A Socio-ecological Approach to Reduce the Physical Activity Drop-out Ratio in Primary Care-based Patients With Type 2 Diabetes: The SENWI Study Protocol for a Randomized Control Trial.

Physical activity (PA) - understood as any bodily movement produced by skeletal muscles that require energy expenditure, related to leisure time, for transport to get to and from places, or part of a person's work - is a powerful force for good regarding type 2 diabetes mellitus (T2DM). A recent meta-analysis has confirmed a positive dose-response relationship between markers of glucose control and increasing daily PA (a 20% increase in adherence or two sessions/month was associated with a 0.15% - 2 mmol/mol - decrease in HbA1c). Adhering to regular PA - understood as not dropping out the new PA behaviour adopted - is a way to control T2DM and promote people living with T2DM self-management. Still, fewer T2DM patients sustain the lifestyle recommendations suggested by health care professionals (HCP): 40% of patients did not follow up on general medical recommendations regarding lifestyle changes.

Socioeconomic status and health or social inequity, immediate and non-negotiable patients' needs and adherence skills rarely discussed by HCP, urban planning and political decisions about PA, or physical inactive workplaces may be reasons for these poor results in sustaining PA lifestyle recommendations.

Researchers have proposed aerobic or resistance exercise - understood as PA planned, structured, and realized during the leisure-time - like Nordic walking, high-intensity training, or lifting weights to increase PA levels throughout exercise among T2DM patients. Despite all options having good results in metabolic and patients' health outcomes, it seems that they are only used in well-controlled studies rather than in healthcare: that may be due to the HCP difficulty and lack of time, support, and knowledge to prescribe this type of aerobic and resistance exercise.

As a result, HCP most common prescription is based on walking, as it is easy to recommend and to do it by people living with T2DM without contraindications. However, only doing that recommendation will be not efficient nor effective to improve PA levels among people living with T2DM. For example, the more prevalent of people living with T2DM belongs to the lower-medium class, which usually live in neighborhoods with poor walkability and parks or green spaces. As a result, patients used to drop out in the long run and despite decades of this type of recommendation, PA population levels are still a problem to be faced. With that panorama, HCP may intentionally withdraw from PA prescriptions to protect patients who find it difficult to keep going.

In this context, ineffective primary-care-based PA prescription risks missing out on the health benefits of the powerful factors that manage people living with T2DM health-related outcomes. Moreover, ineffective primary-care-based PA prescription may enhance socioeconomic barriers and health inequity in these patients. Therefore, given the scale and span of these PA biological and social benefits, it remains a Public Health priority to deploy more effective ways to implement day-to-day PA life. Doing so will be helpful for health patients and for both HCP that used to have not enough time to prescribe exercise effectivity and Public Health expenses in T2DM patients.