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Azimi H, Masroor D, Haghani H, Rafii F. Effect of Aerobic Exercise on Blood Pressure of Patients With Type 2 Diabetes: A Randomized Controlled Trial. JCCNC 2016; 2 (3) :169-176
URL: http://jccnc.iums.ac.ir/article-1-87-en.html
1- Department of Medical Surgical Nursing, School of Nursing and Midwifery, Iran University of Medical Sciences, Tehran, Iran.
2- Department of Biostatistics, School of Public Health, Iran University of Medical Sciences, Tehran, Iran.
3- Nursing Care Research Center, Department of Medical Surgical Nursing, School of Nursing and Midwifery, Iran University of Medical Sciences, Tehran, Iran , rafiee.f@iums.ac.ir
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1. Background 
Diabetes mellitus (DM), a metabolic disorder of carbohydrate, fat, and protein, is characterized by the lack of insulin secretion or reduced sensitivity of tissues to insulin (Gayton 2008). DM is referred to as “silent epidemic” and also considered as a public health problem worldwide, including Iran.
The disease incurs direct costs to the amount of 5.2% to 15% of the total health budget and indirect costs for many times as direct ones. It may also cause other problems such as ischemic heart disease, high blood pressure, and retinopathy. Moreover, it is also responsible for many deaths in the world (Ahmann 2007; Wild et al. 2004).
The most common type of diabetes is type 2 diabetes, and its prevalence is increasing globally (Hu 2011). The World Health Organization has termed DM as a “hidden epidemic,” based on the increasing trend of diabetes globally. In 2010, the prevalence of DM among adults (age range, 20-79 years) was 6.4%, which is equivalent to 285 million, and this prevalence is expected to increase to 7.7% in 2030, which is equivalent to 439 million people. The prevalence of the disease will increase to 69% in developing countries and 20% in developed countries between 2010 and 2030 (Shaw et al. 2010). In addition, the Iranian Health Ministry has reported 7.7% increase in the prevalence of diabetes type 2 in people aged 25 to 64 years, and the total number of people with diabetes has been reported to be 2 million (Ghorbani et al. 2008).
In a study conducted in 2008, it was found that 5.8% of Iranian women and 5.1% of Iranian men suffered from diabetics (Ghorbani et al. 2008). A common complication of diabetes is high blood pressure, which affects about 20% to 60% of patients with diabetes (American Diabetes Association 2003). In a study in Isfahan, it was reported that the prevalence of complications of diabetes such as high blood pressure is about 50% (Azizi et al. 2010).
 In Iran, the prevalence of high blood pressure has increased significantly during the past few years. In the latest studies, a 23.3% increase in the prevalence of the disease has been reported. Due to lack of appropriate treatment, 50% of the patients die because of stroke, heart attack, or kidney failure (Azizi et al. 2010). High blood pressure is a silent killer and is often neglected by the patient. In 2000, despite having advanced and extensive education, only one-third of the patients with high blood pressure could control their blood pressure and keep it within the normal range (Yeh et al. 2009). 
Nowadays, experts believe that diet and medications are not sufficient for the treatment and control of DM, but changing lifestyle and balancing known risk factors for diabetes should be done to control blood pressure. In other words, monitoring and controlling blood sugar and blood pressure and supporting health education and providing professional nursing care are necessary for preventing complications of this chronic and complex disease (Borhani et al. 2013; Nahin et al. 2012). Preventing the worsening of the patient’s condition is a very important nursing intervention (Fetherston & Wei 2011). 
With an emphasis on self-care and utilization of new relevant therapies such as non-pharmacological methods, nurses could have a significant contribution in improving the physical and mental conditions of diabetic patients (Delavari et al. 2005; Pena et al. 2009). Physical activity and exercise are among the non-pharmacological methods and can be considered as the most important changes in the lifestyle of people with diabetes (American Diabetes Association 2013). A research in 2006, showed that the mean systolic and diastolic blood pressures were significantly reduced after 8 weeks of exercise (Macfarlane et al. 2006). 
Weight loss due to exercise leads to the reduction of triglycerides and low-density lipoproteins, loss of excess body fat, and regulation of blood pressure (Yosefi poor et al. 2015). The American Diabetes Association recommends 150 minutes of moderate-intensity aerobic exercise or 90 minutes of vigorous aerobic activity per week for patients with type 2 diabetes (Praet & Loon 2007). These exercises will also improve the maximum oxygen uptake in diabetic patients by 10% (due to the improvement in the cardiovascular and respiratory system), and at this rate, it is expected that the risk of cardiovascular disease reduces significantly (Boule et al. 2003). The best time to exercise is usually 1-3 hours after meals in patients with diabetes (Khaliqi 2009). 
Aerobic exercise is the common type of exercise for people with diabetes (Bello et al. 2011). Many studies have confirmed the positive impact of aerobic exercise in lowering blood pressure (Macfarlane et al. 2006; Collier et al. 2008). A research, conducted in 2008, showed that 4 weeks of aerobic and power exercise has markedly decreased systolic and diastolic blood pressure (Macfarlane et al. 2006); however, some other studies have not verified the effect of aerobic exercise on the reduction of blood pressure (Andersson et al. 2008; Lin et al. 2009; Alizadeh et al. 2011). 
Walking is also an excellent way to control type 2 diabetes and improve the health of patients with diabetes (Loretod et al. 2005). Walking or doing any aerobic exercise for 38 minutes (4400 steps) per day will significantly decrease hemoglobin A1C value in patients with diabetes. Moreover, walking 5 km a day that takes approximately 90 minutes can improve up to 1.1% hemoglobin A1C (Karstoft et al. 2012). Reduction in glycosylated hemoglobin A1C has lots of benefits in reducing cardiovascular complications (Rizos & Mikhailidis 2001); each 1% increase in glycosylated hemoglobin is associated with 18% increase in cardiovascular disease risk. Therefore, aerobic exercise can be an ideal exercise for people with diabetes (Sigal et al. 2007).
Due to the increasing incidence and prevalence of DM and its impact on all aspects of life in these patients, it is important to further study the different aspects of DM. There is an increasing prevalence of high blood pressure in Iran, especially in people with type 2 diabetes (about 71%), which is two times more than that in the general population. Furthermore, 35% to 75% of cardiac complications such as cardiovascular and renal hypertension have been attributed to high blood pressure in patients with diabetes (Azizi et al. 2010; Farvid et al. 2010). Given this background, conducting multiple studies in this area seems necessary. Therefore, the aim of this study is to examine the effect of walking exercise on the blood pressure of patients with type 2 diabetes.
2. Materials and Methods
This randomized clinical trial was approved by the Ethics Committee of Iran University of Medical Sciences (Code No. IR.IUMS.REC.2015.9311686019), and the proposal was registered in Iran Clinical Trials (Code No. IRCT 201511197101N3). Permission was obtained to enter the research settings, i.e. hospitals affiliated to Iran University of Medical Sciences (Hazrat-e Rasool and Firouzgar), by explaining the aim of the study to the hospital authorities. 
The inclusion criteria were as follows: having type 2 diabetes according to physician’s diagnosis, lack of musculoskeletal disorders and cardiovascular problems, lack of limits on physical exercise, aged 20-60 years, and having blood pressure less than 220/120 mm Hg. Exclusion criteria were as follows: hospitalizations during the study, exercise intolerance (expressing discomfort, lethargy, imbalance, sweating, tachycardia, and severe dizziness), irregular participation in exercise, and developing any complications in the foot. According to the previous studies, the sample size was calculated.
In this study, 67 males and females (20-60 years old) with type 2 diabetes, were randomly assigned to walking (n = 33) and control (n = 34) groups. Both groups signed the consent form. The control group received no intervention and continued their normal life. The walking exercise group was asked to walk with moderate intensity for 30 minutes one to two hours after eating breakfast in the morning, 3 days a week, for 8 consecutive weeks. The experimental group was told to report the researcher in the case of severe and unbearable palpitations. In such a case, the patient’s pulse rate was measured; if it was 60-70% of the maximum initial pulse rate, the patient would break up walking till the pulse rate returned to baseline. After returning pulse to baseline, they began walking the prescribed distance (2 km) over time prescribed (30 minutes) till the walking task was finished. Exercises were done in the gym and supervised by the researcher or research assistant and a coach. Blood pressure was measured by a reliable needle bounce manometer the day before and one day after the end of the intervention. The data was analyzed by descriptive statistics (the frequency, mean and standard deviation), the Kolmogorov – Smirnov test, t-test, and Chi-square test using SPSS (version 16). The significance level was considered as less than 0.05. 
3. Results 
The results showed that the mean age of the patients in the walking and control groups was 53.18 ± 4.99 years and 51.88 ± 7.83 years, respectively. There was no significant difference between the average age of the groups (P = 0.412) (Table 1).
There was no significant difference between groups with regard to sex (P = 0.729) (Table 2). Most participants were high school graduates, and there was no significant difference between the two groups in terms of educational level (P = 0.690) (Table 3). Most participants in the walking group (48%) used Metformin, and about 47% in the control group used Metformin and Glibenclamide. There was no significant difference between the groups in terms of the type of taking oral diabetes tablets (P = 0.574) (Table 4).



 
Before the intervention, the mean systolic and diastolic pressure of the groups was not significantly different. There was no statistically significant difference between walking and control group in terms of the mean systolic and diastolic pressure before and after the intervention (P > 0.05) (Table 5). The difference between mean systolic and diastolic pressure of experimental and control groups was not statistically significant (P > 0.05 ) (Table 6).

 4. Discussion 
Based on the results of this study, 8 weeks of walking exercise had no effect on reducing systolic and diastolic blood pressure of the patients with type 2 diabetes.
The results of this research are congruent with the findings of other related studies (Modeste et al. 2007; Lin et al. 2009; Alizadeh et al. 2011; Yosefipoor et al. 2015). In a research conducted by Alizadeh, 45 women were randomly assigned into 3 groups including intermittent exercise, continuous exercise, and control groups. The first group practiced 40 minutes of walking with the intensity of 64% to 76% of the maximum heart rate, 3 sessions a day for 5 days; the second group practiced 40 minutes of walking with moderate intensity 1 session a day, for five days, and the control group did not engage in any exercise. 
No significant changes occurred in the systolic and diastolic blood pressure of the groups (Alizadeh et al.2011). In another research, 8 weeks of aerobic exercise, 3 times a week by 60% to 80% of maximum heart rate had no significant effect on blood pressure (Yosefipoor et al. 2015). However, other studies have shown that aerobic exercises have reduced participants’ systolic and diastolic blood pressure. In Macfarlane’s study and Collier’s study, significant changes were seen in systolic and diastolic blood pressure after 8 weeks and 4 weeks of aerobic exercise, respectively (Macfarlane et al. 2006; Collier et al. 2008).
In Murphy’s study, there was also a reduction in diastolic blood pressure over the 6-week intermittent and continuous exercise with moderate intensity (Murphy et al. 2002). Whelton has confirmed the positive impact of aerobic exercise on the reduction of blood pressure (Whelton et al. 2002). It seems that aerobic exercise reduces blood pressure by reducing the levels of triglycerides and low-density lipoprotein and loss of excess body fat (Yosefipoor et al. 2015). It also increases oxidation of total body fat and activates lipoprotein lipase (Mokhtari et al. 2014), which can play an important role in lowering blood pressure. 
The different results of the above-mentioned studies could be due to the failure of interventions to reduce blood pressure (Lin et al. 2009Alizadeh et al. 2011Yosefipoor et al. 2015), lack of relationship between exercise and blood pressure (Modeste et al. 2007), increasing systolic or diastolic blood pressure after a period of aerobic exercise (Andersson et al. 2008; Fargad 2005), and failure of our intervention to reduce blood pressure. Other factors such as the type of exercise, intensity and frequency of daily exercise, diet, and body mass index could also be involved. Therefore, some researchers recommend and emphasize the concurrent use of exercise, appropriate diet, and certain drugs to control blood pressure (Jorgea et al 2011). 
Acknowledgments
Forough Rafii was responsible for the intervention program, the scientific content of the paper, and the overall design. Daryadokht Masroor was in charge of the control and proper implementation of the study. Hamid Haghani was responsible for data analysis. Hamideh Azimi provided the study design and was responsible for sampling the participants and preparing the article draft.
The paper is a result of a Master’s thesis in medical surgical nursing of Iran University of Medical Sciences. The researchers of this study appreciate the deputy of research affairs of Iran University of Medical Sciences for its financial support and all those people who helped us in this research.
Conflicts of Interest
The authors of this study declared no conflict of interests.
 

References 
Ahmann, A. 2007. ‘Guideline and performance measures of diabetes‘. American Journal of Managed Care, 13(2), pp. 41-6. PMID: 17417932

Alizadeh, Z., Kordi, R., Hossein Zadeh Attar, M. J., & Mansournia, M. A. 2011. ‘[The effects of continuous and intermittent aerobic exercise on lipid profile and fasting blood sugar in women with a body mass index more than 25 kg/m: A randomized controlled trial (Persian)]’. Tehran University Medical Journal, 69(4), pp. 253-59.

American Diabetes Association. 2013. ‘Standards of medical care in diabetes’. Diabetes Care, 36(1), pp. 11-66. PMCID: PMC3537269 

American Diabetes Association. 2003. ‘Treatment of hypertension in adults with diabetes’. Clinical Diabetes, 21(3), pp. 122-7. doi: 10.2337/diaclin.21.3.122

Andersson, K., Karlström, B., Fredén, S., Petersson, H., Ohrvall, M., & Zethelius, B. 2008. ‘A two-year clinical lifestyle intervention program for weight loss in obesity’. Food & Nutrition Research, 52. doi: 10.3402/fnr.v52i0.1656

Azizi, F., Hatami, H., & Jonghorbani, M. 2010. ’[Epidemiology and control disease in Iran (Persian)]’. Eshtiagh Publication, Tehran.

Bello, A. I., Owusu-Boakye, E., Adegoke, B. O., & Adjei, D. N. 2011. ‘Effects of aerobic exercise on selected physiological parameters and quality of life in patients with type 2 diabetes mellitus’. International Journal of General Medical, 4(2), pp. 723-727. doi: 10.2147/ijgm.s16717 

Borhani, F., Ranjbar, H., Abbaszadeh, A., Abazari, F., & Ranjbar, A. 2013. ‘[The effect of telenursing (cellphone software) on A1C hemoglobin in patients with type 2 diabetes mellitus (Persian)]’. Annals of Military & Health Sciences Research, 11(2), pp. 130-7.

Boule, N., Kenny, G., Haddad, E., Wells, G., & Sigal, R. 2003. ‘Meta-analysis of the effect of structured exercise training on cardiorespiratory fitness in Type 2 diabetes mellitus’. Diabetologia, 46(8), pp. 1071-81. doi: 10.1007/s00125-003-1160-2 

Collier, S. R., Kanaley, J. A., Carhart, R. J., Frechette, V., Tobin, M. M., Hall, A. K., et al. 2008. ‘Effect of 4 weeks of aerobic or resistance exercise training on arterial stiffness, blood flow and blood pressure in pre- and stage 1 hypertensives’. Journal Human Hypertension, 22(10), pp. 678-86. doi: 10.1038/jhh.2008.36 

Delavari, A., Mahdavi-zadeh, A., Noroozi-nezhad, A., & Yarahmadi, S. 2005. [Nursing and diabetes (Persian)]. Seda Publication, Tehran.

Farvid, M., Homayoni, F., Neyestani, D. T., & Amiri, Z. 2010. ‘[Blood pressure lowering effects of micronutrients in type 2 diabetic patients (Persian)]’. Iranian Journal of Endocrinology Metabolism, 12(1), pp. 7-15.

Fagard, R. H. 2005. ’Physical activity, physical fitness and the incidence of hypertension’. Journal Hypertension, 23(2), pp. 265-7. doi: 10.1097/00004872-200502000-00005 

Fetherston, C. M., & Wei, L. 2011. ‘The benefits of tai chi as a self management strategy to improve health in people with chronic conditions’. Journal of Nursing and Health Care of Chronic Illness, 3, pp. 155-64. doi: 10.1111/j.1752-9824.2011.01089.x 

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Hu, F. B. 2011.‘Globalization of diabetes’. Diabetes Care, 34(6), pp. 1249-57. doi: 10.2337/dc11-0442 

Jorgea, M. L. M. P., Oliveiraa, V. N. D., Resendea, N. M., Paraisoa, L. F., Calixtob, A., Diniza, A. L. D., et al. 2011. ‘The effects of aerobic, resistance, and combined exercise on metabolic control, inflammatory markers, adipocytokines, and muscle insulin signaling in patients with type 2 diabetes mellitus’.

Metabolism Clinical Experimental, 60(9), pp. 1-9. doi: 10.1016/j.metabol.2011.01.006 

Karstoft, K., Winding, K., Knudsen, S. H., Nielsen, J. S., Thomsen, C., & Pedersen, B. K. 2012. ‘The effects of free-living interval-walking training on glycemic control, body composition, and physical fitness in type 2 diabetes patients’. Diabetes Care, 36(2), pp. 228-36. doi: 10.2337/dc12-0658 

Khaliqi, H. 2009. ‘Exercise and fitness’. Salamat, 197(20). 

Lin, X. Y., Wang, L., Zhu, D. B., Xu, Y. H., & Wang, J. F. 2009. ‘The effect of different intensity aerobic exercise training on blood pressure control in hypertensive patients’. Zhonghua Nei Ke Za Zhi, 48(12), pp. 1023-5. PMID: 20193521

Di Loreto, C. H., & Fanelli, C., Lucidi, P., Murdolo, G., De Cicco, A., Parlanti, N., et al. 2005. ‘Make your diabetic patients walk: Long –term impact of different amounts of physical activity on type 2 diabeties’. Diabetes Care, 28(6), pp. 1295-302. PMID: 15920042

Pena, V., Watson, A. J., Kvedar, J. C., & Grant, R. W. 2009. ‘Mobile phone technology for children with type 1 and type 2 diabetes: A parent survey’. Journal of Diabetes Science and Technology, 3(6), pp. 1481-9. doi: 10.1177/193229680900300630

Praet, S. & Loon, L. V. 2007. ‘Optimizing the therapeutic benefits exercise in type 2 diabetes’. Journal of Applied Physiology,  103(4), pp. 1113-20. doi: 10.1152/japplphysiol.00566.2007

Rizos, E., & Mikhailidis, D. P. 2001. ‘Glycated Haemoglobin: A Predictor of Vascular Risk?’. International Journal Diabetes & Metabolism, 9, pp. 3-7.

Shaw, J. E., Sicree, P. Z. & Zimmet, P. Z. 2010. ‘Global estimates of the prevalence of diabetes for 2010 and 2030’. Diabetes Research and Clinical Practice, 87(1), pp. 4-14. doi: 10.1016/j.diabres.2009.10.007 

Sigal, R., Kenny, G., Boule, N., Wells, G., Prudhomme, D., & Fortier, M., et al. 2007. ‘Effects of aerobic training, resistance training, or both on glycemic control in type 2 diabetes: A randomized trial’. Annual International Medical, 147(6), pp. 357-69. PMID: 17876019

Macfarlane, D. J., Taylor, L. H., & Cuddihy, T. F. 2006. ‘Very short intermittent vs continuous bouts of activity in sedentary adults’. Preventive Medicine, 43(4), pp. 332-6. doi: 10.1016/j.ypmed.2006.06.002

Modeste, N. N., Brathwaite, N., Fraser, H. S. & Toh, S. W. 2007. ‘Exercise, blood sugar, blood pressure, and cholesterol levels in a Caribbean population’. International Quarterly of Community Health Education. 27(1), pp. 75-86. doi: 10.2190/iq.27.1.f

Mokhtari, F., Esfarjami, F., & Kargar Fard, M. 2014. ‘[The effect of combined aerobic exercise and barley B-glucan on lipid profile and glucose of women with diabetes type two (Persian)]’. Iran Journal OF Endocrinol Metabolic, 13(4), pp. 340-51.

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Nahin, R. L., Byrd-Clark, D., Stussman, B. J., & Kalyanaraman, N. 2012. ‘Disease severity is associated with the use of complementary medicine to treat or manage type-2 diabetes: data from the 2002 and 2007 national health interview survey’.BMC Complement Alternative Medicine, 12, pp. 193. doi: 10.1186/1472-6882-12-193

Whelton, S. P., Chin, A., Xin, X., & He, J. 2002. ‘Effect of aerobic exercise on blood pressure: a meta-analysis of randomized, controlled trials’. Annual International Medical, 136(7), pp. 493-503. doi: 10.7326/0003-4819-136-7-200204020-00006 

Wild, S., Roglic G., Green, A., Sicree, R., & King, H. 2004. ‘Global prevalence of diabetes: Estimates for the year 2000 and projections for 2030’. Diabetes Care, 27(5), pp. 1047-53. doi: 10.2337/diacare.27.5.1047 

Yeh, G., Wang, C., Wayne, P., & Phillips, R. 2009. ‘T’ai chi exercise for patients with cardiovascular conditions and risk factors: A systematic review’. Journal Cardiopulm Rehabitation and Prevention, 29(3), pp. 152–60. doi: 10.1097/hcr.0b013e3181a33379 

Yosefipoor, P., Taedibi, V., Behpoor, N., Parno, A., Delbari M. E., & Rashidi, S. 2015. ‘[Effects of aerobic exercise on glucose control and cardiovascular risk factor in type 2 diabetes patients (Persian)]’. Medical Journal of Mashhad University of Medical Sciences, 57(9), pp. 976-84. doi: 10.22038/mjms.2015.3882
Type of Study: Research | Subject: Special
Received: 2016/09/3 | Accepted: 2016/08/1 | Published: 2016/12/22

References
1. Ahmann, A. 2007. 'Guideline and performance measures of diabetes'. American Journal of Managed Care, 13(2), pp. 41-6. PMID: 17417932
2. Alizadeh, Z., Kordi, R., Hossein Zadeh Attar, M. J., & Mansournia, M. A. 2011. '[The effects of continuous and intermittent aerobic exercise on lipid profile and fasting blood sugar in women with a body mass index more than 25 kg/m: A randomized controlled trial (Persian)]'. Tehran University Medical Journal, 69(4), pp. 253-59.
3. American Diabetes Association. 2013. 'Standards of medical care in diabetes'. Diabetes Care, 36(1), pp. 11-66. PMCID: PMC3537269 [PMID]
4. American Diabetes Association. 2003. 'Treatment of hypertension in adults with diabetes'. Clinical Diabetes, 21(3), pp. 122-7. doi: 10.2337/diaclin.21.3.122 [DOI:10.2337/diaclin.21.3.122]
5. Andersson, K., Karlström, B., Fredén, S., Petersson, H., Ohrvall, M., & Zethelius, B. 2008. 'A two-year clinical lifestyle intervention program for weight loss in obesity'. Food & Nutrition Research, 52. doi: 10.3402/fnr.v52i0.1656 [DOI:10.3402/fnr.v52i0.1656]
6. Azizi, F., Hatami, H., & Jonghorbani, M. 2010. '[Epidemiology and control disease in Iran (Persian)]'. Eshtiagh Publication, Tehran.
7. Bello, A. I., Owusu-Boakye, E., Adegoke, B. O., & Adjei, D. N. 2011. 'Effects of aerobic exercise on selected physiological parameters and quality of life in patients with type 2 diabetes mellitus'. International Journal of General Medical, 4(2), pp. 723-727. doi: 10.2147/ijgm.s16717 [DOI:10.2147/IJGM.S16717]
8. Borhani, F., Ranjbar, H., Abbaszadeh, A., Abazari, F., & Ranjbar, A. 2013. '[The effect of telenursing (cellphone software) on A1C hemoglobin in patients with type 2 diabetes mellitus (Persian)]'. Annals of Military & Health Sciences Research, 11(2), pp. 130-7.
9. Boule, N., Kenny, G., Haddad, E., Wells, G., & Sigal, R. 2003. 'Meta-analysis of the effect of structured exercise training on cardiorespiratory fitness in Type 2 diabetes mellitus'. Diabetologia, 46(8), pp. 1071-81. doi: 10.1007/s00125-003-1160-2 [DOI:10.1007/s00125-003-1160-2]
10. Collier, S. R., Kanaley, J. A., Carhart, R. J., Frechette, V., Tobin, M. M., Hall, A. K., et al. 2008. 'Effect of 4 weeks of aerobic or resistance exercise training on arterial stiffness, blood flow and blood pressure in pre- and stage 1 hypertensives'. Journal Human Hypertension, 22(10), pp. 678-86. doi: 10.1038/jhh.2008.36 [DOI:10.1038/jhh.2008.36]
11. Delavari, A., Mahdavi-zadeh, A., Noroozi-nezhad, A., & Yarahmadi, S. 2005. [Nursing and diabetes (Persian)]. Seda Publication, Tehran. [PMID]
12. Farvid, M., Homayoni, F., Neyestani, D. T., & Amiri, Z. 2010. '[Blood pressure lowering effects of micronutrients in type 2 diabetic patients (Persian)]'. Iranian Journal of Endocrinology Metabolism, 12(1), pp. 7-15.
13. Fagard, R. H. 2005. 'Physical activity, physical fitness and the incidence of hypertension'. Journal Hypertension, 23(2), pp. 265-7. doi: 10.1097/00004872-200502000-00005 [DOI:10.1097/00004872-200502000-00005]
14. Fetherston, C. M., & Wei, L. 2011. 'The benefits of tai chi as a self management strategy to improve health in people with chronic conditions'. Journal of Nursing and Health Care of Chronic Illness, 3, pp. 155-64. doi: 10.1111/j.1752-9824.2011.01089.x [DOI:10.1111/j.1752-9824.2011.01089.x]
15. Gayton, A. 2008. 'Gayton physiology [D. Ramzi (Persian trans.)]'. Mir Publishing, Tehran.
16. Ghorbani, R., Askandarian, M., Malek, M., & Rashidei-Pour, A. 2008. '[Prevalence of hypertension among the adult population of Semnan Province (Persian)]'. Iranian Journal of Endocrinology Metabolism, 10(5), pp. 495-503.
17. Hu, F. B. 2011.'Globalization of diabetes'. Diabetes Care, 34(6), pp. 1249-57. doi: 10.2337/dc11-0442 [DOI:10.2337/dc11-0442]
18. Jorgea, M. L. M. P., Oliveiraa, V. N. D., Resendea, N. M., Paraisoa, L. F., Calixtob, A., Diniza, A. L. D., et al. 2011. 'The effects of aerobic, resistance, and combined exercise on metabolic control, inflammatory markers, adipocytokines, and muscle insulin signaling in patients with type 2 diabetes mellitus'. Metabolism Clinical Experimental, 60(9), pp. 1-9. doi: 10.1016/j.metabol.2011.01.006 [DOI:10.1016/j.metabol.2011.01.006]
19. Karstoft, K., Winding, K., Knudsen, S. H., Nielsen, J. S., Thomsen, C., & Pedersen, B. K. 2012. 'The effects of free-living interval-walking training on glycemic control, body composition, and physical fitness in type 2 diabetes patients'. Diabetes Care, 36(2), pp. 228-36. doi: 10.2337/dc12-0658 [DOI:10.2337/dc12-0658]
20. Khaliqi, H. 2009. 'Exercise and fitness'. Salamat, 197(20).
21. Lin, X. Y., Wang, L., Zhu, D. B., Xu, Y. H., & Wang, J. F. 2009. 'The effect of different intensity aerobic exercise training on blood pressure control in hypertensive patients'. Zhonghua Nei Ke Za Zhi, 48(12), pp. 1023-5. PMID: 20193521 Di Loreto, C. H., & Fanelli, C., Lucidi, P., Murdolo, G., De Cicco, A., Parlanti, N., et al. 2005. 'Make your diabetic patients walk: Long –term impact of different amounts of physical activity on type 2 diabeties'. Diabetes Care, 28(6), pp. 1295-302. PMID: 15920042 [DOI:10.2337/diacare.28.6.1295]
22. Pena, V., Watson, A. J., Kvedar, J. C., & Grant, R. W. 2009. 'Mobile phone technology for children with type 1 and type 2 diabetes: A parent survey'. Journal of Diabetes Science and Technology, 3(6), pp. 1481-9. doi: 10.1177/193229680900300630 [DOI:10.1177/193229680900300630]
23. Praet, S. & Loon, L. V. 2007. 'Optimizing the therapeutic benefits exercise in type 2 diabetes'. Journal of Applied Physiology, 103(4), pp. 1113-20. doi: 10.1152/japplphysiol.00566.2007 [DOI:10.1152/japplphysiol.00566.2007]
24. Rizos, E., & Mikhailidis, D. P. 2001. 'Glycated Haemoglobin: A Predictor of Vascular Risk?'. International Journal Diabetes & Metabolism, 9, pp. 3-7.
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