**4. Regular physical activity and exercise**

Exercise is often classified as aerobic, strength (resistance) and flexibility exercise and each of them has their own utility and limitations. The common recommendation (e.g. 150 minutes or more of moderate-to-vigorous intensity physical activity per week, spread over at least 3 days/week, with no more than 2 consecutive days without activity) is applicable to most adults and help to achieve cardiovascular fitness and other benefits. Brisk walking can be regularly included into the daily life. Two to three sessions/week of resistance exercise on non-consecutive days are also recommended [25]. Increased physical activity is effective in preventing diabetes, and the protective benefit is especially pronounced in persons at the highest risk for the disease [26]. At higher BMI, exercise is protective against diabetes and is dose-dependent. The prevention of diabetes and reduction of hyperglycemia in diabetes occur even without significant weight reduction [27]. American Diabetes Association recommends that prolonged sitting should be interrupted every 30 minutes for blood glucose benefits, particularly in adults with type 2 diabetes [25]. Possible physical activity even while seated (e.g. by leg exercise with or without sit down leg exercise machines) may also help. A more intensive physical activity program including at least 275 minutes per week may be needed to assist weight loss and avoid regain [21]. Higher levels of physical activity before pregnancy or in early pregnancy are associated with a significantly lower risk of developing gestational diabetes mellitus [28]. NICE guideline recommends women with gestational diabetes to take regular exercise (such as walking for 30 minutes after a meal) to improve blood glucose control [29]. **Figure 2** summarizes the potential benefits of regular physical activity and exercise in relation to diabetes.

reducing 1 mmol/L of LDL cholesterol and is about four times more effective than lowering 0.9% of glycated hemoglobin (HbA1c), and thus, in diabetes, BP control is more efficacious

**Clinical management perspective:** The current guidelines recommend to treat hypertension in type 2 diabetes to an systolic BP target of 130–140 mmHg and a diastolic BP target of 80 mmHg and to consider the lower targets if the patients are younger or when additional CV risk factors or microvascular diseases are present [21]. In the studies, the number of antihypertensive drugs required to achieve the systolic blood pressure around 130–140 mmHg are often more than two and even more than three in many patients. Treatment of hypertension in patients with diabetes is

**Public health perspective:** In non-industrialized countries, there is urgent need of establishing the network of the State supported rural and particularly urban health centers/clinics with general practitioners (preferably well trained with residential training in General Practice after medical graduation). It is required (i) for the comprehensive longitudinal health care of the people with diabetes, hypertension, CVD and other conditions, (ii) for supervision of healthcare workers to implement various public health programs including that for hypertension and CVDs and (iii) to provide the State supported diagnostic facilities and antidiabetic, antihypertensive and other CVD drugs and antibiotics (then only it may be possible to restrict the over-the-counter sale of antibiotics and other drugs as the

**Research perspective:** Study of the occurrence of CVD complications in the people with pre-hypertension level of BP and impaired glucose intolerance may indicate the different levels of HbA1c and BP to start antihypertensive treatment. The combined presence of the subclinical or borderline hypertension and glucose intolerance (as 'subclinical or borderline syndrome') may be another CVD risk factor, as a residual risk factor of CVDs, at the population level.

The health effects of tobacco use, including on CVD, and various public health measures to control it are well known [2, 10]. Harmful tobacco products also include smokeless tobacco

**Clinical management perspective:** The five A's framework (Ask, Advise, Assess, Assist, Arrange) has been developed to allow physicians to incorporate smoking cessation counseling into busy clinical practices [23]. Others have further added 'Assess again'. There are various pharmacological agents available to help patients quit smoking and tobacco use. However, before such products were available and even now hundreds of thousands of people including health professionals have had stopped tobacco use once they realized the possible complications to them. Physicians' priority, repeated advice and time spent on explaining its importance and its process of quitting play a crucial role for the motivation of the patients to quit tobacco use. Smokers who quit smoking abruptly ('Cold Turkey' method) have been reported to be successful than those who quit gradually [24]. However, the most important wellknown point, to emphasize to the patients repeatedly, is that after stopping tobacco use whether abruptly or slowly,

Exercise is often classified as aerobic, strength (resistance) and flexibility exercise and each of them has their own utility and limitations. The common recommendation (e.g. 150 minutes

like snuff, gutkha, gul, chimo, mawa, nass, pan masala, tambaku and others [22].

and more easy than lowering glucose [20].

180 Diabetes and Its Complications

**3. Promoting cessation of smoking and tobacco use**

people otherwise would not have any access to such life-saving drugs) [15].

lucidly reviewed in the position paper of American Society of Hypertension [12].

**4. Regular physical activity and exercise**

it should not be used even once; otherwise the habit is likely to be resumed.

**Figure 2.** Potential benefits of regular physical activity and exercise in relation to diabetes.

**Research perspective:** Although type 2 diabetic subjects are insulin resistant, they are not resistant to the stimulatory effects of exercise on glucose utilization [30]. The local cellular and other metabolic adaptations could explain the increase in glucose utilization and improvement in the glucose tolerance in exercise and trained muscles. A major challenge has been to elucidate the molecules or cascade of molecules that act through insulin-independent, exercise-stimulated signaling pathway [30]. If such molecules produced during exercise are secreted in the blood and act like hormones in other tissues, organs, muscles and fat, study of the effect in the resting state by the reuse of serum of blood collected during exercise in the same person may give insight into such actions and the difference in the contents of resting and post-exercise sera may help to elucidate the molecules.

**Research perspective:** Many overweight older people with diabetes have knee osteoarthritis which may prevent them to walk freely. Exercises to strengthen the quadriceps—for example, quadriceps-setting exercise and straightleg raises—are effective in reducing pain and improving function in patients with knee osteoarthritis. However, people often may not adhere to the recommended methods of quadriceps strengthening exercises. Regular exercise with a bicycle ergometer in such patients can have beneficial effects not only for knee osteoarthritis but also for diabetes and CVD [31].
