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Diabetes NewsOctober 2012

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Fear of Injury With Physical Activity is Greater in Adults with Diabetes Than in Adults Without Diabetes

Diabetes Care • August, 2011

Physical activity is the cornerstone of diabetes treatment, yet people with diabetes are less physically active than people without diabetes, especially with regard to moderate and vigorous physical activity (MVPA). Identifying and removing barriers to physical activity is important because of the strong relationship between physical inactivity and cardiovascular disease in people with type 2 diabetes and the likely cardiovascular benefits for people with type 1 diabetes. Some barriers have been identified that may be considered specific, including ‘fear of hypoglycemia’, the presence of ‘bad feet due to diabetes’ and an ‘unwillingness to exercise in the presence of people who do not have type 2 diabetes’. In the laboratory setting, diabetes is associated with impaired submaximal exercise performance and greater perceived effort during low intensity exercise. While these potential diabetes-specific barriers to physical activity have been identified, this area has been understudied.

Other barriers to physical activity exist with type 2 diabetes, lack of social support, lack of knowledge of the types of exercise to perform, health problems, pain/difficulty taking part in exercise, lack of local exercise facilities and aversion to exercising in poor weather. Although several studies have identified barriers to physical activity in people with type 2 diabetes, only one study used population-based sampling, only one study assessed whether usual activity levels influence barriers by diabetes status (diabetes vs. no diabetes) has not been compared.

The current study compares barriers to physical activity by diabetes status in a rural, biethnic population-based sample within two strata of physical activity: ‘less active’ (<150 min weekly MVPA) and ‘more active’ (≥150 min weekly MVPA). Because walking activity differences by diabetes status have been understudied, walking and MVPA in this study compared walking and MVPA differences in participants with and without diabetes.

Objective - Physical activity is a cornerstone of treatment for diabetes, yet people with diabetes perform less moderate and vigorous physical activity (MVPA) than people without diabetes. In contrast, whether differences in walking activities exist has been understudied. Diabetes-specific barriers to physical activity are one explanation for lower MVPA in diabetes. It was hypothesized that people with diabetes would perform less walking and MVPA and would be less likely to anticipate increasing physical activity if barriers were theoretically absent, compared with people without diabetes.    

Research Design and Methods - The adult population of Alamosa County were studied from 2002 to 2004 (estimated eligible population aged ≥ 18 years = 10,976). Alamosa County is rural, biethnic (50% Hispanic), low-income county in south central Colorado. The survey was designed, in part to assess the physical habits of Alamosa County residents. Trained staff from the Colorado Department of Public Health and Environment (CDPHE) followed the standard random-digit dial telephone survey techniques used by the CDPHE to conduct the annual Behavioral Risk Factor Surveillance System (BRFSS). To maintain population-based sampling, a random selection algorithm accounting for household members’ age and sex selected one adult to survey. Up to twenty calls were made to reach the selected adult.  

Conclusion - In a rural, low income, biethic (~50% Hispanic) Colorado population, people with diabetes walked less than people without. To the author’s knowledge, it is the first study in a population-based sample to demonstrate that people with diabetes walk less than people without diabetes. People with diabetes also performed less overall physical activity (combined MVPA) than people without diabetes, as has been previously observed. One potential reason for the observed lower activity level is the finding that ‘fear of injury’ was a greater barrier to physical activity in people with diabetes than those without.

Fear of injury is a previously indentified barrier to physical activity in populations without diabetes, but this study is the first to identify it as an important barrier for people with diabetes. Perhaps related to fear of injury, fear of hypoglycemia has been described as a significant barrier to physical activity in people with type 1 and type 2 diabetes. However, in the study group differences in ‘fear of injury’ by diabetes status appear mostly related to older age and greater BMI in the study group with diabetes rather than to the presence of a diabetes-specific fear of injury. It is also possible that the sample size was too small to detect a true association for diabetes status and fear of injury after adjustment for age and BMI. Further study should clarify the nature of ‘fear of injury’ in diabetes to inform strategies to overcome this fear.

Other studies have assessed physical activity barriers for people with diabetes but not typically in population-based samples. A recent review identified numerous barriers to exercise for people with type 2 diabetes, including unmet needs for social support, lack of knowledge of types of exercise to perform, pain/difficulty taking part in exercise and lack of exercise facilities. However, the majority of these studies were performed in convenience samples of medical settings. This study represents one of few population-based samples where barriers to physical activity were compared by diabetes status. One other population-based survey of barriers to physical activity in diabetes identified lack of social support and health problems as barriers to exercise but did not ask about fear of injury. To the author’s knowledge, this is the first study to evaluate and identify fear of injury as a potential barrier to physical activity in diabetes.

Unmet needs for social support were important barriers to physical activity for all respondents. Regardless of diabetes status, the lack of ‘someone to exercise with’ was the most highly ranked barrier. Suggesting that helping individuals identify and use supportive exercise setting and supportive personal contacts as an important avenue to increase physical activity.

The study found that people with diabetes performed less combined MVPA than people without diabetes, similar to the findings of others. The majority of respondents with diabetes (53%) reported < 150 min of weekly MVPA, showing that most respondents with diabetes were not optimally active. Physical activity levels for our participants with and without diabetes were somewhat greater than those observed in other studies, and this may be due in part to greater levels of physical activity in Western regions and/or social desirability bias. However, the data available to the authors does not allow a determination of the exact reason why the personal reports are greater than those observed in other studies.

Although diabetes is consistently associated with performing less MVPA, to the author’s knowledge this is the first population-based study to demonstrate lower walking activity levels in people with diabetes than without diabetes. The walking data are in contrast with two other population-based studies, which found that walking activity was comparable or greater in people with diabetes than those without diabetes.

In this population-based sample of rural adults, ‘fear of injury’ was a greater barrier to physical activity in people with diabetes than those without diabetes. Older age and greater BMI were more strongly related to having a ‘fear of injury’ barrier than was the presence of diabetes itself. For clinicians, these data support asking patients with diabetes, particularly older and heavier patients, whether they are worried about ‘injury’ or ‘hurting themselves’ during physical activity in order to identify safe ways to exercise when fear of injury is a barrier. Barriers other than fear of injury are also important to consider because participants with diabetes commonly reported social barriers to physical activity. These data, in combination with data from other studies, suggest that helping patients develop social support for exercise is an important strategy to facilitate increased physical activity.

Further research is needed to identify and overcome physical activity barriers for people with diabetes. One possible approach is to is to develop and validate efficient questionnaires that could be used in clinical care settings to identify and address the most important and modifiable barriers to physical activity for individuals with diabetes. Responses to such questionnaires could be used to provide tailored recommendations to overcome barriers. From a public health perspective, we need to identify key modifiable physical activity barriers that are related to physical activity levels in larger studies that are representative of the overall population with diabetes. The identification of key modifiable barriers should guide health policy decisions and the design of future behavioral intervention trials to increase physical activity for people with diabetes.      


Reprinted with permission from the American Diabetes Association


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