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A programme to increase physical activity in people at risk of developing diabetes was no more effective in the long term than an information leaflet. Research suggested that, when the programme was combined with calls and text messages, it led to a small but meaningful increase in activity after 1 year. The effect was not sustained at 4 years.

People who are physically active are less likely to develop type 2 diabetes. The programme, called Walking Away from Diabetes, gives advice about physical activity and healthy eating, along with information about how these behaviours can reduce diabetes risk. It aims to promote understanding of diabetes risk, and increase the number of steps people take each day.

The Walking Away programme is delivered in some parts of the country to help prevent diabetes in people at high risk. It informed the development of the current Healthier You programme.

Researchers explored whether the programme increased long-term physical activity (4 years). They also looked at whether adding text messages and phone calls (Walking Away Plus) made the programme more effective. Both versions of the programme were compared with an information leaflet.

At 1 year, people in the Walking Away Plus group took 500+ more steps per day than either leaflet group. There was no difference in the Walking Away only group. However, the effect in the Walking Away Plus group was not sustained at 4 years. People from the most socially deprived areas, who typically need most support to increase activity levels, were least likely to benefit from the Walking Away Plus programme .

The team concluded that adding text messages and phone calls to the Walking Away programme made it no more successful in increasing people’s step counts at 4 years. New strategies are therefore needed to help people maintain a healthy lifestyle, they say.

More information about type 2 diabetes is available from the NHS website.

What’s the issue?

Almost 5 million people in the UK have type 2 diabetes (a long-term condition that causes high levels of sugar in the blood). A further 13 million are at high risk of developing the condition, but they can reduce their risk with physical activity and a healthy diet. Less sedentary behaviour (sitting still) might also help.

Early studies have investigated the short-term impact (less than a year) of programmes to increase physical activity. However, people need to participate in programmes over the long-term. Some groups of the population (such as some ethnicities) are known to be less likely to participate.

The Walking Away from type 2 diabetes programme is a 3-hour group session, which provides education about physical activity and healthy lifestyles. It aims to encourage people to take extra steps (up to 3000 extra) each day. People are given pedometers to record their steps and encouraged to complete step diaries. They can also attend an annual refresher session.

‘Walking Away Plus’ is the same programme, but coupled with motivational text messages and calls. These prompt people to set activity goals and text their step counts. Participants receive automated feedback on their progress.

A previous study by the group showed that the Walking Away programme increases activity at 1 year. The present research aimed to establish whether the programme is effective in the long term, and whether adding text messages and telephone calls increases the benefits.

What’s new?

The study was carried out in the East Midlands (which has a large ethnic minority community), and Cambridgeshire. All 1,366 participants had high blood sugar levels recorded previously, and were at risk of developing type 2 diabetes. Half (49%) were women and 25% were South Asian. A few (5%) were from other ethnic minority groups. The average age was 61 years.

Participants received the Walking Away programme, Walking Away Plus (with texts and calls), or a leaflet about diabetes prevention and the importance of physical activity. Participants who attended Walking Away or Walking Away Plus, were given a pedometer to help them monitor their physical activity. The step counts and overall physical activity levels of all participants were also measured by the researchers at 1 and 4 years. Weight loss and other health changes were also measured at these time points.

At 1 year, people on the Walking Away programme had not increased their step count compared with the leaflet group. Those on Walking Away Plus took slightly more steps per day than the leaflet group (an extra 547 steps). They were also more likely (1.6 times more) to achieve the UK Government physical activity target of 150 minutes per week of moderate-to-vigorous physical activity.

At 4 years:

  • daily step counts were similar in all groups; the Walking Away group took 303 more steps, and Walking Away Plus group took 317 more steps than those receiving the leaflet, but these differences were not meaningful
  • moderate-to-vigorous physical activity levels were the same in all groups
  • people in the Walking Away group lost more weight (by 1 kg), reduced their waist size (by 2 cm) and reduced their body fat (by 1%) more than the leaflet group; these differences were not seen with Walking Away Plus
  • the Walking Away Plus group had a small decrease in blood fats (triglycerides) and the Walking Away group had fewer markers of liver damage; both groups slightly increased their intake of fruit and vegetables, and their understanding of diabetes risk
  • type 2 diabetes developed in similar numbers of people in the 3 groups.

Age, ethnicity, sex, family history of diabetes, diabetes risk and obesity did not affect the results.

However, social deprivation had an impact on the number of steps. At 4 years, people on Walking Away Plus who were from more socially deprived areas, took 370 fewer steps (on average) than those who received the leaflet. Those from wealthier areas took 480 more steps than those who received the leaflet.

Why is this important?

This was the largest and longest-running study of a programme to increase physical activity in people at high risk of type 2 diabetes. It found that, at 12 months, the Walking Away programme did not increase step count. Extra features, such as telephone calls and interactive text messages, slightly increased the number of steps in the short-term (1 year), but not in the long-term (4 years). These results are similar to other research, showing small or no long-term benefits from physical activity programmes.

However, the researchers say that even the small increase in steps with Walking Away Plus after 1 year could have a positive impact on health.

Social deprivation reduced the impact of the programme at both 1 and 4 years. The researchers suggest that people’s financial concerns may reduce their motivation to increase their step counts. They may also lack safe, well-lit and appealing surroundings to exercise in.

In the Walking Away group, weight loss was sustained over the long-term (4 years). However, the effect was less than is generally seen with weight loss programmes. And, since similar numbers in each group developed diabetes, the weight loss was not shown to impact people’s health.

The Walking Away Plus group did not lose more weight than the leaflet group. This could be because the additional calls and text messages focused on physical activity only. The researchers say this might have diluted messages about diet.

What’s next?

Many people in this study were still occasionally wearing their pedometers at 4 years (64% of those on Walking Away Plus; 50% of those on Walking Away programme). This suggests that people had engaged with the programme, but in general, they did not keep up with changes to their lifestyle. Further research is needed on how to help people sustain positive changes. Motivators may not be the same in different ethnic groups.

During the study period, NHS England rolled out ‘Healthier You: The NHS Diabetes Prevention Programme’. The Healthier You programme adopts aspects of Walking Away and members of this research team helped guide its implementation. An initial one-to-one assessment with a health and wellbeing coach is followed by further group or one-to-one sessions on prevention of type 2 diabetes. Sessions give advice about nutrition, physical activity, and strategies and tools to help sustain progress in the long term.

The PROPELS study suggests that benefits from such interventions may be difficult to sustain over the long term. More innovative ways are needed to keep people engaged with their health.

You may be interested to read

This Alert was based on: Khunti K, and others. Promoting physical activity in a multiethnic
population at high risk of diabetes: the 48-month PROPELS randomised controlled trial
. BMC Medicine 2021;19:130

The charity, Diabetes UK, provides information about type 2 diabetes.

The diabetes prevention programme being rolled out by the NHS: ‘Healthier You’: The NHS Diabetes Prevention Programme.

The impact of increasing daily steps: Paluch AE and others. Daily steps and all-cause mortality: a meta-analysis of 15 international cohorts. The Lancet Public Health 2022;7:3

Funding: This study was funded by the NIHR Health Technology Assessment programme.

Conflicts of Interest: The study authors declare no conflicts of interest.

Disclaimer: NIHR Alerts are not a substitute for professional medical advice. They provide information about research which is funded or supported by the NIHR. Please note that views expressed in NIHR Alerts are those of the author(s) and reviewer(s) at the time of publication. They do not necessarily reflect the views of the NHS, the NIHR or the Department of Health and Social Care.


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Comments

Study author

Research has already demonstrated the benefits of lifestyle interventions (such as healthy diet and more physical activity), but more research is needed into how to encourage the public to engage with and adhere to the advice given.

The results were similar in White and ethnic minority groups, which is encouraging. But we need to consider further why the most socially deprived were least likely to benefit.

The study took place during a period when there were rapid advances in mobile health interventions (such as using automated texts and calls). The UK now has the second highest number of people using smartphones in the world. We need to explore how to use this continuously advancing technology to deliver lifestyle advice, and to support monitoring.

Kamlesh Khunti, Professor of Primary Care Diabetes, University of Leicester; Tom Yates, Professor of Physical Activity, Sedentary Behaviour and Health, University of Leicester

Diabetes UK

Getting active is one of the key ways to prevent or delay type 2 diabetes. We know increasing physical activity levels, especially over the long term, can be a big challenge. This study helps us to understand what support works well and not so well, and indicates that a particular group-based intervention did not lead to long-term changes in activity levels in people at high risk of type 2 diabetes. The study also highlights that people living in socially deprived areas may have different support needs to reduce their risk of type 2 diabetes.

There is, however, a wealth of evidence showing that with the right support many type 2 diabetes cases can be delayed or prevented. The Healthier You: NHS Diabetes Prevention Programme provides participants with personalised support to manage their weight, eat more healthily and be more physically active and has been shown to be very effective in reducing the risk of type 2 diabetes.

Faye Riley, Research Communications Manager, Diabetes UK

Researcher

I work as a statistician on population-level physical activity and nutrition data. The reduced improvements at 4 years are typical of many programmes in this population. But the initial benefits, such as increased knowledge about diabetes, are interesting. They provide a platform for mobile and digital services to be used more routinely. I believe that mobile health components will become much more commonplace post-COVID. Adding mobile health to existing interventions is relatively easy to implement, and potentially very beneficial.

Public health messaging would need to be sustained and not repetitive to maintain interest. Support needs to be based on what patients want, but for this to happen, teams need to be resourced. Setting up and maintaining mobile and digital services is straightforward but can become burdensome if support is not available. Improvements in automated messaging is likely to help.

This approach could be valuable for much of the general population. People with pre-diabetes, or those seeking support for weight loss, could find it useful.

Cain Clark, Senior Research Fellow, Faculty Research Centre for Intelligent Healthcare, Coventry University 

Researcher

I am an epidemiologist with a special interest in life course influences on healthy ageing. This is effectively a negative finding (no long-term effect), and it is important that it is known by clinicians, carers, and healthcare and allied professionals involved in weight management, exercise, and diabetes programmes.

Holly Syddall, Senior Enterprise Fellow, NIHR Research Design Service, South Central, University of Southampton 

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