Last week, the Centers for Disease Control and Prevention released a report on the percentage of adults with activity limitations. The report stated that adults aged at least 75 years are almost three times as likely as adults aged 65-74 years (11.0% versus 3.7%) to require the help of another person with activities of daily living (ADLs) and with instrumental activities of daily living (IADLs) (18.8% versus 6.5%). ADLs were defined as eating, bathing, dressing, or getting around inside this home. IADLs were defined as everyday household chores, doing necessary business, shopping, or getting around for other purposes. Although not specifically analyzed in this report, my clinical observations tell me that activity limitations among patients with diabetes are higher than those without.
Serendipitously, the New England Journal of Medicine recently published data from the Look AHEAD (Action for Health in Diabetes) study investigating the effects of a lifestyle intervention to improve fitness and decrease loss of mobility among diabetics. In this study, 5,145 overweight or obese adults between the ages of 45 and 74 years with type 2 diabetes were randomized to an intensive lifestyle intervention or an educational session control (N Engl J Med 2012; 366:1209-17).
The intensive lifestyle intervention was designed to achieve a mean weight loss from baseline of more than 7% and to increase the duration of physical activity to more than 175 minutes a week. Intervention components included: 1) a portion-controlled diet; 2) a multi-component approach to intervention (including behavioral techniques, diet modification, physical activity, and social support); 3) ongoing regular contact throughout the follow-up period; and 4) weight loss medication and advanced behavioral strategies for participants having difficulty achieving or maintaining weight loss. Moderate-intensity walking was encouraged as the primary type of physical activity. At four years, the lifestyle-intervention group had a relative reduction of 48% in the risk of loss of mobility, as compared with the support group (odds ratio, 0.52; 95% confidence interval, 0.44 to 0.63). Weight loss was slightly more influential in preventing loss of mobility than improved fitness, but both contributed to the effect.
Findings from this study have important implications for our clinical practice. First, physical activity was a cornerstone in this intervention and relied on unsupervised exercise. For our patients with diabetes, we can give the following exercise prescription: total of 175 minutes of moderate intensity (e.g., walking) exercise over at least 5 days a week with a minimum of 10 minutes per exercise session. Second, we can work toward removing barriers to exercise such as foot pain by assisting our patients in obtaining supportive footwear and writing prescriptions as necessary. Medicare will cover the cost of one pair of therapeutic shoes (diabetic shoes) and inserts for people with diabetes. Third, since weight loss plays a critical role in reducing mobility loss, we can use this information to motivate our patients to achieve an ideal body weight with dietary modifications (e.g., portion control plates, reducing carbohydrate consumption), exercise prescriptions, and possibly medications (e.g., orlistat).
Virtually all of our patients with diabetes want to remain in their current living environments. We now have data to motivate lifestyle changes to increase the probability that they can.
Jon O. Ebbert, M.D., is professor of medicine and primary care clinician at the Mayo Clinic in Rochester, MN. The opinions expressed are solely those of the author. Email: firstname.lastname@example.org.