Limited impact of the PEP1 structured physical activity program on perceived barriers to physical activity in people living with type 1 diabetes

Abstract

Physical activity (PA) has many benefits for people living with type 1 diabetes (T1D), including improved glycemic control and reduced cardiovascular risk.¹ Despite these advantages, only 32% of people living with T1D (pwT1D) meet PA recommendations.² In 2008, Brazeau et al. identified fear of hypoglycemia as the primary barrier to PA in pwT1D.³ Subsequent studies have echoed these findings, suggesting that education and promotion of PA may help mitigate these barriers.^{2, 3} Brazeau et al. developed 3 months ‘physical exercise promotion’ (PEP1) programme aiming to increase PA levels.⁴ Although no significant change in objectively measured PA level was reported, participants in the intervention group presented a trend toward increased intention to practice PA post-intervention and at the 1-year follow-up (both p = 0.07). However, whether perceived barriers to PA were reduced remains unclear.

To address this question, the data from the PEP-1 study⁴ were analyzed for participants who completed the Barriers to Physical Activity in Type 1 Diabetes (BAPAD) questionnaire at baseline, post-intervention, and 1-year follow-up. The BAPAD questionnaire, validated by Dubé et al.,⁵ calculates an average score over the first 11 items. Each item is scored on a scale of 1–7, with 7 indicating more barriers. Inclusion criteria were age between 18 and 65 years, a T1D diagnosis for at least 12 months, and less than 150 min of physical activity per week at baseline. Exclusion criteria included major microvascular and macrovascular complications in the previous 6 months and pregnancy. Participants were randomized into two groups: control group and intervention group. All participants received brochures with information on the benefits of PA and how to incorporate it into their daily lives. The intervention group consisted of 12 sessions divided into two parts: 60 min of different activities (cardiovascular, muscular and flexibility) to initiate PA and introduce participants to a variety of exercises and sports, and 30 min of advice on PA and glycemic management in relation to PA. BAPAD scores were compared before the intervention, after the intervention and 1 year after inclusion using the MIXED procedure for repeated measures in SPSS statistical software.

Data was available for 41 participants; 21 completed the intervention group, and 20 the control group. The rate of attendance at the sessions in the intervention group was 82 ± 12%. Mean BAPAD scores for the intervention group changed from 2.7 ± 1.0 at baseline to 2.5 ± 0.7 post intervention and remained at 2.5 ± 1.1 at the 1-year follow-up, while control group scores changed from 2.8 ± 1.0 at baseline to 2.5 ± 0.9 post intervention and then to 2.7 ± 0.9 at the 1-year follow-up. No significant difference was observed in BAPAD scores between the time points or between the groups (p > 0.05).

A 12-week PA-promotion programme with a total of 18 h of interventions did not significantly reduce overall perceived barriers to PA. One potential explanation for this finding is the relatively low BAPAD score at baseline, though it is consistent with the mean score reported by other studies.^{2, 3, 6} Future research might benefit from targeting pwT1D who report higher baseline barriers to PA. Nevertheless, this study was conducted with individuals who do not meet PA recommendations (i.e. ≥150 min of moderate to vigorous PA per week), potentially already including people who perceive a higher level of barriers to PA. Furthermore, the programme focused on diabetes management and PA, introducing simple and practical activities that could be easily integrated into daily life. Adopting new behaviors and modifying perceptions, particularly regarding barriers, remain significantly challenging. Another potential reason for the absence of significant results could be the relatively short duration of the intervention. Shifting perceptions of barriers to PA often requires sustained exposure to interventions over a longer period. It is possible that the intervention was insufficient in duration to induce meaningful psychological or behavioral changes. Furthermore, the participants may have required a more tailored approach, addressing individual-specific barriers rather than a generalized programme. It is also important to note that pwT1D face many of the same barriers as the general population, such as lack of time, motivation, and energy, which are not fully addressed by the BAPAD questionnaire. It is thus unclear if reducing barriers for PA in pwT1D is extremely hard or if the BAPAD score needs some update to better capture all issues.

To conclude, the intervention did not significantly reduce barriers to PA among pwT1D. Future programmes should explore new strategies, including extended durations and personalised approaches, to address these challenges and encourage greater PA engagement. Updating the BAPAD questionnaire might be necessary to inform better intervention design.

This study was funded by the J-A DeSève diabetes research cahir to RRL. Authors have no conflict of interest to declare.