Physical activity and incident type 2 diabetes mellitus: a systematic review and dose-response meta-analysis of prospective cohort studies

Andrea D Smith, Alessio Crippa, James Woodcock, Søren Brage, Andrea D Smith, Alessio Crippa, James Woodcock, Søren Brage

Abstract

Aims/hypothesis: Inverse associations between physical activity (PA) and type 2 diabetes mellitus are well known. However, the shape of the dose-response relationship is still uncertain. This review synthesises results from longitudinal studies in general populations and uses non-linear models of the association between PA and incident type 2 diabetes.

Methods: A systematic literature search identified 28 prospective studies on leisure-time PA (LTPA) or total PA and risk of type 2 diabetes. PA exposures were converted into metabolic equivalent of task (MET) h/week and marginal MET (MMET) h/week, a measure only considering energy expended above resting metabolic rate. Restricted cubic splines were used to model the exposure-disease relationship.

Results: Our results suggest an overall non-linear relationship; using the cubic spline model we found a risk reduction of 26% (95% CI 20%, 31%) for type 2 diabetes among those who achieved 11.25 MET h/week (equivalent to 150 min/week of moderate activity) relative to inactive individuals. Achieving twice this amount of PA was associated with a risk reduction of 36% (95% CI 27%, 46%), with further reductions at higher doses (60 MET h/week, risk reduction of 53%). Results for the MMET h/week dose-response curve were similar for moderate intensity PA, but benefits were greater for higher intensity PA and smaller for lower intensity activity.

Conclusions/interpretation: Higher levels of LTPA were associated with substantially lower incidence of type 2 diabetes in the general population. The relationship between LTPA and type 2 diabetes was curvilinear; the greatest relative benefits are achieved at low levels of activity, but additional benefits can be realised at exposures considerably higher than those prescribed by public health recommendations.

Keywords: Cohort studies; Dose–response; Meta-analysis; Physical activity; Systematic review; Type 2 diabetes.

Conflict of interest statement

Access to research materials

Information about how the data can be accessed is available from the corresponding author.

Duality of interest

The authors declare that there is no duality of interest associated with this manuscript

Contribution statement

JW and SB conceived this study. ADS and AC contributed to the design of the study. ADS conducted data collection. ADS and AC conducted the analysis. JW, SB, AC and ADS interpreted the results. ADS wrote the initial draft of the manuscript, with revisions by all authors. The final manuscript was approved by all authors. ADS, JWS and SB are the guarantors of this work.

Figures

Fig. 1
Fig. 1
Forest plot of the study-specific RRs for type 2 diabetes for every 10 MET h/week exposure of PA, sorted by PA domain and publication year. Study-specific estimates obtained by a generalised least squares regression assuming a linear relationship of the RR to the referent in a random-effects model. Referents for PA were the individuals reporting no or lowest level of PA within the specific study. (I)/(II) indicate subcohorts with independently reported risk estimates for type 2 diabetes. The black midline indicates the line of no effect. The diamond indicates the pooled (subgroup) estimate. Grey boxes are relative to study size and the black vertical lines indicate 95% CIs around the effect size estimate
Fig. 2
Fig. 2
(a–d) Dose–response association between LTPA and incidence of type 2 diabetes modelled using restricted cubic splines and comparison of predicted RR point estimates for type 2 diabetes using different dose-assignment assumptions. LTPA converted to MET h/week with results pooled in a two-stage random-effects model. RRs were derived from a common lowest PA category within each study. Listed exposure levels were chosen to represent meaningful and easy to interpret PA volumes equivalent to the following: 30 min of MVPA; 1 h MVPA; rounded value to allow for comparison with GLS PA exposure increment; 150 min PA/current recommended guidelines; double the recommended guidelines and two high PA exposure levels investigating the risk reductions at the higher end of the LTPA spectrum. The bold lines indicate the pooled restricted cubic spline model and the black dashed line indicates the 95% CIs of the pooled curve. Duration assumption was necessary in nine out of 27 observations, applied as 45 min/session in scenarios (a) and (c), and 30 min/session in scenarios (b) and (d). Intensity assumption was necessary in 15 out of 27 observations, applied as low-intensity PA (LPA) = 3 MET, MVPA = 4.5 MET and VPA = 8 MET in scenarios (a) and (b), and LPA = 2 MET, MVPA = 3.5 MET and VPA = 7 MET in scenarios (c) and (d)

References

    1. Lozano R, Naghavi M, Foreman K, et al. Global and regional mortality from 235 causes of death for 20 age groups in 1990 and 2010: a systematic analysis for the Global Burden of Disease Study 2010. Lancet. 2012;380:2095–2128. doi: 10.1016/S0140-6736(12)61728-0.
    1. Roglic G, Unwin N. Mortality attributable to diabetes: estimates for the year 2010. Diabetes Res Clin Pract. 2010;87:15–19. doi: 10.1016/j.diabres.2009.10.006.
    1. International Diabetes Federation . IDF diabetes atlas. 7. Brussels: International Diabetes Federation; 2015.
    1. Moore P. Type 2 diabetes is a major drain on resources. BMJ. 2000;320:732. doi: 10.1136/bmj.320.7237.732.
    1. Hex N, Bartlett C, Wright D, Taylor M, Varley D. Estimating the current and future costs of Type 1 and Type 2 diabetes in the UK, including direct health costs and indirect societal and productivity costs. Diabet Med. 2012;29:855–862. doi: 10.1111/j.1464-5491.2012.03698.x.
    1. Pan XR, Li GW, Hu YH, et al. Effects of diet and exercise in preventing NIDDM in people with impaired glucose tolerance. The Da Qing IGT and Diabetes Study. Diabetes Care. 1997;20:537–544. doi: 10.2337/diacare.20.4.537.
    1. Ramachandran A, Snehalatha C, Mary S, Mukesh B, Bhaskar AD, Vijay V. The Indian Diabetes Prevention Programme shows that lifestyle modification and metformin prevent type 2 diabetes in Asian Indian subjects with impaired glucose tolerance (IDPP-1) Diabetologia. 2006;49:289–297. doi: 10.1007/s00125-005-0097-z.
    1. Laaksonen DE, Lindström J, Lakka TA, et al. Physical activity in the prevention of type 2 diabetes: the Finnish diabetes prevention study. Diabetes. 2005;54:158–165. doi: 10.2337/diabetes.54.1.158.
    1. Knowler WC, Barrett-Connor E, Fowler SE, et al. Reduction in the incidence of type 2 diabetes with lifestyle intervention or metformin. N Engl J Med. 2002;346:393–403. doi: 10.1056/NEJMoa012512.
    1. Manson JE, Nathan DM, Krolewski AS, Stampfer MJ, Willett WC, Hennekens CH. A prospective study of exercise and incidence of diabetes among US male physicians. JAMA. 1992;268:63–67. doi: 10.1001/jama.1992.03490010065031.
    1. Hu FB, Manson JE, Stampfer MJ, et al. Diet, lifestyle, and the risk of type 2 diabetes mellitus in women. N Engl J Med. 2001;345:790–797. doi: 10.1056/NEJMoa010492.
    1. Weinstein AR, Sesso HD, Lee IM, et al. Relationship of physical activity vs body mass index with type 2 diabetes in women. JAMA. 2004;292:1188–1194. doi: 10.1001/jama.292.10.1188.
    1. Lynch J, Helmrich SP, Lakka TA, et al. Moderately intense physical activities and high levels of cardiorespiratory fitness reduce the risk of non-insulin-dependent diabetes mellitus in middle-aged men. Arch Intern Med. 1996;156:1307–1314. doi: 10.1001/archinte.1996.00440110073010.
    1. Helmrich SP, Ragland DR, Leung RW, Paffenbarger RS. Physical activity and reduced occurrence of non-insulin-dependent diabetes mellitus. N Engl J Med. 1991;325:147–152. doi: 10.1056/NEJM199107183250302.
    1. Yates T, Khunti K, Bull F, Gorely T, Davies MJ. The role of physical activity in the management of impaired glucose tolerance: a systematic review. Diabetologia. 2007;50:1116–1126. doi: 10.1007/s00125-007-0638-8.
    1. Garber CE, Blissmer B, Deschenes MR, et al. American College of Sports Medicine position stand. Quantity and quality of exercise for developing and maintaining cardiorespiratory, musculoskeletal, and neuromotor fitness in apparently healthy adults: guidance for prescribing exercise. Med Sci Sports Exerc. 2011;43:1334–1359. doi: 10.1249/MSS.0b013e318213fefb.
    1. Department of Health (2011) Start active, stay active - a report on physical activity for health from the four home countries’ Chief Medical Officers. Available from: . Accessed 22 Jan 2016
    1. Hallal PC, Andersen LB, Bull FC, Guthold R, Haskell W, Ekelund U. Global physical activity levels: surveillance progress, pitfalls, and prospects. Lancet. 2012;380:247–257. doi: 10.1016/S0140-6736(12)60646-1.
    1. Hamer M, Stamatakis E, Steptoe A. Dose-response relationship between physical activity and mental health: the Scottish Health Survey. Br J Sports Med. 2009;43:1111–1114. doi: 10.1136/bjsm.2008.046243.
    1. Kelly P, Kahlmeier S, Götschi T, et al. Systematic review and meta-analysis of reduction in all-cause mortality from walking and cycling and shape of dose response relationship. Int J Behav Nutr Phys Act. 2014;11:132. doi: 10.1186/s12966-014-0132-x.
    1. Sattelmair J, Pertman J, Ding EL, Kohl HW, Haskell W, Lee I-M. Dose response between physical activity and risk of coronary heart disease: a meta-analysis. Circulation. 2011;124:789–795. doi: 10.1161/CIRCULATIONAHA.110.010710.
    1. Williams PT. Dose-response relationship of physical activity to premature and total all-cause and cardiovascular disease mortality in walkers. PLoS One. 2013;8:e78777. doi: 10.1371/journal.pone.0078777.
    1. Woodcock J, Franco OH, Orsini N, Roberts I. Non-vigorous physical activity and all-cause mortality: systematic review and meta-analysis of cohort studies. Int J Epidemiol. 2011;40:121–138. doi: 10.1093/ije/dyq104.
    1. Arem H, Moore SC, Patel A, et al. Leisure time physical activity and mortality: a detailed pooled analysis of the dose-response relationship. JAMA Intern Med. 2015;175:959–967. doi: 10.1001/jamainternmed.2015.0533.
    1. Aune D, Norat T, Leitzmann M, Tonstad S, Vatten LJ. Physical activity and the risk of type 2 diabetes: a systematic review and dose-response meta-analysis. Eur J Epidemiol. 2015;30:529–542. doi: 10.1007/s10654-015-0056-z.
    1. Jeon CY, Lokken RP, Hu FB, van Dam RM. Physical activity of moderate intensity and risk of type 2 diabetes: a systematic review. Diabetes Care. 2007;30:744–752. doi: 10.2337/dc06-1842.
    1. Johnson M, Jones R, Freeman C, et al. Can diabetes prevention programmes be translated effectively into real-world settings and still deliver improved outcomes? A synthesis of evidence. Diabet Med. 2013;30:3–15. doi: 10.1111/dme.12018.
    1. Colberg SR, Sigal RJ, Fernhall B, et al. Exercise and type 2 diabetes: The American College of Sports Medicine and the American Diabetes Association: joint position statement. Diabetes Care. 2010;33:2692–2696. doi: 10.2337/dc10-1548.
    1. Gill JMR, Cooper AR. Physical activity and prevention of type 2 diabetes mellitus. Sports Med. 2008;38:807–824. doi: 10.2165/00007256-200838100-00002.
    1. Warburton DER, Nicol CW, Bredin SSD. Health benefits of physical activity: the evidence. CMAJ. 2006;174:801–809. doi: 10.1503/cmaj.051351.
    1. Venables MC, Jeukendrup AE. Physical inactivity and obesity: links with insulin resistance and type 2 diabetes mellitus. Diabetes Metab Res Rev. 2009;25(Suppl 1):S18–S23. doi: 10.1002/dmrr.983.
    1. Reiner M, Niermann C, Jekauc D, Woll A. Long-term health benefits of physical activity--a systematic review of longitudinal studies. BMC Public Health. 2013;13:813. doi: 10.1186/1471-2458-13-813.
    1. Greenland S, Thomas DC, Morgenstern H. The rare-disease assumption revisited. A critique of ‘estimators of relative risk for case-control studies’. Am J Epidemiol. 1986;124:869–883.
    1. Ainsworth BE, Haskell WL, Herrmann SD, et al. Compendium of Physical Activities: a second update of codes and MET values. Med Sci Sports Exerc. 2011;43:1575–1581. doi: 10.1249/MSS.0b013e31821ece12.
    1. Grøntved A, Pan A, Mekary RA, et al. Muscle-strengthening and conditioning activities and risk of type 2 diabetes: a prospective study in two cohorts of US women. PLoS Med Publ Libr Sci. 2014;11:e1001587. doi: 10.1371/journal.pmed.1001587.
    1. Haapanen N, Miilunpalo S, Vuori I, Oja P, Pasanen M. Association of leisure time physical activity with the risk of coronary heart disease, hypertension and diabetes in middle-aged men and women. Int J Epidemiol. 1997;26:739–747. doi: 10.1093/ije/26.4.739.
    1. Meisinger C, Löwel H, Thorand B, Döring A. Leisure time physical activity and the risk of type 2 diabetes in men and women from the general population. The MONICA/KORA Augsburg Cohort Study. Diabetologia. 2005;48:27–34. doi: 10.1007/s00125-004-1604-3.
    1. Steinbrecher A, Erber E, Grandinetti A, Nigg C, Kolonel LN, Maskarinec G. Physical activity and risk of type 2 diabetes among Native Hawaiians, Japanese Americans, and Caucasians: the Multiethnic Cohort. J Phys Act Health. 2012;9:634–641. doi: 10.1123/jpah.9.5.634.
    1. Ekelund U, Palla L, Brage S, et al. Physical activity reduces the risk of incident type 2 diabetes in general and in abdominally lean and obese men and women: the EPIC-InterAct Study. Diabetologia. 2012;55:1944–1952. doi: 10.1007/s00125-012-2532-2.
    1. Magliano DJ, Barr ELM, Zimmet PZ, et al. Glucose indices, health behaviors, and incidence of diabetes in Australia: the Australian Diabetes, Obesity and Lifestyle Study. Diabetes Care. 2008;31:267–272. doi: 10.2337/dc07-0912.
    1. Carlsson S, Midthjell K, Tesfamarian MY, Grill V. Age, overweight and physical inactivity increase the risk of latent autoimmune diabetes in adults: results from the Nord-Trøndelag health study. Diabetologia. 2007;5:55–58.
    1. Ding D, Chong S, Jalaludin B, Comino E, Bauman AE. Risk factors of incident type 2-diabetes mellitus over a 3-year follow-up: results from a large Australian sample. Diabetes Res Clin Pract. 2015;108:306–315. doi: 10.1016/j.diabres.2015.02.002.
    1. Hamling J, Lee P, Weitkunat R, Ambühl M. Facilitating meta-analyses by deriving relative effect and precision estimates for alternative comparisons from a set of estimates presented by exposure level or disease category. Stat Med. 2008;27:954–970. doi: 10.1002/sim.3013.
    1. Micha R, Wallace SK, Mozaffarian D. Red and processed meat consumption and risk of incident coronary heart disease, stroke, and diabetes mellitus: a systematic review and meta-analysis. Circulation. 2010;121:2271–2283. doi: 10.1161/CIRCULATIONAHA.109.924977.
    1. FAO/WHO/UNU Expert Consultation (2011) Human energy requirements. Chapter 5: Energy requirements of adults. Available from: , Accessed 12 Nov 2015
    1. Fretts AM, Howard BV, Kriska AM, et al. Physical activity and incident diabetes in American Indians: the Strong Heart Study. Am J Epidemiol. 2009;170:632–639. doi: 10.1093/aje/kwp181.
    1. Villegas R, Shu X-O, Li H, et al. Physical activity and the incidence of type 2 diabetes in the Shanghai women’s health study. Int J Epidemiol. 2006;35:1553–1562. doi: 10.1093/ije/dyl209.
    1. Orsini N. Generalized least squares for trend estimation of summarized dose–response data. Stata J. 2006;6:40–57.
    1. Bagnardi V, Zambon A, Quatto P, Corrao G. Flexible meta-regression functions for modeling aggregate dose-response data, with an application to alcohol and mortality. Am J Epidemiol. 2004;159:1077–1086. doi: 10.1093/aje/kwh142.
    1. DerSimonian R, Laird N. Meta-analysis in clinical trials. Control Clin Trials. 1986;7:177–188. doi: 10.1016/0197-2456(86)90046-2.
    1. Shi L, Shu X-O, Li H, et al. Physical activity, smoking, and alcohol consumption in association with incidence of type 2 diabetes among middle-aged and elderly Chinese men. PLoS One. 2013;8:e77919. doi: 10.1371/journal.pone.0077919.
    1. Hsia J, Wu L, Allen C, et al. Physical activity and diabetes risk in postmenopausal women. Am J Prev Med. 2005;28:19–25. doi: 10.1016/j.amepre.2004.09.012.
    1. Higgins JPT, Green S (eds) (2011) Cochrane handbook for systematic reviews of interventions 5.1.0 [updated March 2011]. The Cochrane Collaboration. Available from . Accessed 5 Oct 2015
    1. Greenland S. Dose-response and trend analysis in epidemiology: alternatives to categorical analysis. Epidemiology. 1995;6:356–365. doi: 10.1097/00001648-199507000-00005.
    1. Wu Y, Zhang D, Kang S. Physical activity and risk of breast cancer: a meta-analysis of prospective studies. Breast Cancer Res Treat. 2013;137:869–882. doi: 10.1007/s10549-012-2396-7.
    1. Core Team R. R: A language and environment for statistical computing. Vienna: R Foundation for Statistical Computing; 2015.
    1. Nakanishi N, Takatorige T, Suzuki K. Daily life activity and risk of developing impaired fasting glucose or type 2 diabetes in middle-aged Japanese men. Diabetologia. 2004;47:1768–1775. doi: 10.1007/s00125-004-1528-y.
    1. Burchfiel CM, Sharp DS, et al. Physical activity and incidence of diabetes: the Honolulu Heart Program. Am J Epidemiol. 1995;141:360–368. doi: 10.1093/aje/141.4.360.
    1. Fan S, Chen J, Huang J, et al. Physical activity level and incident type 2 diabetes among Chinese adults. Med Sci Sports Exerc. 2014;47:751–756. doi: 10.1249/MSS.0000000000000471.
    1. Siegel LC, Sesso HD, Bowman TS, Lee I-M, Manson JE, Gaziano JM. Physical activity, body mass index, and diabetes risk in men: a prospective study. Am J Med. 2009;122:1115–1121. doi: 10.1016/j.amjmed.2009.02.008.
    1. Grøntved A, Rimm EB, Willett WC, Andersen LB, Hu FB. A prospective study of weight training and risk of type 2 diabetes mellitus in men. Arch Intern Med. 2012;172:1306–1312. doi: 10.1001/archinternmed.2012.3138.
    1. Folsom AR, Kushi LH, Hong CP. Physical activity and incident diabetes mellitus in postmenopausal women. Am J Public Health. 2000;90:134–138. doi: 10.2105/AJPH.90.1.134.
    1. James SA, Jamjoum L, Raghunathan TE, Strogatz DS, Furth ED, Khazanie PG. Physical activity and NIDDM in African-Americans. The Pitt County Study. Diabetes Care. 1998;21:555–562. doi: 10.2337/diacare.21.4.555.
    1. Krishnan S, Rosenberg L, Palmer JR. Physical activity and television watching in relation to risk of type 2 diabetes: the Black Women’s Health Study. Am J Epidemiol. 2009;169:428–434. doi: 10.1093/aje/kwn344.
    1. Monterrosa AE, Haffner SM, Stern MP, Hazuda HP. Sex difference in lifestyle factors predictive of diabetes in Mexican-Americans. Diabetes Care. 1995;18:448–456. doi: 10.2337/diacare.18.4.448.
    1. Okada K, Hayashi T, Tsumura K, Suematsu C, Endo G, Fujii S. Leisure-time physical activity at weekends and the risk of Type 2 diabetes mellitus in Japanese men: the Osaka Health Survey. Diabet Med. 2000;17:53–58. doi: 10.1046/j.1464-5491.2000.00229.x.
    1. Lee D, Park I, Jun T-W, et al. Physical activity and body mass index and their associations with the development of type 2 diabetes in Korean men. Am J Epidemiol. 2012;176:43–51. doi: 10.1093/aje/kwr471.
    1. Chien K-L, Chen M-F, Hsu H-C, Su T-C, Lee Y-T. Sports activity and risk of type 2 diabetes in Chinese. Diabetes Res Clin Pract. 2009;84:311–318. doi: 10.1016/j.diabres.2009.03.006.
    1. Wannamethee SG, Shaper AG, Alberti KG. Physical activity, metabolic factors, and the incidence of coronary heart disease and type 2 diabetes. Arch Intern Med. 2000;160:2108–2116. doi: 10.1001/archinte.160.14.2108.
    1. Hu G, Lindström J, Valle TT, et al. Physical activity, body mass index, and risk of type 2 diabetes in patients with normal or impaired glucose regulation. Arch Intern Med. 2004;164:892–896. doi: 10.1001/archinte.164.8.892.
    1. Demakakos P, Hamer M, Stamatakis E, Steptoe A. Low-intensity physical activity is associated with reduced risk of incident type 2 diabetes in older adults: evidence from the English Longitudinal Study of Ageing. Diabetologia. 2010;53:1877–1885. doi: 10.1007/s00125-010-1785-x.
    1. Misra A, Nigam P, Hills AP, et al. Consensus physical activity guidelines for Asian Indians. Diabetes Technol Ther. 2012;14:83–98. doi: 10.1089/dia.2011.0111.
    1. Misra A, Chowbey P, Makkar BM, et al. Consensus statement for diagnosis of obesity, abdominal obesity and the metabolic syndrome for Asian Indians and recommendations for physical activity, medical and surgical management. J Assoc Physicians India. 2009;57:163–170.
    1. Keum N, Ju W, Lee DH, et al. Leisure-time physical activity and endometrial cancer risk: dose-response meta-analysis of epidemiological studies. Int J Cancer. 2014;135:682–694. doi: 10.1002/ijc.28687.
    1. Woodcock J, Tainio M, Cheshire J, O’Brien O, Goodman A. Health effects of the London bicycle sharing system: health impact modelling study. BMJ. 2014;348:g425. doi: 10.1136/bmj.g425.
    1. Department of Transport. WebTAG: Transport Analysis Guidance (TAG) overview (2013) Available from: , accessed 22 Nov 2015
    1. Prince SA, Adamo KB, Hamel ME, Hardt J, Connor Gorber S, Tremblay M. A comparison of direct versus self-report measures for assessing physical activity in adults: a systematic review. Int J Behav Nutr Phys Act. 2008;5:56. doi: 10.1186/1479-5868-5-56.
    1. Ekelund U, Ward HA, Norat T, et al. Physical activity and all-cause mortality across levels of overall and abdominal adiposity in European men and women: the European Prospective Investigation into Cancer and Nutrition Study (EPIC) Am J Clin Nutr. 2015;101:613–621. doi: 10.3945/ajcn.114.100065.
    1. Sparling PB, Howard BJ, Dunstan DW, Owen N. Recommendations for physical activity in older adults. BMJ. 2015;350:h100. doi: 10.1136/bmj.h100.

Source: PubMed

Sponsorit ja yhteistyökumppanit

Sairaudet

Huumeiden interventiot

3
Tilaa