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Cardiopulm Phys Ther J. 2010 June; 21(2): 5–12.
PMCID: PMC2879421

Outcomes of an Education and Exercise Program for Adults with Type 2 Diabetes, and Comorbidities that Limit their Mobility: A Preliminary Project Report

Gina Pariser, PT, PhD,corresponding author1 Mary Ann DeMeuro, ARNP, MSN, CDE,2 Patricia Gillette, PT, PhD,1 and Winters Stephen, MD2

Abstract

Purpose: Some adults with type 2 diabetes mellitus (T2DM) have comorbidities and mobility impairments that limit their exercise capacity. In consideration of this, we developed and piloted a program called Active Steps for Diabetes for people with T2DM, comorbidities, and mobility impairments. The purpose of this paper was to report outcomes for the pilot program. Methods: Active Steps for Diabetes, an 8-week program, included instruction on diabetes self-care andgroup and home exercise programs. Twenty-two females (62.7 ± 6.1yrs) with T2DM and self-reported mobility impairments completed the program. Six participants used a walking aid. Outcome measures included two risk factors for coronary artery disease [daily physical activity and body mass index (BMI)], cardiovascular fitness (6-minute walk distance), and knowledge of diabetes-specific exercise guidelines. A two-way repeated measures ANOVA was used to compare outcomes before and after the program and between participants who did and did not use a walking aid. Results: Active Steps for Diabetes was effective in increasing daily physical activity in both groups of subjects (walking aid group: 2.6 days/week [95% confidence interval (CI) = 2.1 to 3.3]; no walking aid group: 1.9 days/week [95% CI=1.2 to 2.5]). This was accompanied by increases in 6-minute walk distances (walking aid group: 54.0 m [95% CI = 36.4 to 71.6]; no walking aid group: 62.6 m [95% CI=55.7 to 69.4]). Changes in BMI were not significant (walking aid group: −0.4 [95% CI = −1.2 to 0.4]; no walking aid group: −.24[95% CI = −.91 to .44]). Increases in knowledge of diabetes-specific exercise guidelines were observed in both groups (walking aid group: 18.8% [95% CI = 11.3 to 26.4]; no walking aid group: 19.3% [95% CI = 16.1 to 22.5]). Discussion:: Physical inactivity and low cardiovascular fitness are predictors of CAD morbidity and mortality in adults with T2DM. This pilot program suggests that a model for diabetes education, incorporating exercise programs developed by a physical therapist, may increase physical activity, improve endurance, and thereby potentially reduce CAD risk in people with T2DM and mobility impairments from comorbidities.

Key Words: type 2 diabetes, physical activity

INTRODUCTION AND PURPOSE

The American Diabetes Association (ADA) recommends that adults with type 2 diabetes (T2DM) accumulate at least 150 minutes of moderate intensity aerobic exercise and 3 sessions of resistance exercise per week.1 The recommendation is based on substantial evidence that moderately intense physical activity (PA) improves glycemic control and coronary artery disease (CAD) risk. Moderately intense PA improves hemoglobin A1c (HbA1c), triglycerides, and adiposity in adults with T2DM.1 Conversely, physical inactivity and low cardiovascular fitness are predictors of CAD morbidity and mortality in adults with T2DM.25 Physical inactivity also contributes to the high prevalence of impaired mobility in adults with T2DM.68 While there is substantial evidence supporting the ADA recommendation, the ability to generalize it is limited since it is based primarily on studies involving subjects with normal mobility and moderate or vigorous intensity exercise interventions.1,9 This is an important limitation to address because many people with T2DM have co-existing chronic conditions that affect their mobility and, in turn, limit their exercise capacity. In the United States over 80% of people with T2DM are overweight or obese, 75% have high blood pressure, 30% have impaired pedal sensation due to diabetic neuropathy, and over 50% have osteoarthritis.10 Older adults with diabetes are 2 to 3 times more likely than those without diabetes to report that they have a mobility impairment.11 Over 70% of older adults with impaired mobility report that they do not achieve recommended amounts of PA.7,12

Research is needed to determine strategies for increasing PA, improving glycemic control, and reducing CAD risk factors for people who have T2DM and mobility impairment. Typical exercise interventions, involving 30 minutes of continuous moderately-intense aerobic exercise may be too demanding for this population. Aerobic exercise training began at a low intensity and gradually increased to a moderate intensity for > 30 minutes has been shown to improve glycemic control, fitness, and blood pressure in adults with T2DM.1316 Resistance training has also been shown to enhance glucose control.1719 Combined training, including both aerobic and resistance exercise, has been shown to improve blood glucose control at least as much as aerobic training only.2024 Recently, interval training with alternating, short bouts of moderately-intense aerobic and resistance exercises has been advocated.25,26 Interval training produces a lower cardiorespiratory challenge than aerobic-only training. Therefore, people with T2DM and a low tolerance for exercise may be able to perform interval training for longer periods of time allowing for a greater amount of total work performed compared to continuous aerobic training. This type of training (using short-duration bouts of stationary cycling followed by resistance exercises) was reported to be effective in improving glycemic control, body composition, blood pressure, and muscle strength in 11 patients with insulin-treated T2DM and a high CAD risk profile.26

While diabetes education programs uniformly include information on ADA diabetes-specific exercise guidelines, few modify the recommendations to address patients' impaired mobility and limited exercise capacity.27 Furthermore, few diabetes education programs include supervised exercise. Physical therapists possess the knowledge and expertise needed to provide individualized physical activity recommendations for people with impaired mobility and complex medical conditions. In consideration of this, we developed Active Steps for Diabetes, a program for adults with T2DM and mobility impairment. Active Steps for Diabetes includes instruction on diabetes self-care behaviors provided by a certified diabetes educator, plus group and home exercise programs provided by a physical therapist. The premise of Active Steps for Diabetes is that while people with T2DM and mobility impairments may not be able to achieve the optimal amount of PA for glycemic control on their own, they can (through PA programs developed by physical therapists) gradually increase their exercise capacity, improve their glycemic control, and reduce their risks for CAD.

The primary purpose of this pilot project was to examine the effects of Active Steps for Diabetes, a specially designed education and exercise program for adults with T2DM and self-reported mobility impairment on 3 types of variables; namely two risk factors for CAD [level of PA and body mass index (BMI)], an index of exercise tolerance [six-minute walk distance (6MWD)], and knowledge of diabetes-specific exercise guidelines. Outcomes were compared before and after the program and between participants who did and did not use a walking aid. The secondary purpose was to identify the limitations of this pilot project and recommend methods for subsequent studies.

METHODS

Subjects

Participants for Active Steps for Diabetes were recruited from outpatient clinics at a local hospital that provides health care for a predominately low-income and ethnically diverse population. Health care providers recruited participants by distributing flyers to individuals eligible for the program. Eligible participants included adults who had: (1) a diagnosis of T2DM from their primary care physician, and (2) used a walking aid or had self-reported mobility impairment. Mobility impairment was defined, per the National Health Interview Survey (NHIS), as use of a walking aid or self-reported inability to do one or more of the following tasks without stopping to rest: walk ¼ mile; walk up 10 steps; stand for 2 hours; or do work involving stooping, bending, or kneeling for 30 minutes.11 Participants also were medically cleared for exercise by their physician in the form of a written clearance form. Individuals interested in participating in Active Steps for Diabetes contacted the primary investigator to enroll in the program. Individuals with medical conditions for which aerobic or resistance exercise is contraindicated as defined by the American College of Sports Medicine28 and the ADA1 [conditions such as severe retinopathy, uncontrolled cardiovascular problems including uncontrolled hypertension [resting blood pressure >160/90], and renal failure requiring dialysis] were excluded from participation.

Active Steps for Diabetes consisted of two classes per week for 8 weeks. The program was offered 4 different times. Thirty females enrolled and 22 (73%) completed the program. Completion was defined as missing no more than 4 of the 16 classes (ie, attending 75%). Reasons for not completing the program included illness (n=2 participants), lack of reliable transportation (n=3 participants), and family/work commitments (n=3 participants). All participants signed a consent form approved by the Institutional Review Board of Bellarmine University.

Demographics for participants who completed the program are shown in Table Table1.1. The mean age of the participants was 62.7 ± 6.1 years. Seventy-three percent of the participants were African American and 27% were Caucasian. Six participants who completed the program used a walking aid (ie, 27%); 5 used a cane and one used a rolling walker. The primary reasons for use of a walking aid were joint pain and peripheral neuropathy. All 5 participants who used a cane reported knee and back pain due to osteoarthritis; 3 had peripheral neuropathy (PN). The participant who used a rolling walker had knee and back pain due to osteoarthritis, a thoracic kyphosis due to osteoporosis, and PN. The prevalence of cardiovascular disease and cardiovascular disease risk factors was high (Table (Table1).1). Ninety-five percent of participants had hypertension and hyperlipidemia. Eighty-six percent were obese. Eighty-two percent were sedentary. Five participants (23%) smoked. Four participants (18%) reported that they had both congestive heart failure (CHF) and chronic obstructive pulmonary disease (COPD) (Table (Table11).

Table 1
Participant Demographics

Intervention

The biweekly Active Steps for Diabetes program classes consisted of 45 minutes of group exercise followed by 30 minutes of diabetes education. Prior to each class, each participant's blood glucose, resting blood pressure (BP), and resting heart rate (HR) were measured and recorded on an exercise log. Pre-exercise BP of < 160/90 mmHg and blood glucose levels between 100-300 mg/dl were required to proceed with exercise. If participants arrived with a blood glucose level between 70-100mg/dl or > 300 mg/dl, the guidelines for exercise and blood glucose levels outlined in an American Physical Therapy Association document on physical fitness for special populations were followed.29

Group exercise classes were led by the primary investigator and a qualified assistant (a student in physical therapy, or a nurse/diabetes educator). The primary mode of exercise was seated aerobic and resistance training. However, several exercises were also demonstrated in the standing position. Participants progressed from performing exercises in sitting to standing based on their abilities. Each session consisted of a warm-up phase (5 min), a balance and posture exercise phase (5 min), an aerobic and resistance training phase (30 min) and a cool-down phase (5 min). The warm-up and cool-down phases consisted of breathing exercises and flexibility exercises for the trunk and extremities. The posture and balance exercise phase consisted of static and dynamic balance activities plus instruction and practice in body mechanics for transition movements from sitting and standing. The aerobic/resistance phase consisted of interval training involving intermittent bouts of low to moderate intensity cardiovascular endurance and muscle strengthening exercises. The Borg perceived exertion scale was used to monitor exercise intensity.28 Participants were instructed to exercise at a rating of perceived exertion (RPE) between 11/20 (light) and 13/20 (somewhat hard). At the beginning of Active Steps for Diabetes the bouts of low to moderate intensity aerobic exercise (such as seated marching with or without simultaneous arm raises) were limited to 2 to 3 minutes and were followed by 2 to 3 minutes of resistance exercises. The duration of the aerobic exercise bouts was gradually increased so that by the end of the 8-week program participants were performing 20 minutes of continuous light to moderately intense aerobic exercise. Muscle strengthening exercises were performed with elastic bands or tubing and principles of progressive resistance training were employed. The resistance training volume for each exercise was 3 sets of 8 to 12 repetitions. Over the duration of the program, participants used elastic bands/tubing that provided progressively greater resistance. While these exercise classes were group-based, the physical therapist/instructor tailored the exercises to each participant's needs.

In addition to the twice weekly group exercise classes, participants were instructed to accumulate 30 minutes of low to moderate intensity exercise on at least one other day of the week. Exercise bouts lasting > 10 minutes were included in their total exercise times. Participants selected a variety of exercise modes; most selected walking or chair aerobics. Participants electing to do chair aerobics followed a video or a television program called Sit and Be Fit™ (SIT AND BE FIT, Spokane, WA). Participants recorded their exercise time on a log.

In addition to group-based and home-based exercise, participants were given a pedometer (Omron HJ-112) to use as a tool for motivating and monitoring their PA. The accuracy of the pedometer given to the participants was deemed acceptable for clinical purposes.30 Participants were instructed in proper placement and use of their pedometers. They were encouraged to wear them each day during waking hours and to record their steps taken each day on their exercise logs. Participants were given weekly step goals. Their average number of steps/day, determined prior to the program, was used to establish their initial step goal (baseline step count plus > 100 additional steps.). Exercise logs were used to establish subsequent step goals (generally 100 steps above their daily average).

Outcome Measures

Participants were assessed within the week prior to and again during the week following completion of the Active Steps for Diabetes program. Outcome measures included: two indicators of daily PA (steps/day and exercise logs), cardiovascular endurance (6MWD), BMI (kg.m2), and knowledge of exercise and diabetes-specific exercise guidelines.

Participants used a 7-day exercise log sheet that had spaces for recording exercise episodes of > 10 minutes (such as walking for exercise). Occupational activities and household chores were not included in the exercise log. The number of days per week participants accumulated > 30 minutes of exercise was recorded. To assess PA (defined as mean number of steps/day), each subject wore a research-grade pedometer (New Lifestyles NL2000 piezo-electric pedometer) over 7 consecutive days during their waking hours. Participants were instructed in proper placement of the pedometer and asked to keep its cover closed so that they could not view their step count. Steps per day, stored in the pedometer, were summed and divided by 7 days of wear. The pedometers are valid for assessing PA in obese individuals and healthy older adults.31,32 However, their accuracy is affected by slow walking speeds. At speeds < 0.7 m/s the pedometers may underestimate actual steps taken by 25%.32 Devices that more accurately record steps taken at slow gait speeds are significantly more expensive and were cost prohibitive when this pilot project was performed.

Cardiovascular endurance was measured using the six-minute walk test (6MWT).33 The 6MWT is a valid measure of responses to exercise training in patients with cardiopulmonary disease.34 The test-retest reliability of the 6MWT has been reported to range from ICC = .92 to .99 in healthy and frail older adults.34 The test was administered by one investigator whose role in the project was limited to testing. This investigator was not involved in the delivery of the intervention. Instructions given to participants were standardized. Participants walked on a 25.9 meter circular path. Encouragement, which was also standardized, was given after 1 minute, 3 minutes, and 5 minutes. Body mass index was determined from measurements of the subject's height and weight obtained using a standard medical scale.

Knowledge of exercise and diabetes-specific exercise guidelines was measured using an 18-question multiple choice test developed by the investigators. The test included questions about benefits of exercise, exercise prescription, and exercise precautions. Test questions were derived from diabetes exercise guidelines published by ACSM28 and ADA.1 Consistent with public health diabetes education materials, the multiple-choice test questions were written in lay language and presumed to be appropriate for people with a 6th to 8th grade English reading level. A pilot study was undertaken to examine the clarity of the test questions. The test was administered to 17 volunteers enrolled in a diabetes self-management class offered by a local department of public health. The demographics for these volunteers and the participants in this project were similar. Upon review, 4 frequently missed questions were rewritten to improve the clarity of the distracters.

Data Analysis

Data were analyzed using SPSS version 16.0. Data were analyzed for the 22 participants who completed the program. Descriptive statistics were calculated for participant characteristics and dependent measures. Characteristics of participants who did (n=6) and did not use a walking aid (n=16) were compared using t tests for independent samples. Parametric t tests were used to compare age, number of years with T2DM, and BMI and 6MWD at baseline. A Mann Whitney U, was used to compare PA because the number of days/week a participant acquired > 30 minutes was ordinal data.

To determine the effects of Active Steps for Diabetes on 4 of the 5 dependent measures (steps/day, 6MWD, BMI, and exercise knowledge), separate 2 × 2 repeated measures analyses of variance were done. Time was the within-subject factor with two levels (pre-test and post-test). Group was the between-subject variable with two levels (those who did and those who did not use a walking aid). When an interaction effect between group and time was found, the mean between group difference and the 95% CI were reported. To further analyze the responses of the groups, the mean within-group difference and the 95% CIs were calculated for all dependent variables. Wilcoxon's Signed-Rank Test, was used to compare pre-and postintervention means for the number of times per week participants exercised at least 30 minutes. The level of statistical significance was set at p < .05.

RESULTS

Participants who did and did not use a walking aid were similar in age and BMI at baseline (Table (Table2).2). Both groups were sedentary. The group that used a walking aid was less active and had a lower 6MWD at baseline than the group that did not use a walking aid (Table (Table22).

Table 2
Baseline Characteristics for Participants Who Did and Did Not Use a Walking Aid

There was a significant main effect for time (p < .001) for number of days per week participants accumulated > 30 minutes of moderately intense exercise. The mean within group change was 2.7 days (95% CI = 2.1 to 3.3) for the group that used a walking aid and 1.9 days (95% CI = 1.2 to 2.5) for the group that did not use a walking aid (Table (Table3).3). Furthermore, there was a significant interaction (p = .027) between group and time with respect to change in number of days per week participants exercised 30 minutes or more. Greater increases were observed in the group that used a walking aid [mean between group difference = .98 days (95% CI = 0.12 to 1.8)]. Prior to Active Steps for Diabetes all 6 participants who used a walking aid reported they did not exercise; afterwards 5 were exercising 3 times per week (two times in Active Steps and one time on their own). Among the 16 participants who did not use a walking aid, 7 reported no exercise prior to the program and only 4 participants (25%) were engaged in 30 minutes of exercise 3 or more days/week. Afterwards the number who exercised 3 or more times per week had increased to 14 participants (88%).

Table 3
Outcomes for Participants Who Did and Did Not Use a Walking Aid

There was a significant main effect for time (p < .001) for steps/day (Table (Table3).3). In addition, there was a significant interaction (p = .012) between group and time with respect to change in steps/day, with greater increases experienced by the group that did not use a walking aid [mean between group difference = 1393.0 steps/day (95%CI = 345.6 to 2440.5)]. Pedometer-determined PA increased about 65% from the baseline mean for both groups. During Active Steps for Diabetes participants were encouraged to increase their daily step count by at least 100 steps above baseline each week (ie, > 800 steps at the conclusion of the program). This goal was achieved by all but 3 participants. These 3 participants, all of whom used a walking aid and had multiple comorbidities, did increase their total step count; increases ranged from 500 to 608 steps/day

There was a significant main effect for time (p < .001) for 6MWD (Table (Table3).3). In addition, there was a significant interaction (p = .029) between group and time with respect to changes in 6MWD, with greater improvements exhibited by the group that did not use a walking aid [mean between group difference = 46.8m (95% CI = 5.2 to 88.3)]. For the 6MWT, the minimal clinically important difference (MCID) is estimated to be 54-80 meters for participants with cardiopulmonary disease.35 Mean gains in 6MWD, 54m for the group that used a walking aid and 62.6m for the group did not use a walking aid, were within the MCID range. The main effect, time, was not significant for BMI (p = .265; Table Table3).3). Furthermore, there was no significant interaction between group and time with respect to changes in BMI (p = .268). There was a significant main effect for time (p < .001) for knowledge of diabetes-specific exercise guidelines (Table (Table3).3). In addition, there was a significant interaction (p = .043) between group and time with respect to changes in knowledge test scores. The group that did not use a walking aid exhibited slightly greater improvements in knowledge [mean between group difference = 4.67% (95% CI = .15 to 8.8)].

DISCUSSION

The pilot Active Steps for Diabetes program was found to be a safe and effective way to improve health outcomes in people with T2DM and mobility impairment. All outcome measures improved except body mass index (Table (Table3).3). Taking into consideration the emphases and the duration of the program, improvement in BMI was not anticipated. Primary emphases included: self monitoring of blood glucose levels, increased physical activity, and healthy food choices and portion control (as opposed to reducing calories). Several examples of healthy meal plans were shared; however, these plans were not aimed at weight reduction. The minimal dose of PA recommended for weight loss is consistent with the dose recommended by the ADA to promote blood glucose control and cardiovascular health (30 minutes of moderate to vigorously intense PA most days of the week) and some individuals may need to do 60 to 90 minutes of daily exercise to lose weight.28 While participants significantly increased their PA due to their mobility limitations and health co-morbities, they were not able to achieve the amount of exercise needed for weight loss within the 8 week study duration.

There were several compelling reasons for choosing 8 weeks as opposed to a shorter or longer duration intervention. Intensive programs, having more than 10 contact times and focusing on behavior-related tasks and feedback, are more effective in improving diabetes care than shorter-term didactic programs focusing on diabetes knowledge.36 With a total of 16 1.25 hour classes and a hands-on approach to teaching and learning, Active Steps for Diabetes is a time and labor intensive program. Eight weeks was sufficient to complete all diabetes education modules and to initiate lifestyle changes.

The 73% completion rate was excellent, especially since the participants had numerous barriers to participation, including mobility impairments and reliance upon public transportation. Weekly incentives for attendance may have facilitated attendance. Items donated to the program such as glucometers, nutrition posters, carbohydrate counters, diabetes skin care product samples, and elastic resistance bands were used as incentives.

Prior to Active Steps for Diabetes, 60% of the participants reported no weekly exercise and only 18% accumulated 30 minutes of exercise on > 3 days/week. These results are consistent with previous reports. In a survey of older adults with diabetes, 55% reported no weekly activity.37 In two large population studies, less than 40% of adults with diabetes reported engaging in regular PA, and adults with mobility impairments reported the least amount of PA.38,39

Physical inactivity has been correlated with several subject demographic characteristics in this pilot study. It is more common in women, African Americans, and individuals with physical limitations.36,40 Individuals with physical limitations are least active.40 Promotion of PA in this at-risk population is a primary focus of Active Steps for Diabetes. Therefore, the program includes attributes (social support, frequent feedback, and a task-oriented focus) that have been shown to help individuals successfully adopt an exercise program.36 These attributes probably contributed to the observed significant increases in PA. At the conclusion of Active Steps for Diabetes the mean days per week participants accumulated 30 minutes of exercise increased from approximately 1 to 3 days per week (or 30 minutes to 90 minutes of exercise/week) bringing them closer to the amount recommended by the ADA.

The pre- and the postintervention means for steps/day found in this study were largely below means reported for people with T2DM. Previously reported means ranged from 4352 to 9049 steps (average = 7123 steps), whereas our participants only averaged 3408 steps/day at the conclusion of the program.41,42 There are two factors that may account for the discrepancy. The first is differences in subject inclusion/exclusion criteria. Previous studies, with the largest step counts, included younger individuals and excluded individuals taking insulin as well as those with mobility impairments.4244 Consistent with this, the step counts for participants in Active Steps for Diabetes were similar to the counts reported in the literature for individuals with osteoarthritis and physical limitations.41 The second factor pertains to accuracy of the pedometer. It is possible that the pedometer step counts for the participants underestimated the actual number of steps they took, particularly for those using a walking aid due to their slow walking speed.

Pedometer focused PA programs have been shown to elicit large increases in daily walking in participants with T2DM free from secondary complications. Araiza and colleagues43 reported a 69% increase in daily walking in 6 weeks; Tudor-Locke and colleagues42 reported an increase of over 100% in 16 weeks. Consistent with this, participants in Active Steps for Diabetes increased their steps/day by approximately 65% over baseline. The small weekly step goals, and logs for tracking steps were well received by Active Steps for Diabetes participants, including participants who used an assistive device for ambulation. Thus pedometers may serve as a useful tool for initiating increases in PA in people who have T2DM and a low capacity for sustained aerobic activity.

The mean preintervention 6MWD for participants in Active Steps for Diabetes was well below mean distances reported for healthy older adults45 and similar to mean distances reported for participants with T2DM and comorbidities.46 Sixty-four percent of the participants had a clinically significant difference between pre- and postintervention distances. The mean increase in distance walked (60.2 ± 20.4m) was somewhat higher than increases reported in two studies involving individuals with T2DM.24,47 In a 12week weight loss program for obese patients with diabetes (n=60 subjects), the mean 6MWD increased 46.9 ± 31.1m.48 The exercise intervention in this program consisted of aerobic and resistance training at a moderate intensity and participants progressed from 20 to 60 minutes of exercise 6 days/week. In a 16-week intervention (n=7 subjects) involving moderate-intensity aerobic and eccentric resistance training 3 times per week, 6MWD improved 45.5m (95% CI: 7.5m to 83.6m).24 Two possibilities that could explain the higher observed gain in distance in this report are: (1) the participants' lack of familiarity with the test and (2) their initial level of conditioning. While the 6MWD is reproducible, prior studies have shown a learning effect in subjects with pulmonary disease, with the majority of the increase in distance walked over 3 or more trials occurring between the first and second trials.48 A practice test was not employed in this pilot study and therefore, preintervention scores may not have reflected participants' best efforts. It has also been suggested that individuals who are more deconditioned may gain more distance than sedentary but otherwise healthy individuals. Participants' in Active Steps for Diabetes were more deconditioned than the subjects in the two studies described above; thus they had more room for improvement.

Participant knowledge of exercise and diabetes specific exercise guidelines improved. To achieve this outcome oral and written instruction on exercise was repeated numerous times throughout the program and participants practiced implementing the exercise guidelines as well. Prior to each class participants measured their own blood glucose and were encouraged to determine whether or not they should proceed with exercise. Knowledge of exercise benefits and guidelines is considered a prerequisite for behavior change.49 While some investigators have shown a relationship between knowledge and initiation and maintenance of exercise others have not. It is important that people with T2DM and diabetic complications are familiar with exercise guidelines for their safety and to allay fears they may have about safety.

STUDY LIMITATIONS AND SUGGESTIONS FOR SIMILAR PROGRAMS

This report is an examination of preliminary outcomes for Active Steps for Diabetes, a unique education and exercise program developed to serve the needs of individuals with T2DM and mobility impairments. The program's “real” clinical service context may be considered a strength of the study. However, by nature of this context, the study has fewer controls than those carried out in laboratory settings. The study sample was not a random sample. Instead it consisted of people who voluntarily registered for Active Steps for Diabetes; therefore they may have been more motivated than people who did not register for the program. In laboratory-based studies, exercise equipment is used to precisely control and accurately measure exercise intensity and duration. Group exercise programs often use less than exact methods of measuring exercise intensity (eg, rating of perceived exertion); consequently, it may be difficult to relate group program outcomes to exercise dosing.

While this preliminary report suggests that Active Steps for Diabetes can improve PA and endurance in people with T2DM and impaired mobility, a longer duration follow-up study is needed to determine if the program has lasting effects on these measures. A comparison between the effects of Active Steps for Diabetes and the effects of standard diabetes education programs on PA and other health outcomes is needed. Additional recommended outcome measures include assessments of participant's waist circumference, mobility, and blood glucose levels. While BMI is unequivocally associated with health risk, waist circumference provides specific information about a person's fat deposition pattern and it is also an important index of cardiovascular disease risk. A test of mobility such as the Modified Physical Performance Test50 is recommended to better describe the severity of mobility impairments exhibited by study participants. To best discern the benefits (if any) of the labor intensive supervised exercise sessions in Active Steps for Diabetes, participants in the control standard diabetes self-management training should receive a pedometer, exercise video, exercise logs, and recommendations for a specific home exercise program over the study duration.

CONCLUSIONS

People with T2DM often demonstrate mobility impairments and low exercise tolerance. This frequently leads to decreased PA and increased risk factors for CVD. Exercise can clearly mitigate these detrimental changes. However, this population must overcome numerous barriers to PA and as a consequence they typically do not engage in any form of physical exercise. Based on the results of this pilot study, the authors suggest that the proposed model for diabetes education, incorporating exercise programs developed by a physical therapist, may effectively increase PA and ultimately improve health in this vulnerable population. Physical therapists possess the expertise in exercise prescription for individuals with physical limitations and multiple health comorbidities, and thus are essential in caring for this population.

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