The adoption and maintenance of physical activity are critical foci for blood glucose management and overall health in individuals with diabetes and prediabetes. Recommendations and precautions vary depending on individual characteristics and health status. In this Position Statement, we provide a clinically oriented review and evidence-based recommendations regarding physical activity and exercise in people with type 1 diabetes, type 2 diabetes, gestational diabetes mellitus, and prediabetes.

Physical activity includes all movement that increases energy use, whereas exercise is planned, structured physical activity. Exercise improves blood glucose control in type 2 diabetes, reduces cardiovascular risk factors, contributes to weight loss, and improves well-being (1,2). Regular exercise may prevent or delay type 2 diabetes development (3). Regular exercise also has considerable health benefits for people with type 1 diabetes (e.g., improved cardiovascular fitness, muscle strength, insulin sensitivity, etc.) (4). The challenges related to blood glucose management vary with diabetes type, activity type, and presence of diabetes-related complications (5,6). Physical activity and exercise recommendations, therefore, should be tailored to meet the specific needs of each individual.

Physical activity recommendations and precautions may vary by diabetes type. The primary types of diabetes are type 1 and type 2. Type 1 diabetes (5%–10% of cases) results from cellular-mediated autoimmune destruction of the pancreatic β-cells, producing insulin deficiency (7). Although it can occur at any age, β-cell destruction rates vary, typically occurring more rapidly in youth than in adults. Type 2 diabetes (90%–95% of cases) results from a progressive loss of insulin secretion, usually also with insulin resistance. Gestational diabetes mellitus occurs during pregnancy, with screening typically occurring at 24–28 weeks of gestation in pregnant women not previously known to have diabetes. Prediabetes is diagnosed when blood glucose levels are above the normal range but not high enough to be classified as …

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Physical Activity/Exercise and Diabetes: A Position Statement of the American Diabetes Association

Cardiovascular disease (CVD) is a common comorbidity in type 2 diabetes (T2DM). CVD’s prevalence has been growing over time. To estimate the current prevalence of CVD among adults with T2DM by reviewing literature published within the last 10 years (2007–March 2017). We searched Medline, Embase, and proceedings of major scientific meetings for original research documenting the prevalence of CVD in T2DM. CVD included stroke, myocardial infarction, angina pectoris, heart failure, ischemic heart disease, cardiovascular disease, coronary heart disease, atherosclerosis, and cardiovascular death. No restrictions were placed on country of origin or publication language. Two reviewers independently searched for articles and extracted data, adjudicating results through consensus. Data were summarized descriptively. Risk of bias was examined by applying the STROBE checklist. We analyzed data from 57 articles with 4,549,481 persons having T2DM. Europe produced the most articles (46%), followed by the Western Pacific/China (21%), and North America (13%). Overall in 4,549,481 persons with T2DM, 52.0% were male, 47.0% were obese, aged 63.6 ± 6.9 years old, with T2DM duration of 10.4 ± 3.7 years. CVD affected 32.2% overall (53 studies, N = 4,289,140); 29.1% had atherosclerosis (4 studies, N = 1153), 21.2% had coronary heart disease (42 articles, N = 3,833,200), 14.9% heart failure (14 studies, N = 601,154), 14.6% angina (4 studies, N = 354,743), 10.0% myocardial infarction (13 studies, N = 3,518,833) and 7.6% stroke (39 studies, N = 3,901,505). CVD was the cause of death in 9.9% of T2DM patients (representing 50.3% of all deaths). Risk of bias was low; 80 ± 12% of STROBE checklist items were adequately addressed. Globally, overall CVD affects approximately 32.2% of all persons with T2DM. CVD is a major cause of mortality among people with T2DM, accounting for approximately half of all deaths over the study period. Coronary artery disease and stroke were the major contributors.

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Prevalence of cardiovascular disease in type 2 diabetes: a systematic literature review of scientific evidence from across the world in 2007-2017

Conflict and Conflict Management.

Thiazolidinediones(TDs)是一类新型的胰岛素抵抗治疗药物。动物及临床实验证实TDs通过激活核受体过氧化物酶体增殖物激活受体-γ(PPAR-γ)显著增加胰岛素敏感性，改善胰岛β-细胞功能，降低血糖和胰岛素水平，缓解高血压及脂代谢紊乱，对2型糖尿病大血管和微血管病变亦具有保护作用。临床使用耐受性好，低血糖发生率低。但其中的Troglitazone具有明显的肝脏毒性。

胰岛素增敏剂一Thiazolidinediones研究现状

Objective: To identify the adherence value cut-off point that optimally stratifies good versus poor compliers using administratively derived adherence measures, the medication possession ratio (MPR) and the proportion of days covered (PDC) using hospitalization episode as the primary outcome among Medicaid eligible persons diagnosed with schizophrenia, diabetes, hypertension, congestive heart failure (CHF), or hyperlipidemia.Research design and methods: This was a retrospective analysis of Arkansas Medicaid administrative claims data. Patients ≥18 years old had to have at least one ICD-9-CM code for the study diseases during the recruitment period July 2000 through April 2004 and be continuously eligible for 6 months prior and 24 months after their first prescription for the target condition. Adherence rates to disease-specific drug therapy were assessed during 1 year using MPR and PDC.Main outcome measure and analysis scheme: The primary outcome measure was any-cause and disease-related hospitali...

Good and poor adherence: optimal cut-point for adherence measures using administrative claims data

Motivational interviewing and outcomes in adults with type 2 diabetes: A systematic review.

This study examines relationships between patient reported outcomes (PROs) and clinical outcomes in Type 2 diabetes mellitus (T2DM). Patients at the outpatient clinics of a university hospital completed measures of generic health status (SF-12), diabetes-specific quality of life (Audit of Diabetes Dependent Quality of Life – ADDQoL), and depressive symptoms (Center for Epidemiologic Studies Depression – CES-D). Patient reported data were merged with a retrospective collection of clinical and utilization data, including HbA1C, from electronic medical records. A Charlson comorbidity score, diabetes complications score, BMI, and total number of ER and hospital visits were calculated. Usable response rate was 44.3% (n = 385). Patients were dichotomized into glycemic control levels based on the ADA recommended A1C level < 7.0, vs. ≥ 7.0. The ADDQoL, PCS-12, and MCS-12 scores were separately examined as dependent variables using hierarchical regression models, with glycemic control as the primary explanatory variable, and controlling for demographics and clinical variables including comorbidities and complications. Glycemic control was not a significant predictor in any regression model. Obesity was a significant predictor leading to poorer PCS-12 and MCS-12 scores, while depressive symptoms significantly resulted in lower PCS-12, MCS-12 and ADDQoL scores. These and other factors related to self-management behaviors may contribute to a greater understanding of how to intervene with patients with T2DM. The use of such PROs alongside biomedical measures such as A1C is recommended.

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Quality of life, health status and clinical outcomes in Type 2 diabetes patients.

As HIV infection rates continue to rise, more and more people are faced with a complex, life-altering highly active antiretroviral therapy (HAART) regimen. With some researchers reporting as few as 50–70% of patients achieving adherence in the first six months of a HAART regimen, many behavioral interventions to increase HAART adherence have been examined. One such intervention, motivational interviewing (MI), has shown promise in previous studies and reviews as a possible successful intervention. Researchers conducted a review of the literature to identify studies analyzing the effect of a MI intervention on HAART adherence, with the objectives of examining this relationship and identifying gaps in the literature. To draw definitive conclusions about these questions and to maintain high methodological quality in the search, researchers used the Cochrane method for systematic reviews while conducting this review. Five studies were retained for review from the search and all were RCTs. Sample size...

Motivational interviewing as a behavioral intervention to increase HAART adherence in patients who are HIV-positive: A systematic review of the literature

Purpose The purpose of this systematic review is to assess and summarize evidence and gaps in the literature regarding the intervention for being active (exercise) among individuals with diabetes. Methods Twelve electronic databases were searched. Publications eligible for inclusion specifically studied learning, behavioral, clinical, and humanistic outcomes for exercise interventions in adult patients with type 1 and type 2 diabetes. Results Seven reviews (2 systematic reviews, 3 meta-analyses, 2 technical reviews) and 34 individual, nonreview studies (18 randomized controlled trials, 16 nonrandomized trials) met inclusion criteria. For type 2 diabetes, findings suggested that exercise had a positive effect on glycemic control and decreased cardiovascular risk, but the impact of exercise on behavioral and humanistic outcomes was unclear; long-term outcomes and adherence to exercise interventions is unknown because most studies were of short duration. The overall impact of varied types of exercise in type 1 diabetes was unclear, especially regarding glycemic control. Potential benefits of exercise in type 1 may include improved cardiovascular health. Conclusion The review did not identify specific successful intervention details because of the heterogeneity of studies, subjects, and research gaps. General findings suggest that physical activity is better than no exercise at all; intensive regimens, if tolerated by patients, achieved better clinical outcomes than less intensive regimens. Reviewed studies using structured exercise regimens exhibited a more significant impact on outcomes. Substantial gaps in the literature include studies measuring direct effects of exercise in the US minority populations most affected by type 2 diabetes and economic evaluations of exercise interventions. Interventions must be tailored to individual patient needs to succeed.

Interventions for being active among individuals with diabetes: a systematic review of the literature.

Background Type 2 diabetes is a major risk factor for cardiovascular disease and microvascular complications. Approximately 20.5% of adults between the ages of 20–79 are diagnosed with type 2 diabetes in Saudi Arabia. Nonadherence with type 2 diabetes medications is an established contributor to higher prevalence in other countries. No published studies have used a theoretical framework to explain or predict medication-taking behavior in Saudi Arabian type 2 diabetes (T2D) patients. Objective The purpose of this study was to investigate type 2 diabetes medication adherence using a theoretical framework, the Health Belief Model (HBM). The specific objectives were to 1) assess self-report of medication-taking in a Saudi T2D convenience sample; 2) investigate self-reported HBM constructs for T2D, its complications, and medication-taking in this sample, and 3) test the ability for self-reported health beliefs to predict specific medication-taking behaviors among the sample. Methods A cross-sectional study was conducted in a convenience sample at an outpatient pharmacy in Saudi Arabia. Adult type 2 diabetes patients on at least one prescribed diabetes medication, who were cognitively capable, and came themselves for prescription pickup, were eligible to participate. Patients completed a questionnaire or were interviewed. Data were collected for demographics, medical history, self-reported medication adherence, and type 2 diabetes medication-taking HBM items. Three measures collected self-report of medication adherence: new multi-dimensional adherence measure (MDAM), previously validated stage of change, and medication-taking recall- 7days (MTR-7). Descriptive statistics were generated and regression analyses were used to explain self-report of adherence. Results Just over half (54%) of the 220 participants were male, mean age was 52 ± 11.2 years, and most (59%) had less than high school education. Approximately 58% were on oral medications only and the rest were on either insulin alone or a combination of oral and insulin; 16.7% reported knowing their hemoglobin A1C (A1C). For adherence, most reported taking the prescribed dose every time taken; however, 60% were not taking it the prescribed number of times per day and 50%, not the prescribed time of day (interval). Over 40% reported low adherence on stage of change and MTR-7. Perceived susceptibility, perceived medication benefits, and self-efficacy were significant HBM predictors for medication adherence ( R 2  = 0.42). Conclusions The MDAM has research and practice potential because it evaluates sub-behaviors of medication-taking separately and as a score. Patient perceptions and beliefs should be assessed as part of a patient-centered medication adherence intervention.

Jan Kavookjian

Papers

Motivational interviewing and outcomes in adults with type 2 diabetes: A systematic review.

Quality of life, health status and clinical outcomes in Type 2 diabetes patients.

Motivational interviewing as a behavioral intervention to increase HAART adherence in patients who are HIV-positive: A systematic review of the literature

Interventions for being active among individuals with diabetes: a systematic review of the literature.

The association between health beliefs and medication adherence among patients with type 2 diabetes.