TOPIC

Aerobic Exercise and Hypertension and Type 2 Diabetes Risk Biomarkers in African,
South Asian, and Aboriginal Australians.

INTRODUCTION
Diabetes Mellitus is a serious disease with chronic complications and causes
considerable problems for patients and the healthcare system as a whole. If preventive
measures are not put in place, according to the International Diabetes Federation (IDF)
Diabetes Atlas 2011, the number of people living with diabetes is expected to increase
from about 366 million in 2011 to 552 million by 2030 (Venugopal et al., 2014).
Hypertension is known to be present in more than 50% of patients with diabetes
mellitus, which contributes to both microvascular and macrovascular disease in
diabetes mellitus. In patients with both diabetes mellitus and hypertension the risk
cardiovascular disease is four times higher than in normotensive nondiabetic
individuals (Lastra et al., 2014).
Implementation of a beneficial lifestyle helps to lower blood pressure and also helps
to reduce the need for pharmacological interventions or drug dosages used.
Commitment to lifestyle changes can be difficult, but clinical trials have shown
improvements in the blood pressure of patients with hypertension with alterations
(Dickey et al., 2001). Aerobic exercise, according to research, plays an important role
in hypertension management and also reduces inflammation, which is beneficial in
lowering the risk of cardiovascular disease (Boeno et al., 2020).
However, despite the advancement in medicine, epidemiological studies have shown
that diabetes mellitus and hypertension is increasing rapidly in people of South Asian
and African origins. Research evidence has shown a cardio-metabolic difference
between populations of White European origins and non-White populations in relation
to physical activity and exercise (Gill et al., 2014).
This study aims to increase knowledge about the effects of aerobic exercise on cardio-
metabolic health and the risk of type 2 diabetes in Black Africans, South Asians, and
Aboriginal Australians, as well as investigate the effect of aerobic exercise on
hypertension biomarkers.
PROBLEM STATEMENT
Individuals of African, South Asian, and Aboriginal Australian origin have greater
risks of cardiovascular disease and diabetes, which manifest 5-10 years earlier than
white Europeans. Blood pressure is proportional to age, and therefore the
development of hypertension shows a dynamic and complex interaction between
environmental factor and genetics. Cardiovascular risk in these groups is associated
with migration, diet, lifestyle, psycho-social factors, and socioeconomic indicators.
One of major determinants of blood pressure levels in these populations is physical
inactivity, which is a risk factor of hypertension and diabetes (Misra et al., 2017;
Tibazarwa and Damasceno 2014; Brown et al., 2014). In summary, further studies is
needed to define the effect of aerobic exercise on biomarkers of hypertension and type
2 diabetes and to create a possible beneficial lifestyle to help reduce the risks of
hypertension and type 2 diabetes mellitus in African, South Asian, and Aboriginal
Australian origins. More specifically, the following research questions need to be
addressed:
1. What is the effect of exercise on the cardio-metabolic health of individuals of
African, South Asian, and Aboriginal Australian origin?
2. What effect do different aerobic exercises have on the biomarkers of
hypertension?
3. How to classify these biomarkers for easier identification in relation to aerobic
exercise?

OBJECTIVES
The long-term goal of this research is to study the effects of aerobic exercise in
African, South Asian, and Aboriginal Australian individuals and investigate the
relationship with biomarkers of hypertension. Since studies have shown that
implementation of beneficial lifestyles can help lower the levels of blood pressure.
This study will provide the impact of different aerobic exercises on cardio-metabolic
health. In particular, the study has the following sub-objectives:
1. To suggest possible aerobic exercises that can help reduce the risk of
hypertension and type 2 diabetes.
2. To extend and understand the effect of exercise on biomarkers of hypertension
in African, South Asian, and Aboriginal Australian individuals.
3. To study the effect of aerobic exercise on type 2 diabetes mellitus risk.
The result of this study will be valuable to the healthcare system in developing a
beneficial lifestyle and reducing the risks of hypertension and type 2 diabetes mellitus
in individuals of African, South Asian and Aboriginal Australian origin.

PRELIMINARY LITERATURE REVIEW

Aerobic Exercise
Physical exercise is an important tool in the treatment of hypertension and type 2
diabetes mellitus and its complications. It helps in the reduction of body weight, lipid
profile, blood pressure, and endothelial dysfunction. Also, it is known that responses
to physical training are the result of cumulative short-term effects over time (Morais
et al., 2011). Prescription of the right amount of exercise is recommended for type 2
diabetes patients, and should be based on intensities that are related to their aerobic
and physical capacities. A recent study shows that a single aerobic session results in
blood pressure reduction for 24 h in individuals with Type 2 diabetes, especially while
sleeping, and the magnitude of this reduction is dependent on the intensity at which
the exercise is performed (de Morais et al., 2015).

Hypertension And Type 2 Diabetes Mellitus

Diabetes mellitus is a metabollic disease characterized by hyperglycemia, resulting
from defects in insulin secretion, insulin action or both (American Diabetes
Association, 2010). In diabetes, chronic hyperglycemia is as result of dysfunction in
insulin secretion and action, which is associated with long-term damage,
inflammation, dysfunction, and various organ failures (American Diabetes
Association, 2007).
Type 2 diabetes is a type of diabetes in which the response to insulin is declined, also
known as insulin resistance. This type of diabetes accounts for about 90-95% of all
cases of diabetes (Goyal and Jialal 2021). This condition is characterized by the
inability of the body cells to utilize insulin produced (Suresh 2016).
Hypertension is a common, chronic, age-related disorder, characterized by
cardiovascular and renal complications. The pathophysiology of hypertension
depends on both the primary and secondary inability of the kidney to excrete sodium
at normal blood pressure. In the diagnosis of hypertension, blood pressure is usually
noted in conjunction with other cardiovascular risk factors (Staessen et al., 2003).
Prevalence of Type 2 diabetes and hypertension
The incidence of Type 2 diabetes is rapidly rising, and studies have shown that the
total number of people with diabetes will rise from about 171 million in 2000 to 366
million in 2030. Adults with hypertension is predicted to increase by 60% in 2025,
which is equivalent to about 1.56 billion. Hypertension and diabetes should be treated
and diagnosed early enough in order to prevent associated microvascular and
macrovascular mortality and morbidity (Lago et al., 2007). Diabetes is more common
in migrant, urban, and African-origin people living abroad, with evidence of an
association with preventable and modifiable risk factors such as physical activity,
obesity, and diabetes (Motala et al., 2003). People living with diabetes in South Asia
are estimated to increase by 10.2% equivalent to about 120.9 million adults by 2030.
South Asians in the diaspora have nearly a fivefold higher risk of Type 2 diabetes and
show higher levels of pro-inflammatory factors and more endothelial dysfunction than
white Europeans (Misra et al., 2014). The incidence rate of diabetes among
Aboriginal men is one in two and two in three among Aboriginal women (Wang et al.,
2010).

Biomarkers of Hypertension
The pathogenesis of hypertension is known to be multifactorial. In hypertensive
individuals, several physiological alterations have been described, including
abnormalities of endothelial dysfunctions, vascular hypertrophy, systemic
inflammation, and enhanced oxidative stress (Wang et al., 2007). There are different
important mechanisms that contribute to the pathogenesis of hypertension. This
enables us to understand the origin, utility, and rational use of a particular biomarker.
Blood pressure is a universal biomarker of hypertension and is the product of cardiac
output and peripheral resistance. Therefore, when there is an increase in cardiac
output and/or peripheral resistance, this results in hypertension. The Renal system
function could serve as a biomarker for hypertension. The biomarkers for kidney,
Renin-Angiotensin-Aldosterone System (RAAS) and Sympathetic Nervous System
dysfunction include: serum creatinine, cystatin-C, urinary albumin creatinine ratio,
interstitial tissue sodium content, and plasma renin concentration. Vascular
dysfunction is a well-known mechanism for the development of hypertension. These
biomarkers include: peripheral artery, brachial artery dysfunction, serum vitamin D.
Studies suggest that the progression and development of hypertension is a result of a
chronic inflammatory state of the vessels. Important biomarkers of inflammation and
oxidative stress include: C-reactive protein, serum uric acid, homocysteine, oxidized
low density lipoprotein, and 8-isoprostaglandin F2a (Pattanaik 2020).

METHODOLOGY
Sedentary normal adults (aged between to 18 to 35 years) from all three ethnicities
will be randomized into three groups: two physical training groups (tread mill and
bicycle ergometer) and control group. Before randomization the following patient
characteristics will be collected: Age, gender, ethnicity, body weight, height, BMI,
blood pressure, fasting blood glucose, family history of cardiovascular disease, and
type 2 diabetes mellitus are all factors to consider (Chapman et al., 2013; Dimeo et al.,
2012).

Inclusion Criteria includes:

 There was no prior history of Type 2 diabetes or hypertension
 Must belong to one of the ethnic groups and be between the ages of 18 and 35
years.

Exclusion Criteria Includes:

 Participants would be excluded if they reported regular aerobic activity for 20
minutes or more more than twice per week.
 Participants with Type 2 diabetes mellitus
 Participants who have a cardiovascular or other chronic health problem.
 Participants that are hypertensive (SBP > 160 mmHg or DBP > 100 mmHg).

Physical Training Program

The physical training program will be designed to ensure the participants meet and
adhere to the 2008 physical activity guidelines of 150 min per week as recommended
for sedentary adults. The training will consist of three 60-minutes sessions of aerobic
exercise training per week for a period of 12 weeks (Chapman et al., 2013). The
participants will be divided into two groups for aerobic exercise training (bicycle
ergometer group and treadmill group).
Physiological Measures
Physiological parameters and biomarkers of hypertension will be assessed at three
points: baseline/pre-training, mid-training (week 6), and upon completion of the
training (week 12). These parameters and biomarkers include: body weight, heart rate,
fasting blood glucose, glycated haemoglobin, blood pressure, serum creatinine,
cystanin-c, C-reactive protein, serum uric acid, 24 hour urine cathecolamine, urine
albumin creatine ratio, and plasma urine concentration.
REFERENCES
American Diabetes Association (2007) “Diagnosis and classification of diabetes
mellitus,” Diabetes care, 30 Suppl 1(suppl_1), pp. S42-7. doi: 10.2337/dc07-S042.

American Diabetes Association (2010) “Diagnosis and classification of diabetes

mellitus,” Diabetes care, 33 Suppl 1(Supplement_1), pp. S62-9. doi: 10.2337/dc10-
S062.

Boeno, F.P., Ramis, T.R., Munhoz, S.V., Farinha, J.B., Moritz, C.E., Leal-Menezes,
R., Ribeiro, J.L., Christou, D.D. and Reischak-Oliveira, A., 2020. Effect of aerobic
and resistance exercise training on inflammation, endothelial function and ambulatory
blood pressure in middle-aged hypertensive patients. Journal of Hypertension, 38(12),
pp.2501-2509.

Brown, A., Carrington, M.J., McGrady, M., Lee, G., Zeitz, C., Krum, H., Rowley, K.
and Stewart, S., 2014. Cardiometabolic risk and disease in Indigenous Australians: the
heart of the heart study. International journal of cardiology, 171(3), pp.377-383.

Chapman, S.B., Aslan, S., Spence, J.S., DeFina, L.F., Keebler, M.W., Didehbani, N.
and Lu, H., 2013. Shorter term aerobic exercise improves brain, cognition, and
cardiovascular fitness in aging. Frontiers in aging neuroscience, 5, p.75.

de Morais, P.K., Sales, M.M., de Almeida, J.A., Motta-Santos, D., de Sousa, C.V. and
Simoes, H.G., 2015. Effects of aerobic exercise intensity on 24-h ambulatory blood
pressure in individuals with type 2 diabetes and prehypertension. Journal of physical
therapy science, 27(1), pp.51-56.

Dickey, R.A. and Janick, J.J., 2001. Lifestyle modifications in the prevention and
treatment of hypertension. Endocrine practice, 7(5), pp.392-399.

Dimeo, F., Pagonas, N., Seibert, F., Arndt, R., Zidek, W. and Westhoff, T.H., 2012.
Aerobic exercise reduces blood pressure in resistant
hypertension. Hypertension, 60(3), pp.653-658.
Gill, J.M., Celis-Morales, C.A. and Ghouri, N., 2014. Physical activity, ethnicity and
cardio-metabolic health: does one size fit all?. Atherosclerosis, 232(2), pp.319-333.

Goyal, R. and Jialal, I. (2021) “Diabetes Mellitus Type 2,” in StatPearls [Internet].
StatPearls Publishing.

Lago, R.M., Singh, P.P. and Nesto, R.W., 2007. Diabetes and hypertension. Nature
clinical practice Endocrinology & metabolism, 3(10), pp.667-667.

Lastra, G., Syed, S., Kurukulasuriya, L.R., Manrique, C. and Sowers, J.R., 2014. Type
2 diabetes mellitus and hypertension: an update. Endocrinology and Metabolism
Clinics, 43(1), pp.103-122.

Misra, A., Ramchandran, A., Jayawardena, R., Shrivastava, U. and Snehalatha, C.,
2014. Diabetes in south Asians. Diabetic Medicine, 31(10), pp.1153-1162.

Misra, A., Tandon, N., Ebrahim, S., Sattar, N., Alam, D., Shrivastava, U., Narayan,
K.V. and Jafar, T.H., 2017. Diabetes, cardiovascular disease, and chronic kidney
disease in South Asia: current status and future directions. bmj, 357.

Mohan, V., Seedat, Y.K. and Pradeepa, R., 2013. The rising burden of diabetes and
hypertension in southeast asian and african regions: need for effective strategies for
prevention and control in primary health care settings. International journal of
hypertension, 2013.

Morais, P.K., Campbell, C.S.G., Sales, M.M., Motta, D.F., Moreira, S.R., Cunha,
V.N.C., Benford, R.E. and Simoes, H.G., 2011. Acute resistance exercise is more
effective than aerobic exercise for 24 h blood pressure control in type 2
diabetics. Diabetes & Metabolism, 37(2), pp.112-117.

Motala, A.A., Omar, M.A. and Pirie, F.J., 2003. Epidemiology of type 1 and type 2
diabetes in Africa. European Journal of Cardiovascular Prevention &
Rehabilitation, 10(2), pp.77-83.
Pattanaik, S., 2020. Biomarkers in essential hypertension. In Kidney Biomarkers (pp.
247-288). Academic Press.

Staessen, J.A., Wang, J., Bianchi, G. and Birkenhäger, W.H., 2003. Essential
hypertension. The Lancet, 361(9369), pp.1629-1641.

Suresh Lal, B. (2016) “Diabetes: Causes, symptoms and treatments,” in Public Health
Environment and Social Issues in India. Unknown, pp. 55–67.

Tibazarwa, K.B. and Damasceno, A.A., 2014. Hypertension in developing

countries. Canadian Journal of Cardiology, 30(5), pp.527-533.

Venugopal, K. and Mohammed, M.Z., 2014. Prevalence of hypertension in type-2

diabetes mellitus. CHRISMED Journal of Health and Research, 1(4), p.223.

Wang, T.J., Gona, P., Larson, M.G., Levy, D., Benjamin, E.J., Tofler, G.H., Jacques,
P.F., Meigs, J.B., Rifai, N., Selhub, J. and Robins, S.J., 2007. Multiple biomarkers
and the risk of incident hypertension. Hypertension, 49(3), pp.432-438.

Wang, Z., Hoy, W.E. and Si, D., 2010. Incidence of type 2 diabetes in Aboriginal
Australians: an 11-year prospective cohort study. BMC public health, 10(1), pp.1-5.