Inroduction
Exercise has been defined as a prospective interruption to homeostasis by muscle activity that is either entirely, or in combination, concentric, eccentric or isometric. (Winter, EM and Fowler, N. 2009).
Anthropometry deals with the physical dimensions, proportions and composition of the human body, as well as the study of related variables that affect them. In other way, it can be defined as
science that deals with the measurement of the size, weight, and proportions of the human body.(
http://medical-dictionary.thefreedictionary.com/anthropometry).
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Walking is an activity in which the body advances at a slow to moderate pace by moving the feet in a coordinated fashion. This includes recreational walking, walking for fitness, and competitive race-walking.(http://www.definitions.net/definition/walking). Isotonic exercises (walking) are those where body movements are performed. Two types of isotonic contractions are concentric isotonic where a muscle shortens and produces movement (eg. flexion of elbow) and eccentric contraction where a muscle gradually lengthens while continuing to contract (eg. gradually lowering a weight held in the hand such as weight lifting). (Ghai, C.L. 2007) Walking is most simple isotonic exercise for all age groups. As per Āyurvedic perspective Vyāyāma is defined as Karma that produces Āyāsa (tiredness) in the body. (Su. Ci. 24/38). Caraka has described that the effort which produces stability and strength in the body is known as Vyāyāma (Ca Su 7/31). Diabetes is one of the most common metabolic disorder. First clearly recognizable description of diabetes was given by Arataeus of Cappadocia in 2th century AD. Charak 2nd century B.C. and Sushruta 2nd century A.D. were the first Indian physicians to recognize the sweetness of diabetic urine. Vāgbhata has also followed the Caraka’s view (A.H. Sū. 2/10). Characteristic features of Prameha are said to be PrabhūtāvilaMūtratā by Vāgbhata- Prameha as frequent and copious urine with turbidity (A.H.Ni. 10/7).
Importance of walking with reference to Diabetes Mellitus:
Walking (Parikrmana) is very important and most convenient exercise among all age groups and it covers the maximum diseases. It can be prescribed for all age group patients mainly in diabetes .In advanced stage Prameha, they should put into practice physical exercise, wrestling, sports, riding elephant, horse and chariot, travelling on foot and moving around and also feats of archery therefore; walking is mainly indicated in Madhumeha (diabetes mellitus) (Su.Chi. 11/11). It is also mentioned that those who are not doing exercise (physical activity) and taking high calorie diet are mostly prone for Prameha (Ch.Chi. 6/4). As per Bhela Sam
hita life style without exercise is also a cause of Prameha (Bh. S. Ni 2/5).
Diabetes Mellitus
Diabetes mellitus often referred simply as a set of symptoms of disordered metabolism, usually due to arrangement of hereditary and environmental causes, resulting in abnormally high blood sugar levels (hyperglycemia). Pass on to a group of common metabolic disorders that share the phenotype of hyperglycemia. Several distinct types of diabetes mellitus exist and are caused by complex interaction of genetics and environmental factors. These physiological changes in multiple organ systems impose a remarkable burden on the individual with diabetes and on health care system. From the above description, it is clear that Prameha is mainly related to metabolic disorder rather than urinary tract pathology. Diabetes, which is a Greek word, meaning siphon (From Dia =through +bainein= to go) of urine.
Prakriti
Qualitative and quantitative, unchangeable Dosika predominance from birth to death is called as Prakriti. Prakriti is a deciding factor during prognosis and treatment of diseases. Vāta Prkriti individuals are very prone to all kinds of diseases on account of this it is the most awful among all.
Prakrti of human being is decided in intra uterine life according to predominance of Dosa and never can be changed throughout life. (Subhas Ranade 2007). It has been predicted that Kapha Pakriti individuals having increased Abdominal circumference due to collection of abdominal fat around umbilical region.
Significance of awareness of Prakrti:
The Āyurvedic system of diagnosing Prakrti offers a sole approach in understanding and assessing one’s health. It is comprehensive in scope, spanning both physical and mental aspect. It is not merely a diagnostic tool but also a guide to action for good health. It provides detailed instructions to adopt one’s food and behavior to suit one’s Prakrti The clinical and the therapeutic utility of the knowledge of Prakrti have been described by Caraka, whereas the detailed schedules that are to be followed by different Dosaja Prakrti have been dealt separately (C.S. Vi. 6/15-18). Suśruta has advised that the patient should be treated by physician according to Prakrti of person. ( Sushma Tiwari et.al 2010).
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Assortment of cases:
Overall, 83 diabetic Patients were recorded from Kayachikitsa, S.S. hospital; O.P.D., IMS, BHU for the duration Jan 2009 to Jan 2011. The selection was arbitrary irrespective of sex, occupation and socioeconomic status. All the patients belonged to the age group of 35 to 65 years. Anthropometric measurements were done initially and after three months.
Methodology:
In the present study, effect of walking has been observed in diabetic individuals. 30 minutes walking was prescribed for diabetic patients for 3 months under physician supervision. Before walking 5 minutes of warm up and after completion of exercise 5 minutes cool down was an indispensable part of this procedure. Breathing exercises kapal bhati, anuloma- viloma and deep slow breathing during expiratory and inspiratory phase have been advised for 15 minutes. Study group was divided as follows.
STUDY GROUPS
Diabetic group again divided into 2 groups
a.
Diabetic control (DMC) - Who did not perform walking
b.
Diabetic Exercise (DME) – Who performed walking
INCLUSION CRITERIA:
In both the groups, subjects suffering from diabetes Mellitus on the basis of ADA classification of blood sugar level.aged from 35 years to 65 years were included. Fasting Blood sugar level above 110 mg/dl and Post Prandial sugar level above 125 mg/dl were included in current study..
EXCLUSION CRITERIA:
In both the groups individuals aged below 35 years and above 65 years were excluded.
Patients suffering from any secondary diseases like diabetic nephropathy, retinopathy, neuropathy etc were excluded..
Anthropometric
Parameters:
Abdominal Circumference:
To
measure abdominal circumference upper hip bone and the top of the right iliac crest was located and a measuring tape was placed in a horizontal plane around the abdomen at the level of the iliac crest. Before reading the measurement of the tape it should be ensured that the tape snug, but does not compress the skin, and is parallel to the floor. The measurement is made at the end of normal expiration (http://www.airforce-pt.com/abdominal-circumference.html).
Hip Circumference:
The hip is recorded at the widest part of the hips; usually this corresponds to the groin level for women and about 2-3 inches below the navel in men (James Krider 2006 WHO site).
Body mass index (Quetelet’s index)
is a statistical measure of weight scaled according to height. It was calculated by using following formula. BMI= Weight in (kg)/Height (m2) (WHO 2002)
H
istory and clinical examination:
A detailed history was taken and physical examination was performed as per proforma prepared by the department of Kriya Sharir.
Prakriti assessment:
Prakrti evaluation is designed on the basis of the clarification found in Caraka Samhitā, which in turn, is based on the specific characteristics of a particular Dosa (Ca.Vi.8/96-98). In this perspective, Caraka has explained the particular features of a particular Dosa and the specific characteristics produced in an individual. Thus, Vāta has eight (8), Pitta has five (5) and Kapha has twelve (12) Gunas in total. Further, each Guna is responsible for producing one or more traits/characters. Thus, three Dosas possess neither equal number of Gunas nor do they produce equal number of characters / traits in the individuals. Prakriti was assessed by the proforma prepared by
Tripathi Piyush 2010 .This proforma has been designed in such a way that each trait/ character as describedin Caraka Samhitā (Vimāna Sthāna) was converted into simple questions/ statements along with maintenance the original version. The subject had to record their concurrence or discrepancy with the statement/question in a column provided for the purpose in the form of YES or NO. The scores to be allotted were specified against the statement in a separate column for a particular type of response.
Statistical analysis:
The data of diabetic patients were collected, coded and fed into the computer
. Analysis was done by using Statistical Package for Social Sciences (SPSS) Software Version 17.0. Data tabulated and appropriate statistical test viz
descriptive mean, paired sample t test and unpaired t-test were applied in order to draw meaningful inferences. The statistical methods were adopted to evaluate the significance of changes after walking and also as compared to control group.
Table no 1: Effect of walking on AC (Abdominal Circumference) and HC (Hip circumference) in diabetic patients
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Group
|
AC(cm)
(Mean
±
S.D)
|
Intra group comparison
Paired t- Test
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DMC
( n= 32 )
|
Initial
|
F 1
|
Initial vs F1
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86.44
±19.55
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88.84
± 20.44
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t=3.417
p<0.001 (HS)
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DME
(n= 51 )
|
88.97
± 10.03
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88.09
± 9.55
|
t=2.693
p <0.02 (S)
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Unpaired t – test
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DMC vs DME
t=0.773
p>0.05 (NS)
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DMC vs DME
t=0.525
p>0.05 (NS)
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Group
|
HC(cm)
(Mean
±
S.D)
|
Intra group comparison
Paired t- Test
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DMC
(n= 32)
|
Initial
|
F 1
|
Initial vs F1
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95.06
±27.85
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97.62
± 29.29
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t=1.620
p>0.05 (NS)
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DME
(n= 51 )
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94.61
± 9.86
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93.18
± 9.19
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t=2.892
p <0.01 (HS)
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Unpaired t – test
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DMC vs DME
t=0.105
p>0.05 (NS)
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DMC vs DME
t=1.002
p>0.05(NS)
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Increase in abdominal circumference was observed in DMC group, whereas slight decrease was observed in DME group. On statistical analysis after first follow up it was highly significant (p<0.001) in DMC group and just significant (p<0.02) in DME group. On intergroup comparison, no significance was observed in both groups. Statistically highly significant (p< 0.001) decrease in Hip circumference was observed in DME (Isotonic exercise) whereas increase was observed in DMC.OnIntergroup comparison no significance was observed. (These observations can be seen from Table no.1)
Table no 2: Effect of walking on HC (Hip Circumference) and AC (Abdominal circumference) in diabetic patients as per Prakriti
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Group
|
Prakrti
|
Hip Circumference ( cm )
(Mean
±S.D)
|
Intragroup Comparison Paired t-Test
|
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BT (Initial)
|
AT (F1)
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Initial vs F1
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DMC
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VP (n=23)
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98.30±28.51
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101.65±30.43
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t=1.534
p>0.05 (NS)
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VK (n=3)
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113.67±2.89
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112.33±40.41
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t=2.00
p>0.05 (NS)
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PK (n=6)
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73.33±20.15
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74.83±20.34
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t=4.392
p<0.01 (HS)
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DME
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VP (n=34)
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94.73±10.29
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92.70±9.47
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t=2.854
p<0.01 (HS)
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VK (n=5)
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99.10±9.77
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98.60±9.24
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t=0.745
p>0.05 (NS)
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PK (n=12)
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92.42±8.70
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92.25±8.3
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t=0.411
p>0.05(NS)
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Group
|
Prakrti
|
Abdominal Circumference (cm)
(Mean
±S.D)
|
Intragroup Comparison Paired t-Test
|
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BT (Initial)
|
AT (F1)
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Initial vs F1
|
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DMC
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VP (n=23)
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89.43±14.80
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92.91±16.16
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t= 2.606
p<0.02 (S)
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VK (n=3)
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108.00±10.39
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112.66±4.61
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t= 1.400
p>0.05 (NS)
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PK (n=6)
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64.17±21.13
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66.67±20.78
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t=5.00
p<0.01 (HS)
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DME
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VP (n=34)
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89.78±10.11
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88.58±9.09
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t=4.069
p<0.001 (HS)
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VK (n=5)
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94.00±8.34
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93.70±7.78
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t =0.612
p>0.05 (NS)
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PK (n=12)
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84.67±9.55
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84.42±10.71
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t=2.30
p>0.05 (NS)
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Table no. 2 suggested
that the individuals with VP Prakrti in DME group, PK Prakrti in DMC group illustrated statistically highly significant (p<0.001) change in hip circumference after walking. Individuals with VP Prakrti in DME group and PK Prakrti in DMC group demonstrated statistically highly significant (p<0.001) change in abdominal circumference after walking. A statistically significant (p<0.05) change was observed in abdominal circumference in only VP Prakrti individuals in DMC group of individuals.
Discussion
Inpresent study, an attempt has been made to study the effect of walking on anthropometric parameters in diabetic patients.
Validation of waist circumference:
A high waist circumference is associated with an increased risk for type 2 diabetes, dyslipidemia, hypertension and CVD in patients with a BMI in a range between 25 and 34.9 kg/m2 (Chan J et al, 1994). Monitoring changes in waist circumference over time may be useful, in addition to measuring BMI, since it can offer an estimate of increased abdominal fat even in the absence of a change in BMI. Furthermore, in obese patients with metabolic complications, amends in waist circumference are useful predictors of changes in CVD risk factors (Lemieux S, 1996). Average waist and hip circumferences were 92.0 cm and 98.7 cm for men and 78.7 cm and 98.2 cm for women, respectively. Men and women in the highest hip quartile also had higher BMI, waist circumference, Furthermore; those smoked more and exercised less, were more frequently menopausal, and encountered more of the end points under the study(Heitmann B, 2004). IP quartile cut-off point 94.0, 98.0, and 102.5 cm) and women (hip quartile cut-off point 92.5, 97.0, and 102.5 cm)
Increase in abdominal circumference was observed in DMC group; whereas slight decrease was observed in DME group this may be due to the decreased glucose level by exercise owing to increased permeability of glucose in peripheral tissues and accumulation of lipid does not take place. On statistical analysis after first follow up it was highly significant (p<0.001) in DMC group and just significant (p<0.02) in DME group. On intergroup comparison, no significance was observed in all the groups (Table no. 1). Abdominal circumference decreased after exercise however it was within normal limits. Table no. 1 showed a statistically highly significant (p< 0.001) decrease in Hip circumference in DME group after walking (Isotonic exercise). Ailsa G. Anderson et al (2007) reported the effects of brisk walking, and brisk walking with abdominal electrical muscle stimulation on anthropometric, body composition, and self-perception measures in sedentary adult women. This study mentioned significant decrease in hip circumference, body mass, BMI and waist circumference as compared with the control group. Table no. 2 suggested that VP diabetic individuals responded with decrease in hip circumference after 3 months walking but this decrease was within normal range but in control group increase in hip circumference was due to sedentary life style. Present study showed that the individuals with VP Prakrti in DME group showed the decreased level of AC because Vāta Prakriti individuals are very reactive to any kind of stimuli. VPindividuals have greater degree of raja Dosa property than KP individuals. So the Vāta Prakriti individuals are more reactive to any kind of stimuli and prone to develop the chronic stress leading to different kind of psychosomatic disorders and Pitta Prakrti individuals possess fast metabolism due this fat does not accumulate at al. PK Prakriti in DMC group demonstrated statistically highly significant (p<0.001) increase in abdominal circumference after walking. A statistically significant (p<0.05) increase was observed in abdominal circumference in only VP Prakrti individuals among DMC group individuals. BMI was also decreased in exercise intervention group. But this decrease was within the normal limits.
Conclusion:
Walking has shown the significant effect on abdominal circumference, hip circumference and BMI. It means walking have very strong correlation with these anthropometric parameters. These parameters directly associated with diseases because if abdominal circumference and hip circumference increases gradually can cause diabetes and obesity. Every body should have awareness for health and avoid sedentary life style. A daily walk enduring 30 minutes along with breathing exercise significantly reduces the risk of diabetes. In our study these anthropometric parameters have been changed significantly but these changes were within normal limits. Therefore, it may be suggested that further study on walking for increased duration with at least one year follow up may have more precise results in terms of anthropometric measurements with reference to Prakrti.
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