Original article:
Will older sedentary people with non-insulin-dependent diabetes mellitus start exercising? A health promotion model. Samaras K, Ashwell S, Mackintosh A-M et al. Diabetes Res Clin Pract 1997; 37: 121-8.

Summary and Comment
Exercise and diet form the basis of management of patients with Type 2 diabetes. However, many older people have difficulty in exercising, thus missing out on the benefits on glycaemic control, weight, cardiac disease and mood. Samaras et al. report the outcomes of a 6-month structured exercise and support programme based on a health promotion model, on physical activity, glycaemic control and parameters of cardiovascular risk in non-exercisers, compared with standard outpatient clinic education. A total of 26 non-exercising patients (10 men, 16 women, mean age 60 years) were randomized to an intervention or a control group.
The structured exercise programme was designed by a nurse educator after a thorough assessment of the needs of the targeted population. Several factors for non-compliance to exercise were identified such as predisposing factors (attitudes, beliefs, knowledge), lack of enabling factors such as skills, and lack of reinforcing factors such as feedback and support. The programme itself consisted of monthly sessions lasting 1 h which dealt with various issues, amongst them safe exercise, exercise-specific education, self-esteem issues, goal-setting and enjoyment of a chosen exercise. Programme participation was not associated with any significant increase in activity. HbA 1c levels tended to stabilize in the intervention group during the 6-month programme, but by 12 months, HbA 1c levels had increased by 0.86% in both groups. Programme participation did not lead to a significant change in anthropometric or metabolic parameters. Although the overall results were disappointing, it became clear that an increase in activity was associated with a significant reduction in body weight, percentage body fat, and fasting glucose and insulin levels. The authors did not find that these changes were related to changes in energy intake or dietary composition.
This study confirms that exercise is indeed beneficial in subjects with Type 2 diabetes. However, even an intensive structured health promotion programme such as this failed to stimulate sufficient numbers of patients to increase their daily exercise. Several other interventions have also failed to significantly increase physical activity in previously sedentary diabetic subjects. This is not surprising: people engage in sports and exercise because they like to do so, not specifically to promote health.
The authors conclude that expenditure on this type of programme is not justified within the current economic constraints on health budgets. Perhaps it is indeed time to rephrase the guidelines for treatment of subjects with Type 2 diabetes, which still consider diet and exercise to be the cornerstone of therapy.