- Email: [email protected]
Barriers to Active Lifestyles in Children with Type 1 Diabetes
Can J Diabetes 40 (2016) 170–172
Contents lists available at ScienceDirect
Canadian Journal of Diabetes journal homepage: w w w. c a n a d i a n j o u r n a l o f d i a b e t e s . c o m
Original Research
Barriers to Active Lifestyles in Children with Type 1 Diabetes Georges Jabbour, PhD a, Mélanie Henderson, MD, PhD a, Marie-Eve Mathieu, PhD b,c,* a
School of Kinesiology and Leisure, Faculty of Health Sciences and Community Services, Université de Moncton, New Brunswick, Canada Division of Endocrinology, Department of Pediatrics, Centre Hospitalier Universitaire Sainte-Justine and Université de Montréal, Montreal, Quebec, Canada c Department of Kinesiology, University of Montreal, Montreal, Quebec, Canada b
a r t i c l e i n f o
a b s t r a c t
Article history: Received 3 July 2015 Received in revised form 30 November 2015 Accepted 3 December 2015
Objectives: To identify the main barriers to active lifestyles in children with type 1 diabetes based on known barriers in adults with type 1 diabetes. Methods: Children with type 1 diabetes (n=201) recruited from the Centre Hospitalier Universitaire (CHU) Sainte-Justine Diabetes Clinic answered a specific questionnaire, the Barriers to Physical Activity in Type 1 Diabetes (BAPAD1), which assesses perceived barriers and parental support in the children’s adoption of active lifestyles. Results: In younger individuals (those younger than 12 years of age), the highest barrier scores were loss of control of diabetes, fear of hypoglycemia, work schedule and external temperature. In the older group (those ≥12 years of age), fear of hypoglycemia, external temperature, loss of control of diabetes and low fitness levels were the most important. Greater parental support was associated with lower overall barrier scores in younger and older children alike (r=−0.71 and r=−0.65, respectively; p<0.001). Conclusions: There are some differences in barriers to active lifestyles between younger and older children with type 1 diabetes. Parental support appears to be the key to active lifestyles in their children. © 2016 Canadian Diabetes Association. Published by Elsevier Inc. All rights reserved.
Keywords: barriers physical activity type 1 diabetes younger and older children
r é s u m é Mots clés : obstacles activité physique diabète de type 1 enfants plus jeunes et plus vieux
Objectif : Déterminer les principaux obstacles à un mode de vie actif chez les enfants atteints du diabète de type 1 en s’appuyant sur les obstacles connus chez les adultes atteints du diabète de type 1. Méthodes : Les enfants atteints du diabète de type 1 (n=201) recrutés de la clinique du diabète du Centre hospitalier universitaire (CHU) Sainte-Justine ont répondu à un questionnaire particulier, le BAPAD–1 (Barriers to Physical Activity in Type 1 Diabetes), qui évalue la perception des obstacles et le soutien parental dans l’adoption d’un mode de vie actif par les enfants. Résultats : Chez les plus jeunes individus (ceux ayant moins de 12 ans), les scores des obstacles les plus élevés étaient la perte de maîtrise du diabète, la peur de l’hypoglycémie, l’horaire de travail et la température extérieure. Dans le groupe plus âgé (ceux ≥12 ans), la peur de l’hypoglycémie, la température extérieure, la perte de maîtrise du diabète et les faibles niveaux de condition physique étaient les plus importants. Un plus grand soutien parental était associé de la même manière à des scores d’obstacles plus faibles chez les enfants plus jeunes et plus vieux (r=−0,71 et r=−0,65, respectivement; p<0,001). Conclusions : Nous observons quelques différences dans les obstacles à un mode de vie actif entre les enfants plus jeunes et plus vieux atteints du diabète de type 1. Le soutien parental semble être la solution à un mode de vie actif de leurs enfants. © 2016 Canadian Diabetes Association. Published by Elsevier Inc. All rights reserved.
Introduction Despite the reported benefits of physical activity in several key cardiometabolic components (1) and quality of life (2) for patients with type 1 diabetes, more than 50% of patients with the disease
* Address for correspondence: Marie-Eve Mathieu, Ph.D., Department of Kinesiology, University of Montreal, P.O. Box 6128, Downtown Station, Montreal, Quebec H3C 3J7, Canada. E-mail address: [email protected]
do not reach the internationally recommended level of physical activity (3). Fear of hypoglycemia, work schedules, loss of control of diabetes and low levels of fitness were identified as the main barriers to physical activity (PA) practices in adults with type 1 diabetes (4), but there are no such data for the pediatric population. The knowledge of barriers to PA among patients with type 1 diabetes appears to be essential to enhancing the efficacy of intervention programs. Given the paucity of available data, our objective was to explore the various barriers to engaging in PA by youth with type 1 diabetes and to determine the influences of parents, medical doctors
1499-2671 © 2016 Canadian Diabetes Association. Published by Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jcjd.2015.12.001
G. Jabbour et al. / Can J Diabetes 40 (2016) 170–172
and physical education teachers on the achievement of an active lifestyle. Methods We asked 201 children with type 1 diabetes who had been diagnosed for at least 3 months to answer a self-administered questionnaire at the Diabetes Clinic of the Sainte-Justine University Hospital Center (Montreal, Canada). Body weight status was determined based on body mass index (BMI) percentiles derived from the Centers for Disease Control and Prevention Clinical Growth Charts for children aged 2 years and older (5) and according to Canadian guidelines (6). The Barriers to Physical Activity in Type 1 Diabetes (BAPAD1) scale was used (7). This questionnaire examines 12 barriers to physical activity on a scale from 1 to 7 (1), (1 being extremely unlikely, to 7, being extremely likely) (7). However, it is important to mention that the BAPAD1 scale had not been validated for young populations with type 1 diabetes. However, given that many of these items may also be true for children, in the context of our study we believed that the use of such a scale might help us at least to compare these barrier items with those of adults and also between our 2 groups. Parents also answered by responding 1 (never), 2 (sometimes) or 3 (very often) if they encouraged their children to engage in PA or to be present with them when they themselves were being physically active. Finally, children answered yes or no if their parents, doctors or physical education teachers encouraged them to be physically active. The project was approved by the ethics and research committee of Sainte-Justine University Hospital Center. The consent and assent from the parents and the children were obtained before the study. The analyses were performed using the IBM SPSS v. 21 software (IBM, Armonk, New York, USA). Preliminary analyses included calculating descriptive scores (mean ± standard deviation). Pearson correlations were performed to determine the relationship between parental support and children’s perceived barriers to PA. Internal consistency reliability (Cronbach alpha-coefficient) for the BAPAD1 scale and parental support was performed; a score of 0.7 and above was judged to be acceptable (8). Finally, differences within and between the younger and the older groups for each barrier score were analyzed using 2-way analysis of variance, and the Scheffe test post hoc was performed. A value of p<0.01 was set as the level of statistical significance. Results A total of 201 children with type 1 diabetes were recruited. We divided the sample into younger children (those younger than 12 years of age) and older children (those 12 years of age or older). There were 58 normal-weight children in the younger group (mean age=9.1±1.6 years, and body mass=44.6±3.5 percentiles). There were 143 normal-weight youth in the older group (mean age=14.7±1.7 years, BMIs=61.2±2.1 percentiles). Both groups agreed to answer to the questionnaire. The mean BAPAD1 total score was 1.6±0.9 for younger children and 1.7±1.2 for older children. Internal consistency reliability (Cronbach alpha coefficient) for the BAPAD1 scale and parental support was 0.74 and 0.81, respectively, for younger patients and was 0.77 and 0.81, respectively, for older children. For younger children, the highest barrier scores were obtained for loss of control of diabetes, fear of hypoglycemia and work schedule and external temperature (Table 1). For older children, the highest barrier scores were obtained for fear of hypoglycemia, external temperature, loss of control of diabetes and low fitness level (Table 1). Moreover, the scores for fear of hypoglycemia and external temperature were significantly higher in the older group compared to the younger group (p<0.01, respectively).
171
Table 1 Barriers to physical activity among younger children and older children with type 1 diabetes, mean scores Barriers
Younger (n=58)
Older (n=143)
1. The loss of control of your diabetes 2. The fear of hypoglycemia 3. The fear of being tired 4. The fear of hurting yourself 5. The fear of suffering a heart attack 6. A low fitness level 7. The fact that you have diabetes 8. The risk for hyperglycemia 9. Your actual physical health status, excluding your diabetes 10. External temperature 11. The location of a gym 12. Work schedule Mean score of overall barriers standard deviation
2.5±1.8 2.5±1.2 2.1±1.11,2,10,12b,c,k,m 2.1±1.51,2,10,12b,c,k,m 1.5±1.1b-e,g-m 2.1±1.7b,c,k,m 1.7±1.3b,c,j,k,m 2.1±1.1b,c,k,m 1.9±1.7b,c,,k,m
2.4±1.7b,k 3.2±1.9a 2.1±1.2b-d,k 2.1±1.3b-d,k 2.1±1.2a,b-d,k 2.2±1.8b,c,k 1.6±1.4b-g,i-m 2.1±1.1b-d,k 1.9±2.6b-d,k
2.3±1.4b,c,m 2.1±1.5b,c,k,m 2.5±1.9 1.6±0.9
2.9±1.7a,bc 2.1±1.5b-d,k 1.9±0.9a,b-g,i-k,11 1.7±1.2
Note: Values are given as mean (standard deviation). a Significant differences between groups (p<0.01). b Significant differences in item 1 within groups (p<0.01). c Significant differences in item 2 within groups (p<0.01). d Significant differences in item 3 within groups (p<0.01). e Significant differences in item 4 within groups (p<0.01). f Significant differences in item 5 within groups (p<0.01). g Significant differences in item 6 within groups (p<0.01). h Significant differences in item 7 within groups (p<0.01). i Significant differences in item 8 within groups (p<0.01). j Significant differences in item 9 within groups (p<0.01). k Significant differences in item 10 within groups (p<0.01). l Significant differences in item 11 within groups (p<0.01). m Significant differences in item 12 within groups (p<0.01).
We found that lack of parental support was associated with a higher number of barriers (r=−0.71 for younger children and r=−0.65 for older children; p<0.001, respectively). Of the younger participants, 88%, and of the older participants, 91% reported that parents discouraged physical activity. On the other hand, 91% and 85% of younger participants and 87% and 77% of older participants reported that doctors and physical education teachers, respectively, encouraged physical activity.
Discussion Some barriers to engaging in PA identified in this study were similar in the younger and the older children with type 1 diabetes, although we found some age-specific barriers. Indeed, loss of control of diabetes, fear of hypoglycemia, work schedules and external temperatures were the first 4 barriers for the younger group. In contrast, for older children, the main barriers were fear of hypoglycemia, external temperatures, loss of control and low fitness levels. Loss of control of diabetes, fear of hypoglycemia, work schedules and low fitness levels have been previously reported as main barriers to PA by adults with type 1 diabetes (4). Surprisingly, and contrary to what is seen in adults, external temperature was identified by children and adolescents as a potential barrier. Individuals with type 1 diabetes have increased risks for dehydration with hyperglycemia, which leads to polyuria. It has been suggested that individuals with type 1 diabetes, when exercising in high heat, become dehydrated more quickly than their nondiabetic peers and consequently have impaired performance and muscle cramps, which limit their physical activities (9). Despite the fact that the BAPAD1 scale was designed and validated only for adults, our new findings serve at least to offer more knowledge about the limits experienced by children with type 1 diabetes when addressing barriers to their PA in comparison with adults with type 1 diabetes. However, developing an adapted BAPAD1 scale is necessary so as to be more
172
G. Jabbour et al. / Can J Diabetes 40 (2016) 170–172
specific about the nature of barriers that affect PA in children with type 1 diabetes. Striking was the fact that 88% of younger participants and 91% of older participants reported that their parents discouraged PA. This is worrisome because parental support has been shown to contribute to PA levels in children with type 1 diabetes (10). For Fereday et al (10), in South Australian children, parental support was an important determinant of children’s participation in PA and there were issues highlighted by the parents about the importance of PA in enhancing the health parameters of their children. These data were in keeping with our results; indeed, the lack of parental support was associated with greater barriers to PA despite the fact that children’s physicians and physical education teachers encouraged them to engage in PA. This suggests that parents play a major role in physical activity practices in children with type 1 diabetes and that educating parents about the importance of PA in children with type 1 diabetes may be an effective strategy to enhance PA levels in this vulnerable population.
Acknowledgements We are grateful for the cooperation and participation of the children and their parents. This study was supported by Diabetes Quebec.
Author Contributions GJ contributed substantially to the conception, design and acquisition of data and to the, analysis, and interpretation of data and
drafted the article and gave final approval of the version to be published; MH revised the article critically and gave final approval of the version to be published; M-EM contributed substantially to the conception, design and interpretation of data and gave final approval of the version to be published.
References 1. Wagner VM, Müller-Godeffroy E, von Sengbusch S, et al. Age, metabolic control and type of insulin regime influences health-related quality of life in children and adolescents with type 1 diabetes mellitus. Eur J Pediatr 2005;164:491. 2. Faulkner MS. Cardiovascular Fitness and Quality of Life in Adolescents with Type 1 or Type 2 Diabetes. J Spec Pediatr Nurs 2010;15:307–16. 3. Trigona B, Aggoun Y, Maggio A, et al. Preclinical noninvasive markers of atherosclerosis in children and adolescents with type 1 diabetes are influenced by physical activity. J Pediatr 2010;157:533. 4. Brazeau AS, Rabasa-Lhoret R, Strychar I, et al. Barriers to physical activity among patients with type 1 diabetes. Diabetes Care 2008;31:2108–9. 5. Kuczmarski RJ, Ogden CL, Guo SS, et al. 2000 CDC growth charts for the United States: Methods and development. National Center for Health Statistics. Vital Health Stat 2002; 11(246). 6. Lau DC. Synopsis of the 2006 Canadian clinical practice guidelines on the management and prevention of obesity in adults and children for the Obesity Canada Clinical Practice Guidelines Steering Committee and Expert Panel. Canadian Obesity Network, June 25, 2011. 7. Dubé MC, Valois P, Prud’homme D, et al. Physical activity barriers in diabetes: Development and validation of a new scale. Diabetes Res Clin Pract 2006;72: 20–7. 8. Nunnally JC. Psychometric theory. 2nd edn. New York: McGraw-Hill, pg. 1–701. 9. Riddell MC, Perkins BA. Type 1 diabetes and vigorous exercise: Applications of exercise physiology to patient management. Can J Diabetes 2006;30:63–71. 10. Fereday J, MacDougall C, Spizzo M, et al. “There’s nothing I can’t do—I just put my mind to anything and I can do it”: A qualitative analysis of how children with chronic disease and their parents account for and manage physical activity. BMC Pediatr 2009;9:1.
Contents lists available at ScienceDirect
Canadian Journal of Diabetes journal homepage: w w w. c a n a d i a n j o u r n a l o f d i a b e t e s . c o m
Original Research
Barriers to Active Lifestyles in Children with Type 1 Diabetes Georges Jabbour, PhD a, Mélanie Henderson, MD, PhD a, Marie-Eve Mathieu, PhD b,c,* a
School of Kinesiology and Leisure, Faculty of Health Sciences and Community Services, Université de Moncton, New Brunswick, Canada Division of Endocrinology, Department of Pediatrics, Centre Hospitalier Universitaire Sainte-Justine and Université de Montréal, Montreal, Quebec, Canada c Department of Kinesiology, University of Montreal, Montreal, Quebec, Canada b
a r t i c l e i n f o
a b s t r a c t
Article history: Received 3 July 2015 Received in revised form 30 November 2015 Accepted 3 December 2015
Objectives: To identify the main barriers to active lifestyles in children with type 1 diabetes based on known barriers in adults with type 1 diabetes. Methods: Children with type 1 diabetes (n=201) recruited from the Centre Hospitalier Universitaire (CHU) Sainte-Justine Diabetes Clinic answered a specific questionnaire, the Barriers to Physical Activity in Type 1 Diabetes (BAPAD1), which assesses perceived barriers and parental support in the children’s adoption of active lifestyles. Results: In younger individuals (those younger than 12 years of age), the highest barrier scores were loss of control of diabetes, fear of hypoglycemia, work schedule and external temperature. In the older group (those ≥12 years of age), fear of hypoglycemia, external temperature, loss of control of diabetes and low fitness levels were the most important. Greater parental support was associated with lower overall barrier scores in younger and older children alike (r=−0.71 and r=−0.65, respectively; p<0.001). Conclusions: There are some differences in barriers to active lifestyles between younger and older children with type 1 diabetes. Parental support appears to be the key to active lifestyles in their children. © 2016 Canadian Diabetes Association. Published by Elsevier Inc. All rights reserved.
Keywords: barriers physical activity type 1 diabetes younger and older children
r é s u m é Mots clés : obstacles activité physique diabète de type 1 enfants plus jeunes et plus vieux
Objectif : Déterminer les principaux obstacles à un mode de vie actif chez les enfants atteints du diabète de type 1 en s’appuyant sur les obstacles connus chez les adultes atteints du diabète de type 1. Méthodes : Les enfants atteints du diabète de type 1 (n=201) recrutés de la clinique du diabète du Centre hospitalier universitaire (CHU) Sainte-Justine ont répondu à un questionnaire particulier, le BAPAD–1 (Barriers to Physical Activity in Type 1 Diabetes), qui évalue la perception des obstacles et le soutien parental dans l’adoption d’un mode de vie actif par les enfants. Résultats : Chez les plus jeunes individus (ceux ayant moins de 12 ans), les scores des obstacles les plus élevés étaient la perte de maîtrise du diabète, la peur de l’hypoglycémie, l’horaire de travail et la température extérieure. Dans le groupe plus âgé (ceux ≥12 ans), la peur de l’hypoglycémie, la température extérieure, la perte de maîtrise du diabète et les faibles niveaux de condition physique étaient les plus importants. Un plus grand soutien parental était associé de la même manière à des scores d’obstacles plus faibles chez les enfants plus jeunes et plus vieux (r=−0,71 et r=−0,65, respectivement; p<0,001). Conclusions : Nous observons quelques différences dans les obstacles à un mode de vie actif entre les enfants plus jeunes et plus vieux atteints du diabète de type 1. Le soutien parental semble être la solution à un mode de vie actif de leurs enfants. © 2016 Canadian Diabetes Association. Published by Elsevier Inc. All rights reserved.
Introduction Despite the reported benefits of physical activity in several key cardiometabolic components (1) and quality of life (2) for patients with type 1 diabetes, more than 50% of patients with the disease
* Address for correspondence: Marie-Eve Mathieu, Ph.D., Department of Kinesiology, University of Montreal, P.O. Box 6128, Downtown Station, Montreal, Quebec H3C 3J7, Canada. E-mail address: [email protected]
do not reach the internationally recommended level of physical activity (3). Fear of hypoglycemia, work schedules, loss of control of diabetes and low levels of fitness were identified as the main barriers to physical activity (PA) practices in adults with type 1 diabetes (4), but there are no such data for the pediatric population. The knowledge of barriers to PA among patients with type 1 diabetes appears to be essential to enhancing the efficacy of intervention programs. Given the paucity of available data, our objective was to explore the various barriers to engaging in PA by youth with type 1 diabetes and to determine the influences of parents, medical doctors
1499-2671 © 2016 Canadian Diabetes Association. Published by Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jcjd.2015.12.001
G. Jabbour et al. / Can J Diabetes 40 (2016) 170–172
and physical education teachers on the achievement of an active lifestyle. Methods We asked 201 children with type 1 diabetes who had been diagnosed for at least 3 months to answer a self-administered questionnaire at the Diabetes Clinic of the Sainte-Justine University Hospital Center (Montreal, Canada). Body weight status was determined based on body mass index (BMI) percentiles derived from the Centers for Disease Control and Prevention Clinical Growth Charts for children aged 2 years and older (5) and according to Canadian guidelines (6). The Barriers to Physical Activity in Type 1 Diabetes (BAPAD1) scale was used (7). This questionnaire examines 12 barriers to physical activity on a scale from 1 to 7 (1), (1 being extremely unlikely, to 7, being extremely likely) (7). However, it is important to mention that the BAPAD1 scale had not been validated for young populations with type 1 diabetes. However, given that many of these items may also be true for children, in the context of our study we believed that the use of such a scale might help us at least to compare these barrier items with those of adults and also between our 2 groups. Parents also answered by responding 1 (never), 2 (sometimes) or 3 (very often) if they encouraged their children to engage in PA or to be present with them when they themselves were being physically active. Finally, children answered yes or no if their parents, doctors or physical education teachers encouraged them to be physically active. The project was approved by the ethics and research committee of Sainte-Justine University Hospital Center. The consent and assent from the parents and the children were obtained before the study. The analyses were performed using the IBM SPSS v. 21 software (IBM, Armonk, New York, USA). Preliminary analyses included calculating descriptive scores (mean ± standard deviation). Pearson correlations were performed to determine the relationship between parental support and children’s perceived barriers to PA. Internal consistency reliability (Cronbach alpha-coefficient) for the BAPAD1 scale and parental support was performed; a score of 0.7 and above was judged to be acceptable (8). Finally, differences within and between the younger and the older groups for each barrier score were analyzed using 2-way analysis of variance, and the Scheffe test post hoc was performed. A value of p<0.01 was set as the level of statistical significance. Results A total of 201 children with type 1 diabetes were recruited. We divided the sample into younger children (those younger than 12 years of age) and older children (those 12 years of age or older). There were 58 normal-weight children in the younger group (mean age=9.1±1.6 years, and body mass=44.6±3.5 percentiles). There were 143 normal-weight youth in the older group (mean age=14.7±1.7 years, BMIs=61.2±2.1 percentiles). Both groups agreed to answer to the questionnaire. The mean BAPAD1 total score was 1.6±0.9 for younger children and 1.7±1.2 for older children. Internal consistency reliability (Cronbach alpha coefficient) for the BAPAD1 scale and parental support was 0.74 and 0.81, respectively, for younger patients and was 0.77 and 0.81, respectively, for older children. For younger children, the highest barrier scores were obtained for loss of control of diabetes, fear of hypoglycemia and work schedule and external temperature (Table 1). For older children, the highest barrier scores were obtained for fear of hypoglycemia, external temperature, loss of control of diabetes and low fitness level (Table 1). Moreover, the scores for fear of hypoglycemia and external temperature were significantly higher in the older group compared to the younger group (p<0.01, respectively).
171
Table 1 Barriers to physical activity among younger children and older children with type 1 diabetes, mean scores Barriers
Younger (n=58)
Older (n=143)
1. The loss of control of your diabetes 2. The fear of hypoglycemia 3. The fear of being tired 4. The fear of hurting yourself 5. The fear of suffering a heart attack 6. A low fitness level 7. The fact that you have diabetes 8. The risk for hyperglycemia 9. Your actual physical health status, excluding your diabetes 10. External temperature 11. The location of a gym 12. Work schedule Mean score of overall barriers standard deviation
2.5±1.8 2.5±1.2 2.1±1.11,2,10,12b,c,k,m 2.1±1.51,2,10,12b,c,k,m 1.5±1.1b-e,g-m 2.1±1.7b,c,k,m 1.7±1.3b,c,j,k,m 2.1±1.1b,c,k,m 1.9±1.7b,c,,k,m
2.4±1.7b,k 3.2±1.9a 2.1±1.2b-d,k 2.1±1.3b-d,k 2.1±1.2a,b-d,k 2.2±1.8b,c,k 1.6±1.4b-g,i-m 2.1±1.1b-d,k 1.9±2.6b-d,k
2.3±1.4b,c,m 2.1±1.5b,c,k,m 2.5±1.9 1.6±0.9
2.9±1.7a,bc 2.1±1.5b-d,k 1.9±0.9a,b-g,i-k,11 1.7±1.2
Note: Values are given as mean (standard deviation). a Significant differences between groups (p<0.01). b Significant differences in item 1 within groups (p<0.01). c Significant differences in item 2 within groups (p<0.01). d Significant differences in item 3 within groups (p<0.01). e Significant differences in item 4 within groups (p<0.01). f Significant differences in item 5 within groups (p<0.01). g Significant differences in item 6 within groups (p<0.01). h Significant differences in item 7 within groups (p<0.01). i Significant differences in item 8 within groups (p<0.01). j Significant differences in item 9 within groups (p<0.01). k Significant differences in item 10 within groups (p<0.01). l Significant differences in item 11 within groups (p<0.01). m Significant differences in item 12 within groups (p<0.01).
We found that lack of parental support was associated with a higher number of barriers (r=−0.71 for younger children and r=−0.65 for older children; p<0.001, respectively). Of the younger participants, 88%, and of the older participants, 91% reported that parents discouraged physical activity. On the other hand, 91% and 85% of younger participants and 87% and 77% of older participants reported that doctors and physical education teachers, respectively, encouraged physical activity.
Discussion Some barriers to engaging in PA identified in this study were similar in the younger and the older children with type 1 diabetes, although we found some age-specific barriers. Indeed, loss of control of diabetes, fear of hypoglycemia, work schedules and external temperatures were the first 4 barriers for the younger group. In contrast, for older children, the main barriers were fear of hypoglycemia, external temperatures, loss of control and low fitness levels. Loss of control of diabetes, fear of hypoglycemia, work schedules and low fitness levels have been previously reported as main barriers to PA by adults with type 1 diabetes (4). Surprisingly, and contrary to what is seen in adults, external temperature was identified by children and adolescents as a potential barrier. Individuals with type 1 diabetes have increased risks for dehydration with hyperglycemia, which leads to polyuria. It has been suggested that individuals with type 1 diabetes, when exercising in high heat, become dehydrated more quickly than their nondiabetic peers and consequently have impaired performance and muscle cramps, which limit their physical activities (9). Despite the fact that the BAPAD1 scale was designed and validated only for adults, our new findings serve at least to offer more knowledge about the limits experienced by children with type 1 diabetes when addressing barriers to their PA in comparison with adults with type 1 diabetes. However, developing an adapted BAPAD1 scale is necessary so as to be more
172
G. Jabbour et al. / Can J Diabetes 40 (2016) 170–172
specific about the nature of barriers that affect PA in children with type 1 diabetes. Striking was the fact that 88% of younger participants and 91% of older participants reported that their parents discouraged PA. This is worrisome because parental support has been shown to contribute to PA levels in children with type 1 diabetes (10). For Fereday et al (10), in South Australian children, parental support was an important determinant of children’s participation in PA and there were issues highlighted by the parents about the importance of PA in enhancing the health parameters of their children. These data were in keeping with our results; indeed, the lack of parental support was associated with greater barriers to PA despite the fact that children’s physicians and physical education teachers encouraged them to engage in PA. This suggests that parents play a major role in physical activity practices in children with type 1 diabetes and that educating parents about the importance of PA in children with type 1 diabetes may be an effective strategy to enhance PA levels in this vulnerable population.
Acknowledgements We are grateful for the cooperation and participation of the children and their parents. This study was supported by Diabetes Quebec.
Author Contributions GJ contributed substantially to the conception, design and acquisition of data and to the, analysis, and interpretation of data and
drafted the article and gave final approval of the version to be published; MH revised the article critically and gave final approval of the version to be published; M-EM contributed substantially to the conception, design and interpretation of data and gave final approval of the version to be published.
References 1. Wagner VM, Müller-Godeffroy E, von Sengbusch S, et al. Age, metabolic control and type of insulin regime influences health-related quality of life in children and adolescents with type 1 diabetes mellitus. Eur J Pediatr 2005;164:491. 2. Faulkner MS. Cardiovascular Fitness and Quality of Life in Adolescents with Type 1 or Type 2 Diabetes. J Spec Pediatr Nurs 2010;15:307–16. 3. Trigona B, Aggoun Y, Maggio A, et al. Preclinical noninvasive markers of atherosclerosis in children and adolescents with type 1 diabetes are influenced by physical activity. J Pediatr 2010;157:533. 4. Brazeau AS, Rabasa-Lhoret R, Strychar I, et al. Barriers to physical activity among patients with type 1 diabetes. Diabetes Care 2008;31:2108–9. 5. Kuczmarski RJ, Ogden CL, Guo SS, et al. 2000 CDC growth charts for the United States: Methods and development. National Center for Health Statistics. Vital Health Stat 2002; 11(246). 6. Lau DC. Synopsis of the 2006 Canadian clinical practice guidelines on the management and prevention of obesity in adults and children for the Obesity Canada Clinical Practice Guidelines Steering Committee and Expert Panel. Canadian Obesity Network, June 25, 2011. 7. Dubé MC, Valois P, Prud’homme D, et al. Physical activity barriers in diabetes: Development and validation of a new scale. Diabetes Res Clin Pract 2006;72: 20–7. 8. Nunnally JC. Psychometric theory. 2nd edn. New York: McGraw-Hill, pg. 1–701. 9. Riddell MC, Perkins BA. Type 1 diabetes and vigorous exercise: Applications of exercise physiology to patient management. Can J Diabetes 2006;30:63–71. 10. Fereday J, MacDougall C, Spizzo M, et al. “There’s nothing I can’t do—I just put my mind to anything and I can do it”: A qualitative analysis of how children with chronic disease and their parents account for and manage physical activity. BMC Pediatr 2009;9:1.