans
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Strength is clinically important…
• Biological aging: lose strength and lean body mass
• Strategies to maintain muscular strength enhance mobility and functional independence further into old age are important
Slides: Marni Armstrong
RCT evidence
• In a systematic review (n=7) all but one study reported strength improvements of at least 50% after completing resistance training in people with type 2 diabetes. Gordon, Diab Res Clin Prac. 2009;83(2):157-17
• Meta-analysis (n=4) reported 0.57% reduction in HbA1c in studies where resistance training alone was compared against a control. Umpierre, JAMA, 2011; 305, (17); 1790-99
A COMBINATION OF BOTH AEROBIC AND RESISTANCE APPEARS TO BE
THE MOST BENEFICIAL…
DARE trial: The Diabetes Aerobic and
Resistance Exercise Trial (n=251)
0.07
-0.3
-0.43
-0.9-1
-0.8
-0.6
-0.4
-0.2
0
0.2
Control RT only AT only Combo
Ch
an
ge i
n A
1C
%
Exercise Group
Sigal RJ; Effects of aerobic training, resistance training, or both on glycemic control in type 2 diabetes: a randomized trial. Ann. Intern. Med. Sep 18 2007;147(6):357-369
HART-D: Health Benefits of Aerobic & Resistance
Training in Individuals with Diabetes
7.20
7.30
7.40
7.50
7.60
7.70
7.80
0 1 2 3 4 5 6 7 8 9
Month
Hb
A1
c,
%
Intention-toTreat Analysis (n=262)
Control
Resistance
Aerobic
Combo
Church T, JAMA. Nov 24 2010;304(20):2253-2262
Sitting Too Much Could be DeadlyResearch is preliminary, but several studies suggest people who spend most of their days sitting are more likely to be fat, have a heart attack or even die.By: Maria Cheng The Baltimore Sun
Are you sitting down? It's slowly killing you Regular workouts don't decrease death risk if you're also a couch potato LifeScience Staff MSNBC.COM
Stand Up While You Read This!By OLIVIA JUDSONNYTIMES
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Typical PA Intensity Break-down During a 24 Hour Time Period
Moderate-vigorousintensity PA
Sleep
Sedentary behavior
Light intensity PA
Objectively Measured
Owen et al. 2010
As populations become more sedentary,
are we approaching the point where we should focus our intervention efforts on
decreasing sedentary time
in addition to increasing
moderate/vigorous physical activity
Sedentary Behavior in youth with T2D compared to Obese youth in NHANES
MalesFemalesKriska et al. Pediatrics, 2013
Av
era
ge
sed
enta
ry
beh
av
ior
mea
sure
d
by
a
ccel
ero
met
er
in
min
ute
s/d
ay
* p<0.05
DPP: TV watching assessed by MAQ (n=3035)
Rockette-Wagner et al., Diabetalogia 2015 Jun;58(6):1198-202
-35
-30
-25
-20
-15
-10
-5
0
5Placebo
Metformin
Lifestyle
Av
erag
e m
inu
tes/
day
Mean change from baseline in minutes/day of TV watching over follow-up (average 3.2 yrs.) by study arm
p-dif < 0.05
DPP: TV watching assessed by MAQ (n=3035)
Rockette-Wagner et al., Diabetalogia 2015 Jun;58(6):1198-202
• The risk of developing diabetes increased 3.4% with each hour per day of reported TV watching; controlling for sex, age, and reported leisure activity (p <0.05)
• This risk was attenuated to 2.1% (ns.) when also controlling for weight.
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Gaps in Knowledge Leading to Next Steps
Specifically, what if we replaced the goal of increasing moderate PA levels with sitting less in community lifestyle intervention programs in diverse settings?
Would we still see significant changes in weight loss and diabetes and cardiovascular disease risk factors?
What about sedentary behavior?
DPP-GLB Translation Team
Vincent Arena, PhDMarni Armstrong, PhDKatie BenchoffYvonne Eaglehouse, MSJustin Kanter, BSKaye Kramer, DrPHAndrea Kriska, PhDBecky Meehan, MS, RD, LDNRachel Miller, MS
Diabetes Prevention Support CenterGraduate School of Public HealthUniversity of Pittsburgh3512 Fifth AvenuePittsburgh, PA 15213412-383-1286 [email protected]
