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Mangeri et al. Diabetology & Metabolic Syndrome 2014, 6:74 
http://www.dmsjournal.eom/content/6/1/74 



Hfe DIABETOLOGY & 

METABOLIC SYNDROME 



RESEARCH Open Access 



A standard ballroom and Latin dance program 
to improve fitness and adherence to physical 
activity in individuals with type 2 diabetes and 
in obesity 

Felice Mangeri 1 , Luca Montesi 2 , Gabriele Forlani 2 , Riccardo Dalle Grave 3 and Giulio Marchesini 2 * 
Abstract 

Objective: To test the effectiveness of a dance program to improve fitness and adherence to physical activity in 
subjects with type 2 diabetes and obesity. 

Research Design and Methods: Following a motivational interviewing session, 100 subjects with diabetes and/or 
obesity were enrolled either in a dance program (DP, n = 42) or in a self-selected physical activity program (SSP, 
n = 58), according to their preferences. Outcome measures were reduced BMI/waist circumference, improved metabolic 
control in type 2 diabetes (-0.3% reduction of HbA1c) and improved fitness (activity expenditure >10 MET-hour/week; 
10% increase in 6-min walk test (6MWT)). Target achievement was tested at 3 and 6 months, after adjustment for baseline 
data (propensity score). 

Results: Attrition was lower in DP. Both programs significantly decreased body weight (on average, -2.6 kg; P < 0.001) 
and waist circumference (DP, -3.2 cm; SSP, -2.2; P < 0.01) at 3 months, and the results were maintained at 6 months. In 
DP, the activity-related energy expenditure averaged 13.5 ± 1.8 MET-hour/week in the first three months and 14.1 ± 3.0 
in the second three-month period. In SSP, activity energy expenditure was higher but highly variable in the first 
three-month period (16.5 ± 13.9 MET-hour/week), and decreased in the following three months (14.2 ± 12.3; P vs. 
first period < 0.001). At three months, no differences in target achievement were observed between groups. 
After six months the odds to attain the MET, 6MWT and A1 c targets were all significantly associated with DP. 

Conclusion: Dance may be an effective strategy to implement physical activity in motivated subjects with type 
2 diabetes or obesity (Clinical trial reg. no. NCT02021890, clinicaltrials.gov). 



Introduction 

Lifestyle changes aiming at healthy diet and habitual 
physical activity are mandatory for the prevention and 
treatment of type 2 diabetes [1], as well as in other 
metabolic disorders [2]. Dietary restrictions and physical 
activity promote weight loss, reduce the progression 
from prediabetes to diabetes [3], improve metabolic 
control and reduce the long-term risk of complications, 
at any stage of disease severity. Most guidelines recom- 
mend 150 min/week of moderate intensity physical 



* Correspondence: giulio.marchesini@unibo.it 

2 Unit of Metabolic Diseases and Clinical Dietetics, "Alma Mater Studiorum" 
University of Bologna, Policlinico S. Orsola, Via Massarenti, 9 1-40138, Bologna, 
Italy 

Full list of author information is available at the end of the article 

(3 BioMed Central 



activity, corresponding to 10-15 MET-hour/week and 
no more than 2 consecutive days without exercise [1,4]. 
Unfortunately, most adult individuals with metabolic dis- 
orders lead a sedentary life [5], and increasing physical ac- 
tivity is particularly challenging for overweight people due 
to aversion and poor tolerance of exercise [6]. 

Behavior changes are driven by personal motivation 
and stage of change to healthier lifestyles [7], and an in- 
creased intrinsic motivation for physical activity remains 
the strongest predictor of long-term results [8]. Specific 
programs to increase motivation and adherence to phys- 
ical activity have been developed in subjects with type 2 
diabetes [9], following the seminal experience of the 
Diabetes Prevention Program [10]. Both the metabolic 
control and the cardiovascular risk profile improve in 



© 2014 Mangeri et al.; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative 
Commons Attribution License (http://creativecommons.Org/licenses/by/4.0), which permits unrestricted use, distribution, and 
reproduction in any medium, provided the original work is properly credited. The Creative Commons Public Domain 
Dedication waiver (http://creativecommons.Org/publicdomain/zero/1.0/) applies to the data made available in this article, 
unless otherwise stated. 



Mangeri et al. Diabetology & Metabolic Syndrome 2014, 6:74 
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parallel with the increased participation in structured 
physical activity programs [11,12]. Nonetheless, procedures 
and strategies derived from motivational interviewing and 
cognitive-behavior therapy are rarely applied outside re- 
search settings, and most patients continue to receive sub- 
optimal or ineffective treatments. 

Exercise adherence tends to increase when patients are 
free to select their own program and less structure is 
imposed [13]. The adoption of pleasant programs of 
leisure-time physical activity may be a reasonable option 
to increase motivation and adherence [14], while main- 
taining a supervised control on the amount of physical 
activity. Among leisure-time activities, dancing has a re- 
markable place [15]. When arranged by patients associa- 
tions, aerobic dance, Latin dance, folk dance and standard 
ballroom dance may all help aging people to enjoy their 
physical activity. Dance exercise also stimulates positive 
emotions, promotes social interaction and creates relation- 
ships with other people in the group, while exchanging ex- 
periences about their common medical problems. Finally, 
the acoustic stimulation and the music might strengthen 
the beneficial effects of aerobic exercise on cognitive func- 
tions [16]. 

We aimed to test the metabolic and clinical effects of 
a 6-month program of dancing in subjects with type 2 
diabetes and/or obesity, chronically cared for in two dia- 
betes/metabolic units. Self-selection of the leisure time 
activity program was allowed to increase adherence to 
the physical activity programs. 

Materials and methods 

Study planning 

BALLANDO (Benefici dellAttivita fisica Ludica sui Livelli 
di Ale e grasso viscerale Nel Diabete e Obesita, i.e., benefi- 
cial effects of leisure-time physical activity on Ale levels 
and visceral body fat in diabetes and obesity) is a pilot study 
carried out in two diabetes/obesity units from January 2012 
to March 2013, with the support of patients' and sports as- 
sociations. During a recruitment session carried out accord- 
ing to the principles of motivational interviewing [17], the 
patients were asked to select two different physical activity 
options: a) a standard ballroom and Latin dance program 
(DP) organized twice a week by diabetes associations, or b) 
a self-selected program (SSAP), with the option to receive 
support from sport associations, for training sessions to be 
carried out at least twice weekly. These patients were in- 
vited to register any bout of physical activity >30 min in a 
diary; the attendance of subjects to the dance sessions was 
systematically registered, not any additional physical activity 
exceeding the dancing program. 

Inclusion criteria were age 40 to 70, type 2 diabetes in 
good-to-fair metabolic control (glycosylated hemoglobin 
(HbAlc) < 8.5%) and/or obesity (Body Mass Index (BMI) > 
30 kg/m 2 or waist circumference >94 cm in males, >80 in 



females), with/without prediabetes or minor alterations of 
HbAlc. Exclusion criteria were previous cardiovascular 
events, muscle-skeletal problems reducing physical ability, 
any condition limiting systematic adherence. 

Primary end-points were a 5% reduction in BMI or 
waist circumference, and improved energy expenditure 
(physical activity expenditure >10 MET-hour/week). 
Secondary outcomes were improved metabolic control 
in diabetes (0.3% reduction of HbAlc) and increased phys- 
ical fitness (10% increase in the 6-min walk test - 6MWT). 
The target of 10 MET-hour/week corresponds to approxi- 
mately 150 min fast/very fast walking, as from the Diabetes 
Prevention Program target [10], Italian Standards of dia- 
betes care [18], and our own lifestyle modification pro- 
grams [19]. The end-points were tested at 3- and 6-month 
follow-up. 

The whole study was conducted in two diabetes/obes- 
ity units. All patients signed an informed consent. The 
protocol was approved by the ethical committee of 
Bologna University (Protocol #105/201 1/U/Sper) (Clin- 
ical trial reg. no. NCT02021890, clinicaltrials.gov). 

Patients 

The study enrolled 100 subjects (47 with type 2 diabetes, 
53 with obesity); in 11 subjects with obesity, prediabetes 
was also present. Fifty-two were males, 48 females, mean 
age 59 [SD 9 (range, 41-70)]. Their complete demo- 
graphic and clinical data are reported in Table 1. Most 
cases were enrolled in the Gavardo Unit, with only 11 
patients recruited in Bologna. All subjects were followed 
in a continuous care model by the recruiting units, and 
had received counseling for healthy diet and habitual 
physical activity, but had not engaged in specific activity 
programs during the previous year. During the study, 
their contact with physicians was similar; both groups 



Table 1 Demographic and clinical variables in the 
population, grouped according to the selected activity 
program 



Demographic and 
clinical variables 


Dance 
program 
(n = 42) 


Self-selected 
program 
(n = 58) 


P value 


Age (years) 


58.5 ± 8.8 


59.4 ± 8.5 


0.611 


Gender (M/F) (%) 


43/57 


59/41 


0.156 


Education (Primary/Secondary/ 
Vocational/Degree) (%) 


26/45/ 
24/5 


17/47/24/12 


0.478 


Occupation (Student/Employee/ 
Self-employed/Retired/Other) (%) 


0/21/19/ 
33/26 


7/28/26/34/5 


0.022 


Smoking (No/Yes/Ex) (%) 


81/7/12 


79/5/16 


0.821 


Alcohol (No/Yes/Ex) (%) 


95/3/2 


88/5/7 


0.364 


BMI class (Normal-weight/ 
Overweight/Obesity) (%) 


7/24/69 


2/14/84 


0.134 


Glucose regulation (Normal/ 


45/14/41 


40/8/52 


0.462 



Prediabetes/Diabetes (%) 



Mangeri et al. Diabetology & Metabolic Syndrome 2014, 6:74 
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attended the specialist Units for ambulatory visits every 
3 months, according to pre-specified protocols. 

The reasons for program selection were largely 
dependent on personal interests, on preferences for 
group or individual programs, or finally on familiar or 
job constraints, making it difficult to adhere to a pre- 
specified time schedule. These differences were discussed 
during motivational interviewing [17], to stimulate adher- 
ence to the selected program. No patient was allowed to 
move from one program to the other after final assignment. 

Methods 

DP consisted of a two-hour dancing session twice a 
week, led by instructors in a private hall of a disco. Both 
solo and partner and group dances were performed 
during each session: an initial one-hour activity, chaired 
by two instructors who taught new steps and choreog- 
raphies to patients (both individually and in group), was 
followed by one hour dancing in pairs (Latin and standard 
ballroom music). Patients were free to dance with other 
participants or with their own partners, thus reinforcing 
family ties and friendship. During the initial four weeks, 
patients were monitored by health care personnel (nurses 
and physician); blood pressure, heart rate, fingertip glucose 
(in diabetes) were checked before and immediately after 
sessions. 

SSAP consisted of a wide variety of activities. The pre- 
ferred activities were walking (36 cases), cycling (4 cases), 
swimming (6 cases), gym sessions (5 cases - with the sup- 
port of sports associations), or home exercising (exercise 
bike, 6 cases), but also included bouts of mountain walking, 
golf, weight lifting, jogging, dancing. Such activities were re- 
corded in a diary, also reporting time, duration and average 
speed, without external confirmation. 

The energy expenditure (in MET-hour per week) was 
calculated using the 2011 Compendium of Physical Ac- 
tivities [20], on the basis of the adherence to the pro- 
grammed dance sessions (number of attended weekly 
sessions), the type of dance (MET, 4-7), as well as the 
recorded self-selected physical activity bouts (from MET 
2.8 (walking, 3 km/hour) to MET 8.5 (aerobic step), ac- 
cording to average speed and perceived fatigue). 

Anthropometric and clinical data, metabolic profile 
(routine biochemistry) and physical fitness were tested 
at baseline and after 3 and 6 months. Weight and height 
were measured using a calibrated scale and stadiometer 
to the nearest 0-5 kg and 0 ♦ 5 cm; waist circumference 
was measured by a tape meter. The 6MWT was carried 
out as described by Enright [21]. 

At baseline, all subjects were tested for motivation to 
habitual physical activity by the EMME-3 test [22], as 
previously reported [23,24]. The test consists of two 
parts: a) an 18-item questionnaire (MAC 2) on a Likert 
scale from 0 (totally false) to 6 (totally true); b) a set of 



6 visual analogue scales (VAS) from 0 to 100. Briefly, 
the test evaluates motivation-to-change according to 
Prochaskas stage of change model (Precontemplation, 
Contemplation, Determination, Action, Maintenance) 
[25], and other psychological factors associated with 
motivation (Discrepancy, Self-Efficacy, Importance, 
Temptation, Readiness-to-change and Stabilization-of- 
change) [26,27]. 

Statistical analysis 

A descriptive analysis of data was carried out in the 
whole population and in different subgroups (e.g., with/ 
without type 2 diabetes; according to activity programs). 
Their time course in response to the activity program 
was tested by repeated measures ANOVA. 

To adjust results for baseline differences between groups, 
a propensity score approach was used [28]. The propensity 
score for the two activity programs was calculated by logis- 
tic regression on clinical, demographic and psychological 
variables at baseline that constitute potential barriers to 
group treatment, i.e., age, sex, educational level, occupation. 
The probability to reach the planned targets was tested by 
logistics regression in different models, having the primary 
targets as dependent variables and the type of program 
(DP vs. SSAP) as independent variable, after adjustment for 
propensity. 

Four sets of variables were simultaneously tested 
(anthropometric, psychological, clinical and activity 
variables), and the significance limit was then adjusted 
to P = l- ( n ~ l) y/{l-p) , where p = 0.05 and n = 4 [29]. 
The final critical value was therefore set at 0.015. 

Results 

The participants covered a wide range of BMI (only 9% 
normalweight) and age (41-70). Thirty-four cases were 
65 or over, mainly in the diabetes group (71%). No dif- 
ferences were recorded in education levels, smoking and 
alcohol intake between groups (Table 1). Also the psy- 
chological profile of motivation to habitual physical ac- 
tivity was similar and characterized by high scores of 
contemplation and determination, low values of precon- 
templation and action, and high rates of importance, 
self-efficacy and readiness-to-change (Table 2). 

DP and SPP had similar rates of obesity, but the aver- 
age BMI was over 2.5 points larger in SSAP (Table 3). 
Biochemistry and physical fitness, as measured by the 
6MWT, were within the expected range of walked dis- 
tance for age and diseases. 

In general, the participation to DP was good (77%), 
with 34/41 attending >70% of planned sessions. One pa- 
tient in DP and four in SSAP dropped out before the 3- 
month control; two patients more were lost in SSAP 
during the following three months (6-month attrition: 



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Table 2 Stage of change and psychological factors 
associated with motivation to habitual physical activity 
in patients grouped according to the selected activity 
program 

Psychological Dance Self-selected P value 

variables program program 

(n = 42) (n = 58) 

Pre-contemplation (%) 24.2 ± 29.6 26.7 ± 20.0 0.626 

Contemplation (%) 67.7 ± 23.1 64.8 ± 1 6.9 0.483 

Determination (%) 80.4 ± 1 8.4 73.7 ±21.2 0.1 1 3 

Action (%) 39.1 ±29.9 47.0 ±27.3 0.183 

Maintenance (%) 47.0 ± 32.3 41 .0 ± 28.5 0.340 

Discrepancy (%) 48.6 ± 25.6 52.5 ±21.2 0.41 9 

Importance (%) 82.6±14.7 81.6 ±14.4 0.745 

Self-efficacy (%) 77.9 ± 1 5.0 70.7 ± 1 6.5 0.031 

Temptation (%) 31.2 ± 24.8 42.1 ± 22.6 0.027 

Readiness-to-change (%) 75.5 ±21.9 73.3 ± 20.4 0.61 3 

Stabilization-of-change (%) 61.8 + 21.5 59.4 ± 25.9 0.665 

All scores are reported mean ± SD in% of maximum score. 



DP 2%, SPP 10%, P = 0.233, Fishers exact test). Both 
physical activity programs produced a significant de- 
crease of body weight (-2.6 kg for both; P < 0.001) and 
waist circumference (DP, -3.2 cm; SSAP, -2.2; P < 0.01) 
at 3 months, which were maintained at 6 months. Fasting 
glucose and liver enzymes decreased in both groups. 
Among biochemical variables, only glycosylated HbAlc 
showed a different time trend. At 3 months it decreased on 
average by approximately 0.2-0.3% in the two groups; in the 
following three months HbAlc decreased by an additional 
0.1% in DP, whereas in SSAP it returned to the pre-study 
values. 

No subject experienced hypoglycemic events. 

Physical activity, energy expenditure, and 6-min walk test 

The distance at 6MWT increased at 3 months in both 
groups; after 6 months, the distance further increased by 
4% in DP and was unchanged in SSAP. The monthly 
time course of activity-related energy expenditure was 
significantly different between groups (ANOVA, P <0.001; 
Figure 1). In DP it averaged 13.5 ± 1.8 MET-hour/week in 
the first 3 months and 14.1 ± 3.0 in the second 3-month 
period. In SSAP it was characterized by a higher and 
highly variable expenditure in the first 3-month period 



Pre-contemplation (%) 


242: 


1: 29.6 


26.7 


± 


20.0 


Contemplation (%) 


67.7: 


b 23.1 


64.8 


+ 


16.9 


Determination (%) 


80.4: 


b 18.4 


73.7 


+ 


21.2 


Action (%) 


39.1 : 


b29.9 


47.0 


± 


27.3 


Maintenance (%) 


47.0: 


b32.3 


41.0 


± 


28.5 


Discrepancy (%) 


48.6: 


b25.6 


52.5 


+ 


21.2 


Importance (%) 


82.6: 


b 14.7 


81.6 


± 


14.4 


Self-efficacy (%) 


77.9: 


b 15.0 


70.7 


± 


16.5 


Temptation (%) 


31.2: 


b24.8 


42.1 


+ 


22.6 


Readiness-to-change (%) 


75.5: 


b 21 .9 


73.3 


± 


20.4 


Stabilization-of-change (%) 


61.8: 


b 21 .5 


59.4 


± 


25.9 



Table 3 Anthropometric and biochemical data and walked distance in the 6-min walk test in the study subjects, 
grouped according to the physical activity program 



Clinical variables 


Dance program 




Self-selected 


program 




ANOVA 




Baseline 
(n = 42) 


3 months 
(n = 41) 


6 months 
(n = 41) 


Baseline 
(n = 58) 


3 months 
(n = 54) 


6 months 
(n = 52) 


P value 


Height (cm) 


163 + 9 






166 + 9 








Weight (kg) 


86.8 ± 1 7.6 


83.4 ±16.3° 


82.9 ±16.5° 


97.3 ±15.6* 


95.0 ±15.3°* 


94.8 ± 15.6°* 


0.884 


Body mass index (kg/m 2 ) 


32.7 ±6.3 


312 + 5.1° 


31.0 + 5.1° 


35.4 ±5.8* 


34.6 ±5.4°* 


34.5 ± 5.3°* 


0.874 


Waist circumference (cm) 


103 ± 12 


99±12° 


99 + 11° 


109+ 10* 


107±11°* 


107 ± 12°* 


0.625 


Systolic pressure (mmHg) 


131 ±19 


1 24 + 1 5 


128+19 


128+ 17 


1 28 + 1 7 


133 + 18 


0.294 


Diastolic pressure (mmHg) 


73 ±3 


73 ±8 


73 ±6 


77 ±9 


76 ± 10 


76 ± 11 


0.705 


Glycosylated hemoglobin (%) A 


7.46 ± 0.49 


7.25 ± 0.73 


7.10 ±0.58 


7.46 ± 0.59 


7.14 ±0.77 


7.48 ± 0.79 


0.011 


Fasting glucose (mg/dL) 


121 ±30 


1 15 ± 25° 


114 ±29° 


123 + 31 


1 1 7 ± 27° 


1 1 8 ± 29° 


0.567 


Fasting insulin (uU/mL) 


14.2 ±6.0 


12.4 ±4.8 


10.3 ±2.8 


18.5 ±28.5 


17.5 ±8.1* 


1 7.9 ± 9.4* 


0.084 


HOMA 


3.21 ±1.81 


2.58 ±1.00 


2.11 ±0.63 


4.41 ±2.33 


4.1 4 ±2.10* 


4.21 ±2.44* 


0.171 


Aspartate aminotransferase (U/L) 


27.9 ± 11.1 


24.9 ± 7.5° 


26.8 + 1 1.5° 


30.8 ±13.4 


27.2 ± 9.6° 


28.8 ± 12.7° 


0.703 


Alanine aminotranferase (U/L) 


32.3 ± 11.7 


28.4 ±10.9° 


30.8 ± 9.5° 


41.7 ±19.5* 


37.5 ± 1 7.4°* 


38.6 ±18.9°* 


0.816 


Creatinine (mg/dL) 


0.78 ±0.1 2 


0.77 ±0.1 2 


0.78 ±0.11 


0.82 ±0.1 7 


0.82 ±0.1 7 


0.83 ±0.1 6 


0.525 


Total cholesterol (mg/dL) 


192 ± 41 


183 + 35 


190 + 37 


1 98 ± 43 


186±44 


189 + 31 


0.791 


HDL cholesterol (mg/dL) 


56.4 ±15.1 


55.5 ±13.9 


58.3 ±16.4 


50.8 ±13.5 


49.7 ± 1 1 .0* 


50.9 ±11.3* 


0.275 


LDL cholesterol (mg/dL) 


1 12 ± 35 


103 ±30° 


1 10 + 33 


1 12 + 38 


1 06 ± 43 


1 15 =h 29 


0.940 


Triglycerides (mg/dL) 


120 + 71 


1 1 9 + 74 


108 + 57 


1 73 + 109* 


149 ±80 


135 ±52°* 


0.275 


6-min walk test (m) 


415 + 90 


479 ± 56° 


499 ±61° 


436 ± 70 


460 ± 68° 


460 ±91* 


0.015 



A Data are limited to the cohort of subjects with diabetes (Dance program, N = 17; Self-selected program, N = 30). 
"Significantly different from the corresponding baseline value in the same group. 
^Significantly different from the corresponding value in the dance program. 



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• Dance program O Self-selected program 

^24 n 



CD 




>■ 

°- o J — ■ ■ 

1st 2nd 3rd 4th 5th 6th 

Time (months) 

Figure 1 Time course of activity-related energy expenditure in 
subjects enrolled in the dance program (black circles) or in the 
self-selected physical activity program (white circles). Data are 
expressed and mean and 95% confidence interval. Note the much 
wider confidence interval in the self-selected program, expression of 
very high variability. 

V J 



(16.5 ± 13.9 MET-hour/week), which decreased thereafter 
to 14.2 ± 12.3 (P vs. first three-month period <0.001). 

Outcome achievement 

At 3 months, no differences in target achievement were 
observed between groups (Table 4). At 6 months the 
odds ratio of weight loss targets were also not different 
between groups, whereas the odds to attain the desired 
10 MET-hour/week target and 10% increased 6MWT 
were both significantly associated with DP. At 3 months, 
the target of 10 MET-hour/week was attained in 39/41 
cases (95%) in DP vs. 33/54 (61%) in SSAP (P <0.001; 
Fishers exact test), with 20 cases >20 MET-hour/week 
in SSAP. In the second 3-month period, the target was 
achieved in 37/41 (77%) in DP vs. 29/52 (56%) in SSAP, 
where 18 cases exceeded 20 MET-hour/week. Also the 
odds for the HbAlc target were in favor of DP (not sig- 
nificant); when the cases with prediabetes were added to 
the analysis, the modest decrease of HbAlc from 7.09 ± 
0.65 to 6.84 ±0.61 in DP (vs. an increase from 7.12 ± 
0.73 to 7.18 ± 0.83 in SSAP; ANOVA, P = 0.005) trans- 
lated into a significant probability to reach the primary 
HbAlc target (OR, 3.92; 95% confidence interval, 1.06- 
14.52) in DP. 

A separate analysis of target achievement in diabetes 
(n = 47) and in obesity (n = 53) did not produce qualita- 
tively different results, although in most cases statistical 
significance was not reached (not reported in details). 

Discussion 

The study identifies the benefits of a supervised dance pro- 
gram as part of leisure-time physical activity in improving 



metabolic control and physical fitness in type 2 diabetes. 
DP was as effective as SSAP (home, gym, or open-air activ- 
ity) in the short-term, but the benefits of SSAP were not 
maintained, with a higher attrition and a progressively re- 
duced energy expenditure along the months, in spite of 
similar stage-of-change and motivation to physical activity 
at entry. This underlines the importance of social support 
and pleasant activities to increase adherence in individual 
patients, according to cultural and social heritage, translat- 
ing into significantly better health and psychosocial targets. 

The clinical benefits of both activity programs extended 
from body weight loss to improved glucose control and re- 
duced liver enzymes, to improved physical fitness. The 
modest but significant reduction of liver enzymes is likely 
to reflect decreased hepatic triglyceride accumulation [30], 
as commonly observed in nonalcoholic fatty liver disease 
entering specific activity programs, also independent of 
weight loss [31,32]. It should be viewed in the context of 
the chronic liver disease associated with obesity and dia- 
betes, where intense behavioral treatment [33], also leading 
to improved glucose control, reduced insulin levels and 
improved insulin sensitivity [34], is expected to stop liver 
disease progression [33,35]. 

The total amount of physical activity was probably 
underestimated in DP and overestimated in SPP. Most 
DP patients added physical activity bouts to the two 
weekly dance sessions, but these events were purposely 
not recorded to let patients completely free of imple- 
menting other activities according to their personal in- 
terests, while focusing on strict adherence to DP. On the 
contrary, all bouts of leisure- time activities were regis- 
tered in SSAP as primary goal of the study, with a well- 
known risk of over-reporting compared with objective 
assessment [36]. Walking, biking and jogging were the 
most common activities selected in SSAP, with peaks of 
over 40 MET-hour/week in 7/54 SSAP cases. 

During each DP session, the amount of activity was 
calculated as 4.3 MET-hour on the basis of a repetitive, 
predetermined Latin and ballroom dance program. Ac- 
cording to the Compendium of Physical Activity [20], 
the energy dance expenditure may vary from 3.5 MET 
(Caribbean dance, beginners [37]) to >10 MET (Aerobic 
step and Swedish folk dancing) [38,39]. The program 
was designed for mature/elderly people, and the theoret- 
ical maximum expenditure was limited between 4 and 7 
MET [40], to avoid the risk of cardiovascular complica- 
tions, without differences between genders [41]. This 
moderate amount was very similar to the amount of su- 
pervised aerobic and resistance training tested against 
physical activity counseling in a large randomized Italian 
study [12], where exercise significantly improved meta- 
bolic parameters. Similarly, 60-min brisk walking three 
times weekly (approximately 10 MET-hour/week) im- 
proved oxygen uptake, lipid and glucose homeostasis 



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Table 4 Odds ratio to reach the planned targets at three and six month follow-up in the dance program vs. the self- 
selected activity program 



Primary targets 



Dance group 

At target/total cases 



Self-selected group 
At target/total cases 



Odds ratio 

(95% confidence interval) 



P 

value 



3-month assessment 

Weight loss (>5%) 12/41 

Reduced waist circumference (>5%) 12/41 

Reduced glycosylated hemoglobin (>0.3%)* 6/17 

Physical activity (>10 MET-hour/week) 39/41 

Increased distance at 6-min walk test (>10%) 20/41 

6-month assessment 

Weight loss (>5%) 10/41 

Reduced waist circumference (>5%) 1 1/41 

Reduced glycosylated hemoglobin (>0.3%)* 10/17 

Physical activity (>10 MET-hour/week) 37/41 

Increased distance at 6-min walk test (>10%) 28/41 



10/54 
13/54 
15/29 
33/54 
24/54 

10/52 

11/52 

5/28 

29/52 

23/52 



1.97 (0.63-6.17) 
2.02 (0.67-6.06) 
0.63 (0.15-2.58) 
9.93 (2.00-49.19) 
2.12 (0.77-5.75) 

1 .25 (0.38-4.07) 
1.27 (0.41-3.99) 
6.23 (0.82-47.62) 
6.21 (1.70-22.75) 
3.08 (1.12-8.47) 



0.246 
0.209 
0.030 
0.005 
0.146 

0.716 
0.678 
0.078 
0.006 
0.029 



^Limited to subjects with diabetes. 

and reduced visceral fat [42]. All studies involving gyms, 
however, need an intense support to limit attrition, 
whereas the social support of dancing was probably 
pivotal to keep patients with diabetes on treatment, 
reducing HbAlc to an extent similar to that achieved in 
SSAP. 

The estimated MET amount was on average >10 
MET-hour/week. Di Lore to et al. have shown that phys- 
ical activity above this target produces metabolic and 
clinical effects, which become large above the 20 MET- 
hour/week threshold [11]. This higher amount of physical 
activity, also associated with reduced costs of pharmaco- 
logical treatment [11], was more frequently attained in 
SSAP, where individual cases attained weekly physical 
activity levels >40 MET-hour/week, but the minimum of 10 
MET-hour/week was more common in DP, both during 
the first and, particularly, during the second 3-month 
period and the last month when 93% of cases (39/42) in DP 
met the target vs. 54% in SSAP (28/52; P <0.0001, Fishers 
exact test, in the per-treatment analysis, corresponding to 
90% vs. 48% on intention-to-treat). 

The study has both strengths and limitations. The 
main strength is its easy implementation in the commu- 
nity with limited resources and the robust results that 
might be exported to other typical clinical settings. The 
limits are the selection of motivated individuals - with 
minor differences between groups -, the non-randomized 
nature of the study, the so far time-limited experience, and 
the methods used to estimate energy expenditure. The se- 
lection of subjects after motivational interviewing may be 
justified by the very low motivation to physical activity 
commonly observed in individuals with type 2 diabetes 
[43], also reported in Italian subjects with diabetes [23] as 
well as other metabolic disorders [24], with a high risk of 



attrition in unselected patients. The lack of randomization 
was justified by inherent difficulties in directing individuals 
to dancing independently of their willingness. To adjust for 
non-randomization, a propensity score approach was se- 
lected. Although less solid than properly planned RCTs, 
adjusting by propensity produces valuable data reflecting 
the "real world" of disease treatment [44], and the proced- 
ure is largely accepted in chronic diseases requiring motiv- 
ation as pre-requisite to accept treatment [44]. The study 
design was chosen to accommodate the patients' desires to 
receive their favorite treatment and achieve physical activity 
benefits while maintaining scientific integrity. In this case, 
we tried to favor patients by providing a DP, which was also 
planned according their cultural heritage. In the real set- 
ting, every effort should be made to offer motivated pa- 
tients their preferred activities, as long as they demonstrate 
long-term effectiveness, and also low-grade activity may be 
effective [42]. Forcing patients, although motivated, to per- 
form activities largely considered unpleasant in the general 
population is likely to result in attrition and treatment 
failure [45]. As to the time-limited experience, the 
study will be continued and further work is needed to 
confirm longer effectiveness. Finally, the methods used 
to estimate energy expenditure has probably led to an 
underestimation of physical activity in DP and over- 
estimation in SSAP. To overcome this limit, future 
studies should use more objective devices (i.e., acceler- 
ometers, not usually available in standard clinical set- 
tings) to assess participants' expenditure. 

In conclusion, dance may be an effective strategy to 
implement physical activity in motivated subjects with 
type 2 diabetes or obesity. Following this seminal posi- 
tive experience, dancing might also be tested as a pre- 
vention strategy in cases at high risk of type 2 diabetes 



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in the community, where physical activity may halt or 
delay disease progression [46]. As a social and pleasant 
form of exercising, it may be potentially useful, par- 
ticularly to older and obese patients, also according to 
cultural and social heritages, to escape isolation and 
improve quality of life. 

Abbreviations 

DP: Dance program; SSAP: Self-selected activity program; MET: Metabolic 
equivalent; 6-MV\^: 6-min walk test; HbA1c: Glycosylated hemoglobin. 

Competing interest 

None in relation to the material presented in this report. 
Authors' contributions 

FM, GF, and GM contributed to conception and design of the study. FM and 
LM collected the data. GF and GM reviewed the literature. RDG and GM 
wrote the initial draft. All authors substantially contributed to data 
interpretation and critical revision of the manuscript. All authors read 
and approved the final manuscript. 

Aknowledgments 

The authors are indebted to Mrs. E. Ceccardi, President of Diabetic 
Association, Brescia Regional area, to nurses E. Neboli and S. Ce, and to Mrs. 
L. Manuzzato (Organizing Committee) for continuous enthusiastic support. 

Previous presentation 

An abstract of the preliminary results of the study was presented at the 
Annual Meeting of the Associazione Medici Diabetologi (AMD); May 29-June 
1, 2013; Rome, Italy. 

Guarantor statement 

Prof. G Marchesini had full access to all the data in the study and takes 
responsibility for the integrity of the data, the accuracy of the data analyses 
and the contents of the article. 

Author details 

1 Unit of Endocrinology and Diabetology, General Hospital, Gavardo, Brescia, 
Italy. 2 Unit of Metabolic Diseases and Clinical Dietetics, "Alma Mater 
Studiorum" University of Bologna, Policlinico S. Orsola, Via Massarenti, 9 
1-40138, Bologna, Italy, department of Eating and Weight Disorders, Villa 
Garda Hospital, Garda, Italy. 

Received: 24 March 2014 Accepted: 14 June 2014 
Published: 22 June 2014 

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doi:1 0.1 186/1 758-5996-6-74 

Cite this article as: Mangeri et al.: A standard ballroom and Latin dance 
program to improve fitness and adherence to physical activity in 
individuals with type 2 diabetes and in obesity. Diabetology & Metabolic 
Syndrome 2014 6:74. 



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