Walking for subjects with type 2 diabetes: A systematic review and joint AMD/SID/SISMES evidence-based practical guideline

Physical activity guidelines for adults with type 2 Diabetes: Systematic review

AIMS

The aim of this study was to systematically review recommendations on physical activity for adults with type 2 diabetes (T2D).

METHODS

Online databases were searched for clinical practice guidelines (CPGs), statements, and recommendations. Two authors screened the guidelines based on eligibility criteria. FITT (Frequency, Intensity, Time, Type) for physical activity and disease-specific precautions were extracted independently. The methodological quality of CPGs was assessed using the AGREE II instrument. Recommendations were categorized according to FITT, with disease-specific adaptations also recorded.

RESULTS

Fifteen guidelines were included. Nine underwent AGREE II evaluation, with three rated high quality and the rest moderate to low. The predominant recommendation was to engage in at least 150 min of moderate aerobic exercise per week. Adaptations for T2D focused on glucose levels, diet, foot care, weather conditions, sedentary behaviour, neuropathy, and retinopathy.

CONCLUSION

While guidelines consistently recommended aerobic exercise, there was limited emphasis on strength and flexibility exercises. Significant limitations in methodological and reporting quality were noted, especially in stakeholder involvement and applicability. Future guidelines should use a standardized FITT framework and adhere to standard development methods to enhance usability for healthcare professionals and patients.

Long Non-Coding RNAs in Diabetic Cardiomyopathy: Potential Function as Biomarkers and Therapeutic Targets of Exercise Training

Recent studies emphasize the beneficial effects of exercise on diabetic cardiomyopathy (DCM), adding to the growing body of evidence that underscores the role of exercise in improving health outcomes. Despite this, a notable gap persists in the number of healthcare providers who actively prescribe exercise as a therapeutic intervention for DCM management. In addition, exercise modulates the expression of lncRNAs, which play a pivotal role in DCM progression. Further investigation into this relationship may facilitate the identification of novel biomarkers and therapeutic targets for DCM. This review consolidates recent advances in identifying lncRNAs biomarkers in DCM, summarizing the current knowledge on dysregulated lncRNAs and their molecular mechanisms. Additionally, it offers new insights into the mechanistic roles of lncRNAs, highlighting their potential as biomarkers and therapeutic targets for DCM. Overall, this review aims to inform future research and reinforce the significance of addressing diabetes-related cardiovascular diseases to potentially improve clinical outcomes.

Why exercise may never be effective medicine: an evolutionary perspective on the efficacy versus effectiveness of exercise in treating type 2 diabetes

Most cases of type 2 diabetes (T2D) can be prevented by adopting a healthy lifestyle, highlighting that lifestyle modifications should be the primary defence against developing T2D. Although accumulating evidence suggests that exercise can be an efficacious therapy for T2D, especially in conjunction with pharmacological interventions, its long-term effectiveness remains controversial owing to significant adherence challenges. In this narrative review, we combine an evolutionary perspective with epidemiological and prospective interventional studies to examine the efficacy versus effectiveness of varying volumes of exercise prescriptions for treating T2D. Commonly prescribed and recommended volumes of moderate-intensity physical activity (150 min/week) have demonstrated low-to-moderate efficacy in improving glycaemic control, reflected by improvements in glycated haemoglobin levels. Higher exercise volumes have been shown to enhance efficacy. While exercise can be moderately efficacious under the optimal circumstances of short-term exercise interventions (≤1 year), there is little evidence of its long-term effectiveness, primarily due to poor adherence. To date, no study has demonstrated long-term adherence to exercise programmes in individuals with T2D (>1 year). From an evolutionary perspective, the finding that exercise interventions are often ineffective over time is unsurprising. Although often overlooked, humans never evolved to exercise. Exercise is a counter-instinctive behaviour that can be difficult to maintain, even in healthy populations and can be especially challenging for individuals who are unfit or have T2D morbidities. We conclude by presenting several considerations informed by evolutionary logic that may be useful for practitioners, policymakers and advocates of exercise as medicine to improve exercise adherence.

Effects of minute oscillation stretching training on muscle and tendon stiffness and walking capability in people with type 2 diabetes

AIM

we investigated the effects of a 10 week training program (i.e., minute oscillatory stretching; MOS) on the mechanical responses and walking capability in people with type 2 diabetes (T2D).

METHODS

seventeen T2D patients performed maximum voluntary contractions of the plantar flexor muscles during which Achilles tendon stiffness (kT) and muscle-tendon stiffness (kM) were evaluated at different percentages of the maximum voluntary force (MVC). In addition, each participant was requested to walk at different walking speeds (i.e. 2, 3, 4, 5, and 6 kmh-1) while their net energy cost of walking (Cnet), cumulative EMG activity per distance travelled (CMAPD) and kinematic parameters (step length, step frequency, the ankle/knee range of motion) were evaluated.

RESULTS

maximum tendon elongation increased after MOS training, and kT significantly decreased (between 0 and 20% of MVC). No differences were observed for muscle elongation or kM after training. Cnet decreased after training (at the slowest tested speeds) while no changes in CMAPD were observed. Step length and ankle ROM during walking increased after training at the slowest tested speeds, while step frequency decreased; no significant effects were observed for knee ROM.

CONCLUSION

these results indicate the effectiveness of 10 weeks of MOS training in reducing tendon stiffness and the energy cost during walking in people with T2D. This training protocol requires no specific instrumentation, can be easily performed at home, and has a high adherence (92 ± 9%). It could, thus, be useful to mitigate mechanical tendon deterioration and improve physical behaviour in this population.

Estimates of walking prevalence and volume for U.S. cancer survivors and those without cancer: overall, by sex, and by race and ethnicity

PURPOSE

This paper estimated overall, by sex, and by race and ethnicity walking behaviors in the cancer survivor population, where prevalence is not known, compared to those without cancer.

METHODS

Data from the 2015 and 2020 National Health Interview Survey (n = 54,542) were used to estimate walking behaviors. Multivariable logistic regression models estimated walking behavior prevalence with predictive margins and volume of weekly minutes overall and stratified by sex and race/ethnicity. Walking behaviors for breast and prostate cancer survivors were also examined.

RESULTS

There were no significant differences in adjusted prevalence for walking behaviors overall or by race/ethnicity for women. However, there were significant differences for men, with cancer survivors' any reported walking at 62.6% (95% CI: 60.1, 65.4) compared to men without cancer, 65.9% (95% CI: 65.1%, 66.8%) (p = 0.02). There was also a difference in transportation only walking for men, with cancer survivors reporting 6.8% (95% CI: 5.5%, 8.2%), compared to men without cancer, 9.1% (8.5%, 9.6%) (p = 0.008); a similar pattern was observed for transportation walking for non-Hispanic white men. There were no differences in walking prevalence among breast cancer survivors, but overall prostate cancer survivors reported less walking for both purposes as did non-Hispanic white survivors. Leisure walking volume for cancer survivors, both women and men, was higher than for those without cancer. Median leisure walking minutes for non-Hispanic white women, 120 min (95% CI: 120, 140) was higher than those without cancer, 105 min (95% CI: 105, 120) (p = 0.002). Median leisure walking minutes for non-Hispanic white men, 120 min (95% CI: 120, 140), was higher than those without cancer, 100 min (95% CI: 100, 105) (p = 0.001).

CONCLUSIONS

Overall, there are no significant differences in walking prevalence for women, but men cancer survivors reported less overall walking, walking for transportation, or walking for both purposes. However, volume of leisure walking was higher for cancer survivors compared to those without cancer.

IMPLICATIONS FOR CANCER SURVIVORS

For cancer survivors, this suggests that even though prevalence of leisure walking was similar, volume of weekly minutes was higher compared to those without cancer. This suggests that for cancer survivors, leisure walking is an accessible and important source of physical activity.

Association between physical activity and diabetes control: multiple cross-sectional studies and a prospective study in a population-based, Swiss cohort

INTRODUCTION

Physical activity (PA) is recommended in patients with type 2 diabetes mellitus (T2DM) to improve their glycaemic control. We aimed to assess PA levels among participants with controlled and uncontrolled T2DM.

RESEARCH DESIGN AND METHODS

Three cross-sectional analyses of a prospective cohort conducted in Lausanne, Switzerland. PA levels (sedentary, light, moderate and vigorous) were either self-reported via questionnaire (first and second survey) or objectively assessed using accelerometry (second and third survey). T2DM control was defined as glycaemia <7.0 mmol/L or glycated haemoglobin <6.5% (48 mmol/mol).

RESULTS

Data from 195 (30.3% women), 199 (30.1% women) and 151 (44.4% women) participants with T2DM were analysed in the first (2009-2012), second (2014-2017) and third (2018-2021) surveys. Approximately half of the participants did not have controlled glycaemia. Using subjective data, over 90% (first survey) and 75% (second survey) of participants reported moderate and vigorous PA >150 min/week. After multivariable adjustment, no differences were found regarding all types of self-reported PA levels between controlled and uncontrolled participants. Objective assessment of PA led to considerable differences according to the software used: 90% and 20% of participants with moderate and vigorous PA >150 min/week, respectively. After multivariable adjustment, no differences were found for all PA levels between controlled and uncontrolled participants, irrespective of the analytical procedure used. Using glycated haemoglobin, almost two-thirds of participants were considered as uncontrolled, and no differences were found for objectively assessed PA between controlled and uncontrolled participants.

CONCLUSIONS

No differences in PA levels were found between participants with controlled and uncontrolled T2DM.

[Strategies for the prevention and non-pharmacological treatment of diabetes. Models of care]

Diabetes is a highly prevalent, chronic disease that over time generates potentially serious complications. In the treatment of diabetes, the use of drugs that have shown significant benefits is important, but, in addition, the use of non-pharmacological interventions is essential, which constitute an efficient and effective way to reduce the appearance of diabetes itself and the complications of the disease. These interventions, which are described here, include health education, aimed at incorporating a healthier lifestyle, dietary modifications, increased physical activity or psychological support. Finally, the characteristics that a care system for people with diabetes must meet to achieve the established objectives are discussed.

'Walk Buds': A walking intervention to increase physical activity, physical fitness, and emotional wellbeing, in 9-13 year old children with intellectual disabilities. Results of a clustered randomised feasibility trial

BACKGROUND

Children with intellectual disability are less physically active and more sedentary than typically developing peers. To date no studies have tested the feasibility of a school-based walking intervention for children with Intellectual Disability.

METHOD

A clustered randomised controlled trial (cRCT), with an embedded process evaluation, was used to test the feasibility of a school-based walking intervention. Eight schools (n = 161 pupils aged 9-13 years) were randomised into either an intervention arm or an 'exercise as usual' arm. Measures included physical activity, physical fitness and emotional wellbeing. Baseline and 3-month follow-up data were collected.

RESULTS

The 'Walk Buds' intervention was found to be acceptable to teaching staff and pupils, with an uptake rate of the walking sessions offered of 84%.

CONCLUSION

A number of challenges were experienced, relating to the COVID-19 pandemic, and difficulties collecting accelerometer data. Barriers, facilitators and required changes identified through the mixed methods process evaluation are discussed.

Walking away from depression: the mediating role of walking activity in depression impacting blood glucose levels of people with diabetes or prediabetes

Introduction

Depression can exacerbate diabetes by impairing self-care behaviors and increasing the risk of complication; however, the underlying mechanism is still unclear. Given the suggested associations between walking activity, depression status, and blood glucose levels this study explores the intricate relationship between depression and blood glucose (BG) control, with a focus on walking activity as a behavioral mediator. The purpose of this study is to examine walking activity's mediating role in depression's impact on BG levels, investigating and validating the non-linear association between BG levels and walking activity. This retrospective real-world study demonstrates the potential of regular walking activity as a simple and accessible intervention to mitigate the negative effects of depression on BG levels in T2D and prediabetes.

Methods

A cohort of 989 users with T2D and prediabetes, who regularly tracked their steps levels and BG levels for 12 months using the Dario digital health platform was evaluated. The mediating role of the monthly average number of steps on the relationship between the self-reported depression status and lagged monthly average BG was assessed. Additionally, the association between monthly walking activity and monthly average BG was tested using a piecewise linear mixed effects model.

Results

Users with self-reported depression demonstrated increased BG levels compared to users without depression (B=8.00, P=.01). The association between depression and monthly average number of steps was significant (B=-.27, P<.005) and monthly average number of steps significantly predicted the following months' average BG (B=-.81, P=.001), adjusting for depression. The monthly average number of steps significantly mediated the effect of self-reported depression on the following month's average BG (M=.22, P<.005). Further sensitivity analysis demonstrated model robustness over various periods. Finally, non-linear dynamics of walking activity over time was validated using unseen data showing a decrease in monthly average BG for users with over an average of 400 steps per day (B=-1.87, P<.01).

Discussion

This study shows how regular walking may reduce the negative impact of depression on BG levels in people with T2D. Our findings advocate for the integration of walking activity into treatment protocols as a cost-effective, accessible intervention strategy to improve glycemic management and depressive symptoms in this population.

The Role of Tele-Exercise for People with Type 2 Diabetes: A Scoping Review

BACKGROUND

Supervised exercise interventions tend to be more effective than unsupervised exercises or physical activity advice alone. However, people with type 2 diabetes may find it difficult to attend supervised exercise interventions due to several obstacles. Tele-exercise, or utilizing technology to deliver home-based exercise, might be a solution.

OBJECTIVE

This scoping review aimed to explore clinical trials investigating the impact of tele-exercise interventions in individuals with type 2 diabetes Methods: Four electronic databases were searched for the period up to January 2024 for clinical trials investigating the impact of tele-exercise on health-related outcomes in adults with type 2 diabetes.

RESULTS

Seven trials involving 460 individuals with type 2 diabetes met the inclusion criteria. In these trials, combined aerobic and resistance exercise programs were the main types delivered remotely. To deliver such programs, both synchronous (n = 4) and asynchronous (n = 3) delivery modes were adopted. Regardless of the delivery mode, all tele-exercise interventions led to improvements in various factors related to type 2 diabetes and its complications, including glycemic control, blood lipids, body composition, functional capacity, muscle strength, and quality of life. The improvements were also found to be as effective as those of supervised exercise.

CONCLUSIONS

Tele-exercise interventions seem to be feasible and as effective as supervised exercise interventions in terms of improving glycemic control, blood lipids, functional capacity, muscle strength, body composition, and quality of life for people with type 2 diabetes.

Participatory development of an mHealth intervention delivered in general practice to increase physical activity and reduce sedentary behaviour of patients with prediabetes and type 2 diabetes (ENERGISED)

BACKGROUND

The escalating global prevalence of type 2 diabetes and prediabetes presents a major public health challenge. Physical activity plays a critical role in managing (pre)diabetes; however, adherence to physical activity recommendations remains low. The ENERGISED trial was designed to address these challenges by integrating mHealth tools into the routine practice of general practitioners, aiming for a significant, scalable impact in (pre)diabetes patient care through increased physical activity and reduced sedentary behaviour.

METHODS

The mHealth intervention for the ENERGISED trial was developed according to the mHealth development and evaluation framework, which includes the active participation of (pre)diabetes patients. This iterative process encompasses four sequential phases: (a) conceptualisation to identify key aspects of the intervention; (b) formative research including two focus groups with (pre)diabetes patients (n = 14) to tailor the intervention to the needs and preferences of the target population; (c) pre-testing using think-aloud patient interviews (n = 7) to optimise the intervention components; and (d) piloting (n = 10) to refine the intervention to its final form.

RESULTS

The final intervention comprises six types of text messages, each embodying different behaviour change techniques. Some of the messages, such as those providing interim reviews of the patients' weekly step goal or feedback on their weekly performance, are delivered at fixed times of the week. Others are triggered just in time by specific physical behaviour events as detected by the Fitbit activity tracker: for example, prompts to increase walking pace are triggered after 5 min of continuous walking; and prompts to interrupt sitting following 30 min of uninterrupted sitting. For patients without a smartphone or reliable internet connection, the intervention is adapted to ensure inclusivity. Patients receive on average three to six messages per week for 12 months. During the first six months, the text messaging is supplemented with monthly phone counselling to enable personalisation of the intervention, assistance with technical issues, and enhancement of adherence.

CONCLUSIONS

The participatory development of the ENERGISED mHealth intervention, incorporating just-in-time prompts, has the potential to significantly enhance the capacity of general practitioners for personalised behavioural counselling on physical activity in (pre)diabetes patients, with implications for broader applications in primary care.

Exploring Possible Links: Thigh Muscle Mass, Apolipoproteins, and Glucose Metabolism in Peripheral Artery Disease-Insights from a Pilot Sub-Study following Endovascular Treatment

Peripheral artery disease (PAD) compromises walking and physical activity, which results in further loss of skeletal muscle. The cross-sectional area of the thigh muscle has been shown to be correlated with systemic skeletal muscle volume. In our previous pilot study, we observed an increase in thigh muscle mass following endovascular treatment (EVT) in patients with proximal vascular lesions affecting the aortoiliac and femoropopliteal arteries. Considering the potential interactions between skeletal muscle, lipid profile, and glucose metabolism, we aimed to investigate the relationship between thigh muscle mass and apolipoproteins as well as glucose metabolism in PAD patients undergoing EVT. This study is a prespecified sub-study conducted as part of a pilot study. We prospectively enrolled 22 symptomatic patients with peripheral artery disease (PAD) and above-the-knee lesions, specifically involving the blood vessels supplying the thigh muscle. The mid-thigh muscle area was measured with computed tomography before and 6 months after undergoing EVT. Concurrently, we measured levels of apolipoproteins A1 (Apo A1) and B (Apo B), fasting blood glucose, 2 h post-load blood glucose (using a 75 g oral glucose tolerance test), and glycated hemoglobin A1c (HbA1c). Changes in thigh muscle area (delta muscle area: 2.5 ± 8.1 cm2) did not show significant correlations with changes in Apo A1, Apo B, fasting glucose, 2 h post-oral glucose tolerance test blood glucose, HbA1c, or Rutherford classification. However, among patients who experienced an increase in thigh muscle area following EVT (delta muscle area: 8.41 ± 5.93 cm2), there was a significant increase in Apo A1 (pre: 121.8 ± 15.1 mg/dL, 6 months: 136.5 ± 19.5 mg/dL, p < 0.001), while Apo B remained unchanged (pre: 76.4 ± 19.2 mg/dL, 6 months: 80.5 ± 4.9 mg/dL). Additionally, post-oral glucose tolerance test 2 h blood glucose levels showed a decrease (pre: 189.7 ± 67.5 mg/dL, 6 months: 170.6 ± 69.7 mg/dL, p = 0.075). Patients who exhibited an increase in thigh muscle area demonstrated more favorable metabolic changes compared to those with a decrease in thigh muscle area (delta muscle area: -4.67 ± 2.41 cm2). This pilot sub-study provides insights into the effects of EVT on thigh muscle, apolipoproteins, and glucose metabolism in patients with PAD and above-the-knee lesions. Further studies are warranted to validate these findings and establish their clinical significance. The trial was registered on the University Hospital Medical Information Network Clinical Trials Registry (UMIN000047534).

Effectiveness of a Smartphone App to Promote Physical Activity Among Persons With Type 2 Diabetes: Randomized Controlled Trial

BACKGROUND

Physical activity is well known to have beneficial effects on glycemic control and to reduce risk factors for cardiovascular disease in persons with type 2 diabetes. Yet, successful implementation of lifestyle interventions targeting physical activity in primary care has shown to be difficult. Smartphone apps may provide useful tools to support physical activity. The DiaCert app was specifically designed for integration into primary care and is an automated mobile health (mHealth) solution promoting daily walking.

OBJECTIVE

This study aimed to investigate the effect of a 3-month-long intervention promoting physical activity through the use of the DiaCert app among persons with type 2 diabetes in Sweden. Our primary objective was to assess the effect on moderate to vigorous physical activity (MVPA) at 3 months of follow-up. Our secondary objective was to assess the effect on MVPA at 6 months of follow-up and on BMI, waist circumference, hemoglobin A1c, blood lipids, and blood pressure at 3 and 6 months of follow-up.

METHODS

We recruited men and women with type 2 diabetes from 5 primary health care centers and 1 specialized center. Participants were randomized 1:1 to the intervention or control group. The intervention group was administered standard care and access to the DiaCert app at baseline and 3 months onward. The control group received standard care only. Outcomes of objectively measured physical activity using accelerometers, BMI, waist circumference, biomarkers, and blood pressure were assessed at baseline and follow-ups. Linear mixed models were used to assess differences in outcomes between the groups.

RESULTS

A total of 181 study participants, 65.7% (119/181) men and 34.3% (62/181) women, were recruited into the study and randomized to the intervention (n=93) or control group (n=88). The participants' mean age and BMI were 60.0 (SD 11.4) years and 30.4 (SD 5.3) kg/m2, respectively. We found no significant effect of the intervention (group by time interaction) on MVPA at either the 3-month (β=1.51, 95% CI -5.53 to 8.55) or the 6-month (β=-3.53, 95% CI -10.97 to 3.92) follow-up. We found no effect on any of the secondary outcomes at follow-ups, except for a significant effect on BMI at 6 months (β=0.52, 95% CI 0.20 to 0.84). However, mean BMI did not differ between the groups at the 6-month follow-up.

CONCLUSIONS

We found no evidence that persons with type 2 diabetes being randomized to use an app promoting daily walking increased their levels of MVPA at 3 or 6 months' follow-up compared with controls receiving standard care. The effect of the app on BMI was unclear, and we found nothing to support an effect on secondary outcomes. Further research is needed to determine what type of mHealth intervention could be effective to increase physical activity among persons with type 2 diabetes.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03053336; https://clinicaltrials.gov/study/NCT03053336.

Plantar pressure gradient and pressure gradient angle are affected by inner pressure of air insole

Clinically, air insoles may be applied to shoes to decrease plantar pressure gradient (PPG) and increase plantar gradient angle (PGA) to reduce foot ulcers. PPG and PGA may cause skin breakdown. The effects of different inner pressures of inflatable air insoles on dynamic PPG and PGA distributions are largely unknown in non-diabetics and people with diabetes. This study aimed to explore the impact of varying inner air insole pressures on PPG and PGA to establish early mitigation strategies for people at risk of foot ulcers. A repeated measures study design, including three air insoles (80 mmHg, 160 mmHg, and 240 mmHg) and two walking durations (10 and 20 min) for a total of six walking protocols, was tested on 13 healthy participants (height, 165.8 ± 8.4 cm; age, 27.0 ± 7.3 years; and weight, 56.0 ± 7.9 kg, BMI: 20.3 ± 1.7 kg/m^2) over three consecutive weeks. PPG, a measurement of the spatial variation in plantar pressure around the peak plantar pressure (PPP) and PGA, a variation in the gradient direction values at the three plantar regions, big toe (T1), first metatarsal head (M1), and second metatarsal head (M2), were calculated. This study indicated that PPG was lower at 80 mmHg air insoles after 20 min of walking in the M1 region (p = 0.010). The PGA in the M2 increased at an air insole of 80 mmHg compared to 240 mmHg (p = 0.015). Compared to 20 min, the 10 min walking duration at 240 mmHg of air insole had the lowest PPG in the M1 (p = 0.015) and M2 (p = 0.034) regions. The 80 mmHg air insole significantly lowered the PPG compared to a 160 mmHg and 240 mmHg air insole. Moreover, the 80 mmHg air insole significantly decreased PPP and increased PGA compared to the 160 mmHg and 240 mmHg air insole. A shorter walking period (10 min) significantly lowered PPG. The findings of this study suggest that people with a higher risk of foot ulcers should wear softer air insoles to have a lower PPG, as well as an increased PGA.

Frequency of regular walking among Croatian adults

The aim of this study was to determine the share of Croatian adults who walk 210 min or more a week and to explore the relationship between regular walking and demographic factors, health-related behaviours, and chronic non-communicable diseases/conditions. To this end, we used the EHIS-PAQ questionnaire and collected self-reported data on minutes spent walking during a typical week from a total of 3,496 respondents. The data were additionally analysed by gender, age, education, residence (urban/rural), counties and regions, smoking, other types of physical activity, and diseases/chronic conditions. The results show that, overall, 40.9 % of the adult Croatian population walks 210 or more minutes a week, with the largest share found among those from the Lika-Senj County (76.8 %), those who spend 300 min or more weekly on health-enhancing (non-work-related) aerobic physical activity (57.6 %), those who reported having diabetes (49.3 %), and those aged 65-74 years (44.7 %). Despite its limitations, our study gives a valuable insight into the frequency and factors determining healthy walking habits in a representative sample of Croatian adults and provides grounds for further research.

Efficacy of StepAdd, a Personalized mHealth Intervention Based on Social Cognitive Theory to Increase Physical Activity Among Patients With Type 2 Diabetes Mellitus: Protocol for a Randomized Controlled Trial

BACKGROUND

Increasing physical activity improves glycemic control in patients with type 2 diabetes (T2D). Mobile health (mHealth) interventions have been proven to increase exercise, but engagement often fades with time. As the use of health behavior theory in mHealth design can increase effectiveness, we developed StepAdd, an mHealth intervention based on the constructs of social cognitive theory (SCT). StepAdd improves exercise behavior self-efficacy and self-regulation through the use of goal-setting, barrier-identifying, and barrier-coping strategies, as well as automatic feedback functions. A single-arm pilot study of StepAdd among 33 patients with T2D showed a large increase in step count (mean change of 4714, SD 3638 daily steps or +86.7%), along with strong improvements in BMI (mean change of -0.3 kg/m2) and hemoglobin A1c level (mean change of -0.79 percentage points).

OBJECTIVE

In this study, we aim to investigate the efficacy and safety of StepAdd, an mHealth exercise support system for patients with T2D, via a large, long, and controlled follow-up to the pilot study.

METHODS

This is a randomized, open-label, multicenter study targeting 160 patients with T2D from 5 institutions in Japan with a 24-week intervention. The intervention group will record daily step counts, body weight, and blood pressure using the SCT-based mobile app, StepAdd, and receive feedback about these measurements. In addition, they will set weekly step count goals, identify personal barriers to walking, and define strategies to overcome these barriers. The control group will record daily step counts, body weight, and blood pressure using a non-SCT-based placebo app. Both groups will receive monthly consultations with a physician who will advise patients regarding lifestyle modifications and use of the app. The 24-week intervention period will be followed by a 12-week observational period to investigate the sustainability of the intervention's effects. The primary outcome is between-group difference in the change in hemoglobin A1c values at 24 weeks. The secondary outcomes include other health measures, measurements of steps, measurements of other behavior changes, and assessments of app use. The trial began in January 2023 and is intended to be completed in December 2025.

RESULTS

As of September 5, 2023, we had recruited 44 patients. We expect the trial to be completed by October 8, 2025, with the follow-up observation period being completed by December 31, 2025.

CONCLUSIONS

This trial will provide important evidence about the efficacy of an SCT-based mHealth intervention in improving physical activities and glycemic control in patients with T2D. If this study proves the intervention to be effective and safe, it could be a key step toward the integration of mHealth as part of the standard treatment received by patients with T2D in Japan.

TRIAL REGISTRATION

Japan Registry of Clinical Trials (JRCT) jRCT2032220603; https://rctportal.niph.go.jp/en/detail?trial_id=jRCT2032220603.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/53514.

Does Walking Have an Association with Osteoarthritis? A Two-Sample Mendelian Randomization Analysis

Objective

Osteoarthritis (OA) is one of the major disabling human diseases. The related studies indicate a potential correlation between walking and OA. However, there is still a lack of evidence in genetics to support the correlation between walking and OA. Therefore, this study aimed to explore the relationship between walking and OA at the genetic level.

Methods

The publicly available Genome Wide Association Study (GWAS) data were used, with inverse variance weighting (IVW, the random-effects model) as the main analysis method, whereas MR-Egger, Weighted median, Simple mode, and Weighted mode as the secondary analysis methods. In addition, Cochran's Q test, pleiotropy test, and MR-Egger intercept test were conducted to examine the heterogeneity and pleiotropy of the outcome.

Results

In the MR analysis, IVW results showed a negative correlation between types of physical activity in last 4 weeks: Walking for pleasure (not as a means of transport) and OA (KOA or HOA) (odds ratio (OR) = 0.3224, 95% confidence interval (CI): 0.1261 to 0.8243), and the difference was of statistical significance (P = 0.0181). Moreover, IVW results also revealed a negative correlation between types of physical activity in last 4 weeks: Walking for pleasure (not as a means of transport) and KOA (OR = 0.1396, 95% CI: 0.0484 to 0.4026), and the difference was statistically significant (P = 0.0003). However, IVW results did not demonstrate any statistical significance types of physical activity in last 4 weeks: Walking for pleasure (not as a means of transport) and HOA (OR = 1.2075, 95% CI: 0.1978 to 7.3727, P = 0.8381).

Conclusion

From genetic studies, types of physical activity in last 4 weeks: Walking for pleasure (not as a means of transport) is negatively correlated with knee osteoarthritis (KOA), but there is no clear evidence supporting its correlation with hip osteoarthritis (HOA).

Physical activity and sedentary behaviour of Bahraini people with type 2 diabetes: A cross-sectional study

Objective

Study patterns of physical activity and sedentary behaviour and the influence of demographics and body mass index (BMI) on these behaviours amongst Bahraini adults with type 2 diabetes over 10 weeks using an activity tracker.

Method

This cross-sectional observational study was conducted at a Bahrain government health centre. Thirty-three Bahraini Arab adults, 30-60 years old, with controlled type 2 diabetes, wore a Fitbit Flex 2TM activity tracker for 10 weeks. Data on age, sex, marital and employment status, education and BMI were collected at the start of the study.

Results

A total of N = 32 participants completed the study. The average steps per day were 7859 ± 4131, and there were no differences between baseline, week 5 and 10. A third of participants were sedentary, based on a threshold of 5000 steps/day. Females accumulated fewer average daily steps than males (6728 ± 2936 vs. 10,281 ± 4623, p = 0.018). Daily averages for physical activity intensity were as follows: sedentary (786 ± 109 min), light (250 ± 76 min), moderate (9 ± 10 min) and vigorous (12 ± 18 min). Males had higher daily averages versus females for moderate (13 ± 9 vs. 5 ± 9 min, p = 0.018) and vigorous physical activity (21 ± 23 vs. 5 ± 7 min, p = 0.034). 91% of participants wore the device ≥10 h/day. The adherence rate was 79% based on percentage of days the device was worn continuously over 10 weeks.

Conclusion

Future physical activity interventions should target sedentary and female participants with type 2 diabetes. In addition, we need to understand the facilitators and barriers to physical activity and the physical activity preferences of these two subgroups.

The multifaceted benefits of walking for healthy aging: from Blue Zones to molecular mechanisms

Physical activity, including walking, has numerous health benefits in older adults, supported by a plethora of observational and interventional studies. Walking decreases the risk or severity of various health outcomes such as cardiovascular and cerebrovascular diseases, type 2 diabetes mellitus, cognitive impairment and dementia, while also improving mental well-being, sleep, and longevity. Dose-response relationships for walking duration and intensity are established for adverse cardiovascular outcomes. Walking's favorable effects on cardiovascular risk factors are attributed to its impact on circulatory, cardiopulmonary, and immune function. Meeting current physical activity guidelines by walking briskly for 30 min per day for 5 days can reduce the risk of several age-associated diseases. Additionally, low-intensity physical exercise, including walking, exerts anti-aging effects and helps prevent age-related diseases, making it a powerful tool for promoting healthy aging. This is exemplified by the lifestyles of individuals in Blue Zones, regions of the world with the highest concentration of centenarians. Walking and other low-intensity physical activities contribute significantly to the longevity of individuals in these regions, with walking being an integral part of their daily lives. Thus, incorporating walking into daily routines and encouraging walking-based physical activity interventions can be an effective strategy for promoting healthy aging and improving health outcomes in all populations. The goal of this review is to provide an overview of the vast and consistent evidence supporting the health benefits of physical activity, with a specific focus on walking, and to discuss the impact of walking on various health outcomes, including the prevention of age-related diseases. Furthermore, this review will delve into the evidence on the impact of walking and low-intensity physical activity on specific molecular and cellular mechanisms of aging, providing insights into the underlying biological mechanisms through which walking exerts its beneficial anti-aging effects.

Improving Metabolic Syndrome in Ghanaian Adults with Type 2 Diabetes through a Home-Based Physical Activity Program: A Feasibility Randomised Controlled Trial

There is a high prevalence of metabolic syndrome (MetS) among people with type 2 diabetes mellitus (T2DM). Physical activity has the potential to improve health outcomes for individuals with type 2 diabetes. Our study aim was to determine the effect of a 12-week culturally appropriate home-based physical activity program on metabolic syndrome markers and quality of life in Ghanaian adults with T2DM. A secondary objective was to examine the feasibility of implementing the PA program. A feasibility randomised controlled trial (RCT) was conducted. A purposive sample of 87 adults with T2DM at the Korle-Bu Teaching Hospital, Ghana, were randomized into either the control group (CG) (n = 43) or the intervention group (IG) (n = 44). Participants in the IG received the physical activity program in addition to their usual diabetes care; those in the CG received their usual diabetes care. Measurements for feasibility, MetS markers, and quality of life (SF-12) were performed at baseline and 12-week follow-up. Following the 12-week program, participants in the IG showed a significant improvement in fasting blood glucose (2.4% vs. 0.4%, p < 0.05), waist circumference (5.4% vs. 0.4%, p < 0.05), and systolic blood pressure (9.8% vs. 1.5%, p < 0.05). There were no statistical differences between the IG and CG regarding high-density lipoprotein, triglycerides, and diastolic blood pressure at the 12-week follow-up. Classification of MetS were reduced in the IG compared to the CG (51.2% vs. 83.3%, p < 0.05). The MetS severity score improved in the IG compared to the CG (8.8% vs. 0.5%, p < 0.05). The IG improved in two of the eight SF-12 dimensions (physical function and vitality, p < 0.05) compared to the CG. Thirty-two (72.7%) participants completed all 36 exercise sessions. Another 11 (25%) participants completed 80% of the exercise sessions. No adverse events were reported. In conclusion, a 12-week home-based physical activity program is feasible and safe. The intervention has the potential to improve MetS and quality of life in Ghanaian adults with T2DM. The preliminary findings of this study need to be confirmed in a large-scale multi-centre RCT.

mHealth intervention delivered in general practice to increase physical activity and reduce sedentary behaviour of patients with prediabetes and type 2 diabetes (ENERGISED): rationale and study protocol for a pragmatic randomised controlled trial

BACKGROUND

The growing number of patients with type 2 diabetes and prediabetes is a major public health concern. Physical activity is a cornerstone of diabetes management and may prevent its onset in prediabetes patients. Despite this, many patients with (pre)diabetes remain physically inactive. Primary care physicians are well-situated to deliver interventions to increase their patients' physical activity levels. However, effective and sustainable physical activity interventions for (pre)diabetes patients that can be translated into routine primary care are lacking.

METHODS

We describe the rationale and protocol for a 12-month pragmatic, multicentre, randomised, controlled trial assessing the effectiveness of an mHealth intervention delivered in general practice to increase physical activity and reduce sedentary behaviour of patients with prediabetes and type 2 diabetes (ENERGISED). Twenty-one general practices will recruit 340 patients with (pre)diabetes during routine health check-ups. Patients allocated to the active control arm will receive a Fitbit activity tracker to self-monitor their daily steps and try to achieve the recommended step goal. Patients allocated to the intervention arm will additionally receive the mHealth intervention, including the delivery of several text messages per week, with some of them delivered just in time, based on data continuously collected by the Fitbit tracker. The trial consists of two phases, each lasting six months: the lead-in phase, when the mHealth intervention will be supported with human phone counselling, and the maintenance phase, when the intervention will be fully automated. The primary outcome, average ambulatory activity (steps/day) measured by a wrist-worn accelerometer, will be assessed at the end of the maintenance phase at 12 months.

DISCUSSION

The trial has several strengths, such as the choice of active control to isolate the net effect of the intervention beyond simple self-monitoring with an activity tracker, broad eligibility criteria allowing for the inclusion of patients without a smartphone, procedures to minimise selection bias, and involvement of a relatively large number of general practices. These design choices contribute to the trial's pragmatic character and ensure that the intervention, if effective, can be translated into routine primary care practice, allowing important public health benefits.

TRIAL REGISTRATION

ClinicalTrials.gov (NCT05351359, 28/04/2022).

Weight-bearing physical activity in people with diabetes-related foot disease: A systematic review

INTRODUCTION

Weight-bearing physical activity is important for people with diabetes-related foot disease but may also contribute to ulceration or delayed ulcer healing. No overview of weight-bearing activity of people at different stages of foot disease is available. We aimed to summarise quantitatively measured daily activity levels in people with diabetes-related foot disease.

METHODS

We systematically searched peer-reviewed literature for studies reporting objectively measured weight-bearing activity in people with diabetes-related foot disease. We calculated daily step counts' means (over studies) and weighted means (over participants). International Working Group on the Diabetic Foot (IWGDF) risk strata, different climates, and activity indoors versus outdoors were compared.

RESULTS

From 1247 publications, 27 were included. Mean steps/day in people with IWGDF risk 1/2: 6125 (12 studies; 345 participants; weighted mean: 5384). In IWGDF risk 3: 6167 (8 studies; 291 participants; weighted mean: 6239). In those with a foot ulcer: 4248 (6 studies; 186 participants; weighted mean: 4484). People living in temperate oceanic climates are more active compared to those in hotter or more humid climates (mean steps/day for no ulcer: 7712 vs. 5224 [18 studies]; for ulcer: 6819 vs. 2945 [6 studies]). People are more active indoors than outdoors (mean 4047 vs. 2514 [3 studies]).

CONCLUSION

Levels of weight-bearing physical activity are similar between people with diabetes at various risk levels for foot ulceration but lower for those with a foot ulcer. Weight-bearing activity differs depending on the climatological environment and is higher indoors than outdoors. These findings provide reference for intervention studies or for clinicians aiming to provide mobility advice in this population.

Effects of walking speeds and durations on the plantar pressure gradient and pressure gradient angle

BACKGROUND

Walking exercise has been demonstrated to improve health in people with diabetes. However, it is largely unknown the influences of various walking intensities such as walking speeds and durations on dynamic plantar pressure distributions in non-diabetics and diabetics. Traditional methods ignoring time-series changes of plantar pressure patterns may not fully capture the effect of walking intensities on plantar tissues. The purpose of this study was to investigate the effect of various walking intensities on the dynamic plantar pressure distributions. In this study, we introduced the peak pressure gradient (PPG) and its dynamic patterns defined as the pressure gradient angle (PGA) to quantify dynamic changes of plantar pressure distributions during walking at various intensities.

METHODS

Twelve healthy participants (5 males and 7 females) were recruited in this study. The demographic data were: age, 27.1 ± 5.8 years; height, 1.7 ± 0.1 m; and weight, 63.5 ± 13.5 kg (mean ± standard deviation). An insole plantar pressure measurement system was used to measure plantar pressures during walking at three walking speeds (slow walking 1.8 mph, brisk walking 3.6 mph, and slow running 5.4 mph) for two durations (10 and 20 min). The gradient at a location is defined as the unique vector field in the two-dimensional Cartesian coordinate system with a Euclidean metric. PGA was calculated by quantifying the directional variation of the instantaneous peak gradient vector during stance phase of walking. PPG and PGA were calculated in the plantar regions of the first toe, first metatarsal head, second metatarsal head, and heel at higher risk for foot ulcers. Two-way ANOVA with Fisher's post-hoc analysis was used to examine the speed and duration factors on PPG and PGA.

RESULTS

The results showed that the walking speeds significantly affect PPG (P < 0.05) and PGA (P < 0.05), and the walking durations does not. No interaction between the walking duration and speed was observed. PPG in the first toe region after 5.4 mph for either 10 or 20 min was significantly higher than 1.8 mph. Meanwhile, after 3.6 mph for 20 min, PPG in the heel region was significantly higher than 1.8 mph. Results also indicate that PGA in the forefoot region after 3.6 mph for 20 min was significantly narrower than 1.8 mph.

CONCLUSIONS

Our findings indicate that people may walk at a slow speed at 1.8 mph for reducing PPG and preventing PGA concentrated over a small area compared to brisk walking at 3.6 mph and slow running at 5.4 mph.

Health effects of reduced occupational sedentary behaviour in type 2 diabetes using a mobile health intervention: a study protocol for a 12-month randomized controlled trial-the ROSEBUD study

BACKGROUND

Short-term trials conducted in adults with type 2 diabetes mellitus (T2DM) showed that reducing sedentary behaviour by performing regular short bouts of light-intensity physical activity enhances health. Moreover, support for reducing sedentary behaviour may be provided at a low cost via mobile health technology (mHealth). There are a wide range of mHealth solutions available including SMS text message reminders and activity trackers that monitor the physical activity level and notify the user of prolonged sitting periods. The aim of this study is to evaluate the effects of a mHealth intervention on sedentary behaviour and physical activity and the associated changes in health in adults with T2DM.

METHODS

A dual-arm, 12-month, randomized controlled trial (RCT) will be conducted within a nationwide Swedish collaboration for diabetes research in primary health care. Individuals with T2DM (n = 142) and mainly sedentary work will be recruited across primary health care centres in five regions in Sweden. Participants will be randomized (1:1) into two groups. A mHealth intervention group who will receive an activity tracker wristband (Garmin Vivofit4), regular SMS text message reminders, and counselling with a diabetes specialist nurse, or a comparator group who will receive counselling with a diabetes specialist nurse only. The primary outcomes are device-measured total sitting time and total number of steps (activPAL3). The secondary outcomes are fatigue, health-related quality of life and musculoskeletal problems (self-reported questionnaires), number of sick leave days (diaries), diabetes medications (clinical record review) and cardiometabolic biomarkers including waist circumference, mean blood pressure, HbA1c, HDL-cholesterol and triglycerides.

DISCUSSION

Successful interventions to increase physical activity among those with T2DM have been costly and long-term effectiveness remains uncertain. The use of mHealth technologies such as activity trackers and SMS text reminders may increase awareness of prolonged sedentary behaviour and encourage increase in regular physical activity. mHealth may, therefore, provide a valuable and novel tool to improve health outcomes and clinical management in those with T2DM. This 12-month RCT will evaluate longer-term effects of a mHealth intervention suitable for real-world primary health care settings.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04219800 . Registered on 7 January 2020.

Promoting Physical Activity in Older Adults With Type 2 Diabetes via an Anthropomorphic Conversational Agent: Development of an Evidence and Theory-Based Multi-Behavior Intervention

Introduction

Anthropomorphic conversational agents (ACA) are a promising digital tool to support self-management of type 2 diabetes (T2D), albeit little explored. There is a dearth of literature on the detailed content of these interventions, which may limit effectiveness and replication. Our aim is to describe the development of an evidence and theory-based intervention to improve physical activity in older adults with T2D, subsumed in a multi-behavior intervention via a mobile application with an ACA.

Methods

Overall decisions on the multi-behavior intervention design, such as the use of standardized behavior change techniques (BCTTv1), guided the development of the physical activity component. Firstly, recommendations on ambulatory activity were used to select the target behavior (walking). Meta-research on effective behavior change techniques (BCTs) was then identified. One meta-analysis linked effective BCTs with the three basic psychological needs of the self-determination theory (SDT). This meta-analysis, taken together with additional evidence on SDT, led to the selection of this theory to inform the design. BCTs were extracted from meta-research; we selected the most appropriate to be operationalized via the conversational agent through multidisciplinary discussions. Rules governing the dialogue flow and BCTs tailoring, taking the form "if some conditions hold then execute some action," were derived based on the Basic Psychological in Exercise Scale (competence, autonomy, and relatedness scores), in conjunction with published evidence and multidisciplinary discussions.

Results

Thirteen BCTs were implemented in the prototype via the ACA (e.g., goal setting behavior 1.1). Six if-then rules were derived and depicted in the dialogue steps through process flow diagrams, which map how the system functions. An example of a rule is "If competence score ≤ 10 then, apply BCT 1.1 with 500 steps increments as options for the daily walking goal; If competence score > 10 then, apply BCT 1.1 with 1,000 steps increments as options for the daily walking goal."

Conclusion

Evidence and SDT were translated into a mobile application prototype using an ACA to promote physical activity in older adults with T2D. This approach, which includes 13 BCTs and six if-then rules for their tailoring, may leverage the efforts of others in developing similar interventions.

Determining thresholds for spatial urban design and transport features that support walking to create healthy and sustainable cities: findings from the IPEN Adult study

An essential characteristic of a healthy and sustainable city is a physically active population. Effective policies for healthy and sustainable cities require evidence-informed quantitative targets. We aimed to identify the minimum thresholds for urban design and transport features associated with two physical activity criteria: at least 80% probability of engaging in any walking for transport and WHO's target of at least 15% relative reduction in insufficient physical activity through walking. The International Physical Activity and the Environment Network Adult (known as IPEN) study (N=11 615; 14 cities across ten countries) provided data on local urban design and transport features linked to walking. Associations of these features with the probability of engaging in any walking for transport and sufficient physical activity (≥150 min/week) by walking were estimated, and thresholds associated with the physical activity criteria were determined. Curvilinear associations of population, street intersection, and public transport densities with walking were found. Neighbourhoods exceeding around 5700 people per km², 100 intersections per km², and 25 public transport stops per km² were associated with meeting one or both physical activity criteria. Shorter distances to the nearest park were associated with more physical activity. We use the results to suggest specific target values for each feature as benchmarks for progression towards creating healthy and sustainable cities.

Contribution of genetic variant identified in HHEX gene in the overweight Saudi patients confirmed with type 2 diabetes mellitus

Background

The rs7932837 polymorphism in the Hematopoietically expressed homeobox (HHEX) gene was discovered through genome-wide association studies and is a promising candidate for type 2 diabetes mellitus (T2DM), which is one of the risk factors for obesity and other complications. T2DM has been identified as a heterogeneous and multifactorial disease characterized by insulin resistance and secretion.

Aim

The aim of this study was to investigate the rs7932837 polymorphism in the HHEX gene in overweight patients diagnosed with T2DM in the Saudi Population.

Methods

In this case-control study, one hundred T2DM cases and 100 controls were selected based on inclusion and exclusion criteria. Genotyping was performed with polymerase chair reaction-restriction fragment length polymorphism analysis and statistical analysis was performed between T2DM cases and controls for clinical characteristics, genotype and allele frequencies and multiple logistic regression analysis.

Results

In this study, T2DM cases were compared with healthy control subjects. Clinical characteristic analysis revealed the statistical analysis between age, weight, BMI, FBG, HDL-c, TC, TG and family history (p < 0.05). HWE analysis was in the accordance (p < 0.05). The rs7932837 polymorphism in the recessive model showed the positive association (AA + AG vs AA: 2.22 [1.25–3.96] & p = 0.006) and none of the genotypes or alleles were in the statistical association. Multiple logistic regression analysis revealed positive association with age, BMI and FBG (p < 0.05).

Conclusion

This study concludes as rs7932837 polymorphism in the HHEX gene showed positive association with recessive model and future studies recommend to carry out with large number of sample size with additional polymorphisms in HHEX gene.

Associations of Walking Activity With Hypertensive Mediated Organ Damage in Community-Dwelling Elderly Chinese: The Northern Shanghai Study

Background: Walking, as the most common campaign in older people, is recommended to improve their cardiovascular health. However, the direct association between weekly walking activity and asymptomatic hypertensive mediated organ damage (HMOD) remains unclear.

Methods: 2,830 community-dwelling elderly subjects (over 65 years) in northern Shanghai were recruited from 2014 to 2018. Weekly walking activity was assessed by International Physical Activity Questionnaires (IPAQ). Within the framework of comprehensive cardiovascular examinations, HMOD, including left ventricular mass index, peak transmitral pulsed Doppler velocity/early diastolic tissue Doppler velocity, creatinine clearance rate, urinary albumin–creatinine ratio, carotid-femoral pulse wave velocity (cf-PWV), carotid intima–media thickness (CIMT), arterial plaque, and ankle-brachial index (ABI), were all evaluated.

Results: 1,862 (65.8%) participants with weekly walking activity showed lower CIMT, lower cf-PWV, fewer abnormal ABI, and lower prevalence of hypertension and coronary heart disease (p < 0.05). Walking activity was negatively correlated with age and smokers (correlation coefficient: −0.066, −0.042; both p < 0.05). After adjusting for cardiovascular risk factors and concomitant diseases, walking activity was significantly associated with better indicator of most vascular HMOD in multivariate logistic regressions, including arterial stiffness [odds ratio (OR) = 0.75, p = 0.01], increased CIMT (OR = 0.70, p = 0.03), and peripheral artery disease (OR = 0.72, p = 0.005), but not cardiac or renal HMOD. Subgroup analysis further showed that walking duration ≥1 h/day was significantly associated with decreased risk of most vascular HMOD after adjustment for confounders and moderate-to-vigorous physical activity based on IPAQ (all p < 0.05).

Conclusions: In the community-dwelling elderly Chinese, there was a significant negative association of weekly walking activity with vascular HMOD, but not cardiac or renal HMOD. Increased daily walking duration, but not walking frequency, was significantly associated with improved vascular HMOD. Hence, increasing daily walking duration seems to encourage a healthy lifestyle in terms of vascular protection.

Clinical Trial Registration:ClinicalTrials.gov, identifier: NCT02368938.

The Therapeutic Effects of Mild to Moderate Intensity Aerobic Exercise on Glycemic Control in Patients with Type 2 Diabetes Mellitus: A Meta-Analysis of Randomized Trials

INTRODUCTION

It has been recommended that physical activity be a part of treatment and management regimens of type 2 diabetes mellitus (T2DM), and research has shown that regular physical exercise facilitates glycemic control in these patients. In this analysis, our aim was to systematically show the therapeutic effects of mild to moderate intensity aerobic exercise on glycemic control in patients with T2DM.

METHODS

From February to April 2021, we searched the https://www.clinicaltrials.gov , EMBASE, MEDLINE, Cochrane Central Register of Controlled Trials (CENTRAL), Web of Science and Google Scholar databases for trials that showed the effects of aerobic exercise on glycemic control in patients with T2DM. Glycated hemoglobin (HbA1c) was the endpoint in the analysis. The RevMan version 5.4 statistical program was used for statistical analysis, and the mean difference (MD) and 95% confidence intervals (CI) used to represent the data following analysis.

RESULTS

Eighteen trials involving 972 participants with T2DM were included in this meta-analysis, of whom 523 were assigned to an exercise group and 449 were assigned to a control group. A comparison pre- versus post-aerobic exercise showed that aerobic exercise significantly improved glycemic control (HbA1c) (MD 0.35, 95% CI 0.23-0.48; P = 0.00001) in these patients with T2DM. A second comparison, T2DM participants in the experimental group post-exercise versus T2DM participants from the control group at the end of the follow-up, also showed that aerobic exercise significantly improved glycemic control (MD - 0.46, 95% CI - 0.69 to - 0.22; P = 0.0001). However, a comparison of HbA1c of T2DM participants in the control group at the beginning of the study compared to those at the end of follow-up did not show any significant improvement in glycemic control (MD 0.08, 95% CI - 0.05 to 0.21; P = 0.21).

CONCLUSION

The current analysis showed that mild to moderate intensity aerobic exercise significantly improved glycemic control in patients with T2DM. Patients with T2DM who regularly participated in aerobic exercise activities had a better control of their disease than those who were not on a regular aerobic exercise regimen. These results lead to the recommendation that at least mild to moderate intensity aerobic exercise should be included in the treatment and management regimens of patients with T2DM.

Home-Based Physical Activity in Patients With Type 2 Diabetes Mellitus: A Scoping Review

To promote optimal healthcare delivery in type 2 diabetes mellitus (T2DM) following the outbreak of coronavirus disease 2019, adopting home-based physical activity (PA) is being seriously considered. Therefore, this study aims to outline the characteristics of exercise protocols for home-based PA and the challenges and limitations in implementing home-based PA in patients with T2DM. This scoping review was carried out by identifying eligible studies in six different databases (Scopus, Cochrane Library, SpringerLink, ProQuest, Science Direct, and Google Scholar). The keywords used in the search strategies were: home-based physical activity, home-based exercise therapy, home-based physical exercise, home-based exercise, home-based exercise training, diabetes mellitus, and T2DM. Two reviewers independently screened all full-text articles to find articles that met the eligibility requirements. A total of 443 articles were identified in the search. Approximately 342 articles were excluded by screening titles and abstracts, which led to the selection of 44 articles relevant to the current study. Further screening of the full-text led to the subsequent removal of 34 other articles, leading to 10 studies that were eligible for data extraction. This review suggested that the exercise protocols for home-based PA include resistance exercise using free weight and own body weight with a frequency of two to three sessions per week at moderate intensity, along with aerobic exercise (particularly walking) with a frequency of three to five times per week at moderate intensity. A combination of resistance and aerobic exercise showed more significant benefits of PA in patients with T2DM. More studies regarding home-based PA in T2DM patients with metabolic disorders are warranted.

Effects of a three-armed randomised controlled trial using self-monitoring of daily steps with and without counselling in prediabetes and type 2 diabetes-the Sophia Step Study

BACKGROUND

This aimed to evaluate the effects of self-monitoring of daily steps with or without counselling support on HbA1c, other cardiometabolic risk factors and objectively measured physical activity (PA) during a 2-year intervention in a population with prediabetes or type 2 diabetes.

METHODS

The Sophia Step Study was a three-armed parallel randomised controlled trial. Participants with prediabetes or type 2 diabetes were recruited in a primary care setting. Allocation (1:1:1) was made to a multi-component intervention (self-monitoring of steps with counselling support), a single-component intervention (self-monitoring of steps without counselling support) or standard care. Data were collected for primary outcome HbA1c at baseline and month 6, 12, 18 and 24. Physical activity was assessed as an intermediate outcome by accelerometer (ActiGraph GT1M) for 1 week at baseline and the 6-, 12-, 18- and 24-month follow-up visits. The intervention effects were evaluated by a robust linear mixed model.

RESULTS

In total, 188 subjects (64, 59, 65 in each group) were included. The mean (SD) age was 64 (7.7) years, BMI was 30.0 (4.4) kg/m2 and HbA1c was 50 (11) mmol/mol, 21% had prediabetes and 40% were female. The dropout rate was 11% at 24 months. Effect size (CI) for the primary outcome (HbA1c) ranged from -1.3 (-4.8 to 2.2) to 1.1 (-2.4 to 4.6) mmol/mol for the multi-component vs control group and from 0.3 (-3.3 to 3.9) to 3.1 (-0.5 to 6.7) mmol/mol for the single-component vs control group. Effect size (CI) for moderate-to-vigorous physical activity ranged from 8.0 (0.4 to 15.7) to 11.1 (3.3 to 19.0) min/day for the multi-component vs control group and from 7.6 (-0.4 to 15.6) to 9.4 (1.4 to 17.4) min/day for the single-component group vs control group.

CONCLUSION

This 2-year intervention, including self-monitoring of steps with or without counselling, prevented a decrease in PA but did not provide evidence for improved metabolic control and cardiometabolic risk factors in a population with prediabetes or type 2 diabetes.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT02374788 . Registered 2 March 2015-Retrospectively registered.

Exercise as a drug for glucose management and prevention in type 2 diabetes mellitus

Physical inactivity and sedentary behavior are risk factors for type 2 diabetes mellitus (T2DM). Therefore, physical exercise (PE) together with medical treatment might be considered as a key strategy to counteract T2DM. Glycemic control is a central objective in the prevention and management of T2DM, and PE might be able to substantially affect the processes that determine it. Just like a drug, exercise can be dosed based on the characteristics of the individual to increase its benefits and reduce side effects. In this brief review, the mechanisms underlying the effects of PE on glucose metabolism in muscle are illustrated, and the effects of modulation of the parameters characterizing this atypical "drug" on glucose homeostasis are described.

Association between Urban Greenspace and Health: A Systematic Review of Literature

The current review aimed to explore the association between urban greenspaces and health indicators. In particular, our aims were to analyze the association between publicly accessible urban greenspaces exposure and two selected health outcomes (objectively measured physical activity (PA) and mental health outcomes (MH)). Two electronic databases—PubMed/Medline and Excerpta Medica dataBASE (EMBASE)—were searched from 1 January 2000 to 30 September 2020. Only articles in English were considered. Out of 356 retrieved articles, a total of 34 papers were included in our review. Of those, 15 assessed the association between urban greenspace and PA and 19 dealt with MH. Almost all the included studies found a positive association between urban greenspace and both PA and MH, while a few demonstrated a non-effect or a negative effect on MH outcomes. However, only guaranteeing access is not enough. Indeed, important elements are maintenance, renovation, closeness to residential areas, planning of interactive activities, and perceived security aspects. Overall, despite some methodological limitations of the included studies, the results have shown almost univocally that urban greenspaces harbour potentially beneficial effects on physical and mental health and well-being.

Wearing of Cloth or Disposable Surgical Face Masks has no Effect on Vigorous Exercise Performance in Healthy Individuals

Wearing face masks is recommended for the prevention of contracting or exposing others to cardiorespiratory infections, such as COVID-19. Controversy exists on whether wearing face masks during vigorous exercise affects performance. We used a randomized, counterbalanced cross-over design to evaluate the effects of wearing a surgical mask, a cloth mask, or no mask in 14 participants (7 men and 7 women; 28.2 ± 8.7 y) during a cycle ergometry test to exhaustion. Arterial oxygen saturation (pulse oximetry) and tissue oxygenation index (indicator of hemoglobin saturation/desaturation) at vastus lateralis (near-infrared spectroscopy) were assessed throughout the exercise tests. Wearing face masks had no effect on performance (time to exhaustion (mean ± SD): no mask 622 ± 141 s, surgical mask 657 ± 158 s, cloth mask 637 ± 153 s (p = 0.20); peak power: no mask 234 ± 56 W, surgical mask 241 ± 57 W, cloth mask 241 ± 51 W (p = 0.49)). When expressed relative to peak exercise performance, no differences were evident between wearing or not wearing a mask for arterial oxygen saturation, tissue oxygenation index, rating of perceived exertion, or heart rate at any time during the exercise tests. Wearing a face mask during vigorous exercise had no discernable detrimental effect on blood or muscle oxygenation, and exercise performance in young, healthy participants (ClinicalTrials.gov, NCT04557605).