Exercise as it relates to Disease/Barriers to Physical Activity Among Patients With Type 1 Diabetes

This article is a discussion and analysis of the article "Barriers to Physical Activity Among Patients With Type 1 Diabetes." published by Brazeau, Rabasa-Lhoret, Strychar & Mircescu in 2008.

What is the background to this research?
Regular physical activity is associated with numerous benefits such as improved quality of life, decreased cardiovascular risk factors and mortality. Everybody benefits from regular exercise. If you have diabetes, or are at risk of diabetes it plays an important role in keeping you healthy. Despite this evidence, >60% of patients with type 1 diabetes remain sedentary. Type 1 diabetes is an auto-immune condition in which the immune system is activated to destroy the cells in the pancreas which produce insulin. The cause for this auto-immune reaction is not known. Type 1 diabetes is not linked to modifiable lifestyle factors. There is no cure and it cannot be prevented.

Type 1 diabetes:


 * Occurs when the pancreas does not produce insulin
 * Represents around 10% of all cases of diabetes and is one of the most common chronic childhood conditions
 * Onset is usually abrupt and the symptoms obvious
 * Symptoms can include excessive thirst and urination, unexplained weight loss, weakness and fatigue and blurred vision
 * Is managed with insulin injections several times a day or the use of an insulin pump.

According to the article 'Barriers to Physical Activity Among Patients with Type 1 Diabetes, there has only been one report that specifically addresses barriers for the practice of physical activity among individuals with type 1 diabetes. The author of the mentioned report developed the Barriers to Physical Activity in Diabetes (Type 1) (BAPAD1) scale, a 12 item self-administered questionnaire. Therefore, objective of the study undertaken were to determine the most salient barriers using the BAPAD1 scale ad to determine the factors associated with these barriers.

Where is the research from?
The research was published in 2008 and is from a number of institutions, including:


 * 1) Metabolic Dysfunction Laboratory, Department of Nutrition, University of Montreal, Montreal, Canada;
 * 2) Research Center of the University of Montreal Hospital Center, Montreal, Canada;
 * 3) Division of Endocrinology, Department of Medicine, Research Center of the University of Montreal Hospital Center, Montreal, Canada
 * 4) Faculty of Medicine, University of Montreal, Montreal, Canada; and
 * 5) Montreal Diabetes Research Center, Research Center of the University of Montreal Hospital Center, Montreal, Canada

What kind of research was this?
The study was a questionnaire where a number of type 1 diabetic patients answered a number of questions relating to the perceived barriers to physical activity and related factors. A1C levels were obtained from the medical chart of each individual.The questionnaire contained closed-ended questions which provided the researchers with quantitative data.

What did the research involve?
The study involved a 44-item questionnaire which was answered by 103 type 1 diabetic patients when attending their regular appointments at the University of Montreal Hospital Center. The project was approved by the ethics and research committee at each institution. The study consisted of a variety of individuals and not a specific population. The final sample consisted of 100 adults with type 1 diabetes (50% Women). 92% of the participants were Caucasian. Mean ± SD age = 43.5 ± 11.6 years, duration of diabetes= 23.3 ± 13.2 years, and BMI= 25.9 ± 4.9 kg/m2 The questionnaire included socio-demographic characteristics and diabetes treatment. The questionnaire consisted of a BADAPD1 scale, where participants rated 12 barriers to physical activity on a scale from 1 to 7 (whether the item would keep them from engaging in regular physical activity over the next 6 months: 1, extremely unlikely, and 7, extremely likely). Social-support questions were assessed by 3 questions derived from the original study this research was based on. In addition, patients were asked to report the number of hypoglycemic episodes in the previous 2 weeks and the number of severe hypoglycaemic episodes in the last year, as well as what actions they took to prevent such episodes. Patients knowledge of insulin pharmacokinetics was also assessed by asking patients to state the time of onset and peak action of their insulin prescription. The World Health Organization-5 Well-Being Index, a validated scale of five questions developed to assess quality of life, was also included in the questionnaire. Pearson’s correlations and Student’s t-tests for independent sample were performed to determine the relation between various factors and perceived barriers. Data was analysed using SPSS Software (Version 15.0).

What were the basic results?
The basic results from this study showed that there is a strong relationship between internal and external factors which are barriers to physical activity in type 1 diabetic patients.The four main barriers to physical activity identified among type 1 diabetic patients attending university hospital outpatient clinics were fear of hypoglycemia, work schedule, loss of control over diabetes, and low fitness level, respectively. Factors associated with barriers to physical activity included basic knowledge about insulin pharmacokinetics and implementation of strategies to prevent hypoglycemia. Half of the participants were not knowledgeable about these fundamental elements. These factors are summarized in Table 1.



How did the researchers interpret the results?
The researchers that conducted the study concluded that fear of hypoglycemia is the strongest barrier to regular physical activity in adults with type 1 diabetes, who should therefore be informed and supported in hypoglycemia management and insulin pharmacokinetics. The researchers also suggest that the relationship between social support and physical barriers suggest that it a major factor impacting physical activity in these patients and support needs to be implemented.

What conclusions should be taken away from this research?
The study has shown that the barriers to physical activity among patients with type 1 diabetes is a major issue. As fear of hypoglycaemia is the strongest barrier to regular physical activity, more support and education needs to be undertaken in order to inform the patients and their immediate support of the benefits and risks of physical activity and the management of hypoglycaemia.

The researchers have addressed numerous factors into the barriers of physical activity among these patients. However, there are a number of limitations in this study including factors such as patients who are already exercising, the age and variety of the participants and the study design. The study design restricts the researchers to establish the causal direction of the associations found and further research is needed using a prospective controlled design. Additionally, the study may address a number of factors, however diabetes is a disease that not only effects the patient, but the immediate support around them. Factors such as the patients psychological and mental health, previous and current exercise history, lifestyle, occupation and a more in depth analyses of the factors such as health and a basic understanding of the patient's past and present would be an additional and beneficial insight into the diabetic patients.

As mentioned in the study, there is only one report known to have addressed specific barriers for the practice of physical activity among individuals with type 1 diabetes. As diabetes is such a common disease around the world, further research into this area must be specifically addressed and undertaken as physical activity is a crucial part of every day life. Furthermore, the types of physical activity need to be addressed. This includes factors such as aerobic or anaerobic, levels of intensity, the frequency and the type of exercise (walking to team sports, to sprinting) across all age groups, and limitating health factors such as the time of the day they participate in physical activity - in accordance to a physical activity program which much be liaised with their treating doctor. Additionally, the study highlighted the need to develop methods to encourage those with type 1 diabetes to regularly participate in physical activity. This is especially crucial to those who avoid exercise due to fear of severe hypoglycaemic events.

What are the implications of this research?
This study has provided an important insight into the barriers to physical activity among patients with type 1 diabetes. Although there were a number of limitations in the study and further research needs to be conducted, the study provides crucial aspects into real world factors which limit these patients from participating in physical activity, and therefore can be used as a good basis for further research to be conducted and a number of additional aspects to be investigated for those living with this condition.