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The COVID-19 pandemic created unprecedented shifts in the way health programs and services are delivered. A national lockdown to prevent the spread of COVID-19 in Australia was introduced in March 2020. This lockdown included the closure of exercise clinics, fitness centers, and other community spaces, which, before the pandemic, were used to deliver Beat It. Beat It is an 8-week in-person, community-based, and clinician-led group exercise and education program for adults self-managing diabetes. To continue offering Beat It, it was adapted from an in-person program to a fully web-based supervised group exercise program for adults with type 2 diabetes (T2DM).
This study aims to assess whether the
Australians with T2DM who were aged ≥60 years were included. They were enrolled in
A total of 171 adults (mean 71, SD 5.6 years; n=54, 31.6% male) with T2DM were included in the study, with 40.4% (n=69) residing in lower socioeconomic areas. On the completion of the 8-week program, significant improvements in waist circumference, aerobic capacity, muscular strength, flexibility, and balance were observed in both male and female participants (all
This study found that
According to the International Diabetes Federation, more than half a billion people worldwide have diabetes [
Physical activity is a cornerstone of T2DM management, along with dietary and pharmacological interventions [
Physical activity has a substantial role in maintaining functional fitness [
Small and large-scale community-based supervised group exercise programs for older adults with T2DM have demonstrated effectiveness in improving physical fitness in the short term (immediately after intervention) [
The short- and long-term health and physical fitness outcomes from the traditionally delivered in-person
Programs were delivered by AEPs to participants who resided in New South Wales (NSW) and the Australian Capital Territory (ACT). Exercise sessions include moderate-intensity aerobic, resistance, flexibility, and balance-based exercises, and the education sessions focus on different areas of diabetes self-management. Participants completed a pre-exercise screening, baseline measures, and fitness testing during a web-based 1-on-1 initial consultation with the AEP. This consultation also included motivational interviewing to ascertain participants’ goals and their facilitators and barriers to change [
The information gathered during the consultation was used to create a customized exercise program with the participant, considering their physical ability, existing fitness levels, and any comorbidities or injuries that could be exacerbated by exercise. Each exercise program comprised home exercise options that participants could replicate with minimal equipment or using items available around the home, including dynamic warm-up and cooldown, and aerobic (eg, walking, stepping, aerobics, and shadow boxing), resistance (eg, body weight, resistance bands, free weights, or household items of equivalent weight—for example, cans of food or bags of rice as hand weights), balance (eg, different standing balance variations), and flexibility exercises (eg, static stretching of major muscle groups). During the web-based group exercise sessions, participants completed their exercise program under the supervision of an AEP, who was able to modify exercises in accordance with the participant’s progress.
Zoom videoconferencing software (version 5.2.1; Zoom Video Communications) was the preferred platform for delivering the group exercise and education sessions. All AEPs purchased a subscription to Zoom as a security precaution to ensure that 2-factor authentication, passcodes, and waiting rooms were available; thus, incidents such as
All AEPs completed a specialized facilitator training program called
From May 2020 to October 2021, participants were recruited through email using the National Diabetes Services Scheme database or advertisements on the Diabetes NSW & ACT website. Prior to commencing, participants were required to provide evidence of medical clearance to exercise from their general practitioner and were then eligible to attend their web-based initial health and fitness assessment with their AEP. Standard exclusion criteria for the
This study was approved by the Macquarie University Human Ethics Committee (5201950887424).
This study used a pre-post evaluation design where participants completed web-based physical assessment sessions at baseline and at 8 weeks of
The Diabetes Empowerment Scale (DES) is a measure of psychosocial self-efficacy that was developed specifically for a diabetes population. The DES short form contains 8 items that can be used to provide a brief general assessment of diabetes psychosocial self-efficacy [
The Patient Activation Measure (PAM) assesses a person’s self-reported knowledge, skill, and confidence for the self-management of their health or chronic condition [
Data analysis was performed using SPSS statistical software (version 27; IBM Corp). Mean and SD were calculated for continuous variables. Frequencies and percentages were calculated for categorical variables, excluding participants with missing data for that variable. Paired 2-tailed
The adaptation of
Model for Adaptation, Design, and Impact.
The
Model for Adaptation, Design, and Impact report of adaptations and mediating and moderating factors.
Adaptation areas | Mediating and moderating factors, program stage | |
|
Beat It (in-person) | Beat It Online |
Facilitator training | 12 hours web-based learning and 1-day in-person practical training | Additional 2 hours covering key considerations for web-based delivery |
Marketing | Direct mail (via post), email, and website | Digital only—email and website |
Participant resources | Additional resources guiding participants on technical requirements and equipment required to access web-based sessions: internet connectivity and speed tests how to set-up or log in to videoconferencing platform participant pre–web-based session checklist outlining key safety considerations to be followed every session |
|
Trainer resources | Additional content added to the assessing participant suitability additional Beat It Trainer requirements required equipment and technical capabilities, safety requirements, legal and professional practice requirements, and privacy and record keeping considerations web-based delivery considerations specific to exercise and education session delivery assisting Beat It trainers in selecting appropriate videoconferencing platforms ways to maintain communication and establish visual cues (eg, Zoom gallery view) to ensure participants are performing exercises confidently and safely trainer checklists and session guides to follow prior, during, and following each session |
|
Medical clearance | Standardized medical clearance form, including recommended program inclusion or exclusion criteria, medical history, medications, and latest Hemoglobin A1c and lipid test results; participants typically bring a physical copy of the medical clearance form to initial consultation with a |
Additional considerations and exclusion criteria for determining suitability to join the web-based program, including: client digital literacy client needs and goals risks including precautions and contraindications physical capacity of client to undertake session client ability to provide consent capacity to access technology need and availability for a client support person (eg, family, carer, and allied health assistant) to assist in consult and sessions further information relating to hypoglycemia frequency and falls risk requested from referring medical practitioner additional instructions relating to sending medical clearance information safely and securely via appropriate web-based methods (eg, encrypted email and fax) to the participant’s Beat It trainer |
Preprogram | Preprogram resources sent including welcome letter confirming program registration, medical clearance, and initial consultation process and the |
Additional resources guiding participants on what equipment is required to access technical requirements (eg, internet connection, appropriate device for video calls, and active email address) initial assessment equipment (eg, measuring tape, weight scales, suitable chair, and hand weight or substitute to perform exercise tests from home) safety considerations (eg, appropriate exercise space, clothing, and access to blood glucose monitor and hypoglycemia treatment) provision of step-by-step guide of how to access the Beat It trainer’s selected videoconferencing platform at the time of assessment booking, the Beat It trainer also assessed participant’s technical proficiency with using the videoconferencing tool |
Initial and final assessment |
Conducted in person Obtain medical clearance, participant informed consent, and emergency contact information and complete prescreening questionnaire Complete baseline measurements, including height, weight, waist circumference, blood pressure, and heart rate Complete exercise tests including the 6-minute walk test, 30-second sit-to-stand test, 30-second seated arm curl test, seated sit-and-reach test, and 1-legged stand test Goal setting |
Differences: both assessments conducted over the web informed consent form sent digitally further participant emergency contact information was collected, including physical address participant would be completing web-based exercise sessions from, presence of friend or family at this address during sessions, and education related to having access to blood glucose monitor and hypoglycemia treatment available during sessions baseline measurement protocols were adapted to support participants complete these themselves with guidance from a Beat It trainer via video (eg, using string or sewers tape to measure waist circumference) and requested from the referring general practitioner as part of medical clearance process (eg, resting blood pressure if participant does not have access to a blood pressure monitor) exercise testing protocols were modified to allow participant completion from home 6-minute walk test was replaced with a 2-minute step-in-place test to account for space constraints and allow participants to be monitored on camera household items were used to facilitate other tests (eg, 2-3 kg bag of rice for seated arm curl test and ruler used for seated sit-and-reach test) |
Exercise sessions | Capped at 12 participants per session; in-person exercise sessions consist of a warm-up, followed by a combination of aerobic, resistance, balance, and flexibility exercises tailored to participants abilities, followed by a cooldown period | Differences: capped at 6 participants per session to enable adequate supervision in a web-based setting corresponding pre-exercise checklists for the Beat It trainer and participants detailing important steps the participants must take leading into each exercise session including ensuring technology is setup correctly allowing the sessions to be viewed clearly, confirming participants have hypoglycemia treatment available, ensuring their exercise area is free from obstructions, and asking participants to take pre- or postexercise blood glucose measurements guidelines on camera and microphone settings to ensure Beat It trainers can be seen and heard, and participants can be monitored effectively and the use of visual cues and telehealth functions to provide feedback and breaking up exercises to check-in with participants Beat It trainers to structure sessions by providing 3-4 different options for each exercise delivered to the group; these options include regressions and progressions for each exercise and ensure participants can complete a similar exercise at the same time, dependent on their ability Beat It trainers encouraged to keep sessions as creative, fun, and engaging as possible with ideas such as dress-up themes, activity-based challenges, and games to encourage social interaction among the group |
Education sessions | 6 x 30 min person-centered education sessions on various lifestyle and diabetes management topics delivered in person | Differences: delivered over the web used screen-sharing functions and web-based whiteboards to collate participant responses |
Summary of assessment data.
Assessment | Male | Female | |||||||
|
n | Baseline, mean (SD) | Postprogram, mean (SD) | n | Baseline, mean (SD) | Postprogram, mean (SD) | |||
Waist circumference (cm) | 54 | 114.3 (12.5) | 110.6 (12.5) | <.001 | 117 | 102.7 (14.3) | 100 (13.3) | <.001 | |
Seated sit-and-reach (cm) | 46 | –7.8 (11.1) | –4.3 (10.2) | <.001 | 106 | –2.5 (11.9) | 0.2 (11.8) | <.001 | |
30-second sit-to-stand (reps) | 51 | 13.2 (3.9) | 16.2 (5.2) | <.001 | 116 | 12.6 (4.6) | 15.7 (5.3) | <.001 | |
1-legged stand test (s) | 52 | 27.1 (20.3) | 34.5 (18.5) | <.001 | 115 | 25.4 (19.9) | 33.2 (20.5) | <.001 | |
2-minute step test (reps) | 45 | 68.5 (22.5) | 87.9 (26.8) | <.001 | 105 | 69.2 (26.2) | 86.8 (30.3) | <.001 | |
Arm curl (reps) | 50 | 20.1 (9) | 26.0 (8.8) | <.001 | 114 | 18.9 (8.6) | 23.5 (8.5) | <.001 |
A total of 171 individuals were included in the study. These individuals were aged ≥60 years, had reported a diagnosis of T2DM, and had participated in
Improvements in waist circumference, aerobic capacity, muscular strength, flexibility, and balance were observed postprogram in both male and female participants (
Survey evaluation data was received from 49 (29%) of the 171 participants. Most participants rated their health as being good to excellent both at baseline and postprogram (n=38, 78% vs n=36, 74%), whereas improvements in their general quality of life rated as being good to excellent were reported postprogram (n=38, 78% vs n=47, 96%).
Significant improvements in DES scores were reported postprogram (3.9 vs 4.3;
Mean fitness and health measures at baseline and at program completion, stratified by gender.
This study found that
In this study, we used MADI, an implementation science framework, to transparently evaluate and report on the adaptations to the
The focus in diabetes care has traditionally been around the optimization of glycemic control and deterrence of complications [
The
A limitation of this study is that it used a pre-post evaluation with no comparison group, which is a common design for translational community-based programs [
This study revealed that a fully web-delivered, clinician-led, and supervised group exercise program provided important health benefits to older adults with T2DM. This study offers important findings for practitioners and policy makers seeking to maintain independence of older persons with T2DM, reversing frailty and maximizing functional and physical fitness while improving overall quality of life. The COVID-19 pandemic has created unprecedented shifts in the way key health programs and services are delivered.
Standard exclusion criteria for Beat It (in-person) and Beat It Online.
Australian Capital Territory
accredited exercise physiologist
Diabetes Empowerment Scale
Model for Adaptation, Design, and Impact
New South Wales
Patient Activation Measure
type 2 diabetes mellitus
The
None declared.