Critique one article using the appraisal form:
Use the information below to help you know which section of the article to use to answer questions in the template:
APPENDIX C
Appraisal Guide
Conclusions of a Systematic Review with Narrative Synthesis
Citation:
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
Synopsis
What organization or persons produced the systematic review (SR)?
How many persons were involved in conducting the review?
What topic or question did the SR address?
How were potential research reports identified?
What determined if a study was included in the analysis?
How many studies were included in the review?
What research designs were used in the studies?
What were the consistent and important across-studies conclusions?
Credibility
Was the topic clearly defined?
Yes
No
Not clear
Was the search for studies and other
evidence comprehensive and unbiased?
Yes
No
Not clear
Was the screening of citations for
inclusion based on explicit criteria?
Yes
No
Not clear
*Were the included studies assessed
for quality?
Yes
No
Not clear
Were the design characteristics and
findings of the included studies displayed
or discussed in sufficient detail?
Yes
No
Not clear
*Was there a true integration (i.e., synthesis) of the findings—not
merely reporting of findings from
each study individually?
Yes
No
Not clear
Brown
APP C-1
*Did the reviewers explore why differences
in findings might have occurred?
Yes
No
Not clear
Did the reviewers distinguish between
conclusions based on consistent findings
from several good studies and those
based on inferior evidence (number or quality)?
Yes
No
Not clear
Which conclusions were supported by
consistent findings from two or more
good or high-quality studies?
List
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
ARE THE CONCLUSIONS
CREDIBLE?
Yes All
Yes Some
No
Clinical Significance
*Across studies, is the size of the
treatment or the strength of the
association found or the
meaningfulness of qualitative findings
strong enough to make a difference
in patient outcomes or experiences of care?
Yes
No
Not clear
Are the conclusions relevant to the
care the nurse gives?
Yes
No
Not clear
ARE THE CONCLUSIONS
CLINICALLY SIGNIFICANT?
Yes All
Yes Some
No
Applicability
Does the SR address a problem,
situation, or decision we are addressing in our setting?
Yes
No
Not clear
Are the patients in the studies or a
subgroup of patients in the studies
similar to those we see?
Yes
No
Not clear
What changes, additions, training, or
purchases would be needed to implement
and sustain a clinical protocol based
on these conclusions?
Specify and list
____________________________________________________________________________
APP C-2
Brown
____________________________________________________________________________
Is what we will have to do to implement
the new protocol realistically achievable
by us (resources, capability, commitment)?
How will we know if our patients are
benefiting from our new protocol?
Yes
No
Not clear
Specify
____________________________________________________________________________
____________________________________________________________________________
ARE THESE CONCLUSIONS
APPLICABLE TO OUR SETTING?
Yes All
Yes Some
No
SHOULD WE PROCEED TO DESIGN
A PROTOCOL INCORPORATING
THESE CONCLUSIONS?
Yes All
Yes Some
No
* = Important criteria
Comments
____________________________________________________________________________
____________________________________________________________________________
Brown
APP C-3
Qual Life Res (2017) 26:515–530
DOI 10.1007/s11136-016-1481-5
REVIEW
Effect of exercise on the quality of life in type 2 diabetes mellitus:
a systematic review
Hong Cai1 • Guichen Li1 • Ping Zhang1 • Duo Xu1 • Li Chen1
Accepted: 7 December 2016 / Published online: 18 December 2016
Ó Springer International Publishing Switzerland 2016
Abstract
Purpose Diabetic patients tend to have a poor quality of
life. A sedentary lifestyle is considered to be a modifiable
risk factor for type 2 diabetes and an independent predictor
of poor quality of life. Exercise is a key treatment for
people living with diabetes. The purpose of this study was
to conduct a systematic review to assess the effect of
exercise on the quality of life of people with type 2
diabetes.
Methods We conducted a systematic review using the
Preferred Reporting Items for Systematic Reviews and
Meta-Analyses guidelines. PubMed, Web of Science,
Embase, Cochrane Library, CINAHL and three Chinese
databases were searched for studies published until January
2016. The review included all clinical trials that evaluated
the effect of exercise on quality of life compared with that
of usual care for people with type 2 diabetes. Two
reviewers independently assessed the quality of all the
included studies, by using the Downs and Black Quality
Index (QI).
Results Thirty studies met inclusion criteria, with 2785
participants. We divided the exercise into four modes:
aerobic, resistance, a combination of aerobic and resistance
Hong Cai and Guichen Li have contributed equally to this work.
& Li Chen
chen_care@126.com
1
and yoga. Aerobic exercise showed a significant effect
between groups. Resistance and combined exercise showed
mixed results. Yoga also showed good intervention effects
on quality of life.
Conclusions The effect of aerobic exercise on the quality
of life in people with type 2 diabetes was safe and effective. Then, most of the studies on aerobic exercise were of
good methodological quality. The effects of resistance
exercise and combined exercise on the quality of life in
people with type 2 diabetes were mixed, and the effect of
yoga on quality of life still need more research.
Keywords Exercise/physical activity Quality of life
Systematic review Type 2 diabetes
Abbreviations
VAS
CES-D
EuroQoL
SF-12
SF-36
WHOQol-BREF
PCS
SWED-QUAL
QOLOD
Hong Cai
caiong722@outlook.com
NQOL
Guichen Li
edith25@163.com
ADS-L
School of Nursing, Jilin University, No.965 Xinjiang Street,
Changchun 130021, Jilin, People’s Republic of China
Visual Analogue Scale
Center for Epidemiologic Depression
Scale
European Quality of Life Questionnaire
12-item Short-Form Health Survey
36-item Short-Form Health Survey
World Health Organization Quality of
Life questionnaire
Physical Component Summary
Swedish Health-Related Quality of Life
questionnaire
Quality of Life, Obesity and Dietetics
questionnaire
Neuropathy-specific Quality of Life
instrument
German version of the general
depression scale CES-D, ADS-L
(Allgemeine Depressionsskala)
123
516
DCCT
HbA1c
BMI
T2DM
NYHA
RCT
PCS
MCS
ES
Qual Life Res (2017) 26:515–530
Diabetes Control and Complication
Trial
Haemoglobin A1c
Body mass index
Type 2 diabetes mellitus
New York Heart Association
Randomized control trials
Physical component score
Mental component score
Effect size
Introduction
Diabetes is one of the most important chronic diseases that
impact human health, and the global indicate a nearly 69%
increase in the number of adults with diabetes in developing
countries and a 20% increase in the number of diabetic
adults in developed countries from 2010 to 2030 [1].
Additionally, the large population of diabetes is a principal
cause of death in worldwide [2]. Studies reported that
people with type 2 diabetes have a low quality of life [3–5].
A sedentary lifestyle is considered to be a modifiable risk
factor for type 2 diabetes and an independent predictor of
poor quality of life [6–9]. It has been recognized that both
complications and comorbid conditions determine the
quality of life of type 2 diabetic patients [10, 11] and that
poor quality of life leads to cardiovascular mortality [12].
The goal for the treatment of diabetes is to prevent complications and to provide a good quality of life for the
diabetes patient [13]. Physical exercise has been proved to
be an effective therapy by mounting evidence [14]. Over
the years, exercise training in particular has been used to
positively impact diabetic persons, playing an increasingly
protective role by favourably altering the body composition, glycaemic control [15, 16], blood pressure [17, 18] and
insulin resistance [19, 20]. In addition, cross-sectional
studies in people with type 2 diabetes have shown that
higher levels of physical activity would improve quality of
life [4, 21, 22].
Exercise is a subset of physical activity [23]. It is
planned, structured, and repetitive bodily movement performed to improve or maintain one or more components of
physical fitness [23]. Many studies have indicated that
exercise could improve sleep quality and prevent chronic
illness for healthy people [24–27]. A meta-analysis on the
effect of exercise on the sleep of good sleepers found that
exercise produces facilitative sleep and slow-wave sleep
and also improves sleep quality [24–26]. Melvyn et al. [27]
conducted a cohort study with an average 8.8 years followup. They concluded that people who were physically active
between the ages of 39–63 at baseline had better work
123
permanence. Moreover, it is hard for these individual to
develop a chronic illness.
One systematic review included randomized controlled
trials of at least 4 weeks’ duration in people with type 2
diabetes that evaluated the effect of exercise training on
quality of life compared with usual care [28]. Quality of life
was assessed in 16 studies. The author found that the effects
of exercise training on quality of life in people with type 2
diabetes were conflicting. The aim of the systematic review
is based on all clinical trials about the effect of exercise on
quality of life for type 2 diabetes and gain greater insight into
the role of exercise training in people with type 2 diabetes.
Methods
Protocol and registration
The review was conducted and reported in accordance with
the Preferred Reporting Items for Systematic Reviews and
Meta-Analyses (PRISMA) guidelines [29].
Search strategy
PubMed, Web of Science, Embase, the Cochrane Library,
CINAHL and three Chinese databases (CNKI, Wan-fang
data and VIP) were electronically searched for papers that
were published until January 2016. The search comprised
the terms ‘type 2 diabetes’ and ‘quality of life’, with
exercise intervention terms such as ‘Exercise’ or ‘Exercise
Therapy’ or ‘Muscle Stretching Exercises’ or ‘Plyometric
Exercise’ or ‘Resistance Training’ or ‘Running’ or ‘Jogging’ or ‘Swimming’ or ‘Walking’ or ‘Sports’ or’ Cycling’
or ‘Physical activity’ or ‘Aerobic’ or ‘Yoga’ or ‘Tai Chi’ or
‘Qigong’. The search species was limited to humans.
Eligibility criteria
Types of studies
All clinical trials were included in this review. No publication date
was imposed on the initial search.
Types of participants
The participants were adults (C18 years) and diagnosed with type 2
diabetes.
Types of interventions
The inclusion criteria applied were as follows: (1) the intervention
group underwent exercise intervention and (2) the control group did
not undergo any exercise intervention. However, studies in which
exercise training was part of an intervention with multiple
components (e.g. combined with a diet intervention) were excluded.
Types of outcome
The studies were required to report quality of life as outcome
measure.
Qual Life Res (2017) 26:515–530
517
Study selection
The study selection process was outlined in Fig. 1. The
eligibility assessment was performed by two independent
reviewers in a standardized manner. All the papers identified by the search strategy were assessed for eligibility
based on the title and abstract according to the defined
inclusion criteria. If there was insufficient information to
include or exclude an article, then full-text version was
sought. A consensus between both reviewers was required.
Full-text versions of all the relevant studies were obtained
and read by two independent reviewers to ensure that the
inclusion criteria were met. Disagreements were settled by
a third independent reviewer. If there was insufficient
information to include an article, then authors were contacted when possible.
Quality assessment
Two reviewers independently assessed the quality of all the
included studies, by using the Downs and Black Quality
Index (QI), which assesses the quality of studies for both
randomized and non-randomized trials [30]. The scale
includes reporting, external validity, bias, confounding and
power, and their maximum scores are 11, 3, 7, 6 and 5,
respectively. The total score is 32. The quality scores were
calculated and ranked on a four-category scale: poor (\18),
moderate (18–23), good (24–29) and excellent (C30).
Data extraction and analysis
The data were extracted from the included articles using a
data extraction form (Table 1). Sample characteristics were
collected, including the sample size and HbA1c. Details on
exercise interventions were collected including the exercise
type, exercise session, frequency, and programme duration.
The effects of the exercise training on quality of life were
collected, including quality of life measures and the study
Fig. 1 Flow diagram of
literature search
result. One investigator performed the data extraction, which
was checked by a second investigator. The authors of an
included study were contacted if more information was
required. The results from different study designs should be
expected to differ systematically to avoid increased heterogeneity [31]. Therefore, no meta-analysis was performed due
to the heterogeneity of study designs and outcomes.
Results
Study searching and selection
We identified 4882 studies based on the database searches;
1584 articles were excluded because of duplicate records
and the initial sifting based on the title and abstract,
resulting in the exclusion of 3234 studies. The full-text
paper of 64 studies were reviewed, and 34 studies were
excluded because they were not exercise interventions,
they contained incomplete data, their control group
underwent an exercise intervention, or they did not report
quality of life as an outcome measurement. Finally, 30
[32–61] studies with 2785 participants were included in the
final analysis (Fig. 1).
Description of studies
The characteristics of the included articles are stated in
Table 1. In the included studies, the sample size ranged
from 17 [35] to 606 [54] participants. The mean HbA1c
ranged from 5.7% [46] to 9.0% [49], excluding four studies
that did not report HbA1c. The duration of the training
sessions varied from at least 10 min [34, 48] to 75 min
[54], excluding five studies [36, 42, 43, 55, 56] that did not
report the duration of the training sessions. The frequency
of the training sessions varied from least once a week
[43, 45] to seven times [49, 60] a week, with the exception
4882 Records identified from database search
1584 Records excluded (duplicate records)
3298 Potentially relevant articles identified for title/abstract
3234 Records excluded on title and/or abstracts
64 Records identified for full text
34 Records excluded on full text
Is not exercise intervention: 10
No quality of life measurements: 18
Incomplete data: 3
Control group undergo exercise intervention: 3
Included papers 30
123
123
7.2 ± 1.0
CG = 22
IG = 6.6 ± 1.5
CG = NR
IG = 98
CG = 119
Bennett [36]
8.07 ± 0.82
CG = 7.7 ± 0.9
CG = 52
N = 18
IG = 7.7 ± 0.9
IG = 51
CG = 7.8 ± 1.3
IG =
CG = 6.9 ± 2.0
CG = 10
IG = 22
IG = 7.9 ± 2.9
CG = 30
IG = 10
IG = 7.0 (6.4–7.7)
CG = 6.7
(6.2–7.1)
IG = 20
IG = 7.4 ± 0.9
CG = 8.0 ± 1.5
IG = 44
CG = 6.7 ± 0.97
CG = 11
CG = 28
IG = 7.4 ± 1.70
CG = 8.10 ± 2.70
CG = 23
IG = 18
IG = 8.30 ± 1.70/
8.10 ± 2.00
IG = 23/
23
IG = 8.20 ± 1.74
CG = 7.91 ± 2.47
CG = 9
CG = 6.8 ± 1.0
CG = 30
IG = 9
IG = 7.0 ± 0.8
HbA1c (%)
(mean ± SD)
IG = 30
Sample
Sample characteristics
Cugusi [39]
Reid [56]
Gram [45]
Asa [33]
Fritz [44]
Myers [53]
Lambers [50]
Sazlina [57]
Bello [37]
Dede [40]
Aerobic
Article
Table 1 Characteristics of included studies
Walking
Swimming and circuit training
Treadmills and/or bicycle
ergometers. Progressive
Nordic walking: walking
distance and intensity were
individually based.
Aquatic exercise
Nordic walking [40% VO2max
Aerobic exercise
4.8 km/h at a grade of
0–2.5%/every 3 min
50–75% VO2max
50 min, 39/week
heated pool
(31–32 °C)
15–45 min, 60–75%
HRmax
39/week.
Months 3–4: 19/week
Months 1–2: 29/week
[40% of_VO2max,
C30 min
39/week,45 min in
33–34 °C,
swimming pool
40–75% of HRR
5 h/week
29/week, 45 min
50–80% VO2max
150 min/week
50 min, 39/week
individually preexercise 60–85%
HRmax
30 min a day on
C5 days in a week
Walking
Walking or jogging, elbow
flexion and extension, cycling,
knee flexion and extension,
stepping
3 9/week,30 min,
50%-75% of HRmax
39/week, 15–20 min
60% HRmax to
45 min 75% HRmax
Exercise session
duration (warming
up and cooling
down not included),
frequency
Bicycle ergometry exercise
5–10 watts
Aerobic 30 subjects gradually
progressing in length and
intensity
Exercise
Intervention characteristics
NR
12 weeks
6 months
4 months
8 weeks
4 months
9 months
3 months
12 weeks
8 weeks
12 weeks
Programme
duration
SF-36
SF-36
SF-36
SF-36
SF-36
SWED-QUAL
SF-36
SF-36
PCS SF-12
WHOQoL-BREF
SF-36
Quality of life
measurements
Outcome
Significant between-group difference for
the physical health (p \ 0.001), physical
problems (p = 0.035), physical
component
Significant between-group difference
(p \ 0.05)
No significant between-group difference
No significant between-group difference
Significant between-group difference for
the subscales vitality scores
Significant between-group differences for
the physical health (p = 0.03) and sleep
(p = 0.03)
Significant between-group differences for
the physical health (P = 0.001), general
health p = 0.024, physical functioning
p = 0.025
No significant between-group difference
Significant between-group difference
(p = 0.032)
No significant between-group difference
Significant between-group difference for
physical functioning and mental health
(p = 0.020, 0.023)
Result
TG = 9
NR
CG = 9
IG = 9
CG = 0
IG = 1d
CG = 1b
IG = 2b
TG = 10
NR
CG = 5
IG = 2a,b
CG = 7
IG = 4/6
TG = 0
CG = 3a,b
IG = 3a,b
Dropout
518
Qual Life Res (2017) 26:515–530
Cheung [38]
Resistance
Dixit [41]
Ahn [32]
Liu [52]
Tsang [59]
Kempf [47]
IG = 8
Baillot [35]
IG = 7.2 ± 1.6
CG = 7.4 ± 1.0
CG = 17
NR
IG = 20
CG = 47
IG = 40
CG = 19
NR
CG = 21
IG = 20
IG = 6.05 ± 1.24
CG = 5.85 ± 0.71
IG = 20
CG = 6.9 ± 0.9
CG = 20
CG = 7.1 ± 1.3
IG = 7.1 ± 0.9
CG = 83
IG = 18
IG = 7.1 ± 1.3
NR
NR
TG = 8.29 ± 1.4
IG = 93
CG = 9
N = 330
CG = 13
IG = 12
IG = 7.1 ± 0.3
CG = 5.7 ± 0.1
CG = 10
HbA1c (%)
(mean ± SD)
IG = 9
Sample
Sample characteristics
Eckert [42]
Kirk [61]
Holton [46]
Article
Table 1 continued
Progressive ,increasing tension
of the bands
Use of exercise bands
Exercise session and home-based
four upper-body and threelower-body exercise
Moderate intensity treadmill
exercises
21 movements from Sun and
Yang Tai Chi styles
Kai Mai-style Tai Chi
‘‘Tai Chi for Diabetes’’ a
‘hybrid’ form of 12
movements from Sun and
Yang Tai Chi styles
Wii Fit Plus
Walking and ergocycling
2 km walking test
Moderate physical activity
Cycling,walking and other
aerobic form of exercise
Exercise
Intervention characteristics
Home-based: 59/week
2 9 12 rep/exercise,
30 min
5–6/week 150 min/
week to a 360 min/
week
40–60 % of HRR
50 min, 29/week
5 min of qigong
exercise, 40 min of
Tai Chi movements,
another 5 min of
qigong exercise
39/week., 30 min
29/week, 45 min
39/week, 30 min
3 days/week at 2
intensities 45 min
NR
30 min, most days of
the week
20–45 min, 39/week
50–65% of HRR
Exercise session
duration (warming up
and cooling down not
included), frequency
4 months
8 weeks
12 weeks
12 weeks
16 weeks
12 weeks
8 weeks
NR
5 weeks
10 weeks
Programme
duration
SF-36
NQOL
SF-36
SF-36
SF-36 social
function subscale
ADS-L
Obesity and
dietetics
questionnaire
(QOLOD)
SF-36
SF-36
SF-36
Quality of life
measurements
Outcome
Significant between-group difference for
the subscales of general health
(p = 0.02)
Significant between-group difference
p \ 0.001
Significant between-group difference for
the subscales including physical
function (p = 0.028), bodily pain
(p = 0.0009),physical role (p = 0.006),
emotion role (p = 0.002) and social
function (p = 0.001)
Significant between-group differences
including physical functioning, role
physical, bodily pain and vitality
(p \ 0.05), controlling for baseline
values
Significant between-group difference for
social function (p = 0.04). No
significant between-group difference
adjusted for body fat, and physical
activity levels
CG = 2
IG = 1
CG = 11
IG = 10
CG = 10
IG = 10
CG = 4
IG = 1
CG = 0
IG = 1b
CG = 17b
IG = 27b
NR
Significant between-group differences for
psychosocial impact dimension in the
obese subjects (p \ 0.05)
Significant between-group difference
(p = 0.03)
NR
CG = 1c,d
IG = 1c,d
NR
Dropout
Significant differences for the physical
function (P \ 0.05) and vitality
(P \ 0.01)
Significant between-group difference for
the mental health (98CI = 0.30) and
vitality(09CI=0.50)
No significant between-group difference
Result
Qual Life Res (2017) 26:515–530
519
123
123
IG = 6.35 ± 1.5
CG = 6.51 ± 0.78
IG = 7.4 ± 1.45
CG = 6.7 ± 0.97
IG = 44
IG = 17
CG = 11
Lambers [50]
CG = 9.0 ± 2.0
CG = 12
CG = 40
IG = 8.3 ± 1.6
CG = 7.7 ± 0.9
CG = 52
IG = 11
IG = 7.7 ± 0.9
CG = NR
CG = 29
IG = 58
IG = NR
CG = 21
IG = 29
IG = 6.9 ± 1.5
CG = 6.8 ± 0.8
IG = 27
IG = 7.6 ± 0.9
CG = 8.0 ± 1.5
IG = 52
HbA1c (%)
(mean ± SD)
CG = 28
Sample
Sample characteristics
Ferrer-Garcı́a
[43]
Combine
Labrunee [49]
Reid [56]
Lincoln [51]
Plotnikoff [55]
Myers [53]
Article
Table 1 continued
Strength exercises: 60–85%
1RM
Endurance training: individually
pre-exercise 60–85% HRmax
(treadmills, stationary bicycles
and steppers).
Circuit training: walking or
jogging, elbow flexion and
extension, cycling, knee
flexion and extension, stepping
Aerobic: various types of both
outdoor and indoor
Resistance: different circuits
involving big muscle groups,
gradually increased from 75 to
95% of the repetition
maximum in 40 s.
Home-based effort training: a
daily cyclergometer session
Progressive
Eight different exercises on
weight machines
Progressive 60–80% of 1RM
Using five pneumatic resistance
training machines
Use a multigym apparatus and
dumbbells. Progressive
Eight exercises per session,four
were core exercises and four
were complementary
assistance exercises
Two sets of four upper body
exercises, three sets of three
leg exercises and two sets of
each abdominal crunches and
back extensions, 10–12 rep/
exercise
Exercise
Intervention characteristics
39/week
3910–15 rep/exercise,
20 min 39/week
Aerobic: 30 min
Resistance:C29/week
Aerobic:C19/week
30 min/day
Resistance: 2/3 9 rep/
exercise
39/week.
35 min, 39/week
3 9 8 rep/exercise
3 months
24 weeks
3 months
6 months
16 weeks
16 weeks
9 months
39/week, 150 min/
week
2 9 10–12 rep at
50–60% of 1RM to
3 9 8–10 rep
exercise 70–85% of
1RM to 3 9 8–10
rep at 80% of 1RM.
Programme
duration
Exercise session
duration (warming up
and cooling down not
included), frequency
SF-36
Euro QoL VAS
Euro Qol
SF-36
SF-36
SF-36
SF-12
SF-36
Quality of life
measurements
Outcome
No significant between-group difference
Significant difference between on the
EuroQol (p \ 0.030) and the EuroQol
VAS (p = 0.045)
No significant between-group difference
Control group participants improved their
mental health status
Significant between-group differences
(p \ 0.001)
No significant between-group differences
Significant between-group differences for
physical health p = 0.005, general
health p = 0.003, bodily pain p = 0.026
Result
CG = 5
IG = 1a,b
CG = 6b
IG = 4b
CG = 1
IG = 1a,b
CG = 9
IG = 9
NR
CG =3
IG = 4
NR
Dropout
520
Qual Life Res (2017) 26:515–530
Yoga
Nicolucci [54]
Reid [56]
IG = 7.1 ± 1.4
CG = 7.2 ± 1.4
CG = 303
CG = 52
IG = 303
IG = 7.7 ± 0.9
CG = 7.7 ± 0.9
IG = 57
IG = 7.5 ± 1.2
CG = 7.3 ± 1.7
CG = 7.8 ± 1.3
CG = 22
CG = 20
IG = 7.2 ± 0.9
IG = 24
Gram [45]
IG = 19
CG = 8.0 ± 1.5
CG = 39
Tessier [58]
IG = 7.4 ± 1.5
IG = 37
IG = 7.7 ± 0.4
CG = 6.8 ± 0.3
IG = 18
CG = 18
IG = 7.5 ± 0.9
CG = 8.0 ± 1.5
IG = 49
HbA1c (%)
(mean ± SD)
CG = 28
Sample
Sample characteristics
Krousel-Wood
[48]
Aylin [34]
Myers [53]
Article
Table 1 continued
10–30 min, up to 59/
week
2910–12 rep 29/week
Resistance :45 min
C29/week
Aerobic: 10–45 min
29/week, 150 min/
week
Exercise session
duration (warming up
and cooling down not
included), frequency
Resistance: four resistance
exercises and three stretching
exercises
Treadmill, step, elliptical, arm or
cycle-ergometer.
Progressive
Resistance: eight different
exercises on weight machines
150 min, 29/week
Resistance: 2/39 rep/
exercise
12 months
6 months
SF-36
SF-36 physical and
mental
component
summary
Aerobic:15–45 min
,60–75% HRmax
39/week.
Aerobic: treadmills and/or
bicycle ergometers.
Research group and
the modified
quality of life
measure for
youths
39/week
A combining the
diabetes quality
of life-DCCT
Progressive: 30–49% VO2max to
60–79% of the HRmax
16 weeks
SF-36
SF-36 physical
function subscale
SF-36
SF-36
Quality of life
measurements
Resistance: 2 9 20
rep/exercise, 20 min
Aerobic: 20 min
4 months
3 months
8 weeks
9 months
Programme
duration
Outcome
Resistance: exercise major
muscle groups
Aerobic: rapid walk
[40% of_VO2max,
Exercise on prescription:
individualized on the basis of a
C30 min
cycle test, access to ergometer Months 1–2:29/week
cycles, rowing machines, step
machines, and strength training Months 3–4:19/week
machines
Progressive 3–6METs
Home-based video-taped
exercise instruction using chair
and foot weights
Resistance: eight exercise using
free weight 50–60% 1RM
Aerobic :home-based walking
Aforementioned nine exercises,
10–12 rep/exercise
Exercise
Intervention characteristics
Significant between-group difference for
all Subscales
(PCS:ES = 0.90,MCS:ES = 0.61),
adjusted for baseline score ,age, sex and
BMI
No significant between-group difference
No significant between-group difference
No significant between-group difference
No significant between-group difference
Significant between-group difference for
the subscales emotional role (p = 0.03),
mental health (p = 0.02) and vitality
(p B 0.001),adjusted for baseline scores
Significant between-group differences for
physical health p = 0.015, general
health p = 0.024, physical function
p = 0.03, mental component score
p = 0.04
Result
CG = 28a,b
IG = 15a,b
CG = 9
IG = 9
CG = 1a,b
IG = 5a,b
CG = 0
IG = 2d
CG = 10a,b
IG = 8
CG = 1a,b
IG = 1
NR
Dropout
Qual Life Res (2017) 26:515–530
521
123
of two studies [36, 42] that did not report the frequency.
The duration of the total training period varied from
5 weeks [61] to 12 months [54], with the exception of two
studies [36, 42] which did not report the duration of the
total training period. Among the included studies, four
studies compared two [45] or three [53, 56, 57] intervention types with a control group. We divided the exercise
into four modes: aerobic, resistance, a combination of
aerobic and resistance and yoga (Table 1).
Quality assessment
Thirty studies were included in the quality assessment.
Most of the studies demonstrated good reporting quality;
however, most of the studies had a high risk of bias in
terms of study design. The quality of the majority of the
studies was moderate, with a mean score of 21. Eight
studies were rated as poor quality, eleven studies were
deemed to be of moderate quality, and eleven studies were
deemed to be of high quality (Table 2).
Outcomes
Dropouts not included in analysis
Unclear whether dropouts are included in baseline statistics
Unclear whether dropouts are included in analysis
c
d
Dropouts not included in baseline statistics
b
Aerobic exercise
a
CG control group, HRmax maximum heart rate, IG intervention group, MET metabolic equivalent which expresses the cost of energy from physical activities as a multiple of the resting
metabolic rate, which is obtained during quiet sitting, NR not reported; rep, repetition, 1RM 1 repetition maximum, TG intervention and control group together, VO2max maximal oxygen uptake,
VAS Visual Analogue Scale, CES-D Center for Epidemiologic Depression Scale, EuroQoL European Quality of Life questionnaire, SF12 12-item Short-Form Health Survey, SF36 36-item
Short-Form Health Survey, WHOQol-BREF World Health Organization Quality of Life questionnaire (abbreviated version), PCS Physical Component Summary, SWED-QUAL Swedish
Health-Related Quality of Life questionnaire, QOLOD Quality of Life, Obesity and Dietetics Questionnaire, NQOL neuropathy-specific quality of life instrument; ADS-L German version of the
general depression scale CES-D, ADS-L Allgemeine Depressionsskala, DCCT Diabetes Control and Complication Trial, HbA1c haemoglobin A1c, BMI body mass index, ES Effect Size
CG = 22
Sudarshan Kriya Yoga and
Pranayam
IG = 7.29 ± 1.02
CG = 6.96 ± 0.67
IG = 27
Viveka [60]
To convert values for HbA1c in % into mmol/mol, subtract 2.15 and multiply by 10.929
TG = 3
Significant between -group difference
(p = 0.01)
WHOQOL-BREF
123
25–35 min, daily
3 months
Dropout
Quality of life
measurements
Exercise
HbA1c (%)
(mean ± SD)
Sample
Article
Table 1 continued
Sample characteristics
Intervention characteristics
Exercise session
duration (warming up
and cooling down not
included), frequency
Programme
duration
Result
Qual Life Res (2017) 26:515–530
Outcome
522
Twenty studies containing 1472 participants examined the
effect of aerobic training on the quality of life in patients
with type 2 diabetes [32, 33, 35–37, 39–42,
44–47, 50, 52, 53, 56, 57, 59, 61]. Walking was the most
common exercise training among the included studies
[35, 36, 42, 44–46, 50, 57]. Other forms of aerobic training
were treadmills and/or bicycle ergometers [37, 41, 56],
aquatic exercise [33, 39], Tai Chi [32, 52, 59] and exercise
game [47]. The remaining three studies did not specify the
aerobic training type [40, 53, 61]. The duration of the
training sessions varied from 15 min [40, 56] to 50 min
[32, 39, 50]. The frequency of the training sessions varied
from two times a week [32, 45, 53, 59] to five times a week
[41, 57]. Fourteen studies used the 36-item Short-Form
Health Survey (SF-36) [32, 33, 36, 39, 40, 42, 45,
46, 50, 52, 53, 56, 59, 61], one used the abbreviated version
of the World Health Organization Quality of Life questionnaire (WHOQol-BREF) [37], one used both the Physical Component Summary (PCS) and the 12-item ShortForm Health Survey (SF-12) [57], one used the Swedish
Health-Related Quality of Life questionnaire (SWEDQUAL) [44], one used the Quality of Life Obesity and
Dietetics Questionnaire (QOLOD) [35], one used the
German version of the general depression scale CES-D,
ADS-L (Allgemeine Depressionsskala) [47], and one used
the 35-item neuropathy-specific quality of life instrument
(NQOL) [41].
Qual Life Res (2017) 26:515–530
523
Table 2 Quality of included studies
Author (years)
Reporting
(11)
External
validity (3)
Bias
(7)
Confounding
(6)
Power
(5)
Total
(32)
Quality as per
cut-off described
Cheung [38]
6
1
3
3
0
13
Poor
Ferrer-Garcı́a [43]
10
3
5
4
5
27
Good
Dede [40]
10
2
5
4
5
26
Good
Bello [37]
8
2
6
3
0
19
Moderate
Nicolucci [54]
10
3
5
4
5
27
Good
Kempf [47]
10
3
6
3
5
27
Good
Sazlina [57]
Tsang [59]
10
10
3
3
5
6
4
5
0
5
22
29
Moderate
Good
Lambers [50]
10
2
7
4
0
23
Moderate
Myers [53]
10
0
7
3
5
25
Good
Fritz [44]
10
2
5
4
5
26
Good
Asa [33]
8
3
5
3
5
24
Good
Plotnikoff [55]
10
2
5
4
0
21
Moderate
Aylin [34]
9
3
5
3
0
20
Moderate
Krousel-Wood [48]
8
2
5
3
5
23
Moderate
Lincoln [51]
5
1
5
1
5
17
Poor
Gram [45]
9
2
5
4
0
20
Moderate
Tessier [58]
8
1
5
2
5
21
Moderate
Reid [56]
9
3
6
4
5
27
Good
Liu [52]
4
2
5
2
0
13
Poor
Dixit [41]
9
2
6
5
5
27
Good
Viveka [60]
Labrunee [49]
6
4
1
2
5
5
2
2
5
0
19
13
Moderate
Poor
Cugusi [39]
9
2
5
2
5
23
Moderate
Ahn [32]
10
2
6
3
5
26
Good
Bennett [36]
5
0
4
1
0
10
Poor
Holton [46]
8
1
3
2
0
14
Poor
Kirk [61]
5
2
4
5
0
16
Poor
Eckert [42]
6
2
5
2
0
20
Moderate
Baillot [35]
7
0
4
0
0
11
Poor
Among 20 studies, five studies (sample sizes between 18
[37] and 103 [56]) reported no significant effects of aerobic
training on quality of life in patients with type 2 diabetes
compared with that of usual care [37, 45, 46, 50, 56]. Gram
et al. [45] evaluated Nordic walking for 4 months with
follow-up after one year.
Fifteen studies reported a significant effect of aerobic
exercise on the quality of life in patients with type 2 diabetes mellitus compared with that of patients in the control
group.
Sazlina et al. [57] examined the effects of personalized
feedback alone or combined with peer support to improve
physical activity in sedentary older Malays with type 2
diabetes. They found that personalized feedback combined
with peer support improved physical activity levels, cardiorespiratory fitness, support from friends and quality of
life. The personalized feedback group performed an
unsupervised walking activity and was required to record
written feedback on physical activity. The peer support
group received the personalized feedback intervention and
telephone call from trained peer mentors. Peer support and
personalized feedback have been shown to influence one
another and develop their own social network outside of
the study. Sazlina et al. [57] evaluated the walking effect
for 12 weeks with a follow-up after 24 and 36 weeks. Fritz
et al. [44] assessed the effect of 4 months of Nordic
walking on health-related quality of life in overweight
individuals with type 2 diabetes mellitus. They found that
Nordic walking significantly improved quality of life
compared with usual care as measured on two of the 13
SWED-QUAL subscales, i.e. ‘physical health’ and ‘sleep’.
Baillot et al. [35] assessed the effect of supervised walking
training on saliva steroid hormones, physical capacity and
quality of life in abdominally obese diabetic men. An
123
524
8-week walking programme improved the 6-min walking
distance and the psychosocial impact dimension of quality
of life, without significantly modifying any other parameter
investigated. The obese diabetic men had significantly
lower scores for physical, psychosocial, and sex life before
and after training compared with the healthy men
(p \ 0.05). Eckert et al. [42] examined the relationship
between health-related quality of life and physical activity
in type 2 diabetics; a walking test of 2 km was performed
to verify their relationship. They found that health-related
quality of life was negatively affected by body mass index
(BMI) and evidence of the efficacy of physical activity for
preventing and treating those who are overweight or obese.
Bennet et al. [36] investigated how aerobic fitness influenced health-related quality of life of those with type 2
diabetes mellitus. Aerobic fitness was assessed by peak
oxygen uptake, determined on a graded exercise treadmill
with a walking speed of 4.8 km/h at an initial grade of 0%;
the grade increased by 2.5% every 3 min until participant’s
volitional fatigue. They found that aerobic fitness significantly affected physical health, physical problems and
physical component scores of the SF-36, after adjusting for
age, sex and race.
Dixit et al. [41] examined the effect of an 8-week
supervised, moderate-intensity treadmill exercise on the
quality of life of patients who had type 2 diabetes with
diabetic peripheral neuropathy and found that moderateintensity treadmill exercise played a vitally important role
in modifying the progression of neuropathy. Modifying the
progression of neuropathy can modulate the quality of life
of patients suffering from diabetic peripheral neuropathy.
Myers et al. [53] evaluated a 9-month aerobic intervention
on the quality of life in individuals with type 2 diabetes and
found significant positive effects compared with that of
usual care on 3 of 8 the subscales, i.e. ‘physical health’,
‘general health’ and ‘physical function’. The 9-month
longer exercise programme may improve mental quality of
life.
Kirk et al. [61] evaluated the effect of exercise consultation on promotion of physical activity in people with type
2 diabetes and found that exercise consultations are more
effective in stimulating exercise behaviour in the short
term. Moderate physical activity for 5 weeks significantly
improved the vitality and mental health subscales of the
SF-36 in the experimental group. The accelerometer
recorded a significant change between the groups after five
weeks of intervention. Dede et al. [40] evaluated a supervised aerobic exercise intervention on the quality of life,
leptin and adiponectin levels in patients with type 2 diabetes mellitus. They reported associations of improved
HbA1c, body fat percentage and mental and physical scores
with a decrease in leptin levels, despite a significant
reduction in serum adiponectin levels. The aerobic exercise
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Qual Life Res (2017) 26:515–530
improved the diabetic control, physical functioning and
mental health and also decreased the adiponectin and leptin
levels. Improvement in diabetic control may result in an
improvement of quality of life in diabetic patients.
Asa et al. [33] and Cugusi et al. [39] evaluated an
aquatic exercise intervention on people with type 2 diabetes and found that exercise had a significant effect on
quality of life. The important finding in this study was that
aquatic exercise was associated with a significant
improvement in VO2 peak. The improvement in VO2peak
may show as general performance. Finally, the participants
felt improving the quality of life. Asa et al. [33] examined
the effect of aquatic exercise intervention in a 33–34 °C
swimming pool on exercise capacity, muscle function and
the quality of life for patients who had heart failure (NYHA
functional class II or III) and type 2 diabetes mellitus. The
result showed that aquatic exercise improved exercise
capacity and muscle function. There were no significant
differences between groups except in the vitality score of
the SF-36. Immersion in warm water resulted in immediate
improvement in cardiac function, probably mediated by
peripheral vasodilation and unloading of left ventricular
function. Cugusi et al. [39] evaluated the effect of a
supervised aquatic-based exercise programme on cardiometabolic profile, quality of life and physical activity
levels in patients with type 2 diabetes. They demonstrated
that 50-minute sessions of an aquatic-based exercise programme in a heated pool (31–32 °C) for 12 weeks produced benefits for the cardiovascular system and, metabolic
profile, improved quality of life and increased physical
activity levels in patients with type 2 diabetes. The subjects
in the intervention group achieved 96% of the prescribed
resistance training.
In the studies that examined Tai Chi, two used the
combination of the Sun and Yang Tai Chi styles [32, 59],
and one used the Kai Mai-style of Tai Chi [52]. Additionally, all the studies concluded that Tai Chi can improve
quality of life. It was plausible that Tai Chi may have an
important role in helping people become more energetic
and physically active. As Tai Chi was a gentle exercise, it
has the potential to help people feel relaxed. Tsang et al.
[59] tested the health benefits of supervised Tai Chi on gait,
balance, musculoskeletal and cardiovascular fitness, selfreported activity and quality of life of older patients with
type 2 diabetes. After the intervention, a significant group
effect was observed in the SF-36 social function subscale.
However, the change in social function was no longer
significant after adjusting for % BF and physical activity
levels. One subject in the Tai Chi group was unable to
perform any physical activity because of pain and fatigue.
Ahn et al. [32] evaluated the effect of a supervised, combined Yang and Sun styles of Tai Chi exercise on the
glucose control, balance and quality of life of patients who
Qual Life Res (2017) 26:515–530
525
had type 2 diabetes with neuropathy. They found that 1-h
session of a supervised Tai Chi intervention for 12 weeks
improved the glucose control, balance and some dimensions of quality of life of patients who had type 2 diabetes
with neuropathy compared with baseline. Diabetes
peripheral neuropathy was usually associated with pain,
infection, sensory loss and fall. The pretest–posttest design
study found significant improvement in the total symptom
score for neuropathy, sensory function and balance after
12-week Tai Chi practice. With improvement in plantar
sensory perception, practicing Tai Chi can help diabetes
peripheral neuropathy patients better control their posture,
leading to better balance and preventing falls. These results
suggested that Tai Chi exercise improved neuropathy-related symptoms. Liu et al. [52] examined the effects of the
Kai Mai-style of Tai Chi on quality of life and found that
12-week of Kai Mai-style of Tai Chi had a significant
effect on four of the eight subscales of the SF-36 subscales,
i.e. ‘physical function’, ‘role physical’, ‘bodily pain’ and
‘vitality’.
Kempf et al. [47] evaluated the effect of an autonomous
exercise game on the metabolic control and quality of life
in type 2 diabetic patients. They found that the exercise
game Wii Fit Plus was able to motivate T2DM patients to
improve physical activity, glucometabolic control and
quality of life. After intervention, the result displayed that
61% intervention participants played the exercise game
together with family members. Playing exercise game with
family members can increase intervention participants
physical activity or motivate players to exercise, may help
participants feeling of physical and mental well-being,
feeling better afterwards and participation in a social
context.
The results indicated that the effect of endurance aerobic
training on quality of life in patients with type 2 diabetes
was safe and beneficial.
type 2 diabetes compared with that of usual care
[49, 55, 56]. Reid et al. [56] evaluated the effect of
6 months of resistance exercise on the patient-reported
health status and well-being of patients with type 2 diabetes
mellitus. There were no significant trends towards
improvement in patient-reported quality of life during the
6-month resistance exercise intervention. They surprisingly
found that the control group participants improved their
mental health status more than resistance group participants after adjusting for age, sex, baseline HbA1C and BMI.
Three studies reported a significant effect of resistance
on the quality of life in patients with type 2 diabetes
compared with that of patients in the control group.
Lincoln et al. [51] examined the impact of a 16-week
resistance exercise training programme on the mental
health of older Puerto Rican adults with type 2 diabetes and
found that progressive resistance training participants had a
significantly improved mental health status as measured by
the SF-36. Myers et al. [53] found a significant effect of
9-month group supervised pneumatic/weight resistance
training on physical component scores of the SF-36 compared with usual care. They also found that the resistance
training group was the greatest improved in bodily pain
compared with the control, aerobic and combined groups.
Cheung et al. [38] conducted a 4-month home-based,
supervised resistance training with exercise bands to
manage of sedentary subjects with type 2 diabetes and
found a significant positive effect compared with that of
usual care on the ‘general health’ of the SF-36 (n = 37).
The subjects in the intervention group achieved 90% of the
prescribed resistance training.
The results indicated that the effect of endurance resistance training on the quality of life in patients with type 2
diabetes was mixed.
Resistance exercise
Nine studies with 1099 participants examined the effect of
combined exercise on the quality of life in patients with
type 2 diabetes [34, 43, 45, 48, 50, 53, 54, 56, 58]. Combined exercise consisted of a combination of aerobic (e.g.
walking, treadmills, cycling) and resistance training (e.g.
weight machines, exercise bands, multigym apparatus).
Seven studies used the SF-36 [34, 45, 48, 50, 53, 54, 56],
one used the European Quality of Life questionnaire
(EuroQoL) [43], and one used a combination of the Diabetes Quality of Life–Diabetes Control and Complications
Trial (DCCT) Research Group questionnaire and the
Modified Quality of Life Measure for Youths [58].
In these nine studies, five studies with sample sizes
between 28 [50] and 109 [56] participants found no significant effects of combined training on the quality of life
in patients with type 2 diabetes compared that of with usual
Six studies with 356 participants examined the effect of
resistance training on the quality of life in patients with
type 2 diabetes [38, 49, 51, 53, 55, 56]. The studies
examined resistance training with pneumatic/weight resistance training machines [51, 53, 56], multigym apparatus/dumbbells [55] or exercise bands [38]. In one study, the
resistance training type was not specified [49]. Most of the
training sessions were 30 min [38, 49]. The most common
training session frequency was three times a week
[51, 53, 55, 56]. Five studies used the SF-36
[38, 49, 51, 53, 56], and one used the 12-item Short-Form
Health Survey (SF-12) [55].
Among six studies, three reported no significant effects
of resistance training on the quality of life in patients with
Combined exercise
123
526
care [45, 48, 50, 56, 58]. Gram et al. [45] was the only
group to assess quality of life for 8 months after intervention, with the lowest training frequency (n = 44). One
hypoglycaemic event and three musculoskeletal symptoms
were observed during the training session. Reid et al. [56]
assessed the effect of 6-month combined exercise intervention on the patient-reported health status and well-being
of patient with type 2 diabetes mellitus and found that there
were no significant trends towards improvement in patientreported quality of life during the intervention. The participants in the combined group may feel more fatigue than
participants in the other groups because they need to work
twice as much as participants assigned to the aerobic or
resistance intervention alone. Krosel-woud et al. [48]
reported that participants in the intervention group
accomplished the combined exercise using videotapes four
times a week for 85 min per week on average over the
3-months intervention, although the study instructed them
to gradually increase their physical activity to achieve
150 min/week.
Four studies reported a significant effect of combined
training on the quality of life of patients with type 2 diabetes compared with that of control. Nicolucci et al. [54]
studied the largest sample and had the intervention with the
longest duration (12 months). Nicolucci et al. [54] evaluated the relationship of exercise volume to improve quality
of life with supervised exercise in patients with type 2
diabetes and found positive effects of intensive combined
exercise on all subscales of the SF-36. Aylin et al. [34]
found significant positive effects of combined home-based
walking with resistance exercise compared with the effect
of usual care on three of eight subscales of the SF-36, i.e.
‘emotional role’, ‘mental health’ and ‘vitality’. The participants in the exercise group completed 96% of the
exercise training programme. Myers et al. [53] found a
significant effect of the aforementioned 9-month supervised exercise training compared with that of usual care on
four subscales of the SF-36, i.e. ‘physical health’, ‘general
health’, ‘physical function’ and ‘mental component score’.
They also found that the combined and aerobic groups had
the more beneficial changes in physical function compared
with the control and resistance groups. Ferrer-Garcia et al.
[43] examined the effect of a home-based physical exercise
programme on the quality of life, metabolic control and
anthropometric and biochemical parameters of older people with type 2 diabetes mellitus. They found that the
home-based physical exercise programme with the smallest
training frequency improved the quality of life and glycaemic control of type 2 diabetic patients. Because in the
combination programme larger muscle mass was involved,
it was possible to increase muscle mass, optimize oxygen
consumption and improve glycemic control. The combined
exercise decreased the total intramypcytic fat or increased
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Qual Life Res (2017) 26:515–530
the fatty acid oxidation capacity, resulting in an increased
glucose uptake.
The results indicated that the effect of endurance combined training on the quality of life in patients with type 2
diabetes was mixed.
Yoga
Practicing yoga based on the principle intimately related
body and mind. Yoga was formed by physical fitness,
relaxation and awareness. The relaxation part produced a
state of physical and mental tension. In yoga, combining
yoga postures with breathing exercise improved participants muscle strength, flexibility, blood circulation and
oxygen uptake. One study with 49 participants examined
the effect of comprehensive yoga breathing programme on
the glycaemic control and the quality of life in patients
with type 2 diabetes [60]. The study used the abbreviated
version of the WHOQol-BREF. They found a significant
improvement in the quality of life of the group enrolled in
the comprehensive yoga breathing programme compared
with that of the group that followed standard treatment
alone.
Discussion
This review systematically assessed the effectiveness of
aerobic exercise, resistance exercise, combined exercise
and yoga on the quality of life in patients with type 2
diabetes. In this systematic review, the 30 included studies
were rather heterogeneous in terms of type of the intervention exercise, exercise session, programme duration and
quality of life measurements. Fifteen of the twenty studies
reported a significant effect of aerobic exercise on the
quality of life in patients with type 2 diabetes mellitus
compared with that of the control group. Three of the six
studies reported a significant effect of resistance exercise
on quality of life in patients with type 2 diabetes compared
with that of the control group. Four of the nine studies
reported a significant effect of combined training on the
quality of life in patients with type 2 diabetes compared
with that of the control group. One study reported a significant effect of yoga on quality of life.
Three studies evaluated the effect of exercise on diabetic
patients with complications [32, 33, 41]. Asa et al. [33]
examined the effect of exercise intervention on patients
with heart failure (NYHA functional class II or III) and
type 2 diabetes mellitus and found that there was no significant difference between groups except in the vitality
score. The author thought that the size of the population in
that study and the short-term treatment were inadequate to
show unequivocal changes in quality of life. Among three
Qual Life Res (2017) 26:515–530
studies, two tested the effect of exercise on a population of
type 2 diabetic with diabetic peripheral neuropathy
[32, 41]. They both demonstrated that exercise could
improve the quality of life of diabetic patients with
peripheral neuropathy. Diabetic peripheral neuropathy
could lead to pain in the legs, foot ulcers and amputations,
which seriously influence quality of life. The body exercise
in sufficient oxygen surrounding will do aerobic exercise,
which has decreased the diabetic peripheral neuropathy
reliance on polyol-sorbitol pathway (an anaerobic process).
Exercise may be reduced among people with painful diabetic peripheral neuropathy, modifying the progression of
neuropathy and advancing neuropathy-related symptoms.
There was no adverse event in the two studies.
Various incentive policies were taken to reduce the
dropout rate, such as telephone follow-up from research
assistants to remind them to exercise at home, supervising
exercise sessions, providing a variety of training programs,
self-monitoring of daily activity, giving exercise consultations, encouraging patients to exercise regularly at home
and providing videos and games to experience with family
members. Among the included studies, nineteen provided
supervised exercise [32–34, 38–41, 44, 45, 50–57, 59, 60].
In these 19 studies, the attendance ranged from 59.5 to
96.5%. Fifteen of these 19 studies reported that exercise
significantly improved the quality of life for diabetes
patients [32–34, 38–41, 51–55, 57, 59, 60]. The majority of
patients said that group-based training sessions were more
enjoyable and motivated them participant in the training
programme, manifesting as increased patient adherence
and effort during the exercise [34]. Supervision by a professional rehabilitation therapist during the exercise sessions possibly made the patients feel more confident and
allowed them to receive information about the management
of their disease and metabolic variables [62]. Mental
components also may improve by contact with other study
participants. Interaction with others may contribute to the
adherence to regular physical activity and may be effective
in increasing daily activity in the short term. Two studies
provided a video and asked participants to exercise along
with the video [47, 48]. One of them reported that their
subjects achieved 53% of prescribed training [47] which
reported that the exercise game improved the quality of life
in patients with type 2 diabetes. Exercising along with the
video at home could encourage family members to participate. Encouraging exercise with family members
strengthened the patients’ motivation to exercise, improving glycaemic control and fostering a positive attitude
towards life. This positive attitude towards life motivated
participants to exercise, made them feel good physically
and mentally and fostered social relationships associated
with physical activity [63]. Exercising together with family
members may reduce sedentary behaviour in diabetic
527
patients. In four studies, the participants were given an
accelerometer/pedometer to objectively record their daily
activity [44, 48, 57, 61]. In these four studies, the attendance exceeded 80%. Three of studies, reported that
exercise significantly improved the quality of life for diabetes patients [44, 57, 61]. Recording daily activity may be
effective in encouraging and motivating diabetic patients to
exercise more and, consequently, promote metabolic control. A variety of training programmes were provided in
one study, and the average adherence rate was 92% in this
research [33].
Six
studies
investigated
adverse
events
[40, 45, 48, 55, 56, 59]. And we observed that four of six
studies reported exercise did not improve the quality of life
for diabetic patients [45, 48, 55, 56]. Four of 6 studies
evaluated a combination of aerobic and resistance exercise.
Combined aerobic and resistance exercise may have caused
greater fatigue and pain than either resistance or aerobic
exercise alone [56]. Musculoskeletal problems or hypoglycaemic were the main adverse event [40, 45, 55]. The
participants did not want to challenge their body to the
necessary limit and simply stopped before their heart rate
was high enough despite instructions and guidance [45].
Five studies performed the diet education or diet
instruction for both the intervention and control group
[32, 40, 41, 43, 48]. Among them, four studies reported an
improvement in quality of life [32, 40, 41, 43]. In these
studies, the intervention group found the exercise improved
the quality of life in patients with type 2 diabetes. But the
control did not report that the exercise improved the quality
of life in patients with type 2 diabetes.
Among the included studies, some studies discussed the
relationship between the quality of life and objective
measurement. In these 12 studies, four [32–34, 52] indicated that exercise intervention can decrease HbA1c and
improve quality of life, while eight studies
[38–40, 43, 44, 57, 59, 60] showed that exercise intervention was only useful for quality of life and did not
decrease HbA1c. In these 12 studies, three [39, 47, 52]
indicated that exercise intervention can decrease BMI and
improve quality of life, while nine studies
[38–40, 43, 44, 53, 57, 59, 60] showed that exercise
intervention was only useful for improving quality of life
and not decreasing BMI. The HbA1c and BMI were the
objective measurement, but the quality of life was subjective measurement. It may be comprehensively affected
by lots of factors such as mental and pain.
In the included studies, six studies provided a weekly
minimum of 150 min of moderate-intensity aerobic
[39, 41, 44, 50, 53, 61]. The results showed that a weekly
minimum of 150 min of moderate-intensity aerobic
improved quality of life. The results were consistent with
the recommendation of the American College of Sport
123
528
Medicine that diabetic patients should take a weekly
minimum of 150 min of moderate-intensity aerobic or
75 min of vigorous-intensity aerobic activity with additional muscle-strengthening exercises [64]. Two studies
provided a weekly minimum of 150 min of moderate-intensity a combination of aerobic and resistance exercise
[53, 54]. The results showed that a weekly minimum of
150 min of moderate-intensity a combined exercise
improved the quality of life. Three studies provided a
weekly minimum of 150 min moderate-intensity resistance
exercise [38, 49, 53]. The results showed that a weekly
minimum of 150 min of moderate-intensity resistance
exercise improved the quality of life. Three studies provided less than 150 min/week low-intensity exercise
interventions [32, 52, 59]. The results showed that less than
150 min per week low-intensity exercise interventions
improved the quality of life.
Conclusion
There are some limitations in our included studies. First,
only one study [60] assessed the effects of yoga. Because
of the small number of studies, the effect of yoga need
more evidence. Second, some included studies did not
provide supervised exercise. We could not determine
whether the participants completed the training programme or whether they reached a moving target, which
might have affected the quality of life outcome. Third,
most of the included studies performed 12–16 weeks of
an exercise intervention. Because of the short duration of
the interventions, we may not be able to form a conclusion on the effect of the exercise interventions [45, 57]. It
has been argued that the duration of exercise was too
short to have an impact on the effect measures [45].
Additionally without a follow-up, we could not observe
the long-term effects.
We concluded that aerobic exercise was safe and
effective to improve the quality of life in patients with type
2 diabetes who were medically stable. Then, most of the
studies on aerobic exercise were of good methodological
quality. The effects of resistance exercise and combined
exercise on the quality of life in people with type 2 diabetes
were mixed, and the effect of yoga on quality of life still
need more research.
Funding Work on this manuscript was supported by Youth Program
of Health and Family Planning Commission of Jilin Province
(2015Q022).
Compliance with ethical standards
Conflict of interest The authors declare that they have no conflicts of
interest.
123
Qual Life Res (2017) 26:515–530
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