A Comparison of Physical Activity in Subjects With and Without Type 2 Diabetes in the

Western Upper Peninsula of Michigan: A Preliminary Investigation.

Authors: Paige N. Papineau, Stacy E. Harwood

Research Advisors: Caroline Gwaltney, Carolyn Duncan, Kelly Kamm

Doctoral Program in Physical Therapy

Central Michigan University
Mount Pleasant, Michigan

April 01, 2023

Submitted to the Faculty of the

Doctoral Program in Physical Therapy at
Central Michigan University
In partial fulfillment of the requirements of the
Doctorate of Physical Therapy

Accepted by the Faculty Research Advisor

Caroline S. Gwaltney PT, DPT, CWS

Date of Approval: _______
ABSTRACT
Type 2 Diabetes (T2D) is becoming increasingly common amongst individuals in the United
States. While current research has shown the benefits of physical activity in management and
reduction of symptoms of T2D, availability and participation can greatly vary. Much of this
variance has been associated with location of residence. Recent studies have characterized the
diabetic population in urban areas, but little is known about the characterization of physical
activity in rural areas, such as the Western Upper Peninsula of Michigan. To fill this void, the
purpose of this preliminary study is to compare physical activity levels and other health-related
behaviors between individuals with and without T2D who reside in rural Western Upper
Peninsula, Michigan. The current report discusses the preliminary findings from the initial cohort
of an ongoing study. Fourteen individuals were included in the study and were separated into two
categories: Type 2 Diabetes and Non-Type 2 Diabetes. Participants completed a total of six self-
report questionnaires characterizing their fall history, health status, health behaviors, and
physical activity levels. Health behaviors of interest include perceived health status, co-
morbidities, and medication use. A chi-square test for independence was then used to analyze the
effect of T2D on the aforementioned areas of interest. Physical activity levels were calculated
and scored into categories per International Physical Activity Questionnaire-Elderly protocol.
Initial findings suggest that there was a greater rate of fear of falling and a greater number of
medications utilized in those with T2D, while there are greater levels of physical activity in those
without T2D.
Introduction
Over 30 million Americans have diabetes, with over 90% being type 2 diabetes (T2D).
T2D has been linked to increased incidence of cardiovascular disease, the leading cause of death
globally, and cause of death amongst 50% of the T2D population worldwide. Barring genetic
components to the disease, the development of T2D is also linked to modifiable lifestyle factors
including diet, smoking, alcohol consumption, and physical activity level. T2D incidence
increases in areas of lower resource availability and economic opportunity, suggesting that
known socioeconomic disadvantages (i.e. access to care and resources, health literacy, and
availability of health-driven organizations) play a role in the development of T2D.
Research suggests that physical activity is a benefit to individuals living with T2D.
Exercise hinders the onset of diabetic peripheral neuropathy, a contributor to fall incidence, and
can improve glycemic control, improving individuals’ lipid profiles, thereby reducing incidence
of cardiovascular disease. However, while the benefits of physical activity to T2D have been
observed, participation is widely variable. Several factors have been discussed as identifiers for
this variability, including accessibility of outlets for physical activity and seasonal changes.
Seasonal changes have illustrated decreased exercise participation amongst older adults in rural
locations, and specifically, a decrease in physical activity with the onset of the winter season.
Living environment has also been shown to have a significant effect on accessibility and
exercise. Recent studies characterizing rural versus urban regions have tied exercise
participation to the concentration and financial assets associated with public services. In rural
areas, investigators noted a prevalence of inactivity related to a need for more exercise-based
facilities. Rural-focused decreases in exercise participation may, in-part, be due to a lack of
accessibility to means of exercising. This includes designated sidewalks and public areas,
exercise centers, as well as cultural norms that negatively affect older adults’ enthusiasm to
participate.
Despite hindering the onset of T2D-related complications, prior diagnoses of T2D alone
may be viewed as a causative agent to decrease exercise participation in rural areas, as well as
socioeconomic status, which is another confounding factor. Employment, educational, and
healthcare resource disparities in rural areas compared to urban counterparts have been well-
documented. Studies have observed various reasons behind such disparities, including
disproportionate allocation of employment opportunities, variable financial structure, and
inconsistent means of economic stability practices based on irregular demand for goods and
services, and variable technological support. These observations, with others such as
geographical complications to resource accessibility, illustrate reduced socioeconomics, thus
resulting in decreased health literacy, health behaviors, and physical activity participation in rural
inhabitants. However, their influence specifically on T2D in rural communities is unknown.
As illustrated by the USDA Economic Research Service (USDA-ERS) and Health
Resources and Services Administration (HRSA), the Western Upper Peninsula (U.P.) of
Michigan has been categorized as not only a rural area, but a rural, low-income population health
provider shortage area (HPSA). Therefore, the Western U.P. serves as a focal magnification of
both secondary socioeconomic and health-related issues stemming from rurality, such as health
literacy, health behaviors, and physical activity participation. Preventable deaths constitute the
majority of deaths in Michigan’s U.P., often being caused by negative lifestyle behaviors that
ultimately lead to disease. In order to directly address the needs of individuals living with T2D
specifically in remote, rural areas like the U.P., it is necessary to first gain an understanding of
the exercise and socio-economic characteristics of these individuals. Therefore, the purpose of
this preliminary analysis aimed to provide a snapshot of potential variations in exercise
participation and health behaviors between non-T2D and T2D residents in Michigan’s Western
U.P. With logged activity monitoring currently ongoing, using self-reported data, it is
hypothesized that when compared to a non-T2D population, those with T2D will report
decreased exercise participation and fewer positive health behaviors including weekly
participation in physical activity, intensity of physical activity participation, self-perceived
weight/BMI, history of falling, and corresponding fear of falling.

Methods
Participants
Participants were divided into two categories: those with Type 2 Diabetes (T2D) and
those without Type 2 Diabetes (Non-T2D). All participants were residents of Michigan’s
Houghton, Baraga and Keweenaw counties, were between 65-85 years of age, and had access to
a smartphone or tablet. To be included in the T2D group, individuals must have a T2D diagnosis
that has been verified by their healthcare provider. Individuals without a verified diagnosis of
T2D were included within the non-T2D. Individuals were excluded from either group if they
had a history of amputations, foot ulcers, blindness, Type 1 diabetes, or cancer for which they
were currently seeking treatment. They were also free of any neurological disorder including, but
not limited to, Parkinson’s disease, multiple sclerosis, dementia, stroke, brain injury, or spinal
injuries. The study protocol was approved by the institutional review board at Michigan
Technological University. All participants provided informed written consent prior to any data
collection.
It is anticipated that 60 participants will be included in this study. Participants will be
divided into several cohorts. As this is a preliminary study of an ongoing investigation, the total
number of participants in the first cohort for this analysis is provided in the results section.

Questionnaire Completion
Participants were instructed to complete six questionnaires at the beginning (November
2021) and at the end (February 2022) of the study to obtain subjective details regarding their
general health status (appendix 1), diabetes control (appendix 2) and medication use (appendix
3), physical activity (appendix 4), lifestyle habits (appendix 5), and fall history (appendix 6).
Table 1 provides a brief summary of the content included within the questionnaires. Participant
responses to the questions regarding physical activity, subjective health status, falls and fear of
falling, co-morbidities, and medication were identified to be of interest and were further
investigated in this preliminary report.
Participants were provided with the option of completing questionnaires via an online, computer-
based form (Survey Monkey) or a paper copy. Responses from pre- and post- survey
questionnaires were then compared over time and between groups to aid in the characterization
of participants health status and levels of physical activity. For the current study, only
participant responses from the pre-surveys were analyzed to provide initial insights into the
characterization of these populations.
Activity Monitoring
Participants were instructed to wear a Fitbit wrist-worn activity monitoring device
(Model FB418; Fitbit, Inc., San Francisco, CA) over the period of three consecutive months
(November 2021 - February 2022) to obtain physical activity data including heart rate, step
count, and activity duration.18 Participants were required to wear their Fitbit activity trackers
continuously during their daily activities, with the exceptions of bathing and charging of the
device to maintain consistent data collection. Although not utilized in the preliminary study, the
data collected from the Fitbits will be utilized as part of the larger study that continues to be
ongoing and will be compared both with the results of prior studies and between non-T2D and
T2D groups.
Data Analysis
Physical activity was measured through self-report using the International Physical
Activity Questionnaire- Elderly (IPAQ-E), a validated measure of physical activity for older
adults. Utilizing its scoring protocol, participants were categorized into three levels (high,
medium, or low) of physical activity. Individuals scores were included in the high physical
activity category if their reported amount of physical activity was calculated to be greater than or
equal to 3000 MET minutes/week. To be included in the moderate level, participants must report
participating in greater than 600 MET minutes/week but less than 3000 MET minutes/week of
physical activity. Finally, to fall within the low level of physical activity, participants must
report activity totaling less than or equal to 600 MET minutes/week. Any measures of physical
activity (walking, moderate intensity, or vigorous intensity) reported to be over three hours, were
capped at three hours. Per protocol, it is unlikely for a participant to complete over three
consecutive hours of activity; therefore, any reported duration above three hours was capped at
three hours. Percentages for each group were calculated to demonstrate participants’
participation in physical activity and other health behaviors by dividing the number of responses
by the number of participants in each group.
For the remaining questionnaires, a data dictionary, in which provided response options
for each question was assigned a specific code, was created. Acting as the base for coding
participant responses, investigators converted participant questionnaire responses to the
associated code. The data was then cleaned, excluding any unanswered questions or
inconsistencies. For any open response questions, participant responses remained word for
word. Investigators calculated body mass index (BMI) from the participant provided height and
weight. For any question in which a participant responded with a numerical range, the lower
value was utilized for consistency between questionnaires and participants. The differences in
fall risk, activity levels, lifestyle habits, and diabetes management between non-T2D and T2D
groups were evaluated via comparison of self-reported questionnaires. A chi-square test of for
independence with ꭤ = 0.05 was used to assess whether having T2D affected each outcome of
interest.
Results
Participant Characteristics
In total, 13 individuals (n=5 T2D, n=8 Non-T2D) completed the pre-survey
questionnaires. Within the T2D group, 60% were males and 40% were females. Within the Non-
T2D group, only 25% of participants were males while 75% were females (Table 2). In relation
to age, 40% and 30% of individuals in the T2D and Non-T2D groups respectfully reported being
65-70 years old, 20% and 30% reported being 71-75 years old, 40% and 20% reported being 76-
80 years old, and 0% and 10% report being 81-85 years old (Table 2). Among the participants in
the T2D group, 80% report being white/Caucasian and 20% being Asian/Asian American, while
100% of the Non-T2D group report being white/Caucasian (Table 2).
Physical Activity
In total, 14 individuals (n=5 T2D, n=9 Non-T2D) completed the IPAQ-E questionnaire.
The relation between Type 2 Diabetes and physical activity level was X2(2, n = 14) =12.39, p
=0.002 (Table 3). Utilizing the IPAQ scoring protocol, participants were categorized into three
levels of physical activity (low, moderate, high). Based on participant responses on the pre-
survey, 60% of individuals with T2D fell into the low physical activity category compared to 0%
of non-T2D individuals (Table 4). Additionally, in individuals with T2D, 20% of respondents
reported moderate and 20% of respondents reported high levels of physical activity. At baseline,
50% of non T2D individuals' scores fell into the moderate and 50% into the high physical
activity categories (Table 4).
Falls History
In total, 14 individuals (n=5 T2D, n=9 Non-T2D) provided responses to questions
highlighting their fall history and fear to falling. The relation between T2D and history of falls
was X2(1, n = 14) =0.048, p =0.826 (Table 3). The relationship between T2D and fear of falling
was X2(2, n = 14) =6.48, p =0.039 (Table 3). When asked the result of their fear of falling the
results for activity avoidance and behavior change were X2(2, n = 14) =2.43, p =0.297 and X2(1,
n = 14) =0.0256, p =0.872 respectfully (Table 3).
General Health
In total, 14 individuals (n=5 T2D, n=9 Non-T2D) provided responses to questions in
regards to co-morbidities and BMI while 13 individuals (n=5 T2D, n=8 Non-T2D) provided
responses in terms of medications and subjective feelings of their health status. The relation
between T2D and co-morbidities was X2(4, n = 14) =4.07, p =0.872 (Table 3). The relation
between T2D and BMI was X2(2, n = 14) =1.84, p =0.398 (Table 3). For the correlations
between T2D and Medications and subjective health status, the chi-square analysis resulted in
X2(4, n = 13) =1.84, p =0.015 and X2(3, n = 13) =7.39, p =0.060 respectively (Table 3).

Discussion
 This preliminary analysis aimed to provide a snapshot potential exercise participation and
health behavior variations between the initial cohort of non-T2D and T2D residents in
Michigan’s Western U.P. Consistent with the hypothesis proposed by the authors, as well as
findings published by Arcrury et al., greater than half of T2D participants reported lower levels
of physical activity levels and less than 5 days per week of participation in walking or
moderate/vigorous intensity activities in initial physical activity surveys (IPAQ) when compared
to the Non-T2D group, who reported levels of moderate to high physical activity in a clean 50/50
split.
Interestingly, while T2D participants did report higher incidences of falling compared to
non-T2D participants, non-T2D participants reported greater fear of falling, referencing activity
and behavior modifications including "mountain biking on less technical trails” and “knowing
limits and taking care to be aware of surroundings.” These observations, however, do not appear
to be significant, nor illustrative of cause-and-effect relationships between participant groups.
This is consistent with findings of self-reported fall data in previous studies, in which falls were
grossly underestimated by study groups. Therefore, it is recommended that authors in the
ongoing study exercise caution when interpreting falls and fear of falling data based on
preliminary and post self-reports alone.
Reports from T2D and non-T2D participants in the current analysis suggest that there
was a higher prevalence of co-morbidities including cardiovascular conditions, joint disorders,
hearing problems, and depression. Additionally, T2D participants reported increased diabetes
and co-morbid medication use, as well as overweight and obese BMI status, when compared to
the non-T2D cohort. Despite discrepancies noted regarding self-reported fall data, general health
characterizations obtained via self-reported data, including co-morbidities, height & weight, and
medication use, appear to be consistent with standardized classification systems, thus
confounding use of questionnaire data alone when analyzing population variations between
diverse groups.
The current analysis recognized several limitations for consideration in the larger
ongoing study, including recruitment and retention difficulties as a result of the Covid-19
pandemic. Due to social distancing practices, as well as those mandated by university policies,
the authors were required to navigate non-physical means of recruitment strategies including
email, social media, and online local news platforms. Individuals were also largely required to
utilize technologically-based platforms to participate, resulting in larger risk of data input error
secondary to discomfort or technical illiteracy. Ultimately, the current study successfully
recruited 10 Non-T2D participants and 5 T2D participants initially, followed by a loss of 3 Non-
T2D participants prior to the study’s conclusion. Inadequate sample size, as well as increased
homogeneity of the current study (99% white/Caucasian) resulted in considerable deficits in
generalizability, which negatively impacted the performance of statistical analysis, and therefore,
strength of observational insights made using the current data points. Therefore, it is
recommended that investigators participating in ongoing data collection practice caution while
analyzing self-reported questionnaire data, and employ controls for fall history versus fear of
falling in addition to proportionately more logged data via Fitbit utilization in order to strengthen
observations made characterizing Michigan’s Western U.P. T2D versus non-T2D cohorts.
References
Table 1. Overview of Information Included in Questionnaires
Table 2. Participant Characteristics

* n=8 in Non-T2D group

Table 3. Summary of Chi-Square Results
Table 4. Physical Activity Categorization of T2D vs. Non-T2D
Appendix 1
Appendix 2
Appendix 3
Appendix 4
Appendix 5
Appendix 6