CC BY
72
UDC 616.379-008.64 DOI: 10.22141/2224-0721.14.1.2018.127085
P.O. Goldobin1, D.V. Shorikova2
1 Private Consultant in Diabetes Mellitus, Kyiv, Ukraine
2 State Higher Education Institution of Ukraine "Bukovinian State Medical University", Chernivtsi, Ukraine
Clinical efficiency of aerobic exercises in the young patients with type 1 diabetes mellitus
For cite: Miznarodnij endokrinologicnij zurnal. 2018;14(1):15-19. doi: 10.22141/2224-0721.14.1.2018.127085
Abstract. Background. The purpose of the study is to investigate the effect of regular aerobic physical exercises with 6-point intensity by Borg scale on glycemic profile, insulin sensitivity, and quality of life of patients with type 1 diabetes mellitus (DM). Materials and methods. The data from 42 patients with type 1 DM were analyzed. There were 20 women and 22 men aged 18 to 35 years (mean age 25.3 ± 7.9 years). The level of glycemia and glycated hemoglobin was estimated. The Medical Outcomes Study Short Form 36 questionnaire was used to assess the quality of life. Results. It has been shown that aerobic exercises can significantly modify the clinical course of type 1 DM and change the quality of life. After 30 days of regular aerobic exercises, the mean daily dose of ultra-short-acting insulin was decreased by 25.4 % versus baseline (p < 0.05). It was found that sensitivity to insulin after regular aerobic exercises was increased by 42.0 % and became 0.60 U per 1 bread unit (BU) by the end of the observation versus 1.03 U per 1 BU before the study. Also, regular physical activity was associated with the decrease in glycated hemoglobin content by 1.5 %. It has been established that regular aerobic exercises contributed to the significant (p < 0.05) increase in the quality of life according to all the scales which form physical and psychological components of health (physical functioning, role-physical functioning, bodily pain, general health, role-emotional functioning, vitality, mental health, social functioning) versus baseline that was accompanied by increase in emotional stability and workability. Conclusions. Regular aerobic exercises had the positive impact on the clinical symptoms of type 1 DM, resulted in improved glycemic profile, increased insulin sensitivity and quality of life of patients.
Keywords: type 1 diabetes mellitus; aerobic exercises; glycemic profile; insulin sensitivity; quality of life
C2> ■ FJ ® Орипнальш досл^ження
/Original Researches/
International journal of endocrinology
Introduction
After great increase in diabetes mellitus (DM) incidence in the 20th century, the term "non-infection epi-demy" has appeared, and this disease has become the global public health threat [1]. The high prevalence of DM determines its significance not only for the patients themselves and the health care system, but also for the society as a whole [8].
The most important task in the treatment of type 1 DM is to prevent microvascular complications, which are the main causes of disability in patients due to blindness, amputations and chronic kidney insufficiency. Only optimal glycemic control individually determined for each patient can prevent this [2].
Insulin therapy is one of the main ways for the best glycemic control in type 1 DM, but lifestyle modification is also important [6]. Most of the people with type 1 DM understand the role of diet, but compliance to the rules and guidelines is not absolute because of the habits influence, surroundings, and the problems in daily regimen. The third component for the optimal glycemic control is physical activity, although the role of this aspect in DM treatment is not often evaluated by patients and medical community [7].
In the number of studies, it has been proved that specific physical activity can significantly improve the control of DM [10, 12].
Unfortunately, such results were obtained only when special conditions were created that required a lot of time
© «Ммнародний ендокринолопчний журнал» / «Международный эндокринологический журнал» / «International Journal of Endocrinology» («Miznarodnij endokrinologicnij zurnal»), 2018 © Видавець Заславський О.Ю. / Издатель Заславский А.Ю. / Publisher Zaslavsky O.Yu., 2018
Для кореспонденци: Шор^ова Дша Валентишвна, кандидат медичних наук, доцент, Вищий державний навчальний заклад УкраТни «Буковинський державний медичний ушверситет», пл. Театральна, 2, м. Чершвц, 58002, УкраТна; е-mail: [email protected]; тел.: +38(050)540-85-61
For correspondence: Dina Shorikova, PhD, Associate Professor, State Higher Education Institution of Ukraine "Bukovinian State Medical University'; Teatralna sq., 2, Chernivtsi, 58002, Ukraine; е-mail: [email protected]; phone: +38(050)540-85-61.
OpMNHOAbHi AOCAiA^eHHfl /Original Researches/
JEI
and effort from the patients, therefore, it could not be represented in the clinical practice.
At the same time, the question of possibility and effectiveness of physical exercises, its impact on the DM management, and the way the regular physical activity can modify the diabetes control are very topical.
The purpose of the research is to investigate the effect of regular aerobic physical exercises with 6-point intensity by Borg scale on glycemic profile, insulin sensitivity, and the quality of life (QL) of patients with type 1 diabetes mellitus.
Materials and methods
The data of 42 patients with type 1 DM were analyzed. There were 20 women and 22 men aged 18 to 35 years (mean age 25.3 ± 7.9 years). All patients included in the study had the compensated DM. Insulin therapy was administered with an ultra-short-acting insulin according to the dietary pattern and basal insulin.
The level of glycemia was measured 6 times a day — in the morning on an empty stomach, before and after aerobic exercise, and during the main meals.
Glycated hemoglobin (HbAlc) level was assessed on InnovaStar analyzer by immunoturbidimetric method. All patients included in the study performed aerobic exercises three times weekly.
The main requirements for physical activity were:
1) taking into account psychological characteristics of a patient;
2) all muscle groups must be involved;
3) no prolonged breaks and pauses;
4) duration 60 minutes or more;
5) energy expenditure at least 500 kcal per hour or more;
6) should be done in the morning.
According to these positions, the most convenient method to control the intensity of training was Borg scale. The main condition was individual and subjective load perception.
All subjects had moderate physical activity — 6 points by Borg scale, or 60.0—70.0 % of the highest possible heart rate. In this case, the simple and complex carbohydrates are the main resources for metabolism.
The team sports (25 patients) and swimming exercises (long, but not with maximum level, 17 patients) meet these requirements.
The Medical Outcomes Study Short Form 36 questionnaire (SF-36, developed and recommended by the International Center for Quality of Life Research) was used to assess the QL of patients. This questionnaire allows evaluating the subjective satisfaction of the patient with his physical and mental state, social functioning [11].
Patients were asked to fill the SF-36 questionnaire before the research and by the end of the controlled observation period. The SF-36 gives the opportunity to evaluate QL according to the eight scales: physical functioning (PF), role-physical functioning (RP), bodily pain (BP), general health (GH), vitality (VT), social functioning (SF), role-emotional functioning (RE) and mental health (MH) [11].
The patients had no previous history of smoking or drinking or gave up at least two weeks before the research. Dietary pattern included three main meals and two snacks.
Statistical analysis was performed using Statistica 7.0 (StatSoft, USA). Differences were statistically significant at p < 0.05.
Results
The clinical features of patients with type 1 DM before the study are presented in the Table 1.
After initial examination, the patients were included into prospective follow-up study (duration 25 to 37 days, the average of 32.50 ± 5.67 days).
The dynamics of ultra-short-acting insulin daily mean dose during controlled period is shown in Fig. 1.
The average insulin daily dose was calculated in accordance to individual observation chart for each patient during 2 weeks preceding the study and throughout the research period. As we can see, the mean daily dose of ultra-short-acting insulin was decreased from 35.1 ± 3.9 U to 28.00 ± 3.52 U (25.4 %, p < 0.05).
The basal bolus insulin doses did not change, with the mean of 19.20 ± 3.91 U/day. The bread units (BU) mean was 15.50 ± 2.71 and did not change before and after the study.
So, the sensitivity to insulin has significantly changed after regular aerobic exercises (Fig. 2).
Table 1. Clinical features of the examined patients
Parameter Mean, M ± m Min-Max
Duration of type 1 DM, years 15.9 ± 10.3 4.5-20.5
HbA1c, % 9.4 ± 1.8 6.7-12.4
Height, cm 164.7 ± 11.0 152.6-180.3
Body weight, kg 61.0 ± 10.4 48.3-76.5
Figure 1. Dynamics of ultra-short-acting insulin daily
mean dose during controlled observation period Note: here and in Fig. 2,4: * — the significant changes (p < 0.05).
Figure 2. The sensitivity to insulin (U/BU) in patients with type 1 DM during observation period
i El
OpuriHOAbHi AOCAÎA^eHHA /Original Researches/
As we can see, the sensitivity to insulin after regular aerobic exercises increased by 42.0 % and was 0.60 U per 1 BU by the end of the observation versus 1.03 U per 1 BU at baseline.
According to the received data, regular morning aerobic exercises induce two episodes of glycemic curve lowering. So, the reduction of glucose level occurred during physical activity and immediately after it, which may be not only due to the direct glucose utilization in response to aerobic exercises, but also the result of lower glucose level throughout the day.
The daily glycemic profile and its dynamics are shown in Fig. 3.
Also, it was interesting to mark the delayed, more pronounced, intense and prolonged glucose level reduction 3—4 hours after physical activity.
HbAlc is an indicator of glycemic control level, marker of DM compensation and relevance of hypogly-cemic therapy.
In our work, after 30 days of controlled observation and regular physical exercises, there was a significant decrease in the level of HbAlc that is shown in Fig. 4.
Thus, regular physical activity such as aerobic exercises in our study was associated with 1.5 % decrease in HbAlc.
During the first visit, SF-36 questionnaire [11] was also filled in.
The measuring model of the SF-36 has 3 levels: 1) the question; 2) eight scales, each ofwhich consists of 2 to 10 points; 3) two aggregate measurements that combine the scales together. After analyzing the results, the answers have been received for all 36 items, which form 8 scales. Items are summed up and converted into values from 0 to 100 points, where 100 points is the maximum value,
and 0 is the minimum. Higher scores represent the higher level of health.
The SF-36 includes one multi-item scale that assesses eight health concepts:
1. Physical functioning — limitations in physical activities because of health problems (self-service, walking, walking down the stairs, carrying weight, etc.).
2. Role limitation due to physical health is the influence of the physical state on the role functioning (work, daily activities).
3. Physical pain — the severity of pain and its impact on the ability to participate in everyday activities, including homework and out-of-home activities.
4. General health — assessing current state of health and the prospects for treatment.
5. Role limitation due to emotional problems implies an assessment of the extent of the emotional state interfering with work or other daily activities (including high time expenditures, reduced scope of work, decrease in its quality, etc.).
6. Vital energy means a feeling of full strength and energy or, conversely, the weakness.
7. Mental health characterizes the mood (presence of depression, anxiety, a general indicator of positive emotions).
8. Social functioning is determined by the extent of social activity (communication) restriction due to the physical or emotional state.
Scales are grouped into two indicators like "physical component of health" and "psychological component of health":
I. Physical health. Components of the scale: 1) physical functioning; 2) role-playing function conditioned by physical condition; 3) pain intensity; 4) general health.
14 13 12 11 10 9 8 7
-A- Final
-■- Initial Á
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.__ ---^S \ * \
Àr N
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/ v
3.00
11.00 14.00 17.00 20.00 23.00
Figure 3. The glycemic curve in patients with type 1 DM during observation period
Figure 4. The level of glycated hemoglobin in patients with type 1 DM during observation period
Table 2. Quality of life in patients with type 1 DM during observation period
Component Population index Patients with type 1 diabetes mellitus
Initial Final
PF 77.02 ± 25.20 37.3 ± 12.3 68.2 ± 10.9 p, p, < 0.05
RP 53.80 ± 22.36 39.20 ± 7.98 48.10 ± 9.14 p, p, < 0.05
BP 61.3 ± 26.2 52.50 ± 5.81 49.2 ± 10.2 p, p, < 0.05
GH 56.6 ± 19.3 36.5 ± 13.5 53.10 ± 7.15 p, p, < 0.05
RE 55.2 ± 21.9 38.30 ± 9.26 53.1 ± 9.7 p, p1 < 0.05
VT 69.7 ± 23.4 40.80 ± 8.62 59.8 ± 10.8 p, p, < 0.05
MH 57.2 ± 18.9 46.4 ± 10.7 64.60 ± 8.45 p, p, < 0.05
SF 58.8 ± 19.9 36.90 ± 7.39 65.2 ± 14.6 p, p, < 0.05
Notes: the significant changes: p — tion index and patients with type 1 dynamics of observation.
between popula-diabetes; p1 — in
OpumaAbHi gocAigweHHA /Original Researches/
II. Psychological health component. Components of the scale: 1) mental health; 2) role-playing function conditioned by the emotional state; 3) social functioning; 4) life activity. Each item was used to process score only by one of the scales.
On the basis of 8 scales, the total assessment of physical and mental health was performed. SF-36 results are presented in Table 2.
It was found that QL decreased in all patients with diabetes mellitus type 1 according to the all scales of SF-36 questionnaire. The lowest scores, when it was compared with the general population, were obtained on the scales of physical (PF, GH and RP) and psychological (RE, VT and SF) health components. Initial results indicate that physical and psychological health has a significant negative impact on routine activities.
The average indicators on the scales of role functioning conditioned by the emotional state, mental health, social functioning have shown that type 1 DM has a negative impact on the psychological component of health.
In the dynamics of treatment, it was found that the quality of life in patients with type 1 DM depends on the degree of glycemic compensation, as well as the level of physical activity. The reliable improvement of both physical and psychological components of health after regular morning aerobic exercises is proved.
Discussion
Physical activity is an important component of self-education that changes the level of compensation and quality of life in patients with type 1 DM.
Physical activity leads to increased insulin sensitivity and activation of non-insulin-sensitive glucose transporters (GLUT-4). Thus, physical activity in patients with type 1 DM may affect glycemia during some hours. The decrease in glycemia is related to the divergence between production and utilization of glucose [3, 9].
This one affects the suppressing level of insulin. In healthy people, in response to physical activity, suppression of insulin secretion and increased glucose production by the liver are proved. In patients with type 1 DM, the level of insulin can be corrected only in advance, and counterregulatory mechanisms are disturbed or absent [5].
Decreased glycemia in this period requires the correction of insulin therapy. This can be achieved by reducing ultra-short-acting insulin dosage, which was confirmed in our study. The second way is lowering the basal insulin dosage, which has to be studied in future.
Low level of physical activity is also associated with poor quality of life [4], so this aspect should be included in the education programs ("Diabetic schools") to improve the patient's social activity and adaptation.
Conclusions
We have revealed the positive effect of regular aerobic exercises on the clinical symptoms of type 1 diabetes mellitus resulted in the improved glycemic profile, increased insulin sensitivity and quality of life.
_iEI
1. It has been shown that aerobic exercises can significantly modify the clinical course of type 1 diabetes mellitus and change the quality of life.
2. After 30 days of regular aerobic exercises, the mean daily dose of ultra-short-acting insulin is decreased by 25.4 % versus baseline (p < 0.05).
3. The sensitivity to insulin after regular aerobic exercises increased by 42.0 % and became 0.60 U per 1 BU by the end of the observation versus 1.03 U per 1 BU before the study.
4. Regular physical activity was associated with the decrease in glycated hemoglobin level by 1.5 %.
5. Regular aerobic exercises contributed to a significant (p < 0.05) improvement of the quality of life by all the scales, which form physical and psychological components of health (PF, RP, BP, GH, RE, VT, MH, SF) versus baseline.
Conflicts of interests. Authors declare the absence of any conflicts of interests that might be construed to influence the results or interpretation of their manuscript.
References
1. UN Resolution on diabetes mellitus. Sakharni Diabet. 2007;1:2-3. (in Russian)
2. Mayorov AYu, Melnikova OG, Filippov YuI. Self-monitoring of blood glucose: a mainstay of effective diabetes treatment. Effektivnaya farmakoterapiya. 2013;35:46-57. (in Russian)
3. Sato K, Nishijima T, Yokokawa T, Fujita S. Acute bout of exercise induced prolonged muscle glucose transporter-4 translocation and delayed counter-regulatory hormone response in type 1 diabetes. PLoS One. 2017 Jun 1;12(6):e0178505. doi: 10.1371/ journal.pone.0178505.
4. Falkowski B, Chudziski M, Jakubowska E, Duda-Sobczak A. Association of olfactory function with the intensity of self-reported physical activity in adults with type 1 diabetes. Pol Arch Intern Med. 2017Aug 9;127(7-8):476-480. doi: 10.20452/ pamw.4073.
5. Jewiss D, Ostman C, King N, Smart NA. Clinical Outcomes to Exercise Training in Type 1 Diabetes: A Systematic Review andMeta-Analysis. Diabetes Res Clin Pract. 2017 Dec 6. pii: S0168-8227(17)31108-7. doi: 10.1016/j.diabres.2017.11.036.
6. Codella R, Terruzzi I, Luzi L. Why should people with type 1 diabetes exercise regularly?Acta Diabetol. 2017 Jul;54(7):615-630. doi: 10.1007/s00592-017-0978-x.
7. Delamater AM, de Wit M, McDarby V. ISPAD Clinical Practice Consensus Guidelines 2014. Psychological care of children and adolescents with type 1 diabetes. Pediatr Diabetes. 2014 Sep;15 Suppl 20:232-44. doi: 10.1111/pedi.12191.
8. Lohse Z, Knorr S, Bytoft B, et al. Differential effects of age and sex on insulin sensitivity and body composition in adolescent offspring of women with type 1 diabetes: results from the EPICOM study. Diabetologia. 2018 Jan;61(1):210-219. doi: 10.1007/ s00125-017-4458-1.
9. Al-Lahham Y, Mendes AK, Souza EM. Interleukin-18 (rs187238) and glucose transporter 4 (rs5435) polymorphisms in Euro-Brazilians with type 1 diabetes. Genet Mol Res. 2017 Sep 21;16(3). doi: 10.4238/gmr16039755.
10. Tikkanen-Dolenc H, Wad n J, Forsblom C, et al. Physical Activity Reduces Risk of Premature Mortality in Patients With
Орипнальш дослiдження /Original Researches/
Type 1 Diabetes With and Without Kidney Disease. Diabetes Care. 2017Dec;40(12):1727-1732. doi: 10.2337/dc17-0615.
11. Ware JE, Snow KK, Kosinski M, et al. SF-36Health Survey. Manual and interpretation guide. 2nd ed. Boston: The Health Institute, New England Medical Center; 1997. 28p.
12. Yates T, Davies MJ. Physical activity and Type 1 diabetes: an underused therapy. Diabet Med. 2017 Nov;34(11):1498-1499. doi: 10.1111/dme.13445.
Received 11.12.2017 ■
Голдобн П.О.1, Шоркова Д.В.2
1 Приватний консультант з питань цукрового Aia6ery, м. Кив, Украна
2ВДНЗ Укра)'ни «Буковинський державний медичний yнiверситет», м. Чернiвцi, Украна
Кл^чна ефективнють аеробних фiзичних навантажень у молодих пащенпв i3 цукровим дiабетом 1-го типу
Резюме. Мета дослгдження: вивчити вплив регулярних аеробних фiзичних навантажень штенсивнютю 6 батв за шкалою Борга на глiкемiчний профшь, чутливють до шсу-лшу, а також якють життя у пащентав i3 цукровим дiабетом (ЦД) 1-го типу. Mamepirnu i методи. Проаналiзовано даш 42 пащенпв i3 ЦД 1-го типу — 20 жшок та 22 чоловтв вь ком вщ 18 до 35 ротв (середнiй вiк 25,3 ± 7,9 року). Рiвень глiкемiï оцiнювався портативним методом 6 разiв на день. Дослщження вмiсту глiкованого гемоглобiну проводилось iмунотурбодиметричним методом. Для оцшки якост1 життя пацiентiв використовувався опитувальник Medical Outcomes Study Short Form 36 questionnaire. Результа-mu. Доведено, що аеробш фiзичнi навантаження можуть значно модифiкувати перебiг ЦД 1-го типу та змшювати якiсть життя. Через 30 дшв регулярних аеробних фiзичних навантажень у ранковий час середньодобова доза ультракороткого шсулшу зменшилася на 25,4 % вщ початкового рiвня (р < 0,05). Виявлено, що чутливiсть до шсул^ при аеробних навантаженнях у хворих на ЦД 1-го типу збшь-шилася на 42,0 % (р < 0,05) та становила 0,60 ОД на 1 хлiб-
ну одиницю (ХО) наприынщ дослщження пор1вняно з 1,03 ОД на 1 ХО перед включенням пащенпв у дослщження, а зниження р1вня глжованого гемоглобшу становить у середньому 1,50 ± 0,12 % (р < 0,05). Установлено, що ре-гулярш аеробш ф1зичш навантаження сприяють значному (р < 0,05) пщвищенню р1вня якост життя за шкалами як ф1зичного, так 1 психолопчного компонента здоров'я (фь зичне функцюнування, рольове ф1зичне функцюнування, штенсивнють болю, загальне здоров'я, рольове емоцшне функцюнування, життева актившсть, психгчне здоров'я, сощальне функцюнування) пор1вняно з початковими по-казниками, що супроводжувалося пщвищенням емоцш-но1 стшкосп та працездатность Висновки. Виявлено пози-тивний вплив регулярних аеробних ф1зичних навантажень на переб1г ЦД 1-го типу, а саме покращання гл1кем1чно-го профшю, пщвищення чутливост до шсулшу, а також якост життя пащенпв.
Ключовi слова: цукровий д1абет 1-го типу; аеробш навантаження; гл1кем1чний проф1ль; чутливють до шсул1ну; яысть життя
Голдобин П.А.1, Шорикова Д.В.2
1 Частный консультант по вопросам сахарного диабета, г. Киев, Украина
2ВГУЗ Украины «Буковинский государственный медицинский университет», г. Черновцы, Украина
Клиническая эффективность аэробных физических нагрузок у молодых пациентов с сахарным диабетом 1-го типа
Резюме. Цель исследования: изучить влияние регулярных аэробных физических нагрузок интенсивностью 6 баллов по шкале Борга на гликемический профиль, чувствительность к инсулину, а также качество жизни у пациентов с сахарным диабетом (СД) 1-го типа. Материалы и методы. Проанализированы данные 42 пациентов с СД 1-го типа — 20 женщин и 22 мужчин в возрасте от 18 до 35 лет (средний возраст 25,3 ± 7,9 года). Уровень гликемии оценивался портативным методом 6 раз в день. Исследование содержания гликированного гемоглобина проводилось иммунотурбодиметрическим методом. Для оценки качества жизни пациентов использовался опросник Médical Outcomes Study Short Form 36 questionnaire. Результаты. Доказано, что аэробные физические нагрузки могут значительно модифицировать клиническое течение СД 1-го типа и изменять качество жизни. Через 30 дней регулярных аэробных физических нагрузок в утреннее время среднесуточная доза ультракороткого инсулина уменьшилась на 25,4 % от исходного уровня (р < 0,05). Выявлено, что чувствительность к инсулину при аэробных нагрузках у больных с СД 1-го типа увеличилась на 42,0 % (р < 0,05) и составила 0,60 ЕД на 1 хлеб-
ную единицу (ХЕ) в конце исследования по сравнению с 1,03 ЕД на 1 ХЕ перед включением пациентов в исследование, а снижение уровня гликированного гемоглобина составляет в среднем 1,50 ± 0,12 % (р < 0,05). Установлено, что регулярные аэробные физические нагрузки способствуют значительному (р < 0,05) повышению уровня качества жизни по шкалам как физического, так и психологического компонента здоровья (физическое функционирование, ролевое физическое функционирование, интенсивность боли, общее здоровье, ролевое эмоциональное функционирование, жизненная активность, психическое здоровье, социальное функционирование) по сравнению с исходными показателями, что сопровождалось повышением эмоциональной устойчивости и работоспособности. Выводы. Выявлено позитивное влияние регулярных аэробных физических нагрузок на течение СД 1-го типа, а именно улучшение гликемического профиля, повышение чувствительности к инсулину, а также качества жизни пациентов.
Ключевые слова: сахарный диабет 1-го типа; аэробные нагрузки; гликемический профиль; чувствительность к инсулину; качество жизни
