應用跨理論模式探討第2型糖尿病患運動行為模式暨介入措施改善成效之系列研究

糖尿病是21世紀罹患率及死亡率增加最快速的慢性病，推動糖尿病衛教措施介入是公共衛生的一大課題，本研究以跨理論模式為基礎，於北區某醫院新陳代謝門診進行三階段計畫。第一階段:橫斷式調查，主要目的為瞭解第2型糖尿病患者運動行為模式，包括運動階段、運動決策平衡（運動利益及運動障礙）、運動自我效能、血糖控握、身體組成及血液指標之現況，並驗證運動階段是否為血糖內在控握對體脂肪與糖化血色素影響之中介變項。採利益取樣共219位個案完成問卷調查，有效問卷為214份（97.72%）。結果顯示，高達138位（64.49%）無運動意願（意圖前期38位及意圖期100位），56位（26.17%）有意願運動（準備期19位及行動期37位)，只有20位（9.34%）運動階段處維持期（過去半年內有規律運動）。身體組成方面，74.8% （n=160）為體位異常、67.3% （n=144）腰圍屬於肥胖、74.3%（n=159）腹部肥胖及49.1%（n=105）體脂肪過高。血糖控制方面，22.0%（n=47）個案糖化血色素控制良好，然而亦有23.4%（n=50）個案血糖控制不良。經路徑分析結果顯示，血糖內在控握對運動階段（β=0.224, p<.0001）的影響力最大，及會透過運動階段直接或間接影響體脂肪百分比與糖化血色素之數值。第二階段，採類實驗設計（單組前、後測比較）法，為了解「認知行為教育課程介入」對其運動階段、運動決策平衡（運動利益及運動障礙）、運動自我效能、身體組成及血液之改善成效。篩選出運動階段位於「意圖前期」及「意圖期」者為研究對象，共招募76位第2型糖尿病患者進行4週共12小時「認知行為教育課程｣，67位完成認知教育課程的介入措施。結果顯示，86.5%個案（58人）進階到下一運動階段，運動自我效能總分顯著提高（t=4.741, p＜.001）、空腹血糖（t=4.286, p＜.001）及糖化血色素（t=3.978, p＜.001）均顯著改善。第三階段，採實驗性研究，主要目的為探討12週中等強度運動計畫介入對葡萄糖代謝及胰臟β細胞功能在12週介入後立即（短期）和介入結束1年（長期）追蹤改善成效，並進一步比較兩種不同型態運動介入之成效差異。招募120位運動階段處於「準備期」及「行動期」第2型糖尿病患者為研究對象，及進行區塊隨機（black random）分派，分為中等強度有氧運動組（n=40）、日累計萬步組（n=40）及控制組（n=40）。結果顯示，中等強度有氧運動組12週運動的遵從率為94.37%，日累計萬步組遵從率為99.20%。廣義估計方程式（GEE）分析呈現，在控制藥物改變、罹病年數、低密度脂蛋白、體脂肪及身體質量指數等影響變項，日累計萬步組無論在12週運動介入後（B=-.506, 95% CI,.863~-.149）或介入結束1年追蹤（B=-1.004, 95% CI,-1.476~-.533）之糖化血色素皆顯著低於控制組，而中等強度有氧運動組僅於1年後追蹤（B=-.698, 95% CI,-1.144~-0.252）顯著低於控制組。兩組運動組之胰臟β細胞功能無論在12週運動介入後或介入結束1年追蹤皆顯著高於控制組。進一步比較兩組之運動成效差異，日累計萬步組無論在12週介入或介入結束1年追蹤，其糖化血色素（B=-.428, 95% CI,-.681~-.174 vs.B=-.500, 95% CI,-.814~-.178）和胰臟β細胞功能（B=.499, 95% CI,-.214~.784 vs B=.398, 95% CI,.132~.664）之改善成效皆優於中等強度有氧運動組。以上結果支持，針對靜態生活形之第2型糖尿病患者運用跨理論模式並結合4週共12小時的認知教育課程介入，除血糖控制有改善趨勢，且能提升運動自我效能並促使個案邁入下一個運動階段。再者，透過12週每週5天的中等強度運動介入，證實日累計萬步運動及中等強度有氧運動之兩種不同型態運動介入，對於葡萄糖代謝及胰臟β細胞功能皆有正向的影響，即便在介入結束1年之追蹤仍可見其成效；且日累計萬步之運動型態較30分鐘中等強度有氧運動成效佳，並有較高的運動遵從率。本研究之衛教課程設計及運動處方可提供醫院及相關醫療機構之健康促進介入計畫模式及內容規劃之參考。

關鍵字

第2型糖尿病；運動行為模式；認知行為教育課程；運動計畫；身體組成；葡萄糖代謝；胰臟β細胞功能

並列摘要

Diabetes mellitus (DM) is the most rapidly increasing chronic disease in the morbidity and mortality in the 21st century. Implementation of health education of diabetes plays a major role in prevention and management of diabetes. A series of studies is based on applying transtheoretical model (TTM) and undergoing three stages in the department of endocrinology at a teaching hospital in the north of Taiwan. Stage one: A cross study, the purpose of this stage was to explore the exercise behavior model (exercise stage, exercise decisional balance, locus of control of blood glucose, anthropometries, and glucose/lip control among type 2diabetics (T2DM). Indeed, to confirm whether exercise stage is a mediator between internal control, body fat % and HbA1c. A total of 219 purposive participants were recruited and 214 (97.72%) completed the survey. The result shows 138 (64.49%) of T2DM were not-intended to exercise (38 of T2DM in "Pre-contemplation" and 100 in "Contemplation"), of 56 (26.17%) T2DM intend to exercise (19 of T2DM in "Preparation" and 37 of T2DM in "Action"), only 20 (9.34%) T2DM had regular exercise in the past 6 months. In anthropometries, 74.8% (n=160) were obese, 67.3% (n=144) had abnormal waist circumference, 74.3% (n=159) with higher waist-hip ratio, and 49.1% (n=105) had higher body fat %. Glucose control, 22.0% (n=47) of T2DM had acceptable control of HbA1c, however 23.4% (n=50) had poor control. Internal control had effectiveness on exercise stage (β=0.224, p<.0001) and had direct and indirect effect on the variables of body fat % and HbA1c. Second stage: aquai-experimental design with one-group having a pre-post test design was used. The purpose of this stage was to explore the impact of applied Cognitive-Behavioral Education Courses (CBEC) on exercise stage, exercise decisional balance, exercise self-efficacy, anthropometries, and glucose/lip control among type 2diabetics. A total of 67 patients who were classified into the "pre-contemplation" and "contemplation" stages of exercise were recruited and completed a 12-hour CBEC in four weeks. The results showed 86.5% of patients moved into an advanced exercise stage. The total score of exercise self-efficacy (t=4.741, p＜.001), fasting glucose (t=4.286, p<.001) and HbA1c (t=3.978, p<.001) significantly improved after a 12-hour CBEC. Third stage: experimental design, the purpose of this stage was to investigate the effectiveness of a 12-week exercise program with moderate intensity on glucose metabolism and pancreatic β cell function in T2DM patients, also to compare the effectiveness of the two exercise modes. A total of 120 T2DM who were classified into the "Preparation" and "Action" stages of exercise were recruited and were assigned by block randomization to either an aerobic exercise group (AEG), an accumulated million steps group (AMSG), or a control group (CG); each consisting of 40 patients. The results shows that the compliance rates for the AEG and AMSG were 94.4% and 99.2% respectively. A generalized estimating equation analysis was done by controlling the confounding factors of medication changes, length of disease, low-density lipoprotein (LDL), body fat % and body mass index (BMI). The AMSG group improved their overall HbA1c and BIGTT-AIR results compared to the AEG group after a 12-week exercise program (B=-.506, 95% CI, .863~-.149) and also after the twelve month follow up (B=-1.004, 95% CI,-1.476~-.533). However, the results of the AEG group only improved after a year of follow up. The insulinogenic index-acute insulin response (BIGTT-AIR) of both exercise groups (AMSG and AEG) was significantly higher than the control group at both 12-week and after a year of follow up. this study demonstrated that regardless of the mode of exercise intervention, the AMSG had better glucose metabolism (B=-.428, 95% CI,-.681~-.174 vs. B=-.500, 95% CI,-.814~-.178) and pancreatic β cell function (B=.499, 95% CI,-.214~.784 vs. B=.398, 95% CI,.132~.664) compared to those in the AEG. In conclusion, the results of this study demonstrated that the sedentary T2DM had improvement of glucose metabolism, and moved to an advanced exercise stage by increased exercise self-efficacy after attending the CBEC. After a five day per week and twelve week moderate exercise program, both exercise groups experienced a positive effect on glucose metabolism and pancreatic β cell function at both 12-week implementation and a year of follow up. The AMSG had better glucose metabolism and pancreatic β cell function compared to those in the AEG. Both the education program and the exercise prescription can be a valuable adjunct for health care promotion in hospitals.