Journal of Human Nutrition and Dietetics (1999), 12 (Suppl. 1), 79±90

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Diabetes Exercise Project

C. Murphy, M. Simkins* and R. Helowicz{Diabetes Nurse Specialist, *Senior Health Promotion Advisor/Dietitian, {Public Health

Specialist, East Surrey Health Authority, West Park Road, Horton Lane, Epsom, Surrey

KT19 8PH, UK

Background: Exercise can play a major role in improving diabetic control and prevention

of complications. In order to encourage overweight people with poorly controlled diabetes

to take more exercise a group exercise programme was set up.

Objectives: To evaluate the effectiveness of the diabetes exercise project 20 months after

professional contact and funding had ceased. The project ran from October 1994 to March

1996 and the evaluation was carried out in November 1997.

Method: Evaluation was carried out through a postal questionnaire, focus group

discussions and clinical data collection on a sample of those referred on to the project.

The project set out to find: (1) the number of the original group who took up the exercise

programme and were still exercising on a regular basis; (2)the clinical outcomes in terms

of changes in body mass index (BMI), glycosylated haemoglobin (HbA1) and diabetes

medication from the start of the exercise project to the evaluation; (3) the self-reported

benefits to those with diabetes on the exercise programme, including any self-reported

effect regular exercise has had on their diabetes control at the time of the evaluation;

(4) the factors associated with their ability to carry on exercising.

Results: Clinical outcomes showed no significant changes in those who continued to

exercise and those who stopped. However, there was a statistically significant increase

(P=0.01) in the proportion of those with non-insulin dependent diabetes (NIDDM) who

were treated with insulin, from 30% to 53%. Of the 42 who had replied to the

questionnaire, 71% continued to exercise for more than 6 months and, of these, 52%

continued to exercise for over 20 months. Self-reported benefits of exercise included

`increased energy levels', a greater ability to concentrate and enjoy exercise, increased

motivation and more positive mood and feelings. Improvement in diabetic control was

reported by 25 (60%). Further benefits reported included a stabilizing of their diabetes,

loss of weight and a more positive attitude towards their health.

Conclusions: It is possible to motivate overweight, poorly controlled people with diabetes

to exercise on a regular basis. To do so successfully, consideration needs to be given to

having the right personnel involved in the exercise programmes, support from the health

professionals and suitable facilities and instruction. Injury and lack of time were given as

the main barriers to exercise.

Key words: diabetes, exercise, overweight, evaluation.

Introduction

Within the clinic population, there is a group of

overweight, `poorly controlled' people with dia-

betes taking large doses of medication who have

been repeatedly told to `lose weight', `be more

careful with their diet' and `take more exercise'.

Despite this advice their diabetes continues to be

poorly controlled, their weight increases, their

medication is increased and they do not `take

more exercise'. This is mainly because they are

poorly motivated, embarrassed about their

weight and do not know where to start. Also

these mainly non-insulin dependent people with

diabetes are still considered to have a `milder'Correspondence: M. Simkins.

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form of the disease but, given the problems with

obesity, insulin resistance, hyperlipidaemia,

hypertension and the increased risk of coronary

heart disease and stroke it is becoming increas-

ingly clear this is not the case.

Although exercise prescription was available

within the area very few people with diabetes

were prescribed it. By setting up the project it

was felt that an exercise programme designed to

fit the needs of this group would encourage more

people to exercise. Throughout the report ex-

ercise is defined as: `Purposeful physical activity

which is often structured and pursued for health

and fitness benefits'; as opposed to physical

activity which refers to: `All forms of bodily

movement which use energy including such tasks

as housework, gardening and cleaning the car'.

Initially a literature review was carried out to

find evidence of the benefits of exercise, espe-

cially in those with diabetes and to identify those

factors which are associated with adherence and

non-adherence to exercise programmes.

Evidence of the benefits of exercise

The benefits of exercise to those with diabetes

have been summarized in Table 1.

Population studies have shown a high incidence

of non-insulin dependent diabetes (NIDDM) in

certain populations which has been attributed to,

too little exercise and too many calories (Ekoe

1989). Studies have also shown that exercise plays

a role in the prevention of NIDDM, with the

greatest effect being seen in those most at risk of

developing diabetes (Helmrich et al. 1991).

Such evidence has led to such statements in

the literature as `exercise should be a primary

means of glucose control'. (Gordon 1993) and

`exercise should now be seen alongside diet and

weight reduction as part of the management of

non-insulin dependent diabetes' (National Insti-

tutes of Health 1987; Horton 1988). Moreover, it

has been reported (Bjorntorp et al. 1970; Leon et

al. 1979) that glucose intolerance related to

obesity will diminish with exercise regardless of

changes in body weight.

Of all the complications associated with dia-

betes, coronary heart disease remains the leading

cause of death. In a review of 40 studies, Powell et

al. (1987) concluded that physical activity was

similar in magnitude to hypertension, hypercho-

lesterolaemia and smoking as a risk factor for

coronary heart disease. McNair (1994) in his

review of risk factors for cardiovascular disease

concluded that it was difficult to see an effective

preventive role for dietary modification. Reviews

of evidence for exercise in the prevention of

disease (Eichner 1983; Fenten 1992; Paffenbarger

et al. 1993) have shown that exercise enhances not

only cardiovascular reserves but also metabolic

and psychological functions. Berg et al. (1994)

reported that despite this knowledge of the

beneficial effects of exercise on lipid metabolism,

physical exercise and training do not receive the

attention they deserve in the treatment of

hyperlipoproteinaemia.

The complications of diabetes as well as

coronary heart disease include intermittent clau-

dication, diabetic retinopathy and nephropathy

and peripheral and autonomic neuropathy; and

Table 1. The benefits of physical activity for those with diabetes

. Reduced risk of coronary heart disease (Blair et al. 1989) (Leon et al. 1987) (Blair et al. 1995) (Berlin &

Colditz 1990).

. Decreased blood pressure (LaPorte et al. 1985) (Powell 1985) (Siscovich 1985)

. Decreased lipid levels (Goldberg & Elliot 1987) (Tran & Weltman 1985)

. Increased cardiovascular performance (Blair et al. 1980)

. Weight control including reduction in weight and percentage of body fat (Williams & Long 1983) (Garrow

& Summerbell 1995) (Prentice & Jebb 1995). (Ballor & Keesey 1991) (Dannenberg et al. 1989) (Fang et al.

1988) (Lingard & Saltin 1981)

. Increased insulin sensitivity (Kovisto et al. 1979) (Lohmann et al. 1978) (Vranic et al. 1990) (Raitakari et al.

1995) (Elliott & Viberti 1993) (Rogers et al. 1988).

. Improved blood sugars

. Prevention and alleviation of diabetic complications

. Improvements in muscle tone strength and flexibility

. Greater sense of well-being including more positive about body image

. Psychological benefits including reduction in anxiety and stress (Powell 1985) (Williams & Long 1983)

(Folkins & Sime 1981)

. Reduced risk of osteoporosis

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they can be prevented by good diabetic control

(American Diabetes Association 1990) with ex-

ercise playing a major role in the prevention and

alleviation of these. In addition, the psychological

benefits of exercise are equally important to

those with diabetes (Jaffee et al. 1990).

Factors which are associated with adherence and

non-adherence to exercise programmes

Those factors identified in the literature that have

helped and hindered individuals' attempts to

exercise are summarized in Table 2.

Despite nearly 10 years' study in the area of

exercise adherence, it is still not possible to

predict who will adhere to exercise programmes.

Studies based on adherence to exercise are also

reported to be of short duration with long-term

follow-up of the effects of various behavioural

techniques on maintenance rare (Robison &

Rogers 1994). Even with the benefits of exercise

being so well documented adherence to exercise

programmes has been reported as typically low,

with 50% of participants dropping out in the first

3±6 months (Dishman 1982; Martin & Dubbert

1985; Blair 1988; Leith 1992; Oldridge 1984). This

50% drop-out includes both `healthy' individuals

as well as those at risk of cardiovascular disease.

Increased adherence has been reported when

formal instruction is given on how to exercise

and the basics of exercising, warming-up, how

they should feel, cooling down and the impor-

tance of drinking water. `Many who wanted to

exercise were unsure how to go about it. They

didn't know what to do, how to do it or where to

go' (Conviser, reported by Schelkum 1993).

Hillsdon et al. (1995) reported that the interac-

tion between professional and client may be of

Table 2. Factors which are associated with adherence and non-adherence to exercise as identified in the

literature

Factor associated with adherence to exercise Factors associated with non-adherence to exercise

Facilities and Instruction Time: including lack of time and

suitable facilities time of exercise classes, e.g. late at night

close proximity of class

small groups as opposed to large Injury

having a variety of activities

formal instruction is given on exercise Obesity

moderate intensity as opposed to high intensity

activities

exercises with low risk of injury Length of time watching television

Support from family, friends and the exercise group

encouragement from others Social class/costs

support from partner

exercise behaviour of family and friends Smoking

having friends at exercise class

Support of Key Personnel Lack of motivation

professional contact through telephone. and home

visits

good interpersonal skills from those promoting Fear of failure

exercise

support from doctor and health professionals

active involvement from doctor and health

professionals

Personal skills

helping people change model (targeting individuals

in various stages of change with appropriate

intervention strategies)

personal skills, e.g. self-regulation, self-monitoring

and the setting of personal goals

development of strategies to deal with barriers to

exercise

confidence in ability to exercise

home-based acitivities

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greater importance than any behavioural techni-

ques. Research from the study of addictive

behaviour indicates that this interaction between

therapist and client is a better predictor of

outcome than either the client's characteristics

or the therapist's theoretical orientation (Miller &

Rollnick 1991). However, a study of GP consulta-

tions (Iliffe & Mitchley 1994) showed that exercise

was discussed less often with their patients than

smoking, weight or diet and when discussed it

was more frequently done so with male patients

and older rather than younger patients. Inter-

views with GPs and practice nurses (Gould et al.

1995), have shown them to have sketchy knowl-

edge of the benefits of exercise with only half of

those interviewed mentioning cardiovascular im-

provement as a health benefit of exercise.

In conclusion, success at long-term exercise

maintenance remains elusive and most people

discontinue in a relatively short time.

Setting up the project

Having identified that there was a need to

encourage overweight, poorly controlled people

with diabetes to take more exercise, short-term

funding was secured to provide a part-time co-

ordinator with a small budget to subsidize

classes at leisure centres and provide promo-

tional materials. The co-ordinator had consider-

able experience both as a diabetes nurse

specialist and a facilitator and was therefore

able to deal with the practicalities of setting up

the project and provide the clinical advice that

the participants would need.

Three group exercise sessions a week were set

up exclusively for those with diabetes. These

included two gym-based classes and one aerobics

class per week, all with an emphasis on low-impact

aerobics and body-toning activities. These sessions

were arranged at off-peak times and the partici-

pants asked to pay £1 per session with any

shortfall being subsidized from the project. It was

felt that a group approach would be the most

effective as the participants could support each

other and the co-ordinator could provide clinical

information to the group. The participants were

able to join the leisure centres at a reduced rate and

use the other facilities. The aim was for the

participants to take three exercise sessions per

week, with each session expected to be a minimum

of half an hour at reasonable intensity. Participants

were asked to keep a record of their exercise.

Information about the project, including the

criteria for inclusion (Table 3) was disseminated

to the GPs and diabetes unit through an

information pack.

Referrals were sent to the co-ordinator and, at

the initial appointment, baseline measurements

were taken including weight, body mass index

(BMI), blood pressure, lipids, all medication and

HbA1. A short history was taken to identify any

other existing health problems or injuries. The

aims of the project were explained and any

concerns that the client had were discussed.

Information was given on the classes and advice

to build up their exercise slowly, monitor their

diabetes carefully and be aware of the possibility

of hypoglycaemia (low blood sugar). Participants

were encouraged to monitor their diabetes

through blood sugar measurements and to assess

for themselves the effect exercise was having on

control. If blood sugars were consistently low, a

reduction in diabetic medication before taking

exercise was advised. This was preferred to

eating more as that would have been counter-

productive to weight loss.

An injury prevention session was set up with

qualified physiotherapists before commencing

the exercise programme. Information was given

on footwear, the importance of warming up prior

to exercise and suitable exercises to improve

muscle tone and posture, as well as advice on the

types and duration of exercise. All leisure staff

instructors involved in the project were also

assessed by a doctor to ensure that they were

suitably qualified to lead the classes.

Of 142 diabetics referred on to the project over

the 18-month period, 128 took up the exercise

programme. Reasons for not starting were mainly

Table 3. Criteria for inclusion in to the exercise

project

Insulin dependent or non-insulin dependent diabetes

Aged up to 65 years and any of the following:

Overweight (BMI 4 25)

Hypertensive

Hyperlipidaemia

Raised HbA1 (above 12%)

Maximum or near maximum oral medication for

diabetes

High insulin dosage

High alcohol intake

Regular smoker

Depression/low self-esteem

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lack of time, travel difficulties, costs and existing

health problems.

Diet sessions

Although exercise was the main focus of the

treatment, all those in the project were invited to

identify any further support they felt necessary.

As a result of this, monthly group sessions with

the dietitian were requested and set up. These

were held in the leisure centre before the aerobics

classes and ran for 14 months with topics for

discussion decided in consultation with the

group. Initially no weighing scales were used as

it was felt there was a need to avoid weight loss

being the main focus of the group sessions.

However, some of the group requested regular

weighing and it was introduced as an option with

most of the group choosing to weigh themselves.

The funding for the project lasted 18 months.

Evaluation

The evaluation set out to assess:

1 the number of the original group who took up

the exercise programme and were still exercising

on a regular basis;

2 the clinical outcomes in terms of changes in

BMI, HbA1 and diabetes medication from the start

of the project October 1994 to November 1997;

3 the self-reported benefits of the exercise pro-

gramme, including any self-reported effect reg-

ular exercise has had on their diabetes control;

4 the factors associated with their ability to carry

on exercising, i.e. what helped and what hindered

exercise adherence of the group since commen-

cing the exercise project?

Methods

Of the 128 who commenced the exercise project

67 could be traced for follow-up (37 females and

30 males). Clinical data including BMI, HbA1 and

medication was collected from the annual re-

views for the years 1994±97. Full clinical data for

BMI, HbAI, and medication for diabetes was

collected for 51 of this group. Those for whom

clinical results were not collected had either

moved away from the area defaulted from the

diabetes clinic or records were unobtainable from

their GP practice.

A questionnaire was sent to the 67 who could

be traced for follow-up with a stamped-addressed

envelope. The opportunity to enter a prize draw

was used as an incentive to encourage response.

Forty-two (63%) returned the questionnaire.

Telephone calls failed to increase the response

rate; people had either moved out of the area,

were away from home, no longer attended the

diabetes clinic or were ex-directory. A sample of

those sent the questionnaire were invited by

telephone to discuss the project as part of a focus

group. Two groups were organized, one repre-

senting those who continued to exercise and the

other comprising those who were no longer

exercising regularly. The exercisers focus group

was made up of three males and four females

who had been attending the leisure centre class

for 2±3 years and the non-exercisers focus group

included seven females who all confirmed they

were no longer exercising regularly. The group

facilitator led the focus groups in identifying

those factors which had encouraged and discour-

aged adherence to exercise. The focus groups

were recorded using shorthand.

The data were analysed using the database

and statistics program Epi Info (Dean et al. 1994).

Results

Sex and age distribution

Of the 67 who had been sent the questionnaire 37

(55%) were female and 30 (45%) were male and of

these 42 (63%) replied (30 (81%) females, 12 (40%)

males). 50% of the respondent males and 53% of

the respondent females were still exercising.

The mean age of the whole group was 58.5

years (range 33.0±76.0 years), of the women was

58.3 years (range 33.0±76.0 years) and of the men

58.8 years (range 43.0±69.0 years) at the time of

the evaluation (1997). 56% of the females who

were exercising were between 50 and 59 years

and 38% were 60 years or more and, of the males

who were exercising, 33% were between 50 and

59 years and 67% were 60 years or more.

Clinical results

Full clinical data was available for 51 of the

group. The data for BMI and HbA1 are presented

in Table 4. No significant differences were seen in

the BMI and HbA1 in the exercisers, non-

exercisers and non-responders between the start

of the project (1994) and the evaluation (1997).

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In 1994, 46 (90%) of those for whom clinical

data was available were taking medication for

their diabetes and in 1997 this had risen to 50

(98%) (for details see Table 5). Four of the group

were insulin-dependent. Fifteen (30%) of those

with NIDDM were being given insulin in 1994,

and a further 12 (24%) were being prescribed

insulin in 1997, giving a total of 27 (53%).

This increase in the number using insulin is

significant (P=0.01; relative risk=1.72

(CI 1.09±2.73)).

As Table 6 shows, starting insulin did not

appear to be influenced by whether the indivi-

dual was exercising or not. Clinical results of the

12 who started insulin showed a rise in mean

BMI from 31.5 to 32.3 and a decrease in mean

HbA1 from 11.2% to 10.0%. The mean insulin

dose was 47 units per day, ranging from 18 to 82

units. Two of those who started insulin during

the project each gained 11 kg in weight; one had

been prescribed 56 units of insulin daily along-

side oral hypoglycaemics and the other 60 units

of insulin daily.

Comparing exercisers and non-exercisers,

there was no significant difference in the

number of people who increased their medication

for diabetes [P=0.34; Relative Risk=0.82

(CI 0.55±1.23)].

Postal questionnaire

Referrals to the Exercise Project were made by

the following clinics or health workers:

1 diabetes clinic, 20 clients (48%);

2 exercise project co-ordinator, 12 clients (28%);

3 other sources including GP, posters and news-

paper articles, 10 clients (24%).

Twenty-four (57%) reported feeling `optimistic/

keen' but 14 (33%) reported feeling `anxious/

worried' before starting the programme.

Exercise

Eleven (26%) of the 42 respondents reported

taking exercise before referral to the project. This

included walking, swimming, yoga and badmin-

ton. The remaining 31 (74%) reported taking no

exercise. At the time of completing the ques-

tionnaire, 22 (52%) were still exercising regularly

and 20 (48%) were not although eight of these 20

(40%) had been exercising regularly for more

than 6 months on the project. Thirty (71%) of the

group had participated in the exercise pro-

gramme for 6 months or more. Reasons given

for stopping exercising included lack of time,

expense, travel problems, injury and not enjoying

Table 4. BMI and HbA1 on joining the exercise project (1994) and at evaluation (1997) for whole group,

exercisers, non-exercisers and non-responders

BMI kg/m2 (range) HbA1% (range)

ÐÐÐÐÐÐÐÐÐÐÐÐÐ ÐÐÐÐÐÐÐÐÐÐÐÐÐÐÐ

1994 1997 1994 1997

Whole group n=51 31.4 (21±40) 31.3 (23±40) 10.3 (7.5±15.6) 10.1 (8.0±13.5)

Exercisers n=16 30.8 (22±38) 31.7 (24±39) 10.8 (8.1±13.5) 10.5 (8.6±13.5)

Non-exercisers n=18 32.4 (21±40) 32.7 (23±40) 10.4 (8.0±15.6) 10.0 (8.0±13.0)

Non-responders n=17 30.2 (23±40) 29.2 (23±39) 9.9 (7.5±14.1) 9.8 (8.0±12.5)

Table 5. Diabetes medication in 1994 and 1997

1994 1997

Treatment n=51 n=51

Diet alone 5 1

Metformin only 5 8

Gliclazide only 7 3

Metformin/Gliclazide 15 8

Metformin/Gliclazide/Insulin 2 6

Insulin only 17* 25*

* 4 were insulin dependent

Table 6. Medication changes from 1994 to 1997 in exercisers, non-exercisers and non-responders

Exercisers Non-exercisers Non-responders

n=16 (%) n=18 (%) n=17 (%)

Started insulin 4 (25%) 3 (17%) 5 (29%)

Increased medication 9 (56%) 9 (50%) 6 (35%)

Same medication 2 (13%) 5 (28%) 5 (29%)

Reduced medication 1 (6%) 1 (5%) 1 (6%)

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it. Of the 22 who had continued to exercise, 12

(55%) reported exercising three times a week or

more and four (19%) said they were exercising

five times a week or more. Exercise taken

included walking, swimming, aerobics, gym, golf

and home-based exercise, for example on an

exercise-bike. This was taking place in leisure

centres, open spaces, private clubs, golf clubs and

in their homes. Most were exercising with family,

friends and other group members, although some

said they were happy to exercise alone.

The whole group was invited to comment on

the recognized benefits of exercise of which 39

(93%) did so. Benefits reported included: `in-

creased energy levels'; a greater ability to

concentrate and enjoy exercise; increased motiva-

tion and more positive mood and feelings. Those

who had continued to exercise were more likely

to report the benefits of exercise.

On being asked to comment upon the effect of

taking up regular exercise on control of their

diabetes 25 (60%) reported changes, 16 of whom

were still exercising and 9 of whom were no

longer exercising. These reported changes/effects

are summarized in Table 7. There was no

significant difference between exercisers and

non-exercisers when self reporting on the influ-

ence exercise had on control of their diabetes

(P=0. 14; RR=1.60 (CI 0.81±3.18)).

All respondents were asked to comment on

how much `others' had influenced their ability to

exercise. Responses showed that the project co-

ordinator and staff at the diabetes unit were

important in getting them started on the exercise

programme with ongoing support coming from

leisure centre staff, family, friends, the co-

ordinator and other members of the group.

Opinion about the influence of GPs was divided

with half reporting they had no influence at all

and half reporting that they either had a great

deal of influence or had influenced them to some

extent (see Table 8).

In response to the question about `periods of not

exercising', 37 (88%) of the respondents reported

`periods of not exercising' and this included 21

(96%) of the exercisers. Most of the group relapsed

for between 1±6 months with injury and other

commitments being the main reasons for stopping.

Factors that had encouraged the exercisers to start

again included self-motivation, pressure from

others and recovery from injury.

Diet sessions

Twenty-three (55%) of the 42 respondents to the

questionnaire had attended the diet sessions,

although the number of times they attended was

not elicited. Of these 20 (87%) had found them

helpful, welcoming the group support it offered and

the improvement in their knowledge of diabetes.

Comments on the project overall

On being invited to make comments 35 (83%) did

so and these are summarized in Table 9.

The benefits of group support, feeling better

and enjoying the exercise was mentioned by the

exercisers and non-exercisers alike, and the

following are examples of comments:

Table 7. Reported effects of exercise on diabetic

control

Reported change/effect n=25

Stabilized or reduced blood sugar 15

Lost weight 5

Reduced medication 3

Reduced blood pressure 2

Lifted depression 2

Other, i.e. felt more positive about health 6

Table 8. Response to the question `How much has the attitude of the following people influenced your

exercising?'

Respondents n=42 Not at all/not much To some extent A great deal

GP clinic 16 13 4

Project Co-ordinator 2 10 23

Diabetes Unit:

Doctor 4 10 10

Nurse 4 14 5

Dietitian 3 9 6

Leisure centre staff 7 5 15

Members of the exercise group 8 7 12

Family 9 11 7

Friend 6 6 9

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I felt good about myself, felt less need to eat

and more determined to lose weight.

I have made new friends, we discuss our

diabetes and I always look forward to my

Friday class.

Success of the group was due to the hard

work of the instructor, the input from the

group and the hard work and constant

support from the project co-ordinator.

Focus groups

Further information on what had affected ad-

herence to exercise was elicited through the focus

groups in which the participants were encour-

aged to identify those factors which helped and

hindered their adherence to exercise.

All reported the importance they attached to

the exercise for both their physical and mental

well-being and on being asked about their initial

attitude to starting the classes the overall

consensus was of being keen to try something

new. Feedback on the appropriateness of the

exercise classes to a group who were initially

unfamiliar to exercising showed that they liked

the formality of going through a health check as

this gave them the confidence to start exercising.

Also, they welcomed the formal training they

received when using the gym and attending the

exercise classes. The informality of the class itself

was welcomed as well as the variety of activities

on offer.

To be part of a group of people with similar

health problems was appreciated and valued by

the group as this gave them the opportunity to

learn from each other as well as from the health

professionals. Those who were unable to make it

to the group exercise sessions reported finding it

difficult to keep up their motivation in the other

classes and activities. All those still exercising

agreed they would not have started on their own

and the attitude of those most closely involved in

the project, i.e. the project co-ordinator, the

dietitian and the fitness instructors had kept

them going. All of the group saw the co-ordinator

as the most important influence on their adher-

ence to the exercise and valued her knowledge of

diabetes. Other people, including both leisure

centre staff and members of the diabetes unit

were identified as important in providing encour-

agement to both start and continue exercise. The

consensus was that the GPs were not interested,

although they were seen by the group as having

an important role in promoting exercise. They

also recognized that the attitude of some staff

could both help and hinder their efforts to

exercise. Personal record cards to monitor atten-

dance at the gym were described as a motivator.

The group, when invited to comment on what

had helped them to start exercising after periods

of relapse, identified self-motivation and pressure

from others. Injury, timing of sessions and lack of

time were the most common reasons cited for

stopping exercise.

Discussion

At the start of the project it was clear that,

although most of the participants had been

previously advised to take more exercise, only a

quarter were doing so. Being so unfit, and not

knowing how best to take exercise, the majority

had avoided exercise completely. Their fears of

going into unfamiliar leisure centres were allayed

by the presence of the co-ordinator, who had

already met them in the diabetes clinic and who

was able to answer their questions on the effect

exercise would have on diabetes management.

Once the exercise classes began the partici-

pants realized they were all `in the same boat' and

they felt comfortable exercising with other

diabetics with similar problems and under the

guidance of sympathetic staff. They appreciated

that the instructors were content for them to go at

their own pace and individual instruction on

using the equipment built up their confidence. It

was notable that there was a high drop-out rate

whenever the classes were not exclusive to the

group, indicating the importance they attached to

having sessions specifically for them.

Social relationships have been found to be

powerful predictors of exercise behaviour and

Table 9. Comments on the diabetes exercise project

Exercisers

and non-

exercisers

n=35

Enjoyed the support of the group 15 (43%)

Benefited from meeting others 6 (17%)

Feel better/enjoyed it 14 (40%)

Didn't enjoy it 3 (9%)

Times were unsuitable 7 (20%)

Sessions were unsuitable 7 (20%)

May rejoin class 5 (14%)

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this was particularly so of this group, with

questionnaires and focus groups highlighting

the value given to making friendships, meeting

others with diabetes and enjoying group support.

The support of staff from the diabetes unit and

leisure centre, together with that shown by family

and friends, were identified as a significant

influence in encouraging the participants to

continue to exercise.

The fact that 71% of those who responded to the

questionnaire participated for 6 months and of

these 52% reported taking regular exercise 18

months after funding and professional support had

been withdrawn is encouraging when compared

with the literature where 50% of participants are

reported to drop out in the first three to 6 months.

Evidence demonstrates that regular, moderate-

intensity activity is needed to provide substantial

health benefits and over half (55%) of the respond-

ents reported exercising three times aweek or more.

Several participants took more responsibility

for their diabetes control and management and,

through the diet sessions, an emphasis was put

on setting their own goals. The group reported

both physical and mental health benefits from

the programme.

Although there was no significant change in

the BMIs, this was not unexpected. The criteria

for referral resulted in overweight clients who

already had ongoing health problems associated

with their diabetes and the absence of weight

gain was seen as a health gain.

Although the clinical results showed no

significant changes in this group in the short

term, the benefits of exercise and evidence for its

clinical effectiveness have been well reported in

the literature. The absence of any changes in the

clinical results is not unexpected as the time-

scale has been relatively short and the clinical

benefits reported may not show up for several

years. However, the increase in medication was a

cause of concern, particularly the rise in insulin

as treatment for their diabetes. This group is

recognized as being insulin-resistant and it is this

rather than the lack of insulin which has

contributed to the onset of NIDDM. Evidence for

exercise and weight loss as the best method to

improve blood glucose has been reported in the

literature and increased physical activity has

been shown to be effective in the prevention of

NIDDM. It had been hoped that regular exercise

would reduce the need for medication and halt

the spiralling increase in weight and medication.

The combination of hyperinsulinaemia (which is

due to insulin resistance) and insulin treatment

may also be an additional risk factor for coronary

heart disease and stroke. In addition there is the

inconvenience to the individual of taking insulin

and the cost for which there appears to be little

clinical benefit.

There were a few general problems with regard

to the running of the project. The most difficult

task was to keep it going, faced with numerous

changes in leisure centre management, exercise

venues and timings of the sessions ± often

prompted by the commercial interests of the

centres. All of these meant there was a constant

need to negotiate suitable classes and inform

participants of changes. The co-ordinator had to

cope with dissatisfaction from the group over

these problems. A considerable burden of re-

sponsibility for safety rested both with the

leisure staff and with the co-ordinator; although

the co-ordinator was a nurse, there were no

doctors directly involved in, the project.

There was, however, a genuine feeling of

satisfaction at being able to offer something

`different' to these clients as well as a tremendous

feeling of achievement when the project was

going well and the group showed appreciation of

the opportunities available.

Conclusion

From the evidence presented exercise needs to

have a much higher profile in the treatment of

diabetes. Few are heeding advice to take exercise

or increase physical activity despite the wealth of

information on the benefits of this. However, it is

possible to take those who are overweight and

considered to be poorly controlled and get them

on to a programme of regular exercise in gyms

and leisure centres, regardless of age. Further-

more this activity can be enjoyable and offers the

added benefit of group support.

For this to be successful the exercise pro-

gramme should consist of:

. a referral system that will identify those suitable

for the exercise programme and recognizes the

responsibilities of all parties involved;

. a stream-lined process to enable individuals to

be referred, assessed and commenced on an

exercise programme in a relatively short time;

. a motivated co-ordinator, with knowledge of dia-

betes, who has responsibility for the promotion

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of exercise to all the key personnel involved.

They must have good communication skills to

ensure that consistent information is given, and

ideally take part in the exercise programme;

. a supportive group of GPs, other doctors and

health professionals who recognize their role not

only in promoting exercise to their patients but

also in helping maintain their efforts to exercise;

. suitable facilities and personnel at leisure

centres conducive to promoting exercise, espe-

cially to those who have never visited a leisure

centre and may not have exercised for several

years. This applies to all personnel in the leisure

centre from reception staff to instructors;

. low to moderate intensity exercise classes run

by instructors who will increase the confidence

of the participants by explaining, at initial

consultation, how to exercise and most im-

portantly how to enjoy exercise. Efforts should

also be made to encourage individuals to

monitor their exercise and if appropriate

initiate `buddying' among the group members;

. an opportunity to discuss health issues in a

non-clinical setting and encourage peer sup-

port. This could be done either formally

through structured diet sessions or informally

through social events;

. a price subsidy on classes to encourage initial

participation and then further incentives to

encourage adherence;

. a marketing strategy to promote exercise, with

promotion of local exercise schemes through

diabetic clinics, GP surgeries, local pharma-

cists and articles in the local press;

. a scheme which encourages participation of

partners, friends and family.

Further facilities which we did not include and

which may increase adherence to exercise include:

. a system to enable those who had stopped

exercising through injury to return to exercise

when fit again;

. the setting of personal goals for the individual;

. development of coping strategies when faced

with situations which would reduce adherence

to exercise;

. more rigid criteria in selecting those suitable

for exercise programmes.

Changes which would benefit the future

treatment of diabetes include:

. a data base to audit clinical effectiveness and

review current treatments;

. review of the appropriateness of commencing

insulin therapy in overweight, non-insulin

dependent diabetics.

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