Is Behavioral Change Among Overweight Diabetics Feasible and Sustainable? Interview with:
Giuseppe Pugliese, MD, PhD
for the Italian Diabetes and Exercise Study 2 (IDES_2) Investigators
Department of Clinical and Molecular Medicine
‘‘La Sapienza’’ University
Diabetes Unit, Sant’Andrea University Hospital
Rome, Italy What is the background for this study?

Response: There is a growing epidemic of obesity and type 2 diabetes worldwide,
which are causally related to the increasing prevalence of “physical
inactivity”, i.e., an insufficient amount of moderate-to-vigorous
physical activity according to current guidelines, and
“sedentariness”, i.e., too many hours, especially if uninterrupted,
spent in a sitting or reclined position.  These two unhealthy
behaviors exert their detrimental effects independently of each other
and are very common among people suffering from type 2 diabetes, who
would therefore benefit from increasing physical activity and reducing
sedentary time, as recommended by current guidelines.

However, such a behavior change is generally difficult for a number of
internal and external barriers and requires behavioral interventions
targeting both physical activity and sedentary habits.  Unfortunately,
there is no definitive evidence that this is indeed feasible and,
particularly, that, if adopted, change in behavior can be maintained
in the long term. What are the main findings?

Response: This randomized clinical trial compared a behavioral intervention
strategy (targeting both physical inactivity and sedentary behavior)
and standard care, in 300 physically inactive and sedentary patients
with type 2 diabetes (both sexes, mean age 61.6 years) from three
outpatient diabetes clinics in Rome (Italy).  Participants in the
behavioral intervention group received one individual theoretical
counseling session (conducted by a diabetologist) and 8 biweekly
individual theoretical and practical counseling sessions (conducted by
a certified exercise specialist in a gym facility), once a year for 3
years.  Participants in the standard care group received only general
physician recommendations for increasing daily physical activity and
decreasing sedentary time.

The results showed a significant increase in physical activity volume,
moderate-to-vigorous-intensity physical activity, and light-intensity
physical activity as well as a reciprocal decrease in sedentary time,
as measured by an accelerometer, in the behavioral intervention versus
standard care group, which were maintained throughout the 3-year
period. Approximately one third of participants from the intervention
group became physically active, i.e., fully met the recommended goal
for moderate-to-vigorous physical activity, and there was a
substantial reallocation of sedentary time to light-intensity physical

This behavior change was associated with several beneficial effects,
despite the fact that the increased amount of physical activity was
more of light intensity than of moderate-to-vigorous intensity. In
particular, there was a sustained improvement in cardiorespiratory and
muscular fitness, i.e., the capacity of performing aerobic and
strength exercise, respectively, which are both independently related
to increased survival. What should readers take away from your report? 

Response: People suffering from type 2 diabetes can achieve a sustained change
in physical activity/sedentary behavior through the implementation of
behavioral intervention strategies targeting maintenance of both
increased physical activity and decreased sedentary time.
Importantly, if sustained, even non-dramatic improvements in behavior
may translate into meaningful clinical advantage.  However, delivering
of counseling intervention requires specifically trained personnel,
including physicians (diabetologists) and exercise specialists, though
also a non-physician may probably deliver the theoretical counseling. What recommendations do you have for future research as a result of this work? 

Response: Future research should address generalizability and implementation in
clinical practice of these results, which need to be validated in
different cohorts or settings.  In addition, cost-effectiveness
analyses should be conducted to compare the costs and the important
health benefits that such interventions certainly provide. Is there anything else you would like to add?

Response: Promoting physical activity and combating sedentary behavior is a
major objective of all industrialized and developing countries, since
it may provide enormous health benefits not only to diabetic
individuals, but also to the entire population, by reducing
cardio-metabolic risk.  However, to achieve this objective is
necessary to involve national and city administrations, urban
planners, universities, health departments, business, and communities
in order to promote campaigns for the promotion of healthy behaviors
and to put into action solutions which help to break down the external
barriers to these behaviors (e.g., safety, crime, traffic, transport,
walkability, cyclability, gym facilities, etc.).

Disclosures: I have no conflicts of interest regarding this work. Outside this
work: lecture and/or consulting fees from Astra-Zeneca, Boehringer
Ingelheim, Eli Lilly, Merck Sharp & Dome, Mylan, Sigma-Tau, and


Balducci S, D’Errico V, Haxhi J, et al. Effect of a Behavioral Intervention Strategy on Sustained Change in Physical Activity and Sedentary Behavior in Patients With Type 2 Diabetes: The IDES_2 Randomized Clinical Trial. JAMA. 2019;321(9):880–890. doi:10.1001/jama.2019.0922

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Last Updated on March 5, 2019 by Marie Benz MD FAAD