Editorial: Exercise and Type 2 Diabetes: Reducing Vascular Comorbidities Across Populations

Elise Catherine Brown^1,2*Allan Knox³Kyle Pierce⁴

• ¹Oakland University, Rochester, United States
• ²Oakland University School of Health Sciences, Rochester, United States
• ³California Lutheran University, Thousand Oaks, United States
• ⁴Louisiana State University Shreveport, Shreveport, United States

Cui et al. conducted a systematic review and network meta-analysis to determine the effectiveness of combined exercise interventions as well as complementary therapies, such as acupuncture, in improving various cardiometabolic markers in overweight and obese patients with T2D. Combined aerobic and resistance exercise (RE) interventions were the most effective in improving body composition, glycosylated hemoglobin, and Interleukin-6. Physical-mental activities, such as yoga and Tai Chi, seemed to be the most promising interventions for improving a range of blood lipids. Cui et al. provided recommendations for clinicians to consider when designing non-pharmacological interventions for their patients, which should be interpreted as a maximum viable threshold. These recommendations included frequency, duration, and intensity for aerobic exercise, RE, combined aerobic exercise and RE, mind-body movement, and acupuncture. While the authors encouraged clinicians to adapt the prescription to the individual based on a range of factors such as how much time they have, work considerations, and social and financial characteristics, individual recovery from high exercise volume should also be a primary consideration (4). Given that high amounts of exercise could be achieved if the clinician prescribes the maximum frequency, duration, and intensity of these recommendations, patients with lower fitness levels may have challenges with recovering from higher doses.Exercise recommendations specific to sensory complication comorbidities in T2D have also been proposed. Lopatin et al. discussed how vascular complications in T2D affect the sensory components of balance (i.e., proprioception, vision, and vestibular), and offered exercise prescription recommendations that account for each specific sensory complication. Recommendations emphasized the benefits of Tai Chi for improving balance in people with diabetic peripheral neuropathy (DPN) through increased vascular function and blood flow to the periphery. Additionally, it was suggested that 30 minutes of aerobic exercise most days of the week and RE at least two days a week is beneficial. Specific exercises for improving vestibular actions in those with diabetic vestibular dysfunction were recommended such as balance movements, goal-directed eye-head exercises, head turns, head-trunk turns, and head walking turns. Potential risks of weight-bearing activities were addressed for those with DPN, as well as higher intensities for those with diabetic retinopathy. These exercise recommendations may aid clinicians in determining exercise guidance for their patients specific to individual sensory complications affecting their balance. RE prescription can be complex, and there is a need for guidance that is tailored to improving physical function and cardiometabolic health in T2D. The perspective article authored by Brown et al. discussed the necessity for accurate, clear, and standard definitions for RE. The authors aimed to address low RE adherence levels by simplifying the language used to prescribe RE with specific focus on functional movement patterns. This approach is intended to assist clinicians, scientists, and exercise practitioners to design and monitor exercise prescriptions, in addition to removing complexities for those engaging in RE. The paper also highlighted the need for medical professionals to become familiar with the potential of RE for clinical populations and encourage the adoption of the proposed definitions to enhance the safe and effective treatment of patients through RE. The authors proposed a small but potentially impactful method to increasing the participation in RE to ultimately improve the outcomes and daily living standards of T2D patients. The use of the proposed standard definitions can provide the framework required for patient care, surveillance, and improve the reproducibility of methodologies across clinical research which can be integrated into current exercise guidelines.Engaging in regular exercise and its relationship to health checkups and hospitalizations has also been explored. The manuscript by Hamasaki & Yanai investigated the link between periodic health checkups and the risk of hospitalization in patients with T2D in a Japanese cohort. The retrospective study included over two years' worth of data which included 1256 patients. The data show a significant positive impact of periodic health checkups on reduced hospitalization risk when adjusting for body composition, social habits, hemodynamics, exercise participation, and metabolic markers. Additionally, traditional body composition and physical activity markers were more favorable in subjects who received periodic health checkups compared to those who did not, which may help interpret lower hospitalizations. The data provided by the authors suggested that the impact of periodic health checkups can reduce the severity of T2D to a magnitude that does not require hospitalization, potentially due to increased clinical oversight. These checkups may provide a platform for consistent, individualized therapy for patients at risk of hospitalization, and could be implemented in populations at high risk of hospitalization.While regular exercise decreases the risk of hospitalizations in T2D, this population is less physically active (5,6), possibly due to the higher perceived and physiological effort required during exercise. Huebschmann et al. investigated whether individuals with T2D experience greater physical physiological and perceptual effort during low to moderate intensity exercise compared to individuals without diabetes. Sex differences were investigated since previous research has shown this effect in women only. More specifically, the researchers measured heart rate and blood lactate, parameters used to estimate the degree of physiological stress imposed by physical exercise. They also included a subjective measure of effort, rating of perceived exertion, during treadmill walking at speeds below the aerobic threshold. Although greater physiological markers of effort were associated with having T2D, perceived effort was similar between groups. The authors addressed a crucial barrier to exercise in diabetes management in that if exercise feels harder physiologically and psychologically, people may be less likely to engage in it regularly. Understanding this struggle to maintain regular physical activity could help design better interventions to promote physical activity and reduce cardiovascular risk in this population.Regular exercise is effective in improving a range of vascular complications in T2D, and guidance for clinicians on how to prescribe exercise is necessary for providing patients with necessary tools for prevention. These exercise prescriptions can be provided in regular checkups, which may further help to reduce the risk of hospitalizations. Clinicians' understanding of higher levels of effort regarding exercise in T2D may also aid in empathetic conversations with patients when discussing exercise barriers.