Can J Diabetes 37 (2013) 367e374

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Canadian Journal of Diabetes journal homepage: www.canadianjournalofdiabetes.com

Original Research

Exercise Facilitators and Barriers from Adoption to Maintenance in the Diabetes Aerobic and Resistance Exercise Trial Heather Tulloch PhD CPsych a, *, Shane N. Sweet PhD b, Michelle Fortier PhD b, c, Gary Capstick PhD b, Glen P. Kenny PhD c, Ronal J. Sigal MD, MPH d a

University of Ottawa Heart Institute, Prevention and Rehabilitation Centre, Ottawa, Ontario, Canada School of Psychology, University of Ottawa, Ottawa, Ontario, Canada c School of Human Kinetics, University of Ottawa, Ottawa, Ontario, Canada d Departments of Medicine, Cardiac Sciences, and Community Health Sciences, Faculties of Medicine and Kinesiology, University of Calgary, Calgary, Alberta, Canada b

a r t i c l e i n f o

a b s t r a c t

Article history: Received 22 March 2013 Received in revised form 30 May 2013 Accepted 9 September 2013

Objective: We conducted a qualitative investigation of patients with type 2 diabetes to determine their perceived facilitators and barriers to exercise at multiple time points while enrolled in a randomized exercise trial including aerobic, resistance or combined exercise. We explored differences in these themes over time, between intervention groups and by adherence level after intervention. Methods: Interviews were conducted by telephone at 3 weeks (run-in period), and at 3 (midintervention), 6 (end of intervention) and 9 months (maintenance) after enrollment to assess factors that facilitated and hampered adherence to the exercise program. Audiotapes were transcribed verbatim and subjected to content analysis. Results: Participants (n¼28) with type 2 diabetes engaged in the interviews. Social support from family and the trainer, future health benefits, a sense of well-being and perceived fitness improvements were exercise facilitators. Experiencing illness or injury, work commitments and inclement weather were highlighted barriers. A sense of well-being, fitness improvements and enjoyment frequently were expressed by participants assigned to the combined and resistance exercise conditions. Participants who maintained prescribed exercise levels tended to be engaged in resistance exercise, and spoke of support from their personal trainers, the importance of strategies and enjoyment more frequently than those who did not maintain their exercise level. Exercise maintainers also cited more facilitators; no differences were found for barriers. Conclusions: Patients with type 2 diabetes require social support, including continued contact with exercise specialists. Patients need assistance with motivational enhancement and strategies to increase facilitators to maintain exercise behaviour. Incorporating resistance exercise improves well-being and enjoymentd2 important factors linked to exercise maintenance. Ó 2013 Canadian Diabetes Association

Keywords: barriers diabetes exercise facilitators maintenance

r é s u m é Mots clés : obstacles diabète exercice facilitateurs maintien

Objectif : Nous avons mené une étude qualitative sur la perception des facilitateurs et des obstacles à l’exercice à divers moments déterminés chez des patients ayant le diabète de type 2 qui participaient à un essai aléatoire sur l’exercice incluant l’exercice aérobique, l’exercice contre résistance ou l’exercice combiné. Nous avons étudié les différences de ces volets au cours du temps, entre les groupes d’intervention et par niveau d’observance après l’intervention. Méthodes : Les entrevues ont été réalisées par téléphone à 3 semaines (période de rodage), à 3 mois (mi-intervention), à 6 mois (fin de l’intervention) et à 9 mois (maintien) après le début de leur participation pour évaluer les facteurs qui ont facilité et nui à l’observance du programme d’exercices. Les bandes magnétiques audio ont été transcrites textuellement et ont fait l’objet d’une analyse de contenu. Résultats : Les participants (N ¼ 28) ayant le diabète de type 2 ont pris part aux entrevues. Le soutien social de la famille et l’entraîneur, les effets positifs sur la santé future, le sentiment de bien-être et la perception d’amélioration de la condition physique ont été des facilitateurs de l’exercice. L’expérience de

* Address for correspondence: Heather Tulloch, PhD, CPsych, Prevention and Rehabilitation Centre, University of Ottawa Heart Institute, 40 Ruskin Street, Ottawa, Ontario K1Y 4W7, Canada. E-mail address: [email protected]. 1499-2671/$ e see front matter Ó 2013 Canadian Diabetes Association http://dx.doi.org/10.1016/j.jcjd.2013.09.002

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la maladie ou de blessures, les engagements professionnels et la météo défavorable ont été des obstacles. Le sentiment de bien-être, les améliorations de la condition physique et le plaisir ont fréquemment été exprimés par les participants assignés à des conditions d’exercice combiné et contre résistance. Les participants qui ont maintenu les niveaux de prescription d’exercice ont eu tendance à participer à l’exercice contre résistance, ont parlé du soutien de leurs entraîneurs personnels, de l’importance des stratégies et du plaisir plus fréquemment que ceux qui n’ont pas maintenu leur niveau d’exercice. Les participants qui ont maintenu l’exercice ont également cité plus de facilitateurs; aucune différence sur le plan des obstacles n’a été observée. Conclusions : Les patients ayant le diabète de type 2 ont besoin de soutien social qui inclut un contact continu avec des spécialistes de l’exercice. Les patients ont besoin d’aide pour le renforcement de leur motivation et de stratégies pour augmenter le nombre de facilitateurs du maintien des comportements liés à l’exercice. L’intégration de l’exercice contre résistance améliore le bien-être et le plaisir d 2 facteurs importants liés au maintien de l’exercice. Ó 2013 Canadian Diabetes Association

Introduction Diabetes has become a highly prevalent disease in North America, and patients with type 2 diabetes account for 90% of the cases (1,2). Exercise provides physical and psychological health benefits for individuals with type 2 diabetes (3,4), but many patients are insufficiently active to gain these benefits. In fact, a recent Canadian population-based study found that 60% to 74% of adults with type 2 diabetes did not achieve recommended levels of physical activity (5). Furthermore, when inactive people start to exercise, it often is short lived, with activity levels reverting back to previously sedentary levels within 1 year. As noted in a recent systematic review of behaviour-change maintenance, only 4 of 15 studies reported significant differences on exercise behaviour between the intervention and control groups at 3 months or more after intervention (6). An increased understanding of the factors involved in the adoption and maintenance of exercise in this population is warranted. To date, the majority of exercise determinants research has been conducted with healthy adults, and only recently have researchers focused on the predictors of exercise in patients with type 2 diabetes (7e9). In brief, positive correlates of exercise in this population include younger age, male sex, being single, higher income, shorter duration since a diagnosis of diabetes, higher education, self-efficacy, autonomous motivation and social and environmental support. However, we do not know whether the factors that impact behavioural adoption differ from those that influence behavioural maintenance. Indeed, a pivotal article (10) published more than a decade ago pointed out our lack of understanding in this area and, unfortunately, little progress has been made since then (6). Of the studies that have investigated both phases in the same trial, different determinants for exercise adoption than for maintenance were identified (11,12). For example, access to exercise equipment predicted initiation, whereas self-efficacy and satisfaction predicted maintenance. To our knowledge, no study has examined factors related to exercise adoption and maintenance in patients with type 2 diabetes. Identifying exercise determinants at different time points (i.e. during and after intervention), may provide new information about which factors are most influential across time. As a result, more effective interventions could be designed to support these patients in their diabetes management. Traditionally, aerobic exercise has been promoted to manage type 2 diabetes, and good evidence to support the inclusion of resistance exercise has appeared only in the past decade. Our Diabetes and Aerobic and Resistance Exercise (DARE) trial (3) was the first adequately powered trial to examine the effects of aerobic exercise training, resistance exercise training and their combination on glycemic control in previously inactive individuals with type 2 diabetes. We found that both aerobic and resistance exercise training reduced glycated hemoglobin (A1C) levels significantly,

and their combination was superior to either type of exercise training alone. Although evidence now exists to support resistance exercise in this population, this modality may present new challenges for patients with type 2 diabetes or, alternatively, enhance their commitment or ability to exercise. Researchers have speculated that barriers to resistance exercise may include the fear of injury, low self-efficacy of an unfamiliar mode of exercise and the assumption that exercise will increase muscle mass and weight gain (13). In contrast, Hill et al (13) also suggest that resistance training may lead to fewer barriers to exercise for obese people with type 2 diabetes. Only 1 study has explored these possibilities (14). When interviewed 8 months after intervention completion, exercise participants (n¼24) noted feeling overwhelmed with the initial challenges of exercise, and that affordable gym memberships and access to personal trainers would have made it easier for them to continue exercising. Because this intervention included resistance training only, an examination of the differences in barriers and facilitators between the exercise modalities was impossible. More research is needed to understand the unique challenges, supports and needs of patients with type 2 diabetes engaging in various modes of exercise. In summary, no study to date has conducted an investigation of exercise determinants in patients with type 2 diabetes at multiple points during (adoption) and after their involvement in a structured, supervised exercise program (maintenance) incorporating more than one exercise modality. Therefore, we do not know what specific factors are involved in each phase, and if these differ by type of exercise. Given this gap, a qualitative exploration was undertaken with a subgroup of participants from the DARE trial (3). Interviewing exercise participants from a trial, such as DARE, ensured experience with exercise for a minimum of 6 months, as well as follow-up evaluation in the maintenance phase. In addition, 3 exercise conditions (i.e. aerobic only, resistance only and combined) were included, allowing for an exploration of facilitators and barriers between groups. Finally, as the DARE exercise program is now recommended by the Canadian Diabetes Association, the American Diabetes Association, and the American College of Sports Medicine, it is imperative that we understand participants’ perceived facilitators and barriers to this specific exercise trial. Patients and Methods Participants Previously inactive individuals with type 2 diabetes, aged 39 to 70 years, were recruited from advertising, physicians and wordof-mouth to participate in the DARE trial. Inclusion criteria included a diagnosis of type 2 diabetes for at least 6 months, and baseline hemoglobin A1C values of 6.6% to 9.9%. Exclusion criteria included current insulin therapy, participation in exercise 2 or more times

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per week for at least 20 minutes per session or any resistance training during the previous 6 months; changes in oral hypoglycemic, antihypertensive, or lipid-lowering agents or body weight change (5%) during the previous 2 months; serum creatinine level of 200 mEq/L or higher; proteinuria more than 1 g/24 hours; blood pressure higher than 160/95 mm Hg; restrictions in physical activity because of disease or other medical conditions making participation inadvisable (e.g. unstable cardiac or pulmonary disease, disabling stroke or severe arthritis). At the time of enrollment in the DARE trial, participants were invited to engage in personal interviews aimed at better understanding factors that influence exercise behaviour. Enrollment was ongoing until we reached saturation in the data; that is, no additional themes/topic areas were beginning to arise. Participants included in the analyses were those who completed at least 3 of 4 possible interviews to ensure that responses were captured during both the adoption and maintenance phases. Because we were interested in exercise facilitators and barriers during the adoption and maintenance phases, individuals randomized to the control group (i.e. sedentary group) were not eligible for this qualitative study. Exercise intervention The DARE study was a single-centre, randomized controlled trial with a parallel-group design. After a 4-week run-in period to assess compliance, previously inactive participants were randomized to 1 of 4 groups: aerobic exercise training, resistance exercise training, combined aerobic and resistance exercise training or a control group (i.e. participants reverted to pre-run-in sedentary levels). The 6-month exercise intervention took place at community-based exercise facilities. Participants exercised 3 times per week, and progressed gradually in duration and intensity. The aerobic group exercised on treadmills or bicycle ergometers. The resistance group performed 7 exercises on weight machines each session. The combined group performed the full aerobic and resistance training programs. Personal trainers provided exercise supervision (e.g. instruction on exercise mechanics and target heart rate and monitored progression of exercise intensity and duration) weekly for the first 4 weeks after randomization, every 2 weeks for the subsequent 2 months and monthly for the remainder of the program. Upon completion of the 6-month intervention, participants were asked to continue to exercise independently for 6 months (i.e. maintenance phase); free gym memberships were provided for the 6 months after the end of the intervention period. Attendance was monitored through direct observation by trainers, exercise logs and electronic scanning of membership cards at the facility. Further details of the exercise intervention may be found in the primary article (3). Interview protocol One-on-one interviews (w20 minutes) were conducted by telephone at 3 weeks (run-in phase), and at 3 (midintervention), 6 (end of intervention) and 9 (3 months after intervention) months after enrollment in the trial. The semistructured interview guide was based on previous research on exercise determinants and motivational theories (e.g. social-cognitive and self-determination theories) used to understand health behaviour change, including exercise (15,16). Participants responded to 13 to 17 questions, depending on the time point, such as “What do you expect to get out of this study? What outcomes are most important for you?” “What motivates you to go to the gym?” and “Were there weeks that were more difficult? If so, could you tell me why?” The interviewer, a graduate student in psychology, prompted the participant for further clarification and exploration of responses

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(e.g. “What did you mean by that?” and “Please tell me more”). Protocols for the clinical trial and qualitative study were approved by the Ottawa Hospital Research Ethics Board, and all participants provided informed consent. Interview data analysis Audiotaped interviews were transcribed verbatim and subjected to content analysis (17) using NVivo Software (Burlington, MA). Via inductive and deductive means, the interviews were analyzed for recurring meaningful units (e.g. codes). Previous research and existing theory helped determine the initial coding scheme (e.g. social and trainer support, motivation to exercise, perceived barriers and facilitators) and deduction was used to code the response content. An inductive approach was used for emerging subthemes; each of these was discussed by the research team until a consensus was reached. Responses then were coded by 2 independent researchers. Inter-rater reliability was high (>0.80). As noted, any discrepant items were discussed and resolved by consensus. The number and percentage of participants endorsing the themes are reported, and qualitative examples are provided with pseudonyms to protect patient confidentiality. At the 9-month interview, participants who maintained their activity were classified as “maintainers,” whereas those whose level of activity decreased to less than recommended levels were “decreasers.” Responses regarding exercise facilitators and barriers were explored over time, between the intervention groups and by exercise adherence level (i.e. maintainers/decreasers). Results Fifty-four participants from the DARE trial were approached to participate in the qualitative study; all participants approached agreed to participate in the interviews. Of those, 11 people were allocated to the control condition, 10 withdrew from the DARE trial and 5 were lost because of technical difficulties (i.e. recording equipment malfunction). These individuals were not included in the analyses. The final sample consisted of 28 participants. Data were unavailable for 3 and 2 participants at the 3-week and 3month interviews, respectively, because technical difficulties and loss to follow-up evaluation (i.e. patient was unavailable during the data collection window). Therefore, the sample size at each time point was as follows: 25, 26, 28 and 28 for the 3-week and 3-, 6- and 9-month time-points, respectively. Participants were mainly men (71%), with a mean age of 55.7 years. The mean body mass index was 35.0 kg/m2 and the mean time since their diabetes diagnosis was 5.4 years. Our sample was representative of the overall DARE sample (p75%) for the exercise program across the time points. During exercise adoption, participants spoke about the positive reinforcement, encouragement and genuine happiness from family members that they were exercising and taking care of their health.

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Table 1 Perceived exercise facilitators by exercise group assignment Perceived facilitators

3 weeks, n (%) (n¼25)

3 months, n (%) (n¼26)

6 months, n (%) (n¼28)

9 months, n (%) (n¼28)

Future health benefits Resistance Aerobic Combined Social support: family Resistance Aerobic Combined Sense of well-being Resistance Aerobic Combined Fitness improvements Resistance Aerobic Combined Personal trainer Resistance Aerobic Combined Enjoyment Resistance Aerobic Combined Weight loss Resistance Aerobic Combined Diabetes improvement Resistance Aerobic Combined

25 10 6 9 23 9 6 6 22 9 5 7 20 9 5 6 16 6 4 6 8 2 3 3 5 2 3 0 3 0 0 0

14 5 5 4 24 10 5 9 19 6 4 9 13 5 1 7 20 9 4 7 10 5 1 4 4 1 1 2 6 2 2 2

21 (75) 9 (90) 5 (83) 7 (78) 22 (79) 10 (91) 4 (67) 8 (73) 23 (82) 10 (100) 3 (50) 10 (91) 28 (100) 11 (100) 6 (100) 11 (100) 17 (63) 6 (60) 3 (43) 8 (80) 8 (29) 4 (36) 1 (17) 3 (27) 11(39) 4 (36) 1 (17) 6 (55) 15 (54) 6 (55) 4 (67) 7 (64)

18 8 2 7 22 8 5 9 15 7 1 7 16 7 3 6 10 4 3 3 11 7 3 2 5 1 1 3 9 3 2 4

(100) (100) (100) (100) (92) (90) (100) (67) (88) (90) (83) (78) (80) (90) (83) (67) (64) (60) (67) (67) (32) (20) (50) (33) (20) (20) (50) (0) (12) (0) (0) (0)

(54) (50) (83) (44) (92) (100) (83) (90) (73) (60) (67) (100) (50) (50) (17) (70) (77) (90) (67) (70) (38) (50) (17) (40) (15) (10) (17) (20) (23) (20) (33) (20)

They reported that family members were interested in their progress and noticed improvements in mood and fitness. As a result, family members made efforts to reduce barriers for participation, and even accompanied them to the gym. Example statements included: “My wife is so delighted I’m doing this program that she’s basically making sure that nothing interferes with the program from her side” (John, 3 weeks), and “My family is very supportive [they have] taken it up, everyone is signed up at the Y.we are all doing it together” (Shirley, 3 months). The positive influence of family members remained strong at 6 and 9 months, albeit with slightly diminished enthusiasm. Enlisting the support of family members was one theme identified to help participants maintain their activity levels, “I get my husband to drag me out of bed in the morning. It’s helped that he’s going with me, so it’s like a combined effort” (Frances, 9 months). The possibility of obtaining health benefits in the future was a powerful facilitator of exercise initiationdall participants noted the hope for better health through exercise at 3 weeks. Participants spoke of their expectations of weight loss, improved strength and muscle tone and better management of sugar levels and blood pressure. This factor decreased somewhat over time but still remained important for up to two-thirds of participants in the maintenance phase. During the maintenance interview, patients reported increased motivation to continue exercising after receiving positive results from their 6-month assessments. Responses included, “It’s the end result that I’m looking for that motivates me to go. I don’t go because I enjoy going to the gym, I go because of the results it will give me, from a health point of view” (Alfred, 6 months), and “that’s why I go.hopefully the reduced sugar level when I measure it and I know it’s healthy” (Dale, 9 months). Another facilitator that played a role in both exercise adoption and maintenance was a general sense of well-being. Participants reported feeling alive, reducing stress, increasing confidence and

(64) (80) (33) (64) (79) (80) (71) (82) (54) (70) (17) (64) (57) (70) (43) (55) (36) (40) (43) (27) (39) (70) (43) (27) (18) (10) (14) (27) (32) (30) (29) (36)

energy and improvements in mood. They also noted the value of doing something for themselves, and a sense of achievement. Interestingly, this motivator fluctuated over time. In response to the question “what motivates you to go to the gym,” most participants made comments at week 3 and at 6 months such as “I feel more alive.my energy and my life and everything, you know, I come alive after going to the gym” (Dale, 6 months). Fewer (about half) made similar remarks at 3 or 9 months, but this general sense of well-being was still captured, “I feel better when I do the exercise.more energy, more vitality, and a satisfaction of doing it” (May, 3 months). Fitness improvements proved to be a significant facilitator (>70%), but this factor also fluctuated over time. Early in the adoption phase, participants noted increased strength, muscle tone, endurance and improved breathing, heart rate and circulation. Comments included, “I like to see how my strength is already starting to get better, like in the first couple of weeks, and it’s motivating, it’s fun” (Shirley, week 3). They reported that positive results motivated their exercise behaviour, especially at the 3-week and 6-month time points. During the maintenance phase, participants described changes in their body shape and better management of hypertension and blood sugar. These improvements also motivated participants to re-engage if they had reduced their activity levels, as underscored by this participant’s remark, “Well, I got my progress report, it was very good, so I’m pleased at the results from exercising even though I’m sliding back a bit, the benefits are really good and I know that, so I want to get back at it.” (Eleanor, 9 months). Support from personal trainers was highlighted by many participants during the adoption phase; however, perceived importance of the trainers fluctuated across time. Many individuals valued the support and guidance they received from their trainer to be active, and felt less embarrassed or intimidated when the trainer attended the sessions at the outset of the program, but about half

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stated that the trainer had little effect on their exercise attendance at the 3-week interview. “I like the trainers.if I didn’t understand how something was done, [trainer] showed me again. I never felt at risk, so it made me feel good. But, they could call me and say they could never come back, I don’t care. I’m still going to exercise” (Sofia, week 3). At 3 months, the majority of participants (77%) spoke of the importance of the trainer for motivation and attendance. In response to “what has helped you continue going to the gym,” a participant reported, “the fact that I had the trainers there.they were right there encouraging me, helping me, directing me, guiding me, they were very, very supportive. They know the equipment, and it is all new to me” (Alfred, 3 months). Not surprisingly, trainer endorsement decreased as their involvement was reduced post-intervention. Exercise facilitators: group differences Group differences were observed for some of the emerging facilitator themes. General well-being, fitness improvements and enjoyment were reported by participants assigned to a group that included resistance exercise (i.e. resistance only or combined exercise groups). Differences were noted particularly for exercise maintenance (i.e. 9 months). A sense of well-being varied minimally across the groups during exercise adoption (week 3 and 3 months), but this facilitator emerged more frequently for those in the resistance or combined group as compared with the aerobic group for exercise maintenance. All participants reported improvements in their fitness levels as a motivator for exercise at 6 months, but more individuals in the resistance and combined groups reported these improvements at the 3-month time point. Participants in the resistance or combined groups reported higher levels of enjoyment at 3 and 6 months, and more participants in the resistance group expressed enjoyment at 9 months. Exercise barriers A list of perceived barriers to exercise that emerged from participant responses is shown in Table 2. Participants reported few impediments at the start of the intervention, in fact, a third of interviewees identified no barriers at 3 weeks, but as their experience with exercise increased over time so did the number of barriers reported. During the maintenance phase, participants reported multiple challenges to exercise including illness or injury, work commitments, poor weather (e.g. snow storm, heat and humidity), time, vacation, boredom and family commitments. Few differences were observed between exercise groups, with the exception of the combined group reporting more difficulty with time, work commitments and boredom. This is not surprising considering that their prescribed exercise was double that of the

Table 2 Perceived Exercise Barriers Perceived barriers

3 weeks, n (%) 3 months, n (n¼25) (%) (n¼26)

6 months, n (%) (n¼28)

9 months, n (%) (n¼28)

Time Work commitments Illness/injury Weather Vacation Tired Boring Family commitments Program changes

4 (16) 3 (12)

5 (19) 7 (27)

8 (29) 10 (36)

5 (18) 10 (36)

2 3 0 2 4 0

8 7 6 8 5 3

16 7 6 7 6 7

15 9 8 5 8 6

(8) (12) (0) (8) (16) (0)

0 (0)

(31) (27) (23) (31) (19) (12)

5 (19)

(57) (25) (21) (25) (21) (25)

3 (11)

(54) (32) (29) (18) (29) (21)

3 (11)

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other conditions. Therefore, the total number and percentage of all participants endorsing each theme are presented. Experiencing an illness or injury was the most frequently (up to 57%) reported barrier to exercise, especially at the later time points. People were contending with colds, flu, muscle soreness and even surgery. Despite an apparent desire, many felt unable to exercise. Sample responses were as follows: “When I’m sick, I’m sick. I don’t have the energy to even walk so really there’s no point to try to get there, I mean, you have to work 45 minutes and lift things and I just don’t have the energy to do it” (Robert, 6 months), and “I’ve had a sore back since about the end of June.at times it’s so bad I can’t even get on the treadmill. I find it really tough to stay motivated at the moment because I try something then I can’t move for about 2 to 3 hours” (Eleanor, 9 months). Difficulties managing work commitments and an exercise regimen were mentioned by participants at each time point. In response to our question, “what made it difficult for you to exercise?” participants stated, “Now my work schedule is I travel to [locations], so I have a very heavy schedule, and I didn’t expect all of this to come in the last 3 months. It’s more demanding. I am gone one and a half weeks every month” (May, 6 months), and “Work. The last week has been just ridiculous.I am not just a teacher, but coach, and going away weekends on tournaments and every night practice or game. That is the number one reason” (Glenn, 9 months). Inclement weather also influenced participation rates. Winter was especially problematic for participants, “It’s just when there is a snowstorm, it is tough to keep everything on track” (Simon, 3 months); however, the summer months proved difficult as well, “I was scheduled to come here on Tuesday. I didn’t want to cause it was too damn hot, so I didn’t come” (Paul, 9 months). At each interview, participants spoke of a general lack of time: “time restraints.it’s probably about a 2-hour commitment 3 nights/week, and that’s difficult.trying to plan myself around my family and my work so that I can meet all people’s needs” (John, 3 months). Breaks in routine because of vacation and holiday time were challenging for maintaining one’s exercise routine, “The Christmas holidays, a busy time, and visitors, and you have to go to this appointment, you have to go to that appointment, then exercise, it’s too much” (Shiela, 3 months). Finally, about one-fifth of participants found exercise boring, which hampered their motivation, “The weight training is not the problem, but I don’t like the treadmill.it’s incredibly boring” (Charles, 3 months). Exercise maintenance: maintainers vs. decreasers An exploration of responses to questions at the 9-month interview from participants who maintained and those who decreased their exercise level after intervention showed some interesting findings. First, maintainers tended to be engaged in resistance exercised80% of those in the resistance group increased or maintained activity levels, whereas only 45% and 29% of those in the combined or aerobic groups, respectively, maintained the trial’s prescribed exercise levels in the 3 months after the intervention ended. Second, maintainers cited, on average, 6.8 facilitators, whereas decreasers mentioned an average of 4.8, and each facilitator was reported by maintainers at an equivalent or greater percentage than decreasers. Third, maintainers and decreasers cited an equivalent number of barriers. More specifically, maintainers spoke of support from the trainer (60% vs. 8%), having a useful strategy for exercising (67% vs. 15%) and enjoyment (56% vs. 36%) to a greater degree than decreasers. One participant who maintained his exercise level noted the advantage of having continued contact with a trainer, “I think having your trainer, you know that if you have any problems you can just bring that up. I think [trainer] helps that you’re not into any

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bad habits and makes sure that you keep up what you are supposed to be doing” (Louis, 9 months). Others noted the importance of strategies, such as keeping a regular schedule or routine, or recording their activities in a daily log, to assist them in maintaining activity levels. “The [log book] is just sort of a little bit of accountability in the sense, not to the trainer, but to me too, I have to put it down on paper and make sure that I do this. It doesn’t give you any excuses to skip and change” (Evelyn, 9 months). Enjoyment of exercise kept some individuals engaged in their activity program over time: “The motivation has increased just by the pleasure I’m getting out of continuing” (George, 9 months). In contrast, boredom was more likely to be endorsed by decreasers than maintainers (27% vs. 12%). Summary of facilitators and barriers overtime The expectation of gaining future health benefits motivated participants to initially engage in the exercise program. Social support from family, guidance from the personal trainer regarding the new exercises, early experiences with perceived fitness improvements and an increased sense of well-being were other facilitators that emerged during the exercise adoption phase. Barriers were almost nonexistent early in the adoption phase; at 3 months, illness/injury, work commitments and poor weather challenged about a third of participants. Facilitators related to exercise maintenance in this sample included fitness improvements and future health benefits (especially after progress reports were provided), family support, meetings with the personal trainer, performing resistance exercise, enjoyment and the use of specific strategies to get to the gym. Reports of barriers increased during the maintenance phase; however, the themes remained constant. Discussion The purpose of this qualitative study was to investigate the experiences of patients with type 2 diabetes in a randomized exercise trial. Previous research on exercise determinants has identified numerous barriers and facilitators to exercise in healthy populations, including demographic, psychological and environmental variables (18). Fewer studies have investigated these factors in patients with type 2 diabetes (7e9). Two qualitative studies examined exercise behaviour in this population; however, both used only 1 data collection time point at 8 (14) and 18 months after intervention (19). Responses likely were affected by retrospective recall. Differences between exercise modality and adherence level were not investigated in either study. The present study is the first to explore type 2 diabetes patients’ perceived facilitators and barriers at multiple time points from the adoption to maintenance phase (i.e. week 3, and at 3, 6 and 9 months), and to investigate differences in these variables across time, between intervention groups, and by adherence level after intervention. Our findings indicated that social support from family and a personal trainer, future health benefits, a sense of well-being and fitness improvements had a positive impact on participants’ exercise behaviour. Social support has long been identified as a dominant factor for activity in the general population (20,21). and has emerged in a diabetes population as well (22,23). The present results are no different: social support from family was in the top 3 facilitators from exercise adoption to maintenance. Some participants noted that family members joined the gym as well, and were encouraged by this support. Future interventions may consider building in a family component in the maintenance phase to enhance participation and adherence. Along a similar line, trainers played an important role in the trial, including introducing participants to their exercise routine and were present during many exercise sessions during the

6-month intervention. This ensured the safety of the participant, treatment fidelity (e.g. attendance and exercise logs, proper mechanics for resistance training) and, although it was not targeted directly, likely served to increase participants’ self-efficacy or perceived competencedan important determinant for exercise behaviour. Initially, trainers were appreciated for providing encouragement, support and exercise instruction; however, participants did not believe they influenced attendance. At midintervention, the trainer was cited as one of the top reasons for attendance and noted to be an essential motivator. The overall level of endorsement for the trainer fell in the maintenance phase. This is not surprising because the trainer no longer met participants on a regular basis. However, a clear distinction was made between those who maintained prescribed exercise levels after the intervention and those who did not. Maintainers were more likely to note the continued importance of the trainer. Previous research also showed the importance of including ongoing monitoring and encouragement, including follow-up prompts (6,19). We would argue that booster sessions with an exercise specialist be implemented to bolster activity levels in the long term. Phase III cardiac rehabilitation (i.e. maintenance phase) aimed to assist the patient in ongoing risk factor modification and exercise behaviour acquired during on-site structured programs that included exercise in one’s community or home with periodic reviews and assessments with cardiac rehabilitation staff and provided a relevant model that may be implemented with the diabetes population to increase the rates of longer-term exercise. The desire to obtain future health benefits (i.e. outcome expectations) and achieving results in terms of improved fitness and a sense of well-being enhanced continued participation in the DARE trial. The impact was most apparent at the 6-month interview because participants received feedback from their end-ofintervention fitness and metabolic control assessment. These results suggest that objective indicators of this success likely would enhance adherence. Exercise programs would do well to include a feedback session with patients on a regular basis. Similar sessions could be conducted by the endocrinologist, diabetes educator or family physician to boost behaviour maintenance after the intervention, especially for those exercising in the community without structured intervention. Common barriers endorsed included illness or injury, work commitments and poor weather. These are consistent with those mentioned in previous research with patients with type 2 diabetes (19,24). Our exploration of responses after the intervention showed that participants who continued to adhere to the exercise prescription (maintainers) cited about the same number of barriers as those who reduced their exercise levels (decreasers). In contrast, maintainers reported more facilitators than decreasers. This finding suggests that encountering barriers to exercise is inevitable for all participants, but maintainers had a greater tendency to implement strategies to overcome them than decreasers. In this study, maintainers were almost 5 times as likely as decreasers to use strategies for exercising. Behaviour change counselling would be an ideal intervention to help patients develop these strategies. Specifically, long-term adherence to exercise is likely to be enhanced by behaviour change components such as “action planning” (i.e. detailed planning of when, where and how the exercise will be preformed) that help participants increase self-efficacy and exercise behaviour (25). Although our participants interacted with a personal trainer, the intervention did not include Behaviour change counselling. We suggest that an exercise specialist trained in behavioural counselling would best serve the needs of these patients and enhance exercise facilitators and adherence. Participants engaging in resistance exercise, alone or in combination with aerobic exercise, experienced a sense of well-being and perceived improvements more than the aerobic-only condition.

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Hills et al (13) concluded that resistance training is an ideal foundational exercise modality for overweight or obese individuals with diabetes because resistance training may lead to more rapid physical gains and less discomfort than high-impact aerobic activity. Because most people have engaged in aerobic activity, but relatively few have performed weight training, we suggest that previous sedentary individuals, such as those participating in the DARE trial, may gain a stronger sense of mastery and self-efficacy as they become adept with this unfamiliar approach to exercise and this, in turn, would be associated with pleasurable outcomes. Resistance-training participants, whether or not they also performed aerobic exercise, tended to enjoy their exercise sessions and maintained their activity levels more than the other groups. Furthermore, participants in the aerobic group reported a desire for more variety in their exercise, and noted a preference for combined aerobic and resistance training. A randomized controlled trial design prohibits participants from choosing their exercise type, which can undermine intrinsic motivation. If choice was possible, overall enjoyment may have been higher and differences between groups might have been negligible. Future interventions could investigate if choice in exercise would result in greater enjoyment and exercise maintenance than predetermined exercise groups. We also suspect that participants in the resistance group had a greater initial reliance on the trainer to learn the novel exercises (e.g. ensure proper use of machines and exercise mechanics). These interactions may have led to a better relationship and fostered continued contact during the maintenance phase that, in turn, led to improved adherence. Theoretical implications Two behavioural-change theories, social cognitive theory (SCT) (15) and self-determination theory (16), have been empirically supported by evidence in the prediction of exercise in healthy adults and, more recently, the diabetes population (9,26,27). Social cognitive theory explains human behaviour in terms of a model of reciprocal determinism between the characteristics of the person, the environment and the behaviour itself. Key SCT constructs that are said to influence behaviour include personal goals, self-efficacy (i.e. one’s confidence to perform a specific behaviour), outcome expectations (i.e. the expectation that an outcome will follow a specific and beneficial behaviour) and one’s social and physical environment. Many of the facilitators identified in our study align with the social cognitive model. For example, Bandura (28) noted that aspects of one’s social environment such as verbal persuasion (i.e. encouragement from a credible source to engage in exercise) enhance self-efficacy (i.e. one’s confidence to perform a specific behaviour) and outcome expectations (i.e. belief that positive outcomes occur in response to behaviour), which, in turn, influences positive behaviour change (6). Participants in our study received support from their families in the form of encouragement, and from the trainers regarding their ability to engage in the activity, likely increasing self-efficacy. Bandura (28) also posited that physiological feedback (emotional or physical responses to exercise) affects efficacy beliefs, expectations and exercise behaviour, especially for those of compromised health. We found that perceived improvements in fitness and a general sense of well-being were facilitators of exercise behaviour. The feedback from the fitness and metabolic control assessments also support the connection between feedback, outcome expectations and behaviour as explained in SCT. Self-determination theory (29) places motivation on a continuum from extrinsic (or external) to intrinsic (or internal). Extrinsic motivation is the lowest level of self-determined behaviour; people engage in these behaviours to avoid negative consequences (e.g. exercise to avoid disappointing a loved one) or to gain a reward

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(e.g. improve appearance). In contrast, intrinsic motivation is the most self-determined motivation; people engage in behaviour for their inherent pleasure (e.g. exercise for fun or pleasure). Self-determination theory postulates that behaviours, such as exercise, most likely will be sustained over the long term if motivation for activity is intrinsic, such as enjoyment, rather than extrinsic (e.g. physician advice) (29). Recent evidence also suggests that intrinsic motivation may take time to develop, and that fostering this type of motivation may enhance behavioural maintenance (30). Our results support this self-determination theory tenet; patients who maintained their activity levels at 9 months reported more enjoyment of the activity. This factor may explain the higher maintenance rates found in this group. This study was not without limitations. First, we relied on telephone interviews. This method was found to be the most efficient way of reaching participants and reduced participant burden; however, face-to-face interviews might have reduced the likelihood of socially desirable responses (e.g. stating that the trainer had more of an effect on adherence than he/she truly did) (31). Second, interviews were conducted throughout the year, with varying demands in terms of work, social obligations and weather conditions, all of which appeared to affect desire to attend the gym. Third, caution also should be used when generalizing the results to the general population of patients with type 2 diabetes. Our sample was enrolled in an exercise trial that offered free gym memberships and personal trainers; these resources are not part of standard diabetes care. In addition, our participants likely were more adherent to exercise than the average patient because eligibility for randomization included compliance during the 4-week run-in period. Finally, because of the lower number of female participants, we lacked sufficient power to examine gender differences. Although the women were distributed fairly evenly across the exercise groups, we unfortunately lacked the foresight to oversample women, which may have shed more light on possible gender disparities. Future research would do well to further explore these factors with more patients in each exercise condition. Larger samples also may allow for statistical comparisons, which would strengthen our understanding and confirm the relationships explored here. In summary, we conducted an in-depth assessment of diabetic patients’ perceived facilitators and barriers during and after participation in a structured exercise trial that included aerobic and/or resistance exercise training. Patient responses provided further insight into the factors that influenced exercise behaviour in this population. Prominent facilitators included social support from family and the trainers, future health benefits, fitness improvements and a sense of well-being and enjoyment, whereas illness or injury, work and poor weather were impediments. Results suggest that engaging in resistance exercise, either alone or in combination with aerobic exercise, helped improve a sense of well-being, perceived fitness improvements, enjoyment and adherence after the intervention. Participants who remained active also reported more facilitators (e.g. strategies and trainer support) than those who decreased exercise levels. Future research could examine an expanded role for exercise specialists, who could provide behaviour change counselling in addition to exercise training. Acknowledgements The DARE trial was funded by grants from the Canadian Institutes of Health Research (MCT-44155) and the Canadian Diabetes Association (The Lillian Hollefriend Grant). Drs. Tulloch and Sweet were supported by Doctoral Research Awards from the Social Sciences and Humanities Research Council of Canada. Dr. Sigal is a Health Senior Scholar of Alberta Innovates-Health Solutions and previously was supported by a New Investigator Award from the

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Canadian Institutes of Health Research and the Ottawa Health Research Institute Chair in Lifestyle Research. Dr. Kenny is supported by a University of Ottawa Research Chair.

Author Contributions Heather Tulloch, M. Fortier, R. Sigal and G. Kenny contributed substantially to the conception and design of the project; Heather Tulloch and G. Capstick were involved in the acquisition of the data; Heather Tulloch, G. Capstick, S. Sweet and M. Fortier were involved in the analyses and interpretation of the data; Heather Tulloch drafted the article and all authors revised it critically for important intellectual content and gave final approval of this version to be published.

References 1. Cowie CC, Rust KF, Ford ES, et al. Full accounting of diabetes and pre-diabetes in the U.S. population in 1988-1994 and 2005-2006. Diabetes Care 2009;32: 287e94. 2. Public Health Agency of Canada. Diabetes in Canada: facts and figures from a public health perspective. In: Division CDSaM, ed. Ottawa: Public Health Agency of Canada; 2011. 3. Sigal RJ, Kenny GP, Boule NG, et al. Effects of aerobic training, resistance training, or both on glycemic control in type 2 diabetes: a randomized trial. Ann Intern Med 2007;147:357e69. 4. Colberg SR, Sigal RJ, Fernhall B, et al. Exercise and type 2 diabetes: the American College of Sports Medicine and the American Diabetes Association: joint position statement executive summary. Diabetes Care 2010;33: 2692e6. 5. Public Health Agency of Canada, Diabetes in Canada: Facts and figures from a public health perspective. Ottawa, 2011. 6. Fjeldsoe B, Neuhaus M, Winkler E, Eakin E. Systematic review of maintenance of behavior change following physical activity and dietary interventions. Health Psychol 2011;30:99e109. 7. Bryan D, Rocheleau CA. Predicting aerobic versus resistance exercise using the theory of planned behavior. Am J Health Behav 2002;226:83e92. 8. Plotnikoff RC, Trinh L, Courneya KS. Predictors of aerobic physical activity and resistance training among Canadian adults with type 2 diabetes; an application of the protection motivation theory. Psychol Sport Exerc 2009;10:320e8. 9. Plotnikoff RC, Lippke S, Courneya KS, et al. Physical activity and social cognitive theory: a test in a population sample of adults with type 1 or type 2 diabetes. Appl Psychol 2008;57:628e43. 10. Rothman A. Toward a theory-based analysis of behavioral medicine. Health Psychol 2000;19:64e9. 11. Boutelle K, Jeffery R, French S. Predictors of vigorous exercise adoption and maintenance over four years in a community sample. Int J Behav Nutr Phys Activity 2004;1:13.

12. Williams D, Lewis B, Dunsiger S, et al. Comparing psychosocial predictors of physical activity adoption and maintenance. Annals Behav Med 2008;36: 186e94. 13. Hills AP, Shultz SP, Soares MJ, et al. Resistance training for obese, type 2 diabetic adults: a review of the evidence. Obes Rev 2010;11:740e9. 14. Wycherley TP, Mohr P, Noakes M, et al. Self-reported facilitators of, and impediments to maintenance of healthy lifestyle behaviours following a supervised research-based lifestyle intervention programme in patients with type 2 diabetes. Diabet Med 2012;29:632e9. 15. Bandura A. Health promotion by social cognitive means. Health Educ Behav 2004;31:143e64. 16. Ryan R, Patrick H, Deci E, Willams G. Facilitating health behaviour change and its maintenance: interventions based on self-determination theory. Eur Health Psychol 2008;10:2e5. 17. Hsieh HF, Shannon SE. Three approaches to qualitative content analysis. Qual Health Res 2005;15:1277e88. 18. Trost SG, Owen N, Bauman AE, et al. Correlates of adults’ participation in physical activity: review and update. Med Sci Sport Exer 2002;34:1996e2001. 19. Casey D, De Civita M, Dasgupta K. Understanding physical activity facilitators and barriers during and following a supervised exercise programme in type 2 diabetes: a qualitative study. Diabetic Med 2010;27:79e84. 20. McAuley E, Jerome GJ, Marquez DX, et al. Exercise self-efficacy in older adults: social, affective, and behavioral influences. Ann Behav Med 2003;25:1e7. 21. Wendel-Vos W, Droomers M, Kremers S, et al. Potential environmental determinants of physical activity in adults: a systematic review. Obes Rev 2007;8:425e40. 22. Chlebowy D, Hood S, LaJoie AS. Facilitators and barriers to self-management of type 2 diabetes among urban African American adults. Diabetes Educ 2010;36: 897e905. 23. Mier N, Medina AA, Ory MG. Mexican Americans with type 2 diabetes: perspectives on definitions, motivators, and programs of physical activity. Prev Chronic Dis 2007;4:A24. 24. Lawton J, Ahmad N, Hannah L, et al. “I can’t do any serious exercise”: barriers to physica activity amongst people of Pakistani and Indian origin with type w diabetes. Health Educ Res 2006;21:43e54. 25. Williams SL, French DP. What are the most effective intervention techniques for changing physical activity self-efficacy and physical activity behavioureand are they the same? Health Educ Res 2011;26:308e22. 26. Sweet S, Fortier M, Guerin E, et al. Understanding physical activity in adults with type 2 diabetes after completing an exercise intervention trial: a mediation model of self-efficacy and autonomous motivation. Psychol Health Med 2009;14:419e29. 27. Fortier M, Sweet S, Tulloch H, et al. Self-determination and exercise stages of change: results from the Diabetes Aerobic and Resistance Exercise Trial. J Health Psychol 2011;17:87e99. 28. Bandura A. Self-efficacy: the exercise of control. New York: W.H. Freeman; 1997. 29. Deci E, Ryan R. Intrinsic motivation and self-determination in human behaviour. New York: Plenum; 1985. 30. Teixeira PJ, Carraça EV, Markland D, et al. Exercise, physical activity, and self-determination theory: a systematic review. Int J Behav Nutr Phys Activity 2012;9:78. 31. Holbrook A, Green M, Krosnick J. Telephone versus face-to-face interviewing of national probability samples with long questionnaires: comparisons of respondent sacrificing and social desirability response bias. Public Opin Quart 2003;67:79e125.