Effects of Exercise on Diabetes

Exercise in the Treatment and Prevention of Diabetes

Western Governors University Abstract
Article Larose J; Sigal RJ; Khandwala F; Prud'homme D; Boulé NG; Kenny GP. (2011 January). Associations between Physical Fitness and Glucosylated Hemoglobin in Type 2 Diabetes Mellitus. Diabetologia, 54(1), 93-102. Retrieved May 17, 2012, from MEDLINE database. 20953579

Background Information Exercise and physical activity has shown to be a significant factor in the management and treatment of diabetes. What is unknown is how benefits from physical activity directly correlate to glucose control as manifested in low glucosylated hemoglobin (HbA1c) levels in diabetic people. The study aims to prove that the decrease in HbA1c is a result of greater aerobic fitness and strength in patients that are performing aerobic or anaerobic exercise. Secondly, it is related to the changes in strength and aerobic fitness that are performing cardiovascular exercise and resistance training.
Review of Literature The purpose of the article is to assess the correlation of reduced HbA1c to physical activity. It is hypothesized that this reduction is related to the changes and increase in aerobic fitness and strength in diabetic people who are engaged in aerobic and anaerobic exercise. The result from the study showed that the link between the changes in glucose control during exercise training is not that high nevertheless; physical activity offers health benefits to diabetic patients.
Methodology The study used experimental method by randomized controlled trial. Random sampling of 251 patients between 39-70 years old with type 2 diabetes mellitus that were previously sedentary was allocated aerobic, resistance, or aerobic plus resistance, or to a control group that was sedentary.
The participants were evaluated prior to the run-in phase (baseline) and at the end of intervention (6 months). The trials consist of 4-week run-in phase and followed by a 22-week intervention phase. Participants performed 15-20 minutes aerobic exercise at moderate intensity (60% VO2 peak) three times a week and one to two sets of seven resistance exercises at moderate intensity twice a week under supervision. Included on the randomization are participants who joined in 10 or more exercise session in the run-in period. Randomization was stratified by age and sex.
HbA1c and cardiorespiratory fitness level from each participant were measure to establish baseline and post intervention testing.

Data Analysis The article analyzed the collected data by measuring health status at baseline, midpoint and end of the study. Factors measured in the study included methods of exercise, which are resistance, aerobic, a combination of both and control. Physical fitness and changes in HbA1c among the exercise groups, was measured of peak oxygen consumption, workload, treadmill time, ventilatory threshold, seated row, leg press and bench press
Conclusion The results of the research showed that both aerobic and resistance training alone lead to the decrease in HbA1c when compared to the control group. There was a greater decrease in HbA1 in the group that performed both aerobic and anaerobic training. There is noted significant reduction in body weight in aerobic training participants. No significant changes in weight where noted in the group that did combined exercise training compared to the aerobic group. Improvements in cardiorespiratory fitness also resulted in better HbA1c. The study also shows that the gains in strengths as a result of resistance training have a direct correlation to improvements in HbA1c. The experiments supports the notion that combined exercise training is the most effective and beneficial for people with type 2 diabetes and improvements in fitness level as a result of aerobic and resistance training are associated with better glucose control.

A3. Assessment of Evidence:
In review of the article, the experiment was well developed and established. A run-in phase was done prior to the implementation phase. Only those that participated in 10 or greater schedule exercise sessions where included in the randomization to maintain compliance. Baseline data was established prior to the run-in phase and at the end of the intervention to establish a comparison.
Results indicate that cardio-respiratory changes as a result of aerobic training is a much better indicator of lowering levels of Hb1Ac than strength training. Much less conclusive is a possible strong connection between fitness and glucose control which suggesting that changes in glucose control during exercise training are not entirely dependent on improvements in fitness.

A4. Ethical Issues:
It was stated that participants for the study were recruited by word of mouth, physician encouragement and advertising. Informed consent was obtained accordingly but it was not stated in the paper how the results from the study was going be utilize and who will have access to the data. It was not mentioned whether the results would be shared to the participants individually or as a group, which can be a source of concern for some individuals since some people are very private. Health status is something that is very personal. The researchers have to be cautious and sensitive to this because the participants may not want their health status known to the group.

A5a. Types of Research:
The research was a primary research that used a randomized controlled trial. A random sampling of 251 participants with type 2 diabetes was recruited. Final participants where selected by implementing a run-in phase where only those that attended 10 or more scheduled sessions were included in the implementation phase for the next 6 months. The participants were divided into different groups. One group performed aerobic exercise that lasted 15- 20 minutes at moderate intensity that gradually increased to a maximum of 45 minutes at high intensity three times a week. The second group performed resistance training that involved two different seven training exercises, which focused on all major muscle groups two times a week. The third group performed both the aerobic and resistance training exercises. A control group was also established and remained sedentary.

A5b. Other Types of Research:
I believe that the use of randomized controlled trial was effective in determining the correlation of physical activity and improvement of glucosylated hemoglobin for the management of diabetes. Randomizing the study provides equal opportunity for the selected population group to be represented. Randomized sample selection of participants was important to preserve the objectiveness of the study.
Prior to the testing phase, the researchers ensured that the participant would be compliant with the experiment by doing a run-in phase. Only the ones that participated in 10 or more scheduled exercise session where included in the randomization. Randomization was further stratified by age and sex.
By using randomized control trial, the study was able to compare and contrast the results from participants that performed aerobic exercise, resistance training, combination exercise training and the control. It was able to effectively measure the gains of physical activity in reducing HbA1c to control diabetes.
B1. Problem:
The number of people who have diabetes in the United States is a staggering 26 million. An estimated 79 million adults are prediabetic. Prediabetes is a condition where the blood sugar of an individual is high but not high enough to be diagnosed as diabetic. A person who is prediabetic is at increase risk for developing type 2 diabetes mellitus.
It important to educated and engages this group into the benefits of physical activity and how it affects the glucose level of an individual. Being able to prevent the development of diabetes by using physical activity will significantly help the nation. The cost is remarkably less than pharmaceutical interventions. Besides lowering glucose level, physical activities have other benefits such as improved cardiovascular health, increased bone density and strengthen muscles, weight control, better self-esteem and enhanced mental health and mood.
B2. Matrix (See Separate Document)
B3. Annotation:
1. Tuttle, L.J., Hasting, Mary K., Mueller, M.J. (2012). A Moderate-Intensity Weight Bearing
Exercise Program, Physical Therapy, 92, 133-41. Retrieved June 12, 2012, from MEDLINE database.
In this article a randomized controlled trial was performed on an individual with diabetes with a goal to determine whether moderate weight-bearing exercise that involves treadmill exercise, muscles strengthening and balance exercises is beneficial. After 12 weeks of moderate exercise regimen, the participant was able to increase his walking distance. His overall health status has improved. He lost weight, gains calf strength and his blood glucose decrease.
2. Taylor, J.D., Fletcher, J.P., Tiarks, J. (2009). Impact of Physical Therapist-Directed Exercise Counseling Combined with Fitness Center Based Exercise Training on Muscular Strength and Exercise Capacity in People with Type 2 Diabetes: A Randomized Clinical Trial, Physical Therapy, 89, 884-892. Retrieved June 12, 2012, from MEDLINE database. In this article the authors concluded that people with type 2 diabetes benefited in physical therapist-directed exercise counseling. The individuals that where involve in the randomized controlled trial that performed aerobic and resistance training under the guidance of a physical therapist. The main outcome measured from this research is the physical therapy directed counseling is as effective as supervised exercised training in increasing muscular strength and exercise capacity which has the potential to prevent type 2 diabetes.
3. Faulker, M.S. (2010). Cardiovascular Fitness and Quality of Life in Adolescents with Type I and Types II Diabetes, Journal for Specialist in Pediatric Nursing, 15(4), 309-313. Diabetes is prevalent not only in adults but also in adolescents. Results of engaging in physical activity are similar to adolescents when compared to adults. Adolescents who participate in exercise regimen have a lower level of blood glucose in relation to those who are sedentary. Having control of the disease during adolescent years results in better management in older years and lowers the other risk factors associated with diabetes.
4. Walker, K.Z., O’Dea, K., Gomez, M., Girgis, S., Colaguri, R. (2010). Diet and Exercise in the Prevention of Diabetes, Journal of Human Nutrition and Dietetics, 23, 344-352. Retrieved June 12, 2012, from MEDLINE database. The article shows that lifestyle changes that involves diet and exercise is effective in reducing the incidence of type 2 diabetes by 28-59%. Follow-up studies are shows that once lifestyle changes occur, the incidence of diabetes continues to decline. The articles shows overwhelming evidence that diabetes is a manageable and preventable disease. The question is how to develop public health method to support the community and the people in maintaining lifestyle changes in diet and exercise.
5. Colberg, S.R., Grieco, C.R. (2009). Exercise in the Treatment and Prevention of Diabetes, Current Sports Medicine Reports, 8, 169-175. Retrieved June 12, 2012, from MEDLINE database. In the article, Colberg and Grieco addressed the benefits of physical training that includes both resistance exercise and aerobic training for the management of diabetes. The article discusses that benefits from physical training is attained through acute and chronic improvements in insulin action. Both aerobic and anaerobic exercise has the ability to increase a diabetic individual’s sensitivity to insulin that can help in the management of glycemia.
6. Johnson, S.T., Bell, G.J., McCargar, L.J., Welsh, R.S., Bell, R.C. (2009). Improved Cardiovascular Health Following a Progressive Walking and Dietary Intervention for Type 2 Diabetes, Diabetes, Obesity & Metabolism, 11, 836-843. Retrieved June 12, 2012, from MEDLINE database. In the study, patients with diabetes were tasked to walk as a means of physicals activity. At the end of 24 weeks, the cardiovascular health of the patients showed significant improvements evidenced by lower pulse rate. There were also measurable decrease in weight and BMI. The article proves that a simple exercise such as walking can affect the health of an individual. Exercise doesn’t have to be strength nous, which can be discouraging and unappealing for some people.
7. Otterman, N.M., Van Schie, C.H., Van Bon, A.C., Busch-Westbroek, T.E., Nollet, F. (2011). An Exercise Programme for Patients with Diabetic Complications: A Study on Feasibility and Preliminary Effectiveness, Diabetic Medicine, 28, 212-217. Retrieved June 12, 2012, from MEDLINE database. Patients prescribed with an exercise program in different stages of diabetes mellitus from people who are pre-diabetic to those who have been diagnosed with diabetes. At the end of the study, it showed that physical activity could also sustain or increase health-related and cardiovascular fitness. The increase in cardiovascular fitness translates into a positive effect on blood glucose condition. A regimented prescribe exercise is key in prevention of the development of diabetes on pre-diabetic patients and for sustaining or developing health associated and physiologic status of diabetic patients. 8. Hordern, M.D., Marwick, T.H., Wood, P., Cooney, L.M., Prins, J.B., Coombes, J.S. (2011).
Acute Response of Blood Glucose to Short-Term Exercise Training in Patients with Type 2 Diabetes, 14, 238-242. Retrieved June 12, 2012, from MEDLINE database. Single exercise session contribute to decreasing glucose level. The study concludes that consistent exercise training augments and is an important element in inducing a decrease in blood glucose for patients with diabetes. The effect over time when one maintains an exercise program is important in preserving the low levels of blood glucose.
9. Zisser H., Gong P., Kelley C.M,, Seidman, J.S., Riddell, M.C. (2010) Exercise and Diabetes, International Journal Of Clinical Practice, 170, 71-75. Retrieved June 12, 2012, from MEDLINE database.
In this article, the authors reviewed different studies. One of the studies included the relationship of exercise and diabetes. Exercise is one of the key components in the foundation of a healthy lifestyle. The study concludes that regular aerobic exercise enhances sensivity to insulin, promotes cardio-respiratory functions decreasing cardiovascular risk on pre-diabetic and diabetic patients. Regular monitoring of exercise effectively decreased the HbA1c level, fasting glucose level and body mass index and also improve the general over all wellbeing of patients.
10. Larose J; Sigal RJ; Khandwala F; Prud'homme D; Boulé NG; Kenny GP. (2011 January). Associations between Physical Fitness and Glucosylated Hemoglobin in Type 2 Diabetes Mellitus. Diabetologia, 54(1), 93-102. Retrieved May 17, 2012, from MEDLINE database.
The article shows evidence that both aerobic and anaerobic exercise is beneficial to diabetics. When they engage in regular physical exercise, their cardiovascular health status improves that results in a decrease in the glucose level. The research shows that aerobic exercise combined with strength training is most advantageous to managing diabetes.

B3b. Efficacy:
Overall, the articles reviewed were effectious in the research performed. The randomized controlled study and cohort methods used in research resulted in positive outcomes. Possible outcomes have been identified prior to the research implementation. The evidence shows in all the articles that exercise whether aerobic or anaerobic can have significant impact on the blood glucose level on a diabetic patient. During the research studies, it proved that consistency in participation and management of regimented exercise plan improves cardiovascular health that result in lower levels of blood glucose for diabetic patient and prevention of diabetes mellitus II in pre-diabetic individuals.

B3c. Tools:
The different studies used similar tools to measure the variables. For example, multiple researchers used either a treadmill or a cycling machine to control the length of aerobic exercise of the participants. Exercise equipment were utilize for anaerobic exercises. Other tools that were used are weighing scale, tape measure and sphygmomanometer. Baseline data was obtained prior to the study. Same tools were utilized to measure changes in the participant health status during and after the study. Pedometer and heart rate monitors where employed during aerobic exercises to measure activity of participants.
B3d.
The tools use for the research did not affect the results. The outcomes are measured quantitatively for example, cardiovascular fitness was objectively measured the comparing the distance covered within a period of time while performing aerobic exercise. There results from the researchers where mechanically measured that would prevent subjectivity in obtaining data. Changes in the health status of the participants were measured by comparing the results from baseline figures such as weight, heart rate, tolerance to exercise and level of blood glucose. Reported data is collected objectively by using factual results on the variable that were being measured.
B4. Evidence Summary of Articles:
In summary, active participation in consistent physical activity that involves both aerobic and anaerobic exercise is effective in improving the glycaemic control in patients with diabetes. Other benefits of exercise include increase cardiovascular fitness, weight loss, boost in self esteem and lowers additional health complications that are associated with diabetes such as peripheral neuropathy, cataracts and glaucoma.
B5. Recommendation
I believe that the different article show enough evidence to support the statement that regular physical activity is beneficial and effective in managing and preventing type 2 diabetes by lowering blood glucose level. In each of the articles, there were measurable marked improvements in the individual’s heath status.
Knowing physical activity as simple as walking and cycling can help manage and prevent diabetes is important to share this information to patients. Patient education is key in successful prevention or managing of diabetes that is responsible for reduced quality of life of those afflicted. I would create a handout that would include fact about diabetes. Definition of diabetes, complications of the disease, how to effectively manage diabetes and the importance of actively engaging and committing to life style changes will be in the handout. This will be written in laymen’s terms that is simple and easy to understand. I will review the handout with the patient and set some goals that would include physical activity. I would encourage the patient to write the goals in a journal and keep track of his/her progress weekly.
It is valuable to engage the patient in setting their own goal because they know best what their limitations and abilities are. It also critical to celebrate progress and achievement of goals as a tools for motivation for the patient.
B6. Theoretical Models: Theoretical models are important when planning the framework for nursing research. There are different types of theories from grand theories to middle range, borrowed, shared and microtherios. Each is important in creating and performing research. Results from sound and effective research studies often translate into implementation of changes in nursing practices that have opportunities for improvement. New nursing practices and standard of care are a direct result of evidence-based. Using both theoretical and conceptual frameworks is critical in establishing a well-structured research study. Research study that is logical and coherent will lend itself to become credible and allot for cross-reference and comparison among studies. Establishing a strong framework is a critical ingredient of a good research. Performing a research that is superior is of necessity because of the impact that it can create on a population of people.
Established theoretical nursing models help defined the research. It allows for promotion of new knowledge because of it’s credibility. Maintains continued knowledge exchange and synthesis of action and inquiry. Creation and implementation of research study and keeps the researchers to stay objective and factual in their pursuit.
References:
1. Tuttle, L.J., Hasting, Mary K., Mueller, M.J. (2012). A Moderate-Intensity Weight Bearing
Exercise Program, Physical Therapy, 92, 133-41.
2. Taylor, J.D., Fletcher, J.P., Tiarks, J. (2009). Impact of Physical Therapist-Directed Exercise Counseling Combined with Fitness Center Based Exercise Training on Muscular Strength and Exercise Capacity in People with Type 2 Diabetes: A Randomized Clinical Trial, Physical Therapy, 89, 884-892.
3. Faulker, M.S. (2010). Cardiovascular Fitness and Quality of Life in Adolescents with Type I and Types II Diabetes, Journal for Specialist in Pediatric Nursing, 15(4), 309-313.
4. Walker, K.Z., O’Dea, K., Gomez, M., Girgis, S., Colaguri, R. (2010). Diet and Exercise in the Prevention of Diabetes, Journal of Human Nutrition and Dietetics, 23, 344-352.
5. Colberg, S.R., Grieco, C.R. (2009). Exercise in the Treatment and Prevention of Diabetes, Current Sports Medicine Reports, 8, 169-175.
6. Johnson, S.T., Bell, G.J., McCargar, L.J., Welsh, R.S., Bell, R.C. (2009). Improved Cardiovascular Health Following a Progressive Walking and Dietary Intervention for Type 2 Diabetes, Diabetes, Obesity & Metabolism, 11, 836-843. 7. Otterman, N.M., Van Schie, C.H., Van Bon, A.C., Busch-Westbrook, T.E., Nollet, F. (2011). An Exercise Programme for Patients with Diabetic Complications: A Study on Feasibility and Preliminary Effectiveness, Diabetic Medicine, 28, 212-217.
8. Hordern, M.D., Marwick, T.H., Wood, P., Cooney, L.M., Prins, J.B., Coombes, J.S. (2011).
Acute Response of Blood Glucose to Short-Term Exercise Training in Patients with Type 2 Diabetes, 14, 238-242.
9. Zisser H., Gong P., Kelley C.M,, Seidman, J.S., Riddell, M.C. (2010) Exercise and Diabetes, International Journal Of Clinical Practice, 170, 71-75.