Preserved Diabetic and Renal Function by Daily Swimming Habit For 35 Years

Bando H, Hayashi K, Yamada K and Kakou C

Published on: 2023-05-29

Abstract

Current case is 88-year-old male patient with type 2 diabetes (T2D) for more than 35 years. He was the principal of elementary school and continued regular swimming 2000m/day every day. His HbA1c kept stable as 5.5-6.1%, and serum creatinine maintained 1.9-2.2 mg/dL with chronic kidney disease (CKD) in 2019-2024. Pulse wave velocity (PWV) showed ankle brachial index?ABI?1.20/1.17 and baPWV 1624/1742 cm/s, and echography of carotid artery showed Vmax 79.6/77.0 cm/s and Intima Media Thickness (IMT) 1.0/1.3 mm (right/left), respectively. His stable clinical status may be due to continued regular swimming exercise habit for long years.

Keywords

Pulse wave velocity (PWV); Ankle brachial index?ABI); Swimming; Intima media thickness (IMT); Type 2 diabetes (T2D); Chronic kidney disease (CKD)

Introduction

Clinical problem of type 2 diabetes (T2D) has been crucial across the world [1]. As the diabetic complication, macroangiopathy and microangiopathy have been important, and American Diabetes Association (ADA) has announced the latest guideline in Jan 2024 as the standard management [2]. The fundamental principle of the treatment would be regular life style [3]. For the elderly T2D patients, chronic kidney disease (CKD) or diabetic kidney disease (DKD) has been the clinical matter to be followed up for long [4]. In order to prevent the exacerbation of diabetic comorbidities, adequate nutritional therapy of calorie restriction (CR) or low carbohydrate diet (LCD) would be required. LCD has been initiated by Doctors of Atkins and Bernstein using their textbooks for medical and health care region [5,6]. Successively, authors and collaborators have started LCD in Japan through the activity of Japan LCD Promotion Association (JLCDPA) [7]. Our LCD group has recommended useful three pattens, that are petite LCD, standard LCD and super LCD with carbo amount ratio of 40%, 26% and 12%, respectively [8].

For diet therapy for T2D patients, light degree of walking around for about 30 minutes has been known for adequate strength and duration [9]. This exercise would be categorized as aerobic training (AT) exercise habit, which seemed to be suitable for everyone [10]. On the other hand, several recent reports have indicated that resistance training (RT) is considered as valid practice method to some degree also for elderly people [11]. In the case of elderly patients with continuing oral hypoglycemic agents (OHAs), RT is likely to give medical effect for better glycemic variability [12]. Consequently, both AT and RT would contribute beneficial clinical effects for T2D patients. Latest report showed cardiovascular benefit by the large study of the Cardiovascular Benefits of Resistance, Aerobic, and Combined Exercise (CardioRACE) trial [13].

Authors and collaborators have for long practiced clinical diabetology with several medical reports so far [14-16]. Among our practice, we have followed an elderly male patient with T2D, who has continued regular swimming exercise every day for 35 years. His general clinical progress and related perspectives are described in this article.

Presentation of Cases

Medical History

The patient is an 88-year-old male with T2D. His profession was school teacher, and he was the principal of the elementary school of Tokushima in 50s. When he received health check-up at 52 years old, he was pointed out to have hyperglycemia. He was introduced to the diabetes and endocrinology department of Tokushima University hospital. Then, the doctor in charge of the patient was the author Bando as one of the staff at that time. By further evaluation and treatment, he was diagnosed as type 2 diabetes (T2D) as elevated HbA1c values as 9%.

In the light of his background for T2D onset, he seemed to have various difficult matters in his school causing much stressful situation. He understood well about the principle of the three fundamental diabetic therapy, including diet, exercise and medicine. Consequently, we provided him sulfonyl urea (SU) as oral hypoglycemic agent (OHA), and advised him to keep diet and exercise treatments.

Concerning exercise method, he started swimming every day, just after the initiation of the diabetic treatment. After his regular working at 17:00, he has continued to swim in the fitness club about 2000m every day. Surprisingly, he continued the lifestyle with swimming every day from 52 years old to 88 years old until now. He has visited our out-clinic once a month, where the author has managed his continuous medical care for long years.

Physicals And Other Exams

His physicals revealed unremarkable changes for long as follows: speech, conversation, consciousness are normal. His vitals showed normal ranges of BP, pulse, temperature, and SpO₂. No abnormal findings are observed in the lung, heart, abdomen, extremities or neurological response. He has not complained of certain symptoms or signs. His physique showed 171.0 cm in height and 70.1 kg in weight with BMI 24.0 kg/m².

His HbA1c values have been almost stable around 5.5% to 6.4% during 52-88 years. The results of blood chemistry for liver function, lipids, renal function, complete blood count (CBC) had been normal from 52 years to 80 years. After 81 years old, his renal function became gradually impaired as elevated serum creatinine (Table 1). The creatinine level has been almost stable as 2.18- 2.24 mg/dL from 2021 to 2024.

Table 1: Changes in laboratory data.

		2017		2018	2019	2020	2021	2022	2023		2024	Units
		Apr	Oct	Mar	Mar	Feb	Feb	Jan	Jan	Jul	Jan	Units
Renal	UA	4.1	4.4	5.1	4.2	3.9	6.3	4.7	7.2	7.0	4.6	(mg/dL)
	BUN	22	21	25	33	32	32	38	34	34	38	(mg/dL)
	Cre	1.30	1.45	1.61	2.03	1.97	2.18	2.23	2.13	2.24	2.22	(mg/dL)
Electrolyte	K	4.4	4.5	4.7	5.1	5.0	5.2	5.1	4.7	4.6	4.8	(mEq/L)
CBC	Hb	11.8	11.2	10.0	10.8	11.4	10.5	10.7	12.5	11.1	12.5	(g/dL)
Diabetes	HbA1c	5.7	5.9	6.1	6.0	5.5	5.9	5.6	5.6	5.8	5.7	(%)
Patient age	years old	81		82	83	84	85	86	87		88	(years)

Chest X-ray revealed negative findings. Electrocardiogram (ECG) presented pulse 52/min, ordinary sinus rhythm (OSR) and no specific ST-T changes. He has received the exam of pulse wave velocity (PWV). As a result, ankle brachial index?ABI?was 1.20/1.17 (right/left), and baPWV was 1624/1742 cm/s (R/L), respectively, which showed stable and slightly better results than average for his current age (Figure 1).

Figure 1: The result of Pulse Wave Velocity.

The echography of carotid artery showed negative examination as follows: Vmax 79.6/77.0 cm/s, Vmin 14.7/11.9 cm/s, Vmean 14.9/15.3 cm/s, as right/left, respectively. Intima Media Thickness (IMT) showed 1.0/1.3 mm (right/left), respectively. Figure 2 showed the normal range of IMT in right carotid artery associated with normal situation of blood stream of carotid artery.

Figure 2: Echography of the carotid artery.

Clinical Progress

He has been treated by the same doctor as the current author Bando for more than 35 years. The diagnoses and related medicines so far can be summarized.

#1 T2D: Dapagliflozin propylene glycolate hydrate (Forxiga 5mg) and alogliptin benzoate (Nesina)12.5-25mg/day.

#2 CKD: Carbonaceous oral Adsorbent as AST120 (Kremezin Tab 500mg) 3.0-6.0g/day, which was studied for Carbonaceous oral Adsorbent’s effectiveness on Progression of Chronic Kidney Disease (CAP-KD).

#3 Hypertension: Nifedipine 20mg/day.

#4 Hyperuricemia: Febuxostat?20 mg/day and potassium citrate/sodium citrate hydrate (Uralyt Combination Tablets) 3-6 g/day.

#5 Gastro esophageal reflux disease (GERD): Lansoprazole (Takepron?15mg/day.

#6 arteriosclerosis: Aspirin (Bayaspirin)100mg/day.

Several medicines mentioned above have been provided the patient.

Ethical Standards

Current article of this case was complied with the ethical guideline of Declaration of Helsinki [17]. Moreover, some commentary was found with the protective regulation for individual information. This principle has been associated with the ethic regulation for clinical practice for human being. Some guidelines have been from Japanese Ministry, as the Ministry of Health, Labor and Welfare (MHLW) and Ministry of Education, Culture, Sports, Science Technology (MEXT). Authors and co-researchers had set up ethic committee for this patient, existing in Hayashi hospital, Tokushima, Japan. It has clinical and legal persons, such as hospital director, doctors, nurse dietician, pharmacist and legal professional. The related members discussed fully this case and agreed the research protocol. We have taken the informed consent by the written style from the case.

Discussion

This case is an 88-year-old male patient with chronic kidney disease (CKD) with slight degree for recent years. Creatinine level increased from 2017-2019, and it keeps 1.9-2.2 mg/dL in 2019-2024 with his age 83-88. His HbA1c has been maintained as 5.5-6.1% for long associated with his regular exercise for more than 35 years. Pulse wave velocity (PWV) exam showed the arteriosclerosis lower than average degree and almost satisfactory data compared with those of 88 years old. The stable situation would be from consistent daily habit of swimming about 2000m/day, which would be aerobic training (AT) and resistant training (RT) to some extent. Concerning the relationship of T2D and exercise, systematic review and meta-analysis of RCT was found [18]. Totally, 21,559 papers were investigated, and average exercise was 45.2 min session, and average follow was 21.9 weeks. Exercise frequency was 3.3 days a week, and intervention has brought significant decrease of HbA1c, fasting blood glucose, BMI and waist circumference.

For decades, swimming has become the recommended physical activities, which is non-pharmacological adequate approach for hypertension, obesity, dyslipidemia and T2D. The protocol included cases of HTN and T2D (n=40, 52.4 years), and they continued swimming for 2 hours three times/week, for 16 weeks [19]. These results showed satisfactory, where significant differences of improvement were found in LDL, HDL, TG, systolic BP, diastolic BP, blood glucose, BMI and body fat ratio. It may indicate effective non-pharmacological approaches for metabolic syndrome. Comparative study was conducted for T2D by three groups by AT and RT method (n=57, 46.2 years in average). Both showed clinical effect of AT or RT, and RT showed more beneficial results than that of AT [20].

Comparative study was performed for 2 groups of aquatic exercise for 10 years and keeping sedentary [21]. The applicants were CKD cases, and the low-intensity of aerobic exercise was conducted regular twice per week. In the former group, no one was reached to endpoint, but the latter group 55% reached renal replacement therapy or all-cause death. The difference was significant as p=0.037. Thus, regularly supervision of aquatic exercise could be refrained from CKD progression. For evaluating the efficacy of aerobic exercise on renal function in CKD patients, meta-analysis study was conducted [22]. Among them 12 randomized controlled trials (RCTs) for CKD were analyzed. As a result, regular aerobic exercise has improved significantly eGFR for 0.65, serum Cre for -0.63, 24-urine protein volume for -0.41, BUN for -0.66. Single exercise for >30 minutes showed significant improvement of eGFR in CKD cases, and running/walking showed significant improvement of Cre values.

Genetic studies in rats regarding swimming and kidney function have been reported. As the experimental study, moderate swimming exercise was given to aged rats and some exams were performed in the light of mRNA expression, biochemistry and renal fibrosis situation [23]. As a result, swimming protocol provided elevated expression of PPAR-α-targeting microRNAs. It would suggest the beneficial effect of swimming loading for aged kidneys. Concerning clinical effect of regular swimming, 3 groups were provided exercise six days a week, including i) exercising of spontaneously hypertensive rats (SHRs), ii) sedentary SHRs, iii) sedentary normotensive Wistar-Kyoto rats (WKY) [24]. As a result, swimming for 8 weeks in group i) brought reduction of weight, BP, BUN and creatinine in comparison with group ii). In addition, expression of TGF-beta 1, Bax and Smad2/3 in ii) showed higher than iii), in which they were remarkably suppressed by the exercise. By the continuous swimming, hypertension-reduced expression of Bcl-2 and Smad7 showed enhancement. The key protein expressions revealed relationships with renal function and lipid profiles. Previous publications reported that swimming could modify miRNA expression profiles in the brain and heart. For experiment protocol, differential miRNA expression in rat kidney was investigated after continuous swimming exercise twice per day for six weeks [25]. As a result, continuous swimming exercise brought modulation of renal miRNAs of rats. These studies were conducted by using Gene Ontology (GO) terminologies and also Kyoto Encyclopedia of Genes and Genomes (KEGG) pathways. From mentioned above, swimming-responsive miRNAs suppose the interaction with various targe genes for regulating renal functions.

Some limitation may exist in this report. Several factors of social, clinical and daily habit have been involved. Consequently, HbA1c, renal function, arteriosclerosis and other symptom/sign will be followed up with close attention.

In summary, current case was 88-year-old T2D and CKD male patient who continued swimming 2000m for more than 35 years. The author has managed his treatment for long with satisfactory clinical progress. It is expected that this report becomes useful reference for T2D, CKD, and gerontology in the future.

Conflict of interest: The authors declare no conflict of interest.

Funding: There was no funding received for this paper.

International Journal of Case Reports and Clinical Images