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physical activity advisement practices in decs

CANADIAN JOURNAL OF DIABETES. 2007;31(2):131-139.

To examine exercise advisement practices in DiabetesEducation Centres (DECs) across Canada, and to review theeducational materials used to promote exercise in compari-son to national guidelines.

Surveys were faxed to 310 DECs identified in the CanadianDiabetes Association 2000/2001 Professional Membership Directory.

The response rate was 27%. Fifty-four percent of DECsreported providing standard exercise information based onnational recommendations. Fewer than 40% of DECs pro-vided information individualized to address diabetes compli-cations or other comorbid diseases, despite the fact that themajority of DECs reported significant cardiac disease(96.5% of DECs), arthritis (90.6%), kidney disease (78.1%)and/or neuropathy (32.3%) among patients.

DECs are translating research to practice when it comes tophysical activity advisement, but DEC patients may requireadditional assessment and modifications to standard physical

Évaluer les conseils en matière d’exercice que l’on donnedans les centres de formation diabétique (CFD) à l’échellecanadienne et passer en revue le matériel d’enseignementutilisé pour faire valoir l’exercice comparativement aux lignesdirectrices nationales.

Des sondages ont été envoyés par télécopieur à 310 CFDdont le nom figure dans le 2000/2001 Professional MembershipDirectory de l’Association canadienne du diabète.

Le taux de réponse a été de 27 %. Cinquante-quatre pourcent des CFD ont dit fournir des renseignements standard surl’exercice en se fondant sur les recommandations nationales.Moins de 40 % des CFD fournissent des renseignementsadaptés aux complications du diabète ou aux maladies con-comitantes, même si la majorité des CFD ont signalé queleurs patients étaient atteints de maladie cardiaques (96,5 %des CFD), d’arthrite (90,6 %), de troubles rénaux (78,1 %)et/ou de neuropathie (32,3 %).

Les CFD mettent les résultats de la recherche en pratiquelorsqu’il s’agit de renseigner les patients sur l’activitéphysique, mais les patients des CFD pourraient avoir besoind’une évaluation plus approfondie et profiter de la modifica-tion des activités physiques standard recommandées dans leslignes directrices pour améliorer leur participation. Les CFDauraient besoin de matériel pour promouvoir la participationà des activités physiques sûres.

exercice, activité physique, formation diabétique, qualité dessoins

Ann Marie Bowman RN BS BSN MS PhD, Catherine Foster RN BN MS MSN

School of Health Studies, Brandon University, Brandon, Manitoba, Canada

Address for correspondence:Ann Marie BowmanSchool of Health StudiesBrandon University 270–18th Street Brandon, ManitobaR7A 6A9 Canada Telephone: (204) 727-7397Fax: (204) 728-7292E-mail: [email protected]

Physical Activity Advisement Practices inDiabetes Education Centres across Canada

O B J E C T I V E

M E T H O D S

O B J E C T I F

M É T H O D E S

A B S T R A C T R É S U M É

R E S U LT S

R É S U LTAT S

C O N C L U S I O N

M OT S C L É S

C O N C L U S I O N

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activity guidelines in order to enhance exercise participation.Materials designed to help DECs promote safe participation inphysical activity are needed for this population.

Diabetes education, exercise, physical activity, quality of care

INTRODUCTIONThe rise in diabetes prevalence and the anticipated rise infinancial costs associated with the disease have resulted instrengthened emphasis on diabetes prevention and manage-ment, including heightened stress on the positive role thatphysical activity can play in delaying the onset and progressionof diabetes and/or its disease-related complications (1-10).

General guidelines for physical activity have been madewidely available by Health Canada (11), the CanadianDiabetes Association (CDA) (2) and the American DiabetesAssociation (ADA) (12). Health Canada recommends thatadults (including older adults) accumulate 30 to 60 minutesof moderate physical activity most days of the week, includ-ing endurance activities 4 to 7 days per week, flexibility activ-ities daily, and strength and balance activities 2 to 4 days perweek. CDA clinical practice guidelines recommend thatindividuals with type 2 diabetes should accumulate at least150 minutes of moderate-intensity aerobic exercise each week,over at least 3 non-consecutive days, or !4 hours of exerciseper week. Both aerobic and resistance exercise are recom-mended 3 times per week (2). The CDA also recommendsthat those who plan to begin an exercise program involvingresistance work should receive initial instruction and period-ic supervision by a qualified exercise specialist. Both CDAand ADA recommendations state that previously sedentaryindividuals, those with severe neuropathy or preproliferativeor proliferative retinopathy, and those at high risk for cardio-vascular disease (CVD) require additional assessment andmodifications to standard exercise recommendations (2,12).Additional assessment involves a graded exercise test withelectrocardiogram monitoring for all individuals over 40 years of age and for individuals over 30 years of age if dia-betes duration is greater than 10 years, or if the individualsmokes, is hypertensive, has dyslipidemia or retinopathy,or has nephropathy (including microalbuminuria) (12).

Diabetes translation research suggests possible gapsbetween national guidelines for diabetes care and educationand the care patients actually receive (13-15).The efficacy ofDiabetes Education Centres (DECs) in helping patientsachieve improvements in self-care behaviour and metaboliccontrol may be influenced by factors such as delivery meth-ods, educator attitudes, qualifications and/or experience, orprogram participant characteristics, including possible mul-tiple comorbid conditions (16-20). However, the character-istics of neither the DEC professionals nor their patients havebeen documented, and the extent to which exercise advice is

provided by DECs and modified for patients with healthcomplications is not known.This study was conducted: i) toexamine the characteristics of professionals who work inDECs and the patients who attend them; ii) to documentexercise advisement practices in DECs across Canada; andiii) to examine how consistent educational materials used byDECs to promote physical activity are with CDA and HealthCanada guidelines (2,11).

METHODS This study was conducted using a cross-sectional descriptivesurvey design and approved by the Brandon UniversityResearch Ethics Committee.The investigator-developed sur-vey (available upon request from the authors) used CDA (2)and Health Canada (11) national guidelines for physical activ-ity as criteria for evaluating physical activity advisementpractices and examining of exercise-related materials. Thesurvey was reviewed for face and content validity by 5 prac-tising diabetes educators, 2 university education specialists(including 1 individual who has worked with the CDA at thenational level) and 2 university researchers with expertise inkinesiology. The reviews resulted in minor wording changesand the incorporation of additional questions to permit amore detailed accounting of DEC demographics.

The final survey consisted of 36 questions (3 questionsnot addressed in this report related to barriers to exerciseadvisement and participation). Response options consistedprimarily of fill-in-the-blank and forced-choice items. A fewquestions required qualitative responses.

The surveys, consent forms and information about thestudy were faxed to 310 DECs identified in the CDA2000/2001 Professional Membership Directory (21), and werere-faxed twice to non-responders. DECs in Quebec werealso faxed surveys to examine whether non-French languagesurveys would elicit responses from Centres in the French-speaking province. The survey consisted of demographicquestions about the DEC staff and its patients, as well asquestions about the characteristics of the DEC’s programs.Demographic information sought about the DECs them-selves included general geographic location, staff members’years of employment in diabetes education and a descriptionof how much education diabetes educators had received onexercise advisement. DECs were also asked to note whetherpatients underwent stress tests before receipt of exercise rec-ommendations; to identify whether it would be helpful to

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include an exercise professional as part of the DEC team; toestimate of the proportion of patients who when referred toexercise professionals followed through with the referral;and to report whether the DEC tracked such information.

Survey questions designed to examine the characteristicsof DEC patients included questions about types of diabetespatients served; percentage of attendees served by agegroup; geographic area(s) served; and ethnic background ofpatients (Table 1). DECs were also asked to indicate typicalcomorbid diseases observed among their patients (Table 2).Descriptive statistics of DEC attendees were calculated sep-arately for populations <65 and !65 years of age withrespect to average BMI; diabetes duration; and estimatedpercentages of patients with retinopathy, neuropathy,nephropathy and retinopathy. Physical function was assessedusing questions from the SF-36, which has demonstratedreliability and validity (22); transformed scores could rangefrom 0 to 100, with higher scores indicating higher function.

Questions that addressed the types of educational materi-als and nature of physical activity instruction used forced-choice “yes,” “no” or “not applicable” options.The survey askedwhether instruction was modified in the presence of diabetescomplications and nondiabetes comorbid disease(s); whethersupervised practice of recommended activities was providedand monitored; and whether specific recommendations weregiven for duration, frequency, intensity and types of activities.

Qualitative information was sought for the last item. DECswere also asked to state whether specific instruction wasgiven regarding initiation of both aerobic and resistance-train-ing activities and which types of each of these activities wererecommended.They were also asked about whether patientswere given standard exercise information and whether thatinformation was modified for diabetes complications and/ornondiabetes comorbidities. DEC provision of diabetes-specif-ic precautionary information was examined using 7 items(Cronbach’s alpha for this subscale was 0.78 in a previousstudy [23] and 0.69 in this study) (Table 3).

Descriptive statistics were calculated for all survey ques-tions, and calculated separately for characteristics of DECpatients <65 years of age vs. those !65 years old;Wilcoxon’ssigned rank test was used to compare the latter using SPSSversion 14.0 (SPSS Inc., Chicago, Illinois).

RESULTS The response rate was 27.4% (n=85). Percentages of totalrespondents by province were as follows: Ontario 40.0%,British Columbia 16.5%, Alberta 9.4%, Nova Scotia 9.4%,Newfoundland 7.1%, Manitoba 7.1%, Saskatchewan 4.7%,New Brunswick 4.7%, Prince Edward Island 0.0% andYukon 0.0%. Provincial location could not be determinedfor one respondent. As anticipated, Quebec DECs did notrespond to our non-French language surveys.

DEC = diabetes education centreSD = standard deviation

Table 1. Survey responses regarding characteristics of and patients served by DECs

Characteristic Value

Years in operation: range, mean (SD) 1–45, 17.2 (9.8)

Number of healthcare professionals employed: range, mean (SD) 1–21, 3.9 (2.9)

Gender of health professionals employed: range, mean (SD) Female Male

1–8, 3.1 (1.8)0–3, 0.4 (2.9)

Diabetes type among patients served by DECs: n (proportion)Type 1Type 2 Children AboriginalOther (gestational, prediabetes)

46 (54.1)82 (86.5)22 (25.9)31 (36.5)20 (28.4)

Ethnic groups served: n (proportion)White Black Aboriginal Asian

84 (98.8) 8 (9.4)

35 (41.2) 18 (21.2)

Geographic locations served by DECs: n (proportion)UrbanSuburban Rural Remote

24 (28.2) 24 (28.2) 65 (76.5) 12 (14.1)

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Characteristics of DECs and DEC healthcare professionals

DEC characteristics and characteristics of the clients served byDECs are summarized in Table 1. Professional DEC staff weregenerally nurses (mean±standard deviation [SD]) (1.5±0.9)and dietitians (1.4±0.8). Eleven DECs employed a full-timephysician or endocrinologist; 8 employed social workers; and2 employed pharmacists.Among DECs, at least one employedone gerontologist, or counsellor, or nephrologist.

The mean age of nurses was 48.0±6.8 years, while themean age of dietitians was 40.3±9.9. Mean ages of endocri-nologists, physicians, physiotherapists and exercise specialists

were 42.5±7.5, 47.4±11.7, 45.6±11.0 and 35.7±5.4 years,respectively. Mean years working in diabetes education fornurses, dietitians, endocrinologists/physicians, physiothera-pists and exercise specialists were 10.6±6.5, 10.2±6.9,9.8±6.0, 2.8±1.7 and 3.2±4.5 years, respectively. In 58DECs, at least 1 nurse held the Certified Diabetes Educator(CDE) designation. In 46 DECs, at least 1 dietitian was desig-nated a CDE. Among other DEC health professionals, only 1psychologist was reported as CDE-qualified.

Eighteen DECs (21.2%) had at least 1 team member withsome exercise training. Of these, 11 had the input of profes-sionals with postsecondary exercise training, 6 employed

Table 2. Characteristics of patients served by DECs

Characteristic Value

Comorbid diseases of patients: n (proportion) ArthritisLung disease or emphysema Parkinson’s disease Memory problemsHigh blood pressureAngina Congestive heart disease Stroke Myocardial infarction Thyroid disorder Kidney disease Cancer

77 (90.6)44 (51.8) 11 (12.9) 29 (34.1) 85 (100) 71 (83.5)58 (68.2) 56 (65.9)76 (89.4) 56 (65.9) 61 (71.8)38 (44.7)

Estimated proportion of patient attendees by age group: %30–40 years 41–50 years51–64 years!65 years

9.1%18.7%33.6% 38.3%

Estimated body mass index of patient attendees: mean (SD) Patients <65 years Patients !65 years

29.1* (5.9)30.8 (2.9)

Perceived physical function scores of patients: mean (SD)Patients <65 yearsPatients !65 years

62.4* (17.9)44.5 (16.5)

Perceived diabetes duration: mean (SD) Patients <65 yearsPatients !65 years

6.4* (5.7)13.5 (12.7)

Perceived proportion of patients with neuropathy: mean (SD) Patients <65 yearsPatients !65 years

25.8* (21.4)38.3 (25.1)

Perceived proportion of patients with nephropathy: mean (SD) Patients <65 yearsPatients !65 years

18.2* (14.7)26.5 (19.2)

Perceived proportion of patients with retinopathy: mean (SD) Patients <65 yearsPatients !65 years

8.2* (10.8)12.7 (14.5)

*p<0.001DEC = diabetes education centreSD = standard deviation

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physiotherapists and 6 employed exercise specialists. Amongnurses and dietitians, 4 had attended a 1-day training pro-gram and 3 others had undertaken more extensive training(e.g., American College of Sports Medicine certification,Canada Fitness Professional/Fitness Instructor Specialist).Thirty-seven DECs (43.5%) without an exercise profession-al agreed it would be helpful to include them. However, 53DECs (62.4%) estimated that patients referred to exerciseprofessionals do not follow through on the referral.

Characteristics of patients served by DECsNearly two-thirds of DECs (61.2%; n=52) estimated thatthe majority of patients they served were "65 years of age.Total number of comorbid diseases reported as commonlyseen among attendees of DECs ranged from 2 to 13 (7.9±3.0) (Table 2). CVD and arthritis in particular were per-ceived to be highly prevalent comorbid diseases.

General exercise advice practices and activitiesSixty-three DECs (74.1%) provided all patients with printedmaterials about physical activity participation; 46 DECs(54.1%) also provided other forms of information, such asvideos, overheads, slide presentations and guest lectures. FiftyDECs (58.8%) reported that they provided standard physicalactivity information to all patients. Thirty-eight DECs(44.7%) did not individualize information by stage of readi-ness to exercise.While 47 DECs (55.3%) reported that theyprovided information individualized to each patient’s physical

status, only 22 (25.9%) reported that their educational mate-rials were modified to address diabetes complications, andonly 26 (30.6%) reported that their educational materialswere modified to address non-diabetes comorbidities.Patients did not routinely have an exercise stress test beforethe delivery of activity recommendations in 61.2% of DECs,while they “sometimes,” “usually” or “always” had an exercisestress test in 28.2%, 7.1% and 2.4% of DECs, respectively.

No equipment or space was available for supervised prac-tice of exercise activities among 79% of DECs. While therewere “no” demonstrations of recommended activities in56.5% of DECs, demonstrations occurred “sometimes” in24.7% of DECs, “usually” in 10.6% and “always” in 8.2%.Return demonstrations of recommended activities were “notmonitored” or reported as “not applicable” by 80% of DECs.When return demonstrations were performed, they weremonitored “some of the time” in 4.7% of DECs, “usually” in3.5% and “always” in 9.4%. Of programs that monitoredreturn demonstrations, 14.1% monitored blood glucose(BG) before and after exercise; 16.5% assessed for perceivedsymptoms of hypoglycemia and documented patient toler-ance for different activities; and 15.3% tracked the occur-rence of unpleasant symptoms or injuries associated withexercise participation.

Qualitative statements from respondents revealed thatadvice about duration, frequency, intensity and types ofactivity, including resistance exercise, were drawn directlyfrom the CDA’s clinical practice guidelines (2) by 29 DECs

Table 3. Survey responses regarding diabetes-specific exercise advisement*

How often were patients on oralagents, insulin, or both instructed to…

Most of thetime, %

Some of thetime, %

None of thetime, %

N/A, %

Reduce diabetes medication dose before orafter physical activity (n=79) 38.0 50.6 8.9 2.5

Carry a fast-acting carbohydrate (n=84) 95.2 2.5 0.0 2.4

Check BG level before or after physical activityor exercise (n=81) 71.6 24.7 1.2 2.5

Check their feet for skin irritation after physicalactivity (n=84) 50.0 38.1 9.5 2.4

Put off physical activity or exercise if BG is "5.5 mmol/L (n=78) 37.2 33.3 25.6 3.8

Put off exercise during the peak effect of diabetes medication (n=84) 41.7 39.3 15.5 3.6

Wear identification as a person with diabetes(n=79) 69.6 24.1 3.8 2.5

*Not all DEC respondents answered every question. Percentages reflect those who provided a response and the effect of rounding.

BG = blood glucoseDEC = diabetes education centreNA = no answer

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(34.1%) and from the Health Canada Canada’s Physical ActivityGuide to Healthy Active Living (11) by 16 DECs (18.8%).Therefore, 52.9% of DECs (n=45) reported that they hadadopted national recommended guidelines for promotingphysical activity. Three centres used both CDA and HealthCanada guidelines.When asked for qualitative information asto what the DEC recommendations involved, most respon-dents stated, “We use CDA guidelines” or “We use HealthCanada guidelines,” without being specific. Others citedtheir recommendations, and these conformed to 2003 CDAclinical practice guidelines (2). Forty DECs (47.1%) used 2or 3 recommended CDA or Health Canada guidelines butdid not address 1 or more of the guidelines for duration, fre-quency, intensity of activity or activity type. Eight DECs(9.4%) stated that their recommendations for intensity,duration or frequency of activity depended on the patient,and 1 (1.2%) stated that patients with problems werereferred to a refit centre (cardiac rehabilitation centre).

Agreement between national guidelines and DEC advisementExercise duration Seventy-nine DECs (92.9%) responded that they providedinstructions regarding exercise duration: 29 DECs (34.1%)recommended 150 minutes of activity per week, and 32(37.7%) recommended 20 to 60 minutes of activity per day.Three DECs recommended less than 150 minutes per weekof accumulated activity. Recommendations for exercise dura-tion varied among and within DECs, depending primarily onpatient status and experience. The lowest suggested activityduration was 5 minutes per day, increasing to 30 minutes.

Exercise frequencyInstructions about exercise frequency were given by 90.6%of DECs (n=77). Suggestions within and among DECs var-ied, with some recommending that patients should “startslow” and attempt to engage in exercise for very short peri-ods daily, to recommending exercise a minimum of 3 daysper week, and some recommending exercise daily. FourteenDECs (16.5%) suggested that patients engage in activity atleast 3 days per week, 51 (60%) recommended a minimumof 5 days per week and 28 (32.9%) encouraged activity daily.

Exercise intensityExercise intensity instructions were given to patients in74.1% of DECs (n=63). Fifteen DECs (17.7%) did not rec-ommend a specific intensity for exercise; 2 (2.4%) recom-mended “low intensity” exercise; and 1 (1.2%) recommendedpatients “walk at a moderate pace.” Most recommended the“talk test,” “low intensity” or “mild to moderate intensity”activity without being specific as to what each meant.Intensity scales such as the “rate of perceived exertion” scalewere submitted with faxed exercise educational materials for“First Step” programs (24) and from centres that employed or

referred patients to an exercise specialist. Other faxed educa-tional materials from DECs using the “10,000 Steps” program(25) or exercise specialists included information on how tocalculate target heart rate as well as warnings to considerwhen engaging in exercise, such as palpitations, chest tight-ness or chest pain with radiation to arms or jaw; extremeshortness of breath, wheezing or coughing; dizziness, faint-ness or nausea; and excessive perspiration or prolongedfatigue after exertion.

Best types of activities Instructions about types of physical activities that were bestfor patients were provided by 80.0% of DECs (n=68), pri-marily those mentioned in the Health Canada and CDAguidelines (2,11).Walking, swimming, biking, dancing, golf-ing, housework and use of a treadmill were the primaryendurance activities recommended by most DECs; elasticbands, light weights or the use of soup cans were recom-mended for resistance exercise. Thirty-one DECs (39.7%)did not recommend resistance exercise of any type, and 1DEC stated that it recommended little resistance exercise.Several DECs suggested that resistance activities be encour-aged only after physician approval was obtained.

Information providedFifteen DECs (17.65%) faxed or mailed the materials theyused for activity advisement, and 3 stated they used “FirstStep,” Health Canada or CDA information. All faxed infor-mation reflected these guidelines. Three DECs supplement-ed information from Health Canada and the CDA withpamphlets developed by pharmaceutical companies; a fewalso provided information on available activity programs intheir geographical area, advertisements for such programs orinformation on local walking trails. One DEC sent a slidepresentation that covered FITT (frequency, intensity, timeand type) principles.

Diabetes-specific exercise recommendationsDiabetes-specific exercise recommendations intended tohelp patients exercise safely if they take insulin and/or oralantidiabetes medications are summarized in Table 3. While~72% of responding DECs routinely recommended thatpatients check BG levels before or after exercise, approxi-mately one-half of DECs did not routinely make recommen-dations about the prevention of hypoglycemia with exercise.

DISCUSSIONOur findings suggest that most DECs are staffed primarily bysome combination of 2 to 3 female nurses and dietitians whoseldom have professional training in exercise advisement.Only a small proportion of DECs had access to professionalswith significant exercise advisement expertise, a fact that isnot surprising since most DECs served rural areas. Despitethis, it is clear that DECs are advising their patients to


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increase physical activity and are providing informationabout the duration, frequency and intensity of physical activ-ity, as well as specific types of activities that might be best. Itis also clear that this information is being drawn chiefly fromcurrent CDA and/or Health Canada guidelines (2,11).

Diabetes educators perceived that the proportions ofattendees experiencing comorbid diseases and diabetes com-plications was high. This is consistent with expectations,since 91% of DECs reported that their patients were typical-ly 40 years or older, had had diabetes for over 10 years andhad limitations of physical function (22,23). Research hasrevealed that over time, the prevalence of neuropathy andCVD becomes high among people with diabetes, and that themajority of costs and deaths associated with diabetes arerelated to CVD (26-28). Nevertheless, among DECs therewas limited modification of activity recommendations toaccommodate comorbid conditions and diabetes complica-tions. DECs might wish to consider routine evaluation ofwhether stress testing among their attendees has been done(if indicated) before recommending physical activity. Theymight also wish to emphasize the importance of carrying dia-betes identification.

Walking was the most frequently recommended physicalactivity among DECs. The ADA, however, recommendsavoidance of treadmill or step exercise, jogging or prolongedwalking for people with significant neuropathy (29). Thus,careful attention to the presence and extent of neuropathyand a stronger emphasis on foot inspection would appear tobe important, since approximately one-half of DECs did notroutinely recommend that their patients check their feet forskin irritation after exercise.

Other diabetes-specific information important for safeexercise for those taking insulin, oral antihyperglycemicagents or both is advice to postpone activity when BG is lowor during the peak effect of diabetes medications. In 1 study,89% of those with type 2 diabetes reported the use of anti-hyperglycemic agents (28% used insulin) (30). Given thelarge proportion of individuals with type 2 diabetes on anti-hyperglycemic agents and research findings regarding signif-icant drops in BG with moderate physical activity (31,32),precautions regarding BG monitoring and exercising duringthe peak effect of medication should be emphasized in dia-betes education.The potential for hypoglycemia among indi-viduals who begin exercise at near normal glycemic levelscould also be of concern.

To date, DECs appear not to be tracking how patientswith comorbidities respond to prescribed activities.Trackingsuch responses when negative outcomes may arise may beworthy of consideration (2,12). As well, the use of individu-alized activity information could be useful. Tracking patientresponses after commencement of prescribed activity wouldalso be important to enable ongoing, accurate evaluation ofprogram effectiveness and implementation fidelity (33).Further to matters of follow-up, DECs might improve suc-

cess in achieving desired patient engagement in physicalactivity by providing stage of readiness–based encourage-ment for exercise. The potential for relapse from physicalactivity in this patient population has been found to be sig-nificant, and our findings suggest DECs do not provide readi-ness-based information (34-36).

Exercise guidelines that translated least well to practicewere those concerned with resistance activities and exerciseintensity. The latter concurs with findings of earlier research(14). Nevertheless, in this study a marked improvement in thedegree to which educators advise about exercise intensity wasapparent. At the same time, there was an apparent reluctanceto prescribe resistance exercises, despite the fact that theymay not only improve glycemic control but be a better—orindeed the only—option for individuals with illnesses thatpreclude the direct application of standard activity recom-mendations. Resistance exercises may, together with moder-ate endurance exercise, provide sufficient volume andintensity of activity to achieve desired long-term health out-comes (35) and should be prescribed when appropriate.

LimitationsStudy limitations arose from the fact that the data were basedon a cross-sectional sample and self-report, which mayreflect biases including self-selection, respondent biases andproblems with recall.The survey was also newly developed,with limited information about its psychometric properties.Another limitation affecting generalizability of the findingswas the low response rate. DECs are clearly taxed for time.However, some regional centres reported on behalf of theiraffiliated DECs, so the reported response rate may be under-estimated. As well, with healthcare reorganization, someDECs in operation in 2000/2001 no longer exist, and somelisted fax numbers were not DEC lines but belonged to pri-vate citizens, private consultants or groups that served onlypediatric patients or provided only nutrition counselling.Practical circumstances led to technical problems with fax-ing, such as poor line conditions and busy lines in larger facil-ities. Despite these limitations, the study drew on a nationalsample and is one of few studies to identify strengths andgaps in the translation of recommended physical activityguidelines in over one-fourth of DECs in Canada.

CONCLUSION Provision of basic information about physical activity is foun-dational for the assumption or resumption of activity amongindividuals living with diabetes. The fact that translation ofrecommended physical activity guidelines to practice haveimproved to the extent they have has perhaps to do withready availability of national guidelines and the increasedemphasis they have received. That said, the provision of dia-betes-specific information/guidelines to help DEC profes-sionals address common disease-related limitations tophysical activity experienced by their patients may favourably



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enhance both activity advisement and safe exercise participa-tion. Materials designed with this in mind could also incor-porate information that takes into account patients’ stage ofreadiness for exercise. While enhancements to exerciseadvisement can be made, it appears that exercise has achievedits rightful place as a cornerstone of diabetes education, in nosmall part due to the existence of and emphasis on nationalexercise guidelines.

ACKNOWLEDGEMENTThis research was funded by a grant from the BrandonUniversity Research Committee.

AUTHOR CONTRIBUTIONSAMB conceived and designed the study, acquired the dataand developed and revised the manuscript. CF assisted in thereview of the proposal, interpretation of the data, and man-uscript review and revision.

AUTHOR DISCLOSURESNo duality of interest declared.

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physical activity advisement practices in diabetes education centres across canada

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