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Type 1 diabetes and physical activity: An assessment of knowledge and needs in healthcare practitioners

Camilla Knight
, Rob Lowe
, Michelle Edwards
, Jane Yardley
, Stephen Bain
, Richard Bracken

This study examined healthcare practitioners’ knowledge and confidence in providing physical activity guidance to people with type 1 diabetes. Data collection occurred in the form of a 23-question, open-ended survey and semi-structured interviews exploring practitioners’ knowledge regarding exercise and type 1 diabetes. Participants had rarely received formal training regarding physical activity for people with type 1 diabetes. They indicated limited knowledge of specific physical activity guidelines, either for the general population or for people with type 1 diabetes. However, participants reported feeling relatively confident in their ability to advise people with type 1 diabetes regarding physical activity. The disparity between practitioners’ knowledge and confidence in advising people with type 1 diabetes about physical activity raises concerns regarding the accuracy of the information being provided to individuals with the condition.

As exercise makes glucose control more difficult in people with type 1 diabetes, exercise avoidance and physical inactivity are common in this population (Plotnikoff et al, 2006). In spite of this, few studies have explored healthcare practitioners’ knowledge regarding physical activity and type 1 diabetes. Similarly, little is known about practitioners’ confidence in prescribing or advising physical activity, exercise and sport to people with the condition. Addressing such limitations is important to ensure that practitioners have a positive influence in the lives of individuals with type 1 diabetes.

The purpose of this study was to examine practitioners’ knowledge of physical activity in people with type 1 diabetes. Specifically, the study asked the following questions:

  1. What training do practitioners receive regarding physical activity and type 1 diabetes?
  2. How confident are practitioners in providing guidance on physical activity to people with this condition?

Method
Participants
In total, 51 healthcare practitioners (16 female and 35 male) were recruited and completed a questionnaire. Of the 51 participants, 23 were consultants, 10 were specialist registrars, five were GPs, three were CT2 doctors and 10 were health practitioner researchers and clinical fellows. Participants ranged in age from 28 to 72 years (mean, 42.7 years), and had an average of 11 years of experience working with individuals with type 1 diabetes (range, 4 months to 44 years). A total of 80 questionnaires were distributed to practitioners registered to attend two separate workshops pertaining to diabetes and exercise. Questionnaires were completed prior to workshop delivery.

An additional 13 practitioners completed semi-structured interviews. Of these 13 participants, six were consultants, four were DSNs, two were diabetes specialist dietitians and one was a podiatrist. The six consultants were all male and the other seven participants were female. They had been working specifically with people with diabetes for 7–37 years. They were recruited from specialist diabetes care units at two hospitals in Wales. To be selected for interview, participants were required to be regularly working in a specialist diabetes care unit. Further participant details are provided in Table 1.

Questionnaire
Following the study’s institutional approval, the survey was distributed to the participants. It comprised questions covering demographic and education information (e.g. age, position, years working with diabetes populations and qualifications); training regarding physical activity and type 1 diabetes (e.g. education within university degree, attendance at additional courses); knowledge of physical activity guidelines for individuals with type 1 diabetes (e.g. what are the general physical activity guidelines for individuals with type 1 diabetes, what are the specific guidelines pertaining to endurance or strength work); practitioners’ confidence in providing specific guidance regarding physical activity to people with type 1 diabetes; and suggestions for material or information needed to support practitioners in giving guidance to individuals with type 1 diabetes. All questions were open-ended, apart from the questions regarding confidence, which asked practitioners to rate on a scale (see Figure 1).

The data obtained from the questionnaires were assessed using content analysis (Sparkes and Smith, 2014), to allow for identification of common responses (participants’ knowledge and attitudes) across the sample. Confidence data were recorded using a scale of 1–10 (1=lowest, 10=highest), and comparisons of participants’ training and knowledge were made.

Semi-structured interviews
Following analysis of the survey data, it was decided that additional information for healthcare professionals working solely with individuals with diabetes would be beneficial to place the data from the questionnaires in context. Thus, a research assistant with extensive experience in qualitative research conducted semi-structured interviews with practitioners working within specialist diabetes units. The main interview questions focussed on practitioners’ knowledge of physical activity guidelines for people with type 1 diabetes; barriers to their knowledge and its application; and issues encountered when trying to encourage physical activity participation in people with type 1 diabetes. Content analysis was also used to assess the interviews. Raw data themes, lower-order themes and higher-order themes were identified. Themes were then placed into a data matrix to allow comparison across participants (Miles and Huberman, 1994). A copy of the interview guide can be obtained from the first author at: c.j.knight@swansea.ac.uk.

Results
Survey results
Education
Of the 51 participants, only 15 (29%) had received any physical activity or exercise education through their formal training. Of these, the majority (21% of the overall cohort) received a small number of exercise physiology lectures, albeit not specific to exercise and type 1 diabetes.

Over 50% of participants had gained some specific information regarding physical activity and type 1 diabetes by completing continuing professional development courses. For example, 40% had attended a DAFNE (Dose Adjustment for Normal Eating) course and 38% had attended single or multiple conference events. However, when asked to recall the information covered in the DAFNE course or lectures, only seven participants could provide any detail on the information covered.

Knowledge
In response to being asked to recall their knowledge of the specific physical activity guidelines for type 1 diabetes, 10 participants made reference to an awareness of NICE or Diabetes UK guidelines. However, only five of these participants could accurately recall the guidelines’ details. Five participants recalled the general physical activity guidelines for adults and another two recalled them incorrectly. Most participants (34 people [66%]) were not aware of any guidelines pertaining to physical activity for individuals with type 1 diabetes.

Confidence
Participants were asked to indicate, on a scale of 1–10, their confidence to provide either general advice on physical activity or specific advice (e.g. weight training versus endurance training) to individuals with type 1 diabetes. For the most part, participants scored their confidence for general guidance more highly than for specific guidance. Participants who rated themselves at the lower end of the scale shared insights such as, “I am quite confident I know nothing about it!” and “Don’t feel I can ever give good advice on this.” In contrast, participants who scored themselves more highly reported that, “I have learnt from experience” and “I have read a lot and committed to learning.” Interestingly, 11 of the 34 practitioners who were unable to accurately recall the physical activity guidelines for type 1 diabetes ranked themselves as quite (6–7) or very (8–10) confident in providing general physical activity advice to individuals with type 1 diabetes.

Barriers to knowledge
Finally, participants were asked to identify what barriers they encountered in providing physical activity guidance to people with type 1 diabetes. The most common response (57% of participants) was a lack of knowledge and unclear guidelines from which to draw recommendations. Following this, participants cited a lack of time in consultations (16%), followed by funding issues (8%) as the main barriers. Funding issues were highlighted by consultants, who perceived that insufficient money was made available to produce education materials or upskill practitioners. To overcome such barriers, participants indicated that easily accessible, online material highlighting key physical activity considerations for individuals with type 1 diabetes would be beneficial. Additionally, participants desired information that could be shared directly with patients.

Interview results
Training and knowledge
The participants unanimously agreed that they had insufficient training regarding type 1 diabetes and physical activity, exercise and sport. In fact, when reviewing their training, none of the practitioners had received any specific information. As participant 1, a consultant, illustrated:

“I don’t. I cannot recall ever having any specific training in type 1 diabetes and exercise whilst training.”

Some practitioners had received training from pharmaceutical companies regarding insulin pumps in sport or physical activity. Others had attended sessions at conferences or worked closely with researchers in this area to extend their knowledge. However, the practitioners perceived that much more extensive training on this topic was required.

Confidence and application of knowledge
All 13 practitioners perceived that additional training, guidance and support were needed to ensure that appropriate information and suggestions were given to people with type 1 diabetes. Despite working with such individuals on a daily basis, practitioners lacked confidence in making suggestions regarding engagement in physical activity and, particularly, sport. Participant 13, a DSN, shared the views of many when she said:

“Because there isn’t anything formalised around exercise or activity, I think that can hold us back as well, because you haven’t got the confidence to relay that over to a patient, you know, when they are trying to discuss things with you. It’s like, if you don’t feel confident about what you are talking about, you tend to shy away from it.”

Practitioners were most concerned about the potential impact of providing incorrect information to their patients. They also explained that people with type 1 diabetes were hesitant to engage in physical activity and sport due to concerns over negative consequences. As participant 2, a consultant, said:

“The thing that is a worry for the patients will be that there have been two major complications with exercise. One is hypoglycaemia and the other one ketoacidosis.”

Given their patients’ fears, practitioners were aware that they needed to provide accurate and appropriate information.

Practitioners indicated that much of the guidance they provided was based on experiences with other patients, who were successfully managing their diabetes when engaging in sport or physical activity. They perceived that such experiences allowed them to pass on general information to patients. However, even though practitioners learned from other patients or from research or conferences, they explained that few patients participated in sport or asked questions about sport or physical activity, and as such they often were unable to recall any specific guidance.

Improving knowledge and advice
All practitioners were in favour of more training, information and support regarding physical activity and sport participation for people with type 1 diabetes. Based on their experiences with the people they see, they provided suggestions around research and knowledge dissemination, their own training, the production of patient information and guidelines, and the use of role models and expert groups. These suggestions are discussed here.

Research and dissemination. The participants perceived that there was insufficient research about physical activity and sport participation for people with type 1 diabetes. As one of the consultants, participant 3, explained:

“It’s not a huge thing, exercise in type 1 diabetes doesn’t feature enormously in diabetic meetings and diabetic journals it has to be said, so it would be useful if there was a bit more of it [research].”

Participants perceived that a more extensive research base would be beneficial in the production of information both for them and for patients. However, they cautioned against using “atypical” patients in research, which might prevent its translation to a broader population. Furthermore, the participants highlighted the importance of considering the range of individuals with type 1 diabetes (e.g. young people, older adults, those with and without health complications and comorbidities) and the range of physical activity and exercise types (e.g. competitive sport, leisure activities) in research. In addition to conducting more studies, the participants also indicated that researchers need to ensure that research dissemination includes clear, applicable suggestions that could be easily used by practitioners working in time- and finance-constrained environments.

Practitioner training and knowledge. The practitioners unanimously believed that they would benefit from continuing upskilling in this area. One consultant, participant 2, explained:

“I think we could do with more courses more periodically because we do tend to, in time, lose our skills; as in refresher courses would be helpful for our people with diabetes, but continuing practice does also help.”

Various suggestions were provided regarding how such training could occur, with another consultant, participant 4, suggesting:

“I think it would be useful to have a modular course, a proper course, you know, which you can keep in touch with regularly and be made part of the regular curriculum for trainees.”

The general consensus was that training and information were necessary to ensure practitioner confidence in providing advice to patients and allow subsequent proactive discussion of this subject rather than relying on patients to raise the issue. In addition to specific training and knowledge updates, practitioners highlighted that clear, accessible (preferably online) guidelines, which they could refer to during consultations, were necessary. Furthermore, practitioners wanted guidelines to address the different types of individuals and issues that might be encountered.

Patients’ knowledge and guidelines. All practitioners expressed that it was the individuals with diabetes who were the experts of their own body and their experiences of sport and physical activity. As such, the individuals should take the lead in managing their diabetes. Ensuring that they had access to patient-friendly guidelines and monitoring mechanisms was perceived to be very important because, as one of the dietitians (participant 12) stated:

“It is their condition and we give them as much knowledge as we can, to empower them to look after their condition then.”

The practitioners indicated that there were some very broad, patient-accessible guidelines available on the Diabetes UK website but that, for most people, knowledge was acquired through trial and error. Participant 10, a DSN, said:

“Sometimes it is literally a case of try and see, and somebody does exercise and you’ve had a discussion [but] they still have a hypo and they’re disappointed. You just got to encourage them to keep going back.”

Consequently, more specific and consistent guidance was desired that people with diabetes themselves could use. Additionally, practitioners suggested that an online insulin and glucose monitoring tool or app, in which people with diabetes could store information to share with their practitioners, would be beneficial in ensuring safe exercise participation.

Role models and expert patients. Finally, the practitioners indicated that they used stories of successful sport role models to inspire and educate their patients. This was something one of the consultants, participant 2, did frequently:

“I’ve had people who have done mountain cycling for long distances, we’ve one that’s been a swimmer and I think we’ve got famous names as well who have achieved a lot with diabetes. So there is a lot of it around, but I think we just need to show them that it’s plausible.”

Practitioners indicated that access to stories and examples of successful individuals with type 1 diabetes would be useful to overcome patients’ fears. Furthermore, practitioners perceived that, if people were able to contact such individuals for direct guidance on how to successfully manage their diabetes while training and competing, it would be beneficial. Practitioners learnt from their patients and they felt that such learning should be expanded to others. Suggestions for clinical champions who could provide direct support and guidance in the areas of exercise and type 1 diabetes were also recommended.

Discussion
The need for more information, resources and training was a common theme throughout the survey and interviews. This is consistent with another observational study of healthcare providers working with people with chronic conditions (Joyce and O’Tuathaigh, 2014). It is also in line with recent examinations of medical education in both the UK (Weiler et al, 2012) and the US (Cardinal et al, 2015), where an overall lack of training related to physical activity has been acknowledged. Where exercise has emerged as a means of treatment, if not primary prevention, for several chronic conditions, it is evident that practitioners need to be better equipped and willing to prescribe exercise with the same regularity and detail as pharmaceutical options (Nunan, 2016).

In addition to providing more information on physical activity and type 1 diabetes during medical training and ongoing education, approaches that have been successful in improving practitioner and patient knowledge around physical activity can be considered. For example, a Canadian programme developed by exercise specialists for diabetes educators was shown to improve the educators’ confidence in providing physical activity and exercise advice to people with type 2 diabetes (Shields et al, 2013). Future programmes such as JDRF’s PEAK (Performance in Exercise and Knowledge) programme, a comprehensive 1-day programme on the management of physical activity in people with type 1 diabetes announced in late 2015 (available at: www.jdrf.org/peak), might fill gaps in both patients’ and healthcare providers’ tools and knowledge. Alternatively, it has been suggested that the inclusion of exercise specialists in primary care and national exercise referral schemes could assist in improving knowledge in both patients and practitioners (Cheema et al, 2014; Johnson et al, 2015).

Participants also expressed a need for people to take more ownership on exploring the impact of physical activity on their blood glucose levels. This might be achieved by the use of secure data repositories of individuals’ glucose information that are accessible to healthcare providers. Furthermore, new online tools and apps (e.g. Glooko, mySugr), and peer support forums (e.g. the Sporty Diabetic Type 1s Facebook group, Runsweet.com) show the growth of patient-driven education and an increase in the collaborative approach to management.

Study limitations
These findings and conclusions must be considered in line with the limitations of the study. Specifically, data were obtained from a small number of individuals from one geographic area in Wales. Further research outlining the experiences of healthcare professionals working in different locations would be beneficial to extend knowledge in this area.

Additionally, to encourage completion of the questionnaire, we decided to limit the number of questions. As such, the depth of information obtained during the first stage of data collection was somewhat restricted. Gaining more detailed insights from the broad range of practitioners included in stage one is an important next step to extend this research area.

Conclusion
These data indicate that a disparity exists between practitioners’ training, knowledge and confidence in advising people with type 1 diabetes about physical activity. This raises concerns regarding the accuracy of the information being provided to these individuals. The findings suggest the need for more productive relationships with allied professionals whose knowledge base might close the gap between healthcare providers directly involved in diabetes care and existing physical activity tools, structures and information.

REFERENCES:

Cardinal BJ, Park EA, Kim M, Cardinal MK (2015) If exercise is medicine, where is exercise in medicine? Review of U.S. medical education curricula for physical activity-related content. J Phys Act Health 12: 1336–43
Cheema BS, Robergs RA, Askew CD (2014) Exercise physiologists emerge as allied healthcare professionals in the era of non-communicable disease pandemics: a report from Australia, 2006–2012. Sports Med 44: 869–77
Johnson ST, Mundt C, Qiu W et al (2015) Increase in daily steps after an exercise specialist led lifestyle intervention for adults with type 2 diabetes in primary care: a controlled implementation trial. J Phys Act Health 12: 1492–9
Joyce CL, O’Tuathaigh CM (2014) Increased training of general practitioners in Ireland may increase the frequency of exercise counselling in patients with chronic illness: a cross-sectional study. Eur J Gen Pract 20: 314–9
Miles MB, Huberman AM (1994) Qualitative Data Analysis: An Expanded Sourcebook (2nd edition). Sage Publications, London
Nunan D (2016) Doctors should be able to prescribe exercise like a drug. BMJ 353: i2468
Plotnikoff RC, Taylor LM, Wilson PM et al (2006) Factors associated with physical activity in Canadian adults with diabetes. Med Sci Sports Exerc 38: 1526–34
Shields CA, Fowles JR, Dunbar P et al (2013) Increasing diabetes educators’ confidence in physical activity and exercise counselling: the effectiveness of the “physical activity and exercise toolkit” training intervention. Can J Diabetes 37: 381–7
Sparkes AC, Smith B (2014) Qualitative Research Methods in Sport, Exercise, and Health: From Process to Product. Routledge, Abingdon
Weiler R, Chew S, Coombs N et al (2012) Physical activity education in the undergraduate curricula of all UK medical schools: are tomorrow’s doctors equipped to follow clinical guidelines? Br J Sports Med 46: 1024–6

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