Telerehabilitation Intervention to Promote Exercise for Diabetes

Approximately two thirds of American adults are overweight (body mass index - BMI > 25), and
nearly one third of American adults are obese (BMI > 30) with veterans exhibiting even
higher rates of being overweight and obese than those in the general population. Obesity is
a significant risk factor for a number of serious medical conditions, including diabetes,
and is associated with high rates of morbidity, and mortality. Greater than 80% of
individuals with diabetes are overweight or obese. Sixteen million Americans have been
diagnosed with diabetes, and it has been speculated that this number will increase to 23
million by the year 2010. Furthermore, there is a substantially higher prevalence of
diabetes in the veteran population as compared to the general population, with nearly 16
percent of veterans being affected. This alarming increase has been associated with the
increasing prevalence of obesity and sedentary lifestyles. In a conference conducted by the
National Institute of Diabetes and Digestive and Kidney Diseases in 1999, it was concluded
that a major research initiative was needed to address the growing problem with physical
inactivity and obesity because of the major impact these behaviors have on the development
and treatment of diabetes.

The benefits associated with exercise in the diabetic population are extensive, and even
though regular exercise is typically prescribed as a significant component of the diabetic
treatment plan, compliance tends to be very poor. The overarching objective of this study
is to adapt a low cost telephone intervention to be used to enhance exercise adoption in a
population of overweight or obese veterans with type 2 diabetes. The primary aim of this
study is to implement and evaluate the effectiveness of this telehealth intervention over a
six month period. The secondary aim is to evaluate the impact this telehealth intervention
has on weight and other diabetes relevant physical health parameters, quality of life and
psychological distress. If the telehealth intervention is found to be efficacious, the
tertiary aim will be to evaluate the cost effectiveness of the intervention. Over a 4-year
period, 140 overweight or obese veterans with type 2 diabetes will be recruited from the VA
Boston Healthcare System. All participants will be evaluated and provided with an exercise
prescription for a home based walking program. Participants will be randomized to either
the Exercise Prescription condition alone, or Exercise Prescription plus TLC-PED (Telephone
Linked Care - Promoting Exercise for Diabetes), an automated telehealth intervention.
TLC-PED will use interactive voice response and recognition telephone technology to provide
individualized phone messages for participants with diabetes. It will be developed to
incorporate theoretical principles that are known to enhance exercise adoption.
Specifically, the intervention will use motivating principles based on the transtheoretical
model of change. Those in the TLC-PED condition will receive weekly automated telephone
calls for a six month period. It is hypothesized that overweight veterans with diabetes
who receive the TLC-PED intervention (versus those who do not) during their six month
participation in a home based walking program will be more likely to engage in regular
physical activity and obtain improvements in self-reported physical activity, and maintain
these changes over a twelve month period.