Journal of Health Communication, Volume 6, pp.

99±115, 2001
Copyright # 2001 Taylor & Francis
1081-0730 /01 $12.00 + .00

Articles

A Comparison of Views of Individuals with Type 2

Diabetes Mellitus and Diabetes Educators About
Barriers to Diet and Exercise

JILL ARMSTRONG SHULTZ

Department of Food Science & Human Nutrition, Washington State University
Pullman, Washington, USA

MAUREEN A. SPRAGUE
St. Joseph Regional Medical Center, Lewiston, Idaho, USA

LAUREL J. BRANEN
School of Family & Consumer Sciences, University of Idaho, Moscow, Idaho, USA

SUZANNE LAMBETH
Diabetes Management Consultant, Moscow, Idaho, USA

Diet and exercise are the cornerstones of treatment for persons with type 2 diabetes
mellitus, yet patients Ž nd these areas of self-management to be the most difŽ cult.
Considerable research has indicated that barriers to diet and exercise are critical
in uences determining adherence to diet and exercise plans. Standards of practice
require educators to assess patient barriers to self-management. However, little
research has investigated whether patients and educators perceive these barriers
similarly. This project’s objectives were to compare and contrast patients’ and edu-
cators’ perspectives of patient barriers to following a meal or exercise plan, and to
identify differences in patients’ perceived barriers as related to patient characteris-
tics. Patients with type 2 diabetes mellitus (n ˆ 97) from three eastern Washington
area hospitals and diabetes educators (n ˆ 143) from the Washington Association of
Diabetes Educators (WADE) were recruited for a mail survey. From the patient
survey, the proportion of patients on a meal plan (52% ) or exercise plan (26% ) was
low. Certain barriers were prominent for both patients and educators relative to diet
(difŽ culty maintaining a diet away from home, liking foods not in the meal plan) and
exercise (not a high priority, weather). However, multivariate analyses indicated that

Address correspondenc e to Jill A. Shultz, Ph.D., Associate Professor of Nutrition, Department of Food
Science & Human Nutrition, Washington State University, Pullman, WA 99164-6376 , USA.
This research was funded by the Margaret Nicholson Schafer Graduate Fellowship and the Margaret Hard
Home Economics Research Award at Washington State University and a grant from the Washington Association
of Diabetes Educators.

99
100 J. Armstrong Shultz et al.

patients and educators view barriers differently. Similarities and differences between
educators and patients in response to barriers are discussed relative to enhancing
diabetes counseling and education, and overall communication between educators
and patients.

Diabetes was the seventh leading cause of death in the United States in 1996 (Centers for
Disease Control and Prevention, 1998) and was the sixth leading cause of death by disease
in both 1987 (Centers for Disease Control, 1991) and 1993 (National Institute s of Health,
1995a). About 90% of persons with diabetes produce some insulin (National Institute s of
Health, 1995b), but have physiologica l resistance to its effects (type 2 diabetes). Patients
with type 2 diabetes mellitus require a combination of diet and medications, possibly
including insulin, to control blood glucose levels. In addition, exercise is often desirable
for its bene®cial effects on insulin sensitivity and to treat the excess body weight asso-
ciated with type 2 diabetes. Being overweight negatively impacts glycemic control and
increases long-term risk for cardiovascular disease (American Diabetes Association,
1998a). Successful management of diabetes requires that the patient carry out numerous
self-care procedures (American Diabetes Association, 1998b) based on goals that are set
by the patient and provider together (American Diabetes Association, 1998c).
Goal setting requires speci®c communication between the patient and provider;
however, the quality of this communication can be problematic. In a study comparing
patients’ perceptions with their physicians’ perceptions of treatment goals, D’Eramo-
Melkus and Demas (1989) found that 53% of the matched patient±physician pairs
showed disagreement on each treatment goal in the patient’s overall plan. Discrepancy
rates were especially notable for weight loss (57%) and blood glucose levels (43%).
Anderson, Fitzgerald, Goren¯o, and Oh (1993) compared the attitudes of nurses, regis-
tered dietitians, and physicians with the attitudes of patients with diabetes (type 1 and
type 2) relative to seven content areas for diabetes education. They reported that patients
were more judgmental than health care providers about patient behavior related to
compliance. Genev et al. (1992) found that patients with type 2 diabetes assessed just
before their diabetes education had different priorities than their educators for most
education topics, even though educators had met with each patient for a one-hour session
prior to their own selection of educational topics and had supposedly individualize d the
educational approach. These studies point to the need to investigate how differently
patients and providers perceive self-management, especially with the current educational
emphasis on goal setting. Underestimating or misidentifyin g the patient’s educational
needs could have a negative impact on educational effectiveness and outcomes.
The theoretical construct of barriers, derived from the Health Belief Model, provides a
framework for understandin g patient learning and behavioral change and has been applied
to the study of adherence to diabetic regimens (Rosenstock, 1985). Barriers to self-man-
agement expressed by patients with diabetes are strongly associated with adherence to
treatment regimens (Ary, Toobert, Wilson, & Glasgow, 1986; Glasgow, 1994; Polly, 1992;
Wilson et al., 1986) and patients’ subjective estimates of diabetes control (Lewis, Jennings,
Ward, & Bradley,1990). Barriers to physical activity and diet occur most often (Ary et al.,
1986), the regimen areas most closely associated with lifestyle changes (Rubin, Peyrot, &
Saudek, 1991; Sprague et al., 1999). Although assessing patient barriers to learning is a
standard of practice for diabetes educators (American Association of Diabetes Educators,
1992), no research was found that compares and contrasts patients’ perceptions about diet
and exercise barriers with diabetes educators’ perceptions of those barriers. The compar-
ison and contrast of barriers expressed by these two groups would help to identify
important adjustments to counseling (Brown, Pope, Hunt, & Tolman, 1998). Speci®c
 Type 2 Diabetes Mellitus 101

information about diet and exercise barriers can be applied to diabetes education programs
to lower patient barriers to education, and to reduce barriers to implementing diet and
exercise behaviors after education.
The objectives of this study, therefore, follow:
1. To compare and contrast patients’ and educators’ perceptions of barriers patients face
in following a meal plan or exercise program.
2. To identify differences in patients’ diet and exercise barriers that relate to selected
personal and sociodemographic characteristics of patients and their experience with
diabetes.
3. To identify educational issues related to lowering barriers to diet and exercise for
patients with type 2 diabetes.

Methods
Patient Survey
The patient sample was obtained through patient medical records at three hospitals in the
eastern Washington region. Two small hospitals (licensed for < 50 beds) were located in
university towns (populatio n ˆ 30,000 to 40,000), while the third was a regional medical
center serving a population of about 53,000 and licensed for > 150 beds. All three hospitals
use goal setting as part of their educational approach with diabetes patients. This approach
emphasizes effective and achievable behavioral changes for diabetes management that are
negotiated between the health care provider and the patient. Records of patients with type 2
diabetes who had completed diabetes education between six months and two years prior to
the start of the study were identi®ed by hospital personnel working in diabetes education.
This screening was designed to select patients who had at least six months of experience in
applying diabetes education on their own, and who were still available. This time period
also represents the early experience with diabetes self-care skills for which educators try to
prepare patients. Hospital personnel compiled a sampling frame of names and addresses of
eligible individuals . Eligible respondents totaled 298, with lists of 36 and 50 patients from
the smaller hospitals, and 212 patients from the regional hospital. All procedures were
approved by the university’ s institutiona l review board.
The 38-item patient questionnair e assessed barriers to following a meal plan and an
exercise plan, self-reported adherence to prescriptions or recommendations for diabetes
care, and diabetes history. Selected diet and exercise barriers were derived from the
Barriers to (Diabetes) Self-Care Scale (Oregon Research Institute , 1994), with additional
barriers derived from an instrument developed by Swift, Armstrong, Beerman, Campbell,
and Pond-Smith (1995). Other diet and exercise barriers were developed from a focus
group of patients (4 women, 4 men) who were recruited through one of the smaller hos-
pitals and later excluded from the survey. Other data included questions about goal setting,
social support, and dif®culty with areas of diabetes management, to be reported elsewhere.
Two lists of barriers were included in the questionnaire : 13 potential barriers to
following a meal plan (Tables 1 and 2) and 14 potential barriers to following an exercise
plan (Tables 3 and 4). Both lists utilized a partially open-ended format with an ``other
(please specify)’’ category that allowed the respondent to write in additional barriers.
Each barrier item was stated in the ®rst person; for example, ``I feel hungry right after
meals.’’ The response scale included 0 ˆ never, 1 ˆ seldom, 2 ˆ sometimes, 3 ˆ usually,
4 ˆ always.
The questionnair e was peer reviewed by nutritionists , dieticians, certi®ed diabetes
educators, and survey specialists at Washington State University. Pretesting was
102 J. Armstrong Shultz et al.

conducted with a small group of patients. The only change to the instrument from pre-
testing was to increase the size of the type for enhanced readability.
Survey implementation was conducted from the hospitals to protect the privacy and
con®dentiality of the patients. The Total Design Method (TDM) for mail surveys
(Dillman, 1978) was followed. Survey elements included a booklet-styl e questionnair e
with an illustratio n on the cover, a cover letter on hospital business letterhead, and
multiple mailings to enhance response. A postcard reminder and thank you was mailed
one week after the initial mailing, followed by a letter and replacement questionnair e sent
to nonresponders after three weeks. To reduce mailing costs, a third mailing normally
conducted with the TDM was not included.

Diabetes Educator Survey

The sample of diabetes educators was obtained by response to a mail survey sent to all
noncorporate members of WADE. Responses from members who had not practiced
diabetes education in the last year (indicated at the top of the questionnaire ) were
excluded.
The 40-item questionnair e sent to educators was designed as a needs assessment,
with ®ve sections of questions addressing program structure and process, program eval-
uation, information related to patients with type 1 or type 2 diabetes, and issues faced by
diabetes educators. Pertinent to this article, the diet and exercise barriers questions
designed for the patient survey were included in the educator survey, with two re®ne-
ments. First, the barrier was stated in the third person; for example, ``Patient feels hungry
after meals.’’ Second, a different response scale allowed the educator to estimate the
proportion of their patients with type 2 diabetes who have experienced the barrier
(1 ˆ none, 2 ˆ few, 3 ˆ some, 4 ˆ most or all). Thus, the educators reported the pro-
portion of their patient population that they believed had experienced the barrier, whereas
the patients reported how often they felt each item was a barrier for them. Although
barriers statements may utilize an agree±disagree scale (Glasgow, 1994; Lewis et al.,
1990; Swift et al., 1995), frequency scales also have been used (Ary et al., 1986;
Glasgow, McCaul, & Schafer, 1986). Our approach was selected to avoid the bias of
respondent s trying to ``average’ ’ a magnitude of barrier impact (patients) or to describe
the ``average’ ’ patient or patient group (educators). We felt that expressing the barriers in
these two ways maximized the validity of the barriers assessment for each group and still
allowed a comparison of responses between the groups, with careful interpretation.

Data Analysis
Descriptive statistics were used to summarize the data. Similaritie s and differences
between patients’ and educators’ perceptions of patient barriers were examined using
ordinal logistic regression in an item-by-ite m comparison of response. Patients’ and
educators’ responses to barriers also were analyzed separately using principal compo-
nents factor analysis (PCFA), and the resulting factor patterns were compared. Para-
meters used in the PCFA included an eigenvalue cutoff ˆ 1, and orthogona l rotation.
Orthogonal rotation results in independent factor patterns. Cattell’s screen test was used
to estimate the number of meaningful factors (Tabachnick & Fidell, 1983a). Factor
loadings ¶ j 0.45 j were considered signi®cant in factor pattern interpretation . Bivariate
tests to examine patients’ responses to barriers relative to other patient characteristics
utilized Pearson’s r, the t test, and the chi-square statistic. The level of statistical sig-
ni®cance was p < .05.
 Type 2 Diabetes Mellitus 103

Results

Patient Sample
Response rates for the two smaller hospitals were 61% (n ˆ 22) and 52% (n ˆ 26),
whereas response from the larger hospital was much lower (23%; n ˆ 49). The total
sample of 97 patients was mostly female (61%) with an average age of 60.6 § 12.5 years.
The group included somewhat more individual s of typical workforce age (28 to 64 years,
58%) than retirement age (65 years and older, 40%). Years since diagnosis averaged
4.3 § 5.9 (range < 1 year to 38 years), but, the majority (58%) had been diagnosed within
the last two years. There was no statistically signi®cant gender difference in years since
diagnosis. Many individuals had received their ®rst diabetes education within two months
of diagnosis (67%), indicating that this group as a whole had received early education.
Diabetes education included physician care (82%), one-on-one counseling (66%), group
instruction (53%), and follow-up (29%). Relatively few patients had been diagnosed
with long-term complications of diabetes, such as heart disease (18%), gastrointestina l
disorders (12%), neuropathy (9%), renal disease (5%), or retinopathy (4%). High blood
pressure was fairly prevalent (58%).
Certain information on diabetes management was considered critical to under-
standing patients’ responses to barriers. Many patients reported taking oral medications
(67%). Although most reported having a currently prescribed or advised number of
routine blood glucose tests (63%), fewer (52%) reported having a speci®c diet or meal
plan. Also, only 26% reported having a prescribed or recommended exercise program.
Following a meal or exercise plan was not signi®cantly related to age. However, patients
not following a meal plan had been diagnosed for a signi®cantly longer time on average
(5.2 § 7.7 years) than other patients (3.4 § 4.3 years) ( p < .001). Eleven individuals
(11%) reported taking insulin as part of their regimen. Adherence was high among
individuals reportedly following a plan: The majority usually or always followed their
regimens for insulin (100%), oral medications (95%), a meal plan (86%), blood glucose
monitoring (77%), or exercise (60%). There was no statistically signi®cant difference
between men and women in exercise adherence.

Diabetes Educator Sample

A ®nal response rate of 64% yielded a group of 143 WADE members consisting of
registered nurses (61%), registered dietitians (27%), nurse practitioners (8%), phar-
macists (5%), and one medical doctor. Most were certi®ed diabetes educators (74%) and
female (92%). Educators had worked an average of 10.8 § 6.4 years in diabetes educa-
tion, but were mostly (75%) part-time workers.

Barriers to Following a Meal Plan

Barriers that were prominent among diabetes educators were not necessarily prominent
among patients (Table 1). The percent of educators responding ``most or all’’ and the
percent of patients responding ``usually’’ or ``always’’ were used for comparison. For
example, ``when eating out, patient eats portions larger than meal plan calls for’’ was
identi®ed by 53% of educators compared with 40% of patients. Two other barrier
statements rated highly among educators, ``patient has dif®culty maintaining meal plan
while away from home’’ (42%) and ``patient is tempted by snacks at home or at the
of®ce’’ (39%), were not rated as prominently by patients (40% and 32%, respectively).
104
TABLE 1 Comparison by Ordinal Logistic Regression of Type 2 Patients’ and Diabetes Educators’ Perceptions of Barriers Experienced by Type 2
Patients to Following a Meal Plan

% of Response1

Barrier Factors p value Dum2 13 2 3 4

Pt DE Pt DE Pt DE Pt DE
I feel=patient feels hungry after meals4 .0001 74.01§ .46 65 0 28 42 4 55 2 3
I am=patient is tempted by snacks at home or at the office .0001 72.96§ .34 22 0 44 8 27 53 5 39
When eating out, I eat=patient eats portion larger than meal .0001 73.09§ .35 27 1 33 4 33 42 7 53
plan calls for
I feel=patient feels meal plan doesn’t give enough to eat .0001 73.00§ .34 58 2 29 36 10 55 3 7
When eating out, I feel=patient feels the choices for healthy .0001 71.92§ .28 27 1 39 23 27 47 7 28
foods are limited
I feel=patient feels self-conscious turning down food in a social setting .0001 73.06§ .33 71 5 15 28 9 53 5 15
I like=patient likes foods not included in meal plan .0001 71.13§ .26 14 4 46 27 24 34 16 34
I feel=patient feels there is no flexibility in meal plan for daily changes .0001 72.34§ .31 58 10 34 45 6 39 2 5
I don’t like=patient doesn’t like eating differently than other people .0001 72.28§ .29 61 4 17 36 10 42 12 18
It is difficult for me=patient to eat at scheduled meal times .0001 72.62§ .31 47 3 36 24 11 56 6 16
I find=patient finds it difficult to eat in front of others when .0001 71.69§ .29 62 12 20 63 14 23 4 2
they are not eating
I have=patient has difficulty maintaining meal plan while .0001 72.13§ .29 29 0 30 14 27 45 13 42
away from home
I find=patient finds it difficult to be around people who consume .0001 73.39§ .35 61 2 25 21 11 52 3 25
foods not in the meal plan
1
Missing values ranged from 4% to 7% of the patient sample and 6% to 17% of the diabetes educator sample.
2
3
Dummy variable mean estimate § standard error (0 ˆ patients, 1 ˆ diabetes educators).
4
Patient scale: 1 ˆ seldom or never, 2 ˆ sometimes, 3 ˆ usually, 4 ˆ always. Diabetes educator scale: 1 ˆ none, 2 ˆ few, 3 ˆ some, 4 ˆ most or all.
Each question was a ®rst person statement for patients and a third person statement for diabetes educators.
 Type 2 Diabetes Mellitus 105

By contrast, the barrier ``I like foods not included in my meal plan’’ seemed to have a
greater impact for patients (40%) than educators (34%). Patients were more likely to
mention food selection, whereas educators were more likely to mention food portion
control.
A few patients and educators wrote in ``other’’ barriers to following a meal plan.
Patients’ barriers included, ``If I’m busy and feeling ok I forget my snacks,’’ and ``I have
to eat what is not in my meal plan to maintain a sugar level to get me through the night.’’
Among educators, ``other’’ barriers related to patient issues (doesn’t organize meals,
doesn’t want to follow a meal plan, doesn’t set limits, spouse has no eating restrictions,
patient is homebound, ®nancial restrictions) or to care providers (lack of referral to an
registered dietician, doctor gives preprinted diets, support personnel ``nag’’ patients about
inappropriat e choices).
Table 1 also shows an item-by-item comparison of responses to meal barriers from
the two samples using ordinal logistic regression. This provided a statistical test of the
homogeneity of responses between the two groups. A negative value for the dummy
variable indicates that patients were measuring lower on the response scale than diabetes
educators. For every barrier that was assessed, diabetes educators estimated the effect on
behavior to be greater than did the patients.
When a principal components factor analysis was conducted of both patients’ and
educators’ responses to barriers to following a meal plan, factor patterns showed different
clusters of concerns for the two groups (Table 2). All factors generated were retained for
analysis. For the patients, the ``restrictive eating’’ and ``eating differently than others’’
factors suggest that the personal constraints of day-to-day eating were a separate issue
from the social problem of feeling different than other people where eating behaviors are
concerned. Also, the ``restrictive eating’’ factor was the ®rst factor extracted and therefore
represents the prominent factor (with the largest variance accounted for by any single
factor from the patient data). By contrast, the ®rst factor from the diabetes educator data
represented social in¯uences that were seen as problematic for patients (``social con-
straints and eating out’’ ). Barriers with food choice and food insuf®ciency were seen as
separate and less prominent issues. For the patient sample, issues related to ``not enough
food’ ’ or ``feeling hungry’ ’ were not separate, but instead integrated with other constraints
that relate to keeping to a meal plan.

Barriers to Following an Exercise Plan

Similar to results with meal barriers, prominent exercise barriers for educators were
reported at a lower magnitude by patients (Table 3). Examples included ``exercise is not a
high priority’’ (48% for educators versus 38% for patients), and ``exercise habits are
dependent on the weather’ ’ (37% for educators, 28% for patients). By contrast, the
barrier ``choices of exercise activities are minimal because of physical limitations’’ was
greater among patients (32%) than educators (6%). A low priority associated with
exercise was a key barrier recognized by patients and educators.
Patients wrote in ``other’’ barriers to following an exercise plan that related mostly
to physical limitations, including, ``hip injury,’’ ``terribly short of breathÐhave a heart
valve problem,’’ ``poor health for exercise,’’ ``have asthma and trouble breathing,’’ and
``rheumatism limits exercise.’’ ``Work’ ’ was also reported. Similarly, several educators
wrote in barriers related to safety or physical ability, such as the patient’s age or
ulcer wounds, and the diminished ability to exercise that is associated with many of the
patients who have had a history of stroke. Other educators mentioned motivationa l
factors, namely, ``not ready to change,’ ’ ``attitude toward exercise,’ ’ ``just don’t like to
 TABLE 2 Principal Components Factor Analysis of Patients’ and Educators’ Responses to Barriers to Diet

106
Patients’ Perceived Diet Barriers (total variance explained ˆ 53%)

``Restrictive Eating’’ ``Eating Differently than Others’’

0.811 No daily flexibility in my meal plan 0.77 Difficult to eat when others are not eating
0.76 Like foods not in my meal plan 0.69 Feel self-conscious turning down food
in social setting
0.75 Meal plan doesn’t give me enough to eat 0.67 Difficult to be around others who
consume foods not in meal plan
0.64 Eating out, healthy food choices are limited 0.65 Difficult to eat on a schedule
0.62 Feel hungry after meals 0.63 Dislike eating different than others
0.57 Difficult maintaining meal plan away 0.53 Tempted by snacks at home or office
from home
0.51 Dislike eating differently from others 0.51 Eat larger portions when eating out

Educators’ Perceived Diet Barriers (total variance explained ˆ 57%)

``Social Constraints and Eating Out’’ ``Food Choice Dif®culty’’ ``Food Insuf®ciency’’

0.77 Eat larger portions when eating out 0.80 No daily flexibility in meal plan 0.88 Feels hungry after meal
0.65 Eating out, healthy food choices are limited 0.73 Dislike eating differently than others 0.66 Meal plan does not
give enough to eat
0.65 Difficult to be around people who 0.71 Like foods not in meal plan
consume foods not in meal plan
0.63 Self-conscious turning down food in 0.59 Difficult to eat when others
social setting are not eating
0.61 Difficult maintaining meal plan away
from home
0.59 Difficult to eat on a schedule
0.55 Tempted by snacks at home or office
 TABLE 3 Comparison by Ordinal Logistic Regression of Type 2 Patients’ and Diabetes Educators’ Perceptions of Barriers Experienced by Type 2
Patients Following an Exercise Program

% of Response1

Barrier Factors p value Dum2 13 2 3 4

Pt DE Pt DE Pt DE Pt DE
Exercise is physically painful for me=patient4 0.0001 71.51 § 0.27 39 2 36 48 11 48 14 2
Choices of exercise activities for me=patient are minimal because 0.0001 71.26 § 0.26 42 1 26 44 13 49 19 6
of physical limitations
When exercising, I worry=patient worries about having 0.0001 73.70 § 0.40 88 13 9 69 2 16 1 1
low blood sugar
I find=patient finds it difficult to balance exercise with food intake 0.0001 72.10 § 0.30 55 5 29 59 11 31 4 4
My=patient’s exercise habits are dependent on the weather 0.0001 72.90 § 0.32 33 1 39 13 25 48 3 37
My=patient’s time schedule does not allow for regular exercise 0.0001 72.96 § 0.32 59 1 22 22 14 48 5 28
Exercise is not a high priority for me=patient 0.0001 72.43 § 0.29 33 0 29 11 25 41 13 48
Exercising makes me=patient feel physically uncomfortable 0.0001 72.39 § 0.31 63 4 20 57 6 34 10 5
I am=patient is too overweight to exercise 0.0001 73.35 § 0.36 85 12 6 42 5 41 3 5
I do=patient does not like to sweat 0.0001 71.92 § 0.31 77 24 10 52 8 20 6 3
I don’t=patient doesn’t have any place to exercise 0.0001 73.30 § 0.36 78 9 16 55 0 35 5 1
I am=patient is not in a convenient location when it is 0.0001 72.62 § 0.33 70 9 20 52 7 36 3 2
time to exercise
I don’t=patient doesn’t have the necessary materials or equipment 0.0001 72.65 § 0.33 77 15 15 54 6 28 2 2
available when it is time to exercise
1
Missing values ranged from 3% to 9% of the patient sample and 3% to 26% of the diabetes educator sample.
2
3
Dummy variable mean estimate § standard error (0 ˆ patients, 1 ˆ diabetes educators).
4
Patient scale: 1 ˆ seldom or never, 2 ˆ sometimes, 3 ˆ usually, 4 ˆ always. Diabetes educator scale: 1 ˆ none, 2 ˆ few, 3 ˆ some, 4 ˆ most or all.
Each question was a ®rst person statement for patients and a third person statement for diabetes educators.

107
108 J. Armstrong Shultz et al.

exercise,’’ ``patient lacks motivation,’ ’ and ``poor self-imageÐdoesn’t want to be seen in

exercise clothes.’’
Table 3 shows the results of an ordinal logistic regression analysis comparing patient
and educator responses for each exercise barrier. Similar to the results with meal barriers,
patient response was signi®cantly lower than the educator response, suggesting that
educators perceived the barriers to have a greater effect than did the patients.
A PCFA of responses to exercise barriers indicated that the patients and educators
had somewhat different perspectives, as evidenced by the order and interpretation of the
factor patterns extracted (Table 4). All factors generated were retained for interpretation .
For the patient data, the ®rst factor pattern appeared to re¯ect the dif®culty of arranging
exercise as it relates to convenience (``dif®cult to arrange exercise’’). By contrast, the ®rst
factor pattern with the educators’ data emphasized physical problems: being uncomfor-
table, being overweight, and not liking to sweat (``physical discomfort’ ’). Physical pro-
blems related to physical limitations or pain with exercise were also expressed by
educators in the third factor pattern (``physical limitations’’) and in the second factor
pattern from the patient data (``exercise is uncomfortable’’). The third factor pattern from
patient data suggested that not liking any type of exercise is related to not liking to sweat.
Exercise that is dependent upon the weather appeared to be a separate barrier for patients
but showed no clear trend in educator data. Finally, the fourth factor pattern from the
educators’ data suggested a concern with low blood sugar that was not expressed in the
patient data. Overall, circumstantial or convenience barriers and physical discomfort or
limitation barriers were similar for both patients and educators but may differ in their
importance to these groups.

Issues Related to Patient Barriers

Further analyses were run to determine if patients following a meal or exercise plan
differed from other patients in perceptions of barriers. Patients not following a meal
plan appeared to weigh more heavily the barrier of liking foods not on the meal plan
(chi square ˆ 5.079, df ˆ 2, p ˆ 0.079). For patients not following an exercise plan at the
time of the study, more frequent barriers included, ``Choices of exercise activities are
minimal for me because of physical limitations’ ’ (chi square ˆ 6.296, df ˆ 2, p < .05), ``I
®nd it dif®cult to balance exercise with food intake’’ (chi square ˆ 9.179, df ˆ 2,
p < .01), and ``Exercise is not a high priority for me’’ (chi square ˆ 8.594, df ˆ 2,
p < .05).
Factor scores from the PCFA results were generated to explore relationships between
barrier patterns and other patient characteristics. A factor score is an estimate of the score
a patient (or educator) would have had on a latent variable (factor pattern) if he or she had
been measured directly (Tabachnick & Fidell, 1983b). Factor scores from both the
``restrictive eating’’ and ``eating differently from others’’ meal barrier patterns correlated
signi®cantly with factor scores from the ®rst exercise factor pattern, ``dif®cult to arrange
exercise’ ’ (Pearson’s r ˆ 0.300, p < .05 and r ˆ 0.374, p < .01, respectively). Also, scores
from the two meal barrier factor patterns correlated with scores from the third exercise
factor pattern, ``don’t value exertion’ ’ (r ˆ 0.282, p < .05 and r ˆ 0.354, p < .01,
respectively). These results show that the meal barrier patterns correlated only with the
exercise barrier patterns that related to convenience or the overall value of exercise. In
addition, age correlated negatively with factor scores from the ``eating differently than
others’ ’ (r ˆ 70.329, p < .01) and ``dif®cult to arrange exercise’ ’ (r ˆ 70.374, p < .001)
factor patterns, implying that social barriers to following a diabetic meal plan and the
inconvenience of arranging exercise are perceived as less of a problem by older patients.
 TABLE 4 Principal Components Factor Analysis of Patients’ and Educators’ Responses to Barriers to Exercise

Patients’ Perceived Exercise Barriers (total variance explained ˆ 65%)

``Dif®cult to Arrange ``Exercise Is ``Exercise In¯uenced by

Exercise’’ Uncomfortable’’ ``Don’t Value Exertion’’ Weather’’

0.861 Not in convenient location 0.93 Exercise is physically painful 0.80 Don’t like any type of 0.76 Exercise dependent
when time to exercise exercise on weather
0.81 No materials or equipment 0.84 Have physical limitations 0.77 Don’t like to sweat 0.60 Too overweight to exercise
available when time to
exercise
0.80 Time schedule does not allow 0.72 Exercise makes me 0.52 Exercise not a high
regular exercise physically uncomfortable priority
0.65 Don’t have a place to 0.51 Too overweight to exercise 0.52 Difficult to balance
exercise exercise with food
0.50 Exercise not a high priority
Educators’ Perceived Exercise Barriers (total variance explained ˆ 61%)

``Low Blood Sugar

``Physical Discomfort’’ ``Circumstantial In¯uences’’ ``Physical Limitations’’ In¯uence’’

0.73 Too overweight to exercise 0.80 Time schedule does not allow 0.80 Have physical 0.78 Difficult to balance exercise
regular exercise limitations with food
0.72 Does not like to sweat 0.66 Not in convenient location 0.78 Exercise is physically 0.71 Worries about low
when time to exercise painful blood sugar
0.67 Exercise makes patient 0.62 Exercise not a high priority 0.57 Exercise dependent on 0.52 No materials or equipment
physically uncomfortable the weather available when time to
exercise
0.63 Does not have a place 0.59 No materials or equipment
to exercise available when time to
exercise
0.48 Exercise dependent on the

109
weather
1
Values represent factor loadings.
110 J. Armstrong Shultz et al.

Certain factor patterns appeared related to adherence for patients reportedly fol-
lowing a meal or exercise plan. Factor scores for the ``eating differently than others’’
factor pattern correlated negatively with frequency of following a meal plan (Kendall’s
tau b ˆ 70.375, p < .001), suggesting that social barriers reduce the likelihoo d of meal
plan adherence. Also, the frequency of following an exercise plan was negatively cor-
related with the convenience-related aspects of exercise (factor scores for ``dif®cult to
arrange exercise’’ factor pattern: r ˆ 70.326, p < .05; and ``exercise in¯uenced by
weather’’ factor pattern: r ˆ 70.312, p < .05).

Discussion
Barriers to Following a Meal Plan
Findings indicated that an important barrier to following a meal plan was liking foods not
in the meal plan and that this barrier may be a signi®cant in¯uence on whether a patient is
on a meal plan. There may be a strong need for educators to recognize patients’ favorite
foods when discussing dietary management and to include these foods in the meal plan.
The patient may need additional education to know how to incorporate these foods and to
be ¯exible within the meal plan. Also, successful adherence to a meal plan appeared most
related to how well a patient is coping with eating differently than others in social set-
tings. It may be that long-term adherence also depends on incorporatin g key familiar
foods because of feelings of deprivation that could develop over time. Social pressures to
eat like other people may exacerbate the problem. Although research with registered
dietitians has indicated that most tailor the diabetes diet to the client’s lifestyle (Brown
et al., 1998), this may not be a routine practice among all providers.
Communicating about how dietary management skills apply to eating away from
home may need more attention in the curriculum. Both patients and educators empha-
sized barriers related to selection and portion size when eating away from home, an
aspect of dietary management skills that is experienced largely after diabetes education.
Most patients reportedly did not receive follow-up education, which could be an
opportunit y to address problems with eating away from home and other meal barriers.
Speci®c problem solving with eating away from home and incorporatin g favorite foods in
a meal plan appear to be important topics for diabetes education with this patient group.
The ®nding that the ``eating differently than others’’ barrier pattern was related
negatively to age may spring from the fact that many patients (58%) were still of
workforce age and faced with ®tting dietary changes into a workday. Patient employment
was not directly assessed. However, in an item assessing coworker support for self-
management, 37% circled ``does not apply.’’ One possible explanation for the different
pattern of social barriers in the educators’ responses is that educators may have had more
patients of retirement age as their reference group, with less need to emphasize dietary
management in a workplace environment. Also, some older patients with more experi-
ence in managing their diabetes may be more assertive in following dietary restrictions in
social settings.
Meal barrier patterns from this and other studies emphasize certain themes poten-
tially affecting diet management. For example, feelings about eating away from home
and eating on a schedule may relate to patients’ perceptions of control or lack of control
over social situations (Swift, Armstrong, Campbell, Beerman, & Pond-Smith, 1997), or
pressure to accommodate social situations (Schlundt, Rea, Kline, & Pichert, 1994).
The feeling of needing more to eat (Swift et al., 1997) and feeling deprived (Schlundt
et al., 1994) also have been expressed by patients and can relate strongly to following the
 Type 2 Diabetes Mellitus 111

meal plan at home and away from home (Swift et al., 1997). Other issues that may be
barriers to adherence include eating in response to negative emotions, resisting tempta-
tion, and lack of support from family and friends (Schlundt et al., 1994). Schlundt and
colleagues (1994) suggested that educators should discuss with the patients the potential
dilemma of choosing between food selection appropriate to a situation and pursuing the
lifelong goal of diabetes self-management. Patients who use insulin may have more
barriers to adherence overall (Davis, Hess, Van Harrison, & Hiss, 1987); however,
relatively few (11%) patients in this study used insulin.

Barriers to Following an Exercise Plan

For patients, exercise barriers stemmed from either physical limitations or a lack of
convenience or interest related to exercise. Perceived physical limitations to exercise
appeared related to whether a patient was on an exercise plan, whereas the convenience
aspect of exercise related to adherence. Educators recognized both the physical and
motivationa l barriers that patients face. However, addressing exercise may be more
challenging for some educators when patients have lifestyle barriers, as opposed to when
patients have concrete physical limitations.
The survey did not investigate why exercise is not a priority for some patients. This
and other research suggests that the reason may be a combination of barriers related to
time, convenience (Glasgow, 1994; Swift et al., 1995), discomfort or fear of complica-
tions from exercise (Swift et al., 1995), and a perception that ``it won’t matter if I don’t
exercise’’ (Glasgow, 1994). Without clinical pro®les on the patients, it was not possible to
verify ability to exercise. Few (26%) patients were on an exercise plan, despite the fact
that the majority did not feel that physical limitations were frequently a problem. Thus,
modi®able barriers to exercise were playing an important role with this group of patients.
For some patients, the feeling that ``exercise is not a priority’ ’ may express how limited
the patient feels with balancing many lifestyle changes at once, as well as a limited
perception of the bene®ts of exercise.
There is evidence that exercise is related to perceived external in¯uences that
patients may not feel they can control. Swift et al. (1995) found that weather is a sig-
ni®cant in¯uence on reported exercise for some patients. In the Swift et al. (1995) study,
patients who were exercising (52%) were more likely than the nonexercisers to think that
external factors such as signi®cant others and chance play a role in their exercise habits.
Social support may also play a role. Krug, Haire-Joshu, and Heady (1991) found that
patients who were exercising reported wanting and receiving more help from family and
friends than nonexercising patients. This external orientation to exerciseÐbeing in¯u-
enced by external forces and social supportÐmay be characteristic of older adults who
have not necessarily had recreational exercise as a part of their lifestyle.

Limits to the Study

Limitations to the study include the size and geographic sample of the patients versus
that of the educators. The patient sample may not have been characteristic of the edu-
cators’ reference patient populations . Hospital data were not available to characterize
nonrespondents ; however, there were more females (61%) and fewer persons over
65 (40%) compared with national data for individual s with type 2 diabetes (58% and
55%, respectively; National Institute s of Health, 1995c). The larger hospital’s patient
population includes those from outlying rural areas, where lower educational levels and
incomes may have reduced the response rate. Other potential explanatory variables were
112 J. Armstrong Shultz et al.

not addressed, such as whether patients received diabetes education that targets barriers to
self-management, and patients’ perceptions of bene®ts of self-management. Research is
needed to improve the comparability of barrier items and response scales as used in this
study without sacri®cing validity. In addition, the study did not differentiate current from
past barriers, or barriers speci®c to initial goal setting versus adherence at different stages
of self-management. Also, more patients in this sample were taking oral medications
(67%) than has been reported nationwide for type 2 patients (49%; National Institutes of
Health, 1995d). A common perception among patients who are not contemplating making
dietary changes for diabetes management is that taking pills will control their diabetes
(Sullivan & Joseph, 1998).
By sampling protocol, all patients completed diabetes education that incorporated
goal setting, and 65% indicated that they had set goals during their most recent diabetes
education. However, goal setting may be initiated with fewer treatment goals than may be
medically optimal as a result of the patient’s decision. This study did not investigate how
extensive and adequate goal setting is from the educators’ perspective, and what edu-
cators think are the barriers to patients using goal setting on their own. With this patient
group, if there was no follow-up related to goals, or the patients did not apply goal-setting
skills on their own, the patients may not have enhanced or even maintained self-care
when faced with some of the barriers tested. Sullivan and Joseph (1998) reported that
when some patients experienced a certain level of success attaining a goal, they felt they
could suspend the behavior and ``get away with it.’’ Goal setting is the educational
response to the need of patients to be self-sustainin g in diabetes management and can be
thought of as a way to combat barriers to management practices. However, beyond the
goal setting that occurs during formal education, we do not know how well goal setting
works for patients when they are on their own.

Conclusions
There was a discrepancy between barriers perceived by educators and barriers perceived by
patients, potentially affecting how well patients learn self-care skills during and after
diabetes education. The educators’ greater emphasis on all barriers suggests that they may
be spending time on issues that are not a barrier for some patients, or that they are not
emphasizing barriers important to patients. Also, educators may have been thinking about
barriers in terms of educational content they need to present, in contrast to the lifestyle
orientation of patients. More open dialogue is needed to fully explore patient barriers. There
may be ways to enhance patient counseling and education based on this interpretation that
could apply not only to education supportin g diabetes management, but also to the man-
agement of other chronic diseases that require long-term diet and exercise changes.
Communication around the meal plan may require assessing potential barriers
identi®ed in this study. Setting dietary goals may be enhanced from the beginning by
having the patient and educator work on incorporating the patient’s favorite foods into the
meal plan, thereby potentially reducing feelings of deprivation and overall dissatisfaction
with the plan. Educators may want to identify core foods and food patterns that help
patients feel that they are eating in a familiar way. Educators may need to address skills
that help with following the meal plan away from home, including problem-solvin g
ability, coping skills, and assertiveness. Speci®c social elements that confound patients’
success with dietary management need to be identi®ed. Using role playing to practice
handling key social situations could be helpful. How the patient communicates with the
physician also may be important; improving the patient’s negotiation skills and reducing
patient barriers to communication with the physician have led to improved self-care
 Type 2 Diabetes Mellitus 113

outcomes (Green®eld, Kaplan, Ware, Yano, & Frank, 1988). In recent research, dietitians
in diabetes care suggested that more patient education can lower patient barriers to self-
care (Williamson, Hunt, Pope, & Tolman, 2000), yet dietitians may not use the complex
counseling skills that facilitate effective behavior change (Brown et al., 1998).
Exercise counseling and goal setting with patients who do not relate to exercise is
clearly an ongoing challenge for both educators and patients. It may be helpful to use the
term ``activity’’ instead of ``exercise’’ with patients who perceive a negative connotation
with the term. More emphasis may be needed on the bene®ts of exercise beyond weight
management. A physical activity assessment or inventory may help educators immedi-
ately identify problematic issues with exercise, such as feelings about various exercise
settings, activities, clothes the patient would wear, and physical and other limitations, as
well as preferred approaches to exercise. Some patients may need to experiment with
different styles of exercise to cope with pain, discomfort or limits to movement, as well
as perceived consequences of exertion. Because patients with diabetes are at higher risk
for cardiovascular disease compared with the general population , some patients who have
experienced cardiac events face the same barriers to exercise as cardiac patients.
Supervised exercise, as provided in some cardiac rehabilitation programs, may help to
reduce anxieties about glycemic control and problems with physical pain.
Part of the difference in perspectives between patients and educators stemmed from
more negative attitudes among educators. As a result, educators may be communicating
more negatively in their interactions with patients. The patients’ response may be to
avoid discussing certain problems for fear of being judged or not well understood. It may
be insightful for educators to follow the diet and exercise plans they recommend to
patients so that they have a better understanding of the dif®culties that patients face.
Both patients and educators need to press the diabetes health care community to
provide adequate follow-up so that educators can help patients with self-management
once they are on their own. Patients may lose motivation for self-management over time
(Masaki, Okada, & Ota, 1990; Sullivan, & Joseph, 1998). Also, for older patients with
longer duration of diabetes, experience with diet and exercise management does not
necessarily mean greater self-ef®cacy, or feelings of self-con®dence, toward diet and
exercise, even after patients receive speci®c training in these areas (Glasgow et al., 1992).
With progression of the disease and other aging factors, patients with type 2 diabetes are
in critical need of continuing education to reduce barriers to diet and exercise that change
over time.
There are implications of this study for other areas of chronic disease management.
For example, management of hypertension and therapy associated with cardiac surgery
may require both dietary and exercise plans for weight loss in tandem with other changes,
such as quitting smoking and managing stress. For these chronic conditions, dietary
change also can represent a permanent lifestyle adjustment, requiring the provider and the
patient to communicate effectively about issues such as feelings of deprivation, coping
with family needs and social pressures, and new food handling skills. The outcomes of
diet therapies for chronic condition s other than diabetes may be slower to manifest
because patients with diabetes can see an immediate impact of diet on daily glycemic
control. For other patients, the support systems and continuing education the provider can
facilitate for the patient may provide the only feedback during early attempts at change.
When the patient is attempting to make numerous behavior changes all at once, it is a
challenge for the provider and patient to agree on goals and benchmarks for measuring
goals, as well as problems and successes. Identifyin g and testing communication issues in
chronic disease management will play an important role in optimizing disease treatment
and recovery.
114 J. Armstrong Shultz et al.

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