Physical Activity Improves Muscle Strength and Reduces Inflammatory Markers in Diabetic Elderly Patients

Regular exercise has an effect on muscle strength and inflammatory markers. The aim of this study is to determine the relation of regular exercise with muscle strength and inflammatory markers (IL-6, CRP) in diabetic elderly compared to non-diabetic ones. A case control study was conducted to 30 elderly by giving them regular exercise. Fifteen subjects were diabetic and the other fifteen were non-diabetic. The data were analyzed using Chi-Square, independent t-Test and Mann Whitney. The result shows handgrip 24,9(14,8-34,6)kg in diabetic vs. 25(6,8-42,1)kg in non-diabetic (p=0,673); 4 meters walk was 3,38(2,34-8,18)s in diabetic vs 3,26(2,06-4,36)s in non-diabetic (p=0,263); IL-6 level was 1,61(0,37-14,02)pg/mL in diabetic vs 1,47(0,52-10,17)pg/mL in non-diabetic (p=0,983); CRP level was 0,23(0,18-0,33)mg/dL in diabetic vs 0,22(0,11-1,01)mg/dL in non-diabetic (p=0,622). HbA1C was 7,35 (5,9-13)%. There is no significant difference in muscle strength and inflammatory markers on the diabetic and non-diabetic groups who exercise regularly. This study shows that regular exercise and well-controlled HbA1C give a good impact on muscle strength and inflammatory markers of the diabetic elderly patients.


INTRODUCTION
informed consent to take part in the study.The university ethics committee accepted the protocol.The proportion of population aged 60 years in Indonesia is projected to exceed 12% by 2020.This condition is STUDY DESIGN associated with the major increase in the number of people with diabetes (1,2).Health ABC study showed that Body composition in community-dwelling, elderly with type 2 diabetes is Body weight was measured on an electronic scale to the associated with accelerated loss of leg muscle strength nearest 0,1 kg.Body height was measured by knee height and quality.These characteristics may contribute to the with formulation 59,01+(2,08xknee height) for men and development of physical disability in elderly with 75+(1,91xknee height)-(0,71xage(year)) for women.Waist diabetes.A few studies also showed that diabetes has circumference at the umbilical midline was measured to been associated with a two to threefold increased risk of the nearest cm with flexible tape.Arm circumference at developing physical disability (3-6).
the half of scapula-elbow was measured to the nearest cm Growing evidence links type 2 diabetes to a state of lowwith flexible tape.Sarcopenia was measured by grade chronic inflammation and it has been suggested formulation of MMAC and MMLee.that Interleukin (IL)-6 promotes insulin resistance and has Muscle Strength detrimental effects on muscle mass, strength, and physical performance in elderly (7,8).Cesari et al reported Three consecutive measurements of handgrip strength of that there was an inverse relation between C-Reactive the dominant hand were performed with a calibrated Protein (CRP) and IL-6 with appendicular muscle mass.
dynamometer (Takei Scientific Instruments, Tokyo, Japan), That study was similar to Taaffe et al which showed that which was reset to zero before each measurement.The high level of IL-6 and CRP was associated with lower measurements were conducted under standardized handgrip.The increase of IL-6 >5pg/ml and CRP >6,1μg/ml conditions: subject stand-up, left leg one step ahead and were associated with two until threefold risk of muscle right hand across the abdomen, the shoulder adducted mass loss by 40% in 3 years (9).This data showed that and neutrally rotated, with the elbow at 90• flexion and the inflammation has been association with the loss of muscle fore arm and wrist in a neutral position.Patients were mass and muscle strength.
encouraged to use a standard phraseology (squeeze the handle as hard as possible).Mean values were recorded.

Aerobic and resistance exercise effectively improve insulin sensitivity and lead to better glycemic control in patients
Inflammatory Markers with diabetes (11).Regular exercise also has a good Interleukin-6 (IL-6) level were measured in duplicate using impact on decreasing IL-6 and CRP which means an ultrasensitive enzyme-linked immunosorbent assay.decreasing the inflammation process.However, the Recombinant IL-6, purified CRP, and pooled human plasma effects of diabetes on muscle strength and inflammatory were used as standards in the respective assays and results markers have never been investigated in Indonesia which were expressed as picograms/milliliter. C Reactive Protein has different culture and life style.We hypothesized that (CRP) level was measured using turbidimetry and results regular exercise will improve muscles strength and were expressed as milligram/deciliter.decrease the inflammatory markers in elderly diabetic patients.

Other Covariates
Other covariates measured are socio-demographic METHODS characteristics included age and sex.Combined chronic diseases such as coronary heart disease, congestive heart Subjects failure, stroke, peripheral artery disease, knee Subjects were collected using consecutive sampling, from osteoarthritis, depression, and cancer were identified by May-July 2013 in Geriatric-Diabetes Outpatient Clinic of self-report and was confirmed by treatment and RSSA Malang and 5 districts in Malang.Three hundred and medication use.Self-reported poor eyesight was thirty five subjects who community-dwelling, aged above considered as impaired vision.Renal insufficiency was 60 years were recruited and consisted of 35 diabetic and defined by serum creatinine level >1,5 mg/dl in men and 300 non-diabetic.All subjects then were interviewed 1,2 mg/dl in women (15).about their regular exercise which is defined as walking more than 150minutes/week.They were given detailed Statistical Analysis interview on their past medical history and co-Data are shown as means with standard deviation if the morbidities.From 35 diabetic subjects, 15 subjects who data have normal distribution and median with range of fulfill the inclusion criteria and 15 non-diabetic subjects as minimum-maximum if the data have skewed distributions.control were taken.The inclusion criteria were Analyses were performed using SPSS 16.Characteristics of community-dwelling aged above 60 years and exercise subjects with type 2 diabetes and non-diabetes as control regularly.Regular exercise was defined as walking were compared using Chi-Square tests, independent t 150minutes/week for at least 6 months.
tests and Mann-Whitney tests, p<0,05 was considered The exclusion criteria were disabled or used supportive significant.device for walking which could interfere the walking speed and any severe concurrent illness.All diabetics RESULTS were well controlled with insulin injections or oral antidiabetes agents such as sulfonylurea alone or combined The baseline demographic and interview variables of the with metformin or acarbose.All patients monitored their subjects in the two groups are summarized in Table 1.blood glucose and HbA1c.Non-diabetic is defined as Thirty elderly subjects with complete assessment were community-dwelling, aged above 60 years with no co-included which consists of 15 diabetic and 15 non-diabetic.morbidities and exercise regularly.All subjects were fully The age, gender, arm circumference and sarcopenia were informed on the purpose of the study and gave their similar in both groups.All non-diabetic subjects as control In Figure 1 data were shown using median.The statistic had no co-morbidities.Body mass index and abdomen test used were Independent T test and Mann-Whitney test circumference were significantly higher in diabetic for categorical-numeric variables.subjects (p=0,032 and p=0,001).HbA1c in diabetes was 7,35(5,9-13)% with 15±4,93 years of diabetes-duration, Figure 1 shows that there is no differences on muscle 3,57±2,64 years of insulin-duration.

DISCUSSION
This study observes the differences of muscle strength and inflammatory markers in elderly diabetic and non-diabetic patients who exercise regularly.Wild et al showed that aerobic and resistance exercise effectively improve insulin sensitivity and lead to better glycemic control in patients with diabetes.Kim HK et al demonstrated that exercise and amino acid supplementation together have significant effects on enhancing not only muscle strength and walking speed in community-dwelling elderly Japanese sarcopenic women.The present study also shows that there is no differences on muscle strength and inflammatory markers between diabetic and non-diabetic elderly who exercise regularly.Hand is an important target for diabetic musculoskeletal complication.The pervious study showed that handgrip values were significantly lower in diabetic group compared to control non-diabetic (13).Distal symmetrical neuropathy which may present sub-clinically is responsible for muscle weakness and attributes to low grip strength.Another potential mechanism is increased levels of inflammatory cytokines in subjects with diabetes.
It has been reported that high level of IL-6 and CRP was associated with lower handgrip (10).In this study, muscle In this study, diabetic subjects showed well controlled HbA1C (median 7,35%) with the duration of diabetes of 15±4,93 years.It has been known that insulin treatment influences lipid and protein metabolism with anabolic and anti-catabolic effects.There were 4 subjects who use insulin with the duration of insulin treatment of 3,57±2,64 years.Although exercise already shows to have a good impact on muscle strength, well controlled HbA1C is also important to improve muscle strength in diabetic subjects, but further follow up studies on larger population are required to confirm the effect of insulin treatment on muscle strength and inflammatory markers.
This study demonstrates that regular exercise has a good impact on muscle strength and inflammatory markers in diabetic elderly.We strongly advise regular exercise for diabetic patient since it makes the muscle strength and inflammatory markers achieved the same level as those of

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mean ± standard deviation; †median (minimum-maximum); strength which is showed by hand grip, walking speed and **p<0,05 statistically significant inflammatory markers of CRP and IL-6 of diabetic subjects ***there are 5 missing data were significantly similar to those of non-diabetic subjects.