Physical Activity as a Lifestyle Modification in Patients With Multiple Comorbidities: Emphasizing More on Obese, Prediabetic, and Type 2 Diabetes Mellitus Patients

In this research, physical activity (PA) was shown to be inversely associated with the incidence of diabetes. This emphasizes the relevance of PA in diabetes prevention lifestyle intervention initiatives and encourages healthcare practitioners to advise high-risk patients on a healthy lifestyle combining PA for the reduction of weight in prediabetic, obese, and type 2 diabetes mellitus (T2DM) patients. The link between PA and diabetes was stronger in people with moderate or higher baseline PA, reflecting national recommendations that imply increasing activity levels may provide larger advantages for those who are comparatively less active. An intensive lifestyle intervention of eating healthier foods and increasing PA resulted in an effective decrease in weight and waist circumference after one year, which has high potential in the long term to prevent T2DM and different comorbidities such as obesity. Studies such as PRomotion Of Physical activity through structured Education with differing Levels of ongoing Support for those with prediabetes (PROPELS) demonstrate that the combination of PA interventions with telemedicine follow-ups results in ambulatory activity changes in the first year, but these changes do not last longer than four years. Acute PA practicing regularly will reduce postprandial glucose excursions. However, it is unknown what type of PA routine will benefit the most from reducing postprandial glucose levels. There are no discernible variations in the effects of different disciplines of training on glucose levels, mainly when the data are compared across time. The combination of a healthy diet and lifestyle with programs based on diabetes prevention results in comparable and clinically significant mean weight reduction with cardiometabolic advantages. Based on the reviewed and cited studies, PA in patients at high risk of T2DM and obese and non-obese patients with T2DM results in favorable outcomes in the first few months. There is a large gap in investigations of the effects of PA in these patients and the benefits of other lifestyle modifications in long-term-based studies. However, in this study, we emphasize the importance of lifestyle modifications, putting in perspective principally the PA that the majority of patients with comorbidities do not practice, especially those with obesity, prediabetes, and T2DM. Thus, it would be necessary to conduct long-interval studies such as randomized clinical trials, where a better outcome can be given about intervals based on daily exercise times and the type of exercise in conjunction with diets that will have the greatest benefit, focusing more on the subjects that our research mentioned.


Introduction And Background
Lifestyle modifications are considered the best therapy for overweight patients. However, rigorous treatments such as the Diabetes Prevention Program [1] have been initially beneficial, but when the study population was retested in a randomized clinical trial, the programs often produced only a 2%-4% weight reduction.
From the prevention perspective, type 2 diabetes mellitus (T2DM) therapy minimizes the likelihood of serious consequences and permanent organ damage [2], demonstrating that exercise training is an essential part of overall diabetes treatment [3]. Physical activity (PA) is one of the four pillars of T2DM treatment. The Look AHEAD research participants attempted to lose more than 7% of their starting weight and increase moderately vigorous PA to more than three hours per week [4]. After 12 months, they showed improvements in their quality of life and a change in psychological outcome, lowering depression symptoms due to their physical appearance and motivation, and enhancing their physical endurance [5]. In T2DM patients, high levels of PA and participation in an organized exercise or sports program are associated with a higher quality of life. Aerobic-type exercise of adequate intensity is a significant factor in enhancing glucose absorption and tolerance as a form of T2DM prevention and treatment [6].
In a study on the impact of physical activity on the prevention of type 2 diabetes, after the diabetes prevention program (DPP) trial phase (3.2 years of average follow-up), the contributions of the two lifestyle objectives of weight reduction and physical activity (PA) were investigated in lifestyle participants. Those who did not fulfill the year one weight objective but did meet the expressed PA goal achieved a 46% reduced diabetes incidence after the DPP compared to those who met neither goal [7].

Review Methodology
A systematic review was conducted putting together free available full-length articles and utilizing the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) checklist to document our methodology and conclusions. We have adhered to the PRISMA 2020 recommendations.

Study Duration
This review started on May 13, 2023.

Eligibility Criteria and Study Selection
To assess eligibility, two investigators carefully read the full title and content of each paper.

Inclusion and Exclusion Criteria
We selected the latest literature and articles published in the past two years, including papers written in the English language or if the full-text English language translation is available. We only included research papers involving human participants.
Articles were excluded if the full text of the papers could not be retrieved. Articles focused on lifestyle modification and physical activity in obese, prediabetic, and T2DM patients. Gray literature and proposal papers were also not included.

Data Management
Two independent writers evaluated papers based on titles and abstracts. Following that, significant abstracts were examined for complete full-text examination. The selected studies were evaluated, and if there was any dispute, the research was evaluated by a third author. Information from relevant publications was then collected. The first author's name, research type, location, year of publication, sample size, and age were collected. Finally, duplicates were deleted.

Quality Assessment
For systematic reviews and meta-analyses, we used the assessment of multiple systematic review (AMSTAR) questionnaire and Cochrane risk of bias assessment tools for clinical trials.

Search Results
A total of 193,307 studies were found after searching PubMed, Google Scholar, and Cochrane Library. A total of 192,662 were marked as ineligible by an automation tool. A total of 645 studies underwent title and abstract screening, and 609 papers were discarded. The remaining 36 papers were chosen for full-text evaluation in the previous two years, and after discarding duplicates, it resulted in the elimination of 27 studies. A total of nine studies were enlisted for the final collection of data ( Figure 1). In one year, WAP raised ambulatory activity by 547 steps daily as opposed to control.

FIGURE 1: Identification of studies via databases and registers
WAP is also more likely to achieve 150 minute/week of moderate-to-vigorous PA.

Aerobic Exercise
In men and women with T2DM, aerobic exercise and enhanced cardiorespiratory fitness reduce morbidity and mortality by 20% [16]. Aerobic exercise is a kind of physical activity that employs the aerobic energyproducing system to enhance capacity and efficiency and build cardiorespiratory endurance [7], and it uses vast muscle groups repeatedly [17]. It enhances insulin sensitivity, vascular compliance, lung function, and immunological function [18]. The effectiveness of PA in people with T2DM has shown a decrease in HbA1c, lipids, blood pressure, and insulin resistance [17].
In other studies, the timed up-and-go test and handgrip strength tests, which attest to the value of the prescribed protocol in this study's intervention [19], showed that older women with T2DM had increased functional capacity after 10 weeks of aerobic training. Raben et al. [12] showed that after 36 months, patients on a high-protein diet with extenuating PA had a lower glycemic index (11.9%) compared to the other three groups (20%-21%). The body weight loss after two months was 11% and after 36 months was 5%, which was not much of a difference.
Amin et al. [9] found that a culturally relevant 12-week program tailored exclusively for the study population with T2DM improved the MetS score. A training program was used in which patients underwent a combination of aerobic and resistance exercises, and the findings indicated that the intervention group had a higher beneficial influence on the MetS severity score than the control group. The program used in patients with T2DM generated better results than aerobics or endurance exercise alone [20,21]. Furthermore, Pattyn et al. [22] concluded that aerobic, moderate, or high-intensity training will mitigate cardiovascular risk factors.
Wewege et al. [23] conducted a study to investigate how exercise helps reduce MetS markers in healthy individuals. There were 11 investigations in all, and patients' lipid profiles, fast glycemic indexes, waist circumferences, and diastolic blood pressures improved significantly [23,24]. Most articles showed favorable effects on the MetS index, lipid levels, and glycemic risk factors; some studies reached therapeutic levels, and the psychological component of patients who were depressed due to being overweight or obese was influenced as well. A substantial part of this systematic review literature is to make known that there are still gaps in the research on the combination of physical disciplines to compare which is the best to prove the outcome of using them as therapies and preventive medicine in patients with T2DM, obesity, and prediabetes.

Conclusions
Exercise affects type 2 diabetes patients' physical stamina and quality of life. An aerobic training program may help with the treatment of type 2 diabetes, and it is a great option for this group because comorbidities such as obesity or lower limb dysfunction typically restrict patients from walking or jogging. Physical exercise on land and in water has substantial biological effects that extend beyond homeostatic systems and are therapeutically effective in the care of patients with musculoskeletal difficulties, cardiovascular illness, rheumatic disorders, and other ailments. In addition, one of the randomized clinical trials collected showed how the Ghanaian population PA regimen has the potential to improve MetS and quality of life in adults with T2DM.
New cases of T2DM will be significantly lower than expected three years after the simultaneous integration of diets, exercise, or both. This is based on maintaining a protein-based diet in conjunction with a continuous PA over three years, leading to favorable outcomes such as weight reduction and healthy food habits. All of these will lead to a 20% reduction in the incidence of T2DM. In older obese adults with T2DM, resistance training did not improve weight loss, a predictor of nonalcoholic fatty liver disease. Further large-scale studies to look for the benefits of aerobic training in patients with obesity, nonobese patients with T2DM, and those at risk of developing T2DM are needed to provide different insights about the possible synergistic effects of exercise and weight loss for the prevention of developing T2DM and as a first-line treatment in patients with T2DM.

Conflicts of interest:
In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work.