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Bogaert L, Willems I, Calders P, Dirinck E, Kinaupenne M, Decraene M, Lapauw B, Strumane B, Van Daele M, Verbestel V, De Craemer M. Explanatory variables of objectively measured 24-h movement behaviors in people with prediabetes and type 2 diabetes: A systematic review. Diabetes Metab Syndr 2024; 18:102995. [PMID: 38583307 DOI: 10.1016/j.dsx.2024.102995] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2023] [Revised: 02/13/2024] [Accepted: 03/25/2024] [Indexed: 04/09/2024]
Abstract
AIM Physical activity (PA), sedentary behavior (SB) and sleep (i.e. 24-h movement behaviors) are associated with health indicators in people with prediabetes and type 2 diabetes (T2D). To optimize 24-h movement behaviors, it is crucial to identify explanatory variables related to these behaviors. This review aimed to summarize the explanatory variables of 24-h movement behaviors in people with prediabetes or T2D. METHODS A systematic search of four databases (PubMed, Web of Science, Scopus & Embase) was performed. Only objective measurements of 24-h movement behaviors were included in the search strategy. The explanatory variables were classified according to the levels of the socio-ecological model (i.e. intrapersonal, interpersonal and environmental). The risk of bias was assessed using the Joanna Briggs Institute appraisal checklist. RESULTS None of the 78 included studies investigated 24-h movement behaviors. The majority of the studies investigated PA in isolation. Most studied explanatory variables were situated at the intrapersonal level. Being male was associated with more moderate to vigorous PA but less light PA in people with T2D, and more total PA in people with prediabetes. An older age was associated with a decrease in all levels of PA in people with T2D. HbA1c was positively associated with sleep and SB in both groups. No associations were found at the interpersonal or environmental level. CONCLUSION The results of this review underscore the lack of a socio-ecological approach toward explanatory variables of 24-h movement behaviors and the lack of focus on an integrated 24-h movement behavior approach in both populations.
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Affiliation(s)
- Lotte Bogaert
- Ghent University, Department of Rehabilitation Sciences, Ghent, Belgium.
| | - Iris Willems
- Ghent University, Department of Rehabilitation Sciences, Ghent, Belgium; Research Foundation Flanders, Brussels, Belgium.
| | - Patrick Calders
- Ghent University, Department of Rehabilitation Sciences, Ghent, Belgium.
| | - Eveline Dirinck
- Department of Endocrinology, Antwerp University Hospital & University of Antwerp, Antwerp, Belgium.
| | - Manon Kinaupenne
- Ghent University, Department of Rehabilitation Sciences, Ghent, Belgium.
| | - Marga Decraene
- Ghent University, Department of Rehabilitation Sciences, Ghent, Belgium; Ghent University, Department of Movement and Sports Sciences, Ghent, Belgium.
| | - Bruno Lapauw
- Department of Endocrinology & Department of Internal Medicine and Pediatrics, Ghent University Hospital & Ghent University, Ghent, Belgium.
| | - Boyd Strumane
- Faculty of Medicine and Health Sciences, Ghent, Belgium.
| | | | - Vera Verbestel
- Faculty of Health, Medicine and Life Sciences, Department of Health Promotion, Research Institute of Nutrition and Translational Research in Metabolism (NUTRIM), Maastricht University, the Netherlands; Faculty of Health, Medicine and Life Sciences, Department of Health Promotion, Care and Public Health Research Institute (CAPHRI), Maastricht University, the Netherlands.
| | - Marieke De Craemer
- Ghent University, Department of Rehabilitation Sciences, Ghent, Belgium.
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Phababpha S, Sri-amad R, Huipao N, Sriwannawit P, Roengrit T. Daily Step Count and its Association with Arterial Stiffness Parameters in Older Adults. Ann Geriatr Med Res 2024; 28:101-109. [PMID: 38350695 PMCID: PMC10982445 DOI: 10.4235/agmr.23.0161] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2023] [Revised: 02/03/2024] [Accepted: 02/07/2024] [Indexed: 02/15/2024] Open
Abstract
BACKGROUND Daily step count is a simple parameter for assessing physical activity. However, the potential advantages of setting daily step goals below the traditional 10,000-step threshold remain unclear. The cross-sectional study aimed to determine the relationship between daily step counts and arterial stiffness outcomes in older individuals. METHODS Forty-eight older adults recorded their daily step counts over a 7-day period using a pedometer. The participants were classified into two groups based on their daily step count: Group 1 (n = 28) consisted of individuals taking fewer than 5000 steps per day, while Group 2 (n = 20) included those who recorded 5,000 to 9,999 steps per day. To evaluate arterial stiffness parameters, we measured pulse wave velocity (PWV), cardio-ankle vascular index (CAVI), and ankle-brachial index (ABI). Hemodynamic and biochemical parameters were also determined. RESULTS Participants who accumulated fewer daily steps exhibited higher PWV compared to each group. An inverse association was observed between average steps per day and PWV. However, no significant differences were found between daily step counts and CAVI or ABI. CONCLUSION Conclusions: As individuals increase their daily step count, they may experience a reduction in arterial stiffness. Consequently, the assessment of daily steps has benefits for enhancing vascular health and overall well-being among older individuals.
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Affiliation(s)
- Suphawadee Phababpha
- Chulabhorn International College of Medicine, Thammasat University, Pathum Thani, Thailand
| | - Ruchada Sri-amad
- Department of Physical Therapy, Faculty of Allied Health Sciences, Chulalongkorn University, Bangkok, Thailand
| | - Nawiya Huipao
- Division of Health and Applied Sciences, Faculty of Science, Prince of Songkla University, Songkhla, Thailand
| | - Porraporn Sriwannawit
- Department of Physical Therapy, Faculty of Medicine, Prince of Songkla University, Songkhla, Thailand
| | - Thapanee Roengrit
- Department of Basic Medical Science, Faculty of Medicine Vajira Hospital, Navamindradhiraj University, Bangkok, Thailand
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Narendrula A, Brinza E, Horvat Davey C, Longenecker CT, Webel AR. Relationship between objectively measured physical activity and subclinical cardiovascular disease: a systematic review. BMJ Open Sport Exerc Med 2024; 10:e001596. [PMID: 38292295 PMCID: PMC10826575 DOI: 10.1136/bmjsem-2023-001596] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/17/2024] [Indexed: 02/01/2024] Open
Abstract
Introduction The association of physical activity (PA) with subclinical cardiovascular disease (CVD) is unclear. Clarifying this relationship may inform cardiovascular prevention strategies. Methods We performed a systematic review (CRD42021226089) using Medline, Embase, CINAHL and Cochrane (1 January 2000 to 1 September 2023). Studies published with adult populations exploring the relationship between objectively measured PA and subclinical CVD were included. Subclinical CVD was assessed using: ankle-brachial index (ABI); arterial stiffness; carotid artery disease; coronary artery atherosclerosis; endothelial function; and measures of cardiac structure and function. The Risk Of Bias In Non-randomised Studies - of Interventions (ROBINS-I) and Cochrane Risk of Bias tools were used for quality review. Results Of 68 included studies, most supported an inverse relationship between PA and subclinical CVD. Arterial stiffness was the most common outcome (n=40), and 33 studies suggested that less sedentary behaviour (SB), increased PA and/or higher intensity PA was associated with less arterial stiffness. Ten studies of carotid artery disease (total n=18), six of endothelial function (n=10), two of coronary artery disease (n=3) and all of ABI (n=6) suggested that PA or less SB is associated with less subclinical disease. Five studies assessing cardiac structure/function (n=6) suggested alterations in structure/function with PA. Conclusions PA reduces the risk of CVD events, and this systematic review demonstrates that some of the benefits may be mediated by an inverse association between PA and subclinical CVD. Interventions to increase PA are important for CVD prevention, so we provide a comprehensive overview of which surrogate outcome measures may be most useful to assess future CVD prevention interventions. PROSPERO registration number CRD42021226089.
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Affiliation(s)
- Aparna Narendrula
- Internal Medicine, NYU Grossman School of Medicine, New York, New York, USA
| | - Ellen Brinza
- Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Christine Horvat Davey
- Case Western Reserve University Frances Payne Bolton School of Nursing, Cleveland, Ohio, USA
| | - Chris T Longenecker
- Division of Cardiology, University of Washington School of Medicine, Seattle, Washington, USA
| | - Allison R Webel
- University of Washington School of Nursing, Seattle, Washington, USA
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Li X, Chattopadhyay K, Chen X, Li J, Xu M, Chen X, Li L. Association Between Physical Activity and Arterial Stiffness in Patients with Type 2 Diabetes in Ningbo, China: A Cross-Sectional Study. Diabetes Metab Syndr Obes 2023; 16:4133-4141. [PMID: 38145257 PMCID: PMC10740718 DOI: 10.2147/dmso.s438344] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2023] [Accepted: 12/12/2023] [Indexed: 12/26/2023] Open
Abstract
Aim The study aimed to investigate the association between physical activity and arterial stiffness in patients with type 2 diabetes mellitus (T2DM) in Ningbo, China. Methods A cross-sectional study was conducted using the Metabolic Management Center (MMC) dataset of The First Affiliated Hospital of Ningbo University from 1st March 2018 to 28th February 2023. 4444 adults with T2DM were included in the study. Physical activity was assessed using the International Physical Activity Questionnaire (IPAQ)-Short and was categorized into high, moderate, and low. Arterial stiffness was defined as brachial-ankle pulse wave velocity (baPWV) ≥1800cm/s or common carotid artery intima-media thickness (CCA IMT) ≥1mm. Multiple logistic regression analyses were performed to identify the association between physical activity and arterial stiffness. Results 6.5%, 47.0%, and 46.5% of patients with T2DM had high, moderate, and low physical activity, respectively. 18.8% and 17.5% of patients had arterial stiffness based on baPWV and CCA IMT, respectively. The odds of arterial stiffness (based on baPWV) were lower in patients having moderate to high physical activity (OR 0.82, 95% CI 0.68 to 0.98 and OR 0.58, 95% CI 0.39 to 0.87, respectively). The odds of arterial stiffness (based on CCA IMT) were found to be lower in patients having high physical activity (OR 0.49, 95% CI 0.33 to 0.74). Conclusion Higher physical activity was found to be associated with lower arterial stiffness in patients with T2DM in Ningbo, China. This was a cross-sectional study, and there is a need to conduct longitudinal studies on this topic.
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Affiliation(s)
- Xueyu Li
- Department of Endocrinology and Metabolism, The First Affiliated Hospital of Ningbo University, Ningbo, People’s Republic of China
| | - Kaushik Chattopadhyay
- Lifespan and Population Health, School of Medicine, University of Nottingham, Nottingham, UK
| | - Xiaoting Chen
- School of Medicine, Ningbo University, Ningbo, People’s Republic of China
| | - Jialin Li
- Department of Endocrinology and Metabolism, The First Affiliated Hospital of Ningbo University, Ningbo, People’s Republic of China
| | - Miao Xu
- Department of Endocrinology and Metabolism, The First Affiliated Hospital of Ningbo University, Ningbo, People’s Republic of China
| | - Xueqin Chen
- Department of Traditional Chinese Medicine, The First Affiliated Hospital of Ningbo University, Ningbo, People’s Republic of China
| | - Li Li
- Department of Endocrinology and Metabolism, The First Affiliated Hospital of Ningbo University, Ningbo, People’s Republic of China
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Associations of steps per day and peak cadence with arterial stiffness in older adults. Exp Gerontol 2021; 157:111628. [PMID: 34798157 DOI: 10.1016/j.exger.2021.111628] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Revised: 10/24/2021] [Accepted: 11/11/2021] [Indexed: 12/13/2022]
Abstract
BACKGROUND There is evidence showing an inverse association between steps/day and arterial stiffness in adults. However, the relationship of steps/day and peak cadence with arterial stiffness is poorly understood in older adults. This study aimed to investigate the association between steps/day and peak cadence with arterial stiffness in older adults. METHODS This cross-sectional study included 222 community-dwelling older adults (66 ± 5 years; 81.5% females; 70.3% with hypertension). Arterial stiffness was measured by aortic pulse wave velocity (aPWV). Steps/day and peak cadence were assessed by accelerometry. The participants were categorized according to the number of steps/day: sedentary <5000; low active 5000-7499; active 7500-9999; highly active 10,000+. Peak cadence was defined as the average of steps/day of the highest 30 min (not necessarily consecutive) for all valid days. Generalized linear models were used for data analyses. RESULTS The active (β = -0.34 m/s, 95% CI -0.60, -0.08) and highly active (β = -0.51 m/s, 95% CI -0.83, -0.20) groups had lower aPWV compared to the sedentary group. No significant difference was found between the low active group and the sedentary group (β = -0.21 m/s, 95% CI -0.46, 0.05). Every increment of 1000 steps/day was associated with a decrease of 0.05 m/s in the aPWV (95% CI -0.08, -0.02). Every increment of 10 steps/min in peak 30-min cadence was associated with a decrease of 0.05 m/s in aPWV (95% CI -0.09, -0.01). CONCLUSIONS Our findings show that easy-to-use proxies of the volume (steps/day) and intensity (peak cadence) of ambulatory behavior are inversely associated with arterial stiffness in older adults. The inverse association of steps/day and peak cadence with arterial stiffness is dose-response.
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Wali MA, Raparelli V, Pilote L, Daskalopoulou SS. Blood pressure variability in normotensive perimenopausal women: Non-dipping status, maximum blood pressure and arterial stiffness. Int J Cardiol 2020; 325:149-154. [PMID: 33075385 DOI: 10.1016/j.ijcard.2020.10.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2020] [Revised: 09/06/2020] [Accepted: 10/09/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND Postmenopausal women are more likely to have uncontrolled hypertension and are at higher risk of cardiovascular disease compared with age-matched men. Blood pressure variability is emerging as a predictor of adverse cardiovascular outcomes and may be implicated in the relationship between menopause and worsened vascular health in women. We conducted an observational study, BRAVE (Blood pRessure And Vascular hEalth around menopause) to study this relationship. METHOD Normotensive perimenopausal women were recruited. Blood pressure variability was measured through 24-h blood pressure monitoring. Vascular health was assessed through arterial stiffness (carotid-femoral pulse wave velocity), carotid intima-media thickness and endothelial function (reactive hyperemic index). Multivariate models were performed to identify factors associated with blood pressure variability and arterial stiffness in perimenopausal women. RESULTS Forty-nine healthy women (mean age 52.9 ± 4.0, 63% postmenopausal) were recruited. There was a high prevalence (40%) of night non-dipping, a measure of an abnormal pattern of blood pressure variability. Aside from night dipping, other measures of blood pressure variability were similar between premenopausal and postmenopausal women. In the multivariate analysis, body mass index was the only factor associated independently with different measures of blood pressure variability, including the maximum overnight blood pressure (ß = 1.95, p < 0.01). The latter was also significantly associated with arterial stiffness (ß = 0.035, p = 0.048). Finally, poor sleep was independently associated with an increase in arterial stiffness. CONCLUSIONS Abnormal blood pressure variability, particularly night non-dipping, is common in normotensive perimenopausal women. Maximum overnight blood pressure is independently associated with arterial stiffness and may identify women at higher cardiovascular risk.
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Affiliation(s)
| | - Valeria Raparelli
- McGill University Health Center Research Institute, Montreal, QC, Canada; Sapienza - University of Rome, Experimental Medicine Department, Rome, Italy
| | - Louise Pilote
- McGill University Health Center Research Institute, Montreal, QC, Canada; Department of Medicine, McGill University, Montreal, QC, Canada.
| | - Stella S Daskalopoulou
- McGill University Health Center Research Institute, Montreal, QC, Canada; Department of Medicine, McGill University, Montreal, QC, Canada
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Cavero-Redondo I, Tudor-Locke C, Álvarez-Bueno C, Cunha PG, Aguiar EJ, Martínez-Vizcaíno V. Steps per Day and Arterial Stiffness. Hypertension 2019; 73:350-363. [DOI: 10.1161/hypertensionaha.118.11987] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Iván Cavero-Redondo
- From the Universidad de Castilla-La Mancha, Health and Social Research Center, Cuenca, Spain (I.C.-R., C.A.-B., V.M.-V.)
| | - Catrine Tudor-Locke
- Department of Kinesiology, University of Massachusetts Amherst, MA (C.T.-L., E.J.A.)
| | - Celia Álvarez-Bueno
- From the Universidad de Castilla-La Mancha, Health and Social Research Center, Cuenca, Spain (I.C.-R., C.A.-B., V.M.-V.)
| | - Pedro G. Cunha
- Center for the Research and Treatment of Arterial Hypertension and Cardiovascular Risk, Internal Medicine Department, Guimarães, Portugal (P.G.C.)
| | - Elroy J. Aguiar
- Department of Kinesiology, University of Massachusetts Amherst, MA (C.T.-L., E.J.A.)
| | - Vicente Martínez-Vizcaíno
- From the Universidad de Castilla-La Mancha, Health and Social Research Center, Cuenca, Spain (I.C.-R., C.A.-B., V.M.-V.)
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Cooke AB, Daskalopoulou SS, Dasgupta K. The impact of accelerometer wear location on the relationship between step counts and arterial stiffness in adults treated for hypertension and diabetes. J Sci Med Sport 2017; 21:398-403. [PMID: 28855085 DOI: 10.1016/j.jsams.2017.08.011] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2017] [Accepted: 08/15/2017] [Indexed: 11/30/2022]
Abstract
OBJECTIVES Accelerometer placement at the wrist is convenient and increasingly adopted despite less accurate physical activity (PA) measurement than with waist placement. Capitalizing on a study that started with wrist placement and shifted to waist placement, we compared associations between PA measures derived from different accelerometer locations with a responsive arterial health indicator, carotid-femoral pulse wave velocity (cfPWV). DESIGN Cross-sectional study. METHODS We previously demonstrated an inverse association between waist-worn pedometer-assessed step counts (Yamax SW-200, 7 days) and cfPWV (-0.20m/s, 95% CI -0.28, -0.12 per 1000 step/day increment) in 366 adults. Participants concurrently wore accelerometers (ActiGraph GT3X+), most at the waist but the first 46 at the wrist. We matched this subgroup with participants from the 'waist accelerometer' group (sex, age, and pedometer-assessed steps/day) and assessed associations with cfPWV (applanation tonometry, Sphygmocor) separately in each subgroup through linear regression models. RESULTS Compared to the waist group, wrist group participants had higher step counts (mean difference 3980 steps/day; 95% CI 2517, 5443), energy expenditure (967kcal/day, 95% CI 755, 1179), and moderate-to-vigorous-PA (138min; 95% CI 114, 162). Accelerometer-assessed step counts (waist) suggested an association with cfPWV (-0.28m/s, 95% CI -0.58, 0.01); but no relationship was apparent with wrist-assessed steps (0.02m/s, 95% CI -0.24, 0.27). CONCLUSIONS Waist but not wrist ActiGraph PA measures signal associations between PA and cfPWV. We urge researchers to consider the importance of wear location choice on relationships with health indicators.
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Affiliation(s)
- Alexandra B Cooke
- Division of Experimental Medicine, Department of Medicine, Faculty of Medicine, McGill University, Canada
| | - Stella S Daskalopoulou
- Division of Experimental Medicine, Department of Medicine, Faculty of Medicine, McGill University, Canada; Division of Internal Medicine, Department of Medicine, Faculty of Medicine, Research Institute of the McGill University Health Centre, Canada
| | - Kaberi Dasgupta
- Division of Internal Medicine, Department of Medicine, Faculty of Medicine, Research Institute of the McGill University Health Centre, Canada; Division of Clinical Epidemiology, Department of Medicine, Faculty of Medicine, McGill University, Canada.
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Zucatti ATN, de Paula TP, Viana LV, DallAgnol R, Cureau FV, Azevedo MJ, Gross JL, Schaan BD, Leitao CB. Low Levels of Usual Physical Activity Are Associated with Higher 24 h Blood Pressure in Type 2 Diabetes Mellitus in a Cross-Sectional Study. J Diabetes Res 2017; 2017:6232674. [PMID: 29018827 PMCID: PMC5606041 DOI: 10.1155/2017/6232674] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2017] [Revised: 07/28/2017] [Accepted: 08/17/2017] [Indexed: 01/08/2023] Open
Abstract
The aim of this study is to evaluate the association between usual physical activity and 24 h blood pressure (BP) profile in people with type 2 diabetes mellitus (DM). This is a cross-sectional study of 151 participants with type 2 DM. Usual physical activity was assessed by step counting and self-reported questionnaire. BP was measured in office and by 24 h ambulatory BP monitoring (ABPM; 24 h, daytime and nighttime). Mean participant age was 61.1 ± 8.4 years, 64% was women, and mean duration of diabetes was 14.3 ± 8.5 years. Ninety-two percent of participants had hypertension, and office BP was 138 ± 18/78 ± 10 mmHg. Inverse correlations were observed between step count and 24 h BP (systolic, r = -0.186; p = 0.022), daytime BP (systolic, r = -0.198; p = 0.015), and nighttime BP (pulse pressure, r = -0.190; p = 0.019). People were categorized into tertiles of daily step count, and the 1st tertile had higher 24 h systolic BP, daytime systolic BP, daytime mean BP, and daytime systolic BP load than those in the other tertiles, even after adjusting for age and HbA1c. Participants with type 2 DM and low levels of physical activity exhibit higher 24 h and daytime systolic ambulatory BP values as compared with those who performed more steps per day, even after adjustments for confounding factors.
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Affiliation(s)
| | - Tatiana Pedroso de Paula
- Endocrine Division, Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil
| | - Luciana Verçoza Viana
- Endocrine Division, Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil
| | - Rafael DallAgnol
- Endocrine Division, Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil
| | - Felipe Vogt Cureau
- Endocrine Division, Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil
| | - Mirela Jobim Azevedo
- Endocrine Division, Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil
| | - Jorge Luiz Gross
- Endocrine Division, Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil
| | - Beatriz D. Schaan
- Endocrine Division, Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil
| | - Cristiane Bauermann Leitao
- Endocrine Division, Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil
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