Physical Activity/Exercise and Diabetes: A Position Statement of the American Diabetes Association

Sedentary behavior and cardiovascular disease in older women: The Objective Physical Activity and Cardiovascular Health (OPACH) Study

Background

Evidence that higher sedentary time is associated with higher risk for cardiovascular disease (CVD) is based mainly on self-reported measures. Few studies have examined whether patterns of sedentary time are associated with higher risk for CVD.

Methods

Women from the Objective Physical Activity and Cardiovascular Health (OPACH) Study (n=5638, aged 63-97, mean age=79±7) with no history of myocardial infarction (MI) or stroke wore accelerometers for 4-to-7 days and were followed for up to 4.9 years for CVD events. Average daily sedentary time and mean sedentary bout duration were the exposures of interest. Cox regression models estimated hazard ratios (HR) and 95% confidence intervals (CI) for CVD using models adjusted for covariates and subsequently adjusted for potential mediators (body mass index (BMI), diabetes, hypertension, and CVD-risk biomarkers [fasting glucose, high-density lipoprotein, triglycerides, and systolic blood pressure]). Restricted cubic spline regression characterized dose-response relationships.

Results

There were 545 CVD events during 19,350 person-years. Adjusting for covariates, women in the highest (≥ ~11 hr/day) vs. the lowest (≤ ~9 hr/day) quartile of sedentary time had higher risk for CVD (HR=1.62; CI=1.21-2.17; p-trend <0.001). Further adjustment for potential mediators attenuated but did not eliminate significance of these associations (p-trend<.05, each). Longer vs. shorter mean bout duration was associated with higher risks for CVD (HR=1.54; CI=1.27-2.02; p-trend=0.003) after adjustment for covariates. Additional adjustment for CVD-risk biomarkers attenuated associations resulting in a quartile 4 vs. quartile 1 HR=1.36; CI=1.01-1.83; p-trend=0.10). Dose-response associations of sedentary time and bout duration with CVD were linear (P-nonlinear >0.05, each). Women jointly classified as having high sedentary time and long bout durations had significantly higher risk for CVD (HR=1.34; CI=1.08-1.65) than women with both low sedentary time and short bout duration. All analyses were repeated for incident coronary heart disease (MI or CVD death) and associations were similar with notably stronger hazard ratios.

Conclusions

Both high sedentary time and long mean bout durations were associated in a dose-response manner with increased CVD risk in older women, suggesting that efforts to reduce CVD burden may benefit from addressing either or both component(s) of sedentary behavior.

Patient and Healthcare Professionals Perspectives on the Delivery of Exercise Education for Patients With Type 1 Diabetes

Objective: One way of improving the prognosis for the growing numbers of people with type 1 diabetes (T1D) is to increase their frequency of exercise. One known barrier to this is the lack of cohesive support and information from care providers. To better understand the issues around existing support for patients wishing to exercise and inform the design of an education package specifically to facilitate safe exercise we interviewed care providers and patients about the existing provision of support. Research Design and Methods: The study was based within two large UK teaching hospitals where four focus groups were undertaken two consisting of patients diagnosed with T1D who undertook regular exercise, and two with health care providers (HCPs) that were part of the diabetes care team. In all 14 patients and 11 staff were involved. These were complemented by two 1:1 interviews with staff unable to attend group discussions. Results: We found the successful provision of education and advice was influenced by factors relating to the individual patient and their service provider. Patient factors included the type of activity and complexity of the exercise regime, the level of engagement with their condition and care and health literacy. Service-related factors included inconsistent training, a lack of capacity and continuity, and limited coherence of information from across their care team. Conclusions: Any education package developed to support exercise in patients with type 1 diabetes should be offered at a time following diagnosis in accordance with patients' preferences and priorities, contain information on how to manage regular and irregular bouts of exercise. Patients described how they related more closely to the stories of their peers than famous sports stars and one way this can be facilitated is by group delivery. The content and relevance of any supporting materials should be closely considered. Training in the delivery of a novel education package should be made available to staff across the care team to enable them to either deliver the course or increase their confidence in offering salient advice as part of routine care.

Association of food groups intake and physical activity with gestational diabetes mellitus in Iranian women

Background: It is suggested that combining a healthy diet with physical activity during and before pregnancy have a significant effect on insulin sensitivity. This study aimed to investigate the relationship between physical activity and diet before and during pregnancy with the risk of gestational diabetes mellitus (GDM).Methods: A case-control study was conducted on 173 women with GDM diagnosed during the pregnancy as the case group and 168 women with a negative test for GDM as controls. Weight and height were measured and BMI was calculated. Dietary intake and physical activity data during pregnancy were collected using 24-hour food recall questionnaire and international physical activity questionnaire (IPAQ).Results: Body mass index and the intake of refined sugars, high fat dairy products, and fried foods were significantly higher and the intake of fruit and animal oil intake were significantly lower in the case group compared to the control group (All p < .05). However, there was not any significant association between the level of physical activity, vegetable intake, and total energy intake with the risk of GDM.Conclusions: According to the results of this study, dietary intake before and during the pregnancy have a critical effect on the risk of GDM. Appropriate dietary planning for pregnant women can reduce the risk of GDM.

Requirements of an Application to Monitor Diet, Physical Activity and Glucose Values in Patients with Type 2 Diabetes: The Diameter

Adherence to a healthy diet and regular physical activity are two important factors in sufficient type 2 diabetes mellitus management. It is recognized that the traditional treatment of outpatients does not meet the requirements for sufficient lifestyle management. It is hypothesised that a personalized diabetes management mHealth application can help. Such an application ideally measures food intake, physical activity, glucose values, and medication use, and then integrates this to provide patients and healthcare professionals insight in these factors, as well as the effect of lifestyle on glucose values in daily life. The lifestyle data can be used to give tailored coaching to improve adherence to lifestyle recommendations and medication use. This study describes the requirements for such an application: the Diameter. An iterative mixed method design approach is used that consists of a cohort study, pilot studies, literature search, and expert meetings. The requirements are defined according to the Function and events, Interactions and usability, Content and structure and Style and aesthetics (FICS) framework. This resulted in 81 requirements for the dietary (n = 37), activity and sedentary (n = 15), glycaemic (n = 12), and general (n = 17) parts. Although many applications are currently available, many of these requirements are not implemented. This stresses the need for the Diameter as a new personalized diabetes application.

A systematic review and meta-analysis of the effects of supervised exercise therapy on modifiable cardiovascular risk factors in intermittent claudication

OBJECTIVE

Cardiovascular events, such as myocardial infarction and stroke, contribute significantly to the prognosis of patients with peripheral artery disease. Therefore cardiovascular risk reduction is a vital element of treatment in patients with intermittent claudication (IC). The cardiovascular risk is largely determined by modifiable risk factors, which can be treated with medical care and lifestyle adjustments, such as increasing physical activity. The objective of this study was to determine the effects of supervised exercise therapy (SET) on modifiable cardiovascular risk factors in IC patients.

METHODS

This is a systematic review and meta-analysis of prospective studies on the effects of SET on cardiovascular risk factors in symptomatic IC patients. Studies were eligible if they presented baseline and follow-up values for at least one of the following risk factors: blood pressure (systolic or diastolic), heart rate, lipid profile (total cholesterol, triglycerides, high-density lipoprotein cholesterol, low-density lipoprotein cholesterol), glucose, glycated hemoglobin, body weight, body mass index, or cigarette smoking. Pooled mean differences between follow-up and baseline were analyzed using a random-effects model. Data were classified into short-term results (6 weeks-3 months) and midterm results (6-12 months). Statistical heterogeneity was presented as I² and Q statistic.

RESULTS

Twenty-seven studies with a total of 808 patients were included in this review. In the short term, SET resulted in significant improvements of systolic blood pressure (decrease of 4 mm Hg; 10 studies; 95% confidence interval [CI], -6.40 to -1.76; I², 0%) and diastolic blood pressure (decrease of 2 mm Hg; 8 studies; 95% CI, -3.64 to -0.22; I², 35%). In the midterm, SET contributed to significant lowering of levels of low-density lipoprotein cholesterol (decrease of 0.2 mmol/L; four studies; 95% CI, -0.30 to -0.12; I², 29%) and total cholesterol (decrease of 0.2 mmol/L, four studies; 95% CI, -0.38 to -0.10; I², 36%). No significant effects of SET were identified for heart rate, triglycerides, high-density lipoprotein cholesterol, glucose, glycated hemoglobin, body weight, body mass index, or cigarette smoking.

CONCLUSIONS

This systematic review and meta-analysis shows favorable effects of SET on modifiable cardiovascular risk factors, specifically blood pressure and cholesterol levels. Despite the moderate quality, small trial sample sizes, and study heterogeneity, these findings support the prescription of SET programs not only to increase walking distances but also for risk factor modification. Future studies should address the potential effectiveness of SET to promote a healthier lifestyle and to improve cardiovascular outcomes in patients with claudication.

Effectiveness of a Behavior Change Technique-Based Smartphone Game to Improve Intrinsic Motivation and Physical Activity Adherence in Patients With Type 2 Diabetes: Randomized Controlled Trial

Background

Regular physical activity (PA) is an essential component of a successful type 2 diabetes treatment. However, despite the manifest evidence for the numerous health benefits of regular PA, most patients with type 2 diabetes remain inactive, often due to low motivation and lack of PA enjoyment. A recent and promising approach to help overcome these PA barriers and motivate inactive individuals to change their PA behavior is PA-promoting smartphone games. While short-term results of these games are encouraging, the long-term success in effectively changing PA behavior has to date not been confirmed. It is possible that an insufficient incorporation of motivational elements or flaws in gameplay and storyline in these games affect the long-term motivation to play and thereby prevent sustained changes in PA behavior. We aimed to address these design challenges by developing a PA-promoting smartphone game that incorporates established behavior change techniques and specifically targets inactive type 2 diabetes patients.

Objective

To investigate if a self-developed, behavior change technique-based smartphone game designed by an interdisciplinary team is able to motivate inactive individuals with type 2 diabetes for regular use and thereby increase their intrinsic PA motivation.

Methods

Thirty-six inactive, overweight type 2 diabetes patients (45-70 years of age) were randomly assigned to either the intervention group or the control group (one-time lifestyle counseling). Participants were instructed to play the smartphone game or to implement the recommendations from the lifestyle counseling autonomously during the 24-week intervention period. Intrinsic PA motivation was assessed with an abridged 12-item version of the Intrinsic Motivation Inventory (IMI) before and after the intervention. In addition, adherence to the game-proposed PA recommendations during the intervention period was assessed in the intervention group via the phone-recorded game usage data.

Results

Intrinsic PA motivation (IMI total score) increased significantly in the intervention group (+6.4 (SD 4.2; P<.001) points) while it decreased by 1.9 (SD 16.5; P=.623) points in the control group. The adjusted difference between both groups was 8.1 (95% CI 0.9, 15.4; P=.029) points. The subscales “interest/enjoyment” (+2.0 (SD 1.9) points, P<.001) and “perceived competence” (+2.4 (SD 2.4) points, P<.001) likewise increased significantly in the intervention group while they did not change significantly in the control group. The usage data revealed that participants in the intervention group used the game for an average of 131.1 (SD 48.7) minutes of in-game walking and for an average of 15.3 (SD 24.6) minutes of strength training per week. We found a significant positive association between total in-game training (min) and change in IMI total score (beta=0.0028; 95% CI 0.0007-0.0049; P=.01).

Conclusions

In inactive individuals with type 2 diabetes, a novel smartphone game incorporating established motivational elements and personalized PA recommendations elicits significant increases in intrinsic PA motivation that are accompanied by de-facto improvements in PA adherence over 24 weeks.

Trial Registration

ClinicalTrials.gov NCT02657018; https://clinicaltrials.gov/ct2/show/NCT02657018

Randomized Controlled Trial of Physical Exercise in Diabetic Veterans With Length-Dependent Distal Symmetric Polyneuropathy

Rationale: Physical exercise is an essential adjunct to the management of patients with type 2 diabetes mellitus. Therapeutic interventions that improve blood flow to peripheral nerves, such as exercise, may slow the progression of neuropathy in the diabetic patient.

Aims: This randomized clinical trial was conducted to determine whether a structured program of aerobic, isokinetic strength, or the combination of aerobic–isokinetic strength exercise intervention alters peripheral nerve function in glycemic-controlled diabetic patients with advanced length-dependent distal symmetric polyneuropathy.

Methods: Forty-five patients with type 2 diabetes mellitus exhibiting tight glycemic control (HbA_1c intergroup range 7.2–8.0%) were randomized by block design across four experimental groups: sedentary controls (n = 12), aerobic exercise (n = 11), isokinetic strength (n = 11), or the combination of aerobic–isokinetic strength training (n = 11). Patients randomized to training groups exercised 3× per week for 12 weeks, whereas patients randomized to the sedentary control group received standard of care. To minimize attention and educational bias, all patients attended a 12-session health promotion educational series. At baseline, immediately following intervention, and again at 12-week post-intervention, detailed nerve conduction studies were conducted as a primary outcome measure. At these same intervals, all patients completed as secondary measures quantitative sensory testing, symptom-limited treadmill stress tests, and a Short-Form 36-Veterans Questionnaire (SF-36V).

Results: Of the 45 patients randomized into this study, 37 (82%) had absent sural nerve responses, 19 (42%) had absent median sensory nerve responses, and 17 (38%) had absent ulnar sensory nerve responses. By comparison, responses from tibial nerves were absent in only three (7%) subjects while responses from peroneal nerves were absent in five (11%) subjects. Eleven (92%) of 12 patients that had volunteered to be biopsied exhibited abnormal levels of epidermal nerve fiber densities. Exercise, regardless of type, did not alter sensory or motor nerve electrodiagnostic findings among those patients exhibiting measurable responses (ANOVA). There was, however, a modest (p = 0.01) beneficial effect of exercise on sensory nerve function (Fisher’s Exact Test). Importantly, the beneficial effect of exercise on sensory nerve function was enhanced (p = 0.03) during the post-intervention interval. In addition, three of six patients that had undergone exercise intervention exhibited a marked 1.9 ± 0.3-fold improvement in epidermal nerve fiber density. By comparison, none of three sedentary patients whom agreed to be biopsied a second time showed improvement in epidermal nerve fiber density. Compared to baseline values within groups, and compared with sedentary values across groups, neither aerobic, isokinetic strength, or the combination of aerobic–isokinetic strength exercise intervention altered peak oxygen uptake. Patients that underwent aerobic or the combined aerobic–isokinetic strength exercise intervention, however, demonstrated an increase in treadmill test duration that was sustained over the 12-week post-intervention period.

Conclusion: A 12-week course of physical exercise, regardless of type, does not alter sensory or motor nerve electrodiagnostic findings. In a subset of patients, a short-term structured program of aerobic exercise may selectively improve sensory nerve fiber function. Large-scale exercise lifestyle intervention trials are warranted to further evaluate the impact of aerobic exercise on sensory nerve fiber function in diabetic neuropathic patients.

Clinical Trial Registration:www.ClinicalTrials.gov, identifier NCT00955201.

Development and Assessment of a Mobile Health Application for Monitoring the Linkage Among Treatment Factors of Type 1 Diabetes Mellitus

Background: In the daily routine of type 1 diabetes mellitus (T1DM), the patients deal with many data and consider many variables to perform actions, decisions, and regimen adjustments. There is a need to apply filtering techniques to extract relevant information and provide appropriate data visualization methods to assist in clinical tasks and decision making. Objective: To present Soins DM, a mobile health tool, for monitoring the linkage among treatment factors of T1DM with an interactive data visualization approach. Methods: First, we performed a literature review, a commercial search, and ideation. Next, we created a prototype and an online survey for its feedback, with participation of 76 individuals. Afterward, the mobile app and its website version were built. Eventually, we conducted a pilot experiment with 4 patients, an online experiment for satisfaction assessment with 97 patients, and an online assessment by 9 health professionals. Results: Prototyping and feedback facilitated the design refinement. Soins DM enables the recording of data from routines of glycemia, insulin applications, meals, and physical exercises. From these logs, the app builds two different ways of interactive data visualization, a timeline and an integrated chart, providing personalized feedback on bad glycemia with its possible causes. The assessments revealed overall satisfaction with the app's characteristics. Conclusions: Soins DM is a novel application with interactive visualization and personalized feedback for easy identification of the linkage among treatment factors of T1DM. The test scenario with patients and health professionals indicates Soins DM as a useful and reliable tool.

Peripheral Mechanisms of Remote Ischemic Conditioning

Ischemic conditioning induces an endogenous protective mechanism that allows organisms to develop resistance to subsequent insults. The conditioning effect occurs across organs and species. Recently, much attention has been given to remote ischemic limb conditioning due to its non-invasive nature and potential therapeutic applications. While tolerance is induced at the primary injury site (e.g. the heart in cardiac ischemia and the brain in stroke), the site of conditioning application is away from the target organ, suggesting the protective factors are extrinsic in nature rather than intrinsic. This review will focus on the peripheral factors that account for the induction of tolerance. Topics of particular interest are blood flow changes, peripheral neural pathways, humoral factors in circulation, and the peripheral immune system. This review will also discuss how conditioning may negatively affect metabolically compromised conditions, its optimal dose, and window for therapy development.

Association Between Cardiorespiratory Fitness and Risk of Type 2 Diabetes: A Meta-Analysis

OBJECTIVE

This meta-analysis aimed to (1) quantify the association of cardiorespiratory fitness (CRF) with type 2 diabetes risk in the general population and statin users and (2) investigate the joint effects of CRF and fatness with type 2 diabetes risk.

METHODS

Databases were searched for cohort studies reporting the association between CRF and type 2 diabetes risk. Summary hazard ratios (HRs) were obtained using random-effects models.

RESULTS

Fifteen studies were included. The HRs of type 2 diabetes for every 1-metabolic equivalent increase in CRF were 0.90 (95% CI: 0.86-0.94) for the general population and 0.92 (95% CI: 0.87-0.97) for statin users, and the HRs were linearly shaped (both P_nonlinearity  > 0.40). Compared with the nonstatin cohort, there was an increased risk of type 2 diabetes in statin users with the lowest and moderate CRF categories, but this was not present in the highest CRF category. The HR of type 2 diabetes for overweight/obesity-fit category versus normal weight-fit category was larger than that of the normal weight-unfit category versus the normal weight-fit category (P_interaction   = 0.004).

CONCLUSIONS

There was an inverse and dose-dependent association between CRF and type 2 diabetes risk. High CRF may eliminate the diabetogenic effect from statins, yet decreased body weight index seems superior in preventing type 2 diabetes.

Reduction in insulin degludec dosing for multiple exercise sessions improves time spent in euglycaemia in people with type 1 diabetes: A randomized crossover trial

AIMS

To compare the time spent in specified glycaemic ranges in people with type 1 diabetes (T1D) during 5 consecutive days of moderate-intensity exercise while on either 100% or 75% of their usual insulin degludec (IDeg) dose.

MATERIALS AND METHODS

Nine participants with T1D (four women, mean age 32.1 ± 9.0 years, body mass index 25.5 ± 3.8 kg/m² , glycated haemoglobin 55 ± 7 mmol/mol (7.2% ± 0.6%) on IDeg were enrolled in the trial. Three days before the first exercise period, participants were randomized to either 100% or 75% of their usual IDeg dose. Participants exercised on a cycle ergometer for 55 minutes at a moderate intensity for 5 consecutive days. After a 4-week wash-out period, participants performed the last exercise period for 5 consecutive days with the alternate IDeg dose. Time spent in specified glycaemic ranges, area under the curve and numbers of hypoglycaemic events were compared for the 5 days on each treatment allocation using a paired Students' t test, Wilcoxon matched-pairs signed-rank test and two-way ANOVA.

RESULTS

Time spent in euglycaemia over 5 days was greater for the 75% IDeg dose versus the 100% IDeg dose (4008 ± 938 minutes vs. 3566 ± 856 minutes; P = 0.04). Numbers of hypoglycaemic events (P = 0.91) and time spent in hypoglycaemia (P = 0.07) or hyperglycaemia (P = 0.38) was similar for both dosing schemes.

CONCLUSIONS

A 25% reduction in usual IDeg dose around regular exercise led to more time spent in euglycaemia, with small effects on time spent in hypo- and hyperglycaemia.

Effects of Moderate Cycling Exercise on Blood Glucose Regulation Following Successful Clinical Islet Transplantation

CONTEXT

Islet transplantation is effective in preventing hypoglycemia in patients with type 1 diabetes (T1D). However, it is unknown whether transplanted islets regulate plasma glucose concentrations appropriately during and after exercise in human islet transplant recipient (ITxs).

OBJECTIVE

To determine the effect of exercise on plasma glucose, insulin, and glucagon concentrations in ITxs compared with control subjects (CONs) without diabetes.

INTERVENTION

Participants completed two conditions in random order: 45 minutes of aerobic exercise (60% VO2peak) and 45 minutes of seated rest. Blood samples were drawn at baseline, immediately after exercise or rest, and every 15 minutes throughout a 60-minute recovery period. Postexercise (24 hours) interstitial glucose was monitored with continuous glucose monitoring (CGM).

RESULTS

Twenty-four participants (12 ITxs, 12 CONs) completed the protocol. Plasma glucose decreased more over time with exercise in ITxs compared with CONs [main effects of treatment (P = 0.019), time (P = 0.001), and group (P = 0.012)]. Plasma glucose was lower during exercise vs rest in ITxs but not CONs [treatment by group interaction (P = 0.028)]. Plasma glucose decreased more during exercise than during rest [treatment by time interaction (P = 0.001)]. One ITx and one CON experienced plasma glucose concentrations <3.5 mmol/L at the end of exercise, both of whom returned above that threshold within 15 minutes. Nocturnal CGM glucose <3.5 mmol/L was detected in two CONs but no ITxs.

CONCLUSION

Despite a greater plasma glucose decline during exercise in ITxs, hypoglycemia risk was similar during and after exercise in ITxs compared with CONs.

High-Intensity Interval Training Improves Aerobic Capacity Without a Detrimental Decline in Blood Glucose in People With Type 1 Diabetes

CONTEXT

We investigated whether 6 weeks of high-intensity interval training (HIT) induced improvements in cardiometabolic health markers similar to moderate-intensity continuous training (MICT) in people with type 1 diabetes (T1D), and whether HIT abolished acute reductions in plasma glucose levels observed after MICT sessions.

METHODS

Two groups of sedentary individuals with T1D (n = 7 per group) completed 6 weeks of thrice weekly HIT or MICT. Pre- and post-training measurements were made of 24-hour interstitial glucose profiles, using continuous glucose monitors, and cardiometabolic health markers [peak oxygen consumption (V˙o2peak), blood lipid profile, and aortic pulse wave velocity (aPWV)]. Capillary blood glucose (BG) concentrations were assessed before and after exercise to investigate changes in BG levels during exercise in the fed state.

RESULTS

Six weeks of HIT or MICT increased V˙o2peak by 14% and 15%, respectively (P < 0.001), and aPWV by 12% (P < 0.001), with no difference between groups. There was no difference in incidence or percentage of time spent in hypoglycemia after training in either group (P > 0.05). In the fed state, the mean change (±SEM) in capillary BG concentration during the HIT sessions was -0.2 ± 0.5 mmol/L, and -5.5 ± 0.4 mmol/L during MICT.

CONCLUSIONS

Six weeks of HIT improved V˙o2peak and aPWV to a similar extent as MICT. That BG levels remained stable during HIT in the fed state but consistently fell during MICT suggests HIT may be the preferred training mode for some people with T1D.

Aerobic exercise training may improve nerve function in type 2 diabetes and pre-diabetes: A systematic review

Diabetic neuropathy is a major complication of type 2 diabetes. Emerging evidence also suggests that people with pre-diabetes may develop similar symptoms related to nerve dysfunction. While regular exercise provides many benefits to patients with diabetes, whether exercise influences nerve function has not been established. As such, the aim of this systematic review was to evaluate current evidence regarding the effect of exercise training on the progression and development of diabetic neuropathy. A systematic search of MEDLINE (Ovid), CINAHL, AMED, PEDro, the Cochrane Library, Embase, and Scopus databases identified a total of 12 studies that were eligible for inclusion in this systematic review. Quality rating and data extraction were performed by two independent reviewers. The 12 included studies examined people with pre-diabetes (n = 1) and with type 2 diabetes (n = 11). There was heterogeneity of study quality and exercise type and dosage among these studies. Eleven studies reported that exercise training had a positive influence on nerve function or neuropathy-related symptoms; and only one study reported mild adverse events. Evidence from this systematic review suggests aerobic exercise training may positively influence nerve function among people with type 2 diabetes, with minimal risk of adverse events. Further research will be required to determine the optimal dosage of exercise training and the effect on nerve function in pre-diabetes and in women with previous gestational diabetes. This review is registered on PROSPERO (CRD42018088182).

Review of general suggestions on physical activity to prevent and treat gestational and pre-existing diabetes during pregnancy and in postpartum

The aim of this review is to provide general suggestions on physical activity (PA) in pre-gestational and gestational diabetes mellitus (GDM) and encourage women to take part in safe and effective activities throughout pregnancy, in the absence of other contraindications. PA before and during pregnancy and in postpartum has many positive effects on the mother, as it could reduce the risk of GDM, excessive weight gain and lower back pain and also prevents, in the postpartum, diabetes mellitus. It may also reduce the duration of labour and complications at childbirth, fatigue, stress, anxiety and depression, thereby leading to an improved sense of wellbeing. Clinically, it is thought to help prevent preeclampsia and premature birth even though RCTs provide conflicting evidence with regard to the prevention of GDM. The main reason for this rests on the fact that the majority of clinical trials have not been able to replicate the preventive effect of PA on the onset of GDM, such as the different adherence of the patient to PA. Herein, we survey the literature regarding exercise and PA on GDM prevention and treatment as well as on clinical outcomes in pre-GDM in pregnancy. On the basis of the current literature, we also present a series of general recommendations and suggestions on PA and exercise training in pregnancy among both diabetic patients and those at risk for GDM.

Circadian clocks and insulin resistance

Insulin resistance is a main determinant in the development of type 2 diabetes mellitus and a major cause of morbidity and mortality. The circadian timing system consists of a central brain clock in the hypothalamic suprachiasmatic nucleus and various peripheral tissue clocks. The circadian timing system is responsible for the coordination of many daily processes, including the daily rhythm in human glucose metabolism. The central clock regulates food intake, energy expenditure and whole-body insulin sensitivity, and these actions are further fine-tuned by local peripheral clocks. For instance, the peripheral clock in the gut regulates glucose absorption, peripheral clocks in muscle, adipose tissue and liver regulate local insulin sensitivity, and the peripheral clock in the pancreas regulates insulin secretion. Misalignment between different components of the circadian timing system and daily rhythms of sleep-wake behaviour or food intake as a result of genetic, environmental or behavioural factors might be an important contributor to the development of insulin resistance. Specifically, clock gene mutations, exposure to artificial light-dark cycles, disturbed sleep, shift work and social jet lag are factors that might contribute to circadian disruption. Here, we review the physiological links between circadian clocks, glucose metabolism and insulin sensitivity, and present current evidence for a relationship between circadian disruption and insulin resistance. We conclude by proposing several strategies that aim to use chronobiological knowledge to improve human metabolic health.

Reproducibility in the cardiometabolic responses to high-intensity interval exercise in adults with type 1 diabetes

AIMS

Patients with type 1 diabetes (T1D) often report a rise in their blood glucose level following brief intense exercise. We sought to determine the reproducibility of the cardiometabolic responses to high-intensity interval training (HIIT).

METHODS

Sixteen adults with T1D, using an optimized multiple daily injection with basal insulin glargine 300 U/mL (Gla-300), performed four fasted HIIT sessions over a 4-6-week period. Exercise consisted of high-intensity interval cycling and multimodal training over 25 min.

RESULTS

Heart rate and rating of perceived exertion rose similarly in all sessions, as did lactate, catecholamine and growth hormone levels. Plasma glucose increased in response to HIIT in 62 of 64 visits (97%), with an overall increase of 3.7 ± 1.6 mmol/L (Mean ± SD) (P < 0.001). In within-patient comparisons, the change in plasma glucose among the four HIIT sessions was significantly correlated with a composite correlation of 0.58 ([r² = 0.34]; 95% CI 0.35-0.80; P < 0.01).

CONCLUSIONS

Intersession observations of four separate HIIT sessions showed high intrasubject reproducibility in the cardiometabolic responses to exercise, including the rise in plasma glucose, when adults with T1D perform the activity in a fasted state.

Individual glucose responses to prolonged moderate intensity aerobic exercise in adolescents with type 1 diabetes: The higher they start, the harder they fall

OBJECTIVE

To evaluate the pattern of change in blood glucose concentrations and hypoglycemia risk in response to prolonged aerobic exercise in adolescents with type 1 diabetes (T1D) that had a wide range in pre-exercise blood glucose concentrations.

METHODS

Individual blood glucose responses to prolonged (~60 minutes) moderate-intensity exercise were profiled in 120 youth with T1D.

RESULTS

The mean pre-exercise blood glucose concentration was 178 ± 66 mg/dL, ranging from 69 to 396 mg/dL, while the mean change in glucose during exercise was -76 ± 55 mg/dL (mean ± SD), ranging from +83 to -257 mg/dL. Only 4 of 120 youth (3%) had stable glucose levels during exercise (ie, ± ≤10 mg/dL), while 4 (3%) had a rise in glucose >10 mg/dL, and the remaining (93%) had a clinically significant drop (ie, >10 mg/dL). A total of 53 youth (44%) developed hypoglycemia (≤70 mg/dL) during exercise. The change in glucose was negatively correlated with the pre-exercise glucose concentration (R² = 0.44, P < 0.001), and tended to be greater in those on multiple daily insulin injections (MDI) vs continuous subcutaneous insulin infusion (CSII) (-98 ± 15 vs -65 ± 7 mg/dL, P = 0.05). No other collected variables appeared to predict the change in glucose including age, weight, height, body mass index, disease duration, daily insulin dose, HbA_1c , or sex.

CONCLUSION

Youth with T1D have variable glycemic responses to prolonged aerobic exercise, but this variability is partially explained by their pre-exercise blood glucose levels. When no implementation strategies are in place to limit the drop in glycemia, the incidence of exercise-associated hypoglycemia is ~44% and having a high pre-exercise blood glucose concentration is only marginally protective.

Patient Perspectives on Managing Type 1 Diabetes During High-Performance Exercise: What Resources Do They Want?

OBJECTIVE

Athletes with type 1 diabetes face unique challenges that make it difficult for health care providers to offer concise recommendations for diabetes management. Moreover, little is known about patient preferences for diabetes management during high-level and competitive exercise. We undertook a qualitative study to understand patient perspectives on managing type 1 diabetes during exercise.

METHODS

A qualitative design using focus groups was selected. Samples of 5-10 participants per group were recruited to participate in one of three 1.5-hour sessions focusing on experiences in managing diabetes, supports, and desired resources. Sessions were audiotaped and transcribed verbatim. Data were analyzed iteratively among team members.

RESULTS

The study included 21 participants (10 male and 11 female) with a mean age of 41 years. Most participants used trial and error to manage their blood glucose around exercise. Frequent monitoring of blood glucose was a common strategy and a challenge during exercise. Hypoglycemia after exercise and adrenaline-fueled hyperglycemia during exercise were the most prevalent concerns. Most participants relied on themselves, an endocrinologist, or the Internet for support but said they would prefer to rely more on peers with type 1 diabetes and mobile apps. Peer support or mentorship was strongly supported with recommendations for moving forward.

CONCLUSION

This study highlights the individualized nature of balancing glycemic control in athletes and athletes' heavy self-reliance to develop strategies. Expanding the availability of resources such as peer mentoring and mobile apps could potentially support athletes with type 1 diabetes.

Aerobic exercise can modulate the underlying mechanisms involved in the development of diabetic complications

Diabetes mellitus is a highly prevalent metabolic disorder that affects many molecular pathways, causing a shift from a physiologic to a pathophysiologic state. Alterations in the molecular pathways promote diabetic complications and, thus, many medical and nonmedical therapies have been directed at preventing these complications. Despite the beneficial effects on moderating glycemic control, medical therapies may also have unfavorable side effects. This makes nonmedical therapeutic approaches more attractive due to lower pharmacological side effects of these strategies compared to medical agents. Aerobic exercise is now considered as a major nonmedical strategy that can promote beneficial and protective effects to counteract the development of diabetic complications via attenuation of the major molecular mechanisms involved in diabetes.

The effect of two exercise modalities on skeletal muscle capillary ultrastructure in individuals with type 2 diabetes

Type 2 diabetes is associated with microvascular dysfunction, but little is known about how capillary ultrastructure is affected by exercise training. To investigate the effect of two types of exercise training on skeletal muscle capillary ultrastructure and capillarization in individuals with type 2 diabetes, 21 individuals with type 2 diabetes were allocated (randomized controlled trial) to 11 weeks of aerobic exercise training consisting of either moderate-intensity endurance training (END; n = 10) or low-volume high-intensity interval training (HIIT; n = 11). Skeletal muscle biopsies (m vastus lateralis) were obtained before and after the training intervention. At baseline, there was no difference in capillarization, capillary structure, and exercise hyperemia between the two groups. After the training intervention, capillary-to-fiber ratio increased by 8% ± 3% in the END group (P < 0.05) and was unchanged in the HIIT group with no difference between groups. Endothelium thickness increased (P < 0.05), basement membrane thickness decreased (P < 0.05), and the capillary lumen tended (P = 0.07) to increase in the END group, whereas these structural indicators were unchanged after HIIT. In contrast, skeletal muscle endothelial nitric oxide synthase (eNOS) increased after HIIT (P < 0.05), but not END, whereas there was no change in vascular endothelial growth factor (VEGF), superoxide dismutase (SOD)-2, or NADPH oxidase after both training protocols. In contrast to END training, HIIT did not alter capillarization or capillary structure in individuals with type 2 diabetes. In conclusion, HIIT appears to be a less effective strategy to treat capillary rarefaction and reduce basement thickening in type 2 diabetes.

The effectiveness of yoga to prevent diabetes mellitus type 2: A protocol for systematic review and meta-analysis

BACKGROUND

Type 2 diabetes mellitus (T2DM) is becoming a leading problem worldwide. Emerging reports reveal alarming evidence of increasing prevalence of T2DM that has reached pandemic levels. Despite the significant incidence, there are limited reliable data resources and comprehensive systematic review and meta-analysis on the effects of yoga on people who are a prediabetic or high risk for developing T2DM.

OBJECTIVE

The objective of this protocol is to conduct a full-scale systematic review and meta-analyses on the effects of yoga on people who are prediabetes or high risk of developing T2DM.

METHODS

The articles enrolled in the study will be retrieved from the online databases between 2002 and the date the searches are executed. The searches will be repeated just before the final analyses and further relevant studies for inclusion. We will conduct a bibliographic search in databases: Medline/PubMed, Scopus, Cochrane Library, EBSCO, and IndMED using keywords including prediabetes state, high risk for diabetes, metabolic syndrome, and yoga. A defined search strategy will be implemented along with selection criteria to obtain full-text articles of relevant studies. This study protocol was prepared according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis for Protocols 2015 guidelines. There will be no language restrictions.

ETHICS AND DISSEMINATION

The proposed study will be based on published studies and publicly available anonymized data without directly involving human participants and therefore requires neither formal human ethical review nor approval by a human research ethics committee. We published an outline of the protocol in the International Prospective Register of Systematic Reviews (PROSPERO) in 2018. We plan to disseminate the findings of this systematic review and meta-analysis through publication in a peer-reviewed journal and presentation at relevant conference proceedings. In addition, we believe the results of the systematic review will have implications for policy and practice. We will prepare policymaker summary using a validated format, disseminate through social media and email discussion groups.

REVIEW REGISTRATION NUMBER

PROSPERO registration number CRD 42018106657.

Clinical and socio-demographic parameters contributing to treatment incompliance in Palestinian patients with diabetes

BACKGROUND

This research study investigates the degree of medication-related satisfaction experienced by Palestinian patients with diabetes. In addition, this study further assesses the association between certain clinical and socio-demographic factors and the degree of satisfaction among the patients.

METHODS

This cross-sectional, descriptive study design consisted of 415 randomly selected patients from the Palestine Medical Complex (PMC), the Palestinian Ministry of Health Clinics, and from the Palestinian Diabetes Institute (also known as: Al-Bireh Medical Center). The Diabetes Medication Satisfaction (DiabMedSat) questionnaire measured patients' satisfaction levels regarding their medications.

RESULTS

Odds ratios from binomial logistic analysis and the analysis of variance determined statistically significant correlations. The analysis has displayed the presence of significant associations between clinical and socio-demographic factors and treatment satisfaction. Significance was determined at p values < 0.05 and p values < 0.01.

CONCLUSION

This research identified statistically significant associations between certain clinical and socio-demographic factors and diabetic patients' satisfaction regarding their treatment. Addressing the concerns and difficulties experienced by the patients may impede treatment incompliance and hinder the development of complications, or at least postpone them.

13. Children and Adolescents: Standards of Medical Care in Diabetes-2019

The American Diabetes Association (ADA) "Standards of Medical Care in Diabetes" includes ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, a multidisciplinary expert committee, are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations, please refer to the Standards of Care Introduction Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.

Optimal Insulin Correction Factor in Post-High-Intensity Exercise Hyperglycemia in Adults With Type 1 Diabetes: The FIT Study

OBJECTIVE

Postexercise hyperglycemia, following high-intensity interval training (HIIT) in patients with type 1 diabetes (T1D), is largely underrecognized by the clinical community and generally undertreated. The aim of this study was to compare four multipliers of an individual's insulin correction factor (ICF) to treat post-HIIT hyperglycemia.

RESEARCH DESIGN AND METHODS

The FIT study had a randomized, crossover design in physically active subjects with T1D (mean ± SD age 34.9 ± 10.1 years, BMI 25.5 ± 2.5 kg/m², and HbA_1c 7.2 ± 0.9%) using multiple daily injections. Following an 8-week optimization period, with 300 units/mL insulin glargine used as the basal insulin, subjects performed four weekly sessions of 25 min of HIIT. If hyperglycemia (>8.0 mmol/L) resulted, subjects received a bolus insulin correction 15 min post-HIIT, based on their own ICF, adjusted by one of four multipliers: 0, 50, 100, or 150%.

RESULTS

Seventeen subjects completed 71 exercise trials, of which 64 (90%) resulted in hyperglycemia. At 40 min postexercise, plasma glucose (PG) increased from mean ± SD 8.8 ± 1.0 mmol/L at baseline to 12.7 ± 2.4 mmol/L (increase of 3.8 ± 1.5 mmol/L). After correction, adjusted mean ± SE PG was significantly reduced for the 50% (-2.3 ± 0.8 mmol/L, P < 0.01), 100% (-4.7 ± 0.8 mmol/L, P < 0.001), and 150% (-5.3 ± 0.8 mmol/L, P < 0.001) arms but had increased further in the 0% correction arm. Both the 100 and 150% corrections were more effective than the 50% correction (P < 0.01 and P < 0.001, respectively) but were not different from each other. Hypoglycemia was rare.

CONCLUSIONS

In post-HIIT hyperglycemia, correction based on a patient's usual ICF is safe and effective. Optimal PG reduction, with minimal hypoglycemia, occurred in the 100 and 150% correction arms.

5. Lifestyle Management: Standards of Medical Care in Diabetes-2019

The American Diabetes Association (ADA) "Standards of Medical Care in Diabetes" includes ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, a multidisciplinary expert committee, are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations, please refer to the Standards of Care Introduction Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.

Exercise Management for Young People With Type 1 Diabetes: A Structured Approach to the Exercise Consultation

Regular physical activity during childhood is important for optimal physical and psychological development. For individuals with Type 1 Diabetes (T1D), physical activity offers many health benefits including improved glycemic control, cardiovascular function, blood lipid profiles, and psychological well-being. Despite these benefits, many young people with T1D do not meet physical activity recommendations. Barriers to engaging in a physically active lifestyle include fear of hypoglycemia, as well as insufficient knowledge in managing diabetes around exercise in both individuals and health care professionals. Diabetes and exercise management is complex, and many factors can influence an individual's glycemic response to exercise including exercise related factors (such as type, intensity and duration of the activity) and person specific factors (amount of insulin on board, person's stress/anxiety and fitness levels). International guidelines provide recommendations for clinical practice, however a gap remains in how to apply these guidelines to a pediatric exercise consultation. Consequently, it can be challenging for health care practitioners to advise young people with T1D how to approach exercise management in a busy clinic setting. This review provides a structured approach to the child/adolescent exercise consultation, based on a framework of questions, to assist the health care professional in formulating person-specific exercise management plans for young people with T1D.

Mechanisms Involved in Glycemic Control Promoted by Exercise in Diabetics

INTRODUCTION

Diabetes mellitus is a metabolic disease characterized by high glycemic levels for long periods. This disease has a high prevalence in the world population, being currently observed an increase in its incidence. This fact is mainly due to the sedentary lifestyle and hypercaloric diets. Non-pharmacological interventions for glycemic control include exercise, which promotes changes in skeletal muscle and adipocytes. Thus, increased glucose uptake by skeletal muscle and decreased insulin resistance through modulating adipocytes are the main factors that improve glycemic control against diabetes.

CONCLUSION

It was sought to elucidate mechanisms involved in the improvement of glycemic control in diabetics in front of the exercise.

Use of apps for physical activity in type 1 diabetes: current status and requirements for future development

Smartphone technologies, and the applications (apps) that they host, are developing rapidly mainly with regard to communication, information processing, design, features and connectivity with other devices. Technologies used in modern treatment modalities and monitoring of type 1 diabetes are also rapidly evolving and can communicate with smartphones and apps. Therefore, numerous web-based and smartphone apps aim to provide information and various patient data metrics (e.g. caloric intake, activity levels, glucose monitoring) that can be accessed and processed for decision support by smartphone apps. In this narrative review, we highlight current information about the effectiveness of interventions through smartphone apps with a focus on apps designed to give guidance to patients with type 1 diabetes on physical activity monitoring and glucose control during and after structured exercise sessions, as these patients are experiencing huge therapeutic challenges during exercise. Furthermore, we propose a number of critical elements for future apps designed for people with type 1 diabetes.

School Personnel Knowledge and Perceived Skills in Diabetic Emergencies in Georgia Public Schools

Diabetes affects tens of thousands of school-aged children in the United States. The ability to appropriately manage their diabetes is essential to preventing life-threatening health complications if occurring during the school day. The purpose of this study was to assess school personnel’s knowledge of diabetes (types 1 and 2) and perceived self-competence in performing diabetes management skills. A non-probability sample of elementary school personnel ( N = 809) from five different school districts in Georgia completed a diabetes knowledge and competence questionnaire. Descriptive statistics, one-way analysis of variance, and principal component analysis were performed to analyze the data. School personnel reported limited knowledge of diabetes basics and an overall low perceived self-competence in performing many of the diabetic management skills. Despite state legislation enacted to assist children with diabetes in school and available training for school districts, the study found that school personnel are not well trained and lack confidence in performing diabetes management.

Objective Measurement of Physical Activity in Adults With Newly Diagnosed Type 1 Diabetes and Healthy Individuals

Aims: Physical activity (PA) has many benefits in type 1 diabetes mellitus (type 1 DM). However, PA levels in people with type 1 DM have not previously been measured accurately. We aimed to compare objectively measured PA in adults recently diagnosed with type 1 DM and healthy adults.

Methods: Accelerometer data from 65 healthy adults [mean (SD) age 31 (13), 29% men] were compared with data from 50 people with type 1 DM [mean (SD) age 33 (10), 64% men], time since diagnosis <3months, HbA1c 76 ± 25 mmol/mol) in the EXTOD (Exercise for Type 1 Diabetes) pilot study. Briefly, EXTOD investigated the feasibility of recruiting recently diagnosed adults with type 1 DM into a yearlong exercise intervention. Multiple-regression models were used to investigate the association between diabetes status and activity outcomes.

Results: Adults recently diagnosed with type 1 DM spent on average a quarter less time in moderate-to-vigorous-physical-activity (MVPA) per day than healthy adults [after adjusting for confounders, predicted values: type 1 DM adults: [mean (SD)] 37.4 mins/day (9.1) Healthy adults: 52.9 mins/day (11.0)]. No difference in MVPA between the groups was seen at the weekend, but adults with type 1 DM spent more time in light physical activity (LPA), and less time in sedentary behavior. Time spent in sedentary or LPA during weekdays did not differ between groups.

Summary: Adults recently diagnosed with type 1 DM do less MVPA. Health care workers should encourage these people to engage in more PA. Further studies are needed to assess PA in people with type 1 DM of longer duration.

Effect of all-extremity high-intensity interval training vs. moderate-intensity continuous training on aerobic fitness in middle-aged and older adults with type 2 diabetes: A randomized controlled trial

Aging and diabetes are associated with decreased aerobic fitness, an independent predictor of mortality. Aerobic exercise is prescribed to improve aerobic fitness; however, middle-aged/older diabetic patients often suffer from mobility limitations which restrict walking. Non-weight-bearing/low-impact exercise is recommended but the optimal exercise prescription is uncertain. The goal of this randomized controlled trial was twofold: 1) to test if high-intensity interval training (HIIT) and moderate-intensity continuous training (MICT), implemented on a non-weight-bearing all-extremity ergometer, are feasible, well-tolerated and safe in middle-aged/older adults with type 2 diabetes; and 2) to test whether all-extremity HIIT is more effective in improving aerobic fitness than MICT. A total of 58 sedentary individuals with type 2 diabetes (46 to 78 years; 63 ± 1) were randomized to all-extremity HIIT (n = 23), MICT (n = 19) or non-exercise control (CONT; n = 16). All-extremity HIIT and MICT, performed 4×/week for 8 weeks under supervision, resulted in no adverse events requiring hospitalization or medical treatment. Aerobic fitness (VO_2peak) improved by 10% in HIIT and 8% in MICT and maximal exercise tolerance increased by 1.8 and 1.3 min, respectively (P ≤ 0.002 vs. baseline; P ≥ 0.9 for HIIT vs. MICT). In conclusion, all-extremity HIIT and MICT are feasible, well-tolerated and safe and result in similar improvements in aerobic fitness in middle-aged/older individuals with type 2 diabetes. These findings have important implications for exercise prescription for diabetic patients; they indicate that all-extremity exercise is a feasible alternative to weight-bearing exercise and those who are unable or unwilling to engage in HIIT may receive similar benefits from MICT.

Effect of Balance Training After Hip Fracture Surgery: A Systematic Review and Meta-analysis of Randomized Controlled Studies

Background

Although balance impairment after hip fracture surgery (HFS) can constitute a long-term problem of limiting mobility and increasing the risk of falls in older adults, little is known about the effect of balance training (BT) on physical functioning after HFS. Thus, we performed a meta-analysis to evaluate whether BT improved the overall physical functioning of patients after HFS.

Methods

We searched the PubMed-Medline, Embase, and Cochrane Library databases in January 2018 and included all randomized controlled trials comparing BT with usual care after HFS. We performed a pairwise meta-analysis using fixed- and random-effects models.

Results

Eight randomized controlled trials including a total of 752 participants were retrieved. The BT group showed significantly improved overall physical functioning after HFS compared with the usual care group (overall standardized mean difference [SMD] = 0.390; 95% confidence interval [CI] = 0.114–0.667; p = .006). Both, balance and gait improved (SMD = 0.570; 95% CI = 0.149–0.992; p = .008 and SMD = 0.195; 95% CI = 0.043–0.347; p = .012, respectively) in the BT group. Lower limb strength, performance task, activity of daily living, and health-related quality of life also improved significantly in the BT group.

Conclusion

Our meta-analysis revealed that BT after HFS improved overall physical functioning. Positive effects on balance, gait, lower limb strength, performance task, activity of daily living, and health-related quality of life were evident. Therefore, BT should be specifically included in postoperative rehabilitation programs and balance must be thoroughly checked in elderly patients with hip fractures.

Exercise and glucose control in children with insulin resistance: prevalence of non-responders

BACKGROUND

Exercise training improves cardiometabolic outcomes in 'mean terms', but little information is available in children about the impact of the frequency/week and the wide inter-individual variability to exercise training reported in adults.

OBJECTIVES

We compared the effects of resistance training (RT) and high-intensity interval training (HIT), and 'high' and 'low' frequency of training/week, for their effectiveness in decreasing insulin resistance (IR) levels in schoolchildren. A second aim was to decscribe and compare the prevalence of non-responders (NRs) between the different frequencies of training protocol.

METHODS

Fifty-three schoolchildren with IR were randomly assigned into four groups: RT at high frequency (three times/week), HIT at high frequency, RT at a low frequency (two times/week) and HIT at low frequency. The intervention lasted 6 weeks. Blood samples and body composition, blood pressure and performance measurements were taken before and after the intervention.

RESULTS

The prevalence of NRs was similar between the RTHF and HITHF (25.0% vs. 25.0%, P > 0.05) and RTLF and HITLF groups (20.0% vs. 46.6%, P = 0.174) for decreasing homeostasis model assessment of IR. However, significant differences in the prevalence of NRs were detected between RTHF and HITHF groups in fasting glucose (FGL) (18.7% vs. 58.3%, P < 0.031).

CONCLUSIONS

Both RT and HIT improves the glucose control parameters in schoolchildren over 6 weeks, but only HIT is independent of a high or low frequency of training/week. The prevalence of NRs is similar for decreasing homeostasis model assessment of IR comparing each exercise mode in high vs. low frequency/week. However, both high- and low-frequency RT and HIT results in differences in the prevalence of NRs for FGL and other cardiometabolic and performance outcomes.

Patterns of Physical Activity Adherence by Adolescents With Diabetes or Obesity Enrolled in a Personalized Community-Based Intervention

PURPOSE

The purpose of this study was to determine the feasibility of a personalized, 16-week community-based physical activity intervention for adolescents with diabetes or obesity and examine the weekly patterns of adherence to the intervention.

METHODS

Physical activity adherence was evaluated throughout the intervention using accelerometers in 46 adolescents with type 1 diabetes (N = 22), type 2 diabetes (N = 12), or obesity (N = 12) (age, 14.4 ± 1.5 years; 56.5% female; 61% Hispanic). Of these, 39 completed the intervention, and 7 did not.

RESULTS

There were no differences in baseline anthropometric characteristics or fitness between the completers versus noncompleters. Completers began above 1060 metabolic equivalent (MET) min/wk-1and stayed above 900 MET min/wk-1 for ~4 weeks and declined 39 MET min/wk-1 until end of study. Noncompleters began at 924 MET min/wk-1 yet dropped below 800 MET min/wk-1 by end of week 1 and declined an average of 151 MET min/wk-1. Interestingly, self-report of barriers to activity were higher in completers versus noncompleters.

CONCLUSIONS

Findings highlight that adolescents completing the intervention could sustain a prescribed level of personalized activity for at least 1 month but had steadfast declines in weekly activity. Even with individualized programs, factors other than barriers to activity need to be considered when designing approaches to physical activity adherence for adolescents with diabetes or obesity.

Design of a randomized controlled trial to decrease depression and improve insulin sensitivity in adolescents: Mood and INsulin sensitivity to prevent Diabetes (MIND)

BACKGROUND

Depressive symptoms often manifest in adolescence and predict worsening insulin sensitivity, a key precursor in the path to β-cell failure and type 2 diabetes (T2D).

OBJECTIVE

To assess the efficacy of a six-week cognitive-behavioral group versus six-week health education group for improving insulin sensitivity and preserving β-cell function in adolescent girls at-risk for T2D with depressive symptoms and evaluate mechanisms underlying the association between depression and insulin dynamics.

DESIGN

Randomized controlled trial of N = 150 12-17-year-old girls with overweight/obesity (body mass index [BMI; kg/m2] ≥85th percentile), elevated depressive symptoms (Center for Epidemiologic Studies-Depression Scale [CES-D] total score > 20), and diabetes family history.

METHODS

Girls at-risk for T2D with elevated depressive symptoms are recruited from the Denver-metropolitan area and randomized to participate in one of two six-week interventions. The cognitive-behavioral group is a depression prevention program involving psycho-education, restructuring negative thoughts, and behavioral activation. The health education group is a didactic control that provides knowledge about healthy living. Participants are assessed at baseline, immediate post-intervention, and one-year follow-up. Primary outcomes are insulin sensitivity and β-cell function from oral glucose tolerance tests. Secondary outcomes are disinhibited eating, physical activity, sleep, and cortisol.

SUMMARY

Results from this adequately powered randomized controlled trial will determine whether decreasing depressive symptoms with a behavioral health program preventatively alters insulin sensitivity and β-cell function trajectories in adolescents at-risk for T2D. Results from the MIND Project will add to knowledge of the contribution of depressive symptoms to T2D risk.

Guidelines for exercise during normal pregnancy and gestational diabetes: a review of international recommendations

OBJECTIVE

Τo summarize and present the main guidelines for exercise during normal pregnancy and pregnancy complicated by gestational diabetes mellitus (GDM).

METHODS

Relevant guidelines were retrieved through the electronic databases PubMed (MEDLINE), CENTRAL (Cochrane), and Embase; reference sections of the retrieved publications; proceedings of the main congresses in the field; and websites of relevant organizations published during the years 2000-2018.

RESULTS

All guidelines recommend aerobic training from 60 to 150 min/week, with an upper limit of 30 min/day. Exercise is safe, even on a daily basis. Resistance exercise is suggested by five national guidelines (Australia, Canada, Denmark, Norway, and the UK). Discrepancies exist regarding the recommended intensity of exercise. Canada, Japan, Spain, and the UK use both objective (heart rate and maximum oxygen consumption) and subjective criteria (Borg's Scale and talk test) to determine the effectiveness and safety of exercise. Only Canada provides specific recommendations, according to the woman's age and level of physical condition. Women with GDM on no insulin treatment do not need to take extra precautions during exercise. However, due to their condition of hyperglycemia, they must comply with the recommendation issued for type 2 diabetes. The prescription and supervision of exercise should be carried out in a similar way as for uncomplicated pregnancies. Finally, women with GDM on insulin treatment need to follow the same recommendations as for those for pregnant women with type 1 diabetes.

CONCLUSION

Health professionals must be informed about the correct planning and execution of physical exercise programs so as to safely achieve the maximum effectiveness of exercise-induced health-related benefits in pregnant women.

Diet and Lifestyle Before and During Pregnancy - Practical Recommendations of the Germany-wide Healthy Start - Young Family Network

Diet and exercise before and during pregnancy affect the course of the pregnancy, the child's development and the short- and long-term health of mother and child. The Healthy Start - Young Family Network has updated the recommendations on nutrition in pregnancy that first appeared in 2012 and supplemented them with recommendations on a preconception lifestyle. The recommendations address body weight before conception, weight gain in pregnancy, energy and nutritional requirements and diet (including a vegetarian/vegan diet), the supplements folic acid/folate, iodine, iron and docosahexaenoic acid (DHA), protection against food-borne illnesses, physical activity before and during pregnancy, alcohol, smoking, caffeinated drinks, oral and dental hygiene and the use of medicinal products. Preparation for breast-feeding is recommended already during pregnancy. Vaccination recommendations for women planning a pregnancy are also included. These practical recommendations of the Germany-wide Healthy Start - Young Family Network are intended to assist all professional groups that counsel women and couples wishing to have children and during pregnancy with uniform, scientifically-based and practical information.

Aging, physical activity, and diabetic complications related to loss of muscle strength in patients with type 2 diabetes

Patients with type 2 diabetes may have motor dysfunctions such as loss of muscle strength. Compared with non-diabetic subjects, patients with diabetes show decreased lower extremity muscle strength. The aim of this review was to describe the influence of factors associated with loss of muscle strength in patients with type 2 diabetes. Aging promotes an accelerated loss of muscle strength in patients with diabetes. Physical inactivity may cause a decline in muscle strength in patients with diabetes. Gradual loss of muscle strength is related to the presence and severity of diabetic neuropathy. Diabetic nephropathy may be a factor contributing to loss of muscle strength, because decrease in skeletal muscle mass is a hallmark of end-stage renal disease. Resistance exercise is an essential component of diabetes treatment regimens and also plays a role in the prevention and management of sarcopenia. Intensive physical therapy intervention should be provided to patients with diabetes having decreased muscle strength.

Are There Limitations to Exercise Benefits in Peripheral Arterial Disease?

Substantial evidence exists indicating that inactivity contributes to the progression of chronic disease, and conversely, that regular physical activity can both prevent the onset of disease as well as delay the progression of existing disease. To that end "exercise as medicine" has been advocated in the broad context as general medical care, but also in the specific context as a therapeutic, to be considered in much the same way as other drugs. As there are non-responders to many medications, there also are non-responders to exercise; individual who participate but do not demonstrate appreciable improvement/benefit. In some settings, the stress induced by exercise may aggravate an underlying condition, rather than attenuate chronic disease. As personalized medicine evolves with ready access to genetic information, so too will the incorporation of exercise in the context of those individual genetics. The focus of this brief review is to distinguish between the inherent capacity to perform, as compared to adaptive response to active exercise training in relation to cardiovascular health and peripheral arterial disease.

The Effects of Postprandial Exercise on Glucose Control in Individuals with Type 2 Diabetes: A Systematic Review

BACKGROUND

Regulation of postprandial hyperglycemia is a major concern for individuals with type 2 diabetes. Exercise can reduce postprandial hyperglycemia by increasing contraction-mediated glucose uptake. However, there is no consensus with which to develop guidelines for optimal postprandial exercise timing and prescription.

OBJECTIVE

The current systematic review was conducted to consolidate the literature surrounding the effects of postprandial exercise on glucose regulation in individuals with type 2 diabetes.

METHODS

Electronic databases were searched on 17 February 2017. Inclusion criteria were: (1) trial was a randomized crossover trial; (2) subjects were diagnosed with type 2 diabetes; (3) a standardized meal was given; (4) exercise was initiated within three hours of the meal; (5) subjects were not treated with insulin.

RESULTS

Twelve studies met the inclusion criteria, involving 135 participants (108 males, 20 females, seven unknown). The included studies varied greatly in their timing, duration, intensity, modality, and glucose measures. Postprandial aerobic exercise (11 studies) decreased short-term glucose area under the curve by 3.4-26.6% and 24-h prevalence of hyperglycemia by 11.9-65%. Resistance exercise (two studies) decreased the short-term glucose area under the curve by 30% and 24-h prevalence of hyperglycemia by 35%.

CONCLUSION

Postprandial exercise may be an effective way to improve glucose control in individuals with type 2 diabetes. The most consistent benefits were seen in long-duration (≥ 45 min), moderate-intensity aerobic exercise. Resistance training also appears to be an effective modality. We recommend that individuals with type 2 diabetes focus on increasing energy expenditure after the largest meal of the day. More research is needed in this area to confirm the results of this systematic review and to provide clinicians with specific exercise recommendations.

Health Benefits of Light-Intensity Physical Activity: A Systematic Review of Accelerometer Data of the National Health and Nutrition Examination Survey (NHANES)

BACKGROUND

The health effects of light-intensity physical activity (PA) are not well known today.

OBJECTIVE

We conducted a systematic review to assess the association of accelerometer-measured light-intensity PA with modifiable health outcomes in adults and older adults.

METHODS

A systematic literature search up to March 2016 was performed in the PubMed, EMBASE, Web of Science and Google Scholar electronic databases, without language limitations, for studies of modifiable health outcomes in adults and older adults in the National Health and Nutrition Examination Survey accelerometer dataset.

RESULTS

Overall, 37 cross-sectional studies and three longitudinal studies were included in the analysis, with considerable variation observed between the studies with regard to their operationalization of light-intensity PA. Light-intensity PA was found to be beneficially associated with obesity, markers of lipid and glucose metabolism, and mortality. Few data were available on musculoskeletal outcomes and results were mixed.

CONCLUSIONS

Observational evidence that light-intensity PA can confer health benefits is accumulating. Currently inactive or insufficiently active people should be encouraged to engage in PA of any intensity. If longitudinal and intervention studies corroborate our findings, the revision of PA recommendations to include light-intensity activities, at least for currently inactive populations, might be warranted.