Cardiovasc Prev Pharmacother.  2022 Jan;4(1):42-55. 10.36011/cpp.2022.4.e3.

Effects of physical activity on cardiovascular outcomes and mortality in Korean patients with diabetes: a nationwide population-based cohort study

• Jung I
• Moon SJ
• Kwon H
• Park SE
• Han KD
• Rhee EJ
• Lee WY

• KMID: 2536932
• DOI: http://doi.org/10.36011/cpp.2022.4.e3

Abstract

Background
Since a sedentary lifestyle is considered a modifiable risk factor for cardiovascular disease (CVD), physical activity (PA) is recommended for type 2 diabetes mellitus (T2DM) patients to prevent CVD. We investigated the association between different levels of PA and the risk for CVD and all-cause mortality in patients with T2DM using nationwide data.
Methods
We examined health examination data and claims records of 2,745,637 participants with T2DM at baseline from the Korean National Health Insurance Service who underwent health examinations between 2009 and 2012. We excluded subjects with a history of myocardial infarction or stroke. Each participant was asked to report their weekly PA levels according to three categories: vigorous, moderate, and walking. The incidence of CVD and death was analyzed until 2017.
Results
The risk of CVD was lower in regular exercisers than in nonexercisers after adjusting for confounding variables. A dose-response trend was evident in the association between the degree of PA and CVD risk. All categories of PA were inversely associated with CVD risk and mortality. The reduction in CVD risk and all-cause mortality was more profound in patients aged ≥65 years.
Conclusions
Augmenting PA might have positive effects on the prevention of CVD and all-cause death, especially in the elderly. The benefits of PA were consistently observed in various subgroups regardless of the presence of chronic conditions. Therefore, clinicians should encourage elderly patients with T2DM to increase their daily PA.

Keyword

Diabetes mellitus; Exercise; Cardiovascular disease; Physical activity; Prevention

Figure

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  Fig. 1. Effects of regular exercise on (A) cardiovascular disease, (B) myocardial infarction, (C) ischemic stroke, and (D) all-cause mortality. HR, hazard ratio; CI, confidence interval; DM, diabetes mellitus.

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  Fig. 2. Effects of vigorous physical activity on (A) cardiovascular disease, (B) myocardial infarction, (C) ischemic stroke, and (D) all-cause mortality. HR, hazard ratio; CI, confidence interval; DM, diabetes mellitus.

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  Fig. 3. Effects of moderate physical activity on (A) cardiovascular disease, (B) myocardial infarction (C) ischemic stroke, and (D) all-cause mortality. HR, hazard ratio; CI, confidence interval; DM, diabetes mellitus.

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  Fig. 4. Effects of walking on (A) cardiovascular disease, (B) myocardial infarction, (C) ischemic stroke, and (D) all-cause mortality. HR, hazard ratio; CI, confidence interval; DM, diabetes mellitus.

Reference

1. Einarson TR, Acs A, Ludwig C, Panton UH. Prevalence of cardiovascular disease in type 2 diabetes: a systematic literature review of scientific evidence from across the world in 2007-2017. Cardiovasc Diabetol. 2018; 17:83.

2. Bansilal S, Castellano JM, Fuster V. Global burden of CVD: focus on secondary prevention of cardiovascular disease. Int J Cardiol. 2015; 201 Suppl 1:S1–7.

3. Nichols M, Townsend N, Scarborough P, Rayner M. Cardiovascular disease in Europe: epidemiological update. Eur Heart J. 2013; 34:3028–34.

4. Park JH, Ha KH, Kim BY, Lee JH, Kim DJ. Trends in cardiovascular complications and mortality among patients with diabetes in South Korea. Diabetes Metab J. 2021; 45:120–4.

5. Sofi F, Capalbo A, Cesari F, Abbate R, Gensini GF. Physical activity during leisure time and primary prevention of coronary heart disease: an updated meta-analysis of cohort studies. Eur J Cardiovasc Prev Rehabil. 2008; 15:247–57.

6. Cheng W, Zhang Z, Cheng W, Yang C, Diao L, Liu W. Associations of leisure-time physical activity with cardiovascular mortality: a systematic review and meta-analysis of 44 prospective cohort studies. Eur J Prev Cardiol. 2018; 25:1864–72.

7. Arnett DK, Blumenthal RS, Albert MA, Buroker AB, Goldberger ZD, Hahn EJ, et al. 2019 ACC/AHA guideline on the primary prevention of cardiovascular disease: a report of the American College of Cardiology/American Heart Association Task Force on clinical practice guidelines. J Am Coll Cardiol. 2019; 74:e177–232.

8. Cosentino F, Grant PJ, Aboyans V, Bailey CJ, Ceriello A, Delgado V, et al. 2019 ESC Guidelines on diabetes, pre-diabetes, and cardiovascular diseases developed in collaboration with the EASD. Eur Heart J. 2020; 41:255–323.

9. Singh R, Pattisapu A, Emery MS. US Physical Activity Guidelines: current state, impact and future directions. Trends Cardiovasc Med. 2020; 30:407–12.

10. Charvat H, Goto A, Goto M, Inoue M, Heianza Y, Arase Y, et al. Impact of population aging on trends in diabetes prevalence: a meta-regression analysis of 160,000 Japanese adults. J Diabetes Investig. 2015; 6:533–42.

11. Yang L, Cao C, Kantor ED, Nguyen LH, Zheng X, Park Y, et al. Trends in sedentary behavior among the US population, 2001-2016. JAMA. 2019; 321:1587–97.

12. Du Y, Liu B, Sun Y, Snetselaar LG, Wallace RB, Bao W. Trends in adherence to the physical activity guidelines for Americans for aerobic activity and time spent on sedentary behavior among US adults, 2007 to 2016. JAMA Netw Open. 2019; 2:e197597.

13. Cheol Seong S, Kim YY, Khang YH, Heon Park J, Kang HJ, Lee H, et al. Data resource profile: the National Health Information Database of the National Health Insurance Service in South Korea. Int J Epidemiol. 2017; 46:799–800.

14. Chun MY. Validity and reliability of Korean version of International Physical Activity Questionnaire Short Form in the elderly. Korean J Fam Med. 2012; 33:144–51.

15. Jeong HG, Kim DY, Kang DW, Kim BJ, Kim CK, Kim Y, et al. Physical activity frequency and the risk of stroke: a nationwide cohort study in Korea. J Am Heart Assoc. 2017; 6:e005671.

16. Oh JY, Yang YJ, Kim BS, Kang JH. Validity and reliability of Korean version of International Physical Activity Questionnaire (IPAQ) Short Form. J Korean Acad Fam Med. 2007; 28:532–41.

17. Lee PH, Macfarlane DJ, Lam TH, Stewart SM. Validity of the International Physical Activity Questionnaire Short Form (IPAQ-SF): a systematic review. Int J Behav Nutr Phys Act. 2011; 8:115.

18. Seo MH, Kim YH, Han K, Jung JH, Park YG, Lee SS, et al. Prevalence of obesity and incidence of obesity-related comorbidities in Koreans based on National Health Insurance Service health checkup data 2006-2015. J Obes Metab Syndr. 2018; 27:46–52.

19. Kim MK, Han K, Koh ES, Kim ES, Lee MK, Nam GE, et al. Blood pressure and development of cardiovascular disease in Koreans with type 2 diabetes mellitus. Hypertension. 2019; 73:319–26.

20. Kim MK, Han K, Kim HS, Park YM, Kwon HS, Yoon KH, et al. Cholesterol variability and the risk of mortality, myocardial infarction, and stroke: a nationwide population-based study. Eur Heart J. 2017; 38:3560–6.

21. Levey AS, Bosch JP, Lewis JB, Greene T, Rogers N, Roth D. A more accurate method to estimate glomerular filtration rate from serum creatinine: a new prediction equation: modification of diet in Renal Disease Study Group. Ann Intern Med. 1999; 130:461–70.

22. Hakim AA, Petrovitch H, Burchfiel CM, Ross GW, Rodriguez BL, White LR, et al. Effects of walking on mortality among nonsmoking retired men. N Engl J Med. 1998; 338:94–9.

23. Schnohr P, Scharling H, Jensen JS. Intensity versus duration of walking, impact on mortality: the Copenhagen City Heart Study. Eur J Cardiovasc Prev Rehabil. 2007; 14:72–8.

24. Rockhill B, Willett WC, Manson JE, Leitzmann MF, Stampfer MJ, Hunter DJ, et al. Physical activity and mortality: a prospective study among women. Am J Public Health. 2001; 91:578–83.

25. Tanasescu M, Leitzmann MF, Rimm EB, Hu FB. Physical activity in relation to cardiovascular disease and total mortality among men with type 2 diabetes. Circulation. 2003; 107:2435–9.

26. Hu FB, Stampfer MJ, Solomon C, Liu S, Colditz GA, Speizer FE, et al. Physical activity and risk for cardiovascular events in diabetic women. Ann Intern Med. 2001; 134:96–105.

27. Brown WJ, McLaughlin D, Leung J, McCaul KA, Flicker L, Almeida OP, et al. Physical activity and all-cause mortality in older women and men. Br J Sports Med. 2012; 46:664–8.

28. Ruby BC, Coggan AR, Zderic TW. Gender differences in glucose kinetics and substrate oxidation during exercise near the lactate threshold. J Appl Physiol (1985). 2002; 92:1125–32.

29. O’Toole ML. Gender differences in the cardiovascular response to exercise. Cardiovasc Clin. 1989; 19:17–33.

30. Tarnopolsky MA. Gender differences in metabolism; nutrition and supplements. J Sci Med Sport. 2000; 3:287–98.

31. Mao HY, Hsu HC, Lee SD. Gender differences in related influential factors of regular exercise behavior among people in Taiwan in 2007: a cross-sectional study. PLoS One. 2020; 15:e0228191.

32. Wisloff U, Nilsen TI, Droyvold WB, Morkved S, Slordahl SA, Vatten LJ. A single weekly bout of exercise may reduce cardiovascular mortality: how little pain for cardiac gain? ‘The HUNT study, Norway’. Eur J Cardiovasc Prev Rehabil. 2006; 13:798–804.

33. Chin SO, Rhee SY, Chon S, Hwang YC, Jeong IK, Oh S, et al. Sarcopenia is independently associated with cardiovascular disease in older Korean adults: the Korea National Health and Nutrition Examination Survey (KNHANES) from 2009. PLoS One. 2013; 8:e60119.

34. Atkins JL, Whincup PH, Morris RW, Lennon LT, Papacosta O, Wannamethee SG. Sarcopenic obesity and risk of cardiovascular disease and mortality: a population-based cohort study of older men. J Am Geriatr Soc. 2014; 62:253–60.

35. Cesari M, Kritchevsky SB, Baumgartner RN, Atkinson HH, Penninx BW, Lenchik L, et al. Sarcopenia, obesity, and inflammation: results from the Trial of Angiotensin Converting Enzyme Inhibition and Novel Cardiovascular Risk Factors study. Am J Clin Nutr. 2005; 82:428–34.

36. Napoli C, Williams-Ignarro S, De Nigris F, Lerman LO, Rossi L, Guarino C, et al. Long-term combined beneficial effects of physical training and metabolic treatment on atherosclerosis in hypercholesterolemic mice. Proc Natl Acad Sci U S A. 2004; 101:8797–802.

37. Nunes RB, Tonetto M, Machado N, Chazan M, Heck TG, Veiga AB, et al. Physical exercise improves plasmatic levels of IL-10, left ventricular end-diastolic pressure, and muscle lipid peroxidation in chronic heart failure rats. J Appl Physiol (1985). 2008; 104:1641–7.

38. Conraads VM, Beckers P, Bosmans J, De Clerck LS, Stevens WJ, Vrints CJ, et al. Combined endurance/resistance training reduces plasma TNF-alpha receptor levels in patients with chronic heart failure and coronary artery disease. Eur Heart J. 2002; 23:1854–60.

39. Loney T, Standage M, Thompson D, Sebire SJ, Cumming S. Self-report vs. objectively assessed physical activity: which is right for public health? J Phys Act Health. 2011; 8:62–70.

40. Ko SH, Kim DJ, Park JH, Park CY, Jung CH, Kwon HS, et al. Trends of antidiabetic drug use in adult type 2 diabetes in Korea in 2002-2013: nationwide population-based cohort study. Medicine (Baltimore). 2016; 95:e4018.

41. Ko SH, Han K, Lee YH, Noh J, Park CY, Kim DJ, et al. Past and current status of adult type 2 diabetes mellitus management in Korea: a National Health Insurance Service database analysis. Diabetes Metab J. 2018; 42:93–100.

42. Kim JY, Kim SJ, Nam CM, Moon KT, Park EC. Changes in prescription pattern, pharmaceutical expenditure and quality of care after introduction of reimbursement restriction in diabetes in Korea. Eur J Public Health. 2018; 28:209–14.