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Achieving Lasting Adoption of Lifestyle Changes

 Learning to overcome barriers that interfere with a more physically active lifestyle is a critical part of effective diabetes self-management, especially when health complications like neuropathy, nephropathy, and retinopathy make being active more challenging1.

Certain physical movements also may pose safety issues, and not all individuals are capable of participating in or willing to start a fitness program, regardless of the health benefits they can achieve1. Efforts to promote physical activity should focus on developing self-efficacy and fostering social support from family, friends, and health-care and fitness professionals2-4. Encouraging mild or moderate activities may be most beneficial to adoption and maintenance of regular participation in individuals with type 2 diabetes (T2D)5,6. In individuals with type 1 diabetes (T1D), addressing the fear of hypoglycemia associated with physical activity is likely important to promoting their participation as well7.

FACTORS INFLUENCING PHYSICAL ACTIVITY PARTICIPATION

Greater effort needs to be focused on the promotion of regular exercise among individuals with and at risk for developing T2D and gestational diabetes mellitus (GDM) in particular because lifestyle choices largely influence their onset, although health behavior change interventions benefit glycemic control in T1D as well8. The central determining factors influencing activity across the life span in all individuals, with and without diabetes, are generally self-efficacy (i.e., having confidence in one’s ability to be active), enjoyment of physical activity, lack of perceived barriers to being physically active, positive beliefs concerning the benefits of physical activity, support from others to continue exercising, and cultural beliefs and practices. Behaviorally based exercise interventions, the use of behavior change strategies, supervision by an experienced fitness instructor, and exercise that is pleasant and enjoyable can improve adoption and adherence to prescribed exercise programs. The availability of facilities, pleasant places to walk, and economical exercise options (i.e., the built environment) also may be important predictors of regular physical activity participation.

Self-Efficacy

Beliefs about self-efficacy influence health behaviors. Individuals tend to pursue tasks they feel competent to perform and avoid those in which they feel incompetent. Self-efficacy may be enhanced by developing realistic activity goals that an individual is likely to attain (thereby promoting feelings of mastery); progressing programs slowly using small, incremental steps; observing others in a similar situation succeeding at being physically active in an exercise class or by watching a video; rehearsing or practicing intended exercise behaviors; and getting regular, supportive feedback from others about their participation and progress2-4.

One of the most consistent predictors of greater levels of physical activity — both aerobic and resistance training — has been higher levels of self-efficacy, which reflect confidence in the ability to exercise2-4. For individuals with T1D, confidence in the ability to avoid hypoglycemia related to activity is an important determinant in their participation7,8, while use of newer continuous glucose monitoring (CGM) technologies may increase exercise compliance in individuals with either T1D or T2D9. In individuals with T2D in particular, interventions should focus on enhancing self-efficacy, problem solving, and social-environmental support to improve self-management (which includes exercise, dietary, and medication behaviors)10.

Goal Setting

When planning to increase physical activity participation by overcoming potential obstacles or problems, individuals also must set realistic and practical goals4,11. Goals that are too vague, too ambitious, or too distant do not provide enough self-motivation to maintain long-term interest (i.e., they should be short-term goals). Health-care and fitness professionals should encourage individuals with diabetes to specifically plan out their exercise participation, track their goals to help see their progress, and identify potential barriers. Individuals should set appropriate physical activity goals that are SMART, as shown in Table 25.1.

Table 25.1. Effective Goal Setting Using SMART Goals

Specific: Set goals that are as precise as possible when identifying details of frequency, duration, intensity, and type of activity

Measurable: Make goals that can be quantified so that individuals can accurately track, measure, and identify progress

Attainable: Set goals that are challenging, but reachable, to increase confidence and the likelihood of setting even more challenging goals in the future

Realistic: Evaluate how likely individuals are to attain their chosen goals in a given situation

Timeframe-Specific: Set short-term goals that provide more immediate feedback, such as setting ones for just the next week

Social Support

Social dynamics may be exploited to increase the effects of interventions beyond the target individual and potentially can help spread exercise behavior among close individuals. In one study, active overweight women were more likely to identify social reasons for participating in physical activity, whereas inactive participants perceived that their laziness prevented their participation12.

Likewise, counseling delivered by professionals also may be a meaningful and effective source of support. On average, physician advice or referral related to exercise occurred at 18% of office visits by diabetic individuals, 73% of whom reported receiving advice at some point to exercise more13. Clearly such advice has not led to widespread adoption of increased physical activity, and such advice from health-care or fitness professionals appears to be associated with lower A1C values only when combined with dietary advice, but not when given alone14.

Even peer mentoring may enhance diabetes management and adoption of healthier lifestyle habits. The unprecedented growth in diabetes-related social media and online support groups in the past decade may provide yet another effective avenue for lasting behavior change15.

Cultural Practices and Health Beliefs

Health-care and fitness professionals must be aware of the cultural practices and beliefs that may influence the adoption of physical activity. Activities should not offend or ignore the cultural beliefs of the individual, and suggestions to help tailor a suitable exercise prescription should be culturally appropriate. By way of example, in one program focusing on Puerto Ricans living in the U.S., these individuals were taught in a culturally appropriate way how inactivity increases the risk for diabetes-related health complications, what the benefits of exercising for people with diabetes are, and how lifestyle activity (e.g., house or yard work, walking a pet, or walking around town to complete errands) can serve as an alternative to traditional, regimented exercise16. Similarly, dance and music are a vital part of tradition and celebration for many ethnically diverse groups, including Native, Hispanic, and African Americans, while Asian and Middle Eastern groups may have other cultural traditions like yoga, tai chi, and dance that can be part of an exercise routine to manage diabetes and body weight. In African American women, religion and spirituality have been found to be associated with their glycemic control17.

In summary, changing behaviors to include regular physical activity is an important aspect of getting people with diabetes physically active for a lifetime. Doing so may involve addressing barriers to participation and devising strategies to overcome them. In particular, self-efficacy is an important factor in physical activity behavior change. Setting appropriate, specific, and realistic exercise goals can help. With all the health benefits to be gained from physical activity participation, all individuals with diabetes need to be encouraged to make and assisted in achieving this critical behavior change.

References:
  1. Costello, E., M. Kafchinski, J. Vrazel, and P. Sullivan: Motivators, barriers, and beliefs regarding physical activity in an older adult population. J Geriatr Phys Ther 34 (3):138–147, 2011
  2. McAuley, E., and B. Blissmer: Self-efficacy determinants and consequences of physical activity. Exercise & Sport Sciences Reviews 28 (2):85–88, 2000
  3. Plotnikoff, R. C., L. Trinh, K. S. Courneya, N. Karunamuni, and R. J. Sigal: Predictors of physical activity in adults with type 2 diabetes. Am J Health Behav 35 (3):359–370, 2011
  4. Luszczynska, A., R. Schwarzer, S. Lippke, and M. Mazurkiewicz: Self-efficacy as a moderator of the planning-behaviour relationship in interventions designed to promote physical activity. Psychol Health 26 (2):151–166, 2011
  5. Shinji, S., M. Shigeru, U. Ryusei, M. Mitsuru, and K. Shigehiro: Adherence to a home-based exercise program and incidence of cardiovascular disease in type 2 diabetes patients. Int J Sports Med 28 (10):877–879, 2007
  6. Negri, C., E. Bacchi, S. Morgante, D. Soave, A. Marques, E. Menghini, M. Muggeo, E. Bonora, and P. Moghetti: Supervised walking groups to increase physical activity in type 2 diabetic patients. Diabetes Care 33 (11):2333–2335, 2010
  7. Brazeau, A. S., R. Rabasa-Lhoret, I. Strychar, and H. Mircescu: Barriers to physical activity among patients with type 1 diabetes. Diabetes Care 31 (11):2108–2109, 2008
  8. Conn, V. S., A. R. Hafdahl, J. W. Lemaster, T. M. Ruppar, J. E. Cochran, and P. J. Nielsen: Meta-analysis of health behavior change interventions in type 1 diabetes.” Am J Health Behav 32 (3):315–329, 2008
  9. Adolfsson, P., S. Nilsson, and B. Lindblad: Continuous glucose monitoring system during physical exercise in adolescents with type 1 diabetes. Acta Paediatr 100 (12):1603–1609, 2011
  10. King, D. K., R. E. Glasgow, D. J. Toobert, L. A. Strycker, P. A. Estabrooks, D. Osuna, and A. J. Faber: Self-efficacy, problem solving, and social-environmental support are associated with diabetes self-management behaviors. Diabetes Care 33 (4):751–753, 2010
  11. Naik, A. D., N. Palmer, N. J. Petersen, R. L. Street, Jr., R. Rao, M. Suarez-Almazor, and P. Haidet: Comparative effectiveness of goal setting in diabetes mellitus group clinics: randomized clinical trial. Arch Intern Med 171 (5):453–459, 2011
  12. Jewson, E., M. Spittle, and M. Casey: A preliminary analysis of barriers, intentions, and attitudes towards moderate physical activity in women who are overweight. J Sci Med Sport 11 (6):558–561, 2008
  13. Morrato, E. H., J. O. Hill, H. R. Wyatt, V. Ghushchyan, and P. W. Sullivan: Are health care professionals advising patients with diabetes or at risk for developing diabetes to exercise more? Diabetes Care 29 (3):543–548, 2006
  14. Umpierre, D., P. A. Ribeiro, C. K. Kramer, C. B. Leitao, A. T. Zucatti, M. J. Azevedo, J. L. Gross, J. P. Ribeiro, and B. D. Schaan: Physical activity advice only or structured exercise training and association with HbA1c levels in type 2 diabetes: a systematic review and meta-analysis. JAMA 305 (17):1790–1799, 2011
  15. Chomutare, T., E. Arsand, and G. Hartvigsen: Mobile peer support in diabetes. Stud Health Technol Inform 169:48–52, 2011
  16. Osborn, C. Y., K. R. Amico, N. Cruz, A. A. O’Connell, R. Perez-Escamilla, S. C. Kalichman, S. A. Wolf, and J. D. Fisher: A brief culturally tailored intervention for Puerto Ricans with type 2 diabetes. Health Educ Behav 37 (6):849–862, 2010
  17. Newlin, K., G. D. Melkus, R. Tappen, D. Chyun, and H. G. Koenig: Relationships of religion and spirituality to glycemic control in Black women with type 2 diabetes. Nurs Res 57 (5):331–339, 2008

This article is excerpted from Chapter 25 of Exercise and Diabetes: A Clinician’s Guide to Prescribing Physical Activity, a case-study based book published by the American Diabetes Association in 2013 and authored by Dr. Sheri Colberg (find more information about the book online at www.shericolberg.com/exercise-diabetes.asp).

In addition, anyone wishing to earn free CME credits through the ADA for completing a new self-assessment program on exercise and diabetes may do so now through the ADA’s web site at http://professional.diabetes.org/ce.

Copyright © 2013 Diabetes In Control, Inc.