As rise in blood pressure has also been observed as a result of depression, stress and anxiety (Jonas et al, 1997). Goldstein (1989) found hypertension was more common in persons with diabetes, with the relative risk being doubled for myocardial events and sudden death, which has more recently been supported by Pierce (1999), especially in younger patients. This is because persons’ with diabetes have been found to have complications including reduced left ventricular function, higher resting heart rates, reduced cardiac reserve, reduced cardiac return, and coronary artery stenosis (Pierce, 1999).
Schneider et al, (1992), observed that regular physical activity lowers blood pressure in persons with type 2 diabetes, with Eriksson (1999) more recently supporting this reporting regular aerobic exercise resulted in significant improvements in lipid profile, blood pressure and body fat distribution in patients with type 2 diabetes.
Diabetes
Diabetes is a group of chronic metabolic disorders characterised by hyperglycaemia resulting from a relative deficiency in insulin through either reduced insulin secretion or reduced insulin action or both. Almost all diabetes falls into two categories: type 1, an absolute deficiency of insulin production, and type 2 which is more common, characterised by resistance to insulin and inadequate compensation (Pierce, 1999). Diabetes is one of the leading causes of death and disability in the U.S with type 2 diabetes accounting for 90-95% of all diabetic cases (Albright et al, 2000).
Sedentary lifestyles have been suggested to play a role in the development of type 2 diabetes (Helmrich et al, 1991; Albright et al, 2000; Manson et al, 1992; Perry et al, 1995; Ruderman et al, 1998). Bloomgarden, (1997) showed that simple lifestyle changes including diet and moderate exercise decreased two-hour glucose and insulin levels. Cross sectional and retrospective epidemiological studies have provided more direct evidence that physical inactivity is significantly associated with glucose intolerance within populations. Persons with type 2 diabetes were found to be less active (Dowse et al, 1990) and reported less physical activity over their lifetime (Albright et al, 2000) than individuals without diabetes. Studies suggest that physical activity can reduce the risk of developing type 2 diabetes (Pierce, 1999; Manson et al, 1992) and have been reported for both genders (Manson et al, 1992).
Mild-to-moderate intensity exercise has been found to lower blood glucose, and this effect is sustained into the post-exercise period (Minuk et al, 1981). Therefore mild-to-moderate intensity exercise has been recommended to facilitate glucose reductions in those with type 2 diabetes (Albright et al, 2000). Pan et al, (1997) had previously supported this, concluding individuals who increased their physical activity, were found to have a decreased incidence of diabetes. Dynamic aerobic exercise, has also been found to enhance a multitude of bodily processes that are inherent in skeletal muscle activity including the metabolism of high-density lipoproteins and insulin/glucose dynamics (Hardman and Morris, 1997), which leads to the incidence of diabetes among people who are more physically active. Studies have shown that exercise increases peripheral and splanchnic insulin sensitivity in those with type 2 diabetes, which persists from 12- 24 hours post exercise (Burstein et al, 1999), however, contradictory findings have been found by Rogers et al, (1988) who did not support these findings. The results obtained by Burstein et al, (1999) could be questionable and caution should be taken when interpreting their results.
Only a small range of participants were used and they were previously not physically active, thus, limiting the reliability of the results to sedentary groups only, physically active persons’ may however incur different results to that of sedentary. The treadmill speed was also only set to adhere to subjective comfort therefore making the intensity sub-maximal and subjective to each participant. Albright et al, (2000) has, however, more recently supported Burstein et al, (1999) concluding physical activity is one of the principle therapies to acutely lower blood glucose in type 2 diabetes due to its synergistic action with insulin in insulin-sensitive tissues. Albright et al, (2000) also found acute bouts of physical activity can favourably change abnormal blood glucose and insulin resistance, which supports that of recent findings.
Psychological effects of exercise on persons’ with diabetes
Diabetic complications are more prevalent with long standing type 2 diabetes and require increased psychosocial adjustments (Wulsin et al, 1993). Surwit and Feinglos (1988) stated the impact of diabetes on life-style and health, and the psychosocial adjustments in those with type 2 diabetes may have important consequences on perceived stress, glucose control, and psychological health. Treuth et al, (1995) further supported this concluding diabetic complications contribute to perceived stress of disease management and affective disorders, especially depression.
Few studies have examined the effect of regular physical activity on various psychosocial, psychological, and stress-related outcomes in type 2 diabetes. There are, however, presumed physiological and psychological benefits of regular exercise in those without diabetes, these include heightened self-esteem (Eriksson, 1999), stress (Albright et al, 2000), self-confidence and general well being (Eriksson, 1999). This appears to have importance relative to augmenting perceived health, sense of self, and lessening the negative impact of stress and depression on disease management.
Obesity
Unhealthy lifestyle habits, being overweight or obese and particularly physical inactive, have been found to play a major role in the development of cardiometabolic disease and have a significant impact on cardiometabolic health (Pescatello 1999). The number of overweight and obese people is increasing constantly, the Health Survey for England (2002) reported that approximately 43% of men and 34% of women are overweight and an additional 22% of men and 23% of women are obese (www.bhfactive.org.uk). The unhealthy lifestyle changes have and continue to affect the younger population. It is estimated that a 22% of boys and 28% of girls ages 16 or under are overweight or obese, with estimated future levels of adult obesity set to increase, which is likely to increase cardiovascular mortality (Grobbee et al, 2003).
Although higher levels of fitness are consistently associated with less risk of CHD, studies have indicated that such relationships may be mediated by body fatness rather than aerobic fitness (Bergstrom et al, 1997; Boreham et al, 2001). Fitness and changes in fitness are strong predictors of CHD risk and mortality, which are largely independent of body fatness (Farrell et al, 1998; Whaley et al, 1999). These results may be subjective, Farrell et al, (1998) results were based on males only exercising at a maximal intensity, which may be questionable to females or persons who are not able to exercise at high intensities.
Relationships between fatness and CHD risk status are somewhat stronger than those previously reported between physical activity and CHD (Boreham et al, 1997). Boreham et al, (2001) revealed moderate to strong correlation between fitness and fatness, and between fitness and CHD risk factors (Bergstrom et al, (1997). Twisk et al, (2000) found the relationship between physical activity, physical fitness, and lipoproteins and blood pressure were highly influenced by body fatness, and concluded physical activity and physical fitness can have an influence on cardiovascular health (e.g. reduction in blood pressure).
Obesity is reported to play an important role in the development of left ventricular (LV) pump dysfunction, and LV geometric enlargement (Devereux et al, 1996). When obesity is present, increased overload on the myocardium can occur resulting in cardiac hypertrophy (Devereux et al, 1996). Therefore systolic dysfunction may develop because of excessive wall stress if wall thickening fails to keep pace with dilatation (Devereux et al, 1996) due to hypertrophy, which in turn can lead to hypertension increasing the risk of CHD. Rocchini (2002) stated hypertension to be an established risk factor for cardiovascular diseases and is common among obese subjects. Numerous previous studies have supported this concluded that being overweight or obese are associated with an increased risk of increased BP (Appel et al, 2000; Dyer and Elliot, 1989; Hu and Tian, 2001; Jousilahti et al, 1995).
Appel et al, (2000) indicated that weight loss is an important approach for primary prevention of hypertension. Haskell, (1994) found approximately 4 kJ/kg of body weight is expended for every kilometre walked. This provides evidence that health gains from improved weight regulation may be achieved through a generally more active lifestyle without the need for exercise of an intensity required through improved fitness. Greebbo et al, (2003) stated that modest weight loss in the range of 3% to 9% of initial body weight was roughly associated with a 3mmHg reduction in BP in overweight, hypertensive persons. Barengo et al, (2004) more recently supported this concluding regular physical activity was associated with a significantly reduced risk for hypertension in men and women, independent of age, BMI, and systolic BP at baseline.
Mcternan (2002) concluded levels of fatty adipose cites which are associated with obesity cause an increase in insulin resistance and glucose tolerance which could therefore lead to the onset of diabetes. Steppan et al, (2001) previously supported this stating obesity is a major risk factor for the development of type 2 diabetes. Exercise and medical nutrition therapy are essential for the initial treatment of type 2 diabetes. Moderate weight loss (~10-15%) has been found to assist in achieving metabolic goals (Albright et al, 2000). Pan et al, (1997) found a reduced risk of developing diabetes was associated with diet, exercise, and diet in conjunction with exercise. Eriksson (1999) reported, lifestyle modification, including a very low fat diet containing a high level of complex carbohydrate diet combined with aerobic exercise was effective in controlling overall metabolic profile in patients with type 2 diabetes, which has also more recently been supported by Albright et al, (2000). The reason for this is weight loss leads to a decrease in insulin resistance and may be most beneficial early in the progression of type 2 diabetes when insulin secretion is still adequate (Pan et al, 1997). Eriksson (1999) reported that regular aerobic exercise resulted in significant improvements in body fat distribution in patients with type 2 diabetes.
Most obese individuals with type 2 diabetes exhibit decreases in blood glucose after mild-to-moderate exercise (Minuk et al, 1981). The magnitude of decrease in blood glucose have been found to be related to the duration and intensity of physical activity and further modified by pre-exercise glucose level and novelty of the activity. Eriksson, (1999) found circuit-type resistance training seemed to be feasible and effective in moderately obese sedentary patients with type 2 diabetes. However, persons with type 2 diabetes who are very obese, may not be able to sustain exercise at a level that is required for significant weight loss to occur and body weight and body fat losses with exercise alone are often reported to be small. This provides support to Albright et al, (2000) suggesting that exercise and prescribed nutritional intake will be more effect than one or the other.
Psychological effects of exercise in persons’ who are obese
Buckworth and Dishman (2002) found that there were positive dietary habits associated with physical activity. Pate et al, (1996) cited in Buckworth and Dishman (2002) had previously supported this, they found that little or no involvement in physical activity was associated poor dietary habits, however, it should be noted that these were among adolescents age 12 – 18. However, research reviewed using an adult populations by Albright et al, (2000) supported this concluded physical activity may improve mood and self-esteem and as a result contribute to better control of food intake and adhere better to nutritional advice.
Studies have looked at weight loss as a factor for improved mood due to increased self-esteem; Grilo et al, (1993) believe that exercise improved weight loss by enhancing self-esteem and mood, which, in turn, may improve adherence to behavioral weight control strategies. In addition, physical activity in the low-to-moderate range of intensity may maintain or even suppress appetite (Pi-Sunyer, 1992), therefore facilitating long-term dietary adherence and weight loss.
General improvements in self-esteem are most likely to occur in those who have most to gain physically from exercise and the greatest improvements are most likely in those with low self-esteem physical self-worth and body image. There is growing evidence that exercise can be effective in improving mental well-being via improved mood and physical self-perception. Furthermore, it is effective in the treatment of clinical depression and both state and trait anxiety (www.sportengland.co.uk).
Age
It is important to remain physically active throughout a persons’ lifespan for the purposes of preserving physical function and preventing premature death (Fried et al, 1998; Pescatello 1999). DiPietro (1996) concluded that physical activity extends the period of active life expectancy by reducing the time period of functional impairment. The prevalence of the various disorders associated with cardiometabolic disease (such as hypertension and obesity) and sedentary behaviour increases with age (Caspersen et al, 1995; Pollock et al 1991).
From the few studies that have addressed this, there has been mounting specific evidence that indicates that moderate intensity habitual physical activity has cardiometabolic health benefits that contribute to the preservation of physical function among older people (Pescatello, 1999). It has also been found that older individuals prefer to walk and engage in activities of daily living at moderate intensity, which has been found to be effective in reducing the risk of cardiometabolic disease (Pescatello, 1999) providing psychological reassurance to older adults trying to retain a general level of fitness.
In a Longitudinal Study of Ageing conducted by Rakowski and Mor (1992) cited in Wannamethee and Shaper, (2001), self-reported physical activity in adults over 70 years were associated with reduced mortality. Hakim et al, (1998) recently supported this showing walking to be beneficial for longevity in men aged 61 to 83 and a subsequent report (Hakim et al, 1999) indicated benefits for CHD in men aged 71 to 93 years. It should be highlighted that these results were obtained using adults of >60 years of age. ‘Older adults’ age should be defined, as they may differ from that of adults aged 40-59. Wannamethee and Shaper (2001) also showed light to moderate activity to be beneficial in men aged over 60 years with optimal benefit in those engaged in moderate levels of physical activity, however intensities above appeared to provide no further benefit. Caution should be taken when interpreting these results, however, participants used were previously physically active, sedentary persons’ may have obtained different results. The question of whether increasing or taking up physical activity later in life is subject to debate. Paffenbarger et al, (1993) suggested that increased physical activity levels or increased physical fitness in sedentary men was associated with a reduction in risk of all-cause mortality. These findings should also be observed with caution though, the results were also based on the participants quitting smoking, maintaining normal blood pressure and avoiding obesity. However, Hein et al, (1994) provided more reliable findings, suggesting an increase in physical activity in the younger men (40-49) was associated with benefit, but in men aged 50-59 years taking up physical activity was associated with a increased risk of heart attacks.
A number of studies have shown that moderate intensity, dynamic, high volume resistance training can be performed effectively and safely, even by elderly and hypertensive patients (Effron, 1989; Fleck, 1998).
Furthermore the fact that type 2 diabetes mellitus increases with age, and that decline in muscle mass with ageing is associated with a decline in metabolic function, gives further support to the usefulness of resistant training (Tzankoff and Norris, 1977). Treuth et al, (1995) found significant reductions in intra-abdominal adipose tissue and increases in strength were observed after strength training in healthy older women, indicating that strength training may be a useful intervention to improve body composition and fat distribution in the older population. Caution should be took when interpreting Treuth et al, (1995) findings however, the study was only related to women aged 67 (± 1) which therefore may not be applicable to persons’ of younger or older ages and men. The results may be inaccurate as a result of their method too, the participants were only given 90 second rest periods between bouts of exercise which may not have been sufficient for restoration of energy fuels such as ATP and phosphocreatine which also reduce with the onset of age.
Psychological effects of physical activity in older adults
It has already been established that exercise adherence declines with age which can therefore lead to a decline in psychological well-being (Thirlaway and Benton, 1992), Ruuskanen and Ruoppila (1995) found there was a significant association between a higher prevalence of depression and no regular physical exercise, and self-rated meaningfulness of life and better subjective health were also significantly related to regular physical exercise. In addition, King et al (1998) studied the effect of differing exercise intensities on the psychological state of adults aged 50-65. The results from the study revealed that lower intensity activity had the biggest impact on anxiety reduction for this specific population and that vigorous activity was not as effective or essential as an anxiety reducing treatment.
Research has also suggested that involvement in physical exercise may promote positive perceptions of psychological well-being, significant improvements in the higher mental processes of memory and the so-called executive functions, which include planning, organization and the ability to mentally juggle different intellectual tasks at the same time in older men and women (.uk). Colcombe and Kramer (2003) supported this, they found fitness training to have robust but selective benefits for cognition, with the largest fitness-induced benefits occurring for executive-control processes in older adults.
Conclusion
To summarise, the writer believes that physical activity performed at a moderate intensity is sufficient to reduce the risk of cardiometabolic disease and associated factors that can lead to it. Resistance type exercise may be used as prevention to loss of muscle mass, which can be detrimental to persons with diabetes, but caution and possible verification from a persons’ doctor should be taken. The writer also believes that physical activity increases persons’ psychological well being, acting as prevention to the onset of depression, stress and anxiety. The writer also believes physical activity can have positive effects on a persons’ psychological well-being if they suffer from CHD, diabetes, are obese and the onset of old age.
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