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Behaviour change techniques
targeting diet and physical
activity in type 2 diabetes:
What's the evidence?
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3
What’s the Evidence?
Cradock, K., Olaighin, G., Finucane, F., Gainforth,
H., Quinlan, L., & Ginis K. (2017). Behaviour change
techniques targeting both diet and physical activity
in type 2 diabetes: A systematic review and meta-
analysis. International Journal of Behavioral
Nutrition and Physical Activity, 14(1), 18.
http://www.healthevidence.org/view-
article.aspx?a=behaviour-change-techniques-
targeting-diet-physical-activity-type-2-diabetes-
30175
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A Model for Evidence-
Informed Decision Making
National Collaborating Centre for Methods and Tools. (revised 2012). A
Model for Evidence-Informed Decision-Making in Public Health (Fact
Sheet). [http://www.nccmt.ca/pubs/FactSheet_EIDM_EN_WEB.pdf]
Stages in the Process of
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National Collaborating Centre for Methods and Tools. Evidence-Informed
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Poll Question #2
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Searchable Questions Think “PICOS”
1.Population (situation)
2.Intervention (exposure)
3.Comparison (other group)
4.Outcomes
5.Setting
How often do you use Systematic Reviews
to inform a program/services?
A. Always
B. Often
C. Sometimes
D. Never
E. I don’t know what a systematic review is
Poll Question #3
Kevin Cradock, PhD student,
National University of Ireland,
Galway
Systematic Review & Meta-
analysis
Affiliations & Collaborators
Affiliations & Collaborators
Kevin A. Cradock
Human Movement Laboratory, NUI Galway,
Physiology, School of Medicine, NUI Galway,
Electrical & Electronic Engineering, School of Engineering & Informatics, NUI Galway
Professor Gearóid Ó Laighin
Electrical & Electronic Engineering, School of Engineering & Informatics, NUI Galway,
National Centre for Biomedical Engineering Science, NUI Galway
Professor Francis M. Finucane
Bariatric Medicine Service, Galway Diabetes Research Centre, HRB Clinical Research
Facility
Professor Kathleen A. Martin Ginis
Assistant Professor Heather L. Gainforth
School of Health and Exercise Sciences, The University of British Columbia, Canada
Dr Leo R. Quinlan
Physiology, School of Medicine, NUI Galway
Funding Sources
Funding
We wish to thank the Irish Research Council (IRC) for
funding this project (Project ID: GOIPG/2013/873).
Session Outcomes
1 Background / introduction
2 Research methods
3 Results
4 Conclusions
5 Future directions
6 Questions
Background / Introduction
• Changing diet and physical activity
behaviour is one of the cornerstones of
type 2 diabetes treatment, but changing
behaviour is challenging.
Incidence
• Type 2 diabetes is one of the fastest growing and
largest global health burdens.
• In 2015, there were 415 million people with
diabetes worldwide (91 % of which were type 2
diabetes) with figures expected to rise to 642
million by the year 2040, [1] which easily
surpasses earlier predictions in 2004 of 366 million
by 2030 [2].
• A 2010 global analysis of mortality reported that
1.3 million deaths worldwide were due to diabetes
that year, twice as many as in 1990 [3].
Diagnosis
• Type 2 diabetes is diagnosed based on a
fasting plasma glucose (FPG ≥126 mg/dL [7
mmol/L]) or the two hour plasma glucose
value following a 75 g oral glucose tolerance
test (>200 mg/DL [11.0 mmol/L]) or having a
HbA1c of ≥ 6.5 % according to the American
Diabetes Association (ADA) [4].
HbA1c
• HbA1c reduction of 0.5 % (6 mmol/mol) is
regarded as clinically significant.
• While other authors suggest 0.3 % (4
mmol/mol) or 0.33 % (4 mmol/mol).
Objectives
• The primary objective of this study was to
identify BCTs and intervention features
which reduced HbA1c.
• A secondary objective was to identify the
frequency of use of BCTs in included
studies.
• A third objective was to describe changes
in HbA1c and weight at different time
points.
Methods (Inclusion Criteria)
(i) Randomized controlled trials (RCTs) of any
duration with a dietary AND physical activity
intervention, published in peer-reviewed journals
between 1/1/ 1975 and 1/6/2015.
(ii) RCTs with a comparison arm or control group that
constituted usual care.
(iii) Human participants older than 18 years of age
with clinically confirmed type 2 diabetes, at time of
recruitment.
(iv) Primary clinical outcome measure was HbA1c,
however studies reporting HbA1c results as an
outcome measure were also included.
Methods (Exclusion Criteria)
(i) RCTs of diabetes prevention OR RCTs of those at
risk of type 2 diabetes.
(ii) RCTs that used pharmacological agents
exclusively to treat type 2 diabetes.
(iii) RCTs that targeted multiple chronic diseases,
gestational diabetes or type 1 diabetes.
(iv) RCTs that used additional interventions beyond
diet and physical activity, or focused on additional
behaviours other than diet and physical activity.
(v) Studies not reported in English.
(vi) Studies not reporting HbA1c as an outcome
measure.
Behaviour change techniques targeting diet and physical activity in type 2 diabetes: What's the evidence?
Methods
• BCT coding
• Intervention features
• Risk of Bias
• Fidelity assessment
BCT Coding
• Michie’s v1 BCT taxonomy was used to identify and code the
BCTs reported in each study (Michie et al 2013).
• This rigorously developed and validated taxonomy consists of
clear definitions of 93 different BCTs, divided into 16 different
categories.
• A coding rubric/ rulebook was developed by three authors of
this review (KC, LQ and HG) to guide the coding process
(Additional file 1: 1.3).
• All included studies were coded independently by two authors
(KC and LQ) who underwent training in the use of Michie’s
taxonomy.
• All BCTs coded and associated text is documented in
Additional file 2.
Intervention Features
• Rationale for features included was
derived from intervention features
identified previously, previous reviews and
the ‘Theory Coding Scheme’.
• Intervention features were included under
the headings “mode of delivery”,
“frequency”, “provider”, “intensity” and
“other” (use of theory and baseline HbA1c,
number of BCTs included).
Risk of Bias
• Risk of bias in individual studies was
assessed using the Cochrane
Collaboration risk of bias tool, whereby
criteria are applied to seven aspects of
trials to yield an appraisal of ‘low risk’,
‘high risk’ or ‘unclear risk’ of bias.
Fidelity Assessment
• Treatment fidelity was assessed using Bellg
et al.’s criteria, which identify treatment
fidelity strategies for improving and
monitoring, provider training, delivery of
treatment, receipt of treatment, and
enactment of treatment skills.
• Each category contains subcategories which
were each assigned a score of yes, no, or
unclear.
Methods (Analysis)
Meta-analysis
HbA1c & weight at 3, 6, 12, 24 months
Overall HbA1c & weight (all time points)
Moderator analysis
Diet & physical activity BCTs
Intervention features
Diet BCTs
Physical activity BCTs
Results
• HbA1c at 3, 6, 12 and 24 months
• HbA1c profile over time
• BCT moderator analysis
• Intervention feature moderator analysis
• Fidelity and risk of bias
Results HbA1c at 3 & 6 Months
HbA1c Changes at 12 & 24 Months
-1.4
-1.2
-1
-0.8
-0.6
-0.4
-0.2
0
0.2
0 3 6 12 24
HbA1c(%) Fig. 1. Mean HbA1c changes (n = 13)
Intervention
group
Control
group
Overall Meta-analysis
BCTs in Moderator Analyses
BCTs Associated with >0.3%
Reduction in HbA1c
BCTs associated with >0.3% reduction in HbA1c HbA1c
Instruction on how to perform a behaviour -0.549
Behavioural practice/rehearsal -0.417
Action planning -0.385
Demonstration of the behaviour -0.343
Graded Tasks -0.217
Frequently used BCTs
Intervention Features
Intervention features associated with >0.3% reduction in
HbA1c
HbA1c
Supervised physical activity -0.572*
Group sessions only -0.448
Contact with exercise physiologist -0.364
Combination of dietitian and exercise physiologist -0.312
Higher frequency of total contacts (median) -0.658*
Higher frequency of face to face contacts (median) -0.621
Intensity: Higher number of face to face contacts (median) -0.484
Intensity: Higher number of total contacts (mean) -0.36
Baseline HbA1c levels >8% -0.502
Baseline HbA1c levels >7% -0.478
Fidelity & Risk of Bias
• Intervention fidelity was poorly reported in
almost all categories and sub-categories.
• Risk of bias overall was low.
Conclusions
• Combined diet and physical activity interventions achieved
clinically meaningful reductions in HbA1c at 3 and 6 months,
but these were not sustained at 12 and 24 months.
• 4 BCTs and 9 intervention features associated with reductions
in HbA1c.
• These exploratory findings may guide future research into
BCTs such as ‘instruction on how to perform a behaviour’,
‘behavioural practice/rehearsal’, ‘action planning’, and
‘demonstration of the behaviour’ which seemed to be
associated with better outcomes in type 2 diabetic adults in
addition to the intervention features identified.
Future Directions
• A formal assessment of the effectiveness of individual and clustered BCTs
in the initiation and maintenance of behaviour change should be a scientific
priority.
• The hierarchical ranking of BCTs and the synergistic effect of certain BCTs
requires further investigation.
• Clearly defined and reported behavioural outcome measures are
incorporated into diet and or physical activity interventions and studies
follow TIdieR guidelines.
• Secondly, more transparent and comprehensive descriptions of BCTs used,
fidelity to intervention protocol and clarity regarding the theoretical
constructs and models used in published studies is required.
• There is support for implementing a graded approach to gradually
increasing frequency and intensity of intervention content.
• Structure interventions so that the key components are delivered by credible
experts (i.e. exercise physiologists and dietitians) and alignment of
behaviour change techniques to target behaviours following a
comprehensive behavioural diagnosis.
References
• Cradock KA, ÓLaighin G, Finucane FM,
Gainforth HL, Quinlan LR, Ginis KAM:
Behaviour change techniques targeting
both diet and physical activity in type 2
diabetes: A systematic review and
meta-analysis. International Journal of
Behavioral Nutrition and Physical Activity
2017, 14(1).
• k.cradock1@nuigalway.ie
Links
https://ijbnpa.biomedcentral.com/articles/10.
1186/s12966-016-0436-0
*Additional files 1 & 2 are only available at
the link above, at the end of the paper.
THANK YOU - QUESTIONS
Poll Question #4
The information presented today was
helpful
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C. Neutral
D. Disagree
E. Strongly disagree
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Poll Question #5
What are your next steps? [Check all
that apply]
A. Access the full text systematic review
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Behaviour change techniques targeting diet and physical activity in type 2 diabetes: What's the evidence?

  • 1. Welcome! Behaviour change techniques targeting diet and physical activity in type 2 diabetes: What's the evidence? You will be placed on hold until the webinar begins. The webinar will begin shortly, please remain on the line.
  • 2. Poll Questions: Consent • Participation in the webinar poll questions is voluntary • Names are not recorded and persons will not be identified in any way • Participation in the anonymous polling questions is accepted as an indication of your consent to participate Benefits: • Results inform improvement of the current and future webinars • Enable engagement; stimulate discussion. This session is intended for professional development. Some data may be used for program evaluation and research purposes (e.g., exploring opinion change) • Results may also be used to inform the production of systematic reviews and overviews Risks: None beyond day-to-day living
  • 3. After Today • The PowerPoint presentation and audio recording will be made available • These resources are available at: – PowerPoint: http://www.slideshare.net/HealthEvidence – Audio Recording: https://www.youtube.com/user/healthevidence/videos 3
  • 4. What’s the Evidence? Cradock, K., Olaighin, G., Finucane, F., Gainforth, H., Quinlan, L., & Ginis K. (2017). Behaviour change techniques targeting both diet and physical activity in type 2 diabetes: A systematic review and meta- analysis. International Journal of Behavioral Nutrition and Physical Activity, 14(1), 18. http://www.healthevidence.org/view- article.aspx?a=behaviour-change-techniques- targeting-diet-physical-activity-type-2-diabetes- 30175
  • 5. • Use CHAT to post comments / questions during the webinar – ‘Send’ questions to All (not privately to ‘Host’) • Connection issues – Recommend using a wired Internet connection (vs. wireless) • WebEx 24/7 help line – 1-866-229-3239 Participant Side Panel in WebEx Housekeeping
  • 6. Housekeeping (cont’d) • Audio – Listen through your speakers – Go to ‘Communicate > Audio Broadcast’ • WebEx 24/7 help line – 1-866-229-3239
  • 7. Poll Question #1 How many people are watching today’s session with you? A. Just me B. 2-3 C. 4-5 D. 6-10 E. >10
  • 8. The Health Evidence™ Team Maureen Dobbins Scientific Director Heather Husson Manager Susannah Watson Project Coordinator Students: Emily Belita (PhD candidate) Jennifer Yost Assistant Professor Olivia Marquez Research Coordinator Emily Sully Research Assistant Liz Kamler Research Assistant Zhi (Vivian) Chen Research Assistant Research Assistants: Claire Howarth Rawan Farran Kristin Read Research Coordinator
  • 10. Why use www.healthevidence.org? 1. Saves you time 2. Relevant & current evidence 3. Transparent process 4. Supports for EIDM available 5. Easy to use
  • 11. A Model for Evidence- Informed Decision Making National Collaborating Centre for Methods and Tools. (revised 2012). A Model for Evidence-Informed Decision-Making in Public Health (Fact Sheet). [http://www.nccmt.ca/pubs/FactSheet_EIDM_EN_WEB.pdf]
  • 12. Stages in the Process of Evidence-Informed Public Health National Collaborating Centre for Methods and Tools. Evidence-Informed Public Health. [http://www.nccmt.ca/eiph/index-eng.html]
  • 13. Poll Question #2 Have you heard of PICO(S) before? A. Yes B. No
  • 14. Searchable Questions Think “PICOS” 1.Population (situation) 2.Intervention (exposure) 3.Comparison (other group) 4.Outcomes 5.Setting
  • 15. How often do you use Systematic Reviews to inform a program/services? A. Always B. Often C. Sometimes D. Never E. I don’t know what a systematic review is Poll Question #3
  • 16. Kevin Cradock, PhD student, National University of Ireland, Galway
  • 17. Systematic Review & Meta- analysis
  • 19. Affiliations & Collaborators Kevin A. Cradock Human Movement Laboratory, NUI Galway, Physiology, School of Medicine, NUI Galway, Electrical & Electronic Engineering, School of Engineering & Informatics, NUI Galway Professor Gearóid Ó Laighin Electrical & Electronic Engineering, School of Engineering & Informatics, NUI Galway, National Centre for Biomedical Engineering Science, NUI Galway Professor Francis M. Finucane Bariatric Medicine Service, Galway Diabetes Research Centre, HRB Clinical Research Facility Professor Kathleen A. Martin Ginis Assistant Professor Heather L. Gainforth School of Health and Exercise Sciences, The University of British Columbia, Canada Dr Leo R. Quinlan Physiology, School of Medicine, NUI Galway
  • 20. Funding Sources Funding We wish to thank the Irish Research Council (IRC) for funding this project (Project ID: GOIPG/2013/873).
  • 21. Session Outcomes 1 Background / introduction 2 Research methods 3 Results 4 Conclusions 5 Future directions 6 Questions
  • 22. Background / Introduction • Changing diet and physical activity behaviour is one of the cornerstones of type 2 diabetes treatment, but changing behaviour is challenging.
  • 23. Incidence • Type 2 diabetes is one of the fastest growing and largest global health burdens. • In 2015, there were 415 million people with diabetes worldwide (91 % of which were type 2 diabetes) with figures expected to rise to 642 million by the year 2040, [1] which easily surpasses earlier predictions in 2004 of 366 million by 2030 [2]. • A 2010 global analysis of mortality reported that 1.3 million deaths worldwide were due to diabetes that year, twice as many as in 1990 [3].
  • 24. Diagnosis • Type 2 diabetes is diagnosed based on a fasting plasma glucose (FPG ≥126 mg/dL [7 mmol/L]) or the two hour plasma glucose value following a 75 g oral glucose tolerance test (>200 mg/DL [11.0 mmol/L]) or having a HbA1c of ≥ 6.5 % according to the American Diabetes Association (ADA) [4].
  • 25. HbA1c • HbA1c reduction of 0.5 % (6 mmol/mol) is regarded as clinically significant. • While other authors suggest 0.3 % (4 mmol/mol) or 0.33 % (4 mmol/mol).
  • 26. Objectives • The primary objective of this study was to identify BCTs and intervention features which reduced HbA1c. • A secondary objective was to identify the frequency of use of BCTs in included studies. • A third objective was to describe changes in HbA1c and weight at different time points.
  • 27. Methods (Inclusion Criteria) (i) Randomized controlled trials (RCTs) of any duration with a dietary AND physical activity intervention, published in peer-reviewed journals between 1/1/ 1975 and 1/6/2015. (ii) RCTs with a comparison arm or control group that constituted usual care. (iii) Human participants older than 18 years of age with clinically confirmed type 2 diabetes, at time of recruitment. (iv) Primary clinical outcome measure was HbA1c, however studies reporting HbA1c results as an outcome measure were also included.
  • 28. Methods (Exclusion Criteria) (i) RCTs of diabetes prevention OR RCTs of those at risk of type 2 diabetes. (ii) RCTs that used pharmacological agents exclusively to treat type 2 diabetes. (iii) RCTs that targeted multiple chronic diseases, gestational diabetes or type 1 diabetes. (iv) RCTs that used additional interventions beyond diet and physical activity, or focused on additional behaviours other than diet and physical activity. (v) Studies not reported in English. (vi) Studies not reporting HbA1c as an outcome measure.
  • 30. Methods • BCT coding • Intervention features • Risk of Bias • Fidelity assessment
  • 31. BCT Coding • Michie’s v1 BCT taxonomy was used to identify and code the BCTs reported in each study (Michie et al 2013). • This rigorously developed and validated taxonomy consists of clear definitions of 93 different BCTs, divided into 16 different categories. • A coding rubric/ rulebook was developed by three authors of this review (KC, LQ and HG) to guide the coding process (Additional file 1: 1.3). • All included studies were coded independently by two authors (KC and LQ) who underwent training in the use of Michie’s taxonomy. • All BCTs coded and associated text is documented in Additional file 2.
  • 32. Intervention Features • Rationale for features included was derived from intervention features identified previously, previous reviews and the ‘Theory Coding Scheme’. • Intervention features were included under the headings “mode of delivery”, “frequency”, “provider”, “intensity” and “other” (use of theory and baseline HbA1c, number of BCTs included).
  • 33. Risk of Bias • Risk of bias in individual studies was assessed using the Cochrane Collaboration risk of bias tool, whereby criteria are applied to seven aspects of trials to yield an appraisal of ‘low risk’, ‘high risk’ or ‘unclear risk’ of bias.
  • 34. Fidelity Assessment • Treatment fidelity was assessed using Bellg et al.’s criteria, which identify treatment fidelity strategies for improving and monitoring, provider training, delivery of treatment, receipt of treatment, and enactment of treatment skills. • Each category contains subcategories which were each assigned a score of yes, no, or unclear.
  • 35. Methods (Analysis) Meta-analysis HbA1c & weight at 3, 6, 12, 24 months Overall HbA1c & weight (all time points) Moderator analysis Diet & physical activity BCTs Intervention features Diet BCTs Physical activity BCTs
  • 36. Results • HbA1c at 3, 6, 12 and 24 months • HbA1c profile over time • BCT moderator analysis • Intervention feature moderator analysis • Fidelity and risk of bias
  • 37. Results HbA1c at 3 & 6 Months
  • 38. HbA1c Changes at 12 & 24 Months
  • 39. -1.4 -1.2 -1 -0.8 -0.6 -0.4 -0.2 0 0.2 0 3 6 12 24 HbA1c(%) Fig. 1. Mean HbA1c changes (n = 13) Intervention group Control group
  • 41. BCTs in Moderator Analyses
  • 42. BCTs Associated with >0.3% Reduction in HbA1c BCTs associated with >0.3% reduction in HbA1c HbA1c Instruction on how to perform a behaviour -0.549 Behavioural practice/rehearsal -0.417 Action planning -0.385 Demonstration of the behaviour -0.343 Graded Tasks -0.217
  • 44. Intervention Features Intervention features associated with >0.3% reduction in HbA1c HbA1c Supervised physical activity -0.572* Group sessions only -0.448 Contact with exercise physiologist -0.364 Combination of dietitian and exercise physiologist -0.312 Higher frequency of total contacts (median) -0.658* Higher frequency of face to face contacts (median) -0.621 Intensity: Higher number of face to face contacts (median) -0.484 Intensity: Higher number of total contacts (mean) -0.36 Baseline HbA1c levels >8% -0.502 Baseline HbA1c levels >7% -0.478
  • 45. Fidelity & Risk of Bias • Intervention fidelity was poorly reported in almost all categories and sub-categories. • Risk of bias overall was low.
  • 46. Conclusions • Combined diet and physical activity interventions achieved clinically meaningful reductions in HbA1c at 3 and 6 months, but these were not sustained at 12 and 24 months. • 4 BCTs and 9 intervention features associated with reductions in HbA1c. • These exploratory findings may guide future research into BCTs such as ‘instruction on how to perform a behaviour’, ‘behavioural practice/rehearsal’, ‘action planning’, and ‘demonstration of the behaviour’ which seemed to be associated with better outcomes in type 2 diabetic adults in addition to the intervention features identified.
  • 47. Future Directions • A formal assessment of the effectiveness of individual and clustered BCTs in the initiation and maintenance of behaviour change should be a scientific priority. • The hierarchical ranking of BCTs and the synergistic effect of certain BCTs requires further investigation. • Clearly defined and reported behavioural outcome measures are incorporated into diet and or physical activity interventions and studies follow TIdieR guidelines. • Secondly, more transparent and comprehensive descriptions of BCTs used, fidelity to intervention protocol and clarity regarding the theoretical constructs and models used in published studies is required. • There is support for implementing a graded approach to gradually increasing frequency and intensity of intervention content. • Structure interventions so that the key components are delivered by credible experts (i.e. exercise physiologists and dietitians) and alignment of behaviour change techniques to target behaviours following a comprehensive behavioural diagnosis.
  • 48. References • Cradock KA, ÓLaighin G, Finucane FM, Gainforth HL, Quinlan LR, Ginis KAM: Behaviour change techniques targeting both diet and physical activity in type 2 diabetes: A systematic review and meta-analysis. International Journal of Behavioral Nutrition and Physical Activity 2017, 14(1). • k.cradock1@nuigalway.ie
  • 49. Links https://ijbnpa.biomedcentral.com/articles/10. 1186/s12966-016-0436-0 *Additional files 1 & 2 are only available at the link above, at the end of the paper.
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