STUDY ON PHYSICAL STRESS ON INSULIN PRODUCTION AND LIPID PROFILE

WITH AEROBIC AND RESISTED EXERCISES IN TYPE II DIABETIC PATIENTS

THESIS
submitted to the University of Madras
in partial fulfillment of the requirements
for the award of the degree of

DOCTOR OF PHILOSOPHY
IN PHYSIOTHERAPY AND ZOOLOGY (INTER-DISCIPLINARY)

By
S. S SUBRAMANIAN, M.P.T. (Advanced Orthopaedics), M.S., M.Phil.,

POSTGRADUATE AND RESEARCH DEPARTMENT OF

ADVANCED ZOOLOGY & BIOTECHNOLOGY
LOYOLA COLLEGE
CHENNAI 600 034
INDIA

January 2013

1
 CERTIFICATE

Certified that the thesis entitled “Study on physical stress on insulin production and

lipid profile with aerobic and resisted exercises in type II diabetic patients”

i. is a record of research work done by the candidate, S.S. SUBRAMANIAN, during the
period 2008-2012 under my guidance and that the thesis has not formed the basis for the
award of any Degree/Diploma, Associateship or any other similar title to the candidate, and

ii. that the thesis submitted by S.S. SUBRAMANIAN represents independent work on the part
of the candidate.

Dr. P. Venkatesan, Ph.D., D.Sc.

Supervisor & Guide

Chennai 600 034

11.01.2013

2
 DECLARATION

The thesis entitled “Study on physical stress on insulin production and lipid profile with

aerobic and resisted exercises in type II diabetic patients” submitted for the Ph. D Degree of

the University of Madras is a record of research work done by me during the period of 2008-2012

and it has not formed the basis for the award of any Degree, Diploma, Associateship, Fellowship or

any other similar title.

S.S. SUBRAMANIAN

Chennai 600 034

11.01.2013

3
4
 ACKNOWLEDGEMENT
I thank God, the Almighty for bestowing His showers of blessings upon me.

I am extremely thankful to my beloved professor and guide, Dr. P. Venkatesan, Ph.D.,

D.Sc., U.G.C.- Professor Emeritus, Department of Advanced Zoology & Biotechnology, Loyola

College, Chennai for his inspiring guidance, valuable suggestions, consistent encouragement and

unfailing support and care. He has enriched and deepened my aptitude for research and is a role

model for my personal life. I thank him for giving right direction and meaning to my research work.

I sincerely thank Rev. Fr. K. Amal S.J., Rector, Rev. Dr. Albert William, S.J., Secretary,

Rev. Dr. B. Jeyaraj S.J., Principal, Loyola College, Chennai for the facilities, support and

encouragement.

I immensely thank Dr. Albin T. Fleming, Head, Department of Advanced Zoology &

Biotechnology and all faculty members of the department for their encouragement and support.

I thank the experts of Doctoral Committee - Dr. Albin T. Fleming, Internal examiner,

Department of Advanced Zoology & Biotechnology and Dr. M. Balasubramanian, External

Examiner, Dr.Mohan’s Diabetic Research Foundation, Chennai for their expert suggestions and

guidance.

I am extremely thankful to Prof. Dr. V. Mohan, M.D., D.Sc., Chairman, Dr.Mohan’s

Diabetes Research Foundation, Chennai for extending his library facilities to me.

5
 I am extremely grateful to the Management, Staff and Students of Sree Balaji College of

Physiotherapy for their constant support in completing this research investigation.

My special thanks to Dr. S Arivoli, Young Scientist, Dr. Samuel Tennyson, Assistant

Professor, Madras Christian College, Mr.J. Ganesh, and Ms. Anjali Upadhyay Research Scholars,

Loyola College for their consistent support and assistance throughout my research work.

My immense thanks to Mrs. Umalakshmi Venkatesan for her blessings and to Dr. V.

Surendranath and Mrs. Swathi Sandeep for keeping my spirits high at the time of writing my

dissertation.

I express my sincere thanks to Dr. A. Siva Subramanian, Chief Medical Officer,

volunteers of SGS Clinic, Velachery, Chennai and all the patients who have formed the pillars of

this study.

I thank the Laboratory assistants and other non-teaching staff of Department of Zoology,

Loyola College, Chennai for all their timely help.

My deepest and special gratitude are to my beloved Parents for their valuable moral support

and constant encouragement.

I am extremely thankful to my wife Mrs. S. Vidhya Subramanian with whose support this

dissertation has become complete and perfect.

Continuous love and affection of my daughters, Ms. Shivani Sharadha and Ms.

Meenakshi Lalitha throughout my research work made my work easy.

6
 S.S. Subramanian

CONTENTS

S. No. TITLE Page No.

1.0 INTRODUCTION 1-44

2.0 MATERIALS AND METHODS 46-70

PILOT STUDY ON LIFE PARAMETERS
3.0 UNDER AEROBIC AND SWISSBALL 71-102
EXERCISES
IMPACT OF QUALITY OF LIFE ON LIFE
4.0 PARAMETERS OF POPULATION UNDER 103-132
AEROBIC AND SWISSBALL EXERCISES
5.0 DISCUSSION 133-146

6.0 OTHER REPORTS 147-148

7.0 SUMMARY 149-152

BIBLIOGRAPHY

PUBLICATIONS

APPENDIX

7
 1.0 INTRODUCTION
1.1 Diabetes mellitus
1.1.1 Classification of Diabetes mellitus
1.1.2 Clinical staging of Diabetes mellitus and other categories of glucose tolerance
1.1.3 Impaired glucose regulation / impaired glucose tolerance (IGT) / impaired
fasting glycemia (IFG)
1.2 Etiological classification of Diabetes mellitus
1.2.1 Other specific types
1.2.2 Gestational Diabetes Mellitus
1.3 Epidemiology and etiopathogenesis
1.3.1 Risk factors and causes
1.3.2 Insulin resistance
1.3.3. Epidemiological transition
1.3.4 Physical inactivity
1.3.5 Obesity
1.3.6 Dietary alterations
1.4 Physical activities and diabetes
1.5 Impact of physioball exercises in diabetes
1.5.1 Practical considerations in using Swissball
1.5.2 Physioball
1.5.3 Clothes and shoes
1.5.4 Long loose hair
1.5.5 Damaged balls
1.5.6 Heat
1.5.7 Over-inflating the ball
1.5.8 Plugs
1.5.9 Weight
8
 1.5.10 Space
1.5.11 Precautions and contraindications

1.6 Points of observation

1.6.1 Ball floor
1.6.2 Ball – body
1.6.3 Body – floor
1.6.4. Base of support
1.6.5 Bisecting plane
1.7 Reports on Swissball activity
1.7.1 Body distances
1.8 Exercise terminology and muscle activity
1.8.1 Body segment
1.8.2 Potential mobility
1.8.3 Dynamic stabilization
1.8.4 Variations and muscle activity
1.8.5 Primary movement, Action – Reaction
1.8.6 Conditio – Limitatio
1.9 Role of aerobic exercises in diabetes
1.10 Aerobic exercises
1.10.1 Production of energy
1.10.2 Phosphogen system
1.11 Anaerobic Glycolysis
1.11.1. Oxidative phosphorylation (aerobic system)
1.12 Energy substrate use
1.13 Slow twitch and fast twitch muscles
1.14 Health screening and medical clearance
1.15 Contraindications for exercise testing absolute contraindications
1.16 Relative contraindication
1.17 Guidelines for attaining an aerobic training effect
1.17.1 General warm up
1.17.2 Pre - exercise stretching

9
 1.17.3 Aerobic warm – up
1.17.4 Taking HR – Palpation technique
1.17.5 Cooling down
1.18 Strength training, rehabilitation, therapeutic exercise
1.18.1 Cool down stretching
1.18.2 Rate of exercise progression

1.19 Earlier reports

1.20 Need and scope of the present study
1.21 Need of the present investigation
1.22 Scope of the present investigation
1.23 Hypothetical statement
1.24 Aim and objectives of the present research work

10
 1.0 INTRODUCTION

1.1 Diabetes mellitus

The term Diabetes mellitus (as framed by WHO, 1999) is a metabolic disorder of
multiple etiology characterized by chronic hyperglycemia with disturbance in carbohydrate,
fat and protein metabolism resulting from defects in insulin secretion, insulin action or both.
The effects of Diabetes mellitus include long term damage, dysfunction and failure of
various vital organs. Diabetes mellitus occurs with characteristic symptoms such as thirsty,
polyuria, blurring of vision and weight loss. In its most severe forms, Ketoacidosis or a
non ketotic hyperosmolar state develops and leads to stupor, coma and in the absence of
effective treatment, death. Often, symptoms are not secure, or may be absent and
consequently hyperglycemia - sufficient to cause pathological and functional changes - may
be present for a long time before the diagnosis is made.

The long term effects of Diabetes mellitus include progressive development of the
specific complications of retinopathy with potential blindness, nephropathy that may lead to
renal failure and / or neuropathy with the risk of foot ulcers, amputation, Charcot joints
and features of autonomic dysfunction, including sexual dysfunction. People with diabetes
are at increased risk of cardio vascular, peripheral vascular and cerebro vascular diseases.
Several pathogenic processes are involved in the development of diabetes. These include process
which destroys the beta cells of the pancreas with consequent insulin deficiency, and others
that result in resistance to insulin action. The abnormalities of carbohydrate, fat and protein
metabolism are due to deficient action of insulin on target tissues resulting from
insensitivity or lack of insulin.

1.1.1 Classification of Diabetes mellitus

WHO (1999) has reported in the tenth revision of the International Classification of
Diseases (ICD – 10) that Diabetes mellitus represents a compromise between clinical and
etiological classification and allowed classification of individual subjects and patients in a

11
clinically useful manner even when the specific cause or etiology was unknown. The
recommended classification includes both stages of Diabetes mellitus based on clinical
descriptive criteria and a complementary etiological classification.

Kuzuyat and Matsuda (1997) have suggested that diabetes, regardless of its etiology,
progresses through several clinical stages during its natural history. Moreover, individual
subjects may move from stage to stage in either direction. Persons, who have or who are
developing Diabetes mellitus, can be categorized by stage according to the clinical
characteristics, even in the absence of information concerning the underlying etiology. The
classification by etiological type results from improved understanding of the causes of
Diabetes mellitus.

All subjects with Diabetes mellitus can be categorized according to clinical stage,
and this is achievable in all circumstances. The stage of glycemia may change over time
depending on the extent of the underlying disease processes. The disease process may be
present and that not have progressed for enough to cause hyperglycemia. The etiological
classification reflects the fact that the defect or process which may lead to diabetes may be
identifiable at any stage in the development of diabetes even at the stage of
normoglycemia. Thus the presence of Islet cell antibodies in a normoglycemic individual
makes it likely that a person has the Type 1 autoimmune process. However, there are a
few sensitive or highly specific indicators of the Type 2 process at present although these
are likely to be revealed as etiology is more clearly defined.

The same disease processes can cause impaired fasting glycemia and / or impaired
glucose tolerance without fulfilling the criteria for the diagnosis of Diabetes mellitus. In
some individuals with diabetes, adequate glycemic control can be achieved with weight
reduction, exercise and / or oral agents. These individuals, therefore, do not require insulin
and may even revert to impaired glucose tolerance (IGT) or normoglycemia. The severity of
the metabolic abnormality can either regress (eg. with weight reduction), progress (eg. with
weight gain) or stay the same.

1.1.2 Clinical staging of Diabetes mellitus and other categories of glucose tolerance

Diabetes mellitus, regardless of underlying cause, is subdivided into;

1. Insulin requiring for survival (corresponding to the former classical class of Insulin
Dependent Diabetes mellitus) e.g.: C-peptide deficient.

2. Insulin requiring for control, that is metabolic control, rather than for survival, e.g.:
some endogenous insulin secretion but insufficient to achieve normoglycemia without
added exogenous insulin and

12
 3. Not insulin requiring, that is those who may be controlled satisfactorily by non –
pharmacological methods or drugs other than insulin. Together, the latter two sub –
divisions (2 and 3) constitute the former class of Non – Insulin Dependent Diabetes
mellitus (NIDDM).

1.1.3 Impaired glucose regulation - impaired glucose tolerance (IGT) / impaired fasting
glycemia (IFG)

Impaired glucose regulation refers to a metabolic state intermediate between normal

glucose homeostasis and diabetes. It should be stated unequivocally, however that IFG and
IGT are not interchangeable and represent different abnormalities of glucose regulation, one
in the fasting state and the other post - prandial (PP).

IGT is categorized as a stage in the natural history of disordered carbohydrate

metabolism. A stage of IFG is also recognized because such subjects, like those with IGT,
have increased risk of progressing to diabetes and macrovascular disease.

1.1.3.1 Normoglycemia

A fasting venous plasma glucose concentration of less than 6.1 mmol/l (110 mg/dl)
has been chosen which is normal. Although this choice is arbitrary, such values are
observed in people with proven normal glucose tolerance, although some may have IGT, if
an oral glucose tolerance test is performed. Values above this are associated with a
progressively greater risk of developing micro- and macrovascular complications.

The pathological or etiological processes which often lead to Diabetes mellitus begin,
and may be recognizable, in some subjects who have normal glucose tolerance. Recognition
of the pathological process at an early stage may be useful, if progression to more
advanced stages can be prevented. Conversely, effective treatments, or occasionally the
natural history of some forms of Diabetes mellitus, may result in reversion of
hyperglycemia to a state of normoglycemia. The proposed classification includes a stage of
normoglycemia in which persons who have evidence of the pathological processes which
may lead to Diabetes mellitus or in which a reversal of the hyperglycemia has occurred are
classified.

1.2 Etiological classification of Diabetes mellitus

As reported by Zimmet et al (1994), Type 1 Diabetes mellitus indicates the processes

of β cell destruction that may ultimately lead to insulin, required for survival to prevent the
development of Ketoacidosis, coma and death. The rapidly progressive form is commonly
observed in children, but also may occur in adults.

13
 The slowly progressive form generally occurs in adults and is referred as latent
autoimmune diabetes in adults. Some forms of Type 1 Diabetes, which have no known
etiology of idiopathic nature, have permanent insulinopenia and prone to Ketoacidosis as
revealed by Japan and Pitsburg childhood diabetes research groups 1985, but have no
evidence of autoimmunity as reported by McLarthy et al. (1990), which is common among
African and Asian origin as studied by Ahren and Corrigan (1984).

Individual with this form of type 1 Diabetes often becomes dependent on insulin for
survival and are at risk for Ketoacidosis (Willis et al, 1996), with lower undetectable levels
of C – peptide at this level (Hother et al., 1988). The peak incidence of this form occurs in
childhood and adolescence but the onset may occur at any age, ranging from childhood to
ninth decade of life (Molback et al., 1994). There is a genetic predisposition to autoimmune
destruction of beta cells; these patients may also have other autoimmune disorders such as
Grave’s disease, Hashimoto’s thyroiditis and Addison’s disease (Betterlee et al., 1983).

People with the type 2 Diabetes mellitus may range from predominant resistant to
the action of insulin with relative insulin deficiency to a predominant secretary defect with
insulin resistance. This form of diabetes is frequently undiagnosed for many years because
hyperglycemia is often not severe enough to provoke noticeable symptoms of diabetes, as
reported by Mooy et a.l (1995). Nevertheless such patients are at an increased risk of
developing macrovascular and microvascular complications. Campbell and Carlson (1993)
claim that the majority of patients with this form of diabetes are obese, which aggravates
insulin resistance. Many of those, who are not obese, have an increased percentage of body
weight predominantly in the abdominal region (Kissebah, 1982). Ketoacidosis is infrequent in
this type. The risk of developing type 2 Diabetes increases with age, obesity and lack of
physical activity.

Harris et al. (1995) have reported that its frequency varies in different racial/ ethnic
subgroups. This is often associated with strong familial, genetic predisposition (Valley et al,
1997). The International Diabetes Federation (IDF) in 2011 has estimated that 61.3 million people
in India are affected by type 2 diabetes (T2DM) with the epidemic expected to increase
exponentially (IDF Atlas, 2011). An ongoing national study by the Madras Diabetes Research
Foundation has shown similar projections of 62.4 million people with diabetes and an estimated
77.2 million people at a prediabetic stage (Anjana et al., 2011).

1.2.1 Other specific types

1.2.1.1 Genetic defects of β cell function

Several forms of the diabetic state may be associated with monogenic defects in beta
cell function, frequently characterized by the onset of mild hyperglycemia at an early age
14
before 25 years. They are usually inherited in an autosomal dominant pattern. Patients with
these forms of diabetes formerly referred to as Maturity Onset Diabetes of the Young
(MODY) have impaired insulin secretion with minimal or no defect in insulin action.
Yamagata et al. (1996) have studied the most common form, which is associated with
mutation on chromosome 12 in a hepatic nuclear transcription factor referred to as HNF1∞.
Froguel et al. (1992) have reported that a second form is associated with mutation in the
glucokinetic gene on chromosome 7P. Yamagatta et al., (1992) has revealed a third form
which is associated with a mutation in the HNF4∞ gene on chromosome 2oq.

Stoffers et al. (1997) have studied a fourth variant, which has recently been ascribed
to mutation in another transcription factor gene, IPF – 1, which in its homozygous form
leads to total pancreatic agenesis. Point mutations in mitochondrial DNA have been found
to be associated with Diabetes mellitus and deafness (Walker and Turnbull , 1997).

1.2.1.2 Genetic defects in insulin action

There are some unusual causes of diabetes which result from genetically determined
abnormalities of insulin action. The metabolic abnormalities associated with mutations of the
insulin receptor may range from hyperinsulinemia and modest hyperglycemia to symptomatic
diabetes (Taylor, 1992).

Some individuals with these mutations have Acanthosis migricans. Women may have
virilization and have enlarged cystic ovaries. In the past, this syndrome was termed Type A
insulin resistance as studied by Kahn et al. (1976). Taylor (1992) have revealed that
Leprechaunism and Rabson Mendenhall syndrome are the two pediatric syndromes that have
mutations in the insulin receptor gene with subsequent alterations in insulin receptor
function and extreme resistance.

1.2.1.3 Diseases of the exocrine pancreas

Any process that diffusely injures the pancreas can cause diabetes. Acquired processes
include pancreatitis, trauma, infection, pancreatic carcinoma and pancreatectomy (Gullo et
al., 1994). Permert et al (1994) have studied that adenocarcinomas that involve only a
small portion have been associated with diabetes. Moran et al. (1994) have revealed that
cystic fibrosis and haemochromatosis will also damage beta cells and impair insulin
secretion. Yajnick et al (1992) have studied that fibrocalculous pancreatopathy may be
accompanied by abdominal pain radiating to the back and pancreatic calcification on X – ray
and doctor dilatation.

1.2.1.4 Endocrinopathies

15
 Several hormones (eg. growth hormones, cortisol, glucagon, epinephrine) antagonize
insulin action. Disease associated with excess secretion of these hormones can cause
diabetes (e.g.. Acromegaly, Cushing’s syndrome, Glucagothoma) and these forms of
hyperglycemia typically resolve when the hormone excess is removed (MacFarlane, 1997).
Somatostatinoma and aldosteronoma induced hypokalemia can cause diabetes, at least in part
by inhibiting insulin secretion (Krejs et al., 1979).

1.2.1.5 Drug or chemical induced

Many drugs can impair insulin secretion. These drugs may not by themselves cause
diabetes but they may precipitate diabetes in persons with insulin resistance (Pandit et al.,
1993). Assan et al. (1995) have recorded that certain toxins such as VACOR (a rat poison)
and Pentamide can permanently destroy pancreatic β cells. As studied by Yajnik et al. (1992),
many drugs and hormones which can impair insulin action include β agonist, diazoxide,
nicotinic acid, glucocorticoid and thyroid hormones.

1.2.1.6 Infections

Certain viruses have been associated with β cell destruction. Diabetes occurs in some
patients with congenital Rubella (Forrest et al., 1971). King et al. (1983) and Pak et al.
(1988) have implicated Coxsackie B, Cytomegalovirus, Adenovirus, Mumps in inducing the
disease.

1.2.1.7 Specific forms of Immune mediated diabetes mellitus

Diabetes may be associated with several immunological diseases with a pathogenesis

different from that leads to the Type 1 Diabetes process. Post-prandial hyperglycemia of a
severity sufficient to fulfill the criteria for diabetes has been reported in rare individuals
who spontaneously develop insulin auto-antibodies (Bodansky et al., 1986).

These individuals generally present with symptoms of hypoglycemia rather than

hyperglycemia. The stiff man syndrome is an autoimmune disorder of the central nervous
system, characterized by stiffness of the axial muscles with painful spasma. Affected people
usually have high titres of the GAD auto-antibodies and approximately 50% will develop
diabetes (Solimena and Decamilli,1991).

Patients receiving interferon alpha have been reported to develop diabetes associated
with Islet cell antibodies and in certain instances, severe insulin deficiency (Fabris et al.,
1992). Flier (1992) has reported that anti–insulin receptor antibodies can cause diabetes by
binding to the insulin receptor, thereby reducing the binding of insulin to target tissues.
Anti–insulin receptor antibodies are occasionally found in patients with Lupus Erethymatosus
and other auto–immune diseases (Tsokor et al., 1985).
16
1.2.1.8 Other genetic syndromes associated with diabetes

Many genetic syndromes are accompanied by an increased incidence of Diabetes

mellitus. These include the chromosomal abnormalities of Down’s syndrome, Turner’s
syndrome, Wolfram’s syndrome, Klinefelter’s syndrome. These are characterized by Insulin –
deficient Diabetes and the absence of β cells at autopsy (Barret et al.,1995).

1.2.1.9 Circadian based variability

Chronobiologically–interpreted 7-day ABPM uncovered no abnormalities in normoglycemics,

whereas prediabetics had a statistically significantly higher incidence of high mean BP (MESOR-
hypertension), excessive pulse pressure and/or circadian hyper-amplitude-tension (CHAT)
(P<0.001) (Gupta et al., 2008).

1.2.2 Gestational Diabetes mellitus

Gestational diabetes is due to carbohydrate intolerance resulting in hyperglycemia of

variable severity with the onset or first recognition during pregnancy. Women, who become
pregnant and who are known to have Diabetes mellitus which antedates pregnancy, do not
have gestational diabetes but have Diabetes mellitus and pregnancy and should be treated
accordingly before, during and after pregnancy. Elevated fasting or post-prandial plasma
glucose levels during first trimester and first half of second trimester in pregnancy may
well reflect the presence of diabetes which has antedated pregnancy.

Individuals at high risk for gestational diabetes include older women, those with
previous history of glucose intolerance, those with a history of large for gestational age
babies and women from certain high - risk ethnic groups. It may be appropriate to screen
pregnant women belonging to high risk populations during the first trimester of pregnancy,
in order to detect previously undiagnosed Diabetes mellitus. Formal systematic testing for
gestational diabetes is usually done between 24 and 28 weeks of gestation. To determine
the presence of gestational diabetes, if any, in pregnant women, a standard oral glucose
tolerance test should be performed after overnight fasting for 8 – 14 hours by giving 75 g
anhydrous glucose in 250 – 300 ml of water.

1.3 Epidemiology and etiopathogenesis

1.3.1 Risk factors and causes

 Risk factors for developing Type 2 Diabetes peculiar to the Indian population are high
familial aggregation, central obesity, insulin resistance and life style changes due to
urbanization.

 In India, nearly 75% of the Type 2 Diabetes have first degree family history of diabetes
17
 indicating a strong familial aggregation (Ramachandran et al., 2000).

 The epidemic increase in diabetes in India along with various studies on migrant and
native Indians clearly indicate that Indians have an increased predilection to diabetes
which could be due to a greater genetic predisposition to diabetes in Indians. Genetic
susceptibility appears to play an important role in the occurrence of Type 2 Diabetes
(Froguel, 1997).

 Insulin resistance has been demonstrated by Ramachandran et al (2003) to be a

characteristic feature of Asian Indians as compared to Europeans and other ethnic
groups. Asian Indians have shown higher insulin response than others at fasting and in
response to glucose. Asian Indians require higher levels of plasma insulin to maintain
normoglycemia. They also have other features of insulin resistance such as central
obesity and higher percentage of body fat in comparison to many other populations as
reported by Ramachandran et al (2003).

 An analysis of family history in the Type 2 Diabetes parents attending the Diabetes
research centre, Chennai showed that 54% of the pro-bands had a parent with known
diabetes and in an additional 22% siblings had diabetes. The prevalence of diabetes
increased with increasing family history of diabetes. Vishwanathan et al (1996) have
noted that the prevalence of diabetes among offspring with one diabetes present was
36% which increased to 54% with positive family history of diabetes on the non –
diabetic parental side. The prevalence rate (62%) and risk (73%) increased further when
both the parents had diabetes as pointed by Ramachandran et al (1990).

 Asian Indians phenotype, an unique clinical and biochemical characteristic, is considered

to be one of the major factors contributing to the increased predilection towards diabetes
(Joshi, 2003; Deepa et al., 2006).

 Despite having lower prevalence of obesity as defined by body mass index (BMI),
Asian Indians tend to have greater waist circumference and waist with hip ratios thus
having a greater degree of central obesity (Ramachandran et al., 1997).

 Asian Indians have lower levels of protective adipokine, adiponectin and have increased
levels of adipose tissue metabolites (Abate et al., 2004).

 Studies on neonates (Yajnick, 2002; Yajnick et al., 2003) have suggested that Indian
babies are born smaller but relatively fatter compared to Caucasian babies. Krishnaveni
et al (2005) have suggested that the thin fat phenotype in neonates persisted in
childhood and could be a forerunner of the diabetogenic adult phenotype.

18
 Abate et al (2005) have shown that some genes seem to confer increased susceptibility
to diabetes in Indians, while some protective genes in Europeans do not appear to
protect Indians.

 Maturity Onset Diabetes of the Young (MODY), a monogenic form of diabetes is

characterized by an autosomal dominant inheritance, age of onset at 25years or younger,
absence of ketosis and response to oral agents is reported at 2 – 5% of all Type 2
Diabetes (Mohan et al, 1985).

1.3.2 Insulin resistance

 Insulin resistance and beta cell deficiency are the two major pathogenic factors in
diabetes. Defronzo et a.l (1992) have suggested that insulin resistance is the primary
event that leads to abnormalities in glucose metabolism and is present much before the
metabolic abnormalities are manifested.

 Ramachandran et al. (1990) have reported that with both the parents having Type 2
Diabetes the non-obese offspring, who developed diabetes, had higher basal insulin
response compared to those who remained normoglycemic. It was indicated that insulin
resistance may precede the development of hyperglycemia.

 Most important factor contributed to Type 2 Diabetes in Asian Indians is that they have a
greater degree of insulin resistance. (Chandalia et al.,1999; Mishra et al., 2002).

1.3.3. Epidemiological transition

Currently India is undergoing a rapid epidemiological transition with increased

urbanization as recorded by King et al. (1998). The current urbanization rate is 35%
compared to 15% in the 1950’s and this could have major implications on the present and
future disease patterns in India with particular reference to diabetic and coronary heart
diseases (Patandin et al, 1994). Socioeconomic development over the last 40 – 50 years has
resulted in a dramatic change in life style from traditional to modern, leading to physical
inactivity due to technological advancements, affluence leading to consumption of diets rich
in fat, sugar and calories and high level of mental stress (Ramachandran et al,1992). All
these could adversely influence insulin sensitivity and lead to obesity which is studied by
Joshi (2003).

Since 1970, studies were conducted comparing urban and rural populations in India,
which have shown higher prevalence of diabetes among urban residents compared to their
rural counterparts, both in southern and northern parts of India (Sing et al, 1998). In a
study conducted by Ahuja (1979) to assess the effect of urbanization and socioeconomic

19
factors on the prevalence of diabetes in India, a population-based study was taken up in
urban south Indians called Chennai Urban Population Study(CUPS) involving two
residential areas representing the lower and middle income groups involving 1262
participants. 12.4% of the middle income group in Chennai had diabetes against 6.5% in
the lower socioeconomic group which clearly demonstrates that with affluence, there is a
marked increase in the prevalence rate of diabetes even within urban setting. Ramachandran
et al (2002) have confirmed that the prevalence of diabetes in India was lower among those
with a low income than among more affluent groups.

1.3.4 Physical inactivity

Physical inactivity is identified as an independent risk factor, fuelling the epidemic

of Type 2 Diabetes, predominantly in the urban areas (Mishra et al, 2001). One of the
important reasons for the low prevalence of diabetes in Indian rural based population could
be that these individuals have a physically vigorous life style (Mishra and Vikram, 2002), as
migration from rural areas to urban slums in metropolitan cities leads to obesity glucose
intolerance and dyslipidemia. Adaptation of western life style with increasing physical
inactivity could be an important contributor to these factors.

In Fiji, Melanesian and Indian men, the prevalence of diabetes was more than twice
as high in those graded as sedentary or undertaking light activity as in those classified as
performing moderate or heavy exercise (Taylor et al, 1984). In the CUPS participants,
prevalence of diabetes was significantly higher among the subjects with light grade activity
(17%) compared to moderate grade (9.7%) and heavy grade activity (5.6%). The risk of
developing diabetes in the subjects who followed a sedentary life style was three times
higher compared to the more physically active (Mohan et al, 2003).

Over the past a few decades, a large number of working population has shifted from
manual labour associated with the agriculture sector to physically less demanding office
jobs. With the advent of highly addictive computer and video games, sedentarism is now
affecting the children and youth, as they tend to spend more time in front of television
sets or computers than playing outdoors, indicating the effect of physical inactivity on the
prevalence of diabetes and cardiovascular diseases in the CUPS 14 and CUPS 15 conducted
by Mohan et al (2003; 2005).

1.3.5 Obesity

The role of obesity in the pathogenesis of Type 2 Diabetes is complex and is

confounded by many reterogenic factors. As studied by Dhingra et al (2003), the intimate
relationship between diabetes and obesity has given rise to the term diabetes to characterize
the close association of these two disorders. Chan et al (1994) have demonstrated that the
20
relative risk of Type 2 Diabetes increases as body mass index increases in the US
population. In this study, men with a BMI of > or = 35 kg/m square had a multivariate of
42 – 1 for of Type 2 Diabetes compared with men with a BMI < 23.0 Kg/m Square. CUPs
by Mohan et al. (2003) have also revealed that the proportion of obesity was significantly
higher among those with Impaired Glucose Tolerance (diabetes + IGT) compared to those
with normal glucose tolerance 54% versus 23.6% and the similar trend was observed in the
proportion of abdominal obesity (62.2% versus 23.5%). Chandalia et al. (1999) have shown
that for any BMI, immigrant Indians had higher body fat and for any given body fat,
many also had higher insulin resistance compared to other ethnic groups independent of
generalized truncal adiposity. Obesity also shows familial aggregation among Indian
population.

Fall et al (1997) have claimed that the increase in Type 2 Diabetes in Indian
population may be triggered by mild obesity in mothers, leading to glucose intolerance
during pregnancy, macroscopic changes in the foetus and insulin deficiency in adults life.
Central obesity is common among Indians, despite low rate of general obesity and this
android pattern of fat typified by more upper body adiposity measured as waist to hip ratio
was found to be a greater risk factor as compared to general obesity (Ramaiya et al, 1990;
Ramachandran et al., 1992).

Vikran et al. (2003) have concluded that in normal Indians, these were strikingly high
with prevalence of abdominal obesity and generalized obesity as determined by body fat
percentage in Type 2 Diabetes individuals. Sing et al. (1998) have shown that overweight /
obesity and central obesity were significantly associated with diabetes. Kapil et al. (2002)
have reported that among affluent adolescent school children in Delhi, obesity is an
emerging health problem (7.4%) with maximum prevalence found during the pubertal period
(10 – 12 years). McKeigue et al (1991) have reported that in Asian Indians, every 0.04 unit
increase in WHR was associated with four fold rise in diabetes (20% in Asians Vs 5% in
Europeans). Must et al (1992) have reported that central obesity indicates deposition of large
quantities of abdominal fat, which consists of visceral fat and subcutaneous fat increases the
risk of diabetes and hyperlipidemia.

1.3.6 Dietary alterations

In India, as urbanization and economic growth occur, there are major deviations in
the dietary pattern which are influenced by the varied cultural and social customs and
industrialized urban environments due to globalization. The major dietary changes that
urbanization and affluence bring about are substitution of unrefined wheat, rice or millets
by highly polished wheat or rice and increased intake of fat in high income groups
(Gopalan, 2001). In the CUPS study by Mohan et al (2001), the dietary profile of the
21
middle income group showed higher intake of calories, total fat, saturated fat and sugar
compared to low income group substantiating the fact that dietary pattern may be
responsible for higher diabetes prevalence rate among the middle income group than their
lower income group counterparts.

Storloin and Unsitupa (2001) have recorded that a high intake of saturated fatty acids
has been associated with increased risk of developing impaired glucose tolerance and
diabetes and of progression to diabetes from IGT, whereas unsaturated fatty acids, especially
R – 3 poly-unsaturated fatty acids, have been inversely associated with the risk of diabetes.
Storloin and Unsitupa (2001) and McAulay and Williams (2002) have reported that higher
consumption of whole grain products and exchanging fat for saturated fat may reduce the
risk for Type 2 Diabetes and impaired glucose tolerance.

1.4 Physical activities and diabetes

Physical activity can be defined as any form of body movement that results in an
increase in metabolic demand. It encompasses work related tasks, normal daily activities,
leisure – time pursuits, recreational and competitive sports (Casperson et al, 1991). Exercise
may be considered the voluntary component of the overall physical activity performed.
When a program of exercise is performed on a regular basis in order to achieve a goal, it
is referred to as Physical training or exercise training. Most exercise training is performed
for therapeutic purposes (Kriska et al, 1994).

Wallberg and Heniksson (1992) have evidenced that regular exercise helps regulating
carbohydrate metabolism and is beneficial in the management of Type 1 and Type 2
Diabetes. The possible benefits of physical activity for the patient with Type 2 Diabetes are
substantial for the treatment and prevention of its complications. During physical activity,
whole body consumption may increase by as much as 20 fold, and even greater increases
may occur in the working muscles, to meet its energy needs under these circumstances,
skeletal muscle uses at a greatly increased rate, its own stores of glycogen and
triglycerides, as well as free fatty acids derived from the breakdown of adipose tissue,
triglyceride and glucose released from the liver as revealed by Ahlborg et al.(1974).

Exercise plays a critical role in patients with Type 2 Diabetes. It can help to
improve insulin sensitivity and assist with reduction and maintenance of body weight in
obese patients. Exercise together with diet and pharmacologic therapies is important as part
of the overall approach to improving glycemic control and reducing cardiovascular risk
factors (Kiens and Limellin,1989). Exercise often is prescribed as a therapy for Type 2
Diabetes. Many benefits of exercise in these patients include improved long term glycemic
22
control as a result of the decrease in insulin resistance and of the cumulative blood glucose
lowering effects of individual bouts of exercise (Haskell, 1986). Whelton et al (2002) have
noticed that regular exercise has shown to improve lipid abnormalities and lower blood
pressure. Krotkiewski (1979) and Hill et al (1987) have claimed that exercise plays an
important component of weight loss regiments for these patients. When used in combination
with dietary changes (especially with calorie restriction), exercise promotes loss of adipose
tissue with preservation of lean body mass.

Irwin et al (2002) have studied that exercise may promote a beneficial redistribution
of body fat. Abdominal adiposity appears to have a greater impact on insulin resistance
than does fat deposition at other sites, and exercise has recently been shown to decrease
abdominal fat in post – menopausal women.

During exercise, sympathetic nervous system is activated with a resultant increase in

heart rate and constriction of the blood vessels supplying the splanchnic bed, the kidneys
and muscles not involved directly in the exercise. This causes an increase in blood flow to
the tissues most in need – the exercising muscles; also epinephrine and nor- epinephrine play
vital roles in stimulating breakdown of adipose tissue (β adrenergic stimulation) and
suppressing insulin secretion (adrenergic stimulation). Catecholamines are important in
stimulating glyconeogenesis during exercise (Stallknech et al, 2001). Kennedy et al (1999)
have studied that skeletal muscle is able to take up glucose from circulation predominantly
via the GLUT4 transporter protein. During exercise, GLUT4 is translocated from an
intracellular location to the plasma membrane, similar to what occurs with insulin
stimulation (Hayashi et al ,1997).

Roberts et al (1999) have established that nitric oxide is a potential mediator of

contraction induced glucose transport, because generation of nitric oxide increases during
exercise. Although the uptake by muscle after contraction is not affected by inhibition of
nitric oxide synthatase, basal rates of glucose transport in muscle appear to be decreased. It
is possible that nitric oxide modulates a unique pathway that affects glucose transport
independent of either the insulin or the exercise pathway (Higaki et al, 2001). Aronson et
al (1997) have studied nitrogen activated protein (MAP) kinase in the process of exercise
induced glucose transport. The MAP kinase signalling pathway contains several enzyme
cascades that are activated with exercise. In addition to potential effects on glucose uptake,
the MAP kinase pathways likely regulate gene – transcription events that are involved in
muscle growth and repair.

Hayashi et al (1998) have evidenced that 5’ – Adenosine monophosphate activated

protein (AMP) kinase serves as a metabolic “Fuel Gauge” and key regulator of glucose
uptake during exercise. AMP kinase activity increases markedly with exercise.
23
 Kruth et al (1999) have recorded the activators and inhibitors of AMP kinase. This is
casually linked to the translocation of GLUT4 transporters. Sakamoto and Schrffer, (2002)
have claimed fatty acid oxidation and insulin sensitivity may also be affected by exercise
via this pathway. Manson et al (1991) have studied that individuals who maintain a
physically active lifestyle are much less likely to develop Type 2 Diabetes than individuals
who have a very sedentary life style.

Helmrich et al (1991) have found that the protective effect of physical activity was
strongest for individuals at higher risk for Type 2 Diabetes. Reitman et al (1984) have
reported a significant improvement in glucose tolerance and insulin action in Pima Indians
with the recent onset of Type 2 Diabetes who exercise vigorously 5 – 6 days / week for an
average of 8 weeks. Hollaszy et al (1986) found 3 – 4 times / week normalized glucose
tolerance while markedly lowering the plasma insulin response of patients classified as Type
2 Diabetes. Lillosa et al (1987) have found significant correlations between glucose clearance
and muscle capillary density and fibre type in human beings during euglycemic camp.

Cuppers et al (1982) have found that an increase in muscle mass may also help the
insulin resistant state by increasing glucose storage space, as evidenced in weight lifters,
who have lower blood glucose and insulin responses to an oral glucose load than sedentary
age matched control subjects or endurance – trained athletes. Miller et al (1984) have
reported that the decline in the plasma insulin response to an oral glucose load following
several months of weight training was significantly related to an increase in muscle mass
achieved by the subjects.

Boule et al (2001) have recorded that glycocelated hemoglobin (HbA1C) level was
significantly lower in the exercise group than in the control group, indicating that exercise
is beneficial to long term glycemic control. Helmrich et al (1991) and Manson et al (1991)
have established that the beneficial effects of physical activity appears to be independent of
corrections in the risk factors for diabetes, where the incidence of diabetes was reduced by
24% from the highest to the lowest activity group in men at high risk for developing
diabetes (based on obesity, high blood pressure and family history).

Pan et al (1997) have evaluated the effects of exercise and life style modification on
the prevention of Type 2 Diabetes, where 577 Chinese patients with impaired glucose
tolerance were divided into four groups;

 a control group,
 a group tolerated with diet alone,

24
  a group tolerated with exercise alone and
 a group tolerated with both diet and exercise.
Patients received an oral glucose tolerance test every 2 years for a total of 6 years of
follow up. All the treatment groups had a significant drop in the incidence of diabetes
compared with the control group. Interestingly, the group with only exercise as an
intervention had the highest overall reduction in diabetes incidence after adjustment for
baseline blood glucose and body mass index.

Tuomilehto et al (2001) have evaluated patients with impaired glucose tolerance in

Finland, where the subjects were randomly divided into two groups: a treatment group
offered intensive life style changes including diet and exercise, and a non treatment group.
At the end of the study of three years of follow- up, the incidence of diabetes in the
treatment group was reduced by 58%. The risk of reduction was most significant in those
patients who exercised for more than 4 hours per week and in those who had the largest
weight loss.

American college of sports medicine (2000) has recommended that patients with
Type 2 Diabetes older than 35 years should be given an exercise test to screen for
potential underlying asymptomatic coronary artery disease before they begin an exercise
regimen. United States, Department of health and human services, (1996) has recommended
moderate physical activity of 30 minutes on most days of the week for health promotion
and disease, especially in the context of diabetes. It is becoming increasingly clear that the
epidemic of Type 2 Diabetes sweeping the globe is associated with decreasing levels of
activity and an increasing prevalence of obesity. Thus the importance of promoting physical
activity as a vital component of the prevention as well as management of Type 2 Diabetes
must be viewed as a high priority. It must also be recognized that the benefit of physical
activity in improving the metabolic abnormalities of type 2 Diabetes is probably greatest
when it is used early in its progression from insulin resistance to impaired glucose
tolerance to overt hyperglycemia requiring treatment with oral glucose lowering agents and
finally to insulin.

1.5 Impact of physioball exercises in diabetes

Swiss ball has been used in Physiotherapy for neuro-developmental treatment for the
past 40 years (Otterly and Larsen,1996). Klein-Vogelbach (1990a) concept of functional
kinetics based on observing, analyzing and teaching human movement integrates the use of
the ball for functional kinetics and then developed ball exercises. The Swissball has become
an accepted therapeutic tool, not only in Physiotherapy departments but also among personal

25
trainers and those seeking to promote a healthy life. It is no longer a rarity but is readily
available for anyone wishing to explore their multiple uses.

1.5.1 Practical considerations in using Swissball

1.5.1.1 Ball conditions

1.5.1.1.1 Exercise surface

The safest use of the Swiss ball is on a firm, non- slippery mat. To avoid sliding, it
is better either to wear shoes with rubber soles such as tennis shoes or to remain bare
footed. Swissball exercises can also be carried out on a low pile carpet, provided that the
patient and the ball do not slide. Rough carpets and surfaces can cause skin burns and injuries.
Concrete can cause dangerous if the patient falls. For the safest use of the Swiss ball, it is
best to place a firm mat on the floor. Soft mats prevent the ball from rolling easily and
inhibit proper balance and equilibrium reactions due to the compliant surface.

1.5.1.1.2 Cleaning the ball

Small Swiss balls (45 cm diameter) can easily be cleaned in the sink. Water and
anti-bacterial soap are used and a wash cloth is to rinse off the ball and thereafter to dry
it. While using the ball in the hospital, putting it on the floor between exercises should be
avoided. To prevent cross contamination, the same ball should be kept with the same
patient and washed it before use.

1.5.1.1.3 Pressure in the ball

For all balance exercises, the ball must be firmly inflated. This can be done best
with a compressor, for inflating tyres or a small vacuum cleaner with attachments for both
exhaust and suction can be used to inflate and deflate the ball easily and quickly. The
pressure must be greater for heavier patients than for lighter ones.

1.5.1.1.4 Size of the ball

The patient’s size does not determine the size of Swiss ball in use. At the most, it
gives a general idea for the person who wants to sit on the ball.

1. Proportions and body build: It is recommended to look closely at the patient’s

proportions and body build (Klein-Vogelbach, 1990 a, b, c). The ball size must be
selected on the basis of whether the patient has a long trunk and short legs or a short
trunk and long legs (Carriere, 1993,1996). While sitting on the Swissball, a long
legged person requires a larger ball (diameter 65cm or more) than a short legged
one (55cm diameter) or less may be sufficient.

26
 2. Mobility: The therapist must observe whether the patient on a Swiss ball has the
mobility to maintain a neutral spine easily while sitting with hips and knees at an
angle of approximately 90º. In neutral spine, the pelvis, thorax and head are aligned
above one another, as three cubes stacked one on another so as to maintain natural
curves of the spine without difficulty or additional strain of the muscles. The Swiss
ball must be larger if the patient has decreased the range of motion at one or both
hip joints.

3. Reduced mobility: A stiff spine or a spine with segments which show decreased
mobility requires adaptation if the therapist does not have access to a larger ball, a
pillow can be used to be accommodated for the lack of motion, increasing the
diameter of the ball were needed.

4. Lower extremity exercise in supine or prone: For exercise of the lower extremities
when the patient is lying on his back (supine) or his stomach (prone), a smaller ball
(45 or 55 cm) is usually sufficient.

1.5.1.1.5 Safety conditions

Regarding the use of Swiss ball, the patient’s safety should be the therapist’s
primary concern. The physiotherapist must be aware of the patient’s physical condition and
any impairment in judgment or impulsiveness. During the physiotherapist’s initial evaluation
of the patient, it is important to know both the history of the patient’s condition and the
diagnosis provided by the physician in order to protect the patient from any injury.

1. Balance : Static and dynamic balances can be tested first in both sitting and standing
postures with a stable base of support before challenging the patient’s balance on the
Swiss ball. Balance on a hard surface requires somato-sensory feedback and balance
on a non-compliant surface such as a ball depends primarily on vestibular feedback.
In the beginning, the exercise can be performed close to a mat table or in the
parallel bars if a patient tends to lean on one side. The patient’s confidence gets
improved if he knows that he cannot fall. Or else, a second person may be required
to stand behind or next to the patient for support.

2. Body awareness: Patients with decreased sensation on one or both sides of the body
and decreased body awareness need to be watched closely. Mirrors and dots should
be used to increase awareness and enable the patient to carry out the exercises
safely if there are no visual spatial deficits.

1.5.1.1.6 Use of belts

27
 A belt placed around the patient’s waist helps the physiotherapist physically to hold
on to the patient until the patient finds his center of gravity. Initially, the patient can keep
his hands on the ball to decrease its mobility and can place his feet apart when sitting on
the ball to increase the base of support.

1.5.2 Physioball

The Physioball is a double ball which rolls in two directions. When a patient is
learning to use the Swissball, it may be safer to begin with the physioball since it has a
wide base of support and functions similarly to training wheels on a bicycle, providing
increased safety and instilling confidence in patients ability.

1.5.3 Clothes and shoes

It is important to wear proper clothes. Slippery pants or tops are not appropriate as
they can cause the patient to slide off the ball and fall. Over size clothes are also unsafe;
they can become entangled or cause the patient to roll with the ball over his clothes,
resulting in tripping or falling.

1.5.4 Long loose hair

If not tied up, long loose hair can cause the patient to become entangled or roll
over it.

1.5.5 Damaged balls

Signs of damages, such as superficial cuts, can cause the ball to break at any time
and become hazardous. Defective balls should never be used with a patient.

1.5.6 Heat

Swiss balls expand when left in the sun or in a hot car and can burst. If kept in
these environments, they should not be fully inflated so to allow for the hot air to expand.

1.5.7 Over-inflating the ball

Use only the recommended diameter, when inflating the ball, as it otherwise may
burst.

1.5.8 Plugs
28
 For additional safety, some Swiss balls have long plugs which cannot be swallowed
easily by children and are more difficult to remove.

1.5.9 Weight

Most Swissballs can bear at least 200kg weight. Check to be sure of how much
weight can be applied working with a very heavy patient.

1.5.10 Space

Provide space and anticipate some of the difficulties which the patient may have
when using the ball. Remove chairs and tables if necessary, so that patient can maneuver
safely.

1.5.11 Precautions and contraindications

Pain :Pain caused by exercises is a contraindication. The therapist must consider two causes
of pain;-

 The exercise is performed incorrectly

 The exercise is performed correctly but is not appropriate at this time for the patient
(Klein-Vogelbach, 1990c). Careful observation leads to find the cause. The patient
can be instructed to perform the exercise correctly, and pain should thus cease. If
the exercise causes the pain, therapist should understand the cause of pain and
interpret correctly, as whether of musculoskeletal region or results from an injury or
is due to stretching or tightening muscles, Adjustments must be made accordingly as
pain is not a good motivator as no one would want to perform exercises with inflict
pain.

Non- weight bearing or partial weight bearing : A weight–bearing limitation of one

or both lower extremities should prevent treatment in the sitting position as the
patient needs to bear weight on his legs if he loses his balance. However a patient
can exercise in supine position and place the ball under his leg (if there are no
orthopaedic / surgical contra-indications) and perform exercises, enabling him to
move without weight-bearing the weight of the trunk or the extremities.

Amputation:If one or both extremities are amputated, the patient’s balance is greatly
affected, and it may be unsafe to seat the patient on the Swiss ball. However a
patient with an amputated leg wearing a prosthesis may learn to balance his body
while sitting on the ball.

Surgeries: Some surgeries may be a contraindication depending on how the exercise

29
 is performed.

Shunts: When a ventricular – peritoneal shunt is present, there may be a

contraindication which should be checked with the surgeon. In the case of a newly
placed shunt, the patient may need to stay flat in the bed; more often his knee is
be elevated at least 30º during initial days following surgery.

Tubes, Monitors, Lines: Especially in the hospitals, physiotherapists must know

where tubes and lines come from and must interact with physicians regarding the
precautions to be taken. There may be contraindications for certain exercises and
positions. Bending the hip with a femoral line in the groin certainly limits the
degree to which the leg can be bent. A gastrostomy tube may prevent the therapist
from putting the patient prone on the ball.

Respirator: In general, a patient on a respirator can exercise with the Swiss ball;
however the tubes should be watched and exercises should not irritate the patient and
exercises must be selected carefully. Patients on a respirator if haemo-dynamically
stable in interaction with the physician, Swiss ball exercises can be carried out.

Seizures: If a patient with seizures is able to walk around without suffering seizures,
and the color of the ball do not irritate him, he can certainly use the Swiss ball for
exercise. If the therapist knows that certain movements or movement speeds cause
the patient problems, the exercises must be individualized to the patient’s ability.

Decreased balance and body awareness: Although decreased balance and body
awareness of the patient must be considered for safety reasons, such factors are not
a contraindication in general.

Geriatric patients: Use of the Swiss ball may be contraindicated in patients with
advanced osteoporosis. In elderly patients with known osteoporosis it is important to
avoid falls.

Pediatric patients: Children should be always supervised. A child should not be left
alone with a ball that is too large, since the patient may try to mount the ball and
fall.

1.6 Points of observation

Physiotherapist must develop keen observational skills to correct exercises and adapt
equipment to the patient’s need (Klein-Vogelbach, 1990b).

30
1.6.1 Ball floor

While looking at the contact point between ball and floor, the therapist can
determine whether the ball is properly inflated for the patient’s size and weight and for the
exercise intended. The ball moves more easily when there is less contact between ball and
floor; greater inflation reduces the ball’s base of support and more equilibrium is required
than on a soft ball, which increases the area of contact with the floor. For balance with
the Swiss ball, the patient may have only vision and vestibular input.

Physiotherapist can also observe whether the ball rolls in a straight line in the intended
direction.

1.6.2 Ball – body

By observing the contact points between the ball and the body, the therapist is able
to evaluate whether the exercise is being carried out as intended. While sitting on the
Swiss ball and bouncing up and down, the patient must maintain contact with the ball at
all times; otherwise the ball may roll away and cause the patient to fall. Also it is
important to ensure that the patient sits on top of the centres of the ball. Sitting off –
centre changes the movement of the ball since it begins to rotate, when the contact point
is more than 45º off-centre (Klein – Vogelbach, 1990a).

1.6.3 Body – floor

Depending on the exercise, the contact point can remain stationary (in a constant
location). Both the Swiss ball and the patient’s feet remain on the same spot when
bouncing. With other exercises, the contact points between body and floor changes slightly,
for example, when alternately lifting the legs while bouncing with non stationary (location
changing) exercises the contact point between body and floor changes completely. For
proper instruction of exercises, the therapist must know whether this contact point should
change or not. Small feet decrease the amount of contact with the floor and the base of
support as well as the distance which the ball can roll.

1.6.4.Base of support

The base of support (BOS) is determined by the contact which the ball has with the
floor and the contact which the body has with the floor. The BOS is the space between all
the contact points. This includes the feet while sitting on the ball, and is smaller when the
feet are placed closer together than when placed far apart. The patient uses a BOS which
makes him feel safe and able to do the exercise. One can use a larger BOS when
beginning to learn an exercise and decrease it when the patient is familiar with the exercise
and ready to make the exercise more challenging.
31
1.6.5 Bisecting plane

The bisecting plane is an imaginary one which Klein-Vogelbach (1990c) created for
observation (Carriere,1993). While planning and adopting exercises, a vertical plane is
imagined and projected through the centre of gravity of the body. It is over the BOS and
at a right angle to the direction of movement. The bisecting plane divides the body into
two halves and allows the therapist to assess the distribution of body weights. It must be
regarded as though it was a scale with weights on either side. The weights on the side of
the direction of movement act to accelerate, while those on the other side act to decelerate
as a brake. If the lever on one side is too long/ heavy compared to the counterweight, the
patient shortens the lever, substitutes with muscles which are not intended to perform the
work (substituting for weak muscles) or falls.

1.7 Reports on Swissball activity

1. Hinds (2004) have studied the effects of Swiss Ball, during wall squat exercise on lower
limb muscle activity . Electromyographical muscle activity was collected from vastus
medialis,vastus lateralis, rectus femoris, semitendinosus, biceps femoris, internal oblique,
gluteus maximus and gluteus medius.

The addition of the Swiss Ball exercise with wall support resulted in a significant increase
in the muscle activity of the vastus medialis at 60 and 90˚ of knee flexion , vastus lateralis at 60, 90,
110˚ of knee flexion and internal oblique at 90˚ of knee flexion .

2. National Strength and Conditioning Association of United States of America (2004) has
conducted a study to analyze the effect of a short term Swiss ball training on core stability
and economy. It has reported that no significant differences were observed for myoelectric
activity of the abdominal and back muscles, treadmill Vo2max, running economy of running
posture in either group . Thus specificity of exercise selected influences the outcome
following Swiss Ball Exercises.

3. Betul et al (2010) have studied the effects of Swiss Ball core Strength Training on strength,
endurance, flexibility and balance in sedentary women. It provides practical implications
for sedentary individuals who can benefit from core strength training with Swiss Balls.

4. Jerrald (2007) have conducted a study on core muscle activity during exercise on a mini
stability ball compared with abdominal crutanes on the floor and on a Swiss ball. Their
result shows that the work and muscle use during the floor crunches was significantly less
for the key muscle groups for each exercise compared with the Swiss ball bridging
exercises.

32
5. SheriColberg (2010) has recommended for healthy adults of at least 30 minutes of moderate
intensity physical activity, five days per week or 20 minutes of more vigorous activity three
days per week. This type of training can be accomplished using body weights, Swissballs,
resistance bands.

1.7.1 Body distances

Observing body distances and their changes is part of the basic training in functional
kinetics (Klein -Vogelbach, 1990a) and it enables the therapist and the patient to identify and
correct or change the exercise.

The body distance that needs to be observed closely when performing exercises includes:

Sternal notch – chin: with a forward head the distance between sternal notch and the tip of the
chin is longer than in a neutral spine posture (with the pelvis, the trunk and the head aligned).

Symphysis Pubis – Navel, Navel – Xiphoid: Sitting slouched with a posterior tilted pelvis and a
flexed spine shortens these distances. Arching the back lengthens them. Dots can be placed on the
symphysis pubis, navel, xiphoid process, sterna notch, and the chin to facilitate observation (Klein –
Vogelbach, 1990b; Carriere, 1996).

Feet – Knees: Patients with problems aligning their legs may be able to correct the position of the
feet or knees when made aware of the lack of alignment and by observing the correction.

Acromioclavicular joint – Ear lobe: It may be useful to detect an elevated shoulder or substitution
for decreased range of motion of the shoulder.

In addition to giving visual feedback, the therapist can provide tactile cues at these
points of reference, such as by touching or letting the patient feel with his own hands to
correct a faulty posture or alignment.

The advantage of using body distances for instruction and correction lies in the fact
that the patient knows these distances, since they are part of his inborn kinesthetic
awareness; It enables the patient to see and feel what changes are required to do exercises
correctly, and how to improve posture and alignment.

Hinge joint: Physiotherapists most frequently move the distal lever, flexing the knee while
sitting and moving the lower leg, pulling it toward the buttocks. However, the patient could
also sit on a Swiss ball, keeping the heels on the floor, and roll the ball toward the feet.
Clinical situations in which it may be helpful to move a hinged joint from the proximal
lever or pivot point in order to flex the knee include;

When the patient is fearful to move a joint,

33
 When the patient is using evasive movements,

To detect errors and give precise instructions.

Klein–Vogelbach (1990 a,b,c) has described ten possibilities for moving a hinge joint.
If we imagine the knee joint as a fulcrum, the proximal lever is near the trochanter, on the
distal lever, the lateral or medial malleolus.

There are five ways to decrease the amount of movement without moving the
fulcrum and five possibilities for movement of fulcrum for example flexing the knee;

1. The proximal lever P moves towards the distal lever D. this means that the malleolus and the
knee do not move in space while the thigh is flexing at the knee joint.

2. The distal lever D moves toward the lever P. the trochanter and the fulcrum knee remain
stationary in space and the lower leg flexes the knee.

3. The knee does not move while the proximal lever P and distal lever D move toward
each other.

4 & 5. Both levers move in the same direction, but one more than the other.

The five possibilities with movement of the fulcrum are:-

1. The proximal lever P and the fulcrum knee move, and the most distal point of the lever
D remains almost stationary.

2. The distal lever and the fulcrum move, and the point of lever P furthest away from the
joint is almost stationary.

3. Both levers P and D move toward each other, and the fulcrum moves.

4 & 5. These can be observed during a sequence of movement, for example a somersault
forward and back. The two levers move in a circular motion in the same direction, the
fulcrum also moves, and the lever moves more than the other, increasing flexion of the
knee.

1.8 Exercise terminology and muscle activity

1.8.1 Body segment

Klein-Vogelbach (1990 b) has described five following body segments as functional

units;-

Head and neck

34
Arms and shoulder girdle

Thoracic spine

Lumbar spine and pelvis

Legs

In an upright neutral posture the head and neck, the lumbar spine and the pelvis
require potential mobility, while the thoracic spine requires dynamic stabilization. There is
close interdependence of these states of activity. The arms and the shoulder girdles need a
dynamically stable trunk to move freely in an open kinetic chain. The head and neck
require a stable base as well. During walking, the weight – bearing leg is in a closed
kinetic chain requiring dynamic stability, while the other leg is potentially mobile in a open
kinetic chain.

1.8.2 Potential mobility

Standing in a neutral posture with pelvis, trunk and head aligned potential mobility
is the readiness of muscles to adapt to constant changes in positions of the joints in
reactions to changes in equilibrium (Klein-Vogelbach, 1990 a). This readiness must be
greater when the base of support is smaller. Potential mobility requires good mobility of
joints, normal strength of muscles and a stable base.

1.8.3 Dynamic stabilization

Dynamic stabilization is fixation of one or several joints of a body segment or parts

thereof through muscle activity. Dynamic stability is maintained during the movement of
these joints in space and when adding weights (body or free weights). Leaning forward
with a poorly dynamically stabilized spine often results in low back or neck strain. The
potential mobility of the low back and pelvis is lost, and the ability to move and adjust to
changes is decreased. The patient should sit slouched and feel the change of posture and
the decrease in movement in spine. The neck and low back lose their potential mobility.
The dynamic stability is restored when sitting upright, allowing head and trunk to move
freely.

1.8.4 Variations and muscle activity

1.8.4.1 Parking function

In the parking function, muscle activity is low and economical. There is enough
muscular activity to maintain the position of the body without causing any strain. Only the
weight of a body segment or part thereof exerts pressure onto the base of support. It is a

35
closed chain position without co - contraction, for example, of the lower extremity muscles,
when sitting on a Swiss ball or on a chair. A parking position is used to start an exercise,
for example, when sitting in a neutral spine position on a ball, with the legs flexed at 90º
to ankles, knees, and hips. The activity of the quadriceps muscles is low.

1.8.4.2 Supporting function

In the supporting function, muscular activity is high and economical. It is a closed

chain activity with co – contraction of muscles exerting pressure on the base of support.
While sitting on a ball and leaning forward, the pressure under the feet and the activity of
the quadriceps muscle increases. While increasing the pressure over the feet by decreasing
the pressure of the buttocks on the ball, the activity of the quadriceps further increases
because the base of support and the bisecting plane change. Consequently part of the thigh,
pelvis and most of the trunk are weights which must be held by the muscles of the legs,
so that the muscular activity begins distally. The lower leg must be stabilized over the foot
and the thigh on the lower leg. Supporting function is very useful when working on
dynamic stabilization.

1.8.4.3 Free play function

Suspension of an extremity from the body in an open kinetic chain with some
activity directed against gravity is referred to in functional kinetics terms as “free play”.
Muscle activity is predominantly on the upper side of the extremity, preventing its fall. It
is greater when the extremity is extended in a more horizontal position because more body
weights must be held against gravity and it extends from proximal to distal. When the
weight of the suspended extremity is too great, it results in compensatory mechanism for
example leaning the trunk backward while lifting forward the extended arms with eights
(Carriere, 1996). This is an adjustment to the distribution of weight on each side of the
bisecting plane. Walking entails a constant change from closed kinetic chain to free play
function.

1.8.4.4 Bridging activity

Activating the abdominal muscles underneath the bridge against the gravity to
prevent the bridge from sagging is called a “bridging activity”. When lying prone over a
ball, the arms serve as two pillars and the Swissball as the other pillar. The activity of the
muscles of the trunk, especially the abdominal muscles, is increased because the ball is
labile and the activity is more challenging. A quadriceps muscle, able to lift some free
weights concentrically in an open kinetic chain, may have difficulty contracting
concentrically in a bridging activity. Also the size of the bridge and the amount of contact

36
of the pillars with the floor determine how difficult the exercise is, which depends on the
strength and skill of the muscles involved.

1.8.5 Primary movement, action – reaction

Action is the primary movement toward the goal and reaction is the automatic
equilibrium reaction resulting from the action.

It is important to understand these terms when planning exercises because the

therapist must decide whether the corrective exercise should be done consciously, or giving
an instruction which results in an automatic use of the muscles (Klein – Vogelbach,1990
a,b,c, 1991; Carriere, 1993,1996). A quadriceps set (tighten the quadriceps) is a very direct
instruction. A quadriceps activation results when the patient sitting on a Swiss ball upright
move the ball as close as possible to the feet or leaning forward and lifting the buttocks
slightly.

1.8.6 Conditio – Limitatio

The terms Conditio and Limitatio were coined by Klein – Vogelbach (1990 a, b, c;
1991) for the purpose of instruction and analyzing movements. Conditios, which are part of
the actio, are verbal instructions given for the exercises to be carried out as intended. One
or more conditios are necessary depending on the difficulty of the exercise and the
awareness and ability of the patient.

Limitatio is the goal to be achieved by the reaction e.g., stabilizing muscle activity,
limiting the primary movement, achieving the ideal speed of movement.

There are three kinds of conditions;

1. maintaining the body distances. This results in a dynamic stabilization because muscles
must hold the weight of the body parts.

2. concerning relative or absolute fixed spatial points.

3. concerning the speed of movement. The limitation is to achieve the ideal speed, that is
the speed at which the patient can best perform the exercise.

Conditios serve to achieve economical movement and for the patient to perform the
exercises correctly. The limitation is not important for the patient but helps the therapist to
determine what to achieve with the exercise, and to observe whether the exercise is carried
out as intended.

1.9 Role of aerobic exercises in diabetes

37
 After several weeks of endurance training, individuals are generally capable of
exercising at higher workload while maintaining sufficient energy production aerobically.
They are capable of exercising for prolonged periods of time in exercise intensities that had
previously resulted in early fatigue. They also demonstrate an increased ability to oxidize
free fatty acids and to use carbohydrate stores more effectively during exercise. The
adaptations that result in an improved aerobic power and endurance reside both in the
cardio-respiratory system and within the skeletal muscle.

Cardiopulmonary adjustments to exercise includes an increase in oxygen delivery to

the active muscular tissue by the cardiopulmonary system. At the onset of exercise,
pulmonary ventilation and heart rate increase rapidly. The increase in pulmonary ventilation
is due to an increase in both the frequency and depth of breathing . During exercise,
ventilation may be
20 – 25 times greater than at rest. The increase in ventilation is proportional to oxygen
consumption up to 60 – 70% Vo2max. The point of delineation between oxygen consumption
and pulmonary ventilation is referred to as the “ventilator threshold”, which is associated
with the onset of blood lactate accumulation or lactate threshold. The increase in
pulmonary ventilation during exercise provides an increased supply of oxygen to the alveoli
of the lungs, where oxygen diffuses into the circulatory system and binds to the
hemoglobin of the red blood cells. The increase in pulmonary ventilation also results in
increased removal of carbon dioxide from the circulatory system. Generally, hemoglobin is
saturated with 95 – 98% oxygen as it leaves the lungs even during maximal exercise.
Oxygen consumption is not limited by pulmonary ventilation except in the case of lung
disease or under conditions of low atmospheric pressure such as altitude. Highly trained
aerobic athletes actually exceed pulmonary ventilations of 200l/mt.

Dempsey et al (1986) have recorded that hemoglobin oxygen binding is close to

100% at Vo2max before and after training. Cardiovascular adaptation to aerobic exercises
includes an increase in cardiac output to the maximum, which is the product of heart rate
and stroke volume. From a resting cardiac output at 5l/mt with increasing exercise, intensity
increases to 20 – 40 l/mt.

Saltin et al (1980) have reported well trained individuals having resting stroke volume
of 100 – 120 ml and maximal stroke volumes of 160 – 220 ml. Resting heart rate decreases
markedly due to endurance training. Heart rate of sedentary individuals averages between 70
and 80 beats / min. Following aerobic training, heart rate is reduced at the same absolute
sub-maximal work rate. The reduction is proportional to the improvement in aerobic
conditioning.

38
 Willmore and Costill (1988) have claimed that monitoring changes in sub-maximal
exercise heart rate is simple and easy means of monitoring improvement in aerobic
conditioning. The decrease in resting and sub maximal exercise heart rate also indicates that
heart has become more efficient through training, i.e., it requires less energy in the trained
condition for the heart to do the same amount of work. Maximal heart rate shows little
change with aerobic training. With aerobic – type exercise, systolic blood pressure increases
in direct proportion to increased exercise intensity. Systolic blood pressure can exceed 200
mmHg in exhaustion. Conversely diastolic blood pressure decreases slightly during aerobic
exercise. The blood pressure response to the same absolute rate of energy expenditure is
determined by the amount of muscle mass being used (Lewis et al, 1985). After aerobic
training, muscle blood flow per gram muscle is lower than in untrained state.

Armstrong (1991) have recorded that there is actually an increase in blood flow
around the most active muscle fibres. Muscle blood flow is distributed differently among
and within muscles after training so that the active high oxidative fibres receive elevated
blood flow and the inactive low oxidative fibres receive reduced flow. Cellular adaptations
of skeletal muscle with aerobic exercise training is an increase in the number of capillaries
around each muscle fibre. In the untrained state, the number of capillaries around Type 1
fibres averages four per fibre and the number around Type 2 fibres about three per fibre.
With aerobic training, the number of capillaries around each fiber has been noted to
increase by 20 – 30% and parallels the increase in the oxidative capacity of the muscles as
studied by Saltin and Rowell (1986).

Another major morphological change with aerobic training is a shift in fibre type
comparison. In untrained individuals, Type 2b fibres may compose 25 – 35% of the total
Type 2 fibres. With aerobic training of several weeks, there is an obvious decline in the
number of low oxidative Type 2b fibres and an increase in moderate oxidative Type 2a
fibres, suggesting that Type 2b fibres are converted to Type 2a fibres (Saltin et al, 1980).

The conversion of Type 2 fibres to Type 1 fibres by aerobic training has not been
established, but Coyle et al (1991) have established that the percentage of Type 1 fibres is
directly related to the number of years of training. It appears that if aerobic exercise
training can cause the conversion of Type 2 fibres to Type 1 fibres, it occurs over many
years of training.

Seals (1984) have studied older Type 2 diabetic patients with aerobic training on a
regular basis exhibiting a greater glucose tolerance and a lower insulin response to a
glucose challenge than sedentary individuals of similar age and weight. Reitman et al (1984)
have reported a significant improvement in glucose tolerance and insulin action in Pima

39
Indians with recent onset Type 2 Diabetes with aerobic training for 8 weeks of 5 – 6
days / week.

Ostergard et al (2006) have established that aerobic exercises are able to enhance
glycemic control in Type 2 Diabetic patients. Americans Diabetes Association (2002) has
recommended that individuals with Type 2 Diabetes perform at least 150 minutes of
moderate intensity aerobic exercise or at least 90 minutes of vigorous exercise per week.

Eves and Plotnikoft (2006) have recorded that aerobic exercise has consistently been
shown to improve glucose control, enhance insulin sensitivity and reduce cardiovascular risk
factors such as visceral adiposity, lipid profile, arterial stiffness and endothelial function.
Dunston et al (2002) have studied that in many older patients with Type 2 Diabetes, the
presence of diabetic complications or coexisting conditions such as obesity, degenerative
arthritis or cardiovascular disease may preclude participation in aerobic activities.

Banks et al (1992), Brozinick et al (1993) and Hentisksen et al (1990) have

documented the effects of Insulin – stimulated glucose transport. GLUT 4 Protein
concentration is related to the oxidative capacity of the skeletal muscle. Rates of insulin
stimulated glucose transport are related to the GLUT 4 protein concentration of the skeletal
muscle and aerobic exercise training results in a coordinated up regulation of these
variables. Brooks et al. (2004) have stated that at least 60 minutes/day of moderate intensity
aerobic exercises should be under taken for effective management of Type 2 Diabetes.

1.10 Aerobic exercises

1.10.1 Production of energy

Metabolism is the production of energy for work that is ultimately produced by food. Energy
and work cannot be considered separate entities since energy is defined as the capacity to perform
work and work is defined as the application of a force through a distance (ATP) Adenosine Tri
Phosphate is the basic unit of energy and chemically consists of the Adenosine and three Phosphate
groups.

ATP can be broken down and re-synthesized by three different series of reactions within the
body cells. Two series of reaction do not require oxygen and are therefore anaerobic. The third
series of reactions operates only when oxygen is present and is therefore referred to as aerobic
metabolism. The two anaerobic metabolic processes are referred to as the Phosphogen system also
called the Phosphocreatine system and anaerobic glycolysis and the third system, which is aerobic
is known as oxidative phosphorylation (Blair et al ,1988).

40
1.10.2 Phosphogen system

Phosphogen system, where the amount of energy available is, involves activities such as
jumping, kicking, throwing and swimming requiring less than 10 seconds to perform and a
maximum amount of power in a short period, relies heavily on the phosphogen energy system
(Astrand and Rodahl, 1977). This system provides quick energy and is important for explosive
power and speed. It does not, however, provide sufficient energy for endurance activities; of the
three energy systems, the phosphogen system provides the fastest forces of energy in a shortest
duration.

1.11 Anaerobic Glycolysis

After the phosphogen stores are depleted which takes approximately 10 seconds, the body
must produce energy from another source. Anaerobic glycolysis provides the next source of energy.
As with phosphagen system, glycolysis involves the breakdown of glycogen to glucose. Bloomfield
et al (1992) has reported that lactate is produced by anaerobic glycolysis. However as exercise
intensity increases, the muscle fibres cannot function, resulting in muscles burn and eventually
stops the muscle contraction process (Walsh and Banister,, 1998).

Under aerobic conditions, lactate removal is equal to lactate formation. Still, some
concentration of blood lactate level remains relatively stable. Bloomfield et al (1992) have reported
that the exercise involving absolutely maximal rate of anaerobic glycolysis can usually be
maintained for only 30 to 90 seconds. Therefore from a practical stand point, only a small amount
of ATP can be broken down and resynthesized.

The phosphogen system provides explosive power and speed for first 10 seconds of
activities such as 220 or 440 meter run. Anaerobic glycolysis provides energy from 10 seconds to
approximately 3 minutes and is valuable in activities such as Weight lifting, sprint – running,
gymnastic, golf, football, jumping or other activities fasting less than 3 minutes but requiring speed
and explosive power. However, anaerobic sources of metabolism are of limited value when
participating in events such as 3 mile run.

1.11.1 Oxidative phosphorylation (Aerobic system)

Oxygen can provide the energy for muscle contraction as long as the exercise intensity is
low. If the intensity of muscle contraction is high, the body is unable to supply or breakdown
oxygen quickly to provide the immediate energy demands. The oxygen system of metabolism
produces the most efficient source of energy. 180g of glycogen can yield up to 39 moles of ATP
compared with approximately 3 moles yielded from anaerobic sources (Bloomfield et al, 1992).

Aerobic metabolism for energy production is not used for quick energy, but rather for
endurance activities. Energy is released more rapidly during anaerobic glycolysis than during
41
aerobic metabolism. However relatively little ATP is re-synthesized; hence the potential is high for
explosive power of short duration. When using aerobic metabolism for energy production, much
more ATP is available, but it is unable to meet the rapid energy requirements needed in activities
such as jumping, swimming and sprinting. For endurance activities exceeding 2 – 3 minutes,
aerobic metabolism is valuable for the final stage of energy transfer. Lea and Febiger (1991) have
recorded that aerobic metabolism uses oxygen from the air, the aerobic system resynthesizes ATP
leaving no fatiguing by products, and allowing sustained exercise. The carbon dioxide produced
diffused freely from the muscle cells into the blood, where it is carried to the lungs and exhaled the
water produced by the reactions is used on the cellular level and excreted through the pores to cool
the body during exercise.

1.12 Energy substrate use

The breakdown of carbohydrates, proteins and fats requires different amounts of oxygen and
they are eventually oxidized to their end products - carbon dioxide and water. Lea and Febiger
(1991) have recorded that the ratio between the amount of carbon dioxide produced to the amount
of oxygen consumed is the respiratory quotient, which is used to determine the nutrients being used
for energy production.

Carbohydrate is a source of quick energy but fat stores have a higher caloric density and are
a good source of stored energy, primarily because more oxygen is required for their oxidation.
However, less energy is released than when carbohydrates are metabolized. Amino acids in proteins
can also enter the Kreb’s cycle and get oxidized to provide the necessary energy for exercise, but
protein use is extremely low during exercise. Hence this food source is disregarded.

During sub-maximal exercise, both carbohydrates and fats are used to varying degrees,
depending on the demands of the exercise. Although a combination of fats and carbohydrates is
used during prolonged exercise at a steady rate, the percentage of fat use increases. However, as the
exercise intensity increases, more carbohydrates are used in aerobic metabolism. Fat cells
(adipocytes) are the most abundant, which are suppliers of fatty acids, diffuse in the circulation,
where they are metabolized for energy. McArdle et al (1991) have recorded 30% to 80% of the
energy used for biologic work derived from intracellular and extracellular fat molecules depending
on a person’s state of nutrition, exercise intensity level and duration of physical activity.

1.13 Slow twitch and fast twitch muscles

Muscle fibre is considered to be of two major types- red and white. The red fibres contain
increased hemoglobin suitable for increased oxidation and good for endurance exercise. White
fibres are glycolytic fibres, which have high power – producing capabilities but are not good for
endurance activities. Bergston (1962) has pioneered muscle fibre classification using biopsy
techniques to determine muscle fibre types. He classified human skeletal muscle fibres into slow
42
twitch oxidative (type I), fast twitch oxidative glycolytic (Type II a) and fast twitch glycolytic (Type
II b) motor units. Type I motor units are preferred for endurance activities such as walking or
jogging. Type II motor units are used for the strength and power needed in activities such as weight
training and sprinting. Athletes, whose sprints have a preponderance of type II fibres, whereas
endurance athletes typically have a preponderance of type I fibres. Goldnick et al (1981) have
recorded that muscle hypertrophy occurs with exercise training results from the formation of new
increased numbers of muscle fibres.

1.14 Health screening and medical clearance

Before any exercise test, participation or rehabilitation program, a careful evaluation of the
individual is important (Lea and Febiger, 1991). Individuals with medical contraindications to
exercise should be identified and excluded from participation. Persons with clinically significant
disease should be identified and referred for a medically supervised exercise program. Individuals
with disease symptoms and risk factors for disease development should receive further medical
evaluation before starting an exercise program for safe exercise prescription.

American college of sports medicine guidelines for exercise testing and prescription (1991)
has described individuals participating in any exercise program or testing procedure to be
categorized as apparently healthy individuals. This is free from any signs and symptoms suggestive
of cardiopulmonary or metabolic diseases, or from any contraindications to exercise testing. A
medical release should be required before exercise testing, participation or rehabilitation to identify
any contraindications, limitations or precautions.

1.15 Contraindications for exercise testing absolute contraindications

 Recent significant change in resting ECG suggesting infarction

 Uncontrolled ventricular dysrythmia
 Uncontrolled atrial dyrythymia
 Third degree A-V block
 Acute congestive heart failure
 Severe aortic stenosis
 Suspected or knowing dissecting aneurism
 Acute or suspected myocarditis or pericarditis
 Thrombophlebitis
 Recent pulmonary or systemic thrombi
 Acute infection
 Significant emotional distress ( Psychosis)
1.16 Relative contraindication

43
 Resting diastolic blood pressure over 120 mm/Hg or resting systolic blood pressure over 200
mm/Hg
 Moderate valvular heart disease
 Known electrolyte abnormalities (Hypo Kalemia, Hypomagnesemia)
 Fixed – rate pacemaker
 Ventricular aneurism
 Cardiomyopathy
 Uncontrolled metabolic disease (Diabetes, thyrotoxicosis, Myxedema)
 Chronic infectious disease (Hepatitis. AIDS)
 Neuromuscular, Musculoskeletal, or rheumatoid disorders that are exacerbated by exercise
 Advanced or complicated pregnancy. (Lea and Febiger, 1991).

1.17 Guidelines for attaining an aerobic training effect

There is a linear relationship between oxygen uptake and heart rate. When monitoring heart
rate (HR), functional capacity (oxygen uptake) can be estimated because it highly correlates with
energy expenditure. Golding et al (1989) have stated that an exercise workload should elicit an HR
response over 50 % of the hearts maximum rate if it is to have a training effect.

American college of sports medicine in its guideline (1991) for exercise testing and
prescription has listed the following:

1. The activity must use large muscle groups for a prolonged period and must be rhythmic,
as would be seen in jogging, bicycling, walking, swimming, rowing and cross country skiing.

2. The recommended intensity of exercise should be between 55 and 90% of maximum

heart rate. The lower intensity may provide important health benefits to those who have health
problems or are at a low fitness level.

3. Recommended duration of exercise is 15 to 60 min of continuous or discontinuous

aerobic exercise.

4. Recommended frequency of exercise is 3 – 5 days per week. The conditioning effect

allows individuals to increase the total work per session. In continuous exercise this result
occurs by increasing the intensity, duration or some combination of the two.

Hornberger (1993) have advocated that an aerobic exercise program for the adult
population, should be started as follows to avoid strains, sprains or other more serious injuries, each
exercise session should include:

 General warm up (5 minutes)

44
 Stretching (5 - 10 minutes)
 Aerobic warm – up (2- 3 minutes)
 Aerobic exercise (15 - 60 minutes)
 Cool down (2 - 10 minutes)
 Strengthen training, rehabilitation or therapeutic exercise
 Cool down stretching (5 - 30 minutes)

1.17.1 General warm up: Before any type of physical exercise, a warm-up for approximately 5
minutes should be performed with moderate continuous movements using activities such as waling,
slow jogging, or bicycling to increase circulation and prepare muscles for stretching. Stretching
before a warm – up period increases chances of injury.

1.17.2 Pre - exercise stretching: Gently stretching out the muscles using gradual static movements
for approximately 5 to 10 minutes is recommended to prepare muscles and joints for more vigorous
activity and to avoid injuries.

1.17.3 Aerobic warm – up: Many safeguards concerning intensity and progression of exercise
should be closely followed as an intense abrupt. Approach to adult fitness can result in injury,
discouraging future motivation for participation in endurance or other activities, (Cooper and
Cooper, 1998). Hence the initial experience with exercise training should be of low to moderate
intensity and flow to moderate progression that allows for gradual adaptation (Pollock and
Willmore, 1978). Warming up to vigorous activity should include a slow start, approximately 50%
of maximum HR for approximately 2 – 3 minutes (Pollock and Willmore, 1984; Hornberger,
1993).

Cooper and Cooper (1998) have indicated that intensity should then gradually increase to
the target HR for 15 – 60 minutes. Housh and Housh (1997) have reported that as adaptation to
exercise occurs, one should exercise aerobically at light to moderate intensity (55 to 70% of age
adjusted maximum HR), 20 to 30 minutes, 5 days per week for best physiologic and psychological
benefit.

During an exercise session, exercise intensity should be adjusted by monitoring HR or by

perceiving pain (fatigue) levels (Golding et al 1989; Hornberger,1993). If training is for
cardiovascular endurance, loss of body fat, or both it is imperative that an individual may not feel
any pain from muscle fatigue during exercise. If steady state HR is above or below recommended
levels, exercise intensity should be adjusted accordingly, during perceived exertion the individual
should slow down or stop if uncomfortable.

45
1.17.4 Taking HR – Palpation technique : To measure exercise HR, HR count should begin
within 5 seconds after stopping, if using palpation technique, for an accurate exercise HR reading.
The full HR count must be completed within 15 seconds after stopping aerobic exercise to get an
accurate working HR (Pollock and Willmore, 1984) exercise should be performed within a training
HR range for optimal results.

Because it is difficult to count HR while exercise, unless monitored by an HR monitor,

counting pulse range manually requires momentarily stopping in most cases. A pulse beat should be
found at the carotid artery and HR countered within 5 seconds of stopping. The HR count is
completed within 10 seconds, otherwise HR starts to decrease to pre-exercise levels (Lea and
Febiger, 1991; Pollock and Willmore, 1984).

1.17.5 Cooling down: After vigorous activity, it is important to cool down before stopping. It
jogging, the individual should slow down to a slow trot. After vigorous bicycling, the athlete should
slow to one-half to one-quarter speed for a few minutes. This practice gives the body time to
reallocate blood and adjust to pre exercise levels. It may also prevent dizziness, fainting, increased
heart beats, and nausea due to inadequate blood supply to the brain, heart and intestine. This cool
down is especially important in the elderly.

1.18 Strength training, rehabilitation, therapeutic exercise

If any participation in strength training, rehabilitation, orthopaedic exercise is

recommended, it should be implemented after the aerobic phase of exercise performing strength
training but before the aerobic portion of a workout is not recommended due to the increased
peripheral blood flow to the muscles and surrounding surface area. Starting an aerobic workout
after strength, training may result in decreased venous return to the heart. First is especially
recommended for fitness training of the elderly or persons with other health problems, since
decreased venous return is more likely to cause fainting in such individuals.

1.18.1 Cool down stretching

After cooling down, stretching is recommended to help prevent muscle soreness and
tightening and aid in the development and maintenance of muscle and joint flexibility. If a person is
not flexible or tends to have frequent musculoskeletal aches and pains or postural problems, a
stretching and therapeutic exercise program is very important. Stretching should be continued as
long as needed for flexibility.

1.18.2 Rate of exercise progression

Cooper and Cooper (1998) have developed the aerobic point system to quality aerobic and is
based on the FIT formula, where F represents frequency (how often to exercise) I – denotes
intensity (how much exercise to exert) and T – Showing time (how long each aerobic session lasts).
46
 The points earned depend on the type of aerobic exercise and the demands it makes on the
heart and lungs, the duration of activity and the intensity with which it is performed and is a goal –
oriented, motivation program that allows specific points for different activities based on aerobic
development. Pollock and Willmore (1978) have suggested that in healthy people, the exercise
prescription has three levels of progression. The initial level is classified as a starter program (in
which intensity is low) that includes stretching and light calisthenics followed by aerobic exercise
of low to moderate intensity.

1.19 Earlier reports

The first national study on the prevalence of Type 2 Diabetes in India was done
between 1972 and 1975 by the Indian Council of Medical Research (ICMR, New Delhi),
where screening was done in about 35,000 individuals above 14years of age, using 50 g
glucose load capillary blood glucose level > 170mg/dl was used to diagnose diabetes. The
prevalence was 2.1 percent in urban population and 1.5 percent in the rural population
while in those above 40 year of age, the prevalence was 5 percent in urban and 2.8
percent in rural areas (Ahuja, 1979).

A population based study was conducted in six metropolitan cities across India and
recruited 11,216 subjects aged 20 years and above representative of all socioeconomic
strata; an oral glucose tolerance test was done using capillary glucose and diabetes was
defined using the WHO criteria. The study reported that the age standardized prevalence of
Type 2 Diabetes was 12.1 percent. This study also revealed that the prevalence in the
southern part of India to be higher 13.5 percent in Chennai, 12.4 percent in Bangalore and
16.6 percent in Hyderabad; compared to eastern India (Kolkata), 11.7%; northern India
(New Delhi) 11.6%; and western India (Mumbai), 9.3%. the study also suggested that there
was a large poor of subjects with IGT (Impaired Glucose Tolerance) 14% with a high risk
of conversion to Diabetes (Ramachandran et al, 2001).

Study was carried out in 108 centers (49 urban and 59 rural) to look at the urban –
rural differences in the prevalence of Type 2 Diabetes and glucose intolerance. Capillary
blood was used to estimate glucose level and glucose intolerance was defined according to
the WHO 1999 as well as the American Diabetic Association (ADA), 2003 criteria.
According to ADA criteria, the prevalence of diabetes was 4.7% in the urban compared to
the 2% in the rural population while the prevalence of diabetes according to the WHO
criteria was 5.6% and 2.7% among urban and rural areas respectively (Sadikot, 2004).

American college of sports medicine (2000) has recommended that patients with
Type 2 Diabetes older than 35 years should be given an exercise test to screen for
potential underlying asymptomatic coronary artery disease before they begin an exercise

47
regimen. United States, Department of health and human services, (1996) has recommended
that moderate physical activity of 30 minutes on most days of the week for health
promotion and disease, especially in the context of diabetes, it is becoming increasingly
clear that the epidemic of Type 2 diabetes sweeping the globe is associated with decreasing
levels of activity and an increasing prevalence of obesity. Thus the importance of promoting
physical activity as a vital component of the prevention as well as management of Type 2
Diabetes must be viewed as a high priority. It must also be recognized that the benefit of
physical activity in improving the metabolic abnormalities of type 2 diabetes is probably
greatest when it is used early in its progression from insulin resistance to impaired glucose
tolerance to overt hyperglycemia requiring treatment with oral glucose lowering agents and
finally to insulin.

In a study conducted on 63 sedentary subjects of both sexes with a mean age of 78 years
using moderate intensity exercises and aerobic exercises for 16 weeks duration have recorded a
reduction of a mean BMI by 1Kg/m2, 4mmHg decrease in mean diastolic blood pressure, 3cm
decrease in the mean triglycerides, 6mg/dl decrease in mean total cholesterol, 13mg/dl reduction in
mean LDL, 5mg/dl increase in HDL (Raul et al, 2010).

Boule et al. (2001) have conducted among 90 overweight subjects of both sexes with a mean
age of 43 years using diet and aerobic exercises for 12 week period demonstrated a reduction in
mean waist circumference by 2cms, mean BMI by 0.5Kg/m2, a reduction in mean resting heart rate
by 4 beats / minute, a decrease in mean diastolic blood pressure by 9mmHg and a decrease in mean
systolic blood pressure by 12 mmHg.

Duke university in 2004 have demonstrated among sedentary overweight individuals of both
sexes with a mean age of 50 years who have performed 30minutes daily aerobic exercises for 8
months period, have shown a reduction in their mean BMI by 1Kg/m2. Olford university in 2001
using diet and aerobic exercises for 6 months period among normal subjects have recorded a
reduction in their participants mean BMI by 1Kg/m2.

Carmen et al. (2009) has conducted among 62 type II diabetic subjects of both sexes with a
mean age of 55 years with resisted exercises for a duration of 16 weeks and thrice a week, reported
the following findings in their subjects;- a reduction of mean by 1Kg/m2, a decrease of mean waist
circumference of subjects by 2cms, a mean reduction in systolic blood pressure by 7mmHg and a
decrease in the mean diastolic blood pressure by 4mmHg, a decrease in resting mean heart rate by 3
beats / min.

Ekta et al. (2009) have conducted a study among 30 type II diabetic subjects of both sexes
with a mean age of 55 years for 8 weeks, with aerobic exercises (n=10) and resisted exercises
(n=10), and reported the following findings;-

48
 Aerobic exercise group have recorded a mean reduction of their BMI by 0.4Kg/m2, a reduction
in the mean HbA1C by 1.45%, reduction in mean diastolic blood pressure by 3mmHg and a
decrease in mean systolic blood pressure by 5mmHg, a decrease in resting mean heart rate by 3
beats / minute.

 Decrease in mean total cholesterol by 11mg/dl, an increased mean HDL by 2mg/dl.

 Resisted exercise group subjects have recorded a reduction in their mean BMI by 0.3Kg/m2, a
decrease in mean HbA1C by 1.34%, a reduction in mean diastolic blood pressure by 5mmHg
and decrease in systolic blood pressure by 8mmHg, a decrease in resting mean heart rate by 6
beats / minute, a decrease in mean total cholesterol by 25mg/dl, an increased mean HDL by 1
mg/dl, a decrease in the mean triglycerides by 40mg/dl.

Yunkee lee et al (2010) have recorded in a study conducted among 54 obese children of both
sexes for a period of ten weeks duration with a frequency of thrice a week using aerobic exercises
have the following findings:

 A reduction in waist circumference by 2.5 cms, with no change in their body mass index (BMI),
 Mean HDL of the participants reduced by 13 mg/dl,
 Mean HDL has increased by 3 mg/dl,
 A mean reduction in diastolic blood pressure by 2 mmHg and
 A decrease in mean systolic blood pressure by 8 mmHg.
Sigal et al (2007) have studied among type II diabetic mellitus patients for ten weeks
duration on the combined aerobic and resisted exercises, reported a reduction of 0.9% reduction of
HbA1C. Dela et al (1998) have studied the effect of moderate intensity resisted exercises among
type II Diabetes mellitus and recorded a 1% reduction of mean HbA1C.

Cuff et al (2003) have demonstrated using resisted exercises among type II Diabetes a
reduction of mean HbA1C by 1%. Bweir et al (2009) have reported in a 10 weeks duration study
conducted among 20 inactive type II diabetic patients with mean age of 53 years using resisted
exercises thrice a week, a 1.6% reduction in mean diastolic blood pressure by 1mmHg.

In a 26 weeks study among 251 type II diabetic patients of both sexes with a mean age of 55
years with the effects of aerobic exercises, resisted exercises and combined effects of aerobic and
resisted exercises, Ronald et al (2007) have recorded a mean reduction of HbA1C by 0.38% among
aerobic group, 0.43% among resisted exercise group and 0.90% among combined aerobic and
resisted exercise group, with waist circumference a 3cm decrease in aerobic and resisted group and
a 4cm decrease among combined exercise group, 3 mm mean reduction of systolic blood pressure
among aerobic exercise, 5mm decrease with resisted and 2mm decrease with combined group. With

49
diastolic blood pressure a 3mm decrease with aerobic, 2mm decrease in resisted and no change in
combined group.

Loimala et al (2009) have reported the effects of combined aerobic and resisted exercises
among type II Diabetes mellitus, who have shown a mean reduction of HbA1C by 0.6%.
Tokmakidas et al (2004) have studied the combined effects of aerobic and resisted exercises for 10
weeks duration among type II diabetic subjects and found a 0.8% decrease in the mean HbA1C of
their subjects. Cauzza et al (2005) have reported the combined effects of aerobic and resisted
exercises for a 4 month period among type II diabetic subjects a mean reduction by 1.2%. In a
metaanalysis study of 54 studies by Mayoclinic (2004), where 2419 subjects inactive adults of both
sexes have performed aerobic exercises daily for two weeks duration have found results with a
mean reduction of systolic blood pressure by 4mmHg, and a decrease in the mean diastolic blood
pressure by 2.5mmHg.

Machesini et al (2004) have found with aerobic exercise training a decrease in mean
diastolic blood pressure by 5.5mmHg and decrease in mean systolic blood pressure by 5.6mmHg.
Klaus et al (2007) have recorded following resisted exercises among 40 type II diabetic subjects of
both sexes for 12 weeks duration with a frequency of thrice a week, a decrease in the mean diastolic
blood pressure by 5mmHg and a decrease in the mean systolic blood pressure by 9mmHg.

In a meta-analysis study of 54, where 2419 subjects inactive adults of both sexes have
performed aerobic exercises daily for two weeks duration Mayoclinic (2004) have found result
with a mean reduction of systolic blood pressure by 4mmHg, and a decrease in the mean diastolic
blood pressure by 2.5 mmHg. Machesini et al (2004) have found with aerobic exercise training a
decrease in mean diastolic blood pressure by 5.5 mmHg and decrease in mean systolic blood
pressure by 5.6mmHg.

Klaus et al (2007) have recorded following resisted exercises among 40 type II diabetic
subjects of both sexes for 12 weeks duration with a frequency of thrice a week, a decrease in the
mean diastolic blood pressure by 5mmHg and a decrease in the mean systolic blood pressure by
9mm Hg.

1.20 Need and scope of the present investigation

There is a rising prevalence of type II Diabetes in developed and developing countries

(Zimmet, 1991). Mohan et al (2004) have claimed that several of the factors associated with
diabetes are potentially modifiable. This epidemic of diabetes can be curbed, if proper measures are
taken to increase physical activities and reduce obesity rates in adults. Mehta et al (2009) have
pointed out life style changes affecting children in developing countries in the last twenty years.

This study strives to analyze the effects of physical activities namely:

50
 Aerobic exercises
 Exercises using physio ball among type II diabetic male patients between the age group of 30 –
60 years; physical and biochemical parameters help to scientifically establish the impact of
physical activity among diabetic type II individuals.
 The outcome of this study can be included in the comprehensive healthcare management of
diabetic patients.
 Various micro and macrovascular complications arising out of diabetes can be prevented and
postponed along with these exercises.
 With an impact of reducing health care cost at individual level and at national level, this study is
of economical value.
 Quality of life of diabetic patients can be enhanced with physical activities as pointed by this
research
1. 21 Need of the present investigation

Identification of the cause of the disease and possible preventive measures that could
be instituted to arrest or delay the onset of this disease has reached epidemic proportions
in both the developed and the developing nations (Zimmet et al, 1994). Rising prevalence
of Type 2 Diabetes mellitus in India is probably related to improved living conditions and
changing life styles in the urbanized regions, with marked changes in the quality of food
consumed. Transition from natural forms of food to more refined food, less physical
activity and sedentary life style could probably lead to unfavourable adiposity and thus
increasing the risk of developing diabetes (Ramachandran, 1995). Among children teenagers
and adolescents, a rising prevalence of Type 2 Diabetes in Japan, United States of America
and in India are alarming (Fagot et al, 2000; Zimmet et al, 1994). In the past 20 years,
the rates of obesity have tripled in developing countries as they have adopted a western
life style involving decreased physical activity and over consumption of cheap, energy dense
food. Such life style changes are also affecting children in these countries (Mehta et al,
2009).

On an average single diabetic patient in India spends Rs 20,000/- per annum. With
its complexity affecting heart, kidney, nervous system, getting involved the magnitude of
percussion it can have on individual, society and the country is too high an expenditure.
This present study attempts on analyzing the effects of two forms of physical activities
namely

 Aerobic exercises

 Exercises using physio ball among Type 2 Diabetes male patients between the age
group of 30 – 60 years with physical and biochemical parameters getting significant;

51
 scientifically establish the effectiveness of different forms of physical exercises in the
management of Type 2 Diabetic patients.

1.22 Scope of the present investigation

1. This research outcome can be considered to be included in the comprehensive

management of diabetic patients.

2. With the magnitude of present and projected Type 2 Diabetic patients in India,
especially South India, with this study health care cost can be curtailed for the
patient, family and economically most important to the country.

3. With an early onset of Type 2 Diabetes among children, teenagers and adolescents,
physical activities with aerobic exercises and physio ball can be made mandatory at
schools and colleges as a preventive means, as rising obesity is recorded and WHO
has already formed a study group in this regard.

4. Various micro and macrocomplications arising out with diabetes can be prevented
and postponed with these specific forms of exercises scientifically.

5. Quality of life among diabetic patients can be enhanced based on this research.

6. This research gives an insight of aerobic and physioball exercises with duration,
frequency and their influence on obesity, glycemic control, cardiovascular system;
hence long term management of this metabolic disorder along with diet and duly
prescribed medications forms a major tool as promoting health as well prophylactic
nature for vulnerable population.

7. Various habits such as smoking, alcoholism, physical inactivity, sedentary life style
and its association with diabetes as evidenced in this research helps to create
awareness among society with due means

8. This research is innovative of comparing aerobic exercises with physioball exercises,

in that physioball exercises are of indoor nature, less time consuming, highly
metabolic, self manageable nature, hence providing an alternate, efficient form of
physical activity in the management of diabetic patients, can be considered for
inclusion into the diabetes prevention program launched by Government of India in
2006.

1.23 Hypothetical statement

Statement of null hypothesis

1. Aerobic exercises have no influence on glycemic control in type II diabetic patients.

52
2. Aerobic exercises have no impact on obesity among type II diabetic patients.

3. Aerobic exercises have no impact on physical parameters such as heart rate and blood
pressure.

4. Aerobic exercises have no impact on lipid profile among type II diabetic patients.

5. Exercises with physioball have no influence on glycemic control in type II diabetic patients.

6. Exercises with physioball have no impact on physical parameters such as heart rate and
blood pressure.

7. Exercises with physioball have no effect on BMI and waist circumference among type II
diabetic patients.

8. There is no relationship between food habits and type II Diabetes.

9. There exists no relationship between diabetes and hypertension.

10. There is no relationship between smoking, alcoholism and type II Diabetes Mellitus.

11. There is no relationship between family history of diabetes and incidence of developing type
II Diabetes.

12. There exists no relationship between nature of occupation and type II Diabetes.

1.24 Aim and objectives of the present research work

1. To establish the influence of aerobic activities on glycemic control.

2. To study the effectiveness of aerobic exercises on lipid profile.

3. To analyze the role of aerobic exercises on body mass index and waist
circumference.

4. To evaluate the effect of aerobic exercises on heart rate and blood pressure.

5. To find nature of occupation and its role among type 2 diabetic patients.

6. To study the influence of habits such as smoking, alcoholism, eating among Type 2
diabetic patients.

7. To establish family history and age of onset among Type 2 diabetes patients.

8. To find duration of being diabetic and its relationship with heart, eyes, musculo-
skeletal, neurological conditions in type 2 diabetic .

9. To establish the effectiveness of physioball exercises influencing glycemic control in

53
 type 2 diabetic patients.

10. To evaluate the impact of physioball exercises on lipid profile among type 2 diabetic
patients.

11. To study the physical parameters such as BMI, Waist circumference, Heart rate,
Blood pressure among type 2 diabetic patients with using physioball exercises.

12. To analyze the quality of life among type 2 diabetic patients following aerobic
exercises.

13. To analyze the quality of life among type 2 diabetic patients following exercises
with physioball.

54
 2.0 MATERIALS AND METHODS
2.1 MATERIALS
2.1.1 Tools used for physical measurement
2.1.2 Questionnaire
2.1.3 Profile of the study area
2.1.4 Selection of sample
2.1.5 Quality of life questionnaire
2.2 METHODS
2.2.1 Research design
2.2.2 Criteria for inclusion in the study
2.2.3 Criteria for exclusion in the study
2.2.4 Phlebotomy
2.2.5 Biochemical methods of Estimation of Blood Glucose profile
2.2.6 Biochemical methods of Estimation of Lipid profile
2.2.7 Administration of questionnaire and consent form
2.2.8 Evaluation of physical measurement
2.2.9 Allotment of subjects in three groups
2.2.10 Duration of the study
2.2.11 Estimation of Post test physical and biochemical parameters

55
 2.0 MATERIALS AND METHODS

2.0 MATERIALS

2.1.1 Tools used for physical measurement

Heart rate was calculated per minute by palpating at lateral aspect of wrist for radial artery
using padded surfaces of lateral three fingers and a wrist watch with a second hand (Fig 2.1).

An inch tape was used to measure the waist circumference of the subjects at iliac crest level
(Fig 2.2).

Weighing machine in Kg and wall mounted height scale in cm were used to record height
and weight of participants in this research, from which their body mass index (BMI) was calculated.

A sphygmomanometer and a stethoscope were used to record subject’s systolic and diastolic
blood pressures respectively.

Reference values of heart rate in beats/minute

a. 61 - 80/minute: Normal

b. 81 – 90/minute: Mild

c. 91 – 100/minute: Moderate

d. Above 100/minute: Severe

Reference range of body mass index (BMI)

a. 18 – 23: Desirable

b. 24 – 25: Normal

c. 26 – 30: Mild

d. 31 – 40: Moderate

e. Above 40: Severe

Reference values of waist circumference in cm

a. up to 85 cm: Normal

b. 86 – 90 cm: Mild

c. 91 – 99 cm: Moderate

d. Above 100: Severe

56
Reference values of blood pressure in mm/Hg

Systolic

a. < 120 mmHg: Normal

b. 120 – 139 mmHg: Mild

c. 140 – 159: Moderate

e. Above 160: Severe

Diastolic

a. < 80 mmHg: Normal

b. 80 – 89mmHg: Mild

c. 90 – 99mmHg: Moderate

d. > 100mmHg: Severe

2.1.2 QUESTIONNAIRE

All the subjects who participated in this research study were given a printed copy of 14 point
questionnaire containing the following information relevant to Diabetes Mellitus.

 Age of the subjects

a. 30 – 40yrs b. 41 – 50yrs c. 51 - 60yrs

 Family history of Diabetes mellitus

a. Father b. Mother c. Both d. Nil e. Not known

 Duration of being diabetic

a. 1 – 5yrs b. 6 – 10yrs c. 11 – 15yrs d. > 15yrs

 Whether insulin therapy was taken

a. No b. Yes c. Once d. Twice e. More times

 Type of diabetic medications as prescribed by the physician

a. Metformin b. Sulphonylurea c. Metformin+Sulphonylurea d. Oralhypoglycemic agents

 Participants who have diabetic neuropathy

57
 a. Who have b. Who don't have

 Participants who have eye complications

a. Who don’t have b. Cataract c. Glaucoma

 Participants with known heart ailments

a. Who don’t have b. Who have heart ailment

 Participants with musculoskeletal ailments

a. Leg b. Spine c. Arm d. Nil e. All joints f. Leg and arm g. Leg & spine h. Spine &
arm
 Participants food habit

a. Vegetarian b. Non- Vegetarian

 Participants smoking habit
a. Smokers b. Non- smokers
 Participants based on alcohol consumption
a. Alcoholics b. Non- alcoholics
 Participants category based on occupation
a. Desk work b. Sedentary c. Physical activity
 Classification of subjects based on medications
a. Antihypertensive b. Anticholesterol c. Antidepressant d. Anticoagulant
2.1.3 Profile of the study area

This research study was conducted at Pallikaranai, situated at the eastern part of Chennai
corporation, Chennai, India originally known as Madraspatnam, was located in the prince of
Thondaimandalam during 2nd century AD as noted in history.

The existing Chennai revenue district spreads over an area of 178.20sq.km situated on the
north east end of Tamil nadu on the coast of Bay of Bengal, lies 12°9' and 13°9' of the northern
latitude 80°12' and 80°19' of the southern longitude. Chennai is a low lying area and the land
surface is almost flat like a pan cake; with density of 24,231per sq.km, a population of 46,81,087
and Literacy rate of 90.3% (Census of India 2011).

Chennai has acted as an important centre and education in South India. A large number of
institutions like Theosophical Society, Kalakshetra and professional colleges like medical,
veterinary, law and teaching. Chennai port provides trade links with Japan, Singapore, Malaysia,
Ceylon and for eastern countries, it is one of the most important industrial cities of India, while
being a productive capital in revenue, providing huge employment opportunities.

58
2.1.4 Selection of sample

Type II Diabetes mellitus male patients attending Sree Balaji College of Physiotherapy,
Chennai, India, between the age group of 30 and 60 years were selected.

Special diabetic camps were organized by duly advertising in national English newspaper
(The Hindu) of Chennai edition and “Velachery times”. In the camp, type II Diabetes mellitus male
patients between 30 and 60 years were provided a questionnaire (Table 2.1) related to this research
was given. Based on the input recorded only relevant to inclusion criteria, subjects were included
for this study.

2.1.5 Quality of life questionnaire

14 items related to quality of life questions of subjective nature with 7 point scale were given
and get processed from all the participants twice, once in 0 period at the beginning, secondly after
the completion of 12 weeks duration of the study. A 5 subjective questions on 3 point scale related
to overall health, well being including the subjects physical well being, emotional state, stress,
enjoyment of life and quality of life were processed once after completion of study from all
participants, which were duly recorded for analysis using statistical methods.

59
 QUESTIONNAIRE FOR QUALITY OF LIFE

Answer each question below by putting a circle around the number that best represents you at this
time.

S. Mostly Mostly
Terrible Unhappy Mixed Pleased Delighted
No dissatisfied satisfied
1 Your personal 1 2 3 4 5 6 7
life
2 Your 1 2 3 4 5 6 7
wife/husband
or “significant
other”
3 Your romantic 1 2 3 4 5 6 7
life
4 Your job 1 2 3 4 5 6 7
5 Your 1 2 3 4 5 6 7
coworkers
6 The actual 1 2 3 4 5 6 7
work you do
7 The handling 1 2 3 4 5 6 7
of problems in
your life
8 What you are 1 2 3 4 5 6 7
actually
accomplishing
in your life
9 Your physical 1 2 3 4 5 6 7
appearance –
the way you
look to others
10 Your self 1 2 3 4 5 6 7
11 Your ability to 1 2 3 4 5 6 7
adjust to
change in your
life
12 Your life as a 1 2 3 4 5 6 7
whole
13 Overall 1 2 3 4 5 6 7
contentment
with your life
14 The extent to 1 2 3 4 5 6 7
which your life
has been as
60
 S. Mostly Mostly
Terrible Unhappy Mixed Pleased Delighted
No dissatisfied satisfied
you want it

Answer each of the questions with respect to when you first came to this office:

S.No BETTER SAME WORSE

1 Overall my physical wellbeing is 1 2 3

2 Overall my emotional state is 1 2 3

3 Overall my ability to handle stress is 1 2 3

4 Overall my enjoyment of life is 1 2 3

5 Overall my quality of life is 1 2 3

2.2 METHODS

2.2.1 Research design

All the subjects included in the present study have continued their duly prescribed diabetic
medication. Participants allotted in Group I (Control) were not given any physical intervention.
Subjects included in Group II (Experimental-1) were treated with aerobic exercises. Subjects in
Group III (Experimental -2) were treated with Swissball exercises.

2.2.2 Criteria for inclusion in the study

 Male Type II Diabetic mellitus patients

 Between the age group of 30 and 60 years
 Medically diagnosed and on due medication for Diabetes Mellitus.

2.2.3 Criteria for exclusion from the study

 Bed ridden diabetic patients
 Female diabetic patients
 Less than 30 years and more than 60 years of male diabetic patients
 Type I Diabetic mellitus
 Uncontrolled diabetic patients with fluctuating haemogram
2.2.4 Phlebotomy

1. The room used to collect blood should be well ventilated with pleasant surroundings. Best

61
 site of puncture is checked first such as upper arm, which is an ideal site. Palpate for visible
vein.

2. Keep the site as sterile as possible with correct chemical for cleaning depending on the test.
Antiseptic such as 70 % isopropyl alcohol can be used to prevent microbial contamination of
patient and sample such as.

3. Clean the site using a circular motion starting at the center of the site and moving outward in
concentric circles applying enough pressure to remove the surface dirt.

4. Apply a pressure cuff to the upper arm and inflate to between 80-100 mm / Hg to make the
veins more prominent.

5. Insert the needle bevel up and in alignment to vein, blood flow and tape the needle in place.
Insert the needle into the skin at about 15 to 30 degrees angle using a smooth motion
penetrating the skin and vein. Try to feel or hear the popping sound as needle penetrate the
vein.

6. Decrease the pressure of the cuff to between 40-60mm / Hg as soon as blood begins to flow.
Ask the donor to squeeze a small rubber ball.

7. When the level of blood has reached the desired mark, bring the pressure to zero. Seal the
tubing 4-5 inches from the needle with the help of metal clip.

8. Use clean surgical cotton and with firm moderate pressure on top of the puncture site,
quickly and swiftly remove the needle maintaining the pressure. Ask the patient to maintain
the pressure on site.

9. If bleeding continues after 5 minutes, raise the arm of the patient in the air above the heart
level for approximately 3-5 minutes. Instruct the patient to leave the bandage on for at least
15 minutes.

All the subjects included in the study have fasted overnight for 12 hours prior to giving
blood. Blood was drawn by a qualified laboratory technologist using standard and sterile means. All
blood collections were done via vernipuncture in the anticubital vein with subjects in a sitting
position. 10 ml of blood was drawn from every subject at each test session, and was collected in a
vacutainer blood collection tube. Following the blood collection, serum blood samples were
allowed to clot on ice for one hour. The collected samples were labeled and processed for blood
glucose profile and lipid profile. Blood was drawn from each subject twice during the study, once at
0 period and again after 12 weeks completion of the study
(Fig 2.3).

2.2.5 Biochemical methods for estimation of blood glucose profile

62
 For Fasting blood glucose (FBS), Post-prandial blood glucose (PPBS) and Glycoelated
haemoglobin (HbA1C), blood sample of all the subjects (included in this study) were collected
twice, first prior to this study and secondly on completion of the study by qualified laboratory
technologists (Fig 2.4).

Fasting plasma glucose and post- prandial blood sugar were calculated by GOD – POD
method:

Method: Glucose-oxidase and peroxidase(GOD-POD) method

Principle: Glucose oxidase (GOD) and peroxidase (POD) are used a long with chromogen 4-
aminoantipyridine and phenol glucose is oxidized by GOD to give D- gluconic acid and hydrogen
peroxide. Hydrogen peroxidase in the presence of the enzyme POD oxidizes phenol which
combines with 4-aminoantipyridine to give a pink coloured dye and the intensity of the colour
developed is directly proportional to the concentration of the substance. The Aldehyde group of
glucose oxidase gives rise to gluconic acid and hydrogen peroxide. The overall reaction is

Glucose+ H2O+O2 Gluconic acid +H2O2

The hydrogen peroxide is broken down to water and oxygen by peroxidase.

H2O2 Peroxidase H2O+O2

Oxygen reacts with 4- aminophenazone in the presence of phenol pink-coloured compound

and intensity of which can be determined at 540nm [green filter]

O2+4- aminophenazone Pink-coloured compound

Sample: Fluoride plasma or serum collected within 30 minutes of blood collection.

Reagents

1. Buffer- enzymes: This reagent is prepared by mixing following constituents in 100ml of

phosphate buffer, [M/10.PH 7.0]

A. Glucose oxidase [Sigma] : 650 Units

B. Peroxidase [Sigma] : 500 Units
C. 4- aminophenazone : 20mg
D. Sodium azide : 30mg
2. Phenol reagent : 100mg/dl
3. Glucose standard : 100mg/dl
Procedure: Three test tubes are taken and labelled as Blank, Standard and Test. 1ml of glucose
reagent is added to all the 3 tubes. Then 20µl of plasma/serum to the ‘test’ tube is added. 20µl of
glucose standard is added to the standard tube. Finally 1ml of distilled water is added to all the 3
63
tubes. All the tubes are then incubated at room temperature for 15 minutes and read at the optical
density at 540 nm.

I. Normal values of fasting blood sugar (FBS) were as follows( mg/dl);

◦ 70 – 110: Normal
◦ 110 – 130: Good
◦ 131 – 150: Fair
◦ 151 – 170: Poor
◦ > 170: Poor control

II. Normal values of post- prandial blood sugar (PPBS) were as follows( mg/dl);

o < 150mg: Normal

o 151 – 170: Good

o 171 – 190: Fair

o > 190: Poor

III. Glycocelated haemoglobin (HbA1C) was calculated by directionally interfaced fully automated
turbidometry method. Normal values of HbA1C as follows in %:

Method

Particle enhanced immunoturbidimetric test

HbA1c is determined directly without measurement of total hemoglobin.

Principle

Total Hb and HbA1c in hemolyzed blood bind with the same affinity to particles in R1. The
amount of binding is proportional to the relative concentration of both substances in the blood.

Mouse anti-human HbA1c monoclonal antibody (R2) binds to particle bound HbA1c. Goat
anti-mouse IgG polyclonal antibody (R3) interacts with the monoclonal mouse anti-human HbA1c
antibody and agglutination takes place. The measured absorbance is proportional to the HbA1c
bound to particles, which in turn is proportional to the percentage of HbA1c in the sample.

Standardization

The assay is standardized according to the approved IFCC reference method [3]. Calibration
according to DCCT/NGSP is also possible. Corresponding calibrator values are listed in the

64
package insert of the calibrator set TruCal HbA1c liquid.

NGSP and IFCC values show a linear relationship and can therefore be calculated from each
other using the following equation:

HbA1c (IFCCB) = (HbA1c (NGSPA) – 2.15) / 0.0915 HbA1c (NGSPA) = 0.0915 x HbA1c (IFCCB) +
2.15

a:NGSP values in %

b:IFCC values in mmol/mol

IFCC: International Federation of Clinical Chemistry [3,4,9] DCCT: Diabetes Control and
Complications Trial [5]

NGSP: National Glycohemoglobin Standardization Program [6]

Specimen

Whole blood collected with EDTA

Discard contaminated specimens.

Sample preparation:

For sample preparation the DiaSys oneHbA1c Hemolyzing Solution Cat. No 1 4570 99 10 113 is
required.

Sample preparation:
Hemolyzing Solution 1000 µL
Sample / Calibrator / Control 20 µL
Mix and allow to stand for 5 minutes or until complete lysis is apparent .

4 – 6: Normal

6 – 7: Good

7 – 8: Fair

8 – 10: Poor

> 10: Poor control

2.2.6 Biochemical methods for estimation of lipid profile

65
 Total cholesterol, high density lipoprotein (HDL), low density lipoprotein (LDL) and
Triglycerides (TG) of all the participants in this study were estimated whose fasting blood sample
collected by qualified laboratory technologists twice once prior to the study and secondly after
completion of 12 weeks duration of the study, in a sterile and scientific way.

 Total cholesterol was estimated by Cholesterol oxidase – peroxidase method.

Method: Enzymatic method.

Principle: The cholesterol ester hydrolase ester cholester, free cholester is oxidized by the
cholestrol oxidase to cholest-4-en-3 one and hydrogen peroxide. Hydrogen peroxide formed reacts
with 4-amino antipyrine and phenol in the presences of peroxidase to produce a pink coloured
quinoneimine dye. The intensity of the colour produced is proportion to the amount of cholesterol
present in the sample.

Cholesterol esterase

Cholesterol ester +H2O Cholesterol+Fattyacids

Cholesetrol + O2 Cholest-4-en-3 one+ H2O

H2O+4-Aminoantipyrine +Phenol Quinoneimine red dye +H2O

Sample: Serum or heparinised plasma

Reagents

1. Buffer/Enzyme /Cromogen: It contain choleserol hydrogen: 10 unit, cholestrol:15 units and

peroxidase:3500 unit, dissolved in 100ml of phosphate buffer(M/L, Ph 7.0) containing 50mg of
4-aminophenozoneand 30mg sodium azide.

2. Phenol: 30mg/dl in distilled water.

3. Cholesterol standard: 200mg/dl.

Preparation of working reagent: It is prepared fresh by mixing two parts of reagent 1and one part
reagent 2.

Procedure: Three test tubes are taken and labeled as Blank, Standard and Test. 1 ml of working
reagent is added to all the 3 tubes. 1 ml of distilled water is added to all the 3 tubes. 20µl of
standard reagent is added to the ‘standard’ tube. 20µl of serum/ plasma is added to the ‘test’ tube.
All the tubes are kept at room temperature for 15 minutes and read at the optical density of 540 nm
[green filter].

Range of total cholesterol is as follows in mg/dl

66
a. < 200: Normal

b. 200 – 240: Risk

c. > 240: High risk

 High density lipoprotein (HDL) and Low density lipoprotein (LDL) were estimated by
(Polyethylene glycol) method.

Method: Polyethylene glycol 6000.

Principle: Low density lipoprotein (LDL) Very low density lipoprotein (VLDL) are precipitated by
a solution polyethylene glycol 6000 leaving behind the density lipoprotein (HDL).

Sample: Serum.

Reagents: Cholesterol reagent: 1, Cholesterol reagent:2

These two reagents are the same as used in the determination of total choleserol.

Additional reagents

1. Phosphotungstic acid reagent (PTA)

2. Magnesium chloride reagent

3. Cholesterol reagent

Precaution: Do not use lipaemic specimen (cloudy or milky) which will give rise to false elevated
values.

Procedure: Take equal amount of sample and polyethylene glycol, shake well and keep it at room
temperature for 10 minutes. Then centrifuge at 3000 RPM for 15 minutes to obtain a clear
supernatant. Three test tubes are taken and labeled as Blank, Standard and Test. 1 ml of cholesterol
reagent is added to all the 3 tubes. 1 ml of distilled water is added to all the 3 tubes. 100µl of
supernatant from the sample is added to the ‘test’ tube, 100µl cholesterol standard reagent is added
to the ‘standard’ tube. All the tubes are kept at room temperature for few minutes and read at the
optical density of 540 nm (green filter].

Reference range of HDL in mg/dl

 > 55: Normal

 35 – 55: Risk

 < 35: High risk

67
Reference range of LDL in mg/dl

 < 130: Normal

 130 – 160: Risk

 > 160: High risk

 Triglycerides were estimated using (enzymatic calorimetric method)

Method: Enzymatic method

Principle: Early clinical method for determining triglycerides involves chemical hydrolysis of a
solvent extract of the serum lipids. These methods required preliminary removal of interfering
substances like phospholipids. The methods were difficult, slow, provided numerous opportunities
for error. They were not readily automotated. The new enzymatic determinations have the
following advantages:

1. Mono step methods,

2. Complex reaction within 10-15 minutes,

3. Good reproducibility,

4. Application to automated analyses,

5. Linearity up to 6000mg/dl, triglycerides concentration.

Chemical principle of test

Triglyceride + H2O Lipoprotein Glycerol + Fatty acids

Lipase

Glycerol +ATP Glycerol Kinase Glycerol-3-phosphate +ATP

Magnesium
Glycerol-3-phosphate+O2
Glycerol-3-phosphate+O2 Dihydroxy acetone phophate+ H2O2

H2O2+4 Aminoantipyrine + ADPS (N-ethyl N sulphopropy l- n- methoxyaniline)

Peroxidase red quinone + 4H2O, which is proportional to the triglycerides concentration

Sample: Serum or plasma

68
Reagents

1. Buffer/ Enzymes / Chromogen: It contains a) Lipo-protein: 30 units, b) Glycerol Kinase:

10 units, c) glycerol phophate oxidase: 5 units, d) Peroxidase: 5 units, e) glycerol phophate 100ml
of phosphate buffer, pH: 7.2(50 M MOL/L)

2. P–Chlorophenol reagent: 30 mg/dl.

Preparation of working reagent:

It is prepared fresh by mixing two parts of reagent 1 and one part of reagent 2

Procedure: Three test tubes are taken and labeled as Blank, Standard and Test. 1 ml of working
reagent is added to all the 3 tubes. 1 ml of distilled water is added to all the 3 tubes. 20µl of
standard reagent is added to the ‘standard’ tube. 20µl of serum/ plasma is added to the ‘test’ tube.
All the tubes are kept at room temperature for 15 minutes and read at the optical density of 540 nm
[green filter].

Reference ranges of triglycerides in mg/dl

a. < 200: Normal

b. 200 – 400: Risk

c. > 400: High risk

2.2.7 Administration of questionnaire and consent form

Known male Type II diabetic patients under due medication were immediately given the
questionnaire. Any relevant clarification sought while processing it was guided by me. A duly filled
in consent form was obtained from each respondent.

2.2.8 Evaluation of physical measurement

The following were the tools used in this research for physical measurements: Weighing
machine, height scale, wrist watch with seconds arm, inch tape, sphygmomanometer, and
stethoscope.

2.2.8.1 Weighing machine: Weighing machine was used to calculate body weight in kilograms,
where the subject stands erect on the platform provided on the weigh machine; his body weight is
then recorded in kilograms.

2.2.8.2 Height scale: Subject stands erect in normal anatomical position, his height in cm was
recorded. Body weight in kg and the height in cm were used to calculate body mass index
(BMI) of the subject, using the formula.

69
 Body weight (Kg)
Body Mass Index (BMI) =
Height (m2)

Normal body mass index is a simple measure expressing relationship of weight to height
that is correlated with fatness. It is used in epidemiological research and has a moderately high
correlation (rxy = 69) with body density.

The following ratings have been applied to the BMI by the National heart, lung and blood
institute of the National Institute of Health (United States of America 2000). Under weight < 18.5,
Normal 18.5 – 24.9, Ner weight 25.0 – 29.9, Obesity class I 30.0 – 34.9 obesity class II 35.0 – 39.9,
Extreme obesity 40.0+

2.2.8.3 Inch tape: Inch tape is used to measure the subject’s waist circumference included in the
research at iliac crest level in cm. Men with a waist circumference greater than 102cm (40”) are
considered to have increased risk for Type 2 Diabetes Mellitus, hypertension and cardiovascular
diseases by the National heart, lung and blood institute (American College of Sports Medicine
2000). Using an inch tape, waist circumference was measured above the umbilicus and below the
xiphoid process and recorded in cm with 10hours of nil by mouth fasting state.

2.2.8.4 Wrist watch with seconds arm: Wrist watch with seconds arm was used to record heart
rate of the subjects measured in beats per minute. For taking the heart rate, palpitation technique is
used, by using padded surface of index, middle and ring finger. Pulse beat was found at radial artery
(on lower lateral aspect of radius bone just above the wrist joint) with just enough pressure to feel
the heart rate rhythm, the heart rate count being started on a full beat with the first count being zero.
The heart rate is counted for 10 seconds then multiplied by 6 for heart beat per minute.

Normal heart rate per minute is around 70 beats /minute

2.2.8.5 Sphygmomanometer and stethoscope

To measure systolic and diastolic pressures of the participants in this research,

sphygmomanometer and stethoscope were used. Measurement of arterial pressure before, during
and after an exercise is routine. The most common method used is brachial artery auscultation. This
technique requires the use of a stethoscope, a manometer and an inflatable cuff of the appropriate
width and length.

The lower edge of the cuff should be approximately one inch above the ante-cubital fossa on
the frontal aspect of the elbow. The brachial artery courses through a grove formed by the
bifurcation of the triceps and biceps brachii muscles on the medial aspect of the arm. It should be
palpated with the first two fingers at the medial antecubital space, as this is the location for the
70
diaphragm of the head of the stethoscope. Two tubes from the cuff - one connected to a manometer
and the other to a small hand pump provided with valves - communicate with the interior of the
cuff. The pressure within the bag is raised by a few compressions of the hand bulb, until the pulse at
the wrist disappears. The cuff is wrapped strongly around the arm above the elbow, the tails of the
cloth being wound bandage fashion to hold it in position.

Where the air pressure overcomes the blood pressure and occludes the brachial artery of the
arm, the observer listens with a stethoscope placed over the artery in front of the elbow just below
the armlet, while he gradually reduces the pressure by opening the valve close to the bulb. As the air
pressure falls and allows the blood to escape beneath the cuff and fill the artery below, faint tapping
sounds synchronous with the heart beats are heard. The reading of the manometer at which the
sounds are first heard is taken as systolic pressure. The sound becomes progressively louder as the
air pressure is reduced further at a pressure level about 5mm above that may disappear with the
sounds acquiring a soft muffled quality. The manometer reading which occurs indicates the diastolic
pressure.

Normal blood pressure is

Systolic 100 – 140mm/Hg

Diastolic 60 – 90mm/Hg

Systolic pressure Diastolic pressure

Category
mm/Hg mm/Hg
Normal < 120 < 80
Pre – hypertension 120 – 139 80 - 89
Stage 1 140 – 159 90 - 99
Hypertension
Stage 2 > 160 > 100
2.2.9 Allotment of subjects in three groups

All the subjects who were included in the study were allotted at random into Group I, Group
II, Group III respectively.

Group I participants allotted in this group were treated only with duly prescribed medication only,
and physical means were not given.

Group II (Experimental) the subjects allotted in this group were treated with aerobic exercises.

Group III (Experimental) the subjects allotted in this group were treated with specific exercises
using the Swissball (The word Swissball is also referred as Physioball or Stability ball in the
thesis).

71
2.2.9.1 Group I: Group I forms the control group. Subjects included in this group are treated only
with due medication as prescribed by the physician and no physical intervention was applied to
those subjects allotted in this group.

2.2.9.2 Group II: Group II forms the experimental group. Subjects allotted to this group are
instructed for stretching exercises for hip flexors, Gastrocnemius and Hamstrings. Each stretching
has to be performed two times with 5 counts hold period prior and at the end of walking. Wearing
due footwear, these participants are prescribed to walk continuously for 45 min duration everyday
and 5 days per week.

The participants were prescribed aerobic activity followed by stretching and mild warming
up with walking. The intensity of the main part of the walking session started with work heart rate
of 20 minutes per session at 60% of maximal heart rate during 0 – 4 week period, increasing
progressively to 30 minutes per session at 70% of maximal heart rate during 5th to 8th week period
and 40 minutes per session at 80% of maximal heart rate during the period from 9th to 12th week,
with a frequency of 5 days per week up to a period twelve week duration. (This is in line with
American college of sports medicine and American Diabetic Association position statement on Type
II Diabetic patients 2010).

Care was taken for hypoglycemic spells and other physical signs such as palpitations,
giddiness and excessive sweating. They were made to stop walking, and seek due medical attention,
if any, needed.

2.2.9.3 Group III : Group III forms experimental group. Participants of this group have performed
physical activities using physio ball. They are warned not to hold breath while performing activities
using the physio ball and advised to inform of any physical signs such as undue pain, palpitation,
giddiness and excessive sweating, for due medical attention to be taken care of. Subjects allotted in
this group have performed an individually monitored progressive physical activity program with
both lower extremities using the stability ball in the following maneuver (Fig.2.5 to Fig 2.11).

During the period from 0 to 4 weeks, a set of ten exercises with 5 repetitions with no
holding period, using circuit training means was done. Time taken to complete each session was 15
minutes with a frequency of thrice a week.

During the period from 5th – 8th weeks, subjects have performed a set of ten exercises with
10 repetitions with 5 count holding period of each of the ten exercises, using circuit training means,
with a frequency of thrice a week, and the time taken to complete each session was 25 minutes.

During the period from 9th – 12th week, subjects have performed a set of ten count holding
period for each of the ten exercises adapting circuit training means; with a frequency of thrice a

72
week and have taken approximately 35 minutes to complete each session. (As prescribed by ACSM
and ADA (2010) in the management of type II diabetic patients).

2.2.9.3.1 Core mechanism of exercises with stability ball

While each physical activity performed using stability ball elicits a co-contraction of
muscles, Resistance is provided by subjects’ own body weight, along with isotonic muscle
contraction occurring with each activity, when holding of posture, added isometric nature of muscle
contraction happens. As most of these activities are of closed kinematic chain exercises, maximal
recruitment of motor units, enhanced stimulation of mechanoreceptors resulting in improved
balance, coordination, increased muscle strength and agility which are unique
(Fig 2.5 to 2.11).

As used with aerobic exercises major muscle groups of both lower extremities such as
quadriceps femoris, hamstrings, gastrocnemius, gluteus maximus, core anterior abdominal muscles,
posterior lumbar spinal muscles, were mostly recruited during each exercises performed with
stability ball is another salient core concept of this study after 12 weeks completed the study.

2.2.10 Duration of the study

Followed by allotment of subjects to concerned groups, fasting state physical measurements

(Height, weight, waist circumference, heart rate and blood pressure) for all the subjects were
recorded prior to initiation of the research. Biochemical estimation of blood sugar (fasting blood
sugar, post prandial and Glycelated haemoglobin HbA1C) were done and Fasting state lipid profile
(LDL, HDL, Total cholesterol and triglycerides) for all the subjects were estimated duly recorded.

2.2.11 Estimation of Post test physical and biochemical parameters

After application of due intervention in the groups concerned for 12 weeks duration, fasting
state physical parameters, biochemical estimation of blood glucose, lipid profile were estimated and
recorded.

73
Fig. 2.1 Phlebotomy

74
Fig. 2.2 Heart rate measurement and discussion

75
 Fig. 2.3 Waist circumference measurement

Fig. 2.4 Blood sample collected followed by fasting

76
Fig.2.5 Supine – face up position, patient pushes the ball
downwards at the knee level

Fig.2.6 Supine – face up position, patient pushes the ball

downwards at the ankle level towards the knee

77
Fig.2.7 Supine – face up position, patient pushes the ball downwards at the
ankle level

Fig.2.8 Supine – face up position, patient squeezes the ball do at the ankle
level

78
Fig.2.9 Prone– face down position, patient pushes the ball downwards at ankle
level

. Fig.2.10 Prone position – face down position squeezes the ball between the ankles

Fig.2.11 Supine – face up position, patient pushes the ball outwards with feet
fixed on the ball

79
80
 3.0 PILOT STUDY ON LIFE PARAMETERS UNDER AEROBIC AND SWISSBALL EXERCISES
3.1 INTRODUCTION
3.1.1 Glucose intolerance
3.1.2 Aerobic exercises
3.1.3 Slow twitch and fast twitch muscles
3.1.4 Health screening and medical clearance
3.1.5 Hypothetical statements
3.1.6 Aims and objectives of this research work
3.2 MATERIALS AND METHODS
3.3 RESULTS AND DISCUSSION
Hypothesis: 1 to 24

81
 3.0 PILOT STUDY ON LIFE PARAMETERS UNDERAEROBIC AND SWISSBALL EXERCISES

3.1 INTRODUCTION

The long term effects of Diabetes mellitus include progressive development of the specific
complications of retinopathy with potential blindness, nephropathy that may lead to renal failure and /
or neuropathy with the risk of foot ulcers, amputation, Charcot joints and features of autonomic
dysfunction, including sexual dysfunction. People with diabetes are at increased risk of cardiovascular,
peripheral vascular and cerebrovascular diseases. Several pathogenetic processes are involved in the
development of diabetes. These include process which destroys the beta cells of the pancreas with
consequent insulin deficiency, and others that result in resistance to insulin action. The abnormalities of
carbohydrate, fat and protein metabolism are due to deficient action of insulin on target tissues
resulting from insensitivity or lack of insulin.

3.1.1 Glucose intolerance

The first national study on the prevalence of Type 2 Diabetes in India was done between 1972
and 1975 by the Indian Council of Medical Research (ICMR, New Delhi), where screening was done
in about 35,000 individuals above 14years of age, using 50g glucose load capillary blood glucose level
> 170mg/dl was used to diagnose Diabetes. The prevalence was 2.1 percent in urban population and
1.5 percent in the rural population while in those above 40 year of age, the prevalence was 5 percent
in urban and 2.8 percent in rural areas (Ahuja, 1979).

Ramachandran et al (2001) conducted a population based study in six metropolitan cities across
India and recruited 11,216 subjects aged 20 years and above representative of all socioeconomic strata;
an oral glucose tolerance test was done using capillary glucose and diabetes was defined using the
WHO criteria. The study reported that the age standardized prevalence of Type 2 Diabetes was 12.1
percent. This study also revealed that the prevalence in the southern part of India to be higher 13.5
percent in Chennai, 12.4 percent in Bangalore and 16.6 percent in Hyderabad; compared to eastern
India (Kolkata), 11.7%; northern India (New Delhi) 11.6%; and western India (Mumbai), 9.3%. the
study also suggested that there was a large poor of subjects with IGT (impaired glucose tolerance)
14% with a high risk of conversion to diabetes.

Sadikot et al (2004) have reported the burden of diabetes and impaired glucose tolerance in India
using the WHO 1999 criteria that the study was carried out in 108 centers (49 urban and 59 rural) to

82
look at the urban – rural differences in the prevalence of Type 2 Diabetes and glucose intolerance.
Capillary blood was used to estimate glucose levels and glucose intolerance was defined according to
the WHO 1999 as well as the American Diabetic Association (ADA) 2003 criteria. According to ADA
criteria, the prevalence of diabetes was 4.7% in the urban compared to the 2% in the rural population
while the prevalence of Diabetes according to the WHO criteria was 5.6% and 2.7% among urban and
rural areas respectively.

Mohan et al (1986) have also reported on the insulin responses in MODY and the beta cell
response in offspring of MODY, which indicates that insulin resistance was more pronounced in
MODY, compared to classical older onset of Indian Type 2 Diabetes patients.

Hughes et al (1994) have compared the effects of a high carbohydrate (60% carbohydrate and
20% fat) high fiber (25g dietary fiber/1000kcal) diet with and without 3 months of high intensity
(75% maximal heart rate reserve. 50 minute/day, 4 days/week) endurance exercise in older, glucose –
intolerant men and women. Subjects were well fed on during the 3 months of the study and were not
allowed to lose weight. Neither the diet nor the diet plus exercise group improved their glucose
tolerance or insulin – stimulated glucose uptake, suggesting that the high – carbohydrate, high calorie
diet countered the effect of the exercise on insulin action.

3.1.2 Aerobic exercises

Oxygen can provide the energy for muscle contraction as long as the exercise intensity is low. If the
intensity of muscle contraction is high, the body is unable to supply or breakdown oxygen quickly to provide
the immediate energy demands. The oxygen system of metabolism produces the most efficient source of energy.
180g of glycogen can yield up to 39 moles of ATP compared with approximately 3 moles yielded from
anaerobic sources (Bloomfield et al, 1992).

Aerobic breakdown of glycogen:

(C6H12O6)n + 6O2 6CO2 + 6H2O + Energy + 39Pi + 39ADP 39ATP

Anaerobic breakdown of glycogen

(C6H12O6)n 2C3H6O3 + Energy +3Pi + 3ADP 3ATP

83
 Aerobic metabolism for energy production is not used for quick energy, but rather for endurance
activities. Energy is released more rapidly during anaerobic glycolysis than during aerobic metabolism.
However relatively little ATP is re-synthesized; hence the potential is high for explosive power of short
duration. When using aerobic metabolism for energy production, much more ATP is available, but it is unable to
meet the rapid energy requirements needed in activities such as jumping, swimming and sprinting. For
endurance activities exceeding 2 – 3 minutes, aerobic metabolism is valuable for the final stage of energy
transfer. Lea and Febiger (1991) have recorded that aerobic metabolism uses oxygen from the air. The aerobic
system re-synthesizes ATP leaving no fatiguing by products, and allowing sustained exercise. The carbon
dioxide produced diffused freely from the muscle cells into the blood, where it is carried to the lungs and
exhaled the water produced by the reactions is used on the cellular level and excreted through the pores to cool
the body during exercise.

The breakdown of carbohydrates, proteins and fats requires different amounts of oxygen and they are
eventually oxidized to their end products - Carbon dioxide and water. Lea and Febiger (1991) have recorded the
ratio between the amount of carbon dioxide produced to the amount of oxygen consumed is the respiratory
quotient, which is used to determine the nutrients being used for energy production.

Substrate use during exercise

Energy content Oxygen equivalent

Fuel Respiratory quotient
Kcal. g -1 Kcal. L-1
Carbohydrate 4.1 5.0 1.00
Fat 9.3 4.7 0.70
Protein 4.3 4.4 0.80

From American college of sports medicine. Guidelines for exercise testing and prescription by Lea and Febiger
(1991).

Carbohydrate is a source of quick energy but fat stores have a higher caloric density and are a good source of
stored energy, primarily because more oxygen is required for their oxidation. However, less energy is released
than when carbohydrates are metabolized. Amino acids in proteins can also enter the Krebs cycle and get
oxidized to provide the necessary energy for exercise, but protein use is extremely low during exercise. Hence
this food source is disregarded.

During sub-maximal exercise, both carbohydrates and fats are used to varying degrees, depending on the
demands of the exercise. Although a combination of fats and carbohydrates is used during prolonged exercise at

84
a steady rate, the percentage of fat use increases. However, as the exercise intensity increases, more
carbohydrates are used in aerobic metabolism. Fat cells (adipocytes) are the most abundant, which are suppliers
of fatty acids, that diffuse in the circulation, where they are metabolized for energy. McArdle et al (1991) have
recorded that 30% to 80% of the energy used for biologic work derived from intracellular and extracellular fat
molecules depending on a person’s state of nutrition, exercise intensity level and duration of physical activity

Four work / effort areas with performance, times, major energy systems involved and examples of the
type of activity.

S. Performance time Major energy Examples of type of activity

no system involved
1 Less than 30 seconds ATP – PC Shot-put, Golf, 100 yard sprint
2 30 seconds to 1.5 ATP – PC – LA 220 – 440 yard sprints, 100
mins yards swimming, speed
skating
3 1.5 to 3 mins LA and O2 880 yards dash, wristling, (2
min period)
4 More than 3 mins O2 Soccer, Cross country, Skiing,
Jogging, Marathon Run

Exercise HR should not be taken until at least 3 minutes into aerobic exercise session (Astrand and
Rodahl, 1977) by then HR has reached a steady state level, in which energy demands are provided by the
oxygen system of metabolism. HR taken at this time represents a working intensity and determines if exercising
is a training HR zone (Lea and Febiger, 1991). If exercise HR is above the recommended level, exercise
intensity should be decreased. If it is below the recommended level, speeding up to increase exercise intensity is
advised. A good rule of thumb to remember is to slow down if pain occurs. To trigger a training effect, exercise
should continue (with in a training HR range) for the recommended period.

There is rising prevalence of type II Diabetes in developed and developing countries (Zimmet, 1991).
Mohan et al (2005) have claimed that several of the factors associated with diabetes are potentially modifiable.
This epidemic of diabetes can be curbed, if proper measures are taken to increase physical activities and reduce
obesity rates in adults. Mehta et al (2009) have pointed out life style changes affecting children in developing
countries in the last twenty years.
85
3.1.3 Slow twitch and fast twitch muscles

Muscle fiber is considered to be of two major types- red and white. The red fibers contain increased
hemoglobin suitable for increased oxidation and good for endurance exercise. White fibers are glycolytic fibers,
which have high power – producing capabilities but are not good for endurance activities. Bergstrom (1962) has
pioneered muscle fiber classification using biopsy techniques to determine muscle fiber types. He classified
human skeletal muscles fibers into slow twitch oxidative (type I)., fast twitch oxidative glycolytic (Type II
a)and fast twitch glycolytic (Type II b) motor units.

Characteristics of motor units comprising human skeletal muscles

Characteristics Type I Type II A Type II B

Contracting Time Slow Fast Fast
Oxidative capacity High Moderate Low
Myofibrillar ATP activity Low High High
Stored phosphagens Low High High
Glycolytic capacity Low Moderate High
Fatigability Low Low High

From American college of sports medicine guide lines for exercise testing and prescription 4 thed.
Philedelphia, Lea and Febiger, 1991:14 ATPase, adenosine triphosphatase.

Type I motor units are preferred for endurance activities such as walking or jogging. Type II motor units
are used for the strength and power needed in activities such as weight training and sprinting.

Athletes who sprint have a preponderance of type II fibers, where as endurance athletes typically have a
preponderance of type I fibers. Goldnick et al (1981) have recorded that muscle hypertrophy occur with
exercise training results from the formation of new increased numbers of muscle fibers.

Hughes et al (1993) have demonstrated that regularly performed aerobic exercise without weight
loss results in improved glucose tolerance and the rate of insulin stimulated glucose disposal and
increased skeletal muscle GLUT4 levels in older glucose intolerant subjects (mean age 64 ± 2 years).
In this present investigation, a moderate intensity aerobic exercise program was compared with a higher
intensity program. (50 vs 75% maximal heart rate reserve, 55 minutes/day; 4 days/week, for 12
weeks). No differences were noted between subjects on the two programs with respect to glucose
tolerance, insulin sensitivity or muscle GLUT4 levels, proposing that a prescription of moderate aerobic
exercise should be recommended for older men or women with Type 2 Diabetes, since it should

86
ensure better compliance and cause fewer musculoskeletal injuries and cardiovascular complications than
a more intense exercise program.

3.1.4 Health screening and medical clearance

Before any exercise test, participation or rehabilitation program, a careful evaluation of the individual is
important (Lea and Febiger, 1991). Individuals with medical contraindications to exercise should be identified
and excluded from participation. Persons with clinically significant disease should be identified and referred for
a medically supervised exercise program. Individuals with disease symptoms and risk factors for disease
development should receive further medical evaluation before starting an exercise program for safe exercise
prescription.

American college of sports medicine guidelines for exercise testing and prescription(1991) has described
individuals participating in any exercise program or testing procedure to be categorized as apparently healthy
individuals. This is free from any signs and symptoms suggestive of cardiopulmonary or metabolic diseases, or
from any contraindications to exercise testing, if a patient falls into the higher risk or with disease category.

Major symptoms and signs suggestive of cardiopulmonary or metabolic disease pain or discomfort in the
chest or surrounding areas that appears to be ischemic unaccustomed shortness of breath or shortness of breath
with mild exertion as below;

Dizziness or syncope

Orthopnea / Paroxysmal nocturnal dyspnea

Ankle edema

Palpitations of tachycardia

Claudication

Known heart murmur

as stipulated from American college of sports medicine guidelines for exercise testing and prescription. 4 th ed
Philadelphia: Lea and Febiger, (1991)

A medical release should be required before exercise testing, participation or rehabilitation to identify
any contraindications, limitations or precautions.

This study strives to analyze the effects of physical activities namely:

87
 Aerobic exercises

 Exercises using physio ball among type II diabetic male patients between the age group of 30 – 60 years;
physical and biochemical parameters help to scientifically establish the impact of physical activity among
type II diabetic individuals.

 The outcome of this study can be included in the comprehensive healthcare management of diabetic
patients.

 Various micro- and macrovascular complications arising out of diabetes can be prevented and postponed
along with these exercises.

 With an impact of reducing health care cost at individual level and at national level, this study is of
economical value.

 Quality of life of diabetic patients can be enhanced with physical activities as pointed by this research

3.1.5 Hypothetical statements

Statement of null hypothesis

 Aerobic exercises have no influence on glycaemic control in type II diabetic patients.

 Aerobic exercises have no impact on obesity among type II diabetic patients.

 Aerobic exercises have no impact on physical parameters such as heart rate and blood pressure.

 Aerobic exercises have no impact on lipid profile among type II diabetic patients.

 Exercises with physioball have no influence on glycaemic control in type II diabetic patients.

 Exercises with physioball have no impact on physical parameters such as heart rate and blood pressure.

 Exercises with physioball have no effect on BMI and waist circumference among type II diabetic patients.

 There is no relationship between food habits and type II Diabetes.

 There exists no relationship between diabetes and hypertension.

 There is no relationship between smoking, alcoholism and type II Diabetes Mellitus.

 There is no relationship between family history of diabetes and incidence of developing type II diabetes.
88
 There exists no relationship between nature of occupation and type II Diabetes.

3.1.6 Aims and objectives of this research work

 To establish the influence of aerobic exercises on glycemic control.

 To study effect of aerobic exercises on lipid profile.

 To evaluate the role of aerobic exercises on body mass index and waist circumference.

 To analyze the effect of aerobic exercise in heart rate, blood pressure.

 To establish family history, age of onset among type II diabetes patients.

 To find nature of occupation and its role among type II diabetes patients.

 To study physical parameters such as BMI, waist circumference, heart rate and blood pressure, with using
physioball exercises.

 To evaluate glycemic control and lipid profile after using physio ball exercises.

89
Table 1: List of countries with the highest number of estimated cases of diabetes for 2000 and
2030 (King et al 1998).

Year – 2000 Year – 2030

People with
S.No People with diabetes
Countries Countries diabetes
(millions)
(millions)
1 India 31.7 India 79.4
2 China 20.8 China 42.3
3 US 17.7 US 30.3
4 Indonesia 8.4 Indonesia 21.3
5 Japan 6.8 Japan 13.9
6 Pakistan 5.2 Pakistan 11.3
7 Russian Federation 4.6 Russian Federation 11.1
8 Brazil 4.6 Brazil 8.9
9 Italy 4.3 Italy 7.8
10 Bangladesh 3.2 Bangladesh 6.7

Table 2: Age – adjusted prevalence of diabetes and Impaired Glucose Tolerance (IGT) among the
urban and rural populations in India (Ramachandran et al 1992).

Prevalence %
Urban Diabetes IGT Rural Diabetes IGT
Men 457 8.4 8.8 520 2.6 8.7
Women 443 7.9 8.3 518 1.6 6.4
Total 900 8.2 8.7 1038 2.4 7.8

IGT – Impaired glucose tolerance

90
Table 3: Prevalence of Diabetes in urban India
Year Author Place Prevalence %
1972 Ahuja et al 1979 ICMR multi centre 2.1%
study
1988 Ramachandran et al 1988 Kudremukh 5%
2000 Raman kutty et al 2000 Thiruvananthapuram 12.4%
2001 Iyer et al 2001 Dombivilli 7.5%
2001 Misra et al 2001 New Delhi 10.3%
2001 Mohan et al 2001 Chennai 12%
2001 Ramachandran et al 2001 National urban diabetes 12.1%
survey
2002 Gupta et al 2003 Jaipur 12.7%

Table 4: Prevalence of cardiovascular risk factors in urban Indians Age >40yrs (Ramachandran
et al., 1997)

Prevalence in %
Combination
Total Isolated
+1 +2
Glucose intolerance 39.1 0.29 3.7 1.5
Increased 2 hour insulin 55.1 0.77 2.9 1
Dyslipidemia 50.8 0.65 2.4 1.3
Obesity 27.0 0.44 4 1.7
Central obesity (Increased waist hip 61.0 0.83 2.5 1.2
ratio)
Hypertension 21.8 1.5 3.8 1.4

Table 5: Estimated prevalence of Diabetes in urban south Indians (Ramachandran et al., 2001)

Year Prevalence of diabetes in urban south Indians in %

1983 5
1988 8.2
1995 11.6
2000 14.8
2005 17.4

3.2 MATERIALS AND METHODS

91
 The Pilot study was conducted with a sample size of 30 male diabetic patients in the age group of 31-60
years. They were administered questionnaire related to diabetes. After obtaining due consent from them,
physical and biochemical parameters were taken and duly recorded.

The subjects were then allotted at random in three groups. The participants continued physical activity
allotted to the group. After 12 weeks of performance, physical and biochemical parameters were taken, recorded
and tabulated. Results prior to the study and at the end of the study were tabulated, analyzed and discussed as
below.

92
 3.3 RESULTS AND DISCUSSION

Data in Tables 3.1 and Fig. 3.1 show respondents sample distribution based on their age.

 6% of the participants were between the age group of 31 – 40 years.

 47% of the subjects were between the age group of 41 – 50 years.

 47% of the participants were among the age group between 51 – 60 years.

 International Diabetes Federation in 2000 has recorded (Table 3.2).

Chennai urban population study conducted by Mohan et al (2006) shows that 10.2% of diabetic population in
Chennai are between the age group of 20 – 40 years.

20.4% Chennai based Diabetic population are between the age group of 40 – 49 years while 29.7% of
Chennai Diabetic population are between the age group of 50 – 59 years.

Data on Table 3.3 and Fig. 3.2 display family history of diabetes among participants.

 7% of the participants have unknown family H/o diabetes

 20% of the subjects (Father) are diabetic.

 20% of the subject (Mother) are diabetic.

 33% of the participants (Father and Mother) are diabetic.

 Hence 73% of the participants have family H/O diabetes in this study.

Ramachandran et al (2000) have reported in India that 75% of the type 2 Diabetes have first degree
family H/o diabetes and in this study 73% of the participants have known first degree family H/O diabetes.

Data on Table 3.4 and Fig. 3.3 display duration of being diabetic patients by the participants.

 53% of the subjects are diabetic patients from 1 – 5 years.

 43% of the subjects are known diabetic patients from 6 – 10 years.

93
  4% of the subjects are known diabetic patients from 11 – 15 years.

Data on Table 3.5 and Fig. 3.4 show whether insulin therapy was administered for subjects.

13% of the subjects have taken Insulin therapy twice for control of blood glucose.

87% of the participants have not been given Insulin therapy in their lifetime so far.

Data on Table 3.6 and Fig. 3.5 display type of diabetic medication in the subjects taken as prescribed by
physicians.

o 43% of the subjects are on Metformin.

o 30% of the subjects are on Sulphonyl urea.

o 17% of the subjects are on oral hypoglycemic agents.

o 10% of the subjects are on Metformin and Sulphonyl urea.

Data on Table 3.7 and Fig. 3.6 display participants distribution based on neuropathy.

o 7% of the subjects have neuropathy.

 II.93% of the subjects don’t have developed neuropathy

Result on Table 3.8 and Fig. 3.7 show participants distribution with known eye complications

 7% of the participants have cataract.

 3% of the participants have Glaucoma.

 90% of the subjects don’t have known eye complications.

Rema et al (2005) have recorded diabetic retinopathy at 17.6% among known diabetic population at Chennai.

Results on Table 3.9 and Fig. 3.8 display subjects distribution based on known heart ailments.

47% of the subjects have known heart ailment.

53% of the subjects don’t have any known heart ailment.

Mohan et al (2005) have recorded 35% diabetic patients to have coronary artery disease.

94
Data on Table 3.10 and Fig. 3.9 display sample distribution based on Hypertension.

33% of the subjects are Hypertensive and on medication.

67% of the subjects are normotensive.

In non communicable diseases, camp analysis conducted in rural Tamil Nadu in 2011 have revealed (covering
21 lakh people who have attended) 46,132 people report prevalence of Hypertension at 14.8%, Diabetes at
13.5% and 8.4% with both Diabetes and Hypertension (Thanikachalam, 2011).

Data on Table 3.11 and Fig. 3.10 show the composition of subjects with musculoskeletal complications. Data
reveal that

▪ People with complications in the leg are the highest with 33%

▪ Those with spine complications are only 7%

▪ People without any complications also exist with a percentage of 23%

▪ Interestingly those with complications in all joints are 27%, which is the second highest in the
present study.

Result on Table 3.12 and Fig. 3.11shows distribution of participants based on their food habits.

 53% of the subjects are non-vegetarians and 47% are vegetarians.

Result on Table 3.13 and Fig. 3.12 shows sample distribution based on alcohol consumption.

While 47% of the subjects are alcoholics, 53% of the subjects are non-alcoholics.

Table 3.14 and Fig. 3.13 display sample distribution based on smoking.

30% of the subjects are smokers and 70% of the subjects are non-smokers.

Chennai Cancer registry from the period of 1982 – 2006 have recorded 89,357 patients with cancer, where
tobacco related cancers accounted for 40 – 45% of all cancers in men and 15 – 20% of all cancers in women in
the study group (Cancer institute, 2011).

Table 3.15 displays the participants’ nature of occupation.

47% of the subjects have occupation of Desk work nature.

95
23% of the subjects have physical activity involved in their occupation.

Mohan et al (2003; 2005) have reported that in the Chennai Urban population study, prevalence of
diabetes was significantly higher among the subjects with light grade activity (17%) compared to moderate
grade (9.7%) and heavy grade activity (5.6%).

Bureau of statistics publication on Australian Social trends (2011) have recorded 55% of the population
suffering from mental stress because of their occupation and 20% suffering from depression resulting from their
occupation.

MV Diabetes research center in 2011 has reported urban life styles, wrong diet and sedentary habits
pushing up the prevalence of diabetes to 21.7% among 2000 normal subjects and risk of overweight persons
with a prevalence of 45.4% and 60% among obese individuals (Mohan, 2010).

Table 3.16 depicts data on sample distribution based on their medication other than for diabetic. It shows
that the highest percentage of 33% is for medication against hypertension than that of cholesterol and
depression. It is interesting to note that 20% of population does not take any medication.

Data obtained in the entire pilot study on various biochemical and physical parameters were subjected to
statistical analysis and the statistical treatments were tabulated (Tables 3.17 to 3.34).

Hypothesis: 1

Statement of null hypothesis

Aerobic exercises have no effect on Body mass index. Body mass index of participants in Group I and
Group II were recorded (pre test). Group II were advocated Aerobic exercises for 12 weeks period while Group
I were given no specific activity, after which their body mass index was calculated and recorded (post test).The
values were then tabulated and the statistical analysis of paired 't' test was applied. 't' value obtained was 3.75,
which is statistically significant at P < 0.01 level. Hence while rejecting null hypothesis, the alternate hypothesis
was accepted i.e.., body mass index reduces following aerobic exercises (Table 3.17 and Fig.3.16).

A Duke university study of sedentary, overweight men and women (aged 40 – 65 years) showed that
they have lost body fat and weight when they walked 30 minutes a day during an 8 month study without
changing their diet. A control group of all non-exercisers gained weight and fat during the eight month study.

Results indicate that

96
 Walking 30 minutes a day: Loss of 1% of body weight, lost 2% of body fat and gained 7% lean muscle.

Non – exercise control group: Gained 1.1% weight, gained 0.5% body fat as published in January 2004.

Another previous study (2003) in the literature has demonstrated that low intensity walking combined
with weight loss could specifically reduce mid-thigh fat while improving glucose metabolism as lipid metabolic
factors for cardio-vascular disease.

24 obese women aged around 58 years, did low intensity walking 3 days per week, at the end of the
study, the women's body weight and BMI had decreased by an average of 8% and the walking intervention
produced an overall 8% increase in aerobic capacity. There was a significant 4% decrease in the circumference
of the mid-thigh which when assessed using a CT scan, showed a 16% decrease in fat and a 7% increase in
muscle.

Hypothesis : 2

Statement of null hypothesis

Exercise using physio ball has no effect on body mass index among type II diabetic patients.

Body mass index of subjects allotted in group III were calculated and recorded (pre test). After having
done exercises for 12 weeks, body mass index of men was calculated and recorded (post test). Values of body
mass index obtained before and after exercises were tabulated and using statistical means paired ’t’ test was
applied (Table 3.18 and Fig. 3.17).

Bweir et al (2009) have conducted a study to analyze the effects of resisted exercises on weight loss, that
has included 19 obese subjects between age group of 35 year men, following resistance training their mean
body weight has decreased from 102 to 99 kg. In this study, mean BMI has decreased from 26 to 25.

Hypothesis : 3

Statement of null hypothesis

Aerobic exercises have no effect on waist circumference among male type II diabetic patients. Waist
circumference of subjects’ allotted in group II was measured and recorded (pre test). After having performed
aerobic exercises for 12 weeks, their waist circumference was measured and recorded (post test). Waist
circumferences measured before and after aerobic exercises were tabulated and were analyzed by statistical
means of applying paired 't' test.

97
 Calculated’t’ value is greater than the table value indicating that the study is statistically significant at P <
0.1. Hence, the alternate hypothesis is accepted that aerobic exercises have statistically effective on influencing
the waist circumference.

54 obese children (45 male, 9 female) aged 12 – 14 years participated in the study. Having divided into
two groups, one control and the other continued aerobic exercises for 10 weeks, waist circumference 82.34 +
8.18 cm vs 79.63 + 7.73 cm in aerobic exercises group and systolic blood pressure 124.25 + 12.11 mmHg vs
116.53 + 10.99mmHg, LDL-c decreased (116.07 + 28.08mg/dl vs. 103.73 + 27.48 mg/dl were noted. In this
study waist circumference following aerobic exercises has decreased in the group II from a mean of 92 to 90
cm, whereas in the control group, waist circumference mean has increased from 94 to 95 cm. (Table 3.19 and
Fig. 3.18).

Hypothesis : 4

Statement of null hypothesis

Exercise with physio ball has no effect on waist circumference among diabetic patients.

Waist circumference of the subjects allotted in group III was measured and recorded before the exercises
(pre test). After having done exercises for 12 weeks, waist circumference was measured and recorded for the
same subjects. Both the values of before and after exercises was tabulated and analyzed using due statistical
means. As observed, 't' value obtained is greater than the table value showing that this study is statistically
significant at P < 0.001.

Hence while rejecting the null hypothesis exercises using physio ball help to reduce waist circumference
among type II diabetic patients was accepted as the alternate hypothesis and conducted a randomized controlled
trial of resistance exercise training to improve glycemic control in older adults with type II diabetes where 62
Latino older adults (40 women and 20 men) with mean age of 66 + 8 years were assigned in a control group and
other group continued supervised progressive resistance exercises for 16 week period; 3 times per week. Results
have shown reduced plasma glycosylated hemoglobin levels (from 8.7 + 0.3 to 7.6 + 0.2 %) control group
showed no change; Progressive resistance training subjects showed decreased trunk fat mass (-0.7 + 0.1 vs _ 0.8
+ 0.1 kg) and reduced systolic blood pressure (-9.7 + 1.6 vs 7.7 + 1.9mmHg) (Table .3.20 and Fig. 3.19).

In this study, waist circumference mean in group III has reduced from a mean value of 94 to 90.

Hypothesis : 5

Statement of null hypothesis

98
 Aerobic exercises have no effect on heart rate among diabetic patients.

Resting heart rate of the subjects allotted in group II are palpated and recorded (pre test) after having
performed aerobic exercises for 12 weeks, their heart rate is palpated and recorded (post test). Heart rate
values before and after the test are tabulated and analyzed using due statistical means such as paired 't' test.

As noted from the above table calculated 't' value is greater than table value, hence this study is statistically
significant at P < 0.01. So while rejecting the null hypothesis, the alternate hypothesis is accepted that aerobic
exercises influences to decrease the heart rate among type II diabetic patients (Table 3.21 and Fig. 3.20).

Bweir et al (2009) have compared the effect of resisted exercises on type II diabetic adults, 20 inactive
type II diabetic patients with a mean age of (53.5 years) enrolled in the study. Heart rate, HbA1C, Blood
pressure and Waist circumference were measured. Results on a 10 week exercise intervention with 3 times /
week have shown that while aerobic group had 0.05% reduction in HbA1C and 0.03% reduction in HbA1C
among resisted exercises, heart rate reduction in the aerobic exercises was from a mean of 85 to a mean of 83.
Following 12 weeks of intervention with aerobic exercises in the present study, heart rate has decreased from a
mean heart rate of 91 to 87.

Hypothesis : 6

Statement of null hypothesis

Exercises with physio ball have no effect on heart rate among diabetic patients.

Resting heart rate per minute of the subjects allotted in group III are palpated and recorded (pre test).
After having done exercises using physio ball for 12 weeks, their resting heart rate was palpated and recorded
(post test) (Table 3.22 and Fig. 3.21).

Heart rate values of the subjects before and after the test were tabulated and analyzed using due
statistical means. As inferred from the above table, calculated to value of 4.87 is greater than the table value;
hence the study is statistically significant at P < 0.001 level. While rejecting the null hypothesis, the alternate
hypothesis was accepted that exercise with physio ball helps to reduce heart rate as shown with due statistical
evidence.

Carmen et al. (2002) have studied the effect of resisted exercises in type ZII diabetic adults, wherein 62
adults above 55 years (40 women and 22 men) with type II diabetic performed resisted exercise for 16 week (3
times per week), HbA1C, trunk fat mass, heart rate, blood pressure were measured. Results have shown a
reduced plasma glycosylated hemoglobin levels (from 8.7 + 0.3 to 7.6 + 0.2%), reduced systolic blood pressure
99
(-9.7 + 1.6 vs +7.7 + 1.9mmHg), decreased trunk fat mass (-0.7 + 0.1 vs 0.8 + 0.1 kg) and heart rate (72 + 1 to
71 + 3). In this study, heart rate from a mean of 85 has reduced to a mean heart rate of 81 following resisted
exercises using physio ball.

Hypothesis : 7

Statement of null hypothesis

Aerobic exercises have no effect on diastolic blood pressure among type II diabetic patients.

Diastolic blood pressure among the subjects of group II was measured and recorded (pre test); after
having performed aerobic exercises for 12 weeks, their diastolic blood pressure was measured and recorded
(post test) (Table 3.23 and Fig. 3.22).

Diastolic blood pressure values recorded before and after the exercises were tabulated and analyzed
using scientific statistical means. Calculated t value is greater than table value, hence the study is statistically
significant at P < 0.05. While rejecting the null hypothesis, the alternate hypothesis was accepted that aerobic
exercises influence to reduce diastolic blood pressure among type II diabetic patients.

In a meta-analysis of 54 studies involving, 2419 inactive adults (normal, overweight, hypertensive &
non-hypertensive) who agreed for aerobic exercise for 2 weeks, was found to reduce diastolic pressure by 2.5
mmHg (US mayo clinic, 2004). In this study, diastolic pressure has reduced by 2 mmHg.

Hypothesis : 8

Statement of null hypothesis

Exercises with physioball have no effect on diastolic blood pressure among type II diabetic patients.

Diastolic blood pressure of the subjects allotted in group III was measured and recorded (pre test). After
having performed for 12 weeks, their diastolic blood pressure was measured and recorded. Diastolic blood
pressure of the subjects in group III before and after exercises was tabulated and analyzed applying due
statistical methods. Calculated t value is greater than the table value; hence the study is statistically significant
at P < 0.001. While rejecting the null hypothesis, the alternate hypothesis was accepted that exercises with
physio ball influence to decrease diastolic blood pressure among type II diabetic patients as evidenced here
statistically (Table 3.24 and Fig. 3.23).

100
 251 adults aged between 39 – 70 years with type II diabetes were divided into 4 groups.

Group I – Aerobic training,

Group II – Resistance training,
Group III – Combined both aerobic and resistance training,
Group IV – sedentary control group.
Exercises were done for 3 times / week for 22 weeks. HbA1C decreased by -0.51% in the group III, -0.38% in
group II and – 0.22% in group I. Diastolic blood pressure from a base mean of 82 has reduced to 79 in aerobic
training and from a base mean of 80 to 78 in resisted exercise group. In this study, while diastolic in control has
reduced by 1 mmHg and in group III from a mean of 81 has reduced to 77.

Hypothesis : 9

Statement of null hypothesis

Aerobic exercises have no influence on systolic blood pressure among type II diabetic patients.

Systolic blood pressure of subjects allotted in group II was measured and recorded (pre test) and after
having done aerobic exercises for 12 weeks, their systolic blood pressure was measured and recorded (post test)
(Table 3.25 and Fig. 3.24).

Systolic blood pressure of subjects in group II before and after exercises was tabulated and analyzed
using statistical mean such as paired 't' test. As the calculated t value is lesser than the table value, this study is
statistically insignificant at P > 0.10, hence the null hypothesis was accepted that aerobic exercises have no
significant effect on type II diabetic patients as evidenced statistically.

In a meta – analysis of 54 studies involving 2,419 inactive adults (normal, overweight, hypertensive and
non hypertensive) who have done aerobic activity for 2 weeks, was found to reduce systolic blood pressure by
nearly 4 mmHg (Mayoclinic, 2004).

In this study, systolic blood pressure has fallen by 10mmHg following 12 weeks of having done aerobic
exercises.

Hypothesis : 10

Statement of null hypothesis

Exercises with physio ball have no effect on systolic blood pressure.

101
 Systolic blood pressure of the subjects allotted in group III was measured and recorded (pre test) and
after having performed exercises using physio ball for 12 weeks, their systolic blood pressure was measured and
recorded. Systolic blood pressure values before and after exercises of group III subjects are tabulated and
analyzed using due statistical means. Calculated t value 3.49 is greater than the table value, and so the study is
statistically significant at P < 0.01 level, hence while rejecting the null hypothesis, the alternate hypothesis was
accepted indicating that exercises with physio ball influences to decrease systolic blood pressure as evidenced
statistically (Table 3.26 and Fig. 3.25).

In a study conducted by Carmen et al (2009) where 62 latino adults (40 women & 22 men) aged 66 + 8
years performed 16 week resisted exercises ( type II diabetic) were randomly assigned in two groups, a control
and a supervised resistance exercises group. 3 times a week has resulted in reduced plasma glycosylated
hemoglobin levels (from 8.7 + 0.3 to 7.6 + 0.2%) and reduced systolic blood pressure (9.7 + 1.6 vs + 7.7 +
1.9mmHg).

In this study while there is no change in the mean of group I a reduction in the mean values from 130 to
120 in group III signifies the impact of physioball exercises on systolic pressure by lowering.

Hypothesis : 11

Statement of null hypothesis

Aerobic exercises have no effect on fasting blood sugar.

Fasting blood sugar of the participants in group I and group II was recorded prior to the study. They
(group II) were advocated aerobic exercises for a period of 12 weeks, while group I subjects did not perform
any specific activity, other than their routine day to day means, fasting blood sugar of both group I and II
subjects were again measured and were recorded.

The values were then tabulated, and statistical method of paired 't' test was applied (Table 3.27 and Fig.
3.26).

The obtained value was 2.87 which is greater than the table value, hence the aerobic exercises influence
in lowering fasting blood sugar among type II diabetic patients which is statistically significant at P < 0.02
level. While rejecting the null hypothesis, the alternate hypothesis was accepted that aerobic exercises help to
lower fasting blood sugar.

102
Hypothesis : 12

Statement of null hypothesis

Exercises with physio ball have no effect on fasting blood sugar.

Fasting blood sugar of the participants in group III was measured and were recorded. They were then
made to do exercises using physio ball for a period of 12 weeks and their fasting blood sugar was again
measured and was recorded.

Fasting blood sugar values obtained before and after exercises were tabulated and analyzed using paired
't' test (Table 3.28 and Fig. 3.27).

Calculated t value is greater than the table value, hence fasting blood sugar is influenced by exercises
with physio ball which is statistically evident at P < 0.02 level.

Hence while rejecting null hypothesis, the alternate hypothesis was accepted indicating that fasting
blood sugar can be lowered using exercises with physio ball is statistically evident.

Hypothesis : 13

Statement of null hypothesis

Aerobic exercises have no effect on post prandial blood sugar.

Post prandial blood sugar of subjects in group I and group II was measured and recorded; group I
subjects have not performed any specific physical activity other than their routine day to day activities, where as
group II participants have performed aerobic exercises for a period of 12 weeks, following which the subjects in
group I and II were measured post prandial blood sugar and recorded.

Post prandial blood sugar before and after a period of 12 weeks for both group I and II was recorded and
tabulated, in order to apply statistical methods (Table 3.29 and Fig. 3.28).

Paired 't' test was applied for group II, were calculated t value, 6.26 is greater than table value at P < 0.001,
hence it is statistically evident that aerobic exercises help to lower post prandial blood sugar.

Hypothesis : 14

103
Statement of null hypothesis

Exercises using physioball have no effect on post prandial blood sugar.

Post prandial blood sugar of group I and III was measured and was recorded. While members of group I
were not given any specific physical activities other than their normal day to day routine, group III subjects
have performed specific exercises using physio ball for a period of 12 weeks. Post prandial blood sugar of both
group I and III were measured and were again recorded.

Values recorded prior to and after the study were tabulated and analysed using statistical means(Table
3.30 and Fig. 3.29).

Calculated ‘t’ value is greater than the table value, while accepting alternate hypothesis, null hypothesis
is rejected that physio ball exercises help to lower post prandial blood sugar is statistically significant at P <
0.001.

Hypothesis : 15

Statement of null hypothesis

Aerobic exercises have no effect on glycelated haemoglobin (HbA1C).

Fasting venous blood was taken from group I and II for the estimation of glycocelated haemoglobin
(before study).

While group I was not allowed any specific physical activity other than their daily routine activities,
group II was assigned aerobic activity for a period of 12 weeks, again fasting blood venous blood sample was
taken from group I and II (after study) for the estimation of glycocelated haemoglobin.

Values of HbA1C obtained for group II before and after the study were tabulated and statistical analysis
were done (Table 3.31 and Fig. 3.30).

It is statistically evident that aerobic exercises halp to lower HbA1C, hence while rejecting null
hypothesis, accepting alternate hypothesis, that aerobic exercises helps to lower HbA1C.

Bweir et al (2009) have studied the effect of aerobic training in adults with type II diabetes, where 20
inactive subjects (mean age 53.5 years) with type II diabetes were given aerobic exercises for 3 times / week for
10 weeks, where HbA1C has reduced by 0.05%.

Hypothesis : 16

104
Statement of null hypothesis:

Exercises using physioball have no effect on glycocelated haemoglobin.

Venous blood sample at fasting state was taken from subjects of group I and III, estimated and were
recorded (before study). While group I was not assigned with any specific physical activity, group III subjects
have done specific exercises using physioball for a period of 12 weeks.

Fasting venous blood sample was taken from the subjects of group I and III again for the estimation and
recorded (after study). Values of HbA1C before and after the study were tabulated for group III and analyzed
using due statistical means.

Exercises using physioball are effective in lowering HbA1C, hence while rejecting the null hypothesis
accepting alternate hypothesis which is evidenced at P < 0.001 (Table 3.32 and Fig. 3.31).

Bweir et al. (2009) have compared resistance exercise training with aerobic training on HbA1C in adults
with type II diabetes in Jordan.

Twenty subjects with type II diabetes (mean age 53.5 years) were allotted in two groups at random
aerobic exercises (n-10) and resisted exercises (n-10), exercise regime was supervised by physical therapist,
consisted of 3 times/week for 10 weeks.

Mean HbA1C during pre intervention period was 8.7 % for treadmill and 8.9 % for resistance exercise
groups respectively.

But at the end of 10th week, HbA1C% change from pre intervention to post intervention was greater in
the resistance group than aerobic group.

But they also reported percent change in HbA1C levels were different between the two groups, none of
the participants in the aerobic group reached target level of 7% HbA1C, where as 40% of the resisted exercises
reached target level of 7% HbA1C.

Hypothesis : 17

Statement of null hypothesis

Aerobic exercises have no effect on triglycerides. Results of paired ‘t’ test have shown significance of
aerobic exercises in lowering triglycerides hence accept the alternate hypothesis, while insignificant results on
control group were noted (Table 3.33 and Fig. 3.32).

105
 A reduction of post mean triglycerides among group II by 6mg/dl, while it has increased among group I
is evident that aerobic exercises are effective in lowering triglycerides.

Hypothesis : 18

Statement of null hypothesis

Aerobic exercises have no influence on total cholesterol

Results of paired ‘t’ test among group II have shown significant changes to lower total cholesterol
statistically, hence accept the alternate hypothesis that aerobic exercises helps to lower total cholesterol, while
the results of control group showed increased total cholesterol. A reduction in post mean of total cholesterol
among group II by 10mg/dl, while it has increased by 19mg/dl among group I; hence is clear that aerobic
exercises helps to lower total cholesterol (Table 3.33 and Fig. 3.32).

Hypothesis : 19

Statement of null hypothesis

Aerobic exercises have no impact on HDL

Paired ‘t’ test results has shown that aerobic exercises are statistically insignificant to increase HDL.
Accepting the hypothesis, the results of control group subjects were also insignificant. As displayed in the
graph 2 , post mean scores of group II has remained unchanged, while among group I has decreased by
1mg/HDL:. It is thus validated that aerobic exercises doesn’t improve HDL among type II diabetic patients
(Table 3.33 and Fig. 3.32).

Hypothesis : 20

Statement of null hypothesis

Aerobic exercises have no effect on LDL

Results of paired ‘t’ test show that aerobic exercises are statistically significant in lowering LDL, hence
the alternate hypothesis was accepted, while the results among control group subjects were insignificant (Table
3.33 and Fig. 3.32).

Reduction in post mean LDL among group II by 4mg/dl and an increased post mean LDL among group I
by 3mg/dl as displayed in graph 2., shows that aerobic exercises are effective in lowering LDL among type II
diabetic patients.

106
Hypothesis : 21

Statement of null hypothesis

Exercises with physioball have no role on triglycerides.

Results of paired ‘t’ test among group III have shown that exercises using physioball are effective in
lowering triglycerides is proven, hence the alternate hypothesis was accepted while the results among control
group subjects were insignificant.

A post mean reduction in triglycerides by 13mg/dl, among group III and an increase by 7mg/dl among
group I shows triglycerides can be lowered among type II diabetes using physioball exercises (Table 3.34 and
Fig. 3.33).

Hypothesis : 22

Statement of null hypothesis

Exercises using physioball have no change on total cholesterol

Results of paired ‘t’ test indicates that physioball exercises group (group III) have shown to have
decrease in total cholesterol, hence while accept the alternate hypothesis and control group subjects have shown
insignificant results.

A post mean score reduction among group III by 13mg/dl, and an increase among group I by 19mg/dl,
indicates that physioball exercises are effective in lowering total cholesterol among type II diabetic patients
(Table 3.34 and Fig. 3.33).

Hypothesis : 23

Statement of null hypothesis

Physioball exercises have no effect on HDL

Results of paired ‘t’ test among group I and group III as displayed in table 2., that while the results of
group I were insignificant and of group III to be significant in improving HDL, so accept alternate hypothesis
that physioball exercises influences to increase HDL.

An increase in post mean HDL by 2mg/dl among group III and a decrease in post mean HDL among
group I subjects further display that physioball exercises to be very effective in increasing HDL among type II
diabetic patients (Table 3.34 and Fig. 3.33).
107
Hypothesis : 24

Statement of null hypothesis

Exercises using physioball has no impact on LDL.

Results of paired ‘t’ test among group I and group III, were statistically significant with group III; hence
the alternate hypothesis was accepted, indicating that physioball exercises help to lower LDL, while the results
of group I were insignificant.,

A decrease in post mean score on LDL by 4mg/dl among group III and an increase in group I by 3mg/dl
indicate physioball exercises to be effective in lowering LDL (Table 3.34 and Fig. 3.33).

Table 3.1: Based on the age of the subjects

S.No Age (Years) Frequency Percentage

1 31 – 40 4 6

2 41 – 50 13 47

3 51 – 60 13 47

Table 3.2: Based on the age of the subjects (IDF, 2000)

108
 Age group of 20 – 44 Age group of 45 - 64
S.No Study Area
(years) in millions (years) in millions

1 Developed Countries 5 23

2 Developing Countries 30 60

3 World 38 82

Table 3.3: Family history of diabetes among respondents

Family members with known history of Percentage

S.No Frequency
diabetes %

1 Mother 6 20

2 Father 6 20

3 Both Father and Mother 10 33

4 Nil 6 20

5 Unknown 2 7

Table 3.4: Duration of being diabetic patients of participants

109
 Duration of being Diabetic Percentage
S.No Frequency
patient (years) %

1 1–5 16 53

2 6 – 10 13 43

3 11 – 15 1 4

Table 3.5: Whether on insulin therapy

Percentage
S.No Insulin Therapy Frequency
%

1 Not taken 26 87

2 Has taken once - -

3 Has taken twice 4 13

Table 3.6: Type of diabetic medication as prescribed by physicians:

Percentage
S.No Type of diabetic medication Frequency
%

1 Metformin 13 43

2 Sulphonyl urea 9 30

110
 3 Metformin + Sulphonyl urea 3 10

4 Oral hypoglycemic agents 5 17

Table 3.7: Sample distribution based on neuropathy

S.No Neuropathy Frequency Percentage %

1 Those who have 2 7

2 Those who don’t have 28 93

Table 3.8: Sample distribution based on known eye complications

S.No Eye complications Frequency Percentage

1 Who don’t have known eye problems 27 90

2 Cataract 2 7

3 Glaucoma 1 3

111
Table 3.9: Subjects composition with known heart ailments

Percentage
S.No Heart Ailment Frequency
%

1 Who have known 14 47

2 Who have not known 16 53

Table 3.10: Sample distribution based on Hypertension

Percentage
S.No Blood Pressure Frequency
%

1 Hypertension 10 33

2 Normo tension 20 67

112
Table 3.11: Composition of subjects with Musculo Skeletal complications

Percentage
S.No Musculo Skeletal Ailments Frequency
%

1 Spine 2 7

2 Arm 3 10

3 Nil 7 23

4 All Joints 8 27

5 Leg 10 33

Table 3.12: Subjects distribution based on food habits

Percentage
S.No Food habits Frequency
%

1 Vegetarian 14 47

2 Non-vegetarian 16 53

113
Table 3.13: Subjects categorization based on alcohol consumption:

Percentage
S.No Alcohol comsumption Frequency
%

1 Yes 14 47

2 No 16 53

Table 3.14: Participants distribution based on smoking

Percentage
S.No Smoking Frequency
%

1 Smokers 9 30

2 Non-smokers 21 70

114
Table 3.15: Participants distribution based on nature of occupation.

Percentage
S.No Nature of occupation Frequency
%

1 Desk work 14 47

2 Sedantry 9 30

3 Physical activity 7 23

Table 3.16: Sample distribution based on their Medication other than for diabetic

Percentage
S.No Type of Medication Frequency
%

1 Anti Hypertensive 10 33

2 Anti Cholesterol 8 27

3 Anti Depressants 2 7

4 Anti Coagulants 4 13

5 Nil 6 20

Table 3.17: Results of paired 't' test pre and post mean scores of group I and Group II, the effect of
aerobic exercise on BMI

Group Type of test Mean SD SE T value Significant/nonsignificant

115
 Pre 28
I 0.70 0.22 - 0.91 Non significant
Post 28
Pre 26
II 0.52 0.16 3.75 Significant
Post 25

Table 3.18: Results of paired t test, and the pre and post mean scores of group I and group III on BMI.

Group Type of test Mean SD SE T value Significant/nonsignificant

Pre 28
I 0.70 0.22 - 0.91 Non significant
Post 28
Pre 26
III 1.05 0.33 4.85 Significant
Post 25

Table 3.19: Results of paired t test pre and post mean scores of group I and group II on waist
circumference.

Group Type of test Mean SD SE T value Significant/nonsignificant

Pre 94
I 0.67 0.21 - 1.42 Non significant
Post 95
Pre 92
II 1.33 0.42 1.78 significant
Post 90

116
Table 3.20: Results of paired 't' test pre and post mean scores on waist circumference of subjects in group
I and group III

Group Type of test Mean SD SE T value Significant/nonsignificant

Pre 94
I 0.67 0.21 - 1.42 Non significant
Post 95
Pre 94
III 8.07 2.69 2.56 Significant
Post 90

Table 3.21: Results of paired t test pre and post mean scores of heart rate among group I and group II.

Group Type of test Mean SD SE T value Significant/nonsignificant

Pre 90
I 1.90 0.60 -1 Non significant
Post 92
Pre 91
II 4.05 1.28 3.28 Significant
Post 87

Table 3.22: Results of paired ‘t’ test pre and post mean scores on heart rate among group I and group III.

Group Type of test Mean SD SE T value Significant/nonsignificant

Pre 90
I 1.90 0.60 -1 Non significant
Post 92
Pre 85
III 2.40 0.76 4.87 Significant
Post 81

117
Table 3.23: Results of paired ‘t’ test pre and post mean scores of diastolic blood pressure among group I
and group II.

Group Type of test Mean SD SE T value Significant/nonsignificant

Pre 88
I 0.97 0.30 -2 Non significant
Post 87
Pre 78
II 3.09 0.98 2.35 Significant
Post 76

Table 3.24: Results of paired ‘t’ test pre and post mean scores of diastolic blood pressure among group I
and group III.

Group Type of test Mean SD SE T value Significant/nonsignificant

Pre 88
I 0.97 0.30 -2 Non significant
Post 87
Pre 81
III 2 0.63 6.98 Significant
Post 77

118
Table 3.25: Result of paired ‘t’ test pre and post mean scores of group I and group II on systolic blood
pressure.

Group Type of test Mean SD SE T value Significant/nonsignificant

Pre 132
I 2.11 0.67 - 1.49 Non significant
Post 132
Pre 120
II 2.10 0.66 1.51 Non significant
Post 110

Table 3.26: Result of paired ‘t’ test pre and post mean scores of group I and group III on systolic blood
pressure.

Group Type of test Mean SD SE T value Significant/nonsignificant

Pre 132
I 2.11 0.67 - 1.49 Non significant
Post 132
Pre 130
III 2.64 0.83 3.49 Significant
Post 120

Table 3.27: Results paired ‘t’ test pre and post mean scores of group I and group II the effect of aerobic
exercise on fasting sugar.

Group Type of test Mean SD SE T value Significant/nonsignificant

Pre 146
I 4.42 1.40 -5 Non significant
Post 149

119
 Pre 141
II 12.11 3.83 2.87 Significant
Post 133

Table 3.28: Results paired ‘t’ test pre and post mean scores of group I and group III the effect of
Physioball on fasting sugar.

Group Type of test Mean SD SE T value Significant/nonsignificant

Pre 146
I 4.42 1.40 -5 Non significant
Post 149
Pre 133
III 11.80 3.73 3.00 Significant
Post 121

Table 3.29: Results paired ‘t’ test pre and post mean scores of group I and group II the effect of aerobic
exercise on post prandial blood sugar.

Group Type of test Mean SD SE T value Significant/nonsignificant

Pre 202
I 6.29 1.99 - 5.55 Non significant
Post 209
Pre 235
II 16.7 5.3 6.26 Significant
Post 202

Table 3.30: Results paired ‘t’ test pre and post mean scores of group I and group III the effect of
Physioball on post prandial blood sugar.

120
 Group Type of test Mean SD SE T value Significant/nonsignificant
Pre 202
I 6.29 1.99 - 5.55 Non significant
Post 209
Pre 192
III 15.76 4.99 5.13 Significant
Post 167

Table 3.31: Results of paired ‘t’ test pre and post mean scores of group I and group II on HbA1C.

Group Type of test Mean SD SE T value Significant/nonsignificant

Pre 8.1
I 0.58 0.18 0.55 Non significant
Post 8.1
Pre 7.7
II 0.20 0.06 5.55 Significant
Post 7.3

Table 3.32: Results of paired ‘t’ test pre and post mean scores of group I and group III on HbA1C.

Group Type of test Mean SD SE T value Significant/nonsignificant

Pre 8.1
I 0.58 0.18 0.55 Non significant
Post 8.1
Pre 7.5
III 0.20 0.06 10.00 Significant
Post 7.2

121
Table 3.33 LIPID PROFILE: showing results of group II (aerobic exercises) and group I, paired 't' test,
pre and post mean scores of group I and group II on lipid profile

Group I Group II
Pre test Post test Pre test Post test Group SD SE T value Result
mean mean mean mean
I 3.26 1.03 - 7.70 Nonsignificant
Triglycerides 178 185 108 102
II 5.17 1.64 4.33 Significant
Total I 5.80 1.93 - 6.4 Nonsignificant
188 207 174 164
Cholesterol II 5.92 1.87 5.24 Significant
I 0.95 0.30 -1 Nonsignificant
HDL 43 42 44 44
II 1.28 0.04 .5 NonSignificant
I 7.63 2.41 - 2.90 Nonsignificant
LDL 94 97 108 104
II 4.46 1.41 3.26 Significant

LIPID PROFILE: Table 3.34 showing results of group III (physio ball exercises) and group I, paired 't'
test, pre and post mean scores of group I and group III on lipid profile

122
 Group I Group III
Post Pre Post
Pre test Group SD SE T value Result
test test test
mean
mean mean mean
I 3.26 1.03 -7.70 Non significant
Triglycerides 178 185 161 148
III 9.89 3.13 4.28 Significant
I 5.80 1.93 - 6.4 Non Significant
Total Cholesterol 188 207 198 179
III 9.76 3.08 6.14 Significant
I 0.95 0.30 -1 Non significant
HDL 43 42 42 44
III 1.03 0.33 2.42 Significant
I 7.63 2.41 - 2.90 Non significant
LDL 94 97 119 110
III 7.57 2.39 3.89 Significant

123
 Figure 3.1 showing subject distribution based on their age

Figure 3.2 sample distribution based on family history of diabetes

124
 Figure 3.3: Showing duration of being diabetic patients

Figure 3.4: Showing sample distribution based on insulin therapy

125
Figure 3.5: Showing sample distribution based on type of diabetic medication.s

Figure 3.6: Showing sample distribution based on neuropathy

126
 Figure 3.7: Showing sample proportion with known eye complications

Figure 3.8: Showing sample distribution based on history of known heart ailments.

127
 Figure 3.9: Showing sample proportion based on hypertension

Figure 3.10: Showing sample distribution based on musculoskeletal ailments

128
 Figure 3.11: Showing subject distribution based on food habits

Figure 3.12: Showing subject distribution based on alcohol consumption

129
 Figure 3.13: Showing sample distribution of smoking.

Figure 3.14: Showing sample distribution based on their nature of occupation

130
Fig. 3.16 showing
mean values of
BMI among
control (Group
I) and Aerobic
exercise (Group
II)

Fig. 3.17 showing mean values of BMI among Group I and Group III

131
 100 94 95
92 90

80
Waist circumference

60

40

20

0
Group I Group II
Pre & Post test mean of group I Pre & Post test mean of group II

Fig. 3.18 showing pre, post mean values of Group I and Group II on waist circumference

100 94 95 94
90

80
Waist circumference

60

40

20

0
Group I Group III
Pre & Post test mean of group I Pre & Post test mean of group II

132
 Fig. 3.19 showing pre, post mean values of Group I and Group III on waist circumference

100
90 92 91
87

80

60
HEART RATE

40

20

0
Group I Group II
Pre & Post test mean of group I Pre & Post test mean of group II

Fig. 3.20 showing pre, post mean values of Group I and Group II

120

90 92
90 85
81
Heart rate

60

30

0
Group I Group III
Pre & Post test mean of group I Pre & Post test mean of group III

133
 Fig. 3.21 showing mean values of heart rate of Group I and Group III

Fig. 3.22 showing pre and post mean values of Group I and II on diastolic blood pressure

Fig. 3.23 showing effect of Physioball exercises on diastolic blood pressure

134
 150

132 132

125 120
110
Systolic blood pressure mmHg

100

75

50

25

0
Group I Group II
Pre & Post test mean of group I Pre & Post test mean of group II

Fig. 3.24 showing effect of aerobic exercises on systolic blood pressure

150

132 132 130

125 120
Systolic blood pressure mmHg

100

75

50

25

0
Group I Group III
Pre & Post test mean of group I Pre & Post test mean of group III

Fig. 3.25 showing mean values of pre & post systolic blood
pressure of group I & III

135
 Fig. 3.26 showing mean pre & post test mean values of group I & II on fasting blood sugar

300

250 235

209
202 202
200
Post prandial Blood sugar

150

100 Fig. 3.27 showing mean pre & post test mean values of group I & III on fasting blood sugar

50
136
0
Group I Group II
Pre Test mean Post test mean
 Fig. 3.28 showing mean pre & post test mean values of group I & II on post prandial blood sugar

250

209
202
200 192

167
Glycocelated haemoglobinPost Prandial Blood Sugar

150

10
100
9
8.1 8.1
8 7.7
7.3
50
7

6
0
5 Group I Group III

4 Pre Test mean Post test mean

Fig.
3 3.29 showing pre and post test mean values of group I and group III on post prandial blood sugar.

1
137
0
Group I Group II
Pre Test mean
Fig. 3.30 showing pre and post test mean values of group I and group II on glycocelated haemoglobin

Fig. 3.31 showing pre and post test mean values of group I and group III on glycocelated haemoglobin

138
Fig. 3.32 showing results of group II (aerobic exercises) and group I, paired 't' test, pre and post mean scores of
group I and group II on lipid profile.

Fig. 3.33: showing results of group III (physio ball exercises) and group I, paired 't' test, pre and post mean scores of
group I and group III on lipid profile.

139
4.0 IMPACT OF QUALITY OF LIFE ON LIFE PARAMETERS OF POPULATION UNDER AEROBIC
AND SWISSBALL EXERCISES

4.1 INTRODUCTION
4.2 MATERIALS AND METHODS
4.3 RESULTS
4.3.1 Medical history
4.3.2 Results of quality of life questionnaire
4.3.3 Physical parameters
4.3.3.1 Heart rate
4.3.3.2 Body mass index
4.3.3.3. Waist circumference
4.3.3.4 Blood pressure
4.3.4 Biochemical parameters
4.3.4.1 Fasting blood sugar (fbs)
4.3.4.2 Post prandial blood sugar
4.3.4.3 Glycelated haemoglobin
4.3.4.4 Lipid profile
4.4 DISCUSSION

140
4.0 IMPACT OF QUALITY OF LIFE ON LIFE PARAMETERS OF POPULATION UNDER AEROBIC
AND SWISSBALL EXERCISES

4.1 INTRODUCTION

The long term effects of Diabetes mellitus include progressive development of the specific
complications of retinopathy with potential blindness, nephropathy that may lead to renal failure and /
or neuropathy with the risk of foot ulcers, amputation, Charcot joints and features of autonomic
dysfunction, including sexual dysfunction. People with Diabetes are at increased risk of cardio -
vascular, peripheral vascular and cerebro – vascular diseases. Several pathogenic processes are involved in
the development of Diabetes. These include process which destroys the beta cells of the pancreas with
consequent insulin deficiency, and others that result in resistance to insulin action. The abnormalities of
carbohydrates, fat and protein metabolism are due to deficient action of insulin on target tissues
resulting from insensitivity or lack of insulin.

The first national study on the prevalence of Type 2 Diabetes in India was done between 1972
and 1975 by the Indian council of medical research (ICMR, New Delhi), where screening was done in
about 35,000 individuals above 14years of age, using 50g glucose load capillary blood glucose level >
170mg/dl was used to diagnose Diabetes. The prevalence was 2.1 percent in urban population and 1.5
percent in the rural population while in those above 40 year of age, the prevalence was 5 percent in
urban and 2.8 percent in rural areas (Ahuja, 1979).

Population based study was conducted in six metropolitan cities across India and recruited
11,216 subjects aged 20 years and above representative of all socioeconomic strata; an oral glucose
tolerance test was done using capillary glucose and Diabetes was defined using the WHO criteria. The
study reported that the age standardized prevalence of Type 2 Diabetes was 12.1 percent. This study
also revealed that the prevalence in the southern part of India to be higher 13.5 percent in Chennai,
12.4 % in Bangalore and 16.6 % in Hyderabad; compared to eastern India (Kolkata), 11.7%; Northern
India (New Delhi) 11.6%; and western India (Mumbai), 9.3%. the study also suggested that there was
a large poor of subjects with IGT (Impaired Glucose Tolerance) 14% with a high risk of conversion to
Diabetes (Ramachandran et al, 2001).

Study was carried out in 108 centers (49 urban and 59 rural) to look at the urban – rural
differences in the prevalence of Type 2 Diabetes and glucose intolerance. Capillary blood was used to
estimate glucose levels and glucose intolerance was defined according to the WHO 1999 as well as
the American Diabetic Association (ADA) 2003 criteria. According to ADA criteria, the prevalence of
141
Diabetes was 4.7% in the urban compared to the 2% in the rural population while the prevalence of
Diabetes according to the WHO criteria was 5.6% and 2.7% among urban and rural areas respectively
(Sadikot et al, 2004).

Patients with Type 2 diabetes older than 35 years should be given an exercise test to screen
for potential underlying asymptomatic coronary artery disease before they begin an exercise regimen.
Department of health and human services, United States (1996) has recommended moderate physical
activity of 30 minutes on most days of the week for health promotion and disease, especially in the
context of diabetes. It is becoming increasingly clear that the epidemic of Type 2 Diabetes sweeping
the globe is associated with decreasing levels of activity and an increasing prevalence of obesity. Thus
the importance of promoting physical activity as a vital component of the prevention as well as
management of Type 2 Diabetes must be viewed as a high priority. It must also be recognized that
the benefit of physical activity in improving the metabolic abnormalities of type 2 Diabetes is probably
greatest when it is used early in its progression from insulin resistance to impaired glucose tolerance
to overt hyperglycemia requiring treatment with oral glucose lowering agents and finally to insulin.

In a study conducted on 63 sedentary subjects of both sexes with a mean age of 78 years using moderate
intensity exercises and aerobic exercises, for 16 weeks duration have recorded a reduction of a mean BMI by
1Kg/m2, 4mmHg decrease in mean diastolic blood pressure, 3cm decrease in the mean triglycerides, 6mg/dl
decrease in mean total cholesterol, 13mg/dl reduction in mean LDL, 5mg/dl increase in HDL (Raul et al.,
2010).

Among 90 overweight subjects of both sexes with a mean age of 43 years using diet and aerobic
exercises for 12 week period demonstrated a reduction in mean waist circumference by 2cms, mean BMI by
0.5Kg/m2, a reduction in mean resting heart rate by 4 beats / minute, a decrease in mean diastolic blood
pressure by 9mmHg and a decrease in mean systolic blood pressure by 12 mmHg (Bweir et al., 2009).

Duke university (2004) have demonstrated among sedentary overweight individuals of both sexes with a
mean age of 50 years who have performed 30 minutes daily aerobic exercises for 8 months period, have shown
a reduction in their mean BMI by 1Kg/m2. Olfdroyd et al. (2001) using diet and aerobic exercises for 6 months
period among normal subjects - have recorded a reduction in their participants mean BMI by 1Kg/m2.

Among 62 type II diabetic subjects of both sexes studied with a mean age of 55 years with resisted
exercises for a duration of 16 weeks and thrice a week, the following findings were reported in their subjects:-

142
a reduction of mean by 1Kg/m2, a decrease of mean waist circumference of subjects by 2cms, a mean reduction
in systolic blood pressure by 7mmHg and a decrease in the mean diastolic blood pressure by 4mmHg, a
decrease in resting mean heart rate by 3 beats / min (Carmen et al., 2009).

4.2 MATERIALS AND METHODS

The study was conducted with a sample size of 150 male diabetic patients in the age group of 31-60
years on life parameters of population under aerobic and Swissball exercises. They were administered
questionnaire related to this diabetes status. After obtaining due consent from them, physical and biochemical
parameters were taken and duly recorded.

The subjects were then allotted at random in three groups. The participants continued activity allotted
to the group. After 12 weeks of performance, physical and biochemical parameters were taken, recorded and
tabulated. Results prior to the study and at the end of the study were tabulated, analyzed and discussed as below.

4.3 RESULTS

4.3.1 Medical history

Data collected from the research study were duly recorded, tabulated and related statistical methods
were applied. Baseline information recorded from the participants by means of processing questionnaire.
Differential statistical “means of frequency” and percentage was used on the data obtained from 150 subjects.
Obtained values were presented using tables, pie diagrams and graphs.

Sample distribution of participants based on their age was with 41% between 51 – 60 years, 38%
subjects between 41 - 50 years and 21% of the subjects between 31 – 40 years (Table 4.1; Fig. 4.1). Table 4.2
and Fig. 4.2 show distribution of family history of diabetes among participants with 28% of the subjects mother
are diabetic, 17% father as diabetic, 36% of the subjects’ parents are diabetic, while 8% of the subjects parents
are non diabetic and 11% of the subjects are unknown of their parents diabetes status.

Table 4.3 and Fig. 4.3 show duration of being diabetic among participants. With 69% of the subjects are
diabetic from 1 – 5 years, 24% of the subjects are diabetic for 6 – 10 years, 4% of the subjects are known
diabetic for 11 – 15 years and 3% of the subjects are known diabetic for 16 – 20 years duration. Table 4.4 and
Fig. 4.4 display subjects’ distribution on whether they have taken insulin therapy. While 81% of the subjects
have not taken insulin therapy, 14% of the subjects were treated once with insulin therapy and 5% of the
subjects were treated more than twice with insulin therapy.

143
 Table 4.5 and Fig. 4.5 display distribution of participants based on the type of diabetic medications as
prescribed by their physicians. While 44% of the subjects were taking metformin, 35% of the subjects were on
sulphonyl urea, 17% of the subjects were on Metformin and sulphonyl urea and 4% of the participants were on
oral hypoglycemic agents. Table 4.6 and Fig. 4.6 show sample distribution based on neuropathy. 22% of the
subjects have neuropathy and 78% of the subjects don't have neuropathy. Table 4.7 and Fig. 4.7 show sample
proportions based on eye complications with 86% of the subjects don’t have known eye problems, 5% of the
subjects have cataract and 9% of the subjects have glaucoma.

Table 4.8 and Fig. 4.8 show sample distribution based on known heart ailments with 59% of the subjects
doesn’t have any known heart ailments while 41% of the subjects have known heart ailments. It is interesting to
note that participants without any musculoskeletal ailments amount to 33% of the case studies. The highest
percentage of ailments was recorded as 18.5% in those with ailments in leg. Ailments in spine with arm were
minimum to an extent of 1.5% of the cases studied (Table 4.9 and Fig. 4.9). Table 4.10 and Fig. 4.10 show
subject’s composition based on their food habits with 37% being vegetarian and 63% of the participants were
non vegetarians.

Table 4.11 and Fig. 4.11 represent participant’s distribution based on their habit of smoking with 43% of
the subjects were smokers and 57% of the subjects were non smokers. Table 4.12 and Fig. 4.12 display sample
categorization based on their habit of alcohol consumption. With 53% of the subjects were alcoholics and 47%
of the subjects were non alcoholics. Table 4.13 and Fig. 4.13 show participants distribution based on their nature
of occupation. With 45% of the subjects had desk work nature, 33% of the subjects had sedentary nature of
occupation and 22% of the subjects had physical activity involved in their occupation.

Table 4.14 and Fig. 4.14 display distribution of subjects based on their type of medication, with 29% of
the subjects were on only hypertensive medication, 4% of the subjects were taking anti-cholesterol, 1% on
antidepressants, 4% had anticoagulant, 44% were not on any medications, 1% on antidepressant and
hypertensive medication, 9% of the subjects were on antihypertensive and anticoagulant, 2% had anti-
cholesterol and anticoagulant and 6% on anti hypertensive and anti-cholesterol medication. On the whole 45%
of the subjects were hypertensive.

4.3.2 Results of quality of life questionnaire

Subjective information of all the participants pertaining to quality of life questionnaire on a 7 point scale
were recorded twice: once at the beginning of the study and secondly after completion of the study. They were
statistically analyzed and their results were as follows:

144
 As shown in the Table 4.15 and Fig. 4.15 on the results of all the participants, subjective evaluation of
their personal life relative to the quality of life, show a decrease among control group post mean score by 0.50,
an increase in score of aerobic exercise by 0.18, and among stability ball exercise subjects an improved by score
by 1.02, hence it is evident that stability ball exercise is effective than aerobic exercise in improving personal
life, relative to the quality of life a major outcome of this study.

Table 4.16 and Fig. 4.16 show the results of all the participant’s feelings of their wife, relative to the
quality of life, that a reduction of post mean score among control group by 0.70, an increase in aerobic exercise
by 0.32, and an improved score of 0.36 among stability ball exercises. Thus it indicate that both aerobic
exercises and stability ball exercises helps to improve their subjects feeling of their wife, relative to quality of
life marginally is evident, as a major finding of outcome of this study.

Results of subjective evaluation on all the participants feelings on their romantic life relative to their
quality of life indicate that a decrease in post mean score among control group by 0.30, an improved score
among aerobic exercise group by 0.20 and stability ball exercise group subjects have an improved score by 1,
indicating that stability ball exercise influences stronger than aerobic exercise on romantic life, thereby
improving quality of life (Table 4.17; Fig. 4.17). As shown in the Table 4.18 and Fig. 4.18, post mean score
among control group has decreased by 0.30, an improvement of score by 0.32 among aerobic exercise group
and among stability ball exercise subjects an improved score by 0.93, on the participant’s subjective evaluation
on their job, relative to the quality of life, clearly indicating stability ball exercise to have stronger influence by
three times than aerobic exercise on the performance of job; hence stability ball exercise is proven to be an
effective tool than aerobic exercise in promoting quality of life among type II Diabetes becomes evident.

As displayed in the Table 4.19 and Fig. 4.19, results of subjective evaluation of all subjects on their
coworkers display a post mean score reduction among control group by 0.30, an increased score by 0.04 among
aerobic exercise group and among stability ball exercise group an increase in the score by 1.10; hence it is quite
prudent that stability ball exercise can influence stronger than aerobic exercise in improving the quality of life.

Table 4.20 and Fig. 4.20 reflect the subjective feelings of participants on the actual work what they do
and the effects of non-intervention and interventions. Among group I subjects while post mean score has
decreased by 0.4, post mean score among group II subjects have increased by 0.38, but among group III
subjects post mean score has increased by 1.86. Results have clearly shown a marginal betterment among
aerobic exercises subjects, pronounced improvement with stability ball exercise subjects and subjects among
control group have marginal reduction in the actual work they do relative to quality of life.

145
 Table 4.21 and Fig. 4.21 show results of all the subjects based on their handling of problems in the
participant’s life and the impact of aerobic exercises, stability ball exercises and control group subjects. While
subjects in group III have an improved score by 1.14, subjects in group II have a marginal increase by 0.28, and
post mean score among control group has decreased by 0.5, indicating that stability ball exercises is quite
effective in improving quality of life among type II diabetes with regard to these subjects ability to handle
problems in their life.

As displayed in the Table 4.22 and Fig. 4.22, the results of all the subjects are based on their actual
accomplishments in their life, the impact of aerobic exercises, stability ball exercises and non intervention.
Subjects with stability ball exercise have an improved score by 1, aerobic exercise subjects have an improved
score by 0.22, while with control group subjects have decreased score by 0.3. Thus the results depict that
stability ball exercise is effective than aerobic exercise in improving quality of life among type II Diabetes in
relevance to these subjects actual accomplishment in life.

Results on subjective evaluation of all the subjects based on their physical appearance as displayed
above show a decrease in post mean score among control group, an improved score among aerobic exercise
subjects by 0.44 and among stability ball exercise subjects an increase score by 0.80, thus pointing that stability
ball exercise is nearly two times effective than aerobic exercise in improving physical appearance as the way
they look to others, hence enhancing their quality of life (Table 4.23; Fig. 4.23).

As displayed in the Table 4.24 and Fig. 4.24, the results of all the subjects feelings on their self, relative
to their quality of life, among control group subjects have decreased score by 0.44, aerobic exercise group have
an increased score by 0.28 and stability ball exercise subjects have an increased score by 0.9, indicating that self
esteem improves with stability ball exercise much better than aerobic exercise; hence stability ball exercise is
shown to be more efficient in improving quality of life among type II diabetic patients.

As shown in the Table 4.25 and Fig. 4.25, the results of subjective feelings on all the participants ability
to change in their life, show a decrease in post mean score by 0.56, an improved score by 0.30 in aerobic
exercise and among stability ball exercise an improved score by 0.80, which concludes stability ball exercise to
be more than two times effective in enhancing the subjects ability to change in their life, so promoting quality of
life, among this group subjects.

As shown in the Table 4.26 and Fig. 4.26, the results of all the subjects subjective feeling on their life as
a whole reflects a decrease in post mean score by 0.58, an improved score by 0.16, in aerobic exercise, and
among stability ball exercise an improved score by 1.10, indicating the influence of stability ball exercise much

146
stronger than aerobic exercise, on the subjects feeling their life as a whole improved, so improving the quality
of life among stability ball exercise gets stronger than with aerobic exercise.

As displayed in the Table 4.27 and Fig. 4.27, on the results of the subjective evaluation on overall
contentment with their life shows a decrease of post mean score in control group by 0.70, an improved score by
0.20 among aerobic exercise group, an improved score by 0.76 with stability ball exercise subjects, indicating
stability ball exercise is more than three times effective in improving the quality of life components.

As displayed in the Table 4.28 and Fig. 4.28, the results of all subjects subjective evaluation on the
extent to which their life has been as they want it, relative to the quality of life, show a decrease in post mean
score by 0.70, an improved score of 0.30 among aerobic exercise subjects, while stability ball subjects have an
improved score by 0.66. Thus more than two times stability ball exercise is found to be effective than aerobic
exercise in enhancing quality of life pertaining to the extent of which life has been as they want by the
participants.

As shown in the Table 4.29 and Fig. 4.29 post mean score of control group has decreased by 3%, among
aerobic exercise group (group II) an increase in score by 5% and among stability ball exercises group subjects
an increase in score by 13%, indicating that stability ball exercises were two times effective than aerobic
exercises in improving the quality of life, which is a major outcome of this study.

The following were the findings from subjective evaluation of all the subjects in a 3 point scale on 5
items such as over all physical well being, emotional state, ability to handle stress, enjoyment of life and quality
of life which was processed at the completion of study only.

As shown in the Table 4.30 and Fig. 4.30, while 70% subjects with stability ball exercises have
improved physical well being, 32% have improved with aerobic exercises and 4% in control group. It is evident
that stability ball exercise is two times effective than aerobic exercise as pointed as outcome of this study in
improving quality of life.

Table 4.31 and Fig. 4.31 display clearly that the 58% of the subjects in control group remaining same
and 42% have worsened, while aerobic subjects 84% remain same as in beginning of the study, 14% have better
emotional state with 2% worsening but among the stability ball exercises group none have worse emotional
state, 44% of the subjects remain same and 56% subjects have overall improved emotional state, as evidenced
that with aerobic exercises only 14% have improved and with stability ball exercise 56% subjects have overall
improved mental state thus enhancing their quality of life.

147
 As displayed in the Table 4.32 and Fig. 4.32, while 62% of the subjects have improved overall
enjoyment of life with stability ball exercise, 34% have improved with aerobic exercise, with none showing
better in control group. Thus as in line with outcome of the study based on subjective evaluation on overall
enjoyment of life, it is evident that stability ball exercise is nearly two times effective than aerobic exercise.

As displayed in the Table 4.33 and Fig. 4.33, while 58% of the participants have better ability to handle
stress following stability ball exercises (SBE) whereas 18% have better ability to handle stress at the end of the
study, with none showing betterment in the interventional group. Hence it is quite clear that stability ball
exercise is quite effective in improving overall ability to handle stress than aerobic exercise, thus having an
impact on by improving their quality of life.

As displayed in the Table 4.34 and Fig. 4.34, while none have shown betterment with overall quality of
life in non-intervention group, 34% have improved with aerobic exercise and 60% have shown improved
quality of life with stability ball exercise group, thus substantiating stability ball exercise is nearly two times
effective in enhancing quality of life than aerobic exercise.

4.3.3 Physical parameters

Physical parameters such as heart rate, Blood pressure, Body mass index, waist circumference of all the
participants in this research study were calculated, recorded, tabulated twice once prior to starting the study and
again after the completion of 12 weeks duration of the study. Appropriate statistical methods were applied and
presented as follows:

4.3.3.1 Heart rate

Hypothesis: 1

Aerobic exercises have no impact on heart rate among type 2 diabetic patients. Heart rate of all the
subjects in group I and group II were palpated and recorded twice, once at 0 period, secondly after 12 weeks of
study used paired test for group I and group II their results were as follows:

As in Group I calculated ‘t’ value is lesser than table value, subjects in this group have no influence on
heart rate as proven statistically.

Where as subjects in group II, as the calculated ‘t’ value is higher than the table value, while accepting
alternate hypothesis of aerobic exercises helps to lower heart rate and reject the null hypothesis as proven
statistically at P< .01 level.

148
 Also as shown in the table 4.35, 4.36, and Fig.4.35, lowering of post mean score of heart rate in group II,
by 2, whereas post mean score of heart rate among group has increased by 1.

Hypothesis: 2

Physio ball has no influence on heart rate among Type 2 diabetic patients.

Heart rate of all the subjects in group I and group III were measured twice, first prior to starting the
study, secondly after completion of the study, which was recorded, tabulated and due statistical methods were
applied.

As displayed in the table 4.37 and Fig. 4.36, exercises using physioball were effective in lowering heart rate
is statistically at P<.01, hence while rejecting the Null hypothesis and accepting alternate hypothesis for group
III, the results were insignificant among control group subjects.

Also the mean values obtained from pre and post scores of subjects in Group I and Group III in the
following Table 4.38 and Fig. 4.36, where post mean score among group III have decreased by 4 and post mean
score of heart rate among Group I has increased by I.

4.3.3.2 Body mass index

Hypothesis: 3

Aerobic exercise have no effect on body mass index among type 2 diabetic patients.

Body mass index of all the subjects in group I and group II were calculated once prior to starting the
study and again after 12 weeks duration of study obtained data were recorded, tabulated and relevant statistical
methods were applied as below.

Aerobic exercises were effecting in lowering the body mass index which is statistically significant at
P<.01, hence reject the Null hypothesis and accepting alternate hypothesis while group I subjects have shown
insignificant results on body mass index as shown with statistical means.

As shown in the table 4.39, 4.40 and Fig. 4.37 a reduction of post mean score of BMI among group II by
0.5, whereas post mean score of BMI among group I has increased by 0.26.

Hypothesis: 4

Exercises using physioball have no effect on body mass index (BMI)

149
 Body mass index of all the subjects in group I and group III were calculated, recorded and tabulated
once prior to starting the study, secondly after completion of 12 weeks duration of study, relevant statistical
means were applied as below:

As displayed in the table 4.41, 4.42 and Fig. 4.38, Group III subjects have shown a lowering of body
mass index as proven statistically highly significant at P< 0.01, hence reject null hypothesis and accept alternate
hypothesis that physio ball exercises helps to lower body mass index, while subjects among Group I have
shown insignificant result on body mass index.

Where among group III subjects there is a reduction of BMI by 1.54, whereas Group I subjects BMI has
increased by 0.26.

4.3.3.3 Waist circumference

Hypothesis: 5

Aerobic exercises have no effect on waist circumference among type 2 diabetic patients.

Waist circumference of all the subjects in group I and group II were measured once prior starting the
study secondly after 12 weeks duration of the study obtained values were recorded, Tabulated and the following
results obtained following statistical means.

As displayed in the table 4.43, 4.44 and Fig. 4.39, waist circumference gets lowered with aerobic
exercises, as evident statistically at P< 0.01, hence while rejecting the null hypothesis and accept alternate
hypothesis. Group I subjects waist circumference, the result were insignificant.

Reduction of waist circumference by 0.20cms among Group II subjects, aerobic exercises are effective
among Type 2 diabetic patient, but waist circumference among Group I subjects has increased by 0.22cm.

Hypothesis: 6

Physioball exercises have no effect on waist circumference on Type 2 diabetic patients.

Waist circumference of all the subjects in group I and group III were measured once prior to study and
secondly after completion of 12 weeks duration of the study. Obtained data were recorded, tabulated and
analyzed using due statistical methods as below:

150
 As displayed in the above table 4.45, 4.46 and Fig.4.40, physioball exercises are effective in lowering
the waist circumference among diabetic patients as evidenced statistically highly significant at P< 0.001, hence
while rejecting the null hypothesis and accept alternate hypothesis.

Post mean scores of Group III has decreased by 3.26 cm, hence is effective among type II diabetic
patients, while post mean scores of group I subjects has increased by 0.22cm, which is insignificant.

4.3.3.4 Blood pressure

Hypothesis: 7

Aerobic exercises have no effect on systolic blood pressure.

Systolic blood pressure of all the subjects in group I and group II were measured, recorded, tabulated,
and analyzed using due statistical methods, whose results were as follows.

As shown in the table 4.47, 4.48 and Fig. 4.41, as the results of group II is statistically significant at
p<0.01, hence while rejecting the null hypothesis, accept alternate hypothesis that aerobic exercises are effective
in lowering systolic blood pressure. As noted from the above table reduction of post mean score by 1.52
mm/Hg, in group II, reveals that aerobic exercises are effective in lowering systolic blood pressure, while post
mean score in group I subjects have increased by 4.70 hence is insignificant.

Hypothesis: 8

Physio ball exercises have no effect on systolic blood pressure.

Systolic blood pressure of all the subjects in group I and group III were measured, tabulated, analyzed
with due statistical methods and their results were as follows;

As displayed in the table 4.49, 4.50 and Fig. 4.42 results of group III is statistically significant at P <
0.001, hence while accepting alternate hypothesis and reject null hypothesis, that exercises using Physioball
were effective in lowering systolic blood pressure. Whereas the results of group I were insignificant statistically.

Post mean score of group III subjects have decreased by 3.38 mm/Hg, hence exercises using Physioball
is useful in lowering systolic blood pressure, while post mean scores of group I have increased by 4.70 mm/Hg:
hence it is insignificant.

Hypothesis: 9

Aerobic exercises have no effect on diastolic blood pressure.

151
 Diastolic blood pressure of all the subjects in group I and group II were measured, recorded, tabulated
analyzed using due statistical methods, whose results were as below.

As displayed in the table 4.51, 4.52 and Fig. 4.43 results of group II is significant at P<.01, hence while
rejecting null hypothesis, accept alternate hypothesis that aerobic exercises are effective in lowering diastolic
blood pressure, while results of group I subjects were statistically insignificant.

Post mean score of group II has decreased by 2.60 mm/Hg, hence aerobic exercises are effective in
lowering diastolic blood pressure, while post mean score diastolic blood pressure of group I subjects has
increased by 1.80 mm/Hg hence is insignificant.

Hypothesis: 10

Exercises using Physioball have no effect on diastolic blood pressure.

Diastolic blood pressure of all the subjects in group I and group II were measured, recorded, tabulated
analyzed using due statistical methods, whose results were as follows.

As shown in the table 4.53, 4.54 and Fig. 4.44, results of group III were statistically significant at P<.01,
so while rejecting null hypothesis, accept alternate hypothesis that exercises using Physio ball were effective in
lowering diastolic blood pressure, while the results of group I subjects were statistically insignificant.

Post mean score of group III subjects have decreased by 3.52 mm/Hg, hence is evident that exercises
with Physio ball helps to lower the diastolic blood pressure among type 2 diabetic, while post mean score of
group I subjects have increased by 1.80 hence is insignificant on diastolic blood pressure of type 2 diabetic
patients.

4.3.4. Biochemical parameters

Blood glucose profile including fasting blood sugar (FBS), Post prandial blood sugar (PPBS),
Glycocylated haemoglobin (HbA1C) and lipid profile including total cholesterol, triglycerides, high density
lipoprotein (HDL), Low density lipoprotein (LDL) of all the subjects participated in the study were estimated,
tabulated, analyzed using due statistical methods and their results are as follows:

4.3.4.1. Fasting blood sugar (FBS)

Hypothesis: 11`

Aerobic exercises have no effect on fasting blood sugar in type 2 diabetic patients.

152
 All the subjects fasting blood sugar in group I and group II were estimated and recorded once prior to
study and secondly after 12 weeks completion of the study, it was then tabulated and due statistical methods
were applied as follows:

As displayed in the table 4.55, 4.56 and Fig. 4.45 fasting blood sugar in the subjects of group II were
lowered as proven statistically with P< 0.05, hence reject the null hypothesis and accept alternate hypothesis
that aerobic exercises were effecting in lowering fasting blood sugar among type 2 diabetic patients, where as
the results were insignificant in subjects of group I. As shown in the above table past mean score of group II
has reduced by 9 , whereas post mean score in group I has increased by 7, thus aerobic exercises are effective
on lowering FBS among type 2 diabetic.

Hypothesis: 12

Physioball exercises have no effect on fasting blood sugar among type 2 diabetes patients.

Fasting blood sugar of all the subjects in group I and group III were estimated twice, once prior to the
study and secondly after 12 weeks duration of the study, which was recorded, tabulated and then due statistical
methods were as followed :

The table displays Physioball exercises were effective in lowering FBS as statistically evident at P<
0.001, so while reject the null hypothesis and accept alternate hypothesis of exercises using Physioball were
effective in lowering FBS among Type II diabetic patients. As displayed in the above table 4.57, 4.58 and
Fig.4.46 a reduction of mean value by 15 among group III subjects is evident that exercises using Physio ball
were effective in lowering FBS among Type 2 diabetic patients is evident, where as an increase of FBS by 7
among group I subjects was recorded.

4.3.4.2. Post prandial blood sugar

Hypothesis: 13

Aerobic exercises have no impact on post prandial blood sugar. Post parandial blood sugar of group I
and group II subjects were estimated twice, first at the beginning of the study, secondly after 12 weeks duration
of the study, they were recorded, tabulated and due statistical methods were applied as follows.

As displayed in the table 4.59, 4.60 and Fig 4.47 calculated value of group II is higher than the table
value of group II is higher than the table value, so while reject the hypothesis, accept alternate hypothesis that
aerobic exercises were effective in lowering PPBS among type 2 diabetic patients as P< 0.001, where
insignificant. As displayed in the above table mean values in group II have reduced by 15, hence aerobic
153
exercises influences PPBS among Type 2 diabetic patients is significant, where as post mean scores of group I
have increased by 10.

Hypothesis: 14

Exercises using Physioball have no effect on PPBS.

Post parandial blood sugar of all the subjects in group I and group III were estimated once prior to
starting the study, secondly after completion of 12 weeks duration of the study, were recorded and statistical
ways were applied and due their results as follows.

As displayed in the above table 4.61, 4.62 and Fig. 4.48 as the calculated value is higher than the table
value for group III while receding the hypothesis, accept alternate hypothesis that Physio ball exercises were
effective in lowering PPBS among Type 2 diabetic patients where as results of group I were statistically
insignificant . As the above table displays post mean score among group III subjects have reduced by 23,
whereas post mean score of group I subjects have increased by 10, hence Physio ball exercises were effective in
lowering PBBS among Type 2 diabetic is evident.

4.3.4.3. Glycocylated haemoglobin

Hypothesis: 15

Aerobic exercises have no effect on glycocylated haemoglobin among Type 2 Diabetes patients.

HbA1c (glycocylated haemoglobin) of all the subjects of group I and group II were estimated twice, once
prior to starting the study and again after 12 weeks duration of the study obtained values were recorded,
tabulated due statistical methods were applied and their result as follows.

As displayed in the above table 4.63, 4.64 and Fig. 4.49 as obtained ‘t’ value is greater than the table
value, for group II, reject the null hypothesis and accept alternate hypothesis that aerobic exercises were
effective in lowering HbA1c among Type 2 diabetic patients becomes evident, while the results of group I were
insignificant.

Hypothesis: 16

Physioball exercises have no effect on HbA1c among Type 2 diabetic patients.

154
 HbA1c of all the subjects in group I and group III were estimated twice, first prior to starting study,
secondly after 12 weeks duration of the study obtained values were duly recorded, tabulates and analyzed with
due statistical methods their results as follows.

As shown in the above table 4.65, 4.66 and Fig. 4.50 obtained P, value is greater than the table value,
while rejecting the null hypothesis, accept alternate hypothesis that exercises with Physio ball group III were
effective in lowering HbA1C among Type 2 diabetic patient, while group I subjects were insignificant. As
shown in the above table, post mean score HbA1C of group III has decreased by 0.67% hence physio ball
exercises were evidently helpful in Type II diabetic patients, where as post mean hbA1C of Group I subjects has
increased by 0.28% hence insignificant.

4.3.4.4 Lipid profile

Hypothesis: 17

Aerobic exercises have no role on total cholesterol among Type 2 diabetic patients.

All the subjects in group I and group II’s total cholesterol were estimated once prior to starting the study
and secondly after 12 weeks duration to the study, obtained values were recorded, tabulated and analyzed with
due statistical methods, whose results were as follows.

As displayed in the table 4.67, 4.68 and Fig. 4.51 results of group II were significant , hence accept
alternate hypothesis that aerobic exercises were effective in lowering total cholesterol among Type 2 diabetic
patients, while results of group I were insignificant. As shown in the above table, post mean score of total
cholesterol in group II has decreased by 11 where as post mean score of group I has increased, hence is evident
that aerobic exercises were effective in lowering the total cholesterol among type II diabetic patients.

Hypothesis: 18

Exercises using Physioball have no effect on total cholesterol among type 2 diabetic patients.

Total cholesterol of all the subject's in group I and group III were estimated twice, first prior to starting
the study and secondly after 12 weeks duration of study obtained values were recorded, tabulated and analyzed
with statistical methods, whose results were as follows,

As displayed in the table 4.69, 4.70 and Fig.4.52 results of group III were statistically highly significant
that exercises using Physio ball were effective in lowering total cholesterol where as results of group I subjects
155
were insignificant. As displayed in the Table 3.50, total cholesterol has decreased by 18mg/dl among group III
mean, where as it has increased among group I, hence is insignificant.

Hypothesis: 19

Aerobic exercises have no role on LDL among type 2 diabetic patients.

Low density lipoptotein ( LDL ) of all the subjects in group I and group II were estimated first prior to
the study and secondly after 12 weeks duration of study, obtained values were recorded tabulated and their
results were as follows.

As shown in the table 4.71, 4.72 and Fig. 4.53 results of group II were statistically significant hence
accept alternate hypothesis that aerobic exercises helps to lower LDL among Type 2 diabetic patients, while
results of group I were insignificant .

Hypothesis: 20

Exercises using Physioball have no effect on LDL among Type 2 diabetic patients.

LDL of all the subjects in group I and group III were estimated twice once prior to starting the study
secondly after 12 weeks duration of the study were recorded tabulated analyzed using due statistical methods
and their results were as bellow.

As shown in the table 4.73, 4.74 and Fig. 4.54 results of group III were significant statistically hence
accept alternate hypothesis that exercises using Physio ball were effective in lowering LDL is evident where as
the results of group I subjects were insignificant statistically. As shown in the above table, results of group III
were significant statistically, as lowering of LDL (post mean score, by 10,were as post mean score of LDL in
subject I were increased by 3.

Hypothesis: 21

Aerobic exercises have no effect on triglycerides among type 2 diabetic patients.

Triglycerides of all the subjects in group I and group II were estimated once prior to starting the study
secondly after completion of 12 weeks duration of the study obtained values were recorded ,tabulated analyzed
using due statistical methods and their results were as below:

156
 As displayed in the table 4.75, 4.76 and Fig. 4.55 results of group II were statistically significant, hence
aerobic exercises were effective in lowering triglycerides, among type 2 diabetic patients, while results of group
I subjects were statistically insignificant. As displayed in the above table, as the post mean score in group II has
lowered by 9; hence aerobic exercises were proven to lower triglycerides among type 2 diabetic patients, where
as among group I subjects post mean value of triglycerides have increases by 10.

Hypothesis: 22

Exercises using Physioball have no role on triglycerides among type 2 diabetic patients.

Triglycerides of all the subjects in group I and group III were estimates, tabulated, analyzed using due
statistical methods and their results were as below.

As shown in the table 4.77, 4.78 and Fig. 4.56 results of group III subjects were statistically significant,
hence accept the alternate hypothesis, that exercises using Physio ball were effective in lowering Triglycerides
among type 2 diabetic patients, while results of group I subjects were statistically insignificant. As displayed in
the above table post mean score of group III subjects have decreased by 13, hence are effective in lowering
triglycerides, where as post mean score of group I subjects have increased hence is insignificant.

Hypothesis: 23

Aerobic exercises have no effect on HDL among Type 2 diabetic patients.

HDL of all the subjects in group I and group II were estimated twice, first prior to the study, secondly
after 12weeks completion of the study were recorded, tabulated, analyzed using due statistical methods and
their results were as follows:

As shown in the table 4.79, 4.80 and Fig. 4.57 results of group II and group I were statistically
insignificant, hence accept the null hypothesis that aerobic exercises have no effect on HDL. As displayed in the
above table, post mean value of HDL of group II subjects have by 0.34, while group I subjects post mean value
has by 0.22.

Hypothesis: 24

Exercises using Physioball have no effect on HDL among type 2 diabetic patients.

HDL of all the subjects in group I and group III were estimated once prior to study and secondly after 12
weeks duration of the study, obtained values were recorded, tabulated, analyses using due statistical methods
and their results were as below;
157
 As shown in the table 4.81, 4.82 and Fig. 4.58 results of group III were statistically highly significant,
hence accept alternate hypothesis that exercises using Physio ball were effecting in increasing HDL among type
2 diabetic patients, while results of group I subjects were in significant statistically. As shown in the above table
post mean of HDL score of group III subjects have increases by 1, hence Physio ball exercises were effective in
increasing HDL among type 2 diabetic patients, while post means score among group I subjects have decreased
which is insignificant.

4.4 DISCUSSION

An important aspect of patient care involves an appreciation of the patients Quality of life, a subjective
assessment of what each patient values most such an assessment requires detailed, sometimes intimate
knowledge of the patient, which can usually be obtained only through deliberate, unhurried and often repeated
conversations, Time pressures will always threaten these interactions, but they should not diminish the
importance of understanding and seeking to full fill the priorities of the patient (Fauci et al., 2010). Obesity is
the driving force behind the metabolic syndrome. Thus weight reduction is the primary approach to the disorder.
With weight reduction, the improvement in insulin sensitivity is often accompanied by favorable modifications
in many components of the metasyndrome. In general recommendations for weight loss includes a combination
of caloric restriction, increased physical activity and behavior modification. For weight reduction, caloric
restriction is the most important component, where as increases in physical activity are important for
maintenance of weight loss greater weight loss from visceral depot is evidenced when caloric restriction +
exercises are combined (Ford, 2005).

As with any chronic debilitating disease Individual with DM faces a series of challenges that affect all
aspects of daily life. The individual with DM must accept that he or she develop complications related to DM.
Emotional stress may provoke a change in behavior so that individuals no longer adhere to a dietary, exercise,
or therapeutic regimen. This can lead to the appearance of either hyper or hypoglycemia. Eating disorders,
including binge eating disorders bulimia and anorexia nervosa, appear to occur more frequently in individuals
with type II DM (Egede and Zheng, 2003). Life style Factors contributing to obesity such as an imbalance
between caloric in -take and energy expenditure, lack of physical activity and a diet rich in saturated fats and
refined sugars, contribute in large part to the lipid and lipoprotein lipid levels in a population (Williamson et al,
2009).

Based on subjective evaluation on their personal life relative to the quality of life in the present study
subjects among aerobic exercise group showed an increase in post mean score by 12.5% and among Physioball
subjects an increased post mean score by 27%, while among control group subjects a decrease of post mean

158
score by 5%; thus its evident that Physio ball is more than two times effective in improving subjective feelings
on their personal life relative to qualities of life, a major outcome of this study.

Subjective evaluation based on their feelings of their wife relative to the quality of life was shown in the
present work. Subjects in aerobic group have an increased post mean score by 9 % and 11% increase was
recorded among Physioball subjects, while control group subjects a decreased score by 17%. Thus indicating
both aerobic and Physioball exercises have a marginal improvement in improving feelings of the subjects of
their wife relative to the quality of life, as outcome of this study.

With regard to the feelings of the participation their romantic life relative to quality of life the present
work shows an increase among aerobic exercise group by 6.10% and among Physioball group an increase by
28.41%, while control group subjects have a decrease by 7.89% indicating Physioball exercises are four times
effective in improving feelings of romantic life relative to the quality of life, a major outcome of this study.

With reference to subjects feelings on their role relative to quality of life,

a decrease of 8.57% among control group subjects, an increase by 9.32% among aerobic subjects and 25.51 %
increase in post mean score by Physioball exercises in subjects, indicating Physioball is 2.5 times effective man
aerobic exercises among Type II diabetic patients in improving their feelings on role relative to quality of life
being a major outcome of this study.

Based on subjective feelings on their coworkers relative to quality of life , a decreased post mean is by
8.33 among control group, while aerobic subjects have an increased score by 17.14 % and Physioball subjects
have an increased score by 31. 61 %; Thus it is evident that Physioball is 1.8 times effective than aerobic
exercises in improving feelings of subjects on their coworkers , relative to the quality of life , a major outcome
of the study.

Subjective evaluation on their actual work they do relative to quality of life by participants of this study,
there is a decrease of score among control group subjects by 10.53%, while an increased score noted among
Aerobic exercise group by 11.87% and 31.35% increase score among Physioball subjects indicating that Physio
ball is 2.8 times effective than aerobic exercises in improving subjects feeling on actual work what they do
relative to quality of life, a major outcome of this study.

Subjective evaluation of all the participants in handling of their problems in life relative to quality of
life, control group subjects have a decreased score by 7% while Aerobic subjects had an increases score by 15
% and Physio ball subjects had an increased score by 23% , is evident that Physioball exercises are effective by

159
1.5 times than aerobic exercises among Type II Diabetes in improving their ability to handle problems in life,
relative to quality of life , a major outcome of this study .

Based on the subjective evaluation of their feelings on actual accomplishing in their life relative to
quality of life , that control group subjects had a decrease score by 8 % , while Aerobic subjects have an
increased score by 6.32 % and Physio ball subjects with an increased score by 27% , depicting that Physioball
exercises are 4 times effective than aerobic exercises in the improvement on their subjects feeling on actual
accomplishment in their life.

Subjective evaluation based on their physical appearance, the way they look to others relative to quality
of life, control group subjects have a decreased score by 11% while Aerobic exercise group subjects have an
increased score by 14 % , and Physioball subjects have an increased score by 20 % thus indicating that
Physioball is 1.4 times effective in improving their physical appearance, the way they look to others , relative to
quality of life ,being a major findings of this study.

Based on subjective evaluation of all the participants feelings on self, relative to quality of life, control
group subjects have a decreased score by 11 % while Aerobic subjects had an increased score by 9 % and
Physioball subjects had an increased score by 24% thus indicating that Physioball exercises are 2.7 times
effective than aerobic exercises in improving their feelings on self, relative to the quality of life on Type II
diabetic patients, a major outcome of this study .

Based on the subjective feeling of all the participants on ability to change in their life, control group
subjects have a decreased score by 14 %, while Aerobic subjects have an increased score by 10 %, and
Physioball subjects have an increased score by 22 % ,thus indicating that Physioball exercises are 2.2 time
effective than aerobic exercises in improving ability to change their life , relative to quality of life , a major
outcome of the study.

Evaluation of all the participants based on their feelings on their life as a whole, relative to the quality of
life, control group subjects have a decreased post mean score by 15% , while Aerobic subjects have an increased
post mean score by 5% , and among Physioball subjects an increased post mean score by 31 % thus is evident
that Physioball exercises are 6 times effective than aerobic exercises in improving feeling on their life, relative
to quality of life , being a major outcome of this study .

Subjective evaluation of all the participants over all contentment with their life, relative to quality of life,
control group subjects have a decrease score by 18 % , while an improved score among aerobic exercises by 6%
and Physio ball subjects have an improved score by 21% ,hence is indicating that Physioball exercises are 3.5

160
times effective than aerobic exercises in improving overall contentment with their life relative to quality of life
remains a major outcome of this study .

Based on all the subjects subjective evaluation on the extent of which life has been as they want it,
relative to the quality of life, among control group a decrease of post mean score is by 17% while an improved
post mean score among Aerobic group by 8% and among Physioball group by an increase of 18% , thus is
evident that Physioball exercises are 2.25 times effective than Aerobic exercises in improving the extent of
which life has been as they want it ,relative to the quality of life, being a major outcome of this study .

Results of overall subjective scores on quality of life by all the participants from 14 point questionnaire
show among control group a decreased post mean score by 6% , while Aerobic subjects had an increased post
mean score by 10. 64% and Physioball subjects had an increased post mean score by 26%. Thus is evident that
Physioball exercises are 2.4 times effective than aerobic exercises in Improving overall quality of life based on
14 items stated in the questionnaire , related to their quality of life. Results of 5 subjective questions of all the
subjects based on their overall physical well being, over all emotional state, over all ability to handle stress
,over all enjoyment of life and overall quality of life processed once at the end of the study are discussed as
below .

Subjective evaluation of all the participants on their overall physical well being as the outcome of the
study reveal that control group subjects 4% have improved and 70 % of Physioball have improved on their
overall physical well being as the outcome of the study, clearly shows Physioball exercises to be more than two
times effective in improving overall physical well being , among type II subjects , as a major outcome of this
study .

Subjective evaluation of all the participants on their overall emotional state at the completion of the
study reveal that no subjects have improved among control group, 14% have improved post mean scores among
aerobic exercise group and 56% of the subjects have improved among Physioball group , indicating that
Physioball exercises are 4 times effective in improving their overall emotional state a major findings of this
study .

Based on subjective evaluation of all the participants on their overall enjoyment of life on completion of
the study, no subjects have shown betterment among control group while 34% of subjects felt better among
Aerobic group and 62% of the Physioball group felt better, thus indicating that Physioball exercises are 1.8
times effective than aerobic exercises in improving participations over all feelings of enjoyment of life among
Type II diabetic patients, being a major outcome of this study.

161
 Subjective evaluation of all the participants on their overall ability to handle stress upon completion of
the study, none of the control group subjects have improved, 18 % subjects among aerobic group have improved
and 58% have shown betterment among Physioball group thus is evident that Physioball exercises are 3.2 times
effective than Aerobic exercises in improving overall ability to handle stresses among Type II Diabetes , being a
major findings of this study .

Results of subjective evaluation of all the participants on their overall quality of life at the completion of
study, none of the control group subjects have shown better, while 34% among Aerobic group have improved
and 60% of the Physio ball subjects have shown betterment , hence it is evident that Physioball exercises are
1.76 times effective than Aerobic exercises in improving overall quality of life among Type II diabetes being a
major outcome of this study.

Apart from medical management, subjective perceptions or feelings, the resultant style of coping and
adaptation to the resultant physical and physiological changes in an individual with chronic diseases leads to
acceptance of the resultant objective limitations (Moos, 1977). A lower level functioning, isolation, resection of
oneself, loss of appreciation escape into nihilism are mal adaptive (Ellis,1973). Cognition and motivation are
the major determinants of individual functioning (Dollard and Miller, 1950), stress and emotions to the result of
individuals cognitive functioning (Kirtz and Moos, 1974). Identical physical or physiological damage will result
in different level a of physical challenges when affecting different individuals (Bourestorm and Horward,
1965).

Emotional factors and emotional disruption are primary contributors to accidents and debilitating disease
(Wittkower, 1969). Psychological factors play an undeniable role in the development of disease (Henry and
Stephens, 1977) and psychosomatic theory posts that physical illness may be secondary to an emotional
condition and should be treated as such (Wool-folk and Lehrer, 1984). Cognitive dysfunction occurs in type II
diabetes with hyperglycemia (Morley and Flood, 1990) and chronic diabetes have an increased prevalence of
depression (Naliboff and Rosenthal, 1989). Quality of life issues involve the patients feelings of self worth
satisfaction with life, functional status or activity level and level of symptom control. These areas are subjective
involved individual values and when measured can be reported differently by the patient (Aaranson, 1991).
Restoration of function with adequate rehabilitation services does not necessarily imply a significant or
meaningful improvement in quality of life (Verville 1990). Outcome of a medical treatment, surgical procedure
or any therapeutic intervention should not only rely on laboratory or clinical indicators or functional outcome
but the yardstick to measure the impact of the intervention is by subjective evaluation of his physical health,
mental well being and his quality of life (Fuhrer, 1987). The concept of quality adjusted life years (QUALYS)
represents a recently proposed method of cost of effectiveness analysis for general medicine. QUALYS
162
compare the relative worth of medical procedures or services by assigning a single numeric value weighed by
expected survival time and quality of life. The value of living or quality of life for a individual given a particular
state of health is measurable and can be inferred from community opinion developed through consensus
(Verville, 1990). Grading service intensity to the needs of the patients rather than to a legislative standard and an
useful approach is cost effective care with both the process of rehabilitation as well as the results (Stireman and
Williams, 1990)

An important aspect of patient care involves an appreciation of the patients Quality of life, a subjective
assessment of what each patient values most such an assessment requires detailed, sometimes intimate
knowledge of the patient, which can usually be obtained only through deliberate, unhurried and often repeated
conversations, Time pressures will always threaten these interactions, but they should not diminish the
importance of understanding and seeking to full fill the priorities of the patient (Fauci et al., 2010). Obesity is
the driving force behind the metabolic syndrome. Thus weight reduction is the primary approach to the disorder.
With weight reduction, the improvement in insulin sensitivity is often accompanied by favorable modifications
in many components of the meta syndrome. In general recommendations for weight loss includes a combination
of caloric restriction, increased physical activity and behaviour modification. For weight reduction, caloric
restriction is the most important component, where as increases in physical activity are important for
maintenance of weight loss greater weight loss from visceral depot is evidenced when caloric restriction +
exercises are combined (Ford, 2005).

With any chronic debilitating disease individual with DM faces a series of challenges that affect all
aspects of daily life. The individual with DM must accept that he or she develops complications related to DM.
Emotional stress may provoke a change in behavior so that individuals no longer adhere to a dietary, exercise,
or therapeutic regimen. This can lead to the appearance of either hyper or hypoglycemia. Eating disorders,
including bulimia and anorexia nervosa, appear to occur more frequently in individuals with type II DM (Egede
and Zheng, 2003). Life style factors, contributing to obesity such as an imbalance between caloric in take and
energy expenditure, lack of physical activity and a diet rich in saturated fats and refined sugars, contribute in
large part to the lipid and lipoprotein lipid levels in a population (Williamson et al., 2009).

163
 TABLE 4 – 1: BASED ON THE AGE OF THE SUBJECTS:

SNO AGE (Yrs) FREQUENCY PERCENTAGE %

38
1 31 - 40 41 32 21
2 41 - 50 57 38
3 51 - 60 61 41

21

164

51 - 60 years 41 - 50 years 31 - 40 years

 Fig. 4-1 Percentage of distribution of subjects based on age of the subjects.

TABLE 4 – 2: FAMILY HISTORY OF DIABETES AMONG RESPONDENTS:

40

36
SNO 35 FAMILY MEMBERS FREQUENCY PERCENTAGE %
1 MOTHER 42 28
2 30 FATHER 25 17
28
3 BOTH 54 36
4 25 NIL 12 8
5 NOT KNOWN 17 11
20
17

15

11
10
8

5
165

0
Mother Father Both Nil Not Known
 Fig. 4 -2: Displaying Family history of diabetes among participants.

TABLE 4 - 3: DURATION OF DIABETES OF THE PARTICIPANTS

SNO AGE (Yrs) FREQUENCY PERCENTAGE %

1 1-5 104 69
2 6 – 10 36 24
3 11 - 15 6 4
4 16 - 20 4 3 4 3

24

69

166

1 - 5 years 6 - 10 years 11 - 15 years 16 - 20 years

 Fig. 4 .3 Data on duration of being diabetic among the respondents

TABLE 4.– 4: DISTRIBUTION OF SUBJECTS BASED ON INSULIN THERAPY

SNO INSULIN THERAPY FREQUENCY PERCENTAGE%

1 Not taken 121 81
2 Has taken once 21 14
3 Has taken more than twice 8 5

90

81
80

70

60

50

40

30

20
14
10
5

0 167
Has taken insulin once
Has not taken insulin Has taken insulin more than twice
 Graph 4 -4: DISTRIBUTION OF SUBJECTS BASED ON INSULIN THERAPY

TABLE 4– 5: TYPE OF MEDICATIONS PRESCRIBED BY PHYSICIAN

SNO DIABETIC FREQUENCY PERCENTAGE%

MEDICATIONS
1 Metformin 66 44
2 Sulphonyl urea 53 35
3 Metformin + Sulphonyl urea 26 17
4 Oral hypoglycaemic agents 5 4

50
45
44
40
35
35
30
25
20 17
15
10
5
4
0
Subjects on sulphonyl urea

Metformin + Sulphonyl urea

Subjects on Metformin

Subjects on OHA

168
 Fig. 4.5: Subjects based on the type of diabetic medication they are prescribed with.

TABLE 4 – 6: SAMPLE DISTRIBUTION BASED ON NEUROPATHY

SNO NEUROPATHY FREQUENCY PERCENTAGE%

1 Those who have 33 22
2 Those who Don't have 117 78

22

78

169

Subjects with neuropathy Subjects without neuropathy

 Fig. 4.6: Subjects’ distribution based on neuropathy.

TABLE 4 – 7: SAMPLE DISTRIBUTION BASED ON EYE COMPLICATIONS

SNO EYE COMPLICATIONS FREQUENCY PERCENTAGE %

1 Who Dont have 129 86
2 Cataract 8 5
3 Glaucoma 13 9

86

Subjects don't have eye problems Subjects with glaucoma

Subjects with cataract 170
 Fig. 4.7Subjects proportion based on their eye cmplications.

TABLE 4– 8: SUBJECTS COMPOSITION WITH KNOWN HEART AILMENTS

SNO HEART AILMENTS FREQUENCY PERCENTAGE %

1 Who don’t have heart 89 59
ailment
2 Who have heart 61 41
ailment

100

90

80

70

60
59

50

41
40

30

20

10

0 171

Subjects with no known heart ailment Subject with known heart ailment
 Fig. 4.8 Subjects’ proportion based on known heart ailments.

TABLE 4 – 9: COMPOSITION OF SUBJECTS WITH MUSCULOSKELETAL AILMENTS

SNO MUSCULOSKELETAL FREQUENCY PERCENTAGE %

AILMENTS
1 Leg 27 18.5
2 Spine 23 15
3 Arm 25 17
4 Nil 50 33
5 All Joints 11 7
6 Leg + Arm 5 3
7 Leg + Spine 7 5
8 Spine + Arm 2 1.5

50

45

40

35 33

30

25

20 18.5
17
15
15

10
7
5
5 3
1.5
0

Subjects with leg issue Subjects with spine problems

Subjects with arm problems Subjects with nil complains
Subject with all joint problems Subject with leg & Arm issue 172
Subjects with leg & spine issue Subjects with spine & arm issue
 Fig. 4.9 Subjects’ distribution based on their musculoskeletal ailments

TABLE 4 – 10: SUBJECTS DISTRIBUTION BASED ON FOOD HABITS:

SNO FOOD HABITS FREQUENCY PERCENTAGE %

1 Vegetarian 55 37
2 Non- Vegetarian 95 63

37

63

Vegetarians Non Vegetarians

173
 Fig. 4.10 Subjects’ proportion based on their food habits.

TABLE 4 – 11: PARTICIPANTS DISTRIBUTION BASED ON SMOKING

SNO SMOKING FREQUENCY PERCENTAGE %

1 Smokers 64 43
2 Non Smokers 86 57

43

57

Smokers Non Smokers

Fig. 4.11 Participants proportion based on their habits of smoking.

174
 TABLE 4 – 12: SUBJECTS CATEGORIZATION BASED ON ALCOHOL CONSUMPTION

SNO ALCOHOL FREQUENCY PERCENTAGE %

CONSUMPTION
1 Alcoholics 79 53
2 Non Alcoholics 71 47

47

53

Alcoholics Non Alcoholics

Fig. 4.12 Sample distribution based on their habit of alcohol consumption

175
 TABLE 4 – 13: PARTICIPANTS DISTRIBUTION BASED ON NATURE OF OCCUPATION

SNO OCCUPATION FREQUENCY PERCENTAGE %

1 Desk work 67 45
2 Sedentary 50 33
3 Physical activity 33 22

100

90

80

70

60
Percentage

50
45

40
33
30

22
20

10

0
Nature of work
Subjects with desk work nature
Subjects with sedentary nature
Subjects where physical activity involved

Fig. 4.13 Participants distribution based on the nature of occupation.

TABLE 4 – 14: CLASSIFICATION OF SAMPLE BASED ON MEDICATION

176
 SNO MEDICATION FREQUENCY PERCENTAGE %
1 Only antihypertensive 43 29
2 Anti cholesterol 6 4
3 Anti depressant 1 1
4 Anticoagulant 6 4
5 NIL 66 44
6 Anti depressant + Anti hypertensive 2 1
7 Antihypertensive + Anticoagulant 14 9
8 Anticholesterol + Anticoagulant 3 2
9 Antihypertensive + Anticholesterol 9 6

50
45 44

40
35
30 29
Percentage

25
20
15
10
9
6
5 4 4
1 1 2
0
Only antihypertensive Anti cholesterol
Anti depressant Anticoagulant
NIL Anti depressant + Anti hypertensive
Antihypertensive + Anticoagulant Anticholesterol + Anticoagulant
Antihypertensive + Anticholesterol

Fig. 4.14 Type of medication participants were on other than diabetic medication

TABLE 4.15: RESULTS OF SUBJECTIVE EVALUATION BASED ON THEIR PERSONAL LIFE RELATIVE
TO THE QUALITY OF LIFE

PERSONAL LIFE Group I Group II Group III

Pre test mean score 4 3.58 3.82
Post test mean score 3.5 3.76 4.80

177
 6

5 4.8

4
4 3.76 3.82
3.5 3.58
Personal life

0
Group I Group II Group III

Pre test mean Post test mean

Fig. 4.15: Subject's subjective feelings based on their personal

life relative to the quality of life

TABLE 4.16: RESULTS OF SUBJECTIVE EVALUATION BASED ON FEELINGS OF THEIR WIFE REATIVE
TO QUALITY OF LIFE:

FEELINGS ON
Group I Group II Group III
WIFE
Pre test mean score 4.20 3.28 4.60
Post test mean score 3.50 3.76 4.96

178
 6

4.96
5
4.6
4.2
4
Significance of wife

3.5 3.6
3.28

0
Group I Group II Group III

Pre test mean Post test mean

Fig. 4.16: Subject's feelings based on significance of their wife

relative to the quality of life
5

4.54
4.5

4 3.8
3.5 3.48 3.52
TABLE
3.5 4.17: RESULTS OF PARTICIPANTS FEELINGS ON THEIR ROMANTIC LIFE RELATIVE TO
3.28
QUALITY OF LIFE
3
Romantic life

2.5 FEELINGS ON
Group I Group II Group III
ROMANTIC LIFE
2
Pre test mean score 3.8 3.28 3.52
1.5 Post test mean score 3.5 3.48 4.54

0.5

179
0
Group I Group II Group III
Pre test mean Post test mean
 Fig. 4.17: Reflecting subjective evaluation of participants of pre and post mean scores on their romantic life
relative to quality of life

5 TABLE 4.18: SUBJECTIVE EVALUATION ON THEIR JOB RELATIVE

4.89TO QUALITY OF LIFE:

JOB RELATIVE
Job relative to quality of life

4 Group I Group II 3.92III

Group
TO QOL 3.52
3.5
Pre test mean
3.2 score 3.5 3.2 3.2 3.92
3 Post test mean score 3.2 3.52 4.89

180
0
Group I Group II Group III
Pre test mean Post test mean
 Fig. 4.18 Subject's feelings on their job relative to quality of life

5
4.58
4.5
TABLE 4.19: SUBJECTS FEELINGS ON THEIR CO WORKERS RELATIVE TO QUALITY OF LIFE
4
3.6 3.56
Subject's feelings on 3.5 3.48
3.5 3.3 Group I Group II Group III
their co-workers
3 Pre test mean score 3.6 3.5 3.48
Co workers

Post test mean score 3.3 3.56 4.58

2.5

1.5

0.5

181
0
Group I Group II Group III
Pre test mean Post test mean
 Fig. 4.19 Subject's feelings on their co workers relative to quality of life

TABLE 4.20: SUBJECTS FEELINGS ON ACTUAL WORK THEY DO RELATIVE TO QUALITY OF LIFE

Actual work what Group I Group II Group III

6 they do
Pre test mean score 3.8 3.20 3.7
5 Post test mean score 3.4 3.58 4.86 4.86

4 3.8 3.7
3.4 3.5
What they do

3.2
3

182
0
Group I Group II Group III
Pre test mean Post test mean
 Fig. 4.20: Displaying pre & post mean scores of all the subject's subjective feelings on actual work they do

TABLE 4.21: RESULTS OF SUBJECTIVE EVALUATION OF HANDLING OF PROBLEMS IN LIFE

Handling of
problems in the Group I Group II Group III
participants life
Pre test mean score 4.2 3.34 4.86
Post test mean score 3.7 3.62 6
7

6
6

5 4.86
Handling of problems in life

4.2
4 3.7 3.62
3.34

1
183
0
Group I Group II Group III
Pre test mean Post test mean
Fig. 4.21: Showing pre and post mean scores of subjective evaluation of all subjects on their handling of problems
in life.

TABLE 4.22: RESULTS OF SUBJECTIVE FEELINGS EVALUATION ON SUBJECTS ACTUAL

ACCOMPLISHING IN THEIR LIFE RELATIVE TO QUALITY OF LIFE:

Actual accomplishment
Group I Group II Group III
in life
Pre test mean score 3.7 3.48 3.75
Post test mean score 3.4 3.70 4.8

5 4.8
Actual accomplishment in life

4 3.75
3.7 3.7
3.4 3.48

184
0
Group I Group II Group III
Pre test mean Post test mean
 Fig. 4.22: Showing pre and post mean scores of subjective evaluation of all subjects on actual accomplishing in
their life relative to the quality of life.

TABLE 4.23: SUBJECTIVE FEELINGS ON THEIR PHYSICAL APPEARANCE - THE WAY THEY LOOK TO
OTHERS RELATIVE TO QUALITY OF LIFE

Physical appearance – the

Group I Group II Group III
way they look to others
Pre test mean score 3.82 3.20 4.00
Post test mean score 3.40 3.64 4.80

5 4.8

4
4 3.82
3.64
Physical appearance

3.4
3.2
3

185
0
Group I Group II Group III
Pre test mean Post test mean
 Fig. 4.23: Showing pre and post mean scores of all subject's subjective evaluation on their physical appearance

TABLE 4.24: SUBJECTIVE FEELING ON SELF, RELATIVE

TO QUALITY OF LIFE

Feelings on self Group I Group II Group III

Pre test mean score 3.94 3.18 3.70
Post test mean score 3.50 3.46 4.60

5
4.6
4.5

4 3.94
3.7
3.5 3.46
3.5
3.18

2.5
Self

1.5

0.5

0
Group I Group II Group III

Pre test mean Post test mean

186
 Fig. 4.24: Showing pre and post mean scores of subjective evaluation of their feelings on themselves relative to
quality of life.

TABLE 4.25: SUBJECTIVE FEELINGS ON THEIR ABILITY

TO CHANGE IN THEIR LIFE

Ability to change in life Group I Group II Group III

Pre test mean score 3.96 3.14 3.60
Post test mean score 3.40 3.44 4.40

4.5 4.4

3.96
4

3.6
3.5 3.4 3.44

3.14
Ability to change in life

2.5

1.5

0.5

0
Group I Group II Group III

Pre test mean Post test mean

187
 Fig. 4.25: Displaying pre and post mean scores of all the subjects feelings on their ability to change in their life,
relative to the quality of life

TABLE 4.26: RESULTS OF SUBJECTS FEELING ON THEIR LIFE AS A WHOLE, RELATIVE TO THE
QUALITY OF LIFE

Life as a whole Group I Group II Group III

Pre test mean score 3.78 3.48 3.50
Post test mean score 3.20 3.64 4.60

5
4.6
4.5

4
3.78
3.64
3.48 3.5
3.5
3.2

3
Life as a whole

2.5

1.5

0.5

0
Group I Group II Group III

Pre test mean Post test mean

Fig. 4.26: Displaying pre and post mean scores on subjective feelings on their life as a whole, relative to the quality
of life

188
 TABLE 4.27: RESULTS OF SUBJECTS EVALUATION ON OVERALL CONTENTMENT WITH THEIR LIFE

Overall contentment Group I Group II Group III

with their life
Pre test mean score 3.90 3.34 3.70
Post test mean score 3.20 3.54 4.46

4.46
4.5

4 3.9
3.7
3.54
Overall contentment with their life

3.5 3.34
3.2

2.5

1.5

0.5

0
Group I Group II Group III

Pre test mean Post test mean

Fig. 4.27: Showing pre and post mean scores of subjective evaluation on their overall contentment with life, relative
to the quality of life

189
 TABLE 4.28 RESULTS OF SUBJECTIVE EVALUATION ON THE EXTENT OF WHICH LIFE HAS BEEN AS
THEY WANT IT

Extent of which life has Group I Group II Group III

been as they want
Pre test mean score 4.20 3.54 3.70
Post test mean score 3.50 3.84 4.36

5
.

4.5 4.36
4.2

4 3.84
3.7
Extent of life has been they want it

3.5 3.54
3.5

2.5

1.5

0.5

0
Group I Group II Group III
Pre test mean Post test mean

Fig. 4.28: Showing pre and post test mean scores of all the subjects on their extent of life has been as they want

190
 TABLE 4.29: SHOWING RESULTS OF OVERALL SUBJECTIVE SCORES ON QUALITY OF LIFE BY ALL
THE PARTICIPANTS BEFORE AND AFTER STUDY FROM 14 POINT QUESTIONNAIRE:

Overall percentage of
subjective scores on 14
Group I Group II Group III
items of quality of life
questionnaire
Pre test mean score 50 47 51
Post test mean score 47 52 64
RESULT -3 +5 + 13

70
64

60

52 51
50
50
47 47
Percentage of quality of life

40

30

20

10

0
Group I Group II Group III
Pre test mean Post test mean

Fig. 4.29: Showing overall percentage of pre and post mean scores of all the participants subjective evaluation on
their qality of life from 14 point questionnaire.

TABLE 4.30: SUBJECTIVE EVALUATION ON OVER ALL PHYSICAL WELL BEING AS OUTCOME OF THE
STUDY

191
 Group I Group II Group III
Better 4 32 70
Same 64 66 30
Worse 28 2 -

80

70
70

60
Overall physical well being

50

40
32 32 33
30

20
15 14

10
4
2
0
Better Same Worse
Group I Group II Group III

Fig. 4.30: Showing subjective evaluation on their overall physical well being as outcome of the study.

TABLE 4.31: THE PARTICIPANTS SUBJECTIVE EVALUATION ON THEIR OVER ALL EMOTIONAL
STATE AT THE COMPLETION OF THE STUDY

Group I Group II Group III

192
 Better 0 14 56
Same 58 84 44
Worse 42 2 -

90
84

80
Overall percentage of emotional state

70

60 58

50
44
42 42
40

30

20

10
2 2
0 0
0
Better Same Worse
Group I Group II Group III

Fig. 4.31: Showing percentage of overall emotional state of participants subjective evaluation as outcome of the
study

TABLE 4.32: SUBJECTIVE EVALUATION OF OVERALL ENJOYMENT OF LIFE

Group I Group II Group III

Better 0 34 62
Same 76 62 38
Worse 24 4 -
193
 80
76

70

62 62
Overall percentage of enjoyment of life

60

50

40 38
34

30
24

20

10
4
0 0
0
Better Same Worse
Group I Group II Group III

90

Fig.804.32: Showing percentage of overall enjoyment

78 of life by subjective evaluation on completion of the study

70

62
Overall ability to handle stress

60
TABLE 4.33: SUBJECTIVE EVALUATION OF OVERALL ABILITY TO HANDLE STRESS
50

Group I Group II Group III

40 38
Better 0 18 58
30 Same 62 78 42
Worse 38 4 -
20 18

10
4
0
194
0
Better Same Worse

Group I Group II Group III

 Fig. 4.33: Showing percentage of overall subjective evaluation of all the participants ability to handle stress up on
completion of the study.

90
84
TABLE
80
4.34: SUBJECTIVE EVALUATION ON OVERALL QUALITY OF LIFE

70
Group I Group II Group III
Better
60
0 34 60 60
Overall Quality of life

Same 84 60 40
50
Worse 16 6 -

40
34

30

20 16

10
6
195
0
0
Better Same Worse
Group I Group II Group III
 Fig. 4.34: Showing subjective evaluation on their quality
of life at the completion of study.

Table 4.35 = results of paired t test of group I and group II on heart rate

Heart Rate Standard Deviation Standard Error Result

Group I .03 .004 P>.1

Group II 4.57 .65 P<.01

Table 4.36 mean scores of group I and group II on heart rate

196
 Heart Rate Pre Mean Score Post Mean score Result

Group I 84 85 +1

Group II 90 88 (-) 2

Table 4.37 Results of paired‘t’ of Group I and Group III on Heart rate

Heart Rate Standard Deviation Standard Error Result

Group I .03 .004 P >.1

Group III 7.82 1.11 P<.001

Table 4.38 mean scores of Group I and Group III on heart rate

Heart Rate Premean score Post mean score Result

Group I 84 85 +

Group III 85 82 -4

Table 4.39 paired‘t’ test of Group I and II on body mass index

Heart Rate Standard Deviation Standard Error Result

Group I .44 .06 P>.1

197
 Group II 1.13 .16 P<.01

Table 4.40 Mean scores of group I and group II on body mass index.

Heart Rate Premean score Post mean score Result

Group I 28.22 28.48 + .26

Group II 26.78 26.28 (-) .5

Table 4.41 Results of paired‘t’ test of group I and group III on Body mass index

Group Standard Deviation Standard Error Result

Group I .44 .06 P>.1

Group III 4.12 .40 P< .001

Table 4.42 Results of mean scores of Group I and Group III

Group Pre Mean Score Post Mean Score Result

Group I 28.22 28.48 (+) .26

Group III 27.50 26.14 (-) 1.54

198
Table: 4.43 Results of paired‘t’ test of Group I and Group II on waist circumference

Group Standard Deviation Standard Error Result

Group I .89 .13 P>.1

Group II 2.81 .40 P< .10

Table 4.44 Mean scores of Group I and group II on waist circumference.

Group Premean score Post mean score Result

Group I 95.22 95.44 + .22

Group II 94.66 93.46 ( - ) .20

Table 4.45 Results of paired‘t’ test of group I and group III on waist circumference

Group Standard Deviation Standard Error Result

Group I .89 .13 P>.1

Group III 7.50 1.06 P< .001

199
Table 4.46 Mean values of Group I and Group III on waist circumference

Group Pre mean score Post mean score Result

Group I 95.22 95.44 + .22

Group III 93.46 89.80 ( - ) 4.66

Table: 4.47 Results of paird‘t’ test of group I and group II on systolic blood pressure.

Group Standard Deviation Standard Error Result

Group I 1.94 .24 p>.1

Group II 5.09 .72 P<.05

Table: 4.48 Results of mean score among group I and group II systolic blood pressure.

Group Pre mean score Post mean score Result

Group I 122.56 127.26 4.70

Group II 122.56 121.04 1.52

200
Table: 4.49 Results of paird ‘t’ test of group I and group III on systolic blood pressure.

Group Standard Deviation Standard Error Result

Group I 1.94 .27 p>.1

Group III 6.60 .93 P<.001

Table: 4.50 Results of mean score of group I and group III on systolic blood pressure.

Group Pre mean score Post mean score Result

Group I 122.56 127.26 + 4.70

Group III 128.02 124.68 - 4.48

Table : 4.51 Results of paird ‘t’ test of group I and group II on diastolic blood pressure.

Group Standard Deviation Standard Error Result

Group I 1.67 .24 p>.1

Group II 5.73 .81 P<.05

Table : 4.52 Results of mean score of group I and group II on diastolic blood pressure.

201
 Group Pre mean score Post mean score Result

Group I 81.86 83.66 + 1.80

Group II 81.86 79.60 - 2.26

Table: 4.53 Results of paird ‘t’ test of group I and group III on diastolic blood pressure.

Group Standard Deviation Standard Error Result

Group I 1.67 .24 p>.1

Group III 6.87 .97 P<.001

Table: 4.54 Results of mean score of group I and group III on diastolic blood pressure.

Group Pre mean score Post mean score Result

Group I 81.86 83.66 + 1.80

Group III 84.76 81.24 - 4.52

Table: 4.55 Results of paired‘t’ test of group I and group II on fasting blood sugar

Group Standard Deviation Standard Error Result

202
 Group I 4.69 .52 P>.1

Group II 18 2.57 P<.05

Table 4.56 Mean scores of group I and group II on fasting blood sugar.

Group Pre Mean Score Post Mean Score Result

Group I 145.52 152.62 +7

Group II 143.08 134.08 -9

Table: 4.57 Results of paired‘t’ test on group I and group III on FBS

Group Standard Deviation Standard Error Result

Group I 3.69 .52 P>. 1

Group III 25.26 4.57 P< .001

Table 4.58 Results of mean scores of group I and group III on FBS.

Group Pre mean score Post mean score Result

Group I 145.52 152.62 +7

203
 Group III 143 138 -9

Table: 4.59Result of paired‘t’ test of group I and group II on PPBS (post parandial
blood sugar)

Group Standard Deviation Standard Error Result

Group I 5.50 .78 P>. 1

Group II 6.56 .93 P< .001

Table. 4.60 Results of mean scores of PPBS on group I and group II

Group Pre mean score Post mean score Result

Group I 190 200 + 10

Group II 193 178 - 15

Table: 4.61 Result of paired‘t’ test of group I and group III on PPBS.

Group Standard Deviation Standard Error Result

Group I 5.50 .78 P>.1

Group III 5.33 .75 P<.001

204
Table: 4.62 Results of mean scores among group I and group III on PBBS.

Group Premean score Post mean score Result

Group I 190.34 200 + 10

Group III 201.6 178.86 - 24

Table: 4.63 Results of paired‘t’ test of group I and group II on HbA1c

Group Standard Deviation Standard Error Result

Group I .28 .04 P>.1

Group II .66 .09 P<.01

Table: 4.64 Results of mean scores of group I and group II on HbA1c

Group Pre mean score Post mean score Result

Group I 7.72 8 .28

Group II 7.79 7.48 .41

205
Table: 4.65 Results of paired‘t’ test of group I and group III on HbA1c

Group Standard Deviation Standard Error Result

Group I .28 .04 P>.1

Group III 1.25 .18 P<.001

Table: 4.66 Results of mean score of group I and group III on HbA1C

Group Premean score Post mean score Result

Group I 7.72 8 + .28

Group III 8.00 7.5 - .67

Table: 4.67 Results of mean scores of group I and group II on total cholesterol

Group Standard Deviation Standard Error Result

Group I 5.06 .72 P>.1

Group II 24.45 4.46 P<.01

206
Table: 4.68 Results of paired‘t’ test of group I and group II on total cholesterol

Group Premean score Post mean score Result

Group I 198 209 + 11

Group II 196 185 - 11

Table: 4.69 Results of paired ‘t’test of group I and group III on total cholesterol

Group Standard Deviation Standard Error Result

Group I 5.06 .72 p>.1

Group III 42 4.53 p<.001

Table: 4.70 Results of mean scores of group I and group III on total cholesterol.

Group Premean score Post mean score Result

Group I 198 210 +12

Group III 202 184 -14

207
Table: 4.71 Results of paired‘t’ test of group I and group II on LDL

Group Standard Deviation Standard Error Result

Group I 5.13 .73 p>.1

Group II 13 1.85 p<.01

Table: 4.72 Results of mean scores of group I and group II on LDL

Group Premean score Post mean score Result

Group I 118 131 +13

Group II 130 121 -9

Table: 4.73 Results of paired‘t’ test of group I and group III on LDl

Group Standard Deviation Standard Error Result

Group I 5.13 .73 p>.1

Group III 22.90 4.24 p<.01

Table: 4.74 Results of mean scores of group I and group III on LDL

208
 Group Premean score Post mean score Result

Group I 118 131 +13

Group II 131 121 - 10

Table: 4.75 Results of paired‘t’ test of group I and group II on triglycerides.

Group Standard Deviation Standard Error Result

Group I 5.12 .72 p>.1

Group II 21.84 4 P<.01

Table: 4.76 Results of mean scores of group I and group II on trizlycerides.

Group Pre mean score Post mean score Result

Group I 182 192 + 10

Group II 164 153 - 11

Table: 4.77 Results of paired ‘t’test of group I and group III on triglycerides

Group Standard Deviation Standard Error Result

209
 Group I 5.12 .72 P>.1

Group III 27.13 4.84 P<.01

Table: 4.78 Results of mean scores of group I and group III on riglycerides.

Group Pre mean score Post mean score Result

Group I 182 192 + 10

Group III 183 170 -7

Table: 4.79 Results of paired‘t’ test of group I and group II on HDL

Group Standard Deviation Standard Error Result

Group I 1.26 .18 > .1

Group II .69 .09 P > .1

Table 4.80 Results of mean score of HDL among group I and group II

Group Pre mean score Post mean score Result

Group I 41.76 41.54 .22

210
 Group II 44.16 44.50 .44

Table: 4.81 Results of paired ‘t’ test of group I and group III on HDL.

Group Standard Standard

Result
Deviation Error

Group I 1.26 .18 P> .1

Group III 1.09 .15 p<.001

Table: 4.82 Results of mean seores of HDL among group I and III on HDL.

Group Pre mean score Post mean score Result

120
Group I 41.16 41.54 .22

Group III100 43.30 44.28 1

90 88
84 85
80
Heart rate beats/min

60

40

20

0
211
Group I Group II

Pre Test Post Test

Fig. 4.35 Pre and Post Mean values of Group I and Group II on heart rate

212
 120

100

84 85 85
81
80
Heart rate beats/min

60

40

20

0
Group I Group III

Pre Test Post Test

Fig 4.36: Showing pre and post mean values on heart rate of Group I and Group III

213
 40

35

30 28.48
28.22
26.78 26.28
Body Mass index Kg/m.sq

25

20

15

10

0
Group I Group II

Pre Test Post Test

Fig. 4.37: Showing pre and post mean values of Group I and Group II on body mass index.

214
 40

35

30 28.22 28.48
27.5
Body Mass index, Kg/m.sq

26.04
25

20

15

10

0
Group I Group III

Pre Test Post Test

Fig. 4.38: Showing pre and post mean values of Graph I and Group III on BMI

215
 100 95.22 95.44
93.66 93.46

80
Waist circumference(cm)

60

40

20

0
Group I Group II

Pre Test Post Test

Fig 4.39: Showing pre and post mean scores of group I and group II on waist circumference.

216
 100 95.22 95.44 93.46
89.8

80
Waist circumference cm

60

40

20

0
Group I Group III

Pre Test Post Test

Fig. 4.40: Showing pre and post mean values of GroupI & Group III on waist circumference.

140
127.26
122.56 122 121.04
Systolic Blood pressure mmHg

120

100

80

60

40

20
217
0
Group I Group II
Pre test Post test
 140
127.26 128.02 124.68
122.56
120
Systolic Blood pressure mmHg

100

80

60

40

20

0
Group I Group III
Pre test Post test
Fig 4.41: Showing
mean scores of group I & group II on systolic blood pressure

218
 .

Fig 4.42: Showing mean scores of group I & group III on systolic blood pressure

100

90
81.86 83.66
81 79.6
80
Diastolic Blood pressure mmHg

70

60

50

40

30

20

10
219
0
Group I Group II
Pre test Post test
Fig 4.43: Showing mean scores of group I & group II on Diastolic blood pressure

220
 .

100
90 83.66 84.76
Diastolic Blood pressure mmHg

81.86 81.24
80
70
60
50
40
30
20
10
0
Group I Group III
Pre test Post test

Fig 4.44 Showing mean scores of group I & group III on Diastolic blood pressure

221
 180

160
152.62
145.52
143.08
140 134.08

120
Fasting blood glucose mg/dl

100

80

60

40

20

0
Group I Group II
Pre Test Post Test

Fig 4.45: showing pre & post mean scores of group I and group II on FBS

222
 180

160
152.62
145.52 143.08
140 134.08
Fasting blood glucose mg/dl

120

100

80

60

40

20

0
Group I Group III

Pre Test Post Test

Fig 4.46: Showing pre and post mean scores of Group I & Group III on FBS

223
 200
200 190 193
178

150
PPBS mg/dl

100

50

0
Group I Group II

Pre Test Post Test

Fig 4.47: Showing pre and post mean values of Group I & II on PPBS

224
 200 201
200
190
178

150
PPBS mg/dl

100

50

0
Group I Group III

Pre Test Post Test

Fig 4.48: Showing PPBS of mean scores of group I & III.

225
 12

10

7.72 8 7.79
8 7.48
HbA1C %

0
Group I Group II
Pre Test Post Test

Fig 4.49: Showing pre & post mean values of group I & II on HbA1C

12

10

8.35
8 8.02
8 7.72
HbA1C %

0 226
Group I Group III

Pre Test Post Test

 250

209
198 196
200
185
Total cholesterol

150 Fig 4.50:

Showing Pre &
post mean
100 scores of HbA1C
of Group I and
Group III
50

0
Group I Group II

Pre Test Post Test

227
Fig 4.51, Total cholesterol on group I and group II Mean Values

228
 250

210
198 202
200
184
Total cholesterol

150

100

50

0
Group I Group III

Pre Test Post Test

Fig 4.52: Total cholesterol on group I and group III Mean Values

229
 160

140 130
121 125
118
120

100

80
LDL

60

40

20

0
Group I Group II
Pre Test Post Test

Fig 4.53: LDL on group I and group II

140
131 131
118 121
120

100

80
LDL

60

40

20

0 230
Group I Group III
Pre test Post test
Fig 4.54: Mean values of Group I and group III on LDL

200 192
182
164
153
150
Triglycerides (mg/dl)

100

50

0
Group I Group II
Pre test Post test

Fig 4.55: Mean Values of Triglycerides on group I & group II

231
 200 192
182 183
170

150
Triglycerides (mg/dl)

100

50

0
Group I Group III
Pre test Post test

Fig 4.56: Mean Values of Triglycerides on group I & group III

232
 60

50
43.54 43.16 43.5
41.76
40

30
LDL

20

10

0
Group I Group II

Pre Test Post Test

Fig 4.57: Mean scores of group I & II on HDL

60

50
43.3 44.28
41.16 41.54
40
HDL (mg/dl)

30

20

10

233
0
Group I Group III
Pre Test Post Test
Fig 4.58: Showing mean values of group I & III on HDL

234
 5.0 DISCUSSION

India leads the world with the largest number of diabetic subjects earning the dubious distinction of
being termed the diabetes capital of the world with nearly 40.9 million people as diabetic patients (Sicree et al.,
2006). Our country in the last two decades having witnessed major advancements in technology healthcare and
communications - earned credential of a potentially dynamic developing country with the reputation of being
economically vibrant, equipped with larger human force enriched human skill on par with global standard.

On the other hand, one should focus on national health care policy and delivery system as many non-
communicable diseases including Diabetes mellitus and obesity are on alarming rise. There is also an increase
in the consumption of alcohol (30 percent increase in liquor consumption in 2011 than previous year, and more
young people turning to be alcoholics in addition to older adults).

Tobacco consumption is a major cause for cancers. India ranks second next to China in global tobacco
usage. Regulation mechanisms by governments of developing countries include mass media campaign
promoting healthier life styles, taxes, subsidies to improve diets, tighter government regulations of food
labeling, restrictions on food advertising targeting on children, broad based prevention strategies tackling
obesity health threats such as alcohol consumption, smoking, high blood pressure and high cholesterol (Lancet,
2010). Otherwise, health care cost of individual as well the nations will be unimaginable. Also the lessening of
human force, productivity, disability, a high mortality associated with non-communicable diseases will become
a big burden in all spheres exceeding the fast track growth we are witnessing currently to be unsustainable
within a decade.

Using aerobic exercise training among obese children, a reduction of LDL by 13 mg/dl (Yunkee lee et
al., 2010) among type II diabetic subjects and a decrease by 8mg/dl (Ronald et al., 2007) and 5mg/dl (Ekta et
al, 2009) were recorded. In this study, LDL has decreased by 5mg/dl among aerobic exercise subjects. With
resisted exercises, a reduction of LDL by 18mg/dl (Ronald et al., 2007) and 10mg/dl (Ekta et al, 2009) were
known. Among physioball exercise subjects in this study, a decrease of LDL by 9mg/dl was recorded.

A 1% reduction in LDL reduces the risk of major coronary events (Census, 1985), which means that
aerobic subjects in this study had a lowered risk of coronary events by 3.8% and physioball subjects by 7.6%.
Hence, it is evident that physioball exercises are twice effective than aerobic exercises in lowering the risk for
coronary events among type II diabetic patients.

235
 With aerobic training among type II diabetic subjects, an increase in HDL by 1mmg/dl (Ekta et al,
2009) and in this study an increase by 34mg/dl was noted. Vanninen and Usotupa (1992) have pointed out in
one year study with increasing intense exercises and over a period of time HDL was found increasing. The
present study is of lesser duration for 3 months only. Another 3 months study on type II diabetics with aerobic
training failed to improve HDL but a 25% reduction in triglycerides (Schneider and Amarosa, 1992).

Resisted exercises have shown to increase HDL by 1mg/dl (Ekta et al, 2009) and findings of this study
among physioball subjects correlates where HDL has increased by 1mg/dl. A decrease of 1% of HDL is
associated with a 2-3% risk for coronary heart disease (Pederson et al., 1998).

In this study, HDL has increased among aerobic subject by 0.8%. Hence a decrease by 2% risk for
coronary heart disease is possible among physioball subjects who had an increase of HDL by 3%. Hence a
decrease in 6% risk for coronary heart disease occurs indicating that physioball exercises are 2-3 times
effective in lowering the risk for CAD than aerobic exercises among type II diabetes by increasing HDL.

Total cholesterol following aerobic exercise training among type II Diabetic subjects have shown a
decrease by 11mg/dl (Ekta et al, 2009) which is similar to this study findings, among aerobic exercise subjects
with a decrease by 11mg/dl. With resisted exercises, a reduction in total cholesterol by 25mg/dl is known and
among physio ball subjects of this study, a reduction of total cholesterol is by 18mg/dl.

A decrease in total cholesterol and triglycerides with resisted exercises among type II Diabetes subjects
are effective in preventing macrovascular complications (Willey et al., 2003) and a reduction of 1% total
cholesterol has shown to reduce their risk for coronary artery disease (CAD) by 2% (Kelley and Kelley,
2006). Hence a 5.6% decrease of total cholesterol in aerobic subjects means 11% decrease in their risk for CAD
and 8 % decrease of total cholesterol among physio ball subjects means 16% decrease in these risk for CAD
thereby showing physio ball exercises to be effective by 1.5 times than aerobic exercises against the risk for
CAD among type II diabetic by lowering total cholesterol.

With aerobic exercise training among type II diabetic subjects, a decrease in triglycerides by 11mg/dl
(Ekta et al, 2009) and findings of this study are the same. Resisted exercise training following reduction of
triglycerides by 40mg/dl (Ekta et al, 2009) and findings from this study among physioball exercise subjects
show a reduction by 13mg/dl.

An elevated triglycerides is associated with obesity, diabetes and fatty liver and 25% reduction of
triglycerides with exercise training among type II diabetes are due to an increased lipoprotein lipase activity,
loss of intra abdominal fat and decreased hepatic lipid synthesis (Schreider and Amorosa, 1992).

236
 Saffola (2008) has shown Indian lipid profiles at higher risk of heart ailments compared to other age
groups points 49.1% of Indian with poor lipid profile (LDL, HDL and Triglycerides). Triglycerides is reduced
among aerobic subjects by 5.49% and among physio ball exercise subjects by 7.10%. Thus physioball exercises
are proven to be effective by 1.34 times than aerobic exercises among type II diabetic subjects by lowering
triglycerides.

Weakest link in the Indian approach to assess disease burden is its surveillance system for non-
communicable diseases. As it stands, it is unable to determine mortality, actual disease burden morbidity and
risk factors with any degree of clarity, because statistical pathways are not robust. Patients often do not report
for any follow up and fall off the map for a variety of reasons including high costs that they must bear out of
pocket, as pointed by global burden of disease study, which underscores significant public health challenges
before Indian. India’s public health policy must in coming years be directed as much towards non –
communicable diseases as infection ones as worldwide a substantial shift in the risk factors to disease burden
from the risk for communicable diseases in children towards those for non communicable diseases in adults.

Diabetes mellitus is a major non communicable disease globally, with almost 1/3 rd adults with diabetes
in India and China alone (Fall et al., 1997). Asian Indians with a genetic predisposition to develop diabetes
(Radha and Mohan, 2007) decreased physical activity. Sedentary occupational habits, higher fat diets which
have accompanied the process of modernization have resulted in doubling of the prevalence of obesity and type
II Diabetes (Mohan et al., 2005). Most disturbing trend is the shift in the age of onset of diabetes to a younger
age in recent years, which could affect health and economy of individual and nation (Mohan et al., 2006).
Diabetes-being a metabolic disorder-can affect other systems such as the renal, visual, nervous and
musculoskeletal systems resulting in various degrees of impairment to disability. With early diagnosis, due
medications, regular monitoring, dietary regulations, improved life style, and enhanced physical activity, a
diabetic patient can have a good quality of life (Mohan, 2010). In Chennai population, 18% are diabetic and
among them 20% have diabetic neuropathy (Vijay, 2011). 19% are hypertensive between the age group of 25
-65 years (Thanikachalam, 2011) and 19% of Chennai diabetic patients have retinopathy (Rema et al., 2005).

Diabetes mellitus, being a chronic metabolic disorder affecting various organs and functioning of human
body, necessitates a total rehabilitation of individual type II diabetic patient, where physiotherapy place a major
role. Physiotherapy, with an unique non pharmacological exercise oriental natural approach, has assumed the
role of a non-separable entity from anybody of medical sciences. Factors like such as high sedentary
mechanical life style, industrialization, early onset of metabolic disease and an alarming increase in non-
communicable diseases risk factors are major challenges faced by our country.

237
 The science of physiotherapy has tremendous potential to face huge challenges because of its
preventive, therapeutic as well as restorative functions (Jayant Joshi and Kotwal, 1999). Physiotherapy
contributes significantly to the achievement of physical independence, improved vocational potentials and
psychological status leading to the attainment of social security among type II Diabetes patients.
Predominantly, multi- disciplinary role by the physiotherapist concept of rehabilitation and the responsibilities
associated with it calls for an excellence to live up to the responsibility and the status of a specialist. Different
modalities of physiotherapy such as aerobic exercise have reported to improve glycemic control (American
heart association, 2009). Vibration exercise is effective in achieving a better glycemic control among type II
diabetic patients (Klaus et al.,, 2007) and resisted exercise training to improve glycemic control in older type II
diabetics in adults (Carmen et al., 2009).

Hence physical modalities help to decrease the cardiovascular risk factors and also helps in the
reduction of blood pressure (Wood et al., 1991; Evenson et al., 2004). An improved lipid profile among type II
diabetic was effective with various physical activities such as aerobic training (Yunkeelee et al.,2010; Ronald et
al., 2007) and with resisted exercise training (Ekta et al, 2009 and Carmen et al., 2009).

Physioball has been widely used in physiotherapy for neurodevelopmental therapy (Otterly and Larsen,
1996) and the concept of using the ball for functional kinetics was developed by German physiotherapist Klein-
Vogelbach (1990 a). In using the ball, patient’s safety is most important as the ball rolls in two directions,
especially when the patient has decreased sensation with the lack of body awareness (Klein-Vogelbach, 1990 b).
Most physioballs can bear at least 200 kg weight and are widely recommended for healthy adults with different
exercises targeting all major muscle groups as a form of strength training (American college of sports medicine,
2003). Core strength training using Swissball improves balance, endurance and flexibility (Betul et al., 2010).
Lower limb muscle activity can be enhanced with Swiss ball better than wall squat (Hinds, 2004). In
rehabilitation of patients with Lumber disc lesions, promoting fitness among gymnasium, various neurological
and sports rehabilitations, Physioball is widely getting used. Concentric, eccentric, isometric and closed
kinematic forms of exercises were the nature of physical activities performed using Physioball.

Closed kinematic chain movements using Physioball, where peripheral segment meets with considerable
external resistance, and the terminal segment remains fixed, the encountered resistance moves the proximal
segments over the stationary distal segments (Steindler, 1955) . In a closed – chain activity, motion in the joint
is accompanied by motions of adjacent joints that occurs in reasonably predictable patterns (Brunnstorm, 1962).
This study is important where lower extremity exercises using physioball involve closed kinematics chain
exercises (Davies, 1985), which are weight bearing nature (Fitzgerald, 1991), Joint approximation with axial
loading increase stability of the joint (Ellenbecker and Cappel, 2000). Co-contraction of muscle groups
238
contributes to end range dynamic stability of the moving joint (Dragnich et al., 1989) stimulation of joint and
muscle mechanoreceptors (Sullivan and Markos, 1995) an improved proprioception and kinesthesia (Baratta,
1991) and an improved neuromuscular control and balance (Kauffman et al., 1997 ).

Physioball activities in this study incorporate isometric (static format) exercise in which a muscle
contracts and produces force without an appreciable change in the length of the muscle and without visible joint
motion. Resisted exercise of maintaining a position against the resistance of body weight using Physioball is an
effective and efficient method of muscle strengthening (Liberson, 1978) . Isometric resisted exercises improves
postural stability during daily living tasks (Mcgill and Cholewicki, 2001) and dynamic stability of joints during
functional activities (Sullivan, 2001). Progression with isometric resisted exercises using Physioball happens
during 0-4th week with no hold, 5th week to 8th week 5 second hold, and from 9 th week to 12th week 10 second
hold with each activities. Hence an increased period of holding strength and endurance of working muscle
improves (Devine, 1981).

Male preponderance among Indian diabetes in spite of increased rates of obesity in women and Asians
have high prevalence by 5 times than Europeans, between the age of 40 – 64 years (Mather and Keln, 1985).
Prevalence of diabetes in different age groups in Chennai between 40 – 49 years are → 20.4%, 50 – 59 years are
→ 29.7% and 60 – 69 years are → 33.6%. (Mohan et al, 2006). Global prevalence by age for 2000 (Diabetic
population) were as follows: 40 – 49 years → 10%, 50 – 59 years → 18%, 60 – 69 years → 24%, 70 – 79 years
→ 26%, below 40 years → 8%, above 80 years → 14% (International diabetic federation, 2009). Age wise
distribution of diabetic subjects from this study being: 21% are between 30 – 39 years, 38% are between 40 –
49 years and 41% are between 50 – 59 years.

Development of carbohydrate intolerance is in offspring of Asian Indian conjugal type II diabetes

parents (Ramachandran et al., 1990). High prevalence of maturity onset of diabetes of the youth in South
Indians of autosomal dominant inheritance is at the age of onset at 25 years or younger (Mohan et al., 1986).
Double gene dose effect (both parents diabetic) is high among Indians and high prevalence of type II diabetic
parents in India (Viswanathan et al., 1996). High calorie intakes by high – income groups in India are due to
high intakes of refined cereals and carbohydrates rather than fat and meat as in Europe and North America
(Ramachandran et al., 2002) Results from this study indicate that 81% of the subjects in this study have family
history of diabetes.

A dynamic muscle contraction causes joint movement and excursion of a body segment as the muscle
shortens (concentric contraction) or lengthens under tension (eccentric contraction). Activities in this study

239
using Physioball involve dynamic muscle loading (from body weight) causing concentric and eccentric muscle
contractions which help to increase muscle strength, power and endurance (Levangie and Norkin, 2001 ).

Obesity is defined on the basis of BMI and is associated with an increased hypertension, Type II
diabetes, lipid profile and cardiovascular risk (Seidell, 1994). Reduction of BMI by 1kg/m2 with moderate
intensity resisted exercises was reported among sedentary subjects (Raul et al., 2010) and among Type II
diabetic subjects (Carmen et al, 2009). Duke University (2004) has recorded 1kg/m2 reduction of BMI with
aerobic exercises among sedentary obese subjects. Stella et al. (2008) have reported with diet and resistance
exercises with 0.5 kg/m2 reduction of BMI among normal subjects. Ekta et al. (2009) have recorded 0.4 kg/m2
reduction of BMI with aerobic exercises and 0.3 kg/m2 reduction of BMI with resisted exercises among type II
diabetic subjects.

Results of this present study among Type II subjects show a reduction of BMI by .5kg/m2 with aerobic
exercises and reduction of BMI by 1.54 kg/m2 with Swissball exercises. Frank et al. (2001) relate obesity to an
increased glucose metabolism. Otsuka et al. (2010) have recorded aerobic training which acts on adipocytes and
improves adipokines and inflammatory markers.

With resisted exercise training, there occurs a fiber shift in exercising muscle with a hypertrophic
response and an increase in whole body glucose utilization with resisted exercise training, an increase in GLUT 4
protein and improved glycemic control (Carmen et al. 2009). An increased health care cost is associated with
obesity (Bijan, 2011). Yach et al. (2006) have recorded that obese with diabetes diminishes quality of life and
considerable economic burden on health care systems. With supervised resisted exercise training and diet
counseling, Lindgreen et al. (2007) have reported a reduction of cardiovascular risk factors, cost effective and
improved individual well being.

Among obese children with aerobic exercises, a decrease in waist circumference by 2.5 cm (Yunheelee
et al. 2010 ), a decrease of 1cm in waist circumference among over weight subjects with aerobic exercises and
diet was shown (Stella et al., 2008). With resisted exercises among type II diabetic, a decrease in waist
circumference by 2cm was reported (Carmen et al, 2009). A decrease in waist circumference among aerobic
subjects by 1.5cm and a decrease among Physioball subjects 3.7cm were recorded in this present study.

It is worthy to note that the reduction in waist circumference is more than two times among Physioball
subjects than aerobic subjects indicating the effectiveness on lowering waist circumference among type II
diabetic subjects as waist circumference is strongly linked to obesity associated cardiovascular risk factor than
BMI (Shankuanzhu et al., 2002). Waist circumference may be a stronger predictor for the identification of
metabolic and cardiovascular diseases associated risk factors (Reeder et al., 1999; Baik et al., 2000).
240
 An increase in waist circumference proportionally increases the risk to complications in type 2 Asian
diabetic patients (Ramachandran et al., 1995). Obesity is a powerful determinant and a risk factor for
developing diabetes (WHO, 2004). Asian Indians have a greater degree of central obesity (Ramachandran et al.,
1997) and any given body fat has increased insulin resistance (Raji , 2001). Increased visceral or abdominal
adipose tissue strongly associated with metabolic cardiovascular disease and a variety of chronic diseases
(Folson et al., 1993; Reeder et al., 1999).

Aerobic exercises have shown to lower cardiovascular mortality (Evenson

et al., 2004). Resisted exercise training results in an improved muscle quality, decreased inflammation and
increased adiponectin level (Brooks et al., 2004 ), increased muscle mass on body composition (Dunsten et al.,
2002; Chambliss, 2005), improved glycemic control (Carmen et al., 2002; Erikson, 1997) and a lowering of
inflammatory cytokines and markers of oxidative stress (Eissentin et al., 2002). Moderate weight loss among
obese results in improvement of cardiovascular risk factors such as blood pressure, improved lipid profile and
an improved glycemic control (Wood et al.,1991; Gostein, 1992) and an urgent need for estimation of obese,
over weight to assess preventive measures, monitor secular trends, identify high risk group as health care cost
can be cut down (Steinberger et al., 2009).

Among overweight subjects using diet and aerobic activities, lowering of resting heart rate is by 4
beats/minute (Stella et al. 2008). Among type II diabetic subjects with resisted exercises lowering of resting
heart beat is by 3 beats/minute (Carmen et al., 2009). Among type II diabetic subjects with lowering of heart
rate by 3 beats/minute among aerobic subjects and among resisted exercises subjects lowering of heart rate by 6
beats /minute (Ekta et al., 2009) are known. Findings of this present study where aerobic subjects had lowering
of resting heart rate by 2 beats /minute and a decrease among Physioball subjects in resting heart rate by 4
beats/minute indicate that exercises using Physioball are two times effective in lowering heart rate.

Among type II diabetic subjects, with exercise training heart rate to be lower at rest and at sub maximal
workload following aerobic conditioning are because of an increased vagal tone, a decrease in sympametic tone
and lower levels of circulatory catacholamines (Winder et al., 1978) This indicates that the heart has become
more efficient through training, since it requires less energy in the trained condition for the heart to do the same
amount of work (Wilmore and Costill, 1988). An increased blood flow in the active musculature provides better
oxygen diffusion from the capillary to the muscle fiber by increasing the volume and surface area of the
capillaries (Armstrong, 1991 ) .

241
 Among Tamil Nadu state population under 30 years of age, 14.8% are hypertensive and 13.5% are
diabetic and between the age group of 25-65 years, 19% are hypertensive and 20% are diabetic
(Thanickachalam, 2011).

Another study among drivers has reported that 41% have diabetes, 22% are hypertensive and 18 % are
with hyperlipidemia (Chief ministers master health check up , Perundurai medical college, 2012). People with
diabetes are also at the risk for high cholesterol, hypertension and obesity. Nine risk factors for coronary artery
disease (CAD) include smoking, hypertension, diabetes, family history of CAD (Inter – heart study conducted
across 52 countries 2011). 49% of heart diseases and 62% of stroke are due to high blood pressure (WHO
2010). 39% of the subjects in this study are known to have hypertension and on due medication.

Smoking is associated with heart attack, stroke and hearing loss. Smoking can lead to nerve damage and
decreased blood flow to feet (Vijay, 1999). A study conducted covering all districts of Tamil Nadu between 25
-65 years found 26% to be smokers (Thanickachalam, 2011). India ranks second among global tobacco users
(Lancet, 2010). Farmingham score for cardiac risk includes smoking along with age, gender, HDL, systolic
blood pressure, total cholesterol where smoking remains a simple modifiable factor, while 43% of the subjects
in this study are smokers and 53% are alcoholics. WHO (2010) has reported that smoking leads to bronchitis,
with poor quality of life, remaining 4 th leading cause of death. 55% of lung cancers were due to smoking.
Tobacco related cancers relate to 40-45 % cancer in men and 15-20% in women .

Only 22% of the participants have physical activity involved in their occupation and the remaining 78%
subjects nature of occupation have sedentary, desk work based on this present study. Bureau of statistics
publication, Australian social trends have reported that 20% of working population experience mild levels of
depression and 55% of people who suffer stress on job take 5 days leave in a row. Hardly moving body and
having little leg room for hours on the end carry the risk of congestion i.e. swollen heavy legs to a blood clot as
recorded by German federal Association for promoting good posture and physical activity. Nine hours of a day
in a high pressure job have 31% risk for heart disease. While strength training was proven to decrease anxiety in
20% of patient (Mathew hearing 2009) and with physical activity positive mood was found in a study conducted
in Indiana university.

With aerobic training among diabetic type II subject of HbA1c by 0.38% (Ronald, 2007) and from
findings of this study, aerobic subjects have shown a reduction of HbA1c by 0.31%. Using persisted exercise
training among type II diabetic subjects, a reduction of HbA1c by 1% (Dunstan et al. 1998 and Cuff et al. 2003)
a reduction of HbA1c by 1.6% using resisted exercise among type II diabetes (Bweir et al.,2009) and findings
of this study have shown among physic ball subjects a decrease in the their HbA1c by 0.67%. Combined

242
aerobic and resisted exercise training among type II diabetic subjects have shown a decrease in HbA1c by
0.9% (Sigal et al., 2007), a decrease in HbA1c by 0.90% (Ronald et al., 2007), a decrease in HbA1c by0 .6%
(Loimala et al., 2009), a reduction in HbA1c by0 .8% (Tokmakidas et al.,2004) and 1.2% reduction of HbA1c
(Cauza et al., 2005).

With aerobic exercise among inactive adults, a reduction of systolic blood pressure (spb) by 4mm/mg
and diastolic blood pressure (dbp) by 2.5mm/mg occurs (Mayo clinic, 2004). Among obese children, with
exercise with diet, a decrease in sbp by 12mm/mg and dbp by 9mm/mg is possible (Stella et al., 2008). The
finding of this study on type II Diabetes aerobic subject shows a decrease in sbp by 2mm/mg and dbp by
2mm/mg. Aerobic subjects have shown to have a decreasing sbp by 5mm/mg and dbp by 3mm/mg (Ekta et al,
2009)

Using resisted exercise training among type II diabetic subjects, a decreasing sbp ny 9mm/mg and dbp
by 5mm/mg is recorded (Klaus et al.,, 2007) with a decreasing sbp by 7mm/mg and decreasing dbp by 4mm/mg
(Carmen et al., 2009) and a decreasing sbp by 8mm/mg and decreasing dbp by 5mm/mg (Ekta et al, 2009).

Whereas, interestingly, findings of this study using a physio ball group lowers sbp by 8mm/mg and dpb
by 5mm/mg. In a combined study with aerobic and resisted exercises among type II diabetic subject, a lowering
of sbp by 3mm/mg and dbp by 2mm/mg was recorded. As findings of this study indicates a lowering of systolic
blood pressure among physic ball subjects, it is two times than aerobic subjects and with diastolic blood
pressure 1.75 times lowering among physioball subjects than aerobic exercises group with aerobic exercise
training.

Increase in capillary allows for greater change of gases, nutrients, waste products, and heat between the
blood and the active muscle tissue (Armstrong, 1991), number of capillary around each fiber increases by 20-
30% and parallels the increasing oxidative capacity of the muscle (Saltin et al., 1980) an improved baroreflex
sensitivity (Loimala et al.,, 2009) and lowering of resting heart rate and submaximal heart rate submaximal
heart rate with endurance training so heart becomes more efficient.

With resisted exercise training an improved arterial function in patients with endothelial function and
arterial stiffness improves (Baynard and Carhort, 2008; Green et al., 2004) and greater the muscle mass use
during exercises lower the blood pressure (Lewis et al.,, 1985). Redistribution of muscle let flow so that active
high oxidative fibers receive elevated blood flow and inactive low oxidative receive and reduce flow
(Armstrong, 1991) and an increase an exercise capacity and muscle strength (Loimala et al., 2009).

243
 Weight loss due to a fat reduced diet, life style modifications and exercises results in a sustained
reduction in blood pressure, even in overweight people who were initially within normotensive (Wood et al.
1991). Changes in vascular function, carotid artery intima-media thickness (Kim et al. 2006) can be reversed.

Findings of this study have shown reduction in HbA1C among physic ball subjects more than two times
than aerobic exercise subjects; hence it is proven to be effective to influence an improved glycemic control of
Type II diabetes. 1% decrement on HbA1c reduces the risk of diabetic complications such as myocardial
ischemia among Type II diabetic (Strattan et al.,, 2006), reduces the risk of developing microvascular disease
(Patel et al.,, 2008), 25% reduction in major cardiovascular events (Selvin et al.,, 2004) and 37% reduction in
micro vascular complications (Strattan et al., 2006). With aerobic exercise, an improved fitness (Vo2mar)
improves glycemic control (Tudor, 2004), decreases visceral adiposity (Bweir et al., 2002) An improved
glycemic control is independent of fat loss (Monrier et al., 1997) and is due to improved effects on glucose
transporters (Good year et al., 1991) and improvement in insulin sensitivity (Borghouts and Keizer, 2000).
Resisted exercises training resulted in an improved glycemic control due to muscle hypertrophy (Erikson et al.,
1997; Dunstan et al., 2002), increased blood flow (Ratigan et al., 2001), improving the storage and utilization of
glucose in muscle (Zanuso et al., 2009), an increased capillary to muscle ratio, muscle contractions can elicit
movement of glucose transporters (GLUT4) to the plasma membrane independent of Insulin and loss of fat
(Plough and Ralston, 2002).

Increased sample size and longer durations of study involving women are recommended further. Also a
prophylactic study for children can be considered (Subramanian and Venkatesan, 20012 a). In addition, a
combination of aerobic and stability ball exercises may provide further evidence (Subramanian and Venkatesan,
20012 b, c).

5.1 Conclusion

The present study has highlighted the importance of physioball in controlling diabetes in patients,
provided they bring into practice I the usage of the same regularly besides other conditions such as diet and
medication. This is evident from the detailed laboratory procedures and research work carried out with subjects
of various age groups among men. The methodology recommended in the usage and quality of the Swissball by
the physiotherapist should be adhered to for better results.

This Physioball method replaces the aerobic exercises on one hand and is suitable for pro-diabetic
subjects since they are already in a state of good health. In addition, subjects whose family history reflects
severe conditions of Type 1 or Type 2 Diabetes can adopt this method of physiotherapy to keep away the
chances of acquiring diabetic disorder in their life.
244
5.2 Future study

The present investigation has been limited to men. Adoption of the same in women should be carefully
tried out in future since they are also under the influence of hormonal changes related to their age and growth.
Such a future study may be of great importance to mankind to overcome the diabetic disorder in men as well as
in women.

Improvised models of Physioball can also be investigated in future studies so as to make the method still
simpler and with least cost effect and easier to carry the physioball with greater comfort. In addition, the present
work was limited to subjects who belong to Type 2 Diabetes. How far the physioball method will have a
positive effect in type 1 Diabetes subject is beyond the scope of the present investigation.

Future studies with other neurological ailments, muscular skeletal ailments and sports injuries with
physioball are worth researching.

245
 6.0 OTHER REPORTS

 Among Tamil Nadu state population under 30 years of age 14.8% to be hypertensive and 13.5% to be
diabetic and between the age group of 25-65 years 19% to be hypertensive and 20% to be diabetic
(thanikachalam, 2011).

 Another study among drivers has reported 41% to have diabetes, 22% to are hypertensive and 18 % with
hyper lipidemia (Chief ministers master health check up, perundurai medical college 2012). People with
diabetes are also at risk for high cholesterol, hypertension and obesity (The Hindu dated 11/11/2010).

 Smoking is associated with heart attack, stroke and hearing loss (The Hindu date 25.09.2009.).

 India ranks second among global tobacco users (Global adult tobacco survey 2010) (Lancet, 2010).
Farmingham score for cardiac risk includes smoking along with age, gender ,HDL, systolic blood pressure,
total cholesterol where smoking remains a simple modifiable factor (The Hindu, dated 10.07.11).

 While 43% of the subjects in this study are smokers and 53% are Alcoholics, Who 2010 has reported that
smoking leads to bronchitis, with poor quality of life, remains 4 th leading cause of death .55% of lung
cancers were due to smoking (The Hindu dated 20.09.2011) Tobacco related cancers relate to 40-45 %
Cancer in men and 15-20% in women (Cancer Institute 2011).

 With only 22% of the participants have physical activity involved in their occupation, remaining 78%
subjects nature of occupation have sedentary, desk work based on this study, Bureau of statistics publication,
Australian social trends have reported that 20% of working population experience mild levels of depression
and 55% of people who suffer stress on job take 5 days leave in a row (The Hindu dated 07/08/11).

 Hardly moving body and having little leg room for hours on the end carries the risk of congestion i.e.
swollen heavy legs to a blood clot as recorded by (German federal Association for promoting good posture
and physical activity (The Hindu dated 12/11/2010 ). Nine hours of a day in a high pressure job has 31%
risk for heart disease (Times of India 2010).

 While strength training was proven to decrease anxiety in 20% of patient (Mathew hearing 2009) and with
physical activity positive mood was found in a study conducted in Indiana university (The Hindu Dated
08/06/2008).

 The simple physical activities performed consistently, monitoring blood glucose life style modifications

246
 careful diet can improve the quality of life as well minimize health care cost and complications (Mohan,
2010 ) published in the Hindu dated 14/11/2010).

 Prevalence rates higher in affluent groups than low income groups and more in urbanities (Chennai urban
population study 2003).

 WHO (2010) report as published in the Hindu, National news paper dated 25/04/2010) that 62% of stroke
and 49% heart disease are due to high blood pressure hence a significant more than two fold reduction with
physic ball exercise than aerobic activities indicates physio ball exercises are effective in reducing
cardiovascular risk factors and stroke.

 Jupiter study published in LANCET 2010 (THE HINDU dated 22/07/2010) shows that levels of HDL in a
person is of no consequences if LDL has been substantially lowered as for as cardio vascular risk is
concerned.

 A recently concluded survey has rated Chennai 150 out of 221 international cities assessed for the quality of
life they provide based on 39 factors including civic hygiene, public transport, water ways, medical facilities
etc (Madras Musings a registered news paper dated 16/12/2012).

7.0 SUMMARY

 Diabetic population in India is projected at 60 million in the year 2011.

 Baseline characteristics from 14 point questionnaire reveals 39% of the subjects to be hypertensive, 43%
of the participants are smokers, 53% are alcoholics, 78% of the subjects had sedentary occupation, Per
cent has known coronary artery disease, % of subjects are found to have % of family history of diabetes,
% of the subjects had eye complications, and % of the participants are found to have musculoskeletal
ailments.

 Results of this study have analyzed the effect of aerobic exercises, physioball exercises and a control
group subjects among male type II diabetic patients using physical and biochemical parameters indicates
as follows.

247
 A reduction in waist circumference among physioball subjects by more than two times than aerobic
exercises is recorded; it is noteworthy that physioball exercises are quite effective in reducing the risk
for cardiovascular complications and improved glycemic control among type II diabetic subjects.

 Body mass index, which has shown a reduction with physioball exercises by three times than aerobic
exercises is effective in lowering hypertension, cardiovascular risk an improved glycemic control, cost
effective and improved individual well being.

 Lowering of resting heart rate indicates that the heart has become more efficient through training, that it
requires less energy in the trained condition for the heart to do the same work which is true among
physioball subjects where resting heart rate is lowered by two times than aerobic exercises, hence an
impact on cardiovascular system is evident among type II diabetic male subjects.

 Physio ball exercises have two fold effect than aerobic exercises in lowering blood pressure among type
II diabetic subject is prudent with its impact on improved health.

 Physio ball exercises are two old effective than aerobic exercises in improving glycemic control and
reducing micro and macro vascular complications associated with type II diabetic subjects, is highly
noteworthy to be included in the comprehensive diabetic management.

 Physio ball subjects benefit by a lowered risk for CAD by 7.6 %; thus physio ball exercises are twice
effective than aerobic exercises in lessening the risk of CAD by lowering LDL among Type II diabetic
patients.

 While aerobic subjects have a benefit of decreased risk of CAD by 2 %, physio ball subjects have a
benefit of decreased risk for CAD by 6 %; Hence physio ball exercises are efficient by improving the
HDL 3 times stronger than aerobic exercises , thereby decreasing the risk for CAD among Type II
diabetic patients .

 Physio ball helps to lower total cholesterol than aerobic exercise, thereby lowering the risk of Type II
diabetic patients for CAD.

 In this study aerobic subjects have a lowering of triglyceride by 5.49 % and physio ball subjects a
lowered triglyceride by 7.10% ; Thus physio ball is stronger than aerobic exercises in lowering the risk
for macro vascular complications among Type II diabetic patients .

 An improved quality of life means a lot with lot to type II diabetic mellitus, a chronic metabolic disorder
having an influence on his mental, psychological and social life.
248
 Subjective evaluation of overall scores on their quality of life, a major outcome of this study points to an
improved score among aerobic subjects by 11% and by 25% among physio ball subjects with a
decreased score by 6% among control group subjects, is quite evident that physio ball exercises helps to
improve the quality of life by more than two than aerobic exercises among type II male diabetic patients.

 Subjective evaluation on overall physical wellbeing of all the participants at the completion of this study
have shown only 4% have improved score and 64% remained the same and 28% with worse state among
control group. Among aerobic subjects 32% have improved score, 66% remained the same, 2% became
worse, and among physio ball exercise group 70% have improved score and 30% remained the same, is
highly indicating that physio ball subjects are more than two fold improved score on their overall
physical well being.

 Subjective scores of evaluation, on their overall emotional state at the completion, have shown among
control group subjects none with better score, 58% remained the same and 42% became worse, among
aerobic subjects 14% have got better, 84% remained the same and 2% got worse, while physio ball
subjects 56% got better, 44% remained the same.

 Subjective evaluation of all the subjects on their overall enjoyment of life, up on completion of the
study, shows while none have improved, 76% remained the same and 24% got worse among control
group. Among aerobic exercise subjects 34% got better, 62% remained the same and 4% got worse,
while among physio ball subjects 62% got better, 38% remained the same, indicating that physio ball
exercises are nearly two times effective in improving overall enjoyment life of subjects with type II
diabetic male, thus enhancing their quality of life to a larger extent, a major outcome of this study, to be
considered a new focus for the diabetic management.

 Subjective evaluation by all the participants overall ability to handle stress on completion of the study,
among control group subjects 62% remained the same and 38% got worse. Among aerobic exercise
subjects 18% have improved, 78% remained the same and 4% got worse, while among physio ball
subjects 58% got better, 42% remained the same, thus physio ball exercises are three fold stronger in
improving overall ability to handle stress among type II male diabetic patient gets proven, and so
improving the quality of life of them.

 Subjective evaluation on overall quality of life, up on completion of the study by all the participants,
indicates 84% remained the same, and 16% among control subjects, among aerobic subjects 34% have

249
 better scores, 60% remained the same and 6% got worse, while physioball subjects 60% have got better
and 40% remained the same, which indicates physioball exercises are nearly two time efficient in
improving the overall quality of life among male type II diabetic subjects gets prudent.

 Exercise prescription for type II diabetic mellitus should include physioball exercises as a modality of
physical activity, a major recommendation of this study’s outcome.

 As a mean of prophylactic, study using physioball for overweight, obese, non diabetic among adults and
children should be considered by researchers.

 Benefits shown in this study using physioball and biochemical parameters among type II diabetic
mellitus can further be studied on female subjects as well type I diabetic subjects.

 Limitations with physioball being it requires supervised performance with activities by a qualified
physiotherapist , being high amount of energy expenditure involved with multiple co contractions
required, for each Activity ,not to hold breath while doing activity, slipping of lower extremities from
ball .

 Advantages apart from, scientific findings in this study being an indoor nature, less frequency of work
out per week, cost effective and time conserving when compared with conventional aerobic exercises.

 Future studies with other neurological ailments, muscular skeletal ailments and sports injuries with
physio ball are worth researching.

BIBLIOGRAPHY

Aaraonson, N.K. 1991. Methodological issues in assessing the quality of life of cancer patients. Cancer, 67:
844 – 850.

Abate, N., Chandlia, M., Satija, P. 2005. Polymorphin and genetic susceptibility to type 2 diabetes.
Diabetes, 54: 1207 – 1213.

250
Abate, N., Chandlia, M., Snell, P.G. and Grundy, S.M. 2004. Adipose tissue metabolites and insulin
resistance in non diabetic Asian Indian men. Journal of clinical endocrinal metabolism, 89: 2750 –
2755.

Ahlborg, G., Felig, P. and Hagenfeld, 1974. Substrate turnover during prolonged exercise. Journal of
Clinical Investigations, 53: 1080 – 1090.

Ahren, B. and Corrigan, C.B. 1984. Intermittent need, for insulin in a subgroup of Diabetic patients in
Tanzania, Diabetic medicine, 2: 262-264

Ahuja, M.M.S. 1979. Epidemiological studies on Diabetes mellitus in India. In : Ahuja M.M.S, (Ed)
Epidemiology of Diabetes in developing countries. New Delhi, 29-38.

Albright, A. and Franz, M., 2000. Exercise and type 2 diabetes medical science sports exercise, American
college of sports medicine (ACSM), 32(7):1345-1360.

American college of sports medicine (ACSM) and American diabetic association (ADA), 2002. Position
statement on type 2 diabetes mellitus, Diabetes Care, 25(Supplement): 564-568.

American college of sports medicine, 1991. Guidelines for exercise testing and prescription, 4th edition Lea
and Febiger, Philadelphia.

American college of sports medicine. 2000. Guidelines for exercise testing and prescription, 6 th edition
Philadelphia, Lipponcott Williams and Wilkins.

American Diabetic Association, 2003. Physical activity / exercise and diabetes mellitus, Diabetes care, 26(1):
S73 - S77.

American Heart Association, 2009. Effects of exercise in type II diabetes mellitus. Circulation.119: 3244 –
3262.

Anjana, R.M., Pradeepa, R., Deepa, M., Datta, M., Sudha, V. and Unnikrishnan, R. et al., 2011.
Prevalence of Diabetes and pre-diabetes (impaired fasting glucose and/or impaired glucose tolerance) in
urban and rural India: Phase 1 results of the Indian Council of Medical Research-(ICMR-INDIAB)
study. Diabetologia (Sweden), 54: 3022- 3027.

Aronson, D., Violan, M.A. and Dufresne S.D., et al., 1997. Exercise stimulates the mitogen activated protein
kinase pathway in human skeletal muscle. Journal of clinical investigations, 99: 1251 – 1257.

251
Armstrong, R.B. 1991. Influence of exercise training on oxygen delivery to skeletal muscle in the Lung,
Scientific foundations. Crystal RG, West JB, Newyork, Raven, 1517 – 1524.

Assan, R., Perronne, C., Assan, D., and Chotard, L. 1995. Pentaridine-induced derangements of glucose
normlostasis. Diabetes care, 18: 47-55.

Astrand, O. and Rodahl, K. 1977. Textbook of work physiology - physiological basis of exercise, 2 nd edition .
New York, McGrawhill, Pp. 16.

UKPDS, 1998. Effect of intensive blood glucose control with metformin on complications in overweight
patients with type 2 diabetes (UKPDS) group. Lancet, 352 (9131): 854-865.

Baik, I., Ascherio, A. and Rimm, E.B. 2000. Adiposity and mortality in men. American journal of
epidemiology, 152: 264-271.

Baldi, J.C. and Snawling, N. 2003. Resistance training improves glycemic control in obese type 2 diabetic
men. International journal of sports medicine, 24: 419-423.

Banks, E.A, Brozinick, J.T., Jr. Yasselkis. N.Y., Kang, B.B and Ivy. J.L. 1992. Muscle glucose transport,
GLUT4 content and degree of exercise training in obese zucker rats. American journal of physiology,
endocrinology metabolism, 263: E1010 – E1015.

Barrett, D.S. 1991. Proprioception and function after anterior cruciate ligament reconstruction. Journal of bone
joint surgery, 73: 83.

Barrett, T.G., Bundey, S.E. and Macleod, A.F. 1995. Neuro degeneration and diabetes: UK nationwide study
of wolfram (DIDMOAD) Syndrome, Lancet, 346: 1458 -1463

Baynard, T. and Carhort, R.L. and Plontz-Snyder, 2008. Short term training effects on diastolic function in
obese persons with metabolic syndrome. Obesity, 16: 1277-1283.

Berg, A., Nellen, Fraz, Kewl, J. 1997. Physical activity and lipoprotein metabolism epidemiological evidence
and clinical trials, European journal of medicine, 2: 259-264.

Bergstrom, J. 1962. Muscle electrolytes in man. Scandinavian journal of clinical laboratory investigations, 68:
11 – 13.

252
Betterle, C., Zanette, F., Pedixi, B., Preseto, P. and Rapp, L.B. 1983. Clinical and subclinical organ specific
auto immune manifestations in type 1(insulin dependent) diabetes patients and their first degree
relatives. Diabetologia, 26: 431-436.

Betul, Sekendiz, Mutln, and Kakkusuz, 2010. Effects of Swiss ball core strength training on strength,
endurance, flexibility and balance in sedentary women. Journal of strength conditioning, 24(11): 3032 –
3040.

Bijan, B., 2011. Analysis of obesity and smoking related health care cost, Mayo clinic international health
economics association.

Blair, S.N., Painter, P. and Pate, R.R. 1988. ACSM resource manual for guidelines for exercise testing and
prescription, Philadlphia, Lea and Febiger, 37: 52.

Bloomfield, J., Fricker, P.A. and Fitch, K.D. 1992. Textbook of science and medicine in sport Campaign,
Human kinetics, Pp.72.

Bodansky, N.J., Grant, P.J., Dean, B.M. and Hambling, M.H. 1986. Islet all antibodies and insulin
autoantibodies in association with common viral infections, Lancet, 1351-1353.

Borghouts, L.B. and Keizer, H.A. 2000. Exercise and insulin sensitivity a review. International Journal of
sports medicine, 21:1-12.

Boule, N.G., Haddad, E. and Kenny, G.P. 2001. Effects of glycemic control and body mass in type 2
diabetes mellitus: a meta analysis of controlled clinical trials, The journal of the American medical
association, 286: 1218 – 1227.

Bourestom, N. and Howard, M. 1965. Personality characteristics of three personality groups. Archives of
physical medicine and rehabilitation, 46: 626 – 632.

Bradly, C. 1994. The well being questionnaire, In: Bradly, C. (ed). Hand book of Psychology and diabetes.
Clur. Switzerland Harwood, Pp. 89-109.

Braith, R.W., Magyari, P.M. and Pierce, G.L. 2005. Effects of resistance exercise on skeletal muscle
myopathy in heart transplant recipient. American journal of cardiology, 95:1192-1198.

Brooks, Layne, J.E. and Gordon, P. 2004. Strength training improves muscle quality and insulin sensitivity in
Hippanic older adults with type 2 diabetes. International journal of medical sciences, 4:19-27.

253
Brozinick, J.T, Etgln, G.J., Yaspellkis, B.B. and Ivy, J.L. 1993. Effects of exercise training on muscle
GLUT4 protein content and translocation in obese zucker rats, American journal of physiology
endocrinology metabolism, 265: E419 – E427.

Brunstorm, S. 1962. Clinical kinesiology, F.A Davis, Philadelphia.

Campbell, P.J. and Carlson, M.G. 1993. Impact of obesity on insulin action in NIDDM. Diabetes, 42: 405-
410.

Cancer institute, 2011. Tobacco related cancers relate to 40 – 45% cancers in men and 15 – 20% in women.
National medical journal of India.

Carmen, C., Layne, J.E., and Munoz-Orians, L., 2009. A randomized controlled trial of resistance exercise
training to improve glycemic control in older adults with type 2 diabetes. Diabetes care, 25: 2335-2341.

Carriere, B. 1993. Swissball exercises, Physiotherapy, 9: 92 – 100.

Carriere, B. 1996. Therapeutic exercises and self correction program. In: Flynn TW. The thoracic spire and rib
cage, Butterworth Boston, Pp 289-310.

Cartee, G.D. 1994. Influence of age on skeletal muscle glucose transport and glycogen metabolism. Medical
sciences sports exercise, 26: 577 – 584.

Caspersen, C.J., Powell, K.E. and Christerson GM. 1991. Physical activity, exercise and physical fitness.
Public health report, 100: 126-131.

Cauzza, E., Kanush-Enserer, U., Strasser, B., Ludvik, B. and George, P. 2005. The relative benefits of
endurance and strength training on the metabolic factors and muscle function of people with type 2
diabetes. Archives of physical medicine and rehabilitation, 86: 1527-1533.

Chambliss, H.O. 2005. Exercise duration and intensity in a weight loss program. Clinical journal of sports
medicine. 15: 113-115.

Chan, J.M., Rimm, E.B., Colditz, G.A., Stampfer, M.J. and Willett, W.C. 1994. Obesity, fat
distribution, and weight gain as risk factors for clinical diabetes in men, Diabetes care, 17: 961
– 969.

254
Chandalia, M., Abate, N., and Gary, A., et al., 1999. Relationship between generalizes and upper body
obesity to insulin resistance in Asian Indian men. Journal of clinical endocrinal metabolism, 84:
2329 – 2335.

Chea, J.S. and Thai, A.C. 1993. Epidemiology of non insulin dependent diabetes mellitus in ASEAN
proceedings of the 7th congress of the ASEAN federation of endocrine societies. 5641 – 5658.

Cheung, N., Cinnadaio, N. and Marek, S. 2009. A pilot randomised controlled trail of resistance exercise
bands in the management of sedentary subject with type 2 diabetes, Diabetic reference of clinical
practice, 83(3): e68 – e71.

Cohen, N., Dunstan, D., Robinson, C. and Show, J. 2008. Improved endothelial function following a 14 –
month resistance exercise training program in adults with type 2 diabetes. Diabetic reference of clinical
practice, 79: 405 – 411.

Collier, S.R., Kanaley, J.A. and Corhort, R. 2008. Effect of four weeks of aerobic or resistance exercise
training on arterial stiffness, blood flow and blood pressure in hypertensives, Journal of hypertensive’s,
22: 678-686.

Consensus development panel. 1985. Consensus conference lowering blood cholesterol to prevent heart
disease, The journal of the American medical association, 253: 2080-2086.

Cooper, K.H. and Cooper, M. 1998. The new aerobics for women. New York: Banton books, 115: 27 – 29.

Corkl, Puddey, B., Morton, A.R. and Masarei, J.R. 1993. The combined effects of aerobic exercise and
alcohol restriction on blood pressure and serum lipids on sedentary men. Journal hypertension, 11: 191
– 201.

Coronil, C.C., Goldberg, A.P. and Roguse. 1994. Seven consecutive days of exercise lowers plasma insulin
responses to an oral glucose challenge in sedentary elderly. Journal of American geriatrics society, 42:
394-398.

Coyle, E.F, Filtner, M.E. and Kautz, S.A. 1991. Physiological and biochemical factors associated with elite
endurance cycling performance. Medical sciences sports exercise, 23: 93-107.

Cuff, D.J., Meneily, G.S. and Martin, A. 2003. Effective exercise modality to reduce insulin resistance in
women with type II diabetes, Diabetes care, 26: 2977 – 2982.

255
Cuppers, H.J., Erdmann, and Berger, M. 1982. Gloucose tolerance, serum insulin, serum lipids and athletes.
In diabetes and exercise, Pp. 115 – 165.

Davis, 1985. A compendium of Isokinetics in clinical usage and rehabilitation techniques, 2nd, S&S publishing,
Lacrosse, W.I.

Deepa, R., Sandeep, S. and Mohan, V. 2006. Abdominal obesity, visceral fat and Type 2 diabetes
Asian Indian phenotype international; In: Mohan, V. and Rao, G.H.R, (eds) Type 2 Diabetes in
South Asians; epidemiology, risk factors and prevention. Pp. 138 – 152.

Defronza, R.A., Bonadonna, R.C. and Ferrannizi, E. 1992. Pathogenesis of NIDDM; A balanced overview.
Diabetes care, 15: 318 – 368.

Dela, F., Mikines, A.J., Sonne, B. and Galbo. H. 1998. Effect training on interaction between insulin and
exercise in human muscle. Journal of applied physiology, 76: 2386-2393.

Dela, F., Larson, J.J., Mikines, K.J. and Ploug. T. 1995. Insulin stimulated muscle glucose tolerance in
patients with NIDDM : Effects of 1 legged physical training. Diabetes: 44: 1010 – 1020.

Dempsey, J.A., Vidruk, E.H. and Mitchell, G.S. 1986. Is the lung built for exercise? Medical sciences sports
exercise, 18: 143 – 155.

United States, Department of Health and Human Services, 1996.

Devine, K. 1981. EMG activity recorded from an unexercised muscle during maximum isometric exercise on
contra lateral agonists and antagonists, Physical therapy, 61: 891- 898.

Dhingra, V., Chalterjel, A., Glulria, R. 2003. Adverse physical activity pattern in urban adolescents.
Journal of association of physicians Indian, 50: 1521.

Dollard, J. and Miller, N.E. 1950. Personality and psychotherapy. An analysis in terms of learning, thinking
and culture, MC Graw Hill, New York.

Dragnich, L.F., Jaeger, R.J. and Kraji, A.R.1989. Co activation of the hamstrings and quadriceps during
extension of knee, Journal of bone joint surgery, 71(A): 1075 – 1989.

Duke University, 2004. Report on sedentary over weight subjects with aerobic exercises.

256
Dunstan, D.W., Daly, R.M. and Owen, N. 2002. High intensity resistance training on glycemic control in
older patients with type 2 diabetes. Diabetes care, 25(10): 1729-1736.

Dunstan, D.W., Daly, R.M., Duen, N. and Jolley, D. 1998. High intensity training improves insulin
sensitivity in NIDDM subjects without altering maximal oxygen uptake, Diabetes care 21: 1353-1355.

Egede, L.E. and Zheng, D. 2003. Independent factors associated with depressive disorder in a national sample
of individuals with diabetes. Diabetes care, 26(1): 104 – 111.

Eisenstein, E.L., Shaw, L.K., Nelson, C.L., Anstrom, K.J. and Mark, D.B. 2002. Obesity and long term
clinical and economic outcomes in coronary artery disease patients. Obesity research, 10: 83 -91.

Ekta, A., Shwetha, S., Sandhya, J.S. 2009. Effects of resistance training on metabolic profile of adults with
type 2 diabetes. Indian Journal of medicine. 12(9): 515-519.

Ellenbecker, T.S. and Cappel, K. 2000. Clinical application of closed kinematic chain exercises in the upper
extremities. Orthopaedics physical therapy, North America 9:231.

Ellis, A. 1973. Humanistic psychology: The rational Emotive approach Julian, New York.

Erikson, J., Taimela, S. and Erikson, K.1997. Resistance training in the treatment of NIDDM. International
journal of sports medicine, 18:242-246.

Evenson, K.R., Stevens, J. and Thomas, R. 2004. Effects of cardio respiratory fitness on mortality among
hypertensive and normo tensive women and men, Epidemiology, 15: 565-572.

Eves, N.D. and Plotnikoff, R. C. 2006. Resistance training and type 2 diabetes: considerations for
implementation at the population level. Diabetes care, 29: 1933-1946.

Fabris, P., Betterle, C., Florlani, A. and Greggion, A. 1992. Development of type I diabetes mellitus during
interform alpha therapy for chronic HCV hepatitis. Lancet, 340: 548.

Fagot-Campagna, A., Pettitt, and Engelgan, M.M. 2000. Type 2 diabetes among north American children and
adolescent: an epidemiologic review and a public health perspective. Journal of paediatrics, 136: 664-
672.

Fall, C.H., Steic, E. and Kumaran, 1997. Size at birth maternal weight and type 2 diabetes in South India,
Diabetes medicine, 15: 220 – 227.

257
Fauci, Brounwald, Hauser, Longo and Jameson, 2010. Harrisons principles of internal medicine, pp 636.

Ferguson, M., Anderson, N. and Trost, S. 1998. Effects of four different single exercise sessions on lipids,
lipoproteins and lipoprotein lipase, Journal applied physiology, 85: 1169-1174.

Fisenstein, E.L., Shaw, L.K., Nelson, C.L., Anstrom and Mark, D.B. 2002. Obesity and long term clinical
and economic outcomes in coronary artery disease patients, Obesity, 10: 83-91.

Fity Gerald, Tanakah, and Tranzv, 1977. Age related declines in maximal aerobic capacity in regularly
exercising versus sedentary women, Journal of applied physiology, 83: 100 – 165.

Fitzgerals, G.K. 1991. Exercise induced muscle soreness after concentric and eccentric isokinetic contractions,
Physical therapy, 7: 503 – 513.

Flier, J.S. 1992. Syndrome of insulin resistance from patient to gene and back again. Diabetes, 41: 1207-1219.

Folson, A.R., Kaye, S.E. and Sellers, T.A. 1993. Body fat distribution and 5 year risk of death in old women.
The journal of the American medical association, 269: 483-487.

Ford, E.S. 2005. Prevalence of the metabolic syndrome defined by the IDF among adult in the US. Diabetes
care, 28: 2745.

Forrest, J.A., Menser, M.A. and Burgess, J.A. 1971. High frequency of diabetes mellitus in young patients
with congenital rubella, Lancet, 11: 332-334.

Fox, EL Mathews DK: 1981 The Physiological basis of physical education and athletics 3 rd edition New York,
CBS College publishing.

Frank, B., Manson, J.E. and Stampfer, M. 2001. Diet, lifestyle, and the risk of type 2 diabetes in women,
New England journal of medicine, 345: 790-797.

Froguel, P. 1997. Tracking down defense to cure diabetes; an achievable task for the 21 st century;
Diabetic metabolism, 23: 813.

Froguel, P., Vaxillaire, M., Sun, F. and Butel, M.O. 1992. Close linkage of glucokinase locus on
chromosome 7P to early – onset non-insulin dependent diabetes, Nature, 356: 162-64.

Fuhrer, M.J. 1987. Rehabilitation outcomes: Analysis and measurements: Baltimore; MD: Brookes.

Fuller, J.A., Stevens, L.K. and Wang, S.L. 2001. Risk factors for cardio vascular mortality and morbidity. The
WHO multinational study of vascular disease in diabetes, Diabetolgia, 44: 554-564.
258
Giff, D.J., Meneilly, G.S. and Martin, A. 2003. Effective exercise modality to reduce insulin resistance in
women with type 2 diabetes. Diabetes care, 26: 2977-2982.

Golding, L.A., Myers, C.R. and Sinning, W.E. 1989. Ys way to physical fitness 3rd edition champaign, IL
Human kinetics publishers, 35: Pp.90.

Gollnick, P.D., Timson, B.F. and Moore, R.L. 1981. Muscular enlargement and number of fibres in skeletal
muscles of rats. Journal of applied physiology, 5: 936 – 943.

Goodyear, L.J., Hishman, M.F. and Norton, E.S. 1991. Exercise induced translocation of skeletal muscle
glucose transports. Journal of physiology, 261: 795-799.

Gopalan, C.2001. Rising incidence of obesity, coronary heart disease and diabetes in the Indian urban
middle class possible or of genetic and environmental factors. World RW nutrition Diabetes, 90:
127 – 143.

Gorden, D.J., Probstfield, J.L. and Garrison, R.J. 1989. High density lipoprotein cholesterol and
cardiovascular disease for prospective American studies. Circulation, 79: 8-15.

Gostein, D.J. 1992. Beneficial effects of moderate weight loss, International journal of obese related metabolic
disorder, 16: 397-415.

Green, D.J., Maiorona, A., Odriscoll, G. and Taylor, R. 2004. Effects of exercise training on endothelium
derived nitric oxide function in humans, Journal of physiology, 561: 1-25.

Gullo, L., Pezzilli, R. and Marselli, L., 1994. Diabetic and the risk of pancreatic cancer, New England
journal of medicine, 331: 81-84.

Harris, M.I., Cowil, C.C., Stern, M.P., Boykoes, and Bennett, P.H. 1995. Diabetes in America, 2nd edition,
Washinton DC: US government printing office, (95-1468).

Haskel, W.L. 1986. The influence of exercise training on plasma lipids and lipoproteins in health and disease.
Acta medical Scandinavian supplement, 711: 25-37.

Hayashi, T., Hirshman, M.F. and Kuth, E.J. 1998. Evidence for 5-AMP activated protein kinase mediation
of the effect of muscle contraction on glucose transport. Diabetes, 47: 1369 – 1373.

Hayashi, T., Jorgan, F.P.W. and Goodyear, L.J. 1997. Exercise regulation of glucose transport in skeletal
muscle, American journal of physiology, 273: 1039 – 1051.

259
Helnrich, S.P., Ragland, D.R. and Leung, R.W. 1991. Physical activity and reduced occurrence on NIDDM ,
England journal of medicine, 325: 147 – 152.

Hentisksen, E.J., Brousery, R.E and Rodnick. L, 1990. Glucose transporter protein content and glucose
transport capacity in rat skeletal muscles. American journal of physiology endocrinology metabolism,
259: E593-E598.

Henry, J.P. and Stephens, P. 1977. Stress, health and the social environment, Springer Verlag, New York.

Higaki, Y., Hirshman, M. and Furiji, N. 2001. Nitric oxide increases glucose up take through a mechanism
that is district from the insulin and contraction pathways in tat skeletal muscle. Diabetes, 50: 241 – 247

Hill, J.O. Sparling, P.B. and Shields, T.W. 1987. Effects of exercise and food restriction on body composition
and metabolic rate in obese women. American journal of clinical nutrition, 46: 622 – 630.

Hinds, E. 2004. The additional effects of Swiss ball use during the wall squat exercise on lower limp muscle
activity: Centre for the sport and exercise medicine, Queen Mary University of London.

Holloszy, J.O., Schultz, J., Kusreer and Epsani, A.A. 1986. Effects of exercise on glucose tolerance and
insulin resistance, Medical Scandinavian journal, 711: 55 – 65.

Holman, R.R., Paul, S.K., Bethel, M.A., Mathews, D.R. and Nail, H.A. 2008. 10 year follow up of intense
glucose control in type 2 diabetes. England journal of medicine, 359:1577-1589.

Holten, M., Zachom, Gaster, M. and Juel, C. 2004. Strength training increases insulin – mediated glucose
uptake , GLUT 4 content and insulin signaling in skeletal muscle in patients with type 2 diabetes,
Diabetes, 53: 294 – 305.

Hornberger, J.P. 1993. Protocal manual; Exercise screening, testing, prescription, therapeutic exercise,
rehabilitation guidelines for a chiropractic and facility. Hornberger publications.

Houmard, J.A., Bruno, N.J. and Bruner, R.K. 1994. Effects of exercise training on the chemical composition
of plasma LDL, Atherosclerosis thrombosis, 14: 325 -330.

Housh, D. and Housh, T., 1993.The effects of unilateral velocity specific concentric strength training. Journal
of orthopedic and sports physical therapy, 17:252 – 256.

Huges, B.A., Fiatarone, M.A. Fielding, R.A. and Evans, W.J. 1994. Long term effects of a high
carbohydrate diet and exercise on insulin action in older subjects with impaired glucose tolerance.

260
 American journal of clinical nutrition,28: 225-232.

Huges.B.A., Fiatarone, M.A., Fielding, R.A. Kahn, B.B. and Evans, W.J. 1993. Exercise increases muscle
GLUT4 levels and insulin action in subjects with impaired glucose tolerance, American journal of
physiology, 264: E855 – 862.

Huizinga, M.M. and Pothman, R.L. 2006. Addressing the diabetes pandemic: A comprehensive approach.
Indian journal of medical research, 124: 481 – 484.

International Diabetes Federation (IDF) 2011, In: Unwin, N., Whiting, D., Guariguata, L., Ghyoot, G. and
Gan, D. (Eds). Diabetes Atlas. 5th edition. International Diabetes Federation, Belgium.

International Diabetes Federation. 2009. Different approaches of physical training used in the management
of type II diabetes mellitus : A brief systematic review of randomized clinical trials, The British
journal of diabetes, 2011.

Irwin, M., Yaswiy and Ulrich, C. 2002. Effect of exercise on total and intra abdominal body fat in post-
menopausal women a randomized controlled trial. The journal of the American medical association,
289: 323 – 330

Ishii, T., Yamakita, T., Sato, T. and Tanaka, S. 1998. Resistance training improves insulin sensitivity in
NIDDM subjects without altering maximal oxygen uptake. Diabetes care, 21: 1353-1355.

Jayanth Joshi and Kotwal, P. 1999. Essentials of orthopaedic and applied physiotherapy. B.I. Churchill
Livingstone publication, New Delhi, ISBN, 81 (7042): 141.

Jerrald, 2007. Core muscle activity during exercise on a mini stability ball, floor, and on Swissball. Journal of
strength and conditioning research, California U.S.

Joshi, S.R. 2003. Metabolic syndrome - emerging clusters of the Indian phenotype. Journal of association of
physicians of India, 51: 445 – 446.

Kahn, C.R., Flier, J.S., Bar, R.S., Arches, J.A. and Gordan, P. 1976. The syndromes of insulin resistance and
a canthosis nigricans. New England journal of medicine, 294: 739-745.

Kanner, A.D. 1981. Comparison of two modes of stress management; daily hassles and up lifts versus major
life events, Journal of behavioural medicine, 4: 1.

261
Kapil, V., Sing, P., Pathak, P., Dwivedi, S.N. 2002. Prevalence of obesity amongst affluent adolescent
school children in Delhi. Indian pediatrics; 39: 449 – 452.

Kauffman, T.L., Nashner, L.M. and Allison, 1997. Balance is a clinical parameter in orthopaedic
rehabilitation. Orthopaedic physical therapy, 6: 43.

McKeigue, M.C., Shah, B., and Marmot, M.G., 1991. Relation of central obesity and insulin
resistance with high diabetes prevalence in south Asian, Lancet, 337: 382 – 386.

Kelly, G.A. and Kelly, K.S. 2006. Aerobic exercises and lipids and lipoproteins in men. A meta analysis of
randomized controlled trials. Journal of mens health gender, 3: 61-70.

Kennedy, J.W., Hirshman, M.F. and Gervino, E.V. 1999. Acute exercise induces GLUT 4 translocation in
skeletal muscle of normal human subjects and subjects with type 2 diabetes. Diabetes, 48: 1192 – 1197.

Kiens, B. and Limelln. 1989. Lipoprotein metabolism influenced by training induced changes in human
skeletal muscle, Journal of clinical investigations, 83: 558-564.

Kims, N., Lee, S.J. Kang, E.S. and Hut, K.Y. 2006. Effects of lifestyle modifications on metabolic parameters
and carotid intima-media thickness in patients with type 2 diabetes, Metabolism, 55: 1053-1059.

King, H., Aubert, R.E. and Herman, W.H. 1998. Global burden of Diabetes, 1995-2025, prevalence,
numerical estimates and projections, Diabetes care, 21: 1414 – 1431.

King, M.L., Bidwell, D. and Voller, A. 1983. Coxsackit B virus-specific Igm, response in children with insulin
dependent diabetes mellitus. Lancet, 1: 1397-1399.

Kirtz, S. and Moos, R.H. 1974. Physiological effects of social environment, Psychosomatic medicine, 36: 96 –
114.

Kissebah, A.H., Murray, R. and Evang, D.F. 1982. Relationship of body fat distribution to metabolic
complications of obesity. Journal of clinical endocrinology metabolism, 54: 254-560.

Klaus, B., Tim Votteler and Jurgen, S., 2007. Efficiency of vibration exercise for glycemic control in type II
diabetic patients, International Journal of medical science, 4(3): 159 – 163.

Klein-Vogelbach, S. 1990 a. Functional kinetics, Springer, Berlin Heidelberg, New York.

Klein-Vogelbach, S. 1990 b. Ball gymnastic 3rd edition, Springer, Berlin, New York.

Klein-Vogelbach, S. 1990 c. Functional kinetics: Swissball videotape. Springer, Berlin, Heidelberg, New York.
262
Klein-Vogelbach, S. 1991. Therapeutic exercises in functional kinetics. Springer, Berlin, Heidelberg, New
York.

Koiviyte, V.A. and Flig, P. 1978. Effect of leg exercise on insulin. England journal of medicine, 298: 279-283.

Krejs, G.J., Orcil, Conlon, J.M. and Rajkimp. 1979. Somatostatioma syndrome. New England journal of
medicine, 301: 285-292.

Krishnaveni, G.V., Hill, J.C. and Veena, S.R. 2005. Truncal adiposity is present at birth and in early
childhood in south Indian children, Indian paediatrics, 42: 527 – 538.

Kriska, A.M. Blair, S.N. and Prejia, M.A. 1994. The potential role of physical activity in the prevention of
non insulin dependent diabetes mellitus : the epidemiological evidence. Exercise and sports sciences
reviews, Pp. 121 – 143

Krotkiewki, M. 1979. The effect of unilateral isokinetic strength training on local adipose and muscle tissue
morphology, thickness and enzymes. European journal of applied physiology 28: 650-658.

Krotkis, W.L. 1986. The influence of exercise training on plasma lipids and lipoproteins in health and disease.
Acta medical Scandinavian supplement, 711: 25 – 37.

Kurth, E., Hirshman, M.P. Goodyear, L.J. 1999. AMP activated protein kinase activation causes GLUT 4
translocation in skeletal muscle. Diabetes, 48: 667 – 671.

Kuzuyat and Matsuda. 1997. A classification of diabetes on the basis of etiologies versus degree of insulin
deficiency. Diabetes care, 20: 219-220.

Lancet (journal), 2010. Global adult tobacco survey 2008 – 2010.

Lapuma, J. and Lawlor, E.F. 1990. Quality adjusted life years. Ethical implications for physicians and policy
makers. The journal of the American medical association, 263 (21): 2917 – 2920.

Lea and Febiger. 1991. American college of sports medicine. Gudelines for exercise testing and prescription,
4th edition, Philadelphia.

Levangie, P.K. and Norkin, C.C. 2001. Joint structure and function: A comprehensive analysis, 3 rd edition, F.A
Davis, Philadelphia.

Lewis, S.F., Snell, P.G. and Taylor, W.F. 1985. Role of muscle mass and mode of contraction in circulatory
response to exercise. Journal of applied physiology, 58: 146 – 151.

263
Liberson, W.T. 1978. Brief isometric exercise In : Basmajian, Therapeutic exercise, 3 rd edition . Williams and
Wilkins, Balltimore.

Lilliosas, Young, A.A., Cutler, C.L. Ivy, L and Seconb, T.W. 1987. Skeletal muscle capillary density and fiber
type are possible determinants of in vivo insulin resistance in man. Journal of clinical investigations, 80:
415 – 24.

Lindgren, P., Lindstrom, J., Tuomilento and Usitupa, M. 2007. Lifestyle intervention to prevent diabetes in
men and women with impaired glucose tolerance is cost effective. International journal of health care,
23(2): 177-183.

Loimala, A., Strolm, K.G. and Rinne, M. 2009. Effect of long term endurance and strength training on
metabolic control and arterial elasticity in patients with type II diabetes mellitus, American journal of
cardiology, 103: 972- 927.

MacFarlane, I.A. 1997. Endocrine diseases and diabetes mellitus. In: Picup, J.C. and Williams G. (eds) Text
Book of diabetes, 2nd edition,Oxford. Pp, 641-642.

Malorana, A., Odriscoll, G., Cheetham, C., Dembo, L. and Taylor, R. 2001. The effect of combined aerobic
and resistance exercise training on vascular function in type 2 diabetes. Journal of cardiology, 38: 860-
866.

Manson, J.E., Pim, E.B., Stampter, M.J., Colditz, G.A., Willett, W.C., Krolewskia, S., Fosner, B. and
Speizer, F.E. 1991. Physical activity and incidence of NID DM in women. Lancet, 338: 77 – 78.

Marshal, P.W. and Murphy, B.A. 2006. Increases deltoid and abdominal muscle activity during stability ball,
bench press. Journal of strength conditioning,
20: 745-750.

Mayo clinic, 2004. Meta Analysis on 54 studies on aerobic training.

McGill, S.M. and Cholewicki, J. 2001. Bio mechanical basis of stability. An explanation to enhance clinical
utility. Journal of orthopaedic sports physical therapy, 31: 96 – 99.

McLarthy, D.G., Athaide, L., Bottazo, G.F., Swai and Alberti. 1990. Islet cell antibodies are not specifically
associated with insulin dependent diabetes in Rural Tanzaxian Africans . Diabetic reference of clinical
practice, 9: 219-224.

264
McArdle, W.D., Katch, F.I. and Katch, V.L. 1991. Exercise physiology ,energy , nutrition and human
performance , Philadelphia 223 – 225.

McAuley, K.A, Williams, S.M. 2002. Intensive life style changes are necessary to improve insulin
sensitivity. A randomized controlled trail diabetes/ core, 25: 445 – 452.

Mehta, S.R. Kashyap.A.S., Das.S. 2009. Diabetes mellitus in India: The modern scourge. MJAFI . 65-1: 50-
54.

Middlebroke, A.R., Elston, L.M., Macleed, K.M., Mawson, D.M., Ball, C.I., Shore, A.C. and Troke, J.E.
2006. Six months of aerobic exercise does not improve microvascular functions in type 2 diabetes.
Diabetolgia, 49: 2263-2271.

Miller, W.J., Sherman, W.M., and Ivy, J.L. 1984. Effects of strength training on glucose tolerance and post
glucose insulin response, Medical science sports exercise, 16: 539 – 543.

Misra, A. and Vikram, N.K. 2002. Insulin resistance syndrome (metabolic syndrome) and Asian Indians.
Current science, 83: 1483 – 1496.

Misra, A., Pandey, R.M. and Jetal, R. 2001. High prevalence of Diabetes, obesity and dyslipidaemia in
urban slum population in northern India. International journal of obesity, 25: 1 – 8.

Misra, A., Chaudhary, D., and Vikram, N.K. 2002. Insulin resistance and clustering of atherogenic risk
factors in women belonging to low socio-economic strata in urban slums of northern India,
Diabetic reference of clinical practice, 56: 73 – 75.

Mohan, V. 2010. Quality of life among type II diabetic patients.

Mohan, V. Farook, Anjana, M. and Sandeep, S., 2004. Viseral and central abdominal fact and
anthropometric in relation to diabetes in Asian Indians Diabetes care (12) : 2948 – 2955.

Mohan, V., Gokulakrishnan, K., Deepa, R., Shanthi Rani, C.S. and Datta, M. 2005, Association of
physical inactivity with components of metabolic syndrome and coronary artery disease. The Chennai
Urban population study (CUPS – 15). Diabetic medicine, 22: 1206 – 1211

Mohan, V., Shanthi Rani,C.S., and Deepa, M., 2003. Glucose intolerance (diabetes and IGT) in selected
south Indian population with special reference to family history, obesity and life style factors The
Chennai Urban population study (CUPS – 14). Journal association of physicians of India, 51: 771 –

265
 777.

Mohan, V., Shanthi Rani, C.S., Deepa, M., Datta, M.and Williams, O.D., 2006. Community empowerment a
successful model for prevention of non communicable disease in India, The Chennai Urban population
study (CUPS – 17). Journal association of physicians of India, 54: 858 – 862.

Mohan, V., Sharp, P.S., Cloke, H.R., Burrin, J. and Kohner, E.M. 1986. Serum immuno reactive insulin
responses to a glucose load in Asian Indian and European Type II diabetic patients. Diabetologia, 29 :
235 – 237.

Mohan, V., Shanthirani, C.S. and Deepa, R.2003. Glucose intolerance in a selected south Indian
population with special reference to family history, obesity and life style factors. (The Chennai
urban population study CUPS 14). Journal of association of physicians Indian, 51: 771 – 777.

Mohan, V., Shanthirani, S., and Deepa, R. 2001. Intra urban differences in the metabolic syndrome
in southern India. The (CUPS). Diabetic medicine, 18: 280 – 97.

Mohan, V., Krishnan, G.K. Deepa, R. and Rani, S.C.S. 2005. Association of physical inactivity with
components of metabolic syndrome and coronary artery disease, Diabetes medicine, 22: 1206 –
1211.

Mohan, V., Ramachandran, A., Snehalatha, C. and Mohan, R. 1985. High prevalence of maturity onset
of diabetes of the young MODY among Indians. Diabetes care, 8: 374 - 374

Mohan, V., Shanthirani, C.S. and Deepa, R. 2003. Glucose intolerance in a selected south Indian
population with special reference to family history, obesity and life style factors, Journal
association of physicians India 51: 771 – 777.

Mohan, V., Snehalatha, C., Ramachandran, A. and Jayashree, R. 1985. C-Peptide responses to glucose
load in maturity onset diabetes of the young MODY, Diabetes care, 1: 69 -71.

Molbak, A.G., Chistan, B. and Nesup, J. 1994. Incidence of insulin dependent diabetes mellitus in age groups
near 30 years in Denmark, Diabetes medicine, 11: 650-655.

Monrier, A., Bigard, A.X. and Roger, B. 1997. Combined effects of caloric restriction and branched amino
acid supplementation on body composition and exercise performance in elite wrestlers. International
Journal sports medicine, 18: 47-55.

266
Moos, R.H. 1977. Coping with physical Illness. Plenuma, New York.

Mooy, J.M., Bonter, L.M. and Kastense, P.J. 1995. Prevalence and determinants of glucose intolerance in a
Dutch population. Diabetes Care, 18: 1270-1273.

Moran, A., Pyzdrawskikl, Sonim, S.A. and Adams, K.S. 1994. Insulin Sensitivity in crystic fibrosis.
Diabetes, 43: 1020-1026.

Morlay, J.E. and Flood, J.F. 1990. Psychological aspects of diabetes in older persons. Journal of American
geriatrics society, 38: 605 – 606.

Mather, H. and Keln, M. 1985. The south hall diabetic survey, prevalence of known diabetes in Asians and
Europeans, Medical journal, 291: 1081 – 1085.

Must, A., Jacques, P.F, and Dallal 1992. Long term morbidity and mortality of overweight adolescents.
A follow up of the Harvard growth study of 1992 to 1935. New England journal of medicine,
327: 1350 – 1355.

Naliboff, B.D. and Rosenthal, M. 1989. Effects of age on complications in adult onset diabetes, Journal of
American geriatrics society, 37: 838 – 842.

National strength and conditioning association, U.S. 2004. The effect of short-term Swissball training on
core stability and running Economy.

Nicklas, B.J., Katzel, L.I. and Goldberg, A.P. 1997. Increases in HDL with endurance exercise training are
blunted in obese compared with lean mean. Metabolism, 46: 556 – 561.

Noris, S.L., Zhang, X., Avenell, A., Gregg, E., and Brown, D.J. 2005. Longterm non pharmacologic weight
loss interventions for adults with type II diabetes. Cochrane database systematic review, CD 00 4095.

Hother Nilson, O., Faber, O., and Sorensenns, 1988. Classification of newly diagnoses diabetes patients as
insulin requiring or non- insulin requiring based on clinical bio chemical variables. Diabetes Care, 11:
531-537.

Oetterly, S. and Larsen, C. 1996 Physiotherapy using Swiss ball: Physical therapy, 6: 23 – 35.

Ohkubo, Y., Kishikawah, Arakie, Miyata, T., Isami, S., Motoyoshi, S. and Kosima, Y. 1995. Intensive
insulin therapy prevents the progression of diabetic microvascular complications in Japanese patients
with NIDDM a randomized prospective 6year study. Diabetes clinical practice, 28: 103-117.

267
Oldroyd, N.C., Winwin, M. and White, 2001. Randomized controlled trial evaluating the effectiveness of
behavioural interventions to modify cardiovascular risk factors in men and women with impaired
glucose tolerance. Diabetes research and clinical practice, 29-43.

Ostergard, T, Andersen, J.L. and Nyholm, 2006. Impact of exercise training on insulin sensitivity physical
fitness and muscle oxidative capacity in first degree relatives of type 2 diabetes patients. American
journal of physiology, endocrinology metabolism, 290: E998-E1005.

Otuska, Y., Miyazakis and Okumura, H. 2010. Abnormal glucose tolerance is a determinant of long term
prognosis in patients treated with balloon coronary angioplasty. European heart journal 21: 1790-1796.

Pak, C.Y, Eunh and Yoon, J. 1988. Association of cytomegalovirus infection with anti immune type I diabetes.
Lancet, 1- 4.

Pan, X.R., Li, G.W., Huyh, Wang, J.X., Vang, W.Y. and Howard, B.V. 1997. Effects of diet and exercise in
preventing NIDDMM, people with impaired glucose tolerance. Diabetes care, 20: 537 -542.

Pandit, M.K., Burke, J., Gustabson, A.B. and Minocha, A. 1993. Drug-induced disorders of glucose
tolerance. Annals of internal medicine, 118: 529-540.

Patandin, S., Bots, M.L., Abel, R. and Burg, V.H.A. 1994. Impaired glucose tolerance and diabetes
mellitus in a rural population in south India. Diabetes research clinical practice, 24: 47 – 53.

Patel, A., Macmohan, S., Chalmers, J. and Billot, L. 2008. Intensive blood glucose control and vascular
outcomes in patients with type 2 diabetes. Northern England journal of medicine 358: 24:2560-2572.

Pederson, T.R., Olsson, N.G., Faergeman, O., Wedel, H. and Cook, T.J. 1998. Lipoprotein changes and
reductions in the incidence of major coronary heart disease events in Scandinavian survival study
circulation, 97:1453-1460.

Permert, J., Larsson, J., Westermaskat, Nerrington, M.K. and Povr, P.M. 1994. Islet armload poly peptide
in patients with pancreatic cancer diabetes, New England journal of medicine, 330: 313-318.

Plough, T. and Ralston, E. 2002. Exploring the where aborts of GLUT 4 in skeletal muscle. Molecular
membrane biology, 19: 39-49.

Poitier, P., Tremblay, A. and Catellier, C. 2002. Impact of moderate aerobic exercise training on insulin
sensitivity in type 2 diabetic men treated with oral hypoglycemic agents. Medical science, 8: 59- 65.

268
Pollock, M.L. Willmore, J.H. 1984. Exercise in health and disease; Evaluation and prescription for prevention
and rehabilitation WB Saunders Pp. 261

Pollock, M.L., Willmore, J.H. 1978. Health and fitness through physical activity . New York, John wiley and
sons.

Radha, V. and Mohan, V., 2007. Genetic pre-disposition of type II diabetes among Asian Indian. Indian
journal of medical research, 125: 259 – 274.

Raji, A. Seely, W., Arky, R.A. and Simson, D.C. 2001. Body fat distribution and insulin resistance in healthy
Asian Indian and Caucasians. Journal of clinical endocrinology metabolism, 86: 5366 – 5371.

Ramachandran, A. 1995. Epidemiology of NIDDM in Indians, International journal of diabetes developing

countries, 15: 42 – 44.

Ramachandran, A., Snehalatha, C. and Vijay, V. 2002. Impact of poverty on the prevalence of
Diabetes and its complications in urban southern India; Diabetes medicine, 19: 130 – 135.

Ramachandran, A., Snehalatha, C., Kapur, A., Vijay, V., Mohan, V. and Das, A.K. 2001. Diabetes
epidemiology study group in India (DESI): High prevalence of Diabetes and impaired glucose
tolerance in India; National urban Diabetes survey, Diabetologia, 44: 1094 –1101.

Ramachandran, A., Snehalatha, C., Mohan, V. and Vishwanathan, M. 1990. Development of

carbohydrate intolerance in offspring of Asian Indian conjugal type 2 Diabetic parents, Diabetic
reference of clinical practice, 8: 269 – 273.

Ramachandran, A., Snehalatha, C., Vishwanathan, V., Vishwanathan, M. and Haffner, S.M. 1997.
Risk of Non Insulin dependent Diabetes Mellitus conferred by obesity and central adiposity in
different ethnic groups; Diabetic reference clinical practice, 36: 121 – 125.

Ramachandran, A., Snehalatha, C. and Kapur, A. 2001. High prevalence of diabetes and impaired
glucose tolerance in India National urban Diabetes survey. Diabetology , 44; 1094 – 1101.

Ramachandran, A., Snehalatha, C., Dharmaraj, D. and Vishwanathan, M. 1992. Prevalence of

glucose intolerance in Asian Indians: urban – rural difference and significant upper body
adiposity. Diabetic care, 15: 1348 – 1355.

269
Ramachandran, A., Davey, G., Snehalatha, C., Hitman, G.A. and Keligue, P.M. 2000. Familial aggregation
of central obesity in southern Indians, International journal of obesity, 24: 1523 -1528.

Ramachandran, A., Snehalatha, C., Latha, E., Satyavani, K. and Visuvanathan, V. 2003. Metabolic
syndrome in urban Asian Indian Adults : A population study using modified ATP III Criteria. Diabetes
reference to clinical practice, 60: 199 -204.

Ramaiya, K.L., Kodali, V.R., Kamm and Alberti. 1990. Epidemiology of diabetes in Asians of the
Indian subcontinent. Diabetic metabolic review. 6: 125 – 146.

Rattigan, S., Wallis, M.G., Youd, J.M. and Clark, M.G. 2001. Exercise training improves insulin mediated
capillary recruitment in association with glucose uptake in hind limb, Diabetes, 50: 2659-2665.

Raul, A. M., Manuel, T., Verissimo, Manuel. J., Coelho E. Silva, Sean. P,, Cumming and Ana M. Teixeira.
2010. The effect of aerobic versus strength based training on high sensitivity C reactive protein in older
adults. European journal of applied physiology, 110(1): 161-169.

Reeder, B.A., Senthilselvan, A. and Despres, J.P. 1997. The association of cardiovascular disease risk factors
with abdominal obesity in Canada, Journal of Canadian medical association, 157: 539-545.

Reitman, J.S., Vasquez, B. and Klimes, I. 1984. Improvement of glucose homeostasis after exercise training
in NIDDM, Diabetes care, 7: 434 -441.

Rema, M., Premkumar, S., Anita, B., Deepa, R., and Mohan,V. 2005. Prevalence of diabetic retinopathy in
Urban India : The Chennai Urban Rural Epidemiology Study (CURES) Eye study. I. Investigations of
Ophthalmology visual sciences, 46: 2328 – 2333.

Roberts, C.K., Barnard, R.J. and Jasman, A. 1999. Acute exercise increases nitric oxide synthase activity in
skeletal muscle. American journal of physiology endocrinology metabolism, 277: E390 – E394.

Ronald, J., Sigal, Glemp. Kenny, Normand .G., George, A. and Wells. 2007. Effects of aerobic training,
resistance training, or both on glycemic control in type II diabetes, Annals of internal medicine, 147(6):
357 – 423.

Sadikot, S.M., Nigam, A., Das, S., Bajaj, S., Zargar, H. and Kumar, P.K.M. 2004. Diabetes India: The
burden of Diabetes and impaired glucose tolerance in India using the WHO 1999 criteria:
Prevalence of Diabetes in India study (PODIS). Diabetes Respiratory Clinical Practice, 66: 301 –
307.

270
Sakamoto and Schrffer, J.E. 2002. Fatty acid transport : The roads taken American journal of Physiotherapy,
282: E 239 – E 246 .

Bweir, S., Muhamed,A.L–jarrah, Abdul-Majed Aalmalty, Mikhled, Lisa stehno and Bittel. 2009.
Resistance exercise training lowers, HbA1c more than aerobic training in adults with Type 2 diabetes,
Diabetology and metabolic syndrome, 1(27): 1 - 27

Saltin, B. and Rowell, L.B. 1986. Functional adaptations to physical activity and inactivity . Federal
proceeding, 39: 1506-1513.

Saltin, B. Lindgarde, F., Lirnell, H., Eriksson, K.and Gad, P. 1980. Metabolic effects of long term physical
training, Excerpta medical Amsterdam 1980.9:345-350

Schreider, S.N. and Amorosa, L.F. 1992. Ten year experience with an exercise based outpatient life style
modification program in the treatment of diabetes mellitus. Diabetes care, 15(4): 1800 – 1810.

Betul, Sekendiz, Mutla and Kakkusuz. 2010. Effects of swiss ball on core strength training on strength,
Endurance, Flexibility and balance in sedentary women. Journal of strength conditioning research.
24(11):3032-3040.

Selvin, F., Marinopoulos, S., Berkenblit, G. and Rathi, T. 2004. Meta analysis ; Glycocelated hemoglobin
and cardio vascular disease in diabetes mellitus . Annals of internal medicine, 141 : 421 – 431.

Shankuanzhu, Wang, Z., StanleyNeshka, Neo, M., Steven, BheySfilld. 2002. Waist circumference and
obesity associated risk factors among whites in the third national health and nutrition examination
survey: clinical action thresholds, American journal of clinical nutrition, 76: 4743.

Sharpps, Mohan, V. and Levy, J.C. 1987. Insulin resistance in patients of Asian Indian and European
origin with non – Insulin dependent Diabetes; Horm. metabolic research, 19: 84 – 85.

Shelgikar, K.M, Hockaday, Yajnik, C.S, 1991. WHR in obese diabetes. Diabetology medicine, 8:
1712 – 1717.

Sheri Colberg, S.R., Albright, A.L., Blissmer, B.J. and Briyan, B., 2010. American College of Sports
Medicine and American diabetes association. Exercise and Type II diabetes: Joint Position statement.

Sicree, R., Shaw, J. and Zimmet, P. 2006. Diabetes and impaired glucose tolerance. Inland editor.
Diabetes atlas International Diabetic federation; pp. 15 – 103.

271
Sedell J.C., Bakker, C.J. Vanderkooy, 1994, Imaging techniques for measuring adipose tissue distribution.
American journal of clinical nutrition, 51: 953 – 957.

Sigal, R.J., Kenny, G.P., Boule, N.G. and Wells, G.A. 2007. Effects of aerobic training resistance training or
both on glycemic control in type 2 diabetes. A randomized trial. American Internal Medicine: 14357-
14369.

Sing, R.B., Bajaj, S., Wiaz, M.A. and Rastogi, S.S. 1998. Prevalence of Type 2 Diabetes mellitus and
risk of hypertension and coronary artery disease in rural and urban population with low rates of
obesity; International journal of cardiology, 66; 65 – 72.

Seals, D.R. 1984. Endurance training in older men and women. Cardiovascular ressonses to exercise. Journal
of applied physiology 57: 1024.

Snawling, N.J. and Hopkins, W.G. 2006. Effects of different modes of exercise training on glucose control
and risk factors for complications in type 2 diabetic patients a meta-analysis. Diabetes care, 29:2518-
2527.

Snehalatha, C., Ramachandran, A., Satyanik, Latha, E., Vijay, V. and Ramachandran M. 1998.
Study of genetic pre diabetic south Indian subjects importance of hyperinsulinaemia and B cell
dysfunction. Diabetes care, 21: 7679.

Sokos, T.G.C., Gorden, P., Antonych, T., Wilson, C.B. and Balaw, J.E. 1985. Lupus rephritis and other
autoimmune. Fractures in patients with diabetes melliting due to autoantibody to insulin receptors.
Anals of internal medicine, 102:176-181.

Solimena, M. and Decamilli, P. 1991. Autoimmunity of glutamic acid decarborxlase(GAD) in stiff man
syndrome and insulin dependent diabetes mellitus. Trends Neurosciences, 14: 452-457.

Stallknecht, B., Lorensten, J. and Enevoldgen, L.H. 2001. Role of the symparthoadrenergic system in
adipose tissue metabolism during exercise in humans. Journal of physiology, 536: 283-294.

Steinberger, J., Daniel, S.R. and Eckel, H. 2009. Progress and challenges in metabolic syndrome in children
and adolescents a scientific statement frame American heart association circulation, 119:628-647.

Stella, L., Volpe, Natikobusingye, M.S., Smita, B., AIlur, M.S. and Stanek, E. 2008. Effect of diet and
exercise on body composition, energy intake and leptin levels in overweight women and men. Journal
of the American college of nutrition, 27(2): 195-208.

272
Stendler, A. 1955. Kinesiology of the human body under normal and pathological conditions. spring field, IL.

Stewart, K.J. 2002. Exercise training and the cardio vascular consequences of type 2 diabetes and hypertension
possible mechanisms for improving cardio vascular health. JAMA, 288:1622-1631.

Stireman, M.G. and Williams, S.V. 1990. Predicting inpatient rehabilitation length of stay, Archives of
physical medicine and rehabilitation, 71 : 881 – 887.

Stoffers, D.A., Ferrer, J. and Clarke, W.L. 1997. Early onset type 2 diabets mellitus(MODY 4 ) linked to IPFI
– Nature genetics, 117:138-139.

Storloin, L.H, and Unsitupa, M. 2001. KANWU study substituting dietary saturated for mono saturated
fat impairs insulin sensitivity in healthy men and women. Diabetologia, 44: 312 – 319.

Stratton, I.M., Cull, C.A., Alder, A.L. and Holman, R.R. 2006 Addictive effects og glycemia and blood
pressure exposure on risk of complication on type 2 diabetes. Diabetolgia, 49: 1761-1769.

Subramanian, S.S and Venkatesan, P. 2012 b. Stability ball on glycemic control in type 2 diabetes mellitus.
Journal of applied chemistry, 1(3): 10-13.

Subramanian, S.S and Venkatesan, P. 2012 a. Stability ball exercises on glycemic control and lipid profile on
type 2 diabetic patients, Journal of applied chemistry, 1(1): 31-35.

Subramanian, S.S and Venkatesan, P. 2012 c. Stability ball exercises in type 2 diabetic patients, Journal of
research in biology, 2(4): 403-409.

Sullivan, P.E. and Markos, P.D. 1995. Clinical decision making in therapeutic exercise Appleton and lange
,Norwalk , CT.

Sullivan, S.B. 2001. Assessment of motor function 4th edition FA Davis, phicadelphia, pp 177.

Taylor, R., Ramp and Zimmet, P. 1984. Physical activity and prevalence of diabetes in Melanesian and
Indian men in Fiji. Diabetologia, 27; 578 – 582.

Taylor, S.I. 1992. Lilly lecture; molecular mechanisms of insulin resistance: lessons from patients with
mutations in the insulin receptor gene. Diabetes, 41:1473-90.

Thalwar, 2011. Coronary heart disease contribute to 1/3rd of global death. Affects 65.4 in 1,000 male and 47.8
in 1,000 female and 25% have CAD among cases of myocardial infarction less than 40 years in India
273
Thanikachalam, 2011. PURSE – HIS project (8,000 subjects screened between 25 – 65 years) 2008 – 2011.

Tokmakidas. S., Zois, C. and Kotsa, K. 2004. The effects of a combined strength and aerobic exercise
program on glucose control and insulin action in women with type II diabetes, European journal of
applied physiology, 92: 437-442.

Tudorlocke, C. and Harris, S.B. 2004. A daily physical activity intervention for individuals with type 2
diabetes, International journal rel.met.disorder, 28:113-119.

Tuomilehte, J., Lindstorm, J., Erikkson, J.G., Valle, T.T. and Salruinen, V. Prevention of Type 2 diabetes
mellitus by changes in lifestyle among subjects with impairable glucose tolerance.

Tuomilehto, J., Lind Strom, Erriksson, J.G. 2001. Prevention of type 2 diabetes mellitus by charges in
lifestyle among subrects with impaired glucose tolerance. New England journal of medicine, 344: 1343-
1350.

U.S. Department of Health and Human Services, 1996. Physical activity and health : A report of the surgeon
general, national centre for chronic disease, prevention and health promotion. Washington D.C., U.S
Government printing office.

Valley, T., Tuomilette and Eriksson, J. 1997. Epidemiology of NIDDM in Europids.In : AlbertiK
GMM,Zimmet P, International Textbook of diabetes mellitus,second edition, chichegter : John wiley,
pp125-134.

Vanninene, and Usotupa, M. 1992. Aerobic capacity and metabolic control in patients with newly diagnosed
type II diabetes mellitus effect of I year diet and exercise ; Diabetologia, 35: 340 – 346.

Verville, R.E. 1990. The Americans with disabilities Act : An analysis Arch phy med rehabilitation, 71 : 1010 –
1013.

Vikran, N.K., Misra, A., Pandey, and R. Meta, 2003. Anthropometry and body composition in
northern asian Indians patients with Type 2 diabetes. Receiver operating characteristics (ROC).
Diabetes nutrition metabolism, 16: 3240.

Vishwanathan, M., Mccarthy, M.I., Snehalatha, C., Hitman, G.A. and Ramachandran, A. 1996.
Familial aggregation of Type 2 (Non Insulin dependent) Diabetes mellitus in South India;
absence of excess maternal transmission; Diabetic medicine, 13; 232 – 237.

274
Voorsa, W., Webber, L.S., and Frerichs, R.R. 1977. Body height and body mass as determinants of basal
blood pressure in children:Bogalusa heart study. American journal of epidemeiology, 106:101-108.

Walker, M. and Turnbull, D.M. 1997. Mite Chendrial related diabetes medicine, 14:1007-1009.

Wallberg and Heniksson, H. 1992. Exercise and Diabetes mellitus, 339 – 368.

Walsh, M.L. and Banister, E.W. 1998. Possible mechanisms of the anaerobic threshold. A review south
medical journal, 5; 269 – 302.

Weinberg, N. 1984. Physically disabled people assess the quality of their lives. Rehabilitation literature, 42:12
– 15.

Whelton, S., China and Xin, X. 2002. Effect of aerobic exercise on blood pressure: A meta analysis of
randomized controlled trials. Annals of Internal medicine, 136: 493 – 503.

WHO, 2004, Technical report series no.920 on ways to promote health.

WHO. 1999. Definition, diagnosis and classification of diabetes mellitus and its complication report of a WHO
consultation. Part 1 : Diagnosis and classification of diabetes – Geneva.

Wild, S., Poglic, G., Green, A., Sicree, R. and King, H. 2004. Global prevalence of diabetes: estimates
for the year 2000 and projections for 2030. Diabetes care, 27; 1047 - 53

Willey, K.A., Fiatore and Sing, M.A. 2003. Battling Insulin resistance in elderly obese with type 2 diabetes
Diabetes care, 26: 1580-1588.

Williamson, D.A., Reseski, J. and Lang, W. 2009. Impact of a weight management program on health related
quality of life in overweight adults with type 2 diabetes . Archives of internal medicine, 169(2): 163
-171.

Willis, J.A., Scott, R.S., Brown., L.J., Forbes, L.V. and Zimmet, P.Z. 1996. Islet all antibodies and
antibodies against glumatic acid dcarboxylase in newly diagnosed adult onset diabetes mellitus.
Diabetes Res. Clinical Practice, 33:89-97

Wilmore, J.H. and Costill, D.H. 1988. Physiological basis of the conditioning process , 3rd ed . Dubuque , I.A
Brown.

Winder, W.W., Hagberg, J.M. and Hickson, 1978. Time course of sympathoadrenal adaptations to endurance
training in men. Journal of applied physiology, 45: 370 -374.

275
Wittkower, E.D. 1969. A global survey of psychosomatic medicine. International journal of psychiatry, 7: 576
– 591.

Wood, P.D., Stephenic, M.L., Williams, P.T., and Haskell, W.L. 1991. The effects of plasma lipoprotein of a
prudent weight reducing diet with or without exercise in over weight men and women, New England
journal of medicine: 325: 461 – 466.

Woolfolk, R.L. and Lehrer, P.M. 1984. Principles and practice of stress management. The Guilford Press ,
New York.

Yach, Y., Stuckler, D. and Brownell. 2006. Epidemiologic and economic consequences of the global epidemics
of obesity and diabetes, Nature of medicine,12: 62-66.

Yajnick, C.S. 2002. The life style effects of Nutrition and body size on adult adiposity, diabetes and
cardiovascular disease. Obesity review, 3: 217.

Yajnick, C.S., Fall, C.H., Coyoji, K.J., Hirve, S.S., Rao, S. and Barker, D.J. 2003. Neonatal
anthropometry the thin – fat Indian baby. The pune maternal nutrition study, International journal
of obesity related metabolic disorder, 27: 173 –180.

Yajnick, C.S., Shelzikar, K.M., Naik, S.S. and Albreti, K.G.M.M. 1992. The Ketoacidosis resistance in fibro
calculations pancrlatic diabetes. Diabetes res clinical practice, 15:149-156.

Yajnick, C.S. 2002. The Life style effects of nutrition and body size on adult adiposity, diabetes and
cardiovascular disease. Observation review, 3: 217 – 224.

Yajrik, C.S., Fall, C.H., Coyaji, K.J., Hirve, S.S., Rao, S. and Barker, D.J. 2003. Neonatal anthropometry:
the thin – fat Indian baby. The Pune maternal Nutrition Study, International journal of obstetrics related
metabolic disorders, 257: 173 – 180.

Yamagata, K., Oolan, Kaisaki, P.J. and Merizel, S. 1996. Mutations in me hepatecyte nuclear factor-1
alphagene in maturity mset diabetes of the young(MODY 3). Nature, 384: 455-458

Yamagatta, K, Furuta, H. and Odan, N. 1992. Mutations in the hepatelyte nuclear factor and Alpha gene in
(MODI), Nature, 384: 458-460.

Yunkee Lee, Young Whan Song, Hong. 2010. The effects of an exercise program on anthropometric metabolic
and cardiovascular parameters in obese children. Korean circulation journal. 40(4):179-184.

276
Zamso, S., Jimenez and Pugliese, G. 2009. Exercise for the management of type 2 diabetes , a review of the
evidence . Acta diabetologia

Zimmet, P. 1991. Diabetes care and prevention around the world in 80 ways; IDF Bulletein; 36; 29 –
32.

Zimmet, P.Z., Tuomi, T., Mackey, Rdvlay, M.J. 1994. Latent, auto immune diabetes mellitus in adult
(LADA) : the role of the anti bodies to gluternic acid decarborylase in diagnosis and prediction of
insulin dependency . Diabetic medicine, 11:299-303.

IOSR Journal of Applied Chemistry (IOSRJAC)

ISSN : 2278-5736 Volume 1, Issue 3 (July-Aug. 2012), PP 10-13
www.iosrjournals.org

Stability Ball on Glycaemic Control in Type 2 Diabetes Mellitus

Subramanian SS1 and Venkatesan P2.

Abstract: Diabetes mellitus, one of the top non-communicable diseases globally, particularly among Indian population,
has huge impact on the health of the individual, nation, as well as economical percussion. Lifestyle modifications
including dietary modifications, improved physical activities remain key components in the therapeutic and preventive
means of Type 2 diabetes mellitus. The effectiveness of Exercises using stability ball in the glycaemic control and weight
reduction among type 2 diabetes mellitus are dealt with in this study.

Key Words: Type 2 diabetes, Stability Ball

NOTE: Stability ball is also called physio ball, swiss ball / gym ball, which is an air inflated ball of 550mm
diameter which is widely used as a rehabilitation tool in physiotherapy.

I. Introduction:

277
 Diabetes poses a major health problem globally and is one of the top 5 leading causes of death (King,
Albert et al 1998). By the year 2025, the worlds 300 million adults with diabetes will be in developing countries,
almost 1/3rd in India and China alone (Fall et al 2001). Asian Indian phenotype is considered to be one of the
major factors contributing to the increased predilection towards diabetes (Joshi R 2003). Asian Indians have a
greater degree of central obesity (Ramachandran, Snehalatha 1997) and have total abdominal and visceral fat
for any given Body mass index and for any given body fat have increased insulin resistance (Raji, Seely et al
2001). Most disturbing trend is the shift in the age of onset of diabetes to a younger age in recent years, which
could have more percussions on health and economy of individual hence on the nation, (Mohan, Deepa et al
2006) with changes in dietry pattern (Sterlin, Baur et al 1996) and decreased physical activities (Mohan, Shanthi
rani et al 2003). Higher prevalence of diabetes in the urban population (Ramachandran, Snehalatha et al 2002)
were well recorded.

Appropriate life style interventions including changes in dietry pattern, regular exercises would greatly
help in preventing or postponing the onset of diabetes and thus reducing the burden on society and nation
(Knavler, Barrett et al 2002). Chennai city has a known prevalence of Type 2 diabetes at 12% (Ramachandran,
Snehalatha et al 2001). Type 2 diabetes accounts for 90% of all diabetic cases (Wild, Foglic et al 2004).

The American diabetes association (ADA) recommends that individuals with Type 2 diabetes should
perform atleast 90minutes of vigorous aerobic exercises per week or should perform atleast 150 minutes of
moderate aerobic exercises per week (ADA 2002). Vibration exercises are an effective, lowtime consuming tool
to enhance glycaemic control in Type 2 diabetic patients (Klans Banm et al 2007). Glycaemic control improves
with resistance training (University of calgary, Ottowa 2007).

The purpose of this study was to evaluate the effects of moderate intensity exercises using stability ball
on glycaemic control among male Type 2 diabetic patients.

II. Materials And Methods:

Participants in this study were recruited by special diabetic camp organised during July 2010. This
study was conducted at Sree Balaji College of Physiotherapy, Chennai-100. 60 subjects, diagnosed with Type 2
diabetes mellitus patients on due medication between the age group of 30-60 years were randomly assigned to
12 weeks supervised control group (n=30) or moderate intensity resistance exercises using stability ball (n=30).

All the subjects glycelated haemoglobin and body mass index (BMI) were recorded before training (i.e.,
0 week) and after 12 weeks of training.

Inclusion criteria were Non insulin dependent, diagnoses with Type 2 diabetes, male between 30-60
years.

Participants of the camp were evaluated by medical and physical means to exclude individuals with
subjective or objective evidence of uncontrolled diabetes mellitus, severe musculoskeletal impairment, those
with uncontrolled hypertension and who underwent coronary artery bypass surgery.

Written informed consent to participate in the study were obtained from all the subjects.

III. Outcome Measure:

278
 All the subjects were tested on two occasions by using same protocols. Venous blood samples of all the
participants were taken, measured and analysed for Glycelated hemoglobin before the intervention i.e., 0 week
and after the intervention (12th week)

IV. Anthropometric Measures:

Height in centimeters and weight in kilogram of all the subjects were measured and body mass index
was calculated and recorded prior to starting this study after completion of 12 weeks of intervention. Height
and weight was measured and BMI was calculated for all the subjects, recorded and analysed using due
statistical means.

V. Intervention:
Subjects alloted to this group have performed systemic supervised resistance training as per the
guidelines of ADA(American Diabetic Association) and ACSM (American College of Sports Medicine).
Subjects have performed three sets of 10 exercises and 5 repetitions of each exercise per session. Thrice a week
they have exercised for a period of 12 weeks. The exercises performed using stability ball involved of using
major muscle groups such as Lumbar spine extensors, Abdominals, Gluteus Maximus, Quadriceps Femoris,
Hamstrings and Gastrocnemius. All the physical activity were of the nature of closed kinematic chain exercises
and using isometric co-contraction of many lower extremity muscles. Also body weight of the subjects
providing resistance to each activity, hence peak torque produced with every physical activity using the
stability ball.

Progression in intensity was designed in such a way that upto four weeks no holding of each physical
activity, Five second hold of each activity during the period from 8-12 weeks were practiced.

Control Group:

Subjects allotted in this group underwent no specific training other than their daily routine physical
activities.

All the subjects in control group and stability ball exercise groups continued their prescribed
medication and daily routine activities.

VI. Results
All the participants completed the training period of 12 weeks. No injuries or hypoglycaemic incidents
occured.

Body Mass Index(BMI);

Subjects in stability ball exercise group where there was a decrease by 1.6 in the mean value which is
significant, where as mean value among control group subjects has increased by 0.5 as shown below in graph 1

279
 Graph 1 - Pre & Post Test means of Control &
Stability ball exercise group

35

30

25

20

15

10

0
Control Group Stability Exercise Group
Pre Test Post Test

Initial measurements and post training changes in Body Mass Index of both control and stability ball exercises
were analysed using paired 't' test. Statistical tests were performed using SPSS software.

Table 1: Results of paired 't' test of control group and stability ball exercise group

BMI Mean S.D Significa

nce
Control Group Pre Test 28.5 0.45 P > 0.000
Post Test 29
Stability Ball Exercise Pre Test 26.60 2.65 P < 0.05
Group Post Test 25

As displayed in above Table 1, stability ball xercise group subjects have lowered body mass index and
is statistically significant at P < 0.05 and 5% probability level, hence is effective in the management of Type 2
diabetic patients.

At the same time subjects in control group, where as BMI have an increased BMI and statistically
insignificant.

Glycelated Haemoglobin;

280
 Graph 2 - Pre & Post Test means of Control &
Stability ball exercise group

9
8
7
6
5
4
3
2
1
0
Control Group Stability Exercise Group
Pre Test Post Test

Mean values among stability ball exercise subjects have decreased by 0.55%, where as mean values of control
group subjects have increased by 0.25%. As displayed above in Graph 2.

Table 2; Results of Paired 't' test among control group and stability ball exercise group.

HbA1C Mean S.D Significa

nce
Control Group Pre Test 7.27 0.22 P > 0.000
Post Test 7.52
Stability Ball Pre Test 7.92 1.21 P < 0.001
Exercise Group Post Test 7.37

As shown in Table 2, stability ball exercises are effective in lowering HbA1C, which is evident
statistically at P < 0.001 and 10% probability level, where as control group results were statistically
insignificant.

VII. Discussion
This research study confirms that stability ball exercises were effective in lowering Body Mass Index
and Glycelated Haemoglobin. Maximal muscle activity of 50% versus 9% on activities performed on stability
ball and stable bench respectively (Marshall, Murphy et al 2006). Exercises using Stability ball were effective in
improving core strength, Endurance and Balance in sedentary women (Sekendez Bet et al 2010).

Insulin absorption is more with exercises to lower extremity than given to upper extremity (Koivitste,
Fligp et al 1978). Glycaemic control improves with resistance training involving major muscle groups (Baldi,
Sandvling et al 2003). A better glucose control was observed due to improvement in Insulin sensitivity and
effects of glucose transporters due to muscular hypertrophy and blood flow (Plong, Raltson et al 2002).

Moderate intensity resistance training results in a mean reduction of Glycelated Haemoglobin by 1% to

2% (Dustan, Puddey et al 1998). Among women with Type 2 diabetes a reduction of 0.5% to 1% of HbA1C in
response to resistance exercises (Cuff, Meneily et al 2003).
281
 1% decrement in HbA1C can reduce the risk of diabetic complications such as myocardial infarction
and microvascular disease (Stratton, Well et al 2006 and Patel, Mcmohan et al 2008).

In this study a reduction of 0.55% Glycelated Haemoglobin was recorded, hence is effective in reducing
cardiovascular complications to a greater extent among diabetic patients.

Obesity is a powerful determinant and a risk factor for developing diabetes (WHO 2004). Increase in
Body Mass Index was demonstrated to increased risk to complications in Type 2 diabetic patients among
Asians (Dr Ramachandran et al 1995). A higher BMI and Waist circumference were recorded among Indian
diabetic patients (Chandalia et al 1999). Moderate weight loss in obese individual is associated with
improvements in a number of cardiovascular risk factors including blood pressure (Dr Golstein 1992),
significant reduction in BMI by 1Kg/m2 following diet and physical activity for 6 months (Oldrogd, Unwin et
al 2001). In this study BMI has decreased by 1.6Kg/ m 2 following stability ball exercise, hence is quite effective
in decreasing obesity related complications among diabetic patients is evident.

Hence Stability ball exercises to lower extremit can form a modality in the comprehensive management
of Type 2 diabetes mellitus. Also as preventive means among obese children and adults can facilitate in
preventing and postponing the onset of Type 2 diabetes along with due dietry measures.

VIII. Conclusion
Life style modifications including regulations in diet, regular physical activities, coupled with medical
monitoring of individual will enable to develop a healthy, vibrant future India. Stability ball exercises widely
used for recreational means, strengthening of core muscles of spine, can be considered for its extensive impact
on neurovascular, endocrine system requires further exploring studies ahead.

Bibliography

[1]. Burden of diabetes 1995-2025; prevalence, numerical estimates and projections. Diabetes care 1998;21;1414-
1131.
[2]. Fall CH: Non industrialized countries and affluence. Bt Med Bull 2001;60;33-50.
[3]. Joshi SR:Metabolic syndrome - emerging clusters of the Indian phenotype. Journal of association of
physicians India; 2003; 51; 445 – 446.
[4]. Ramachandran A, Snehalatha C, Vishwanathan V, Vishwanathan M, Haffner SM;Risk of Non Insulin
dependent Diabetes Mellitus conferred by obesity and central adiposity in different ethnic groups;
Diabetic reference clinical practice; 1997; 36; 121 – 5
[5]. Raji A, Seely EW, Arky RA, Simonson DC; Body fat distribution and insulin resistance in healthy Asian
Indians and Caucasians. J Clin Endocrinology metab 2001; 86; 5366-71.
[6]. Mohan V, Deepa M, Deepa R, Shanthi rani CS, Farooq S, Ganesan A et al. Scular trends in the prevalence of
diabetes and glucose intolerance in urban south india – the chennai urban rural epidemiology study
(CURES-17) Diabetologia 2006; 49; 1175-8.
[7]. Storlein LH, Baur LA, Kriketos AD et al. Dietry fats and Insulin action. Diabetologia 1996; 39;621-31.
[8]. Mohan V, Shanthirani CS, Deepa R.Glucose intolerance in a selected south Indian population with
special reference to family history, obesity and life style factors – The (UPS14) Journal association
of physicians india 2003; 51; 771 – 777.
[9]. Ramachandran A, Snehalatha C, Vijay V. Impact of poverty on the prevalence of Diabetes and its
complications in urban southern India; Diabetes medicine 2002; 19; 130 – 135.

282
[10]. Knavler WC, Barrett-connor E, Pauler SE, Hamman RF, Laclin JM, Walker EA et al. Diabetes prevention
program research group. Reduction in the incidence of Type 2 diabetes with life style intervention. N
engl J med 2002; 346; 393-403.
[11]. Ramachandran A, Snehalatha C, Kapur A, Vijay V, Mohan V, Das AK et al. Diabetes
epidemiology study group in India (DESI). High prevalence of Diabetes and impaired glucose
tolerance in India. National urban Diabetes survey; Diabetologia 2001; 44; 1094 – 101.
[12]. Wild S, Roglic G, Green A, Sicree R, King H, "Global Prevalence of diabetes: Estimates for the year 2000
and projections for 2030, diabetes care 2004; Volume- 27, Page: 1047-1053.
[13]. American Diabetes Association; Diabetes mellitus and exercise (Position statement) Diabetes care 2002,
564-568.
[14]. Klans Banm et al, "Efficiency of vibration exercise for glycaemic control in Type 2 diabetes patients",
International Journal of Medical sciences, 2007, Volume:4, Issue:3, Page: 159-163.
[15]. Koiviste VA, Fligp, "Effects of leg exercise on insulin", England Journal of medicine, Jan-12-1978, Volume:
298, Page: 279-283.
[16]. University of calgary ottowa 2007. Glycaemic control in Type 2 diabetic patients improves with resistance
training.
[17]. Baldi JC, Snawling N, 2003. Resistance training improves glycaemic control in obese Type 2 diabetic man.
International Journal of sports medicine 24; 419-423.
[18]. Ploug T, Ralston E, "Exploring the whereabouts of GLUT4 in skeletal muscle", Molecular Membrane
Biology, 2002, volume:19, Page: 39-49.
[19]. Dustan DW, Puddey, Burkey V. 1998, Effects of a short term circuit weight training programme in non-
insulin dependent diabetes mellitus; Diabetes research and clinical practice 40, 53-61.
[20]. Advance Colloborative group; Patel A, Macmohan S, Chalmers J, Neal B, Billot L et al 2008. Intensive
blood glucose control and vascular outcomes in patients with Type 2 diabetes, Northern england journal
of medicine; 358; 24; 2560-2572.
[21]. IM Stratton, CA Cull, AI Adler, DR Mathews, HAW Neil, RR Holman, "Additive effects of glycaemia and
blood pressure exposure on risk of complications in type 2 diabetes, diabetologia, 2006, Volume:49, Page:
1761-1769.
[22]. Marshal PW, BA Murphy. Increased deltoid and abdominal muscle activity during stability ball bench
press. J strength conditioning res 20(4); 745-750. 2006.
[23]. National strength and conditioning association 2010, Sekendiz, Betul, Mutlu, Kakkusuz, Feza on effects
of Swiss ball core strength training on strength. Endurance, flexibility and balance in sedentary women. J
strength cond res 24(11) – 3032 – 3040, 2010. Studied on core strength training on trunk extensor, flexor,
lower limb extensor and flexor.
[24]. WHO 2004 Technical report No: 920 on ways to promote health.
[25]. Dr A Ramachandran et al, "BMI & Waist Circumference in Type 2 diabetes", International journal of
diabetes, 1995, Volume:15.
[26]. Chandalia M, Abate N, Gary A et al. Relationship between generalizes and upper body obesity to
insulin resistance in asian Indian men. Journal of clinical endocrinal metabolism; 1999; 84; 2329 –
35.
[27]. DJ Golstein. Beneficial effects of modest weight loss, Int J obes related met disorder 16(1992) 397-415.
[28]. Randomised controlled trial evaluating the effectiveness of behavioural interventions to modify
cardiovascular risk factors in men and women with impaired glucose tolerance. JC oldrayd, NC Unwin,
M White, K Imrie, JC nathus. Diabetes research and clinical practice 52 (2001) 29-43.

283
IOSR Journal of Applied Chemistry (IOSRJAC)
Volume 1, Issue 1 (May-June 2012), PP 31-35
www.iosrjournals.org

Stability ball exercises on glycemic control and lipid profile on type 2 diabetic patients

SUBRAMANIAN* & P. VENKATESAN**S.S.

* Principal, Sree Balaji College of Physiotherapy, Chennai – 100, India.

**UGC Professor Emeritus in Zoology, Loyola College, Chennai – 34, India.

ABSTRACT: In an era of technological advancements, improved life style, more dietary intake with lowered physical
activity, increased longevity of life and early onset of many non – communicable diseases including type 2 diabetic
mellitus resulting in many health complications on functioning of cardiac, nervous, renal system. This study aims to
minimize such complications among diabetic patients, provide better health care with an improved quality of life.

KEY WORDS: Type 2 diabetes, Stability Ball

284
ABBREVIATIONS:

 Stability Ball Exercises (SBE)

 High Density Cholesterol (HD2)
 Low Density Cholesterol (HD2)
 Body Mass Index (BM+)
NOTE:

Stability ball is also called physio ball, swiss ball / gym ball, which is an air inflated ball of 55cm size
widely used as a rehabilitation tool in physiotherapy.

INTRODUCTION

India leads the world with largest number of diabetic subjects earning the dubious distinction of being
termed the diabetes capital of the world, with around 40.9 million diabetic patients currently, as in expected to
rise to 69.9 million by 20251 with genetic predisposition to develop diabetes 2, decreased physical activity,
sedentary occupational habits, higher fat diets which have accompanied the process of modernization has
resulted in the doubling of the prevalence of obesity and Type 2 diabetes 3. What was considered as a mild
disorder of the elderly, 30 years back, there is a shift in aged of onset of diabetes affecting the youth, middle
aged people, adolescents and children which could have long lasting adverse effects on individual health care
cost and economy of the nation4. With 15 – 25% of the urban school children in India are at risk of developing
Type 2 diabetes at an early age5.

Exercises apart from influencing glycaemic control, has important effects on the development of
cardiovascular complications in Type 2 Diabetes mellitus 6. Aerobic training have reported to influence lipid
profile and glycaemic control7. Vibration exercises are effective in achieving a better glycaemic control among
Type 2 diabetic patients8.

Resistance exercise training can improve insulin sensitivity and can allow for blood glucose levels to be
better managed in adult with Type 2 diabetes 9. Also the potential benefits of increase in muscle mass on body
composition and other cardiovascular diseases, risk factors are well recorded 10.

The decrease in the total cholesterol and triglyceride levels is important in preventing macrovascular
complications associated with Type 2 diabetes mellitus is well documented with resisted exercises 11.

285
 MATERIALS AND METHODS:

50 male Type 2 diabetic subjects between 30 – 60 years have participated in the study. Subjects were
recruited through diabetic camps organized during July 2010, through advertisements given in regional
English news paper, The Hindu, and Velachery Times. The study was conducted at Sree Balaji College of
Physiotherapy, Chennai – 100 in July 2010.

INCLUSION CRITERIA AS FOLLOWS:

II. Male subjects between 30 – 60 years

III. Not on regular Insulin therapy
IV. Established Type 2 diabetes
The eligible subjects were medically screened an physically evaluated to exclude individuals with
advanced retinopathy, uncontrolled hypertension, neuropathy and severe orthopaedic conditions restricting
any physical activity.

Subjects were assigned at random to one of the two groups: Stability ball exercises (n=25) or control group
(n=25). All the subjects gave their written informed consent to participate in the study.

OUTCOME MEASURES:

All the subjects were tested on two occasions by using same protocols. Baseline measurements were
taken before the intervention and after the study again. Venous blood sample of all participants were taken for
analysis of Lipid profile and Glycelated Haemoglobin.

Anthropometric measurements: Waist circumference at iliac crest was measured in centimetres before
and after the study.

INTERVENTION

STABILITY BALL EXERCISE GROUP (SBE):

Subjects assigned to this group have performed systematic supervised resistance training inline with
Exercise guidelines notified by American diabetic association and American college of sports medicine.
Having done the exercises for three times per week, each exercise session comprising of ten different exercises
for major muscle groups of Lower extremities including Gluteus maximus, Quadriceps femoris, Hamstrings,
Gastrocnemius, Abdominal muscles, Lumbar spine extensors. For a period of 12 weeks subjects have
performed 3 sets of 5 repetitions of each exercises per session. Progressive increase in intensity was designed in
such a way that up to 4 weeks no holding period of each physical activity, from 4 – 8 weeks 5 second hold of
each exercises, and 10 seconds hold of each exercise during the period from 8 – 12 weeks.

286
 CARE POINTS:

Subjects were advised and ensured of no breath holding during exercises.

CARE OF THE TECHNIQUE:

Each exercise performed on Stability Ball in this study involves closed kinematic chain exercises and
isometric muscle contractions of both lower extremities. Also subjects own body weight providing resistance
to each activity, peak torque with every exercises are unique in this study.

CONTROL GROUP (CG):

Subjects underwent no training other than their day to day routine physical activities.

All the subjects participated in this study have continued their prescribed medications and their daily routine
activities.

RESULTS

All the subjects have completed the study. 3 hypoglycaemic incidents have occured and was duly
medically treated and no other complications reported.

Initial measurements and post training changes were analysed using paired “t” test. Statistical tests
were performed using SPSS software.

Table 1: Results of paired “t” test among Stability Ball Exercises group:

MeanS.DSE“t25”ResultGlycelated HaemoglobinPre Test8.091.390.287P < .001Post

Test7.40Total CholesterolPre Test18948.629.617.07P < .001Post Test171HDLPre
Test43.602.980.622.72P < .05Post Test44.32

A LDLPre Test11523.154.634.4P < .001Post Test105TriglyceridePre

Test176.4429.945.997.18P < .001Post Test162.88

BMIPre Test262.940.597.12P < .001Post Test25

287
 s shown in the above table post mean value of Glycelated haemoglobin has decreased by 0.69% and is
statistically significant at 0.1% probability level as P < .001 among stability ball exercises group. Total
cholesterol of post mean score has decreased by 18 and is highly significant at 1% probability level at P < .001.
High Density Lipoprotein of post mean value has increased by 0.72% and is highly significant at 5 level as P < .
05.

Low Density Lipoprotein of post mean score of Stability Ball Exercise Group has decreased by 9.88 is
more significant at 0.1% level as P < ).001. Triglycerides of Stability Ball Exercise Group’s post mean value
score has decreased by 13 and is highly significant at 0.1% level as P < 0.001. Body Mass Index of Stability Ball
Exercise group has decreased in their post mean value by 1 and is significant at P < 0.001 level.

Where as among the control group subjects, Body Mass Index, Glycelated Haemoglobin, Total
Cholesterol, Low Density Lipoprotein, High Density Lipoprotein, Triglycerides level were statistically
insignificant among their pre and post test scores.

DISCUSSION:
This study showed following Stability Ball Exercises significant improvement in Glycelated Haemoglobin,
Lipid profile and Body mass index among male Type 2 diabetic patients.

Exercises accelerates more insulin absorption from the leg, than arm exercises (12). 1% decrement in Glycelated
haemoglobin following therapies to lower Glycelated haemoglobin can reduce the risk of diabetic
complications such as myocardial infarction and microvascular disease(13).

288
 A better glucose control due to improvement in insulin sensitivity and effects of glucose transporters
due to muscular hypertrophy and blood flow following resisted exercises (14).In this study 0.69% reduction in
Glycelated haemoglobin among the post mean score value, hence is effective for better glycaemic control.

Exercises lowers the risk of death by up to 25% in coronary heart disease patients, and the benefits
include decreased Total Cholesterol, LDL, and an increased HDL (22). A single bout of moderate exercise will
increase after exercise regardless of training or intensity(23).

A reduction of 1% on Total Cholesterol has been shown to reduce their risk for coronary artery disease
by 2% which implies that participants in this study have reduced about 3.6% of their risk.
(18)

Moreover a 1% reduction in Low Density Lipoprotein reduces risk of major coronary events by
approximately(19), which means that the subjects in this study have about 42% gain . As a decrease of 1% on
High Density Lipoprotein has been associated with a 2 – 3% increase in the risk for coronary heart disease (20)
and the reverse is true that an increase in High Density Lipoprotein by 0.87% among the participants should
decrease the coronary artery disease by 2%.

Obesity is a most powerful determinant and a risk factor for developing diabetes (15) also an increase in
Body Mass Index was demonstrated to increased risk to complications in Type 2 diabetic patients among
Asian men(16). Increased visceral or abdominal tissue in particular have been shown to be more strongly
associated with metabolic and cardiovascular disease risk(17).

CONCLUSION:

A early rise in age of onset, complications associated with Type 2 diabetic mellitus, individual health
care cost, economy of nation are all needs more focus, hence this study outcome can better be used in the
overall diabetic care of patients.

LIMITATIONS AND RECOMMENDATIONS:

Increased sample size and longer duration of study involving women are recommended further. Also a
prophylactic study for children can be considered.

289
 REFERENCES

[1] Sicree R, Show J, Zimmet P, "Diabetes and impaired glucose tolerance, Ingand, editor diabetes atlas",
International diabetes federation, 3rd edition, Belgium, 2006,Page: 15-103.

[2] Radha V, Mohan V, Genetic predisposition of Type 2 diabetes among Asian Indians. Indian J Med res 2007;
125; 259-74.

[3] Mohan V, Gokula Krishnan K, Deepa R, Shanthirani CS, Datta M, Association of physical inactivity with
components of metabolic syndrome and coronary artery disease – The CUPS no;15, Diab Med 2005, 22;
1206-11.

[4] Wild S, Roglic G, Green A, Sicree R, King H, "Global Prevalence of diabetes: Estimates for the year 2000
and projections for 2030, diabetes care 2004; Volume- 27, Page: 1047-1053.

[5] Ramachandran A, Sanehlatac, Vinitha R, et al, Prevalence of overweight in urban Indian adolescent school
children, Diab Res Cli Practical 2002; 57; 185-90.

[6] American Heart Association: Scientific statement on circulation 2009; 119; 3244-3262.

[7] American college of sports medicine and the American diabetic association; Exercise and Type 2 diabetes:
Joint position statement, diabetes care; July 2010.

[8] Klans Banm et al, " Efficiency of vibration exercise for glycaemic control in Type 2 diabetes patients",
International Journal of Medical sciences, 2007, Volume:4, Issue:3, Page: 159-163.

[9] Carmen castaneda et al, "A randomized controlled trial of resistance exercise training to improve glycaemic
control in older adults with Type 2 diabetes", Diabetes care, 2002, Volume: 25, Number: 12, Page: 2335-
2341.

[10] Erikson J, Taimela S, Erikson K, Assistance training in the treatment of Non – minsulin dependent
diabetes mellitus, Int J. Sports Med, 1997; 18; 242-246.

[11] Willey KA, Fiatore sing MA, Battling insulin resistance in elderly obese with Type 2 diabetes, Diab care
2003, 26; 1580-8.

[12] Koiviste VA, Fligp, "Effects of leg exercise on insulin", England Journal of medicine, Jan-12-1978,
Volume: 298, Page: 279-283.

[13] IM Stratton, CA Cull, AI Adler, DR Mathews, HAW Neil, RR Holman, "Additive effects of glycaemia
and blood pressure exposure on risk of complications in type 2 diabetes, diabetologia, 2006, Volume:49,
Page: 1761-1769.

[14] Ploug T, Ralston E, "Exploring the whereabouts of GLUT4 in skeletal muscle", Molecular Membrane
Biology, 2002, volume:19, Page: 39-49.

[15] WHO 2004 Technical report series No: 920 on ways to promote health.

[16] Dr A Ramachandran et al, "BMI & Waist Circumference in Type 2 diabetes", International journal of
diabetes, 1995, Volume:15.

[17] Stevens J, Keil JE, Rust PF, Davis CE, Body mass index and body girths as predictors of mortality in
black and white women, Arch Intern med, 1992, 152; 1257-62.

290
[18] Kelley GA, Kelley KS, Aerobic exercises and lipids and lipoproteins in men: A metaanalysis of
randomized controlled trials, J mens health gend 2006;3;61-70.

[19] Consensus development panel. Consensus conference lowering blood cholesterol to prevent heart
disease, JAMA, 1985; 253; 2080-2086.

[20] Pederson TR, Olsson NG, Faergeman O, Kjekshens J, Wedel H, Cook TJ, Lipoprotein changes and
reduction in the incidence of major coronary heart disease events in the Scandinavian simvastatis survival
study (4S) circulation 1998;97;1453-60.

[21] Gorden DJ, Probstfield JL, Garrison RJ, Neaton JD, Bangdiwala S, High density lipoprotein cholesterol
& cardiovascular disease. Four prespective American studies circulation, 1989;79;8-15.

[22] Berg A, Hellen, Franz I, Keul J, Physical activity & lipoprotein metabolism ; epidemiological evidence &
clinical trials, Eur J med res, 1997, 2; 259-64.

[23] Ferguson M, Alderson N, Trost S, Effects of 4 different single exercise sessions on lipids, lipoproteins
and lipoprotein lipase. J Applied physiology, 1998; 85; 1169-74.

291
292
293
294
295
296
297
298
299
300
301
302
303