Exercise Adherence in Patients with Diabetes: Evaluating the role of psychosocial factors in managing diabetes Natalie N. Young,1, 2 Jennifer P. Friedberg,1, 3 Michelle E. Ulmer,1 Hoyune E. Cho,1 Stuart R. Lipitz,4 Sundar Natarajan1,3 1VA New York Harbor Healthcare System 2University of Hawaii John A. Burns School of Medicine 3NYU School of Medicine 4Brigham and Women’s Hospital/Harvard Medical School

Presenter Disclosures Natalie Young The following personal financial relationships with commercial interests relevant to this presentation existed during the past 12 months: No relationships to disclose

Background Patients with diabetes and high blood pressure (BP), or hypertension, suffer from high rates of cardiovascular complications Hypertension in patients with diabetes: Systolic BP >130 mmHg and/or Diastolic BP > 80mmHg Regular exercise effective for uncontrolled hypertension in patients with diabetes Despite established benefits, adherence to exercise remains low Factors that affect exercise in patients with diabetes and hypertension is unclear

Specific Aims Identify psychosocial factors related to exercise duration in patients with diabetes and hypertension Assess the relationships of these factors with adherence to exercise

Methods- Data Source Data collected from 227 participants with diabetes and uncontrolled BP in a Randomized Control Trial (RCT) to control HTN Study Sites: VA New York Harbor Healthcare System- New York and Brooklyn campuses Patients assessed multiple times over a year in the RCT Data from Baseline Visits Exercise duration and exercise adherence were examined Looked at a priori demographic, health, and psychosocial variables

Variables of Interest Dependent Variables Independent Variables Exercise Duration Exercise Adherence Independent Variables Age Exercise Self-Efficacy Exercise-Related Social Support Number of Prescribed Blood Pressure Medications Body Mass Index

Dependent Variables- Exercise Outcomes Exercise Duration Hours/week Measured using the 7-day Physical Activity Recall (PAR), a validated measure Exercise Adherence Yes/No Classified using previous aerobic exercise recommendations by the Centers for Disease Control and Prevention (CDC) and the American College of Sports Medicine (ACSM) >3 days/ week for at least 20 minutes each day

Independent Variables- Demographic, Health, and Psychosocial Factors Age Years Obtained from patient records at the Baseline visits Exercise Self-Efficacy Examines how confident one is to exercise when other variables interfere (i.e. stress, lack of time, weather) Assessed using a validated 6-30 point scale Exercise-Related Social Support Measures the perceived social support from others Assessed using a validated 3-15 point scale Exercise-Related Social Support (continued) Specific to encouragement or discouragement from others related to exercise (i.e. given rewards for exercising vs. criticized or made fun of for exercising) Number of Prescribed Blood Pressure Medications Proxy for severity of HTN Obtained from patient records at the Baseline visits Body Mass Index (BMI) Measure of obesity in kg/m2 Calculated at the Baseline visits

Statistical Analysis Regression models used to evaluate relationship between the independent variables and exercise outcomes Dependent Variables: Exercise Duration (hrs/wk) and Exercise Adherence (yes/no) Independent Variables: Demographic, Health, and Psychosocial Factors among Patients Robust regressions examined independent variables’ relationship to duration of exercise (continuous) Robust regression used because data not normally distributed Logistic regression evaluated predictors of adherence to exercise (dichotomous)

Sample Characteristics N= 227 Demographics Frequency (%) Sex Male 227 (100%) Race Black 89 (40.1%) White 81 (36.5%) Hispanic 40 (18.0%) Other 12 (5.4%) Employment Status Retired 131 (58.0%) Unemployed 52 (23.0%) Employed 43 (19.0%) Marital Status Married 85 (37.8%) Separated or Divorced 78 (34.7%) Never Married 41 (18.2%) Widowed 21 (9.3%) Education Status Some College and Beyond 119 (52.9%) High School Graduate or GED 75 (33.3%) Some High School or Less 31 (13.8%)

Number of Prescriptions Summary Statistics N= 227 Variables Scale Median Range Exercise Adherence % Yes/%No 40.3 Yes/ 59.7 No Exercise Duration Hours/ Week 2.5 1.0-2.5 Age Years 63.2 57.8-73.1 Exercise Self-efficacy 6-30 20.0 16.0-24.0 Exercise-Related Social Support 3-15 3.0 3.0-4.5 BP Medications Number of Prescriptions 2.0-4.0 BMI kg/m2 30.4 27.5-33.7

Results- Robust Regression for Exercise Duration Independent Variables Coefficient Bivariate Multivariate Age -.0089 -.0085 Exercise Self-efficacy .11* Exercise-Related Social Support .23** .21** Number of BP medications -.21† -.26** BMI -.0096 *p<.01; **p<.05 †p<.10

Results- Logistic Regression for Exercise Adherence Independent Variables Odds Ratio [95% CI] Bivariate Multivariate Age 1.00 [.97-1.03] Exercise Self-efficacy 1.09 [1.03-1.15]* 1.08 [1.02-1.15]* Exercise-Related Social Support .98 [.84-1.14] .94 [.79-1.11] Number of BP medications .81 [.67-.99] ** .81 [.66-1.00] ** BMI .97 [.92-1.03] .99 [.93-1.05] *p<.01; **p<.05

Conclusions Lower number of blood pressure medications associated with increased exercise adherence Higher number of BP medications could indicate more severe HTN  affect adherence to exercise Increased BP medications could increase side effects  decrease exercise adherence May promote negative perception of health  negatively influence adherence to exercise Age and BMI had less impact on exercise than self-efficacy and social support Psychosocial factors may have more significant role than demographic and physiological factors

Implications May be beneficial to focus on psychosocial factors when trying to increase exercise duration and adherence in the treatment of patients with diabetes and hypertension Intervention should address psychosocial aspects: Increase self-efficacy Emphasize social support Reduce number of medications Goal is to achieve better exercise adherence and longer duration of exercise and improve management of diabetes

Questions? Thank You!