Challenges in Physical Activity for Diabetics

Executive summary:

Diabetes is in the fifth rank among the most common causes of death in the world. The life expectancy due to type 1 diabetes had been reduced to higher than 20 years and it was reduced up to 10 years for type 2 diabetes, among the population. The major life style risk factors that are contributing to the diseased condition are the sedentary lifestyle of the modern people, obesity and high cholesterol level. The practice of the recommended levels of exercise or physical activities may control all the associated causes of mortality. Therefore, in the present study a review had been conducted to estimate the significance of physical activity to control the condition of diabetes especially type 2 diabetes. The study highlighted that the daily physical activity recommended for these patients involves various activities such as walking during the leisure time, performing the daily household activities but that should not involve too much of physical burden, gardening etc along with the recommended levels of 150 minutes of moderate to vigorous level of daily exercise per week as per the American College of Sports Medicine and the American Diabetes Association. Walking is considered to be the most considered form of physical activity which reduces the mortality rate associated with diabetes by about 50%. The report highlighted outcomes of several research trials to evaluate the efficacy of physical activity for the diabetic patients. The study also highlighted that the patients with type 2 diabetes have lower threshold of physical activity and due to this they are unable to perform the recommended level of physical activities. There are other conditions such as autonomic neuropathy, peripheral neuropathy, the peripheral arterial disease, the condition of hypoglycaemia, active retinal haemorrhage or current retinal photocoagulation during which the patients with diabetes are unable to perform physical activities. Therefore government should plan a new exercise regime based on the individualised needs of the patients and introducing new exercises will also encourage the patients to sustain the activities for a longer time.

Introduction:

Several researchers across the globe have identified the usefulness of the regular exercise on the primary and secondary level protection against diseases which are chronic in nature such as the heart diseases, diabetic condition, obesity, cancer, hypertension, osteoporosis and depression. The recent Health Canada physical activity guidelines highlighted the benefits of physical activity among the people who used to lead a sedentary lifestyle before. A linear relation can be established between the physical activity and the status of health which depicts that the increase in the daily level of physical activity and the fitness is directly related with the improvement of the health status of the individuals. Therefore, physical activity can be considered as a part of the lifestyle developmental approach for every individual (Warburton, et al, 2006). Physical activity can be defined as the movement of the body with the help of the skeletal muscles which requires the expenditure of energy. It includes all the activities of the body that can be performed at any time of day and it may include exercise and the integrated incidental activity throughout the day. This integrated activity can be classified as planned, repetitive, structured which improves the fitness level of the individuals. The physical activity can be divided into three categories such as: Low Physical Activity (LPA) such as slow walking; Moderate Physical Activity (MPA) such as brisk walking, light swimming, jogging; Vigorous Physical Activity (VPA) such as fast running and cycling. The other forms of physical activity are aerobic physical activity, anaerobic activity and muscle strengthening activity. The daily practice of exercises increases the flexibility and the motion involving the joints. The balance exercises benefit the way of walking and prevents from falling. With the practice of yoga or tai chi combined benefits of flexibility, resistance and balance can be achieved. The classification of the physical activity is generally depends on the intensity level and the duration. The term metabolic equivalent (MET) is considered as a valid measurement tool for the intensity of physical activity and it is based on the uptake amount of oxygen by the individual at the resting position. The basal resting metabolic rate is equivalent to the oxygen uptake of 3.5 mL/kg per minute and it corresponds to MET 1. For example the light intensity physical activity such as walking is considered to be MET 2 and the moderate intensity physical activity is equivalent to MET 4 (Colberg, et al, 2016; Schellenberg, et al, 2013; Hamasaki, et al, 2016).

Recommended level of Physical Activity for Adults:

According to the recommendations of the World Health Organisation, adults aged between 18 to 64 years should perform 150 minutes of moderate level of aerobic physical activity or 75 minutes of vigorous intensity of aerobic physical activity within a week or an equivalent combination of both forms of activity. The guidelines also mentioned that the activity should be performed with a gap of duration 10 minutes and to get additional benefits every adult should extend the physical activity level to 150 minutes of vigorous physical activity every week. The adults who are belonging within this span of time should also perform the activities that strengthen the muscles involving the major muscles for 2 days or more every week. Adults above the age of 65 years should also perform 150 minutes of moderate level of aerobic physical activity all through the week for a span of at least 10 minutes. Those adults, who are facing the problem of poor mobility, should practice the physical activity to maintain the physical strength and body balance at least for 3 days per week. Therefore, the significance of physical activity for individuals suffering from diabetes is taken into consideration for the present study (World Health Organization, 2019).

Diabetes and its classification:

The primary classification of diabetes includes the following two types: type 1 and type 2 diabetes (T2D). The type 1 diabetes can be observed among 5 – 10% of the cases and it mainly occurs due to the cell mediated destruction by the autoimmune system of the β cells of the pancreas responsible for the condition of insulin deficiency. The condition can affect individuals of any age but the rate of destruction of the β cells varies with the age of the individuals with more number of cases being reported among youth than in adults. The rate of incidence of T2D can be observed among 90 -95% of cases and it occurs due to the consistent lower insulin production or due to the resistance developed against insulin. During the time of pregnancy, the occurrence of gestational diabetes mellitus can be observed in between the 24-28 weeks of the gestation period with no past medical records of diabetes. The condition of prediabetes can be described as a state where the sugar level of blood is above the normal range but the condition cannot be referred as diabetes. But these individuals show an enhanced risk of developing the type 2 diabetes. The individuals who are in the prediabetic condition can alleviate the risk of developing type 2 diabetes with the daily practice of physical activity (American Diabetes Association, 2016; American Diabetes Association, 2014).

Prevalence of Diabetes:

As per the reports of Global Diabetes Community 2019, the number of individuals diagnosed with diabetes in the United Kingdom was approximately 3.5 million. Moreover, it was also predicted that the number of people who were yet to be diagnosed are approximately around 549,000. Therefore, the data indicated that the total numbers of individuals living with the condition of diabetes in the UK which includes both the diagnosed and undiagnosed was above 4 million. This data represented approximately 6% of the population of UK or 1 out of 16 people. The data also suggested that about 56% of the men and 44% of the women suffered from diabetes in the UK. The overall data of the world stated that about 415 million people were suffering from diabetes which represented about 1 out of 11 of the adult population. Approximately 46% of the population living with diabetes were undiagnosed. It was predicted that the figure was expected to rise up to 642 million people by the end 2040. The prevalence of the T2D is considered to be the most prevalent one in UK as it accounted for about 90% of the total diabetic cases and only 10% of the cases are due to type1diabetes. According to the report of the International Diabetic Federation, T2D cases are rising constantly among most of the countries. The countries which were reported with the high prevalence of diabetes were: China with 109 million, India with 69 million, United States with 29 million, Brazil with 14 million and Russian Federation with 12 million populations (Shaw, et al, 2010; Ohlson, et al, 1988) (Refer Fig: 1).

Risk Factors associated with Diabetes:

The type 1 diabetes occurs due to the damage of the pancreatic cells which may have triggered due to an infection or due to genetic deficiency in the action of insulin; disease of the pancreas; surgery and due to the use of drugs and chemicals. The type 2 diabetes is common among the adults and also among the youths who are obese and are part of certain ethnic group. The risk of developing T2D is also because of the family genes but the exact factors are not clear. The risk also increases with age, sedentary lifestyle of the patient and obesity. The T2D is most often observed among the people with hypertension, high cholesterol level, women suffering from the gestational diabetic mellitus (GDM). The risk factors can be controlled by changing the life style developmental approach such with the daily routine of physical exercise and in this way the associated mortality rate can also be reduced (Ohlson, et al, 1988).

Physical Activity and Diabetes:

Diabetes is considered to be the fifth most common reason of death in the world. The life expectancy due to type 1 diabetes had been reduced to higher than 20 years and for type 2 diabetes, it was reduced up to 10 years among the population. It has been established from various studies that the condition of T2D can be managed with the daily practice of moderate to vigorous level of physical activity. The individuals who are suffering from T2D can be physically weak in nature which makes it difficult for them to practice the recommended levels of physical activities. The daily physical activity recommended for these patients involves various activities such as walking during the leisure time, performing the daily household activities but that should not involve too much of physical burden, gardening etc along with the recommended levels of 150 minutes of moderate to vigorous level of daily exercise per week as per the American College of Sports Medicine and the American Diabetes Association. According to a study, the most recommended physical activity on a daily basis for the patients of T2D is walking for a minimum period of 30 minutes every day which reduces the risk by approximately 50% along with the reduction in mortality. Evidence concerning the housework activities and the gardening are very limited for the patients of T2D. For the patients suffering from the type 1 diabetes, favourable effects on the blood sugar control and on the other outcomes in relation to health had been observed with the practice of daily exercise though the evidences are very limited. Few recent studies have stated that the daily practice of physical activity which also includes the thermogenesis generated from the non exercise activity are associated with metabolic risk and mortality but further well structured longitudinal studies have established to explicate its effect on the on the whole health of the individuals. Moreover, the guidelines provided by NICE are generalised concerning the physical activities for type 2 diabetic patients (Yardley, et al, 2014; Fagour, et al, 2013; Sayer, et al, 2005).

It is evident that with the daily practice of exercise, the various parameters such as the lipid profile (reduction in the level of triglyceride and increase in the level of high density lipoprotein (HDL)), the resistance developed to insulin can be improved though the blood pressure can also rise during the exercise. The benefits observed in the metabolic rate with the daily practice of exercise become negligible within a span 3 -10 days of stopping the regular practice of exercise. Therefore as per the recommendation of the United Kingdom, at least 30 minutes of physical exercise for five days every week should be practiced by the adults to reduce the developmental risk of T2D. It should also be taken into consideration that the individuals should also enjoy while performing the exercise. Both the aerobic and the resistance training augment the action of insulin and controls the other related blood parameters thus improving the life quality of the patient. The other factors that have to be considered before the practice of exercise by the T2D patients are: the individual should take care of his oral hypoglycaemic therapy and the schedule of meal, the blood glucose level before exercise, if the blood glucose level is low one should postpone the exercise for having snacks or should keep glucose at hand; the other major clinical conditions should also be monitored for the diabetic patients such as the autonomic neuropathy, peripheral neuropathy, the peripheral arterial disease, the condition of hypoglycaemia after long hours of exercise. A diabetic patient should also avoid the high impact exercise that may traumatise the feet and exercise should not be performed if the individual is suffering from the associated condition of active retinal haemorrhage or current retinal photocoagulation (Colberg, et al, 2010).

Apart from the above mentioned conditions, the diabetic patients are also unable to perform the recommended levels of exercise for the exact duration as it appears as a physical burden to them which eventually results in the cessation of the exercise therapy. They are reported to have lower level of physical performance threshold in comparison to the normal healthy individuals. Specifically the patients of T2D reports a lower level of energy expenditure, less duration of physical activity, lower level of fitness associated with the cardiorespiration, lesser muscle strength and number of steps when compared to individuals without the condition of diabetes. Evidence has also supported the fact that there is an inverse level of association between the muscle strength of upper and lower extremity and degree of the diabetic complications which clearly indicates that with the progression of diabetic condition hindrance comes in the performance of physical activities. Therefore the percentage rate of the individual taking part in the exercise therapy is 40% and merely 28.2% of the diabetic patients could perform the recommended level of exercise in the United States. As per the data outcomes of another large scale cohort study, the individuals who performed low level of physical activity, i.e., 15 mins/day or 90 mins/week showed 14% reduction in the risk of mortality associated with various causes and also enhanced the span of life for about 3 years. The targeted goals of treatment for T2D are to maintain the optimal level of the blood glucose, lipid, BP so that the chronic complications of diabetes can be avoided. The level of blood glucose can be maintained by maintaining a healthy diet chart and a proper exercise or physical activity program. Losing the excess weight, the execution of the essential self care behaviours, intake of oral medications and supplemental insulin also helps in the lowering of the BG level. Therefore, diet and exercise are considered to be the central management techniques for the preclusion of type 2 diabetes (Nelson, et al, 2002; Pan, et al, 1997; Hamdy, et al, 2001).

The effects of physical activity:

1) The three factors that are associated with acute level of physical activities are: mobilization of fuel; production of glucose and the muscle glycogenolysis. Although the level of glucose in the blood is maintained by glycogenolysis and gluconeogenesis in the liver and by the mobilization of free fatty acids (FFAs), the muscle contraction also enhances the uptake of glucose of the blood. The fuel consumption is mostly due to the intensity and duration of physical activity.

2) Insulin dependent and independent glucose uptake by the muscles: It involves the two well structured pathways for the uptake of glucose by the muscle cells. At resting condition, the glucose uptake is via the insulin dependent pathway. At the time of exercise the increased level of blood glucose uptake to compliment the intramuscular glycogenolysis (Colberg, et al, 2010).

Therefore several studies had reported about the associations between moderate walking along with vigorous activity with the decreased risk of T2D. According to the study conducted in China, which included only physical activity as treatment reported that with a modest change in the exercise level (10 min of strenuous or 5 min of very strenuous exercise one to two times a day, 20 min of mild or moderate intensity activity), the risk of diabetes can be reduced by 46% when compared with 42% reported for diet combined with exercise and 31% for the diet alone. The Look AHEAD (Action for Health in Diabetes) was the biggest randomised trial evaluating the lifestyle intervention among the older adults with T2D when compared with the support group of diabetes and control education group. The outcome of the trial highlighted about the potential health benefits from the varied lifestyle interventions such as loss in weight, control of BG, BP, lipid level, cardiorespiratory fitness. The study outcome recommended that adults with T2D should practice both the aerobic and resistance exercise program to obtain the optimal glycemic and health outcomes. Therefore, the Finnish Diabetes Prevention Study and the United States Diabetes Prevention Program (DPP) have incorporated the lifestyle modification including the diet regime and the physical activity for the control of diabetes. As the patients of T2D are unable to meet the recommended levels of exercise on a daily basis due to their body weakness a well designed longitudinal study should be conducted focusing on the physical activity devoid of the structured activity in the near future. The recommendations of physical activity should be tailored according to the personalised conditions of the patient such as age, type of diabetes, the activities performed and the presence of any diabetes related complications. The adoption of behavioural change may promote the sustenance of life time physical activity (Blair, et al, 1995; Mettelinge, et al, 2013; Hameed, et al, 2011).

Conclusion and Recommendation:

Diabetes is considered to be the fifth common cause of mortality in the whole world and the numbers of individuals affected with the condition are rising rapidly throughout the globe. The major life style risk factors that are contributing to the diseased condition are the sedentary lifestyle of the modern people, obesity and high cholesterol level. The risk factors can be controlled by changing the life style developmental approach such with the daily routine of physical exercise and a healthy diet plan and in this way the associated mortality rate can also be reduced. The recommended level of physical activity for the adults with diabetes is 150 minutes of moderate to vigorous level of daily exercise per week as per the American College of Sports Medicine and the American Diabetes Association. This should be supplemented with light intensity activity such as walking, performing less strenuous house work or gardening as it reduces the risk of developing T2D. As per the recommendations of UK at least 30 minutes of physical exercise for five days every week should be practiced by the adults to reduce the risk of development of T2D. The significance of physical activity lies in the fact that it results in weight loss, control of BG, BP, lipid level, cardiorespiratory fitness, enables proper sleep and lowers the stress level. But the patients with T2D have lower physical activity threshold limit so well designed longitudinal study focusing on the physical activity devoid of structured activity should be taken into consideration and the physical activity should be tailored based on the individual conditions of the patient. The behavioural change approach may help in the sustenance of the activity among the patients. Therefore, government should plan a physical activity regime along with a healthy diet plan to get the optimum benefit among the diabetic patients. Patients should be consulted before preparing their physical activity regime based on their individual conditions. As most of the individuals with T2D can continue with the physical activity as long as specific safety measures are included within the regime. An addition of a new exercise plan or other activities that would increase the overall physical activity of the individual is essential for the optimal health conditions of the people with type 2 diabetes. Identification of new exercise opportunities will also increase the encouragement among the patients.

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