Coronary artery disease (CAD) is the leading killer of Americans with diabetes. While it is well established that increased physical activity is associated with a reduced risk of CAD in the general population, research on the association between levels of physical activity and CAD among diabetic patients is limited. In the Jan. 16 issue of Annals of Internal Medicine, a new study investigates whether physical activity decreases CAD risk among diabetic women.

Researchers from Harvard School of Public Health, Harvard Medical School, and Brigham and Women’s Hospital in Boston examined the relationship between levels of physical activity and occurrence of coronary heart disease and stroke among women with diabetes mellitus. They found that “among diabetic women, boosted physical activity, is associated with substantially reduced risk for cardiovascular disease.”

The study included 5,125 female nurses who were part of the larger Nurses’ Health Study. All participants had type 2 diabetes — the more common form of diabetes in which the body produces insulin but does not use it properly — and all had no prior history of heart attack or stroke. The nurses completed a questionnaire about medical history, lifestyle and physical activity at the time of entry and then every two years thereafter. They also conducted two sets of analyses. First, they examined the long-term effects of moderate to vigorous activities, and second, they looked at the specific effects of regular walking. The study started in 1980 and ended in 1994.

During the fourteen years of follow-up, the researchers documented 225 new cases of CAD and 98 new cases of stroke. For the long-term effects, there was a strong association between physical risk and activity of cardiovascular events, with the risk of coronary heart disease and stroke decreasing as the level of physical activity increased. Indeed, “diabetic women who spent 4 hours per week performing moderate or vigorous exercise had an approximately 40% lower risk for cardiovascular disease than those who did not,” the authors noted. A similar reduction in risk was also found for stroke.

Looking specifically at the effects of regular walking, the authors reported strong evidence that “regular walking, especially brisk walking, is associated with lower risk for coronary heart disease and stroke among diabetic women.”

The authors made it clear, however, that the findings from this observational study do not mean that there is a cause-and-effect relationship. In other words, they cannot conclude that an increase in exercise is directly responsible for a reduction in cardiovascular events. Such a statement would require that prospective randomized clinical trials be conducted to allow the researchers to control which subjects would exercise and which would not, and then measuring the changes that result.

Nevertheless, the authors concluded that “[b]y using more detailed and repeated measurements of physical activity over 14 years of follow-up, our study provides strong evidence that increased physical activity, including such moderately intense exercise, may substantially reduce incidence of stroke and coronary heart disease among diabetic persons.”

“Because walking is accessible and relatively safe and can be easily incorporated into daily routines, it is a form of exercise that is practical and suitable for most diabetic patients, especially elderly persons. Nevertheless, optimal planning and precautions are needed in any exercise program for diabetic patients so that exercise-induced hypoglycemia and other complications can be minimized,” they added.

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