a 44-item questionnaire was answered by 103 type 1 diabetic patients when attending their regular appointment at the university of montreal hospital center or the montreal institute of clinical research outpatient clinics . for the bapad1 scale , participants rated 12 barriers to physical activity on a scale from 1 to 7 ( whether the item would keep them from engaging in regular physical activity over the next 6 months : 1 , extremely unlikely , and 7 , extremely likely ) . in addition , social support for physical activity was assessed by three questions adapted from the questionnaire by sallis et al . ( 7 ) ; participants indicated on a scale from 1 ( never ) to 5 ( very often ) how often family or friends encouraged them to do physical activity , proposed to do physical activity with them , or did physical activity with them . patients were asked to report the number of hypoglycemic episodes in the previous 2 weeks and the number of severe hypoglycemic episodes in the last year . for management of exercise - induced hypoglycemia , patients were asked what actions they took to prevent such episodes ( insulin dose reduction and/or snacks for exercise or at bedtime ) . knowledge of insulin pharmacokinetics was assessed by asking patients to state the time of onset and peak action of their insulin prescription ( correct / incorrect ) . the world health organization-5 well - being index , a validated scale of five questions developed to assess quality of life , was included in the questionnaire ( 8) . the most recent value ( within 3 months ) of a1c pearson 's correlations and student 's t tests for independent sample were performed to determine the relation between various factors and perceived barriers . internal consistency reliability ( cronbach 's -coefficient ) for the bapad1 scale , social support measure , and the world health the final sample consisted of 100 adults with type 1 diabetes ( 50% women ) . mean  sd age was 43.5  11.6 years , duration of diabetes 23.3  13.2 years , and bmi 25.9  4.9 kg / m . glucose control was suboptimal with a mean a1c of 7.7  1.1% and a mean number of hypoglycemic episodes in the previous 2 weeks of 7.47  7.25 ; 25% of the participants experienced severe hypoglycemia in the previous year . one - third of the cohort had a low income ( 20,000 usd per year ) and/or a low level of education ( secondary education or less ) , while one - fifth reported active smoking . the highest barrier scores were fear of hypoglycemia ( 3.58  2.02 ) , work schedule ( 3.05  1.98 ) , loss of control over diabetes ( 2.83  1.80 ) , and low levels of fitness ( 2.83  1.95 ) . perceived well - being , knowledge of insulin pharmacokinetics , implementation of strategies to reduce the probability of exercise - induced hypoglycemia , and greater social support were associated with fewer barriers . moreover , having someone with whom to perform physical activity was also associated with fewer barriers ( r = 0.36 ; p < 0.001 ) . glycemic control , as assessed by a1c , was positively correlated with bapad1 total score . the frequency of mild or severe hypoglycemia was not associated with the level of perceived barriers . as fear of hypoglycemia was the strongest barrier , we investigated factors associated with this specific item of the bapad1 scale . the number of severe hypoglycemic episodes in the previous year was significantly associated ( r = 0.26 ; p = 0.009 ) with fear of hypoglycemia . the number of strategies used to prevent hypoglycemic episodes related to physical activity was not associated with perceived fear of hypoglycemia , but some subitems , such as eating an evening snack after physical activity to prevent nocturnal hypoglycemia , were associated with less fear of hypoglycemia ( t = 3.00 ; p = 0.007 ) . knowledge of insulin pharmacokinetics , demonstrated by only 52% of participants , was also associated with less fear of hypoglycemia ( t = 2.34 ; p = 0.021 ) . the four main barriers to physical activity identified among type 1 diabetic patients attending university hospital outpatient clinics were fear of hypoglycemia , work schedule , loss of control over diabetes , and low fitness level . factors associated with barriers to physical activity included basic knowledge about insulin pharmacokinetics and implementation of strategies to prevent hypoglycemia . half of the participants were not knowledgeable about these fundamental elements , suggesting that there is a major gap in information and support required by individuals with type 1 diabetes in this field . thus , programs intended to increase physical activity in adults with type 1 diabetes should incorporate diabetes - specific actions to prevent hypoglycemia . furthermore , the striking inverse relationship between social support , a powerful motivator to help initiate and then maintain a physically active lifestyle ( 9 ) , and perceived barriers suggests that this factor should also be considered in programs to enhance physical activity participation . finally , we found that individuals with greater perceived barriers to physical activity had poorer glycemic control as measured by a1c . the association between a1c and barriers suggests that the bapad1 scale probably captures general aspects related to type 1 diabetes care . it is possible that patients able to manage barriers for physical exercise are also the ones able to cope with other problems . with regard to limitations , our study design does not allow us to establish the causal direction of the associations found ; further research is needed using a prospective controlled design .
objective  to determine , in an adult population with type 1 diabetes , barriers to regular physical activity using a diabetes - specific barriers measure ( the barriers to physical activity in diabetes [ type 1 ] [ bapad1 ] scale ) and factors associated with these barriers.research design and methods  one hundred adults with type 1 diabetes answered a questionnaire assessing perceived barriers to physical activity and related factors . 
 a1c was obtained from the medical chart of each individual.resultsfear of hypoglycemia was identified as being the strongest barrier to physical activity . 
 greater knowledge about insulin pharmacokinetics and using appropriate approaches to minimize exercise - induced hypoglycemia were factors associated with fewer perceived barriers . 
 greater barriers were positively correlated with a1c levels ( r = 0.203 ; p = 0.042 ) and negatively with well - being ( r = 0.45 ; p < 0.001).conclusions  fear of hypoglycemia is the strongest barrier to regular physical activity in adults with type 1 diabetes , who should therefore be informed and supported in hypoglycemia management .