The objective of this study was to investigate the effects of the combination of elastic band resistance exercise (EBRE) with modified Thai yoga on the alleviation of blood glucose and oxidative stress in type 2 diabetes mellitus (T2DM). Forty-two patients with T2DM were enrolled and allocated to an exercise or control group (n=21/group). The exercise group participated in EBRE combination with modified Thai yoga for 40 min, 5 days/wk, for 12 consecutive weeks. Blood glucose, oxidative stress markers, antioxidants, pulmonary function, respiratory muscle strength, and airway inflammation were measured before and after the 12 weeks. The results showed that the exercise group had a significant reduction in fasting blood glucose and glycated hemoglobin. Moreover, T2DM patients in the exercise group showed a significant reduction in plasma malondialdehyde, while superoxide dismutase and catalase were significantly increased. The exercise group also observed a significant improvement in pulmonary function; forced expiratory volume in the first second (FEV1), forced vital capacity (FVC), FEV1/FVC, peak expiratory flow, and forced midexpiratory flow as well as respiratory muscle strength. Interestingly, the combination of EBRE with modified Thai yoga markedly improved airway inflammation through the reduction in fractional exhaled nitric oxide. In conclusion, these findings suggest that the combination of EBRE with modified Thai yoga improves blood glucose, oxidative stress, antioxidants, pulmonary function, respiratory muscle strength, and airway inflammation in T2DM patients. Hence, it could be considered as a possible exercise program for T2DM patients.
Type 2 diabetes mellitus (T2DM) is one of the most common metabolic disorders which is an important cause of neuropathy, retinopathy, nephropathy, diabetic foot ulcers, coronary arterial disease, hypertension, and stroke (
Oxidative stress is characterized by increasing reactive oxygen species, and/or reducing antioxidants leading to tissue damage. Hyperglycemia is the primary underlying pathophysiological mechanism connecting diabetes with oxidative stress (
Oxidative stress has been implicated in the development of insulin resistance, β-cell dysfunction, and vascular complications (
The core of T2DM treatment is living a healthy lifestyle to maintain control of blood sugar levels, which includes increasing physical activity and eating a balanced diet. The importance of exercise training in the prevention and management of T2DM is becoming more widely acknowledged. Resistance training has been shown to significantly improve insulin sensitivity, mitochondrial function, lean body mass (
Although, resistance exercise and yoga have been well documented, beneficial outcomes among patients with T2DM, in addition to the effects of combined training, have not yet been reported. Therefore, the objective of this study was to investigate the effects of combined elastic band resistance exercise (EBRE) with modified Thai yoga on the alleviation of blood glucose and oxidative stress in T2DM. Furthermore, the combined effects of combination exercise on the improvement of pulmonary function, respiratory muscle strength, and airway inflammation were also determined in patients with T2DM.
Sample size was calculated using a power of 0.90, power analysis with an effect size f of 0.78, and alpha of 0.05. The sample size was 20 per group. In addition, 5% dropout was calculated. Finally, the number of participants was 21 per group. This study was a randomized control trial. As shown in experimental design in
The control group (n=21) was instructed to carry on with their regular daily routine for 12 weeks. The exercise group (n=21) participated in EBRE with Thai yoga (40 min per day, 5 days per week) throughout the same 12-week period. The 40-min EBRE with Thai yoga has three phases: a 5-min warm-up phase (
All outcome measurements were carried out by an experienced observer in our research group. The observer was also blinded for avoidance of bias.
Fasting blood sugar (FBS), HbA1c, malondialdehyde (MDA), superoxide dismutase (SOD), and catalase (CAT) were measured in blood samples taken from the antecubital vein. FBS was measured by glucose oxidase technique using glucose reagent kits (DIRUI Industrial Co. Ltd., Changchun, Jilin, China) following the manufacturer’s instructions. Briefly, glucose in the blood sample was catalyzed by glucose oxidase of the reagent to form gluconic acid and hydrogen peroxide. Under the existence of peroxidase, hydrogen peroxide reacts with aniline and 4-aminoantipyrine to produce H2O and quinone imine pigment. The generated volume of quinone imine pigment is proportional to the glucose content in the blood sample. The final pigment volume was read at 505 nm. HbA1c was measured by HbA1c assay kits (Lifotronic, Shenzhen Lifotronic Technology Co. Ltd., Shenzhen, Guangdong, China), following the manufacturer’s protocol. Briefly, HbA1c monoclonal antibody (T line) and rabbit anti-mouse IgG were coated on the NC membrane, and the fluorescein labeled HbA1c monoclonal antibodies were coated on the conjugate pad. The blood sample was then added to the sample pad. The HbA1c reacts with the antibodies to form immune complexes. The concentration of immune complexes has a positive correlation to the concentration of HbA1c in the blood sample. HbA1c in the sample can be calculated through the standard curve. The level of plasma MDA was assessed utilizing the techniques as previously described (
A pulmonary function test was performed by using spirometer (DATOSPIR touch, Sibelmed, Rosellón, Barcelona, Spain), following a spirometry standardization method according to the American Thoracic Society (ATS)/European Respiratory Society (ERS) guidelines. The spirometer was calibrated using a 3-L syringe connected to the transducer as previously described following a spirometry normalization method. A calibration check of an expiration and inspiration volume report of less than 3% was considered acceptable. Subjects underwent pulmonary function testing while seated. A Spirometer was employed to measure pulmonary functions including FEV1, FVC, peak expiratory flow (PEF), and forced midexpiratory flow (FEF25%–75%). Measurements were taken from the greatest of three recordings made while the subject was seated and wearing a nose clip in accordance with the ATS/ERS recommendation. Values were represented as percentages of the predicted normal values (%predicted) in the Thai population.
Maximal inspiratory pressure at functional residual capacity (PImaxFRC), maximal inspiratory pressure at residual volume (PImaxRV), and maximal expiratory pressure (PEmax) were measured to assess respiratory muscle strength using a respiratory pressure meter (MicroMedical MicroRPM 01, CareFusion, Basingstoke, UK) following the ATS/ERS guidelines. The instrument has been calibrated within 3% of a pressure manometer reading. The highest value among the three PImaxFRC, PImaxRV, and PEmax values were reported.
FeNO was measured with the NO monitor (Quark NObreath, COSMED Srl, Pavona di Albano, Rome, Italy) with a single breath online method at a constant flow of 50 mL/sec for 12 sec of exhalation according to ATS/ERS guidelines, with a sensitivity of one part per billion (ppb). The software carried out the analyzer calibration automatically. The subjects inhaled to their total lung capacity, then exhaled through a mouthpiece into an exhalation circuit. Before the FeNO measurement, all volunteers were requested to abstain from eating, drinking, and performing intense exercise for 2 hr beforehand.
Data were presented as means±standard deviation. Stata 14.0 (StataCorp, College Station, Texas, TX, USA) was employed for all analyses. The Shapiro–Wilk test was utilized to test normal distribution of the data, paired
Forty-two T2DM patients aged 60–72 years, 20 males (47.7%) and 22 females (52.3%) took part in the study. All participants completed the study by participating in the 12-week assessment. There were no significant differences regarding baseline characteristic consists comprising of age, weight, height, body mass index, waist circumference, hip circumference, waist to hip ratio, and pulse oxygen saturation on comparison between the control and exercise groups (
The primary outcomes of this study are blood glucose (FBS and HbA1c) and oxidative stress markers (plasma MDA, SOD, and CAT). Secondary outcomes include pulmonary function, respiratory muscle strength, and airway inflammation.
FBS and HbA1c were significantly decreased by 3.48% (
Pulmonary function tests are used to quantify lung function, evaluate effectiveness, diagnose lung disease, and determine disability. The most widely employed pulmonary function test evaluates dynamic lung volume consisting of FEV1, FVC, FEV1/FVC, PEF, and FEF25%–75%. These variables reflect pulmonary abnormalities such as airflow limitation and restriction amid lung expansion. Pulmonary functions were exhibited as %predicted values (
Respiratory muscle strength is an indicator of good respiratory system function. It can be assessed by measuring PImaxFRC, PImaxRV, and PEmax. PImaxFRC reflects the strength of the diaphragm, PImaxRV reflects the strength of the diaphragm and accessory inspiratory muscles, and PEmax reflects the strength of the expiratory muscles. The values of PImaxFRC, PImaxRV, and PEmax were significantly increased following 12 weeks of EBRE with modified Thai yoga compared to the control group (
Exhaled NO is mainly produced by the endothelial cells of micro vessels in the airways and alveoli, with only a small portion produced by pulmonary vessels which can be assessed from the FeNO level. FeNO levels are elevated in the inflammatory condition. Subsequent to 12 weeks of exercise, FeNO level was significantly reduced by 17.2% (30.13±5.10 ppb vs. 24.95±6.41 ppb,
The evidence demonstrating the significant health benefits of EBRE with modified Thai yoga in T2DM patients led to the development of this study. T2DM patients exhibit elevated blood glucose levels and oxidative stress markers and reduced pulmonary function. This is the first study to evaluate the combination of EBRE and modified Thai yoga efficacy as an adjuvant therapy for reducing blood glucose levels, lowering oxidative stress, and enhancing antioxidant and pulmonary function in older T2DM patients.
The current study revealed substantial decreased levels of FBS and HbA1c in the exercise group who performed EBRE with modified Thai yoga. The crucial factor in lowering the probability of chronic DM complications was reported to be an improvement in glycemic control (
Oxidative stress is evidenced by an increase in MDA and a decrease in antioxidants such as SOD, CAT, and glutathione (GSH) (
EBRE with modified Thai yoga showed significant therapeutic effects on pulmonary function in older T2DM patients (FEV1, FVC, FEV1/FVC, PEF, and FEF25%–75%). Similarly, progressive aerobic and resistance training in T2DM were observed to enhance pulmonary function (FEV1 and FVC) following 12 weeks (
The exercise group exhibited a significant increase in respiratory muscle strength (PImaxFRC, PImaxRV, and PEmax). The respiratory muscles will therefore become stronger resultant of exercising the diaphragm, abdominal muscles, and other respiratory muscles. These improvements support the findings of
FeNO measurement is a simple tool for assessing airway inflammation. Our findings demonstrate a decrease in FeNO level following a 12-week EBRE with modified Thai yoga. Yoga practice has been associated with reductions in systemic inflammation cytokine as indicated by lowering the levels of C-reactive protein, tumor necrosis factor-alpha (TNF-α), and interleukin 6 (IL-6) (
The study has some limitations. Firstly, the effect of elastic resistance combined with yoga exercise on variables was only evaluated twice prior to and post intervention. The tendency to alter during intervention is unknown. For this reason, future studies should also evaluate these variables during training. Second, diabetes has a significant bearing on the functioning of the cardiovascular system. Nonetheless, this study lacked the effect of elastic resistance combined with yoga exercise on this system. Thus, further research could investigate the parameters of cardiovascular function such as lipid profiles, blood pressure, heart rate, and autonomic nerve system. Third, in this study, FeNo was employed to assess airway inflammation. To confirm that elastic resistance combined with yoga exercise is able to reduce inflammation, future studies ought to evaluate proinflammatory cytokines markers. Fourth, there were no data available on monitoring dietary intake in participants. This could have an impact on their antioxidant status. However, during the trial, the participants were asked and reminded not to change their eating behaviors. Finally, this study did not specify the consequences of elastic bands with unaccompanied. But previous studies have shown the benefits of both methods of exercise in patients with T2DM, leading to the combination of elastic bands and Thai yoga exercise into a new exercise program. Therefore, further study is required performing elastic bands and Thai yoga exercise in separately to provide more extensive data.
In conclusion, the current findings suggest that EBRE with modified Thai yoga can improve blood glucose, oxidative stress, antioxidants, pulmonary function, respiratory muscle strength, and airway inflammation in older T2DM patients. Thus, EBRE with modified Thai yoga could be recommended to the elderly with T2DM.
This research was supported by the Thailand Science Research and Innovation Fund and the University of Phayao (Grant No. FF64-UoE023 and FF66-RIM049). The participants’ contributions to the study are very much appreciated.
No potential conflict of interest relevant to this article was reported.
Flow chart of participants through the experiment.
Warm-up postures (A1–5), elastic band resistance exercise with modified Thai yoga postures (B1–10), and cool-down postures (C1–5).
Fasting blood sugar (FBS) (A), glycated hemoglobin (HbA1c) (B) before and after 12 weeks in the control and exercise groups. Values are presented as mean±standard deviation. *
Malondialdehyde (MDA) (A) and fractional exhaled nitric oxide (FeNO) (B) before and after 12 weeks in the control and exercise groups. Values are presented as mean±standard deviation. *
Superoxide dismutase (SOD) (A) and catalase (CAT) (B) before and after 12 weeks in the control and exercise groups. Values are presented as mean± standard deviation. *
The clinical characteristics of control and exercise groups at baseline period
Variable | Control group (n=21) | Exercise group (n=21) |
---|---|---|
Gender, male:female (%) | 47.62:52.38 | 47.62:52.38 |
Age (yr) | 64.86±3.55 | 64.29±3.74 |
Weight (kg) | 57.52±8.48 | 58.75±11.86 |
Height (cm) | 155.10±5.63 | 155.14±9.01 |
BMI (kg/m2) | 23.84±2.67 | 24.21±2.98 |
Waist circumference (inch) | 33.42±2.91 | 33.64±3.65 |
Hip circumference (inch) | 37.87±1.93 | 37.21±2.36 |
Waist to hip ratio | 0.88±0.05 | 0.90±0.06 |
SpO2 (%) | 98.10±0.77 | 98.24±0.83 |
Values are presented as mean±standard deviation unless otherwise indicated.
BMI, body mass index; SpO2, pulse oxygen saturation.
The measurement of blood glucose and oxidative stress markers at before and after 12 weeks in control and exercise groups
Variable | Group | Before | After | Within-group | Effect size (Cohen | |
---|---|---|---|---|---|---|
| ||||||
Statistic | ||||||
FBS (mg/dL) | Control group | 154.24±20.93 | 155.00±21.51 | 0.638 | 0.04 | |
Exercise group | 155.86±31.68 | 150.43±33.44 | 0.025 |
0.17 | ||
Statistic | ||||||
0.669 | 0.217 | |||||
| ||||||
HbA1c (%) | Control group | 8.60±1.28 | 8.69±1.26 | 0.354 | 0.07 | |
Exercise group | 8.77±1.85 | 8.50±2.04 | 0.048 |
0.13 | ||
Statistic | ||||||
0.722 | 0.747 | |||||
| ||||||
MDA (μM) | Control group | 5.29±1.09 | 5.30±1.16 | 0.945 | 0.01 | |
Exercise group | 5.31±1.01 | 4.85±0.53 | 0.048 |
0.57 | ||
Statistic | ||||||
0.964 | 0.111 | |||||
| ||||||
SOD (Inhibition rate %) | Control group | 60.73±12.36 | 59.93±12.75 | 0.372 | 0.06 | |
Exercise group | 60.37±18.93 | 62.82±18.51 | 0.040 |
0.13 | ||
Statistic | ||||||
0.942 | 0.558 | |||||
| ||||||
CAT (U/mL) | Control group | 67.77±19.87 | 66.96±20.00 | 0.330 | 0.04 | |
Exercise group | 67.55±16.23 | 70.34±16.13 | 0.040 |
0.17 | ||
Statistic | ||||||
0.880 | 0.551 |
Values are presented as mean±standard deviation unless otherwise indicated.
FBS, fasting blood sugar; HbA1c, glycated hemoglobin; MDA, malondialdehyde; SOD, superoxide dismutase; CAT, catalase;
The measurement of pulmonary function at before and after 12 weeks in control and exercise groups
Variable | Group | Before | After | Within-group | Effect size (Cohen | |
---|---|---|---|---|---|---|
| ||||||
Statistic | ||||||
FEV1 (%pred) | Control group | 87.85±9.64 | 87.20±14.03 | 0.803 | 0.05 | |
Exercise group | 86.86±13.69 | 92.96±17.47 | 0.004 |
0.39 | ||
Statistic | ||||||
0.788 | 0.246 | |||||
| ||||||
FVC (%pred) | Control group | 88.67±12.56 | 88.57±16.02 | 0.975 | 0.01 | |
Exercise group | 87.22±16.62 | 91.78±18.37 | 0.008 |
0.26 | ||
Statistic | ||||||
0.752 | 0.549 | |||||
| ||||||
FEV1/FVC (%) | Control group | 82.48±14.02 | 81.54±11.46 | 0.689 | 0.07 | |
Exercise group | 83.45±9.38 | 84.64±9.60 | 0.023 |
0.13 | ||
Statistic | ||||||
0.795 | 0.348 | |||||
| ||||||
PEF (%pred) | Control group | 81.80±7.47 | 80.87±8.03 | 0.260 | 0.12 | |
Exercise group | 80.60±13.40 | 85.31±16.18 | 0.039 |
0.32 | ||
Statistic | ||||||
0.155 | 0.267 | |||||
| ||||||
FEF25%–75% (%pred) | Control group | 84.70±17.88 | 84.13±21.13 | 0.768 | 0.03 | |
Exercise group | 82.66±11.33 | 108.29±34.71 | 0.036 |
0.99 | ||
Statistic | ||||||
0.661 | 0.019 |
Values are presented as mean±standard deviation unless otherwise indicated.
FEV1, forced expiratory volume in the first second; FVC, forced vital capacity; PEF, peak expiratory flow; FEF25%–75%, forced mid-expiratory flow; %pred, %predicted value;
The measurement of respiratory muscle strength at before and after 12 weeks in control and exercise groups
Variables | Group | Before | After | Within-group | Effect size (Cohen | |
---|---|---|---|---|---|---|
| ||||||
Statistic | ||||||
PImaxFRC (cm H2O) | Control group | 79.25±10.06 | 79.09±9.91 | 0.939 | 0.02 | |
Exercise group | 78.02±10.24 | 83.69±11.47 | 0.005 |
0.52 | ||
Statistic | ||||||
0.699 | 0.172 | |||||
| ||||||
PImaxRV (cm H2O) | Control group | 92.90±13.22 | 92.26±18.03 | 0.818 | 0.04 | |
Exercise group | 92.33±15.30 | 107.17±17.40 | 0.023 |
0.91 | ||
Statistic | ||||||
0.538 | 0.009 |
|||||
| ||||||
PEmax (cm H2O) | Control group | 124.04±10.89 | 123.24±11.28 | 0.408 | 0.07 | |
Exercise group | 123.40±5.87 | 130.43±11.46 | 0.006 |
0.77 | ||
Statistic | ||||||
0.815 | 0.047 |
Values are presented as mean±standard deviation unless otherwise indicated.
PImaxFRC, maximal inspiratory pressure at functional residual capacity; PImaxRV, maximal inspiratory pressure at residual volume; PEmax, maximal expiratory pressure;