Type 2 diabetes sits in a chair

The Fidget Factor and the obesity paradox. How small movements have big impact

The hypothesis is that the Fidget Factor is the innate neurological pulse that propels humans and other species to move to support their health. Fidgets, previously thought to be spontaneous, are neurologically regulated and highly ordered (non-random). Modern societies being chair-based overwhelm Fidget Factor pulses and consequently inflict chair-based living for transportation, labor, and leisure. Despite impulses firing through the nervous system, people sit because environmental design overwhelms the biology. Urbanization and chair-based societies were designed after the industrial revolution to promote productivity; however, the consequence has been opposite. Crushing the natural urge to move—the Fidget Factor—is a public health calamity. Excess sitting is associated with a myriad of detrimental health consequences and impairs productivity. Fidgeting may reduce all-cause mortality associated with excessive sitting. The Fidget Factor offers hope; data demonstrate that workplaces and schools can be designed to promote activity and free people's Fidget Factors. Evidence shows that people are happier, healthier, wealthier, and more successful if their Fidget Factors are freed.

Non‐Obese MKR Mouse Model of Type 2 Diabetes Reveals Skeletal Alterations in Mineralization and Material Properties

Obesity is a common comorbidity of type 2 diabetes (T2D). Therefore, increased risk of fragility fractures in T2D is often confounded by the effects of obesity. This study was conducted to elucidate the mechanistic basis by which T2D alone leads to skeletal fragility. We hypothesized that obesity independent T2D would deteriorate bone's material quality by accumulating defects in the mineral matrix and undesired modifications in its organic matrix associated with increased oxidative stress and hyperglycemia. To test this hypothesis, we used 15‐week‐old male non‐obese mice with engineered muscle creatine kinase promoter/human dominant negative insulin growth factor 1 (IGF‐I) receptor (MKR) and FVB/N wild‐type (WT) controls (n = 12/group). MKR mice exhibit reduced insulin production and loss of glycemic control leading to diabetic hyperglycemia, verified by fasting blood glucose measurements (>250 mg/dL), without an increase in body weight. MKR mice showed a significant decrease in femoral radial geometry (cortical area, moment of inertia, cortical thickness, endosteal diameter, and periosteal diameter). Bone mineral density (BMD), as assessed by micro–computed tomography (μCT), remained unchanged; however, the quality of bone mineral was altered. In contrast to controls, MKR mice had significantly increased hydroxyapatite crystal thickness, measured by small‐angle X‐ray scattering, and elongated c‐axis length of the crystals evaluated by confocal Raman spectroscopy. There was an increase in changes in the organic matrix of MKR mice, associated with enhanced glycoxidation (carboxymethyl‐lysine [CML] and pentosidine) and overall glycation (fluorescent advanced glycation end products), both of which were associated with various measures of bone fragility. Moreover, increased CML formation positively correlated with elongated mineral crystal length, supporting the role of this negatively charged side chain to attract calcium ions, promote growth of hydroxyapatite, and build a physical link between mineral and collagen. Collectively, our results show, for the first time, changes in bone matrix in a non‐obese T2D model in which skeletal fragility is attributable to alterations in the mineral quality and undesired organic matrix modifications. © 2021 The Authors. JBMR Plus published by Wiley Periodicals LLC on behalf of American Society for Bone and Mineral Research.

Targeting Sedentary Behavior in CKD: A Pilot and Feasibility Randomized Controlled Trial

BACKGROUND AND OBJECTIVES

We tested the feasibility of reducing sedentary behavior common in CKD.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

We carried out a Sit Less, Interact, Move More intervention in a 24-week parallel-group, randomized controlled trial in patients with stages 2-5 CKD. In the intervention group (n=54), accelerometry performed at baseline and repeated every 4 weeks was used to develop and monitor adherence to individualized plans targeting sedentary and stepping durations. The control group (n=52) was provided national physical activity recommendations; accelerometry was performed at baseline and every 8 weeks. Between-groups changes from baseline to the average follow-up values at weeks 8, 16, and 24 of the sedentary and stepping durations were the coprimary end points.

RESULTS

The mean age was 69±13 years. Fourteen percent were on dialysis or received a kidney transplant. Eight percent of the control group and 17% of the intervention group were lost to follow-up. Sedentary and stepping durations did not change in the control group. Within the intervention group, the maximum decrease in sedentary duration (-43; 95% confidence interval, -69 to -17 min/d) and increase in stepping duration (16; 95% confidence interval, 7 to 24 min/d) and the number of steps per day (1265; 95% confidence interval, 518 to 2012) were seen at week 20. These attenuated at week 24. In mixed effects models, overall treatment effects between groups on sedentary (-17; 95% confidence interval, -43 to 8 min/d) and stepping (6; 95% confidence interval, -3 to 15 min/d) durations and the number of steps per day, a secondary end point (652; 95% confidence interval, -146 to 1449), were not significantly different. The intervention significantly reduced secondary end points of body mass index (-1.1; 95% confidence interval, -1.9 to -0.3 kg/m2) and body fat percentage (-2.1%; 95% confidence interval, -4.4% to -0.2%).

CONCLUSIONS

It is feasible to reduce sedentary duration and increase stepping duration in patients with CKD, but these were not sustained.

CLINICAL TRIAL REGISTRY NAME AND REGISTRATION NUMBER

National Health and Nutrition Examination Survey (NHANES), NCT02970123.

Comparing the Efficacy of Supervised and Unsupervised Exercise Training on Glycaemic Control in Type 2 Diabetes: A Systematic Review

BACKGROUND

Exercise training is vital for glycaemic control in patients with type 2 diabetes mellitus (T2D). While the positive effects of supervised exercise training are well established, unsupervised training may offer an alternative and more sustainable means of realising the benefits of exercise away from a resource-heavy supervised setting.

OBJECTIVE

To evaluate the available literature and compare the efficacy of supervised and unsupervised exercise training programs on glycemic control in patients with T2D.

METHODS

CINAHL, MEDLINE, PubMed, and EMBASE, searched from inception to 20 July 2018. Only studies that included both supervised and unsupervised training were included.

RESULTS

Four studies, involving 115 participants, were included. One compared supervised with unsupervised exercise training and three investigated the efficacy of unsupervised training following supervised training. While supervised training is effective for improving glycaemic control in patients with T2D, unsupervised training may not maintain these changes. Included studies lacked detail relating to the supervised and unsupervised training programs.

CONCLUSIONS

Given that exercise is a critical component for maintenance of glycaemic control in patients with T2D, and because unsupervised training has been shown to be effective in improving clinical outcomes in other disease populations, further research is warranted to compare supervised and unsupervised exercise training in patients with T2D. It is important that future studies report standardised and detailed descriptions of key elements that form the basis of supervised and unsupervised exercise training groups.

A Systematic Review Comparing Dose Response of Exercise on Cardiovascular and All-Cause Mortality

It is well established that exercise improves cardiovascular and all-cause mortality, although an ideal dose of exercise is not known. The physical activity guidelines currently recommend 150 minutes per week of moderate-intensity exercise or 75 minutes of vigorous-intensity activity. Most individuals do not engage in adequate exercise, although a safe upper limit does not exist and a too much exercise hypothesis has recently emerged. This review of the literature analyzes studies that have evaluated exercise dose response on all-cause and cardiovascular mortality for the purpose of determining safe and effective exercise prescriptions. Searches were performed in PubMed and CINAHL between 2010 and 2018 to identify six studies that met inclusion criteria. Moderate-intensity exercise reduced all-cause mortality in five of six studies, whereas low-dose exercise most effectively improved all-cause mortality in three studies, and cardiovascular mortality in one study. Vigorous-intensity exercise or extreme doses demonstrated variable outcomes and remain controversial; two studies found vigorous-intensity exercise beneficial to improve health, two studies discouraged vigorous exercise, and two studies had less conclusive outcomes. It is not surprising that any amount of exercise improves health compared with none at all, with the greatest benefits observed when sedentary individuals began exercising. Low-dose exercise should be recommended to everyone with a goal of meeting the minimal requirements according to guidelines for decreased all-cause and cardiovascular mortality. Additional research to more thoroughly understand exercise dose response and motivate individuals to improve exercise engagement is currently warranted.

Bariatric Surgery Resistance: Using Preoperative Lifestyle Medicine and/or Pharmacology for Metabolic Responsiveness

Bariatric surgery is an effective and durable treatment for individuals with obesity and its associated comorbidities. However, not all patients meet weight loss and/or cardiometabolic goals following bariatric surgery, suggesting that some people are bariatric surgery resistant. The reason for this resistance is unclear, but potential factors, such as adiposity-derived inflammation, insulin resistance, hyperglycemia, and aerobic fitness prior to surgery, have been related to blunted surgery responsiveness. Exercise, diet, and/or pharmacology are effective at reducing inflammation and improving insulin action as well as physical function. Herein, we present data that supports the novel hypothesis that intervening prior to surgery can enhance disease resolution in people who are resistant to bariatric surgery.

Breaks in Sitting Time: Effects on Continuously Monitored Glucose and Blood Pressure

PURPOSE

We examined the effects of interrupting prolonged sitting with multiple 2-min walking breaks or one 30-min continuous walking session on glucose control and ambulatory blood pressure (ABP).

METHODS

Ten overweight/obese, physically inactive participants (five men; 32 ± 5 yr; BMI, 30.3 ± 4.6 kg·m) participated in this randomized four-trial crossover study, with each trial performed on a separate, simulated workday lasting 9 h: 1) 30 min of continuous moderate-intensity (30-min MOD) walking at 71% ± 4% HRmax; 2) 21 × 2 min bouts of moderate-intensity (2-min MOD) walking at 53% ± 5% HRmax, each performed every 20 min (42 min total); 3) 8 × 2 min bouts of vigorous-intensity (2-min VIG) walking at 79% ± 4% HRmax, each performed every hour (16 min total); 4) 9 h of prolonged sitting (SIT). Participants underwent continuous interstitial glucose monitoring and ABP monitoring during and after the simulated workday spent in the laboratory, with primary data analysis from 12:30 h to 07:00 h the next morning.

RESULTS

Compared with SIT (5.6 ± 1.1 mmol·L), mean 18.7-h glucose was lower during the 2-min MOD (5.2 ± 1.1 mmol·L) and 2-min VIG (5.4 ± 0.9 mmol·L) trials and mean 18.7-h glucose during the 30-min MOD trial (5.1 ± 0.8 mmol·L) was lower than all other trials (P < 0.001). Postprandial glucose was approximately 7% to 13% lower during all trials compared with SIT (P < 0.001), with 30-min MOD having the greatest effect. Only the 30-min MOD trial was effective in reducing systolic ABP from 12:30 to 07:00 h (119 ± 15 mm Hg) when compared with SIT (122 ± 16 mm Hg; P < 0.05).

CONCLUSIONS

Replacing sitting with 2-min MOD walking every 20 min or 2 min of vigorous-intensity walking every hour during a simulated workday reduced 18.7 h and postprandial glucose, but only 30-min MOD walking was effective for reducing both glucose and systolic ABP.

From Diabetes Care to Diabetes Cure-The Integration of Systems Biology, eHealth, and Behavioral Change

From a biological view, most of the processes involved in insulin resistance, which drives the pathobiology of type 2 diabetes, are reversible. This theoretically makes the disease reversible and curable by changing dietary habits and physical activity, particularly when adopted early in the disease process. Yet, this is not fully implemented and exploited in health care due to numerous obstacles. This article reviews the state of the art in all areas involved in a diabetes cure-focused therapy and discusses the scientific and technological advancements that need to be integrated into a systems approach sustainable lifestyle-based healthcare system and economy. The implementation of lifestyle as cure necessitates personalized and sustained lifestyle adaptations, which can only be established by a systems approach, including all relevant aspects (personalized diagnosis and diet, physical activity and stress management, self-empowerment, motivation, participation and health literacy, all facilitated by blended care and ehealth). Introduction of such a systems approach in type 2 diabetes therapy not only requires a concerted action of many stakeholders but also a change in healthcare economy, with new winners and losers. A "call for action" is put forward to actually initiate this transition. The solution provided for type 2 diabetes is translatable to other lifestyle-related disorders.

Low-Force Muscle Activity Regulates Energy Expenditure after Spinal Cord Injury

Reduced physical activity is a primary risk factor for increased morbidity and mortality. People with spinal cord injury (SCI) have reduced activity for a lifetime, as they cannot volitionally activate affected skeletal muscles. We explored whether low-force and low-frequency stimulation is a viable strategy to enhance systemic energy expenditure in people with SCI.

PURPOSE

This study aimed to determine the effects of low stimulation frequency (1 and 3 Hz) and stimulation intensity (50 and 100 mA) on energy expenditure in people with SCI. We also examined the relationship between body mass index and visceral adipose tissue on energy expenditure during low-frequency stimulation.

METHODS

Ten individuals with complete SCI underwent oxygen consumption monitoring during electrical activation of the quadriceps and hamstrings at 1 and 3 Hz and at 50 and 100 mA. We calculated the difference in energy expenditure between stimulation and rest and estimated the number of days that would be necessary to burn 1 lb of body fat (3500 kcal) for each stimulation protocol (1 vs 3 Hz).

RESULTS

Both training frequencies induced a significant increase in oxygen consumption above a resting baseline level (P < 0.05). Energy expenditure positively correlated with stimulus intensity (muscle recruitment) and negatively correlated with adiposity (reflecting the insulating properties of adipose tissue). We estimated that 1 lb of body fat could be burned more quickly with 1 Hz training (58 d) as compared with 3 Hz training (87 d) if an identical number of pulses were delivered.

CONCLUSION

Low-frequency stimulation increased energy expenditure per pulse and may be a feasible option to subsidize physical activity to improve metabolic status after SCI.

The Systematic Design of a Behavioural Mobile Health Application for the Self-Management of Type 2 Diabetes

Patients with diabetes often face serious complications due to limited self-management skills, the inability to adhere to care regimens, and psychosocial factors. Although regular self-monitoring of blood glucose is known to benefit patients receiving insulin therapy, its role in patients not treated with insulin has been unclear. However, recent studies have demonstrated that structured self-monitoring of blood glucose can significantly benefit patients who are not taking insulin, facilitating improved self-awareness and clinical decision making. We hypothesize that effective self-management by patients with type 2 diabetes who do not need insulin requires a behavioural intervention that enables the association between lifestyle behaviours, such as dietary intake and physical activity, and overall glycemic control. Mobile health applications (apps), coupled with wireless medical peripheral devices, can facilitate self-monitoring; deliver tailored, actionable knowledge; elicit positive behaviour changes and promote effective self-management of diabetes. Although existing apps incorporate tracking and feedback from healthcare providers, few attempt to elicit positive behaviour changes for the purposes of developing patients' self-care skills. The purpose of this article is to present a systematic approach to the design and development a diabetes self-management mobile app, which included 1) a scoping review of literature; 2) the development of an overarching theoretical approach and 3) validation of the app features through user-centred design methods. The resulting app, bant II, facilitates 1) self-monitoring of blood glucose, physical activity, diet and weight; 2) identification of glycemic patterns in relation to lifestyle; 3) remedial decision making and 4) positive behaviour change through incentives.

Cross-sectional and longitudinal associations between objectively measured sedentary time and metabolic disease: the Coronary Artery Risk Development in Young Adults (CARDIA) study

OBJECTIVE

Prolonged sedentary time (ST) might be contributing to the diabetes epidemic, but most studies have been cross-sectional and few have objectively measured ST. The purpose of this study was to evaluate cross-sectional and 5-year longitudinal relationships between ST and metabolic parameters and outcomes.

RESEARCH DESIGN AND METHODS

This was an analysis of 2,027 Coronary Artery Risk Development in Young Adults (CARDIA) study participants (aged 38-50 years, 57% female, and mean BMI of 29.0 ± 7.0 kg/m(2)) with accelerometry data (≥4 days with ≥10 h/day) measured at the year 20 follow-up exam (2005-2006). Metabolic variables (fasting glucose, fasting insulin, 2-h postchallenge glucose, HOMA of insulin resistance [HOMA-IR], and HbA1c) and outcomes (impaired fasting glucose [IFG], impaired glucose tolerance [IGT], prediabetes by HbA1c, and diabetes) were assessed concurrently and 5 years later.

RESULTS

Average ST was 8.1 ± 1.7 h/day or 55 ± 10% of wear time. Each additional hour per day of ST was cross-sectionally associated with a 3% higher fasting insulin and HOMA-IR (both P < 0.01) but not 5-year changes in metabolic parameters. Having ≥10 h/day vs. <6 h/day of ST was associated with an odds ratio (OR) = 2.74 (95% CI 1.13, 6.62) for IGT and an OR = 3.80 (95% CI 1.39, 10.35) for diabetes. ST was not associated with prevalent IFG, prevalent prediabetes by HbA1c, or 5-year incidence of any metabolic outcomes (all P > 0.05).

CONCLUSIONS

ST was independently related to insulin, HOMA-IR, and prevalent diabetes and IGT but did not predict 5-year changes in metabolic parameters or incidence of metabolic outcomes. These results suggest that higher ST may not be a risk factor for future metabolic outcomes, but more research with repeated ST measurement and longer follow-up is needed.

Physical Activity and Health: "What is Old is New Again"

Much recent interest has focused on the relationship between physical activity and health and supported with an abundance of scientific evidence. However, the concept of Exercise is Medicine™ copromoted by the American College of Sports Medicine and American Medical Association and similar august bodies worldwide is far from new--the importance of exercise for health has been reported for centuries. Participation in regular physical activity and exercise provides numerous benefits for health with such benefits typically varying according to the volume completed as reflected by intensity, duration, and frequency. Evidence suggests a dose-response relationship such that being active, even to a modest level, is preferable to being inactive or sedentary. Greatest benefits are commonly associated with the previously sedentary individual assuming a more active lifestyle. There is an apparent linear relationship between physical activity and health status and as a general rule, increases in physical activity and fitness result in additional improvements in health status. This narrative review provides a selective appraisal of the evidence for the importance of physical activity for health, commencing with a baseline historical perspective followed by a summary of key health benefits associated with an active lifestyle.

Sick of sitting

Sitting too much kills. Epidemiological, physiological and molecular data suggest that sedentary lifestyle can explain, in part, how modernity is associated with obesity, more than 30 chronic diseases and conditions and high healthcare costs. Excessive sitting--sitting disease--is not innate to the human condition. People were designed to be bipedal and, before the industrial revolution, people moved substantially more throughout the day than they do presently. It is encouraging that solutions exist to reverse sitting disease. Work environments, schools, communities and cities can be re-imagined and re-invented as walking spaces, and people thereby offered more active, happier, healthier and more productive lives.

Exercise strategies to optimize glycemic control in type 2 diabetes: a continuing glucose monitoring perspective

IN BRIEF The introduction of continuous glucose monitoring (CGM) several years ago enabled researchers to investigate the impact of exercise strategies on 24-hour glycemic control. Such unique information on the glucoregulatory properties of exercise will ultimately lead to more effective exercise programs to prevent and treat type 2 diabetes. This article reviews the role of exercise and physical activity in the treatment of type 2 diabetes, complemented by recent data obtained by CGM.

Impaired glycemia increases disease progression in mild cognitive impairment

Insulin resistance and type 2 diabetes are associated with cognitive decline and increased risk for Alzheimer's disease (AD). Relatively few studies have assessed the impact of metabolic dysfunction on conversion to AD in mild cognitive impairment (MCI), and it is unclear whether glycemic status is associated with clinically relevant measures of cognitive decline and brain structure in MCI. This study used the Alzheimer's Disease Neuroimaging Initiative database to examine the relationship of baseline glycemia with conversion to AD and longitudinal clinical, cognitive, and imaging measures of decline. Subjects with MCI (n = 264) with baseline and 2-year Clinical Dementia Rating data available were classified according to American Diabetes Association criteria for fasting glucose at baseline. The groups were normoglycemic (fasting glucose, <100 mg/dL; n = 167) or impaired glycemia (fasting glucose, ≥ 100 mg/dL, n = 97). The impaired glycemia group included individuals with fasting glucose that either reached the American Diabetes Association cut point for impaired fasting glucose or individuals with diagnosed diabetes. Two-year change in Clinical Dementia Rating-Sum of Boxes, cognitive performance testing (global cognition), brain volume (whole-brain and hippocampal volume), fluorodeoxyglucose-positron emission tomography, and conversion to AD were assessed. Subjects with normoglycemia at baseline had less functional (Clinical Dementia Rating-Sum of Boxes) and global cognitive decline over 2 years than subjects with impaired glycemia. Subjects with normoglycemia also lost less whole-brain volume and exhibited lower conversion from MCI to AD. There was no difference in hippocampal volume change or fluorodeoxyglucose-positron emission tomography between groups. These results suggest that baseline glycemia is related to cognitive decline and progression to AD.