Exercise in the Management for Type 2 Diabetes Mellitus in Adults - Research Proposal Example

EXERCISE IN THE MANAGEMENT FOR TYPE 2 DIABETES MELLITUS IN ADULTS Introduction: In the modern era type 2 diabetes mellitus is becoming an issue of growing concern. The prevalence of type 2 diabetes mellitus is reaching epidemic proportions with more and more people leading sedentary lives accompanied by unhealthy food habits (Rizvi, 2004). Increase in body weight and sedentary live styles increase the risk of insulin resistance and beta cell dysfunction, which cause the typical clinical signs of hyperglycaemia (Rizvi, 2004).Many others demonstrate poor glucose tolerance or impaired ability to tolerate glucose in what may be considered a stage of pre-diabetes. Such individuals have a high risk of developing frank diabetes. In addition such individuals face the risk of hypertension, dyslipidemia and central adiposity, which characterise the condition of metabolic syndrome (Rizvi, 2004). Diabetes mellitus has a profound impact on society, because the complications that result from diabetes mellitus have a very high rate of morbidity and overall mortality. This puts a heavy economic load on society and nations in meeting the direct and indirect costs of diabetes mellitus. When viewed from the perspective of the increased prevalence of diabetes mellitus the economic impact becomes even more significant and even more relevant for measures to prevent and manage diabetes mellitus more effectively (Rizvi, 2004). Complications that result from diabetes mellitus are very common. The CODE-2 study, which evaluated data from seven thousand people with type 2 diabetes from eight European studies, found that seventy eight percent had developed at least one complication and twenty four percent had developed both microvascular and macrovascular complications. Over a period of six months thirteen percent of these patients needed hospitalisation. The average annual cost per patient was estimated at $3585. Only seven percent of these costs were attributable to insulin and oral drugs for lowering blood sugar levels, while fifty percent of the costs were related to hospital admissions. These figures suggest that complications with type 2 diabetes are common and have a significant cost impact on the individual, society and the nation. The risks for developing complications are variable. In the case of nephropathy there is evidence to suggest that it has a strong genetic influence (Marshall & Flyvbjerg, 2006). However in most other complications the duration of diabetes, the efficiency rate of the glycaemic control and hypertension are the most significant risk factors(Marshall & Flyvbjerg, 2006). In addition to these risk factors smoking, lipids, and albuminuria are important risk factors for macrovascular complications (Marshall & Flyvbjerg, 2006). As a result of complications with type 2 diabetes, patients with type 2 diabetes have a reduced life expectancy, ranging from five to ten years. Premature cardiovascular diseases may be considered as the most significant factor in this (Marshall & Flyvbjerg, 2006). Diabetes mellitus has been found to be the most common cause for the requirement of renal replacement therapy all over the world (Marshall & Flyvbjerg, 2006). The most common reason for blindness in individuals below the age of sixty-five has been found to be type-2 diabetes (Marshall & Flyvbjerg, 2006). In addition diabetic foot resulting from diabetes mellitus is the cause of the most non-traumatic amputations. Thus complications as a result of type 2 diabetes have a wide scope and severity on the life of an individual (Marshall & Flyvbjerg, 2006). Preventing the onset of type 2 diabetes, adequate glycaemic control and preventing the onset of complications of type 2 diabetes become important aspects in managing diabetes mellitus, which is reaching alarming proportions. Identifying high risk populations, as the incidence of diabetes mellitus is impacted on by genetic factor and life styles and delaying or reducing the onset of diabetes mellitus is an essential ingredient in the prevention of diabetes mellitus. Adequate glycaemic control reduces the onset of complications in diabetes mellitus. Insulin, oral anti-diabetic drugs, diet and exercise form the means of adequate glycaemic control and combating complications in type 2 diabetes (Jerreat, 1999). Diet and exercise constitute the first means used for normalising blood sugar levels (Jerreat, 1999). Diet with exercise and drugs are the second means available. Finally a combination of diet, exercise, insulin and/or drugs forms the last means to maintain glycaemic control (Jerreat, 1999). Significantly exercise forms a part of all the means used to maintain adequate glycaemic control (Jerreat, 1999). Exercise has been perceived to be of significant beneficial importance in maintaining glycaemic control in patients with type 2 diabetes. The impact of exercise on glycaemic control has been the subject of several studies. Such studies provide a means to the understanding of the utility of exercise in glycaemic control and avoidance of complications that arise from type 2 diabetes. Despite small sampling sizes in some studies a better understanding of exercise in glycaemic control and reducing factors that contribute to complications are possible through an evaluation of research and studies that have gone into the beneficial role of exercise in type 2 diabetes (Boul, Haddad, Kenny, Wells & Sigal, 2001). Literature Review: Exercise has a beneficial impact on individuals with type 2 diabetes. Regular exercise has the benefit of preventing or delaying the onset of non-insulin dependent diabetes (NIDD). In NIDD patients, regular exercise improves the balance of blood glucose. Exercise enhances insulin sensitivity, improves glucose tolerance and in combination with diet provides a means for weight reduction. For exercise to be fully beneficial it is essential that the exercise is done on a regular basis and extends for twenty to thirty minutes every day, as far as possible. The rate of exercise should be such that the heart rate is maintained between sixty percent and eighty-five percent of the maximum heart rate. The maximum heart rate is obtained by subtracting the age of the individual fro 220. This means that exercise as intended for type 2 diabetic patients is not meant to be an arduous task like weight lifting or long distance running. A brisk walk is capable of lifting the pulse rate to within the training zone and maintaining the brisk walk for a minimum period of twenty to thirty minutes is sufficient for providing the beneficial aspects of diabetes on individuals with type-2 diabetes (Hillson, 2002). Maintaining of normal glucose levels during exercise is partly due to the response of the endocrines to exercise. A decrease in the levels of plasma insulin and the presence of glucagon has been found to be necessary for the increased production of glucose by the liver during exercise. Increase in plasma glucagon and the presence of catecholamines have a prominent role to play in the case of prolonged exercise. Exercise has a beneficial role to play in type 2 diabetes with its capacity to produce improved sensitivity to insulin with the resultant improvement in glycaemic control. However determining the extent of exercise required needs to be done on an individual basis and should be evaluated from a medical perspective with a meticulous evaluation of any macro and micro vascular complications that may be present. Young type 2 diabetic patients having good metabolic control have minimal limitations in performing any from of exercise. It is in the middle and elderly type 2 diabetic patients with lower metabolic control that necessary caution need s to be employed in exercise decisions. The first phase of the exercise regimen needs to be a low intensity aerobic activity like walking or cycling for a period of ten minutes to prepare the skeletal muscles, heart and lungs for a progressive enhancement in the intensity level of the exercise. While performing exercises it is essential that adequate care of the feet is taken. Podiatric evaluation of type of foot wear and protection required is useful. Good hydration is another requisite. Proper regular exercise is useful in prevention of cardiovascular diseases, reduction in triglyceride and VLDL cholesterol levels with elevation of HDL cholesterol levels, decrease in overall blood pressure levels, and contributes to weight reduction, when combined with a diet regime (Gomis & Page, 2001) The main reason why exercise is an essential ingredient in the management of diabetes mellitus is because of its beneficial effects on blood glucose profiles. Studies that evaluate these beneficial effects are of interest to clinicians in their management of type 2 diabetes, as it allows them to decide on exercise regimens for their diabetic patients. One such study involved the use of six sedentary individuals consisting of five males and six females with recently diagnosed and diet treated diabetes mellitus as the test group and four sedentary males of similar age group without type-2 diabetes as the control group. Diet treated individuals were selected for the control group as such groups are encouraged to increase their physical activity. All the subjects participated in a six-week physical training in a physical laboratory. The intensity of the exercise was retained at fifty percent of VO2 maximum initially and then gradually increased to seventy to seventy-five percent initial VO2 maximum stretched over a period of two weeks. Heart rate was the parameter used as the basis for fixing the exercise. Following the period of training, measurements for glucose tolerance and other parameters were repeated subsequent to the measurements prior to the train8ing period. The findings based on these measurements were that there was a significant decrease in HbA1 levels, suggesting that there was overall improvement in glucose homeostasis. There was only a minimal improvement in glucose tolerance, which was similar to the control group. Improved glucose disposal was as was higher as expected. Several studies have noted a rapid deterioration in glucose tolerance levels with the cessation of training, which was the case observed here too. These findings are in keeping with the hypothesis that a major part of the improved glucose disposal observed during physical exercise is correlated to the summed effects of the physical activity involved (Schneider, Amorosa, Khachadurian & Ruderman, 1984). In another study the effect of long term exercise on glycaemic control and metabolic control was evaluated. Four months of strength training or endurance training was provided to five male and five female type 2 diabetic subjects with an average age of fifty-seven years, who made up the test group. During a further period of four months randomized strength or endurance training was provided to this subject group, while another five male and five female type 2 diabetic subjects of similar average age group ceased training. Measurements of several parameters were taken to evaluate glycaemic control and metabolic control. Long term glycaemic control was found to have improved in the test group. In a similar vein HbA1C values dropped from 6.9 to 6.2 in the active test group, while these values rose from 7.5 to 8.7 in the inactive control group. Similarly baseline levels of total cholesterol fell in the active test group from 205.5 mg/dl to 177.5 mg/dl, while an increase from 185.9 mg/dl to 220.2 mg/dl was witnessed in the control group. In the case of LDL-cholesterol and triglycerides a significant drop in levels was observed in the training group, when compared to the control group. This study showed that by extending the training period beyond four months highly beneficial effects are continued in type 2 diabetic patients. These beneficial effects include reduction in fasting blood glucose, HbA1C, total cholesterol, LDL-cholesterol, triglyceride levels and elevation of HDL-cholesterol concentration (Cauza, et al, 2006). Cardiovascular morbidity has been found to be the major cause of mortality in diabetes mellitus. The United Kingdom Prospective Diabetes Study (UKPDS) has found that systolic hypertension, dyslipedaemia and hyperglycaemia were major factors responsible for coronary artery disease. A study was conducted to describe the effects of low intensity exercise program, which most diabetic patients are capable of, on metabolic control and cardiovascular risk factors in type 2 diabetes. Twenty-seven patients made up the intervention group and thirty-one the control group. Patients in the intervention group increased their exercise by forty-five minutes of brisk walking thrice weekly for a period of four months. The period of four months was believed to be sufficient for observing changes in the parameter under consideration. No advice on changes in dietary patterns or life style was provided and both the groups continued their medication regimen. Only eighty percent of the intervention group was found to have followed the exact exercise regimen recommended at the end of the four month period. Measurement of relevant parameters showed that there was no significant effect on the parameters relevant to glucose metabolism, namely HbA1C, plasma glucose and plasma insulin levels. HDL and LDL cholesterol levels were found to have improved in the intervention group. There was a slight decrease in the systolic and diastolic blood pressure levels in the intervention group, while there was a slight tendency for elevated levels in the control group. When these parameters of the intervention group, where eighty percent of the exercise regimen was followed was examined, it was found that systolic and diastolic blood pressure, body mass index (BMI) and total plasma cholesterol levels were significantly lowered (Fritz, Wandell, Aberg, Engfeldt, 2006). In a study designed to study the utility of a pedometer in ensuring 10,000 steps of walking as exercise over a period of six weeks in type 2 diabetes mellitus patients, several parameters of interest to this literature review were evaluated. The study involved thirty subjects between the age group thirty-three and sixty-nine years of age with diagnosed diabetes mellitus. These subjects were randomized into test and control groups. The exercise component consisted of 10,000 steps a day, measured with the help of a pedometer, for a minimum of five days a week over a period of six week measures. Measurements of the required parameters were made at the start of the exercise period and after six weeks. The findings of the study were that there were no significant changes in BMI, percentage of body fat, blood pressure and waist circumference after the six week period, though a trend for decrease in systolic blood pressure and waist circumference was seen. There was a significant increase in the HDL-C in the active or test group, when compared to the control group. No significant changes were observed in total cholesterol, homocysteine, fasting triglycerides, LDL-C, HbA1C, fasting serum glucose, insulin. This study suggests that though quantum of exercise may be ensured through a pedometer, a period of six weeks may be too less to bring about beneficial affects of exercise on type 2 diabetic patients (Araiza, et al, 2006). Insulin resistance is a major contributor to the development of cardiovascular diseases. Regular enhanced exercise enhances the activity of insulin. A study was conducted to arrive at the proper exercise regimen for improved activity of insulin. One hundred and fifty four subjects were selected after training and testing and randomly divided into control group, low-volume moderate intensity group, low-volume high intensity group and high volume high intensity group. The exercise regimes differed in volume and intensity according to the groups and extended over a period of six months. The findings of the study were that there was a slight increase in body mass in the case of the control groups, while the activity groups tended to show a decline in body mass increasing with intensity and volume of activity. Fasting insulin was found to have increased levels in the control groups, whereas it was seen to decrease in the activity groups. There was no variation in fasting plasma glucose levels. Insulin sensitivity increased in each of the activity groups in comparison to the control group. This study concluded that exercise regimens have an impact on insulin sensitivity and that lack of exercise over a period of six months ca increase insulin resistance (Houmard, et al, 2004). Sixteen type 2 diabetic patients were the subject of a study to investigate the effect of an eight week regimen of combined aerobic and resistance exercises on indices of glycaemic control, cardio-respiratory fitness, muscular strength and body composition. These parameters were measured prior to and after the eight week exercise regime. The study found no significant changes in plasma total, HDL or LDL cholesterol or triglycerides counts after the exercise regimen. Mean arterial pressure was found to be lower along with glycated haemoglobin and fasting blood glucose (Maiorana, et al, 2001). Tokmakidis et al, 2004 conducted a study to evaluate the effect of short term and long term effects of combined strength and aerobic training program on glycaemic control, insulin action, exercise capacity, and muscular strength in postmenopausal women with type 2 diabetes. Nine women meeting the criteria with an average age of fifty five years made up the subjects. The test period spread over four months with evaluation tests conducted at the start, after four weeks and after sixteen weeks. The exercise regimes were adjusted to sixty to seventy percent of maximum heart rates in the beginning and enhanced to seventy to eighty percent after two months. Significant improvements of glucose tolerance and insulin sensitivity were observed after four weeks, which were further enhanced at the end of the sixteen week period. Glycated haemoglobin levels were found to be lowered slightly after four weeks and sixteen weeks. No significant changes were observed in body mass and BMI (Tokmakidis et al, 2004). The major purpose of physical exercise for primary prevention and treatment of lifestyle-related diseases is to improve insulin sensitivity. It is known that, during physical exercise, glucose uptake by the working muscles rises 7 to 20 times over the basal level, depending on the intensity of the work performed. However, intense exercise provokes the release of insulin-counter regulatory hormones such as glucagons and catecholamines, which ultimately cause a reduction in the insulin action. Continued physical training improves the reduced peripheral tissue sensitivity to insulin in impaired glucose tolerance and Type II diabetes, along with regularization of abnormal lipid metabolism. Furthermore, combination of salt intake restriction and physical training ameliorates hypertension. In practical terms, before diabetic patients undertake any program of physical exercise, various medical examinations are needed to determine whether they have good glycaemic control and are without progressive complications. Because the effect of exercise that is manifested in improved insulin sensitivity decreases within 3 days after exercise and is no longer apparent after 1 week, a continued program is needed. For a safety practice, moderate- or low-intensity exercise is preferable (Sato, Nagasaki, Nakai & Fushimi, 2003). Wagner, et al, 2006 undertook a study to evaluate the impact of a three week anaerobic/aerobic exercise regimen of fifty minutes over a period of three weeks, on forty-eight type 2 diabetics. Exercise resulted in a 92% improvement in insulin sensitivity on insulin clamp measurements in patients randomized to exercise therapy alone. Total body and truncal fat decreased significantly and systolic blood pressure improved. Exercise had no effect on haemoglobin HbA1C levels (Wagner, et al, 2006). Aims and Objectives: The objective of this study is to evaluate the beneficial role of exercise in type 2 diabetes mellitus. The aims include evaluating the volume and intensity of exercise that is required to provide the beneficial aspects of exercise in type 2 diabetes with respect to its influence on glycaemic control, on cholesterol and triglyceride serum levels, and on body mass index. An additional aim is the evaluation of the impact of exercise. The final aim of the study will involve the impact of lack of exercise or the discontinuation of exercise on the parameters that have an impact on the complications that arise from diabetes mellitus. Methods: Criteria for the Study: The criteria for selecting articles for the literature review for providing the appropriate data has been the inclusion of those research studies that have been undertaken on the impact of exercise on glycaemic control, cholesterol and triglyceride serum levels and BMI, which have an influence on the complications that are normally associated with type 2 diabetes. The articles selected have been such that they provide adequate data for analysis to come to the necessary findings to address the objective and aims of the study. Exclusion Criteria: To make the study more relevant to the current information available on type 2 diabetes, research articles selected have been as recent as possible, and in any case have not extended beyond twenty-five years. Articles that are dated beyond this period have been excluded. In addition articles on the role of exercise in type diabetes that do not contain relevant information have been left out. Articles pertaining to exercise in type 2 diabetes, where pregnant women were involved have been excluded. In addition articles pertaining to the role of exercise in the case of children with juvenile diabetes have been excluded from the scope of this study. Search Strategy: Local libraries were the initial target for locating books and journals for background information and articles with the appropriate relevant information. Subsequently the Internet was utilised with a similar search pattern. The medical databases of Medscape, Medline and PubMed were the target of the Internet based search. Search terms used included. ‘Diabetes mellitus’, ‘type 2 diabetes’, ‘complications associated with type 2 diabetes’, ‘influence of exercise on type 2 diabetes’, ‘influence of exercise on glycaemic control in type 2 diabetes’, ‘influence of exercise on cholesterol serum levels in type 2 diabetes, ‘influence of exercise on triglyceride serum levels in type 2 diabetes’, ‘influence of exercise on BMI in type 2 diabetes’, ‘volume and intensity factors on benefits of exercise in type 2 diabetes’ and ‘result of exercise cessation in type 2 diabetes mellitus’. Search Results: The search at the local libraries provided three books that have provided the background material included in the study. In addition four journal articles were found in different medical journals that have been included in the study. The search on the Internet medical databases of Medscape, Medline and PubMed provided one article that has been used for background material and seven journal articles for inclusion in the literature review for data extraction. Thus in all three books and one journal article form the sources for the background material, while eleven journal articles make up the relevant sources for the literature review. Data Extraction: The literature reviewed articles form the bank from which the required data has been acquired. The data has been acquired through a detailed study of the eleven articles that have been reviewed. Findings: The findings are being divided into subheadings to address the aims of the study. Exercise on Glycaemic Control: Maintaining of normal glucose levels during exercise is partly due to the response of the endocrines to exercise. A decrease in the levels of plasma insulin and the presence of glucagon has been found to be necessary for the increased production of glucose by the liver during exercise. (Gomis & Page, 2001) Increase in plasma glucagon and the presence of catecholamines have a prominent role to play in the case of prolonged exercise. Exercise has a beneficial role to play in type 2 diabetes with its capacity to produce improved sensitivity to insulin with the resultant improvement in glycaemic control. (Schneider, Amorosa, Khachadurian & Ruderman, 1984). However determining the extent of exercise required needs to be done on an individual basis and should be evaluated from a medical perspective with a meticulous evaluation of any macro and micro vascular complications that may be present. Young type 2 diabetic patients having good metabolic control have minimal limitations in performing any from of exercise (Hillson, 2002). It is in the middle and elderly type 2 diabetic patients with lower metabolic control that necessary caution need s to be employed in exercise decisions (Hillson, 2002). Exercise has a beneficial role to play in type 2 diabetes with its capacity to produce improved sensitivity to insulin with the resultant improvement in glycaemic control. Since a majority of the subjects with type 2 diabetes were beyond their middle age it was found that exercise used in type 2 diabetes needs to be on a controlled basis. The basis for the control is both in the intensity and in the duration. Exercise should be based on the maximum heart rate and should start at sixty percent of the maximum heart rate and be gradually built up over time to reach, but not exceed eighty-five percent of the maximum heart rate. The exercise should be continued for at least five days in a week, extending for a period of forty-five minutes per day. The beneficial aspect of glycaemic control starts displaying after four weeks. Exercise should not be discontinued for insulin resistance is renewed within a short span of time from stopping exercise leading to poor glycaemic control. Exercise on LDL and HDL Cholesterol, and Triglyceride Serum Levels: Proper regular exercise is useful in prevention of cardiovascular diseases, reduction in triglyceride and VLDL cholesterol levels with elevation of HDL cholesterol levels, decrease in overall blood pressure levels, and contributes to weight reduction, when combined with a diet regime (Gomis & Page, 2001) In type 2 diabetes it was found that exercise lowers LDL cholesterol and triglyceride serum levels and elevates HDL cholesterol serum levels. However these beneficial aspects of exercise are not an immediate benefit of exercise and develop over time. Lowering of LDL cholesterol and triglyceride serum levels and elevation of HDL cholesterol serum levels are demonstrated only after eight weeks of regular exercise. Stoppage of exercise leads to a slow return to the original serum levels of cholesterol of triglycerides Exercise on BMI: In NIDD patients, regular exercise improves the balance of blood glucose. Exercise enhances insulin sensitivity, improves glucose tolerance and in combination with diet provides a means for weight reduction (Houmard, et al, 2004). The picture on the impact of exercise on body mass and body mass index (BMI) in type 2 diabetes is not very clear with varying findings in the studies reviewed. On the whole exercise does not appear to lower body mass index in type 2 diabetes. It may be speculated that any loss of body mass is compensated by strengthening of muscles and thereby there is no significant change in BMI. Methodological Issues: Inclusion and exclusion criteria were not observed in all the studies reviewed. Sedentary and overweight patients with type 2 diabetes were the main inclusion factors. Exclusion criteria included smoking, history of coronary artery disease, renal impairment, hepatic impairment, gout and uncontrolled hypertension (Tokmakidis et al, 2004). Since all the studies reviewed used an experimental basis using test groups and control groups, data was collected on a quantitative basis. Sample sizes varied. Some of the studies reviewed had small sample sizes. The smallest sample size was nine (Tokmakidis et al, 2004). Such a small sample size has a limitation in that it may not be applicable across wide populations and regions. However a larger study with as many as one hundred and fifty four subjects was part of the review (Houmard, et al, 2004). The studies with a larger sample size provide for more validity when applied to larger populations. Data analysis for all the studies was based on statistical methods giving credence to the findings. Conclusion: This study concludes that regular exercise has a beneficial impact in type 2 diabetes. The intensity of exercise needs to be regulated using the maximum heart rate as the basis. The volume of exercise needs to be for a minimum of forty five minutes per day and regularly done for at least five days in a week. Exercise should not be stopped, and needs to be continued. This study recommends that exercise be made a regular part of the prevention and management type 2 diabetes. Most of the studies reviewed are based on few subjects and with short duration, thus limiting the validity of the studies. More research on a larger number of subjects and over an extended period of time needs to be undertaken for a more definite picture on the beneficial aspects of exercise in type 2 diabetes to emerge. Literary References Araiza, P. et al. (2006). Efficacy of pedometer-based physical activity program on parameters of diabetes control in type 2 diabetes mellitus. Metabolism Clinical and Experimental, 55, 1382-1387. Boul, N.G., Haddad, E., Kenny, G.P., Wells, G.A. & Sigal, R.J. (2001). Effects of exercise on glycemic control and body mass in type 2 diabetes mellitus: a meta-analysis of controlled clinical trials. JAMA. 285(10), 1218-1227. Cauza, E. et al. (2006). The metabolic effects of long term exercise in Type 2 Diabetes patients. Wien Med. Wochenschr, 156 (17-18), 515-519. Fritz, T., Wandell, P., Aberg, H. & Engfeldt, P. (2006). Walking for exercise – does three times per week influence risk factors in type 2 diabetes? Diabetes Research and Clinical Practice, 71, 21-27. Gomis, R. & Page, S. (2001). Diabetes Mellitus and exercise. Diabetes Care, 24(Suppl.1), S51-S54. Hillson, R. (2002). Practical diabetes care. Second Edition. London: Oxford University Press. Houmard, A.J. et al. (2004). Effect of the volume and intensity of exercise training on insulin sensitivity. Journal of applied physiology, 96, 101-106. Jerreat, L. (1999). Diabetes for Nurses. London: Whurr Publishers Ltd. Maiorana, A. et al.(2001). Combined aerobic and resistance exercise improves glycemic control and fitness in type 2 diabetes. Marshall, M. & Flyvbjerg. A. (2006). Prevention and early detection of vascular complications of diabetes. BMJ, 333(7566), 475-480. Rizvi, A. A. (2004). Type 2 Diabetes: Epidemiologic Trends, Evolving Pathogenic Concepts, and Recent Changes in Therapeutic Approach. Southern medical journal, 97(11), 1079-1087. Sato, Y., Nagasaki, M., Nakai, N. & Fushimi, T. (2003). Physical exercise improves glucose metabolism in lifestyle-related diseases. Experimental biology and medicine, 228(10), 1208-1212. Schneider, S.H., Amorosa, L.F., Khachadurian, A.K & Ruderman, N.B. (1984). Studies on the mechanism of improved glucose control during regular exercise in Type 2(non-insulin-dependent) diabetes. Diabetologia, 26, 355-360. Tokmakidis, P.S. et al. (2004). The effects of a combined strength and aerobic exercise program on glucose control and insulin action in women with type 2 diabetes. European journal of applied physiology, 92, 437-442. Wagner, H, et al. (2006). Acarbose Plus Exercise Improves Glycemic Control in Type 2 Diabetics. Diabetes Care, 29, 1471-1477. Read More