Next Article in Journal
Implementing E-Cigarettes as an Alternate Smoking Cessation Tool during Pregnancy: A Process Evaluation at Two UK Sites
Previous Article in Journal
Community Pharmacy Needle Exchange Programme: What Can Analysis of the Data Tell Us about the Changing Drug Market in Ireland?
 
 
Search for Articles:
Title / Keyword
Author / Affiliation / Email
Journal
Article Type
 
 
Advanced Search
 
Section
Special Issue
Volume
Issue
Number
Page
 
Journals
IJERPH
Volume 21
Issue 3
10.3390/ijerph21030290
ijerph-logo
Submit to this Journal Review for this Journal Propose a Special Issue
► Article Menu

Article Menu

share Share announcement Help format_quote Cite question_answer Discuss in SciProfiles thumb_up
...
Endorse textsms
...
Comment
first_page
settings
Order Article Reprints
Font Type:
Arial Georgia Verdana
Font Size:
Aa Aa Aa
Line Spacing:
Column Width:
Background:
Systematic Review

The Effect of Community-Based Exercise on Health Outcomes for Indigenous Peoples with Type 2 Diabetes: A Systematic Review

by
Lauren Hurst
1,2,
Morwenna Kirwan
1,
Vita Christie
2,3,*,
Cara Cross
3,
Sam Baylis
1,
Liam White
1 and
Kylie Gwynne
2
1
Department of Health Sciences, Macquarie University, Talavera Road, Sidney, NSW 2109, Australia
2
Djurali Centre for Aboriginal and Torres Strait Islander Health Research, Heart Research Institute, Eliza Street, Newtown, NSW 2042, Australia
3
DVC Indigenous Office, University of New South Wales, High Street, Sidney, NSW 2052, Australia
*
Author to whom correspondence should be addressed.
Int. J. Environ. Res. Public Health 2024, 21(3), 290; https://0-doi-org.brum.beds.ac.uk/10.3390/ijerph21030290
Submission received: 13 December 2023 / Revised: 13 February 2024 / Accepted: 17 February 2024 / Published: 1 March 2024
Browse Figure
Review Reports Versions Notes

Abstract

:
Indigenous peoples globally experience a high burden of type 2 diabetes in comparison to non-Indigenous peoples. While community-based exercise interventions designed for type 2 diabetes (T2D) management have garnered success in non-Indigenous populations, they likely require adjustments to meet the needs of Indigenous people. This systematic review aims to determine if health outcomes in Indigenous peoples with T2D could be improved by community-based exercise programmes and the features of those programmes that best meet their needs. The CINAHL, Embase, Informit Indigenous Collection, Medline, PubMed, Scopus, SportDiscus, and Web of Science databases have been searched to identify peer-reviewed literature with original outcome data that report on the health effects of community-based exercise interventions for the management of T2D among Indigenous peoples. The Mixed Methods Appraisal Tool and Indigenous Community Engagement Tool were implemented to assess methodological quality. Three moderate-to-high-quality studies were selected for review, including participants of Polynesian or Native American Zuni Indian descent. Results indicated positive effects of group exercise on glycated haemoglobin (HbA1c), body mass index, body weight, total cholesterol, blood pressure, quality of life, and patient activation levels in high-adhering participants. This review concludes that community-based exercise interventions may improve health outcomes for Indigenous adults with T2D when conducted with strong community engagement.

1. Introduction

On a global scale, Indigenous peoples experience a high burden of chronic disease and health outcome inequalities [1,2,3]. These inequalities arise from the socioeconomic disadvantage that originated with colonisation and are perpetuated by the ongoing discrimination and marginalisation faced by Indigenous peoples [1,4,5,6]. The impact of colonisation on Indigenous communities is so substantial that it is recognised by the World Health Organisation as the most significant social determinant of health for Indigenous peoples worldwide [6,7]. This includes, but is not limited to, Aboriginal and Torres Strait Islander peoples in Australia; Māori and Pacific peoples in New Zealand and the Pacific Islands; American Indian and Alaskan Native peoples in the United States of America; and First Nations, Inuit, and Métis peoples in Canada [6,8,9,10,11,12]. For these populations, the introduction of the Western diet, tobacco, and a sedentary lifestyle has increased their risk of developing lifestyle-related chronic diseases such as type 2 diabetes (T2D) [7,13,14]. Despite this, Indigenous peoples continue to overcome adversity and maintain connections to community, culture, land, and ancestry [15,16,17].
Diabetes is the fastest-growing chronic disease worldwide, with one in every eleven adults currently having the condition [2,18]. This number is disproportionately higher for Indigenous peoples. For example, in New Zealand, Polynesian peoples are three times more likely than non-Indigenous peoples to have diabetes [19]. In 2019, diabetes was the direct cause of 1.5 million deaths and the indirect cause of millions more due to diabetes-related kidney disease and cardiovascular deaths as a result of elevated blood glucose [18,20]. In the same year, diabetes mortality rates for American Indian/Alaska Native communities in the United States of America (USA) were 3.2 times higher than for other American populations [21].
The three main types of diabetes are type 1, type 2 (T2D), and gestational diabetes, of which approximately 90–95% of cases are T2D [2,20,22,23]. T2D significantly contributes to the substantial disease burden among Indigenous populations worldwide. It is noteworthy that more than 50% of Indigenous peoples aged 35 and above are affected by this condition [7,24]. T2D involves the body becoming resistant to the effects of insulin and/or producing less insulin from the pancreas [18,23]. Unlike type 1 diabetes, T2D is strongly associated with lifestyle [25]. Key risk factors for developing T2D are being overweight, having a poor diet, low physical activity levels, smoking, high blood pressure, and high cholesterol [2,22]. The high prevalence of these risk factors in Indigenous peoples can be attributed largely to social determinants of health, presenting a greater challenge for engagement in health-promoting behaviours such as physical activity and maintaining a healthy diet [2,4,7,13].
Regular physical activity is a key component of T2D management [26,27,28]. Exercise is a form of structured, deliberate physical activity to maintain or improve physical fitness [29]. Physical activity and exercise can have multiple beneficial effects, including weight loss, increased physical fitness, an increase in sensitivity to insulin, improved mood, improved self-management, improvements in glycaemic control, and a decrease in cardiovascular disease risk [17,30]. There is evidence that community-based, supervised group exercise interventions can improve health outcomes, including glycaemic control, physical fitness, functional capacity, waist circumference, and mental health, for non-Indigenous individuals with T2D [17,30,31]. However, the generalisability of these results to Indigenous populations is limited, as it has been demonstrated that Indigenous input into the design, implementation, and evaluation of health interventions improves Indigenous health outcomes to a greater degree than interventions designed for non-Indigenous populations [32]. Whilst there is some evidence that group-based exercise provides biopsychosocial benefits for healthy Indigenous populations [33], the health impacts of community-based, supervised group exercise interventions for Indigenous populations with T2D have not been sufficiently evaluated.
This systematic review aims to assess the effectiveness of community-based exercise interventions on health outcomes for Indigenous peoples with T2D. Secondly, we aim to explore the factors which impact participation in community-based exercise among Indigenous peoples.

2. Materials and Methods

2.1. Study Design

This systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement [34] and was registered with the International Prospective Register of Systematic Reviews (PROSPERO: ID no. CRD42023414591).

2.2. Search Strategy

The search strategy was developed in consultation with two senior health researchers and a health research librarian. The search was conducted in April 2023 in two stages. The following databases were initially searched: CINAHL, Embase, Informit Indigenous Collection, Medline, and Scopus, but due to limited search results in the domain of interest, PubMed, SportDiscus, and Web of Science databases were added to the search.
  • Participants/population
    Indigenous adults 18 years of age or older participate in community-based exercise programmes intended to prevent or manage type 2 diabetes.
  • Intervention(s), exposure(s)
    Community-based group exercise programmes are intended to prevent or manage type 2 diabetes.
  • Comparator(s)/control
    Participants who receive usual care. Those who do not receive community-based group exercise programmes intended to prevent or manage type 2 diabetes.
  • Main outcome(s)
    Pre and post-health outcomes using behavioural, clinical, or psychosocial measures. Primary outcomes of interest include glycaemic control (measured by HbA1c), body mass index (BMI), waist circumference, physical fitness measures, functional capacity, and psychosocial outcomes, e.g., quality of life (QOL).
  • Additional outcome(s)
    Clinician-type, clinician experience, setting of intervention, mode of delivery, and level of adherence to the intervention.

2.3. Inclusion-Exclusion Criteria

This review included full-text, published, peer-reviewed literature with original outcome data that reported on the effectiveness of community-based exercise interventions for the management of T2D among Indigenous peoples. The inclusion criteria included lifestyle interventions where exercise was a purposeful, structured, and required part of the program; Indigenous peoples from high-income colonised countries, including Aboriginal and Torres Strait Islander peoples in Australia; Māori and Pacific peoples in New Zealand and the Pacific Islands; American Indian and Alaskan Native peoples in the USA; and First Nations, Inuit, and Métis peoples in Canada.
Studies were excluded if the intervention was not primarily based in the community. Studies predominantly examining adolescents or women with gestational diabetes were excluded if data for adults with T2D was not disaggregated. Articles published prior to 2002 that were not published in English were also excluded. Studies were also excluded if they were not peer-reviewed and did not include original pre-post intervention outcome data, case series or letters to the editor.

2.4. Study Selection

Citations of all relevant literature from the selected databases were exported into Endnote citation software, version 20 [35], and any duplicates were removed. A screen of the titles and abstracts eliminated all studies that did not align with the inclusion criteria. The remaining articles underwent full-text screening by two reviewers (LH and LW) to determine eligibility, with any disagreements settled by a third reviewer (SB). The reference lists of all selected studies were also examined for any additional relevant articles.

2.5. Outcome Measures

Outcome measures of interest for this review included pre and post-health outcomes using biomedical or psychosocial measures. Primary outcomes of interest included glycaemic control (measured by HbA1c), body mass index (BMI), waist circumference (WC), physical fitness measures, functional capacity, and psychosocial outcomes, e.g., quality of life (QoL). Additional outcomes of interest were the level of adherence to the intervention and the degree of input Indigenous peoples had into the design and implementation of the intervention.

2.6. Quality Appraisal

The quality of selected studies was assessed using the Mixed Methods Appraisal Tool (MMAT) and the Community Engagement Tool (CET) [36,37,38].

2.6.1. Mixed Methods Appraisal Tool (MMAT)

The included studies were assessed by two reviewers (LH and SB) using the MMAT [36]. A score of 1 was given for ‘yes’, and 0 for ‘no’, for each of the five assessment categories, producing a total score out of 5. This score was then translated to a percentage and used to determine an overall rating of ‘low’ (0–30%), ‘medium’ (30–70%), or ‘high’ (70–100%) for methodological quality. Any disagreements were settled with discussion and a third reviewer (LW) where necessary.

2.6.2. Community Engagement Tool (CET)

The included studies were scored for the degree of Indigenous community engagement in the study design and implementation by three reviewers (LH, SB, and CC) using the CET. The CET is a modified evaluation tool [37] based on the Australian National Health and Medical Research Council (NHMRC) guidelines for ethical research with Indigenous communities. This tool was implemented in collaboration with an Indigenous research fellow and co-author (CC). The perspective of the Indigenous reviewer was privileged over the other two reviewers for the assessment and overall rating of each study.
The CET includes five criteria: issues identified by the community, Indigenous governance, capacity building, cultural consideration in design, and respecting community experience. The included studies were assessed against these five criteria by three reviewers, and a score out of 5 was determined. Each article was then categorised as weak (0–1), moderate (2–3), or strong (4–5). The full process of using the CET is described elsewhere [37].

2.7. Data Extraction

All relevant information was extracted into a data extraction table created using Microsoft Excel. Data were exported by one reviewer (LH) and cross-checked by a second (SB). Data of interest included population details, study design, intervention description, and pre and post-measures of relevant health outcomes (as per outcome measures).

2.8. Data Synthesis

A thematic analysis of the qualitative data was conducted. Findings involving outcome measures relevant to the research question were categorised into ‘biomedical’ and ‘psychosocial’. Cross-study comparisons were made where possible. The research team found insufficient homogeneity in the studies for a meta-analysis.

3. Results

3.1. Study Selection

The results of the study selection process, including identification, screening, and inclusion, are reported in Figure 1. A total of 291 articles were identified from the selected databases, and 211 of these were screened using the inclusion and exclusion criteria following the removal of duplicates. Following a title and abstract screen, 21 articles were selected for full-text review, of which three were eligible for inclusion in the review, noting that two of the three publications were about the same study. Reasons for exclusion following full-text screening included: results for Indigenous participants with T2D were not disaggregated; exercise was not a structured and required part of the intervention; the study did not examine health-related outcome measures; no results had been published when the search was conducted. Finally, a reference list screen of the included studies yielded no relevant articles.

3.2. Quality Appraisal

The results of the quality appraisal using the MMAT and CET are presented in Table 1. The Shah et al. [12] study was determined to be of high methodological quality, while the two remaining articles were graded to be of medium quality [10,11]. The lower score for the two articles by Sukala et al. [10,11] was predominately due to the low retention rate and compliance level of the intervention.
Regarding community engagement, two of the included studies were rated moderate using CET [10,11], with one appraised as strong [12]. The article by Shah et al. [12] was given ‘yes’ for criteria 1; issue identified by community; and criteria 3; capacity building, whilst all included studies were scored ‘yes’ for criteria 4; cultural consideration in design; and criteria 5; respecting community experience. Criteria 2, Indigenous governance, was rated ‘no’ across all included studies.

3.3. Study Characteristics

The characteristics of the three included studies are summarised in Table 2 and Table 3. Two studies analysed the same intervention with different outcome measures and, as such, were grouped together for the presentation of results [10,11]. These two studies were randomised parallel arm designs conducted with participants of Polynesian descent in New Zealand [10,11], and the remaining study was a prospective cohort design with Native American Zuni Indian participants in New Mexico, USA [12]. Participants in all three studies were predominantly female, with 72% [10,11] and 68% [12]. The median age was consistent across all studies at approximately 49 years of age [10,11,12]. Comorbidities included visceral obesity (BMI = 43.8 ± 9.5 kg/m2), reported in two studies [10,11]. The participant retention rate was low for two articles [10,11], with a total of 69% of recruited participants completing the intervention in comparison to the 100% completion rate reported in the third study [12].
The exercise interventions implemented across the three studies followed the guidelines of either the American College of Sports Medicine [10,11] or the American Diabetes Association [12]. In adherence to these guidelines, one study required 150 min of exercise a week, including three walking sessions (individual or group) and optional additional aerobic exercise, as part of a larger education-based lifestyle intervention lasting 6 months [12]. The remaining two studies evaluated the effect of resistance versus aerobic exercise conducted in 40–60-min sessions three times weekly across a 4-month period [10,11]. Exercise intensity was reported in two articles [10,11] and included 2–3 sets of 6–8 repetitions until neural fatigue for the resistance exercise group and 65–85% of heart rate reserve (HRR) for the aerobic exercise group.
Cultural consultation was present across all included studies, with all receiving appropriate ethical and cultural approval for study procedures [10,11,12]. The choice of study design was influenced by cultural consultation, as participating communities believed a control group to be unethical [10,11,12], prompting a change from a randomised controlled trial to a randomised parallel arm study in the studies by Sukala et al. [10,11]. Community engagement by Shah et al. [12] also included the intervention being designed and implemented according to information gathered from community focus group consultation, resulting in supportive elements including training and employment of community health representatives (CHRs), provision of transport, home-based testing, class reminders, and individualised exercise and nutrition plans [12].

3.4. Outcome of Interventions

Biomedical and psychosocial outcomes measured across studies included HbA1c (recorded as A1c by Shah et al. [12]), glucose, total cholesterol, triglycerides, BMI, body weight, WC, body fat percentage, Patient Activation Measure (PAM), and QoL measured by the Medical Outcomes Trust Short Form-36 Health Survey (SF-36) [10,11,12].

3.4.1. Biomedical Outcomes

Biomedical outcome measures reported across more than one included study are summarised in Table 4. Statistically significant improvement in HbA1c was only reported in one of three studies [12], recording a change from 8.12 ± 2.16 at baseline to 7.39 ± 1.6 after the 6-month intervention (p = 0.001). Total cholesterol, glucose, and BMI were significantly reduced in the Shah et al. [12] study, whilst no significant change was found by Sukala et al. [10]. Post-intervention triglycerides were reduced in one study [12] and increased in another secondary to aerobic exercise [10]. This aerobic exercise group also showed a reduction in systolic and diastolic blood pressure after being elevated at baseline. No other relevant biomedical outcomes reached statistical significance. However, when adherence to the resistance or aerobic exercise interventions reached 75% or greater, WC reduced (p < 0.001) and body weight tended to improve (p = 0.11) [10].

3.4.2. Psychosocial Outcomes

Sukala et al. [11] examined the impact of community-based aerobic and resistance exercise interventions on QoL using the SF-36, whilst Shah et al. [12] evaluated the effects of a lifestyle intervention involving education, diet change, and individualised group exercise on PAM levels. Of the eight SF-36 QoL domains, the resistance exercise group showed significant improvements in six domains, whilst the aerobic training group improved in four domains. The Physical Component Summary Score improved in both groups, and the Mental Component Summary Score trended towards improvement (p = 0.11 resistance, p = 0.14 aerobic) [11]. Pooled analyses of both exercise types identified a moderate to large significant time effect for all QoL domains and summary scales, with the exception of the mental health domain (p = 0.09) [11]. Social interaction was acknowledged as an important contributor to these QoL improvements, in particular the 18% increase reported in the social functioning domain [11].
Similarly, post-interventional changes in PAM levels also reached statistical significance, with 58% of participants increasing their level by one or more, 40% maintaining their level, and 2% showing a decrease (p < 0.0001) [12]. Despite being unable to demonstrate a correlation between increased patient activation and metabolic improvements, these changes occurred concurrently. The study by Shah et al. [12] concluded that the use of CHRs, point-of-care (POC) testing, and programme individualisation were contributors to participant empowerment by removing barriers to care such as access to care, travel, language barriers, wait times, and a lack of patient–clinician relationships.

4. Discussion

The aim of this systematic review was to determine if community-based exercise interventions can improve biopsychosocial health outcomes in Indigenous peoples with T2D. Despite the considerable body of epidemiological research relating to T2D in Indigenous communities [39,40,41,42,43,44,45,46,47] and a comprehensive search strategy, this review was only able to identify three translational studies that were eligible for inclusion [10,11,12]. This dearth of commensurate translational research is indicative of a discrepancy between the proficiency of researchers in identifying concerns and the inadequacy of efforts directed towards implementing culturally appropriate translational solutions [48,49,50]. As such, this review highlights the limited translational research evaluating the health impacts of community-based, supervised group exercise interventions for Indigenous populations with T2D. Furthermore, in support of current recommendations, this review determined that to best facilitate the development of robust, feasible, and culturally safe evidence in this domain, interventions should be adequately contextualised to culture through consistently strong Indigenous governance and community engagement [37,38,50,51].
With consideration of the small number of included studies, this review found that community-based exercise can improve glycaemic control [12], anthropometric measures [10,12], blood lipids [12], haemodynamic measures [10], patient activation [12], and quality of life [10] in Indigenous peoples with T2D [17,30,31]. However, upon comparing the two featured interventions [10,11,12], these adaptations appear to be largely dependent on successful cultural contextualisation of the intervention and subsequently, greater participation in the planned intervention [37,38,50,51,52,53,54]. Shah et al. [12] demonstrated that biomedical outcomes, including glycaemic control, can be improved with group walking and aerobic exercise programmes as part of a holistic lifestyle intervention, including education and individualised nutrition advice. This community and home-based, CHR-implemented intervention was created and implemented to remove community-specific barriers to diabetes care and improve patient activation following community focus group consultation [12,55]. As such, with the exception of Indigenous governance (due to inadequate levels of Indigenous leadership), this intervention met all other CET criteria and was determined to have strong community engagement [12,37,38]. In conjunction with wider literature [37,38,50,51,52,53], it can, therefore, be hypothesised that the strong community engagement contributed to the 100% compliance rate and the significant improvement in biomedical outcomes [12].
In comparison, in the study by Sukala et al. [10], several post-intervention biomedical outcome measures were inconsistent with expectations despite the length [28,56], frequency, duration [27,28,57], and mode of exercise [58,59] being appropriate to elicit significant change [27,28,57]. The lack of improvement in most biomedical outcomes, including HbA1c, was likely due to an interaction of several factors, including participant characteristics, insufficient contextualisation, and low participation in the intervention [10,54,60]. Participants’ obesity levels and high baseline HbA1c may have required a longer intervention with a higher frequency and duration of exercise sessions to obtain these adaptations [54,61]. Furthermore, with less than 70% participation in the exercise intervention, for many participants, the exercise frequency would have fallen below physical activity guideline recommendations [10,26,27,57]. When adherence reached 75%, clinically meaningful adaptations in anthropometric measures were demonstrated [10]. The low participation can be attributed, at least in part, to the lower community engagement and subsequent insufficiency of the intervention to meet participants’ cultural and healthcare needs when compared to the Shah et al. intervention [12].
Although biomedical improvements were limited, post-intervention quality scores by Sukala et al. [10] approached or surpassed levels reported for the general population (of New Zealand), aligning with strong evidence that exercise can improve health-related quality of life in healthy adult populations [62] and non-Indigenous populations with T2D [17,63]. This is of particular significance given the low baseline SF-36 scores [10] and low quality of life associated with both T2D diagnosis and Indigenous Polynesian peoples [10,64]. Sukala et al. [10] also acknowledged the importance of the socialisation aspect of community-based group exercise, as evidenced by the 18% improvement in the SF-36 Social Functioning domain. Social interaction in a familiar community environment has been shown to improve quality of life and help facilitate exercise participation in both Polynesian and non-Indigenous populations [10,53,65].
Participation in exercise and other healthy behaviours may be related to the level of patient activation [12,66,67,68]. The strong community engagement in the study facilitated the increase in patient activation through the removal of the barriers that were identified to inhibit patient empowerment [12]. In particular, the use of CHRs was a vital contributor to participant empowerment by removing language barriers and the lack of patient–clinician relationships [12,53].
This review was limited due to the small number of eligible studies that fit the inclusion criteria and the variation of outcome measures used across the included studies. As such, outcome comparison across studies was limited, and there was insufficient data to perform a meta-analysis. This review included two studies reported in three papers. One study was reported in two papers. Secondly, selection bias may have occurred as a result of expanding the search strategy and inclusion criteria. Further research on community-based exercise interventions in Indigenous peoples with T2D using biomedical and psychosocial health outcomes would, therefore, allow for more in-depth analysis and refinement of the characteristics of effective interventions.

5. Conclusions

This systematic review highlights the paucity of literature evaluating community-based group exercise interventions for Indigenous adults with T2D. Despite the limited available research, this review determined that community-based exercise interventions may improve health outcomes for Indigenous adults with T2D when conducted in a culturally safe manner. Furthermore, strong Indigenous community engagement may increase intervention adherence and, therefore, effectiveness by removing barriers to diabetes care identified by the community. Additional research with Indigenous involvement and governance is required to determine the extent of this effect and work towards narrowing the gap in Indigenous and non-Indigenous health outcomes in this domain.

Author Contributions

Conceptualisation, K.G. and M.K.; methodology, K.G.; formal analysis, L.H., C.C. and S.B.; investigation, L.H. and C.C.; data curation, L.H. and L.W.; writing—original draft preparation, L.H. and C.C.; writing—review and editing, V.C., M.K. and K.G. All authors have read and agreed to the published version of the manuscript.

Funding

This research received no external funding.

Informed Consent Statement

Not applicable.

Data Availability Statement

Data can be made available upon request.

Conflicts of Interest

The authors declare that there is no conflict of interest.

References

  1. Axelsson, P.; Kukutai, T.; Kippen, R. The field of Indigenous health and the role of colonisation and history. J. Popul. Res. 2016, 33, 1–7. [Google Scholar] [CrossRef]
  2. Burrow, S.; Ride, K. Review of diabetes among Aboriginal and Torres Strait Islander people. Aust. Indig. Health 2016. Available online: https://nla.gov.au/nla.obj-279724722/view (accessed on 27 October 2023).
  3. Sushames, A.; van Uffelen, J.G.; Gebel, K. Do physical activity interventions in Indigenous people in Australia and New Zealand improve activity levels and health outcomes? A systematic review. Int. J. Behav. Nutr. Phys. Act. 2016, 13, 129. [Google Scholar] [CrossRef]
  4. Czyzewski, K. Colonialism as a Broader Social Determinant of Health. Int. Indig. Policy J. 2011, 2. [Google Scholar] [CrossRef]
  5. Sherwood, J. Colonisation—It’s bad for your health: The context of Aboriginal health. Contemp. Nurse 2013, 46, 28–40. [Google Scholar] [CrossRef] [PubMed]
  6. Diabetes Canada Clinical Practice Guidelines Expert Committee; Crowshoe, L.; Dannenbaum, D.; Green, M.; Henderson, R.; Hayward, M.N.; Toth, E. Type 2 Diabetes and Indigenous Peoples. Can. J. Diabetes 2018, 42 (Suppl. 1), S296–S306. [Google Scholar] [CrossRef]
  7. United Nations. Chapter V: Health; United Nations: New York, NY, USA, 2009; pp. 156–187. [Google Scholar]
  8. Meyer, W.H. Indigenous Rights, Global Governance, and State Sovereignty. Human Rights Rev. 2012, 13, 327–347. [Google Scholar] [CrossRef]
  9. National Congress of American Indians. Tribal Nations & the United States: An Introduction. Available online: https://www.ncai.org/about-tribes (accessed on 27 October 2023).
  10. Sukala, W.R.; Page, R.; Rowlands, D.S.; Krebs, J.; Lys, I.; Leikis, M.; Pearce, J.; Cheema, B.S.; Sukala, W.R.; Page, R.; et al. South Pacific Islanders resist type 2 diabetes: Comparison of aerobic and resistance training. Eur. J. Appl. Physiol. 2012, 112, 317–325. [Google Scholar] [CrossRef] [PubMed]
  11. Sukala, W.R.; Page, R.; Lonsdale, C.; Lys, I.; Rowlands, D.; Krebs, J.; Leikis, M.; Cheema, B.S. Exercise improves quality of life in indigenous Polynesian peoples with type 2 diabetes and visceral obesity. J. Phys. Act. Health 2013, 10, 699–707. [Google Scholar] [CrossRef]
  12. Shah, V.O.; Carroll, C.; Mals, R.; Ghahate, D.; Bobelu, J.; Sandy, P.; Colleran, K.; Schrader, R.; Faber, T.; Burge, M.R. A home-based educational intervention improves patient activation measures and diabetes health indicators among Zuni Indians. PloS ONE 2015, 10, e0125820. [Google Scholar] [CrossRef]
  13. Australian Institute of Health Welfare. Determinants of Health for Indigenous Australians; AIHW: Canberra, Australia, 2022. [Google Scholar]
  14. Marmot, M. Social determinants and the health of Indigenous Australians. Med. J. Aust. 2011, 194, 512–513. [Google Scholar] [CrossRef]
  15. Kirmayer, L.J.; Dandeneau, S.; Marshall, E.; Phillips, M.K.; Williamson, K.J. Rethinking resilience from indigenous perspectives. Can. J. Psychiatry 2011, 56, 84–91. [Google Scholar] [CrossRef]
  16. Usher, K.; Jackson, D.; Walker, R.; Durkin, J.; Smallwood, R.; Robinson, M.; Sampson, U.N.; Adams, I.; Porter, C.; Marriott, R. Indigenous Resilience in Australia: A Scoping Review Using a Reflective Decolonizing Collective Dialogue. Front. Public Health 2021, 9, 630601. [Google Scholar] [CrossRef]
  17. Kirwan, M.; Chiu, C.L.; Hay, M.; Laing, T. Community-Based Exercise and Lifestyle Program Improves Health Outcomes in Older Adults with Type 2 Diabetes. Int. J. Environ. Res. Public Health 2021, 18, 6147. [Google Scholar] [CrossRef]
  18. Diabetes Australia. Diabetes Globally. Available online: https://www.diabetesaustralia.com.au/about-diabetes/diabetes-globally/ (accessed on 27 October 2023).
  19. Ministry of Health. A Portrait of Health. Key Results of the 2006/07 New Zealand Health Survey; Ministry of Health: Wellington, New Zealand, 2008.
  20. World Health Organisation. Diabetes. Available online: https://www.who.int/news-room/fact-sheets/detail/diabetes (accessed on 28 October 2023).
  21. U.S. Department of Health and Human Services, I.H.S. Indian Health Disparities; HIS: Rockville, MD, USA, 2019.
  22. International Diabetes Federation. Type 2 Diabetes. Available online: https://www.idf.org/aboutdiabetes/type-2-diabetes.html (accessed on 27 October 2023).
  23. National Institute of Diabetes and Digestive and Kidney Diseases. What is Diabetes? Available online: https://www.niddk.nih.gov/health-information/diabetes/overview/what-is-diabetes (accessed on 27 October 2023).
  24. Cheran, K.; Murthy, C.; Bornemann, E.A.; Kamma, H.K.; Alabbas, M.; Elashahab, M.; Abid, N.; Manaye, S.; Venugopal, S. The Growing Epidemic of Diabetes among the Indigenous Population of Canada: A Systematic Review. Cureus 2023, 15, e36173. [Google Scholar] [CrossRef] [PubMed]
  25. Diabetes Australia. Type 2 Diabetes. Available online: https://www.diabetesaustralia.com.au/about-diabetes/type-2-diabetes/ (accessed on 27 October 2023).
  26. Colberg, S.R.; Sigal, R.J.; Fernhall, B.; Regensteiner, J.G.; Blissmer, B.J.; Rubin, R.R.; Chasan-Taber, L.; Albright, A.L.; Braun, B. Exercise and type 2 diabetes: The American College of Sports Medicine and the American Diabetes Association: Joint position statement. Diabetes Care 2010, 33, e147–e167. [Google Scholar] [CrossRef] [PubMed]
  27. American Diabetes Association. Standards of medical care in diabetes—2011. Diabetes Care 2011, 34 (Suppl. 1), S11–S61. [Google Scholar] [CrossRef] [PubMed]
  28. Umpierre, D.; Ribeiro, P.A.B.; Kramer, C.K.; Leitão, C.B.; Zucatti, A.T.N.; Azevedo, M.J.; Gross, J.L.; Ribeiro, J.P.; Schaan, B.D. Physical Activity Advice Only or Structured Exercise Training and Association with HbA1c Levels in Type 2 Diabetes: A Systematic Review and Meta-analysis. JAMA 2011, 305, 1790–1799. [Google Scholar] [CrossRef]
  29. Dasso, N.A. How is exercise different from physical activity? A concept analysis. Nurs. Forum 2019, 54, 45–52. [Google Scholar] [CrossRef] [PubMed]
  30. Plotnikoff, R.C.; Costigan, S.A.; Karunamuni, N.D.; Lubans, D.R. Community-based physical activity interventions for treatment of type 2 diabetes: A systematic review with meta-analysis. Front. Endocrinol. 2013, 4, 3. [Google Scholar] [CrossRef] [PubMed]
  31. Kirwan, M.; Gwynne, K.; Laing, T.; Hay, M.; Chowdhury, N.; Chiu, C.L. Can Health Improvements from a Community-Based Exercise and Lifestyle Program for Older Adults with Type 2 Diabetes Be Maintained? A Follow up Study. Diabetology 2022, 3, 348–354. [Google Scholar] [CrossRef]
  32. Banna, J.; Bersamin, A. Community involvement in design, implementation and evaluation of nutrition interventions to reduce chronic diseases in indigenous populations in the U.S.: A systematic review. Int. J. Equity Health 2018, 17, 116. [Google Scholar] [CrossRef] [PubMed]
  33. Pressick, E.L.; Gray, M.A.; Cole, R.L.; Burkett, B.J. A systematic review on research into the effectiveness of group-based sport and exercise programs designed for Indigenous adults. J. Sci. Med. Sport 2016, 19, 726–732. [Google Scholar] [CrossRef] [PubMed]
  34. Page, M.J.; McKenzie, J.E.; Bossuyt, P.M.; Boutron, I.; Hoffmann, T.C.; Mulrow, C.D.; Shamseer, L.; Tetzlaff, J.M.; Akl, E.A.; Brennan, S.E.; et al. The PRISMA 2020 statement: An updated guideline for reporting systematic reviews. BMJ 2021, 372, n71. [Google Scholar] [CrossRef] [PubMed]
  35. The EndNote Team. EndNote, EndNote 20; Clarivate: Philadelphia, PA, USA, 2013. [Google Scholar]
  36. Hong, Q.N.; Pluye, P.; Fàbregues, S.; Bartlett, G.; Boardman, F.; Cargo, M.; Dagenais, P.; Gagnon, M.-P.; Griffiths, F.; Nicolau, B. Mixed methods appraisal tool (MMAT), version 2018. BMJ Open 2018, 10, 1148552. [Google Scholar]
  37. Christie, V.; Green, D.; Amin, J.; Pyke, C.; Littlejohn, K.; Skinner, J.; McCowen, D.; Gwynne, K. What Is the Evidence Globally for Culturally Safe Strategies to Improve Breast Cancer Outcomes for Indigenous Women in High Income Countries? A Systematic Review. Int. J. Environ. Res. Public Health 2021, 18, 6073. [Google Scholar] [CrossRef] [PubMed]
  38. Christie, V.; Amin, J.; Skinner, J.; Green, D.; Littlejohn, K.; Gwynne, K. Comparison of Study Quality as Determined by Standard Research and Community Engagement Metrics: A Pilot Study on Breast Cancer Research in Urban, Rural, and Remote Indigenous Communities. Int. J. Environ. Res. Public Health 2022, 19, 5008. [Google Scholar] [CrossRef]
  39. Dyck, R.; Osgood, N.; Lin, T.H.; Gao, A.; Stang, M.R. Epidemiology of diabetes mellitus among First Nations and non-First Nations adults. CMAJ 2010, 182, 249–256. [Google Scholar] [CrossRef]
  40. Wedekind, L.E.; Mitchell, C.M.; Andersen, C.C.; Knowler, W.C.; Hanson, R.L. Epidemiology of Type 2 Diabetes in Indigenous Communities in the United States. Curr. Diabetes Rep. 2021, 21, 47. [Google Scholar] [CrossRef]
  41. Batal, M.; Chan, H.M.; Fediuk, K.; Ing, A.; Berti, P.; Sadik, T.; Johnson-Down, L. Associations of health status and diabetes among First Nations Peoples living on-reserve in Canada. Can. J. Public Health 2021, 112, 154–167. [Google Scholar] [CrossRef]
  42. Wang, M.L.; McElfish, P.A.; Long, C.R.; Lee, M.S.; Bursac, Z.; Kozak, A.T.; Ko, L.K.; Kulik, N.; Kim Yeary, K.H.-C. BMI and related risk factors among U.S. Marshallese with diabetes and their families. Ethn. Health 2021, 26, 1196–1208. [Google Scholar] [CrossRef] [PubMed]
  43. Taylor, S.; McDermott, R.; Thompson, F.; Usher, K. Depression and diabetes in the remote Torres Strait Islands. Health Promot. J. Austr. 2017, 28, 59–66. [Google Scholar] [CrossRef] [PubMed]
  44. McElfish, P.A.; Purvis, R.S.; Esquivel, M.K.; Sinclair, K.A.; Townsend, C.; Hawley, N.L.; Haggard-Duff, L.K.; Kaholokula, J.K. Diabetes Disparities and Promising Interventions to Address Diabetes in Native Hawaiian and Pacific Islander Populations. Curr. Diabetes Rep. 2019, 19, 19. [Google Scholar] [CrossRef]
  45. Minges, K.E.; Zimmet, P.; Magliano, D.J.; Dunstan, D.W.; Brown, A.; Shaw, J.E. Diabetes prevalence and determinants in Indigenous Australian populations: A systematic review. Diabetes Res. Clin. Pract. 2011, 93, 139–149. [Google Scholar] [CrossRef]
  46. Apidechkul, T. Prevalence and factors associated with type 2 diabetes mellitus and hypertension among the hill tribe elderly populations in northern Thailand. BMC Public Health 2018, 18, 694. [Google Scholar] [CrossRef] [PubMed]
  47. Hare, M.J.L.; Zhao, Y.; Guthridge, S.; Burgess, P.; Barr, E.L.M.; Ellis, E.; Butler, D.; Rosser, A.; Falhammar, H.; Maple-Brown, L.J. Prevalence and incidence of diabetes among Aboriginal people in remote communities of the Northern Territory, Australia: A retrospective, longitudinal data-linkage study. BMJ Open 2022, 12, e059716. [Google Scholar] [CrossRef]
  48. McNamara, B.J.; Sanson-Fisher, R.; D’Este, C.; Eades, S. Type 2 diabetes in Indigenous populations: Quality of intervention research over 20 years. Prev. Med. 2011, 52, 3–9. [Google Scholar] [CrossRef]
  49. Sanson-Fisher, R.W.; Campbell, E.M.; Perkins, J.J.; Blunden, S.V.; Davis, B.B. Indigenous health research: A critical review of outputs over time. Med. J. Aust. 2006, 184, 502–505. [Google Scholar] [CrossRef]
  50. Stanley, L.R.; Swaim, R.C.; Kaholokula, J.K.a.; Kelly, K.J.; Belcourt, A.; Allen, J. The Imperative for Research to Promote Health Equity in Indigenous Communities. Prev. Sci. 2020, 21, 13–21. [Google Scholar] [CrossRef]
  51. Liu, H.; Huffman, M.D.; Trieu, K. The role of contextualisation in enhancing non-communicable disease programmes and policy implementation to achieve health for all. Health Res. Policy Syst. 2020, 18, 38. [Google Scholar] [CrossRef]
  52. Whitesell, N.R.; Mousseau, A.; Parker, M.; Rasmus, S.; Allen, J. Promising Practices for Promoting Health Equity through Rigorous Intervention Science with Indigenous Communities. Prev. Sci. 2020, 21, 5–12. [Google Scholar] [CrossRef]
  53. Heinrich, K.; Kurtz, B.; Patterson, M.; Crawford, D.; Barry, A. Incorporating a Sense of Community in a Group Exercise Intervention Facilitates Adherence. Health Behav. Res. 2022, 5, 1. [Google Scholar] [CrossRef]
  54. Sukala, W.R.; Page, R.; Cheema, B.S. Exercise training in high-risk ethnic populations with type 2 diabetes: A systematic review of clinical trials. Diabetes Res. Clin. Pract. 2012, 97, 206–216. [Google Scholar] [CrossRef]
  55. Newman, S.; Cheng, T.; Ghahate, D.M.; Bobelu, J.; Sandy, P.; Faber, T.; Shah, V.O. Assessing knowledge and attitudes of diabetes in Zuni Indians using a culture-centered approach. PLoS ONE 2014, 9, e99614. [Google Scholar] [CrossRef]
  56. Kirwan, J.P.; Sacks, J.; Nieuwoudt, S. The essential role of exercise in the management of type 2 diabetes. Cleve Clin. J. Med. 2017, 84, S15–S21. [Google Scholar] [CrossRef]
  57. Sigal, R.J.; Kenny, G.P.; Wasserman, D.H.; Castaneda-Sceppa, C.; White, R.D. Physical activity/exercise and type 2 diabetes: A consensus statement from the American Diabetes Association. Diabetes Care 2006, 29, 1433–1438. [Google Scholar] [CrossRef]
  58. Farzad, N.; Majid, M.; Abbas, Y.; Haidar, N.; Akbar, A.; Naimeh Mashinchi, A.; Mitra, N.; Jalil Houshyar, G.; Vahideh, S. Effect of regular exercise training on changes in HbA1c, BMI and VO2max among patients with type 2 diabetes mellitus: An 8-year trial. BMJ Open Diabetes Res. Care 2017, 5, e000414. [Google Scholar] [CrossRef]
  59. Sherwani, S.I.; Khan, H.A.; Ekhzaimy, A.; Masood, A.; Sakharkar, M.K. Significance of HbA1c Test in Diagnosis and Prognosis of Diabetic Patients. Biomark. Insights 2016, 11, 95–104. [Google Scholar] [CrossRef] [PubMed]
  60. Nicolucci, A.; Balducci, S.; Cardelli, P.; Cavallo, S.; Fallucca, S.; Bazuro, A.; Simonelli, P.; Iacobini, C.; Zanuso, S.; Pugliese, G.; et al. Relationship of exercise volume to improvements of quality of life with supervised exercise training in patients with type 2 diabetes in a randomised controlled trial: The Italian Diabetes and Exercise Study (IDES). Diabetologia 2012, 55, 579–588. [Google Scholar] [CrossRef] [PubMed]
  61. Alison, R.H.; Mark, R.E. Amount and frequency of exercise affect glycaemic control more than exercise mode or intensity. Br. J. Sports Med. 2015, 49, 1012. [Google Scholar] [CrossRef]
  62. Bize, R.; Johnson, J.A.; Plotnikoff, R.C. Physical activity level and health-related quality of life in the general adult population: A systematic review. Prev. Med. 2007, 45, 401–415. [Google Scholar] [CrossRef]
  63. Jing, X.; Chen, J.; Dong, Y.; Han, D.; Zhao, H.; Wang, X.; Gao, F.; Li, C.; Cui, Z.; Liu, Y.; et al. Related factors of quality of life of type 2 diabetes patients: A systematic review and meta-analysis. Health Qual. Life Outcomes 2018, 16, 189. [Google Scholar] [CrossRef] [PubMed]
  64. Scott, K.M.; Tobias, M.I.; Sarfati, D.; Haslett, S.J. SF-36 health survey reliability, validity and norms for New Zealand. Aust. N. Z. J. Public Health 1999, 23, 401–406. [Google Scholar] [CrossRef] [PubMed]
  65. Foliaki, S.; Pearce, N. Prevention and control of diabetes in Pacific people. BMJ 2003, 327, 437–439. [Google Scholar] [CrossRef] [PubMed]
  66. Hibbard, J.H.; Mahoney, E.R.; Stock, R.; Tusler, M. Do increases in patient activation result in improved self-management behaviors? Health Serv. Res. 2007, 42, 1443–1463. [Google Scholar] [CrossRef]
  67. Rask, K.J.; Ziemer, D.C.; Kohler, S.A.; Hawley, J.N.; Arinde, F.J.; Barnes, C.S. Patient activation is associated with healthy behaviors and ease in managing diabetes in an indigent population. Diabetes Educ. 2009, 35, 622–630. [Google Scholar] [CrossRef]
  68. Remmers, C.; Hibbard, J.; Mosen, D.M.; Wagenfield, M.; Hoye, R.E.; Jones, C. Is patient activation associated with future health outcomes and healthcare utilization among patients with diabetes? J. Ambul. Care Manag. 2009, 32, 320–327. [Google Scholar] [CrossRef]
Ijerph 21 00290 g001
Figure 1. Preferred Reporting Items for Systematic Reviews (PRISMA) flow diagram [34].
Figure 1. Preferred Reporting Items for Systematic Reviews (PRISMA) flow diagram [34].
Ijerph 21 00290 g001
Table 1. Final scores and quality rating of MMAT and CET quality appraisal with CET criteria scoring.
Table 1. Final scores and quality rating of MMAT and CET quality appraisal with CET criteria scoring.
CriteriaSukala et al. 2012 [10]Sukala et al. 2013 [11]Shah et al. 2015 [12]
MMAT
Total (%)40%40%80%
RatingMediumMediumHigh
CET
Issue Identified by the Community001
Indigenous Governance000
Capacity Building001
Cultural Consideration in Design111
Respecting Community Experience111
Total/5224
RatingModerateModerateStrong
MMAT, Mixed Methods Appraisal Tool; CET, Community Engagement Tool.
Table 2. Summary characteristics of included studies and participants.
Table 2. Summary characteristics of included studies and participants.
Reference
(Author, Year)		AimDesignCountryIndigenous PopulationProgramParticipants
Included (n)Completed (n)Sex (%)Age (Years)Co-Morbidities
(i) Sukala et al., 2012 [10]
(ii) Sukala et al., 2013 [11]		(i) To evaluate the effectiveness of two exercise modalities for improving glycosylated hemoglobin (HbA1c) and associated clinical outcomes in Polynesian adults diagnosed with type 2 diabetes and visceral obesity
(ii) To evaluate the differential effect of 2, group-based exercise modalities on quality of life (QoL) in indigenous Polynesian peoples with type 2 diabetes (T2DM) and visceral obesity		Randomised parallel armNew ZealandPolynesian descent (self-identified): New Zealand Māori (10), Cook Islands Māori (3), Samoan (2), Fijian (1), Tokelauan (1), Tongan (1)Resistance vs. Aerobic Exercise Interventionn = 26n = 18F: 72%
M: 28%		49 ± 5Visceral Obesity
Shah et al., 2015 [12]To evaluate the use of a novel chronic disease prevention approach for improving clinical outcomes and health-related quality of life in Zuni Indians with chronic diseaseProspective cohortZuni Pueblo, New Mexico, USANative American ancestry: Zuni IndiansLifestyle Intervention: group educational classes and home-based teaching, point of care testing, and individualized exercise and nutritional programsn = 60n = 60F: 68%
M: 32%		49.4 ± 12.0None Reported
Table 3. Summary of exercise intervention characteristics, outcome measures, and results of included studies.
Table 3. Summary of exercise intervention characteristics, outcome measures, and results of included studies.
Reference (Author, Year)Exercise TypeExercise CharacteristicsExercise IntensityExercise VolumeLength of InterventionIntervention ComplianceOutcome
BiomedicalPsychosocial
(i) Sukala et al., 2012 [10]
(ii) Sukala et al., 2013 [11]		Resistance ExerciseResistance: Eight exercises using machine weights targeting all the major muscle groups of the body: seated leg press, knee extension, knee flexion, chest press, lat pulldown, overhead press, biceps curl, and triceps extension2–3 sets of 6–8 repetitions with 1 min rest between sets and exercises. Load increased by 5% when 10 repetitions could be performed40–60 min per session
3 sessions per week		16 weeks67 ± 18%(i) HbA1c (%), HOMA2-IR index, McAuley index, Glucose (mmol/L), Insulin (pmol/L), C-peptide, Free fatty acids (mEq/L), Log C-reactive protein, Adiponectin, Blood Lipids (mmol/L): Total cholesterol, HDL cholesterol, LDL cholesterol, Triglycerides, Body weight (kg), BMI (kg/m2), Waist circumference (cm), Body fat (%), SBP & DBP(ii) Quality of life: Medical Outcomes Trust Short Form-36 Health Survey (v. 1.0) (SF-36)
Aerobic ExerciseAerobic: Exercises on a cycle ergometerFirst 2 weeks: progression from 65% to 85% of participants heart rate reserve (HRR)
Remaining program: 85% of HRR		73 ± 19%
Shah et al., 2015 [12]Walking Program
Aerobic Exercise		Exercise in addition to normal activity within peer groups of 4–6 individuals: walking at least 3× weekly (on their own or within CHR organised walking groups), and optional additional aerobic exercise at Zuni Health FacilityNot Reported150 min weekly
3× weekly (walking)		6 months100%A1c%, Glucose(mg/dL), Total Cholestrol (mg/dL), Triglyceride (mg/dL) Blood Urea Nitrogen/BUN (mg/dL), Creatinine (mg/dL), Urine Albumin-to-Creatinine ratio/UACR (mg ALB/g CR), Uric Acid (mg/dL), BMIPAM levels: Patient Activation Measure (PAM)-short form PAM questionnaire
Abbreviations: CHR, Community Health Representative; HbA1C/A1c, haemoglobin A1C; HOMA2-IR, Homeostatic Model Assessment for Insulin Resistance; BMI, Body Mass Index; SBP, Systolic Blood Pressure; DBP, Diastolic Blood Pressure; QoL, Quality of Life; PCS, Physical Component Summary.
Table 4. Summary of biomedical outcomes.
Table 4. Summary of biomedical outcomes.
AuthorYearGroupHbA1c (%) Glucose (mmol/L) Total Cholesterol (mmol/L) BMI (kg/m2)
PrePost% Changep ValuePrePost% Changep ValuePrePost% Changep ValuePrePost% Changep Value
Sukala et al.2012 [10]RET10.7 ± 2.110.6 ± 2.4−0.1 ± 1.10.869.5 ± 3.511.4 ± 41.9 ± 3.20.174.9 ± 1.54.5 ± 1−0.4 ± 0.90.2142.7 ± 12.142.7 ± 11.70.0 ± 1.10.91
AET8.9 ± 1.98.8 ± 2.1−0.1 ± 0.60.610.2 ± 3.310.4 ± 2.90.2 ± 1.60.724.5 ± 0.44.7 ± 0.40.3 ± 0.60.2245 ± 6.544.5 ± 6.9−0.5 ± 1.30.32
Shah et al.2015 [12] 8.12 ± 2.167.39 ± 1.6Not Reported0.0018.8 ± 3.97.5 ± 2.5Not Reported0.00034.1 ± 1.03.8 ± 0.8Not Reported0.00333.8 ± 8.432.4 ± 8.2Not Reported0.001
RET, Resistance Exercise Training; AET, Aerobic Exercise Training; BMI, Body Mass Index.
Disclaimer/Publisher’s Note: The statements, opinions and data contained in all publications are solely those of the individual author(s) and contributor(s) and not of MDPI and/or the editor(s). MDPI and/or the editor(s) disclaim responsibility for any injury to people or property resulting from any ideas, methods, instructions or products referred to in the content.

Share and Cite

MDPI and ACS Style

Hurst, L.; Kirwan, M.; Christie, V.; Cross, C.; Baylis, S.; White, L.; Gwynne, K. The Effect of Community-Based Exercise on Health Outcomes for Indigenous Peoples with Type 2 Diabetes: A Systematic Review. Int. J. Environ. Res. Public Health 2024, 21, 290. https://0-doi-org.brum.beds.ac.uk/10.3390/ijerph21030290

AMA Style

Hurst L, Kirwan M, Christie V, Cross C, Baylis S, White L, Gwynne K. The Effect of Community-Based Exercise on Health Outcomes for Indigenous Peoples with Type 2 Diabetes: A Systematic Review. International Journal of Environmental Research and Public Health. 2024; 21(3):290. https://0-doi-org.brum.beds.ac.uk/10.3390/ijerph21030290

Chicago/Turabian Style

Hurst, Lauren, Morwenna Kirwan, Vita Christie, Cara Cross, Sam Baylis, Liam White, and Kylie Gwynne. 2024. "The Effect of Community-Based Exercise on Health Outcomes for Indigenous Peoples with Type 2 Diabetes: A Systematic Review" International Journal of Environmental Research and Public Health 21, no. 3: 290. https://0-doi-org.brum.beds.ac.uk/10.3390/ijerph21030290

Note that from the first issue of 2016, this journal uses article numbers instead of page numbers. See further details here.

Article Metrics

Back to TopTop