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Effect of Exercise on Blood Glucose Metabolism of Type 2 Diabetes Patients in East Asian Population: A Meta-Analysis
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摘要:目的
探究不同运动处方在东亚人群2型糖尿病患者血糖代谢中的作用，并比较人群特征和运动要素对血糖代谢影响的差异。
方法系统检索PubMed、Cochrane Library、EmBase、Web of Science、中国知网、万方数据知识服务平台，获取从建库至2024年6月15日东亚人群中运动对2型糖尿病患者血糖代谢影响的相关文献。文献类型限定为随机对照研究，其中试验组进行运动干预，对照组不进行运动干预。由2名研究人员按照纳入与排除标准对文献进行筛选，并提取相关数据。采用Stata 17.0软件的Egger检验及RevMan 5.3软件的漏斗图评估发表偏倚，采用RevMan 5.3软件进行Meta分析。
结果共纳入21篇随机对照研究，包含1289例研究对象。其中试验组675例、对照组614例。经发表偏倚风险评估，文献质量整体良好。随机效应模型显示，试验组患者经运动干预后空腹血糖(MD=-1.31 mg/L, 95% CI：-1.55~-1.07, P＜0.001)、糖化血红蛋白(MD=-0.34, 95% CI：-0.45~-0.22, P＜0.001)、胰岛素抵抗指数(MD=-0.39, 95% CI：-0.54~-0.23, P＜0.001)、空腹胰岛素(MD=-0.71 μIU/mL, 95% CI：-1.18~-0.24, P=0.003)均显著降低。不同运动方式改善血糖代谢的作用存有异质性，其中有氧运动(MD=-1.49 mg/L, 95% CI：-2.53~-0.44, P=0.005)和联合运动(MD=-1.41 mg/L, 95% CI：-1.87~-0.95, P＜0.001)降低空腹血糖的效果优于抗阻运动；联合运动(MD=-0.47, 95% CI：-0.81~-0.31, P=0.007)降低糖化血红蛋白的效果优于有氧运动和抗阻运动；仅有氧运动(MD=-0.48，95% CI：-0.89~-0.07，P=0.020)和联合运动(MD=-0.35，95% CI：-0.69~-0.01，P=0.040)降低胰岛素抵抗指数的作用具有统计学意义，且有氧运动的效应优于联合运动。按照年龄组、运动周期、运动时间、运动频率、运动强度进行亚组分析显示，每周进行小于5次、每次不超过1 h的有氧运动对于改善东亚人群2型糖尿病患者空腹血糖有显著效果。
结论运动干预可降低东亚人群2型糖尿病患者血糖，减轻胰岛素抵抗，其中有氧运动和联合运动是更适合东亚人群2型糖尿病患者降糖的运动处方。
Abstract:ObjectiveTo explore the effects of different exercise prescriptions on glycemic metabolism in East Asian patients with type 2 diabetes mellitus (T2DM) and to compare the differences in the impact of population characteristics and exercise components on glycemic metabolism.
MethodsA systematic search was conducted in PubMed, Cochrane Library, EmBase, Web of Science, CNKI, and Wanfang Data Knowledge Service Platform to identify relevant studies published from database inception to June 15, 2024, on the effects of exercise on glycemic metabolism in East Asian patients with T2DM. The study type was limited to randomized controlled trials (RCTs), where the intervention group received exercise interventions and the control group did not. Two researchers independently screened the literature based on inclusion and exclusion criteria and extracted relevant data. Publication bias was assessed using Egger's test in Stata 17.0 and funnel plots in RevMan 5.3. Meta-analysis was performed using RevMan 5.3.
ResultsA total of 21 RCTs involving 1289 participants (675 in the intervention group and 614 in the control group) were included. Publication bias assessment indicated overall good quality of the included studies. The random-effects model showed that exercise interventions significantly reduced fasting blood glucose (MD=-1.31 mg/L, 95% CI: -1.55 to -1.07, P < 0.001), glycated hemoglobin A1c (HbA1c) (MD=-0.34, 95% CI: -0.45 to -0.22, P < 0.001), homeostatic model assessment of insulin resistance (HOMA-IR) (MD=-0.39, 95% CI: -0.54 to -0.23, P < 0.001), and fasting insulin (MD=-0.71 μIU/mL, 95% CI: -1.18 to -0.24, P=0.003) in the intervention group. Heterogeneity was observed in the effects of different exercise modalities on glycemic metabolism. Aerobic training (MD=-1.49 mg/L, 95% CI: -2.53 to -0.44, P=0.005) and combined training (MD=-1.41 mg/L, 95% CI: -1.87 to -0.95, P < 0.001) were more effective than resistance training in reducing fasting blood glucose. Combined training (MD=-0.47, 95% CI: -0.81 to -0.31, P=0.007) was superior to aerobic and resistance training in reducing HbA1c. Only aerobic training (MD=-0.48, 95% CI: -0.89 to -0.07, P=0.020) and combined training (MD=-0.35, 95% CI: -0.69 to -0.01, P=0.040) significantly reduced HOMA-IR, with aerobic training showing a greater effect than combined training. Subgroup analyses based on age group, exercise duration, session length, frequency, and intensity revealed that aerobic training performed less than 5 times per week for no more than 1 hour per session significantly improved fasting blood glucose in East Asian patients with T2DM.
ConclusionsExercise interventions can improve glycemic control and reduce insulin resistance in East Asian patients with T2DM. Aerobic exercise and combined exercise are more effective exercise prescriptions for glycemic management in this population.
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作者贡献：孙宇欣、韩炳泰负责文献检索和论文初稿撰写；郭晓湲、郑雪晴负责文献检索和论文修改；陈适、阳洪波负责对论文内容进行指导、审核；潘慧负责论文选题、设计及写作指导。利益冲突：所有作者均声明不存在利益冲突
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图 2 试验组与对照组FBG水平比较的森林图
FBG：同表 1
Figure 2. Forest plot of FBG in the experimental group versus the control group
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图 3 试验组与对照组HbA1c水平比较的森林图
HbA1c：同表 1
Figure 3. Forest plot of HbA1c in the experimental group versus the control group
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图 4 试验组与对照组HOMA-IR水平比较的森林图
HOMA-IR：同表 1
Figure 4. Forest plot of HOMA-IR in the experimental group versus the control group
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图 5 试验组与对照组FINS水平比较的森林图
FINS：同表 1
Figure 5. Forest plot of FINS in the experimental group versus the control group
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图 6 血糖代谢的合并结果漏斗图
A.FBG；B.HbA1c；C.HOMA-IR；D.FINS
FBG、HbA1c、HOMA-IR、FINS: 同表 1Figure 6. Funnel plot for the combined results of blood glucose metabolism
表 1 纳入研究的基本特征
Table 1 Basic characteristics of included studies
作者 发表年份 国家/ 地区 平均年龄(试验组/ 对照组，岁) 总样本(n) 各组样本(试验组/ 对照组, n) 运动措施 运动周期 单次运动量 运动频率(次/周) 运动强度 纳入指标 Choi等[5] 2012 韩国 55.0/53.8 75 37/38 有氧运动 12周 60 min 5 3.6~6.0 MET& FBG、HbA1c、HOMA-IR Lee等[6] 2015 中国台湾 54.5/56.1 80 40/40 有氧运动 3个月 30 min 5 60%~80% HRmax▲ FBG、HbA1c Kim等[7] 2004 韩国 53.8/52.8 45 22/23 有氧运动 3个月 30 min 3~5 40%~75% VO2max# FBG、HbA1c Koo等[8] 2010 韩国 57/53 31 13/18 有氧运动 12周 120 min 7 500 kcal/d FBG、HbA1c Matsushita等[9] 2022 日本 62/61 36 18/18 有氧运动 8周 30 min 3 40%~60% VO2max FBG、HbA1c Tan等[10] 2018 中国 63.0/62.9 31 16/15 有氧运动 12周 20~40 min 3 个体化FATmax HR* FBG、HOMA-IR、FINS 包勤文等[11] 2016 中国 70.4/68 107 58/49 有氧运动 6个月 120 min 12 50%~70% HRmax FBG、HbA1c 黄为均等[12] 2018 中国 49.2/52.2 58 29/29 有氧运动 12周 30 min 3 / FBG 谢丽娜等[13] 2021 中国 46.4/44.3 60 30/30 有氧运动 12周 60 min 5 50%~70% HRmax FBG、HbA1c、HOMA-IR、FINS 黄葵等[14] 2021 中国 67.8 (整体人群) 47 24/23 有氧运动 10周 40 min 3 80% VO2max、50%VO2max交替 FBG、HbA1c 张燕等[15] 2012 中国 51.2/50.8 99 49/50 有氧运动 8周 30 min 5 120~150步/min、80~100步/min交替 FBG 晁敏等[16] 2015 中国 54/53 30 15/15 有氧运动 12周 55 min 3 50% VO2max FBG、HbA1c 杨晓荣等[17] 2020 中国 59.3/59 100 50/50 抗阻运动 3个月 4组 1 50%~60% HRmax FBG、HbA1c、FINS 魏钦[18] 2018 中国 56.6/52 36 19/17 抗阻运动 12周 10组 3 50%~60% 1RM至60%~70% 1RM△ FBG、HOMA-IR Terauchi等[19] 2022 日本 54.6/55 224 110/114 有氧运动+ 抗阻运动 12周 30 min 3 40%~60% VO2max FBG、HOMA-IR、FINS Sung等[20] 2012 韩国 70.2/70.1 40 22/18 有氧运动+ 抗阻运动 24周 30~40 min 3 55%~64% HRmax至65%~75% HRmax FBG、HbA1c Park等[21] 2015 韩国 71.2/69 37 24/13 有氧运动+ 抗阻运动 12周 40 min 3 45%~55% 1RM进阶至65%~75% 1RM HbA1c Jeon等[22] 2020 韩国 62.1/61 35 21/14 有氧运动+ 抗阻运动 12周 50 min 3 70% 1RM HbA1c、HOMA-IR 柯海宝等[23] 2016 中国 61.4/62.3 38 20/18 有氧运动+ 抗阻运动 12周 50 min 3 60%HRmax FBG、HbA1c 常凤[24] 2018 中国 53.3/54.3 38 18/20 有氧运动+ 抗阻运动 24周 60 min 3 50% VO2max FBG、HbA1c、FINS 孟晴等[25] 2018 中国 61.4/63 80 40/40 有氧运动+ 抗阻运动 3个月 30~60 min 3 50%~80% HRmax FBG、HbA1c、HOMA-IR & MET：每千克体质量每小时消耗1千卡能量；▲HRmax：最高心率，计算方法为220-年龄；# VO2max：最大摄氧量；*FATmax HR：运动强度为测量脂肪氧化最高时的心率；△1RM：单次最大负荷重量；FBG(fasting blood glucose)：空腹血糖；HbA1c(glycated hemoglobin A1C)：糖化血红蛋白；HOMA-IR(homeostasis model of assessment insulin resistance)：胰岛素抵抗指数；FINS (fasting insulin)：空腹胰岛素 
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表 2 纳入文献的偏倚风险评估情况
Table 2 Bias risk status of included literature
作者 随机分配 分配隐藏 对研究对象及干预者实施盲法 对结果评价者实施盲法 结局指标数据完整性 选择报告偏倚 其他偏倚 Choi等[5] 不清楚 不清楚 低风险 低风险 低风险 低风险 低风险 Lee等[6] 不清楚 不清楚 低风险 低风险 低风险 低风险 低风险 Kim等[7] 不清楚 不清楚 低风险 低风险 低风险 低风险 低风险 Koo等[8] 高风险 不清楚 低风险 低风险 低风险 低风险 低风险 Matsushita等[9] 低风险 低风险 低风险 低风险 低风险 低风险 低风险 Tan等[10] 不清楚 不清楚 低风险 低风险 低风险 低风险 低风险 包勤文等[11] 不清楚 不清楚 低风险 低风险 低风险 低风险 低风险 黄为均等[12] 不清楚 不清楚 低风险 低风险 低风险 低风险 低风险 谢丽娜等[13] 低风险 低风险 低风险 低风险 低风险 低风险 低风险 黄葵等[14] 低风险 低风险 低风险 低风险 低风险 低风险 低风险 张燕等[15] 低风险 低风险 低风险 低风险 低风险 低风险 低风险 晁敏等[16] 低风险 低风险 低风险 低风险 低风险 低风险 低风险 杨晓荣等[17] 不清楚 不清楚 低风险 低风险 低风险 低风险 低风险 魏钦[18] 低风险 低风险 低风险 低风险 低风险 低风险 低风险 Terauchi等[19] 低风险 低风险 低风险 低风险 低风险 低风险 低风险 Sung等[20] 低风险 低风险 低风险 低风险 低风险 低风险 低风险 Park等[21] 低风险 低风险 低风险 低风险 低风险 低风险 低风险 Jeon等[22] 不清楚 不清楚 低风险 低风险 低风险 低风险 低风险 柯海宝等[23] 低风险 低风险 低风险 低风险 低风险 低风险 低风险 常凤[24] 不清楚 不清楚 低风险 低风险 低风险 低风险 低风险 孟晴等[25] 低风险 低风险 低风险 低风险 低风险 低风险 低风险
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表 3 试验组与对照组FBG水平亚组分析
Table 3 Subgroup analysis of FBG levels between the experiment group and the control group
亚组 文献数量(篇) 异质性检验 合并效果值 I2 P值 MD(95% CI) P值 年龄 45~＜60岁 12 87% ＜0.001 -1.39(-2.22~-0.57) ＜0.001 ≥60岁 6 61% 0.020 -1.34(-2.10~-0.58) ＜0.001 组间差异 0.920 运动周期 ≤12周 12 86% ＜0.001 -1.35(-2.20~-0.48) 0.002 ＞12周 6 70% 0.005 -1.61(-2.57~-0.64) 0.001 组间差异 0.700 运动时间 ＜1 h 11 87% ＜0.001 -1.59(-1.92~-1.25) ＜0.001 ≥1 h 5 73% 0.005 -1.38(-1.87~-0.89) ＜0.001 组间差异 0.030 运动频率 ＜5次/周 12 86% ＜0.001 -1.39(-1.67~-1.10) ＜0.001 ≥5次/周 6 75% 0.001 -1.13(-1.57~-0.70) ＜0.001 组间差异 0.070 运动强度 ＜60% VO2max 4 0 0.70 -1.28(-1.96~-0.61) ＜0.001 ≥60% VO2max 2 17% 0.27 -0.08(-1.15~0.99) 0.880 组间差异 0.160 FBG、VO2max：同表 1；MD(mean deviation)：均数差
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表 4 试验组与对照组HbA1c水平亚组分析
Table 4 Subgroup analysis of HbA1c levels between the experiment group and the control group
亚组 文献数量(篇) 异质性检验 合并效果值 I2 P值 MD(95% CI) P值 年龄 45~＜60岁 7 42% 0.11 -0.23 (-0.40~-0.07) 0.005 ≥60岁 6 57% 0.04 -0.44 (-0.61~-0.28) ＜0.001 组间差异 0.330 运动周期 ≤12周 7 26% 0.23 -0.26 (-0.42~-0.11) ＜0.001 ＞12周 6 66% 0.01 -0.44 (-0.63~-0.26) ＜0.001 组间差异 0.230 运动时间 ＜1 h 8 53% 0.04 -0.44 (-0.60~-0.29) ＜0.001 ≥1 h 3 0% 0.40 -0.08 (-0.36~ 0.20) 0.580 组间差异 0.700 运动频率 ＜5次/周 10 53% 0.02 -0.40 (-0.54~-0.27) ＜0.001 ≥5次/周 3 0% 0.66 -0.08 (-0.33~0.18) 0.540 组间差异 0.390 运动强度 ＜60% VO2max 3 0% 0.53 -0.26 (-0.42~-0.10) 0.002 ≥60% VO2max 3 0% 0.42 -0.19(-0.58~0.19) 0.320 组间差异 0.760 HbA1c、VO2max：同表 1；MD：同表 3
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