Impact of Walking on Glycaemic Control and Other

Cardiovascular Risk Factors in Type 2 Diabetes: A

Meta-Analysis
Shanhu Qiu, Xue Cai, Uwe Schumann, Martina Velders, Zilin Sun, Jürgen Michael
Steinacker

Summarized research paper:

Background

Regular exercise is crucial for managing type 2 diabetes, but many patients struggle with
high-impact exercise due to physical limitations. Walking, a low-impact exercise, is popular
among patients with type 2 diabetes due to its ease of performance, minimal adverse effects,
and low impact. Previous studies have shown that walking can improve risk factors for
cardiovascular disease, but none have investigated its effects on glycemic control.
Supervision is recommended to optimize exercise training effects on glycemic control, but it
is not always feasible due to limited medical care resources. This meta-analysis aims to
examine the association of walking with glycemic control and other cardiovascular risk
factors among patients with type 2 diabetes and evaluate whether supervised walking leads to
better improvement in glycemic control compared to non-supervised walking.
Methods
Data sources and searches

The following databases were searched for primary articles: PubMed, the Cochrane Central
Register of Controlled Trials and Web of Science. Searches were limited to human beings.
Study selection

The study included participants with type 2 diabetes who participated in a structured walking
program, compared them to a control group, reported sufficient data for weight reduction,
blood pressure, and lipoprotein profiles, and had a randomized, controlled design. The
primary outcome, HbA1c, was based on average blood glucose concentration over 8-12
weeks.
Studies excluded from the study include those with pre-diabetes, gestational diabetes, type 1
diabetes, multiple exercise interventions, motivational tools, or dietary interventions,
compared to regular exercise training, reported only categorical data, were non-randomized,
posters, or abstracts, or provided insufficient information about aerobic exercise
interventions.
Data extraction and quality assessment
The study screened publications based on titles or abstracts, evaluating full-text articles if
necessary. Data on study sources, population characteristics, walking interventions,
outcomes, adherence, and dropout rates were extracted. The methodological quality of each
eligible study was assessed using the Cochrane Collaboration's risk of bias tool. Two authors
independently performed literature selection, data collection, and quality assessment, with
discrepancies resolved through consensus or discussion.
Data synthesis and analysis

The study used a meta-analysis to compare walking interventions with a single control group.
The standard deviation was calculated by multiplying the square root of the corresponding
sample size. The study assessed heterogeneity among studies using the Cochran Q test and I2
statistic. Pooled-effect estimates were calculated using a random-effects model. Subgroup
analyses were performed to investigate differences in outcome estimates across studies.
Univariate, weighted meta-regression analyses were conducted to determine if changes in
outcome estimates were mediated by participant characteristics or walking interventions.
Sensitivity analyses were used to assess the robustness of outcome estimates.
Results
The search identified 2266 articles, with 18 meeting inclusion criteria. 20 trials were included
in the final meta-analysis due to the presence of two different walking groups. A total of 20
trials included 866 participants, mostly overweight or obese, with varying walking structures
and durations. The walking intensity was moderate. Eleven trials were under supervision,
while the remaining nine had strategies for promoting training. The trials were conducted in
North America, South America, Asia, Europe, and South Africa. The participants were
generally overweight or obese, with a baseline mean BMI between 25.6 kg/m2 to 32.7 kg/m2.
The 20 trials included in the study reported poor randomization sequence generation,
allocation concealment, and incomplete outcome data. None had complete blinding, but the
outcome assessment was likely influenced by standard approaches. Adherence to the walking
intervention was high, with all trials reporting over 60% adherence. No major adverse events
were reported, except for mild hypoglycemia.
Primary outcome
Effect on glycemic control.

A meta-analysis of 16 trials involving 724 participants found a significant decrease in HbA1c

compared to the non-walking control. Supervised walking was associated with a 0.58%
decrease, while non-supervised walking had a statistically non-significant association. Non-
supervised walking with motivational strategies was associated with a significant decrease in
HbA1c, but made no difference from supervised walking. None of the covariates were
potential modifiers of HbA1c change.
Secondary outcomes
Effect on weight reduction.

Sixteen trials found walking significantly reduces BMI by 0.91 kg/m2 in 649 participants,
with negligible heterogeneity among trials.
Effect on blood pressure.

The study found a non-significant decrease in SBP among walking participants compared to
controls, while a larger reduction in DBP was observed in walking groups. The overall WMD
for DBP remained unchanged after removing individual trials, while the WMD for SBP was
changed to -3.20 mmHg after removing a 16-week Nordic walking intervention.
Effect on lipoprotein profiles.

A study of 290 participants found no significant changes in HDL-C levels or LDL-C levels
after walking training. The results showed that walking training did not significantly increase
HDL-C levels or change LDL-C levels among intervention participants. When individual
trials were removed from each meta-analysis, pooled results regarding HDL-C or LDL-C
were largely unchanged. The findings suggest that walking training may not be a significant
intervention for improving HDL-C levels.
Discussion
A meta-analysis suggests that walking is associated with a significant decrease in HbA1c in
patients with type 2 diabetes. Supervision is essential for walking training, and motivational
strategies are effective in decreasing HbA1c when performing non-supervised walking.
Walking is also associated with reduced BMI and lowered DBP. However, the study shows
inadequate evidence regarding the effects of walking on lowering SBP or altering lipoprotein
levels. A recent meta-analysis by Chudyk and Petrella and Snowling and Hopkins
demonstrated that aerobic exercise improves glycemic control in patients with type 2
diabetes. It is recommended to prescribe walking at a moderate intensity, 3-5 times/week,
120-150 minutes/week, for patients with type 2 diabetes to gain benefits on glycemic control.
Despite non-supervised walking being associated with a non-significant decrease in HbA1c,
motivational strategies such as peer support and step counters can help reduce HbA1c.
Walking is also associated with a significant reduction in BMI compared to non-walking
controls.
This meta-analysis reveals that walking significantly lowers diastolic blood pressure (DBP)
but not systolic blood pressure (SBP) among patients with type 2 diabetes. This finding
contradicts the current guideline that reductions in DBP from aerobic exercise training are
less common in patients with type 2 diabetes. The study also found no statistical support for
the positive relationship between walking and increased HDL-C levels and decreased LDL-C
levels among patients with type 2 diabetes. The meta-analysis is the most comprehensive
assessment of the beneficial effects of walking on glycemic control and cardiovascular risk
factors among patients with type 2 diabetes. However, it has several limitations, including
internal validity, publication bias, heterogeneity of HbA1c, and the short-term effects of
walking intervention. Future research should focus on a head-to-head design and more
comprehensive studies to better understand the long-term effects of walking on lipid
regulation.
Conclusions

The meta-analysis indicates walking reduces HbA1c in type 2 diabetes patients, requiring
supervision and motivational strategies. It also reduces BMI and DBP, but lacks evidence for
improved lipoprotein profiles. Future RCTs are needed.