Acute glycemic and pressure responses of continuous and interval aerobic exercise in patients with type 2 diabetes

CLINICAL AND EXPERIMENTAL HYPERTENSION
2018, VOL. 40, NO. 2, 179–185
https://doi.org/10.1080/10641963.2017.1339075
Acute glycemic and pressure responses of continuous and interval aerobic exercise
in patients with type 2 diabetes
Éder Santiagoa, Rodrigo Sudatti Delevattia,b, Cláudia Gomes Brachta, Nathalie Nettoa, Salime Chedid Lisboaa,
Alexandra Ferreira Vieiraa, Rochelle Rocha Costaa, Alexandra Hübnerc, Marco Antônio Fossatic,
and Luiz Fernando Martins Kruela
a
Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, Brasil; bFaculdade Sogipa, Porto Alegre, Brasil; cHospitalar ATS, Porto Alegre, Brasil
ABSTRACT
ARTICLE HISTORY
Background: Aerobic training has been widely indicated to patients with type 2 diabetes. However, there are
still few studies comparing acute glycemic and blood pressure effects of different methods of aerobic
training. The aim is to compare glycemic and pressure acute responses of continuous aerobic exercise to
interval aerobic exercise in patients with type 2 diabetes. Materials and Methods: This study is a randomized,
crossover clinical trial. Fourteen patients with type 2 diabetes performed two sessions of aerobic training
with different methods (continuous and interval). Continuous session had duration of 35 minutes with
intensity of 85–90% of heart rate corresponding to anaerobic threshold (HRAT), while interval session had
45 minutes, with stimulus in intensity of 85–90% of HRAT with recovery in intensity under 85% of HRAT.
Capillary glycemia, systolic and diastolic blood pressure were analyzed before and after the sessions. Results:
Patients were 63.5 ± 9.8 years old. Glycemia was reduced in both sessions (p < 0.001). Only glycemia
measured at 25 minutes after continuous session was not lower than pre-session values. Systolic blood
pressure was also reduced in both sessions (p = 0.010) with similar behavior between them. In the diastolic
blood pressure, there were differences only between the values measured immediately after exercise and
the values measured 20 minutes (p = 0.002) and 30 minutes after exercise (p = 0.008). Conclusion: Both
continuous and interval aerobic exercise, in a same intensity, are effective for glycemic and pressure acute
reductions in individuals with type 2 diabetes. For patients with greater risk of hypertension, we believe that
the interval method is safer.
Received 29 March 2017
Revised 23 May 2017
Accepted 24 May 2017
Introduction
Physical exercise is considered as an important therapeutic tool
for patients with type 2 diabetes mellitus (T2DM) (1) and high
blood pressure (BP) (2), two diseases of high prevalence and
highly associated to each other (3), being hypertension the main
comorbidity of patients with T2DM (4). Among exercise types,
those with aerobic characteristic are strongly recommended for
patients with both diseases, because there are consistent evidences about the benefits in glycemic and pressure control
(1,4,5). However, the acute responses of different methods of
aerobic exercise are not clearly elucidated.
Among methods of aerobic exercise, continuous and interval
are highlighted, which have their effects investigated on glycemic
and pressure levels of patients with T2DM (6) and hypertension
(7,8). However, the studies that compared these methods of
exercise in these outcomes manipulated high intensity interval
exercises in comparison to low-to-moderate intensity continuous exercise, possibly generating greater glycemic or pressure
reduction due to the intensity in the periods of stimulus of the
interval method and not necessarily due to the characteristics of
the interval exercise.
As current evidences of physical training for patients with
T2DM and hypertension indicate the importance of exercise
KEYWORDS
Acute; diabetes; exercise;
glucose; hypertension
duration (9–11), it becomes necessary to compare continuous
aerobic exercise with interval aerobic exercise, conducting both
exercises with the same intensity and different durations. The
focus on duration has relevance not only for the effectiveness
perspective, but also due to adherence and safety, because these
patients (generally with excessive body mass) may present some
difficulty in exercising for longer durations in a continuous way,
besides of the possible risk associated with blood pressure elevation in supporting workloads for a long period of time.
In this way, the aim of this study was to compare glycemic
and pressure acute responses of continuous aerobic exercise to
interval aerobic exercise in patients with T2DM. As hypothesis,
it is believed that both exercises induce similar glycemic reductions that continuous exercise presents greater blood pressure
elevation immediately after exercise and that both present
similar hypotension after the first five minutes after exercise.
Materials and methods
This study is a randomized, crossover clinical trial. Patients with
T2DM were selected through advertising media or through
forwarding of the Hospitalar Home care, a company that monitors people with chronic non-communicable diseases in the city
of Porto Alegre/RS/Brazil. All patients were adults (aged over 18)
CONTACT Éder Santiago da Silva
[email protected]
Rua Emília Gaúna Bochehin, 664, Cachoeirinha 94950-545, RS, Brasil.
Color versions of one or more of the figures in the article can be found online at www.tandfonline.com/iceh.
© 2017 Taylor & Francis
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É. SANTIAGO ET AL.
and were in medical treatment for T2DM. As exclusion criteria,
we had severe non-proliferative diabetic retinopathy, uncompensated heart failure, lower-limbs amputation, body mass index
(BMI) ≥ 45 kg/m2, kidney insufficiency or any problem that
could impair the accomplishment of physical exercises. All
patients filled an Informed Consent Form in the terms approved
by the Ethics Committee in Research of the Federal University of
Rio Grande do Sul (nº 1.571.144). This research did not receive
any specific grant from funding agencies in the public, commercial or not-for-profit sectors.
Experimental procedures
After recruitment and selection of the sample, the subjects were
informed of all the procedures involved in the study, presented
an exercise electrocardiography of the previous six months and
were inserted in a program called pre-training, which had the
aim to minimally prepare the individuals for the accomplishment of the main exercise sessions with greater safety and in
order to know the pressure and glycemic acute effects in slightly
trained patients, which is something generally studied in sedentary people. At the end of this period, the patients performed an
anthropometric evaluation, only for the characterization of the
sample, and a progressive maximal test, in order to determine
exercise intensity.
After the determination of the exercise intensity, the order
of the experimental sessions (continuous and interval) was
randomically determined through the software www.randomi
zation.com. The patients performed the sessions (one for each
regimen—continuous and interval) in the determined order
with a minimum of 48 hours of interval between them.
Before sessions, the patients remained seated at rest for five
minutes, then their glycemia, SBP and DBP were assessed, and
after this, they performed the exercise. Finally, the same outcomes were analyzed immediately, five, 10, 15, 20, 25 and
30 minutes after the end of the sessions.
Progressive maximal test
After the pre-training period, the participants underwent a maximal exercise test for the determination of the heart rate deflection
point (HRDP), which is in concordance with the anaerobic
threshold in patients with T2DM (14). For the accomplishment
of this test, in which protocol was already used in a clinical trial
with the same population (15), a treadmill was used with resolution of speed and slope of 0.1 km/h−1 and 1%, respectively. Initial
speed was 3 km/h in the first three minutes, and it was incremented by 1 km/h at every two minutes until exhaustion. Heart rate
was monitored using a heart rate monitor, and it was registered at
each interval of 10 seconds.
Food control
In the preceding 24 hours of the experimental sessions, the
patients registered all the ingested food in a food record of
24 hours. Total energy intake, of macronutrients, of water and
sodium was evaluated by a nutritionist and demonstrated using
a percentage distribution.
Capillary glycemia
Capillary glycemia was assessed using a clinical glucometer
(Accu-Check Performa, Roche, São Paulo, Brazil), which
assessed glycemic levels in approximately five seconds, and
disposable lancets (Accu-Check Safe-T-Pro Uno, Roche, São
Paulo, Brazil).
Systolic and diastolic blood pressure
SBP and DBP were assessed using an ambulatory blood pressure
monitoring (MAPA) of the brand MEDITECH, model ABPM-04,
Budapest, Hungary.
Anthropometric measurements
For the evaluation of anthropometric variables, a day was
scheduled in which the participants attended wearing costumes
with two pieces. Initially, the height was measured with metal
stadiometer of the brand Filizola, with resolution of 1 mm, and
body mass was assessed with analogic scale of the brand
Filizola, with resolution of 0,1 kg. With these values body
mass index (BMI) was calculated by using the formula body
mass(kg)/height2(m). After this, waist circumference was measured with flexible and inelastic tape of the brand Cescorf, with
resolution of 1 mm, in the midpoint between the iliac crest and
the last rib. With this value, waist/height ratio was calculated.
Finally, the measurement of seven skinfolds was taken, with
adipometer of the brand Cescorf, with resolution of 1 mm. The
seven measured skinfolds were triciptal, subscapular, suprailiac, abdominal, mid-axillary, thigh and leg. With these values,
body density was estimated using the appropriate equations for
men and women (12). Body fat percentage of both sexes was
also estimated (13). The resulting value of the sum of seven
skinfolds was considered as the sum of skinfolds.
Pre-training period
Pre-training period consisted of eight weeks. In the first four
weeks, the sessions were of continuous exercise with Borg’s
rating of perceived exertion (16) (RPE) between 11 and 13 with
progressive volume, starting with 20 minutes and increasing
5 minutes per week. In the last four weeks, the sessions were
interval, with 400 m with RPE between 13 and 15 interpersed
with 400 m with RPE between 11 and 13.
Interventions (continuous and interval sessions)
Continuous session had a warm-up period consisted of five
minutes of light walk, main part of 35 minutes between 85 and
90% of anaerobic threshold (AT) and stretching for the main
muscle groups at the end. Interval session differed only in the
main part, which had duration of 45 minutes, with stimuli in the
same intensity and recovering at intensity lower than 85% of AT.
The structure of the sessions can be visualized on Table 1.
CLINICAL AND EXPERIMENTAL HYPERTENSION
Table 1. Description of the sessions.
Model
Duration (min)
Description
35
45
85 to 90% of AT
9 x 5 min (4 min 85–90% of
AT + 1 min < 85% AT)
Continuous
Interval
AT: Anaerobic Threshold.
Statistical analysis
Sample characterization data are expressed by mean and standard deviation in continuous variables and by n and percentage
in categorical variables. The outcomes (glycemia, SBP and DBP)
were presented as mean and standard error. For comparison of
the outcomes in different moments and sessions, Generalized
Estimating Equations (GEE) with post hoc of Bonferroni was
used, adopting a significance level of 0,05. The analyzes were
conducted in the statistical program SPSS (Armonk, NY, USA),
version 20.0.
Results
Twenty-four patients initiated the study, and 10 did not conclude
the pre-training period, claiming some health problem that
impaired the transportation to the training sessions. Of the 14
volunteers able to accomplish the experimental sessions, 10 were
randomically distributed to perform the continuous session first
and in other day the interval session, and the opposite happened
to the other volunteers. Sample characterization, as well as medicines of regular use for the control of diabetes and hypertension,
is presented on Table 2.
The food records analyses did not demonstrate any difference
between the percentage distributions of macronutrients ingested
in the 24 hours preceding the continuous and interval exercise
sessions (carbohydrates: p = 0.397; proteins: p = 0.993; lipids:
181
Table 2. Sample characterization, consisting of mean ± standard deviation of
age, height, body mass, body mass index (BMI), waist circumference, waist/
height ratio (WHtR), fat percentage (%F), fat mass and sum of 7 skinfolds (Σ7
skinfolds). The use of medication is expressed by absolute frequency (“n”).
Patients with type 2 diabetes
Age (years)
63.58 ± 9.8
Height (m)
1.63 ± 0.1
Body mass (Kg)
81.50 ± 13.8
BMI (Kg)
30.27 ± 4.4
Waist circumference (cm)
102.17 ± 7.4
WHtR
0.62 ± 0.0
%F
23.71 ± 6.2
Fat mass (kg)
19.45 ± 6.5
∑7 skinfolds(mm)
206.11 ± 58.8
Medication (n)
Metformin
10
Sulfonylureas
4
Dipeptidyl peptidase-4 inhibitor
2
Insulin
3
Diuretics
6
ACE inhibitors
10
Beta-blockers
2
ACE: Angiotensin-converting enzyme
p = 0.161), as well as in relation to total energetic value
(p = 0.061).
Glycemia
Figure 1 presents glycemic behavior resulting from experimental
sessions. In a general way, both exercise prescription models
resulted in significant glycemic reductions to the patients
(p < 0.001); however, session x time interaction (p = 0.026)
demonstrated a distinct behavior over time, given that in the
analysis of the continuous session, the only moment that glycemia had the same value of the pre-session occurred at 25 minutes
post-session, which is not observed in the interval session, when
all post-exercise measurements was shown different and lower
than pre-exercise values. In the continuous session, glycemia
varied from 168.00 (± 14.69) mg.dl−1 before exercise to 122.79
Figure 1. Glycemic behavior resulting from continuous and interval exercise sessions, presenting mean and standard error for the values of pre-exercise, immediately
post-exercise, 5, 10, 15, 20, 25 and 30 minutes after the end of exercise sessions. * Different from Pre-exercise for both models, p < 0,050; † Different from 5 min after
the end of exercise in interval session, p < 0,050.
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É. SANTIAGO ET AL.
(± 10.00) mg.dl−1 immediately after exercise (−27.4%), and, in a
similar manner, in the interval session, the mean variation was
from 179.79 (± 14.12) mg.dl−1 before sessions to 131.43 (± 10.96)
mg.dl−1 in the first data collection after the end of session
(−26.9%). After the glycemic reductions observed immediately
post-exercise, the values remained stable in the following 30 minutes after the end of sessions.
Systolic blood pressure
The results regarding to SBP are presented on Figure 2. Just as in
glycemia, SBP behavior did not show significant difference
between sessions (p = 0.064), and however, there was a difference
in time effect, which showed significant statistical difference
(p = 0.010) in this outcome resulting from both protocols. Time
x session interaction did not show significance (p = 0.363).
In the continuous session, mean initial SBP values of the
participants were 135.29 ± 4.95 mmHg, which showed a
nonsignificant increase to 148.46 ± 5.93 mmHg immediately
post-exercise. In the following 30 minutes, SBP behavior
remained stable, varying from 124.64 ± 3.14 mmHg to
130.92 ± 2.29 mmHg. In the interval session, mean initial
SBP value of the participants was 133.71 ± mmHg, with a
modest (nonsignificant) alteration to 136.43 ± 3.74 mmHg
immediately after exercise session, remaining stable with
values that varied in average from 121.14 ± 2.58 mmHg to
123.00 ± 4.98 mmHg. In both models of session, in the last
collection—conducted with 30 minutes of rest after the end of
exercise—the lowest SBP was measured, which reached
124.64 ± 3.14 mmHg in average in the continuous exercise
session and 121.14 ± 2.58 mmHg in average in the interval
exercise session, representing reductions of 7.86% and 9.40%,
respectively, in relation to the mean values measured before
the exercise sessions.
Diastolic blood pressure
The results referring to DBP are presented on Figure 3. The
execution of the different models of aerobic session did not
result in significant difference in the DBP behavior (p = 0.357).
However, a significant reduction in this outcome over time was
observed (p = 0.034). The significant session x time interaction
(p < 0.001) indicated that only in the continuous session a
significant alteration of the DBP was shown, and this difference
only occurred in the comparisons between immediately after
exercise and 20 (p = 0.002) and 30 minutes (p = 0.008) after
exercise. All the other moments of the continuous session did
not show significant difference between them, as well was
observed in the interval session.
Individual responsiveness
Although significant differences were not observed in the
glycemic and pressure behavior of the participants between
the exercise sessions performed, in an analysis of individual
responsiveness, it becomes evident that some of the participants showed glycemic and pressure reductions more
expressively in the continuous session and others in the
interval one. Continuous session induced better responsiveness in glycemia of half of the participants, and the other
half responded better in the interval session. SBP presented
better responses in four participants for the continuous
session and in ten for the interval session. On the other
hand, DBP showed better responses in six participants for
the continuous session and in eight for the interval session.
Graphically, the individual responsiveness of the glycemia,
SBP and DBP of the participants resulting from the exercise
sessions proposed can be visualized on Figure 4, in which preexercise and immediately post-exercise data are included.
Figure 2. Systolic blood pressure (SBP) behavior resulting from continuous and interval exercise sessions, presenting mean and standard error for the values of pre-exercise,
immediately post-exercise, 5, 10, 15, 20, 25 and 30 minutes after the end of exercise sessions. * Different from pre- and post-exercise for both models, p < 0,050.
CLINICAL AND EXPERIMENTAL HYPERTENSION
183
Figure 3. Diastolic blood pressure (DBP) behavior resulting from continuous and interval exercise sessions, presenting mean and standard error for the values of preexercise, immediately post-exercise, 5, 10, 15, 20, 25 and 30 minutes after the end of exercise sessions. * Different from post-exercise in interval session, p < 0,050.
Figure 4. Individual responsiveness of the glycemia, systolic (SBP) and diastolic blood pressure (DBP) of the participants resulting from exercise sessions in the continuous and
interval exercise sessions. Absolute values in the pre-session and immediately post-session moments. Different lines represent different participants of the sample.
Discussion
In relation to glycemic behavior, our findings confirm our
hypothesis, because continuous and interval aerobic exercise
sessions induced similar glycemic reductions. This reduction
was demonstrated immediately after exercise, and it was
maintained during the following 30 minutes in which glycemia was evaluated. SBP behavior was also similar between
sessions, in which a reduction occurred 5 minutes post-
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É. SANTIAGO ET AL.
exercise, remaining stable until 25 minutes after exercise, and
a further reduction was demonstrated 30 minutes after the
end of exercise. Regarding DBP, while the patients showed
stability in all measurements made in the interval session, the
values registered 20 and 30 minutes after continuous session
were smaller than those registered immediately after exercise.
Our findings regarding to SBP and DBP only partially support
our hypothesis, because despite the nonsignificance, the continuous session seems to result in greater values immediately
after the session, although only SBP presented the expected
hypotensive effect.
We believe that the similarity found between the proposed
sessions is due to the identical intensity and similar volume of
exercise performed, because whereas continuous session had
35 minutes of stimulus between 85 and 90% of AT, interval
session had 36 minutes of stimulus at the same intensity (9 ×
5 min – 4 min stimulus: 1 min recovery). Unlike our results,
Karstoft et al. (2014) (6) found greater glycemic reduction in
the interval session compared to continuous session in patients
with T2DM. The characteristics of this study (duration, energy
expenditure and similar mean intensity between interval and
continuous exercise groups) demonstrated that just the fact
that interval group performed excursions in higher intensities
provided glycemic reductions in greater magnitude. Thus,
intensity is perceived as a characteristic that is more associated
to glycemic decreases than just the exercise training method,
which was something already expected, because while intensity
is a variable with physiological character, the fact that the
exercise is performed in a continuous or interval manner has
only methodological character, without any relation to metabolic alteration.
In the same context, Terada et al. (2013) (17) compared the
glycemic response to a continuous exercise session in an intensity lower or equal to 40% of VO2res with an interval exercise
session with periods composed of one minute of stimulus at
100% do VO2res and three minutes of recovery in an intensity
lower or equal to 20% VO2res and found a bigger reduction after
the interval session. In the protocols used by Karstoft et al. (2014)
(6) and Terada et al. (2013) (17), the same exercise duration
between the continuous and interval methods and the structure
of the periods of stimulus (time and magnitude of the stimulus:
time and magnitude of the recovery) favored an equalization
between the protocols compared. However, when the organism
is working in high physiologic intensities during the stimuli
periods, the decrease of the physiologic variables in the recovery
can be very slow, especially in sedentary individuals, which can
explain the superiority of the interval strategy, once it permits
the accomplishment of stimuli in high intensities.
Along with intensity, the duration of the session is another
fundamental variable in the structure of the aerobic training. In
chronic studies, this variable has been showing itself very important to glycemic control (9,10) in patients with T2DM, whereas
in studies carried out with acute protocols, it has not been
focused as primary outcome of the investigations. While some
studies (6,17) proposed interval sessions with higher intensities
than the continuous sessions, our proposal was to make the
interval session longer than the continuous one, by adding
10 minutes in the total duration of the session, which did not
result in a greater glycemic reduction. Based on our findings,
caution should be exercised when associating glycemic reduction
with the aerobic exercise method, because when a method does
not represent a substantial energetic contribution in relation to
the other method, both seem to promote similar responses, even
that the duration of the session is augmented in the interval
protocol.
The elevation of the SBP immediately after exercise was not
significant. However, a clinical overview becomes necessary,
because even without statistical difference between the sessions,
the continuous model implied in an elevation of the SBP,
whereas the interval model showed stabilization; thus, in the
pressure point of view, the interval session proved to be safer.
Regarding to efficacy, we did not find expressive difference
between the sessions, both caused hypotension after exercise
from five minutes post-exercise, with a more pronounced effect
in the last measurement (30 minutes after exercise). The
mechanisms by which aerobic exercise provokes post-exercise
hypotension have been well documented, highlighting the
decrease of the sympathetic activity, the increase of the nitric
oxide vasodilator action and a greater action of the baroreflex
system (7).
Our findings corroborate with other studies (18–20) that did
not find difference in the blood pressure reduction between
continuous and interval exercise sessions, even that in these
studies the interval sessions had greater intensities than those
used in the continuous sessions. By the fact that these studies, as
well as our study, were conducted with sedentary or minimally
trained, hypertensive individuals and that the greater intensities
did not add any effect in the reduction of the blood pressure, we
believe that a safe and effective exercise prescription for this
public can have moderate intensity (~60%HRres – 85–90%AT),
interval method and duration of approximately 40 minutes. Due
to the more stable behavior of the BP immediately after exercise
in the interval exercise session, we believe that the use of this
method might promote a greater safety in the progression of the
intensity throughout the training periodizations for these
patients. This is because in a trained physiological state, these
patients will need a higher training intensity to keep having
cardiovascular benefits, which they can achieve in a safer way
by not sustaining the intensity in the continuous manner.
Although we did not expect an elevation of the DBP in
dynamic exercises and this was not demonstrated in the present
study, Figure 4 presents a behavior of increase, which is still not
expressive. By analyzing the measurements performed from five
minutes post-exercise sessions, we can perceive stability in this
outcome, because there were minor differences in the continuous sessions (20 and 30 minutes post-exercise) that did not
stabilize even in two consecutive moments. This little alteration
of the DBP is primarily explained by the amplitude of improvement that it offers, which is lower than SBP. This amplitude can
be very attenuated in this study, because although the individuals
were hypertensive, they were with a well controlled DBP (presession DBP: 74.25 ± 2.25 mmHg), with values considered
normal (60 to 84 mmHg) according to the Brazilian Society of
Cardiology (21). The greater stability of the DBP can be
explained because while the bigger cardiac output during exercise is a stimulus of increased DBP, the vasodilation derived
from exercise reduces peripheral vascular resistance, minimizing
or even nullifying the increase in DBP (22).
CLINICAL AND EXPERIMENTAL HYPERTENSION
Our findings corroborate with those of Tomasi et al. (2008)
(23), which conducted a study with 10 men who performed
resistance (3 series of 12 repetitions with 60% of 1RM) and
aerobic (40 minutes at 60% of HRmax) exercises in distinct days
and found a reduction in DBP only 20 minutes after the exercise
sessions for normotensive individuals. On the other hand, Reis
et al. (2012) (24) evaluated 75 individuals after 60 minutes of
aerobic continuous exercise between 50 and 70% of HRmax and
did not find any difference in DBP in the individuals with presession DBP lower than 85 mmHg, similar to the present study
(74,24 ± 2,26 mmHg). In this way, we considered both sessions
positive for DBP, because in patients who have this outcome well
controlled, the non-elevation of this outcome can be already
considered a positive result.
This study had as main limitation the reduced post-session
time in which the outcomes evaluated were measured, because
we believe that a follow-up longer than 30 minutes would be
interesting to enlarge the knowledge about the glycemic and
pressure impact of the proposed sessions. However, to our
knowledge, the investigation of the acute glycemic and pressure
effects of aerobic exercise in patients with T2DM has not been
investigated in a same study. As strong points of the present
study, we highlight the methods used, with the order of the
sessions conducted randomically, having food record and a
post-session curve with seven measurements.
Conclusion
We conclude that both continuous and interval aerobic exercise,
in a same intensity, are effective for glycemic and pressure acute
reductions in individuals with T2DM. For patients who do not
present high blood pressure or maintain it well controlled, the
choice of the exercise method can be due to time saving (continuous session) or to less monotony (interval session), thus favoring
adherence to exercise. For patients with greater risk of hypertension, we believe that the interval method is safer, with similar
efficacy to the continuous method.
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