Association between physical activity and risk of all-cause mortality and cardiovascular disease in patients with diabetes: a meta-analysis

The Influence of Metabolic Risk Factors on the Inflammatory Response Triggered by Myocardial Infarction: Bridging Pathophysiology to Treatment

Myocardial infarction (MI) sets off a complex inflammatory cascade that is crucial for effective cardiac healing and scar formation. Yet, if this response becomes excessive or uncontrolled, it can lead to cardiovascular complications. This review aims to provide a comprehensive overview of the tightly regulated local inflammatory response triggered in the early post-MI phase involving cardiomyocytes, (myo)fibroblasts, endothelial cells, and infiltrating immune cells. Next, we explore how the bone marrow and extramedullary hematopoiesis (such as in the spleen) contribute to sustaining immune cell supply at a cardiac level. Lastly, we discuss recent findings on how metabolic cardiovascular risk factors, including hypercholesterolemia, hypertriglyceridemia, diabetes, and hypertension, disrupt this immunological response and explore the potential modulatory effects of lifestyle habits and pharmacological interventions. Understanding how different metabolic risk factors influence the inflammatory response triggered by MI and unraveling the underlying molecular and cellular mechanisms may pave the way for developing personalized therapeutic approaches based on the patient's metabolic profile. Similarly, delving deeper into the impact of lifestyle modifications on the inflammatory response post-MI is crucial. These insights may enable the adoption of more effective strategies to manage post-MI inflammation and improve cardiovascular health outcomes in a holistic manner.

Accelerometer-derived physical activity and mortality in individuals with type 2 diabetes

Physical activity (PA) has been shown to reduce diabetes mortality, but largely based on imprecise self-reported data, which may hinder the development of related recommendations. Here, we perform a prospective cohort study of 19,624 individuals with type 2 diabetes (T2D) from the UK Biobank with a median follow-up of 6.9 years. Duration and intensity of PA are measured by wrist-worn accelerometers over a 7-day period. We observe L-shaped associations of longer duration of PA, regardless of PA intensity, with risks of all-cause and cancer mortality, as well as a negatively linear association with cardiovascular disease mortality. 12.7%, 15.8%, and 22.3% of deaths are attributable to the lowest level of light-intensity, moderate-intensity PA, and vigorous-intensity PA, respectively. Collectively, our findings provide insights for clinical guidelines that should highlight the potential value of adherence to greater intensity and duration of PA for patients with T2D.

The effects of physical activity on sleep architecture and mood in naturalistic environments

Physical activity has been found to alter sleep architecture, but these effects have been studied predominantly in the laboratory and the generalizability of these findings to naturalistic environments and longer time intervals, as well as their psychological effects, have not been evaluated. Recent technological advancements in wearable devices have made it possible to capture detailed measures of sleep outside the lab, including timing of specific sleep stages. In the current study, we utilized photoplethysmography coupled with accelerometers and smartphone ambulatory assessment to collect daily measurements of sleep, physical activity and mood in a sample of N = 82 over multi-month data collection intervals. We found a robust inverse relationship between sedentary behavior and physical activity and sleep architecture: both low-intensity and moderate-to-vigorous physical activity were associated with increased NREM sleep and decreased REM sleep, as well as a longer REM latency, while higher levels of sedentary behavior showed the opposite pattern. A decreased REM/NREM ratio and increased REM latency were in turn associated with improved wellbeing, including increased energy, reduced stress and enhanced perceived restfulness of sleep. Our results suggest that physical activity and sleep account for unique variance in a person's mood, suggesting that these effects are at least partially independent.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Association of aerobic and muscle-strengthening physical activity with all-cause and cardiovascular disease mortality among adults with type 2 diabetes: A prospective cohort of US adults

OBJECTIVE

To investigate the relationship of moderate physical activity (MPA), vigorous physical activity (VPA), and muscle strengthening activity (MSA), independently and jointly, with all-cause, cardiovascular disease (CVD), and non-CVD mortality in individuals with type 2 diabetes (T2D).

MATERIAL AND METHODS

This cohort study included 47,538 adults with T2D and 561,963 adults without T2D from the National Health Interview Survey 1997-2018 who provided data on self-reported physical activity (PA). Mortality data were obtained from the National Death Index through 2019. Cox regression was used to estimate hazard ratio (HR) and 95% confidence interval (CI).

RESULTS

In analyses mutually adjusted, versus no MPA adults with T2D, performing the recommendations of MPA (150-299 min/week) associated with lower all-cause mortality (HR, 0.72; 95% CI, 0.66-0.78), CVD mortality (HR, 0.68; 95% CI, 0.58-0.79), and non-CVD mortality (HR, 0.72; 95% CI, 0.65-0.79). Similar benefits were observed in those meeting recommendations for VPA and MSA. Higher levels of PA beyond current recommendations may provide a few additional benefits without adverse effects on mortality risk, regardless of diabetes onset age, duration of diabetes, and medication status. The joint analysis indicates that combining MSA with aerobic PA could further lower mortality risk, and lowest all-cause mortality was observed among individuals engaging in either 75-150 min/week of VPA and 1 time/week of MSA (HR, 0.30; 95% CI, 0.13-0.70) or 150-299 min/week of MPA and 1 time/week of MSA (HR, 0.33; 95% CI, 0.20-0.55).

CONCLUSION

Our study supports the current PA guidelines and suggests that there may be limited benefits gained from exercising beyond recommended levels in adults with T2D, combining recommended levels of aerobic and resistance exercises could yield the greatest benefits.

Leisure-Time Physical Activity and Risk of Microvascular Complications in Individuals With Type 2 Diabetes: A UK Biobank Study

OBJECTIVE

The aim of this study was to determine dose-response associations, including the minimal effective level, between leisure-time physical activity and risk of incident neuropathy, nephropathy, and retinopathy.

RESEARCH DESIGN AND METHODS

This cohort study included 18,092 individuals with type 2 diabetes from the UK Biobank. Self-reported leisure-time physical activity was converted into MET-hours per week. Participants were categorized into no physical activity (0 MET-h/week), below recommendations (0-7.49 MET-h/week), at recommendations (7.5-14.9 MET-h/week), and above recommendations (≥15 MET-h/week). Microvascular complications were identified from hospital inpatient records using diagnosis codes. We used Cox proportional hazards regression analysis to calculate adjusted hazard ratios (aHRs) and restricted cubic splines to identify the minimal effective level of physical activity.

RESULTS

During a median follow-up of 12.1 years, 672 individuals (3.7%) were diagnosed with neuropathy, 1,839 (10.2%) with nephropathy, and 2,099 (11.7%) with retinopathy. Any level of physical activity was associated with a lower risk of neuropathy and nephropathy but not retinopathy. Compared with those reporting no physical activity, the aHR of neuropathy was 0.71 (95% CI 0.53, 0.90) below recommendations, 0.73 (0.56, 0.96) at recommendations, and 0.67 (0.52, 0.87) above recommendations. Corresponding aHRs for nephropathy were 0.79 (0.68, 0.92), 0.80 (0.67, 0.95), and 0.80 (0.68, 0.95). The association with retinopathy was weaker, with aHRs of 0.91 (0.78, 1.06), 0.91 (0.77, 1.08), and 0.98 (0.84, 1.15), respectively.

CONCLUSIONS

Any level of leisure-time physical activity was associated with a lower risk of neuropathy and nephropathy but not retinopathy in individuals with type 2 diabetes. For both neuropathy and nephropathy, the minimal effective physical activity level may correspond to <1.5 h of walking per week.

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

AIMS

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Time trajectories of key cardiometabolic parameters and of cardiovascular risk in subjects with diabetes in a real world setting

BACKGROUND AND AIMS

Diabetes is associated with increased cardiovascular risk. Glycated haemoglobin (HbA_1c), lipid parameters and blood pressure are known risk factors for adverse outcome. The aim of the study was to explore the time trajectories of these key parameters and of the associated cardiovascular risk.

METHODS

We linked the diabetes electronic health records to the laboratory information system so as to investigate the trajectories of key metabolic parameters from 3 years prior to the diagnosis of diabetes to 10 years after diagnosis. We calculated the cardiovascular risk at the different time points during this period using the United Kingdom Prospective Study (UKPDS) risk engine.

RESULTS

The study included 21,288 patients. The median age at diagnosis was 56 years and 55.3% were male. There was a sharp decrease in HbA_1c after diagnosis of diabetes, but there was a progressive rise thereafter. All lipid parameters after diagnosis also improved in the year of diagnosis, and these improvements persisted even up to 10 years post-diagnosis. There was no discernible trend in mean systolic or diastolic blood pressures following diagnosis of diabetes. There was a slight decrease in the UKPDS-estimated cardiovascular risk after diagnosis of diabetes followed by a progressive increase. Estimated glomerular filtration rate declined at an average rate of 1.33 ml/min/1.73 m²/year.

CONCLUSIONS

Our data suggest that lipid control should be tightened with increasing duration of diabetes since this is more readily achievable than HbA_1c lowering and since other factors such as age and duration of diabetes are unmodifiable.

Empowering People with Diabetes: Role of Continuous Glucose Monitor Systems

Continuous glucose monitoring in a person with diabetes who is embracing lifestyle changes can be greatly impactful in numerous ways. There are many factors that have been identified to affect blood glucose, and for someone who may be implementing the six pillars of lifestyle medicine, their blood sugar may require closer monitoring. Lifestyle medicine interventions may lead to improved glucose levels or even remission. The continuous glucose monitor allows people to see glucose levels, trends, and how rapidly their glucose levels are rising or dropping, empowering them to make connections with how they feel and how their actions are impacting their blood sugar, as well as giving information about how medications may need to be adjusted or deprescribed. CGM, when appropriately used, can help determine how to best manage diabetes, optimize outcomes, minimize risks, and empower the person and healthcare team.

The physical exercise-induced oxidative/inflammatory response in peripheral blood mononuclear cells: Signaling cellular energetic stress situations

Peripheral blood mononuclear cells (PBMCs) are a variety of specialized immune cells produced in the bone marrow from hematopoietic stem cells (HSCs) that work together to protect our bodies from harmful pathogens. From a metabolic point of view, these cells can serve as sentinel tissue source for distinguishing multiple types of whole-body physiological perturbations. The significant interaction of PBMCs with systemic physiology makes these cells an attractive target for several interventions such as physical exercise. Analyses of oxidative/inflammatory and metabolic markers of PBMCs obtained from unhealthy and healthy humans have been used in monitoring immune response in different exercise conditions. It is already a common consensus that regular practice of physical exercise, that is planned, structured, and repetitive, influences personal health by altering the metabolic state and the immune system. However, the role of distinct metabolic processes responsible for maintaining metabolic balance during physical exercise in PBMCs is not fully understood. Furthermore, a complete dose-response analysis between different exercise protocols and biomarkers capable of predicting physical performance needs to be better elucidated. The absence of published reviews on this topic compromises the understanding of the crosstalk between the metabolic adaptations of PBMCs and exercise-induced changes in the immune system. Given the above, this review highlights the main findings in the literature involving the responses of PBMCs in the inflammatory/oxidative stress induced by physical exercise. The present review also highlights how distinct phenotypes and functional diversity of PBMCs make these cells an accessible alternative for assessing exercise-induced metabolic adaptations.

A novel health behaviour intervention to promote adherence in kidney failure

BACKGROUND

Health behaviour adherence is associated with improved survival in kidney failure (KF); however, most patients with KF do not adhere to one or more health behaviours. Existing health behaviour interventions have significant limitations and do not focus on psychological factors that are associated with adherence and health.

OBJECTIVES

To examine the feasibility, acceptability, and preliminary efficacy of a 12-week, phone-delivered, positive psychology-motivational interviewing (MI) intervention to promote psychological well-being and adherence in KF.

DESIGN

Single-arm, proof-of-concept trial (N = 10).

PARTICIPANTS

Participants were adults with KF undergoing haemodialysis and reporting suboptimal adherence to physical activity, diet, and/or medications. Participants attended weekly phone sessions with a study trainer, completed weekly positive psychology exercises (focused on gratitude, strengths, and meaning), and worked towards physical activity, diet, and/or medication goals.

MEASUREMENTS

Feasibility was measured by the percentage of sessions completed, while acceptability was assessed through participant ratings of positive psychology and MI session ease and utility (0-10 Likert scales). We explored the intervention's impact on psychological outcomes and health behaviour adherence using validated scales and accelerometers.

RESULTS

Participants completed 78% of sessions and rated the program's components as easy to complete (positive psychology: 8.7 ± 1.5; MI: 8.3 ± 2.0) and subjectively helpful (positive psychology: 8.8 ± 1.2; MI: 8.8 ± 1.6). The intervention led to promising but nonsignificant improvements in psychological and adherence measures.

CONCLUSIONS

This 12-week, phone-delivered program was feasible, well-accepted, and associated with nonsignificant improvements health behaviour adherence, highlighting the need for a larger efficacy trial.

The Effect of Exercise on Serum Resistin and Leptin Values in Rats Fed with a High Fat Diet

Aim: This study was performed to investigate the effect of exercise on serum resistin and leptin values in rats fed with a high-fat diet. Material and Method: 24 Wistar albino male rats were used in the study. They were randomly divided into 4 groups, with 6 rats in each group. The groups were determined as the control group (C), exercise group (E), high-fat diet (HFD) group, and high-fat diet + exercise (HFDE) Group. Results: When the findings obtained in this study were evaluated statistically, it was determined that the resistin values were similar in the C, E and HFDE groups, and higher in the HFD group compared to the other groups. It was observed that resistin value increased with high-fat diet and decreased with exercise. When evaluated in terms of leptin levels, the C and E groups showed similarity, while the HFD and HFDE groups showed similarity with each other. Although exercise decreased the leptin level, which was highly increased with a high-fat diet, it was not statistically significant. Conclusion: It has been determined that feeding with a high-fat diet causes an increase in serum resistin and leptin levels, and exercise provides a significant decrease in resistin values, but is not effective in leptin levels.

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

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

Physical activity, cardiorespiratory fitness, and cardiovascular health: A clinical practice statement of the American Society for Preventive Cardiology Part II: Physical activity, cardiorespiratory fitness, minimum and goal intensities for exercise training, prescriptive methods, and special patient populations

The prescription of exercise for individuals with and without cardiovascular disease (CVD) should be scientifically-based yet adapted to the patient. This scientific statement reviews the clinical and physiologic basis for the prescription of exercise, with specific reference to the volume of physical activity (PA) and level of cardiorespiratory fitness (CRF) that confer significant and optimal cardioprotective benefits. Recommendations are provided regarding the appropriate intensity, frequency, and duration of training; the concept of MET-minutes per week; critical components of the exercise session (warm-up, conditioning phase, cool-down); methodologies for establishing the training intensity, including oxygen uptake reserve (V̇O2R), target heart rate derivation and rating perceived exertion; minimum and goal intensities for exercise training; and, types of training activities, including resistance training, adjunctive lifestyle PA, marathon/triathlon training, and high-intensity interval training. In addition, we discuss the rationale for and value of exercise training programs for patients with peripheral artery disease, diabetes mellitus, and heart failure.

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

BACKGROUND

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

PURPOSE

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

DATA SOURCES

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

STUDY SELECTION

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

DATA EXTRACTION

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

DATA SYNTHESIS

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

LIMITATIONS

Limitations include residual confounding and misclassification of exposure.

CONCLUSIONS

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

Type 2 diabetes

Type 2 diabetes accounts for nearly 90% of the approximately 537 million cases of diabetes worldwide. The number affected is increasing rapidly with alarming trends in children and young adults (up to age 40 years). Early detection and proactive management are crucial for prevention and mitigation of microvascular and macrovascular complications and mortality burden. Access to novel therapies improves person-centred outcomes beyond glycaemic control. Precision medicine, including multiomics and pharmacogenomics, hold promise to enhance understanding of disease heterogeneity, leading to targeted therapies. Technology might improve outcomes, but its potential is yet to be realised. Despite advances, substantial barriers to changing the course of the epidemic remain. This Seminar offers a clinically focused review of the recent developments in type 2 diabetes care including controversies and future directions.

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

AIM

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

METHODS

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

RESULTS

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

CONCLUSION

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

Type 2 Diabetes Incidence and Mortality: Associations with Physical Activity, Fitness, Weight Loss, and Weight Cycling

Cardiometabolic diseases, including cardiovascular disease (CVD) and type 2 diabetes (T2D), are the leading cause of death globally. Because T2D and obesity are strongly associated, weight loss is the cornerstone of treatment. However, weight loss is rarely sustained, which may lead to weight cycling, which is associated with increased mortality risk in patients with T2D. Meta-analyses show that weight loss is not generally associated with reduced mortality risk in T2D, whereas weight cycling is associated with increased all-cause and CVD mortality. This may be attributable in part to increased variability in CVD risk factors that often accompany weight cycling, which studies show is consistently associated with adverse CVD outcomes in patients with T2D. The inconsistent associations between weight loss and mortality risk in T2D, and consistent findings of elevated mortality risk associated with weight cycling, present a conundrum for a weight-loss focused T2D prevention and treatment strategy. This is further complicated by the findings that among patients with T2D, mortality risk is lowest in the body mass index (BMI) range of ~25-35 kg/ m 2 . Because this "obesity paradox" has been consistently demonstrated in 7 meta-analyses, the lower mortality risk for individuals with T2D in this BMI range may not be all that paradoxical. Physical activity (PA), cardiorespiratory fitness (CRF), and muscular fitness (MF) are all associated with reduced risk of T2D, and lower risk of CVD and all-cause mortality in individuals with T2D. Reducing sedentary behavior, independent of PA status, also is strongly associated with reduced risk of T2D. Improvements in cardiometabolic risk factors with exercise training are comparable to those observed in weight loss interventions, and are largely independent of weight loss. To minimize risks associated with weight cycling, it may be prudent to adopt a weight-neutral approach for prevention and treatment of individuals with obesity and T2D by focusing on increasing PA and improving CRF and MF without a specific weight loss goal.

Exercise for Primary and Secondary Prevention of Cardiovascular Disease: JACC Focus Seminar 1/4

Regular exercise that meets or exceeds the current physical activity guidelines is associated with a reduced risk of cardiovascular disease (CVD) and mortality. Therefore, exercise training plays an important role in primary and secondary prevention of CVD. In this part 1 of a 4-part focus seminar series, we highlight the mechanisms and physiological adaptations responsible for the cardioprotective effects of exercise. This includes an increase in cardiorespiratory fitness secondary to cardiac, vascular, and skeletal muscle adaptations and an improvement in traditional and nontraditional CVD risk factors by exercise training. This extends to the role of exercise and its prescription in patients with CVDs (eg, coronary artery disease, chronic heart failure, peripheral artery disease, or atrial fibrillation) with special focus on the optimal mode, dosage, duration, and intensity of exercise to reduce CVD risk and improve clinical outcomes in these patients.

Fresh fruit consumption, physical activity, and five-year risk of mortality among patients with type 2 diabetes: A prospective follow-up study

BACKGROUND AND AIMS

We explored the associations among fruit consumption, physical activity, and their dose-response relationship with all-cause and cardiovascular disease (CVD) mortality in type 2 diabetic patients.

METHODS AND RESULTS

We prospectively followed 20,340 community-dwelling type 2 diabetic patients aged 21-94 years. Information on diets and physical activity was collected using standardized questionnaires. All-cause and CVD mortality were assessed. Hazard ratios (HRs) for all-cause mortality were estimated with Cox regression models, and HRs for CVD mortality were derived from a competing risk model. Restricted cubic spline regression was used to analyze dose-response relationships. We identified 1362 deaths during 79,844 person-years. Compared to non-consumption, fruit consumption >42.9 g/d was inversely associated with all-cause mortality (HR 0.76; 95% CI 0.64-0.88), CVD mortality (HR 0.69, 0.51-0.94) and stroke mortality (HR 0.57, 0.36-0.89), but not with heart disease mortality (HR 0.93, 0.56-1.52). The HRs comparing the top vs bottom physical activity quartiles were 0.44 (0.37-0.53) for all-cause mortality, 0.46 (0.33-0.64) for CVD mortality, 0.46 (0.29-0.74) for stroke mortality and 0.51 (0.29-0.88) for heart disease mortality. Lower fruit consumption combined with a lower physical activity level was associated with a greater mortality risk. A nonlinear threshold of 80 g fruit/day was identified; all-cause mortality risk was reduced by approximately 24% at this value. A physical activity threshold of eight metabolic equivalents (MET) h/day was also identified, after which the risk of mortality did not decrease.

CONCLUSIONS

Fruit consumption and physical activity may reduce all-cause, CVD, and stroke mortality in type 2 diabetic patients.

The association between sedentary behavior and low back pain in adults: a systematic review and meta-analysis of longitudinal studies

Background

Low back pain (LBP) is a common musculoskeletal problem globally. While spending a longer time in sedentary behaviors is linked to several health problems; the quantitative association between different amounts of sedentary time and LBP is still unknown. This study aims to systematically review studies that examined the association between sedentary behavior and LBP development and LBP-related outcomes.

Methods

This systematic review and meta-analysis retrieved journal articles published from inception to March 2020 and were obtained by searching bibliographical databases. We included longitudinal study designs, including adult (aged ≥18) individuals with nonspecific LBP, and reporting estimates of the association between sedentary behavior and LBP development and LBP-related outcomes (i.e., pain intensity and disability).

Results

Sixteen longitudinal studies with 100,002 participants were included in this review (eight studies included in quantitative syntheses with 83,111 participants). The results of meta-analyses showed that a sedentary time of 3-<6 (Odds ratio (OR) 0.95, 95% CI [0.85-1.07]), 6-8 (OR 0.95, 95% CI [0.88-1.02]), and >8 (OR 0.92, 95% CI [0.85-1.00]) hours per day (h/d) was not associated with LBP development. A sedentary time of ≥3 h/d was associated with poor LBP-related disability (OR 1.24, 95% CI [1.02-1.51]), but not with pain intensity.

Conclusion

A meta-analyses of longitudinal studies indicated that sedentary behavior of different durations was not associated with LBP development. However, the results showed that sedentary behavior ≥3 h/d was associated with worse LBP-related disability. These conclusions are tentative as the evidence was derived from mostly fair-quality studies using subjective measures of sedentary behavior.

Systematic review registration

PROSPERO (registration number CRD42018107078).

A phone and text message intervention to improve physical activity in midlife: initial feasibility testing

Background

Physical activity during midlife (ages 45-64) plays a major role in the prevention of chronic and serious medical conditions. Unfortunately, many midlife adults struggle to be physically active in the setting of low levels of psychological well-being and the management of multiple confluent sources of stress. Effective, scalable, midlife-specific interventions are needed to promote physical activity and prevent the development of chronic medical conditions.

Objectives

In an initial proof-of-concept trial, we assessed the feasibility and acceptability of a new, midlife-adapted, phone- and text message-based intervention using positive psychology (PP) skill-building and motivational interviewing (MI) techniques. We secondarily analyzed post-intervention changes in accelerometer-measured physical activity and self-reported outcomes.

Methods

The PP-MI intervention included six weekly phone sessions with a study trainer, with completion of PP activities and physical activity goals between calls, and in the subsequent six weeks briefer phone check-ins were conducted. Text messages over the 12-week intervention period were utilized to support participants and identify barriers to goal completion. Feasibility (session completion rates) and acceptability (participant ratings of intervention ease and utility) were assessed via descriptive statistics, and pre-post improvements in psychological, functional, and physical activity outcomes at 12 weeks were examined via mixed effects regression models.

Results

Twelve midlife adults with low baseline physical activity enrolled in the single-arm trial. Overall, 76.8% of all possible sessions were completed by participants, and mean ratings of weekly phone sessions were 8.9/10 (SD 1.6), exceeding our a priori thresholds for feasibility and acceptability. Participants demonstrated generally medium to large effect size magnitude improvements in accelerometer-measured physical activity, psychological outcomes, and function.

Conclusions

A novel, midlife-specific phone- and text-based PP-MI intervention was feasible and had promising effects on physical activity and other clinically relevant outcomes, supporting next-step testing of this program via a randomized controlled trial.

Effect of the interaction between physical activity and estimated macronutrient intake on HbA1c: population-based cross-sectional and longitudinal studies

INTRODUCTION

Healthy diet and physical activity (PA) are essential for preventing type 2 diabetes, particularly, a combination of diet and PA. However, reports on interaction between PA and diet, especially from large epidemiological studies, are limited. We investigated the effect of interaction between PA and macronutrient intake on hemoglobin A1c (HbA1c) levels in the general population.

RESEARCH DESIGN AND METHODS

We conducted a cross-sectional study of 55 469 men and women without diabetes who participated in the baseline survey of the Japan Multi-Institutional Collaborative Cohort Study. A self-administered questionnaire ascertained PA and macronutrient intake (carbohydrate, fat, and protein). Multiple linear regression analyses were performed to adjust for confounding variables and examine the interactions. In addition, we conducted a longitudinal study during a 5-year period within a subcohort (n=6881) with accelerometer-assessed PA data.

RESULTS

Overall, PA had a weak inverse association (β=-0.00033, p=0.049) and carbohydrate intake had a strong positive association (β=0.00393, p<0.001) with HbA1c. We observed a tendency of interactions between PA and carbohydrate or fat intake, but not protein intake, on HbA1c levels after adjusting for age, sex, study area, total energy intake, alcohol consumption, smoking, and medication for hypertension or hypercholesterolemia (Pinteraction=0.054, 0.006, and 0.156, respectively). The inverse associations between PA and HbA1c level were more evident in participants with high-carbohydrate (or low-fat) intake than in participants with low-carbohydrate (or high-fat) intake. Although further adjustment for body mass index slightly attenuated the above interactions (Pinteraction=0.098 for carbohydrate and 0.068 for fat), the associations between PA and HbA1c level in stratified analyses remained unchanged. Similar associations and interactions were reproduced in the longitudinal study.

CONCLUSIONS

The present results suggest that the effect of PA on HbA1c levels is modified by intake of macronutrient composition.

Association between physical activity and mortality in end-stage kidney disease: a systematic review of observational studies

BACKGROUND

End-stage Kidney Disease patients have a high mortality and hospitalization risk. The association of these outcomes with physical activity is described in the general population and in other chronic diseases. However, few studies examining this association have been completed in end-stage Kidney Disease patients, raising the need to systematically review the evidence on the association of physical activity with mortality and hospitalization in this population.

METHODS

Electronic databases (EBSCO, Scopus and Web of Science) and hand search were performed until March 2020 for observational studies reporting the association of physical activity with mortality or hospitalization in adult end-stage Kidney Disease patients on renal replacement therapy (hemodialysis, peritoneal dialysis and kidney transplant). Methodological quality of the included studies was assessed using the Quality in Prognosis Studies tool. The review protocol was registered in PROSPERO (CRD42020155591).

RESULTS

Eleven studies were included: six in hemodialysis, three in kidney transplant, and two in hemodialysis and peritoneal dialysis patients. Physical activity was self-reported, except in one study that used accelerometers. All-cause mortality was addressed in all studies and cardiovascular mortality in three studies. Nine studies reported a significant reduction in all-cause mortality with increased levels of physical activity. Evidence of a dose-response relationship was found. For cardiovascular mortality, a significant reduction was observed in two of the three studies. Only one study investigated the association of physical activity with hospitalization.

CONCLUSIONS

Higher physical activity was associated with reduced mortality in end-stage Kidney Disease patients. Future studies using objective physical activity measures could strengthen these findings. The association of physical activity with hospitalization should be explored in future investigations.

Association between Physical Activity and Seasonal Variations in Metabolic and Vascular Function in Adults

This article highlights the association between physical activity (PA) and seasonal variations in metabolic and vascular function in adults. Increasing PA is an important method for preventing cardiovascular disease (CVD) and all-cause mortality by improving blood glucose, blood pressure, blood lipid profiles, body fat, insulin resistance, and vascular function, such as endothelial function. Conversely, various factors, such as seasonal climate conditions, may affect the amount of PA that individuals undertake. Changes in PA often induce seasonal variations in metabolic and vascular function; the deterioration of such functions in winter is the most prominent, and there is clear evidence of an increased risk of CVD in this season. Understanding the influence of PA on seasonal variations observed in metabolic and vascular function is necessary for the management of these physiological functions. In this article summary, few studies have proven that maintaining PA can suppress the variations, and it remains unclear what types, intensities, and durations of regular PA are effective for circumventing seasonal impact. In addition to further studies, there is a need to educate individuals about the strategies to manage PA and other aspects of their lifestyles throughout the year, particularly in winter.

Insulin-mediated muscle microvascular perfusion and its phenotypic predictors in humans

Insulin increases muscle microvascular perfusion and enhances tissue insulin and nutrient delivery. Our aim was to determine phenotypic traits that foretell human muscle microvascular insulin responses. Hyperinsulinemic euglycemic clamps were performed in 97 adult humans who were lean and healthy, had class 1 obesity without comorbidities, or controlled type 1 diabetes without complications. Insulin-mediated whole-body glucose disposal rates (M-value) and insulin-induced changes in muscle microvascular blood volume (ΔMBV) were determined. Univariate and multivariate analyses were conducted to examine bivariate and multivariate relationships between outcomes, ΔMBV and M-value, and predictor variables, body mass index (BMI), total body weight (WT), percent body fat (BF), lean body mass, blood pressure, maximum consumption of oxygen (VO2max), plasma LDL (LDL-C) and HDL cholesterol, triglycerides (TG), and fasting insulin (INS) levels. Among all factors, only M-value (r = 0.23, p = 0.02) and VO2max (r = 0.20, p = 0.047) correlated with ΔMBV. Conversely, INS (r = - 0.48, p ≤ 0.0001), BF (r = - 0.54, p ≤ 0.001), VO2max (r = 0.5, p ≤ 0.001), BMI (r = - 0.40, p < 0.001), WT (r = - 0.33, p = 0.001), LDL-C (r = - 0.26, p = 0.009), TG (r = - 0.25, p = 0.012) correlated with M-value. While both ΔMBV (p = 0.045) and TG (p = 0.03) provided significant predictive information about M-value in the multivariate regression model, only M-value was uniquely predictive of ΔMBV (p = 0.045). Thus, both M-value and VO2max correlated with ΔMBV but only M-value provided unique predictive information about ΔMBV. This suggests that metabolic and microvascular insulin responses are important predictors of one another, but most metabolic insulin resistance predictors do not predict microvascular insulin responses.

Green space and cardiovascular health in people with type 2 diabetes

Associations between green space type and 9-year risk of incident cardiovascular disease (CVD) hospitalisations and deaths were analysed in 4166 people with type 2 diabetes in the Sax Institute's 45 and Up Study. Incidence of all-cause mortality, cardiovascular mortality, fatal or non-fatal CVD events and acute myocardial infarctions (AMI) were 14.67%, 7.23%, 47.36%, and 4.51%, respectively. After full adjustment, more tree canopy was associated with lower CVD mortality, lower fatal or non-fatal CVD events, and lower AMI risk. More open grass was associated with lower all-cause mortality, lower CVD mortality and lower fatal or non-fatal CVD events, but higher AMI risk.

Physical activity and the risk of rheumatoid arthritis: evidence from meta-analysis and Mendelian randomization

BACKGROUND

There is very little information about the association between physical activity (PA) and the risk of rheumatoid arthritis (RA). The purpose of this study is to understand the effect of PA on subsequent risk of developing RA.

METHODS

A literature search was performed in PubMed and Web of Science up to 19 September 2020. Observational studies examining associations between PA and the RA development were identified. Categorical and dose-response meta-analyses were both performed. Then two-sample Mendelian randomization (MR) analysis was conducted to interrogate the causal relationship by utilizing genetic instruments identified from a genome-wide association study of self-reported and accelerometer-based PA traits.

RESULTS

Four eligible studies were included in the meta-analyses, involving 4213 RA cases among 255 365 participants. The summary relative risk (RR) of RA risk was 0.79 [95% confidence interval (CI): 0.72, 0.87] for the highest vs the lowest PA, and 0.85 (95% CI: 0.79, 0.92) for PA vs inactivity/occasional PA. However, we found no convincing evidence supporting a causal role of genetically predicted accelerometer-measured PA [odds ratio (OR): 0.97; 95% CI: 0.88, 1.08 per 1-SD unit increment], genetically predicted moderate-to-vigorous PA (OR: 1.08; 95% CI: 0.49, 2.39 per 1-SD unit increment) or genetically predicted vigorous PA ≥3 days/week (OR: 2.63; 95% CI: 0.05, 130.96) with RA risk.

CONCLUSIONS

The meta-analyses of the observational studies indicated that higher PA levels correlate with reduced risk of RA. In contrast to meta-analyses, the MR analyses reported here suggested PA may not help to prevent RA.

Acute high-intensity aerobic exercise increases gene expression of calcium-related proteins and activates endoplasmic reticulum stress responses in diabetic hearts

Regular aerobic exercise training has a wide range of beneficial cardiac effects, but recent data also show that acute very strenuous aerobic exercise may impose a transient cardiac exhaustion. The aim of this study was to assess the response to acute high-intensity aerobic exercise on properties of mitochondrial respiration, cardiomyocyte contractile function, Ca2+ handling and transcriptional changes for key proteins facilitating Ca2+ handling and endoplasmic reticulum (ER) stress responses in type 2 diabetic mice. Diabetic mice were assigned to either sedentary control or an acute bout of exercise, consisting of a 10×4 minutes high-intensity interval treadmill run. Mitochondrial respiration, contractile and Ca2+ handling properties of cardiomyocytes were analysed 1 hour after completion of exercise. Gene expression levels of key Ca2+ handling and ER stress response proteins were measured in cardiac tissue samples harvested 1 hour and 24 hours after exercise. We found no significant changes in mitochondrial respiration, cardiomyocyte contractile function or Ca2+ handling 1 hour after the acute exercise. However, gene expression of Atp2a2, Slc8a1 and Ryr2, encoding proteins involved in cardiomyocyte Ca2+ handling, were all significantly upregulated 24 hours after the acute exercise bout. Acute exercise also altered gene expression of several key proteins in ER stress response and unfolded protein response, including Grp94, total Xbp1, Gadd34, and Atf6. The present results show that despite no significant alterations in functional properties of cardiomyocyte function, Ca2+ handling or mitochondrial respiration following one bout of high intensity aerobic exercise training, the expression of genes involved in Ca2+ handling and key components in ER stress and the unfolded protein response were changed. These transcriptional changes may constitute important steps in initiating adaptive remodelling to exercise training in type 2 diabetes.

Responses to Low- and High-Intensity Exercise in Adolescents with Type 1 Diabetes in Relation to Their Level of VO2 Max

The purpose of this study was to investigate the influence of maximal oxygen uptake (VO₂ max) on the glycemic changes during low and high intensity exercises in young type 1 diabetic patients. Twenty boys (age: 14.3 ± 1.6 years; height: 171.0 ± 11.3 cm; weight; 59.5 ± 12.8 kg) were divided into low-fit group (LFG, n = 10) and high-fit group (HFG, n = 10). According to the experimental design, participants performed three physical efforts (VO₂ max test, mixed aerobic-anaerobic effort and aerobic effort) on the cycloergometer, during which real-time glycemia was measured. Mixed aerobic-anaerobic exercise demanded significantly smaller carbohydrate supplementation (0.2 ± 0.2 g/kg during exercise) than the aerobic test session (0.4 ± 0.3 g/kg during exercise). Moreover, patients with higher VO₂ max had lower tendency for glycemic changes during the aerobic effort. The results of the current study suggest that young type 1 diabetic patients should perform different intensity activities using continuous glycemic monitoring system to avoid acute and chronic complications of the disease.

Prescription of Physical Activity by General Practitioners in Type 2 Diabetes: Practice and Barriers in French Guiana

BACKGROUND

General practitioners (GPs) are the major primary healthcare players in the management of type 2 diabetes. In addition to a well-balanced diet, physical activity (PA) appears as a necessary non-medicinal therapy in the management of diabetic patients. However, GPs emphasize several obstacles to its prescription. The aim of this study is to evaluate the practices, barriers, and factors favoring the prescription of PA in type 2 diabetic patients by GPs in French Guiana.

METHOD

We conducted a cross-sectional descriptive study using a questionnaire, designed to interview 152 French Guiana GPs and describe their practice in prescribing PA in type 2 diabetic patients.

RESULTS

Our results revealed that the prescription of PA as a non-medicinal therapeutic choice in the management of type 2 diabetes was practiced by 74% of the French Guiana GPs. However, only 37% of GPs responded that they implemented the recommendations; indeed, only one-third knew about them. The majority of GPs were interested in PA training, but only 11% were actually trained in this practice. The lack of structure adapted to the practice of PA and the lack of awareness of the benefits of PA in metabolic pathology appeared as the main obstacles to PA prescription.

CONCLUSION

This study highlights the importance of improving the training of GPs in the prescription of PA, the development of adapted PA structures, and collaboration between the different actors within the framework of the sport-health system in type 2 diabetes in French Guiana.

Work-related factors among people with diabetes and the risk of cardiovascular diseases: A systematic review

BACKGROUND

Diabetes is a major risk factor for cardiovascular diseases (CVD). This systematic review aims to explore the work-related factors among people with diabetes in developing CVD.

METHODS

Four electronic databases were searched on 1 February 2021 using a comprehensive search strategy without any time restriction. Two independent researchers screened the articles and extracted data. The risk of bias was assessed independently using the risk of bias assessment tool for non-randomized studies (RoBANS). A narrative synthesis was conducted considering the heterogeneity of the included articles.

RESULTS

A total of five articles incorporating 4 409 810 participants from three geographic regions were included that highlights the research gap. As per the included studies, Occupational drivers with diabetes were at a higher risk of CVD in comparison to the nondrivers, workers with diabetes having a long working hour were at a higher risk of CVD mortality, workers with a lower occupational status were at a higher risk of 10-years stroke risk, and occupational physical activity and occupational commuting lowered the risk of CVD deaths.

CONCLUSIONS

This systematic review summarized the available evidence on work-related factors influencing the risk of CVD in people with diabetes. The findings should be interpreted cautiously pondering the limited evidence and imprecision. We identified only five articles related to the topic, and there were no studies from Japan. The scarcity of studies on work-related factors on the prognosis of diabetic patients implies the need for more research in this field. We recommend further exploration of the topic designing primary studies.

Global Public Health Guidelines on Physical Activity and Sedentary Behavior for People Living With Chronic Conditions: A Call to Action

Background: In 2020, the World Health Organization (WHO) released global guidelines on physical activity (PA) and sedentary behavior, for the first time providing population-based recommendations for people living with selected chronic conditions. This article briefly presents the guidelines, related processes and evidence, and, importantly, considers how they may be used to support research, practice, and policy. Methods: A brief overview of the scope, agreed methods, selected chronic conditions (adults living with cancer, hypertension, type 2 diabetes, and human immunodeficiency virus), and appraisal of systematic review evidence on PA/sedentary behavior is provided. Methods were consistent with World Health Organization protocols for developing guidelines. Results: Moderate to high certainty evidence (varying by chronic condition and outcome examined) supported that PA can reduce the risk of disease progression or premature mortality and improve physical function and quality of life in adults living with chronic conditions. Direct evidence on sedentary behavior was lacking; however, evidence extrapolated from adult populations was considered applicable, safe, and likely beneficial (low certainty due to indirectness). Conclusions: Clinical and public health professionals and policy makers should promote the World Health Organization 2020 global guidelines and develop and implement services and programs to increase PA and limit sedentary behavior in adults living with chronic conditions.

Effect of moderate-intensity seated exercise on the management of metabolic outcomes in hypertensive individuals with or without exercise habits

Background

We aimed to evaluate the effect of moderate-intensity seated exercise on metabolic outcomes in hypertensive individuals with or without exercise habits.

Methods

Forty-two hypertensive individuals volunteered for this study and were classified into 3 groups by their habits and place for moderate-intensity exercise prior to this study: NONE (<2 days/week or no exercise; n = 13), HOME (≥30 min/day and ≥2 days/week at home; n = 15), and GYM (≥30 min/day and ≥2 days/week at a hospital gym; n = 14). They performed their daily activities as usual and seated exercise (stepping and stepping with trunk rotation; a range of 11–13 on the Borg rating of perceived exertion scale) for at least 15 min/day and at least 3 days/week for 12 weeks.

Results

Thirty-five participants (age: 67.7 ± 5.9 years) completed the study, and there was no difference among the 3 groups regarding weekly exercise. The homeostasis model assessment of insulin resistance (HOMA-IR) value in the NONE group was significantly higher than that in the GYM group at baseline (p < 0.05), but it decreased significantly after 12 weeks (from 2.2 ± 0.8 to 1.7 ± 0.7, p < 0.05). Changes in HOMA-IR in the NONE group after 12 weeks was greater than that in the HOME and GYM groups (both p < 0.01). The HOME and GYM groups showed no significant changes in any of the variables.

Conclusion

Moderate-intensity seated exercise may be an effective strategy to improve insulin resistance in hypertensive individuals without exercise habits.

Dose-response relationship between physical activity and mortality in adults with noncommunicable diseases: a systematic review and meta-analysis of prospective observational studies

Background

This study aims to investigate the relationship between post-diagnosis physical activity and mortality in patients with selected noncommunicable diseases, including breast cancer, lung cancer, type 2 diabetes, ischemic heart disease, stroke, chronic obstructive pulmonary disease (COPD), osteoarthritis, low back pain and major depressive disorder.

Methods

A systematic search was conducted of PubMed, Scopus and the Web of Science from their inception to August 2018. Additionally, the search was updated in August 2019. Eligibility criteria included prospective observational studies examining the relationship between at least three physical activity categories (e.g. low, moderate, high) and all-cause mortality as the primary outcome.

Results

In total, 28 studies were included in the meta-analysis: 12 for breast cancer, 6 for type 2 diabetes, 8 for ischemic heart disease and 2 for COPD. The linear meta-analysis revealed that each 10 metabolic equivalent task hours increase of physical activity per week was associated with a 22% lower mortality rate in breast cancer patients (Summary Hazard Ratio [HR], 0.78; 95% CI: 0.71, 0.86; I²: 90.1%), 12% in ischemic heart disease patients (HR, 0.88; 95% CI: 0.83, 0.93; I²: 86.5%), 30% in COPD patients (HR, 0.70; 95% CI: 0.45, 1.09; I²: 94%) and 4% in type 2 diabetes patients (HR, 0.96; 95% CI: 0.93, 0.99; I²: 71.8%). There was indication of a non-linear association with mortality risk reductions even for low levels of activity, as well as a flattening of the curve at higher levels of activity. The certainty of evidence was low for breast cancer, type 2 diabetes and ischemic heart disease but only very low for COPD.

Conclusion

Higher levels of post-diagnosis physical activity are associated with lower mortality rates in breast cancer, type 2 diabetes, ischemic heart disease and COPD patients, with indication of a no-threshold and non-linear dose–response pattern.

Spoken Animated Self-Management Video Messages Aimed at Improving Physical Activity in People With Type 2 Diabetes: Development and Interview Study

Background

Web-based tailored interventions are a promising approach to help people with type 2 diabetes successfully adopt regular physical activity. Spoken animation seems to be effective regardless of the characteristics of the user and may be a relevant strategy to communicate complex health information

Objective

The objectives of our study were to evaluate (1) pretesting communication elements and user appreciation, and (2) the applied behavior change techniques of the previously designed spoken animated video messages in a tailored self-management program for people with type 2 diabetes.

Methods

We conducted semistructured interviews with patients with type 2 diabetes recruited from general practices located in different socioeconomic status urban neighborhoods. Based on the pretesting key communication elements of Salazar’s model, we asked participants about the spoken animated video messages’ attractiveness, comprehensibility, acceptance, believability, involvement, and relevance and to what extent the video messages motivated them to become more physically active. We also assessed participants’ intention to use the spoken animated video messages and to recommend them to others. To evaluate participants’ appreciation of the different applied behavior change techniques, we conducted a post hoc analysis of the qualitative data using the MAXQDA program. Transcripts were coded by 2 coders using iterative qualitative content analysis methods to uncover key health communication issues.

Results

Of 23 patients who expressed an interest in participating, 17 met the inclusion criteria and 15 took part in the interviews. The positive appreciation of the comprehensibility, believability, and personalization was supported by participants’ statements on behavior change techniques and other communication elements. Reinforcement of and feedback on participants’ answers were positively evaluated as was the simplicity and concreteness of the spoken animated video messages. Most participants indicated reasons for not feeling motivated to increase their physical activity level, including being already sufficiently physically active and the presence of other impeding health factors.

Conclusions

Spoken animated video messages should be simple, short, concrete, and without the use of medical terminology. Providing positive reinforcement, feedback on participants’ answers, examples that match user characteristics, and the possibility to identify with the animation figures will enhance involvement in the health message. To connect more with patients’ needs and thereby increase the perceived relevance of and motivation to use an animated video program, we suggest offering the program soon after diabetes mellitus is diagnosed. We recommend piloting behavior change techniques to identify potential resistance.

Towards better evidence-informed global action: lessons learnt from the Lancet series and recent developments in physical activity and public health

In the past few decades, the field of physical activity has grown and evolved in scope, depth, visibility and impact around the world. Global progress has been observed in research and practice in physical activity regarding surveillance, health outcomes, correlates/determinants, interventions, translation and policy. The 2012 and 2016 Lancet series on physical activity provide some of the most comprehensive global analysis on various topics within physical activity. Based on the Lancet series and other key developments in the field, literature searches, and expert group meetings and consultation, we provide a global summary on the progress of, gaps in and future directions for physical activity research in the following areas: (1) surveillance and trends, (2) correlates and determinants, (3) health outcomes and (4) interventions, programmes and policies. Besides lessons learnt within each specific area, several recommendations are shared across areas of research, including improvement in measurement, applying a global perspective with a growing emphasis on low-income and middle-income countries, improving inclusiveness and equity in research, making translation an integral part of research for real-world impact, taking an 'upstream' public health approach, and working across disciplines and sectors to co-design research and co-create solutions. We have summarised lessons learnt and recommendations for future research as 'roadmaps' in progress to encourage moving the field of physical activity towards achieving population-level impact globally.

Association of moderate and vigorous physical activity with incidence of type 2 diabetes and subsequent mortality: 27 year follow-up of the Whitehall II study

AIMS/HYPOTHESIS

This work examined the role of physical activity in the course of diabetes using data spanning nearly three decades. Our first aim was to examine the long-term association of moderate and vigorous physical activity with incidence of type 2 diabetes. Our second aim was to investigate the association of moderate-to-vigorous physical activity post-diabetes diagnosis with subsequent risk of all-cause and cardiovascular disease mortality.

METHODS

A total of 9987 participants from the Whitehall II cohort study free of type 2 diabetes at baseline (1985-1988) were followed for incidence of type 2 diabetes, based on clinical assessments between 1985 and 2016 and linkage to electronic health records up to 31 March 2017. We first examined the association of moderate and vigorous physical activity measured by questionnaire in 1985-1988 (mean age 44.9 [SD 6.0] years; women, 32.7%) with incident type 2 diabetes, using the interval-censored, illness-death model, a competing risk analysis that takes into account both competing risk of death and intermittent ascertainment of diabetes due to reliance on data collection cycles (interval-censored). The second analysis was based on individuals with type 2 diabetes over the follow-up period where we used Cox regression with inverse probability weighting to examine the association of moderate-to-vigorous physical activity after diagnosis of type 2 diabetes with risk of all-cause and cardiovascular disease mortality.

RESULTS

Of the 9987 participants, 1553 developed type 2 diabetes during a mean follow-up of 27.1 (SD 6.3) years. Compared with participants who were inactive in 1985-1988, those who undertook any duration of moderate-to-vigorous physical activity had a lower risk of type 2 diabetes (HR 0.85 [95% CI 0.75, 0.97], p = 0.02; analysis adjusted for sociodemographic, behavioural and health-related factors). In 1026 participants with a diagnosis of type 2 diabetes over the follow-up period, data on moderate-to-vigorous physical activity after diabetes diagnosis were available; 165 all-cause deaths and 55 cardiovascular disease-related deaths were recorded during a mean follow-up of 8.8 (SD 6.1) years. In these participants with diabetes, any duration of moderate-to-vigorous physical activity was associated with lower all-cause mortality (HR 0.61 [95% CI 0.41, 0.93], p = 0.02) while the association with cardiovascular mortality was evident only for physical activity undertaken at or above recommendations (≥2.5 h per week of moderate-to-vigorous physical activity or ≥1.25 h per week of vigorous physical activity; HR 0.40 [95% CI 0.16, 0.96], p = 0.04) in fully adjusted models.

CONCLUSIONS/INTERPRETATION

Moderate-to-vigorous physical activity plays an important role in diabetes, influencing both its incidence and prognosis. A protective effect on incidence was seen for durations of activity below recommendations and a marginal additional benefit was observed at higher durations. Among individuals with type 2 diabetes, any duration of moderate-to-vigorous physical activity was associated with reduced all-cause mortality while recommended durations of physical activity were required for protection against cardiovascular disease-related mortality.

DATA AVAILABILITY

Whitehall II data, protocols and other metadata are available to the scientific community. Please refer to the Whitehall II data sharing policy at https://www.ucl.ac.uk/epidemiology-health-care/research/epidemiology-and-public-health/research/whitehall-ii/data-sharing.

A Randomized, Double-Blind, Placebo-Controlled Study to Evaluate the Effectiveness of a Food Supplement Containing Creatine and D-Ribose Combined with a Physical Exercise Program in Increasing Stress Tolerance in Patients with Ischemic Heart Disease

The aim of this study is to establish whether a supplement of creatine and ribose combined with a physical exercise program can improve the total work capacity during exercise in a population of patients with known ischemic heart disease. A double-blind, six-month study was designed in which 53 patients were enrolled and randomized to take either a nutraceutical composition containing creatine, D-ribose, vitamin B₁, and vitamin B₆ (active treatment) or the placebo. Both the nutraceutical supplement and the placebo were supplied by Giellepi S.p.A. Health Science in Lissone, Italy. After six months of study, the cardiac double product at the peak of the load, the delta double product, and the chronotropic index were higher in the active treatment group than in the placebo group. We can conclude that a supplementation with creatine, D-ribose, vitamin B₁, and vitamin B₆, in addition to standard therapy and a physical exercise program, seems to be helpful in improving exercise tolerance compared to the placebo in a population with cardiovascular disease. However, this needs to be further studied, given that there is no clear evidence that the double product can be used as a surrogate measure of exercise tolerance.

Social inequality in lifestyle, motivation to change lifestyle and received health advice in individuals with diabetes: A nationwide study

Aims: The aim was to investigate the association between socioeconomic position (SEP) and physical activity, alcohol consumption and smoking, motivation to change lifestyle and health advices from general practitioners (GPs) in individuals with diabetes. Methods: Data were provided by the Danish National Health Survey 2013 and 7504 adults (⩾ 40 years) with diabetes were included. Educational level was used as SEP indicator and categorized into low, middle and high SEP. Dependent variables included physical activity, alcohol consumption, smoking, motivation to change lifestyle and GP lifestyle advices. Multiple logistic regression analyses adjusted for age, body mass index and ethnic background were performed. Results: Higher SEP were associated with reduced odds of being physically inactive (middle SEP odds ratio (OR) men 0.58 (95% confidence intervals 0.47–0.72) and women 0.59 (0.47–0.75)) and non-smoking (middle SEP OR men 0.74 (0.59–0.93) and high SEP OR women 0.54 (0.38–0.77)) compared to participants with a low SEP. Alcohol consumption above the recommended maximum was associated with high SEP in men, OR 1.83 (1.30–2.61). Elevated SEP was associated with a motivation to increase physical activity levels (middle SEP OR men 1.45 (1.19–1.76) and women 1.35 (1.09–1.67)), high SEP was associated with none advice from GPs regarding smoking cessation among women, OR 0.47 (0.25–0.89). Conclusions: Socioeconomic position was strongly associated with lifestyle in individuals with diabetes. The most pronounced inequalities were found in physical activity levels, smoking status and the motivation to become more physically active. Municipalities and GPs may need a greater focus on SEP in interventions to change lifestyle in individuals with diabetes.