Oils and fatty products generally undergo oxidation during production and storage. A major problem of the preparation of FPHs is their extreme susceptibility to such oxidation fats (Hoyle & Merritt, 1994). This oxidation process in food causes a sequence of unfavorable changes, consisting mainly in deterioration of the sensory properties of the product such as rancidity, changes in color and texture and reduced nutritional value. It also increases health risks, along with economic losses and may even influence the development of bitter flavors (Palić & Lucan, 1995; Valenzuela *et al*., 2003; Gramza & Korczak, 2005; Mendis *et al*., 2005; Dong *et al*., 2008).

strategies used for prevention of the development of prediabetes and diabetes are discussed and a brief up-to-date review of summarizes the dietary strategies for the nutrition of diabetic

Control and Prevention of Obesity and Diabetes Type 2 Through Non-Pharmacological Treatments…

In the following section we briefly describe the main impact of historic nutritional transitions and illustrate how the social impact of present day food production, distribution and con‐ sumption is exacting a high toll on public health (and also on the environment). To amend this general pattern, large changes of society on a global scale are needed. Since these do not seem realistic in the short term, alternative strategies to address particular problems are suggested, such as nutritional intervention with high quality nutrients of low economic value such as

A discussion of the different procedures for obtaining fish derived protein hydrolysates is presented, centered on the advantages of enzymatic hydrolysis, with respect to chemical procedures. The use of antioxidants during the hydrolysis process is also analyzed and not found to be essential for obtaining a high quality product. The organoleptic properties of hydrolysates obtained by our group have proven acceptable in trials to healthy volunteers. In addition, fish derived protein hydrolysates may contain peptides and/or aminoacids which

To summarize, healthy dietary habits are part of the necessary lifestyle to prevent obesity and DM2; an increased intake of marine products is also recommended as a means to control risk

, Nicolas Palou1

1 Department of Biochemistry, Faculty of Chemical and Pharmaceutical Sciences, University

2 Diabetes Unit, Department of Medicine, Faculty of Medicine, University of Chile, Santiago,

[1] Aguirre, P. (2010). Ricos flacos y gordos pobres: la alimentación en crisis. 1rst Ed.

[2] Ahn, J, Grün, I, & Mustapha, A. (2007). Effects of plant extracts on microbial growth, color change, and lipid oxidation in cooked beef. Food Microbiol, , 24, 7-14.

Capital Intelectual S.A., Buenos Aires, Argentina.

, Sergio Lobos1

and Rodrigo González1

http://dx.doi.org/10.5772/56427

403

supplementing foods with marine-derived protein hydrolysates.

may bear additional beneficial effect.

Daniela Seelenfreund1\*, Pilar Durruty2

of Chile, Providencia, Santiago, Chile

**Author details**

Chile

**References**

factors of cardiovascular disease of DM2 patients.

patients.

Marine oils are rich in polyunsaturated fatty acids (PUFAs), especially of the ω3 family such as EPA and DHA, however diets containing these oils are more susceptible to oxidation than those containing other types of oils, because of their high concentrations of long chain PUFAs; the aforementioned examples are DHA and EPA (Gonzalez *et al*., 1992; Fritsche & Johnston, 1988; Wanasundara & Shahidi, 1998).

PUFA degradation *via* chain reaction mechanisms of free radicals, results in changes of smell and taste (rancidity) of edible oils and oil-containing foods. The chemical reactions involved in oxidative processes require low activation energy, and do not significantly change their ranges at low storage temperatures; therefore, it is necessary to delay the onset of oxidation of the marine oil to maintain its flavor and odor (Wanasundara & Shahidi, 1998; Ahn *et al*., 2007).

#### **5.6. Antioxidants**

Antioxidants, natural and synthetic, are commonly used by the food processing industry, to prolong the storage stability of food. The main commonly used synthetic antioxidants are butylhydroxybutilanisol, butylated hydroxytoluene, propyl gallate and tertiary butylhydro‐ quinone (BHA, BHT, PG and TBHQ, respectively, for their acronyms in English). Natural antioxidants such as tocopherols, rosemary extracts (Herbalox, commercial product) and ascorbic acid are often preferred (Gramza & Korczak, 2005; Yu *et al*., 2006).

#### **5.7. Preliminary trials**

Preliminary tests of the organoleptic properties of enzymatic hydrolysis of marine proteins with different commercial enzymes, among them Alcalase, and Colorasa Protamex (papain) and different commercial antioxidants, showed greater acceptability of the process than with the protease Colorasa L-10. These results were observed after organoleptic analysis of the obtained products in trials with healthy volunteers (unpublished results).

While the use of antioxidants improves the stability of the oil fraction obtained together with the protein fraction, products derived from an antioxidant-free process were more acceptable (organoleptic properties) than those obtained in a process in which antioxidants were are used, although the oil fraction underwent faster oxidation (unpublished results). These results suggest that the addition of antioxidants is not of vital importance in the course of an organo‐ leptically suitable product with a high proportion of proteins of marine origin.

#### **6. Concluding comments**

In this chapter we present general data concerning the worldwide epidemic of obesity and diabetes and discuss the present day goals of metabolic control of affected patients. The current strategies used for prevention of the development of prediabetes and diabetes are discussed and a brief up-to-date review of summarizes the dietary strategies for the nutrition of diabetic patients.

In the following section we briefly describe the main impact of historic nutritional transitions and illustrate how the social impact of present day food production, distribution and con‐ sumption is exacting a high toll on public health (and also on the environment). To amend this general pattern, large changes of society on a global scale are needed. Since these do not seem realistic in the short term, alternative strategies to address particular problems are suggested, such as nutritional intervention with high quality nutrients of low economic value such as supplementing foods with marine-derived protein hydrolysates.

A discussion of the different procedures for obtaining fish derived protein hydrolysates is presented, centered on the advantages of enzymatic hydrolysis, with respect to chemical procedures. The use of antioxidants during the hydrolysis process is also analyzed and not found to be essential for obtaining a high quality product. The organoleptic properties of hydrolysates obtained by our group have proven acceptable in trials to healthy volunteers. In addition, fish derived protein hydrolysates may contain peptides and/or aminoacids which may bear additional beneficial effect.

To summarize, healthy dietary habits are part of the necessary lifestyle to prevent obesity and DM2; an increased intake of marine products is also recommended as a means to control risk factors of cardiovascular disease of DM2 patients.

#### **Author details**

consisting mainly in deterioration of the sensory properties of the product such as rancidity, changes in color and texture and reduced nutritional value. It also increases health risks, along with economic losses and may even influence the development of bitter flavors (Palić & Lucan, 1995; Valenzuela *et al*., 2003; Gramza & Korczak, 2005; Mendis *et al*., 2005; Dong *et al*., 2008). Marine oils are rich in polyunsaturated fatty acids (PUFAs), especially of the ω3 family such as EPA and DHA, however diets containing these oils are more susceptible to oxidation than those containing other types of oils, because of their high concentrations of long chain PUFAs; the aforementioned examples are DHA and EPA (Gonzalez *et al*., 1992; Fritsche & Johnston,

PUFA degradation *via* chain reaction mechanisms of free radicals, results in changes of smell and taste (rancidity) of edible oils and oil-containing foods. The chemical reactions involved in oxidative processes require low activation energy, and do not significantly change their ranges at low storage temperatures; therefore, it is necessary to delay the onset of oxidation of the marine oil to maintain its flavor and odor (Wanasundara & Shahidi, 1998; Ahn *et al*., 2007).

Antioxidants, natural and synthetic, are commonly used by the food processing industry, to prolong the storage stability of food. The main commonly used synthetic antioxidants are butylhydroxybutilanisol, butylated hydroxytoluene, propyl gallate and tertiary butylhydro‐ quinone (BHA, BHT, PG and TBHQ, respectively, for their acronyms in English). Natural antioxidants such as tocopherols, rosemary extracts (Herbalox, commercial product) and

Preliminary tests of the organoleptic properties of enzymatic hydrolysis of marine proteins with different commercial enzymes, among them Alcalase, and Colorasa Protamex (papain) and different commercial antioxidants, showed greater acceptability of the process than with the protease Colorasa L-10. These results were observed after organoleptic analysis of the

While the use of antioxidants improves the stability of the oil fraction obtained together with the protein fraction, products derived from an antioxidant-free process were more acceptable (organoleptic properties) than those obtained in a process in which antioxidants were are used, although the oil fraction underwent faster oxidation (unpublished results). These results suggest that the addition of antioxidants is not of vital importance in the course of an organo‐

In this chapter we present general data concerning the worldwide epidemic of obesity and diabetes and discuss the present day goals of metabolic control of affected patients. The current

ascorbic acid are often preferred (Gramza & Korczak, 2005; Yu *et al*., 2006).

obtained products in trials with healthy volunteers (unpublished results).

leptically suitable product with a high proportion of proteins of marine origin.

1988; Wanasundara & Shahidi, 1998).

**5.6. Antioxidants**

402 Type 2 Diabetes

**5.7. Preliminary trials**

**6. Concluding comments**

Daniela Seelenfreund1\*, Pilar Durruty2 , Nicolas Palou1 , Sergio Lobos1 and Rodrigo González1

1 Department of Biochemistry, Faculty of Chemical and Pharmaceutical Sciences, University of Chile, Providencia, Santiago, Chile

2 Diabetes Unit, Department of Medicine, Faculty of Medicine, University of Chile, Santiago, Chile

#### **References**

[3] Alberti KGMZimmet P, Shaw J, (2007). International Diabetes Federation: a consen‐ sus on Type 2 diabetes prevention. Diabetic Medicine, , 24, 451-463.

[19] González-torres, M, Betancourt-rule, M, & Ortiz, R. (2000). Daño oxidativo y antioxi‐

Control and Prevention of Obesity and Diabetes Type 2 Through Non-Pharmacological Treatments…

http://dx.doi.org/10.5772/56427

405

[20] Gramza, A, & Korczak, J. (2005). Tea constituents (Camellia sinensis L.) as antioxi‐ dants in lipid systems. Trends in Food Science & Technology, , 16, 351-358.

[21] Guadix, A, Guadix, E, Páez-dueñas, M, González-tello, P, & Camacho, F. (2000). Procesos tecnológicos y métodos de control en la hidrólisis de proteínas. Ars Phar‐

[22] Hoyle, N. T, & Merritt, J. H. (1994). Quality of Fish Protein Hydrolysates from Her‐

[23] Iglesias de la Cruz CRuiz-Torres P, García del Moral R, Rodríguez-Puyol M, Rodrí‐ guez-Puyol D, (2000). Age-related progressive renal fibrosis in rats and its prevention

with ACE inhibitors and taurine. Am J Physiol Renal Physiol, 278: FF129., 122.

[24] Iso, H, Date, C, Wakai, K, Fukui, M, & Tamakoshi, A. and the JACC Study Group, (2006). The relationship between green tea intake and type 2 diabetes in Japanese

[25] Kim, S. W, Rogers, Q. R, & Morris, J. G. (1996). Maillard reaction products in purified diets induce taurine depletion in cats which is reversed by antibiotics. J Nutr, , 126(1),

[26] Kohama, Y, Kuroda, T, Itoh, S, & Mimura, T. (1996). Tuna muscle peptide, PTHIKWGD, inhibits leukocyte-mediated injury and leukocyte adhesion to cultured

[27] Kondo, K, Iwamoto, T, Hooda, K, Kamiyama, M, Hirano, R, Kidou, T, Matsumoto, A, Watanabe, S, & Itakura, H. (2000). Inhibition of low-density lipoprotein oxidation by fish protein and antioxidants. XIIth International Symposium on Atherosclerosis, Ab‐

[28] Kristinsson, H. G, & Rasco, B. A. (2000). Fish protein hydrolysates: production, bio‐

[29] Liaset, B, Julshamn, K, & Espe, M. (2003). Chemical composition and theoretical nu‐ tritional evaluation of the produced fractions from enzyme hydrolysis of salmon

[30] Liceaga-gesualdo, A, & Li-chan, E. (1999). Functional properties of fish protein hy‐

[31] Lindström, J, Ilanne-parikka, P, Peltonen, M, Aunola, S, Eriksson, J, & Hemio, K. (2006). Sustained reduction in the incidence of type 2 diabetes by lifestyle interven‐ tion: follow-up of the Finnish Diabetes Prevention Study. Lancet, , 368, 1673-1679. [32] Lindström, J, & Tuomilehto, J. (2003). The Diabetes Risk Score. A practical tool to pre‐

chemical, and functional properties, Crit Rev Food Sci Nutr, , 40, 43-81.

dantes. Bioquímica, , 25, 3-9.

maceutica, , 40, 79-89.

195-201.

ring (Clupeaharengus). J Food Sci, , 59, 76-80.

adults. Ann Inter Med, , 144, 554-562.

endothelial cells. Biol Pharm Bull, , 19(1), 139-41.

stract W12: 113. June Stockholm, Sweden.(TuP18), 25-29.

frames with Protamex. Process Biochemistry, , 38, 1747-1759.

drolysate from herring," J Food Sci, , 64-1000.

dict type 2 diabetes risk. Diabetes Care, , 26, 725-731.

[19] González-torres, M, Betancourt-rule, M, & Ortiz, R. (2000). Daño oxidativo y antioxi‐ dantes. Bioquímica, , 25, 3-9.

[3] Alberti KGMZimmet P, Shaw J, (2007). International Diabetes Federation: a consen‐

[4] American Diabetes Association(2004). Nutrition Principles and Recommendations in Diabetes.. oi: 10.2337/diacare.27.2007.S36 Diabetes Care January 2004 no. suppl 1 s36.,

[5] Aranceta, J, Pérez-rodrigo, C, & Ribas, L. Serra-Majem, Ll, (2003). Sociodemographic and lifestyle determinants of food patterns in Spanish children and adolescents: the

[6] Aspmo, S. (2005). Enzymatic hydrolysis of Atlantic cod (Gadusmorhua L.) viscera.

[7] Aurrekoetxea, G, & Pereira, M. (2002). Aprovechamiento de recursos pesqueros in‐ frautilizados para la obtención de alimentos mejorados para el cultivo de peces. Bole‐

[8] Bass, M. A, Wakefield, L, & Kolasa, K. (1979). Community nutrition and individual

[9] Benítez, R, Ibarz, A, & Pagan, J. (2008). Hidrolizados de proteína: procesos y aplica‐

[10] Contreras, J, & Gracia, M. (2005). Alimentación y Cultura: perspectivas antropológi‐

[12] Diabetes Prevention Program Research Group(2002). Reduction in the incidence of type 2 diabetes with lifestyle intervention or metformin. N Engl J Med, , 346, 393-403.

[13] Dragnes, B. T, Larsen, R, Ernstsen, M. H, Mæhre, H, & Elvevoll, E. O. (2009). Impact of processing on the taurine content in processed seafood and their corresponding

[14] ENSMinisterio de Salud Chile. Encuesta Nacional, htpp:www.minsal.cl/portal/url/

[15] FitzGerald RO`Cuinn G, (2006). Enzymatic debittering of food protein hydrolysates.

[16] Fritsche, K, & Johnston, P. (1988). Rapid autoxidation of fish oil in diets without add‐

[17] Fujita, H, & Yoshikawa, M. (1999). LKPNM: a prodrug-type ACE-inhibitory peptide

[18] Galardy, R, Podhasky, P, & Olson, K. R. (1984). Angiotensin-converting enzyme ac‐

derived from fish protein. Immunopharmacology, 44( 1-2): 123-127.

tivity in tissues of the rainbow trout. J Exp Zool, , 230(1), 155-158.

[11] Danescu, L. G, Levy, S, & Levy, J. and diabetes mellitus. Endocrine, , 35, 11-17.

sus on Type 2 diabetes prevention. Diabetic Medicine, , 24, 451-463.

enKid study. Eur J Clin Nutr, 57: Suppl 1, SS44., 40.

tín del Instituto Español de Oceanografía, , 18, 87-93.

cas. Editorial Ariel. Barcelona, Spain. (Ibid. 2005: 96).

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food behavior. Publisher Burgess Pub. Co., Minneapolis (USA).

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unprocessed raw materials. Int J Food Sci Nutr, , 60(2), 143-152.

Process Biochem, , 40, 1957-1966.

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404 Type 2 Diabetes

[33] Mendis, E, Rajapakse, N, & Kim, S. (2005). Antioxidant properties of a radical-scav‐ enging peptide purified from enzymatically prepared fish skin gelatin hydrolysate. J Agric Food Chem, , 53, 581-587.

**Chapter 18**

**Beneficial Effects of Alternative Exercise in Patients with**

First of all, let's define the meaning of alternative exercise which means exercise activities aside from the ones that generally perform: running, walking, swimming, or biking [1]. This chapter provides reasons for encouraging alternative exercise to patients with diabetes type II. Moreover it provides knowledge of general modes of alternative exercise and their effects in diabetes and non-diabetes individuals. The exercise modes which are too difficult, aggressive, sports or normally performed such as swimming, cycling or running are not included. The clinical instruction such as indication or contraindication of the exercise is not described because it has already been mentioned elsewhere in this book. Moreover, other recommenda‐ tion for these patients is well suggested in a previous study [2]. Finally, it described scientific knowledge of an alternative exercise i.e. Arm swing exercise (ASE) on improving glycaemic control and antioxidant activity in patients with diabetes type II. Further studies investigating

the effects of ASE on other systems in patients with Diabetes Type II are needed.

**2. Reasons for encouraging alternative exercise to patients with diabetes**

Although moderate exercise (mostly are western style e.g. swimming, running or aerobic dance) at least 30 minutes of moderate-intensity exercise at least three days per week was recommended to prevent cardiovascular disease in diabetes patients [3], it is difficult to encourage them to these modes of exercise regularly. Alternative exercise is defined as various exercise modes performed alternatively e.g. Yoga, Martial Arts, TaeKwonDo and many others. Factors affecting the boring in exercise are intensity, equipment, complicated mode and

> © 2013 Leelayuwat; licensee InTech. This is an open access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use,

© 2013 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons Attribution License http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution,

distribution, and reproduction in any medium, provided the original work is properly cited.

and reproduction in any medium, provided the original work is properly cited.

**Diabetes Type II**

Naruemon Leelayuwat

http://dx.doi.org/10.5772/56610

**1. Introduction**

**type II**

Additional information is available at the end of the chapter

## **Beneficial Effects of Alternative Exercise in Patients with Diabetes Type II**

Naruemon Leelayuwat

[33] Mendis, E, Rajapakse, N, & Kim, S. (2005). Antioxidant properties of a radical-scav‐ enging peptide purified from enzymatically prepared fish skin gelatin hydrolysate. J

[34] Nittynen, L, Nurminen, M. L, Korpela, R, & Vapaatalo, H. (1999). Role of arginine, taurine and homocysteine in cardiovascular diseases. Ann Med, , 31(5), 318-326. [35] Palic, A, & Lucan, Ž. (1995). Antioxidative Effect of 'Herbalox' on Edible Oils. Lipid/

[36] Redsalud(2006). www.redsalud.gov.cl/archivos/guiasges/diabetesGES.pdf http://

[37] Rizzo, M. R, Abbatecola, A. M, Barbieri, M, et al. (2008). Evidence for anti-inflamma‐ tory effects of combined administration of vitamin E and C in older persons with im‐

[38] Sathivel, S, & Smiley, S. (2005). Functional and nutritional properties of red salmon

[39] Smith, A, & Munro, N. D. (2009). A holistic approach to examining ancient agricul‐

[40] Valenzuela, A, Sanhueza, J, & Nieto, S. (2003). Natural antioxidants in functional

[41] Van Dam, R, Willett, W, Manson, J, & Hu, F. (2006). Coffee, caffeine, and risk of type

[42] Vioque, J, & Millán, F. (2005). Los hidrolizados proteicos en alimentación: Suplemen‐ tos alimenticios de gran calidad funcional y nutricional. Agro CSIC, , 2-8.

[43] Wanasundara, U, & Shahidi, F. (1998). Antioxidant and pro-oxidant activity of green

[44] World Health Organization Prevalence of Diabetes(2010). htpp://www.who:int/

[45] Yu, H-H, Liu, X, Xing, R, Liu, S, Guo, Z, Wang, P, Li, C, & Li, P. (2006). In vitro deter‐ mination of antioxidant activity of proteins from jellyfish. Food Chemistry, , 95,

foods: from food safety to health benefits. Grasas y aceites, , 104, 754-760.

paired fasting glucose: impact on insulin action. J Am Coll Nutr, , 27, 505-11.

Agric Food Chem, , 53, 581-587.

www.fao.org/docrep/016/i3027e/i3027e03.pdf

ture. Curr Anthropol, , 50, 925-936.

2 diabetes. Diabetes Care, , 29, 398-403.

enzymatic hydrolysates. Journal of Food, , 70, 401-406.

tea extracts in marine oils. Food Chemistry, , 63, 335-342.

diabetes/facts/world:figures/en/indexx2.html

123-130.

Fett, , 97, 379-381.

406 Type 2 Diabetes

Additional information is available at the end of the chapter

http://dx.doi.org/10.5772/56610

#### **1. Introduction**

First of all, let's define the meaning of alternative exercise which means exercise activities aside from the ones that generally perform: running, walking, swimming, or biking [1]. This chapter provides reasons for encouraging alternative exercise to patients with diabetes type II. Moreover it provides knowledge of general modes of alternative exercise and their effects in diabetes and non-diabetes individuals. The exercise modes which are too difficult, aggressive, sports or normally performed such as swimming, cycling or running are not included. The clinical instruction such as indication or contraindication of the exercise is not described because it has already been mentioned elsewhere in this book. Moreover, other recommenda‐ tion for these patients is well suggested in a previous study [2]. Finally, it described scientific knowledge of an alternative exercise i.e. Arm swing exercise (ASE) on improving glycaemic control and antioxidant activity in patients with diabetes type II. Further studies investigating the effects of ASE on other systems in patients with Diabetes Type II are needed.

#### **2. Reasons for encouraging alternative exercise to patients with diabetes type II**

Although moderate exercise (mostly are western style e.g. swimming, running or aerobic dance) at least 30 minutes of moderate-intensity exercise at least three days per week was recommended to prevent cardiovascular disease in diabetes patients [3], it is difficult to encourage them to these modes of exercise regularly. Alternative exercise is defined as various exercise modes performed alternatively e.g. Yoga, Martial Arts, TaeKwonDo and many others. Factors affecting the boring in exercise are intensity, equipment, complicated mode and

© 2013 Leelayuwat; licensee InTech. This is an open access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. © 2013 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons Attribution License http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

duration. This alternative exercise should reduce boring and encourage people to do exercise regularly.

#### **3. General modes of alternative exercise**

This topic described many modes of alternative exercise which some of them are scientific proved in patients with diabetes type II but some are not proved.

#### **3.1. Yoga**

The word yoga means "union" in Sanskrit, the ancient Indian language [6].

**•** Yoga-nidra with drug regimen had better control in their fluctuating blood glucose and symptoms associated with diabetes, compared to those were on oral hypoglycaemics

Beneficial Effects of Alternative Exercise in Patients with Diabetes Type II

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409

**•** Yoga asanas and pranayama improve glycaemic control and pulmonary functions [10].

mechanisms of reduction in stress and increase relaxations or noninvasive nature.

Moreover, yoga practice was shown to improve pre-existing complication for those diabetic patients. Importantly, Yoga have a role even in prevention of diabetes. Yoga helps improving mind, body and spirit, leading to well-being and increased lovingly [15]. This may be due to

Bikram yoga is a system of yoga that Bikram Choudhury synthesized from traditional hatha yoga techniques [17] and popularized beginning in the early 1970s [18, 19]. Bikram Yoga sessions run for exactly 90 minutes and consist of a set series of 26 postures including 2 breathing exercises [20]. Bikram Yoga is ideally practiced in a room heated to 105°F (≈ 40.6°C)

Bikram is a newer form of the practice that benefits blood circulation, improves cardiovascular

Koga combines the stretching and strengthening of Yoga with the cardiovascular workout of Kickboxing. Like yoga, Koga connects body with mind, and maintaining balance throughout.

conditioning and improves detoxification by increasing perspiration.

alone. [13]

**Figure 2.** Postures of Surya Namaskara [5]

**3.2. Bikram yoga**

**3.3. Koga**

with a humidity of 40%,.

**Figure 1.** A posture of Warrior which is one of yoga positions [4]

Yoga is an old, traditional, Indian psychological, physical and spiritual exercise regimen that already has been known for its beneficial effects both the symptom and complication of patients with diabetes type 2 including;

**Figure 2.** Postures of Surya Namaskara [5]

Moreover, yoga practice was shown to improve pre-existing complication for those diabetic patients. Importantly, Yoga have a role even in prevention of diabetes. Yoga helps improving mind, body and spirit, leading to well-being and increased lovingly [15]. This may be due to mechanisms of reduction in stress and increase relaxations or noninvasive nature.

#### **3.2. Bikram yoga**

duration. This alternative exercise should reduce boring and encourage people to do exercise

This topic described many modes of alternative exercise which some of them are scientific

Yoga is an old, traditional, Indian psychological, physical and spiritual exercise regimen that already has been known for its beneficial effects both the symptom and complication of

**•** Can be incorporated along with the conventional medical therapy for improving cognitive brain functions in diabetes [8] and improve nerve function in mild to moderate Type 2

**•** Improving blood pressure, insulin, triglycerides and exercise self-efficacy indicated by small

regularly.

408 Type 2 Diabetes

**3.1. Yoga**

**3. General modes of alternative exercise**

**Figure 1.** A posture of Warrior which is one of yoga positions [4]

patients with diabetes type 2 including;

**•** Decreasing reaction time [7]

**•** Improving lipid profile [7]

**•** Reducing anxiety [8]

to large effect sizes. [12]

**•** Improving oxidative stress [8, 9],

diabetes with sub-clinical neuropathy [10]

**•** Reducing Body mass index (BMI) and improving well-being [11]

proved in patients with diabetes type II but some are not proved.

The word yoga means "union" in Sanskrit, the ancient Indian language [6].

Bikram yoga is a system of yoga that Bikram Choudhury synthesized from traditional hatha yoga techniques [17] and popularized beginning in the early 1970s [18, 19]. Bikram Yoga sessions run for exactly 90 minutes and consist of a set series of 26 postures including 2 breathing exercises [20]. Bikram Yoga is ideally practiced in a room heated to 105°F (≈ 40.6°C) with a humidity of 40%,.

Bikram is a newer form of the practice that benefits blood circulation, improves cardiovascular conditioning and improves detoxification by increasing perspiration.

#### **3.3. Koga**

Koga combines the stretching and strengthening of Yoga with the cardiovascular workout of Kickboxing. Like yoga, Koga connects body with mind, and maintaining balance throughout.

and even transitions between them. Tai Chi is also situated in a wider philosophical context of Taoism. This is a reflective, mystical Chinese tradition first associated with the scholar and mystic Lao Tsu, an older contemporary of Confucius. He taught in the province of Honan in

Beneficial Effects of Alternative Exercise in Patients with Diabetes Type II

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411

the 6th century B.C. and authored the seminal work of Taoism, the Tao Te Ching.

**Figure 5.** Postures and movements of Taichi [22]

malondialdehyde [26]

Tai chi was shown to have many beneficial effects as the following;

diabetes who were not on diabetes medication [23]

**•** Improvements in physical and social functioning [25]

**•** Improved indicators of health related quality of life (HR-QOL) including physical func‐ tioning, role physical, bodily pain and vitality in people with elevated blood glucose or

**•** Improvements in fasting blood glucose and peripheral nerve conduction velocities [24].

**•** Improvements in many parameters, such as BMI, lipid profile, C-reactive protein, and

**Figure 3.** A posture of Bikram yoga [16]

Practicing Koga can help improve flexibility, increase muscle toning, relieve stress, increase lung capacity and decrease overall body fat.

#### **3.4. Tai Chi**

The Chinese characters for Tai Chi Chuan can be translated as the 'Supreme Ultimate Force' which is often associated with the Chinese concept of yin-yang, the notion that one can see a dynamic duality in all things. Tai Chi, can be thought of as a moving form of yoga and meditation combined. Many of these movements are originally derived from the martial arts although the way they are performed in Tai Chi is slowly, softly and gracefully with smooth and even transitions between them. Tai Chi is also situated in a wider philosophical context of Taoism. This is a reflective, mystical Chinese tradition first associated with the scholar and mystic Lao Tsu, an older contemporary of Confucius. He taught in the province of Honan in the 6th century B.C. and authored the seminal work of Taoism, the Tao Te Ching.

**Figure 5.** Postures and movements of Taichi [22]

Practicing Koga can help improve flexibility, increase muscle toning, relieve stress, increase

The Chinese characters for Tai Chi Chuan can be translated as the 'Supreme Ultimate Force' which is often associated with the Chinese concept of yin-yang, the notion that one can see a dynamic duality in all things. Tai Chi, can be thought of as a moving form of yoga and meditation combined. Many of these movements are originally derived from the martial arts although the way they are performed in Tai Chi is slowly, softly and gracefully with smooth

lung capacity and decrease overall body fat.

**Figure 3.** A posture of Bikram yoga [16]

410 Type 2 Diabetes

**Figure 4.** A posture of Koga [21]

**3.4. Tai Chi**

Tai chi was shown to have many beneficial effects as the following;

However, few studies did not support these beneficial effects of Tai chi [29]. Most of the studies are based on within group changes rather than attention control group comparisons [27].

#### **3.5. Thai yoga (TY)**

TY is a traditional form of exercise which appears to be a very light- to light-intensity exercise and have a low-impact alternative to jogging and walking for elderly individuals and requires no special equipment. TY may also have benefits in terms of stress management stemming from the meditation, relaxation and message aspects of the system. If individuals perform TY for longer duration especially standing position, they may gain benefits including reduction in cardiovascular mortality, reduction of symptoms, improvement in exercise tolerance and function capacity, and improvement in psychological well-being and quality of life [32].

#### **3.6. Thai wand exercise**

General health perceptions subscale of health related quality of life, functional capacity, body flexibility and obesity can be improved by Thai Wand Exercise training in older individuals [33].Thismaypartlyreduce some cardiovasculardisease riskfactors.Anadvantage ofthis form of exercise is that this is a convenient, low impact on the joints and effective at home fitness program, with the only equipment need, a four feet long stick. But the major attraction is that it is also suited for the elderly who are not allegeable for the common training procedures.

#### **3.7. Martial arts**

Most people who are concerned with fitness often overlooked the martial arts. Besides learning to fight, it provides a true total body workout with improving core, upper and lower body strength. The core muscle generated the power in kicking and punching techniques. Impor‐ tantly, its training provides other benefits that are simply not found in an exercise class. First, it can help protecting someone from danger. It can also improve confidence and self-discipline

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which may change someone's life. Finally, it creates the friendships during training.

Example; Boxing-chaiya, Muay Thai, Chinese martial art, Judo, TaeKwonDo

**Figure 7.** Postures and movements of Thai wand exercise

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**Figure 7.** Postures and movements of Thai wand exercise

**•** Preventing and improving psychological health and was associated with general health

**•** Tai chi for those with type 2 diabetes could be an alternative exercise intervention to increase

However, few studies did not support these beneficial effects of Tai chi [29]. Most of the studies are based on within group changes rather than attention control group comparisons [27].

TY is a traditional form of exercise which appears to be a very light- to light-intensity exercise and have a low-impact alternative to jogging and walking for elderly individuals and requires no special equipment. TY may also have benefits in terms of stress management stemming from the meditation, relaxation and message aspects of the system. If individuals perform TY for longer duration especially standing position, they may gain benefits including reduction in cardiovascular mortality, reduction of symptoms, improvement in exercise tolerance and function capacity, and improvement in psychological well-being and quality of life [32].

General health perceptions subscale of health related quality of life, functional capacity, body flexibility and obesity can be improved by Thai Wand Exercise training in older individuals [33].Thismaypartlyreduce some cardiovasculardisease riskfactors.Anadvantage ofthis form of exercise is that this is a convenient, low impact on the joints and effective at home fitness program, with the only equipment need, a four feet long stick. But the major attraction is that it is also suited for the elderly who are not allegeable for the common training procedures.

Most people who are concerned with fitness often overlooked the martial arts. Besides learning to fight, it provides a true total body workout with improving core, upper and lower body strength. The core muscle generated the power in kicking and punching techniques. Impor‐

glucose control, diabetic self-care activities, and quality of life [28].

benefits for older people [27]

**Figure 6.** Postures of Thai yoga [30] [31]

**3.6. Thai wand exercise**

**3.7. Martial arts**

**3.5. Thai yoga (TY)**

412 Type 2 Diabetes

tantly, its training provides other benefits that are simply not found in an exercise class. First, it can help protecting someone from danger. It can also improve confidence and self-discipline which may change someone's life. Finally, it creates the friendships during training.

Example; Boxing-chaiya, Muay Thai, Chinese martial art, Judo, TaeKwonDo

**Figure 10.** A posture of Chinese martial art [36]

**Figure 11.** A posture of Judo [37]

systolic BP and body fat in diabetes [42].

Dancing burns 2015 kilojoules an hour. It was shown to reduce risks for heart disease and diabetes in elementary school children [41]. Dancing 2 times per week for 12 weeks can reduce

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**3.8. Dancing**

**Figure 8.** A posture of Boxing-chaiya [34]

**Figure 9.** A posture of Muay Thai [35]

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**Figure 10.** A posture of Chinese martial art [36]

**Figure 11.** A posture of Judo [37]

#### **3.8. Dancing**

**Figure 8.** A posture of Boxing-chaiya [34]

414 Type 2 Diabetes

**Figure 9.** A posture of Muay Thai [35]

Dancing burns 2015 kilojoules an hour. It was shown to reduce risks for heart disease and diabetes in elementary school children [41]. Dancing 2 times per week for 12 weeks can reduce systolic BP and body fat in diabetes [42].

**Figure 14.** Postures of dancing [40]

Walking is recommended for preventing or treating diabetes patients [43]. However, walking

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with others can actually help patients stick with their health and fitness goals [44].

**Figure 15.** Detail of various postures and movements during walking

**3.9. Walking**

**Figure 12.** A posture of Taekwondo [38]

**Figure 13.** A posture of dancing [39]

**Figure 14.** Postures of dancing [40]

#### **3.9. Walking**

**Figure 13.** A posture of dancing [39]

**Figure 12.** A posture of Taekwondo [38]

416 Type 2 Diabetes

Walking is recommended for preventing or treating diabetes patients [43]. However, walking with others can actually help patients stick with their health and fitness goals [44].

**Figure 15.** Detail of various postures and movements during walking

#### *3.9.1. Brisk walking*

The prescription of brisk walking represents an equally effective intervention to modulate glycaemic control and cardiovascular risk profile in type 2 diabetes patients when compared with more individualised medical fitness programmes. The Centers for Disease Control and Prevention (CDC) defined that brisk walking is at a pace of three miles per hour or more (but not race walking) or roughly 20 minutes per mile. This equates to about five kilometers per hour or 12 minutes per kilometer [45]. The exercise intensity of Brisk walking is moderate which heart rate is about 50-70% maximum heart rate or shouldn't be able to sing.

#### **3.10. Go Ape**

An exciting range of forest-based high-wire activities, comprise challenging courses that involve climbing, zip wires, balance beams and a whole range of fun-filled activities [47].

**•** The foils (i.e. the daggerboard or centreboard and rudder and sometimes lifting foils as

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**•** Side to side balance of the dinghy by movement of the crew, particularly in windy weather

**•** The choice of route (in terms of existing and anticipated wind shifts, possible obstacles, other

Dinghy sailing increases stamina because of the vigorous sailing especially shifting position to balance the boat. Rigging and de-rigging to hauling on the sheets increase upper body strength. Additionally, if there is a less stable boat situation abdominal and back muscles will be stimulated. Good flexibility is very necessary for dinghy sailing. Having a good range of movement and being able to stretch during balancing against the wind is vital. Successful small boat sailing requires because of frequently hauling on the sheets, tacking, shifting position and

Training of horse riding can increase insulin sensitivity in patients with diabetes type 2 [51, 52].

Generally, horse riding increases stamina according to maintaining an upright posture while continually controlling a moving horse at speed. It also strengthens core muscles in order to control horse's movements while maintaining an upright posture. However, there are few flexibility benefits from horse riding, but a good measure of all-round mobility to successfully riding is still needed. Coordination is important for marrying up small body movements with control of the reins — plus hand-to-eye coordination will be required during negotiating trails

balancing all at the same time. This will certainly improve coordination.

found on the Moth).

("move fast or swim").

**3.12. Horse riding**

and obstacles [47].

water traffic, currents, tides etc.).

**•** The trim (forward/rear angle of the boat in the water)

**Figure 17.** Movement of the crew during Dinghy sailing [48]

**Figure 16.** Different activities of Go Ape [46]

This activity lasts for 2 to 3 hours which some stamina to complete the course is needed. Upper body and legs will get benefit from this activity. Arm and leg flexibility will be maintained stretching and reaching for hand-holds along the course. Coordination will be definitely improved because of continually coordinating hands and feet as traverse the various obstacles.

#### **3.11. Dinghy sailing**

Dinghy sailing is the activity of sailing small boats by using five essential controls: [47]

**•** The sails

**Figure 17.** Movement of the crew during Dinghy sailing [48]

Dinghy sailing increases stamina because of the vigorous sailing especially shifting position to balance the boat. Rigging and de-rigging to hauling on the sheets increase upper body strength. Additionally, if there is a less stable boat situation abdominal and back muscles will be stimulated. Good flexibility is very necessary for dinghy sailing. Having a good range of movement and being able to stretch during balancing against the wind is vital. Successful small boat sailing requires because of frequently hauling on the sheets, tacking, shifting position and balancing all at the same time. This will certainly improve coordination.

#### **3.12. Horse riding**

*3.9.1. Brisk walking*

418 Type 2 Diabetes

**3.10. Go Ape**

**Figure 16.** Different activities of Go Ape [46]

**3.11. Dinghy sailing**

**•** The sails

The prescription of brisk walking represents an equally effective intervention to modulate glycaemic control and cardiovascular risk profile in type 2 diabetes patients when compared with more individualised medical fitness programmes. The Centers for Disease Control and Prevention (CDC) defined that brisk walking is at a pace of three miles per hour or more (but not race walking) or roughly 20 minutes per mile. This equates to about five kilometers per hour or 12 minutes per kilometer [45]. The exercise intensity of Brisk walking is moderate

An exciting range of forest-based high-wire activities, comprise challenging courses that involve climbing, zip wires, balance beams and a whole range of fun-filled activities [47].

This activity lasts for 2 to 3 hours which some stamina to complete the course is needed. Upper body and legs will get benefit from this activity. Arm and leg flexibility will be maintained stretching and reaching for hand-holds along the course. Coordination will be definitely improved because of continually coordinating hands and feet as traverse the various obstacles.

Dinghy sailing is the activity of sailing small boats by using five essential controls: [47]

which heart rate is about 50-70% maximum heart rate or shouldn't be able to sing.

Training of horse riding can increase insulin sensitivity in patients with diabetes type 2 [51, 52].

Generally, horse riding increases stamina according to maintaining an upright posture while continually controlling a moving horse at speed. It also strengthens core muscles in order to control horse's movements while maintaining an upright posture. However, there are few flexibility benefits from horse riding, but a good measure of all-round mobility to successfully riding is still needed. Coordination is important for marrying up small body movements with control of the reins — plus hand-to-eye coordination will be required during negotiating trails and obstacles [47].

**•** Push off the weight with your right foot and bring it forward to starting position (#1). This

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Activities outdoors such as park benches, the kerb, and stairs for simple exercises are health

completes one rep.

**•** Do 2 sets of 15 reps.

**•** Next step forward and repeat with the right leg.

**Figure 20.** Series of movements of Lunge walking [54]

benefit according to exposure to sun shine.

**Figure 21.** Activities outdoors such as park benches, and stairs [55] [56]

Feel the sun on your face and the thrill of catching waves along beautiful coastlines.

**3.16. Surf**

**3.15. Make the most of the outdoors**

**Figure 18.** Upright postures during Horse riding [49] [50]

#### **3.13. Fishing**

During fishing, endurance is important for spending the best part of a day standing in a river, walking up and down a beach or fighting with a really big specimen for a few hours. Leg strength is increased from continually working a fly at full stretch. Casting a line is a skill that needs excellent arm and shoulder flexibility so upper body flexibility in particular will be improved by fishing. Casting the line and controlling the rod when reeling fish in requires good hand-to-eye coordination.

**Figure 19.** Standing posture during Fishing [53]

#### **3.14. Lunge walking**

The following is the movement of Lunge walking [54]:

**Figure 18.** Upright postures during Horse riding [49] [50]

good hand-to-eye coordination.

**Figure 19.** Standing posture during Fishing [53]

The following is the movement of Lunge walking [54]:

**•** Take a controlled step forward with your left leg.

**3.14. Lunge walking**

facing in).

During fishing, endurance is important for spending the best part of a day standing in a river, walking up and down a beach or fighting with a really big specimen for a few hours. Leg strength is increased from continually working a fly at full stretch. Casting a line is a skill that needs excellent arm and shoulder flexibility so upper body flexibility in particular will be improved by fishing. Casting the line and controlling the rod when reeling fish in requires

**•** Stand upright, feet together, holding two light (5-8 pound) dumbbells at your sides (palms

**•** Lower hips toward the floor and bend both knees (almost at 90 degree angles). The back knee should come close but never touch the ground. Your front knee should be directly over

the ankle and the back knee should be pointing down toward the floor.

**3.13. Fishing**

420 Type 2 Diabetes

**Figure 20.** Series of movements of Lunge walking [54]

#### **3.15. Make the most of the outdoors**

Activities outdoors such as park benches, the kerb, and stairs for simple exercises are health benefit according to exposure to sun shine.

**Figure 21.** Activities outdoors such as park benches, and stairs [55] [56]

#### **3.16. Surf**

Feel the sun on your face and the thrill of catching waves along beautiful coastlines.

Each class includes 5-10 minutes warm-up segment including stretching and footwork drills

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Housework is so useful because it both increases energy expenditure, cardiovascular response and tidy a house. But if someone have balance problems, they must be careful going down‐ stairs. It's very easy to fall, especially when carrying a vacuum cleaner. Whenever you see a set of stairs, use them. If there's time (and you're really enthusiastic), go back down and climb

them again. If flexibility and balance aren't an issue, take two steps at a time.

and 50-55 minutes cardio segment including fun drills [58].

**•** Elevate your heart rate into your aerobic training zone

**•** The focus is on getting a great workout while having fun!

**•** It's a fun group activity for advanced beginner and above players

**•** Much more fun than working out on a machine

It provides:

**3.18. Housework**

**Figure 24.** A posture of Housework [59]

**Figure 22.** A posture under the wave during surfing [57]

#### **3.17. Cardio tennis**

Cardio Tennis is a new kind of group exercise that combines endurance with tennis skills. It includes thinking how to hit a backhand, followed by footwork exercises on a rope ladder and running drills. Then it's back to the volley line and hitting balls again. It was started in the US by the Tennis Industry Association as a way to get more people into tennis, but the programme has since rolled out to 1500 work-out sites in 25 countries.

**Figure 23.** Activities of Cardio Tennis [58]

Each class includes 5-10 minutes warm-up segment including stretching and footwork drills and 50-55 minutes cardio segment including fun drills [58].

It provides:

#### **3.18. Housework**

**Figure 22.** A posture under the wave during surfing [57]

has since rolled out to 1500 work-out sites in 25 countries.

Cardio Tennis is a new kind of group exercise that combines endurance with tennis skills. It includes thinking how to hit a backhand, followed by footwork exercises on a rope ladder and running drills. Then it's back to the volley line and hitting balls again. It was started in the US by the Tennis Industry Association as a way to get more people into tennis, but the programme

**3.17. Cardio tennis**

422 Type 2 Diabetes

**Figure 23.** Activities of Cardio Tennis [58]

Housework is so useful because it both increases energy expenditure, cardiovascular response and tidy a house. But if someone have balance problems, they must be careful going down‐ stairs. It's very easy to fall, especially when carrying a vacuum cleaner. Whenever you see a set of stairs, use them. If there's time (and you're really enthusiastic), go back down and climb them again. If flexibility and balance aren't an issue, take two steps at a time.

**Figure 24.** A posture of Housework [59]

**3.20. Feeldenkrais method**

**Figure 27.** A posture of Feeldenkrais method [64]

**Figure 28.** Postures of Pilates [67] [67] [68]

**3.21. Pilates**

Developed in the 1940s, Moshé Feldenkrais (1904–1984) is a practical discipline to help develop awareness of body movement [65]. Feldenkrais aims to reduce pain or limitations in move‐ ment, to improve physical function, and to promote general wellbeing by increasing students'

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Invented in the early 20th century by Joseph Pilates, Pilates combines East and West, gymnastic and yogic principles, mind and body [70]. Pilates is a body conditioning routine that may help build flexibility, muscle strength, and endurance in the legs, abdominals, arms, hips, and back. It puts emphasis on spinal and pelvic alignment, breathing, and developing a strong core or center, and improving coordination and balance. Pilates' system allows for different exercises to be modified in range of difficulty from beginning to advance. Intensity can be increased

over time as the body conditions and adapts to the exercises [71].

awareness of themselves and by expanding students' movement repertoire [66].

**Figure 25.** Activities of Housework [60] [61]

#### **3.19. Alexander technique**

Invented by an Australian in the 1890s, this technique helps to restore the body's capacity for ease by releasing tension, particularly in the head and neck. It aims to allow the body to reach its full potential.

**Figure 26.** Alexander Technique [62]

"The Alexander Technique is a way of learning to move mindfully through life. The Alexander process shines a light on inefficient habits of movement and patterns of accumulated tension, which interferes with our innate ability to move easily and according to how we are designed. It's a simple yet powerful approach that offers the opportunity to take charge of one's own learning and healing process, because it's not a series of passive treatments but an active exploration that changes the way one thinks and responds in activity. It produces a skill set that can be applied in every situation. Lessons leave one feeling lighter, freer, and more grounded." [62]

The Alexander technique has been shown to be helpful for back pain and Parkinson's [63].

#### **3.20. Feeldenkrais method**

Developed in the 1940s, Moshé Feldenkrais (1904–1984) is a practical discipline to help develop awareness of body movement [65]. Feldenkrais aims to reduce pain or limitations in move‐ ment, to improve physical function, and to promote general wellbeing by increasing students' awareness of themselves and by expanding students' movement repertoire [66].

**Figure 27.** A posture of Feeldenkrais method [64]

#### **3.21. Pilates**

**Figure 25.** Activities of Housework [60] [61]

Invented by an Australian in the 1890s, this technique helps to restore the body's capacity for ease by releasing tension, particularly in the head and neck. It aims to allow the body to reach

"The Alexander Technique is a way of learning to move mindfully through life. The Alexander process shines a light on inefficient habits of movement and patterns of accumulated tension, which interferes with our innate ability to move easily and according to how we are designed. It's a simple yet powerful approach that offers the opportunity to take charge of one's own learning and healing process, because it's not a series of passive treatments but an active exploration that changes the way one thinks and responds in activity. It produces a skill set that can be applied in every situation. Lessons leave one feeling lighter, freer, and more

The Alexander technique has been shown to be helpful for back pain and Parkinson's [63].

**3.19. Alexander technique**

**Figure 26.** Alexander Technique [62]

grounded." [62]

its full potential.

424 Type 2 Diabetes

Invented in the early 20th century by Joseph Pilates, Pilates combines East and West, gymnastic and yogic principles, mind and body [70]. Pilates is a body conditioning routine that may help build flexibility, muscle strength, and endurance in the legs, abdominals, arms, hips, and back. It puts emphasis on spinal and pelvic alignment, breathing, and developing a strong core or center, and improving coordination and balance. Pilates' system allows for different exercises to be modified in range of difficulty from beginning to advance. Intensity can be increased over time as the body conditions and adapts to the exercises [71].

**Figure 28.** Postures of Pilates [67] [67] [68]

study period. During the exercise period, patients performed the ASE program as prescribed. They were requested to record the 24-hour dietary composition and energy expenditure for 2

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ASE is a traditional Chinese exercise which has been practiced for 50 years (Figure 1) and claimed for treatment of cancer and alimentary disorders by increasing blood flow [73]. The number of swing was 200 or 300 repetitions in the beginning and gradually increased to 1000-2000 repetitions or up to half an hour depending on the strength of the patients. The intensity of ASE is mild because it was around 23 percentage of maximal oxygen consumption

During ASE period participants learned to perform the ASE correctly on the first day of the experiment. For the next 8 weeks they performed the training at home via a video tape recording one session per day (30 minutes), 3 days/week. Each participant was telephoned every week to check their compliance to the program and to emphasize them to maintain their

All dependent variables were analyzed using a two-way ANOVA with repeated measures (within subject factors were exercise and time) by Sigma Stat version 2 program. The Bonfer‐ roni method was used to adjust the multiple comparisons. A probability of p<0.05 was taken

Nine male and 33 female patients with type 2 diabetes mellitus completed the study. Before the experiment, they had high cardiovascular risks such as hyperglycaemia, overweight or obesity (based on criteria of World Health Organization Western Pasific region), high fasting blood glucose, haemoglobin A1c (HbA1c), high sensitive C reactive protein (hsCRP), MDA and low reduced glutathione (GSH) concentrations. There were no differences in body mass, body

weekdays and 1 weekend day before the start and the last week of each period.

**4.3. Arm Swing Exercise (ASE)**

and 45 percentage of maximal heart rate.

**Figure 30.** Postures and movements of body during the ASE

**4.4. Statistical analysis**

**4.5. Results**

usual daily physical activity apart from the ASE program.

to indicate significance. Results are presented as means SE.

**Figure 29.** A posture of Pilates [69]

#### **4. Beneficial effects of arm swing exercise on glycaemic control and oxidative stress in patients with diabetes type II [72]**

#### **4.1. Introduction**

Although moderate exercise (mostly are western style e.g. swimming, running or aerobic dance) at least 30 minutes for five days per week was recommended to prevent cardiovascular disease in diabetes patients [2], it is difficult to encourage them to exercise regularly. Many Asian styles of exercise such as arm swing exercise seem to be more appropriate because of its simple, low impact to joint and easily accessible exercise.

Arm Swing Exercise (ASE) is a traditional Chinese exercise [73] which is convenient for diabetes patients to perform. It is believed to improve cardiovascular systems. However there were no scientific data concerning the beneficial effect and mechanism of this exercise on the glycaemic control. Therefore, this study aimed to investigate effects of the ASE training on blood glucose (glycated haemoglobin; HbA1c), oxidant (determined by malondialdehyde; MDA) and antioxidant (determined by glutathione; GSH) in subjects with type 2 diabetes.

#### **4.2. Experimental design and protocol**

All subjects performed 2 study periods consecutively; i) maintaining daily life without regular exercise for 8 weeks (week 1-8) ii) performing 30-min ASE per day, 3 days per week for 8 weeks (week 9-16). Fasting blood glucose, HbA1c, insulin, lipid profiles, C reactive protein (CRP), MDA and reduced GSH concentrations were analyzed using blood samples collected from the antecubetal vein. Anthropometry and body composition were also measured before and after of each study period. HbA1c was used to determine glycaemic control because it is more stable throughout 2-3 months and related to the complications.

Insulin sensitivity was determined using Homeostatic Model Assessment – Insulin Resistance (HOMA-IR) [74]. Pharmacology, dietary and exercise treatment, were not modified during the study period. During the exercise period, patients performed the ASE program as prescribed. They were requested to record the 24-hour dietary composition and energy expenditure for 2 weekdays and 1 weekend day before the start and the last week of each period.

#### **4.3. Arm Swing Exercise (ASE)**

**Figure 29.** A posture of Pilates [69]

**4.1. Introduction**

426 Type 2 Diabetes

**4. Beneficial effects of arm swing exercise on glycaemic control and**

Although moderate exercise (mostly are western style e.g. swimming, running or aerobic dance) at least 30 minutes for five days per week was recommended to prevent cardiovascular disease in diabetes patients [2], it is difficult to encourage them to exercise regularly. Many Asian styles of exercise such as arm swing exercise seem to be more appropriate because of its

Arm Swing Exercise (ASE) is a traditional Chinese exercise [73] which is convenient for diabetes patients to perform. It is believed to improve cardiovascular systems. However there were no scientific data concerning the beneficial effect and mechanism of this exercise on the glycaemic control. Therefore, this study aimed to investigate effects of the ASE training on blood glucose (glycated haemoglobin; HbA1c), oxidant (determined by malondialdehyde; MDA) and antioxidant (determined by glutathione; GSH) in subjects with type 2 diabetes.

All subjects performed 2 study periods consecutively; i) maintaining daily life without regular exercise for 8 weeks (week 1-8) ii) performing 30-min ASE per day, 3 days per week for 8 weeks (week 9-16). Fasting blood glucose, HbA1c, insulin, lipid profiles, C reactive protein (CRP), MDA and reduced GSH concentrations were analyzed using blood samples collected from the antecubetal vein. Anthropometry and body composition were also measured before and after of each study period. HbA1c was used to determine glycaemic control because it is more stable

Insulin sensitivity was determined using Homeostatic Model Assessment – Insulin Resistance (HOMA-IR) [74]. Pharmacology, dietary and exercise treatment, were not modified during the

**oxidative stress in patients with diabetes type II [72]**

simple, low impact to joint and easily accessible exercise.

throughout 2-3 months and related to the complications.

**4.2. Experimental design and protocol**

ASE is a traditional Chinese exercise which has been practiced for 50 years (Figure 1) and claimed for treatment of cancer and alimentary disorders by increasing blood flow [73]. The number of swing was 200 or 300 repetitions in the beginning and gradually increased to 1000-2000 repetitions or up to half an hour depending on the strength of the patients. The intensity of ASE is mild because it was around 23 percentage of maximal oxygen consumption and 45 percentage of maximal heart rate.

**Figure 30.** Postures and movements of body during the ASE

During ASE period participants learned to perform the ASE correctly on the first day of the experiment. For the next 8 weeks they performed the training at home via a video tape recording one session per day (30 minutes), 3 days/week. Each participant was telephoned every week to check their compliance to the program and to emphasize them to maintain their usual daily physical activity apart from the ASE program.

#### **4.4. Statistical analysis**

All dependent variables were analyzed using a two-way ANOVA with repeated measures (within subject factors were exercise and time) by Sigma Stat version 2 program. The Bonfer‐ roni method was used to adjust the multiple comparisons. A probability of p<0.05 was taken to indicate significance. Results are presented as means SE.

#### **4.5. Results**

Nine male and 33 female patients with type 2 diabetes mellitus completed the study. Before the experiment, they had high cardiovascular risks such as hyperglycaemia, overweight or obesity (based on criteria of World Health Organization Western Pasific region), high fasting blood glucose, haemoglobin A1c (HbA1c), high sensitive C reactive protein (hsCRP), MDA and low reduced glutathione (GSH) concentrations.  Mean daily dietary intakes were similar in both periods (1,468.6 ± 58.6 kJ and 1,462.2 ± 56.0 kJ; control and exercise periods, respectively). Mean energy expenditure in the exercise period was signifi‐ cantly higher than that in the control period (1,593.4 ± 54.6 and 1,472.7 ± 47.6 kJ, respectively; p<0.05).

improved glycaemic control positively indicate a preventive action of ASE training in the vascular complications in type 2 diabetic patients via the improved oxidative stress [82].

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The second mechanism is due to the effect of exercise per se on improving the oxidative stress. This is supported by the absence of relationship between HbA1c and MDA and GSH at any periods in this study. Importantly, this may remind that only improvement of HbA1c from medication or diet control may not be enough to prevent the complication. Previous studies in both animal and human also supports that low-intensity exercise could itself improve oxidative stress [83-86]. Moien-Afshari et al have confirmed that the low-intensity exercise could enhance antioxidant agent giving rise to less endothelial dysfunction independently on

The present study showed that ASE has no adverse effects such as exercise-related injury or hypoglycaemia. This was shown by the similar level of CRP in both periods. Therefore ASE is appropriate and safe for the patient with diabetes. The other strength of the present study is a study design which each subject performed both control and exercise periods. This eliminates

In conclusion, the present study showed that the ASE training, a low-intensity exercise contribute to protective effects on vascular complication which is a major problem of type 2 diabetic patients. This may attribute to an improved oxidative stress according to either improved glycaemic control or exercise per se. The major attraction is that it is suited for not only diabetic patients but also other people who are not allegeable for the common training

There are many possible mechanisms explaining the beneficial effects of exercise training on

**1.** Exercise leads to an insulin independent increase in glucose transport, mediated in part by AMP activated protein kinase. Changes in protein expression may be related to increased signal transduction through the mitogen-activated protein kinase (MAPK)

signaling cascades, a pathway known to regulate transcriptional activity [87].

procedures such as elderly adults and patients with lower limb disorders.

**5. Beneficial mechanisms of exercise on type 2 diabetic patients**

the improvement of hyperglycaemia.

the effect of inter-individual variation.

type 2 diabetic patients (T2D).

**6. Improve glucose control**

**6.1. Insulin-independent mechanism**

These are described based on their roles.

**4.9. Conclusion**

#### **4.6. Clinical chemistry**

HbA1c concentration was 0.2% lower after ASE training for 8 weeks compared with the control period (p<0.05, Table 1). However, there was no significant difference in fasting blood glucose between periods. There were no effect of ASE training on insulin sensitivity, hsCRP concen‐ tration and lipid profiles between periods

#### **4.7. Oxidative stress**

ASE training significantly reduced plasma MDA concentration (p<0.05) and increased antioxidant blood GSH concentration (p<0.05). No correlation between oxidative stress and HbA1c at any periods was found.

#### **4.8. Discussion**

The results showed that the ASE training improves glycaemic control and oxidative stress in patients with type 2 diabetes. Thus, this simple and accessible exercise may have a potential effect on the prevention of complications of diabetes mellitus.

Previous studies also found the decreased HbA1c after the arm exercise training [75-77]. Jeng et al (2002) have reported that arm exercise training for 10-40 min could induce a significant decrease in the HbA1c concentration in patients with type 2 DM. Data from the United Kingdom Prospective Diabetes Study Group (UKPDS) have suggested that a 1% rise in HbA1c concen‐ tration represents a 37% increased risk for microvascular complications (95% CI 33 to 41, P < 0.0001) [78]. Based on this information, a 0.2% decrease in HbA1c after the ASE training detected in this study may reduce 7.4% of risk for microvascular complications.

Possible mechanisms that could explain for the benefit effect of the ASE training on improving glycaemic control include the reduced HbA1c and the effect of exercise per se on improving the oxidative stress. The reduced HbA1c may decrease many adverse effects of hyperglycaemia such as hyperglycaemia-induced glucose autoxidation, non-enzymatic glycation of proteins, and reactive oxygen species generation, in leading to the progression of diabetic vascular complications. These processes were shown to increase oxidant stress and decrease antioxidant agent [79-81]. The imbalance of oxidative stress with greater oxidant stress contributed to the cellular destruction and therefore vascular complications [82]. The decreased MDA found in this study indicated a reduction in lipid peroxidation, a process of oxidative stress, which then reflects an attenuation of the cellular damage in the patients. The increased level of nonenzymatic antioxidant GSH after the ASE training observed in the present study also supports the preventive effect of exercise on vascular complication. As found in the present study, the improved glycaemic control positively indicate a preventive action of ASE training in the vascular complications in type 2 diabetic patients via the improved oxidative stress [82].

The second mechanism is due to the effect of exercise per se on improving the oxidative stress. This is supported by the absence of relationship between HbA1c and MDA and GSH at any periods in this study. Importantly, this may remind that only improvement of HbA1c from medication or diet control may not be enough to prevent the complication. Previous studies in both animal and human also supports that low-intensity exercise could itself improve oxidative stress [83-86]. Moien-Afshari et al have confirmed that the low-intensity exercise could enhance antioxidant agent giving rise to less endothelial dysfunction independently on the improvement of hyperglycaemia.

The present study showed that ASE has no adverse effects such as exercise-related injury or hypoglycaemia. This was shown by the similar level of CRP in both periods. Therefore ASE is appropriate and safe for the patient with diabetes. The other strength of the present study is a study design which each subject performed both control and exercise periods. This eliminates the effect of inter-individual variation.

#### **4.9.  Mean daily dietary intakes were similar in both periods (1,468.6 ± 58.6 kJ and 1,462.2 ± 56.0 kJ; control and exercise periods, respectively). Mean energy expenditure in the exercise period was signifi‐ cantly higher than that in the control period (1,593.4 ± 54.6 and 1,472.7 ± 47.6 kJ, respectively;

HbA1c concentration was 0.2% lower after ASE training for 8 weeks compared with the control period (p<0.05, Table 1). However, there was no significant difference in fasting blood glucose between periods. There were no effect of ASE training on insulin sensitivity, hsCRP concen‐

ASE training significantly reduced plasma MDA concentration (p<0.05) and increased antioxidant blood GSH concentration (p<0.05). No correlation between oxidative stress and

The results showed that the ASE training improves glycaemic control and oxidative stress in patients with type 2 diabetes. Thus, this simple and accessible exercise may have a potential

Previous studies also found the decreased HbA1c after the arm exercise training [75-77]. Jeng et al (2002) have reported that arm exercise training for 10-40 min could induce a significant decrease in the HbA1c concentration in patients with type 2 DM. Data from the United Kingdom Prospective Diabetes Study Group (UKPDS) have suggested that a 1% rise in HbA1c concen‐ tration represents a 37% increased risk for microvascular complications (95% CI 33 to 41, P < 0.0001) [78]. Based on this information, a 0.2% decrease in HbA1c after the ASE training detected

Possible mechanisms that could explain for the benefit effect of the ASE training on improving glycaemic control include the reduced HbA1c and the effect of exercise per se on improving the oxidative stress. The reduced HbA1c may decrease many adverse effects of hyperglycaemia such as hyperglycaemia-induced glucose autoxidation, non-enzymatic glycation of proteins, and reactive oxygen species generation, in leading to the progression of diabetic vascular complications. These processes were shown to increase oxidant stress and decrease antioxidant agent [79-81]. The imbalance of oxidative stress with greater oxidant stress contributed to the cellular destruction and therefore vascular complications [82]. The decreased MDA found in this study indicated a reduction in lipid peroxidation, a process of oxidative stress, which then reflects an attenuation of the cellular damage in the patients. The increased level of nonenzymatic antioxidant GSH after the ASE training observed in the present study also supports the preventive effect of exercise on vascular complication. As found in the present study, the

p<0.05).

428 Type 2 Diabetes

**4.6. Clinical chemistry**

**4.7. Oxidative stress**

**4.8. Discussion**

tration and lipid profiles between periods

effect on the prevention of complications of diabetes mellitus.

in this study may reduce 7.4% of risk for microvascular complications.

HbA1c at any periods was found.

In conclusion, the present study showed that the ASE training, a low-intensity exercise contribute to protective effects on vascular complication which is a major problem of type 2 diabetic patients. This may attribute to an improved oxidative stress according to either improved glycaemic control or exercise per se. The major attraction is that it is suited for not only diabetic patients but also other people who are not allegeable for the common training procedures such as elderly adults and patients with lower limb disorders.

#### **5. Beneficial mechanisms of exercise on type 2 diabetic patients**

There are many possible mechanisms explaining the beneficial effects of exercise training on type 2 diabetic patients (T2D).

These are described based on their roles.

#### **6. Improve glucose control**

#### **6.1. Insulin-independent mechanism**

**1.** Exercise leads to an insulin independent increase in glucose transport, mediated in part by AMP activated protein kinase. Changes in protein expression may be related to increased signal transduction through the mitogen-activated protein kinase (MAPK) signaling cascades, a pathway known to regulate transcriptional activity [87].

**1.** More recent observations indicate that interactions exist at the distal signaling level of

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**2.** Acute exercise reverses TRB3 expression and insulin signaling restoration in muscle. Thus, these results provide new insights into the mechanism by which physical activity ameliorates whole body insulin sensitivity in type 2 diabetes [96]. TRB3 is an inducible gene whose expression is regulated by stress response and insulin and associated with

**3.** Exercise training increases skeletal muscle Nicotinamide phosphoribosyltransferase (NAMPT) which is known as pre-B-cell colony-enhancing factor 1 (PBEF1) or visfatin, is an enzyme belonging to the family of glycosyltransferases, to be specific, the pentosyl‐ transferases. NAMPT was reported to be an activate insulin receptor and has insulin-

**4.** Blood glucose concentration can be improved by exercise training-induced increases in muscle glycogen content. This could be regulated by multiple mechanisms, including enhanced insulin sensitivity, glycogen synthase expression, allosteric activation of glycogen synthase, and PP1 activity [98]. The increased muscle glycogen also plays important role in muscle strength [99]. This can improve glucose uptake and then glucose

**5.** Exercise overrules free fatty acid-mediated inhibition of pyruvate dehydrogenase (i.e., carbohydrate oxidation). This may improve carbohydrate oxidation although high fat was ingested [100]. The improved carbohydrate oxidation then enhances insulin sensitivity

**6.** The metabolic outcomes were divided into six domains: glycogen, glucose facilitated transporter 4 (GLUT4) and insulin signaling, enzymes, markers of inflammation, lipids metabolism and so on. Beneficial adaptations to exercise were seen primarily in muscle fiber area and capillary density, glycogen, glycogen synthase and GLUT4 protein expressions [101]. This adaptation then play important role on improved glycaemic

**7.** Exercise training results in a persistent increase in insulin sensitivity in skeletal muscle from obese and insulin-resistant individuals [102]. Chronic exercise upregulated phos‐ phorylation and expression of AMPK upstream kinase, LKB1. Particularly exercise reversed the changes in protein kinase C (PKC)ζ/λ phosphorylation, and PKCζ phos‐ phorylation and expression. In addition, exercise also increased protein kinase B (PKB)/ Akt1, Akt2 and GLUT4 expression, but AS160 protein expression was unchanged. Chronic exercise increased Akt (Thr (308)) and (Ser(473)) and AS160 phosphorylation. Finally, exercise increased peroxisome proliferator-activated receptor-γ coactivator 1 (PGC1) mRNA expression in the soleus of diabetic rats. These results indicate that both chronic and acute exercise influence the phosphorylation and expression of components of the

AMPK and downstream to PIK3 (aPKC, Akt), and improve GLUT4 [103].

**8.** Exercise training reversed abnormality in subjects with type 2 diabetes i.e. increase in both IkappaB alpha and IkappaB beta protein, IkappaB alpha and IkappaB beta protein,

mimetic effects, lowering blood glucose and improving insulin sensitivity [97].

AS160 and atypical protein kinase C (aPKC) [95].

insulin resistance and metabolic syndrome.

resulting in improved glucose control.

control.

control.

**Figure 31.** Exercise training-induced changes in insulin signaling via insulin-independent pathway in skeletal muscle [87].

#### **6.2. Insulin dependent mechanism**

The beneficial effect of exercise training on the control of glucose via insulin signaling has been reviewed by many previous studies [92-94]. In addition, many studies investigated the effects of exercise

**Figure 31.** Exercise training-induced changes in insulin signaling via insulin-independent pathway in skeletal muscle

**2.** Exercise increased skeletal muscle c-Jun N-terminal kinase (JNK) activity throughout the experiment, whereas insulin did not significantly increase JNK activity. The p38 activity was slightly stimulated by exercise and not by insulin [88]. However, the other previous study noted that exercise training improves basal glucose metabolism without a change in the stress kinases, JNK, the nuclear factor B (NF-B) pathway and Hsp72. Moreover, nuclear regulation of NF-B activity in diabetic muscle could be regulated independently

**3.** The sodium-dependent glucose co-transporter system (hSGLT3), an insulin-independent glucose transporter, is activated by exercise and it may play a significant role in improving

**4.** Exercise training increases insulin-stimulated glucose disposal primarily by increasing GLUT4 protein expression without enhancing insulin-stimulated PI 3-kinase signaling, and that once the glucose enters the myocyte, increased glycogen synthase activity

The beneficial effect of exercise training on the control of glucose via insulin signaling has been reviewed by many previous studies [92-94]. In addition, many studies investigated the effects

[87].

430 Type 2 Diabetes

of the cytosolic pathway [89].

preferentially shunts it into glycogen synthesis [91].

glycemic control [90].

**6.2. Insulin dependent mechanism**

of exercise

decrease in tumor necrosis factor alpha muscle content and an increase in insulinstimulated glucose disposal [104].

**6.4. Normalization of blood lipid profiles**

**6.6. Improvement of nervous system function**

peripheral nerves of STZ-induced diabetes. [118]

increase antioxidant and decrease oxidant [72]

**6.7. Improved oxidative stress**

**6.8. Prevention of microangiopathy**

control and diabetic groups [120].

**6.5. Improved nitric oxide-mediated skeletal muscle blood flow**

[115].

Decreases in total cholesterol, increases in HDL, oxidized LDL (oxLDL), leukocyte mRNA expression for PPARgamma which was reinforced by increased PPARgamma DNA-binding activity and gene expression were observed for the oxLDL scavenger receptor CD36 LXRalpha. Two LXRalpha-regulated genes involved in RCT, namely, ATP-binding cassette transporters A1 and GI (ABCA1 and ABCG1, respectively), were significantly up-regulated post-exercise

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**1.** Exercise training improves endothelium-dependent vasodilator function, not only as a localised phenomenon in the contracting muscle group, but also as a systemic response when a relatively large mass of muscle is activated regularly during an exercise training program. Shear stress-mediated improvement in endothelial function provides one

plausible explanation for the cardioprotective benefits of exercise training [116].

mechanism by which exercise training takes benefit in the prevention [117].

Progressive exercise training significantly decreases diabetes-associated neuropathic pain, including thermal hyperalgesia and mechanical allodynia. In rats, this protective effect is related to the increase of Hsp72, but not TNF-α and IL-6, expression in the spinal cord and

Acute exercise was reported to elevate Ox LDL, SOD and GSH-Px levels which are associated with in type 2 diabetic patients [119]. Exercise training including low-intensity exercise can

Mitochondrial oxidative capacity appears to be involved in the overall mechanism by which exercise prevents microangiopathy in rats with type 2 diabetes. Luminal capillary diameter of the diabetic group was significantly lower than that of the control group, succinic dehydro‐ genase (SDH) activity was significantly higher in the diabetic with exercise group than in the

**2.** In addition to being a possible modulator of blood flow, nitric oxide (NO) from skeletal muscle regulates muscle contraction and metabolism. Recently, human data indicate that NO plays a role in muscle glucose uptake during exercise independently of blood flow. Exercise training in healthy individuals increased NO bioavailability through a variety of mechanisms including increased NOS enzyme expression and activity. This contributed to increased exercise capacity and cardiovascular protection. Exercise training with high cardiovascular risk can increase NO bioavailability and may represent an important

#### **6.3. Weight reduction**

Swim training can effectively prevent body weight gain, adiposity and lipid disorders caused by leptin receptor deficiency, in part through activation of UCPs in adipose tissue and skeletal muscle [113]. The training also increased carnitine palmitoyl transferase (CPT I) activity and became less sensitive to inhibition by malonyl-CoA, reduced both total ceramide content. In addition, it improved capacity for mitochondrial FA uptake and oxidation leads not only to a reduction in muscle lipid content but also to change in the saturation status of lipids [114]. These may contribute to alleviating weight reduction for patients with diabetes type 2.

#### **6.4. Normalization of blood lipid profiles**

decrease in tumor necrosis factor alpha muscle content and an increase in insulin-

**9.** Training significantly improved glucose tolerance in obese humans [105]. This may be benefit in control blood glucose concentration leading to prevention for patients diabetes

**10.** Both moderate- and vigorous-intensity exercise training improved beta-cell function to the extent that the disposition index (DI) accurately reflects beta-cell function. Although through distinct mechanisms [106] were modeled from an intravenous glucose tolerance test. [DI = S(i) x AIRg (insulin sensitivity (S(i)), acute insulin response to glucose (AIRg)]

**11.** In diabetic rats, exendin-4 and exercise stimulate insulin receptor substrate (IRS)-2 expression [107, 108] through the activation of cAMP responding element binding protein in the islets [109]. This enhanced their insulin/insulin like growth factor-1 signaling. The potentiation of the signaling increased the expression of pancreas duodenum homeo‐ box-1, involved in beta-cell proliferation. In conclusion, exendin-4 and exercise equiva‐ lently improved glucose homeostasis due to the induction of IRS-2 in the islets of diabetic

**12.** Exercise training substantially reduces the exposure of islets to exogenous lipid, thereby providing a potential mechanism by which exercise can prevent islet beta-cell failure

**13.** Exercise may have beneficial effects via monocyte since monocyte peroxisome proliferator activated receptors gamma (PPARγ) activation has been linked to beneficial antidiabetic effects. This is supported by the association between exercise-induced upregulation of monocytic PPARγ-controlled genes and reverse cholesterol transport and anti-inflam‐ matory effects. Thus, exercise-induced monocyte PPARγ activation may contribute to

**14.** High-intensity progressive resistance training, in combination with moderate weight loss, effectively improved glycemic control in older patients with type 2 diabetes. This may

Swim training can effectively prevent body weight gain, adiposity and lipid disorders caused by leptin receptor deficiency, in part through activation of UCPs in adipose tissue and skeletal muscle [113]. The training also increased carnitine palmitoyl transferase (CPT I) activity and became less sensitive to inhibition by malonyl-CoA, reduced both total ceramide content. In addition, it improved capacity for mitochondrial FA uptake and oxidation leads not only to a reduction in muscle lipid content but also to change in the saturation status of lipids [114]. These may contribute to alleviating weight reduction for patients with diabetes type 2.

result from increased muscle mass leading to increased glucose uptake [112].

rationale for prescribing exercise to type 2 diabetes patients [111].

stimulated glucose disposal [104].

rats through a cAMP dependent common pathway.

leading to diabetes type 2 [110].

**6.3. Weight reduction**

type II.

432 Type 2 Diabetes

Decreases in total cholesterol, increases in HDL, oxidized LDL (oxLDL), leukocyte mRNA expression for PPARgamma which was reinforced by increased PPARgamma DNA-binding activity and gene expression were observed for the oxLDL scavenger receptor CD36 LXRalpha. Two LXRalpha-regulated genes involved in RCT, namely, ATP-binding cassette transporters A1 and GI (ABCA1 and ABCG1, respectively), were significantly up-regulated post-exercise [115].

#### **6.5. Improved nitric oxide-mediated skeletal muscle blood flow**

#### **6.6. Improvement of nervous system function**

Progressive exercise training significantly decreases diabetes-associated neuropathic pain, including thermal hyperalgesia and mechanical allodynia. In rats, this protective effect is related to the increase of Hsp72, but not TNF-α and IL-6, expression in the spinal cord and peripheral nerves of STZ-induced diabetes. [118]

#### **6.7. Improved oxidative stress**

Acute exercise was reported to elevate Ox LDL, SOD and GSH-Px levels which are associated with in type 2 diabetic patients [119]. Exercise training including low-intensity exercise can increase antioxidant and decrease oxidant [72]

#### **6.8. Prevention of microangiopathy**

Mitochondrial oxidative capacity appears to be involved in the overall mechanism by which exercise prevents microangiopathy in rats with type 2 diabetes. Luminal capillary diameter of the diabetic group was significantly lower than that of the control group, succinic dehydro‐ genase (SDH) activity was significantly higher in the diabetic with exercise group than in the control and diabetic groups [120].

#### **6.9. Improve metabolic control**

Exercise training results in an increase in the oxidative capacity of skeletal muscle by upregulating lipid oxidation and the expression of proteins involved in mitochondrial biogenesis. This decreased liver triacylglycerol content [121].

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#### **Acknowledgements**

This study was supported by a grant from Thailand Research Fund (TRF). The authors appreciate Associate Professor Jongonnee Wattanapermpool for her excellent assistance with critical commentary and suggestions. The authors thank Assistant Professor Dr. Thongchai Pratipanawatr for his invaluable assistance with data acquisition. The authors also thank Ms Saovanee Luangaram for her excellent measurement of oxidative stress. The authors appreci‐ ate all patients who participated in this study.

This chapter was supported by Exercise and Sport Sciences Research and Development Group.

#### **Author details**

Naruemon Leelayuwat\*

Address all correspondence to<EMAIL_ADDRESS>
Department of Physiology, Faculty of Medicine, Khon Kaen University, Thailand

#### **References**

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**6.9. Improve metabolic control**

434 Type 2 Diabetes

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Exercise training results in an increase in the oxidative capacity of skeletal muscle by upregulating lipid oxidation and the expression of proteins involved in mitochondrial biogenesis.

This study was supported by a grant from Thailand Research Fund (TRF). The authors appreciate Associate Professor Jongonnee Wattanapermpool for her excellent assistance with critical commentary and suggestions. The authors thank Assistant Professor Dr. Thongchai Pratipanawatr for his invaluable assistance with data acquisition. The authors also thank Ms Saovanee Luangaram for her excellent measurement of oxidative stress. The authors appreci‐

This chapter was supported by Exercise and Sport Sciences Research and Development Group.

Department of Physiology, Faculty of Medicine, Khon Kaen University, Thailand

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**Chapter 19**

**Understanding the Effects of Roux-en-Y Gastric Bypass**

Obesity is a grave public health concern in the United States today. From 2007 to 2008, the prevalence of obesity was over one-third of the U.S. adult population [1]. It contributes to significant morbidity and mortality including heart disease, stroke, cancer, arthritis and sleep apnea. *Type 2* diabetes mellitus (T2DM) also has been shown to increase with increasing obesity. Findings from the National Health and Nutrition Examination Survey (NHANES) (1999 – 2006) showed that nearly half of individuals with a body mass index greater than 40

 have diabetes [2]. Results from various studies have shown that weight reduction significantly reduces the risk of developing T2DM in obese individuals [3], as well as improv‐

> © 2013 Lau et al.; licensee InTech. This is an open access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use,

© 2013 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons Attribution License http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution,

distribution, and reproduction in any medium, provided the original work is properly cited.

and reproduction in any medium, provided the original work is properly cited.

Long term medical therapy for obesity is often unsuccessful for the majority of patients in clinical practice. Bariatric weight loss surgery has remained the most effective means of achieving and maintaining weight loss. More significantly, it has been shown to decrease mortality [6]. The Roux-en-Y gastric bypass (RYGB) is a type of bariatric surgery that involves the creation of a smaller stomach with a connection to the middle portion of the small intestine, bypassing the duodenum and a portion of the jejunum (see figure 1). Two limbs are created after the surgery. One limb, referred to as the alimentary or *Roux limb*, is where nutrient boluses pass from the stomach pouch. The other limb, which is the bypassed portion of the gastroin‐ testinal tract, is known as the biliopancreatic limb. This limb transports secretions from the pancreas, liver, and gastric remnant. Most remarkably, many obese *diabetic* patients who undergo RYGB are relieved of their anti-diabetic medications in a matter of days. This

improvement in glycemic control occurs before any significant weight loss [7].

**(RYGB) Surgery on** *Type 2* **Diabetes Mellitus**

Raymond G. Lau, Michael Radin,

http://dx.doi.org/10.5772/56398

**1. Introduction**

kg/m2

Collin E. Brathwaite and Louis Ragolia

Additional information is available at the end of the chapter

ing glycemic control in those already with T2DM [4,5].

## **Understanding the Effects of Roux-en-Y Gastric Bypass (RYGB) Surgery on** *Type 2* **Diabetes Mellitus**

Raymond G. Lau, Michael Radin, Collin E. Brathwaite and Louis Ragolia

Additional information is available at the end of the chapter

http://dx.doi.org/10.5772/56398

#### **1. Introduction**

Obesity is a grave public health concern in the United States today. From 2007 to 2008, the prevalence of obesity was over one-third of the U.S. adult population [1]. It contributes to significant morbidity and mortality including heart disease, stroke, cancer, arthritis and sleep apnea. *Type 2* diabetes mellitus (T2DM) also has been shown to increase with increasing obesity. Findings from the National Health and Nutrition Examination Survey (NHANES) (1999 – 2006) showed that nearly half of individuals with a body mass index greater than 40 kg/m2 have diabetes [2]. Results from various studies have shown that weight reduction significantly reduces the risk of developing T2DM in obese individuals [3], as well as improv‐ ing glycemic control in those already with T2DM [4,5].

Long term medical therapy for obesity is often unsuccessful for the majority of patients in clinical practice. Bariatric weight loss surgery has remained the most effective means of achieving and maintaining weight loss. More significantly, it has been shown to decrease mortality [6]. The Roux-en-Y gastric bypass (RYGB) is a type of bariatric surgery that involves the creation of a smaller stomach with a connection to the middle portion of the small intestine, bypassing the duodenum and a portion of the jejunum (see figure 1). Two limbs are created after the surgery. One limb, referred to as the alimentary or *Roux limb*, is where nutrient boluses pass from the stomach pouch. The other limb, which is the bypassed portion of the gastroin‐ testinal tract, is known as the biliopancreatic limb. This limb transports secretions from the pancreas, liver, and gastric remnant. Most remarkably, many obese *diabetic* patients who undergo RYGB are relieved of their anti-diabetic medications in a matter of days. This improvement in glycemic control occurs before any significant weight loss [7].

© 2013 Lau et al.; licensee InTech. This is an open access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. © 2013 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons Attribution License http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

 demonstrates glucoregulatory variables that RYGB appears to modify. Cumulatively, this will permit the reader to develop an understanding of the relationship of how RYGB affects diabetes. We will begin our discussion describing the clinical potency of RYGB on T2DM.

Understanding the Effects of Roux-en-Y Gastric Bypass (RYGB) Surgery on *Type 2* Diabetes Mellitus

http://dx.doi.org/10.5772/56398

447

**2. Problem statement: What is the effect of roux-en-Y gastric bypass on type**

Since the early portion of the 21st century, there has been a growing interest in bariatric surgeries and their effect on ameliorating the diabetic state. Pories et al was arguably the first to describe remission of diabetes following gastric bypass. He reported gastric bypass not only caused weight loss, it also led to normalization of blood sugars in over 80% of his diabetic patients [9]. Initially, the normalization of blood sugars was thought to be directly caused by the weight loss. However, it has subsequently been noted that blood glucose control improves immediately following the surgery, prior to any significant weight loss. The concept that weight loss alone was not the reason for diabetes improvement after RYGB was a paradigm shift in the world of weight loss surgery, as well as the world of diabetes. This led to an

There were few to no trials evaluating the efficacy of surgical treatment of obesity until the creation of the Swedish Obesity Study (SOS). The SOS trial is one of the largest prospective data collections to date that studies the clinical effects of various types of bariatric surgery. The SOS data demonstrates durable weight loss by as much 25% reduction at 10 years with various surgery types. The greatest weight loss is observed with RYGB [6] as compared to gastric

**2.1. Roux-en-Y Gastric Bypass (RYGB) and its weight independent effect on T2DM**

explosion of research that attempts to understand how the surgery works.

**Figure 2.** Glucoregulatory Variables

**2 diabetes mellitus?**

Dirksen C, Jorgensen NB, Bojsen-Moller KN et al. Mechanisms of improved glycemic control after Roux-en-Y Gastric Bypass. *Diabetologia. 2012*;55:1890-1901.

#### **Figure 1.** Roux-en-Y Gastric Bypass (RYGB)

This dramatic effect of gastric bypass on T2DM is not well understood. Improvement or remission of T2DM was thought to be due to weight loss in obese subjects [3, 5]. This was further supported by studies with gastric banding, a form of enforced caloric restriction [8]. However, clinicians began to observe that glucose levels were significantly lower in RYGB subjects as compared to weight matched controls [7]. Although malabsorption also likely contributes to the improved dysglycemia, there are other hormonal changes that are likely contributing to this effect. The most significant hormone changes occur in the secretion patterns of gut hormones. These are hormones that are secreted by enteroendocrine cells from the stomach, pancreas, and small intestine. A unique but significant post-prandial elevation of gut hormones is observed after RYGB. This is a well accepted phenomenon seen with RYGB subjects, and is believed to contribute significantly to this improvement of hyperglycemia in diabetics.

To better understand how RYGB affects those with *T2DM*, we will review the changes that occur with RYGB in key glucoregulatory organ systems within the body. In the ensuing sections, we will discuss in detail, the changes of *peripheral insulin sensitivity* and *insulin secretion* brought on by gastric bypass, and their effects on hyperglycemia. Identifying these changes will permit us to better understand how RYGB improves diabetes. We will also discuss the role that *caloric restriction* and *gut hormone elevation* may have in this process. Figure 2  demonstrates glucoregulatory variables that RYGB appears to modify. Cumulatively, this will permit the reader to develop an understanding of the relationship of how RYGB affects diabetes. We will begin our discussion describing the clinical potency of RYGB on T2DM.

**Figure 2.** Glucoregulatory Variables

Dirksen C, Jorgensen NB, Bojsen-Moller KN et al. Mechanisms of improved glycemic control after Roux-en-Y Gastric

This dramatic effect of gastric bypass on T2DM is not well understood. Improvement or remission of T2DM was thought to be due to weight loss in obese subjects [3, 5]. This was further supported by studies with gastric banding, a form of enforced caloric restriction [8]. However, clinicians began to observe that glucose levels were significantly lower in RYGB subjects as compared to weight matched controls [7]. Although malabsorption also likely contributes to the improved dysglycemia, there are other hormonal changes that are likely contributing to this effect. The most significant hormone changes occur in the secretion patterns of gut hormones. These are hormones that are secreted by enteroendocrine cells from the stomach, pancreas, and small intestine. A unique but significant post-prandial elevation of gut hormones is observed after RYGB. This is a well accepted phenomenon seen with RYGB subjects, and is believed to contribute significantly to this improvement of hyperglycemia in

To better understand how RYGB affects those with *T2DM*, we will review the changes that occur with RYGB in key glucoregulatory organ systems within the body. In the ensuing sections, we will discuss in detail, the changes of *peripheral insulin sensitivity* and *insulin secretion* brought on by gastric bypass, and their effects on hyperglycemia. Identifying these changes will permit us to better understand how RYGB improves diabetes. We will also discuss the role that *caloric restriction* and *gut hormone elevation* may have in this process. Figure 2

Bypass. *Diabetologia. 2012*;55:1890-1901.

**Figure 1.** Roux-en-Y Gastric Bypass (RYGB)

diabetics.