Physical Activity and Mortality in Individuals With Diabetes Mellitus: A Prospective Study and Meta-analysis

Impact of High-Intensity Interval Exercise With Elastic Bands Versus Continuous Moderate-Intensity Aerobic Exercise on Glycemic Control in People With Type 1 Diabetes

BACKGROUND

Engaging in physical exercise is recommended to enhance cardiovascular health and manage blood sugar levels in people with type 1 diabetes (T1D).

HYPOTHESIS

The impact of high-intensity interval exercise with elastic bands (EB-HIIE) versus continuous moderate-intensity aerobic exercise (CONT) on glycemic control is different in men with T1D.

STUDY DESIGN

Crossover study design.

LEVEL OF EVIDENCE

Level 3.

METHODS

Participants (39 men with T1D) underwent either an EB-HIIE or a CONT session in randomized order, with a separation of ≥72 hours to avoid carry-over effects. Changes in glucose values during exercise were measured simultaneously from venous blood (YSI) and interstitial fluid (Dexcom G6 glucose sensor). Subsequent 24-hour glucose was monitored using the glucose sensor.

RESULTS

Blood glucose was lower in CONT vs EB-HIIE (P < .01). Post hoc analysis revealed clinically relevant differences during exercise (-35.1 mg/dl; P = .02), at its end (-49.5 mg/dl; P < .01), and at 10 and 20 minutes after completion (-51.2 mg/dl; P < .01 and -45.9 mg/dl; P < .01, respectively). Time-in-range 24 hours after exercise completion was significantly higher with EB-HIIE than with CONT (66.5% vs 59.3%), although both were significantly better than the previous 24 hours before exercise (50%).

CONCLUSION

Results suggest that EB-HIIE is a safe training method for male adults with diabetes, resulting in euglycemia during and immediately after exercise and improving glucose outcomes in the subsequent 24 hours.

CLINICAL RELEVANCE

This study provides new evidence and practical information on how to implement safe physical activity in daily life of patients with diabetes. EB-HIIT exhibited lower hypoglycemia risk during exercise and better glycemic control in the subsequent 24 hours. In contrast, practicing CONT exercise is associated with higher risk of hypoglycemia. Healthcare providers should take this information into account when prescribing exercise.

The Effects of Exercise Training on Body Composition and Cardiometabolic Risk Factors in Type 1 Diabetes Mellitus: A Systematic Review and Meta-Analysis

INTRODUCTION AND AIM

We performed a systematic review and meta-analysis to investigate the effects of exercise training on body composition and cardiometabolic health in patients with Type 1 diabetes (T1D).

METHOD

A search in three main databases including PubMed, Web of Science, and Scopus was conducted from the inception of this review until June 2024 to identify randomized control trials investigating the effects of exercise training compared to a control on body composition and cardiometabolic risk factors in patients with T1D. The data were pooled using random effects models to calculate weighted mean differences (WMDs), standardized mean differences (SMDs), and 95% confidence intervals (CIs).

RESULTS

Overall, 25 studies involving 1120 patients with T1D were included in the meta-analysis. Exercise training decreased body mass index (BMI) [WMD: -0.18 kg.m2, p = 0.02], fasting glucose [WMD: -14.97 mg/dl, p = 0.01], and HbA1c [WMD: -0.49%, p = 0.003], and increased VO2max/peak [WMD: 2.76 mL/kg/min, p = 0.001] as compared with controls. Exercise training had no effect on body fat percentage or lean body mass, lipid profiles, or blood pressure. Subgroup analysis indicated that age, exercise mode, and intervention duration were the main moderators for the beneficial effects of exercise training.

CONCLUSIONS

In patients with T1D, exercise training is effective for decreasing body weight and cardiometabolic risk factors.

5. Facilitating Positive Health Behaviors and Well-being to Improve Health Outcomes: Standards of Care in Diabetes-2025

The American Diabetes Association (ADA) "Standards of Care in Diabetes" includes the 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, an interprofessional 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 and a full list of Professional Practice Committee members, please refer to Introduction and Methodology. Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.

Effects of concurrent aerobic and strength training in patients with type 2 diabetes: Bayesian pairwise and dose-response meta-analysis

This study aimed to investigate the effects of concurrent aerobic and strength training (CT) in patients with type 2 diabetes and determine the most effective dose of CT. From the inception of the databases to March 2024, we conducted a systematic search of four electronic databases (PubMed, Embase, Web of Science, and Cochrane Library) to identify randomized controlled trials (RCTs) on CT intervention in patients with type 2 diabetes. Two independent authors assessed the risk of bias of the study using the Cochrane Risk of Bias Assessment Tools. Results analyzed included glycosylated hemoglobin (HbA1c), fasting blood glucose (FBG), body mass index, body fat percentage, blood pressure, and VO2max. Pairwise and dose-response meta-analyses using Bayesian hierarchical random-effects modeling were performed to analyze the effects of CT in patients with type 2 diabetes. From the inception of the databases to March 2024, we conducted a systematic search of four electronic databases (PubMed, Embase, Web of Science, and Cochrane Library) to identify randomized controlled trials (RCTs) on CT intervention in patients with type 2 diabetes. Two independent authors assessed the risk of bias of the study using the Cochrane Risk of Bias Assessment Tools. Results analyzed included glycosylated hemoglobin (HbA1c), fasting blood glucose (FBG), body mass index, body fat percentage, blood pressure, and VO2max. Pairwise and dose-response meta-analyses using Bayesian hierarchical random-effects modeling were performed to analyze the effects of CT in patients with type 2 diabetes. A total of 1948 participants (935 males) were included in 23 RCTs. The male/female ratio of participants was 52/48; the mean age range was 50-65 years. The results show that CT significantly reduced HbA1c levels (MD=-0.48%, 95% CrI: -0.55 to -0.40), with some heterogeneity among different levels (SD=0.31, 95% CrI: 0.17 to 0.51), and the model converged well. Similarly, FBG levels were also significantly improved (MD=-0.48 mmol/L, 95% CrI: -0.55 to -0.40), with greater heterogeneity (SD=17.73, 95% CrI: 11.23 to 28.09). Additionally, we found a non-linear dose-response relationship between CT and HbA1c levels, with an optimal dose of 1030 METs-min/week (MD=-0.47%, 95% CrI: -0.68 to -0.26, SE=0.11). CT significantly improves several health indicators in patients with type 2 diabetes. A non-linear dose-response relationship was observed between the training dose of CT and HbA1c, and it is recommended that 270 min of moderate-intensity CT or 160 min of vigorous-intensity CT be performed weekly.PROSPERO registration number: CRD42024547119.Keywords: meta-analysis; concurrent aerobic and strength training.

Titration of Sedentary Behavior With Varying Physical Activity Levels Reduces Mortality in Patients With Type 2 Diabetes

CONTEXT

Both physical activity (PA) and sedentary behavior (SB) exert an important impact on type 2 diabetes, but it remains unclear regarding how the maximum impact on improving mortality by an optimized proportion of the two lifestyles can be achieved.

OBJECTIVE

To explore the impacts of PA/SB combinations on mortality in patients with diabetes.

METHODS

Patients with type 2 diabetes samplings were collected from the National Health and Nutrition Examination Survey dataset. Their lifestyles were categorized into 8 groups based on combinations of the PA and SB levels. Cox proportional hazards models were used to calculate hazard ratios and 95% confidence intervals.

RESULTS

During the follow-up period, 1148 deaths (18.94%) were recorded. High SB (sedentary time ≥6 hours/day) was significantly associated with higher all-cause mortality [hazards ratio (HR) 1.65]. In participants with low SB (<6 hours/day), low PA was associated with lower all-cause mortality (HR 0.43), while a further increase of PA level did not show further reductions in either all-cause or cardiovascular mortality. In contrast, in participants with high SB, all levels of PA were associated with lower all-cause mortality (P < .05), but only moderate PA was associated with lower cardiovascular mortality (HR 0.30).

CONCLUSION

In patients with type 2 diabetes, different combinations of various levels of PA and SB are associated with different degrees of risk for all-cause or cardiovascular mortality.

Clinical and Sociodemographic Profile, Self-Care, Adherence and Motivation for Treatment, and Satisfaction with Social Support in Portuguese Patients with Type 2 Diabetes

Objective: This study aimed to characterize the sociodemographic and clinical profiles of Portuguese patients with type 2 diabetes mellitus (T2DM) and to assess their self-care practices, treatment adherence, motivation, and satisfaction with social support. Methods: A cross-sectional observational study was conducted at an endocrinology unit in northern Portugal from January 2021 to December 2022. The sample included 303 adult patients with T2DM who provided informed consent. Data were collected using a structured questionnaire addressing sociodemographic, clinical, and self-care aspects. Validated scales were used to assess diabetes knowledge, self-care activities, treatment adherence, motivation, and social support. Results: Of the 303 patients enrolled, with a median age of 67 years, 51.2% were female and 68.2% retired. Clinical measures showed a median systolic blood pressure of 135 mmHg, abdominal circumference of 104.6 cm, and BMI of 29.3 kg/m2. Self-care practices were suboptimal, with only 25.1% of patients consistently following a healthy diet, and 31% engaged in weekly physical activity. Although treatment adherence was generally high, issues like forgetfulness were reported. Satisfaction with social support varied, with 30% of patients feeling isolated. Conclusions: The study identifies significant gaps in diet and physical activity adherence among T2DM patients. There is a need for targeted educational interventions and enhanced support systems to improve self-care and treatment outcomes. Personalized care strategies addressing educational, motivational, and social support factors are crucial to better managing T2DM and improving patient well-being.

Mortality and Years of Life Lost from Diabetes Mellitus in Poland: A Register-Based Study (2000-2022)

BACKGROUND

The aim of the study was to assess mortality and years of life lost from diabetes mellitus in Poland between 2000 and 2022.

METHODS

The database was created from death cards made available for the purposes of this study by Statistics Poland. The study used data on deaths caused by type 1 diabetes mellitus, T1DM (N = 33,328), and type 2 diabetes mellitus, T2DM (N = 113,706). Standardized death rates (SDRs) and standard expected years of life lost per person (SEYLLp) and per death (SEYLLd) were calculated. A time trend analysis was performed using joinpoint models. The annual percentage change (APC) and the average annual percentage change (AAPC) were estimated.

RESULTS

Between 2000 and 2022, 33,328 people died from T1DM in Poland. The SDR rate increased from 6.0 to 8.8 per 100,000 population in the analyzed period. The APC was 1.3% (p < 0.05). SEYLLp rates per 100,000 population were 79.3 in 2000 and 109.2 in 2022. SEYLLd rates were 22.9 and 17.9 years, respectively (APC = -1.0%, p < 0.05). The mean age of those who died from T1DM increased from 66.1 in 2000 to 72.5 in 2022. Between 2000 and 2022, 113,706 people died from T2DM. The SDR increased from 12.5 to 37.7 per 100,00 (APC = 5.5%, p < 0.05). SEYLLp rates were 88.8 and 296.0 per 100,000 population (APC = 6.4%, p < 0.05). SEYLLd rates decreased from 16.9 in 2000 to 13.4 in 2022 (AAPC = -1.0%, p < 0.05). The mean age of those who died from T2DM increased from 73.1 to 78.1 years.

CONCLUSIONS

The study showed a growing problem of diabetes as a cause of death and years of life lost.

Impact of Gender on Patient Experiences of Self-Management in Type 2 Diabetes: A Qualitative Study

Purpose

This study aims to identify gender disparities in knowledge, attitudes and behaviors related to self-management and control of Type 2 diabetes Mellitus (T2DM) among primary care patients. The research was conducted across multiple Spanish cities.

Patients and Methods

The study involved 8 Primary Care Centres located in four distinct regions of Spain: East (Barcelona), Centre (Madrid), North (Pamplona and Zumaia) and South (Vélez-Málaga and Málaga). A total of 111 individuals diagnosed with T2DM, comprising 52 women and 59 men, participated in 12 group discussions at these primary healthcare centers from February to June 2015. Participation was voluntary, and all participants provided informed consent by signing the consent form. A qualitative hermeneutic phenomenological study with a maximum variation sample was done. Participant profiles were defined based on gender, age, place of residence, type of treatment, years living with T2DM and the presence or absence of a cardiovascular event. Thematic analysis was used to analyze the data.

Results

Participants were aware that diabetes is a chronic condition, with varied levels of concern regarding the diagnosis. Participants' locus of control influenced their perception of the disease's cause, with women attributing it to stress and emotional situations, while men linked it to risky behaviors. Self-management strategies were shaped by beliefs about diabetes, with both genders facing challenges in implementing recommended practices. Gender differences were also evident in caregiving roles, with men receiving more family support for diet adherence, while women prioritized family needs over their self-care. Participants expressed satisfaction with professional-patient interactions but highlighted the need for more accessible information and specialist care, suggesting support groups for women and clear health guidelines for men.

Conclusion

Gender differences significantly influence how patients perceive and manage type 2 diabetes, with women experiencing greater concern and care burden compared to men. Effective diabetes management requires tailored support that addresses these gender-specific challenges. Enhancing healthcare services with clear guidelines and support groups can improve self-management outcomes in both men and women.

The Impact of Depression on Adherence to Diabetes Self-Management Behaviors in Breast Cancer Survivors

OBJECTIVE

Breast cancer survivors (BCS) have higher rates of depression which is associated with lower adherence to medications, diet, and physical activity. Managing diabetes (DM) requires adherence to several of these self-management behaviors (SMB), and BCS have an increased risk of DM. We investigated whether depressive symptoms were associated with adherence to DM SMB in a cohort of BCS.

METHODS

BCS with DM were surveyed semiannually for 2 years. Depression was assessed with the Hospital Anxiety and Depression Scale (HADS). Adherence to DM medication, diet, and physical activity was self-reported using the Medication Adherence Report Scale (MARS), Summary of Diabetes Self-Care Activities Assessment (SDSCA), and International Physical Activity Questionnaire (IPAQ), respectively. Using generalized linear equation modeling, the association of depressive symptoms with nonadherence to SMB was assessed, adjusting for age, race, marital status, education level, and beliefs about cancer and DM risk.

RESULTS

Among 244 BCS with DM, those who were nonadherent to medication, diet, and/or physical activity had higher depression scores (p < 0.01). In adjusted analyses, higher depression scores were independently associated with dietary (OR = 1.16, p < 0.001) and physical activity nonadherence (OR = 1.18, p < 0.001) but not with medication nonadherence. Concerns about medications was independently associated with medication nonadherence (OR = 1.17, p = 0.024).

CONCLUSIONS

Higher depression scores are associated with nonadherence to DM SMB in this cohort of BCS. These findings highlight the importance of addressing depressive symptoms in BCS to help improve adherence to DM medications, diet, and physical activity.

Personalized insulin dosing using reinforcement learning for high-fat meals and aerobic exercises in type 1 diabetes: a proof-of-concept trial

In type 1 diabetes, high-fat meals require more insulin to prevent hyperglycemia while meals followed by aerobic exercises require less insulin to prevent hypoglycemia, but the adjustments needed vary between individuals. We propose a decision support system with reinforcement learning to personalize insulin doses for high-fat meals and postprandial aerobic exercises. We test this system in a single-arm 16-week study in 15 adults on multiple daily injections therapy (NCT05041621). The primary objective of this study is to assess the feasibility of the novel learning algorithm. This study looks at glucose outcomes and patient reported outcomes. The postprandial incremental area under the glucose curve is improved from the baseline to the evaluation period for high-fat meals (378 ± 222 vs 38 ± 223 mmol/L/min, p = 0.03) and meals followed by exercises (-395 ± 192 vs 132 ± 181 mmol/L/min, p = 0.007). The postprandial time spent below 3.9 mmol/L is reduced after high-fat meals (5.3 ± 1.6 vs 1.8 ± 1.5%, p = 0.003) and meals followed by exercises (5.3 ± 1.2 vs 1.4 ± 1.1%, p = 0.003). Our study shows the feasibility of automatically personalizing insulin doses for high-fat meals and postprandial exercises. Randomized controlled trials are warranted.

Type 2 Diabetes and Fracture Risk in Older Women

Importance

The reasons for the increased fracture risk in type 2 diabetes (T2D) are not fully understood.

Objective

To determine if poorer skeletal characteristics or worse physical function explain the increased fracture risk in T2D.

Design, Setting, and Participants

This prospective observational study is based on the population-based Sahlgrenska University Hospital Prospective Evaluation of Risk of Bone Fractures study cohort of older women, performed in the Gothenburg area between March 2013 and May 2016. Follow-up of incident fracture data was completed in March 2023. Data analysis was performed between June and December 2023.

Exposures

Data were collected from questionnaires and through examination of anthropometrics, physical function, and bone measurements using bone densitometry (dual-energy x-ray absorptiometry), and high-resolution peripheral computed tomography. A subsample underwent bone microindentation to assess bone material strength index (BMSi).

Main Outcomes and Measures

Baseline assessment of bone characteristics and physical function and radiograph verified incident fractures.

Results

Of 3008 women aged 75 to 80 years, 294 women with T2D (mean [SD] age, 77.8 [1.7] years) were compared with 2714 women without diabetes (mean [SD] age, 77.8 [1.6] years). Women with T2D had higher bone mineral density (BMD) at all sites (total hip, 4.4% higher; femoral neck (FN), 4.9% higher; and lumbar spine, 5.2% higher) than women without. At the tibia, women with T2D had 7.4% greater cortical area and 1.3% greater density, as well as 8.7% higher trabecular bone volume fraction. There was no difference in BMSi (T2D mean [SD], 78.0 [8.3] vs controls, 78.1 [7.3]). Women with T2D had lower performance on all physical function tests. The study found 9.7% lower grip strength, 9.9% slower gait speed, and 13.9% slower timed up-and-go time than women without diabetes. During a median (IQR) follow-up of 7.3 (4.4-8.4) years, 1071 incident fractures, 853 major osteoporotic fractures (MOF), and 232 hip fractures occurred. In adjusted (for age, body mass index, clinical risk factors, and FN BMD) Cox regression models, T2D was associated with an increased risk of any fracture (HR, 1.26; 95% CI, 1.04-1.54) and MOF (HR, 1.25; 95% CI, 1.00-1.56).

Conclusions and Relevance

In this cohort study of older women, T2D was associated with higher BMD, better bone microarchitecture, and no different BMSi but poorer physical function, suggesting that poor physical function is the main reason for the increased fracture risk in T2D women.

Alternative therapeutic strategies in diabetes management

Diabetes is a heterogeneous metabolic disease characterized by elevated blood glucose levels resulting from the destruction or malfunction of pancreatic β cells, insulin resistance in peripheral tissues, or both, and results in a non-sufficient production of insulin. To adjust blood glucose levels, diabetic patients need exogenous insulin administration together with medical nutrition therapy and physical activity. With the aim of improving insulin availability in diabetic patients as well as ameliorating diabetes comorbidities, different strategies have been investigated. The first approaches included enhancing endogenous β cell activity or transplanting new islets. The protocol for this kind of intervention has recently been optimized, leading to standardized procedures. It is indicated for diabetic patients with severe hypoglycemia, complicated by impaired hypoglycemia awareness or exacerbated glycemic lability. Transplantation has been associated with improvement in all comorbidities associated with diabetes, quality of life, and survival. However, different trials are ongoing to further improve the beneficial effects of transplantation. Furthermore, to overcome some limitations associated with the availability of islets/pancreas, alternative therapeutic strategies are under evaluation, such as the use of mesenchymal stem cells (MSCs) or induced pluripotent stem cells for transplantation. The cotransplantation of MSCs with islets has been successful, thus providing protection against proinflammatory cytokines and hypoxia through different mechanisms, including exosome release. The use of induced pluripotent stem cells is recent and requires further investigation. The advantages of MSC implantation have also included the improvement of diabetes-related comorbidities, such as wound healing. Despite the number of advantages of the direct injection of MSCs, new strategies involving biomaterials and scaffolds have been developed to improve the efficacy of mesenchymal cell delivery with promising results. In conclusion, this paper offered an overview of new alternative strategies for diabetes management while highlighting some limitations that will need to be overcome by future approaches.

Unexplained Residual Risk In Type 2 Diabetes: How Big Is The Problem?

PURPOSE OF REVIEW

What is new? Cardiovascular disease (CVD) is the leading cause of mortality in type 2 diabetes (T2D) individuals. Of the major risk factors for CVD, less than 10% of T2D people meet the American Diabetes Association/American Heart Association recommended goals of therapy. The present review examines how much of the absolute cardiovascular (CV) risk in type 2 diabetes patients can be explained by major CV intervention trials.

RECENT FINDINGS

Multiple long-term cardiovascular (CV) intervention trials have examined the effect of specific target-directed therapies on the MACE endpoint. Only one prospective study, STENO-2, has employed a multifactorial intervention comparing intensified versus conventional treatment of modifiable risk factors in T2D patients, and demonstrated a 20% absolute CV risk reduction. If the absolute CV risk reduction in these trials is added to that in the only prospective multifactorial intervention trial (STENO-2), the unexplained CV risk is 44.1%. What are the clinical implications? Potential explanations for the unaccounted-for reduction in absolute CV risk in type 2 diabetes (T2D) patients are discussed.

HYPOTHESIS

failure to take into account synergistic interactions between major cardiovascular risk factors is responsible for the unexplained CV risk in T2D patients. Simultaneous treatment of all major CV risk factors to recommended AHA/ADA guideline goals is required to achieve the maximum reduction in CV risk.

Life's Essential 8 in Relation to Cardiovascular Disease and Mortality in Individuals With Diabetes

Background

Evidence regarding the potential health effects of Life's Essential 8 (LE8) score among individuals with type 2 diabetes (T2D) is limited.

Objectives

The purpose of this study was to examine the associations of LE8 score with risk of cardiovascular disease (CVD) and mortality among individuals with T2D.

Methods

We prospectively followed 19,915 Chinese participants with T2D at baseline or diagnosed during follow-up (Kailuan Study: 2006-2020), who were free of CVD at diagnosis of diabetes. Diet, lifestyle, and health conditions were repeatedly assessed every 2 years. The LE8 score (range 0-100), was calculated based on 8 components: diet quality, physical activity, smoking status, sleep health, body mass index, blood lipids, blood glucose, and blood pressure. We used time-varying cox models to model the associations.

Results

During a median follow-up of 11.5 years in participants with T2D, there were 3,295 incident CVD cases and 3,123 deaths. Higher LE8 score was associated with lower risk of CVD incidence and total mortality among participants with diabetes. The multivariate-adjusted HRs for the highest quintile of LE8 score compared with the lowest quintile were 0.56 (95% CI: 0.53-0.59) for CVD, 0.57 (95% CI: 0.53-0.62) for heart disease, 0.53 (95% CI: 0.49-0.57) for stroke, and 0.73 (95% CI: 0.69-0.78) for total mortality (all P trend <0.001). Furthermore, compared with participants with stable or decreased LE8 score after diabetes diagnosis, those with increased LE8 score had 17% to 42% lower risk of CVD, heart disease, stroke, and mortality.

Conclusions

A higher LE8 score was associated with a substantially lower risk of CVD incidence and total mortality among adults with T2D.

Promotion of Physical Activity by Québec Primary Care Physicians: What Has Changed in the Last Decade?

OBJECTIVE

This study aimed to assess the changes in the frequency of physical activity (PA) counseling and in the predictors of primary care PA promotion in Québec primary care physicians (PCPs) between 2010 and 2020.

METHODS

In 2010, we conducted a survey among Québec PCPs. Questions included: frequency of promoting PA to patients, perceived barriers, needs to improve PA promotion practice, frequency of PCPs' PA practice, and sociodemographic information. In 2020, we took over the 2010 questionnaire to document the evolution of the PA promotion practice.

RESULTS

The proportion of PCPs discussing PA with their patients significantly increased (P < .05) in 2020 for the following health conditions: depression, low back pain, chronic obstructive pulmonary disease, and cancer; it declined (P < .05) for overweight patients, those with metabolic syndrome, and in primary prevention. Collaboration with PA professionals was the major need identified, and it increased in 2020. PCPs' own practice of PA was a predictor of PA promotion in 2010 (odds ratio = 6.679; P < .001) and in 2020 (odds ratio = 6.679; P < .001). In both 2010 and in 2020, older or more experienced PCPs were more likely to discuss PA with their patients without diagnosed diseases than younger ones or those with less experience.

CONCLUSIONS

Over the last 10 years, there has been a significant increase in PCPs promoting PA in Québec; however, it has been mainly oriented toward secondary prevention. It is concerning that PA counseling in primary prevention has declined, notably among younger PCPs. The stronger claim for closer collaboration with kinesiologists suggests that PCPs are in favor of an interprofessional strategy, namely collaboration with PA specialists.

Postprandial glucose-management strategies in type 1 diabetes: Current approaches and prospects with precision medicine and artificial intelligence

Postprandial glucose control can be challenging for individuals with type 1 diabetes, and this can be attributed to many factors, including suboptimal therapy parameters (carbohydrate ratios, correction factors, basal doses) because of physiological changes, meal macronutrients and engagement in postprandial physical activity. This narrative review aims to examine the current postprandial glucose-management strategies tested in clinical trials, including adjusting therapy settings, bolusing for meal macronutrients, adjusting pre-exercise and postexercise meal boluses for postprandial physical activity, and other therapeutic options, for individuals on open-loop and closed-loop therapies. Then we discuss their challenges and future avenues. Despite advancements in insulin delivery devices such as closed-loop systems and decision-support systems, many individuals with type 1 diabetes still struggle to manage their glucose levels. The main challenge is the lack of personalized recommendations, causing suboptimal postprandial glucose control. We suggest that postprandial glucose control can be improved by (i) providing personalized recommendations for meal macronutrients and postprandial activity; (ii) including behavioural recommendations; (iii) using other personalized therapeutic approaches (e.g. glucagon-like peptide-1 receptor agonists, sodium-glucose co-transporter inhibitors, amylin analogues, inhaled insulin) in addition to insulin therapy; and (iv) integrating an interpretability report to explain to individuals about changes in treatment therapy and behavioural recommendations. In addition, we suggest a future avenue to implement precision recommendations for individuals with type 1 diabetes utilizing the potential of deep reinforcement learning and foundation models (such as GPT and BERT), employing different modalities of data including diabetes-related and external background factors (i.e. behavioural, environmental, biological and abnormal events).

Examining the association between delay discounting, delay aversion and physical activity in Chinese adults with type-2 diabetes mellitus

BACKGROUND

The role of physical activity in diabetes is critical, influencing this disease's development, man-agement, and overall outcomes. In China, 22.3% of adults do not meet the minimum level of physical activity recommended by the World Health Organization. Therefore, it is imperative to identify the factors that contributing to lack of physical activity must be identified.

AIM

To investigate the relationship among delay discounting, delay aversion, glycated hemoglobin (HbA1c), and various levels of physical activity in Chinese adults diagnosed with type 2 diabetes mellitus (T2DM).

METHODS

In 2023, 400 adults with T2DM were recruited from the People's Hospital of Linxia Hui Autonomous Prefecture of Gansu Province. A face-to-face questionnaire was used to gather demographic data and details on physical activity, delay discounting, and delay aversion. In addition, HbA1c levels were measured in all 400 participants. The primary independent variables considered were delay discounting and delay aversion. The outcome variables included HbA1c levels and different intensity levels of physical activity, including walking, moderate physical activity, and vigorous physical activity. Multiple linear regression models were utilized to assess the relationship between delay discounting, delay aversion, and HbA1c levels, along with the intensity of different physical activity measured in met-hours per week.

RESULTS

After controlling for the sample characteristics, delay discounting was negatively associated with moderate physical activity (β = -2.386, 95%CI: -4.370 to -0.401). Meanwhile, delay aversion was negatively associated with the level of moderate physical activity (β = -3.527, 95% CI: -5.578 to -1.476) in the multiple linear regression model, with statistically significant differences.

CONCLUSION

Elevated delay discounting and increased delay aversion correlated with reduced levels of moderate physical activity. Result suggests that delay discounting and aversion may influence engagement in moderate physical activity. This study recommends that health administration and government consider delay discounting and delay aversion when formulating behavioral intervention strategies and treatment guidelines involving physical activity for patients with T2DM, which may increase participation in physical activity. This study contributes a novel perspective to the research on physical activity in adults with T2DM by examining the significance of future health considerations and the role of emotional responses to delays.

Association Between Physical Activity and Physical Function in a Marshallese Population with Type 2 Diabetes

Physical activity can delay functional decline in people with type 2 diabetes (T2D), but these associations have not been studied within a sample of Native Hawaiian or Pacific Islander adults with T2D. Using data from a randomized control trial in which 218 Marshallese adults with T2D participated in a 10-week diabetes self-management education intervention, this study tested our hypothesis that physical activity would predict physical function when controlling for time and other variables. Levels of physical activity were positively associated with levels of physical function, even after controlling for time and other covariates. These findings provide a more robust understanding of the relationship between physical activity and physical function in a sample of minority adults with T2D. Future studies should further explore levels of physical activity needed to maintain and improve physical function so that culturally appropriate physical activity interventions can be developed.

Leisure-time physical activity and all-cause mortality and cardiovascular disease in adults with type 2 diabetes: Cross-country comparison of cohort studies

PURPOSE

This study aimed to quantify the dose-response association and the minimal effective dose of leisure-time physical activity (PA) to prevent mortality and cardiovascular disease in adults with type 2 diabetes.

METHODS

Cross-country comparison of 2 prospective cohort studies including 14,913 and 17,457 population-based adults with type 2 diabetes from the UK and China. Baseline leisure-time PA was self-reported and categorized by metabolic equivalent hours per week (MET-h/week) according to World Health Organization recommendations: none, below recommendation (>0-7.49 MET-h/week); at recommended level (7.5-14.9 MET-h/week); above recommendation (≥15 MET-h/week). Mortality and cardiovascular disease data were obtained from national registries.

RESULTS

During a median follow-up of 12.4 and 9.7 years, in the UK and China cohorts, repectively, higher levels of leisure-time PA were inversely associated with all-cause (1571 and 2351 events) and cardiovascular mortality (392 and 1060 events), mostly consistent with a linear dose-response relationship. PA below, at, and above recommendations, compared with no activity, yielded all-cause mortality hazard ratios of 0.94 (95% confidence interval (95%CI): 0.79-1.12), 0.90 (95%CI: 0.74-1.10), and 0.85 (95%CI: 0.70-1.02) in British adults and 0.87 (95%CI: 0.68-1.10), 0.88 (95%CI: 0.74-1.03), and 0.77 (95%CI: 0.70-0.85) in Chinese adults. Associations with cardiovascular mortality were more pronounced in British adults (0.80 (95%CI: 0.58-1.11), 0.75 (95%CI: 0.52-1.09), and 0.69 (95%CI: 0.48-0.97)) but less pronounced in Chinese adults (1.06 (95%CI: 0.76-1.47), 1.01 (95%CI: 0.80-1.28), and 0.79 (95%CI: 0.69-0.92)). PA at recommended levels was not associated with lower rates of major adverse cardiovascular events (2345 and 4458 events).

CONCLUSION

Leisure-time PA at the recommended levels was not convincingly associated with lower mortality and had no association with risk of major adverse cardiovascular events in British or Chinese adults with type 2 diabetes. Leisure-time PA above current recommendations may be needed to prevent cardiovascular disease and premature mortality in adults with type 2 diabetes.

Cardio-renal-metabolic disease in primary care setting

In the primary care setting providers have more tools available than ever before to impact positively obesity, diabetes, and their complications, such as renal and cardiac diseases. It is important to recognise what is available for treatment taking into account diabetes heterogeneity. For those who develop type 2 diabetes (T2DM), effective treatments are available that for the first time have shown a benefit in reducing mortality and macrovascular complications, in addition to the well-established benefits of glucose control in reducing microvascular complications. Some of the newer medications for treating hyperglycaemia have also a positive impact in reducing heart failure (HF). Technological advances have also contributed to improving the quality of care in patients with diabetes. The use of technology, such as continuous glucose monitoring systems (CGM), has improved significantly glucose and glycated haemoglobin A1c (HbA1c) values, while limiting the frequency of hypoglycaemia. Other technological support derives from the use of predictive algorithms that need to be refined to help predict those subjects who are at great risk of developing the disease and/or its complications, or who may require care by other specialists. In this review we also provide recommendations for the optimal use of the new medications; sodium-glucose co-transporter-2 inhibitors (SGLT2i) and Glucagon-like peptide-receptor agonists 1 (GLP1RA) in the primary care setting considering the relevance of these drugs for the management of T2DM also in its early stage.

Effects of high-intensity interval training and its different protocols on lipid profile and glycaemic control in type 2 diabetes: A meta-analysis

This meta-analysis of randomised clinical trials aimed to compare the effects of high-intensity interval training (HIIT) and its different protocols versus moderate-intensity continuous training (MICT) and/or control on total cholesterol, HDL, LDL, triglycerides, HbA1c levels, and fasting glucose in individuals with type 2 diabetes mellitus (T2DM). The search strategy was performed in PubMed/MEDLINE, Cochrane CENTRAL, EMBASE, Web of Science, Sport DISCUS, and PEDro, until January 2023. A total of 31 studies (1092 individuals) were included. When compared to control, HIIT decreased total cholesterol by -0.31 mmol/L (95% CI -0.49; -0.12), LDL by -0.31 mmol/L (95% CI -0.49; -0.12), triglycerides by -0.27 mmol/L (95% CI -0.33; -0.2), HbA1c by -0.75% (95% CI -0.97; -0.53), fasting glucose by -1.15 mmol/L (95% CI -1.44; -0.86), and increased HDL by 0.24 mmol/L (95% CI 0.06; 0.42). No difference was found in the comparison between HIIT versus MICT for any of the outcomes analysed, however subgroup analysis showed that a moderate-interval (>30s to < 2 min) and moderate-term (>4 to < 12 weeks) HIIT protocol reduced total cholesterol, when compared to MICT. HIIT is able to improve lipid profile and glycaemic control in T2DM individuals, and specific protocols can be recommended for improving total cholesterol levels.

Impact of a 4-week intensive track and field training intervention on glycaemia in adolescents with type 1 diabetes: The ChilDFiT1 study

AIM

To investigate the safety and efficacy of track and field training compared with intensification of insulin treatment only in adolescents with type 1 diabetes (T1D).

MATERIALS AND METHODS

Eighteen adolescents (seven females) with T1D were included (age 15.1 ± 1.1 years, HbA1c 7.3% ± 1.0% [56.3 ± 10.9 mmol/mol]). After a 4-week observational control phase, participants were randomized to either stand-alone intensive glycaemic management (IT; telemedicine or on-site visits, three times/week) or additionally performed track and field exercise (EX; three 60-minute sessions/week) for 4 weeks. Glycaemia was assessed via continuous glucose monitoring during observational control and intervention phases.

RESULTS

Time in range (70-180 mg/dL; 3.9-10.0 mmol/L) significantly improved from the observational control phase to the exercise intervention phase in EX (69% ± 13% vs. 72% ± 11%, P = .049), but not in IT (59% ± 22% vs. 62% ± 16%, P = .399). Time below range 1 (54-69 mg/dL; < 3.9 mmol/L) improved in IT (3.1% ± 1.9% vs. 2.0% ± 0.8%, P = .017) and remained stable in EX (2.0% ± 1.7 vs. 1.9% ± 1.1%, P = .999). The EX group's HbA1c ameliorated preintervention to postintervention (mean difference: ΔHbA1c -0.19% ± 0.17%, P = .042), which was not seen within the IT group (ΔHbA1c -0.16% ± 0.37%, P = .40). Glucose standard deviation was reduced significantly in EX (55 ± 11 vs. 51 ± 10 mg/dL [3.1 ± 0.6 vs. 2.8 ± 0.6 mmol/L], P = .011), but not in IT (70 ± 24 vs. 63 ± 18 mg/dL [3.9 ± 1.3 vs. 3.5 ± 1.0 mmol/L], P = .186).

CONCLUSION

Track and field training combined with intensive glycaemic management improved glycaemia in adolescents with T1D, which was not observed in the non-exercise group.

Patterns of Timing and Intensity of Physical Activity and HbA1c Levels in Hispanic/Latino Adults With or at Risk of Type 2 Diabetes

BACKGROUND

Despite the clear benefits of increased physical activity (PA) on glycemic control, little is known about the importance of the timing of exercise among people with diabetes. Our objective was to compare the time of day of PA with concurrent HbA1c levels and body mass index (BMI) among Hispanic/Latino adults with or at risk of type 2 diabetes (T2D).

METHODS

Monitored activity data obtained from Hispanic/Latino adults were summarized as number of steps per day, moderate-to vigorous-intensity physical activity (MVPA), and energy expenditure (kcals/day). We next examined the association between PA measures and participants' HbA1c. K-means clustering analysis was applied to identify daily PA patterns by time of day and intensity.

RESULTS

Three dominant clusters were identified: low-intensity PA, and early and late PA by time of day. The step counts were correlated with HbA1c in the late-active group (P = .01). Furthermore, independently in younger adults (age ≤ 50 years) and in overweight adults 25 ≤ BMI < 30 kg/m2), there was an association between HbA1c and step counts (P < .01 and P < .005, respectively) as well as HbA1c and MVPA (P < .05 and P < .035, respectively).

CONCLUSIONS

For Hispanic/Latino adults with or at risk of T2D, there appears to be clustering of PA by intensity and time of day which, in turn, may influence achieved HbA1c and BMI. Our findings demonstrate that the amount of activity is more efficacious on HbA1c in participants who are more active later during the day and separately in overweight and younger individuals. This finding may help design more personalized PA recommendations in this population.

CLINICALTRIALS.GOV IDENTIFIERS

NCT03830840 and NCT03736468.

5. Facilitating Positive Health Behaviors and Well-being to Improve Health Outcomes: Standards of Care in Diabetes-2024

The American Diabetes Association (ADA) "Standards of Care in Diabetes" includes the 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, an interprofessional 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 and a full list of Professional Practice Committee members, please refer to Introduction and Methodology. Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.

A Longitudinal Dose-Response Curve Between Leisure-Time Physical Activity and the Prevalence of Diabetes Based on the Different Levels of Cognitive Function Among Older Adults

This study investigated a dose-response relationship between Leisure-Time Physical Activity participation (LTPA) and the risk of diabetes and a comparison of the risk across different cognitive function groups among older adults. The Health and Retirement Study data were used from 2012 to 2020 (n = 18 746). This study conducted a Cox Proportional Hazard Regression to investigate the Dose-Response Curve between the prevalence of diabetes and the covariates following a level of LTPA participation. The result presented that the Odds Ratio continuously decreased as the level of LTPA participation increased. Among the three cognitive function groups, the high group (OR = .43, P < .05) and the mid group (OR = .71, P < .05) had a larger negative slope coefficient than the low group. This study found that LTPA participation reduces the risk of diabetes and gives evidence for the importance of cognitive function in reducing the prevalence of diabetes.

Role of diet and exercise in aging, Alzheimer's disease, and other chronic diseases

Alzheimer's disease (AD) is a progressive neurodegenerative disease, characterized by memory loss and multiple cognitive impairments. Genetic mutations cause a small proportion (1-2%) of early-onset AD, with mutations in amyloid precursor protein (APP), presenilin 1 (PS1) and presenilin 2 (PS2). Major contributing factors of late-onset AD are ApoE4 genotype, traumatic brain injury, diabetes, obesity, hypertension, cardiovascular conditions, in addition to lifestyle factors, such as unhealthy diet and lack of physical exercise. Disease progression can be delayed and/or prevented to a greater extent by adopting healthy lifestyle with balanced and antioxidant enriched diet and daily exercise. The interaction and interplay of diet, exercise, age, and pharmacological interventions holds a crucial role in the progression, pathogenesis and management of AD and its comorbidities, including diabetes, obesity, hypertension and cardiovascular conditions. Antioxidant enriched diet contributes to brain health, glucose control, weight management, and cardiovascular well-being. Regular exercise removes toxins including free radicals and enhances insulin sensitivity, and supports cardiovascular function. In the current article, we discussed, the role of diet, and exercise in aging, AD and other conditions including diabetes, obesity, hypertension, cardiovascular conditions. This article also highlights the impact of medication, socioeconomic and lifestyle factors, and pharmacological interventions. These aspects were discussed in different races and ethnic groups in Texas, and the US.

Moderate- and High-Intensity Endurance Training Alleviate Diabetes-Induced Cardiac Dysfunction in Rats

Exercise training is an encouraging approach to treat cardiac dysfunction in type 2 diabetes (T2DM), but the impact of its intensity is not understood. We aim to investigate whether and, if so, how moderate-intensity training (MIT) and high-intensity interval training (HIIT) alleviate adverse cardiac remodeling and dysfunction in rats with T2DM. Male rats received standard chow (n = 10) or Western diet (WD) to induce T2DM. Hereafter, WD rats were subjected to a 12-week sedentary lifestyle (n = 8), running MIT (n = 7) or HIIT (n = 7). Insulin resistance and glucose tolerance were assessed during the oral glucose tolerance test. Plasma advanced glycation end-products (AGEs) were evaluated. Echocardiography and hemodynamic measurements evaluated cardiac function. Underlying cardiac mechanisms were investigated by histology, western blot and colorimetry. We found that MIT and HIIT lowered insulin resistance and blood glucose levels compared to sedentary WD rats. MIT decreased harmful plasma AGE levels. In the heart, MIT and HIIT lowered end-diastolic pressure, left ventricular wall thickness and interstitial collagen deposition. Cardiac citrate synthase activity, mitochondrial oxidative capacity marker, raised after both exercise training modalities. We conclude that MIT and HIIT are effective in alleviating diastolic dysfunction and pathological cardiac remodeling in T2DM, by lowering fibrosis and optimizing mitochondrial capacity.

Detailed descriptions of physical activity patterns among individuals with diabetes and prediabetes: the Lolland-Falster Health Study

INTRODUCTION

This study aimed to describe objectively measured physical activity patterns, including daily activity according to day type (weekdays and weekend days) and the four seasons, frequency, distribution, and timing of engagement in activity during the day in individuals with diabetes and prediabetes and compared with individuals with no diabetes.

RESEARCH DESIGN AND METHODS

This cross-sectional study included data from the Danish household-based, mixed rural-provincial population study, The Lolland-Falster Health Study from 2016 to 2020. Participants were categorized into diabetes, prediabetes, and no diabetes based on their glycated hemoglobin level and self-reported use of diabetes medication. Outcome was physical activity in terms of intensity (time spent in sedentary, light, moderate, vigorous, and moderate to vigorous physical activity (MVPA) intensities), adherence to recommendations, frequency and distribution of highly inactive days (<5 min MVPA/day), and timing of engagement in activity assessed with a lower-back worn accelerometer.

RESULTS

Among 3157 participants, 181 (5.7 %) had diabetes and 568 (18.0 %) had prediabetes. Of participants with diabetes, 63.2% did not adhere to the WHO recommendations of weekly MVPA, while numbers of participants with prediabetes and participants with no diabetes were 59.5% and 49.6%, respectively. Around a third of participants with diabetes were highly inactive daily (<5 min MVPA/day) and had >2 consecutive days of inactivity during a 7-days period. Mean time spent physically active at any intensity (light, moderate, and vigorous) during a day was lower among participants with diabetes compared with participants with no diabetes and particularly from 12:00 to 15:00 (mean difference of -6.3 min MVPA (95% CI -10.2 to -2.4)). Following adjustments, significant differences in physical activity persisted between diabetes versus no diabetes, but between participants with prediabetes versus no diabetes, results were non-significant after adjusting for body mass index.

CONCLUSIONS

Inactivity was highly prevalent among individuals with diabetes and prediabetes, and distinct daily activity patterns surfaced when comparing these groups with those having no diabetes. This highlights a need to optimize current diabetes treatment and prevention to accommodate the large differences in activity engagement.

The relationship between mortality and daily number of steps in type 2 diabetes

BACKGROUND

Physical activity (PA) is an established modifiable factor for the prevention of cardiovascular disease. Our objective was to assess the association of PA with mortality rates in a national sample of patients with diabetes.

METHODS

We analyzed a nationally representative sample from The National Health and Nutrition Examination Survey (NHANES, periods 2003-2004 and 2005-2006) that used PA Monitors. Individuals were matched for BMI, number of steps/per day and age. Three groups were created: subjects with less than 5000/steps per day (low), 5000-7500/steps per day (moderate) and more than 7500/steps per day (high levels of physical activity). All-cause mortality was ascertained through December 2015.

RESULTS

A sample of 3072 individuals (1018 with diabetes) was analyzed. Patients with diabetes had 30% increased risk of mortality of all causes (RR: 1.298, 95% CI [1.162-1.451], P<0.001), higher levels of PA (>7500 steps/day) provided similar relative risk for subjects with diabetes compared to their controls (RR:1.256 [95% CI 0.910-1.732]). In a Poisson model adjusted for sex, history of previous cardiovascular event or cancer, ethnicity, Hb1ac, SBP, and total cholesterol to HDL ratio, patients with diabetes and moderate or high PA had an associated 44% to 80% lower risk of all-cause mortality compared to those with low PA.

CONCLUSIONS

The subgroup of patients with diabetes and high PA had no excess of mortality compared to the general population. PA can reduce the gap for all-cause mortality, used as an index of cardiovascular fitness and a clinical tool for the assessment of mortality risk.

Atherosclerotic Disease: Pathogenesis and Approaches to Management

Atherosclerotic disease, including stroke and myocardial infarction, is the leading cause of morbidity and mortality worldwide. Atherosclerotic plaque formation occurs in the setting of excess oxidative and hemodynamic stress and is perpetuated by smoking, poor diet, dyslipidemia, hypertension, and diabetes. Plaque may rupture, resulting in acute thrombotic events. Smoking cessation, lifestyle modification, risk factor optimization, and antithrombotic therapies are the mainstays of atherosclerotic disease management and are the cornerstones to reduce morbidity and mortality in this high-risk patient population. Novel therapeutics are in development and will add to the growing armamentarium available to physicians who manage atherosclerotic disease.

Association of Physical Activity with Total and Cause-specific Mortality in Patients with Diabetes: A Nationwide Population-based Cohort Study

AIMS

Physical inactivity is a modifiable risk factor for cardiovascular disease (CVD) in patients with type 2 diabetes mellitus (T2DM); however, little is known about its association with mortality due to other causes. Herein, we investigated the association between physical activity (PA) and cause-specific mortality in patients with T2DM.

METHODS

We analyzed data from the Korean National Health Insurance Service and claims database of adults with T2DM aged >20 years at baseline (n=2,651,214). Each participant's PA volume was measured as the metabolic equivalent of tasks (METs)-min per week, and hazard ratios of all-cause and cause-specific mortality relative to PA levels were estimated.

RESULTS

During the 7.8 years of follow-up, all-cause, CVD, respiratory, cancer, and other causes of mortality were lowest in patients engaged in vigorous PA. MET-min/week was inversely associated with mortality after adjusting for covariates. The reduction in total and cause-specific mortality was greater in patients aged ≥65 years than in those aged <65 years.

CONCLUSIONS

Increasing PA may facilitate a reduction in mortality from various causes, especially among older patients with T2DM. Clinicians should encourage such patients to increase their daily PA levels to reduce their risk of mortality.

New Insights and Potential Therapeutic Interventions in Metabolic Diseases

Endocrine homeostasis and metabolic diseases have been the subject of extensive research in recent years. The development of new techniques and insights has led to a deeper understanding of the mechanisms underlying these conditions and opened up new avenues for diagnosis and treatment. In this review, we discussed the rise of metabolic diseases, especially in Western countries, the genetical, psychological, and behavioral basis of metabolic diseases, the role of nutrition and physical activity in the development of metabolic diseases, the role of single-cell transcriptomics, gut microbiota, epigenetics, advanced imaging techniques, and cell-based therapies in metabolic diseases. Finally, practical applications derived from this information are made.

Comprehensive Cardiovascular and Renal Protection in Patients with Type 2 Diabetes

Type 2 diabetes (T2DM) is one of the main public health care problems worldwide. It is associated with a marked increased risk of developing atherosclerotic vascular disease, heart failure, chronic kidney disease and death. It is essential to act during the early phases of the disease, through the intensification of lifestyle changes and the prescription of those drugs that have been shown to reduce these complications, with the aim not only of achieving an adequate metabolic control, but also a comprehensive vascular risk control. In this consensus document, developed by the different specialists that treat these patients (endocrinologists, primary care physicians, internists, nephrologists and cardiologists), a more appropriate approach in the management of patients with T2DM or its complications is provided. A particular focus is given to the global control of cardiovascular risk factors, the inclusion of weight within the therapeutic objectives, the education of patients, the deprescription of those drugs without cardiovascular benefit, and the inclusion of GLP-1 receptor agonists and SGLT2 inhibitors as cardiovascular protective drugs, at the same level as statins, acetylsalicylic acid, or renin angiotensin system inhibitors.

The importance of exercise for glycemic control in type 2 diabetes

Exercise is a first-line therapy recommended for patients with type 2 diabetes (T2D). Although moderate to vigorous exercise (e.g. 150 min/wk) is often advised alongside diet and/or behavior modification, exercise is an independent treatment that can prevent, delay or reverse T2D. Habitual exercise, consisting of aerobic, resistance or their combination, fosters improved short- and long-term glycemic control. Recent work also shows high-intensity interval training is successful at lowering blood glucose, as is breaking up sedentary behavior with short-bouts of light to vigorous movement (e.g. up to 3min). Interestingly, performing afternoon compared with morning as well as post-meal versus pre-meal exercise may yield slightly better glycemic benefit. Despite these efficacious benefits of exercise for T2D care, optimal exercise recommendations remain unclear when considering, dietary, medication, and/or other behaviors.

Is Type 2 Diabetes Mellitus a Behavioural Disorder? An Evidence Review for Type 2 Diabetes Mellitus Prevention and Remission through Lifestyle Modification

The prevalence of type 2 diabetes mellitus (T2DM) is steadily rising worldwide due to an increasingly sedentary lifestyle combined with unhealthy food habits. Currently, the burden of diabetes on healthcare systems is unprecedented and rising daily. Several observational studies and randomized controlled trials provide clinical evidence that T2DM remission is possible by adopting dietary interventions and a strict exercise training protocol. Notably, these studies provide ample evidence for remission in patients with T2DM or for prevention in those with risk factors for the disease through various non-pharmacological behavioural interventions. In this article, we present two clinical cases of individuals who showed remission from T2DM/prediabetes via behavioural changes, especially through the adoption of a low-energy diet and exercise. We also discuss the recent advances in T2DM and obesity research, focusing on nutritional interventions and exercise and their benefits for weight loss, improved metabolic profile, enhanced glycaemic control and remission of diabetes.

Comprehensive Approach to Medical Nutrition Therapy in Patients with Type 2 Diabetes Mellitus: From Diet to Bioactive Compounds

In the pathogenesis of type 2 diabetes mellitus (T2DM), diet plays a key role. Individualized medical nutritional therapy, as part of lifestyle optimization, is one of the cornerstones for the management of T2DM and has been shown to improve metabolic outcomes. This paper discusses major aspects of the nutritional intervention (including macro- and micronutrients, nutraceuticals, and supplements), with key practical advice. Various eating patterns, such as the Mediterranean-style, low-carbohydrate, vegetarian or plant-based diets, as well as healthy eating plans with caloric deficits have been proven to have beneficial effects for patients with T2DM. So far, the evidence does not support a specific macronutrient distribution and meal plans should be individualized. Reducing the overall carbohydrate intake and replacing high glycemic index (GI) foods with low GI foods have been shown as valid options for patients with T2DM to improve glycemic control. Additionally, evidence supports the current recommendation to reduce the intake of free sugars to less than 10% of total energy intake, since their excessive intake promotes weight gain. The quality of fats seems to be rather important and the substitution of saturated and trans fatty acids with foods rich in monounsaturated and polyunsaturated fats lowers cardiovascular risk and improves glucose metabolism. There is no benefit of supplementation with antioxidants, such as carotene, vitamins E and C, or other micronutrients, due to the lack of consistent evidence showing efficacy and long-term safety. Some studies suggest possible beneficial metabolic effects of nutraceuticals in patients with T2DM, but more evidence about their efficacy and safety is still needed.

Historical loss: Implications for physical activity levels in American Indian adults

PURPOSE

To investigate the relationship between daily thoughts about historical loss and daily levels of moderate to vigorous physical activity (MVPA) in American Indian (AI) adults residing on the Blackfeet reservation in Browning, Montana.

METHODS

The study was designed and conducted using a community-based participatory research framework and ecological momentary assessment. Over a period of 1 week, 100 AI adults (mean age = 42.18, SD = 14.92) reported how often they thought about historical loss at the end of each day. During this week-long period, all participants wore a wrist-accelerometer to passively and objectively measure levels of physical activity.

FINDINGS

We found that Blackfeet AI adults who reported thinking about historical loss more frequently over the course of the week had lower average levels of MVPA over the course of the week compared to Blackfeet AI adults who reported thinking about historical loss less frequently (B = -10.22, 95% CI = -13.83, -6.60). We also found that on days when Blackfeet AI adults thought more about historical loss compared to their weekly average, they had fewer minutes of MVPA compared to their weekly average of minutes of MVPA (B = -0.87, 95% CI = -1.48, -0.27).

CONCLUSIONS

Our data indicate that thoughts about historical loss are linked to lower levels of MVPA. Given high incidence of chronic health conditions linked to physical inactivity in AIs, more work is needed to identify the mechanisms through which thoughts about historical loss may inhibit physical activity in this population.

Exercise in adults with type 1 diabetes mellitus

Regular physical activity improves cardiometabolic and musculoskeletal health, helps with weight management, improves cognitive and psychosocial functioning, and is associated with reduced mortality related to cancer and diabetes mellitus. However, turnover rates of glucose in the blood increase dramatically during exercise, which often results in either hypoglycaemia or hyperglycaemia as well as increased glycaemic variability in individuals with type 1 diabetes mellitus (T1DM). A complex neuroendocrine response to an acute exercise session helps to maintain circulating levels of glucose in a fairly tight range in healthy individuals, while several abnormal physiological processes and limitations of insulin therapy limit the capacity of people with T1DM to exercise in a normoglycaemic state. Knowledge of the acute and chronic effects of exercise and regular physical activity is critical for the formulation of clinical strategies for the management of insulin and nutrition for active patients with T1DM. Emerging diabetes-related technologies, such as continuous glucose monitors, automated insulin delivery systems and the administration of solubilized glucagon, are demonstrating efficacy for preserving glucose homeostasis during and after exercise in this population of patients. This Review highlights the beneficial effects of regular exercise and details the complex endocrine and metabolic responses to different types of exercise for adults with T1DM. An overview of basic clinical strategies for the preservation of glucose homeostasis using emerging technologies is also provided.

Long-Term Tailor-Made Exercise Intervention Reduces the Risk of Developing Cardiovascular Diseases and All-Cause Mortality in Patients with Diabetic Kidney Disease

This study aimed to determine the effect of long-term exercise on the risk of developing cardiovascular diseases (CVD) and all-cause mortality in patients with diabetic kidney disease (DKD). A single-center, prospective intervention study using propensity score matching was performed over 24 months. The intervention group (n = 67) received six months of individual exercise instruction from a physical therapist, who performed aerobic and muscle-strengthening exercises under unsupervised conditions. New events were defined as the composite endpoint of stroke or CVD requiring hospitalization, initiation of hemodialysis or peritoneal dialysis, or all-cause mortality. The cumulative survival rate without new events at 24 months was significantly higher in the intervention group (0.881, p = 0.016) than in the control group (n = 67, 0.715). Two-way analysis of variance revealed a significant effect of the group factor on high density lipoprotein-cholesterol (HDL-C) which was higher in the intervention group than in the control group (p = 0.004); eGFRcr showed a significant effect of the time factor, which was lower at 24 months than before intervention (p = 0.043). No interactions were observed for all items. In conclusion, aerobic exercises combined with upper and lower limb muscle strengthening for six months reduce the risk of developing CVD and all-cause mortality in patients with DKD.

5. Facilitating Positive Health Behaviors and Well-being to Improve Health Outcomes: Standards of Care in Diabetes-2023

The American Diabetes Association (ADA) "Standards of Care in Diabetes" includes the 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 and a full list of Professional Practice Committee members, please refer to Introduction and Methodology. Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.

Physical Activity Reduces the Risk of Developing Diabetes and Diabetes Medication Use

Diabetes is a global public health challenge, exerting a large socioeconomic burden on healthcare systems. This study aimed to explore Diabetes prevalence and Diabetes medication use in diabetics regarding sex, age group, Physical Activity Level (PAL) and Body Mass Index (BMI) by studying possible differences and calculating the risks of developing Diabetes and Diabetes medication use in the population according to their PAL. A cross-sectional study was conducted using data extracted from the Spanish National Health Survey (ENSE2017). The sample was finally composed of 17,710 participants. A descriptive analysis was performed to characterise Diabetes prevalence and Diabetes medication use (Chi-square test and a z-test for independent proportions). Odds Ratios (OR) and 95% Confidence Intervals (CI) were calculated for Diabetes prevalence and Diabetes medication use according to the participants’ PAL. Both the Diabetes and Diabetes medication use was higher in men than in women, increasing with age and BMI, and decreasing with increasing PAL (p < 0.001). Higher prevalence levels were observed in the inactive group versus very active or active people (p < 0.001). Inactive people had a higher risk of Diabetes and use of Diabetes medication risk compared to the very active and active groups. Prevalence decreased the higher the PAL both in men and women.

Physical Activity and Risk of Major Diabetes-Related Complications in Individuals With Diabetes: A Systematic Review and Meta-Analysis of Observational Studies

BACKGROUND

Physical activity is a cornerstone in diabetes management; however, evidence synthesis on the association between physical activity and long-term diabetes-related complications is scarce.

PURPOSE

To summarize and evaluate findings on physical activity and diabetes-related complications, we conducted a systematic review and meta-analysis.

DATA SOURCES

We searched PubMed, Web of Science, and the Cochrane Library for articles published up to 6 July 2021.

STUDY SELECTION

We included prospective studies investigating the association between physical activity and incidence of and mortality from diabetes-related complications, i.e., cardiovascular disease (CVD), coronary heart disease, cerebrovascular events, heart failure, major adverse cardiovascular events, and microvascular complications such as retinopathy and nephropathy, in individuals with diabetes.

DATA EXTRACTION

Study characteristics and risk ratios with 95% CIs were extracted. Random-effects meta-analyses were performed, and the certainty of evidence and risk of bias were evaluated with use of the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) and Risk Of Bias In Non-randomised Studies - of Interventions (ROBINS-I) tools.

DATA SYNTHESIS

Overall, 31 studies were included. There was moderate certainty of evidence that high versus low levels of physical activity were inversely associated with CVD incidence, CVD mortality (summary risk ratio 0.84 [95% CI 0.77, 0.92], n = 7, and 0.62 [0.55, 0.69], n = 11), and microvascular complications (0.76 [0.67, 0.86], n = 8). Dose-response meta-analyses showed that physical activity was associated with lower risk of diabetes-related complications even at lower levels. For other outcomes, similar associations were observed but certainty of evidence was low or very low.

LIMITATIONS

Limitations include residual confounding and misclassification of exposure.

CONCLUSIONS

Physical activity, even below recommended amounts, was associated with reduced incidence of diabetes-related complications.

Developing a research agenda on exercise and physical activity for people with limb loss in Canada

PURPOSE

There is a lack of high-quality evidence about the effects of exercise or physical activity interventions for adults with lower limb amputations (LLAs). A planning meeting involving stakeholders (i.e., people with LLA, community advocates, health care providers, researchers) was organized to identify key research priorities related to exercise and physical activity for people with LLAs.

METHODS

We used a collaborative prioritized planning process with a pre-meeting survey and 2-day virtual meeting that included: identification and prioritization of challenges or gaps; identification and consolidation of solutions; and action planning. This process integrated a modified Delphi approach, including anonymous feedback in two surveys.

RESULTS

Thirty-five stakeholders participated. Six challenges related to exercise and physical activity for people with LLA were prioritized. One solution was prioritized for each challenge. After consolidation of solutions, participants developed five research action plans for research including: developing an on-line interface; developing and evaluating peer-support programs to support physical activity; examining integration of people with LLA into cardiac rehabilitation; development and evaluation of health provider education; and determining priority outcomes related to physical activity and exercise.

CONCLUSIONS

This collaborative process resulted in an action plan for amputation research and fostered collaborations to move identified priorities into action.IMPLICATIONS FOR REHABILITATIONLower limb amputations impact mobility leading to lower levels of physical activity.There are research gaps in our understanding of the effects of exercise or physical activity interventions for adults with lower limb amputations.Through a collaborative planning process, participants prioritized research directions on physical activity and exercise for people with LLA to advance research in the field.Action plans for research focused on developing online resources, peer support, cardiac rehabilitation for people with LLA, health provider education and determining priority outcomes related to physical activity and exercise.

Personal Activity Intelligence and Ischemic Heart Disease in a Healthy Population: China Kadoorie Biobank Study

BACKGROUND

Personal Activity Intelligence (PAI) is a physical activity metric that translates heart rate during physical activity into a simple score, where a weekly score of 100 or greater is associated with a lower risk of cardiovascular disease and mortality. Here, we prospectively investigated the association between PAI and ischemic heart disease (IHD) mortality in a large healthy population from China.

METHODS

Using data from the China Kadoorie Biobank, we studied 443,792 healthy adults (60% women). The weekly PAI score of each participant was estimated based on the questionnaire data and divided into four groups (PAI scores of 0, ≤50, 51-99, or ≥100). Adjusted hazard ratios (aHRs) and 95% confidence intervals (CIs) for fatal IHD and nonfatal myocardial infraction (MI) related to PAI were estimated using Cox proportional hazard regression analyses.

RESULTS

There were 3050 IHD deaths and 1808 MI events during a median follow-up of 8.2 years (interquartile range, 7.3-9.1; 3.6 million person-years). After adjustments for multiple confounders, a weekly PAI score ≥ 100 was associated with a lower risk of IHD (aHR: 0.91 (95% CI: 0.83-1.00)), compared with the inactive group (0 PAI). The corresponding aHR for MI was 0.94 (95% CI: 0.83-1.05). In participants aged 60 years or older at baseline, the aHR associated with a weekly PAI score ≥ 100 was 0.84 (95% CI, 0.75-0.93) for IHD and 0.84 (95% CI, 0.73-0.98) for MI.

CONCLUSION

Among healthy Chinese adults, a weekly PAI score of 100 or greater was associated with a lower risk of IHD mortality across all age groups; moreover, a high PAI score significantly lowered the risk of MI but only in those 60 years and older at baseline. The present findings extend the scientific evidence that PAI may have prognostic significance in diverse settings for IHD outcomes and suggest that the PAI metric may be useful in delineating the magnitude of weekly physical activity needed to reduce the risk of IHD mortality.

Leisure-time physical activity and mortality risk in type 2 diabetes: A nationwide cohort study

AIM

Physical activity improves insulin resistance, inhibits inflammation, and decreases the incidence of cardiovascular disease. These are major causes of death in patients with diabetes.

METHODS

The Taiwan National Health Interview Survey collected baseline characteristics of socioeconomic level, education, marriage, and health behaviour, including leisure time physical activity in 2001, 2005, 2009, and 2013. The National Health Insurance research dataset 2000-2016 contained detailed information on medical conditions, including all comorbidities. All-cause and cardiovascular deaths were confirmed by the National Death Registry.

RESULTS

A total of 4859 adults with type 2 diabetes were included in the analysis; 2389 (49 %) were men and the mean±SD age was 60±13 years. Kaplan-Meier curve of all-cause (log-rank P<0.001) and cardiovascular death (log-rank P=0.038) categorized by leisure-time physical activity showed a significant difference. The multivariable Cox regression model showed that those who had more leisure time physical activity had a significantly lower risk of all-cause death than those with no physical activity (physical activity of 1-800 MET-min/week HR = 0.66, 95% CI: 0.54-0.81, physical activity of >800 MET-min/week HR = 0.67, 95% CI: 0.56-0.81). A significant trend was also observed (P <0.001). Similar results were also observed for cardiovascular mortality (physical activity of 1-800 MET-min/week HR = 0.54, 95% CI: 0.36-0.84, physical activity of >800 MET-min/week HR = 0.78, 95% CI: 0.55-1.13).

CONCLUSION

For those with diabetes, increased leisure-time physical activity significantly reduced risk of all-cause and cardiovascular death. Further research is warranted to determine the proper prescription for physical activity to prolong healthy life.

American Association of Clinical Endocrinology Clinical Practice Guideline: Developing a Diabetes Mellitus Comprehensive Care Plan-2022 Update

OBJECTIVE

The objective of this clinical practice guideline is to provide updated and new evidence-based recommendations for the comprehensive care of persons with diabetes mellitus to clinicians, diabetes-care teams, other health care professionals and stakeholders, and individuals with diabetes and their caregivers.

METHODS

The American Association of Clinical Endocrinology selected a task force of medical experts and staff who updated and assessed clinical questions and recommendations from the prior 2015 version of this guideline and conducted literature searches for relevant scientific papers published from January 1, 2015, through May 15, 2022. Selected studies from results of literature searches composed the evidence base to update 2015 recommendations as well as to develop new recommendations based on review of clinical evidence, current practice, expertise, and consensus, according to established American Association of Clinical Endocrinology protocol for guideline development.

RESULTS

This guideline includes 170 updated and new evidence-based clinical practice recommendations for the comprehensive care of persons with diabetes. Recommendations are divided into four sections: (1) screening, diagnosis, glycemic targets, and glycemic monitoring; (2) comorbidities and complications, including obesity and management with lifestyle, nutrition, and bariatric surgery, hypertension, dyslipidemia, retinopathy, neuropathy, diabetic kidney disease, and cardiovascular disease; (3) management of prediabetes, type 2 diabetes with antihyperglycemic pharmacotherapy and glycemic targets, type 1 diabetes with insulin therapy, hypoglycemia, hospitalized persons, and women with diabetes in pregnancy; (4) education and new topics regarding diabetes and infertility, nutritional supplements, secondary diabetes, social determinants of health, and virtual care, as well as updated recommendations on cancer risk, nonpharmacologic components of pediatric care plans, depression, education and team approach, occupational risk, role of sleep medicine, and vaccinations in persons with diabetes.

CONCLUSIONS

This updated clinical practice guideline provides evidence-based recommendations to assist with person-centered, team-based clinical decision-making to improve the care of persons with diabetes mellitus.

Physical Activity Treatment in Adults with Type 2 Diabetes Mellitus per National Treatment Guidelines for Germany: A Telephone-Survey-Based Analysis

Physical activity (PA) is effective in the prevention of type 2 diabetes mellitus (T2DM). According to the German national treatment guidelines for T2DM, PA is recommended at all stages of the treatment process. Adults with T2DM were recruited within the cross-sectional telephone survey 'Disease knowledge and information needs-Diabetes mellitus (2017)'. Self-reported data on socio-demographic characteristics, previous and current T2DM treatment, and PA behavior were collected. Using multivariable logistic regression models, the correlation between PA treatment (referrals and recommendations) and PA was investigated. Overall, 1149 adults diagnosed with T2DM are included in the analysis. Of the participants, 66.7% reported having ever received PA as part of their T2DM treatment with 61% of the participants reporting PA treatment at the time of the initial T2DM diagnosis and 54% at the time of the interview. Women, older participants, and those with a lower educational level were less likely to have ever been treated with PA. Currently being treated with PA as part of the T2DM treatment was associated with higher rates of achieving the World Health Organization's PA recommendations (≥150 min per week) (OR = 1.95, 95% CI: 1.42-2.68), as well as ever being treated with PA (OR = 1.74, 95% CI: 1.20-2.38). The analyses showed that PA treatment plays a role in the treatment process of T2DM, but not all patient subgroups benefit in the same way. Efforts to increase PA treatment as part of T2DM treatment are needed, especially for those who are currently not treated with PA. Further research is needed to better understand the type of PA (e.g., structured or unstructured) undertaken by adults with T2DM to develop tailored PA interventions for adults with T2DM and for those in vulnerable subgroups.

Integrating a physical activity coaching intervention into diabetes care: a mixed-methods evaluation of a pilot pragmatic trial

Physical activity (PA) counseling is under-utilized in primary care for patients with type 2 diabetes mellitus (T2D), despite improving important health outcomes, including physical function. We adapted evidence-based PA counseling programs to primary care patients, staff, and leader's needs, resulting in "Be ACTIVE" comprised of shared PA tracker data (FitBit©), six theory-informed PA coaching calls, and three in-person clinician visits. In a pilot randomized pragmatic trial, we evaluated the feasibility, acceptability, and effectiveness of Be ACTIVE. Sedentary patients with T2D were randomized to Be ACTIVE versus an enhanced control condition. Mixed methods assessments of feasibility and acceptability included costs. Objective pilot effectiveness outcomes included PA (primary outcome, accelerometer steps/week), the Short Physical Performance Battery (SPPB) physical function measure, and behavioral PA predictors. Fifty patients were randomized to Be ACTIVE or control condition. Acceptability was >90% for patients and clinic staff. Coaching and PA tracking costs of ~$90/patient met Medicare reimbursement criteria. Pre-post PA increased by ~11% (Be ACTIVE) and ~6% in controls (group difference: 1574 ± 4391 steps/week, p = .72). As compared to controls, Be ACTIVE participants significantly improved SPPB (0.9 ± 0.3 vs. -0.1 ± 0.3, p = .01, changes >0.5 points prevent falls clinically), and PA predictors of self-efficacy (p = .02) and social-environmental support (p < .01). In this pilot trial, Be ACTIVE was feasible and highly acceptable to stakeholders and yielded significant improvements in objective physical function consistent with lower fall risk, whereas PA changes were less than anticipated. Be ACTIVE may need additional adaptation or a longer duration to improve PA outcomes.