Effectiveness of Different Physical Activities toward Glycemic Control in Prediabetes Mellitus Clients

Background : the proportion of people with prediabetes is 2-4 times higher than the proportion of people with diabetes. One of the prevention efforts is through physical activity. Several studies have shown that physical activity has a significant effect on glycemic control. Purpose : this study aims to determine the effectiveness of different physical activities to glycemic control in prediabetic clients in Semarang municipality. Methods : a randomized control trial (RCT) with a pretest-posttest design was conducted on 60 prediabetic clients using different treatments (healthy / slow walking, brisk walking, combination of both slowly and brisk walking). An initial measurement (pretest) of glycemic control was carried out using an indicator of HbA1c levels and was remeasured (posttest) after 3 months. Results : the average level of glycemic control (HbA1c levels) before intervention in the healthy walking group was 5.57% and decreased to 5.46% after intervention; the combination group decreased from 5.93% to 5.78%, and in the slowly walking group decreased from 5.74% to 5.71%. However, there was no significant effect of slowly walking on glycemic control (HbA1c levels). Meanwhile, brisk walking and combination of slowly walking and brisk walking had a significant effect on glycemic control (HbA1c levels) (p<0.05). Conclusion : the combination of physical activity group (brisk walking and slowly walking) has a better effect on glycemic control (HbA1c levels).

For complete information author guidelines please check http://ejournal.poltekkes-smg.ac.id/ojs/index.php/jnj/about/submissions#authorGuidelines BACKGROUND Nowadays, diabetes mellitus becomes global health problem. Epidemiologically, the prevalence of people with diabetes mellitus at all ages in 2000 was 2.8% and is estimated to increase to 4.4% in 2030 (Wild, et.al., 2004). People with diabetes mellitus in 2035 are estimated to increase almost twice from 2030, which is as many as 592 million cases (Malik, et.al., 2006). According to the WHO report there were 422 million people worldwide suffering from diabetes mellitus, and a prevalence of 8.5% occurred in the adult age group (Bull, et.al., 2020).
In Indonesia, the prevalence rate of diabetes mellitus based on relevant diagnoses or symptoms is 2.1%, and it is estimated that in 2030 the number of people with diabetes mellitus will increase to 21.3 million (Ministry of Health of Indonesia (2018). In Central Java, based on the report of the 3rd quarter of 2015 of the Provincial Health Office of Central Java, diabetes mellitus ranks second to non-communicable diseases after hypertension with the number of cases which tends to increase every year, which is 110,860 cases in 2013 and increasing to 121,203 cases in 2014 (Semarang City Health Office, 2020). On the other hand, the number of people with prediabetes also shows a number that tends to increase. There was an increase in the prediabetes population from 11.6% in 2003 to 35.3% in 2011.
Prediabetes is an important factor related to metabolic conditions that predispose individuals to a high probability of developing diabetes. Individuals with prediabetes have a high risk for pathological disorders such as diabetic retinopathy, neuropathy, nephropathy, and macrovascular complications. The results showed that the prevalence of diabetic retinopathy was 7.9%, and the prevalence of peripheral neuropathy was higher in individuals with prediabetes than in individuals based on normal glucose tolerance. Prediabetes also increases the risk of chronic kidney disease (CKD) cardiovascular disease, coronary heart disease, and stroke (Gottwald-Hostalek & Rett, 2019).
Healthy behavior for people with diabetes mellitus who require long-term care is important. The health behavior recommended by WHO to manage diabetes mellitus effectively is the behavior of controlling sugar levels (glycemic control) to keep it stable (Bull, et.al., 2020). Long-term control of glucose concentration which is relatively stable is carried out through examination of HbA1c levels which can be used as material for treatment planning. Good glycemic control (A1c < 7%) provides benefits for people with type 2 diabetes mellitus. heart disease by 78%. On the other hand, poor glycemic control can cause death in elderly people with type 2 diabetes mellitus.
Stability of sugar levels in people with type 2 diabetes mellitus can be performed in various ways, including through physical activity. Several research results show that there is a relation between physical activity and type 2 diabetes mellitus. Patients with type 2 diabetes mellitus who participate in self-management training for type 2 diabetes mellitus have an impact on the level of knowledge, frequency and accuracy of self-monitoring of blood sugar, and self-reporting behavior eating habits (diet) (Amanat, et.al., 2020). Other studies have shown that people with type 2 diabetes mellitus who engage in regular physical activity have a positive impact on preventing the development of Impaired Glucose Tolerance (IGT) into type 2 diabetes mellitus (Klimek, et.al., 2019). Similar studies also concluded that people with type 2 diabetes mellitus who perform physical activity in the form of aerobic (aerobic exercise) and resistance training (resistance training), both increase insulin sensitivity (Klimek, et.al., 2019). Increased insulin sensitivity will have an impact on decreasing the concentration of blood glucose levels in people with type 2 diabetes mellitus (Whillier, 2020).
Lack of physical activity, especially for people with type 2 diabetes mellitus, will have a negative impact on the health status of people with diabetes mellitus. Physical activity that is carried out For complete information author guidelines please check http://ejournal.poltekkes-smg.ac.id/ojs/index.php/jnj/about/submissions#authorGuidelines irregularly will increase the risk of diabetes mellitus, and if this continues for a long time it will lead to unwanted complications of diabetes mellitus such as increased heart disease and stroke, neuropathy in the legs which can lead to gangrene of diabetes mellitus and amputation, diabetic retinopathy which leads to blindness and kidney failure. Conversely, if physical activity is carried out regularly, it will generally have a positive impact on blood sugar levels (glycemic control) and can prevent diabetes mellitus (Ministry of Health of Indonesia, 2018). The impact of regular physical activity or exercise can also be seen from the level of Hemoglobin A1c (HbA1c) which is below the value of 48 mmol/mol (6.5%) (d' Emden, et.al., 2015). This is understandable because HbA1c is formed by glycation of the N-terminal valine in the beta chain in hemoglobin, a nonenzymatic reaction occurring in red blood cells. So that the more glucose in the bloodstream, the higher the HbA1c value (Rakhis, et.al., 2020).
Physical activity can be performed in various ways. In general, physical activity can be implemented in 3 ways: light-intensity physical activity, moderate-intensity physical activity, and vigorous-intensity physical activity (Bull, et.al., 2020). Light-intensity physical activity is physical activity that requires light effort, such as walking slowly, sitting, standing, fishing, and playing music. Moderate-intensity physical activity is physical activity that requires sufficient effort and significantly increases the heart rate. Examples of this type of physical activity are brisk walking, dancing, gardening, housework, painting the walls of the house, installing tiles, moving items < 20 kg. Meanwhile, vigorous-intensity physical activity is physical activity that requires more effort and causes breathing and heart rate to increase significantly. This type of activity can be done by running, walking on an incline, cycling quickly, aerobics, swimming, and carrying / moving objects > 20 kg.

OBJECTIVE
This study aims to determine the effectiveness of different physical activities to glycemic control in prediabetic clients in Semarang municipality.

Study Design, Setting and Sampling/ Participants
This study was a randomized control trial (RCT) using a pretest -posttest design. The study was conducted in the working area of the Puskesmas (public health center) in Semarang municipality in 2021. The study invited 60 prediabetic clients who was literate, lived with their families, became active participants in PROLANIS (Programs for the management of chronic diseases), and participated in the entire series of studies. Clients who suffered from chronic kidney failure, suffered from anemia (Hb levels below normal values), and refused to participate were excluded from the study. The samples were randomly allocated to determine the research sample in each group (group 1= slowly walking, group 2= brisk walking, group 3= combination of slowly walking and brisk walking).
The intervention was given differently in each study group. Group 1 was given a slowly walking intervention which was carried out 5 times per week with a minimum duration of 20 minutes for each walk Intervention. Group 2 was given a brisk walking intervention 5 times per week for 4 weeks with a minimum duration of 15 minutes each time, and group 3 was given an intervention of a combination of physical activity (slowly walking and brisk walking) which was carried out for 4 weeks with details on day 1, 2, 3, and 4 with a duration of time each day for a minimum of 25 minutes for slowly walking and the third day 5, 6 and 7 with a minimum duration of 25 minutes each day for brisk walking. An For complete information author guidelines please check http://ejournal.poltekkes-smg.ac.id/ojs/index.php/jnj/about/submissions#authorGuidelines initial measurement (pretest) of glycemic control was carried out using an indicator of HbA1c levels and was measured for the second measurement (posttest) after treatment for 3 months.

Instrument
The data collection tool used in this study was an observation sheet which was used to measure glycemic control by examining HbA1c levels. Other data collection tools were media for taking blood preparations (3 cc syringe), and the materials in the study include blood samples and chemical reagents needed to check HbA1c levels.
Data analysis Univariate data analysis used mean and standard deviation included the value of minimummaximum. Bivariate data analysis used repeated ANOVA statistical test to determine the effect of intervention between intervention groups, and post-hoc test to determine which intervention was most effective in stabilizing glycemic control through HbA1c levels measurement. The level of confidence used in this study was 95%, with the error rate was 5% (0.05).

Ethical considerations
The research sample was given information about the overall research, and all samples agreed to participate by signing the consent form provided. The research has received proper information from the Health Research Ethics Committee of Politeknik Kesehatan Kemenkes Semarang -Ministry of Health of Indonesia number 535/EA/KEPK/2021. HbA1c development (before and after intervention) Figure 1. HbA1c development (before and after intervention) Figure 1 shows that the three groups had different initial HbA1c levels (pretest), and this situation affected the post-test HbA1c levels. In such circumstances, in measuring the effect of brisk walking activity and the combination of slowly walking and Brisk walking compared to slowly walking, there will be an overestimation. Therefore, to measure the exact effect, it is necessary to control the initial HbA1c data.

Effectiveness of Physical Activity in Lowering HbA1c
The results of the analysis of the effectiveness of physical activity in lowering HbA1c levels without controlling HbA1c levels (pretest), as shown in Table 2. The results of this analysis are provisional, because the magnitude of the effect is still disturbed by the pre HBA1c data. Therefore, the effect analysis must be controlled by pre HbA1c data with multivariate tests, in order to obtain the right amount of activity effect.

HbA1c development before and after intervention
The development of HbA1c levels in patients with diabetes mellitus (DM) type 2 before and after carrying out activities in the three groups after controlling for pre HbA1c data, can be seen in Figure 2.  Figure 2 shows that after the control was carried out through analysis of the pre HbA1c data, the initial HbA1c data appeared to be in the same condition at the position of the HbA1c level of 5.75. In the brisk walking group, HbA1c was reduced to 5.61; Likewise, the combination group (brisk walking and slowly walking) can reduce HbA1c to 5.63; while in the slowly group it can only decrease by 5.71. From the three treatments, it appears that the brisk walking group and the combination group (brisk walking and slowly walking) were able to lower HbA1c which was greater than that of the leisurely walking group.

The Effectiveness of Physical Activity in Lowering HbA1c
The effectiveness of physical activity in reducing HbA1c levels after being controlled through analysis of pre-HbA1c data with a regression model with a multivariate t test, as shown in the Table 3.

Effect of Physical Activity on HbA1c Levels
The results showed that in the three study groups there was a decrease in HbA1c levels after physical activity. In the brisk walking group, the HbA1c can be reduced to 5.61, as well as the combination walking and brisk walking group can reduce the HbA1c to 5.63. while in slowly walking alone group can only decrease by 5.71. From the three treatments, it appears that the brisk walking group and the combination group (brisk walking and slowly walking) were able to lower HbA1c which was greater than that of the slowly walking group.
The results showed that physical activity was able to have a significant effect on glycemic control or HbA1c levels. Regular physical activity or exercise will reduce the level of HbA1c formed by the glycation of N-terminal valine in the beta chain in hemoglobin which will become more normal in levels due to the decrease in blood glucose levels as a result of using it for energy when doing physical activity (Rakhis, et.al., 2020;Mahajan & Mishra, 2011).
Physical activity is all forms of body movement as carried out in this study (slowly walking, brisk walking, and a combination of both) produced from skeletal muscles that require energy expenditure. When a person does physical activity, there will be a process of hydrolysis of ATP to produce energy. Hydrolysis of 1 mole of ATP in muscle tissue will produce energy of 31kJ (7.3 kcal), and will produce other products in the form of ADP (Adenosine diphosphate) and Pi (inorganic phosphate). During physical activity, there are three energy metabolism pathways that can be used by the body to produce ATP, namely hydrolysis of phosphocreatine (PCr), anaerobic glycolysis of glucose, and burning of stored carbohydrates, fats and proteins (Kagaku, 2018). This condition allows glucose reserves in the blood to be taken to meet the energy needed in the process of physical activity. The heavier the physical activity, the greater the use of energy reserves. The results of this study indicate that the lowest ability to reduce HbA1c levels is in the group of leisurely walking physical activity. Casual walking is included in the category of light-intensity physical activity, namely physical activity that requires light effort that does not cause the respiratory and heart rates to increase significantly when compared to moderate-intensity physical activity and vigorous-intensity physical activity (Bull, et.al., 2020). While brisk walking physical activity and the combination of brisk walking and leisurely walking are physical activities that have a significant impact on the use of the body's energy stores, namely carbohydrate stores (blood glucose, muscle and liver glycogen), and fat stores in the form of triglycerides to contribute to the rate of energy production in the body (Kagaku, 2018). This condition has a direct impact on the use of energy sources including blood sugar levels so that it has an impact on the value or level of glycemic control, namely HbA1c levels.
The Most Effective Physical Activity in Lowering HbA1c Levels The results of the study showed that the physical activity of a healthy walk and a combination of a healthy walk and a leisurely walk had a better effect on HbA1c levels than leisurely walking. In this study, it was found that patients with pre-diabetes mellitus (DM) type 2 who did brisk walking were able to significantly reduce HbA1c levels by 7% compared to patients with pre-diabetes mellitus (DM) type 2 who did a leisurely walk. Likewise, patients with pre-diabetes mellitus (DM) type 2 who did a combination of brisk walking and leisurely walking were able to significantly reduce HbA1c levels by 11% compared to patients with pre-diabetes mellitus (DM) type 2 who did a slowly walking alone.
The results of this study concluded that although brisk walking physical activity and a combination of brisk walking and leisurely walking both significantly affected HbA1c levels, combined physical activity gave a better effect because it was able to lower HbA1c levels higher than brisk walking. Combination activities of brisk walking and slowly walking are carried out by combining physical activities of walking-slowly and brisk walking which are carried out for 4 weeks with details on day 1, 2, 3, and 4 with the duration of each -each day for a minimum of 25 minutes for normal/slowly walking and days 5, 6 and 7 with a minimum time duration of 25 minutes for each day for brisk walking. This method has an impact on the process of burning carbohydrates as a process of energy metabolism from blood glucose or muscle glycogen from the consumption of carbohydrates consumed. The glucose formed is stored as energy reserves as glycogen in the liver and muscles and can be stored in the bloodstream as blood glucose or can also be carried into the body's cells that need it. Blood glucose or from muscle glycogen will undergo a glycolysis process that can produce ATP molecules, where as many as 2 ATP molecules can be produced if the source of glucose comes from blood glucose and as many as 3 ATP molecules if the glucose comes from muscle glycogen (Kagaku, 2018). The process can be achieved well when a person performs regular physical activity such as brisk walking.
In the combination group, physical activity was also given a leisurely walk. This combination of physical activity will provide a comfortable feeling after the person concerned does physical activity that is sufficient to trigger heart and respiratory rates. This comfortable feeling allows a person to feel unburdened by physical activity so that it triggers stress which can affect blood sugar levels that rise. The accumulation of high blood sugar levels in the blood vessels will give an idea of higher HbA1c levels (Iemetsu, et.al., 2016;Alqudah, et.al., 2019).

Implication and limitations
The results of this study can be used in the management of people with type 2 diabetes mellitus, especially in stabilizing glycemic control. However, this study has limitation as many factors have an influence on glycemic control (HbA1c levels), but in this study it was not possible to completely control these factors, including: behavior in carrying out a special diet, drinking alcohol, and also body mass index (BMI). Another factor that was not controlled in this study is the forms of family support that may have an influence on the pattern of physical activity carried out even though in this study it was controlled with SOPs for physical activity.

CONCLUSION
The average picture of glycemic control (HbA1c levels) before the intervention in the healthy walking group was 5.57% and decreased to 5.46% after the intervention; the combination group from 5.93% to 5.78%, and in the leisurely walking group from 5.74% to 5.71%. There was no significant effect of slowly walking on glycemic control (HbA1c For complete information author guidelines please check http://ejournal.poltekkes-smg.ac.id/ojs/index.php/jnj/about/submissions#authorGuidelines levels), and there was a significant effect of both brisk walking and the combination of brisk walking and slowly walking on glycemic control (HbA1c levels). The combination physical activity (slowly and brisk walking) has a better effect on glycemic control (HbA1c levels), compared to the slowly walking group.