Health Evidence hosted a 60 minute webinar examining the behaviour change techniques (BCTs) and features of dietary and physical activity interventions associated with reducing HbA1c in people with type 2 diabetes. Click here for access to the audio recording for this webinar: https://youtu.be/Fb6_t7_TGxw Kevin Cradock, PhD student, National University of Ireland, Galway led the session and presented findings from his recent systematic review: 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. Changing diet and physical activity behaviour is one of the cornerstones of type 2 diabetes treatment, but changing behaviour is challenging. The objective of this study was to identify behaviour change techniques (BCTs) and intervention features of dietary and physical activity interventions for patients with type 2 diabetes that are associated with changes in HbA1c. Thirteen RCTs were identified. Diet and physical activity interventions achieved clinically significant reductions in HbA1c at three and six months, but not at 12 and 24 months. Specific BCTs and intervention features identified may inform more effective structured lifestyle intervention treatment strategies for type 2 diabetes.

1. Welcome!
Behaviour change techniques
targeting diet and physical
activity in type 2 diabetes:
What's the evidence?
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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

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14. Searchable Questions Think “PICOS”
1.Population (situation)
2.Intervention (exposure)
3.Comparison (other group)
4.Outcomes
5.Setting

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Poll Question #3

16. Kevin Cradock, PhD student,
National University of Ireland,
Galway

17. Systematic Review & Meta-
analysis

18. Affiliations & Collaborators

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

40. Overall Meta-analysis

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

43. Frequently used BCTs

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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