Attaining Glycemic Goals in Type 2 Diabetes: Diet & Exercise
Diabetes Exercise Project
Transcript of Diabetes Exercise Project
Journal of Human Nutrition and Dietetics (1999), 12 (Suppl. 1), 79±90
# 1999 Blackwell Science Ltd. 79
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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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