Evaluation of the Effectiveness of In-Hospital Exercise Rehabilitation in Middle-Aged and Elderly Patients with Type 2 Diabetes Mellitus Combined with Sarcopenia Effect of Lifestyle Management on Disease Status in Patients with Type 2 Diabetes Mellitus

ABSTRACT Objective The aim of this study was to explore the effects of in-hospital exercise rehabilitation on glucose and lipid metabolism and healthy physical fitness in middle-aged and elderly patients with type 2 diabetes mellitus (T2DM) combined with sarcopenia, and to provide a reference for the effective implementation of exercise rehabilitation for middle-aged and elderly patients with T2DM combined with sarcopenia in healthcare institutions. Methods This study retrospectively included 122 patients with T2DM combined with sarcopenia treated at the General Hospital of Ningxia Medical University from August 2017 to August 2020 and randomly divided into a control group and an experimental group. The control group was given conventional treatment and the experimental group was given exercise rehabilitation in the hospital for 12 weeks to compare the indexes related to glucose and lipid metabolism and healthy fitness in the two groups. Results After the intervention, the experimental group showed significant decreases in fasting blood glucose (FBG), glycated hemoglobin (HbA1c), insulin resistance index (HOMA-IR), triglycerides (TG), total cholesterol (TC), low-density cholesterol (LDL-C) and body fat percentage (p < 0.05), while high-density cholesterol (HDL-C), grip strength, lower limb extension, lower limb flexion, peak oxygen uptake were significantly higher (p < 0.05) and were more significant at 12 weeks compared to the 6-week intervention (p < 0.05). However, there were no significant changes in any of the glucose metabolism indicators in the control group before and after the intervention. A two-way repeated measures ANOVA showed that at control baseline levels, HbA1c decreased significantly in the experimental group after both 6 and 12 weeks of intervention compared to the control group (p < 0.05). After 6 weeks of intervention, the experimental group showed a significant decrease in body fat percentage and a significant increase in grip strength. After 12 weeks of intervention, the experimental group showed an increase in glycemic control from 33.3% to 73.3%, a significant decrease in body fat percentage and a significant increase in grip strength, lower limb extension and lower limb flexion strength and peak oxygen uptake. Conclusion In-hospital exercise rehabilitation can effectively improve the glycemic and lipid profiles of patients with T2DM combined with sarcopenia and enhance their health fitness, with good clinical rehabilitation effects.


Introduction
Obesity is associated with increased inflammatory burden, 1 and losing weight cause amelioration in the inflammatory level. 2 Besides, both type 2 diabetes mellitus (T2DM) 3 and sarcopenia 4 are characterized with high burden of inflammation.T2DM is a common chronic metabolic disease caused by defects in insulin secretion or action. 5Sarcopenia is a degenerative disease of the elderly that is mainly characterized by a decrease in muscle mass, muscle strength and muscle function in the skeletal muscles of the limbs, both of which increase in prevalence with age. 6Patients with T2DM combined with sarcopenia have a greatly increased risk of reduced muscle mass, decreased muscle strength, falls and fractures, and reduced mobility, which greatly affects the quality of life and prognosis of T2DM patients. 7hysical activity, diet and medication have long been considered the basis of T2DM treatment. 80][11] Current basic research on the mechanisms of exercise for the prevention and treatment of diabetes suggests that exercise can improve the body's glucose metabolism at three levels: first, at the overall level, exercise can increase fat metabolism and reduce excess fat accumulation, thereby reducing lipotoxicity in myocytes, pancreatic cells and hepatocytes, which in turn improves insulin resistance and insulin sensitivity and promotes normal glucose metabolism. 12Secondly, at the cellular level, exercise allows the glucose carrier 4 (Glut-4) on the membrane of the valued cells to transport more glucose into the myocyte for use. 13Third, at the intracellular signaling level, exercise induces increased expression of proteins related to the signaling pathway of Glut-4 translocation, resulting in increased translocation of Glut-4 to the cell membrane and increased uptake of glucose in the blood by myocytes. 146][17][18] Marcus et al. divided 15 T2DM patients into two groups, an aerobic training group 11 and an aerobic training combined with centrifugal resistance training group. 12Subjects trained three times per week, with an initial intensity of 60% maximal heart rate in the aerobic group, aiming for an intensity of 80% maximal heart rate and a duration of 50 minutes per exercise session.The combined exercise group did centrifugal training on a reclined centrifugal stager on top of aerobic exercise, increasing the training time from 5 to 20 minutes.After 16 weeks of exercise intervention, there were significant improvements in long-term glycemic control, thigh muscle proportions, and motor function in both groups.Subjects in the combined exercise group showed greater improvements in thigh muscle tissue and height body mass index. 18xercise therapy has been shown to improve insulin sensitivity, lower blood glucose concentrations and improve glycemic control in patients with T2DM combined with sarcopenia, [15][16][17][18] but the reality is that exercise is not well used in daily clinical practice in T2DM for a variety of reasons.This may be due to the lack of attention or implementation conditions for exercise rehabilitation by the endocrinology medical staff in charge of T2DM diagnosis and treatment, or because current clinical practice does not yet have a practical and effective mode of conducting business, and exercise is only used as part of self-management in the form of health education and health promotion; in addition, patients may lack the professional knowledge and skills related to exercise and are unable to well.Of course, this type of exercise based comprehensive diabetes rehabilitation model exists in general tertiary care hospitals, but there are not many reports of this type of detailed research.
In view of this, this study attempts to investigate the clinical effects of exercise rehabilitation for T2DM combined with sarcopenia in hospitals by conducting exercise rehabilitation for T2DM combined with sarcopenia in hospitals and observing the changes in the indexes of patients' blood glucose, blood lipids and health fitness.

Study Population
A total of 122 patients with T2DM combined with sarcopenia treated at the General Hospital of Ningxia Medical University from August 2017 to August 2020 were retrospectively included and randomly divided into a control group and an experimental group.The control group implemented conventional treatment and the experimental group underwent exercise rehabilitation in the hospital to compare the effects of different treatments on patients' disease status.All subjects attended the outpatient clinic of the endocrinology department of our hospital.
Inclusion criteria: All subjects came to the outpatient department of endocrinology of our hospital.① Meets diagnostic criteria for T2DM: According to the diagnostic criteria of DM proposed by WHO in 1999 with symptom 19 and random blood glucose ≥11.1 mmol/l (200 mg/dl), or FBG ≥7.0 mmol/L (126 mg/dl), or 2-hour plasma glucose ≥11.1 mmol/L (200 mg/dl) in oral glucose tolerance test.Those with atypical symptoms need to be confirmed again on another day.②Meets diagnostic criteria for sarcopenia: according to the diagnostic criteria in the Asian Consensus on the Diagnosis of Sarcopenia 2019, 20 with calf measurement as the initial screening, those need to meet both grip strength and gait speed criteria.122 patients with T2DM were randomly divided into intensive lifestyle intervention group and general intervention group.Exclusion criteria: ① Serious cardiovascular and cerebrovascular diseases, hyperlipidemia and chronic pulmonary diseases; ② Severe diabetic chronic complications such as severe diabetic retinopathy and severe diabetic nephropathy; ③ Malignant tumor; ④ Chronic liver disease and nephropathy; ⑤ Patients with critical diseases such as malignant tumor or serious infection; ⑥ Pregnant or lactating women; ⑦ Patients with incomplete follow-up records.

Interventions and Subgroups
Control group: Receive the routine treatment plan for health management of T2DM combined with sarcopenia formulated by the doctor in charge of health management (general practitioner), i.e. standardized and individualized guidance on diabetes medication, dietary guidance and exercise guidance in the form of verbal preaching and distribution of health education booklets, with no supervision of the exercise implementation process.
Experimental group: On top of the conventional treatment protocol, exercise rehabilitation will be carried out in hospital for 12 weeks and will receive a precise functional assessment prior to the exercise intervention, including history of underlying diseases and relevant supplementary tests (routine blood count, blood glucose, blood lipids, liver and kidney function, etc.), cardiopulmonary exercise test and health fitness assessment.

In-Hospital T2DM Combined with Sarcopenia Exercise Programme
The exercise programme in this study used a modular exercise programme of aerobic exercise combined with resistance training (Table 1).The exercise training started with a warm-up, followed by resistance training, a 5-minute rest after resistance training and a blood glucose monitoring (to determine whether there was hypoglycemia), followed by aerobic exercise, and finally relaxation training and stretching.All exercise rehabilitation is carried out in the Medical Sports Rehabilitation Centre in the Rehabilitation Department of the hospital under the supervision of a sports rehabilitation therapist on a one-to-one basis.
Aerobic training: Aerobic training using a power bike with the LABTECH [S25R] full-lead cardiac monitoring cardiorespiratory training system from the USA.The bike load corresponding to the exercise intensity was determined based on the results of the cardio exercise test, and a second test will be performed after 6 weeks of the experiment to adjust the exercise intensity based on the test results.The cardiorespiratory exercise test is performed using a pedal cycle test (Ramp protocol), 21 with reference indicators including maximum heart rate, maximum oxygen uptake, anaerobic valve, maximum load and load@AT.This protocol uses 60%-75% of maximum heart rate as the target heart rate and adjusts the exercise intensity load in conjunction with the patient's subjective physical sensations.
Resistance training: individualized programmes of resistance training are developed based on the results of muscle strength tests at baseline.Sports rehabilitation training is not only about increasing and improving muscle mass, but also about promoting the coordination and balance of the overall muscle group.The resistance training programme is based on the principles of overload recovery and the rule of thirds.
Post-training stretching and relaxation: After all training sessions, stretching and relaxation of the major muscle groups was performed, including mainly the latissimus dorsi, pectoralis major and quadriceps.Each muscle group was stretched twice for 40s each time, with the intensity of the stretches as tolerated by the participant.Relaxation was performed with a fascial gun for 10 min/relaxation.

Evaluation Indicators
This trial tested subjects before the intervention, at 6 weeks of the intervention and 12 weeks after the intervention.The identity, grouping and intervention status of the subjects were not known to the test and testers.
Indicators of glucose metabolism: tested by the hospital laboratory department.A fully automated biochemical analyzer (Beckman Coulter AU5800) was used to measure fasting blood glucose (FBG), glycated hemoglobin (HbA1c) and serum insulin in the subjects.
Lipid metabolism indicators: tested by the hospital's Laboratory Department, using a Beckman Coulter AU5800 fully automated biochemistry analyzer, for four lipid tests, namely triglycerides (TG), total cholesterol (TC), low density cholesterol (LDL-C) and high density cholesterol (HDL-C).
Health fitness index: cardiorespiratory fitness index, tested by the Hospital Cardiopulmonary Rehabilitation Centre, using a multifunctional exercise cardiorespiratory testing system of the Italian COSMED model.Subjects sit on a power bike for a 2 min warm-up of unloaded pedaling, then the load is increased in 15 W/min increments, keeping the speed at 50 r/min and stopping the test when the patient develops symptoms of exhaustion, panic and chest tightness.The main index used for evaluation in this test was: maximum oxygen uptake (VO2Max).Body fat percentage and muscular strength of some muscle groups: The tests were conducted by the rehabilitation medicine department of the hospital, and the subjects' body mass index and body fat percentage were tested using the Korean Bystronic Inbody body composition analyzer; the BTE Primus RS simulation test and evaluation training system produced by the American company BTE was used to evaluate the maximum muscular strength and muscular endurance of some muscle groups.
Maximum strength test method: ① The isokinetic assessment module of the BTE simulation test evaluation training system is used to test the strength of the two groups of active/antagonist muscles of the lower limb in turn, and the subjects are familiarized with the test equipment through warm-up exercises before the test.Each test is performed three times and the maximum force data will be recorded and averaged by the system; force consistency is expressed quantitatively by calculating the coefficient of variation (CV) score through the software that comes with the system.For the grip strength test, the patient is asked to stand in a standing position, feet naturally open, hands naturally down, not close to the body, and hold the grip strength meter in one hand with the left (right) hand.Repeat 3 times and take the maximum value.

Quality Control
Randomized grouping and blinded design: This study was a randomized controlled trial in which 122 subjects were coded prior to the trial and a person from outside the study was asked to randomly divide the subjects into control and experimental groups of 61 each according to the random number table method.Given the nature of the intervention, the subjects and the exercise rehabilitation therapist were not blinded, but the test assessor was unaware of the grouping.All tests in this study, particularly the primary blood glucose indicator, will be performed by someone other than the independent program participants and will be mixed in with the normal variety of tests performed in the hospital to avoid subjective influence of the test assessors.
Implementation process control: Subject compliance and attrition rates are key to the quality of clinical research, so the subjective perceptions and feedback on the effects of exercise rehabilitation given to the subjects during the intervention should be positive.The exercise intervention protocol was developed by the rehabilitation team and implemented by the exercise rehabilitation therapists on a one-to-one basis.The therapists' exercise rehabilitation training and related tests were carried out in strict compliance with the relevant operational standards to reduce variability and strictly control the experimental variables.During the trial, the staff conduct daily shift debriefings to record in detail the subjects' exercise rehabilitation and special conditions; weekly trial summary debriefings are conducted to analyze shortcomings, organize study of relevant theories and summarize experiences.

Research Ethics
The study was conducted in strict accordance with the relevant scientific and clinical requirements and all subjects participated voluntarily and were free to withdraw from the study at any time.There are minimal safety risks associated with any of the tests in this study.Medical supervision was provided by a physician at all times during the study.All data were treated confidentially and kept under seal.All subjects were required to sign an informed consent form and informed in detail of the possible risks involved in the study.Signed informed consent forms were kept on file.The implementation of the subject was reviewed by the ethical review committee of the hospital where it was conducted.

Statistical Analysis
Data were analyzed using IBM SPSS23.0software; measures were expressed as mean ± standard deviation; independent samples t-test was used for comparison between different groups at baseline; the study variables were analyzed for normality using the Shapiro-Wilk test; paired samples t-test was used to analyze changes within groups before and after the intervention; two-factor repeated measures ANOVA was used to compare changes between groups before and after the intervention; chi-square test was used to compare control rates of each indicator before and after the intervention.

Subjects in General
In the experimental group, there were 34 males and 27 females; in the control group, there were 33 males and 28 females (Table 2).There was no significant difference between the two groups in terms of gender, age and duration of disease (p > 0.05).

Changes in Glucose Metabolism Indicators Before and After the Intervention
Independent sample t-tests comparing baseline fasting glucose, fasting insulin, HbA1c and HOMA-IR between the experimental and control groups showed no significant differences (p > 0.05) in all indicators between the two groups.Within-group comparisons by pairedsamples t-test for pre-and post-intervention showed that after 6 weeks of intervention, there was a significant decrease in FBG (p = 0.005), HbA1c (p = 0.003) and HOMA-IR (p = 0.008) in the experimental group; after 12 weeks, FBG (p = 0.002), fasting insulin (p = 0.007), HbA1c (p = 0.000) and HOMA-IR (p = 0.002) all showed significant decreases, and FBG (p = 0.004), HbA1c (p = 0.00) and HOMA-IR (p = 0.07) all showed further decreases compared to 6 weeks.No significant changes in all glucose metabolism indicators were observed in the control group before and after the intervention (Table 3).A two-factor repeated measures ANOVA comparing the differences between the two groups before and after the intervention showed that at control baseline levels, HbA1c decreased significantly in the experimental group after both 6 and 12 weeks of intervention compared to the control group (p = 0.017, 0.001).
According to the Chinese Guidelines for the Prevention and Treatment of Type 2 Diabetes (2020 Edition), the target of HbA1c control for T2DM patients in China is < 7.0%.In this study, at baseline, the HbA1c control rates of T2DM patients in the experimental and control groups were 27.9% and 45.9%, respectively, and the difference in HbA1c control rates between the two groups was not statistically significant (p = 0.428) (Table 4); while after 12 weeks, the HbA1c control rate in the experimental group was 73.8%, an increase of 45.9% compared to baseline, and the HbA1c control rate in the control group was 41.0%, a 4.9% decrease compared to baseline, and the chi-square test showed that the HbA1c control rate tended to differ between the two groups after the intervention (p = 0.064).

Changes in Lipid Metabolism Indicators Before and After the Intervention
Independent sample t-tests showed no significant differences in baseline levels of triglycerides (TG), total cholesterol (TC), LDL-C and HDL-C between the experimental and control groups.Within-group comparisons before and after the intervention by paired samples t-test showed that TG (p = 0.018), TC (p = 0.003) and LDL-C (p = 0.038) were significantly  lower in the experimental group after 6 weeks of intervention; after 12 weeks, TG (p = 0.003), TC (p = 0.004) and LDL-C (p = 0.003) were significantly lower and HDL-C (p = 0.001) was significantly higher, and compared to 6 weeks, TG (p = 0.004) and LDL-C (p = 0.007) decreased further and HDL-C (p = 0.018) increased further.For the control group, LDL-C (p = 0.012, 0.026) was significantly reduced and HDL-C (p = 0.000, 0.000) was significantly increased after both 6 and 12 weeks.There was no significant change in any other index in the control group before and after the intervention (Table 5).A two-factor repeated measures ANOVA comparing the differences between the two groups before and after the intervention showed no significant differences in the changes in any of the metabolic indicators between the two groups.
According to the Chinese Guidelines for the Prevention and Treatment of Type 2 Diabetes Mellitus (2020 Edition), 22 the control targets for lipids in patients with T2DM in China are TG <1.7 mmol/L, TC <4.5 mmol/L, LDL-C <2.6 mmol/L and HDL-C >1.0 mmol/L (male) or 1.3 mmol/L (female).In this study, before the experiment, the control rates of TG were 32.8% and 68.9%, TC were 32.8% and 52.5%, LDL-C were 45.9% and 47.5%, and HDL-C were 60.7% and 77.5% in the experimental and control groups respectively, and the control rate of TG was significantly higher in the control group than in the experimental group (p = 0.046).After 12 weeks, the control rate of TG and TC in the experimental group remained unchanged at 32.8%, the control rate of LDL-C increased by 21.3% to 67.2%, and the control rate of HDL-C increased by 26.2% to 86.9%; the control rate of TG and TC in the control group decreased slightly, and the control rate of LDL-C and HDL-C increased slightly (Table 6).12 After 12 weeks, there was no significant difference in lipid control rates between the two groups (p > 0.05).

Changes in Health Fitness Before and After the Intervention
As seen in Figure 1, there was no significant difference in baseline BMI (Figure 1a) and body fat percentage (Figure 1b) between the experimental and control groups.After 6 weeks of exercise intervention, the body fat percentage (Figure 1b) in the experimental group decreased significantly from 34.8% to 32.0% (p = 0.000) and was significantly different compared to the control group (p = 0.000); after 12 weeks of exercise training, the body fat percentage (Figure 1b) in the experimental group decreased further to 31.0%(p = 0.000), again a significant difference compared to the control group (p = 0.000).Regarding BMI (Figure 1a), the experimental group decreased significantly from 29.3 to 28.1 (p = 0.003) after 12 weeks of exercise training, but not significantly different compared to the control group.
After 6 weeks of exercise training, grip strength, lower limb extension and lower limb flexion in the experimental group increased significantly by 2.1 kg, 3.6 kg and 1.5 kg respectively (p = 0.000, 0.017, 0.000); after 12 weeks of exercise training, grip strength, lower limb extension and lower limb flexion in the experimental group increased significantly by 2.3 kg, 3.4 kg and 2.7 kg respectively (p = 0.000).After 6 weeks of training, only lower limb extension (p = 0.022) and  lower limb flexion (p = 0.018) increased slightly in the control group; after 12 weeks of training, grip strength and lower limb extension increased slightly in the control group.Compared to the control group, the experimental group showed a significant increase in grip strength at both 6 and 12 weeks (p = 0.001, 0.001), and a significant increase in lower limb extension and lower limb flexion at 12 weeks (p = 0.027, 0.001).As shown in Figure 2. As seen in Figure 3, there was no significant difference in maximum oxygen uptake between the experimental and control groups.After 12 weeks of intervention, only the peak oxygen uptake level in the experimental group was significantly higher than at 6 weeks.In all other cases, there was no significant change in peak oxygen uptake in either the experimental or control groups.

Discussion
Exercise can improve the body's metabolic status, increase muscle uptake and utilization of glucose in the blood and improve systemic insulin sensitivity, thus helping the body to achieve better blood glucose homeostasis. 23In this study, 6 or 12 weeks of in-hospital exercise rehabilitation significantly reduced FBG, glycated hemoglobin and insulin resistance levels in patients with T2DM combined with sarcopenia.This was similar to the results of the majority of previous exercise intervention studies.The study concluded that long-term exercise significantly improves the body's oxidative stress levels and increases autonomic nervous system stability, thereby improving blood glucose levels. 13In addition, exercise increases the body's energy expenditure, resulting in a decrease in liver glycogen and muscle glycogen, while glucose is reconverted to glycogen for storage in the liver and muscle after exercise, and glycogen and muscle glycogen are reduced, while glucose is reconverted to glycogen for storage in the liver and muscle after exercise, thus lowering blood glucose.Exercise improves muscle capillary levels and increases muscle blood volume, which in turn increases muscle insulin and blood glucose levels and enhances insulin sensitivity.Long-term exercise increases muscle glycogen levels, thereby allowing more glucose to be converted to glycogen and stored in muscle, thereby lowering blood glucose. 14The results of this study also showed that exercise intervention improved insulin resistance in patients with T2DM combined with sarcopenia.For patients with T2DM combined with sarcopenia, long-term glycemic control is of even greater importance, as HbA1c is a key clinical indicator of glycemic control as it reflects the body's overall glycemic status over a three-month period.This study found that in-hospital exercise rehabilitation helped to significantly reduce HbA1c levels in patients with T2DM combined with sarcopenia, and the effect increased with time (from 6 weeks to 12 weeks).HbA1c is formed by the non-enzymatic attachment of glucose to valine at the N-terminal end of the b chain of hemoglobin. 24Since the life span of red blood cells is about 120 days, this indicator represents the average glucose concentration during the previous 8 to 12 weeks and is an important indicator for monitoring the level of glycemic control, which can represent the average change in glycemic control over time. 25HbA1c is associated with a variety of diabetes-related complications, and lowering the HbA1c value significantly reduces the rate of progression of microvascular complications. 26The HbA1c value has been shown to be associated with a number of diabetes-related complications. 27Several studies have shown that aerobic combined with resistance exercise is effective in lowering HbA1c levels and is more therapeutically effective than either aerobic exercise alone or resistance exercise alone. 28,29Sigal et al. demonstrated that combined exercise significantly lowered glycated hemoglobin in 251 adults with type 2 diabetes mellitus aged between 39 and 70 years over a 22-week period (0.9%).0.9%). 30This difference may be due to the longer duration of exercise in the combined exercise programme relative to aerobic or resistance exercise alone (210 min/week to 270 min/week).This suggests that exercise intervention in a professional rehabilitation facility can achieve long-term glycemic control in patients with T2DM combined with sarcopenia, with a cumulative effect over time.
Patients with T2DM combined with sarcopenia usually have varying degrees of dyslipidemia, including elevated levels of triglycerides and LDL-C, and decreased levels of HDL-C.Abnormal lipid metabolism is an important risk factor for cardiovascular disease, which will further increase the risk of cardiovascular disease in patients with T2DM combined with sarcopenia.For this reason, the Chinese Medical Association's Diabetes Division has included lipid status in the index system of comprehensive control goals for T2DM combined with sarcopenia as well. 31Numerous studies have shown that exercise can improve dyslipidemia, lower blood triglyceride, total cholesterol and LDL-C, and increase HDL-C levels. 12,32,33In this study, after 12 weeks of in-hospital exercise rehabilitation, the lipid profile of patients with T2DM combined with sarcopenia improved significantly, with significant decreases in triglyceride, total cholesterol, and LDL concentrations, and significant increases in HDL concentrations.However, as the control group also showed significant changes in LDL and HDL levels before and after the intervention, resulting in no significant difference in the changes between the experimental and control groups.Considering the effect of diet on blood lipid levels, it is possible that this result was due to dietary changes.This is because both the experimental and control groups in this study received regular treatment for diabetes, which included dietary instruction and health promotion.As the patients' diet was not monitored in this study, it was not possible to analyze the possible effect of diet.However, in terms of lipid control attainment, the experimental group showed a significant increase in lipid attainment before and after the intervention, with both LDL and HDL control rates increasing by more than 20%, while the control group showed a decrease in attainment of some lipid markers.This means that inhospital exercise rehabilitation can help patients with T2DM combined with sarcopenia to achieve better lipid control goals, reduce the risk of cardiovascular disease and achieve comprehensive control goals for T2DM combined with sarcopenia.
The main mechanisms by which exercise improves lipid metabolism are 5 : exercise increases the activity of lecithin cholesterol acyltransferase (LCAT), which facilitates the reverse cholesterol transport and promotes the gradual conversion of free cholesterol into cholesteryl esters, reducing the total cholesterol content in blood 6,12 ; exercise causes increased secretion of adrenaline and norepinephrine, increases lipoproteinase (LPL) activity, and accelerates the hydrolysis of triglyceridecontaining celiac particles and very low-density lipoproteins 7,32 ; exercise improves the body's utilization of free fatty acids, promotes the conversion of triglycerides to free fatty acids, reduces plasma total cholesterol and triglyceride levels, and aerobic exercise can increase the level of HDL-C in the blood while the concentration of LDL-C decreases, resulting in an increase in the HDL-C/LDL-C ratio up, thus increasing the reversephase transport capacity of total cholesterol, contributing to the transport and degradation of total peripheral cholesterol to the liver and promoting an increase in the level of lipid free fatty acids involved in the body's energy supply. 33uscle strength is fundamental to the body's ability to maintain normal physiological and life functions and is important for daily living and work. 34Decreased muscle strength in patients with T2DM combined with sarcopenia affects their ability to perform activities of daily living, increases the risk of developing chronic metabolic diseases, thus affecting the quality of life of diabetic patients and ultimately increasing the risk of premature death. 35Therefore, enhancing muscle strength in patients with T2DM combined with sarcopenia is of great importance for patients' daily life and quality of life.Grip strength is the most commonly used strength indicator in practice and can be used to some extent to evaluate the overall muscle strength of an individual and can be a useful predictor of falls, level of function, quality of life status, length of hospital stay and mortality. 36,37he present study showed that 6 weeks of in-hospital exercise rehabilitation significantly improved grip strength in patients with T2DM combined with sarcopenia, and that grip strength increased further as the duration of training increased from 6 to 12 weeks.Insufficient muscle strength in the lower limbs is an important cause of falls, especially for middle-aged and elderly people, and is a major cause of limitation of physical activity, an important risk factor for physical disability and affects quality of life. 38The study found that older patients with T2DM combined with sarcopenia had a faster rate of decline in thigh muscle content, strength and function compared to healthy older adults, and over a 3-year period, older patients with T2DM combined with sarcopenia had lower thigh muscle strength than those with normal blood glucose. 39The results of this study show that in-hospital exercise rehabilitation in patients with T2DM combined with sarcopenia can also significantly improve their lower limb muscle strength.Therefore, inhospital exercise intervention can effectively improve the muscle strength level of patients with T2DM combined with sarcopenia, which can reduce the risk of falls in patients with T2DM combined with sarcopenia and is of great value in improving the quality of life of patients with T2DM combined with sarcopenia.
In conclusion, in-hospital rehabilitation training can effectively improve the glycemic and lipid profiles of patients with T2DM combined with sarcopenia, increase the overall control rate of T2DM combined with sarcopenia, greatly enhance the health fitness of patients with T2DM combined with sarcopenia, and demonstrate good clinical practice results in T2DM combined with sarcopenia.

Figure 1 .Figure 2 .
Figure 1.Change in body composition before and after the intervention.A, change in BMI before and after the intervention; B, change in body fat percentage before and after the intervention.Within-group comparisons by paired samples t-test, 6 weeks compared to baseline, p-value less than 0.01, flagged with 2 stars (**); 12 weeks compared to 6 weeks, p-value less than 0.01, flagged with 2 ( ## ); 12 weeks compared to baseline, p-value less than 0.01, flagged with 2 ( && ).Between-group comparisons by two-factor repeated measures ANOVA, controlling for baseline levels, 6 weeks compared between groups, p-value less than 0.01, flagged with 2 ( ✝✝ ); and p-value less than 0.01, flagged with 2 ( aa ) when compared between groups at 12 weeks.

Figure 3 .
Figure 3. Changes in cardiopulmonary function before and after the intervention.Intra-group comparison by paired samples t-test, p-value less than 0.01, flagged with 2 ( ## ) for 12 weeks compared to 6 weeks.

Table 1 .
In-hospital T2DM combined with sarcopenia exercise programme.

Table 2 .
General conditions of patients in both groups.

Table 3 .
Changes in glucose metabolism-related indexes before and after the experiment.

Table 4 .
Glycemic control achieved in both groups.

Table 6 .
Attainment of lipid control in both groups.