diabetes mellitus type 2 ( t2 dm ) is a chronic disease that has been increasing globally over 
 the past 2 decades including in thailand1 . 

it is a significant health problem with microangiopathy and macroangiopathy resulting in 
 many complications , i.e , neuropathy2 , 
 retinopathy3 , nephropathy4 , and coronary artery disease5 .
in addition , hyperglycemia - induced 
 microangiopathy via increased oxidative stress has also been shown to impair pulmonary 
 function5 .
lung impairment due to 
 microangiopathy is indicated by a decrease in spirometric parameters , forced vital capacity 
 ( fvc ) , and the forced expiratory volume in the first second of expiration ( fev1)6,7,8 .
human autopsy9 , 10 and transbronchial biopsy 
 studies11 of diabetic patients have 
 revealed an increase in alveolar - capillary basement membrane thickness , which may contribute 
 to the limitation of lung expansion caused by an enlarged interstitium and decreased 
 diffusion because of the thickening and fibrotic changes in the alveolar - capillary and 
 pulmonary arteriole basement membranes6 , 12 .
in fact , glycemic status was negatively 
 correlated with the dynamic lung functions in t2 dm patients13 .
in addition , impaired lipid metabolism indicated by an increase of body fat mass14 and chronic low - grade tissue 
 inflammation14 , autonomic neuropathy 
 involving the respiratory muscles15 , and 
 loss of elastic recoil according to collagen glycosylation of lung parenchyma16 are considered to contribute to 
 respiratory impairments in t2 dm patients . therefore , the modalities that improve glycemic 
 status and control lipid metabolism , e.g , exercise , diet restriction , and intake of 
 medicinal herbs , may be useful in improving the pulmonary functions of t2 dm patients .
low - intensity exercise is known to effectively reduce body mass and fat mass17 , 18 , glucose and triglyceride levels19 , and blood pressure and waist and hip circumferences18 .
in addition , it is known to increase 
 lipid oxidation and insulin sensitivity in patients with metabolic syndrome20 , provide an anti - inflammation effect21 , decrease hba1c22 and oxidative stress23 , and increase lipid oxidation in patients with t2dm24 .
the arm swing exercise ( ase ) , a low - intensity exercise , is easy and convenient to perform 
 without any equipment .
we previously 
 demonstrated that performance of the ase for 8 weeks conclusively improved hyperglycemia via 
 improvement of oxidative stress in t2dm23 .
we also demonstrated that , in untrained men and women , fat was used 
 as a major source of energy for low - intensity exercise more than in the case of 
 higher - intensity exercise25 .
the ase may 
 thus increase fat usage , leading to improvement of the lipid profile and a reduction in fat 
 mass .
we hypothesized that the ase may have beneficial effects on pulmonary functions via 
 improvement of hyperglycemia , antioxidant activity , and fat metabolism in the t2 dm patients . 

in this study , we aimed to investigate the effects of the ase on dynamic pulmonary function 
 of overweight t2 dm patients . in relation to the effects of the ase on the pulmonary 
 functions ,
the effects of the ase on oxidative stress , lipid profiles , obesity , and glycemia 
 of t2 dm patients were investigated .
twenty - four thai patients with t2 dm ( 20 women and 4 men ) were recruited in khon kaen 
 province , thailand .
their mean age (  se ) was 59.51.46  years , and they had no 
 cardiovascular and/or respiratory complications . they were informed verbally and in writing 
 before signing a consent form approved by the ethical committee of khon kaen university in 
 accordance with the 1964 declaration of helsinki .
if the subjects could not attend 90% of 
 the total exercise sessions or could not maintain their usual therapy for at least 80% of 
 all interventions throughout the experiment , they were excluded from the study .
all subjects maintained their sedentary daily lives for the first 8 weeks ( control period ) , 
 and then they performed the ase for 8 weeks ( 30 minutes per day , 3 days per week ) ( ase 
 period ) . on the first day of the ase period , the participants learned how to perform the ase 
 correctly in our laboratory .
they then performed it with video tape recorder monitoring at 
 home for the following 8 weeks . once a week , all subjects were telephoned to check on their 
 ase training .
anthropometric parameters and body composition were measured before and after 
 each period . at the same points of time ,
blood samples were collected from the antecubital 
 vein to determine glucose , lipid , hba1c , malondialdehyde ( mda ) , reduced glutathione ( gsh ) , 
 oxidized glutathione ( gssg ) , and insulin concentrations .
the ase is a traditional chinese exercise with an intensity of approximately 23% of the 
 maximal oxygen consumption ( unpublished data ) . in starting position of the ase
, each subject 
 stood with his / her head erect , but relaxed , with the mouth naturally closed and the tip of 
 the tongue placed against the hard palate and with the trunk of the body straight .
they 
 gazed forward with their eyes focused on a point while they concentrated their minds on 
 swinging their arms .
the arms initially hung naturally at the sides with the palms of both 
 hands facing backward and with the fingers spreading naturally .
the feet were firmly placed on the ground , at shoulder width 
 apart . then both arms were swung forward about 30 degrees with a smooth and even force and 
 then backward to about 60 degrees .
however , during 
 the first week of the training , the speed of swinging was actually 30 times / minute . body weight and height were measured without shoes using a balance beam scale .
the body 
 mass index ( bmi ) was calculated from the body weight ( kg ) and height ( m ) .
waist 
 circumference was measured at the midpoint between the lower margin of the last palpable rib 
 and the top of the iliac crest .
body fat was determined by measuring the skinfold thickness at 4 points on the right 
 side of the body including the biceps , triceps , supra - iliac crest , and the subscapular 
 area . to assess pulmonary functions , forced expiratory volume in the first second 
 ( fev1 ) and forced vital capacity ( fvc ) were measured using a vitalograph 2120 
 according to the ats ( american thoracic society ) criteria .
maximal voluntary ventilation ( mvv ) was 
 calculated from fev1 by the following equation : mvv = fev1 ( l )  
 4026 . at each visit ,
one milliliter 
 of blood was collected into tubes containing fluoride - oxalate for subsequent determination 
 of whole blood glucose by using glucose oxidase and l - lactate oxidase methods ( yellow 
 springs instrument analyzer , ysi , 2300 stat plus ) . after placing 4  ml into edta and
2  ml 
 into clotting tubes , all samples were placed immediately on ice .
the tubes were then 
 centrifuged at 3,000  g for 15  min to remove red blood cells , and the serum and plasma were 
 separated .
the serum obtained was used to analyze tc , hdl , ldl , tg , and hscrp levels using 
 standard automated laboratory methods ( roche integra 800 , roche , basel , switzerland ) and to 
 analyze insulin by using the radioimmunoassay technique .
these methods are routinely used in 
 srinagarind hospital , faculty of medicine , khon kaen university .
two milliliters of residual 
 plasma was used for analysis of mda by the authors .
insulin sensitivity was examined using homeostatic model assessment - insulin resistance 
 ( homa - ir)27 .
the basis of the tba method is the reaction of mda with 
 0.6% of tba at low ph and 95  c ( boiled for 30  min ) to form a colored complex .
acid 
 hydrolysis and heat are necessary to release mda bound to the amino groups of proteins and 
 other amino compounds .
the mda - tba complex , with an absorption at 532  nm , was measured using 
 a spectrophotometer ( genesys 20 , sn:35 gk 130009 ; thermo fisher scientific , waltham , ma , 
 usa ) .
the serum hscrp concentration was determined using a roche / hitachi cobas c system ( cobas c 
 501 , roche ) .
the hscrp level was determined using a particle - enhanced immunoturbidimetric 
 method , in which formation agglutinates of human crp with latex particles coated with 
 monoclonal anti - crp antibody was determined turbidimetrically .
ongoing diabetes therapies that patients had been receiving , such as pharmacotherapy , 
 dietary control , and exercise , were not modified during the study period .
the data from 3 
 days of records ( 2 days during the week and 1 day on the weekend ) for dietary intake and 
 physical activity were averaged to estimate daily energy intake and expenditure .
a two - way anova with repeated measures ( within subject factors of exercise and time ) was 
 used to analyze all dependent variables with the sigmastat version 2 software .
backward stepwise regression 
 was used to analyze correlation between parameters at each time point .
the percentage of body fat was found to be significantly reduced after the ase compared 
 with that before the ase ( p<0.05 ) .
all other anthropometric parameters were not 
 significantly changed by the ase ( table 
 1table 1.anthropometric parameters and body composition of the subjects during the control 
 and ase periodscontrol ( n=24)ase ( n=24)beforeafterbeforeafterage ( yrs)59.57.159.77.259.77.259.77.2height ( cm)156.57.3156.57.3156.57.3156.57.3body mass ( kg)63.67.664.112.164.112.164.311.8bmi25.93.826.110.026.14.025.84.5waist ( cm)92.610.793.810.893.810.892.811.3hip ( cm)98.08.597.48.497.48.496.88.8waist to hip ratio0.90.11.00.11.00.11.00.1% body fat41.76.141.86.041.86.040.86.0fat mass ( kg)27.36.626.86.226.86.226.86.6fat free mass ( kg)37.96.337.75.837.75.838.65.9rest hr ( /min)71.19.670.810.470.810.471.88.3data are expressed as means  se ( n = 20 women and 4 men ) .
analysis was performed 
 using the paired t - test for within groups and analysis of covariance between groups . 

significant difference after exercise ( adjusted by its baseline ) between groups : 
  p<0.05ase : arm swing exercise ; bmi : body mass index ) . the changes in mean daily dietary intakes were similar after both periods 
 ( table 2table 2.daily dietary intake and total energy expenditure during the control and ase 
 periodscontrol ( n=24)ase ( n=24)beforeafterbeforeafterdietary intake ( mj / day)6.880.46.980.46.760.36.770.5total energy expenditure ( mj / day)6.540.36.740.36.880.59.880.5data are expressed as means  se ( n = 20 women and 4 men ) .
significant difference 
 after exercise ( adjusted by its baseline ) between groups :   p<0.05 .
ase : 
 arm swing exercise ) . the mean total energy expenditure after the exercise period was 
 significantly higher than that after the control period after adjustment with the 
 pre - exercise values ( p<0.05 , table 2 ) . drug 
 therapies , eating situations , and momentum did not change throughout the study period of 8 
 weeks .
data are expressed as means  se ( n = 20 women and 4 men ) .
analysis was performed 
 using the paired t - test for within groups and analysis of covariance between groups . 

significant difference after exercise ( adjusted by its baseline ) between groups : 
  p<0.05 ase : arm swing exercise ; bmi : body mass index data are expressed as means  se ( n = 20 women and 4 men ) .
significant difference 
 after exercise ( adjusted by its baseline ) between groups :   p<0.05 .
ase : 
 arm swing exercise hba1c , ldl , mda , and gssg were significantly lowered after 8 weeks of the ase ( p<0.05 ) . 

however , there were no significant differences in fbg , insulin , lipid profiles , and hscrp 
 concentrations .
also , homa - ir was not altered after the ase ( table 3table 3.blood parameters in the control and ase periodscontrol ( n=24)ase ( n=24)beforeafterbeforeafterhba1c ( % ) 9.50.49.10.48.80.48.40.5fbg ( mg / dl)15612150101541014410insulin ( pmol / l)28.23.827.03.824.95.129.35.8*homa - ir11.42.410.42.110.42.710.42.1hdl ( mg / dl)483483514483ldl ( mg / dl)1136125811461075tg ( mg / dl)19524185171922320725tc ( mg / dl)20072061019991977hscrp ( mg / dl)8.32.011.05.56.10.95.10.7mda ( m)1.80.21.80.11.80.21.30.1*gsh ( m)538.724.1581.915.2524.719.3566.217.7***gssg ( m)21.31.919.01.220.91.314.70.8***gssg / gsh0.040.010.030.010.040.000.030.00**data are expressed as means  se ( n = 20 women and 4 men ) .
analysis was performed 
 using the paired t - test for within groups and analysis of covariance between groups . 
 significantly different from before exercise within group : * p<0.05 ; * * p<0.01 ; 
 * * * p<0.001.significant difference after exercise ( adjusted by its baseline ) between groups : 
 p<0.05 ; # # p<0.01 .
ase : arm swing 
 exercise ; hba1c : haemoglobin a1c ; fbg : fasting blood glucose ; homa - ir : homeostatic 
 model assessment - insulin resistance ; hdl : high - density lipoprotein ; ldl : low - density 
 lipoprotein ; tg : triglycerides ; tc : total cholesterol ; hscrp : high - sensitive 
 c - reactive protein ; mda : malondialdehyde ; gssg : oxidized glutathione ; gsh : reduced 
 glutathione ) . in all the participants ,
data are expressed as means  se ( n = 20 women and 4 men ) .
analysis was performed 
 using the paired t - test for within groups and analysis of covariance between groups . 
 significantly different from before exercise within group : * p<0.05 ; * * p<0.01 ; 
 * * * p<0.001 .
significant difference after exercise ( adjusted by its baseline ) between groups : 
 p<0.05 ; # # p<0.01 .
ase : arm swing 
 exercise ; hba1c : haemoglobin a1c ; fbg : fasting blood glucose ; homa - ir : homeostatic 
 model assessment - insulin resistance ; hdl : high - density lipoprotein ; ldl : low - density 
 lipoprotein ; tg : triglycerides ; tc : total cholesterol ; hscrp : high - sensitive 
 c - reactive protein ; mda : malondialdehyde ; gssg : oxidized glutathione ; gsh : reduced 
 glutathione all dynamic lung parameters were within normal ranges ( table 4table 4.pulmonary function tests and predicted values in the control and ase 
 periodscontrol ( n=24)ase ( n=24)beforeafterbeforeafterfev1 ( l)1.910.11.840.091.840.092.00.10fvc ( l)2.210.142.080.122.080.122.290.13fev1/fvc ( % ) 89.01.2388.51.2588.51.2588.50.91mvv ( l / min)76.23.8373.53.7073.53.7079.84.05values are expressed as means  se ( n = 20 women and 4 men ) .
significant difference 
 after exercise ( adjusted by its baseline ) between groups : p<0.05 . 

fev1 : forced expiratory volume in first second ; fvc : forced vital 
 capacity ; mvv : maximal voluntary ventilation ) .
fev1 , fvc , and mvv were significantly increased at the end of the 
 ase period ( p<0.05 ) ( table 4 ) .
values are expressed as means  se ( n = 20 women and 4 men ) .
significant difference 
 after exercise ( adjusted by its baseline ) between groups : p<0.05 . 

fev1 : forced expiratory volume in first second ; fvc : forced vital 
 capacity ; mvv : maximal voluntary ventilation
the present results showed that ase training slightly improved the dynamic lung volumes 
 including fev1 , fvc , and mvv of overweight t2 dm patients .
this may have been due 
 to a reduction of hyperglycemia and fat metabolism and a decrease in obesity .
the results support our hypothesis that ase training may have beneficial effects on 
 pulmonary function via reduced hyperglycemia , fat metabolism , and oxidative stress in 
 overweight t2 dm patients .
moreover , due to the movement of both arms and rhythmic breathing 
 during the ase , the ase training may mobilize the chest wall and stimulate all the 
 respiratory muscles ( intercostals , diaphragm , abdominals , and scalenii ) to do more work 
 during the period of exercise .
this is supported by a previous study that demonstrated that 
 exercise at low levels of intensity increased expiratory muscle activity in healthy men29 .
in addition , although the expired gas 
 composition was not measured , ventilatory efficiency ( increased ventilation ( ve)/carbon 
 dioxide output ( vco2 ) slope ) may be improved by ase training .
this is supported 
 by a previous study demonstrating that weight reduction resulting from ase training may 
 improve ventilatory efficiency during graded exercise in obese children30 .
the reductions in hyperglycemia ( decreased hba1c ) and oxidative stress ( after the ase ) are 
 supported by our previous study23 in that 
 the hypoglycemic effect of the ase might be attributed to a reduction in oxidative stress or 
 exercise per se .
this may result in decreased nonenzymatic glycosylation of tissue proteins 
 and the formation of advanced glycosylation end products , resulting in microvascular 
 complications31 , 32 in various organ systems including the alveolar - capillary network 
 in the lung33 , 34 moreover , it may attenuate reduced pulmonary elastic recoil . thus , 
 the decrease in hba1c may have improved the lung function of the subjects after the ase 
 training in this study .
it is known that normal lung mechanics and gas exchange are affected by the integrity of 
 pulmonary connective tissue and microvasculature .
abnormalities in either of these two 
 structural components of the lung may result in the development of pulmonary 
 dysfunction34 . in a previous report
, it 
 was reported that a 10% decrease in fev1 was related to a 12% increase in 
 all - cause mortality8 .
the measured airflow 
 limitation is expected to increase all - cause mortality in patients with diabetes .
rigorous 
 blood management may reduce the risk of death through improved ventilatory function 
 independent of other beneficial effects . the ase decreased obesity and increased the dynamic lung volumes .
the fact that a reduction 
 in body fat or obesity improved the pulmonary functions after the ase training in this study 
 is consistent with many previous studies investigating low - intensity exercise training in 
 patients with diabetes24 , patients with 
 metabolic syndrome20 , and obese 
 subjects35 .
moreover , miyatake , et 
 al.36 reported that reduction of body 
 fat by low - intensity exercise in obesity leads to increased lung elasticity , which is 
 reflected in improvements in fev1 , fvc , and mvv .
the presence of extensive 
 microvascular circulation and abundant connective tissue in the lungs raises the possibility 
 that lung tissue may be affected by a microangiopathy process and nonenzymatic glycosylation 
 of tissue proteins .
the decrease in body fat in this study may be due to increased fat oxidation during the 
 exercise .
although we did not measure fat oxidation during the exercise , previous studies 
 support this finding25 , 37 .
( 2002 ) demonstrated that 
 low - intensity exercise contributed to increased fat oxidation during exercise in obese 
 subjects .
our previous study showed that fat was mostly used as an energy source during 
 low - intensity exercise compared with higher - intensity exercise in young lean thai 
 individuals25 .
the reason for this 
 result could be due to a lower rate of glycolysis resulting in lower malonyl coa production 
 from a low level of muscle contraction during low - intensity exercise .
malonyl coa inhibits 
 carnitine palmitoyl transferase ( cpt ) , which carries free fatty acid into mitochondria for 
 fat oxidation38 . therefore , with a lower 
 level of malonyl coa , more fat is taken up and oxidized during the exercise .
however , we did 
 not measure the amount of fat oxidation or the fat source that was used during the exercise . 
 instead , we used lipid profiles from routine clinical investigation to indicate the source 
 of fat in the blood stream during rest in this study , and it was found that it was unchanged 
 by the ase .
free fatty acids from either adipocytes or intramuscular triglycerides may be 
 the source of fat involved in the increased fat oxidation during exercise in this study . 

thus , further research investigating fat oxidation and the fat source during the ase needs 
 to be performed . in summary , the present results indicate that the ase can be an alternative mode of 
 exercise to reduce pulmonary function impairment of t2 dm patients , especially pulmonary 
 function impairment .
this reduction of pulmonary function impairment as a result of the ase 
 may be due to the improvement of hyperglycemia and fat metabolism and the decrease in 
 percent body fat .
 [ purpose ] obesity and hyperglycemia play roles in the impairment of pulmonary function in 
 type 2 diabetes mellitus ( t2 dm ) patients . 
 low - intensity exercise is known to reduce body 
 fat and improve hyperglycemia . 
 the arm swing exercise ( ase ) , a low - intensity exercise , is 
 easy and convenient to perform without any equipment and is suitable for daily practice . 
 
 therefore , we aimed to investigate the effects of ase on lung function and obesity in 
 overweight t2 dm patients . 
 [ subjects and methods ] twenty - four subjects continued their 
 daily life routines for 8 weeks ( control period ) , and then performed ase for 8 weeks ( 30 
 minutes per day , 3 days per week ) ( ase period ) . 
 pulmonary function tests were performed , 
 and fasting blood glucose , haemoglobin a1c ( hba1c ) , lipid profiles , high - sensitive 
 c - reactive protein ( hscrp ) , insulin concentration , and anthropometric parameters were 
 measured before and after each period . [ results ] after the ase period , the forced vital 
 capacity , forced expiratory volume in the first second of expiration , and maximal 
 voluntary ventilation were increased when compared with after the control period . 
 hba1c , a 
 low - density lipoprotein , malondialdehyde , oxidized glutathione , and the percent body fat 
 were significantly decreased when compared with after the control period 
 . however , other 
 parameters , such as lung volume , anthropometric parameters , and fasting blood glucose , 
 insulin , high - density lipoprotein , triglycerides , total cholesterol and glutathione 
 concentrations , showed no differences between the two periods . 
 [ conclusion ] these data 
 suggest that there is improvement of pulmonary functions in t2 dm patients after ase 
 training . 
INTRODUCTION
SUBJECTS AND METHODS
RESULTS
DISCUSSION