Original Article
A STUDY TO FIND THE CORRELATION BETW EEN SIX M INUTES
W ALK DISTANCE AND BLOOD GLUCOSE LEVEL IN DIABETIC
PATIENTS
Sw adita Dinakar *
1, S. Sridevi
2.
*1 M PT (Cardio Pulmonary Sciences), 2 PhD, Assistant Professor. Facult y of Physiot herapy, Sri Ramachandra Universit y, Chennai, India.
Int roduction: Physical act ivit y has been recom m ended for pat ient s w it h Type 2 Diabet es M ellit us (T2DM ) as it provides enorm ous physiological benefit s by r educing t he risk fact ors f or developm ent of com plicat ions, im proves blood glucose cont rol, over all healt h and qualit y of life. Form ulat ion of an individualized exercise prescr ipt ion based on exercise capacit y and baseline plasm a glucose levels is m andat ory, as an exercise int ensit y w hich is considered m oderat e for one m ight t urn out t o be ext rem ely rigorous for anot her pat ient w it h T2DM .
M at erials and M ethods: The relat ionship bet w een 6 m inut e w alk t est (6M WT) & som e cor relat es of T2DM w as invest igat ed in order t o form ulat e an exercise prescript ion. This observat ional st udy of 102 T2DM pat ient s fr om w hom an inf orm ed consent w as obt ained, w as conduct ed at t he diabet ic clinic of Sri Ram achandra m edical college and research inst it ut e. The pat ient s w ere inst ruct ed and m ade t o perf orm a 6M WT according t o ATS guidelines. The m easurem ent s included t he 6-M inut e Walk Dist ance (6M WD) for exercise capacit y and t he T2DM cor relat es including age, gender, fast ing blood glucose, post prandial blood glucose, HbA1C, durat ion of diabet es, BM I and w aist hip rat io (WHR).
Results: The relat ionships bet w een t he param et ers w ere det erm ined using Pearson’s correlat ion coefficient at a signif icance level of 0.05. The part icipant s consist ed of 55 m ales (53.1%) & 47 fem ales (46.1%). The m ean 6M W D for m ales w as 353.73±53.750m t s & fem ales w as 317.55±58.037m t s.The 6M W D correlat ed significant ly (P < 0.05) w it h fast ing blood glucose [r = -0.319] , post prandial blood glucose (r = -0.320), HbA1C(r = -0.381), BM I(r = -0.378), w hile t he 6M WD didn’t show a correlat ion (P >0.05) w it h W HR (r = 0.191 (fem ales),r=-0.058 (m ales),durat ion of diabet es (r = -0.020) and age( r = -0.112).
Conclusion: Thus low exercise capacit y in pat ient s w it h T2DM w as associat ed w it h higher adiposit y & poor glycaemic cont rol. Therefore t hese fact ors should be given considerat ion w hen prescribing exercises for pat ient s w it h T2DM in order t o ensure safet y and efficiency of t he exercise session.
KEY W ORDS: Diabet es M ellit us, 6M WD, Fast ing Blood Glucose, W aist Hip Rat io, HbA1C.
ABSTRACT
INTRODUCTION
Address for correspondence: Dr. Swadita Dinakar. PT, Plot No:75, Adhi Bhagwan Nagar, 1st st reet , Porur, Chennai-600116, Tamil Nadu, India. E-M ail: swadhit ha@gmail.com
Int J Physiother Res 2015, Vol 3(4):1099-04. ISSN 2321-1822 DOI: ht t p:/ / dx.doi.org/10.16965/ ijpr.2015.150
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International Journal of Physiotherapy and Research
ISSN 2321- 1822
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DOI: 10.16965/ ijpr.2015.150
Received: 26-05-2015 Peer Review : 26-05-2015 Revised: 02-06-2015
Accept ed: 15-06-2015 Published (O): 07-07-2015 Published (P): 11-08-2015
Type 2 Diabetes mellitus (T2DM ), A combinat ion o f i n su l i n r esi st an ce an d i n adeq u at e com pensat ory insulin secret ory response, is considered t o be a “ complex disease” as t his disorder is polygenet ic and st rongly influenced
M ETERIALS AND M ETHODS
Hypo and Hyper glycaemia being t he t w o ends of a broad spect rum are considered t o be t he major complicat ions result ing in severe micro and macro vascular complicat ions. Some of t he risks associat ed w it h t hese complicat ions are correlated w it h age [1], gender, poorly controlled blood glucose levels [2], w aist circumference, w aist hip rat io [3] body mass index [4] & HbA1c levels [5] . These variables are easily measured in clinic.
According t o Sigal et al. (2006), it is essent ial t hat before beginning a program of physical act ivit y w hich is anyt hing more st renuous t han brisk w alking, people w it h diabet es should be assessed & screened for vascular, neurological, cardiovascular complicat ions & ot her coexist ing m o r b i d it i es as t h ese ar e i m p o r t an t considerat ions for physiotherapist designing the exercise program for t he individual t o avoid adverse react ions result ing in delet erious and life t hreatening effect s on the individual’s healt h st at us [6] .
For m ulat ion of an in dividualized exer cise prescript ion is essent ial because variat ions exist s depending on individual’s age, previous levels of physical act ivit y, exercise capacit y, body mass index, body composit ion , lifest yle and base line plasma blood glucose levels [7,8]. St ruct ured exercise plan is considered an import-ant cornerst one t o achieve good glycaem ic cont rol inT2DM . This can be achieved via a thorough pre-act ivity screening. The developme-nt of an effect ive, easily accessible and safe assessment pat t ern t o det ermine t he exercise capacit y and t hen using t hose result s t o plan a exercise prescript ion is t he need of t he hour.
Therefore t his st udy has been aimed t o find t he r elat i on sh ip b et w een 6-m i n u t e w al k t est dist ance and t he variables t hat correlat e t o T2DM (age, gender, BM I, WHR, FBG, PP, HbA1C, VO2 max). This has been achieved using a 6 M WT in accordance t o ATS (2002 guidelines) w hich is an effective met hod of det ermining t he safet y levels for a T2DM pat ient t o engage in exercising and his funct ional exercise capacit y. PAR-Q quest ionnaire has been used t o ensure m edical oversight in evaluat ing t he pat ient ’s healt h profile [8].
The observat ional st udy of pat ient s w it h T2DM w as conduct ed at Sri Ram achandra M edical Cent er an d Ho spi t al, Dep ar t m en t o f Endocr inology, w here et hical approval w as sought and obt ained.
The st udy w as int roduced to all t he patient s w it h T2DM at t ending t he clinic on t heir respect ive clinic day. The set eligibilit y criteria included: Patient s in t he outpatient department diagnosed w it h of T2DM , aged bet ween t hirty t o sixt y nine year s w it hout any appar ent cardiovascular disorders, Absence of posit ive response t o any quest ion on t he Physical Act ivit y Readiness Quest io n n ai r e(PAR-Q ),w i l l in gn ess t o giv e infor m ed consent and part icipat e in t he Six minut e w alk t est . Pat ient s excluded from t he st udy w ere t hose w ho had Absolut e/ Relat ive cont ra indicat ions for t he 6M WT.
Out of t he 207 T2DM pat ient s at t ending t he Diabet ic clinic only 102 agreed t o part icipat e in t he st udy and met t he inclusion crit eria. These pat ient s w ere screened. The t ools used w ere PAR-Q w hich assessed t he self reported fit ness of t he individuals for t he exercise t est and blood glucose report s having FBG,PP,Hba1c levels. The part icipant s w ere request ed t o indicat e t heir w illingness t o part icipat e aft er det ailed briefing on t he requirements for the st udy. The interested and consented subject s w ere taken up for data collect ion. The nat ure and purpose of t he st udy w as explained t o all t he par t icip ant s. The dem ographic det ails, Body M ass Index (BM I), Waist –Hip rat io, w aist circum f erence and duration of diabetes, occupation, and fasting and post prandial blood glucose levels (FBG & PP) on t h e d ay of t est in g, HbA1C lev els w er e assessed and values w ere not ed.
DIABETIC PATIENTS.
RESULTS AND TABLES
using bright ly colored t ape. A port able pulse oxymet er w as connect ed t o t he pat ient and t he
rest ing heart rat e and oxygen sat urat ion (SPO 2) were monitored and documented before the start of t he t est . All vit als w er e m onit or ed and docum ent ed. The pat ient was asked t o st art w al k in g and st op w at ch w as st ar t ed, t h e t herapist cont inuously monit ored t he pat ient during t he t est .t he pat ient w as inst ruct ed t o inform if he feels any discomfort through act ion. When t he t est w as performed the heart rat e and SPO2 w as monit ored and changes w ere not ed. Pat ient w as encouraged t o w alk as much as possible. Test was st opped exact ly at t he end of six minut es. The no. of laps and ext ra dist ance walked was not iced and documented. The post act ivit y vit als w ere cont inuously monit ored for t w o t o t hree minut es, w hich is considered as t ime period for t he vit als t o come back t o t he rest ing level.
COM PARISON BETW EEN
6 M W D AN D N UM BER M EAN STD.DEV t / F
LEVEL OF SIGN IFICAN CE
Upt o 130 (norm al) 41 35 4.51 5 8.17
>130 (uncont rolled) 61 32 5.33 5 5.96
Upt o 180(cont r olled) 34 35 0.74 5 7.92
>180 (uncont rolled) 68 33 0.22 57.8
5 TO 6.5 19 36 2.37 49.0 57
6.6 TO 8 38 34 8.55 53.1 69
8.1 TO 15 45 31 6.66 6 0.65
Under w e ight (<1 8.5) 0 0 0
N orm al (18.6-24.9 ) 29 36 6.72 57.6 21
Ove r w eight (25-2 9.9) 64 32 6.48 55.9 17
Obesit y class 1 (30-34.9) 7 31 0.71 52.4 74
Obesit y class 2 (35-39.5) 0 0 0
Obesit y class 3 (>40) 2 305 .6 50.6 07
<52 50 335 .1 5 5.02
>/ =52 52 33 8.94 61.9
Upt o 9 yrs 80 33 7.69 5 9.52
>9 yr s 22 33 4.77 5 5.24
Upt o 1.066 28 304 .137 9 5 3.62
>1.06 6 19 34 2.75 57.8 44
Upt o 1.040 17 34 8.52 4 9.85
>1.04 0 38 35 6.05 57.6 93
W HR i n ma l es
Durat ion of DM
t=2 .399 3 0.0 204
t=0 .476 2 0.6 359 t=0 .206 4 0.8 369
FBG (m g/ dl)
HbA1c
BM I (Kg/ m2)
Age groups
W HR i n femal es
PP (m g/ dl)
F=4.0 0.01
t=0.33 0.7 414 t=2 .541 8 0.01 2
t=1 .688 5 0.05 4
F=5.7 24 0.00 4 In t his st udy dat a w ere collect ed f rom 102
subject s. The collect ed dat a w ere t abulat ed and analyzed w it h SPSS 17.0 version, t he variables
such as age, gender, BM I, WHR, FBG, PP, HbA1C, VO2 max w ere calculat ed and t heir mean and st an d ar d dev i at i o n w er e com p u t ed . Th e norm alit y of t he variables w as ident ified by Shapiro-Wilk normalit y t est. In bivariat e analysis t o find t he significance diff erence bet w een independent sam ples (M ale & Fem ale) non paramet ric t est M ann-Whit ney t -t est w as used. To assess t he relationship bet w een t he variables non param et ric Spearm an’s correlat ion w as used. In all t he above st at ist ical t ools t he p r o b abi l i t y v al u e P=.05 i s co nsi d er ed as significant level. The 6M W D and t he ot her variables namely age, gender, BM I, WHR, FBG, PP, and HbA1C w ere compared w it h ANOVA and unpaired t -Test .
The part icipant s comprised of 55 males (53.9%) and 47 fem ales (46.1%).The mean 6M W D for males w as 353.73 met ers and 317.55 met ers in females. Comparison and correlat ion w as made bet w een 6M WD and t he variables of T2DM .The result s w ere as follow s:
Comparison between 6M WD and varying ranges of FBG,PP, HbA1c, BM I, WHR in females show ed
st at ist ical significance at (p=0.012), (p=0.054), (p=0.004), (p=0.010), (p=0.204) respect ively. Thu s as t he FBG, PP, Hb A1c, BM I, W HR (fem ales) levels increased, t he w alk dist ance covered reduced considerably.
Com parison bet w een 6M WD in differing age groups, durat ion of DM , WHR in males show ed no signif icance w it h (p=0.7414), (p=.8369), (p=0.6359) r esp ect i v ely. Th er e exist ed a significant (P<0.05) inverse correlation betw een 6M WD and FBG (r= -.319), PP (r= -.320), HbA1c (r = -.381) and BM I (r = -.378) w hile 6M W D show ed no correlat ion (P>0.05) w it h WHR in f em ales(r =.191), W HR in m ales (r = -.058), durat ion of D.M (r= -.020) and age (r= -0.1125).
6M W D AGE F.B.G P.P HbA1C W HR DURATION
OF DIABETES BM I VO2 M AX
(M ,F) (M ,F) (M ,F) (M ,F) (M ,F) (M ,F) (M ,F) (M ,F) (M ,F)
6M W D (1,1)
AGE (-0.08,-0.13) (1,1)
F.B.G (-0.20,O.37* *) (-0.22,-0.32* ) (1,1)
P.P (-0.22,-0.40* *) (-0.22,-0.26) (0.74* *,0.72* * ) (1,1)
HbA1C (-0.18,-O.55* * ) (-0.11,-0.07) (0.72* *,0.69* * ) (0.64* *,0.74** ) (1,1)
W HR (-0.06,0.19) (-0.14,0.04) (0.16,-0.29* ) (O.38* *,-O.37* *) (0.18,-0.33* ) (1,1)
DURATION OF
DIABETES (-0.07,-0.01) (0.51* *,0.46) (0.08,0.0) (-0.01,-0.09) (0.20,0.04) (-0.04,-0.60) (1,1)
BM I (-0.21,0.34* ) (-0.19,0.12) (0.20,0.15) (0.19,0.22) (0.21,0.17) (0.27*,0.09) (-0.08,0.02) (1,1)
VO2 M AX (1.0* * ,0.99** ) (-0.08,-0.14) (-0.20,-0.36* ) (-0.22,-0.38* * ) (-0.18,-0.54* * ) (-0.06,0.18) (-0.07,-0.01) (-0.21,-0.33) (1,1)
Table 2: Correlat ion bet w een 6M WD and correlat es of T2DM using spearm an correlat ion coef ficient .
Not es: * Signif icant at p < 0.05; * * Signif icant at p < 0.01
(M , F) = (M ale, Fem ale); 6M WD = 6 M inut e Walk Dist ance; FBG = Fast ing Blood Glucose; PP-Post prandial blood glucose, HbA1C-Glycat ed Haem oglobin, VO2 M ax-M axim um Oxygen Upt ake, BM I = Body M ass Index; WHR = Waist Hip Rat io.
DISCUSSION
Si x- m in ut e w alk t est co r r el at es w it h t h e capacit y t o carry out ADL. It t est s at t he sub maximal exercise capacit y of an individual w hich is safe & feasible. In t he present st udy t he mean 6M WD w as found t o be 337.1±58.37 m et ers among t he 102 T2DM subject s, w hich is far less t han t heir apparent ly healt hy count erpart s w ho were found t o have an average of 698±96 meters [9].
Var iou s var i ables h ave been at t r i but ed t o cont ribut e t o t he onset of t he disease and it s influence on Physical act ivit y levels on subject ’s with T2DM . In t his st udy t he variables influencing t he blood glucose levels w ere compared w it h t heir sub maximal exercise capacit y levels using a 6 M WT, and t he follow ing inferences w ere made:
Body M ass Index (BM I): Overweight and obesity are convent ional measurement of BM I. In t his st udy t he subject s w ere cat egorized based on t heir BM I values int o normal, overw eight , obese (class 1,2,3 ) cat egories t o w hich t he 6M W D w as compared .It w as found t hat t he 6M WD & BM I show ed sign if icant (p =0.010)negat ive correlat ion (r=-0.378). This result is sim ilar t o t he st udy by M . Hulens et al (2003) [4] w ho concluded t hat exercise capacit y is decreased in bot h sub m axim al and peak int ensit y in individuals w it h varying ranges of BM I .
Fasting Blood Glucose (FBG): The comparison made bet w een t he 6M WD & varying ranges of FBG levels w hich ranged bet w een 60-460 mg/ dl. These w ere t hen divided int o t w o groups , as upt o 130 mg/ dl w hich is considered cont rolled & ab o ve 130 m g/ d l w h i ch i s co nsi d er ed uncont rolled in accordance t o ADA guidelines 2007 [10]. It w as found t hat t he 6M WD & FBG show ed significant (p=0.012) inverse correlation (r=-0.319).This was in accordance t o t he st udy by Jam es. S. Reit m an et al 1984 [11], w ho concluded t hat aerobic exercises has profound influence in regulat ing FBG levels.
corre-DIABETIC PATIENTS.
-lat ion (r=-0.320). M oshe S. et al 1989 [12] concluded t hat low physical act ivit y in T2DM increases FBG and PP levels due t o decreased cat abolism.
Glycated Haemoglobin (HbA1C): In t his st udy t he dist ance covered during a 6M W T for t he subj ect s w er e com pared am ongst var ying ranges of HbA1C levels. Classificat ion int o t hree categories (i.e. 5-6.5%-good cont rol,6.6-8% -fair cont rol,>8%-poor cont rol) w ere made based on t heir HbA1C levels. This st udy show ed t hat t he 6M W D & Hb A1C w er e h i ghl y si gn if i can t (p=0.004) w it h inverse correlat ion (r=-0.381). The low exercise capacit y in T2DM could be relat ed t o high affinit y of HbA1c t o oxygen & energy met abolism of t he cell leads t o chronic f at i gue and sev er e d ecr ease i n exer cise capacit y [13].
Waist Hip Ratio (W HR): The 6M WD amongst varying ranges of WHR in females & males w ere separat ely analyzed in t his st udy aft er dividing t hem int o t w o groups based on t heir respect ive mean values (i.e in males t he mean W:H rat io w as 1.04 ,t hus t hey w ere divided int o one group havi ng u pt o 1.04 and o t h er gr ou p havi ng >1.04,similarly among t he female populat ion the mean w as found t o be 1.066,t hus t hey w ere divided int o one group consist ing of W:H rat io upt o 1.06 and ot her group, >1.06). It w as found t hat t here did not exist a significant correlat ion bet w een W HR and 6M W D. This r esult w as similar t o t he st udy performed by A.F.Adeniyi et al (2010) [17] w ho concluded t hat t he w aist hip rat io correlat ed w it h t he 6M WD in t he m ale part icipant s and not in t he female part icipant s. In t he present st udy, t he populat ion w asn’t evenly dist ribut ed. This could be t he reason for not having found a correlat ion.
AGE: Aging w hich is associat ed w it h increased oxidat ive st r ess and im pair ed ant i-oxidant defense has been a cont r ibut or y fact or f or init iat ion and progression of complicat ions in Diabetes mellit us [15]. The 102 subject s taken for t he st udy fell bet w een t he age of 30 yrs t o 70 yrs, t herefore t heir mean age w as calculat ed w hich 52 yrs. They w ere t hen divided int o t w o groups (i.e. Less t han 52 yrs and more t han or equal t o 52 years). The mean 6M WD in t hese tw o groups w ere compared and it w as concluded t hat t hat t here does not exist a correlat ion
bet w een t he dist ance covered during a 6M WT in ranges of varied age groups (p=0.7414).
DURATION: The subject s w ere categorized int o 2 broad cat egories of onset of D.M i.e. up t o 9 years and more than 9 years, based on t he mean durat ion of diabet es. When t he 6M WD w ere compared t here existed no correlation (p=.8369) bet w een durat ion of t he disease and dist ance covered in 6M WT. This result w as similar t o t he conclusion draw n from t he st udy performed by Adeniyi et al (2010) [17].
Thus In t his st udy it w as found t hat high fast ing blood glucose, post prandial blood glucose, HbA1C levels, BM I, W HR in f em ales, w er e relat ed t o low er exercise capacit y in pat ient s w it h T2DM . It w as how ever not ed t hat t he durat ion of diabet es, WHR in males and age did not correlat e significant ly w it h t he 6M WD. The limit at ion of t his st udy w as t hat The 6M WD w as assessed only during t he post prandial phase. The t est could have been adm inist ered bot h during fast ing and post prandial phase. Furt her scope for t his st udy w ill be t hat Comparison of HbA1C prior t o exercise t raining and 12 w eeks post exercise t raining can be done & Regression equat ion can be formulat ed for six minut e w alk dist ance in pat ient s wit h varying ranges of blood glucose levels
The clinical implicat ion of t he st udy finding is t hat regardless of t he durat ion of diabet es and W HR, p r escr ip t io n of ph ysical exer cise t o pat ient s w it h T2DM w ho are older, w it h poor glycaemic cont rol and w it h high values of body mass index, has to be done wit h caut ion as t hese f act or s li m i t t h e in t ensit y at w hi ch t hese cat egories of pat ient s should exercise. These fact ors should be given due considerat ion w hen prescribing exercises.
Conflicts of interest: None
REFERENCES
[1] . Teslim e Ayaz, Serap Baydur Sahin, Osm an Zi krullah Sah i n , Ozl em Bi l i r, an d Hal i l Rakýcý, Fact o r s Affect ing M ort alit y in Elderly Pat ient s Hospit alized f o r No n m al i gn an t Reaso n s. Jo u r n al o f Agi n g Resear ch, vol.2014; Ar t icle ID 584315, 7 pages, 2014. doi:10.1155/2014/584315
[ 3] . Kr i st i n a Jack so n Be h an , Ju st i ce M b i zo . Th e Relat ionship Bet w een Waist Circum ference and Biom arkers f or Diabet es and CVD in Healt hy Non-Obese Wom en. The Pensacola St udy. Lab M ed. 2007;38(7):422-427. DOI: 10.1309/ VV1N2FGHN T84 JKJF.
[4] . Hulens M , Vansant G, Claessens AL, Lysens R, M uls E. Predict or s of 6-m inut e w alk t est result s in lean, obese and m orbidly obese w om en. Scandinavian Jo u r n al o f M ed i ci n e & Sci e n ce i n Sp o r t s. 2003;13(2):98-105.
[5] . Daniel Um pierre, Paula A. B. Ribeiro, Car oline K. Kram er. Physical Act ivit y Advice Only or St ruct ured Exercise Tr ai nin g and Associ at i on W i t h HbA1c Lev e l s i n Ty p e 2 Di ab et es. JAM A. 2011;305(17):1790-1799.
[ 6]. Sigal RJ, Kenny GP, Wasser m an DH, Cast aneda-Sceppa C, W hit e RD. (2006). Physical act ivi t y/ exercise and t ype 2 diabet es: a consensus st at em ent from t he Am erican Diabet es Associat ion. Diabet es Car e. 2006;29:1433-1438.
[7]. Albright A (2003). Diabet es and Clinical Exercise Physiology. Cham paign(IL). Hum an Kinet ics. P.no. 133.
[ 8 ] . Am e r i can Th o r aci c So ci e t y. ATS St at em en t : Guidelines for t he Six-M inute Walk Test . Am J Respir Crit Care M ed. 2002;166:111-117.
[9]. Gibbons WJ, Frucht er N, Sloan S, Levy RD. Reference Values for a M ult iple Repet it ion 6-M inut e Walk Test in Healt hy Adult s Older Than 20 Years. Journal of Cardiopulm onary Rehabilit at ion 2001;21(2):87-93. [ 10] .Am er i can Di abet es Asso ciat io n. Diagn osi s and Classif icat ion of Diabet es M ellit us. Diabet es care. 2012;35(1):64-71.
[11]. Jam es S. Reit m an, Bar bara Vasquez, Iw ar Klim es. Im p r o vem ent o f Glu co se Ho m eo st asi s Af t er Exe r ci se Tr ai n i n g i n N o n -i n su l i n - d e p e n d en t Diabet es. Diabet es care. 1984;7: 434-441. [ 12] . M oshe S. Physical Exer cise Condit ioning in t he
Absen ce of W ei gh t Loss Red uces Fast i n g an d Po st p r an d i al Tr i gl ycer i d e- Ri ch Li p o p r o t ei n
Levels. Circulation . 1989;79(5):750-755.
[13]. Demir I, Erm iº C, Altunbaº H, Balci M K. Serum HbA1c levels and exercise capacit y in diabet ic patient s,Jpn Heart J. 2001;42(5):607-16.
[14]. Casanova C, Celli BR, Bar ria P, Casas A, Cot e C, de Tor res JP, Jardim J, Lopez M V, M arin JM , M ont es de Oca M , Pint o-Plat a V, Aguir re-Jaim e A; Six M inut e Walk Dist ance Pro ject (ALAT). The 6-m i n w alk dist ance in healt hy subject s: reference st andards from seven countries. European respirat ory journal. 2011;37(1):150-156.
[15]. At li Teslim e, Kevan Kenan, Aslihan. Oxidat ive st ress and ant i-oxidant st at us in elderly diabet es m ellit us & gl u co se i n t o l e r an ce p at i e n t s. Ar ch i v e s o f ger ont ology and geriat rics. 2004;39(3):269-275. [16]. Paul L. Enr ight ,M ary Ann M cBurnie, Vera Bitt ner.
ATS Stat em ent : Guidelines for t he Six-M inut e Walk
Test. Am J Respir Crit Care Med. 2002;166(3):111-117.
[17] . Adeniyi A.F, Uloko A.E, Sani-Suleim an. Relat ionship Bet w een t he 6-m inut e Walk Test and Correlat es of Type 2 Diabet es: Indicat ion for caut ion in exercise
prescription. AJPARS. 2010;2(1):21-24.
