有氧運動訓練對第二型糖尿病患者生理指標、生活品質與憂鬱狀態之成效運動對糖尿病患影響之研究

Transcription

1 OGTT (p<.0001)ogtt (p<.0001) (p<.0001) -- VO 2max OGTT 1

2 (120 )OGTT OGTT OGTT 30 (PCS & MCS) (BP) (PCS) (PF) (RP) (BP) (GH) (VT) (SF) (RE) (MH) (MCS) (p<.05) (p<.05) 2

3 Abstract Little is known about the relation of planed exercise training to insulin sensitivity and psychosocial effects in type 2 diabetes. The purpose of this study was to explore the effects of 12-week endurance training on insulin sensitivity, metabolic control, serum lipids, body composition, cardiorespiratory fitness, blood pressure, the improvement of quality of life and depression among patients with type 2 diabetes. The quesi-experimental design and purposive sampling were fulfilled in this study. The samples consisted of 13 eligible cases with type 2 diabetes. Each subject underwent 12-week exercise program (30 minutes a day, 3days a week, at 60% maximum oxygen uptake). Every 4 weeks training, insulin, glucose level were measured after an overnight fast and 75-g oral glucose challenge (OGTT). Besides, other physical parameters and psychosocial effects were also performed. The major instruments in this study include demographic scale, Medical Outcomes Study (MOS) Short-Form-36 (SF-36) for quality of life, and Beck Depression Inventory (BDI) for depression. Descriptive analysis were performed first to understand the frequencies and distributions of the characteristics of the samples and data of all pre-training and post-training parameters; Generalized Estimating Equation (GEEs) were used to examined the differences between pre-training and post-training among patients, further, GEEs were simultaneously used to determinate the time effects of exercise training on all parameters. After 12-week exercise training program, the results indicate that almost either the physiological parameters, or the psychosocial aspects were significantly improved. Especially the OGTT glucose area under the curve 3

4 (p<.0001) and OGTT glucose level (0, 60, 90, 120 ), triglyceride (p<.05) were lower after adjusting possible confounding factors. Furthermore, fasting glucose, HgbA 1c, body weight, BMI, waist-to-hip ratio, HR rest, SBP and DBP were decreased (p<.0001) significantly, too. Physical training also resulted in a significant improvement in VO 2max. However, fasting insulin, OGTT insulin OGTT insulin area under the curve, total cholesterol, LDL, and HDL didn t change except the 120 OGTT insulin. And the more time of exercise training they received, the more they improved except for the OGTT insulin AUC, OGTT insulin, TC, LDL, and HDL. Another significant improvement on quality of life and depression were investigated in this study. Among eight subscales and two main components (PCS & MCS) of SF-36, physical function, role-physical, general health, vitality, social function, role-emotional, and mental health, mental component scale(mcs) were elevated(p<.05) except bodily pain and physical component scale(pcs). And the more time of exercise training they received, the more their QOL and depression improved (p<.05). It is concluded that exercise-induced improvement in insulin sensitivity, metabolic control, serum lipids, body composition, cardiorespiratory fitness and blood pressure in type 2 diabetes. Even the physical training may result in a better quality of life and lower depression. We would like to propose our clinics the importance to educate patients with type 2 diabetes how to do the adequate exercise training, and provide precise exercise prescriptions for these patients to improve their physical status, quality of life, and depression. Key words: type 2 diabetes, exercise training, insulin sensitivity, quality of life, depression, maximal oxygen uptake 4

5 2010 Quinn, European Association for the Study of Diabetes; EASD,

6 % Wei, Gibbons, Mitchell, Kampert, Lee, & Blair, 1999 Rice, Janssen, Hudson, & Ross, 1999 Lehmann, Bonrad, Kaplan, Spinas, & Bingisser, Dubbert et al., 1994Gowans et al.,

7 1920 Leedle, 1991 Rice et al.,

8 OGTT OGTT OGTT OGTT 8

9 type 1 type 2 90%American Diabetes Association; ADA, 2002 insulin resistance Short & Joyner, 2002 Garrett & Kirkendall, 2000Powers & Howley, 2001 Beta Beta Polaski & Tatro, 1996Wallberg-henriksson, Riicon, & Zierath,

10 180 mg/dl Andreoli & Carpenter, 1997Ganong, 2001Polaski & Tatro, 1996 Ganong, 2001Garrett & Kirkendall, 2000Powers & Howley,

11 1960 Hanestad, 1989 Dubos1976 Calman, 1987 Marashall, 1990 Burckhardt Ferrans 11

12 social utility natural capacityware physical component scale, PCS mental component scale, MCS Ware, 1987Ware & Kosinski, 2001 Quittan, Sturm, Wiesinger, Pacher, & Fialka-Moser, 1999 Ware Beck 1961 Beck 12

13 Egede, Zheng, & Simpson, 2002Fisher, Chesla, Mullan, Skaff, & Kanter, 2001Hanninen, Takala, & Keinanen-Kiukaanniemi, 1999Peyrot & Rubin, EASD, 1996 Stewart1989 Ahroni, Davignon, Boyko,Pecoraro1994 SF-20 13

14 1992 Creviston & Quinn, 2001 Glasgow et al., 1997Quittan et al., 1999 Ahroni et al., 1994Edelman, Olsen, Dudley, Harris, & Oddone, 2002Franch, 1999Trief, Katja, William, & Ruth, 1998 Guttwann-Bauman, Flaherty, Strugger, & McEvoy, 1998Trief et al.,

15 Fisher et al., 2001Gavard, Lustman, & Clouse, 1993Lustman, Griffith, Gavard, & Clouse, 1992 Lustman % 3~4 Hanninen, Takala, & Keinanen -Kiukaanniemi % Egede Anderson, Freedland, Clouse,Lustman2001 Fisher 2001 Fisher et al., 2001Hanninen et al., 1999 Talbot & Nouwen, 2000 Anderson et al.,

16 Hanninen et al., 1999Talbot & Nouwen, 2000 Talbot & Nouwen,

17 2002ACSM, 2000 Ulbrich1999 Michel & Kugler, 1998Ulbrich, 1999 American College of Sports Medicine, 2000 mode frequency intensity duration progression cardiovascular endurance 17

18 exercise resistance exercise stretching-flexibility exercise walking Creviston & Quinn, 2001 warm-up10 endurance phase20-60 cool-down % VO 2max ACSM, Creviston & Quinn, 2001 Garrett & Kirkendall, 2000 Standerland

19 ACSM, 2000 angiotensin converting enzyme inhibitor; ACEI Creviston & Quinn, %VO 2max RPE: ACSM 4-7 low intensity ACSM, 2000Creviston & Quinn, THR 2 Rating of perceived exertion scale CR-10 Category Ratio-10 Scale 3 talk testacsm, 2000Borg, 1982Borg, 1998Creviston & Quinn, % VO 2max % Campaigne, Devlin, & Schneider, 1997Creviston & Quinn, 2001 ACSM, 2000 Powers & Howley

20 weight-bearing activity Campaigne et al., 1997Creviston & Quinn, 2001 Campaigne et al., 1997 Campaigne et al., 1997 Creviston & Quinn, 2001 type2 DM>10 type1 DM>15 ECG graded exercisetesting <60% 20

21 maximal heart rate ACSM, 2000ADA, 2000 Campaigne et al., 1997 Creviston & Quinn, 2001 valsalva exercise Campaigne et al., 1997ADA, 2000 Creviston & Quinn, diabetic autonomic neuropathy-cardiovascular reflex test; DAN-CVR

22 Creviston & Quinn, ~ mg/dl SBP> 250 mmhg DBP> 120mmHg ACSM, 2000Campaigne et al., 1997Creviston & Quinn, 2001 Reynolds et al.,

23 mg/dl catecholamine transportersglut Creviston & Quinn, 2001Dela et al., 1994Garrett & Kirkendall, uptake GLUT4 GLUT4 40 free fatty acid; FFA 2001Garrett Kirkendall

24 insulin glucagon CRF Helmrich 5990 cohort study 500Kcal 6% 24% % 40% Wei et al.,

25 Bogardus et al.,1984ruderman, Ganda, & Johansen, Ruderman 14~ Trovati ~60% VO 2max 48 OGTT glucose AUCarea under curveogtt glucose OGTT insulin AUC OGTT insulin Rice ~85%VO 2max 5 1 5~10 OGTT OGTT glucose AUC OGTT insulin AUC c-peptides Dela et al., 1994Ganong, 2001 GLUT4 Wojtaszewski & Hansen,

26 36 residual effects Mikins, Sonnie, Farrell, Tronier, & Galbo, 1988 Segal ~10 OGTT insulin AUC chronic effects Gunton, Davies, Wilmshurist, Fukher, & McElduff Saltin

27 60 Campaigne HbA 1C Dela et al., 1994Lampman et al., 1987Lehmann et al., 1995Rice et al., 1999Trovati et al., 1984Walker, Piers, Putt, Jones, & O Dea, 1999 Fujinuma % 25.9% Powers & Howley,

28 Creviston & Quinn, 2001Lampman et al., 1987Rice et al., 1999Ruderman et al., 1979Trovati et al., 1984 Lahmann ~70% VO 2max Walker Dela et al., 1994 Yananouchi et al., 1995 TC TG LDL HDL Ganong, 2001 TC>=240 mg/dltg>400 mg/dlldl>160 mg/dl high risktc mg/dltg mg/dl LDL mg/dl borderline high risk HDL 35 mg/dl ACSM,

29 Powers & Howley, 2001 Ruderman et al., 1979Lahmann TG HDL Tanaka %HR max TCLDL HDL Lampman 1987 IGT 9 12 Sgouraki, A. Tsopanakis, & C. Tsopanakis, Powers & Howley,

30 Bogardus et al., 1984Milani & Lavie, 1998 Dela %HR max Lampman et al., 1987Lehmann et al., 1997Rice et al., 1999Trovati et al., 1984 Tanaka et al.,

31 Ruderman et type 2 DM bicycle VO 2max 15 al. erdermeter 5 (p<0.025)oral glucose tolerance test insulin kpm(p<0.025)cholesterol p<0.001tg p< Saltin et al. 48type 2 DM OGTT p<0.001vo 2max 20 n=25 n=12 n=11 p<0.001 muscle capillary supply p<0.001 metabolic potential HK35 SDH75 (p<0.001) 1984 Bogardus et al. Impaired glucose tolerance type 2 12 VO 2max p< DM 18 p<0.025 p< p<0.025 n=10 75HR max c-peptide p<0.025 n= Dela et al. 7 NIDDM 9 VO2max p< HR max BMI p<0.05 p<0.05 GLUT4 GLUT4 mrna p< Walker et al. 31 type 2 DM 5 60 type 2 DM BMI (n=11) p< HgbA 1C (p<0.05)ldl p<0.05cholesteral (p<0.005) HgbA 1C p< Reitman et al 6 type DM 5-6 p< p< % VO 2max 1997 Lehmann et al 20type 1 DM waist-to-hip ratio 50-70% VO 2max p<0.001vo 2max 45 p<0.001 p< Trovati et al. 5 type 2 DM 6 VO 2max 15, 7 60 p<0.025,hgba 1C 50-60%VO 2max p<0.05 p<0.025 OGTT 31

32 1987 Lampman et al y/o type 3 VO 2max 2 DM HR max 9 p< peak VO 2 19 p< p<0.05bmi p<0.001 n= %HR max waist-to-hip ratio (p<0.05) 5-10 OGTT p>0.02 n=10 30 (n=9) 1999 Rice et al Dubbert Milani SF-36 SF

33 Cotman & Engessor-Cesar, Greist 2000Elizabeth, Doyne, Kent, Ilona, & Robbert, 1987Gowans et al.,

34 Cotman Engessor-Cesar2002 BDNFBrain-derived neurotrophic factor p= p<.001 p< p< p= p<.01 p< p= Karper et al. 13 FMS(fibromyalgia syndrome) p<.05 p<.05 34

35 1987 Elizabeth et al. 40 HDRSBDI 3-5 LDAL p< Segar et al (BDI)p<.01 (stait 4 anxiety inventory, STAI) 30 p<.02 p<.01 Rice et al., 1999Trovati et al.,

36 qusai-experimental design %60%VO 2max 5-10 ACSM, O1 X O2 O3 O4 1. O1 : baseline X: 12 O2: O3: O4: 36

37 2 1. OGTT OGTT

38 2 38

39 ??? 39

40 1. >126 mg/dl 2 >200 ADA, dynamic rhythmic ACSM, 2000Creviston & Quinn, %VO 2max treadmill 3. OGTT glucose AUC OGTT insulin OGTT OGTT glucose AUCOGTT insulin AUC OGTT 40

41 4. insulin resistance insulin sensitivity 2001Gowans et al., 2001 Lustman et al., 1997 Homeostasis model assessment method-insulin resistance index; HOMA-IR index 2002 Gowans et al., 2001 Lustman et al., 1997 area under the curves, AUCs Allison, Micholas, Paultre, Pi-Sunyer, & Maggio, 1995 AUCs pharmacokinetics Trapezoidal Trapezoidal method Allison al., 1995 OGTT glucose AUC OGTT insulin AUC OGTT 41

42 5. VO 2max ml/kg/min Powers & Howley, 2001 Graded exercise test; GXT treadmill ergometer ACSM, 2000Powers & Howley, Ware, 1987Ware & Kosinski, 2001 Quittan et al., 1999 John Ware SF-36 Ware & Kosinski,

43 7. Gowans et al., 2001Lustman et al., 1997 Beck 1961 Beck Depression Inventory; BDI 8. oral glucose tolerance test; OGTT Gowans et al., 2001Lustman et al., kg/m kg/m 2 over- weight 30.0 obesity ACSM, weist-to-hip ratio; WHR / 0.94/0.82 / 1.03/0.90 ACSM,

44 purposive sampling (1) (2) 20~60 (3) (4) mg/dl (5) 200/110 mmhg 160/100 mmhg(6) ACLS 44

45 2000 sedentary 60%VO 2max treadmill VO 2max HR max 5%7.5%10%12.5%15% 17.5%20% 3mph 2 1~2 3~5 10% Rating of Perceived Exertion; RPE: 18~19 RERrespiratory exchange ratio >

46 ST 2mmT Q 2~3 A-V BlockPVCpremature ventricular contraction 250 mmhg 120 mmhg 10 mmhg 1~ % VO 2max VO 2max HR max target heart rate; THR 60% VO 2max =72% HR max Polar Electro OY. Kempele, Finland 60%VO 2max ACSM2000 [VO 2 =0.1 (speed) 1.8 (speed)(grade)3.5ml/kg/min] 46

47 OGTT VO 2max (1) (2)SF-36 (3) SF Item Short-Form Health Survey; SF-36 New England Medical Center Hospitals; NEMCH SF physical function; PF, 3a~3j 10 role-physical; RP, 4a~4d 4 role-emotional; RE, 5a~5c 3 social function; SF, bodily pain; BP, 78 2 vitality; VT, 9a9e9g9i 4 mental health; MH, 9b9c9d 9f9h 5 general health; GH, 111a~11d 5 47

48 1 health transition; HTWare & Kosinski, low score70~100 small impairment 100 Quittan et al., 1999 functional status well-being overall healthquittan et al., 1999 physical conponent scale; PCS mental conponent scale; MCS SF norm-based PCS=50 MCS=50 Ware & Kosinski, /demos/sf-36.html Beck s Depression Inventory; BDI Beck

49 TAKASUMA 928 0~12% 0~16kmh Polar S510 Heart Rate Monitor Polar Electro OY Professorintie 5 Fin kempele Polar Freestyle 50~500 mg/dl 180 mg/dl CV 0.8%2.1% 49

50 1.0% SF-36 Cronbach s alpha Ware & Kosinski, 2001 n=30 Cronbach s alpha PF=0.72 RP=0.90BP=0.75GH=0.72VT=0.74SF=0.70RE=0.90MH=0.80 Beck Depression Inventory Gowans et al., 2001Lustman et al., 1997 Gavard, Lustman, & Clouse, 1993Lustman et al., 1997 Cronbach s alpha Gowans et al., n=30 Cronbach s alpha

51 ~10 2 mmhg 5~10 1 YSI model 2300 glucose analyzer, Yellow Springs Instrument Company, Inc, USA YSI model 1500 glucose analyzer, Yellow Springs Instrument Company, Inc, USA Pearson product-moment correlation 0.85 radioimmunoassay, RIA CV 0.5% HgbA 1c high performance liquid chromatography, HPLC CV 0.7% 51

52 3 30 Type 2 n=13 52

53 20~ ~ mmhg 100 mmhg mg/dl 240 mmhg 120mmHg 53

54 GXT OGTT 60%VO 2max 30 3 week OGTT 3. 54

55 1 2 3 Excel Sigmaplot /2001 SPSS 11.0/Win98 SAS V8.2/Win98 longitudinal data General linear model Generalized Estimating Equation, GEE GEE GEE confounding factors longitudinal.05 55

56 4-1. M SE M SEM categorical variable General Linear Model Generalized Estimating Equation contineous variable General Linear Model Generalized Estimating Equation 56

57 17 200/98 mmhg % % 48.2SE= % % 23.1% 15.4% 15.4%1 7.7% % 62.8SE= % % % % 57

58 3 23.1% % N=13 %

59 5-2 OGTT insulin AUCOGTT glucose AUC OGTT insulinogtt glucose FBGHgbA 1c TCTGLDLHDL BWBMIWHR VO 2max SBPDBPHR rest OGTT glucose AUC OGTT insulin AUC 5-2 OGTT glucose AUC ± min mmol/l 13 OGTT insulin AUC 12 OGTT OGTT glucose OGTT insulin 4 8 OGTT

60 163.6±15.79 mg/dl 8.96±0.51% 134.8±12.35 mg/dl 8.35±0.50% 138.4±13.38 mg/dl 8.27±0.48% 138.4±9.20 mg/dl 7.9±0.49% ±10.62 mg/dl 149.7±13.96 mg/dl 134.4±10.78 mg/dl 47.5±2.90 mg/dl 201.4±10.55 mg/dl 142.0±14.36 mg/dl 124.0±10.10 mg/dl 49.1±2.82 mg/dl 202.4±9.32 mg/dl 134.3±14.80 mg/dl 125.3±9.39 mg/dl 50.2±2.89 mg/dl 192.4±6.80 mg/dl 124.0±13.75 mg/dl 118.6±7.48 mg/dl 49.1±2.59 mg/dl 60

61 ±3.11 kg 26.7±1.32 kg/m ± ±3.05 kg 26.4±1.33 kg/m ± ±2.96 kg 26.2±1.32 kg/m ± ±2.99 kg 25.9±1.35 kg/m ± VO 2max 30.64±1.50 ml/kg/min 83.8±2.54 beats/min 133.5±13.90 mmhg 83.4±2.92 mmhg 77.1±2.73 beats/min 119.1±3.85 mmhg 74.2±2.81 mmhg 73.2±2.32 beats/min 110.6±2.57 mmhg 71.8±2.11 mmhg VO 2max 34.46±2.06 ml/kg/min 71.5±2.44 beats/min 112.0±2.42 mmhg 61

62 71.5±2.17 mmhg

63 5-2 N=13 OGTT glucose level OGTT insulin level 0min ± ± ± ± min ± ± ± ± min ± ± ± ± min ± ± ± ± min ± ± ± ± min. 5.46± ± ± ± min ± ± ± ± min ± ± ± ± min ± ± ± ± min ± ± ± ±4.51 OGTT glucose AUC ± ± ± ±94.58 OGTT insulin AUC ± ± ± ± FBG 163.6± ± ± ±9.20 HgbA 1c 8.96± ± ± ±0.49 TC 211.9± ± ± ±6.80 TG 149.7± ± ± ±13.75 LDL 134.4± ± ± ±7.48 HDL 47.5± ± ± ±2.59 BW 69.7± ± ± ±2.99 BMI 26.7± ± ± ±1.35 WHR 0.90± ± ± ±0.009 VO 2max 30.64± ±2.06 HR rest 83.8± ± ± ±2.44 SBP 133.5± ± ± ±2.42 DBP 83.4± ± ± ± ± M±SEM 2.OGTT glucose AUCOGTT (min mmol/l)ogtt insulin AUCOGTT (minµu/ml) OGTT glucose level (mg/dl)ogtt insulin level µu/ml FBG (mg/dl)hgba 1c BWkgBMI (kg/m 2 ) WHRTC TG LDL HDL VO 2max SBP DBP HR rest

64 400 Plasma glucose(mg/dl) pre-ex 4weeks 8weeks 12weeks TIME(min) 4. OGTT 400 pre-ex 4weeks Plasma glucose(mg/dl) TIME(min) 5. OGTT 64

65 400 Plasma glucose(mg/dl) pre-ex 8weeks TIME(min) 6. OGTT pre-ex 12weeks Plasma glucose(mg/dl) TIME(min) 7. OGTT 65

66 30 Plasma insulin(µu/ml) pre-ex 4weeks 8weeks 12weeks TIME(min) 8. OGTT 30 Plasma insulin(µu/ml) pre-ex 4weeks TIME(min) 9. OGTT 66

67 30 Plasma insulin(µu/ml) pre-ex 8weeks TIME(min) 10. OGTT pre-ex 12weeks Plasma insulin(µu/ml) TIME(min) 11. OGTT 67

68 2500 exercise training min DµU/mL pre-ex 4weeks 8weeks 12weeks OGTT insulin AUC 12. OGTT min Dmmol/L exercise training 1000 pre-ex 4weeks 8weeks 12weeks OGTT glucose AUC 13. OGTT 68

69 Fasting glucose(mg/dl) exercise training 0 pre-ex 4weeks 8weeks 12weeks TIME exercise training HgbA1c(%) pre-ex 4weeks 8weeks 12weeks TIME

70 exercise training pre-ex 4weeks 8weeks 12weeks mg/dl TC TG 16. exercise training pre-ex 4weeks 8weeks 12weeks mg/dl LDL HDL

71 exercise training 70 kg pre-ex 4weeks 8weeks 12weeks TIME exercise training kg/m pre-ex 4weeks 8weeks 12weeks TIME

72 WHR exercise training pre-ex 4weeks 8weeks 12weeks exercise training 35 ml/kg/min pre-ex 12wls VO 2max

73 90 exercise training 80 beats/min pre-ex 4weeks 8weeks 12weeks HR rest exercise training pre-ex 4weeks 8weeks 12weeks mmhg SBP DBP

74 5-3 PCS MCS 50.6± ± ± ± ± ± ± ± PF 85.0±3.88 RP 69.2±11.02 BP 86.3±4.90 GH 50.8±5.03 VT 61.9±3.90 SF 78.8±3.85 RE 76.9±7.90 MH 69.8±3.16 PF 93.5±3.32 RP 78.8±10.53 BP 90.6±3.04 GH 68.8±5.19 VT 73.5±4.44 SF 81.7±4.39 RE 84.6±8.94 MH 75.7±3.55 PFRPBPGHVTSFREMH 74

75 96.2± ± ± ± ± ± ± ±2.67 PFRPBPGHVTSFREMH 96.5± ± ± ± ± ± ± ± (N=13) PCS 50.6± ± ± ±0.96 MCS 47.2± ± ± ±1.20 PF 85.0± ± ± ±2.13 RP 69.2± ± ± ±7.77 BP 86.3± ± ± ±2.37 GH 50.8± ± ± ±3.40 VT 61.9± ± ± ±2.48 SF 78.8± ± ± ±2.96 RE 76.9± ± ± ±5.13 MH 69.8± ± ± ± ± M±SEM 2.PFphysical function RErole function limitation due physical disturbance BPbodily pain GH general health VTvitality SFsocial function RErole function limitation due to emotional disturbance MHmental health PCSphysical component score MCSmental component score 75

76 60 50 exercise training pre-ex 4weeks 8weeks 12weeks score PCS SF-36 MCS 24. PCS & MCS 100 pre-ex 4weeks 8weeks 12weeks 80 score PF RP BP GH VT SF RE MH SF

77 10.5± % ± ± ± (N=13) BDI 10.46± ± ± ± ± M±SEM 2.BDI 77

78 BDI exercise training score pre-ex 4wks 8wks 12wks TIME

79 categorical variable Generalized Estimating Equation, GEE contineous variable GEE 24 normality testing 16 8 HDLBMI insulin AUC insulin0 insulin30 insulin60 insulin90 insulin glucose AUC 5-5 p<.05 p 79

80 p=.05 insulin AUC insulin AUC borderline significantp insulin AUC min µu/ml OGTT p< OGTT 120 p<.0001 p= p=.0019~

81 5-5. (N=13) z p>z OGTT insulin AUC / / / OGTT glucose AUC / <.0001**** / * / OGTT insulin AUC: OGTT glucose AUC: *p<.05 **p<.01 ***p<.001 ****p<

82 5-6. OGTT glucose (N=13) z p>z Glucose0 / <.0001**** / * / * Glucose30 / / * / Glucose60 / *** / / Glucose90 / <.0001**** / ** / * Glucose120 / <.0001**** / / * 1.glucose0 : 30 :OGTT30 glucose 60 :OGTT60 glucose 90 :OGTT90 glucose 120 :OGTT *p<.05 **p<.01 ***p<.001 ****p<

83 5-7. OGTT insulin (N=13) z p>z Insulin0 / / / Insulin30 / / / Insulin60 / / / Insulin90 / / / Insulin120 / / ** / ** 1.insulin0 : insulin30 :OGTT30 insulin60 :OGTT60 insulin90 :OGTT90 insulin120 : OGTT *p<.05 **p<.01 ***p<.001 ****p<

84 2. glucose AUC p< minmmol/l 5-8 insulin AUC minµu/ml OGTT OGTT mg/dl p< mg/dlp< mg/dlp<.01 OGTT 120 borderline significant µu/mlogtt 84

85 µu/ml 5-8. N=13 z p>z InsulinAUC TIME glucoseauc TIME * OGTT insulin 0min TIME min TIME min TIME min TIME min TIME OGTT glucose 0min TIME ** 30min TIME min TIME * 90min TIME * 120min TIME ** 1.TIME OGTT glucose AUCOGTT (minmmol/l)ogtt insulin AUCOGTT (minµu/ml)ogtt glucose level (mg/dl)ogtt insulin level µu/ml *p<.05 **p<.01 ***p<.001 ****p<

86 FBG FBG p<.05 HgbA 1c 0.26 p= p<.05 HgbA 1c 0.87p< N=13 z p>z FBG / <.0001**** / * / * HgbA 1c / / * / ** 1.FBG: HgbA 1c : *p<.05 **p<.01 ***p<.001 ****p<

87 p<.01 p< N=13 z p>z FBG TIME *** HgbA 1c TIME *** 1.TIME FBG (mg/dl)hgba 1c *p<.05 **p<.01 ***p<.001 ****p<

88 TG p<.0001 TG p= TCLDL HDL 88

89 5-11. N=13 z p>z TC TG LDL HDL / / / / / / <.0001**** / / / / / / TC: TG: LDL: HDL: *p<.05 **p<.01 ***p<.001 ****p< p=

90 5-12. N=13 z p>z TC TIME TG TIME *** LDL TIME HDL TIME TIME TC TG LDL HDL *p<.05 **p<.01 ***p<.001 ****p< GEE BWBMIWHR p< BMI BMI p<.05 WHR 5-13 WHR 90

91 p< N=13 z p>z BW / * / ** / <.0001**** BMI / * / ** / <.0001**** WHR / *** / ** / <.0001**** 1.BW: BMI: WHR: *p<.05 **p<.01 ***p<.001 ****p< p<

92 p<.0001 p< N=13 z p>z BW TIME <.0001**** BMI TIME <.0001**** WHR TIME <.0001**** 1.TIME BWkg BMI (kg/m 2 )WHR *p<.05 **p<.01 ***p<.001 ****p< GEE SBPDBPHR rest VO 2max 5-15 VO 2max p<

93 p<.001 GEE 5-15 p= p<.0001 p<.0001p<.0001 p= p< N=13 z p>z VO 2max HR rest SBP DBP / <.0001**** / *** / <.0001**** / *** / ** / <.0001**** / * / <.0001**** / <.0001**** / <.0001**** 1.VO 2max : HR: SBP: DBP: *p<.05 **p<.01 ***p<.001 ****p<

94 p<.0001 TIME SEX THERAPY EXHABIT p< p<.0001 TIME SEX THERAPY EXHABIT 94

95 p< N=13 z p>z VO 2max TIME <.0001**** TIME*THERAPY <.0001**** TIME*THERAPY TIME*EXHABIT * TIME*EXHABIT TIME*SEX ** TIME*SEX HR TIME <.0001**** SBP TIME <.0001**** DBP TIME <.0001**** 1.TIME VO 2max HR SBP DBP TIME*THERAPY THERAPY0 THERAPY1 TIME*EXHABIT EXHABIT0 EXHABIT1 TIME*SEX SEX0 SEX *p<.05 **p<.01 ***p<.001 ****p<

96 11 normality testing PCSMCSPFRPBPSFRE GEE 1. PCSMCS GEE 5-17 PCS MCS MCS p= p<.0001p<.0001 PFRPBPGH VTSFRE MH BP PF RP GH VT 96

97 SF RE MH 5-18 PF p<.01 RP p<.0001 GH GH p<.0001p= p<.0001 VT 5-18 p=.0001p< SF p= p=.0009p<.0001 RE RE p<.05p<.05 MH 97

98 p<.0001p<.0001p< PCS & MCS N=13 z p>z PCS / / / MCS / ** / <.0001**** / <.0001**** 1.PCS: SF-36 MCS: SF *p<.05 **p<.01 ***p<.001 ****p<

99 5-18. N=13 z p>z PF / / ** / ** RP / <.0001**** / <.0001**** / <.0001**** BP / / / GH / <.0001**** / * / <.0001**** VT / *** / / <.0001**** SF / ** / *** / <.0001**** RE / / * / * MH / <.0001**** / <.0001**** / <.0001**** 1.PF: RP: BP: GH: VT: SF: RE: MH: *p<.05 **p<.01 ***p<.001 ****p<

100 2. TIME PCSMCS MCS p< TIME THERAPY PCS PCS TIME PFRPBPGHVTSFRE MH BP PFRPGHVTSFRE MH p< PF TIME EXHABIT PF 100

101 PF RP TIME THERAPY RP BP TIME EXHABIT BP RE TIME SEX RE PCS & MCS N=13 z p>z MCS TIME <.0001**** PCS TIME TIME*THERAPY *** TIME*THERAPY TIME PCSphysical component score MCSmental component score TIME*THERAPY *p<.05 **p<.01 ***p<.001 ****p<

102 5-20. N=13 z p>z PF TIME <.0001**** TIME*EXHABIT ** TIME*EXHABIT RP TIME * TIME*THERAPY * TIME*THERAPY BP TIME TIME*EXHABIT * TIME*EXHABIT GH TIME *** VT TIME *** SF TIME ** RE TIME <.0001**** TIME*SEX <.0001**** TIME*SEX MH TIME <.0001**** 1.TIME PFphysical function RErole function limitation due physical disturbance BPbodily pain GHgeneral health VTvitality SFsocial function RErole function limitation due to emotional disturbance MHmental health *p<.05 **p<.01 ***p<.001 ****p<

103 normality testing 123 normal distribution p< N=13 z p>z BDI / <.0001**** / <.0001**** / <.0001**** 1.BDI:Beck *p<.05 **p<.01 ***p<.001 ****p<

104 2. TIME GEE p<.0001 TIME THERAPY N=13 z p>z BDI TIME <.0001**** 1.TIME BDI *p<.05 **p<.01 ***p<.001 ****p<

105 5-23 OGTT

106 GEE HgbA 1c =9.0% 2~3 BMI26.7 kg/m 2 overweight 0.90SEM= SEM= mg/dl mg/dl mg/dl 106

107 134.4 mg/dl borderline high risk 47.5 mg/dl mg/dl Bogardus et al., 1984Kang et al., 1996Reitman et al., 1984Rice et al., 1999Trovati et al., 1984Yamanouchi et al., 1995 Kang et al., 1996Lampman et al., 1987Ruderman et al., 1979 OGTT Kang et al., 1996Rice et al., 1999Ruderman et al., 107

108 1979 Kang % VO 2max 50% VO 2max Kang % 163.6mg/dL 5.46 µu/ml normal range: <30 µu/ml mg/dL316.5mg/dL339.8mg/dL339.8mg/dL 10.79µU/mL21.94µU/mL21.82µU/mL 19.75µU/mL OGTT insulin AUC residual effect Mikins Ruderman et al., 1979Mikins et al., 1988 Segal et al., 1991 Rice

109 5~10 OGTT OGTT insulin AUC OGTT 24 OGTT OGTT OGTT % Fujinuma et al., 1999Trovati et al., 1984 Yamanouchi 19956~8 Walker

110 % Fujinuma 3~4 4~6 50~ % % 110

111 211.9 mg/dl mg/dl mg/dl mg/dl Lehmann et al., 1995Ruderman et al., 1979Walker et al., 1999 Lampmam et al., Lehmann et al., 1995Ruderman et al., 1979Sgouraki et al., 2001 Lampman Sgournki 2001 Lehmann 1995 HDL Sgournki et al., 2001 Sgournki 111

112 et al., % Bogardus et al., 1984 Reitman et al., 1984Rice et al., kg/m kg/m 2 overweight 25~29 kg/m 2 Lehaman et al., 1995 Rice et al., 1999Walker et al., 1999Yamanouchi et al., 1995 WHR> 0.95>

113 Rice et al., % VO 2max VO 2max 12.4% 30.6 ml/kg/min 34.5 ml/kg/min Bogardus et al., 1984Dela et al., 1994Rice et al., 1999Ruderman et al., 1979Sgournki et al., 2001 Lampman et al., 1987Sgournki et al., 2001Tanaka et al., 2000Trovati et al., 1984 Lehmann et al., 1995Tanaka et al., 2000 Powers & Howley, mmhg mmhg 113

114 112.0 mmhg 16.1% Lehmann et al., 1995Tanaka et al., 2000 Bogardus et al., 1984Milani & Lavie, 1998 VO 2max VO 2max 30 VO 2max 85.0 SEM= SEM= SEM= SEM=7.90 small impairment 69.2± ± ± ±3.16 low score 114

115 PCS 50.6±2.55M±SEMMCS 47.2±2.07 Johnson ± ± Ahroni Glasgow EASD, 1996Stewart, 1989 GEE

116 Weinberger1994 Guttmann-Bauman 1998 HgbA 1c 1999 Dubbert 1994 Milani

117 p<.0001 Glasgow et al., 1997Trief et al., Quittan 10.5SEM= % 10~ David Gary % Egede et al., 2002Gavard et al., 1993Lustman et al.,

118 6.38SEM= ± ± fibromyalgia syndrome Karper et al., 2001 Segar et al., Greist et al., 1979 Cotman & Engessor -Cesar2002 Anderson

119 1996Elizabeth et al., % VO 2max 30 /

120 30 60%VO 2max GEE OGTT OGTT 120 HgbA 1c FBG TG BWBMIWHRVO2 max HR rest SBP rest DBP rest 120

121 OGTT BP PCS PF RP BP GH VT SF RE MH MCS OGTT OGTT 30 BP 121

122 PCS PF RP BP GH VT SF RE MH MCS Wei et al.,

123 1. 1 Quasi-Experimental design 2 Powers & Howley

124 Tichenals, 1988Wilmore,

125 1~4 Ruderman et al., 1979Mikins et al., 1988Rice et al.,

126 126

127 127

128 2002 () 1997 SF (6) (2) (3) (3) (2)

129 GLUT4 2(1) (3) (2) Nutrition Science Journal27(2) (5) (4) SF-36 4(1) (4)

130 1999 7(1) (1) (3)

131 Ahroni, J. H., Davignon, D., Boyko, E. J., & Pecoraro, R. E. (1994). The health and functional status of veterans with diabetes. Diabetes Care, 17(4), Allison, D. A., Mezzitis, N., Paultre, F., Pi-Sunyer, F. X., & Maggio, C. (1995). The use of areas under curves in diabetes research. Diabetes Care, 18(2), American Diabetes Association (2000). Diabetes mellitus and exercise. Diabetes Care, 23(1), S50-S54. American Diabetes Association (2002). Standards of medical care for patients with diabetes mellitus. Diabetes Care, 25(1), S33-S49. American College of Sports Medicine. (2000). ACSM s guidelines for exercise testing and prescription(6 th ed). Lippincott: Willams & Wilkins. Anderson, R. J., Freedland, E., Clouse, R. E., & Lustman, P. J. (2001). The prevalence of comorbid depression in adults with diabetes: A meta-analysis. Diabetes Care, 24(6), Andreoli, T. E., Bennett, J. C., Carpenter, C. J., & Plum, F. (1997). Cecil essentials of medicine(4 th ed.). Philadelphia: W. B. Saunders. Beck, A., et al. (1961). An inventory for measuring depression. Archives of General Psychiatry, 4, Borg, G. (1982). Psychophysical bases of perceived exertion. Medicine Science 131

132 in Sports Exercis, 14(4), Borg, G. (1998). Borg s perceived exertion and pain scales. Champagn, IL: Human Kinetics. Borgardus, C., Ravussin, E., Robbins, D. C., Wolfe, R., Horton, E. S., & Sims, E. A. (1984). Effects of physical training and diet therapy on carbohydrate metabolism in patients with glucose intolerance and non-insulin-dependent diabetes mellitus. Diabetes, 33, Burckhardt, C. S. (1985). The impact of arthritis on quality of life. Nursing Research, 34(1), Campaigne, B. N., Devlin, J. T., & Schneider, S. H. (1997). Diabetes mellitus and exercise. Diabetes Care, 20(12), Calman, D. C. (1987). Definition and dimentions of quality of life. In N. K. Aaronson & J. H. Beckman(Eds.), The quality of life of cancer patients(pp. 1-18). New York: Raven Press. Cotman, C. W., & Engessor-Cesar, C. (2002). Exercise Enhances and Protects Brain function. Exercise and Sport Sciences Review, 30(2), Creviston, T. & Quinn, L. (2001). Exercise and physical activity in the treatment of type 2 diabetes. Nursing Clinics of North America, 36(2), Dela, F., Ploug, T., Handberg, A., Petersen, L. N., Larsen, J., Mikines, K.J., & Galbo, H. (1994). Physical training increases muscle GLUT4 protein and 132

133 mrna in patients with NIDDM. Diabetes, 43, Dubos, R. (1976). The state of health and the quality of life. The Western Journal of Medicine, 125(1), 8-9. Edelman, D., Olsen, M. K., Dudley, T. K., Harris, A. C., & Oddone, E. Z. (2002). Impact of diabetes screening on quality of life. Diabetes Care, 25(6), Egede, L. E., Zheng, D., & Simpson, K. (2002). Comorbid depression is associated with increased health care use and expenditures in individuals with diabetes. Diabetes Care, 25(3), Elizabeth, J. D., Doyne, J. O., Kent, M. O., Ilona, B. M., & Robert, A. N. (1987). Running versus weight lifting in the treatment of depression. Journal of Consulting and Clinical Psychology, 5, European Association for the study of Diabetes (1996). Diabetes research in Europe. Diabetologia, 39(9), EASD New Section, Ferrans, C. E. (1990). Quality of life: Conceptual issues. Seminars in Oncology Nursing, 6(4), Fisher, L., Chesla, C. A., Mullan, J. T., Skaff, M., & Kanter, R. A. (2001). Contributors to depression in Latino and European-American patients with type 2 diabetes. Diabetes Care, 24(10), French, L. (1999). Quality of life and therapy in type 2 diabetes. The Journal of Family Practice, 48(10),

134 Fujinuma, H., Abe, R., Yamazaki, T., Seino, T., Kikuchi, H., Hoshino, T., Hirano, R., & Yoshida, S. (1999). Effect of exercise training on doses of oral agents and insulin. Diabetes Care, 22(10), Ganong, W. F. (2001). Review of medical physiology. New York: McGraw-Hill. Garrett, W. E. & Kirkendall, D. T. (2000). Exercise and sport science. Lippincott: Williams & Wilkins. Gavard, J. A., Lustman, P. J., & Clouse, R. E. (1993). Prevalence of depression in adults with diabetes. Diabetes Care, 16(8), Glasgow, R. E., Dryfoos, J., Ruggiero, L., Chobanian, L., & Elizabeth, E. (1997). Quality of life and associated characteristics in large national sample of adults with diabetes. Diabetes Care, 20(4), Gowans, S. E., DeHueck, A., Voss, S., Silaj, A., Abbey, S. E., & Reynolds, W. J. (2001). Eeffect of a randomized, conrolled trial of exercise on mood and physical function in individuals with fibromyalgia. Arthritis Care & Research, 45, Greist, J. H., Kleun, M. H. Eischens, R. R., Faris, J., & Gurman, A. S. (1979). Running as a treatment for depression. Comprehensive Psychiatry, 20, Gunton, J. E., Davies, L., Wilmshurist, E., Fulcher, G., & McElduff, A. (2002). Cigarette smoking glycemic control in diabetes. Diabetes Care, 25(4), 134

135 Guttmann-Bauman, I., Flaherty, B. P., Strugger, M., & McEvoy, R. C. (1998). Metabolic control and quality of life self-assessment in adolescents with IDDM. Dibetes Care, 21(6), Hanestad, B. R. (1989). Insulin-dependent diabetes mellitus and quality of life. Scandinavian Journal of caring science, 3(3), Hanninen, J. A., Takala, J. K., Keinanen-Kiukaanniemi, S. N. (1999). Depression in subjects with type 2 diabetes: Predictive factors and relation to quality of life. Diabetes Care, 22(6), Helmrich, S. P., Ragland, D. R., Leung, R. W., & Paffenbarger, R. S. (1991). Physical activity and reduced occurrence of non-insulin-dependent diabetes mellitus. The New England Journal of medicine, 325(3), Johnson, J. A., Nowatzki, T. E., & Coons, S. T. (1996). Health-related quality of life of diabetic Pima Indians. Medical Care, 34(2), Kang, J., Robertson, R. Hagberg, J. M., Kelley, D. E., Goss, F. L., DaSilva, S. G., et al. (1996). Effect of exercise intensity on glucose and insulin metabolism in obese individuals and obese NIDDM patients. Diabetes Care, 19(4), Karper, W. B., Hopewell, R., & Hodge, M. (2001). Exercise program effects on woman with fibromyalgia syndrome. Clinical Nurse Specialist, 15(2), 135

136 Lampman, R. M. (1987). The influence of physical training on glucose tolerance, insulin sensitivity, and lipid and lipoprotein concentrations in middle-aged hypertriglyceridaemic, carbohydrate intolerant men. Diabetologia, 30, Leedle, B. (1991). Exercise. In D. W. Guthrie, & R. A. Guthrie (Eds), Nursing management of diabetes mellitus(pp ). New York: Springer. Lehmann, R., Bonrad, K. E., Kaplan, V., Spinas, G. A., & Bingisser, R. (1995). Impact of physical activity on cardiovascular risk factors in IDDM. Diabetes Care, 20(10), Lustman, P. J., Clouse, R. E., Griffith, L. S., Carney, R. M., & Freedland, K. E. (1997). Screening for depression in diabetes using the Beck Depression Inventory. Psychosomatic Medicine, 59, Lustman, P. J., Griffith, L.S., Gavard, J. A., & Clouse, R. E. (1992). Depression in adults with diabetes. Diabetes Care, 15(11), Marshall, P. A. (1990). Cultural influences on perceived quality of life. Seminars in Oncology Nursing, 6(4), Michel, T. C., & Kugler, J. P. (1998). Predicting exercise in older Americans: Using the Theory of Planned Behavior. Military Medicine, 163(8), Mikins, K. J., Farrell, P. A., Sonne, B., Tronier, B., & Galbo, H. (1988). Effect of physical exercise on sensitivity and responsiveness to insulin in humans. 136

137 American Journal of Physiology, 254, Mikins, K. J., Sonne, B., Farrell, P. A., Tronier, B., & Galbo, H. (1988). Effect of training on dose-response relationship for insulin action in men. Journal of Applied Physiology, 66, Milani, R. V. & Lavie, C.J. (1998). The effects of body composition changes to observed improvements in cardiopulmonary parameters after exercise training with cardiac rehabilitation. Chest, 113(3), Peyrot, M., & Rubin, R. (1999). Persistence of depressive symptoms in diabetic adults. Diabetes Care, 22(3), Polaski, A. L. & Tatro, A. (1996). Luckmann s core principles and practice of medical-surgical nursing. Philadelphia: W.B. Saunders. Powers, S. K., & Howley, E. T. (2001). Exercise physiology: Theory and application to fitness and performance(4 th ed.). New York: McGraw-Hill. Quinn, L. (2001). Type2 diabetes epidemiology, pathophysiology, and diagnosis. Diabetes, 36(2), Quittan, M., Sturm, B., Wiesinger, G. F., Pacher, R., & Fialka-Moser, V. (1999). Quality of life in patients with chronic heart failure: A randomized controlled trial of changes induced by a regular exercise program. Scandinavian Journal of Rehabilitation Medicine, 31, Reitman, J. S., Vasquez, B., Klimes, I., & Nagulesparan, M. (1984). Improvement of glucose homeostasis after exercise training in non-insulin-dependent diabetes. Diabetes Care, 7(5),

138 Reynolds, K. L., Harman, E. A., Worsham, R. E., Sykes, M. B., Fryknan, P. N., & Backus, V. L. (2001). Injuries in woman associated with a periodized strength training and running program. Journal of Strength & Conditioning Research, 15(1), Rice, B., Janssen, I., Hudson, R., & Ross, R. (1999). Effects of aerobic or resistance exercise and/or diet on glucose tolerance and plasma insulin levels in obese men. Diabetes Care, 22(5), Ruderman, N. B., Ganda, O. P., & Johansen, K. (1979). The effects of physical training on glucose tolerance and plasma lipids in maturity-onset diabetes. Diabetes Care, 28(1), Saltin, B., Lindgarde, F., Houston, M., Horlin, R., Nygaard, E., & Gad, P. (1979). Physical training and glucose tolerance in middle-aged men chemical diabetes. Diabetes, 28(1), Segal, K. R., Edano, A., Abbulos, A., Albu, J., Blando, L., Tomas, M. B., & Pi-Sunyer, F. X. (1991). Effect of exercise training on insulin sensitivity and glucose metabolism in lean, obese, and diabetic men. Journal of applied physiology, 71, Segar, M. L., et al. (1998). The effect of aerobic exercise on self-esteem and depressive and anxiety symptoms among breast cancer survivors. Oncology Nursing Forum, 25(1), Sgouraki, E., Tsopanakis, T., & Tsopanakis, C. (2001). Acute exercise: Response of HDL-C, LDL-C lipoproteins and HDL-C subsfractions levels in selected 138

139 sport disciplines. Journal of Sports Medicine and Physical Fitness, 43(1), Short, K. R. & Joyner, M. J. (2002). Activity, Obesity, and Type 2 Diabetes. Exercise and Sport Sciences Review, 30(2), Steptoe, A. & Butler, N. (1996). Sports participation and emotion wellbeing in adolescents. Lancet, 347(9018), Talbot, F., & Nouwen, A. (2000). A review of the relationship between depression and diabetes in adults: Is there a link? Diabetes Care, 23(10), Tanaka, H., Frank, A., Monahan, K. D., Clevenger, C. M., DeSouza, C. A., & Seals, D. R. (2000). Aging, habitual exercise, and dynamic arterial comliance. Circulation, 102(11), Tichenal, C. A. (1988). Exercise and food intake: What s the relationship? Sports Medicine, 6, Trief, P. M., Katja, E., William, G., & Ruth, S. W. (1998). Family environment, glysemic control, and the psychosocial adaptation of adults with diabetes. Diabetes Care, 21(2), Trovati, M. (1984). Influence of physical training on blood glucose control, glucose tolerance, insulin secretion, and insulin action in non-insulin-dependent diabetic patients. Diabetes Care, 7(5), Ulbrich, S. L. (1999). Nursing practice theory of exercise as self-care. Image- the Journal of Nursing Scholarship,31(1),

140 Walker, K. Z., Piers, S., Putt, R. S., Jones, A. J., & O Dea, K. (1999). Effects of regular walking on cardiovascular risk factors and body composition in normoglycemic womaen and women with type 2 diabetes. Diabetes Care, 22(4), Wallberg-henriksson, H., Rincon, J., & Zierath, J. (1998). Exercise in the management of non-insulin-dependent diabetes mellitus. Sports Medicine, 25(1), Ware, J. E. (1987). Standards for validating health measures: Definition and content. Journal of chronic disease, 40(6), Ware, J. E., & Kosinski, M. (2001). SF-36 Physical & Mental Health Summary Scale: A Manual for User of Version 1(2 nd ed.). Lincoln: QualityMetric. Ware, J. E. & Sherbourne, C. D. (1992). The MOS 36-Item short-form health survey (SF-36). Conceptual framework and item selection. Medical Care, 30(6), Wei, M., Gibbons, L. W., Mitchell, T. L., Kampert, J. B., Lee, C. D., & Blair, S. N. (1999). The association between cardiorespiratory fitness and impaired fasting glucose and type 2 diabetes mellitus in men. Annals of Internal Medicine, 130(2), Wilmore, S. (1988). Appetite and body composition consequent to physical activity. Research Quarterly for exercise and sport, 54, Wojtaszewski, J. F. & Hansen, B. F. (2002). Use of transgenic models to understand effects of exercise on glucose metabolism. Exercise and Sport 140

141 Sciences Review, 30(2), Yamanouchi, K., Ozawa, N., Shinozaki, T., Suzuki, Y., Chikada, K., Maeno, H., et al., (1995). Daily walking combined with diet therapy is a useful means for obese NIDDM patients not only to reduce body weight but also to improve insulin sensitivity. Diabetes Care, 18,