Physical activity and sedentary time levels among Moroccan type 2 diabetes patients

1 Introduction

Physical activity (PA) has long been known to reduce the risk of major non-communicable diseases such as hypertension, cardiovascular disease, type 2 diabetes mellitus (T2DM), obesity, depression, and some types of cancer [1–4]. Furthermore, PA has a significant role in the treatment of various non-communicable diseases such as T2DM [5]. Indeed, it has been demonstrated that PA improves glycaemic control and increases insulin sensitivity [6]; improves beta-cell function [7]; lower the risk of heart disease, contributes to weight loss [8]; as well as improve overall well-being in T2DM patients [5, 9]. However, despite the various health benefits of PA, many T2DM patients do not achieve the recommended PA levels [10].

Sedentary behaviors (SB) have also been shown to be deleterious for health, regardless of these levels [11]. A systematic review of published research documenting PA and SED-time showed that T2DM patients are less active and more sedentary than their healthy counterparts, regardless of the methods used in the study [10].

The evidence on PA levels in T2DM patients varies by country and low levels of PA were reported in several studies [12]. For instance, the recommended level of PA was achieved by only 21.6% in Oman [13]; 34.1% in Scottish adults with diabetes [14] and 40.2% to 42.9% in the USA [15].

Gender, age, body mass index (BMI), education, and socioeconomic level are all factors that influence PA. As a result, obesity is a major barrier to PA [16, 17]. Men were more active than women [16, 18]. PA levels were inversely associated to education, income, and age, as they are in the general population [13, 18].

Measuring PA and SED-time levels, as well as learning about the factors that influence them, was an important initial step and a public health priority. However, no data on this topic is currently available among Moroccan T2DM patients, and PA assessments in Morocco were only conducted among the general population and youth [19, 20].

Thus, the aim of this study were to assess firstly, the prevalence of PA and SED-time among T2DM in Beni Mellal Khenifra region located in the north-central area of Morocco; and secondly, to determine the associated factors with meeting PA recommendations and sedentary time (SED-time). This permits identification of diabetics with a reduced likelihood of engaging in PA and a higher SED-time, which could be important in the development of programs and policies aimed at encouraging these individuals to live an active lifestyle.

2 Methods

2.1 Data collection and study participants

From February to June 2019, a cross-sectional study was carried out among 1143 diabetes patients who visited primary health centres in the Beni-Mellal Khenifra region. Recruiting participants for this study was done using a multilevel random-sampling method.

The following parameters were used to determine the minimum study sample size: prevalence of meeting PA recommendation among diabetics (50%), 99 % confidence level (z = 2.57) and 4% margin of error (e = 0.04). As a result, the sample size was 1032 people. This number was rounded up to 1200 to compensate for probable exclusions. The Fig. 1 represents the flow diagram of the participant recruitment process (Fig. 1).

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Fig. 1

Flow diagram of the participant recruitment process.

A face to face interview was used to collect socio-demographic data such as, gender, age, area of residence, family size, marital status, level of education, and employment. Diabetes-related information, such as diabetes duration, family history of diabetes, and diabetes treatment were also gathered.

Anthropometric measures used to assess the nutritional status were weight (measured to the nearest 0.1 kg using a digital scale), and height (recorded to the nearest 0.1 cm using a wall-mounted stadiometer). Based on these measures, BMI was calculated by taking a person’s weight, in kilograms, divided by their height, in meters squared (kg/m²), and it was further categorized into underweight (less than 18.5 kg/m²), normal (18.5–24.9 kg/m²), overweight (25–29.9 kg/m²) and obese (30 kg/m² or more) [21].

Participants eligible for this study were those diagnosed with T2DM for at least a year, had an available medical file, had a haemoglobin A1c (HbA1c) test within the previous three months, aged at least 18 years old, physically and mentally capable of providing all data required for the study, and willing to participate.

Exclusion criteria were age < 18 years, patients with type1 diabetes, pregnant women with diabetes and hospitalized patients.

3 Results

Our sample was composed of 1143 T2DM patients (395 men and 748 women). The results of the analysis of the study participants’ characteristics are presented in Table 1.

The mean age was 55.95±12.34 years old with no significant difference between males (57.22±13.51) and females (55.29±11.62) in mean age. In terms of category of age, there was a significant difference between the number of males and females aged 61 years old and above (p < 0.001). Regarding marital status, a significant difference was observed between males and females (p < 0.001). The largest proportion of females were illiterate (75.1%), while this proportion was only 41.8% for males (p < 0.001). In terms of occupation, 70.1% of males had a work, while only 5.2% of females were active, showing a significant difference (p < 0.001). A significant difference was also observed in terms of BMI, with 35.7% of females were obese, compared to only 12.2% of males (p < 0.001). The diabetes duration, glycemic control, type of treatment, were not significantly different between the two sexes.

Regarding physical activity recommendations, 77.7% of the study participants met the recommended PA levels of ≥600 MET min/wk. Overall, there were no significant gender differences in the frequency of meeting PA recommendations (t = 0.531; p = 0.46).

For females participants, the bivariate analysis revealed that single and widow/er marital status (p = 0.013), literate (p = 0.020), using OA drugs (p = 0.008) and having a family history of diabetes (p = 0.001) were all significantly associated with the ADA recommendations of PA (Table 2).

The prevalence of meeting PA recommendations for males was significantly associated in bivariate analysis with age (p = 0.012), educational level (p = 0.028), duration of diabetes (p < 0.001), occupation (p = 0.008), BMI (p < 0.001), type of treatment (p < 0.001) and family history diabetes (p = 0.048) (Table 2). In females, meeting the PA recommendations was significantly associated with marital status (p = 0.013), educational level (p = 0.020), type of treatment (p = 0.008) and family history diabetes (p = 0.001)

The multivariate analysis showed that, the odds of reaching PA recommendations in males participants were higher in individuals using OA alone compared to those using a combination of OA and insulin (OR 1.944 [95% CI = 1.019–3.708] p = 0.044); in individuals with a duration of diabetes less than 7 years compared to participants with a duration more than 7 years (OR 2.575 [95% CI = 1.449–4.576] p = 0.001), and in those who were normal weight (OR 2.289 [95% CI = 1.050–4.980] p = 0.037), or overweight (OR 4.656 [95% CI = 2.063–10.508] p = 0.001), compared to obese participants (Table 3).

In females participants, the odds of reaching PA recommendations was significantly higher only in participants with a family history of diabetes (OR 1.691 [95% CI = 1.177–2.429] p = 0.004) (Table 3).

The mean weekly sitting time was 35.66±16.88 hours with no significant gender difference (t = 1.55; p = 0.213).

The gender differences in SED time based on general characteristics are shown in Table 4. For female participants, the SED-time was significantly associated to age, marital status, and PA level. Those above > 60 years were more sedentary than those less than 60 years old (t = 6.67; p < 0.001). Regarding marital status, widowers and divorced showed higher SED-time than married (t = 6.61; p < 0.001). The result was the same for PA level where females with low level showed more SED-time than those with high and moderate level (t = 9.20; p < 0.001).

For male participants, a statistically significant difference was observed in the SED-time by age, education, duration of diabetes, occupation, BMI, type of treatment, and PA level. The mean SED-time was statistically higher in males aged more than 60 years old (t = 11.683; p < 0.001), in illiterate (t = 11.683; p < 0.001), in those with a duration of diabetes more than 7 years (t = 13.956; p < 0.001), in unemployed participants (t = 8.010; p = 0.005), overweight males (t = 4.563; p = 0.05), in individuals using OA alone (t = 3.771, p = 0.005) and in males with low level of PA (t = 61.92; p < 0.001).

The aim of this study were to assess the level of PA, the prevalence of SED-time and to determine factors associated with meeting PA recommendations and prolonged SED-time among Moroccan type 2 diabetics patients residing Beni-Mellal Khenifra region. The current investigation adds to the limited literature on PA and SED-time among T2DM at the national level.

The response rate in this study was high (95.91%), which was probably related to the collection of data in health centres where diabetics felt comfortable during their waiting time for their consultation or to get their medication.

The proportion of participants meeting the PA recommendations was 77.7%. To the best of our knowledge, no previous Moroccan studies have assessed PA in type 2 diabetics, specifically by IPAQ. This makes it difficult to compare our findings appropriately. However, this proportion was lower than that reported in previous study using comparable definitions of PA levels in the general Moroccan population (83.5%) [20]. Our findings were consistent with those of other research done outside of Morocco, such as in Malaysia (80.33%), and in Ghana (78.67%) [27, 28]. In contrast, our data are not consistent with findings in other countries. For example, it was reported that only 40.2% met the PA recommendations among US adults with diabetes (type 2 or type 1) [29]. Similarly, the majority of T2DM individuals in Canada (71.9%) were considered insufficiently active [30]. In Oman, only 21.6% of T2DM patients met the PA recommendations [13]. The use of different measurement techniques and definitions of activity may partly explain these differences in activity rates [12]. Furthermore, it was reported that PA estimates vary widely, even within the same nation, when studies were carried out using different surveys over similar time periods [31].

Multivariate analysis showed differences in factors associated with meeting the PA recommendations in males and females. The same pattern has been found in the general population [20]. These differences might be attributed to the difference in social obligations between men and women. Women are usually restricted around the house, preoccupied with their family or taking care of children.

The present investigation found that for males, the proportion of participants meeting recommended levels of PA were significantly different depending on duration of diabetes type of treatment and BMI level.

Regarding the duration of diabetes, male patients who were diagnosed recently (< 7 years) showed higher levels of adherence to physical activity than those with a longer duration of disease. A study in Saudi Arabia reported similar findings [32].

This study also reported that the use of OA medication was associated with meeting PA recommendations. This finding can be explained by the fact that the strongest barrier to PA was the fear of hypoglycaemia [33], which occurs more frequently in people treated with insulin than in those with an OA drug [34].

Our findings revealed that obese males showed low level of PA. The findings of this study concur with the results of the study in USA and in Saudi Arabia which found that Patients who adhered to the recommended level of physical activity tended to have a lower BMI [32, 35]. This could be attributed to the barriers mentioned by obese patients such as physical discomfort and embarrassment [36].

For female participants, it is interesting to note that having a family history of the diseases was associated with meeting PA recommendations. Further findings indicated that subjects with a family history of diabetes were more likely to engage in PA [37, 38]. A family member who suffers from diabetes could be a source of information about their management. As a result, T2DM patients with a family history of diabetes were more aware of diabetes risk factors and more likely to engage in certain health behaviours such as PA than those without a family history of diabetes [39].

In terms of SB, the respondents’ average SED time was 5.09 hours/day, which is consistent with earlier studies that used self-reported measurements. This time was 5.13 hours/day among T2DM patients in Canada [40], 4.8 h/d in Nigeria [41], 5.8 h/d in Botswana [42], 5.8 h/d in the United States [43], and in the European general population 5.15 h/d [44]. Finally, a higher SED-time (11.6 hours/day) was reported in Italian T2DM [18].

The SED-time in this study was more prevalent among participants aged over than 61 years (both males and females). This finding is similar to that reported in Nigeria [41], and Canada [40] in a sample of adults with T2DM. Another study in the general population found that as people became older, they watched more television, which was used as a SED-time indicator [45].

The examination of SED-time according to PA levels showed that participants (males and females) with high SED-time have low PA, which represents a combined risk of sitting and inactivity in this subgroup. A similar inverse relationship between SED-time and levels of PA was also reported by other studies [46–48].

Being male illiterate was associated to higher SED-time among the participants. It’s possible that illiterate people spend more time sitting than educated people because educated people are more aware of the dangers of sitting for lengthy periods of time. Other studies, on the other hand, have found that those with a higher educational level reported more SED-time than people with a lower educational level [40]. Most of these studies compared university level to other educational levels, which was not the case in our analysis, and the authors of these studies explained their finding by the fact that high educational degree is frequently associated with professional office setting environments.

When marital status is considered, our findings showed that being females Widowers or divorced were associated with higher levels of SED-time. Conversely, sedentary activities were found to be more prevalent among singles in Japanese [49].

Our data revealed also that male participants with diabetes for more than 7 years were more sedentary than those with diabetes for less than 7 years. On the contrary, Brazeau et al., reported that shorter diabetes duration was associated with more SED-time [40].

The findings around SED-time and BMI in males showed that obese patients spending longer sedentary time. This results are consistent with previous research which found a strong relationship between an increased BMI and prolonged sedentary activity [32, 50]. Other studies showed that, obesity is a major barrier to PA and therefore increases the SED-time [16, 17].

Unemployed subjects in this study are more sedentary compared to currently employed subjects. This result may be explained by the fact that majority of employed in morocco are manual workers and therefore, their work not requires prolonged sitting.

This study showed also that higher SED-times was observed among men participants with poor glycaemic control (HbA1c > 7%) and participants under insulin alone and combination of insulin and OA. It’s well documented that an active lifestyle decreases the level of glycosylated haemoglobin, and reduces the dose of oral hypoglycaemic agents and the modification in lifestyle is the first line of management of diabetes mellitus [51]. It should be noted that it is difficult to verify the direction of this association.

To the best of our knowledge, this is the first study to investigate PA and SB among Moroccan T2DM and the current findings may help us better understand the determinants of PA and SB among Moroccan T2DM. Thus our findings might give a first insight for comparing the Moroccan situation to that of other countries where PA and SB surveillance among diabetics is well established.

The cross-sectional design of our study limits conclusions about the causality of the identified associations, so longitudinal investigations are greatly needed. Second, to assess the PA and SB, the study was based on questionnaire that is subject to recall bias and limited by subjective interpretations. Third, comparing our findings to previous research was problematic because different studies utilize different ways to interpret and report data across different recording time periods.

5 Conclusions

The prevalence of patients reaching recommended level of PA was high among participants and their SED-time is over 5 h/d. Our study showed also that participants with high SED-time have low PA, which represents a combined risk of sitting and inactivity in this subgroup. As a result, reduction of SED-time and participation in regular PA in T2DM patients should be encouraged in future lifestyle interventions. Additional evidence on factors that influence PA and the prolonged sitting are needed to develop relevant public health interventions. Therefore, identifying ways to decrease sitting time in diabetic adults is an obvious target for further research.