Exercise as it relates to Disease/Promoting exercise with cognitive behavioural strategies in people with Type 2 diabetes

This article is an analysis critiquing of the paper: "Increasing Physical Activity in People With Type 2 Diabetes"

Background to Research
The benefits of exercise on the body are widely known, and there are many guidelines recommending types and amounts of exercise in order to maintain optimal health. Exercise that does not improve fitness components, still has the capacity to improve overall health. Type 2 diabetes makes it challenging to meet these exercise requirements. Previous interventions have been conducted using subjects that are motivated and in good health, although adherence rates are low. There is a lack of promotion for physical activity with those living with the condition and increases in motivation have high potential to improve adherence rates, and in turn, overall health.

Where is the research from?
The primary authors of this article are Alison Kirk (BSCI), Nanette Mutrie (PHD1) Paul Macintyre (MD1) and Miles Fisher (MD2). The article was published to the American Diabetes Association, an organisation that funds research aiming to inform and alleviate diabetes. Alison Kirk has completed a BSC in Physiology and Sports Science at the university of Glasgow, before partaking in her PHD study. Nanette Mutrie is a psychologist with the British Psychological Society specialising with interventions aimed at increasing physical exercise. Paul Mcintyre has been involved in the production of multiple papers involving cardiopulmonary health, myocardial infarction and more. Miles Fisher has written on hyperglycaemia, ketoacidosis papers and more.

What kind of research is this?
This research was an intervention study. Intervention research is the systematic study process where a change in strategy or conditions is implemented. Under this type of research falls randomized controlled trials. This study is a randomised control trial as 50% of the participants were randomly assigned to either receive an intervention, or not (see the following section for more information).

What did the research involve?
The research involved a subject pool of 70 individuals with type 2 diabetes consisting of 50% males and 50% females. The following characteristics were observed within the gorup:

- mean BMI was 34.6 +- 6.8kg/m2

- mean age was 57.6 +-7.9 years

- mean diabetes duration was 6.0 +- 4.5 years.

16 subjects were overweight (BMI 25-30 kg/m2), 50 subjects were obese (BMI 30 kg/m2 +) and 4 subjects were of normal weight with a BMI equal to or- under 25 kg/m2. Participants with medical conditions preventing them from exercising were not included in the study. Half the sample was cut out as the study was a randomized control trial, where only 35 subjects received an intervention. Diabetes was controlled by insulin, oral hypoglycaemic agents or diet. Participants were categorised into either a contemplation of exercise group or a preparation to exercise group. Participants were encouraged to increase exercise levels via an individualised approach, utilising the trans theoretical model to identify which stage of change the participant was at and was then capitalised on for greater chance of success. Individuals were required to self report on the exercise they completed. Primary outcome measures including physical activity levels, behaviour change and cardiopulmonary fitness were established. These were measured by accelerometers, short surveys and individualised exercise protocols. Secondary outcome measures were blood pressure, BMI, glycaemic control, lipid profile and fibrinogen. Participants then completed maximum of five visits, where the first two visits saw health questionnaires, demographic details and other information was collected. Participants with underlying medical issues were removed and then one-on-one discussions were conducted where the transtheoretical model was used to induce change in participant behaviours and motivate them to exercise. Follow-up meetings saw the duration and exercise demands (low, moderate low vigorous) which was self reported by participants discussed in further detail. Follow up phone calls and information was provided to participants, discussing positives and negatives of the intervention.

Results
Within the results, no between-group differences were observed, signalling randomisation was successful. There was an increase in minutes of activity along with activity counts. Furthermore, there was an increase in exercise duration in the case group, and no differences in the control group. The following were recorded physiological changes:

- decrease in oxygen uptake within the control group

- increase in exercise duration in the experimental group

- decreases in systolic blood pressure (BP), but not diastolic BP

- increase in fibrinogen in the control group

Conclusions
The study concluded that consultation for exercise led to an increased physical activity level, improved glycemic control and cardiovascular risk factors in people with type two diabetes, more so than a standard leaflet would. The study acknowledges there is minimal research available on the effects off long term exercise interventions in people with type 2 diabetes. Results observed were an increase in exercise duration within the experimental group, a decrease in oxygen uptake in the control group and more. The intervention, a family minimal one, was successful in promoting physical activity and resulted in positive health effects.

Practical Advice
Upon review and critiquing of the article, it has come to light that the competency of the authors is an issue and it is clear that not all authors are sufficiently skilled for such an experiment. Kirt is qualified in exercise physiology, but as the paper focuses on psychological methods to increase motivation to exercise, this does not fall within her skillset. Mutrie, a qualified psychologist who has previously worked on and specialises in interventions for increasing physical activity, is far more qualified for such an intervention and excellently suited for the study. Little information was available on the qualifications of Macintyre and Fisher, only previous papers they had co-edited, none aligning with the nature of this study.

While the author(s) have stated in the conclusion of the article that there was 'increased physical activity and improved glycemic control and cardiovascular risk factors in people with type 2 diabetes' and this has been supported by the results of the study, there is a great chance that the results have been skewed due to inaccurate and biased reporting. This is due to the exercise records being self-reported records. It is widely known that self-reported methods of tracking exercise have a high chance of being biased as individuals participating in group studies (despite confidentiality of results) do not wish to be record lower amounts of exercise, or more importantly, less improvements and adaptations. While it is clear patient physiological abilities have increased due to response to the increase in exercise, the degree to which the self reported exercise was actually conducted, remains unknown. It is acknowledged patient ability has improved, however multiple factors on testing day (pressure, placebo affect of being watched, sleep, diet) may have enhanced the subjects ability. As the method of recording exercise is unreliable, the claim of the exercise being the sole purpose of the improvements is weakened and the chance the results are due to other variables increases.

Further Readings/Insights
Exercise for mental health - https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1470658/

When Adults Don’t Exercise: Behavioral Strategies to Increase Physical Activity in Sedentary Middle-Aged and Older Adults - https://academic.oup.com/innovateage/article/2/1/igy007/4962182

Strategies to Increase Physical Activity - https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4626000/

Behavior therapy for nonalcoholic fatty liver disease: The need for a multidisciplinary approach - https://aasldpubs.onlinelibrary.wiley.com/doi/abs/10.1002/hep.22009