P hd Research topic

PhdResearch topic Nigatfathima.P.A Guide: Dr Abhaynirgude H.O.D community medicine

IMPACT OF COMMUNITY BASED EXERCISE –PROGRAMME ON PHYSICAL FITNESS, GLUCOSE CONTROL AND QUALITY OF LIFE IN TYPE-2 DIABETIC and PRE-DIABETIC FEMALE PATIENT-A quasi experimental study

Diabetes is a chronic disease that occurs either when the pancreas does not produce enough insulin or when the body cannot effectively use the insulin it produces. Insulin is a hormone that regulates blood sugar . • Hyperglycaemia, or raised blood sugar, is a common effect of uncontrolled diabetes and over time leads to serious damage to many of the body's systems, especially the nerves and blood vessels.

Type 2 diabetes • Type 2 diabetes (formerly called non-insulin-dependent or adult-onset) results from the body’s ineffective use of insulin 3. Type 2 diabetes comprises the majority of people with diabetes around the world 3, and is largely the result of excess body weight and physical inactivity. • Symptoms may be similar to those of Type 1 diabetes, but are often less marked. As a result, the disease may be diagnosed several years after onset, once complications have already arisen. • Until recently, this type of diabetes was seen only in adults but it is now also occurring increasingly frequently in children.

Introduction and need of my study • The estimated global prevalence of diabetes in 2010 was 6.4% (equating to ∼285 million adults). Type two diabetes (T2D) has contributed to the majority of these cases . T2D is largely related to weight gain associated with a combination of low physical activity (PA) levels and a consumption of an energy dense diet • Evidence suggests engaging in regular PA can have beneficial outcomes for adults with T2D , including improved self-management of T2D, weight loss, increased fitness, reduction of medication usage and improvements in HbA1c/fasting glucose .

Genetic and environmental factors are strongly implicated in the development of type 2 diabetes • India leads the world with largest number of diabetic subjects earning the dubious distinction of being termed the “diabetes capital of the world”

The magnitude of the problem of diabetes is vast and its impact is very severe on the individual, family and the community. • A majority of persons with diabetes live in rural areas. There is a need for grass-root educators to work at the community level

Healthy diet, regular physical activity, maintaining a normal body weight and avoiding tobacco use are ways to prevent or delay the onset of type 2 diabetes1. • Diabetes can be treated and its consequences avoided or delayed with diet, physical activity, medication and regular screening and treatment for complications

On the other hand, community-based approaches may help improve self-management of T2D by addressing barriers encountered in both facility-based approaches and individual-based approaches. • For example, community-based interventions can deliver culturally appropriate health education which can improve self-care compliance and adherence to self-management practices • Further, community-based interventions can be more cost-effective and practical, may have better long-term effectiveness, and the potential to reach a large proportion of individuals who are in most need of treatment

Research question • whether there is an impact of community based rehabilitation programmeon glucose control ,physical fitness and their quality of life in type-2 diabetic and pre diabetic female patients.

Proposed Objective • Physical fitness is related to all-cause mortality, quality of life and risk of falls in patients withtype 2 diabetes. • This study aimed to analyse the impact of a long-term community-based combined exercise program (aerobic + resistance + agility/balance + flexibility) developed with minimum and low-cost material resources on physical fitness,glucose control and quality of life in type 2 diabetic and pre-diabetic female patients

Inclusion criteria Participant with type 2 diabetes will be randomly selected : aged 18 to 45years; diagnosis of type 2 diabetes for at least one year • glycated hemoglobin less than 10%; • pharmacological regimen sta-bilized for at least three months • without limitations in gait or balance • Independent living in the community • without participation in supervised exercise programs in the last6 months; • non-smokers in the last 6 months; and • Dietary pattern stabilized for at least 6 months.

Exclusion criteria • Diabetes status was confirmed by medical history review. • Exclusion criteria included body mass index (calculated as weight in kilograms divided by height in meters squared) of 48.0 or higher. • blood pressure of 160/100 mm Hg or higher, • fasting triglycerides 500 mg/dL or higher, • use of an insulin pump, • urine protein greater than 100 mg/dL, • serum creatinine greater than 1.5 mg/dL, • history of stroke, • advanced neuropathy or retinopathy, • or any serious medical condition that prevented participants from adhering to the protocol or exercising safely.

QUALITY OF LIFE • Change in QOL was evaluated using the SF-36 questionnaire . The SF-36 is a validated, self-administered questionnaire that measures QOL through the evaluation of physical functioning, role limitations attributable to physical health problems, bodily pain, general health, vitality, social functioning, emotional health, and mental health . QOL measures were administered at baseline and at the 9-month follow-up.

Habitual physical activity was evaluated using the Inter-national Physical Activity Questionnaire (IPAQ, short format,self-administered version). • Final evaluations only included non-supervised physical activity in order to control lifestyle-relatedphysical activity. IPAQ assesses the minutes per week spenton vigorous-intensity physical activities (energy expenditure of8 METs), moderate-intensity physical activities (energy expendi-ture of 4 METs) and walking (energy expenditure of 3.3 METs). • Total score is calculated based on the total energy expenditureof these three types of activities per week and is presented inMET-minutes/week (less than 600 MET-min/week is consideratea low level of physical activity).

Proceedure • Procedures Aerobic fitness was assessed through the performance in the6-Minute Walk Test (6MWT)15–the participant is encouraged to walk as far as possible in 6 minutes in a closed circuit. • Muscle strength (lower limbs) was assessed through the performance in30-Second Chair Stand Test (30SCST)16–from the seated position. • the participant is encouraged to complete as many full stands as possible within 30 seconds.

Agility/balance was assessed through the performance in Timed Up and Go Test (TUGT)17–from the seated position, the participant is encouraged to rise from the chair, walk three meters, turn around, walk back to the chair, and sit down, in the shortest time possible. • Flexibility (lower limbs and lumbar spine) was assessed through the performance in Chair stand Reach Test (CSRT)18–seated on a chair, with the preferred leg

1. Warm-up (5 min) consisting of continuous brisk walking at theall-weather running track. • 2. Aerobic exercise (30 min) at the all-weather running track andlawns, consisting of moderate-continuous brisk walking (12-13points on Borg’s scale) • and high-intensity interval walking(relay-races, walking with external load, obstacles and stair scircuits; 14-17 points on Borg’s scale).

The ratio between moderate-continuous and high-intensity interval walking acti-vities was 1:1.3. Resistance exercise for muscle strengthening (20 min) in the exercise room. • In each session six exercises were performed–three for the lower limbs and three for the upper limbs and torso

And torso– performed with bodyweight, chairs, sand bottles, dumb-bells and fitness balls. • Exercises were organized in circuit mode(exercises for lower limbs alternated with exercises for upper limbs and torso), with no rest between each exercise, and 1-min rest between each circuit. • The number of circuits ranged progressively from one (adaptation phase) to four (last 2 months). • In the bilateral exercises 20 repetitions were performed, and in the unilateral exercises 30 repetitions were performed alternately.

Exercise load was selected in order to achieve local muscle fatigue during the execution of the last repetitions of each exercise. • Load increase was promoted when the last repetitions of each exercise were performed without local muscle fatigue. • All exercises were performed simultaneously by all participants ,and the movement’s execution time and the rest time were con-trolled .

Agility/balance exercise (10 min) consisting of small-sided and conditioned team games • Flexibility exercise (5 min) through a sequence of static and dynamic stretches performed with the support of chairs. Static positions were held for 15 seconds and dynamic stretching were performed during 10 repetitions

Five different exercise sessions were prepared, each of them with different aerobic, resistance and agility/balance exercises ,successively applied over time to induce stimuli variability. • Exer-cise sessions were planned to have moderate-to-vigorous intensity(12-17 points on a rate of perceived exertion scale with 6-20points). • Exercise intensity was systematically controlled using Borg’s scale and adjusted if necessary during aerobic, resistance and agility/balance exercise. At the end of each session all par-ticipants were asked to register each session’s overall intensity.

COMMUNITY BASED EXERCISES Program structure The content of this program has been prepared in accordance with international recommendations for physical activity and exercise to control diabetes type 2 and taking into consideration , is overweight, sedentary and has low physical fitness. And exercises are always performed soon after meals

Exercise sessions are held three times per week on non consecutive days (Mondays, Wednesdays and Fridays) with a duration of around 70 minutes. Sessions consist of five phases: • 1) Warm up (5 min), which includes brisk walking • 2) cardiovascular training with aerobic exercise (30 min), which includes walking at different speeds, relay races, obstacle and stairs courses

3) Muscle strength training through resistance exercises (20 min) performed with chairs, dumbbells, fitness balls and bodyweight exercises. • 4) Agility training (10 min) consisting of reduced, simplified and adapted team ball games; and • 5) Cool down/flexibility (5 min) through static and dynamic stretching exercise

Exercising after meals • When it comes to preventing postprandial spikes in blood glucose, exercising after dinner is much more effective than doing it before. • Others have shown that for people with type 2 diabetes, a prior meal helps enhance the glucose-lowering effect of physical activity.

The stretching and relaxation conditioning was developed specifically for this trial (e.g., control group) and has not be validated. It included 45-min weekly sessions focused on increasing flexibility and reducing stress. The control group intervention was optional and was designed to be light-intensity stretching and relaxation exercises

Hypothesis • Research hypothesis: There will be a significant difference in glycemic control, physical fitness and quality of life in type 2 diabetic and pre-diabetic female patients Null hypothesis: There will not be any difference in glycemic control, physical fitness and quality of life in type 2 diabetic and pre-diabetic female patients

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P hd Research topic