RESULTS OF AEROBIC EXERCISE ON KIDNEY FUNCTION AMONG TYPE II DIABETES MELLITUS PATIENTS IN KANO METROPOLIS, NIGERIA

Abstract

Type 2 Diabetes is one of the most common physiological disorders worldwide. Kidney's role in and associated problems linked to T2DM has long been acknowledged as an important factor in the long term effects of the disease. Aerobic exercises has proved beneficial to blood pressure and glucose control in patients with diabetes, however, the potentials of aerobic exercise as a tool to support exercise-based prevention activities for kidney degeneration among diabetics is uncommon. The purpose of this study was to investigate the effect of bench-step aerobics (BSA) on Blood pressure, blood sugar, albumin and creatinine among type 2 diabetes mellitus patients in Kano, Nigeria. Thirty male T2DM patients were randomly assigned to one of two groups that performed 30 min of BSA or served as a control group that did not perform the bench step aerobics but continue with drugs and activities of daily living. The training was performed at 55% maximal heart rate (HR max), which was also in line with the ACSM recommendation of 50-60% of HR max (ACSM, 2000). Direct assessments for the four variable (blood sugar, blood pressure, albumin and creatinine) were performed on both groups (experimental and control) before the commencement of the training, at week four, week eight and after week twelve of the training. Statistical procedures selected for the analysis included means and standard deviations. The hypotheses were tested with inferential statistics of two-way repeated measure ANOVA. The result showed significant difference in the mean level of Creatinine P< 0.003, and in systolic and diastolic blood pressure P < 0.025. No significant difference was observed in the blood sugar P > 0.684 and albumin P > 0.487. BSA is recommended as an exercise modality effective for improving the selected body parameters of diabetic patients, especially their blood pressure and creatinine levels. Therefore, the inclusion of BSA as an exercise adjunct for managing T2DM and kidney function was recommended but for relatively longer number of weeks since most observed significance was made between the baseline and the twelfth week of exercise.

CHAPTER ONE INTRODUCTION

1.10     Background of the Study

Type 2 Diabetes Mellitus (T2DM) is a disease that is characterized by an abnormal accumulation of sugar in the blood affecting almost all functions of the body and it is the most common and fastest growing form of diabetes globally attracting considerable medical attention (Anas, 2011), it has some specific long-term complication affecting the retina, kidney, and nervous system (International Diabetes Federation, (IDF), 2014). An increasing number of people presenting Type 2 diabetes mellitus very late in Kano state is raising concern because sometimes the patients are faced with further complications. The consistent recommendations for patients on lifestyle adjustment with emphasis on physical activity made it further necessary that the physical activities should be cost effective and practically possible. One other factor is the large patients turn out in major hospitals within Kano metropolis that implied a significant health challenge that requires serious attention and actions to alleviate the disease and prevent complications. Also the number of T2DM patients presenting kidney disease and other cardio-metabolic complications on several visits to hospitals has made it imperative to professionals in the field of exercise and sports science to participate in intervening to reduce the number of T2DM patients deteriorating to kidney disease. Diabetics are subject to different types of complications based on duration, age at onset, lifestyle and compliance to medical advice and prescribed drugs. It is expected that exercise in general and aerobic exercise in particular has significant benefit in the prevention and management of diabetes. The choice of physical activity remained a challenge to many individuals both healthy and those facing challenges of debilitating ailments such as obesity, diabetes, hypertension and other cardiovascular diseases that may subject patients to higher risks such as kidney disease and end stage renal disease.

Kidney disease takes time to develop manifesting in different presentations that if effectively monitored the progression to end stage renal disease could be prevented or delayed. Having T2DM and high blood pressure increases the chances of developing other diabetes-related diseases, such as kidney disease and retinopathy. A high level of sugar in blood can cause problems in many parts of the body, including the heart, kidneys, eyes, and brain. Over time, this can lead to kidney disease and kidney failure.  The combination of hypertension and T2DM is particularly lethal and can significantly raise the risk of having a heartattack or stroke. Most people with early kidney damage do not have symptoms and the best way to determine early kidney damage is through a urine test to check for protein in the urine called albumin and Creatinine that are measured to determine whether a diabetic patient has incipient nephropathy. Urinary albumin and urinary creatinine are measured in a random urine collected and are used in the diagnosis and treatment of diseases involving the liver and/or kidneys. Increased microalbuminuria is a sign of renal disease and may be predictive of nephropathy risk in patients with TDM and it is also associated with hypertension and cardiac disease. Creatinine is produced by creatine and creatinine phosphate as a result of muscle metabolic processes. It is then excreted by glomerular filtration during normal renal function (Martin, 2011). Creatinine may be measured in both serum and urine. Creatinine measurement is useful in the diagnosis and treatment of renal diseases, in monitoring renal dialysis, and as a calculation basis for other urinary analytes (e.g., total protein and microalbumin).Over time, the high blood glucose levels associated with uncontrolled diabetes can cause a number of complications, including blindness, heart disease, kidney disease, nerve damage and erectile dysfunction (Wolf & Ritz,2003). Proper T2DM care and management can prevent or delay the onset of these complications, (Ontario Local Health Integration Network LHIN, 2013). Diabetic complications are mainly a consequence of macrovascular and microvascular damages of the target organs, (Shravya, Sharanm, Bandi, Suresh, Preetham & Mallikarjuna, 2012). Managing and or avoiding possible short term as well as long term problems and complications of diabetes is most important and these includes patient education, dietary support, prescribed exercise and self glucose monitoring with the goal of maintaining blood glucose levels and preventing complications (Anas, 2011). To achieve a proper management of diabetes may require a combination of diet, exercise and weight loss, in addition, given the associated higher risks of cardiovascular disease, lifestyle modifications should be undertaken to control blood pressure and cholesterol by exercising more and consuming balanced diet

With the progression of T2DM, the small blood vessels in the kidneys are injured and therefore the kidneys cannot clean the blood properly. The body will then retain more water and salt than it should, protein may then be presented in the patient‘s urine and often waste materials will build up in the blood. The earliest sign of diabetic kidney disease is an increased excretion of albumin in the urine which is present long before the usual tests are done to show evidence of kidney disease. As the kidneys fail, blood urea nitrogen (BUN) levels will rise as well as the level of creatinine in your blood. Measuring the levels of creatinine in the bloodstream and in the urine can be helpful for tracking the progression of diabetic kidney disease. The determination of creatinine clearance can reflect the status of renal plasma flow or renal microvascular disease as well as the status of chronic kidney disease in T2DM, since creatinine clearance or glomerular filtration rate correlates directly with renal plasma flow (Futrakul and Futrakul, 2011). The variables in this study are blood sugar, urine albumin, urine creatinine and blood pressure of the T2DM patients

1.11     Statement of the Problem

As at 2013, there were more than 382 million people living with T2DM worldwide that has implication for significant impact on the health, quality of life and life expectancy of patients as well as on the health care system (Pandey, Tripathy, Pandey, Srivatava & Goswani, 2011). T2DM is a leading public health problem with increasing incidence and long term complications such as diabetic nephropathy, diabetic neuropathy and diabetic retinopathy, and according to the World Health Organisation

(WHO, 2016), the prevalence of diabetes mellitus has reached epidemic proportions.  T2DM often goes undiagnosed for many years because early symptoms are not severe, and it is estimated that by the time someone is diagnosed with Type 2 diabetes, the disease has been present for four to seven years. Since diabetes may have been present for some time, the chances for kidney damage increase and that 8% of new patients diagnosed with T2DM have nephropathy, or kidney damage (Bakris, Sharma, and Ecelbarger, 2011). Given the enormous public health and economic burden posed by the global epidemic of T2DM, intervention in the stages of the disease process to prevent progression to kidney disease and its vascular complications would be a most sensible approach (Rosentock, 2007). It is expected that diabetics can live for more than 20 years with compliance to proper treatment and lifestyle adjustment (Ulasi and Ijoma, 2010), while being a complex disease Type 2 Diabetes Mellitus (T2DM) involves multiple organs and tissues with its progression and the onset of secondary complications (Dabla, 2010). The alarming increase in the number of patients diagnosed with most particularly T2DM increased from 6% as at 1999 to 10% in 2006, particularly in Kano, Kaduna, Borno, and Sokoto States, and it was ranked third in prevalence in Kano State among the most frequently nominated rural health priorities (Dutse, 2006).

The rising prevalence of kidney disease among T2DM patients and the increasing risk of degeneration to chronic kidney disease remains a global public health challenge particularly in developing countries, including our local environments where patients present late and may already be in need of renal replacement or at best require hemodialysis. Increased urinary albumin excretion is a strong predictor for the development of overt diabetic nephropathy and overall cardiovascular morbidity and mortality in patients with T2DM (Lazarevic, Antic, Vlahovic, Djordjevic, Zvezdanovic, & Stefanovic, 2007). It has been recorded recently that about 15,000 new cases of kidney failure occur every year in Nigeria and that 30 million Nigerians are suffering from Kidney disease most of whom had suffered diabetes and specifically T2DM. Patients are paying high charges for dialysis every week while costs of transplant varies from hospitals, patients also need so much money to get immunosuppressive drugs monthly after a successful transplant (Obinna, 2013). Kidney disease has remained at the background, while patients continue to die without any form of assistance (Usman, Umar, Shehu, Wali, and Nasir (2012); Obinna, 2013). The magnitude of the existing burden of illness caused by renal failure, the projections for increasing incidence of ESRD, and the limitations of the existing treatments for renal insufficiency in Nigeria all point to the need for interventions aimed at prevention of ESRD (Alebiosu et al, 2006). Early detection of modifiable risk factors and other preventive or management strategies may reduce this prevalence and burden among which physical activity may be beneficial. Kidney function and associated problems linked to T2DM is a very important issue in long term effects of the disease (Christian & John, 2002). Currently available therapies for diabetes management do not address the various components of the disease that have to be treated, to prevent progression and to improve overall mortality and morbidity (Family Doctor, 2014). People living with T2DM are more vulnerable to various forms of both short- and long-term complications, which often lead to premature death, the tendency of increased morbidity and mortality because of the commonness of its insidious onset and late recognition, especially in low resource developing countries (Olokoba,Obateru, & Olokoba, 2012). It has been observed that no fewer than six million Nigerians are living with T2DM and that it has accounted to several deaths (Adebayo, 2013). Renal function complications are the leading cause of death in T2DM patients and the resulting cardiovascular complications are responsible for more than seventy percent (70%) of deaths and it is also responsible for the increase in the number of patients going blind and suffering from stroke and kidney diseases (Adler, Stevens, Manley, Bilous, Cull & Holman, 2003; Dutse, 2006).

Hawkins, Richardson, Fried, Arena and Kriska, (2011) observed that kidney disease is a condition characterized by the deterioration of the kidney's ability to remove waste products from the body, although treatments to slow the progression of the disease are available chronic kidney disease may eventually lead to a complete loss of kidney function. Studies have shown that physical activities of moderate intensity may have renal benefits while few studies have examined the effects of total movement on kidney function (Hawkins, 2010). Han, Bai, Lin, Sun, and Chen, (2010) explained that decline in kidney function is an independent predictor for cardiovascular events and death among type 2 diabetics. Moreover, the majority of currently available diabetes drugs are plagued with serious and life-threatening side effects that limits their long term usage, which is a major disadvantage because of the life-long nature of the disease. (Padmalayam, 2014)

A number of lifestyle factors and genetics are known to be important to its development, these includes insufficient physical activity, sedentary lifestyle, cigarette smoking and generous consumption of alcohol (Olokoba,Obateru, and Olokoba, 2012).

Prudent life style changes have been shown to significantly reduce the risk of progression in individuals with T2DM, although lifestyle modifications are difficult to maintain, there is evidence that intensive intervention results in continued preventive benefit after the stopping of structured counseling (Dutse, 2006). A number of drug therapies, have also been proven effective in preventing progression, but unresolved issues still remain. Specifically, whether large numbers of individuals with T2DM who may not necessarily progress to kidney disease should be exposed to the risk of pharmacological adverse effects remains a topic of discussion and debate (Rosentock, 2007). Studies have shown that there is significant reduction in the incidence of T2DM with a combination of regular exercise, maintenance of body mass index of 25 kg/m², eating high fibre food and unsaturated fat and diet low in saturated and trans-fats, abstinence from smoking and less or non consumption of alcohol (Olokoba,Obateru, and Olokoba, 2012). Low awareness, lack of physical exercise and increased consumption of foods high in fats and sugars were identified as reasons why Nigeria has a high population of people suffering from diabetes than those living with HIV/AIDS, which affects just 3.5 million Nigerians (Adebayo, 2013; Obinna, 2013). However, patients with diabetic complications remain at high risk of complications as available therapies may not successfully enable all patients to reach glycaemic goals and the drugs with new mechanisms of action are not available (Deshpande, Harris-Hayes and Schootman, 2008). Patients may face spikes in blood glucose, weight gain, hypoglycaemia, and a loss of effectiveness of their treatments and often they have to struggle to make the necessary life style changes to control blood sugar levels, while medications have limitations and can have adverse gastrointestinal side effects (Genc, Karadurmus, Kisa, Tapan, Naharci, Sonmez and Dogru, 2010).

Population based studies of the United States population have shown that individuals with diabetic kidney disease are less active than the general population, an examined cross-sectional data showed that physically inactive individuals had over twice the prevalence of diabetic kidney disease compared to very active individuals (Toyama. Sugiyama, Oka, Sumida, & Ogawa, 2010). Therefore, there is an urgent need for approaches which are effective in all-around diabetes management and are at the same time safe enough for long time use.Exercise is recommended for the management of T2DM and in addition to being effective in improving glycaemic control it may exert beneficial effects in preserving beta-cell function (Rosentock, 2007), but its effect on diabetic nephropathy are not clear, it may be assumed that appropriate exercise improves early attenuation of inflammation and oxidative damage in diabetic nephropathy.

Exercise is perhaps the most under utilised way to help prevent onset and or control diabetes and delay further, which except contrary to medical advice may be an effective non therapeutic measure in the management of diabetes. Plowman and Smith (2003), opined that exercise is directly related to the body‘s demands and functions and it affects psychological, nutritional, behavioural, and physiological aspects in humans. Therefore, exercise effects the development of the body and serves as a means of managing health problems. The prohibitive costs of diabetic complication therapies predispose many patients to complications including kidney disease and this underscores the need for preventive measures to reduce the impact of diabetes and consequent risks of kidney disease. This forms the basis for this research and aerobic exercise interventions may prove effective in preventing and controlling these complications. The chance of developing T2DM as well as its complications may be cut by between 30 and 40 per cent with just three and a half hours of exercise a week, half an hour‘s exercise a day and that at least 150 minutes of aerobic activity in a week, and at least an hour of musclestrengthening had the best results (Leehey, Moinuddin, Bast, Qureshi, Jelinek, Cooper, Edwarsd, Smith & Collins, 2009). Awareness of the potential benefits of increased physical activity for improved kidney function as just an hour‘s work-out every seven days can reduce the risk of kidney disease by 13 per cent (Medical Express, 2014; Snowling & Hopkins, 2006)..

Jogging, running, cycling and recreational sports are effective forms of physical activities that may improve general body conditions and enhance kidney function but they have not always been attractive modes of exercise to adult diabetics in Kano and the constraint of decision on the right choice of exercise and making it a daily routine in their lives is a challenge. Making aerobic exercise affordable and accessible to diabetics may ensure their regular participation, especially when it can be performed indoors and at home such as the bench step aerobic which can be performed on the local women‘s stool, bench and door steps. Physical activity and known regular exercise can prevent diabetes and effectively manage risk factors, but most diabetics in Kano do not exercise enough to beneficially manage the risk. Tailored aerobic exercise has shown promise as a means to increase fitness and reduce risk, but optimal implementation practices remain unknown especially in communities with reduced access to exercise and or fitness facilities. Moderate aerobic exercises have proved to be beneficial tools to achieve stable blood pressure and glucose control in patients with diabetes. However, the potentials of bench step aerobic exercise as a tool to support exercise-based prevention activities for kidney degeneration among diabetics is uncommon. Therefore, there was the need to investigate the effects of bench step aerobic training on kidney function among T2DM. patients.

1.3. Research questions

1. What are the effects of bench step aerobic exercise on blood glucose levels of

T2DM patients?

1. What are the effects of bench step aerobic exercise on albumin levels of T2DM patients? iii. What are the effects of bench step aerobic exercise on creatinie levels of T2DM patients?
2. What are effects of bench step aerobic exercise on systolic blood pressure of

T2DM patients?

1. What are effects of bench step aerobic exercise on diastolic blood pressure of

T2DM patients?

1.4 Purpose of the study

This study was designed to determine the effects of bench step aerobic training on:

1. Blood glucose levels of T2DM patients
2. Albumin of T2DM patients iii. Creatinine of T2DM patients iv.    Systolic blood pressure of T2DM patients.
3. Diastolic blood pressure of T2DM patients.

1.5 Basic assumption

1. It was assumed that T2DM patients have problems blood glucose
2. It was assumed that improper blood glucose control may lead to T2DM complications such as hypertension and kidney disease.
3. It was assumed that aerobic exercise would help to control and/or improve the conditions of T2DM patients

1.6 Hypotheses

One major and three sub-hypothesis were formulated for this study:

Major hypothesis:

There is no significant effect of bench step aerobics training on glycaemic status, kidney function and blood pressure of the of T2DM patients.

Sub-hypotheses:

1. There is no significant effect of 12week bench step aerobic exercise on blood glucose status of T2DM patients. ii. There is no significant effect of 12week bench step aerobic exercise on the albumin of T2DM patients

iii. There is no significant effect of 12week bench step aerobic exercise on the creatinine of T2DM patients iv. There is no significant effect of 12week bench step aerobic exercise on systolic blood pressure of T2DM patients.

1. There is no significant effect of 12week bench step aerobic exercise on diastolic blood pressure of T2DM patients.

1.7 Significance of the study

The evidence of the effects of aerobic exercise on kidney function among Type 2 diabetics is very scanty. Few studies have suggested non-exhaustive evidence relating to variable effects of aerobic exercise on Albumin and creatinine which are markers of kidney function among type 2 diabetics. The findings of this study would be beneficial in guiding patient and clinicians on the roles of exercise in the prevention of T2DM complications, and consequent morbidity and mortality rates.

The findings of the study would be a useful tool in planning treatment for type 2 diabetics and other people at risk of kidney diseases and, therefore, possibly bring hope to T2DM patients, their families and other people at risk of kidney problem, who may not afford the high cost of chemotherapy or even attend fitness centres. It is also expected to add to the body of knowledge in the field of exercise and sport science, physical education, sports and exercise medicine, family medicine, community medicine, health educations and preventive medicine. It should also support gymnasium managers and students interested in preventive and management approach to renal complications of

T2DM and related cases.

 

 

 

1.8 Delimitations of the Study

The study is delimited to the following:

1. Male adults diagnosed with T2DM three years or more and do not have any

clinical condition that is contraindicated to exercise

2. Patients who were attending diabetic clinics in Kano City

1.9 Limitations of the Study

The patients of both exercise and control groups were instructed to continue with their medications as prescribed by their physicians, comply by dietary advice and not to participate in any structured physical activity during the study period. Patients in the control group were asked to attend health education sessions weekly where they were lectured on the importance of complying to drug therapy, dietary control, while their blood sugar, blood pressure, albumin and creatinine were assessed. Other medications outside the diabetic drugs being administered to patients were not considered for possible influence in this study other than contraindications to exercise or diabetes.

RESULTS OF AEROBIC EXERCISE ON KIDNEY FUNCTION AMONG TYPE II DIABETES MELLITUS PATIENTS IN KANO METROPOLIS, NIGERIA

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