Key Points from the Updated Guidelines on Exercise and Diabetes

Impact of Concurrent Exercise Training on Cardiac Autonomic Modulation, Metabolic Profile, Body Composition, Cardiorespiratory Fitness, and Quality of Life in Type 2 Diabetes with Cardiac Autonomic Neuropathy: A Randomized Controlled Trial

Background: Type 2 diabetes mellitus (T2DM) often leads to cardiac autonomic neuropathy (CAN), a severe complication affecting cardiovascular health. Exercise training is a proven intervention for improving metabolic control and cardiovascular health in T2DM, but the effects of concurrent exercise training (CET), combining aerobic and resistance exercises, on CAN are not fully understood. Objective: This randomized controlled trial investigates the impact of a structured CET program on cardiac autonomic modulation, metabolic profile, body composition, cardiorespiratory fitness (CRF), and quality of life (QoL) in individuals with T2DM and CAN. Methods: A total of 96 participants, aged 35-70 years, with T2DM and CAN, were randomized into CET (n = 48) and control (n = 48) groups. The CET group engaged in combined aerobic and resistance training three times per week for 13 weeks, while the control group received standard care. Primary outcomes included heart rate variability (HRV) and heart rate recovery (HRR). Secondary outcomes were metabolic profile, body composition, CRF, and QoL, which were assessed using standardized protocols and validated questionnaires. The trial was registered with the Clinical Trials Registry-India (CTRI/2021/09/036711). Results: Significant improvements were noted in the CET group compared to controls. HRV metrics (SDNN, RMSSD, pNN50, TP, LF power, HF power, and LF/HF ratio) and HRR metrics (HRR30s, HRR1, HRR2, and HRR3) all showed significant enhancements (p < 0.01). The CET group also exhibited substantial reductions in fasting blood glucose, postprandial blood glucose, HbA1c, waist circumference, hip circumference, and percentage body fat (p < 0.01). Improvements were observed in lipid profile markers and CRF (VO2max) (p < 0.01). QoL scores improved significantly in the CET group as per the ADDQoL-19 (p < 0.01). Conclusions: CET significantly enhances cardiac autonomic modulation, metabolic profile, body composition, CRF, and QoL in individuals with T2DM and CAN. These findings support the integration of CET into standard T2DM management to improve clinical outcomes and QoL. Further research is needed to explore the long-term benefits and broader applicability of CET in diverse diabetic populations.

The Role of Physiotherapy in Peripheral Artery Disease in Patients With Diabetes Mellitus: A Narrative Review

Diabetes mellitus (DM) comprises a spectrum of metabolic disorders distinguished by the persistent elevation of glucose levels in the bloodstream. It stands as a primary risk factor for peripheral arterial disease (PAD), denoted by atherosclerosis affecting the lower extremities. One clinical manifestation of symptomatic PAD is intermittent claudication alleviated by rest but also capable of presenting as atypical leg pain. Confirmatory diagnostic measures, including the ankle-brachial index (ABI), toe-brachial index (TBI), or Doppler waveform analysis, are imperative in the verification of PAD. For management, the recommendation is to incorporate physiotherapy alongside concurrent medical interventions, such as anticoagulants, antiplatelet agents, statins, or, in certain cases, surgical procedures. This narrative review seeks to elucidate the advantages of physiotherapy in diabetic patients with PAD, contributing to the deceleration of disease progression and improving symptoms. Although supervised exercise therapy is strongly supported by empirical evidence as more beneficial, the absence of supervised environments is a common issue. Consequently, the preference lies in the combination of supervised exercise with home-based regimens. The objective is that each patient exercises for more than three days per week, progressively extending their duration weekly. This approach has demonstrated a noteworthy enhancement in walking functionality, exercise tolerance, pain alleviation, and an overall improvement in the quality of life for patients.

Saudi Arabian Physical Therapists' Knowledge, Attitudes, and Clinical Practice in Diabetes Prevention and Management

Objective

This study explores physical therapists' current knowledge, attitudes, and practice toward the management and prevention of diabetes in Saudi Arabia.

Patients and Methods

A cross-sectional survey was distributed among physical therapists in Saudi Arabia. The questionnaire included several sections concerning their knowledge, attitude, and current practice toward diabetic management. A total of 301 physical therapists (32% female) participated in our study.

Results

The results suggest that only half of the participants agreed that diabetes management and prevention were within physical therapy's scope of service. However, approximately 30% of the participants did not regularly check or ask about the glucose levels of their patients with diabetes. Only 55% of the participants correctly answered the knowledge test questions.

Conclusion

This study found that physical therapists in Saudi Arabia have a modest level of diabetes knowledge. The findings indicate that physical therapy educational programs should address diabetes management. Furthermore, continued education is required for current practicing physical therapists in Saudi Arabia.

Device-measured sitting time and musculoskeletal pain in adults with normal glucose metabolism, prediabetes and type 2 diabetes-The Maastricht Study

BACKGROUND

Detrimental associations of sedentary behaviour (time spent sitting) with musculoskeletal pain (MSP) conditions have been observed. However, findings on those with, or at risk of, type 2 diabetes (T2D) have not been reported. We examined the linear and non-linear associations of device-measured daily sitting time with MSP outcomes according to glucose metabolism status (GMS).

METHODS

Cross-sectional data from 2827 participants aged 40-75 years in the Maastricht Study (1728 with normal glucose metabolism (NGM); 441 with prediabetes; 658 with T2D), for whom valid data were available on activPAL-derived daily sitting time, MSP [neck, shoulder, low back, and knee pain], and GMS. Associations were examined by logistic regression analyses, adjusted serially for relevant confounders, including moderate-to-vigorous intensity physical activity (MVPA) and body mass index (BMI). Restricted cubic splines were used to further examine non-linear relationships.

RESULTS

The fully adjusted model (including BMI, MVPA, and history of cardiovascular disease) showed daily sitting time to be significantly associated with knee pain in the overall sample (OR = 1.07, 95%CI: 1.01-1.12) and in those with T2D (OR = 1.11, 95%CI: 1.00-1.22); this was not statistically significant in those with prediabetes (OR = 1.04, 95%CI: 0.91-1.18) or NGM (OR = 1.05, 95%CI: 0.98-1.13). There were no statistically significant associations between daily sitting time and neck, shoulder, or low back pain in any of the models. Furthermore, the non-linear relationships were statistically non-significant.

CONCLUSION

Among middle-aged and older adults with T2D, daily sitting time was significantly associated with higher odds of knee pain, but not with neck, shoulder, or low back pain. No significant association was observed in those without T2D for neck, shoulder, low back, or knee pain. Future studies, preferably those utilising prospective designs, could examine additional attributes of daily sitting (e.g., sitting bouts and domain-specific sitting time) and the potential relationships of knee pain with mobility limitations.

The relationship between family support and the level of self care in type 2 diabetes patients

AIMS

The purpose of the study was to determine the relationship between family support and self-care in patients with type 2 diabetes in Middle Anatolia Region of Turkey.

METHODS

This descriptive relation-seeker-type study conducted with 284 patients who met inclusion criteria between February and May 2020 in the internal medicine and endocrinology clinics and polyclinics of a university hospital. Data were collected using, a demographic questionnaire, Hensarling's Diabetes Family Support Scale (HDFSS), and Diabetes Self-Care Scale (DSCS).

RESULTS

Participants had a mean DSCS and HDFSS score of 83.20 ± 18.63 and 82.44 ± 28.04, respectively. There was a strong correlation between DSCS and HDFSS scores (r:.621) (p < 0.001). Participants' DSCS totals score was strongly correlated with their HDFSS "empathetic support" (p = 0.001, r = 0.625), "encouragement" (p = 0.001, r = 0.558), "facilitative support" (p = 0.001, r = 0.558), and "participative support" scores (p = 0.001, r = 0.555).

CONCLUSIONS

Patients with more family support have higher levels of self-care. The results underline the significance of focusing on the relationship between self-care and family support in patients with type 2 diabetes.

Blood glucose response to running or cycling in individuals with type 1 diabetes: A systematic review and meta-analysis

AIMS

The aim of this systematic review and meta-analysis was to assess how running and cycling influence the magnitude of blood glucose (BG) excursions in individuals with type 1 diabetes.

METHODS

A systematic literature search was conducted in EMBASE, PubMed, Cochrane Central Register of Controlled Trials, and ISI Web of Knowledge for publications from January 1950 until February 2021. Parameters included for analysis were population (adults and adolescents), exercise type, intensity, duration and insulin preparation. The meta-analysis was performed to estimate the pooled mean with a 95% confidence interval (CI) of delta BG levels. In addition, sub-group and meta-regression analyses were performed to assess the influence of these parameters on delta BG.

RESULTS

The database search identified 3192 articles of which 69 articles were included in the meta-analysis. Due to crossover designs within articles, 151 different results were included for analysis. Data from 1901 exercise tests of individuals with type 1 diabetes with a mean age of 29 ± 4 years were included. Overall, exercise tests BG decreased by -3.1 mmol/L [-3.4; -2.8] within a mean duration of 46 ± 21 min. The pooled mean decrease in BG for running was -4.1 mmol/L [-4.7; -2.4], whilst the pooled mean decrease in BG for cycling was -2.7 mmol/L [-3.0; -2.4] (p < 0.0001). Overall results can be found in Table S2.

CONCLUSIONS

Running led to a larger decrease in BG in comparison to cycling. Active individuals with type 1 diabetes should be aware that current recommendations for glycaemic management need to be more specific to the mode of exercise.

Quality improvement tools to manage emergency callbacks from patients with diabetes in a prehospital setting

Diabetes is rising at an alarming rate, as 1 in 10 adults worldwide now lives with the disease. In Qatar, a middle eastern Arab country, diabetes prevalence is equally concerning and is predicted to increase from 17% to 24% among individuals aged 45 and 54 years by 2050. While most healthcare strategies focus on preventative and improvement of in-hospital care of patients with diabetes, a notable paucity exists concerning diabetes in the prehospital setting should ideally be provided. This quality improvement study was conducted in a middle eastern ambulance service and aimed to reduce ambulance callbacks of patients with diabetes-related emergencies after refusing transport to the hospital at the first time. We used iterative four-stage problem-solving models. It focused on the education and training of both paramedics and patients. The study showed that while it was possible to reduce the rate of ambulance callbacks of patients with diabetes, this was short-lived and numbers increased again. The study demonstrated that improvements could be effective. Hence, changes that impacted policy, systems of care and ambulance protocols directed at managing and caring for patients with diabetes-related prehospital emergencies may be required to reify them.

Association between socioeconomic status and health behaviour change before and after non-communicable disease diagnoses: a multicohort study

BACKGROUND

Behavioural risk factors of non-communicable diseases (NCDs) are socially patterned. However, the direction and the extent to which socioeconomic status (SES) influences behaviour changes before and after the diagnosis of NCDs is not clearly understood. We aimed to investigate the influence of SES on behaviour changes (physical inactivity and smoking) before and after the diagnosis of major NCDs.

METHODS

In this multicohort study, we pooled individual-level data from six prospective cohort studies across 17 countries. We included participants who were diagnosed with either diabetes, cardiovascular disease, chronic lung disease, or cancer after recruitment. Participants were surveyed every 2 years. Education and total household wealth were used to construct SES. We measured behaviour changes as whether or not participants continued or initiated physical inactivity or smoking after NCD diagnosis. We used multivariable logistic regression models to estimate odds ratios (ORs), prevalence ratios (PRs), and 95% CIs for the associations between SES and continuation or initiation of unfavourable behaviours.

FINDINGS

We included 8107 individuals recruited between March, 2002, and January, 2016. Over the 4-year period before and after NCD diagnosis, 886 (60·4%) of 1466 individuals continued physical inactivity and 1018 (68·8%) of 1480 participants continued smoking; 1047 (15·8%) of 6641 participants with physical activity before diagnosis initiated physical inactivity after diagnosis and 132 (2·0%) of 6627 non-smokers before diagnosis initiated smoking after diagnosis. Compared with participants with high SES, those with low SES were more likely to continue physical inactivity (244 [70·3%] of 347 vs 23 [50.0%] of 46; PR 1·41 [95% CI 1·05-1·99]; OR 2·28 [1·18-4·41]), continue smoking (214 [75·4%] of 284 vs 39 [60·9%] of 64; PR 1·27 [1·03-1·59]; OR 2·08 [1·14-3·80]), but also to initiate physical inactivity (188 [26·1%] of 720 vs 47 [7·4%] of 639; PR 3·59 [2·58-4·85]; OR 4·31 [3·02 - 6·14]).

INTERPRETATION

Low SES was associated with continuing or initiating physical inactivity and continuing smoking after NCD diagnosis. Reducing socioeconomic inequality in health behaviour changes should be prioritised and integrated into NCD-prevention programmes.

FUNDING

Zhejiang University and Fundamental Research Funds for the Central Universities.

Exercise as Treatment for Neuropathy in the Setting of Diabetes and Prediabetic Metabolic Syndrome: A Review of Animal Models and Human Trials

BACKGROUND

Peripheral neuropathy is among the most common complications of diabetes, but a phenotypically identical distal sensory predominant, painful axonopathy afflicts patients with prediabetic metabolic syndrome, exemplifying a spectrum of risk and continuity of pathogenesis. No pharmacological treatment convincingly improves neuropathy in the setting of metabolic syndrome, but evolving data suggest that exercise may be a promising alternative.

OBJECTIVE

The aim of the study was to review in depth the current literature regarding exercise treatment of metabolic syndrome neuropathy in humans and animal models, highlight the diverse mechanisms by which exercise exerts beneficial effects, and examine adherence limitations, safety aspects, modes and dose of exercise.

RESULTS

Rodent models that recapitulate the organismal milieu of prediabetic metabolic syndrome and the phenotype of its neuropathy provide a strong platform to dissect exercise effects on neuropathy pathogenesis. In these models, exercise reverses hyperglycemia and consequent oxidative and nitrosative stress, improves microvascular vasoreactivity, enhances axonal transport, ameliorates the lipotoxicity and inflammatory effects of hyperlipidemia and obesity, supports neuronal survival and regeneration following injury, and enhances mitochondrial bioenergetics at the distal axon. Prospective human studies are limited in scale but suggest exercise to improve cutaneous nerve regenerative capacity, neuropathic pain, and task-specific functional performance measures of gait and balance. Like other heath behavioral interventions, the benefits of exercise are limited by patient adherence.

CONCLUSION

Exercise is an integrative therapy that potently reduces cellular inflammatory state and improves distal axonal oxidative metabolism to ameliorate features of neuropathy in metabolic syndrome. The intensity of exercise need not improve cardinal features of metabolic syndrome, including weight, glucose control, to exert beneficial effects.

Exercise and Neuropathy: Systematic Review with Meta-Analysis

INTRODUCTION

Peripheral neuropathies are a prevalent, heterogeneous group of diseases of the peripheral nervous system. Symptoms are often debilitating, difficult to treat, and usually become chronic. Not only do they diminish patients' quality of life, but they can also affect medical therapy and lead to complications. To date, for most conditions there are no evidence-based causal treatment options available. Research has increased considerably since the last review in 2014 regarding the therapeutic potential of exercise interventions for patients with polyneuropathy.

OBJECTIVE

Our objective in this systematic review with meta-analysis was to analyze exercise interventions for neuropathic patients in order to update a systematic review from 2014 and to evaluate the potential benefits of exercise on neuropathies of different origin that can then be translated into practice.

METHODS

Two independent reviewers performed a systematic review with meta-analysis according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). Inclusion criteria according to the PICOS approach were: neuropathic patients, exercise interventions only, an inactive or non-exercising control group, and solely randomized controlled trials with the following outcome parameters: neuropathic symptoms, balance parameters, functional mobility, gait, health-related quality of life, and HbA1c (glycated hemoglobin).

RESULTS

A total of 41 randomized, controlled trials met all inclusion criteria, 20 of which could be included in the quantitative analysis. Study quality varied from moderate to high. Current data further support the hypothesis that exercise is beneficial for neuropathic patients. This is best documented for patients with diabetic peripheral neuropathy (DPN) (27 studies) as well as for chemotherapy-induced peripheral neuropathy (CIPN) (nine studies), while there are only few studies (five) on all other causes of neuropathy. We found standardized mean differences in favor of the exercise group of 0.27-2.00 for static balance, Berg Balance Scale, Timed-up-and-go-test, nerve conduction velocity of peroneal and sural nerve as well as for HbA1c in patients with DPN, and standardized mean differences of 0.43-0.75 for static balance, quality of life, and neuropathy-induced symptoms in patients with CIPN.

CONCLUSION

For DPN, evidence-based recommendations can now be made, suggesting a combination of endurance and sensorimotor training to be most beneficial. For patients with CIPN, sensorimotor training remains the most crucial component. For all other neuropathies, more high-quality research is needed to derive evidence-based recommendations. Overall, it seems that sensorimotor training has great potential to target most neuropathies and combined with endurance training is therefore currently the best treatment option for neuropathies. REGISTRATION NUMBER: (PROSPERO 2019 CRD42019124583)/16.04.2019.

Residual Impact of Concurrent, Resistance, and High-Intensity Interval Training on Fasting Measures of Glucose Metabolism in Women With Insulin Resistance

We sought to assess the residual effects (post 72-h training cessation) on fasting plasma glucose (FPG) and fasting insulin (FI) after 12-weeks of high-intensity interval training (HIIT), resistance training (RT), or concurrent training (CT) in women with insulin resistance (IR). We also aimed to determine the training-induced, post-training residual impact of CT. A total of adult 45 women (age 38.5±9.2years) were included in the final analysis and were assigned to a control (CG; n=13, BMI 28.3±3.6kg/m2), HIIT [n=14, BMI 28.6±3.6kg/m2, three sessions/wk., 80-100% of the maximum heart rate (HRmax)], RT [n=8, BMI 29.4±5.5kg/m2, two sessions/wk., 8-10 points of the modified Borg, corresponding to 20 to 50% range of one maximum repetition test (1RM)], or CT group (n=10, BMI 29.1±3.0kg/m2, three sessions/wk., 80-100% of HRmax, and 8-10 Borg, or 20 to 50% range of 1RM, to each HIIT and RT compounds), with the latter including both HIIT and RT regimens. Training interventions lasted 12-weeks. The main outcomes were FPG and FI measured at pre- and 24-h and 72-h post-training (FPG24h, FI24h, and FPG72h, FI72h, respectively). Secondary endpoints were body composition/anthropometry and the adiposity markers waist circumference (WC) and tricípital skinfold (TSF). The residual effects 72-h post-training [delta (∆)] were significantly poorer (all p<0.01) in the CT group (∆FPG72h+6.6mg/dl, η 2: 0.76) than in the HIIT (∆FPG72h+1.2mg/dl, η 2: 0.07) and RT (∆FPG72h+1.0mg/dl, η 2: 0.05) groups. These findings reveal that HIIT reduces FPG and RT reduces FI 24-h post-training; both exercise interventions alone have remarkably better residual effects on FPG and FI (post-72h) than CT in women with insulin resistance.

Effect of foot-ankle flexibility and resistance exercise in the secondary prevention of plantar foot diabetic ulcer

AIMS

The study aimed to evaluate the effects of foot-ankle flexibility and resistance exercises on the recurrence rate of plantar foot diabetic ulcers, HbA1c levels, diabetic neuropathy examination (DNE) scores, ankle brachial index (ABI), and walking speed within 12 and 24weeks.

METHODS

We conducted a double-blind randomized clinical trial. Fifty patients with recently healed plantar foot diabetic ulcers were randomized to an intervention group that performed foot-ankle flexibility and resistance exercise three times a week in their home (n=25) or a control group (n=25). Both groups were given foot care education. Outcomes were assessed at plantar foot diabetic ulcer recurrence or at 12 and 24weeks whichever came first. Outcome measures included plantar foot diabetic ulcer recurrence, changes of HbA1c levels, DNE scores, ankle brachial index ABI, and walking speed.

RESULTS

There were significant difference between groups in ulcer recurrence at either 12weeks (intervention 8%, control 68%, RR 0.288; 95% CI 0.156-0.534, P=0.000) within 12weeks. or 24weeks (intervention 16%, control 72%, RR 0.222; 95% CI 0.088-0.564, P=0.000).). There were significant differences in the DNE score delta (P=0.000) and walking speed delta (P=0.000), but there were no significant differences in the HbA1c delta and ABI delta between groups at either 12 or 24weeks.

CONCLUSIONS

Foot-ankle flexibility and resistance exercises can reduce the recurrence of plantar foot diabetic ulcer incidence and improve diabetic neuropathy and walking speed. Clinical trial number: NCT04624516.

Patients with Diabetes Complicated by Peripheral Artery Disease: the Current State of Knowledge on Physiotherapy Interventions

Diabetes mellitus (DM) is one of the major public health problems that account for morbidity, mortality, and disability worldwide. The presence of DM increases the risk of peripheral artery disease (PAD), as well as accelerates its course, making these patients more susceptible to ischemic events and impaired functional status. Unfortunately, alternative treatments for vascular complications in diabetes are poorly researched. Physiotherapy (kinesitherapy combined with different physical therapy agents) in individuals with DM and coexisting PAD may offer an important complementary therapy alternative. Early therapeutic measures can significantly improve patient outcomes, reduce cardiovascular risk, and improve daily life quality. The article provides an update on the current state of knowledge on physiotherapy interventions in the course of DM in patients with coexisting PAD.

Effects of aerobic training with and without progression on blood pressure in patients with type 2 diabetes: A systematic review with meta-analyses and meta-regressions

AIMS

To analyze the effects of aerobic training with and without progression on blood pressure in patients with type 2 diabetes.

METHODS

The databases used for the systematic search were PubMed, Cochrane Central, SPORTDiscus and LILACS. Studies which analyzed blood pressure before and after an intervention period of eight or more weeks of aerobic training compared to a control group without training in patients with type 2 diabetes were included.

RESULTS

Of the 4186 studies found, 17 clinical trials were included (912 participants). Systolic blood pressure (SBP) decreased after aerobic training with progression (-6.78 mmHg; 95% CI -8.36, -5.19; p < 0.001) and without progression (-8.07 mmHg; 95% CI -9.37, -6.77; p < 0.001). The same happened regarding diastolic blood pressure (DBP), which decreased with aerobic training with progression (-3.10 mmHg; 95% CI -4.90, -1.31; p < 0.001) and without progression (-5.71 mmHg; 95% CI -7.15, -4.28; p < 0.001).

CONCLUSION

Aerobic training is effective in reducing blood pressure in patients with type 2 diabetes, regardless of progression in training variables.

Glycemic and cardiometabolic effects of exercise in South Asian Sri Lankans with type 2 diabetes mellitus: A randomized controlled trial Sri Lanka diabetes aerobic and resistance training study (SL-DARTS)

BACKGROUND AND AIMS

To examine the effects of aerobic training (AT) and resistance training (RT) compared to standard care on glycemic control in South Asian Sri Lankan adults with Type 2 Diabetes Mellitus (T2DM).

METHODS

Randomized controlled trial (RCT) with parallel-group design recruited 86 sedentary Sri Lankans (aged 35-65 years) with T2DM into aerobic training (AT, n = 28), resistance training (RT, n = 28) and control (CN, n = 30) groups. Supervised progressive exercise training consisting of 75 min per session, 2 days per week for 12 weeks was conducted. The primary outcome was pre- and post-intervention absolute change in hemoglobin A1c (HBA1c). Secondary outcomes were serum lipids, liver enzymes, chronic inflammatory status, anthropometry, body composition and blood pressure.

RESULTS

The absolute change in HbA1c of RT vs. CN was -0.08% (95% CI, 0.8% to -0.7%, p = 0.8) and AT vs. CN was -0.22% (95% CI, 0.95% to -0.5%). Subgroup analysis (n = 49) with a high baseline HbA1c (>7.5%), absolute reduction in HbA1c in exercise groups were statistically significant (RT vs. CN was -0.37%; 95% CI 1.3% to -0.6%, p = 0.04 and AT vs. CN was -0.57%; 95% CI 1.7% to -0.6%, p = 0.03). The effect sizes (total and subgroup HbA1c >7.5%) ranged from 0.7 to 1.0 in AT, 0.4 to 1.1 in RT compared to 0.35 to 0.6 for the CN. Secondary outcomes did not significantly differ among groups.

CONCLUSIONS

Exercise training 2 days/week improved glycemic control in Sri Lankan adults with T2DM and the effects were significant in high baseline HbA1c (>7.5%) groups (RT > AT).

Leg dominance as a determinant in laterality of lower extremity amputation in diabetic patients: retrospective study and literature review

Background/Aims

Diabetic patients with peripheral vascular manifestations often develop foot ulcers and sometimes have to undergo lower extremity amputation. This retrospective study investigated leg dominance and laterality of lower extremity amputation in diabetic, dysvascular amputees.

Methods

All patients who met the inclusion criteria had their medical records reviewed for their dominant side and a correlation with a side of amputation was analysed. This information is routinely obtained as part of the admission history. For the literature review, PubMed, Google Scholar, ScienceDirect and Cochrane Library were searched with no date restriction until February 2018. Relevant studies were included and analysed.

Results

Of all the patients (n=27), 16 had diabetes and of these, 12 (75%) had their dominant leg amputated.

Conclusions

The data and literature analysis suggest that diabetic, dysvascular patients' dominant legs may be at higher risk for amputation than the non-dominant side. Larger studies are needed to clarify the relationship between leg dominance and laterality of lower extremity amputation.

Physical Activity Frequency Among Older Adults With Diabetes or Prediabetes: Associations With Sociodemographics, Comorbidity, and Medical Advice

To examine the differences in physical activity (PA) between older adults with and without diabetes/prediabetes and the correlates of PA frequency and associations between medical advice on PA and/or diet/weight loss and increasing PA among those with diabetes/prediabetes. Multinomial and binary logistic regression models using 2016-2017 National Health Interview Survey data (N = 4,860 aged 65+ years with diabetes/prediabetes). About 44.2% of those with diabetes/prediabetes, compared with 48.1% of a matched sample without, engaged in any PA three plus times a week. The low PA group (PA frequency was zero to two times a week) was more socioeconomically disadvantaged and had more chronic illnesses than the medium (three to four times a week) or high (five plus times a week) PA groups. Any PA and/or diet/weight loss medical advice was associated with two to three times higher odds of increasing PA. Health care providers should consider prescribing PA and/or diet/weight loss for patients with diabetes/prediabetes.

Biochemical and Molecular Mechanisms of Glucose Uptake Stimulated by Physical Exercise in Insulin Resistance State: Role of Inflammation

Obesity associated with systemic inflammation induces insulin resistance (IR), with consequent chronic hyperglycemia. A series of reactions are involved in this process, including increased release of proinflammatory cytokines, and activation of c-Jun N-terminal kinase (JNK), nuclear factor-kappa B (NF-κB) and toll-like receptor 4 (TLR4) receptors. Among the therapeutic tools available nowadays, physical exercise (PE) has a known hypoglycemic effect explained by complex molecular mechanisms, including an increase in insulin receptor phosphorylation, in AMP-activated protein kinase (AMPK) activity, in the Ca2+/calmodulin-dependent protein kinase kinase (CaMKK) pathway, with subsequent activation of peroxisome proliferator-activated receptor gamma coactivator 1-alpha (PGC-1α), Rac1, TBC1 domain family member 1 and 4 (TBC1D1 and TBC1D4), in addition to a variety of signaling molecules, such as GTPases, Rab and soluble N-ethylmaleimide-sensitive factor attached protein receptor (SNARE) proteins. These pathways promote greater translocation of GLUT4 and consequent glucose uptake by the skeletal muscle. Phosphoinositide-dependent kinase (PDK), atypical protein kinase C (aPKC) and some of its isoforms, such as PKC-iota/lambda also seem to play a fundamental role in the transport of glucose. In this sense, the association between autophagy and exercise has also demonstrated a relevant role in the uptake of muscle glucose. Insulin, in turn, uses a phosphoinositide 3-kinase (PI3K)-dependent mechanism, while exercise signal may be triggered by the release of calcium from the sarcoplasmic reticulum. The objective of this review is to describe the main molecular mechanisms of IR and the relationship between PE and glucose uptake.

Effect of Exercise Intervention on Cardiac Function in Type 2 Diabetes Mellitus: A Systematic Review

BACKGROUND

The effect of exercise on cardiac function/structure in type 2 diabetes mellitus (T2DM) with or without diabetic cardiomyopathy (DCM) is not yet completely understood. To date, results of studies have been controversial with variable outcomes due to the variety of exercise modalities.

OBJECTIVES

The aim of the present review was to examine the impact of exercise intervention, and different types of exercise, on cardiac function and structure in T2DM through a systematic literature review, combining both pre-clinical and clinical studies.

METHODS

A systematic literature search was performed on PubMed, Web of Science, and PEDro to identify studies up to 2 April 2018. Articles were included when well-defined exercise protocols were provided, and cardiac function in T2DM patients or validated animal models was examined.

RESULTS

In diabetic animals, improvements in both diastolic and systolic function through exercise therapy were mainly attributed to reduced collagen deposition. In T2DM patients, improvements were observed in diastolic function, but not consistently in systolic function, after endurance (and combined resistance) exercise training. Different exercise intervention modalities and exercise types seemed equally effective in improving cardiac structure and function.

CONCLUSION

Exercise training elicits significant improvements in diastolic function and beneficial remodeling in T2DM and DCM animal models, but not necessarily improvements in systolic function and left ventricular structure, regardless of exercise type. Therefore, exercise intervention should be a cornerstone in the treatment of T2DM patients not only to improve glycemic control but also to specifically enhance cardiac function.

How prepared are healthcare professionals for delivering physical activity guidance to those with diabetes? A formative evaluation

BACKGROUND

Physical activity is recognised as important for diabetes management and improved overall health of individuals with diabetes, yet many adults with diabetes are inactive. Healthcare professionals have been identified as key to promoting physical activity, including individuals with diabetes, but are ill-prepared to deliver this. Our paper evaluates the barriers/facilitators of healthcare professionals' delivery of physical activity guidance to adults with diabetes and aims to inform efforts to investigate and enhance their preparedness to promote physical activity.

METHODS

A sequential mixed method, two-phase design was adopted involving a purposeful sample of healthcare professionals. Phase one was an online pilot survey designed to test assumptions around healthcare professionals' knowledge, training and preparedness to deliver physical activity guidance. Phase two comprised eighteen semi-structured interviews, thematically analysed to provide an in-depth exploration of healthcare professionals' experiences of delivering physical activity guidance to adults with diabetes.

RESULTS

Healthcare professionals are committed to promoting physical activity to adults with diabetes and are reasonably confident in giving basic, generic guidance. Yet, significant challenges prevent them from achieving this in their practice, including: lack of education and training around physical activity, diabetes and health; ignorance of recommended physical activity and diabetes guidelines; lack of awareness of referral options; limited time and accessibility to appropriate resources. Nevertheless, healthcare professionals believed discussions around physical activity needed to be an integral part of consultations, incorporating improved communication strategies for conveying key physical activity messages.

CONCLUSIONS

HCPs have a key role in the promotion of physical activity to people with long-term conditions such as diabetes and they are identified within both the strategic policy context and national interventions for physical activity. Yet, this study indicated that HCPs face multiple and at times complex barriers to physical activity promotion generally and with diabetes patients. Conversely HCPs also reported what works, why and how, when promoting physical activity. Rich information derived from the day-to-day, working healthcare professional is integral to shaping future practices going forward. The bottom up, iterative design adopted in this study provides an approach to tap into this information.

Exercise Testing in Individuals With Diabetes, Practical Considerations for Exercise Physiologists

Exercise and sports activities are crucial for individuals with diabetes. Diabetic patients are often referred to sports clinics for cardiopulmonary exercise testing to evaluate physical capacity, exercise-related symptoms, or to obtain medical clearance. While there is an abundance of literature on cardiopulmonary testing, practical recommendations for exercise physiologists and sports clinic specialists performing exercise testing for this specific population are lacking. The goal of this report is to provide a practical framework to understand, prepare, and perform exercise testing in patients with diabetes, maximizing exercise physiology outcomes, diagnostic value, and ensuring safety.

Type 2 diabetes mellitus, physical activity, yoga and telomere length: A literature review

Background: Type 2 diabetes mellitus (DM), a chronic metabolic disease prevalent in adults, is also prevalent amongst children, adolescents and young adults. On understanding the molecular basis of diabetes, a significant association is found between telomere length (TL) and type 2 DM.Aim: The aim of the study was to review the available evidence on effect of physical activity and yoga on DM including their effect on TL.Setting: The study was conducted in Bangalore.Method: A number of databases such as Google Scholar, PubMed and Cochrane Review were searched for relevant articles using keywords such as ’diabetes’, ‘type 2 DM’, ‘physical activity’, ‘yoga’, ‘TL’ and ‘telomerase activity’. All types of articles were included for the study, such as randomised controlled trial, systematic reviews, literature review and pilot study. Non-English articles were excluded from the study.Results: Studies have demonstrated the effectiveness of yoga and physical exercise in type 2 DM in various ways, such as reducing fasting blood glucose and glycosylated haemoglobin; improving lipid profile, blood pressure and waist-to-hip ratio; reducing inflammatory, oxidative and psychological stress markers; and improving the quality of life of patients. However, limited information is available on the effect of these interventions on TL in type 2 DM and mechanisms involved.Conclusion: Recent studies have shown positive effects of yoga and physical activity on TL. However, there is a dearth of good-quality studies evaluating the effects of yoga on TL in type 2 DM. Future studies need to be conducted with standard treatment protocols, long-term follow-up, appropriate control groups and large sample size.

Impact of energy turnover on the regulation of glucose homeostasis in healthy subjects

Objective

Sedentary lifestyle increases the risk of type 2 diabetes. The aim of this study was to investigate the impact of different levels of energy turnover (ET; low, medium, and high level of physical activity and the corresponding energy intake) on glucose metabolism at zero energy balance, caloric restriction, and overfeeding.

Methods

Sixteen healthy individuals (13 men, 3 women, 25.1 ± 3.9 years, BMI 24.0 ± 3.2 kg/m²) participated in a randomized crossover intervention under metabolic ward conditions. Subjects passed 3 × 3 intervention days. Three levels of physical activity (PAL: low 1.3, medium 1.6, and high 1.8 achieved by walking at 4 km/h for 0, 3 × 55, or 3 × 110 min) were compared under three levels of energy balance (zero energy balance (EB): 100% of energy requirement (Ereq); caloric restriction (CR): 75% Ereq, and overfeeding (OF): 125% Ereq). Continuous interstitial glucose monitoring, C-peptide excretion, and HOMA–IR, as well as postprandial glucose and insulin were measured.

Results

Daylong glycemia and insulin secretion did not increase with higher ET at all conditions of energy balance (EB, CR, and OF), despite a correspondingly higher CHO intake (Δ low vs. high ET: +86 to 135 g of CHO/d). At CR, daylong glycemia (p = 0.02) and insulin secretion (p = 0.04) were even reduced with high compared with low ET. HOMA–IR was impaired with OF and improved with CR, whereas ET had no effect on fasting insulin sensitivity. A higher ET led to lower postprandial glucose and insulin levels under conditions of CR and OF.

Conclusion

Low-intensity physical activity can significantly improve postprandial glycemic response of healthy individuals, independent of energy balance.

Moderate-intensity continuous training: is it as good as high-intensity interval training for glycemic control in type 2 diabetes?

In Egypt, type 2 diabetes is higher in females than in males. Moderate-intensity continuous training (MICT) has been the most widely used exercise form in type 2 diabetes. This study aims to compare the classical MICT to the newly popular high intensity interval training (HIIT) with regard to changes in glycosylated hemoglobin (HbA1c) and estimated average glucose (eAG) in female type 2 diabetics. Twenty-six female patients with type 2 diabetes were assigned into three groups: a control group (n=9), a MICT group (n=9), and a HIIT group (n=8). Patients in both groups exercised on treadmill three days/week for 8 weeks. Patients in MICT exercised continuously for about 40 min at 65%–75% of peak heart rate (HRpeak). Patients in HIIT exercised for 4×4 min at 85%–90% of HRpeak with 3-min recovery in between at 65%–75% of HRpeak. Results showed that HbA1c was reduced significantly from 8.2% (7.45%–8.65%) to 6.9% (6.6%–7.15%) in MICT and from 8.23% (7.94%–8.85%) to 6.25% (6.1%–6.89%) in HIIT after interventions. Likewise, eAG was significantly reduced from 188.64 mg/dL (167.11–201.55 mg/dL) to 151.33 mg/dL (142.72–158.50 mg/dL) in MICT and from 189.64 mg/dL (181.18–207.29 mg/dL) to 136.69 mg/dL (128.37–151.04 mg/dL) in HIIT. No significant difference was found between HIIT and MICT in the measured variables. It is concluded that the less physically demanding MICT is as good as HIIT for normalizing hyperglycemia in type 2 diabetic females. Therefore, recent interests surrounding HIIT should not overemphasize it compared to the traditional MICT for improving glycemic outcomes.

An Overview of Current Physical Activity Recommendations in Primary Care

Primary care physicians should encourage their patients to engage in adequate physical activity. Current recommendations for physical activity in adults are as follows: at least 150–300 minutes per week of moderate-intensity, 75–150 minutes per week of vigorous-intensity aerobic physical activity, or an equivalent combination of moderate- and vigorous-intensity aerobic activity. Adults should also perform muscle-strengthening activities of moderate intensity or higher that involve all major muscle groups for 2 or more days per week. The elderly should perform additional balance training and fall prevention exercises more than 3 times a week. Children and adolescents should perform at least 1 hour of moderate-to-vigorous physical activity daily, which includes vigorous aerobic activity at least 3 days per week. As part of their 60 minutes or more of daily physical activity, resistance training and bone strengthening exercise should be done at least 3 days per week. According to new evidence, one bout of any exercises can be shorter than 10 minutes. Previously, physical activities were recommended for more than 10 minutes. For patients with diabetes, it is advisable to perform resistance exercise or short-distance running before aerobic exercise to prevent hypoglycemia. New evidence shows that dynamic resistance training is safe and effective in patients with hypertension provided the load is not too heavy. Exercise reduces pain and improves quality of life and physical function in patients with osteoarthritis,. Therefore, the treatment guidelines for osteoarthritis have been changed recently from not recommending exercise to highly recommending it.

Into the deep blue sea: A review of the safety of recreational diving in people with diabetes mellitus

People with diabetes, particularly those being insulin treated, have been for many years considered ineligible for diving, because of the high risk of adverse events. Blood glucose levels tend to decline during diving, probably because of changes in insulin requirements and resistance, due to increased physical activity and effects of hyperbaric environment on glucose tolerance. Strict adherence to safety protocols, in conjunction with optimal physical status, lack of diabetic complications (especially impaired awareness of hypoglycaemia) and satisfactory baseline glycaemic control, seem to minimise the risk of complications during diving. The integration of modern technology into diabetes management, providing potential for underwater continuous glucose monitoring, can be useful in optimising metabolic control before, during and after diving. Despite the significant progress been made on safety issues, there is still a need to implement the relevant recommendations into divers' everyday practice. Existing evidence is mainly derived from small studies and there is a wide heterogeneity in terms of study designs and explored outcomes, rendering the extraction of definitive conclusions challenging. The aim of this review is to present and critically evaluate available evidence, use of technology, and gaps in existing knowledge that deserve further evaluation by future studies.

Role of myokines in the development of skeletal muscle insulin resistance and related metabolic defects in type 2 diabetes

Due to its mass, skeletal muscle is the major site of glucose uptake and an important tissue in the development of type 2 diabetes (T2D). Muscles of patients with T2D are affected with insulin resistance and mitochondrial dysfunction, which result in impaired glucose and fatty acid metabolism. A well-established method of managing the muscle metabolic defects occurring in T2D is physical exercise. During exercise, muscles contract and secrete factors called myokines which can act in an autocrine/paracrine fashion to improve muscle energy metabolism. In patients with T2D, plasma levels as well as muscle levels (mRNA and protein) of some myokines are upregulated, while others are downregulated. The signalling pathways of certain myokines are also altered in skeletal muscle of patients with T2D. Taken together, these findings suggest that myokine secretion is an important factor contributing to the development of muscle metabolic defects during T2D. It is also of interest considering that lack of physical activity is closely linked to the occurrence of this disease. The causal relationships between sedentary behavior, factors secreted by skeletal muscle at rest and during contraction and the development of T2D remain to be elucidated. Many myokines shown to influence muscle energy metabolism still have not been characterized in the context of T2D in skeletal muscle specifically. The purpose of this review is to highlight what is known and what remains to be determined regarding myokine secretion in patients with T2D to uncover potential therapeutic targets for the management of this disease.

Patient and Healthcare Professionals Perspectives on the Delivery of Exercise Education for Patients With Type 1 Diabetes

Objective: One way of improving the prognosis for the growing numbers of people with type 1 diabetes (T1D) is to increase their frequency of exercise. One known barrier to this is the lack of cohesive support and information from care providers. To better understand the issues around existing support for patients wishing to exercise and inform the design of an education package specifically to facilitate safe exercise we interviewed care providers and patients about the existing provision of support. Research Design and Methods: The study was based within two large UK teaching hospitals where four focus groups were undertaken two consisting of patients diagnosed with T1D who undertook regular exercise, and two with health care providers (HCPs) that were part of the diabetes care team. In all 14 patients and 11 staff were involved. These were complemented by two 1:1 interviews with staff unable to attend group discussions. Results: We found the successful provision of education and advice was influenced by factors relating to the individual patient and their service provider. Patient factors included the type of activity and complexity of the exercise regime, the level of engagement with their condition and care and health literacy. Service-related factors included inconsistent training, a lack of capacity and continuity, and limited coherence of information from across their care team. Conclusions: Any education package developed to support exercise in patients with type 1 diabetes should be offered at a time following diagnosis in accordance with patients' preferences and priorities, contain information on how to manage regular and irregular bouts of exercise. Patients described how they related more closely to the stories of their peers than famous sports stars and one way this can be facilitated is by group delivery. The content and relevance of any supporting materials should be closely considered. Training in the delivery of a novel education package should be made available to staff across the care team to enable them to either deliver the course or increase their confidence in offering salient advice as part of routine care.