Type II diabetes (T2D) is a metabolic disease characterized by a chronic rise in blood sugar above normal, glycated hemoglobin A1c (HbA1c) levels above 6.5%. T2D results mainly from the "western" lifestyle, associated with a sedentary lifestyle, overweight and obesity, and an aging population. If T2D generally appeared around 40 years of age, it is increasingly present in young populations. It represents 90% of diabetes cases and the International Diabetes Federation predicts that the number of diabetics could increase from 285 million in 2010 to 438 million in 2030, not counting the number of people with prediabetes (HbA1c levels between 6 and 6.5%).
To improve the people health with T2D and limit the risks associated with this disease (retinopathy, nephropathy and cardiovascular diseases), the current treatment combines changes in lifestyle, diet, regular physical activity and drug therapy. However, studies show that taking hypoglycemic, lipid-lowering and blood pressure-lowering medications affects the quality of life of patients. As for physical activity, the WHO, the American Diabetes Association and the American College of Sports Medicine today recommend approximately 150 minutes per week of aerobic training of moderate to high intensity and 2-3 sessions per week of resistance training, and this, for everyone. Many studies have obtained mixed results by adopting these recommendations or even a lower volume of physical activity. However, this lack of result can be explained by an insufficient training volume and by a problem in measuring actual physical activity, since most of the studies didn't directly measure the physical activity of patients. It was self-reported and it is generally overestimated. Would more physical activity be beneficial for people with T2D? Is there a dose-response relationship regarding the volume of physical activity and the associated benefits? And what would be the impact on the drug therapy of these patients?
To answer these questions, a team of international researchers analyzed the data from the U-TURN cohort study with the aim of analyzing the impact of training volume on stopping drug treatment and on various metabolic variables, risk factors of cardiovascular diseases. For this, the researchers selected 92 patients (including 43 women), with T2D for less than 10 years, with a body mass index (BMI) between 25 and 40 kg/m², not taking insulin and not having an HbA1c level higher than 9%.
The patients were divided into 2 groups: a Standard group (n = 31) and a U-Turn group (n = 61). For 12 months, all participants received standard care (medical and nutritional advice) by a nurse at the start of the study and every 3 months. The goal for patients was to fall below 6.5% for HbA1c. If this rate was reached, the dosage of the drugs taken was halved. If at the next appointment, this rate was the same, or even lower, the drugs were stopped until the next evaluation.
The U-Turn group had to practice a physical activity with a high volume: at least 240 minutes per week during the first 4 months and at least 300 minutes weekly during the last 8 months. Physical activity combined cardiovascular endurance activity (60-90% of the heart rate reserve) and 2-3 resistance training sessions (30 minutes). They also received dietary counseling. Participants in these groups had to wear a Polar watch non-stop throughout the study period to monitor the heart rate. Any activity lasting less than 10 minutes and whose intensity was lower than 57% of the maximum heart rate was not considered as exercise and was therefore not considered for the analysis.
In addition to measuring HbA1c, the researchers analyzed the impact of exercise volume on body composition, fasting insulinemia, fasting glucose, postprandial glucose, cardiorespiratory fitness, energy intake, lipidemia, blood pressure and lipid-lowering and blood pressure-lowering drugs.
Finally, the researchers obtained 3 (tertiles) U-TURN subgroups based on the volume of exercise actually performed during the 12 months of intervention: U-TURN Low, between 121-213 minutes per week; U-TURN Medium, between 261-310 min./week; and U-TURN High, between 355-446 min./week.
The main results of this study show that exercise is associated with a reduction in hypoglycemic drug treatment in a dose-dependent manner. The greater the volume of exercise, the greater the number of patients who were able to stop their treatment (Fig. 1). Compared to the Standard group, only the Medium and High U-TURN groups significantly reduced HbA1c levels (-07% and -1.2%, respectively).
In terms of cardiovascular risk variables, only the Medium and High U-TURN groups were able to obtain significant reductions compared to the Standard group. They lost more body mass, between 7.2 and 10.9 kg for the Medium and High groups, respectively. Concerning body fat, the Medium and High groups lost 6.6 and 10.6 kg, respectively. For the triglyceride level, only the High U-TURN group obtained a significant reduction (0.5 mmol/L) compared to the Standard group. Finally, the VO2MAX of the Medium and High U-TURN groups increased significantly more than the Standard group (7.91 and 9.6 ml/kg/min, respectively). No difference was observed between the groups as regards a reduction in the use of lipid-lowering and blood pressure-lowering drugs.
In T2D, a drastic change in the level of physical activity allows for improvements in health and the possible discontinuation of hypoglycemic drugs (but the latter depends of different factors like fat loss, the beta cell capacity of recovery, the gut microbiome fermentation, etc.). However, for these improvements to be seen in blood sugar level and cardiovascular risk factors, the amount of physical activity must exceed the official recommendations, which are to do at least 150 minutes per week.
If many people invoke the lack of time to practice physical activity up to the official recommendations, it is important to note that the participants in this study knew how to find the time and how to maintain their adherence to physical activity for 1 year, at much higher levels. Indeed, people in the High U-TURN group have practiced up to more than 400 minutes weekly (a little less than an hour per day)… It is therefore important to work on organizing the day in order to find the time to deal with the problem at its source. It is also essential that the impact of physical activity be seriously considered. An alternative exists with High-Intensity Interval Training, the benefits are similar but the time spent to train is reduce.
Of course, this study has certain limitations, the first being that it is only intended for T2D patients whose prognosis was less than 10 years old. In addition, since the glycated hemoglobin A1c levels at the start of the study in all participants was not too high, it was "easier" to decrease it. However, this is not the first study to demonstrate that remission of type II diabetes is possible, and that it is lasting if the change in lifestyle is also sustainable. It therefore seems imperative for all patients diagnosed with type II diabetes to take matters into their own hands as soon as possible in terms of diet and physical activity, to reverse the trend in the long term. If you have type II diabetes, make an appointment with your physician and discuss with a certified coach to be well advised. If you are a certified coach and one of your clients has diabetes, do not hesitate to contact his physician in order to work together.
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