Diabetes Fitness

Running head: LIFESTYLE INTERVENTIONS TO IMPROVE THE QUALITY OF
LIFE IN ELDERLY WITH TYPE 2 DIABETES
Lifestyle Interventions to Improve the Quality of Life in Elderly with Type 2 Diabetes
Kelly Brandon
Northeastern University
LIFESTYLE INTERVENTIONS TO IMPROVE THE QUALITY OF LIFE IN

ELDERLY WITH TYPE 2 DIABETES
Abstract
We are approaching an epidemic of diabetes in the elderly. This epidemic and its
associated complications will have a significant impact on quality of life. Diabetes
Mellitus is a chronic disease that requires several adjustments in patients lifestyle and
has been referred to as the most demanding of all chronic diseases in terms of
management. Diabetes in ageing populations is characterized by complexity of illness,
an increased risk of medical comorbidities, and the development of functional
decline and risk of frailty. This has become an especially relevant issue in our current
society with the rapid growth of an aging population and the corresponding increased
burden on health-care resources. Exercise has been cited by numerous studies to have a
positive effect on diabetic patients, however, little has been published regarding the
implementation of such recommendations on one of the largest groups of our population:
the aging adult. As such, elderly individuals need definitive physical activity
recommendations that are based on comprehensive understanding of the elderly patient
with diabetes.

When caring for our elderly patients with type 2 diabetes we must consider the
safest most effective approach when prescribing physical activity. The aim of this paper is
to gain a comprehensive understanding of the effects of physical activity for elderly
patients with type two diabetes. To fully understand this concept this paper aims to
review the most recent evidence of the complications of diabetes, the effect of the aging
process, how diabetes effects the aging process, the effects of exercise on diabetes, the
aging process and physical abilities, complications and risks associated from diabetes and
aging, current guidelines for exercise and diabetes, and evaluate the safest and most
effective options for physical activity that clinicians can recommend elderly diabetics.
Diabetes Overview
Diabetes mellitus type 2 is a chronic metabolic disorder characterized by relative
resistance to insulin and dysfunction of the -cells in the pancreatic islets of Langerhans.
Onset is slow and insidious; the disease tends to present in middle-aged and elderly adults
but may occur at any age. The natural course of the disease is progressive deterioration
of glucose control, which can lead to significant microvascular and macrovascular
complications.
Treatment of Diabetes
There is no cure for diabetes. It must be managed through a strict daily regimen of
medication, use of insulin, exercise and diet. The aim of treatment for type 2 diabetes is
to prevent or slow progression of the disease and the development of micro- and macrovascular complications including cardiovascular disease, retinopathy, neuropathy and
kidney disease. This is typically approached with a combination of medication, dietary

modification and exercise prescription to reduce blood glucose concentrations and blood
pressure, induce weight loss and modify blood lipid levels. (O'Hagan 2013)
These patients are, therefore, faced with behavioral and psychological challenges
that put them on an increased risk of developing several co-morbidities. Moreover, both
old age and diabetes are independently associated with increased risk of cognitive
dysfunctions (Mushi et al., 2006), as well as an increased risk of psychological distress,
anxiety, depression, hypertension, mood disorders, and functional impairment,
therefore, affecting negatively patients well-being.
Pathogenesis of Aging
A general tendency toward age-related decline in human organ systems is well
documented, including the cardiovascular, pulmonary, renal, neurologic, and
musculoskeletal systems. (Vopat 2014) Diabetes is an important health condition for the
aging population. More than 20% of individuals over the age of 60 years have diabetes,
and another 14% have impaired glucose tolerance. (Greenspan 2011) As age increases, on
average, a small increase in fasting hepatic glucose output is reported, with impairment of
non-insulin-dependent glucose disposal. In addition, insulin secretion is impaired with
age, with less insulin being released in the early and late phase after challenges. The
distribution of insulin moieties also appears to be shifted with age, and insulin resistance
increases with age. (Vopat 2014) It is therefore almost certain that those involved in the
care of elderly patients will encounter many with type 2 diabetes.

Pathogenesis of Aging with Diabetes
Premature mortality caused by diabetes mellitus results in an estimated 12-14
years shorter lifespan than in people without diabetes mellitus. (Barengo 2012) It is also
associated with considerable morbidity and mortality in the elderly and is the most
prevalent metabolic disease and one of the significant medical and socioeconomic
problems all over the world. (Cokolic 2013) As a result, the approach to therapy in the
elderly differs from that in younger patients. Also, the aging process itself may place
elderly individuals at an even greater risk for metabolic abnormalities. (Coker 2009)
Diabetes causes a number of complications that negatively impact on the
musculoskeletal system and the individuals capacity to perform a number of daily
physical activities. It leads to impaired physical capacity through a number of
mechanisms such as muscle weakness, limited joint range of motion, and damage to
peripheral nerves (neuropathy). Persons affected tend to walk more slowly, with greater
variability of gait, and are at increased risk of falling. Lower extremity complications are
common, in particular 25% of diabetics develop a foot ulcer at some point. These
difficult to heal ulcers commonly lead to amputation secondary to infection.
Chronic hyperglycemia may damage vascular tissue and endothelial function,
DNA, and mitochondria in the brain and increase free radicals, inflammatory responses,
and amyloid deposition.(Richarson 2009) Chronic hyperglycemia may also influence
cerebral blood flow, neurotransmitter function, or nutrient delivery to the brain. In
addition, diabetes could influence cognitive function by leading to cardiovascular events,
transient ischemic attacks, and strokes. Repeated hypoglycemic events and related
metabolic and vascular disruption might influence long-term cognitive function. Diabetes

may also be a marker of other factors, such as insulin resistance and hypertension, or may
represent a common genetic susceptibility to both diabetes and Alzheimers disease
dementia
The increase in obesity and inactivity with advancing age are directly associated
with the pathogenesis of metabolic abnormalities, including hypertension, dyslipidemia,
and insulin resistance. This cluster of interrelated conditions, which increases the risk of
type 2 diabetes (T2D) and cardiovascular disease (CVD), is known as the metabolic
syndrome. Prevalence of the metabolic syndrome increases with age and exists in an
alarming ~43% of people aged over 60 years. Therefore, from a public health standpoint,
efficacious strategies must be developed to prevent and/or treat metabolic complications
in our aging population. (Coker 2009)
Older individuals with diabetes have more functional disability and coexisting
illnesses such as hypertension, coronary heart disease (CHD), and stroke than those
without diabetes. Older adults with diabetes are also at greater risk for urinary
incontinence, injurious falls, and issues related to polypharmacy. (Greenspan 2011)
The normal aging process is associated with an increase in vascular stiffness, a
process that is accelerated by the presence of type 2 diabetes. The normal process of
aging is known to result in increased arterial stiffness because of an increase in intima
and media thickness, smooth muscle cell hyperplasia, and extracellular matrix
proliferation. Diabetes has been shown to accelerate this age associated stiffening mainly
through nonenzymatic glycation, the reaction between glucose and the extracellular
matrix proteins in the arterial wall. Nonenzymatic glycation leads to the formation of
increased collagen crosslinks that result in increased arterial stiffness. (Cuff 2008)

Complications And Risks Associated From Diabetes And Aging
Overweight and obesity are common among older persons with type 2 diabetes,
and elevated BMI has been related to increased fat infiltration into the skeletal muscle.
Increased muscle fat infiltration has been associated with reduced oxidative activity and
reduced maximal aerobic capacity and, in epidemiological studies of older persons, fat
infiltration predicted the risk of mobility disability over time. (Bandinelli 2012) In older
persons, diabetes is associated with reduced muscle strength and worse muscle quality.
These impairments are important contributors of walking limitations related to diabetes.
(Bandinelli 2012) Cross-sectional and longitudinal analyses of the Health Aging and
Body Composition study have demonstrated that older diabetic individuals had lower
muscle strength and muscle quality compared with their nondiabetic counterparts
(Bandinelli 2012) These analyses also demonstrated that older persons with type 2
diabetes had accelerated loss of muscle strength over time, suggesting an additional
biological mechanism to explain the association between diabetes and poor physical
function. (Bandinelli 2012) Overall people with diabetes tend to have slower gait speed,
lower muscle strength, muscle power, and muscle quality than people without diabetes.
Other barriers for diabetics include lack of energy related to glycolysis, the
process that enables sugar to be broken down into adenosine triphosphate (ATP) is
affected. (Nazarko 2011) Causing a diabetic to inadequately obtain energy from cellular
function. Diabetics also have a lack of energy reserves because glycogen, normally
stored in the liver is broken down when the body uses up its reserves. High blood glucose
prevents the body drawing on emergency reserves of glycogen (Nazarko 2011) Diabetics

also have an increased risk of tissue damage due to poor circulation. Alterations in
circulation and blood chemistry affect the rate of wound healing. (Nazarko 2011)
Individuals with diabetes mellitus and peripheral neuropathy lack the critical level of
sensory feedback to protect their feet from injury. (Tuttle 2012)
Older individuals with diabetes had impaired balance, slower reactions, and
consequently a higher falls risk than age-matched control subjects. However, all these
variables improved after resistance/balance training. Together these results demonstrate
that structured exercise has wide-spread positive effects on physiological function for
older individuals with type 2 diabetes. (Colberg 2010) Following training, the diabetic
group exhibited a significant decline in falls risk, dropping from a mild-to-moderate to a
low-to-mild risk of falling. This decline was reflected by improved proprioception and
increased hamstring/ quadriceps strength. (Colberg 2010)
However, aerobic exercise is hindered in many type 2 diabetic because of
advancing age and other comorbid conditions and unlike aerobic exercise, Yoga postures
are slow rhythmic movements which emphasize the stimulation of the organs and glands
by easy bending and extensions which do not over-stimulate muscles but concentrate on
glandular stimulation and also induce a mild oxidative stress that stimulates the
expression of certain antioxidant enzymes. This is mediated by the activation of redoxsensitive signaling pathways; thus we can say that yogic practice is the best choice in
older age. (Rani 2013)
Current Guidelines for Physical Activity in the Aging Adult
Published guidelines for the management of type 2 diabetes all include the
common triad of medication, medical nutrition therapy and engagement in physical

activity. These guidelines generally provide extensive discussion of the evidence bases,
mechanisms of action and recommended dosage regimens for pharmacological therapies
as well as comprehensive recommendations for medical nutritional therapy, but physical
activity recommendations are seldom afforded the same degree of promotion. (O'Hagan
2013) The guidelines from the ADA and ACSM have recently changed to indicate that
people with DMPN may participate in moderate weightbearing exercise. Prior to this
change in guidelines, it was recommended that people with DMP limit weight-bearing
activity due to concerns about increased risk for skin injury. (Tuttle 2012)
Physical Activity Benefits for Diabetics

It is a generally well-accepted notion that a positive imbalance between caloric
intake and caloric expenditure contributes to the development of insulin resistance.
Epidemiological data consistently link increased physical activity to reduced mortality
risk in type 2 diabetes patients (De Bourdeaudhuij 2011) Physical activity is considered
to be important in the treatment and control of type 2 diabetes mellitus. (Barengo 2012)
Exercise training programs for people with type 2 diabetes have been shown to have
beneficial effects on body weight, fasting glucose, fasting insulin and insulin resistance,
rate of fat oxidation, blood cholesterol, and blood pressure. Importantly, several longterm exercise-training studies have shown a reduction in glycosylated hemoglobin
(HbA1c), used clinically as a key marker of long-term glycemic control, and therefore
frequently considered as an indicator of treatment efficacy. (O'Hagan 2013)
Decades of research support the fact that much age-related deterioration is the
result of the effects of sedentary lifestyles and the development of medical conditions

rather than of aging itself. (Vopat 2014) For older adults, prolonged intense resistance
training can increase muscle strength, lean muscle mass, and bone mass more
consistently than does aerobic exercise alone. (Vopat 2014)
Physical activity reduces total, cardiovascular disease, and coronary heart disease
mortality in type 2 diabetic patients with elevated high-sensitivity C-reactive protein
levels. This suggests that the anti-inflammatory effect of physical activity may counteract
increased cardiovascular disease and coronary heart disease morbidity and mortality
associated with high C-reactive protein levels. (Juutilainen 2011) Although there have
been some proposed pharmacological treatments for arterial stiffness the results of the
study by Cuff Lockhart at el (2009) indicate that aerobic exercise should be the first-line
treatment to reduce arterial stiffness in older adults with type 2 diabetes, even if the
patient has additional cardiovascular risk factors such as hypertension and
hypercholesterolemia. (Cuff 2009) It has been theorized that pulsatile stretching of
collagen fibers during aerobic exercise can break these collagen crosslinks, resulting in a
decrease in arterial stiffness. (Cuff 2009)
Physical activity has repeatedly been proven to reduce a persons stress level. This
is particularly important for diabetics because stress has negative effect on health and
type 2 diabetes patients may be at an increased risk. Abnormally high levels of free
radicals and the simultaneous decline of antioxidant defense mechanisms can increase
lipid peroxidation and insulin resistance. (Rani 2013) The potential benefits of physical
activity such as Yoga in elderly people are the improved insulin resistance and glucose
tolerance, maximum oxygen consumption, increased muscle strength, improved lipid
profile and improved sense of well-being.

Counter Argument
As older adults make up an increasingly larger portion of the diabetic population,
the spectrum of diabetes complications will likely expand. In addition to the traditional
vascular complications, diabetes has been associated with excess risk for cognitive and
physical decline, falls, fractures, and depression. These complications, which are
common and can profoundly affect quality of life, will challenge clinicians, health care
systems, and public health organizations to identify effective ways of optimizing quality
of life among older adults with diabetes.
The increase in diabetes among the elderly is concerning because, in addition to
the wide range of traditional diabetes complications (including acute hyperglycemic and
hypoglycemic events and vascular complications that may lead to vision loss, renal
failure, foot ulcers and amputation, myocardial infarction, stroke, and cardiovascular
death) evidence has been growing that diabetes is associated with increased risk of
cognitive decline, physical disability, falls and fractures, and other conditions associated
with geriatric syndromes. These less traditional complications are common and may be as
damaging as the commonly recognized vascular outcomes of the disease to older diabetic
people because of their direct influence on quality of life. Indeed, for older people with
diabetes, the threat of loss of independence due to progressing cognitive and physical
decline may be of greater direct concern than the clinical progression of diabetes
complications.
Although there are many reasons to suspect that diabetes could lead to increased
physical disability, the magnitude or key factors explaining such a relationship have
rarely been examined. In the Third National Health and Nutrition Examination Survey

(NHANES III), women and men aged 60 years with diagnosed diabetes were 23 times
more likely to be unable to walk one-fourth of a mile, climb stairs, and do housework
than similar-aged adults without diabetes.( Schwartz 2013) Women with diabetes also had
significantly slower walking speed, worse balance, and a 58% higher likelihood of falling
than did nondiabetic women. In a prospective study of women in the Study of
Osteoporotic Fractures, women with diabetes had twice the yearly incidence of becoming
unable to walk one-fourth of a mile (4.3 vs. 1.9% among nondiabetic women), doing
heavy housework (8.5 vs. 4%), or preparing meals (1.5 vs. 0.7%). Recent analyses from
the Womens Health and Aging Study have found similar degrees of association between
diabetes and mobility problems, activities of daily living disabilities, and balance among
a cohort of older women at high risk for disability.( Volpato 2009)
Conclusion
The benefits of exercise training in the treatment of type 2 diabetes are well established,
but physician implementation and patient engagement are low. Current guidelines for the
prescription of exercise as treatment in type 2 diabetics are generic in nature, and most do
not specifically target the metabolic disturbances that contribute to disease progression
and development of secondary complications. The development of prescription
guidelines that both target the specific metabolic disturbances of the type 2 diabetes and
incorporate individualization of prescription for the patients may improve adherence,
improve clinical outcomes and contribute to reducing the economic burden of the disease.

Future interventions should give particular attention to teach participants how to cope
with high-risk situations, to train their skills and self-efficacy to overcome physical
activity barriers, and to mobilize family members to support them to be active or to
engage in physical activity together with them. As this is one of the few studies focusing
on mediators of change in a physical activity intervention for adults with type 2 diabetes,
additional research is necessary to confirm and extend these findings.

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Reflective Note: I am planning to add this piece to my final portfolio. I am passionate
about this topic and did a lot of research for this project, and I hope after some editing
and feedback I can make this a piece of work I am truly proud of

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Running head: LIFESTYLE INTERVENTIONS TO IMPROVE THE QUALITY OF

LIFE IN ELDERLY WITH TYPE 2 DIABETES

LIFESTYLE INTERVENTIONS TO IMPROVE THE QUALITY OF LIFE IN

LIFESTYLE INTERVENTIONS TO IMPROVE THE QUALITY OF LIFE IN

LIFESTYLE INTERVENTIONS TO IMPROVE THE QUALITY OF LIFE IN

LIFESTYLE INTERVENTIONS TO IMPROVE THE QUALITY OF LIFE IN

LIFESTYLE INTERVENTIONS TO IMPROVE THE QUALITY OF LIFE IN

LIFESTYLE INTERVENTIONS TO IMPROVE THE QUALITY OF LIFE IN

LIFESTYLE INTERVENTIONS TO IMPROVE THE QUALITY OF LIFE IN

LIFESTYLE INTERVENTIONS TO IMPROVE THE QUALITY OF LIFE IN

Physical Activity Benefits for Diabetics

LIFESTYLE INTERVENTIONS TO IMPROVE THE QUALITY OF LIFE IN

LIFESTYLE INTERVENTIONS TO IMPROVE THE QUALITY OF LIFE IN

LIFESTYLE INTERVENTIONS TO IMPROVE THE QUALITY OF LIFE IN

LIFESTYLE INTERVENTIONS TO IMPROVE THE QUALITY OF LIFE IN

LIFESTYLE INTERVENTIONS TO IMPROVE THE QUALITY OF LIFE IN

LIFESTYLE INTERVENTIONS TO IMPROVE THE QUALITY OF LIFE IN

LIFESTYLE INTERVENTIONS TO IMPROVE THE QUALITY OF LIFE IN

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