Health Promotion International, Vol. 24 No. 4 doi:10.1093/heapro/dap031 Advance Access published 30 September, 2009

# The Author (2009). Published by Oxford University Press. All rights reserved. For Permissions, please email: [email protected]

Barriers to regular exercise among adults at high risk or diagnosed with type 2 diabetes: a systematic review EVELIINA E. KORKIAKANGAS*, MAIJA A. ALAHUHTA and JAANA H. LAITINEN Finnish Institute of Occupational Health, Oulu, Finland *Corresponding author. E-mail: [email protected]

SUMMARY The aim of this systematic review was to identify the reported barriers to regular exercise among adults either at high risk or already diagnosed with type 2 diabetes (T2D), because of the importance of exercise in the prevention of T2D. We searched the MEDLINE, Cinahl and PsycINFO databases. All potentially relevant articles were reviewed by two researchers, and 67 titles were found, of which 13 papers met inclusion criteria. Internal and external barriers to exercise were identified among adults either at high risk

of T2D or already diagnosed. Internal barriers were factors which were influenced by the individual’s own decisionmaking, and external barriers included factors which were outside of the individual’s own control. It is important for counselling to identify the internal and external barriers to regular exercise. In this way, the content of counselling can be developed, and solutions to the barriers can be discussed and identified. Further research on the barriers to regular exercise is needed.

Key words: barriers; exercise; type 2 diabetes; high risk of type 2 diabetes

INTRODUCTION An increase in the number of sedentary adults is one reason behind today’s continuously rising prevalence of type 2 diabetes (T2D). The total number of people with diabetes is estimated to increase from 171 million in 2000 to 366 million by 2030 (Wild et al., 2004). This predicted diabetes pandemic means that hundreds of millions of people are at high risk of T2D. Lifestyle changes such as regular exercise, healthy dietary habits and weight loss are important in the prevention of T2D (Hu et al., 1999, 2001; Tuomilehto et al., 2001; Knowler et al., 2002; Kosaka et al., 2005; Laaksonen et al., 2005; Lindstro¨m et al., 2006). Exercise improves insulin sensitivity, and thus prevents T2D (Swartz et al., 2003; Yamanouchi et al., 1995). It also has several benefits to the health of type 2 diabetic individuals (Albright et al., 2000). The

question of how to motivate sedentary adults to exercise regularly is an important issue which needs to be answered. Perceived barriers to exercise are important in the self-management of T2D (Glasgow et al., 1997; Hays and Clarke, 1999; Koch, 2002; Cox et al., 2004) because by identifying the barriers, an individual can find solutions to them and possibly focus on the benefits more strongly than the barriers or disbenefits (Nagelkerk et al., 2006). This information is needed in order to develop effective exercise counselling contents, methods and campaigns to motivate and help sedentary overweight adults at high risk or already diagnosed with T2D to exercise regularly. Earlier studies on barriers to regular exercise have been carried out in several patient groups such as those with osteoporosis and osteoarthritis (Shin et al., 2006), urinary incontinence (Nygaard et al., 2005) and haemodialysis 416

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(Goodman and Ballou, 2004) and also among healthy adults of different ages (Plonczynski, 2000; Resnick and Spellbring, 2000; Stutts, 2002; Schneider et al., 2003; Schutzer and Graves, 2004; Thurston and Green, 2004; Kilpatrick et al., 2005; Allender et al., 2006; Kaewthummanukul et al., 2006; Teixeira et al., 2006; Lee et al., 2007; Sit et al., 2008). The purpose of this systematic review was to evaluate what is known about the barriers to regular exercise among individuals either at high risk or already diagnosed with T2D.

METHOD Search protocol An extensive search of the literature published up to June 2008 was undertaken using the electronic databases MEDLINE, PsycINFO, Cochrane and Cinahl (Cumulative Index to Nursing and Allied Health Literature). The used keywords and phrases were barrier or barriers, and the following MeSH terms: exercise or physical activity, and T2D. The Cochrane database contained no paper on this subject.

Paper selection A total of 67 potentially relevant papers were identified from the databases. The inclusion criteria were that the paper was: (i) written in English; (ii) a peer-reviewed scientific article and (iii) involved barriers to exercise or physical activity among persons either at high risk or already diagnosed with T2D. Exclusion criteria of the papers were: (i) focus on children or adolescents; (ii) focus on persons with serious mental illness or (iii) no focus on the content of the barriers. Both quantitative and qualitative studies were included in this review due to the limited number of papers. A five-phase process was used (Figure 1). During the first stage, the researcher (E.E.K.) examined the titles and in the second stage, the abstracts. In the third stage, the researcher (E.E.K.) evaluated the retained papers as whole articles. Next the researcher (M.A.A.) examined the papers again, independently, according to the selection criteria. The researchers discussed papers considered ‘borderline’ for inclusion until consensus was reached.

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After screening titles and abstracts, we retrieved 30 articles in full text. Sixteen studies were eliminated, mainly due to no mention of barriers in the focus and results of the study (Hays and Clarke, 1999; Aljasem et al., 2001; Koch, 2002; Cox et al., 2004; Wen et al., 2004). One of the eliminated studies did not include any factors on how the risk of T2D was evaluated (Carter-Nolan et al., 1996). In their review, Kirk et al. (Kirk et al., 2007) studied physical activity consultation for people with T2D and also demonstrated barriers to regular exercise. Their review contained two studies, one of which (Swift et al., 1995) is also included in this review. The other was eliminated because its content did not deal with barriers to regular exercise (Wilson et al., 1986). Due to this, Kirk et al.’s study (2007) was not included in the present review. A process of this systematic review is described in Figure 1. Inclusion criteria were met by 13 articles altogether. Table 1 shows the included qualitative studies and Table 2 contains the quantitative studies.

Data analyses Data were analysed by inductive content analysis (Graneheim and Lundman, 2004; Elo and Kynga¨s, 2008), the process of which is presented in Table 3. First, the results from the included papers were gathered; the barriers with the same meaning were grouped into subcategories named according to the content. Then the main categories were identified.

RESULTS Methodological characteristics of the studies Aims, designs, samples and data collection of the study reports were analysed (Tables 1 and 2). The included studies had several different aims, but each of them described barriers to regular exercise. Data were collected by questionnaires in quantitative studies (n ¼ 9) and by interviews with different techniques in qualitative studies (n ¼ 4). The studies were executed between 1991 and 2007 in six countries: the UK, the USA, South Africa, Kuwait, Australia and Canada. The numbers of interviewed individuals were from 23 to 39 in qualitative studies. The total number of study participants was 3465, ranging from 23 to 1000 in the

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Fig. 1: Process of systematic review of barriers to exercise among adults at high risk or already diagnosed with type 2 diabetes.

individual studies. One study included individuals at high risk of T2D, and the others (n ¼ 12) included individuals already diagnosed with T2D. The barriers to regular exercise among persons at high risk or already diagnosed with T2D Two kinds of barriers to regular exercise were identified within the papers reviewed. These were internal and external barriers (Table 3). The internal barriers included factors which could be influenced by the individual’s own decision-making, for example lack of time. Due to these factors, the individual feels that the

reasons, goals and benefits of exercise are insufficient (health problems, exercise is not motivating) compared to the costs of exercising ( pain, tiredness, feeling that exercise is uncomfortable, negative emotions). Internal barriers also included emotions such as shame (Swift et al., 1995; Shultz Armstrong et al., 2001; Mier et al., 2007), laziness (Van Rooijen et al., 2002; Dye et al., 2003; Mier et al., 2007; White et al., 2007) and fear of exercise (Swift et al., 1995; Wanko et al., 2004; Donahue et al., 2006; Lawton et al., 2006; Mier et al., 2007). At the root of these feelings was poor health or overweight (Swift et al., 1995; Shultz Armstrong et al., 2001; Mier et al., 2007). Overweight subjects often found exercise

Table 1: Qualitative studies reviewed regarding barriers to regular exercise among subjects either at high risk or already diagnosed with type 2 diabetes Reference

Country

Aim of the study

Sample

Qualitative/ quantitative

Findings

Roles, norms and responsibilities: lack of time (work, home duties), fear and shame (being unfamiliar with their local neighbourhood and difficulties in speaking English); external constraints: lack of culturally sensitive facilities (in cases of cultural taboos such as not being allowed to swim) and weather conditions; perceptions and experiences of disease; activities and active respondents: short term goals in exercising, ‘I do enough already’ Lack of time due to work and family obligations, taking care of children or grandchildren, physical pain, depression, lack of motivation, being overweight, weather, environmental barriers such as traffic, lack of sidewalks, poor street lighting, gang activity, lack of facilities and transportation Tiredness, health problems, lack of convenient venue for exercise, unwillingness to exercise on Thursdays because church obligations, or on a clinic day because of the long waiting periods, unwillingness to exercise with people who do not have type 2 diabetes, social responsibilities, cost of transport, family affairs, difficulties at home, laziness, feeling unwell Bad feet because of diabetes, arthritis, not wanting others to know unfit they are, no energy to exercise, feeling too sleepy to exercise

Lawton et al., UK 2006

To study experiences of physical activity as part of diabetes self care

23 Pakistani and 9 Indian diabetes patient

Qualitative

Subjects were interviewed in depth

Mier et al., 2007

USA

To identify barriers to physical activity in a population of Mexican Americans with type 2 diabetes

39 Mexican Americans with type 2 diabetes in six groups (aged 30– 55 years)

Qualitative

60– 90 min discussions in groups, questionnaire on demographic characteristics. Qualitative study

Van Rooijen et al., 2002

South Africa To study barriers to exercise

28 black women diagnosed with type 2 diabetes

Qualitative

Interview study

Dye et al., 2003

USA

31 people over the age of 55 with type 2 diabetes

Qualitative

Focus group interview (four focus group)

To identify factors that affect the nutrition and exercise behaviours of people over the age of 55 with type 2 diabetes

Barriers to regular exercise

Data collection

419

420

Reference

Country

Aim of study

Sample

Qualitative/ quantitative

Serour et al., 2007

Kuwait

334 Kuwaiti adults with hypertension, type 2 diabetes or both

Quantitative

Questionnaire

Weather, always busy, co-existing disease

Donahue et al., 2006

USA

522 adults at high risk of type 2 diabetes

Quantitative

Mail survey Questionnaire

97 patient with type 2 diabetes

Quantitative

Mail survey Questionnaire

To study perceived factors that 406 patient with type 1 or type 2 prevent patients from diabetes, mean age 56, mean increasing physical activity duration of diabetes 10 years

Quantitative

Questionnaire

To study attitudes, beliefs and barriers to exercise

Quantitative

Questionnaire

Exercise is a low priority, worrying about injury, difficulty finding time for exercise. Fewer physically active individuals reported these than active individuals Exercise not high priority; weather; choices of exercise activities; health problems, work, disliking exercise, disliking sweating, too overweight to exercise Serious illness, changing job, having children, developing diabetes, moving house, starting first job, getting married, separating from partner, leaving home, lack of local facilities for exercise, lack of time, difficulty taking part in exercise, tiredness or depression, something good on television or other plans with friends, bad weather Disliking sweating, too overweight to exercise, no support from family to exercise, exercise ‘makes me feel uncomfortable’, afraid of low blood sugar reaction, exercise not important

Shultz Armstrong et al., 2001

USA

To study patients’ perceptions of barriers to exercise

Thomas et al., 2004

UK

Swift et al., 1995

USA

To measure adherence and barriers to complying with lifestyle recommendations among patients with high cardiovascular risk factors To describe physical activity barriers and support of patients at risk of type 2 diabetes

83 people with non-insulin-dependent diabetes

Data collection

Findings

E. E. Korkiakangas et al.

Table 2: Papers reviewing barriers to regular exercise among subjects either at high risk or already diagnosed with type 2 diabetes

White et al., 2007

Australia To examine why subjects do or do not engage in regular physical activity

Wanko et al., 2004

USA

To determine physical activity preferences and barriers to exercise in an urban diabetes clinic population

Dutton et al., 2005

USA

To study barriers to physical activity among predominantly low-income African-American patients with type 2 diabetes

Searle and Ready 1991

Canada

To determine what factors may inhibit participation in an exercise and weight control programme

192 adults diagnosed with type 2 diabetes and or cardiovascular disease, mean age 61 years, 67% diagnosed type 2 diabetes only, 7% diagnosed with cardiovascular disease only, 25% diagnoses with both 605 patients mean age 50 years, mean duration of diabetes ¼ 5.6 years

Questionnaire

Laziness, lack of time, feeling unwell, weather

Quantitative

Questionnaire

105 patient with type 2 diabetes mean age 53 years

Quantitative

Questionnaire

1000 randomly selected subjects with diabetes

Quantitative

Questionnaire

Pain, no willpower, insufficient health, not knowing what kind of exercise to do, no one to exercise with, no convenient or nearby place to exercise, nowhere safe to exercise, exercise not important Health problems and pain, lack of time, lack of social support, lack of child care, lack of access to exercise facilities or equipment, bad weather, lack of physician advice, special occasions Lack of energy, health problems, lack of time, lack of partner, lack of personal knowledge, too expensive, shyness, lack of transportation, no family support

Barriers to regular exercise

Quantitative

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Table 3: Barriers to exercise among adults either at high risk or already diagnosed with type 2 diabetes, presented by original expressions of results, both subcategories and main categories based on content analysis Previous results

Lack of time (work or home duties) Difficulty finding time for exercise Lack of time Unwillingness to exercise on clinic day because of long waiting periods at clinic Exercise is a low priority Exercise is not important Laziness Lack of motivation Activities and active respondents: short-term goals in exercising, ‘I do enough already’ No willpower Something good on television or other plans with friends Lack of energy Disliking exercise Disliking sweating Exercise ‘makes me feel uncomfortable’ Physical discomfort from exercise Too overweight to exercise Perceptions and experiences of disease Health problems Fear of hypoglycaemia Feeling unwell Pain Insufficient health Afraid of low blood sugar reaction Physical pain Coexisting disease Feeling unwell Depression Tiredness Too overweight to exercise Shyness Unwillingness to exercise with people who do not have type 2 diabetes Not wanting others to know how unfit they are Laziness Lack of motivation No willpower Serious illness, changing job, having children, developing diabetes, moving house, starting first job, getting married, separating from partner, leaving home Lack of child care Taking care of children/grandchildren Special occasions Social responsibilities Family affairs Difficulties at home Nowhere safe to exercise Poor street lighting Gang activity Fear and shame (not being familiar with their local neighbourhood and difficulties in speaking English) Worrying about injury Fear of hypoglycaemia

Subcategory

Lack of time

Subcategory

Exercise is not motivating

Main category Internal barriers

Exercise is not interesting

Exercise is uncomfortable Physical health

Health problems

Mental health Shame

Emotions

Feeling lazy Stressful life situation

Fears

Continued

Barriers to regular exercise

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Table 3: Continued Previous results

No support from family for exercise Lack of social support No one to exercise with Unwillingness to exercise with persons who do not have type 2 diabetes No knowing what type of exercise to do Lack of physician advice Lack of personal knowledge Leaders not informed Lack of convenient venue for exercise Choices of exercise activities Lack of local facilities for exercise Difficulty in taking part in exercise No convenient or nearby place to exercise Nowhere safe to exercise Lack of access to exercise facilities or equipment Environmental barriers such as traffic Lack of sidewalks Poor street lighting Gang activity Environmental barriers such as traffic Lack of facilities Lack of transportation Cost of transport Too expensive Lack of culturally sensitive facilities (in cases cultural taboos such as not being allowed to swim) Unwillingness to exercise on Thursdays because of church obligations Weather conditions Whether

uncomfortable (Swift et al., 1995; Shultz Armstrong et al., 2001; Mier et al., 2007). Difficult life situations also presented barriers to exercise (Searle and Ready 1991; Van Rooijen et al., 2002; Thomas et al., 2004; Dutton et al., 2005; Mier et al., 2007), and lack of time was a common excuse (Searle and Ready, 1991; Shultz Armstrong et al., 2001; Van Rooijen et al., 2002; Thomas et al., 2004; Dutton et al., 2005; Donahue et al., 2006; Lawton et al., 2006; White et al., 2007). Difficulties in finding time for exercising were due to work or home duties. External barriers included factors which are independent of an individual’s decision-making, such as weather (Shultz Armstrong et al., 2001; Thomas et al., 2004; Lawton et al., 2006; White et al., 2007; Mier et al., 2007; Serour et al., 2007) or cultural barriers (Van Rooijen et al., 2002; Lawton et al., 2006). These factors prevented exercising through, for instance, the lack of exercise facilities (Searle and Ready, 1991; Mier et al., 2007). Factors such as lack of social

Subcategory

Lack of prompting/ acceptance

Subcategory

Lack of social support

Main category External barriers

Lack of knowledge about exercising Poor local facilities for exercise

Lack of facilities for exercise

Unsafe local facilities for exercise Lack of transportation Costs Religious and cultural barriers

Cultural barriers

Weather

Weather

support (Searle and Ready, 1991; Dutton et al., 2005) also affect motivation to exercise.

DISCUSSION We evaluated in this review what is known about the barriers to regular exercise among individuals at high risk or already diagnosed with T2D. We identified two kinds of barriers to regular exercise: internal and external barriers. This systematic review shows that limited knowledge exists on the barriers to regular exercise among adults at high risk or already diagnosed with T2D. Exercise was not motivating because it was uncomfortable and involved sweating, and physical discomfort. The feeling of being too fat to exercise is a common barrier among overweight adults (Ball et al., 2000); adults of normal weight experience less barriers to exercise than overweight adults (Deforche et al., 2006). Greater weekly exercise and weight loss are significantly

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associated with fewer difficulties with exercise (Carels et al., 2005). Furthermore, physically active adults experience less barriers to exercise compared with those leading more sedentary lives (Kowal and Fortier 2007). Vandelanotte et al. (Vandelanotte et al., 2008) have considered that being overweight might be an extra motivator for changing health behaviours. Thus, obesity and overweight need to be taken into account in exercise counselling. Health problems included pain, insufficient health, depression and tiredness. Exercise, either alone, or combined with weight management may reduce self-reported depressive symptoms (Smith et al., 2007). Regular exercise helps increase the quality and amount of sleep (Verkasalo et al., 2005) and sufficient sleep improves weight control (Knutson et al., 2007), while short sleep duration is associated with overweight and obesity (Taheri et al., 2004; Gangwisch et al., 2005). Prioritizing physical activity, making time for exercise and lessening worry about injuries should be focused on in counselling (Donahue et al., 2006). In this way, counselling could succeed in increasing physical activity in sedentary individuals at high risk of T2D. Based on the results of this review, we suggest that both external and internal barriers to regular exercise are concrete challenges to the counselling of adults either at high risk or already diagnosed with T2D. The external barriers can be overcome through public knowledge of different facilities for exercise and by further developing the facilities. Information is often insufficient in order to motivate people to exercise, but is an essential part of the content of counselling. However, we suggest that the internal barriers may demand more individual counselling. It is possible that all individuals are not aware of the meaning of subjective barriers to motivation to exercise, or own level of exercise. The present review provided and suggested some content the exercise counselling among adults either at high risk or already diagnosed with T2D. The methods in the counselling should support motivation to exercise and at the same time help to recognize and evaluate one’s own behaviour. Adults need help to identify the barriers to regular exercise during counselling, followed by support to make decisions and plans to overcome the barriers and thus make changes to their own behaviour. Our review is the first of its kind to try and bring together the earlier knowledge-based

research on barriers to regular exercise among adults either at high risk or already diagnosed with T2D. Although we tried to widely search studies from different databases, some relevant studies in other databases or published in a language other than English may have been missed. The studies were executed mainly between 2004 and 2007. T2D has only been globally topical since the results of some prevention studies (Hu et al., 1999, 2001; Tuomilehto et al., 2001; Knowler et al., 2002; Kosaka et al., 2005; Laaksonen et al., 2005; Lindstro¨m et al., 2006) demonstrated that T2D can be prevented by lifestyle changes such as dietary habits and exercise. Thus, it is understandable that barriers to regular exercise among adults either at high risk of T2D or already diagnosed with T2D have only been studied since those studies for a few years. Limitations in inclusion and exclusion criteria are possible. Four reviewed qualitative studies were comprehensively executed and reported (Van Rooijen et al., 2002; Dye et al., 2003; Lawton et al., 2006; Mier et al., 2007). Qualitative data were based on interviews with different methods (Van Rooijen et al., 2002; Dye et al., 2003; Lawton et al., 2006; Mier et al., 2007). Interviewed individuals are not necessarily reflective of the entire adult population either at risk or already diagnosed with T2D. Although the generalizability of qualitative studies is limited, they provide valuable basic outcomes regarding barriers to exercise which are necessary in order to deepen further research and verify the barriers using statistical methods. The present paper reviewed nine quantitative studies, mostly variables and items for questionnaires, based on earlier literature and studies, and were at most pretested, or the content validity of the questionnaire ensured by a panel of experts (Searle and Ready, 1991; Thomas et al., 2004; Wanko et al., 2004; Dutton et al., 2005; Donahue et al., 2006; White et al., 2007). However, in order to make it possible to compare the results of studies on barriers to regular exercise between adults at high risk or already diagnosed with T2D, further research using repeatedly validated measures is needed. As a conclusion to this review, we suggest that it is important to help adults either at high risk or already diagnosed with T2D to identify the barriers to regular exercise and to learn how to solve these problems. In order to achieve

Barriers to regular exercise

this, we need to develop the content and methods of counselling. Further research is also important because of a need to intensify counselling and improve its effectiveness.

FUNDING This study was financially supported by the Academy of Finland (grant no: 118176 and grant no: 129248).

REFERENCES Albright, A., Franz, M., Hornsby, G., Kriska, A., Marrero, D., Ullrich, I. et al. (2000) Exercise and type 2 diabetes. Medicine and Science in Sport and Exercise, 32, 1345– 1360. Aljasem, L. I., Peyrot, M., Wissow, L. and Rubin, R. R. (2001) The impact of barriers and self-efficacy on selfcare behaviours in type 2 diabetes. The Diabetes Educator, 27, 393–404. Allender, S., Cowburn, G. and Foster, C. (2006) Understanding participation in sport and physical activity among children and adults: a review of qualitative studies. Health Education Research, 21, 826– 835. Ball, K., Crawford, D. and Owen, N. (2000) Too fat to exercise? Obesity as a barrier to physical activity. Australian and New Zealand Journal of Public Health, 24, 331– 333. Carels, R., Darby, L. A., Rydin, S., Douglass, O. M., Cacciapaglia, H. M. and O’Brien, W. H. (2005) The relationship between self-monitoring, outcome expectancies, difficulties with eating and exercise, and physical activity and weight loss treatment outcomes. Annual Behavioral Medicine, 30, 182–190. Carter-Nolan, P. L., Adams-Campbell, L. L. and Williams, J. (1996) Recruitment strategies for black women at risk for noninsulin-dependent diabetes mellitus into exercise protocols: A qualitative assessment. Journal of the National Medical Association, 88, 558–562. Cox, R. H., Carpenter, J. P., Bruce, F. A., Poole, K. P. and Gaylord, C. K. (2004) Characteristics of low-income African-American and Caucasian adults that are important in self-management of type 2 diabetes. Journal of Community Health, 29, 155– 170. Deforche, B. I., DeBourdeaudhuij, I. M. and Tanghe, A. P. (2006) Attitudes toward physical activity in normal weight, overweight and obese adolescents. Journal of Adolescents Health, 38, 560–568. Donahue, K. E., Mielenz, T. J., Sloane, P. D., Callahan, L. F. and Devellis, R. F. (2006) Identifying supports and barriers to physical activity in patients at risk for diabetes. Preventive Chronic Diseases, 3, 3 –12. Dutton, G. R., Johnson, J., Whitehead, D., Bodenlos, J. and Brantley, P. J. (2005) Barriers to physical activity among predominantly low-income African-American patients with type 2 diabetes. Diabetes Care, 28, 1209– 1210.

425

Dye, C. J., Haley-Zitlin, V. and Willioughby, D. (2003) Insights from older adults with type 2 diabetes: making dietary and exercise changes. The Diabetes Educator, 29, 116– 127. Elo, S. and Kynga¨s, H. (2008) The qualitative content analysis process. Journal of Advanced Nursing, 62, 107–115. Gangwisch, J. E., Malaspina, D., Boden-Alpala, B. and Heymsfield, S. B. (2005) Inadequate sleep as a risk factor for obesity: Analyses of the NHANES I. Sleep, 28, 1289–1296. Goodman, E. D. and Ballou, M. B. (2004) Perceived barriers and motivators to exercise in hemodialysis patients. Nephrology Nursing Journal, 31, 23–29. Glasgow, R. E., Hampson, S. E., Stryker, L. A. and Ruggiero, L. (1997) Personal-model beliefs and social-environmental barriers related to diabetes selfmanagement. Diabetes Care, 20, 556– 561. Graneheim, U. H. and Lundman, B. (2004) Qualitative content analysis in nursing research: concepts, procedures and measures to achieve trustworthiness. Nurse Education Today, 24, 105 –112. Hays, L. M. and Clarke, D. O. (1999) Correlates of physical activity in a sample of older adults with type 2 diabetes. Diabetes Care, 22, 706 –712. Hu, F. B., Sigal, R. J., Rich-Edwards, J., Coldit, G. A., Solomon, C. G., Willett, W. C. et al. (1999) Walking compared with vigorous physical activity and risk of type 2 diabetes in women: a prospective study. Journal of American medical Association, 282, 1433–1439. Hu, F. B., Manson, J. A., Stampfer, M. J., Colditz, G., Liu, S., Solomon, C. G. et al. (2001) Diet, lifestyle, and the risk of type 2 diabetes mellitus in women. The New England Journal of Medicine, 345, 790– 797. Kaewthummanukul, T., Brown, K., Weaver, M. T. and Thomas, R. R. (2006) Predictors of exercise participation in female hospital nurses. Journal of Advanced Nursing, 54, 663 –675. Kilpatrick, M., Hebert, E. and Bartholomew, J. (2005) College students‘ motivation for physical activity: differentiating men’s and women’s motives for sport participation and exercise. Journal of American College Health, 54, 87–94. Kirk, A. F., Barnett, J. and Mutrie, N. (2007) Physical activity consultation for people with type 2 diabetes. Evidence and guidelines. Review. Diabetic Medicine, 24, 809– 816. Knowler, W. C., Barrett-Connor, E. and Fowler, S. E. (2002) Reduction in the incidence of type 2 diabetes with lifestyle intervention or metformin. The New England Journal of Medicine, 346, 393– 403. Knutson, K. L., Spiegel, K., Penev, P. and Van Cauter, E. (2007) The metabolic consequences of sleep deprivation. Sleep Medicine Reviews, 11, 163–178. Koch, J. (2002) The role of exercise in the African-American woman with type 2 diabetes mellitus: applications of the health belief model. Journal of the American Academy of Nurse Practitioners, 14, 126–129. Kosaka, K., Noda, M. and Kuzuya, T. (2005) Prevention of type 2 diabetes by lifestyle intervention: a Japanese trial in IGT males. Diabetes Research and Clinical Practice, 67, 152 –162. Kowal, J. and Fortier, M. S. (2007) Physical activity behavior change in middle-aged and older women: the role of barriers and of environmental characteristics. Journal of Behavioral Medicine, 30, 233–242.

426

E. E. Korkiakangas et al.

Laaksonen, D., Lindstro¨m, J., Lakka, T., Eriksson, J., Niskanen, L., Wikstro¨m, K. et al. (2005) Physical activity in the prevention of type 2 diabetes. Diabetes, 54, 158 –165. Lawton, J., Ahmad, N., Hanna, L., Douglas, M. and Hallowel, N. (2006) I can’t do any serious exercise´: barriers to physical activity amongst people of Pakistani and Indian origin with Type 2 Diabetes. Health Education Reseaarc, 21, 43–54. Lee, L.-L., Avis, M. and Arthur, A. (2007) The role of self-efficacy in older people’s decision to initiate and maintain regular walking as exercise—findings from a qualitative study. Preventive Medicine, 45, 62–65. Lindstro¨m, J., Ilanne-Parikka, P. and Peltonen, M. (2006) Sustained reduction in the incidence of type 2 diabetes by lifestyle intervention: follow-up of the Finnish Diabetes Prevention Study. Lancet, 368, 1673–1679. Mier, N., Medina, A. and Ory, M. G. (2007) Mexican Americans with type 2 diabetes: perceptives on definitions, motivators, and programs of physical activity. Preventive Chronic Diseases, 4, 1– 8. Nagelkerk, J., Reick, K. and Meengs, L. (2006) Perceived barriers and effective strategies to diabetes selfmanagement. Journal of Advanced Nursing, 54, 151–158. Nygaard, I., Girts, T., Fultz, N. H., Kinchen, K., Pohl, G. and Sterfeld, B. (2005) Is urinary incontinence a barrier to exercise in women? Obsteterics and Gynecology, 106, 307 –314. Plonczynski, D. J. (2000) Measurement of motivation for exercise. Health Education Research, 15, 695– 705. Resnick, B. and Spellbring, A. M. (2000) Understanding what motivates older adults to exercise. Journal of Gerontological Nursing, 26, 34–42. Schneider, J. K., Eveker, A., Bronder, D. R., Meiner, S. E. and Binder, E. F. (2003) Exercise training program for older adults. Incentives and disincentives for participation. Journal of Gerontological Nursing, 29, 21– 31. Schutzer, K. A. and Graves, B. S. (2004) Barriers and motivations to exercise in older adults. Preventive Medicine, 39, 1056– 1061. Searle, M. S. and Ready, A. E. (1991) Survey of exercise and dietary knowledge and behaviour in persons with type 2 diabetes. Canadian Journal of Public Health, 82, 344 –348. Serour, M., Alqhenaei, H., Al-Saqabim, S., Mustafam, A.-R. and Ben-Nakhi, A. (2007) Cultural factors and patients’ adherence to lifestyle measures. British Journal of General Practice, 57, 291– 295. Shin, Y. H., Hur, H. K., Pender, N. J., Jang, H. J. and Kim, S. (2006) Exercise self-efficacy, exercise benefits and barriers, and commitment to a plan for exercise among Korean women with osteoporosis and osteoarthritis. International Journal of Nursing Studies, 4, 3 –10. Shultz Armstrong, J., Sprague, M. A., Branen, L. J. and Lambeth, S. (2001) A comparison of views of individuals with type 2 diabetes mellitus and diabetes educators about barriers to diet and exercise. Journal of Health Communication, 6, 99–115. Sit, C. H. P., Kerr, J. H. and Wong, I. T. F. (2008) Motives and barriers to physical activity participation in middle-aged Chinese woman. Psychology of Sport and Exercise, 9, 266– 283. Smith, P. J., Blumenthal, J. A., Babyak, M. A., Georgiades, A., Hinderliter, A. and Sherwood, A. (2007) Effects of exercise and weight loss on depressive

symptoms among men and women with hypertension. Journal of Psychosomatic Research, 63, 463– 469. Stutts, W. C. (2002) Physical activity determinants in adults. Perceived benefits, barriers, and self Efficacy. The American Association of Occupational Health Nurses, 50, 499–507. Swartz, A. M., Strath, S. J., Bassett, D. R., Moore, J. B., Redwine, B. A., Groer, M. et al. (2003) Increasing daily walking improves glucose tolerance in overweight women. Preventive Medicine, 37, 356–362. Swift, C. S., Armstrong, J. F., Beerman, K. A., Campbell, R. K. and Pond-Smith, D. (1995) Attitudes and beliefs about exercise among persons with non-insulin-dependent diabetes. The Diabetes Educator, 21, 533–540. Taheri, S., Lin, L., Austin, D., Young, T. and Mignot, E. (2004) Short sleep duration is associated with redused leptin, elevated ghrelin, and increased body mass index. PloS Medicine, 1, 210–217. Teixeira, P. J., Going, S. B., Cussler, E. C., Metcalfe, L. L., Blew, R. M., Sardinha, L. B. et al. (2006) Exercise motivation, eating, and body image variables as predictors of weight control. Medicine and Science in Sport and Exercise, 38, 179– 188. Thomas, N., Alder, A. and Leese, G. P. (2004) Barriers to physical activity in patients with diabetes. Postgraduate Medicine, 80, 287– 291. Thurston, M. and Green, K. (2004) Adherence to exercise in later life: how can exercise on prescription programmes be made more effective? Health Promotion International, 19, 379–387. Tuomilehto, J., Lindstro¨m, J., Eriksson, J. G., Valle, T. T., Ha¨ma¨la¨inen, H., Ilanne-Parikka, P. et al. (2001) Prevention of type 2 diabetes mellitus by changes in lifestyle among subjects with impaired glucose tolerance. The New England Journal of Medicine, 344, 1343– 1350. Vandelanotte, C., Reeves, M. M., Brug, J. and De Bourdeaudhuij, I. (2008) A randomized trial of sequential and simultaneous multiple behavior change interventions for physical activity and fat intake. Preventive Medicine, 46, 232– 237. Van Rooijen, A. J., Rheeder, P., Eales, C. J. and Molatoli, H. M. (2002) Barriers to and expectations of performing physical activity in female subjects with type 2 diabetes. South African Journal of Physiotherapy, 58, 3– 10. Verkasalo, P. K., Lillberg, K., Stevens, R. G., Hublin, C., Partinen, M., Koskenvuo, M. et al. (2005) Sleep duration and breast cancer: A prospective cohort study. Cancer Research, 65, 9595–9600. Wanko, N. S., Braxler, C. W., Young-Rogers, D., Dunbar, V. G., Boud, B., George, C. D. et al. (2004) Exercise preferences and barriers in urban African Americans with type 2 diabetes. The Diabetes Educator, 30, 502– 512. Wen, L. K., Shepherd, M. D. and Parchman, M. L. (2004) Family support, diet, and exercise among older Mexican Americans with type 2 diabetes. The Diabetes Educator, 30, 980– 993. White, K. M., Terry, D. J., Troup, C. and Rempel, L. A. (2007) Behavioral, normative and control beliefs underlying low-fat dietary and regular physical activity behaviours for adult diagnosed with type 2 diabetes and/or cardiovascular disease. Psychology, Health and Medicine, 12, 485– 494.

Barriers to regular exercise Wild, S., Roglic, G., Green, A., Sicree, R. and King, H. (2004) Global prevalence of diabetes. Diabetes Care, 27, 1047– 1053. Wilson, W., Ary, D. V., Biglan, A., Glasgow, R. E., Toobert, D. J. and Campbell, D. R. (1986) Psychosocial predictors of self-care behaviors, compliance and glycemic control in non-insulin-dependent diabetes mellitus. Diabetes Care, 9, 614–622.

427

Yamanouchi, K., Shinozaki, T., Chikada, K., Nishikawa, T., Ito, K., Shimizu, S. et al. (1995) Daily walking combined with diet therapy is a useful means for obese NIDDM patients not only to reduce body weight but also to improve insulin sensitivity. Diabetes Care, 18, 775– 778.