Fasting plasma glucose and lipid profiles of diabetic patients improve with aerobic exercise training

Objective: This study presents the effects of aerobic exercise training on fasting plasma glucose and lipid profiles (FPG/LP) of diabetic patients in Kumasi. Design: A randomised experimental with control design. Setting: The study was conducted at the diabetic unit of KATH in Kumasi, Ghana. Participants: Twelve diabetic patients [grouped into intervention (IG) and control (CG)] attending the diabetic unit of KATH with diabetes diagnosis durations less than fifty years, ambulant status/age of 20-68years, sedentary and free from complications. Interventions: Eight weeks aerobic exercise training between August 2015 and March 2016 Main outcome measures: Body weight (BW), Body mass index (BMI), fasting plasma glucose (FPG), high density lipoprotein cholesterol (HDL-C), low density lipoprotein cholesterol (LDL-C), triglycerides (T) and total cholesterol (TC). Results: Body weight (4.85kg, 7.0%), body mass index (4.08kg/m, 7.3%), FPG (5.28mmol/L, 43.5%), LDL-C (.33mmol/l, 11.9%), TC (.47 mmol/l, 5.3%) and T (.48mmol/l, 29.4%) profiles of the patients in IG declined while HDL-C (.11mmol/l, 7.1%) increased. IG patients improved significantly in FPG [6.27 ± 0.91 < 8.00 ± 0.96; t=52.00, P = 0.000], BW [58.60 ± 15.34 < 75.35 ± 22.00; t= 3.29, P = 0.040] and BMI [23.45 ±5.03<27.04 ±4.78, t=4.24, P = .050] compared to CG. Conclusion: Patients in IG, in addition to conventional care, experienced non-significant decline in LDL-C, TC, T, increase in HDL-C and significant reduction in FPG, BW, and BMI over those receiving conventional care only. Exercise Scientists are recommended to handle exercise sessions for healthcare prevention and management routines of diabetic patients.


INTRODUCTION
Diabetes Mellitus (DM) is a global health problem and one of the leading causes of morbidity and mortality for 90-95% of all chronic diseases. 1[5] The increase in DM prevalence can partly be attributed to the increasing prevalence of obesity and sedentary lifestyle 6 , insulin resistance, beta-cell dysfunction, environmental and genetic factors. 7Uncontrolled hyperglycemia and insulin resistance in patients with diabetes results in lipid abnormalities. 8eatment of DM is solely centered on healthcare management using prescribed medication and dietary lifestyle modifications. 9ealthcare cost of managing individuals with DM is however a huge financial burden for individuals hence the need for support from family members and other donors. 10ercise has been considered a cornerstone of diabetic management, along with diet and medication. 4,5he American Diabetes Association (ADA) recommends at least 150minutes per week of moderate intensity aerobic physical activity or at least 90minutes per week vigorous aerobic exercise distributed over at least 3 days per week and with no more than 2 consecutive days without physical activity. 11udies have shown aerobic exercise training as a convenient, cheap, effective and efficient technique in diabetes management in some countries. 3,9,11It has also been reported that regular aerobic exercise reduces the indices of cardiovascular and all-cause mortality, increases skeletal muscle capitalization and blood flow, muscular glucose transporter type 4 (GLUT4) levels, hexokinase and glycogen synthase activities. 12,13buga et al reported an estimation credited to Ghana Diabetes Association that a Ghanaian dies of diabetes every 10 seconds. 14These deaths occur as a result of potentially life-threatening complications that include stroke, heart attack, diabetic ketoacidosis, retinopathy and nephropathy. 15,16,17Kumi-Ampofo researched into the household cost of seeking diabetic healthcare of 424 diabetic patients aged 12 and 80 years in the Tano North District of the Brong Ahafo region of Ghana with the conclusion that both financial and non-financial cost of diabetes mellitus accounts for more than two-thirds of the household's income. 18e further reiterated that the adverse effect of the cost has implications on the healthcare and quality of life of the diabetic patients and their household; hereby calling for intervention treatment. 18Kubuga et al's study also found that diabetic patients suffer the risk of posttraumatic stress disorder where psychological treatment was recommended. 14A recent study on the qualitative information about current food knowledge, attitudes and practices among type 2 diabetes mellitus (T2DM) patients and their caregivers in the region of Kumasi, Ghana, endorsed educational intervention as preventive measure. 19though there are many studies in Ghana [20][21][22][23][24][25][26][27] on diabetes management, study on the use of exercise intervention as vital tool in the management of diabetic patients, trending diabetes healthcare management technique of developed countries [28][29][30][31][32] cannot be overemphasised.
This study therefore examined the effects of aerobic exercise training on fasting plasma glucose and lipid profiles (FPG/LP) of diabetic patients in Komfo Anokye Teaching Hospital (KATH), Kumasi.

Study design and population
A randomised experimental pre-posttest design was used in the study.This was considered appropriate for explaining the variation of result hypothesized and abide by the rules that is generally associated with true experiments. 33The population was made up of Ghanaian diabetic patients who attend the diabetes unit of KATH, Kumasi, Ghana.

Sample
The participants were twelve out-patients from the KATH diabetes unit admitted between January and December 2015.The participants were patients with a diagnosis of diabetes with varied years but more than ten, ambulant status/age 20-68years, who do not meet the standard physical activity guidelines of 150 minutes per week of moderate physical activity 34 and free from complications (e.g.nephropathy, neuropathy, cataracts, glaucoma, heart diseases, stroke and hypertension) ascertained through medical records.
Participants were excluded if both systolic and diastolic blood pressure were more than 140 and 90 mmHg respectively, existence of bilateral or unilateral lower or upper limbs amputation and patients using insulin pump.Twenty patients who met the inclusion criteria were contacted and taken through the objectives of the study.Twelve (60.0%) out of the twenty who voluntarily consented to participate in the study were given informed consent form to read and sign.On the subsequent visit to the participants, the signed informed consent forms were retrieved.
Thereafter participants were randomly assigned to the intervention or control group by ballot (choose a folded pre-engraved paper of intervention or control in a box, without replacement). 35Of the twelve subjects used, seven were in the eight weeks intervention group (IG) while five were in the control group (CG).

Study setting
The study was conducted at the diabetic unit of the KATH in Kumasi, Ghana.KATH is one of the most accessible tertiary healthcare facilities in the country.The hospital receives referrals from all the northern regions (namely, Northern, Upper East and Upper West Regions), Brong Ahafo, Central, Western, Eastern and part of the Volta Region.
A number of patients also come in from the neighbouring countries.The hospital is equipped with state of the art health facilities and equipment needed for this project.
The diabetic center of KATH is situated beneath the medicine block (D Block), between the chest clinic and diagnostic center and behind the emergency unit of the hospital.

Assessment Procedure
Assessment of weight (kg) and height (m), and calculation of body mass index (kg/m 2 ) were in accordance with standardized anthropometric protocol. 34Fasting plasma glucose and lipid profiles also followed ethical protocol 34 .

Fasting Plasma Glucose and Lipid Profiles
Subject's pre and post training FPG/LP profiles were measured early in the morning (7:00AM) with the following methods and procedures: 5ml of venous blood sample was taken from the subjects after cleaning the venipuncture site with 70% alcohol, 3ml of the blood sample (whole blood) was dispensed into fluoride oxalate tube for the fasting plasma glucose test and 2ml into a gel separator sample tube for lipid test.The samples were centrifuged using the centrifuge SM80-2 to separate the plasma (for the fasting plasma glucose) and serum (for the lipid studies) from the red blood cells.
The samples were then analyzed using the BA-88A Chemistry Analyzer manufactured by Mindray Bio-Medical Electronics Co. Ltd, China.Pre-post training HDL-C, LDL-C, TC, T, BW and FPG were conducted as earlier described in the testing procedure section using standardized protocols, techniques and methods.The choice of FPG as a marker of glycemic control in this study was based on the report that it is clinically acceptable and affordable within Ghana. 23All pre and post-test measurements were recorded for analysis.

Training Procedure
The participants continued with their regular medical/clinical routines during the period of the study.

Intervention Group
Blood pressure and heart rate were measured each day before exercise training while physicians were always available during training.The intervention group participated in walking aerobic exercise sessions without using treadmill.After a 10-minutes warm up, subjects walked for 30-minutes at a moderate intensity of between 50% -60% of their maximum heart rate (obtained during exercise session with pulse oximeter-version 803, China and online Pace Calculator application).
The starting workload was slow pace (3.5m/s, 3.95miles) which was increased to a faster pace (4.0m/s, 4.5miles) to obtain HR max 60%.The initial exercise session was increased from 30-minutes in the first two weeks of training to 45-minutes (2.35m/s, 3.95miles -2.68m/s, 4.5miles) throughout the remaining part of the training.After each of the aerobic exercise training session, 10-minutes cool down was established.The aerobic exercise session of three times per week was maintained throughout the eight weeks training period.
Control Group: Participants in the control group were instructed not to engage in any organized/ structured physical activity apart from the activity of daily living and monitored during the 8 weeks period of study.

Data Analysis
Data analysis was performed using statistical package for social science (SPSS) for window program version 23.0.Descriptive statistics of means and standard deviations were recorded and within-group comparisons were performed to test for differences in these parameters before and after the exercise programme with paired t-test analysis (P<0.05 was considered statistically significant).

Ethical issues
The study received approval of the KATH

Key: body mass index (BMI), fasting plasma glucose (FPG), total cholesterol (TC), triglycerides (T), high density lipoprotein (HDL-C), low density lipoprotein (LDL-C).
There are no statistically significant differences (p > 0.05) in the baseline values between pre-test of both IG and CG.There is no statistically significant difference in all the pre-post FPG/LP in the control group at 0.05 alpha level.

DISCUSSION
The aim of the study was to examine the effects of aerobic exercise training on fasting plasma glucose and lipid profiles (FGP/LP) of diabetic patients in Komfo Anokye Teaching Hospital (KATH), Kumasi.The participants in IG experienced 4.85kg (7.0%) body weight loss after eight weeks aerobic exercise training.This supports Okada et al's work that showed significant weight loss in the intervention group programme that included exercise plus nutrition classes (which may have an additional positive effect, confirming this study). 391][42] The discrepancies in these studies could be attributed to varying factors ranging from differences in study design to socioeconomic and socio-demographic factors and the sample size.A significant 4.08kg/m 2 (7.3%) decrease was observed in the BMI of the participants as reported in previous studies with the same principles but longer duration. 43,44is study shows that FPG reduced by 43.5% (5.28mmol/l) after eight weeks aerobic exercise training which is significantly different from the FPG of the control group (tables 2 & 3).This is in line with earlier studies where six months continuous aerobic exercise training were reported to significantly reduce the mean of FPG as compared to non-exercisers. 45,46Other studies concluded that since working muscles are more sensitive to insulin, aerobic exercise facilitates glucose uptake by the muscles, and can thus be a definitive tool in blood glucose control. 47,39,44These findings imply that aerobic exercise could serve as therapeutic and defensive antidotes to FPG in patients with diabetes mellitus.
The positive decline in the LDL-C (.33mmol/l, 11.9%), TC (.47mmol/l, 5.3%) and T (.48mmol/l, 29.4%) profiles of the patients in IG and increase in HDL-C-C (.11mmol/l, 7.1%), although not significant, indicate the value inherent in aerobic exercise training.In addition, positive changes were also evident in a three-week walking programme reported in the study of Goldhaber-Fiebert et al although insignificantly small. 48,49e percentage decline in LDL-C (11.9%) observed in this study is greater than the value in the meta-analysis conducted by Kelly and Kelly which indicated a significant reduction by 5% for LDL-C. 50The improvement in TC, T, HDL-C-C and LDL-C exhibits clear evidence of reduction in atherogenic traits of risk factors 51,52 and better quality of life 53-55 of the sample studied.Authors observed that there are variations in the findings associated with this study in literature which are attributed to intensity, duration and frequency of exercise trainings and sample sizes.

LIMITATION
This study is limited on the fact that it is an experimental study with a sample size of only twelve patients and duration of the aerobic exercise programme was 8 weeks.The dietary lifestyle of the participants was not controlled which could also be a limitation.

CONCLUSION
Based on the findings of this study after 8 weeks of aerobic exercise programme in addition to conventional care of patients with diabetes mellitus, we concluded that there is non-significant decline in LDL-C, TC and Research and Development Unit (R&D) and clearance was sought from the Committee on Human Research, Publications and Ethics (CHRPE) of the Kwame Nkrumah University of Science and Technology, Kumasi, Ghana [Ref.CHRPE/AP/209/16].All the participants signed consent of participation form after attaining personal understanding of the rationale of the study.

Table 1
Descriptive Distribution of Pre-post FPG/LP among Groups

Table 2
Mean differences of pre-post FPG/LP mean values in the intervention group

Table 3
Mean differences of Pre-Post FPG/LP Mean Values in the Control Group

Table 4
Mean differences of post FPG/LP between intervention and control groups T, increase in HDL-C and significant improvements in BW, BMI and FPG over those receiving conventional care only.The inclusion of aerobic exercise programme in the healthcare prevention and management routine of diabetic patients would be beneficial in the long run.Hence a scheduled aerobic exercise training programme handled by Exercise Scientists is recommended to be emphasized by physicians as part of healthcare prevention and management routines of diabetic patients.interval versus traditional endurance training: similar initial adaptations in human skeletal muscle and exercise performance.J Physiol.2006;575(Pt 3):901-11.50.Kelley GA, Kelley KS, Roberts S, Haskell W. Krauss RM.Lipids and Lipoproteins in Patients With Type 2 Diabetes.Diabetes Care.2004;27(6):1496-504. 52.Schwartz EA, Koska J, Mullin MP, Syoufi I, Schwenke DC, Reaven PD.Exenatide suppresses postprandial elevations in lipids and lipoproteins in individuals with impaired glucose tolerance and recent onset type 2 diabetes mellitus.Atherosclerosis.2010;212(1):217-22.53.Rizos C V, Elisaf MS, Liberopoulos EN.Effects of Thyroid Dysfunction on Lipid Profile.Open Cardiovasc Med J. 2011;5:76-84.54.Yang W, Zhuang X, Li Y, Wang Q, Bian R, Shen J, et al.Improvements in quality of life associated with biphasic insulin aspart 30 in type 2 diabetes patients in China : results from the A 1 chieve ® observational study.Health Qual Life Outcomes.2014;12(1):1-7.55.Giordano, Roberta, Guaraldi Federica, Marinazzo Elisa, Fumarola Federica, Rampino Alessia, Berardelli Rita, Karamouzis Ioannis, Lucchiari Manuela, Manetta Tilde, Mengozzi Giulio, Arvat Emanuela GE.Improvement of anthropometric and metabolic parameters, and quality of life following treatment with dual-release hydrocortisone in patients with Addison's disease.Endocrine [Internet].2016;51(2):360-8.Available from: http://link.springer.com/article/10.1007/s12020-015-0681-z✪