Never Too Late to Start: Exercise Cuts CVD Death in Diabetes

Becky McCall

November 25, 2013

Patients with type 2 diabetes who fail to exercise regularly show a 70% greater risk for cardiovascular death than those who exercise at least 3 times a week, new research shows. In particular, the data indicate significant benefits to starting to exercise after being sedentary, strongly suggesting it is never too late to get active.

These latest results, from a large follow-up study conducted in Sweden, support a growing body of evidence that patients with type 2 diabetes benefit greatly from participating in regular physical activity.

The study is also unique in that, unlike previous work in this field, it adjusts for cardiovascular risk factors and thereby elicits a clearer association between physical activity and CVD risks.

Furthermore, a subanalysis showed patients who were less physically active at both baseline and follow-up time points "had considerably higher risk estimates of 70% to 110% for coronary and cardiovascular disease and mortality than all other study subjects," said Björn Zethelius, MD, from the University of Uppsala, Sweden, the lead author of the study.

Results also show that those in the low-activity group had a 25% greater risk for coronary and cardiovascular events than those in the higher-activity group.

"So stepping up the duration and the frequency of exercise will lower the risk of cardiovascular complications and death; conversely, remaining inactive will maximize the risk in type 2 diabetes patients," emphasized Dr. Zethelius.

Regular physical activity should be an important part of the diabetes management plan, he stressed. "Our study findings underline the importance of implementing regular physical activity as part of lifestyle measures. Avoid a sedentary lifestyle and engage in physical activity."

The study was published online November 13 in the European Journal of Preventive Cardiology.

Isolating Physical Activity as a Key Factor in Investigation

The researchers explain that while there have been a range of prior studies that have clearly established the fact that high levels of exercise reduce CVD risk, this current study differs because the primary aim was to look at the relationship between the actual level (low or high) of physical activity and CVD risk and mortality, with the added adjustment for conventional CVD risk factors in those with type 2 diabetes.

The large observational study used information held within the Swedish National Diabetes Register (NDR). A total of 15,462 female and male patients of mean age 60, with type 2 diabetes, were included in the analysis, which extended over a period from baseline in 2004–2006 to follow-up in December 2009. Patients who participated in low-level activity (6963) were compared with those who participated in high-level activity (8499).

Low-level activity was defined in the study as never or once- or twice-a-week exercise for 30 minutes, while high-level activity was defined as 30 minutes 3 or more times a week.

The results were fully adjusted for age, gender, diabetes duration, type of hypoglycemic treatment, and smoking and showed that the risk of CVD events and the mortality increase in type 2 diabetes patients who failed to exercise regularly was still significant.

Björn Eliasson, MD, PhD, a diabetologist at the University of Gothenburg Hospital, Sweden and coauthor on the paper, said he regularly sees the patients typified in this study. "These are classic type 2 diabetic patients who were free of previous cardiovascular disease history — this enabled us to isolate physical activity as a key factor in our investigation."

Hazard Ratios (HR) Related to Low Physical Activity vs High Physical Activity

End point HR P
Fatal/nonfatal CHD 1.25 .01
Fatal/nonfatal CVD 1.26 .002
Fatal CVD 1.69 .004
Total mortality 1.48 < 0.001

The study highlights the importance of clinicians emphasizing the message about participating in physical activity to their patients, said Dr. Eliasson.

But he acknowledged, "Our study was conducted in the real-life setting, and these patients are ordinary. When we work in the clinic, it is difficult to make patients change lifestyle. It takes a lot of effort to do this. We can prescribe a pill that is easy to take."

Dr. Zethelius also stressed how important the message about upping physical activity in type 2 diabetes is, in public-health terms, given the backdrop of the increasing prevalence of the disease in an aging population.

These results have "high validity" because they were obtained from nationwide registers with wide coverage and real-life data, he stressed.

Elite Endurance Athletes Most Protected Against Diabetes

Meanwhile, a separate, smaller study confirms the effect of physical activity in protecting against the development of type 2 diabetes, albeit in former elite athletes.

Such individuals were shown to have a 28% reduced risk of type 2 diabetes in later life (OR 0.72) compared with controls in the study, published online November 21 in Diabetologia.

The researchers, led by Merja Laine, MD, from the University of Helsinki, Finland, set out to investigate whether the intense physical activity in elite athletes in younger adulthood had subsequent effects on glucose regulation later in life.

All former athletes were male and broadly grouped according to whether they participated in endurance, mixed, or power sports. A total of 392 former sportsmen were compared with 207 controls.

In addition to the overall 28% reduction in prevalence of type 2 diabetes in later life, endurance athletes specifically showed a statistically significant risk reduction of 61% for diabetes, while for mixed sports the reduction was 21% and for power sports it was 23%, both of which were not statistically significant.

Also, all participants (former elite athletes and controls) who engaged in the most leisure-time physical activity in later life had the lowest prevalence of type 2 diabetes.

None of the contributors to either study have declared any relevant financial relationships. The Swedish National Diabetes Register is funded by the Swedish Association of Local Authorities and Regions.

Eur J Prev Cardiol. Published online November 13, 2013. Abstract

Diabetologia. Published online November 21, 2013. Abstract

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