Physical activity and peripheral artery disease: Two prospective cohort studies and a systematic review

Sarcopenia and type 2 diabetes: Pathophysiology and potential therapeutic lifestyle interventions

AIMS

Sarcopenia generally refers to the age-related reduction in muscle strength, functional ability, and muscle mass. Sarcopenia is a multifactorial condition associated with poor glucose disposal, insulin resistance, and subsequently type 2 diabetes (T2D). The pathophysiological connection between sarcopenia and T2D is complex but likely involves glycemic control, inflammation, oxidative stress, and adiposity.

METHODS AND RESULTS

Resistance exercise and aerobic training are two lifestyle interventions that may improve glycemic control in older adults with T2D and counteract sarcopenia. Further, there is evidence that dietary protein, Omega-3 fatty acids, creatine monohydrate, and Vitamin D hold potential to augment some of these benefits from exercise.

CONCLUSIONS

The purpose of this narrative review is: (1) discuss the pathophysiological link between age-related sarcopenia and T2D, and (2) discuss lifestyle interventions involving physical activity and nutrition that may counteract sarcopenia and T2D.

A cross-sectional study explores the association of physical activity with the severity of peripheral arterial disease from the Hispanic Community Health Study/Study of Latinos (HCHS/SOL)

Engaging in physical activity (PA) has been proved to reduce the risk of developing cardiovascular diseases. In patients with peripheral arterial disease (PAD), diminished PA predicts high overall mortality. However, the extent of the association of participation in PA with PAD severity is unknown. Therefore, the overarching aim of this study was to investigate the association between PAD severity, PA levels and patterns using the Hispanic Community Health Study/Study of Latinos. This was a cross-sectional cohort study that included 495 participants with PAD and a total of 12,281 participants without PAD from the Hispanic Community Health Study/Study of Latinos database. The Global Physical Activity Questionnaire was administered to assess the time spent weekly in performing moderate-to-vigorous PA (MVPA) during work, leisure time, and transportation. The ankle-brachial index (ABI) was used to measure PAD. PA status was categorized on the basis of MVPA as follows: physically active and physically inactive to insufficient. In addition, all participants were classified as follows: those with normal ABI who were physically active, those with normal ABI but who were physically inactive, those with PAD but were physically active, and those with PAD who were physically inactive. Complex sample for regression models were used to investigate the association between PA and the severity of PAD. Of the participants, 235 (47.5%) were physically inactive to insufficient, and 260 participants (52.5%) engaged in at least 150 min/wk of MVPA, which is the recommended PA level according to the guidelines of World Health Organization. Compared with who were highly active, the participants who engaged in low PA were twice as likely to have moderately severe ABI and 4 times as likely to have severe ABI, after adjustment for the covariates (age, smoking status, and body mass index). Hispanic/Latino adults with sever PAD in the US showed pattern of physical inactivity. Findings of this study highlight the association between PA and severity of PAD. These findings highlight the necessity of interventions in increasing PA in these participants. Future studies are required to identify appropriate exercise regimens or home-based programs to help patients with severe PAD meet the current PA recommendations.

Causal Association of Cardiovascular Risk Factors and Lifestyle Behaviors With Peripheral Artery Disease: A Mendelian Randomization Approach

Background

We investigated the causal associations between the genetic liability to cardiovascular and lifestyle risk factors and peripheral artery disease (PAD), using a Mendelian randomization approach.

Methods and Results

We performed a 2‐sample inverse‐variance weighted Mendelian randomization analysis, multiple sensitivity analyses to assess pleiotropy and multivariate Mendelian randomization analyses to assess mediating/confounding factors. European‐ancestry genomic summary data (P<5×10⁻⁸) for type 2 diabetes, lipid‐fractions, smoking, alcohol and coffee consumption, physical activity, sleep, and education level were selected. Genetic associations with PAD were extracted from the Million‐Veteran‐Program genome‐wide association studies (cases=31 307, controls=211 753, 72% European‐ancestry) and the GoLEAD‐SUMMIT genome‐wide association studies (11 independent genome‐wide association studies, European‐ancestry, cases=12 086, controls=449 548). Associations were categorized as robust (Bonferroni‐significant (P<0.00294), consistent over PAD‐cohorts/sensitivity analyses), suggestive (P value: 0.00294–0.05, associations in 1 PAD‐cohort/inconsistent sensitivity analyses) or not present. Robust evidence for genetic liability to type 2 diabetes, smoking, insomnia, and inverse associations for higher education level with PAD were found. Suggestive evidence for the genetic liability to higher low‐density lipoprotein cholesterol, triglyceride‐levels, alcohol consumption, and inverse associations for high‐density lipoprotein cholesterol, and increased sleep duration were found. No associations were found for physical activity and coffee consumption. However, effects fully attenuated for low‐density lipoprotein cholesterol and triglycerides after correcting for apoB, and for insomnia after correcting for body mass index and lipid‐fractions. Nonsignificant attenuation by potential mediators was observed for education level and type 2 diabetes.

Conclusions

Detrimental effects of smoking and type 2 diabetes, but not of low‐density lipoprotein cholesterol and triglycerides, on PAD were confirmed. Lower education level and insomnia were identified as novel risk factors for PAD; however, complete mediation for insomnia and incomplete mediation for education level by downstream risk factors was observed.

Assessing Wear Time and Perceptions of Wearing an Ankle Foot Orthosis in Patients with Peripheral Artery Disease

BACKGROUND

Peripheral artery disease (PAD) is a cardiovascular disease that effects patients' walking ability. An ankle foot orthosis (AFO) may improve patients' walking distances. Little research has explored if patients wear a prescribed AFO and their perceptions of wearing the device.

OBJECTIVE

To assess wear time of an AFO and explore perceptions of wearing the device in patients with peripheral artery disease.

DESIGN

Convergent mixed methods.

SETTING

The study was administered through a tertiary care medical center and the research subjects used the device in an outpatient setting in and out of their homes during their regular activities.

PARTICIPANTS

Patients were referred to the study by their vascular surgeon. Thirty-six patients, all older adult males, were enrolled in this study. Fourteen patients completed the study and 11 supplied sufficient accelerometer data.

INTERVENTIONS

An AFO was worn for 3 months. An accelerometer was placed on the AFO for 7 days at midpoint (1.5 months) and endpoint of the intervention (3 months) to assess wear time. Semi-structured interviews explored patients' perceptions of wearing the AFO.

MAIN OUTCOME MEASURE

The primary outcome measure was wear time measured objectively via accelerometer and subjectively via interview.

RESULTS

Patients (n = 14) wore the AFO around 8 hours/day. Most patients felt they wore the AFO a majority of the time. Patients reported barriers such as challenges wearing the AFO during daily household activities (using stairs, being on uneven terrain), discomfort, clothing or footwear issues, and driving challenges. Positive impacts of wearing the AFO were also reported, primarily the ability to walk further.

CONCLUSIONS

An AFO may be an acceptable therapeutic intervention to improve perceived walking performance in older adult males with PAD. Addressing patients' perceptions of the AFO and barriers to wear are essential to increasing the positive impact the device has on patients' ambulatory activity. This article is protected by copyright. All rights reserved.

Impact of the COVID-19 pandemic on health lifestyle in patients with peripheral artery disease: A cross-sectional study

Background

Social isolation has been one of the main strategies to prevent the spread of Coronavirus 2019 (COVID-19). However, the impact of social isolation on the lifestyle of patients with peripheral artery disease (PAD) and claudication symptoms remains unclear.

Objectives

To analyze the perceptions of patients with PAD of the impact of social isolation provoked by COVID-19 pandemic on health lifestyle.

Design

Cross-sectional.

Setting

The database of studies developed by our group involving patients with PAD from public hospitals in São Paulo.

Methods

In this cross-sectional survey study, 136 patients with PAD (61% men, 68 ± 9 years old, 0.55 ± 0.17 ankle-brachial index, 82.4% with a PAD diagnosis ≥5 years old) were included. Health lifestyle factors were assessed through a telephone interview using a questionnaire containing questions related to: (a) COVID-19 personal care; (b) mental health; (c) health risk habits; (d) eating behavior; (e) lifestyle; (f) physical activity; (g) overall health; and (h) peripheral artery disease health care.

Results

The majority of patients self-reported spending more time watching TV and sitting during the COVID-19 pandemic and only 28.7% were practicing physical exercise. Anxiety and unhappiness were the most prevalent feelings self-reported among patients and 43.4% reported a decline in walking capacity.

Conclusion

Most patients with PAD self-reported increased sedentary behavior, lower physical activity level, and worse physical and mental health during the COVID-19 pandemic. Thus, it is necessary to adopt strategies to improve the quality of life of these patients during this period.

Patient and clinician experiences and opinions of the use of a novel home use medical device in the treatment of peripheral vascular disease - a qualitative study

BACKGROUND

Peripheral vascular diseases have a significant impact on functional quality of life. Previous research has demonstrated the complex, limiting and costly economic implications of these conditions such as lower limb ulceration chronicity and ischaemic amputation. These complex, limb and life threatening conditions demand the development of novel interventions with objective research as part of that development. Hence, a novel intermittent negative pressure medical device in the form of a wearable boot (FlowOx™) was developed. As part of the development process, this study aimed to explore patient and clinician opinions of the boot.

METHODS

A qualitative approach was used to collect patient and clinician experiences in Norway. An advisory group informed the semi-structured questions used in seven patient interviews and one clinician focus group (n = 5). The data were recorded digitally and transcribed verbatim. Patient and clinician data were analysed as distinct groups using a thematic process.

RESULTS

Data analysis resulted in five themes from the patients which gave insight into; the impact of the disease process; practicalities of using the boot, positive experiences of use; perceived outcomes; reflecting on use. Six themes were created from the clinicians. These gave insight into; ideal outcomes and how to measure them; ways to potentially use the boot; using research in healthcare; positives of the device; observed effects and next steps; potential improvements to the device.

CONCLUSION

This study provides insight into the experiences and opinions of FlowOx™. Patients and clinicians were positive about the device due to its ease of use. Those patients with peripheral arterial disease experienced significantly more benefit, especially for ischaemic ulceration than those with a chronic venous condition. Clinicians placed value on the patient reported outcomes in the treatment decision-making process. This preliminary study into experiences of FlowOx™ use provides valuable feedback that will inform design modification and ongoing research into implementation points and prospective user groups. FlowOx™ demonstrates potential as a conservative therapy offering users a convenient, home use, self-care management solution for improving symptomatic peripheral arterial disease and quality of life.

The Interaction Between Self-Reported Sleep Duration and Physical Activity on Peripheral Artery Disease in Chinese Adults: A Cross-Sectional Analysis in the Tianning Cohort Study

Purpose

Sleep duration was associated with large artery atherosclerosis, but its association with atherosclerosis in lower extremity arteries was not well studied. Together with sleep, physical activity constitutes main component of our daily life and influences sleep. Here, we aimed to examine the independent and joint associations of sleep duration and physical activity with peripheral artery disease (PAD) in Chinese adults.

Patients and Methods

In Tianning cohort, night-time sleep duration and physical activity were assessed by the Pittsburgh Sleep Quality Index and the Global Physical Activity Questionnaire, respectively, for 5130 participants (51.0±15.6 years, 58.7% female). PAD was defined as ankle-brachial index (ABI) <0.9. General linear, and logistic regression models were used to assess the associations of sleep duration and physical activity with PAD. The biological interaction between sleep duration and physical activity on PAD was examined using additive model.

Results

Compared to participants sleeping 6-8.9 h, those sleeping ≥9 h had a 0.02 lower ABI (β=-0.02, P=0.007) and 38% higher odds of PAD (OR=1.38, P=0.035). Compared to physically active participants sleeping 6-8.9 h, among ≥9 h group, physically inactive individuals had significantly increased odds of PAD (OR=2.40, P<0.001), whereas physically active individuals did not (OR=1.15, P=0.472). On additive scale, attributable proportion due to interaction (0.40, 95% CI: 0.07, 0.73) indicated a significant interaction between sleep duration and physical activity on PAD.

Conclusion

Being physically active may attenuate the detrimental association between prolonged sleep duration and PAD. Moreover, we found a significant interaction between prolonged sleep duration and physical inactivity in the prevalence of PAD.

[Relationship between physical activity during leisure time and progression of ankle-brachial index]

OBJECTIVE

To study the relationship between physical activity during leisure time and progression of ankle-brachial index (ABI) in the Spanish general population.

METHOD

Prospective, multicentre cohort study with 1941 subjects over 49 years of age, free of peripheral arterial disease at the time of recruitment of the cohort, were studied. Physical activity during leisure time variable was obtained using the VREM questionnaire. Peripheral arterial disease was considered to be an ankle-brachial index (ABI) <0.9. A multivariate logistic regression analysis was performed to evaluate the independent association between physical activity during leisure time and ABI.

RESULTS

The mean age was 63.4 years and 54.6% were women. In the multivariate analysis, there was a positive relationship between physical activity during leisure time and ABI in patients with an energy consumption of more than 5000 MET in 14 days (odds ratio: 0.37; 95% confidence interval: 0.18-0.80). These specific activities doing sports or dancing, going shopping on foot, and cleaning the house for more than an hour a day showed a protective effect. In the group of subjects who maintained the physical activity during leisure time during the time of the research, a protective effect was observed with overall physical activity (MET) and going shopping on foot.

CONCLUSIONS

In our research, PALT was favorably associated with ABI, in a sample of the Spanish general population that is very active and has a low-cardiovascular risk.

A Retrospective Comparison of Fitness and Exercise Progression in Patients With Coronary and Peripheral Artery Disease in Cardiac Rehabilitation

BACKGROUND

Cardiac rehabilitation (CR) is recommended for patients with coronary (CAD) and peripheral (PAD) artery disease. However, no study has compared changes in cardiorespiratory fitness (VO_2peak) or exercise prescription progression among PAD, CAD, and concomitant PAD and CAD (BOTH). The objectives of this study were to 1) compare change in VO_2peak among patients with PAD, CAD, and BOTH, and 2) examine progression in exercise prescription parameters in a comprehensive 6-month cardiac rehabilitation (CR) program.

METHODS

A retrospective analysis of patient data recorded from 2006 to 2017 from a large urban hospital was conducted. Patients with PAD (n = 63) and BOTH (n = 164) were included in the analyses. Patients with CAD (n = 63) were matched to PAD by sex (36.5% female), age (69 years), smoking status, diabetes, and year in program.

RESULTS

There were significant improvements in VO_2peak from baseline to 6 months in all groups (CAD +2.7 ± 3.4 mL⋅kg^-1⋅min^-1, PAD +2.4 ± 3.8 mL⋅kg^-1⋅min^-1, BOTH +1.8 ± 3.1 mL⋅kg^-1⋅min^-1; all P < 0.001). Between-group differences were significant between PAD and CAD as well as between CAD and BOTH (P = 0.001). Walking distance, duration, and pace increased for all groups over 6 months (P < 0.001), with a significant difference in pace between CAD and BOTH (P = 0.006).

CONCLUSIONS

Patients with PAD, CAD, and BOTH had significant improvements in VO_2peak following a 6-month CR program. However, despite similar prescribed walking distance and duration, improvements in VO_2peak were mitigated in PAD and BOTH compared with CAD. These results support benefits of CR for patients diagnosed with PAD, but alternate exercise strategies should be explored for patients with PAD.

Relationship Between Disease Specific Quality of Life Measures, Physical Performance, and Activity in People with Intermittent Claudication Caused by Peripheral Artery Disease

OBJECTIVE

The aims of this study were firstly to assess the correlation between disease specific measures of quality of life (QOL) and physical performance and activity, and secondly to identify demographic, clinical, functional, and physical activity measures independently associated with QOL in people with intermittent claudication.

METHODS

This was a cross sectional observational study of 198 people with intermittent claudication caused by peripheral artery disease who were recruited prospectively. QOL was assessed with the intermittent claudication questionnaire (ICQ) and the eight-theme peripheral artery disease quality of life questionnaire. Physical performance was assessed with the six minute walk test (6MWT) and short physical performance battery (SPPB), and an accelerometer was used to measure seven day step count. The associations between QOL scores and 6MWT distance, SPPB scores and seven day step count were examined using Spearman Rho's (ρ) correlation and multivariable linear regression.

RESULTS

ICQ scores were significantly correlated with 6MWT distance (ρ = 0.472, p < .001), all four SPPB scores (balance ρ = 0.207, p = .003; gait speed ρ = 0.303, p < .001; chair stand ρ = 0.167, p = .018; total ρ = 0.265, p < .001), and seven day step count (ρ = 0.254, p < .001). PADQOL social relationships and interactions (ρ = 0.343, p < .001) and symptoms and limitations in physical functioning (ρ = 0.355, p < .001) themes were correlated with 6MWT distance. The 6MWT distance was independently positively associated with ICQ and both PADQOL theme scores (ICQ: B 0.069, p < .001; PADQOL social relationships and interactions: B 0.077, p < .001; PADQOL symptoms and limitations in physical functioning: B 0.069, p < .001).

CONCLUSION

Longer 6MWT distance independently predicted better physical and social aspects of QOL in people with intermittent claudication supporting its value as an outcome measure.

Motivating Structured walking Activity in people with Intermittent Claudication (MOSAIC): protocol for a randomised controlled trial of a physiotherapist-led, behavioural change intervention versus usual care in adults with intermittent claudication

INTRODUCTION

Walking exercise is a recommended but underused treatment for intermittent claudication caused by peripheral arterial disease (PAD). Addressing the factors that influence walking exercise may increase patient uptake of and adherence to recommended walking. The primary aim of this randomised controlled trial (RCT) is to evaluate the efficacy of a physiotherapist-led behavioural change intervention on walking ability in adults with intermittent claudication (MOtivating Structured walking Activity in people with Intermittent Claudication (MOSAIC)) in comparison with usual care.

METHODS AND ANALYSIS

The MOSAIC trial is a two-arm, parallel-group, single-blind RCT. 192 adults will be recruited from six National Health Service Hospital Trusts. Inclusion criteria are: aged ≥50 years, PAD (Ankle Brachial Pressure Index ≤0.90, radiographic evidence or clinician report) and intermittent claudication (San Diego Claudication Questionnaire), being able and willing to participate and provide informed consent. The primary outcome is walking ability (6 min walking distance) at 3 months. Outcomes will be obtained at baseline, 3 and 6 months by an assessor blind to group allocation. Participants will be individually randomised (n=96/group, stratified by centre) to receive either MOSAIC or usual care by an independent randomisation service. Estimates of treatment effects will use an intention-to-treat framework implemented using multiple regression adjusted for baseline values and centre.

ETHICS AND DISSEMINATION

This trial has full ethical approval (London-Bloomsbury Research Ethics Committee (17/LO/0568)). It will be disseminated via patient forums, peer-reviewed publications and conference presentations.

TRIAL REGISTRATION NUMBER

ISRCTN14501418.