Physical Activity: a Cheaper and Better Way to Save Lives in Patients with Diabetes

Effective preventive strategies including emphasizing physical activity are needed to reduce cardiovascular disease, the leading cause of mortality and morbidity globally.

Cardiovascular disease still represents the leading cause of mortality and morbidity globally; therefore, effective preventive strategies are needed. It is well known that physical activity (PA), regardless of sex or ethnicity, is associated with increased longevity and decreased risk of CVD. However, studies that have investigated PA exclusively in the elderly remain scarce. Therefore, opportunities remain to refine our understanding of the association of PA and dose of PA, in older people, with risk of CVD. A better understanding of whether exercise in late life may promote healthy aging is essential given the increasing life expectancy and the significant impact of CVD-related morbidity on both the individual and healthcare resources. In the journal, Barbiellini Amidei et al. 3 (CIT) presented the results of the “Progetto Veneto Anziani-ProVA,” a study which evaluated a cohort of 2754 Italians aged 65 years or older (mean age 75.1±7 years), with a baseline assessment in 1995–1997 and follow-up visits at 4 and 7 years and extended surveillance to 2018. In this cohort study, the authors evaluated whether the persistence of an active lifestyle over time, a dose of PA, and increasing or decreasing levels of PA are associated with a reduced risk of CVD (coronary heart diseases, heart failure, and stroke) overall mortality. Twenty minutes of daily moderate to vigorous exercise in early old age (70-75) may best stave off primary heart disease, including heart failure, in late old age (80+). At the start of the study, women were more likely than men to have 4+ coexisting conditions, with a higher prevalence of osteoarthritis, osteoporosis, and chronic kidney disease; chronic obstructive pulmonary disease (COPD) and diabetes were more common among the men.

Participants filled in questionnaires on their physical activity levels at each time point. Moderate physical activity included walking, bowls, and fishing, while vigorous physical activity included gardening, gym work-outs, cycling, dancing, and swimming. Those whose physical activity added up to 20 or more minutes a day were defined as active; those who clocked up less than this were defined as inactive. Men were more likely to be physically active than women. Changes in physical activity patterns were defined as: stable-low (inactive-inactive); high-decreasing (active-inactive); low-increasing (inactive-active); and stable-high (active-active). Other potentially key background information on household income, educational attainment, number of household members, and smoking and drinking was also collected. The health of all the participants was then tracked through linkage to hospital discharge records and death certification up to the end of December 2018. The final analysis included 2754 participants with complete data, of whom 1398 were women (60%).

One thousand thirty-seven new heart diseases, heart failure, and stroke were reported during the monitoring period. Increasing physical activity levels and maintaining an active lifestyle over time were associated with lower risks of cardiovascular disease and death in both men and women. The most significant risk reduction was observed for new coronary heart disease and heart failure cases in late old age. No significant association between physical activity and stroke was observed. Most of the participants had stable active physical activity patterns over time. Patterns of stable-high physical activity were associated with a significantly (52%) lower risk of cardiovascular disease among men than those with stable-low patterns. The most significant benefits seemed to occur at the age of 70. The risk was only marginally lower at the age of 75 and no lower at the age of 80-85, suggesting that improving physical activity earlier in old age might have the most impact, say the researchers. A J-shaped curve for exercise length was also observed, with the sharpest reduction in heart disease and heart failure associated with between 20 and 40 minutes of moderate to vigorous physical activity every day. While the observed associations were strongest among men, the researchers emphasize that women doing more physical activity had consistently lower incidence rates of almost all cardiovascular outcomes even though the risk reduction did not reach statistical significance. Still, risks were significantly reduced when considering overall mortality.

In conclusion, these results suggest that public health policies should be targeted at promoting or beginning physical activity in mid-and early late life, given a probable greater effectiveness in reducing cardiovascular risks. At least 20 minutes of moderate to vigorous physical activity per day should be recommended to achieve the most significant cardiovascular benefits; the study explains that physical activity helps to improve arterial blood flow and may reduce its stickiness and the formation of blood clots. However, the detailed mechanisms by which physical activity can reduce the future risk of cardiovascular disease remain not fully understood. The favorable effect of physical activity may be explained by slowing down the atherosclerosis process through better control of blood pressure, blood glucose level, and lipid profile. Even a tiny amount of physical activity may benefit older people if undertaken early rather than late.

Practical Pearls:

• People with diabetes are at risk of CVD and should be encouraged to have at least 20 minutes of exercise daily to prevent this risk of CVD.
• Physical activities are the cheapest way of managing diabetes and can be done everywhere; healthcare providers should encourage their patients with diabetes to do so.
• It is also essential to let patients understand that it is not late to start physical activities and explain that this could be beneficial later in life, not just for the present.

Fabris, Enrico, and Gianfranco Sinagra. “Physical activity in older people: better late than never, but better early than late.” Heart (British Cardiac Society) vol. 108,5 (2022): 328-329. doi:10.1136/heartjnl-2021-320462

Milaine Kenguim, PharmD Candidate 2022, South College School of Pharmacy