What are the barriers and facilitators to physical activity among young adults with diabetes attending a primary care clinic?

Barriers and Facilitators to Physical Activity Among Young Adults with Diabetes in Primary Care

Young adults with diabetes face distinct psychological and social barriers to physical activity that require targeted interventions addressing knowledge gaps, fear of hypoglycemia, family support systems, and professional guidance—not just generic exercise prescriptions.

Key Barriers Identified in Young Adults with Diabetes

Diabetes-Specific Barriers

Fear of hypoglycemia is the single most significant barrier to physical activity in young adults with diabetes, particularly those on insulin or insulin secretagogues 1, 2. This fear is compounded by:

• Inadequate knowledge about managing blood glucose during and after exercise 1, 3, 4
• Lack of understanding about carbohydrate adjustment and insulin dose modification 5
• Concerns about delayed hypoglycemia occurring hours after exercise due to increased insulin sensitivity 5
• Insufficient self-monitoring skills and glucose pattern recognition 1

Stigma and embarrassment about diabetes management in public settings emerged as a major social barrier 1. Young adults report reluctance to check blood glucose, consume carbohydrates, or manage diabetes devices during group exercise activities.

Psychosocial and Practical Barriers

The most prominent non-diabetes-specific barriers include:

• Lack of time and competing family commitments, particularly childcare responsibilities 1, 3, 4
• Work-related scheduling conflicts 3, 4
• Inadequate guidance from healthcare professionals about exercise prescription 1, 3
• Lack of motivation and perceived self-efficacy 1, 4
• Body image concerns and embarrassment about exercising in public 4
• Limited access to facilities and infrastructure 3, 4
• Weather-related barriers 4

Healthcare System Barriers

A critical gap exists in physician counseling practices—only one-third of patients report receiving physical activity counseling from their primary care physician 6. Additional system-level barriers include:

• Lack of adherence to standard exercise guidelines by physicians when counseling patients 3
• Insufficient emphasis on exercise compared to medication management 3
• Absence of structured, individualized exercise prescriptions 1, 3

Key Facilitators to Physical Activity

Knowledge and Education

Patient education about diabetes management during exercise is the most commonly discussed facilitator 2. Effective education should address:

• How to adjust insulin doses or carbohydrate intake before, during, and after exercise 5
• The need to ingest added carbohydrate if pre-exercise glucose is <90 mg/dL (5.0 mmol/L) 5
• Understanding that no more than 2 consecutive days should elapse between exercise sessions to maintain insulin sensitivity 5
• Recognition that prolonged sitting should be interrupted every 30 minutes for blood glucose benefits 5

Social Support Systems

Positive family support and interactive physical activity with others are powerful facilitators 1, 3. Young adults benefit from:

• Emotional support from family members 1
• Group exercise settings that provide social interaction 4
• However, one-to-one educational support is preferred over group diabetes education 4

Healthcare Professional Engagement

Emphasis and encouragement from both physicians and nursing staff significantly facilitates exercise adherence 3. Effective approaches include:

• Comprehensive counseling based on standard guidelines 3
• Brief, efficient counseling that is cost-effective 6
• Addressing patient-specific barriers rather than generic advice 6

Perceived Benefits

Young adults are motivated by understanding:

• Physical benefits including improved glycemic control, reduced A1C, and decreased diabetes complications 5
• Mental health improvements 1
• Enhanced body image 4
• Social role fulfillment and responsibility 1

Evidence-Based Exercise Recommendations for Young Adults

For Young Adults (18-40 years) with Diabetes

Young adults should engage in at least 150 minutes per week of moderate-to-vigorous aerobic activity, spread over at least 3 days per week, with no more than 2 consecutive days without activity 5. For younger, more physically fit individuals, a minimum of 75 minutes per week of vigorous-intensity or interval training may be sufficient 5.

Specific Exercise Prescription Components

• Aerobic exercise bouts should last at least 10 minutes, building toward 30 minutes per day 5
• Add 2-3 sessions per week of resistance exercise on nonconsecutive days 5
• Include accessible activities such as walking, yoga, housework, gardening, swimming, and dancing 5
• Progress intensity, frequency, and duration gradually 5

Critical Safety Considerations

For patients on insulin or insulin secretagogues, medication dose or carbohydrate consumption must be adjusted 5. Specific guidance:

• Check blood glucose before and after exercise 5
• Consider ingesting carbohydrate if pre-exercise glucose <90 mg/dL 5
• Adjust insulin doses during workouts when possible (e.g., with insulin pumps) 5
• Monitor for delayed hypoglycemia lasting several hours post-exercise 5
• Recognize that intense activities may raise rather than lower blood glucose, especially if pre-exercise levels are elevated 5

Practical Clinical Approach for Primary Care

Assessment Phase

Evaluate baseline physical activity and sedentary behavior at every visit 5. Specifically assess:

• Current activity level and barriers to meeting guidelines 5
• Patient-specific barriers (time, knowledge, motivation, fear of hypoglycemia) 1, 3, 6
• Family support systems and social opportunities 1
• Understanding of diabetes management during exercise 1, 3, 4

Intervention Strategy

Provide targeted education addressing hypoglycemia management as the priority intervention 1, 2. This includes:

• Specific instructions on glucose monitoring timing 5
• Carbohydrate adjustment protocols 5
• Insulin dose modification strategies 5

Encourage incremental increases in physical activity above baseline for those not meeting guidelines 5. Set stepwise goals rather than overwhelming patients with full recommendations immediately 5.

Address social barriers by facilitating access to facilities and group activities 1, 3, 4. Consider:

• Free or reduced admission to gyms and pools 4
• Time management strategies 4
• Interactive physical activity options 1

Follow-up and Support

Provide ongoing encouragement and monitoring 3. Both physicians and nursing staff should emphasize exercise at each encounter 3.

Use one-to-one counseling approaches rather than group education 4, as young adults with diabetes prefer individualized support.

Common Pitfalls to Avoid

• Failing to provide specific diabetes management education around exercise—generic exercise advice without addressing hypoglycemia management is insufficient 1, 2, 4
• Underestimating the impact of fear of hypoglycemia—this requires explicit, detailed education and reassurance 1, 2
• Ignoring social and family barriers—young adults face unique challenges with childcare and family commitments that must be acknowledged 1, 3
• Providing only verbal advice without written protocols—patients need concrete instructions for glucose monitoring and carbohydrate/insulin adjustment 5
• Allowing more than 2 consecutive days between exercise sessions—this diminishes insulin sensitivity benefits 5
• Not addressing stigma and embarrassment—young adults need strategies for managing diabetes discreetly during social exercise activities 1