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Jlali I, Touil I, Ibn Haj Amor H, Bouzid MA, Hammouda O, Heyman E, Fontaine P, Chtourou H, Rabasa-Lhoret R, Baquet G, Tagougui S. Impaired muscle oxygenation despite normal pulmonary function in type 2 diabetes without complications. Am J Physiol Endocrinol Metab 2024; 326:E640-E647. [PMID: 38536038 DOI: 10.1152/ajpendo.00392.2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2023] [Revised: 03/22/2024] [Accepted: 03/24/2024] [Indexed: 05/01/2024]
Abstract
Long-term hyperglycemia in individuals with type 2 diabetes (T2D) can detrimentally impact pulmonary function and muscle oxygenation. As a result, these factors can impede the body's adaptation to physical exertion. We aimed to evaluate the oxygen pathway during maximal exercise among overweight/obese individuals with type 2 diabetes free from complications, in comparison with a group of matched overweight/obese individuals without diabetes, specifically concentrating on the effects on pulmonary function and muscle oxygenation. Fifteen overweight/obese adults with type 2 diabetes [glycated hemoglobin (HbA1c) = 8.3 ± 1.2%] and 15 matched overweight/obese adults without diabetes underwent pre- and post exercise lung function assessment. A maximal incremental exercise test was conducted, monitoring muscle oxygenation using near-infrared spectroscopy and collecting arterial blood gas samples. Both groups exhibited normal lung volumes at rest and after exercise. Spirometric lung function did not significantly differ pre- and post exercise in either group. During maximal exercise, the type 2 diabetes group showed significantly lower augmentation in total hemoglobin and deoxygenated hemoglobin compared with the control group. Despite comparable usual physical activity levels and comparable heart rates at exhaustion, the type 2 diabetes group had a lower peak oxygen consumption than controls. No significant differences were found in arterial blood gas analyses ([Formula: see text], [Formula: see text], [Formula: see text], and [Formula: see text]) between the groups. Individuals with type 2 diabetes free from complications displayed normal pulmonary function at rest and post exercise. However, impaired skeletal muscle oxygenation during exercise, resulting from reduced limb blood volume and altered muscle deoxygenation, may contribute to the lower V̇o2peak observed in this population.NEW & NOTEWORTHY Individuals with type 2 diabetes free from micro- and macrovascular complications have normal resting pulmonary function, but their V̇o2peak is impaired due to poor skeletal muscle oxygenation during exercise. Tailoring exercise regimes for this population should prioritize interventions aimed at enhancing muscle oxygenation and blood flow improvement.
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Affiliation(s)
- Islem Jlali
- Univ. Lille, Univ. Artois, Univ. Littoral Côte d'Opale, ULR 7369 - URePSSS - Unité de Recherche Pluridisciplinaire Sport Santé Société, Lille, France
| | - Imen Touil
- Pulmonology Department, Taher Sfar Hospital, Mahdia, Tunisia
| | | | - Mohamed Amine Bouzid
- UR15JS01: Education, Motricité, Sport et Santé (EM2S), High Institute of Sport and Physical Education, University of Sfax, Sfax, Tunisia
| | - Omar Hammouda
- Interdisciplinary Laboratory in Neurosciences, Physiology and Psychology: Physical Activity, Health and Learning (LINP2), UFR STAPS, UPL, Paris Nanterre University, Nanterre, France
| | - Elsa Heyman
- Univ. Lille, Univ. Artois, Univ. Littoral Côte d'Opale, ULR 7369 - URePSSS - Unité de Recherche Pluridisciplinaire Sport Santé Société, Lille, France
- Institut Universitaire de France (IUF), Paris, France
| | - Pierre Fontaine
- Department of Diabetology, University Hospital, Lille, France
| | - Hamdi Chtourou
- Higher Institute of Sport and Physical Education of Sfax, University of Sfax, Sfax, Tunisia
- Physical Activity, Sport, and Health, UR18JS01, National Observatory of Sport, Tunis, Tunisia
| | | | - Georges Baquet
- Univ. Lille, Univ. Artois, Univ. Littoral Côte d'Opale, ULR 7369 - URePSSS - Unité de Recherche Pluridisciplinaire Sport Santé Société, Lille, France
| | - Sémah Tagougui
- Univ. Lille, Univ. Artois, Univ. Littoral Côte d'Opale, ULR 7369 - URePSSS - Unité de Recherche Pluridisciplinaire Sport Santé Société, Lille, France
- Montreal Clinical Research Institute, Montreal, Quebec, Canada
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Fang NN, Wang ZH, Li SH, Ge YY, Liu X, Sui DX. Pulmonary Function in Metabolic Syndrome: A Meta-Analysis. Metab Syndr Relat Disord 2022; 20:606-617. [PMID: 36125502 DOI: 10.1089/met.2022.0045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
Background: This study aims to systematically evaluate the association between metabolic syndrome (MS) and pulmonary function through meta-analysis. Methods: Electronic databases, including PubMed, Embase, Web of Science, and Cochrane Library, were systematically searched to obtain articles associated with MS and lung function published before December 31, 2021. According to the including and excluding criteria, certain studies were obtained and data were extracted. The Newcastle Ottawa Scale was used to evaluate the quality of the studies. A pooled standardized mean difference (SMD) was calculated by means of random-effects meta-analysis. Different effect models were used according to the heterogeneity. Meta-regression and sensitivity analyses were performed to examine the possible sources of heterogeneity. The Begg's funnel plot and Egger's test were used to evaluate publication bias. Analyses were performed using Stata MP, version14.0 (StataCorp LP, College Station, TX, USA). Results: A total of 15 studies, involving 10,285 cases of MS and 25,416 cases of control, were included in this meta-analysis on the relationship between MS and forced vital capacity (FVC). The pooled SMD for FVC was -0.247 (95% CI = -0.327 to -0.2167, P < 0.001) using random effect model, indicating the decrease of FVC in the patients with MS. In the same studies, the pooled SMD for forced expiratory volume in 1 sec (FEV1) was -0.205 (95% CI = -0.3278 to -0.133, P < 0.001), indicating the decrease of FEV1 also existed in the MS cases. A total of 13 studies, involving 8167 cases of MS and 19,788 cases of control, were included in this meta-analysis on the relationship between MS and FEV1/FVC. The pooled SMD for FEV1/FVC was 0.011 (95% CI = -0.072 to 0.093, P = 0.798) using random effect model, indicating that there was no significant difference between the patients with MS and the control. After introducing the diastolic blood pressure and glycemia into the regression model of the relationship between MS and FVC, the variance of the studies (tau2) decreased from 0.0190 to 0.006694 and 0.007205, which could explain 66.70% and 78.04% of the sources of heterogeneity, and the P values were 0.038 and 0.023. The results suggested that hypertension (diastolic pressure) and hyperglycemia were the factors linked to the heterogeneity among the included studies on both FVC and FEV1. The Begg's funnel plot and Egger's test both showed no evidence of publication bias. Conclusions: Our results show that FVC and FEV1 decrease in MS patients, while FEV1/FVC has no significant difference compared with the control group. It indicates that the patients with MS have restrictive ventilatory functional disturbance. Meta-regression analysis suggests that hypertension (diastolic pressure) and hyperglycemia are the factors linked to the heterogeneity among the included studies on both FVC and FEV1.
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Affiliation(s)
- Ning-Ning Fang
- Department of Anesthesiology, Qilu Hospital of Shandong University, Jinan, Shandong, China
| | - Zhi-Hao Wang
- Department of Geriatric Medicine, Qilu Hospital of Shandong University, Jinan, Shandong, China.,Key Laboratory of Cardiovascular Proteomics of Shandong Province, Qilu Hospital of Shandong University, Jinan, Shandong, China
| | - Shao-Hua Li
- Department of Cardiology, Shandong Provincial Hospital of Shandong University, Jinan, Shandong, China
| | - Yu-Yan Ge
- Department of Anesthesiology, Qilu Hospital of Shandong University, Jinan, Shandong, China
| | - Xin Liu
- Department of Anesthesiology, Qilu Hospital of Shandong University, Jinan, Shandong, China
| | - Dong-Xin Sui
- Department of Respiration, The Second Hospital of Shandong University, Jinan, Shandong, China
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Furian M, Tannheimer M, Burtscher M. Effects of Acute Exposure and Acclimatization to High-Altitude on Oxygen Saturation and Related Cardiorespiratory Fitness in Health and Disease. J Clin Med 2022; 11:jcm11226699. [PMID: 36431176 PMCID: PMC9697047 DOI: 10.3390/jcm11226699] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2022] [Revised: 11/08/2022] [Accepted: 11/09/2022] [Indexed: 11/16/2022] Open
Abstract
Maximal values of aerobic power (VO2max) and peripheral oxygen saturation (SpO2max) decline in parallel with gain in altitude. Whereas this relationship has been well investigated when acutely exposed to high altitude, potential benefits of acclimatization on SpO2 and related VO2max in healthy and diseased individuals have been much less considered. Therefore, this narrative review was primarily aimed to identify relevant literature reporting altitude-dependent changes in determinants, in particular SpO2, of VO2max and effects of acclimatization in athletes, healthy non-athletes, and patients suffering from cardiovascular, respiratory and/or metabolic diseases. Moreover, focus was set on potential differences with regard to baseline exercise performance, age and sex. Main findings of this review emphasize the close association between individual SpO2 and VO2max, and demonstrate similar altitude effects (acute and during acclimatization) in healthy people and those suffering from cardiovascular and metabolic diseases. However, in patients with ventilatory constrains, i.e., chronic obstructive pulmonary disease, steep decline in SpO2 and V̇O2max and reduced potential to acclimatize stress the already low exercise performance. Finally, implications for prevention and therapy are briefly discussed.
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Affiliation(s)
- Michael Furian
- Pulmonary Division, University Hospital Zurich, 8092 Zurich, Switzerland
- Research Department, Swiss University of Traditional Chinese Medicine, 5330 Bad Zurzach, Switzerland
| | - Markus Tannheimer
- Department of Sport and Rehabilitation Medicine, University of Ulm, 89075 Ulm, Germany
| | - Martin Burtscher
- Department of Sport Science, University of Innsbruck, 6020 Innsbruck, Austria
- Correspondence:
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Díez-Manglano J, Asìn Samper U. Pulmonary function tests in type 2 diabetes: a meta-analysis. ERJ Open Res 2021; 7:00371-2020. [PMID: 33569495 PMCID: PMC7861023 DOI: 10.1183/23120541.00371-2020] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2020] [Accepted: 09/30/2020] [Indexed: 12/18/2022] Open
Abstract
OBJECTIVES The aim of this study was to determine the association between type 2 diabetes (T2D) and pulmonary function tests. METHODS After conducting an exhaustive literature search, we performed a meta-analysis. We employed the inverse variance method with a random-effects model to calculate the effect estimate as the mean difference (MD) and 95% confidence interval (CI). We calculated the heterogeneity with the I2 statistic and performed a meta-regression analysis by sex, body mass index (BMI), smoking and geographical region. We also conducted a sensitivity analysis according to the studies' publication date, size of the T2D group and the study quality, excluding the study with the greatest weight in the effect. RESULTS The meta-analysis included 66 studies (one longitudinal, two case-control and 63 cross-sectional), with 11 134 patients with T2D and 48 377 control participants. The pooled MD (95% CI) for the predicted percentage of forced expiratory volume in 1 s (FEV1), forced vital capacity (FVC), forced expiratory flow at 25-75% of FVC, peak expiratory flow, and diffusing capacity of the lung for carbon monoxide were -7.15 (95% CI -8.27, -6.03; p<0.001), -9.21 (95% CI -11.15, -7.26; p<0.001), -9.89 (95% CI -14.42, -5.36; p<0.001), -9.79 (95% CI -13.42, -6.15; p<0.001) and -7.13 (95% CI -10.62, -3.64; p<0.001), respectively. There was no difference in the ratio of FEV1/FVC (95% CI -0.27; -1.63, 1.08; p=0.69). In all cases, there was considerable heterogeneity. The meta-regression analysis showed that between studies heterogeneity was not explained by patient sex, BMI, smoking or geographical region. The findings were consistent in the sensitivity analysis. CONCLUSIONS T2D is associated with impaired pulmonary function, independently of sex, smoking, BMI and geographical region. Longitudinal studies are needed to investigate outcomes for patients with T2D and impaired pulmonary function.
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Affiliation(s)
| | - Uxua Asìn Samper
- Dept of Internal Medicine, University Hospital Miguel Servet, Zaragoza, Spain
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Saini M, Kulandaivelan S, Bansal VK, Saini V, Sharma S, Kaur J, Sondh A. Pulmonary Pathology Among Patients with Type 2 Diabetes Mellitus: An Updated Systematic Review and Meta-analysis. Curr Diabetes Rev 2020; 16:759-769. [PMID: 31333139 DOI: 10.2174/1573399815666190716130324] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2019] [Revised: 05/18/2019] [Accepted: 06/26/2019] [Indexed: 12/21/2022]
Abstract
BACKGROUND Restrictive lung pathology was reported in the previous meta-analysis among patients with Type 2 Diabetes mellitus (T2DM) which is date back to 2010. OBJECTIVE To see the effect of T2DM on pulmonary functions through updated systematic review and meta-analysis. DATA SOURCE PubMed. STUDY ELIGIBILITY CRITERIA English language case-control or cross-sectional studies, published between 1 January 2010 to 31 August 2018. PARTICIPANTS AND INTERVENTION T2DM and non-diabetic subjects were compared for at least one of the pulmonary function variables i.e. Forced expiratory volume in 1st second (FEV1), % FEV1, Forced vital capacity (FVC), % FVC and % FEV1/FVC. STUDY APPRAISAL AND SYNTHESIS METHODS Methodological quality of the study was assessed using Newcastle-Ottawa Quality Assessment Scale. Meta-analysis was done using Review Manager 5.3 (RevMan 5.3) and meta-regression was conducted using R statistical software. RESULTS We selected 22 articles that met our inclusion and exclusion criteria. Results reveal that among patients with T2DM all variables were reduced except %FEV1/FVC which shows statistically nonsignificant results with P=0.46. This confirms that T2DM patients have a restrictive type of lung pathology. LIMITATION Only articles from the PubMed database were included. Conclusion and Implications of Key Findings: This review affirms the existing evidence of restrictive pathology among patients with T2DM. The future study could be conducted to see the effect of various rehabilitation protocols on pulmonary function among patients with T2DM.
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Affiliation(s)
- Minaxi Saini
- Mother Teresa Saket College of Physiotherapy, Chandimandir, Panchkula, India
| | | | | | - Vikram Saini
- Maharaja Agrasen Medical College, Agroha, Haryana, India
| | - Suresh Sharma
- Department of Statistics, Panjab University, Chandigarh, India
| | - Jaspreet Kaur
- Guru Jambheshwar University of Science and Technology, Hisar, Haryana, India
| | - Aparajita Sondh
- Mother Teresa Haryana Saket Council, Panchkula, Haryana, India
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Wilms B, Ernst B, Schmid SM, Thurnheer M, Weisser B, Schultes B. Spiroergometric assessment of cardiorespiratory fitness in subjects with severe obesity: A challenge of reference. Nutr Metab Cardiovasc Dis 2019; 29:1382-1389. [PMID: 31558415 DOI: 10.1016/j.numecd.2019.07.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2019] [Revised: 07/10/2019] [Accepted: 07/18/2019] [Indexed: 11/15/2022]
Abstract
BACKGROUND AND AIMS Severe obesity is associated with poor physical performance but objective data are scarce. METHODS AND RESULTS Bicycle spiroergometry data with focus on peak oxygen uptake (V˙O2,peak) and workload (Wpeak) from 476 subjects with severe obesity (BMI ≥ 35.0 kg/m2; 70% women) were analysed. In a first step, V˙O2,peak values were compared with reference values calculated upon different formulas (Wassermann; Riddle). Thereafter, multivariate regression analyses were performed to identify determinants of cardiorespiratory fitness. Cardiorespiratory fitness reference classes for V˙O2,peak and Wpeak were established by stratifying the sample upon identified determinants. Absolute V˙O2,peak (1.87 ± 0.47 vs. 2.40 ± 0.59 l/min) and Wpeak (131 ± 26 vs. 168 ± 44 W) were lower in women than men (both p<0.001). Same pattern was found for relative V˙O2,peak and Wpeak, respectively (both p < 0.05). In women, measured V˙O2,peak was lower than predicted by Wasserman (p < 0.001) but not by Riddle (p = 0.961). In men, V˙O2,peak was lower than calculated by both Wasserman and Riddle formulas (both p ≤ 0.003). Multivariate analyses revealed height and age to be the main determinants of cardiorespiratory fitness in both sexes. Subsequent statistical analyses of calculated reference fitness classes revealed that V˙O2,peak and Wpeak differed between the age- and height-defined groups in both sexes (all p < 0.001). CONCLUSION Data indicate that the evaluation of cardiorespiratory fitness in subjects with severe obesity is largely biased by selected references values for comparison. Our newly established reference fitness classes upon height and age might be helpful in the clinical context when dealing with obese patients.
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Affiliation(s)
- Britta Wilms
- Medizinische Klinik 1, Universitätsklinikum Schleswig-Holstein, Campus Lübeck, Lübeck, Germany; German Center for Diabetes Research (DZD), Neuherberg, Germany.
| | - Barbara Ernst
- Metabolic Center St. Gallen, friendlyDocs Ltd., St. Gallen, Switzerland
| | - Sebastian M Schmid
- Medizinische Klinik 1, Universitätsklinikum Schleswig-Holstein, Campus Lübeck, Lübeck, Germany; German Center for Diabetes Research (DZD), Neuherberg, Germany
| | | | | | - Bernd Schultes
- Metabolic Center St. Gallen, friendlyDocs Ltd., St. Gallen, Switzerland
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Ma CM, Liu Q, Li ML, Ji MJ, Zhang JD, Zhang BH, Yin FZ. The Effects of Type 2 Diabetes and Postoperative Pneumonia on the Mortality in Inpatients with Surgery. Diabetes Metab Syndr Obes 2019; 12:2507-2513. [PMID: 31819576 PMCID: PMC6890188 DOI: 10.2147/dmso.s232039] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2019] [Accepted: 11/19/2019] [Indexed: 01/19/2023] Open
Abstract
OBJECTIVE The aim of the study was to explore the relationship between type 2 diabetes (T2DM) and postoperative pneumonia, and the effects of T2DM and postoperative pneumonia on the mortality in inpatients with surgery. METHODS A retrospective study was conducted on 43,174 inpatients with surgery in The First Hospital of Qinhuangdao. These patients were divided into four groups according to T2DM and postoperative pneumonia, Group A subjects without T2DM and postoperative pneumonia, Group B subjects with T2DM only, Group C subjects with postoperative pneumonia only and Group D subjects with T2DM and postoperative pneumonia. In-hospital mortality was collected. RESULTS The incidences of postoperative pneumonia were higher in patients with T2DM than patients without T2DM (T2DM 3.2% vs Non-diabetes 1.7%, χ 2=36.219, P<0.001). The mortalities were 0.3% in Group A, 0.3% in Group B, 4.6% in Group C and 8.6% in Group D. In multiple logistic regression analysis, adjusted for sex, age, emergency admissions, coronary heart disease, heart failure, chronic kidney disease, hypoproteinemia, stroke and transient ischemic attack, the mortalities of Group C and Group D were 4.515 (95% CI: 2.779~7.336, P<0.001) times and 8.468 (95% CI: 3.567~20.099, P<0.001) times than the mortality of Group A. CONCLUSION T2DM is susceptible to postoperative pneumonia. The mortality increased in patients with postoperative pneumonia. When patients with T2DM and postoperative pneumonia at the same time, the mortality increased further. In T2DM patients with postoperative pneumonia, perioperative management should be improved for patient safety.
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Affiliation(s)
- Chun-ming Ma
- Department of Endocrinology, The First Hospital of Qinhuangdao, Qinhuangdao, Hebei066000, People’s Republic of China
| | - Qin Liu
- Department of Endocrinology, The First Hospital of Qinhuangdao, Qinhuangdao, Hebei066000, People’s Republic of China
| | - Ming-li Li
- Department of Endocrinology, The First Hospital of Qinhuangdao, Qinhuangdao, Hebei066000, People’s Republic of China
| | - Mei-jing Ji
- Department of Endocrinology, The First Hospital of Qinhuangdao, Qinhuangdao, Hebei066000, People’s Republic of China
| | - Jian-dong Zhang
- Department of Endocrinology, The First Hospital of Qinhuangdao, Qinhuangdao, Hebei066000, People’s Republic of China
| | - Bo-hua Zhang
- Department of Endocrinology, The First Hospital of Qinhuangdao, Qinhuangdao, Hebei066000, People’s Republic of China
| | - Fu-Zai Yin
- Department of Endocrinology, The First Hospital of Qinhuangdao, Qinhuangdao, Hebei066000, People’s Republic of China
- Correspondence: Fu-Zai Yin Department of Endocrinology, The First Hospital of Qinhuangdao, Qinhuangdao, Hebei066000, People’s Republic of ChinaTel +86-335-5908368Fax +86-335-3032042 Email
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Okur I, Taspinar B, Telli Atalay O, Pasali Kilit T, Toru Erbay U, Okur EO. The effects of type 2 diabetes mellitus and its complications on physical and pulmonary functions: A case-control study. Physiother Theory Pract 2018; 36:916-922. [PMID: 30183496 DOI: 10.1080/09593985.2018.1517198] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
AIMS This study was planned to determine the effects of type 2 diabetes mellitus (DM) and its complications on physical and pulmonary functions. Methods: A total of 110 individuals aged 40-65 years were included in the study, 58 with type 2 DM (study group) and 52 without DM (control group). Physical activity level, functional capacity, pulmonary function, and comorbidity levels were compared between the groups. Results: The mean age of the individuals was 52.42 ± 5.88 years. Six-minute walk test distance was 507.2 ± 51.70 m in the study group and 532.23 ± 50.32 m in the control group (p < 0.05, Cohen's d = 0.49). The pulmonary function test results of the study and control groups were determined as forced vital capacity (FVC) (%): 99.17 ± 14.13 and 104.65 ± 16.01 (p > 0.05), forced expiratory volume in one second (FEV1) (%): 96.78 ± 14.43 and 99.73 ± 15.80 (p > 0.05), and FEV1/FVC ratio: 81.97 ± 4.62 and 80.16 ± 5.27 (p > 0.05), respectively. The Charlson Comorbidity Index scores of the study and control groups were 1.83 ± 0.82 and 0.12 ± 0.32 (p < 0.05). Conclusions: Type 2 DM was associated with lower functional capacity and higher rates of comorbid diseases. Therefore, potential causes of these parameters should be considered in the rehabilitation of type 2 diabetic patients.
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Affiliation(s)
- Ismail Okur
- Department of Physiotherapy and Rehabilitation, Dumlupinar University , Kutahya, Turkey
| | - Betul Taspinar
- Department of Physiotherapy and Rehabilitation, Dumlupinar University , Kutahya, Turkey
| | - Orcin Telli Atalay
- School of Physical Therapy and Rehabilitation, Pamukkale University , Denizli, Turkey
| | - Turkan Pasali Kilit
- Department of Internal Medicine, Faculty of Medicine, Dumlupinar University , Kutahya, Turkey
| | - Umran Toru Erbay
- Department of Chest Diseases, Faculty of Medicine, Dumlupinar University , Kutahya, Turkey
| | - Eda Ozge Okur
- Department of Physiotherapy and Rehabilitation, Dumlupinar University , Kutahya, Turkey
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