Progress in Chronic Disease Prevention Community-Based Exercise Intervention -- The Zuni Diabetes Project

The Zuni Indians of New Mexico, traditionally a physically active tribe noted for the grueling footrace that is a part of their heritage, have more recently experienced an increased prevalence of obesity and noninsulin-dependent diabetes mellitus (NIDDM)* (1). In response to this public health need, the Zuni Diabetes Project was initiated in July of 1983. The project is a community-based exercise program designed primarily to facilitate weight loss and improve glycemic control among patients with NIDDM (2,3). It began with two aerobics sessions per week and has grown to more than 48 sessions, offered 5 days a week, several times daily, in a variety of sites in the Zuni community. Ongoing sessions are offered for the general public as well as for individuals with NIDDM. Participants with NIDDM are recruited through personal invitations and recommendations from the medical staff and through a community advertisement campaign. A number of exercise-oriented community events, including footraces, are also offered throughout the year and are supported and sponsored by local agencies and businesses.

In October 1985, the Indian Health Service and CDC jointly evaluated the program (3). Participants were defined as individuals who had NIDDM and had attended at least one exercise session. Thirty patients met this definition. They represented 14% of the 220 persons participating in the exercise sessions and 7% of the 406 patients in the NIDDM registry as of September 1985.

A random start method was used to select a comparison group from the registry of patients with NIDDM. Nonparticipants were matched to participants on the basis of residence, age (plus or minus 2 years), sex, health-care provider, and duration of NIDDM (Plus or minus 2 years). A total of 56 nonparticipants were selected, two nonparticipants for each participant with the exception of four for whom only one match could be found.

All patients were seen in the local clinic on a regular basis and had received similar verbal counseling and written instructions regarding medications, diet, and home exercise. Weight, height, hypoglycemic medications, fasting blood-glucose values, resting blood pressure, complications of diabetes (e.g., neuropathy, retinopathy, and amputation), and history or presence of other diseases (e.g., coronary heart disease, hypertension, renal disease, and stroke) were abstracted from the medical records of participants and nonparticipants.

Participants and nonparticipants were of similar height, weight, and blood pressure and had similar lengths of follow-up and rates of major diabetic complications. The mean duration of program attendance was 37 weeks, with a mean of 1.7 exercise sessions per week and a range of 1 to 102 weeks. Thirty-three percent of the partic- ipants had engaged in exercise sessions for less than 3 months. The average length of follow-up was 50 weeks, with a range of 4 to 102 weeks. Forty-three percent of the participants had begun a home exercise program during the follow-up period; 18% of the nonparticipants had begun similar home programs.

The mean weight loss for participants was 4 kg (8.8 lb), which was significantly greater than the mean weight loss of 0.9 kg (2.0 lb) for nonparticipants. Participants' mean fasting blood-glucose values dropped significantly, from 238 mg/dl to 195 mg/dl. Nonparticipants experienced an insignificant drop, from 228 mg/dl to 226 mg/dl. The differences between the two groups were statistically significant. Thirty percent (9/30) of the participants developed normal fasting blood-glucose levels (less than or equal to140 mg/dl). In contrast, only 9% (5/56) of the nonparticipants developed normal blood-glucose levels.

The data showed evidence of a dose-response relationship when examined on the basis of duration of participation in the exercise sessions. That is, participants attending sessions for the longest period of time (greater than 52 weeks) showed the greatest weight loss (mean 9 kg (19.8 lb)), whereas those participating less than 8 weeks had the least weight loss (mean 2 kg (4.4 lb)). There was a similar dose-response for fasting blood- glucose levels.

The pattern of hypoglycemic medication dosage over the study period was examined for alterations in the prescribed dose (Figure 1). Participants were two times more likely than nonparticipants to have decreased their medication (rate ratio (RR) = 2.2; 95% confidence interval (CI), 1.3 to 3.7). During their exposure to the program, 7 of 24 participants (29%) were completely withdrawn from hypoglycemic agents, compared with 3 of 43 nonparticipants (7%) (RR = 4.2; 95% CI, 1.3 to 13.3).

Compared with all diabetics in the registry, participants were more likely to be younger and to be women. However, when stratified by age, duration of diabetes, and body mass index, the changes in weight, fasting blood-glucose levels, and hypoglycemic agent usage were no different from the unstratified results. These findings suggest that age, duration of diabetes, and body mass index did not influence the effect of participation on the metabolic outcomes. Reported by: BE Leonard, RH Wilson, MD, Zuni Comprehensive Health Center, Indian Health Svc, Zuni; D Gohdes, MD, Diabetes Program, Indian Health Svc, Albuquerque; HF Hull, MD, State Epidemiologist, New Mexico Health and Environment Dept. Div of Health Education, Center for Health Promotion and Education, CDC.

Editorial Note

Editorial Note:

This study demonstrated that participation in a community-based exercise program can successfully facilitate weight loss in a group of individuals with NIDDM. Furthermore, participation decreased fasting blood-glucose values and decreased the need for insulin or oral hypoglycemic agents or both. According to the current literature, this is the largest group of patients with NIDDM enrolled in an evaluated community-based program.

Because weight loss results in improved glucose tolerance and increased insulin sensitivity (4,5), intervention programs have recently focused on weight reduction as a method of improving metabolic control in patients with NIDDM. Studies have employed a variety of clinic-based intervention strategies for weight reduction, including increased exercise (6-8). Results from these studies have indicated average reductions in weight, ranging from 1 kg (2.2 lb) after 10 weeks of intervention to 5 kg (11 lb) after 6 months. One study showed weight loss of 6.4 kg (14.1 lb) after 4 months of intervention; however, after 16 months of follow-up, patients had gained back more than half of this weight (6). The Zuni Diabetes Project differs from other clinic-based intervention studies with defined termination points in that it is a continuous program. In addition, it reinforces exercise behavior by offering numerous exercise sessions and exposures to the exercise message throughout the community.

The Zuni community is unique because of its geographic location and the historical tradition of the Zuni as a socially close-knit people. Controlling for age, duration of diabetes, and body mass index did not alter the results; therefore, it appears that participation in the program and not these characteristics determined success. Thus, modifying the program to make it more appealing or accessible to men or to older persons may produce equivalent changes in weight, fasting blood-glucose levels, and hypoglycemic agent usage. In addition, the success of this community-based intervention suggests that it may be effective for the prevention and control of NIDDM in other community settings.

References

1. Long TP. The prevalence of clinically treated diabetes among Zuni reservation residents. Am J Public Health 1978;68:901-3.

2. Leonard B, Leonard C, Wilson R. Zuni Diabetes Project. Public Health Rep 1986;101:282-8.

3. Heath GW, Leonard BE, Wilson RH, Kendrick JS, Powell KE. Community-based exercise intervention: The Zuni Diabetes Project. Diabetes Care 1987;10:579-83.

4. Ohlson L-O, Larsson B, Svadardsudd K, et al. The influence of body fat distribution on the incidence of diabetes mellitus: 13.5 years of follow-up of the participants in the study of men born in 1913. Diabetes 1985;34:1055-8.

5. Karam JH. Obesity and diabetes in humans. In: Brodoff BN, Bleicher SJ, eds. Diabetes mellitus and obesity. Baltimore: Williams and Wilkins, 1982:294-300.

6. Wing RR, Epstein LH, Nowalk MP, Koeske R, Hagg S. Behavior change, weight loss, and physiological improvements in Type II diabetic patients. J Consult Clin Psychol 1985; 53:111-22.

7. Saltin B, Lindgadarde F, Houston M, Horlin R, Nygaard E, Gad P. Physical training and glucose tolerance in middle-aged men with chemical diabetes. Diabetes 1979;28(suppl 1):30-2.

8. Kaplan RM, Wilson DK, Hartwell SL, Merino KL, Wallace JP. Prospective evaluation of HDL cholesterol changes after diet and physical conditioning programs for patients with type II diabetes mellitus. Diabetes Care 1985;8:343-8. *Individuals are diagnosed as having NIDDM if their fasting blood-glucose level is greater than or equal to140 mg/dl on at least two occasions or if they have at least two oral 75-gm glucose-tolerance tests that result in a blood-glucose level greater than or equal to200 mg/dl after 2 hours.

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