Efficacy of Exercise Interventions for Type 2 Diabetes and Hypertension Co-Morbidity: A Systematic Review Protocol

Efficacy of Exercise Interventions for Type 2 Diabetes and Hypertension Co-Morbidity: A Systematic Review Protocol | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Efficacy of Exercise Interventions for Type 2 Diabetes and Hypertension Co-Morbidity: A Systematic Review Protocol Nombeko Mshunqane, BRIDGETTE Opoku, Martins Nweke This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6636610/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 5 You are reading this latest preprint version Abstract Background Hypertension and diabetes often occur together, contributing to morbidity and mortality, particularly in environments with limited resources. Inadequate control of hypertension (HTN)-type 2 diabetes (T2DM) is a significant concern in Ghana because of the increasing burden of associated mortality. While medication and traditional therapies remain essential for the management of HTN-T2DM comorbidity, exercise interventions are glaringly lacking. Therefore, this systematic review aims to identify, examine, and synthesise existing evidence regarding the efficacy of exercise interventions for HTN-T2DM comorbidity via an integrated care approach. Methods A systematic review with meta-analysis will be performed. The PubMed, Medline, Cochrane Library, Academic Search Complete, SPORT Discus, and Cumulative Index for Allied Health Literature (CINAHL) databases were systematically searched. Terms related to type 2 diabetes, hypertension, and exercise interventions following the PICO framework. Interventional studies that are randomised and non-randomised controlled trials will be included. Two reviewers will independently screen the studies, extract data via EndNote 22, and assess the quality of the studies and the evidence via the PEDro scale of risk of bias tool and the GRADE approach, respectively. A third reviewer will be consulted to resolve possible conflicts. The analysis will be performed via RevMan (version 5.4; the Cochrane Collaboration). Results This study is currently at the proposal stage and in preparation for the search phase. We aim to start searching peer-reviewed articles in February 2025 and project to complete data extraction in June 2025. Conclusion This systematic review protocol outlines a rigorous methodology for evaluating the effects of exercise interventions for patients with type 2 diabetes and hypertension comorbidity. The findings will inform clinical practice and guide the development of a model of care via an integrated approach. Trial registration CRD420251016833 Figures Figure 1 Introduction Type 2 diabetes (T2DM) is increasingly recognised as a global pandemic, impacting approximately 9.3% (463 million) of the world’s population as of 2019 (1). Approximately 80% of people diagnosed with diabetes reside in low- and middle-income countries (LMICs), often presenting with multiple comorbidities (2). The prevalence in Ghana in the adult population (20–79 years old) was 2.80%– 3.95% (3). Hypertension (HTN) is the predominant diabetes-related comorbidity in sub-Saharan Africa and affects a significant number of people with diabetes. In recent years, LMICs have been witnessing a significant shift toward increased blood pressure; however, in LMICs, only 1 in 3 are aware of their hypertension status, and approximately eight percent have their blood pressure controlled (4). HTN and T2DM frequently coexist as comorbidities (5). HTN occurs twice as often in individuals with T2DM as in those without T2DM. Furthermore, individuals with HTN frequently have insulin resistance and are at increased risk of developing diabetes compared with individuals who are not hypertensive. As many as 75% of individuals with T2DM suffer from HTN, whereas individuals with HTN alone frequently present signs of insulin resistance(6). Hypertension and diabetes are prevalent, interconnected illnesses that exhibit considerable overlap in their underlying risk factors, including ethnicity, family history, dyslipidaemia, and lifestyle choices, as well as in their consequences. These problems include microvascular and macrovascular diseases. Macrovascular consequences, which are frequently observed in patients with T2DM and HTN, include coronary artery disease, myocardial infarction, stroke, congestive heart failure, and peripheral vascular disease (6). Cardiovascular disease, aggravated by hypertension, is the primary cause of morbidity and mortality in individuals with diabetes (5). While microvascular consequences (retinopathy, nephropathy, and neuropathy) are often associated with hyperglycaemia, research indicates that hypertension is a significant risk factor, particularly for nephropathy (6). The Global Diabetes Compact, initiated by the World Health Organisation (WHO), aims to diminish disparities in access to diagnosis and treatment, guaranteeing that all individuals can obtain care in primary health settings by incorporating affordable diabetes management to address this critical public health concern (7). Effective management of these conditions demands continuous self-care, which can be challenging and expensive because patients frequently lack the requisite knowledge, resources, and support for optimal management outcomes (8). Recent clinical studies have shown that positive results in the management of type 2 diabetes and hypertension are strongly associated with aerobic exercise (9, 10). In 2010, the WHO released a Package of Essential NCDs (PEN) intervention for primary healthcare (WHO PEN) to aid LMICs in identifying and managing NCDs at the primary healthcare level. The WHO PEN offered a set of cost-effective interventions to be implemented at minimal expense and acceptable quality of care; however, it did not specify how these interventions could be linked with chronic illness management. Hence, NCDs such as diabetes and hypertension are still managed separately (11, 12). Patients with T2DM and HTN are at particular risk of poor quality of care because the need for multiple specialists increases the likelihood of medical errors, such as poor outcomes because of adherence challenges, lower quality of life, and higher cost (13). The suboptimal quality of healthcare accounts for 10–15% of mortality (5.7 million–8.4 million deaths) annually (14). Additional barriers to effective care for people with T2DM and HTN include financial costs, stigma, and shortages of health professionals (13). These barriers are pervasive in LMICs and lead to avoidable poor outcomes for an increasing number of people with comorbid diseases (13). The World Health Organisation has endorsed a feasible and efficient integrated care model to address the growing burdens of comorbid conditions globally, increase access to health care, and improve health outcomes. In Ghana, these patients are mostly managed at tertiary hospitals, which also serve as referral centres. Patients diagnosed with this condition are managed by medications, dieticians, and ophthalmologic consultations in Ghana. There remains a need to systematically review the available evidence concerning exercise interventions for patients with T2DM and HTN comorbidity toward an integrated care approach. Objective To identify, examine, and synthesise existing evidence on the incorporation and efficacy of exercise interventions (type, duration, and frequency) for patients with type 2 diabetes and hypertension comorbidity via an integrated care approach. Method The design will be guided by an evidence synthesis using the Preferred Reporting Items for Systematic Reviews (PRISMA) checklist, the meta-analysis (PRISMA) checklist, and the P-Population, I-Intervention, C-Comparator, O-Outcome (PICO). The PubMed, Medline, Cochrane Library, Academic Search Complete, SPORTDiscus, and Cumulative Index for Allied Health Literature (CINAHL) databases will be systematically searched via terms related to Type 2 Diabetes, Hypertension, and Exercise Interventions via the PICO framework. Interventional studies that are randomised and non-randomised controlled trials will be included. Three reviewers will independently screen the studies, extract data via the COVIDENCE software, and assess the quality of the studies and evidence via the Pedro scale of risk of bias tool and the GRADE approach, respectively. If feasible, a meta-analysis will be performed via RevMan (version 5.4; the Cochrane Collaboration). All eligible studies will be included, irrespective of the setting, since it is an evidence synthesis. The protocol is registered on PROSPERO ( https://www.crd.york.ac.uk/PROSPERO/view/CRD420251016833 ). Eligibility criteria Inclusion criteria Randomised controlled trials (RCTs), non-RCTs, controlled before-and-after studies of patients diagnosed with T2DM and/or HTN, and quasi-experimental designs. All the articles should use a type, duration, and frequency of exercise as an intervention or as part of managing the disease, such as either diabetes alone or hypertension alone. All the articles reporting on the effects of the multidisciplinary (MDT) integrated approach in managing type 2 diabetes and hypertension. Articles should be published in English. Exclusion criteria Observational studies When the full text of the article cannot be found When the intervention does not include exercise. When the participants do not meet the inclusion criteria. When any of the data required for research is not available. Research articles with a high risk of bias. Information Sources The PubMed, Medline, Cochrane Library, Academic Search Complete, SPORTDiscus, and Cumulative Index for Allied Health Literature (CINAHL) databases will be systematically searched via terms related to Type 2 Diabetes, Hypertension, and Exercise Interventions via the PICO framework. Search strategy The PI (BO) and an information specialist (MN) will create, test, and improve the search strategies. The key review concepts will be used to determine the search terms. Various terms from the medical subject categories will be used in all searches. The suitability of the search strings will be determined by conducting a pilot PubMed search. After that, the search terms would be changed to match the subject headings and syntax of the other databases, which include PubMed and Medline. African Journals through the SABINET platform, Cumulative Index for Nursing and Allied Health Literature (CINAHL), and Cochrane Library. Wildcard searches will be conducted for keywords in the MeSH terms, abstract, and title sections. Additionally, truncated keywords will be used. Boolean operators (AND, OR, and NOT), along with index terms and keywords, will be combined to help find the most comprehensive results. Databases are structured and indexed differently, so a separate search strategy may be required to search the databases. Study selection and data extraction The full-text screening and article selection will be performed by three impartial reviewers (WL, GA, and VBT) according to the eligibility requirements. Discussions and consultation with BO will be used to resolve disagreements and conflicts. BO and JT will perform data extraction. BO will be consulted before any discrepancies are handled. Data extraction will be guided via a prespecified template. The principal investigator (BO) will be in charge of training the WL, GA, and VBT. If information not specifically stated in the eligible articles is needed, we will contact the authors of those papers. The PRISMA diagram provides a detailed explanation of the flow of the research during the selection process and the rationale for exclusion. Data Items The primary data sought in this study phase are risk of bias, the efficacy of exercise interventions for type 2 diabetes-hypertension comorbidity, the pooled odds ratio per risk and their corresponding heterogeneity measure (I2), publication bias, risk responsiveness, risk weight, clinically minimum importance difference (CMID) status, clinical strata, and critical risk points. The predictive potential will be assessed via the OR. The secondary data items include study characteristics, namely, sample size, sampling technique, setting, and year of publication. Data management After completing the literature search, the results will be exported to EndNote 22 for duplicate removal. Using EndNote 22, articles will be screened for titles and abstracts after duplicates have been eliminated. The PRISMA flow chart will be constructed by organising and exporting included and excluded articles to EndNote 22. The data will be stored for at least 10 years at the Department of Physiotherapy, University of Pretoria. Assessment of risk of bias (ROB) The risk of bias will be evaluated via the tool recommended by the Cochrane Handbook for Systematic Reviews of Interventions 5.1.0. WL, GA, and VBT will independently appraise 20% of the included studies until at least 80% interrater agreement is achieved. Thereafter, the PO will assess the remaining publications. Missing data If feasible, we will contact the authors to acquire any missing data, particularly information crucial for conducting a meta-analysis. If the authors cannot provide the missing data or do not respond after 3 attempts, the study will be excluded from subsequent statistical analyses. With respect to the documentation of significant protocol alterations, this section will log the date of each amendment along with a description of the modification and its rationale. These changes will be recorded without integration into the protocol itself. Summary measures, data synthesis, and analysis We will summarise sociodemographic and study characteristics using frequency, mean, and standard deviation. The primary aim of this review is to determine the efficacy of exercise intervention for diabetes and hypertension comorbidity. Therefore, we will use the standardised mean difference as a measure to assess the effectiveness of strategies for preventing secondary strokes. To do this, we will compare the groups that received the intervention with the control/placebo group. For continuous outcomes, we will present the results by using the average values within each group and calculating variances on the basis of their standard deviations. To calculate the overall standardised difference in means between the intervention and control groups, along with a 95% confidence interval (CI), we will employ a random effects meta-analysis approach. We chose the random-effects model because we anticipate several factors: (1) eligible studies may exhibit significant functional heterogeneity; (2) we aim to determine a common effect size applicable to a diverse adult population; (3) some studies may have extreme effect sizes that could introduce bias; and (4) there is a substantial number of studies, allowing for a precise estimation of the variation between studies. In cases where post-treatment outcomes were measured multiple times, we use the most recent measurement available. We will conduct a subgroup analysis, focusing on the follow-up point with the most extensive data, to evaluate the long-term effectiveness of the interventions. We will employ a random-effects Mantel‒Haenszel meta-analysis for binary outcomes and present odds ratios (ORs) with 95% confidence intervals (CIs). Heterogeneity will be assessed via I2, and heterogeneity exceeding 50% will be considered substantial (15). We will also determine publication bias via a funnel plot and Egger's regression intercept. Our meta-analysis will be conducted via Comprehensive Meta-Analysis Version 3. Sensitivity To determine whether questionable judgments made during the review process impact the meta-analysis results, a sensitivity analysis employing a "one study removed" technique will be performed (16). Studies with an effect size beyond the 95% confidence interval of the mean effect size will be regarded as outliers in this method. Meta-bias and meta-regression The funnel plot will be visually evaluated to detect publication bias. Additionally, Egger's test will be used to analyse the symmetry of the funnel plot statistically. A nonsignificant test statistic demonstrates funnel plot symmetry and suggests the absence of publication bias. Meta-regression will be employed to consider the impact of moderator variables such as age and dosage. Confidence in cumulative evidence Using the GRADE approach according to (17), the strength (certainty) of the evidence, namely, the predictive potential of the determinants of death among patients with type 2 diabetes and hypertension comorbidity in Ghana and sub-Saharan Africa, will be assessed as follows: Bias risk: To assess the quality of the eligible articles, the JBI risk of bias assessment tool for cohort studies will be used. There will be three categories for bias risk: low, moderate, and high. If there are serious concerns about the possibility of bias, the grade of evidence, also known as the level or certainty of the evidence, may be lowered by one level for a high risk of bias or by two levels for a moderate risk of bias (17). Inconsistency refers to the significantly different effect estimates derived from the heterogeneity and variation in study findings. It shows the real variations in effect estimates with less bias (17). We will evaluate inconsistency with I2. Values below 40% are deemed low, those between 30% and 60% are classified as moderate, those ranging from 50–90% are regarded as substantial, and those ranging from 75–100% are identified as necessary. In the event of significant heterogeneity, the evidence will be downgraded by one level. Indirectness: The evidence supporting a research question may be implicit because patient differences, exposures, comparisons, or outcomes state that when (17) there are significant differences between the population, comparisons, or outcomes of interest and those measured in the available evidence, the degree of certainty in the evidence will be decreased by one level. Imprecision: Results with wider confidence intervals and lower precision are usually obtained from research involving small numbers of patients, small numbers of events observed, or a high degree of variability in patient effects (17). A study is considered imprecise if its confidence interval is greater than the predefined threshold or if its dataset is not as large as it could be. These factors reduce the certainty of the evidence. However, the result may be imprecise if the confidence intervals overlap in clinically significant differences. Relative risks of 0.75 and 1.25 were used as benchmarks for assessing the precision of findings (17). Publication bias: Reporting biases may occur when studies are not fully reported in the published literature(17), indicating that publication bias makes studies more eligible for guidelines or systematic reviews. Therefore, depending on the degree of bias, the existence of publications may lower the grade of evidence by one or two points (17). Results This systematic review protocol was developed in February 2025 to assess the efficacy of exercise interventions for HTN-T2DM comorbidity. To our knowledge, this will be the first systematic review focused specifically on exercise interventions for HTN-T2DM comorbidity. This review aims to synthesise evidence on the efficacy of exercise interventions for HTN-T2DM comorbidity via an integrated care approach. Upon completion (anticipated by April 2025), the outcome of this study will be submitted for publication in an academic journal that uses an expert peer-review process to evaluate research manuscripts. Discussion Overview It was hypothesised that there would be enough literature for qualitative and quantitative synthesis and analysis showing the positive effects of exercise interventions for managing patients with HTN-T2DM. This systematic review protocol aims to identify, examine, and synthesise existing evidence regarding the efficacy of exercise interventions for HTN-T2DM comorbidity via an integrated care approach. This review will synthesise evidence on the efficacy of exercise interventions for HTN-T2DM comorbidity. Principal Findings Previous RCTs and systematic reviews have demonstrated the effectiveness of exercise interventions in improving clinical outcomes in the general population with either diabetes or hypertension. This review will synthesise evidence on the efficacy of exercise interventions for HTN-T2DM comorbidity. Abbreviations CI: Causality index CINAHL: Cumulative index for nursing and allied health literature CMID: Clinical minimum important difference HTN: Hypertension PRISMA: Preferred items for reporting systematic reviews and meta-analyses T2DM: Type 2 Diabetes HTN-T2DM: Hypertension-Type 2 Diabetes Comorbidity. Declarations Ethics approval and consent to participate : Not applicable Consent for publication : Not applicable Availability of data and materials: Study data will be available upon reasonable request. Competing interests The authors declare that there are no conflicts of interest. Funding The primary reviewer, Bridgette Opoku, is a PhD student with the Department of Physiotherapy, University of Pretoria, South Africa. Acknowledgement The authors thank the librarian who helped with setting keywords and the search strategy for the study. Clinical Trial Number : Not Applicable Authors' contributions Bridgette Opoku (BO), Martins Nweke (MN), and Nombeko Mshunqane (NM) conceived and designed the study. Both BO and a trained research assistant will carry out the search and data screening. Data will be extracted by a trained research assistant and verified by BO. BO will carry out data curation and analysis. MN and NM contributed to the drafting of the review manuscript. Both authors approved the final manuscript for submission to the journal. References Mapa-Tassou C, Katte J-C, Mba Maadjhou C, Mbanya JC. The economic impact of diabetes in Africa. Current diabetes reports. 2019;19:1-8. Al Dawish, MA, Robert, AA. Diabetes Mellitus in Saudi Arabia: challenges and possible solutions. Handbook of healthcare in the Arab world: Springer; 2021. p. 1083-100. Kazibwe J, Gad M, Abassah-Konadu E, Amankwah I, Owusu R, Gulbi G, et al. The epidemiological and economic burden of diabetes in Ghana: A scoping review to inform health technology assessment. PLOS global public health. 2024;4(3):e0001904. Schutte AE, Srinivasapura Venkateshmurthy N, Mohan S, Prabhakaran D. Hypertension in low-and middle-income countries. Circulation research. 2021;128(7):808-26. Petrie JR, Guzik TJ, Touyz RM. Diabetes, hypertension, and cardiovascular disease: clinical insights and vascular mechanisms. Canadian Journal of Cardiology. 2018;34(5):575-84. Long AN, Dagogo‐Jack S. Comorbidities of diabetes and hypertension: mechanisms and approach to target organ protection. The journal of clinical hypertension. 2011;13(4):244-51. Silva-Tinoco R, Cuatecontzi-Xochitiotzi T, Castillo-Martínez L, de la Torre-Saldaña V, Guzman-Olvera E, Bernal-Ceballos F. Impact of a multicomponent integrated care delivery program on diabetes care goals achievement: a primary care quality improvement initiative. Primary Care Diabetes. 2023;17(6):568-74. Liu L, Quang ND, Banu R, Kumar H, Tham Y-C, Cheng C-Y, et al. Hypertension, blood pressure control and diabetic retinopathy in a large population-based study. PLoS One. 2020;15(3):e0229665. Opoku B, de Beer-Brandon CR, Quartey J, Mshunqane N. Effects of brisk walking on fasting blood glucose and blood pressure in diabetic patients. Journal of Metabolic Health. 2023;6(1):7. Lotsu E, Kwakye S, Mohammed T, Opoku B, Quartey J, Lawson H. Effects of aerobic exercise on fasting blood glucose and blood pressure levels of diabetic-hypertensive clients at a diabetes clinic in Accra, Ghana. Journal of Preventive and Rehabilitative Medicine. 2021;3(2):75-84. Vaidya A, Simkhada P, Lee A, Jones S, Mukumbang FC. Implementing a package of essential noncommunicable diseases interventions in low-and middle-income countries: a realist review protocol. BMJ Open. 2023;13(9):e074336. Demaio AR, Nielsen KK, Tersbøl BP, Kallestrup P, Meyrowitsch DW. Primary Health Care: a strategic framework for the prevention and control of chronic noncommunicable disease. Global health action. 2014;7(1):24504. Uwimana Nicol J, Rohwer A, Young T, Bavuma CM, Meerpohl JJ. Integrated models of care for diabetes and hypertension in low-and middle-income countries (LMICs): Protocol for a systematic review. Systematic reviews. 2018;7:1-9. Ali MK, Chwastiak L, Poongothai S, Emmert-Fees KM, Patel SA, Anjana RM, et al. Effect of a collaborative care model on depressive symptoms and glycated haemoglobin, blood pressure, and serum cholesterol among patients with depression and diabetes in India: the INDEPENDENT randomised clinical trial. Jama. 2020;324(7):651-62. Jpt H. Cochrane Handbook for systematic reviews of interventions. http://www cochrane-handbook org. 2008. Tadesse K, Amare H, Hailemariam T, Gebremariam T. Prevalence of hypertension among patients with type 2 diabetes mellitus and its sociodemographic factors in Nigist Ellen Mohamed Memorial Hospital, Hosanna, Southern Ethiopia. J Diabetes Metab. 2018;9(4):4-10. Guyatt GH, Oxman AD, Vist G, Kunz R, Brozek J, Alonso-Coello P, et al. GRADE guidelines: 4. Rating the quality of evidence—study limitations (risk of bias). Journal of Clinical Epidemiology. 2011;64(4):407-15. Cite Share Download PDF Status: Under Review Version 1 posted Reviewers agreed at journal 12 Aug, 2025 Reviewers invited by journal 11 Aug, 2025 Editor assigned by journal 11 Aug, 2025 First submitted to journal 08 Aug, 2025 Editorial decision: Major revision 19 Jul, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6636610","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":498961335,"identity":"fc5b77ab-1c22-4aba-94fe-8fdb93629c66","order_by":0,"name":"Nombeko Mshunqane","email":"","orcid":"","institution":"University of Kwazulu-Natal","correspondingAuthor":false,"prefix":"","firstName":"Nombeko","middleName":"","lastName":"Mshunqane","suffix":""},{"id":498961336,"identity":"b118c409-0974-47d7-b23f-7ca211ea6c29","order_by":1,"name":"BRIDGETTE Opoku","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA7ElEQVRIie3QMWvCUBDA8QtP7i2Jb80h1K9wIoiFfphAwLljtz4Q4hJw9SF+h3TrqDxwErrGLaFroXbrEGjjWsozbg7vP9+POw7A57vFhLDVV4PPS6kh0J2IxNnI6H5gctuVqJAHkb4LijLtSNiGPI5eJ4LM555WDQwVyPrkJvhYbw4zVIMU6SWD9kpIYzcRBX/gPqR1S2oNCW9he4EAxyH+xHy0SFVzJsH82016TFGGzKVAKvBMBDq3kG2fvDpgQnk6vjdZPDJzxKmL9N+srU5PmCi5q4958zBUcvFeusjf2pPENfM+n8/n+7dfVwJHyG1diIQAAAAASUVORK5CYII=","orcid":"https://orcid.org/0000-0001-9005-2098","institution":"University of Pretoria","correspondingAuthor":true,"prefix":"","firstName":"BRIDGETTE","middleName":"","lastName":"Opoku","suffix":""},{"id":498961337,"identity":"067f8942-e424-48d2-b5cb-a320dc291b41","order_by":2,"name":"Martins Nweke","email":"","orcid":"","institution":"University of Pretoria","correspondingAuthor":false,"prefix":"","firstName":"Martins","middleName":"","lastName":"Nweke","suffix":""}],"badges":[],"createdAt":"2025-05-10 20:07:50","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6636610/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6636610/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":89386202,"identity":"94a430f9-cff9-4772-a92f-258a870544f8","added_by":"auto","created_at":"2025-08-19 12:34:53","extension":"jpeg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":302824,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003ePRISMA flow diagram\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"floatimage1.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-6636610/v1/1d6a2dbe8460ef11ce8b9672.jpeg"},{"id":89389816,"identity":"750c83dc-ea72-4474-9cbc-c918a1ff3e73","added_by":"auto","created_at":"2025-08-19 12:50:58","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":848883,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6636610/v1/c56c438a-a1f2-4e0a-a53b-212f6606c2bf.pdf"}],"financialInterests":"","formattedTitle":"\u003cp\u003eEfficacy of Exercise Interventions for Type 2 Diabetes and Hypertension Co-Morbidity: A Systematic Review Protocol\u003c/p\u003e","fulltext":[{"header":"Introduction","content":"\u003cp\u003eType 2 diabetes (T2DM) is increasingly recognised as a global pandemic, impacting approximately 9.3% (463\u0026nbsp;million) of the world’s population as of 2019 (1). Approximately 80% of people diagnosed with diabetes reside in low- and middle-income countries (LMICs), often presenting with multiple comorbidities (2). The prevalence in Ghana in the adult population (20–79 years old) was 2.80%– 3.95% (3). Hypertension (HTN) is the predominant diabetes-related comorbidity in sub-Saharan Africa and affects a significant number of people with diabetes. In recent years, LMICs have been witnessing a significant shift toward increased blood pressure; however, in LMICs, only 1 in 3 are aware of their hypertension status, and approximately eight percent have their blood pressure controlled (4).\u003c/p\u003e\u003cp\u003eHTN and T2DM frequently coexist as comorbidities (5). HTN occurs twice as often in individuals with T2DM as in those without T2DM. Furthermore, individuals with HTN frequently have insulin resistance and are at increased risk of developing diabetes compared with individuals who are not hypertensive. As many as 75% of individuals with T2DM suffer from HTN, whereas individuals with HTN alone frequently present signs of insulin resistance(6). Hypertension and diabetes are prevalent, interconnected illnesses that exhibit considerable overlap in their underlying risk factors, including ethnicity, family history, dyslipidaemia, and lifestyle choices, as well as in their consequences. These problems include microvascular and macrovascular diseases. Macrovascular consequences, which are frequently observed in patients with T2DM and HTN, include coronary artery disease, myocardial infarction, stroke, congestive heart failure, and peripheral vascular disease (6). Cardiovascular disease, aggravated by hypertension, is the primary cause of morbidity and mortality in individuals with diabetes (5). While microvascular consequences (retinopathy, nephropathy, and neuropathy) are often associated with hyperglycaemia, research indicates that hypertension is a significant risk factor, particularly for nephropathy (6).\u003c/p\u003e\u003cp\u003eThe Global Diabetes Compact, initiated by the World Health Organisation (WHO), aims to diminish disparities in access to diagnosis and treatment, guaranteeing that all individuals can obtain care in primary health settings by incorporating affordable diabetes management to address this critical public health concern (7). Effective management of these conditions demands continuous self-care, which can be challenging and expensive because patients frequently lack the requisite knowledge, resources, and support for optimal management outcomes (8).\u003c/p\u003e\u003cp\u003eRecent clinical studies have shown that positive results in the management of type 2 diabetes and hypertension are strongly associated with aerobic exercise (9, 10). In 2010, the WHO released a Package of Essential NCDs (PEN) intervention for primary healthcare (WHO PEN) to aid LMICs in identifying and managing NCDs at the primary healthcare level. The WHO PEN offered a set of cost-effective interventions to be implemented at minimal expense and acceptable quality of care; however, it did not specify how these interventions could be linked with chronic illness management. Hence, NCDs such as diabetes and hypertension are still managed separately (11, 12). Patients with T2DM and HTN are at particular risk of poor quality of care because the need for multiple specialists increases the likelihood of medical errors, such as poor outcomes because of adherence challenges, lower quality of life, and higher cost (13). The suboptimal quality of healthcare accounts for 10–15% of mortality (5.7 million–8.4\u0026nbsp;million deaths) annually (14).\u003c/p\u003e\u003cp\u003eAdditional barriers to effective care for people with T2DM and HTN include financial costs, stigma, and shortages of health professionals (13). These barriers are pervasive in LMICs and lead to avoidable poor outcomes for an increasing number of people with comorbid diseases (13). The World Health Organisation has endorsed a feasible and efficient integrated care model to address the growing burdens of comorbid conditions globally, increase access to health care, and improve health outcomes. In Ghana, these patients are mostly managed at tertiary hospitals, which also serve as referral centres. Patients diagnosed with this condition are managed by medications, dieticians, and ophthalmologic consultations in Ghana. There remains a need to systematically review the available evidence concerning exercise interventions for patients with T2DM and HTN comorbidity toward an integrated care approach.\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eObjective\u003c/strong\u003e\u003c/p\u003e\u003cp\u003eTo identify, examine, and synthesise existing evidence on the incorporation and efficacy of exercise interventions (type, duration, and frequency) for patients with type 2 diabetes and hypertension comorbidity via an integrated care approach.\u003c/p\u003e"},{"header":"Method","content":"\u003cp\u003eThe design will be guided by an evidence synthesis using the Preferred Reporting Items for Systematic Reviews (PRISMA) checklist, the meta-analysis (PRISMA) checklist, and the P-Population, I-Intervention, C-Comparator, O-Outcome (PICO). The PubMed, Medline, Cochrane Library, Academic Search Complete, SPORTDiscus, and Cumulative Index for Allied Health Literature (CINAHL) databases will be systematically searched via terms related to Type 2 Diabetes, Hypertension, and Exercise Interventions via the PICO framework. Interventional studies that are randomised and non-randomised controlled trials will be included. Three reviewers will independently screen the studies, extract data via the COVIDENCE software, and assess the quality of the studies and evidence via the Pedro scale of risk of bias tool and the GRADE approach, respectively. If feasible, a meta-analysis will be performed via RevMan (version 5.4; the Cochrane Collaboration). All eligible studies will be included, irrespective of the setting, since it is an evidence synthesis. The protocol is registered on PROSPERO (\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.crd.york.ac.uk/PROSPERO/view/CRD420251016833\u003c/span\u003e\u003cspan address=\"https://www.crd.york.ac.uk/PROSPERO/view/CRD420251016833\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e).\u003c/p\u003e\u003ch3\u003eEligibility criteria\u003c/h3\u003e\u003cp\u003e\u003cb\u003eInclusion criteria\u003c/b\u003e\u003c/p\u003e\u003col\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003eRandomised controlled trials (RCTs), non-RCTs, controlled before-and-after studies of patients diagnosed with T2DM and/or HTN, and quasi-experimental designs.\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003eAll the articles should use a type, duration, and frequency of exercise as an intervention or as part of managing the disease, such as either diabetes alone or hypertension alone.\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003eAll the articles reporting on the effects of the multidisciplinary (MDT) integrated approach in managing type 2 diabetes and hypertension.\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003eArticles should be published in English.\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003c/ol\u003e\u003cp\u003e\u003cb\u003eExclusion criteria\u003c/b\u003e\u003c/p\u003e\u003col\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003eObservational studies\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003eWhen the full text of the article cannot be found\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003eWhen the intervention does not include exercise.\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003eWhen the participants do not meet the inclusion criteria.\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003eWhen any of the data required for research is not available.\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003eResearch articles with a high risk of bias.\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003c/ol\u003e\u003ch2\u003eInformation Sources\u003c/h2\u003e\u003cp\u003e\u003cb\u003eThe\u003c/b\u003e PubMed, Medline, Cochrane Library, Academic Search Complete, SPORTDiscus, and Cumulative Index for Allied Health Literature (CINAHL) databases will be systematically searched via terms related to Type 2 Diabetes, Hypertension, and Exercise Interventions via the PICO framework.\u003c/p\u003e\u003ch3\u003eSearch strategy\u003c/h3\u003e\u003cp\u003eThe PI (BO) and an information specialist (MN) will create, test, and improve the search strategies. The key review concepts will be used to determine the search terms. Various terms from the medical subject categories will be used in all searches. The suitability of the search strings will be determined by conducting a pilot PubMed search. After that, the search terms would be changed to match the subject headings and syntax of the other databases, which include PubMed and Medline. African Journals through the SABINET platform, Cumulative Index for Nursing and Allied Health Literature (CINAHL), and Cochrane Library. Wildcard searches will be conducted for keywords in the MeSH terms, abstract, and title sections. Additionally, truncated keywords will be used. Boolean operators (AND, OR, and NOT), along with index terms and keywords, will be combined to help find the most comprehensive results. Databases are structured and indexed differently, so a separate search strategy may be required to search the databases.\u003c/p\u003e\u003ch3\u003eStudy selection and data extraction\u003c/h3\u003e\u003cp\u003eThe full-text screening and article selection will be performed by three impartial reviewers (WL, GA, and VBT) according to the eligibility requirements. Discussions and consultation with BO will be used to resolve disagreements and conflicts. BO and JT will perform data extraction. BO will be consulted before any discrepancies are handled. Data extraction will be guided via a prespecified template. The principal investigator (BO) will be in charge of training the WL, GA, and VBT. If information not specifically stated in the eligible articles is needed, we will contact the authors of those papers. The PRISMA diagram provides a detailed explanation of the flow of the research during the selection process and the rationale for exclusion.\u003c/p\u003e\u003ch3\u003eData Items\u003c/h3\u003e\u003cp\u003eThe primary data sought in this study phase are risk of bias, the efficacy of exercise interventions for type 2 diabetes-hypertension comorbidity, the pooled odds ratio per risk and their corresponding heterogeneity measure (I2), publication bias, risk responsiveness, risk weight, clinically minimum importance difference (CMID) status, clinical strata, and critical risk points. The predictive potential will be assessed via the OR. The secondary data items include study characteristics, namely, sample size, sampling technique, setting, and year of publication.\u003c/p\u003e\u003ch3\u003eData management\u003c/h3\u003e\u003cp\u003eAfter completing the literature search, the results will be exported to EndNote 22 for duplicate removal. Using EndNote 22, articles will be screened for titles and abstracts after duplicates have been eliminated. The PRISMA flow chart will be constructed by organising and exporting included and excluded articles to EndNote 22. The data will be stored for at least 10 years at the Department of Physiotherapy, University of Pretoria.\u003c/p\u003e\u003ch2\u003eAssessment of risk of bias (ROB)\u003c/h2\u003e\u003cp\u003eThe risk of bias will be evaluated via the tool recommended by the Cochrane Handbook for Systematic Reviews of Interventions 5.1.0. WL, GA, and VBT will independently appraise 20% of the included studies until at least 80% interrater agreement is achieved. Thereafter, the PO will assess the remaining publications.\u003c/p\u003e\u003ch3\u003eMissing data\u003c/h3\u003e\u003cp\u003eIf feasible, we will contact the authors to acquire any missing data, particularly information crucial for conducting a meta-analysis. If the authors cannot provide the missing data or do not respond after 3 attempts, the study will be excluded from subsequent statistical analyses. With respect to the documentation of significant protocol alterations, this section will log the date of each amendment along with a description of the modification and its rationale. These changes will be recorded without integration into the protocol itself.\u003c/p\u003e\u003ch3\u003eSummary measures, data synthesis, and analysis\u003c/h3\u003e\u003cp\u003eWe will summarise sociodemographic and study characteristics using frequency, mean, and standard deviation. The primary aim of this review is to determine the efficacy of exercise intervention for diabetes and hypertension comorbidity. Therefore, we will use the standardised mean difference as a measure to assess the effectiveness of strategies for preventing secondary strokes. To do this, we will compare the groups that received the intervention with the control/placebo group. For continuous outcomes, we will present the results by using the average values within each group and calculating variances on the basis of their standard deviations.\u003c/p\u003e\u003cp\u003eTo calculate the overall standardised difference in means between the intervention and control groups, along with a 95% confidence interval (CI), we will employ a random effects meta-analysis approach. We chose the random-effects model because we anticipate several factors: (1) eligible studies may exhibit significant functional heterogeneity; (2) we aim to determine a common effect size applicable to a diverse adult population; (3) some studies may have extreme effect sizes that could introduce bias; and (4) there is a substantial number of studies, allowing for a precise estimation of the variation between studies. In cases where post-treatment outcomes were measured multiple times, we use the most recent measurement available. We will conduct a subgroup analysis, focusing on the follow-up point with the most extensive data, to evaluate the long-term effectiveness of the interventions. We will employ a random-effects Mantel‒Haenszel meta-analysis for binary outcomes and present odds ratios (ORs) with 95% confidence intervals (CIs). Heterogeneity will be assessed via I2, and heterogeneity exceeding 50% will be considered substantial (15). We will also determine publication bias via a funnel plot and Egger's regression intercept. Our meta-analysis will be conducted via Comprehensive Meta-Analysis Version 3.\u003c/p\u003e\u003ch2\u003eSensitivity\u003c/h2\u003e\u003cp\u003eTo determine whether questionable judgments made during the review process impact the meta-analysis results, a sensitivity analysis employing a \"one study removed\" technique will be performed (16). Studies with an effect size beyond the 95% confidence interval of the mean effect size will be regarded as outliers in this method.\u003c/p\u003e\u003ch2\u003eMeta-bias and meta-regression\u003c/h2\u003e\u003cp\u003eThe funnel plot will be visually evaluated to detect publication bias. Additionally, Egger's test will be used to analyse the symmetry of the funnel plot statistically. A nonsignificant test statistic demonstrates funnel plot symmetry and suggests the absence of publication bias. Meta-regression will be employed to consider the impact of moderator variables such as age and dosage.\u003c/p\u003e\u003ch2\u003eConfidence in cumulative evidence\u003c/h2\u003e\u003cp\u003eUsing the GRADE approach according to (17), the strength (certainty) of the evidence, namely, the predictive potential of the determinants of death among patients with type 2 diabetes and hypertension comorbidity in Ghana and sub-Saharan Africa, will be assessed as follows:\u003c/p\u003e\u003cp\u003eBias risk: To assess the quality of the eligible articles, the JBI risk of bias assessment tool for cohort studies will be used. There will be three categories for bias risk: low, moderate, and high. If there are serious concerns about the possibility of bias, the grade of evidence, also known as the level or certainty of the evidence, may be lowered by one level for a high risk of bias or by two levels for a moderate risk of bias (17).\u003c/p\u003e\u003cp\u003eInconsistency refers to the significantly different effect estimates derived from the heterogeneity and variation in study findings. It shows the real variations in effect estimates with less bias (17). We will evaluate inconsistency with I2. Values below 40% are deemed low, those between 30% and 60% are classified as moderate, those ranging from 50–90% are regarded as substantial, and those ranging from 75–100% are identified as necessary. In the event of significant heterogeneity, the evidence will be downgraded by one level.\u003c/p\u003e\u003cp\u003eIndirectness: The evidence supporting a research question may be implicit because patient differences, exposures, comparisons, or outcomes state that when (17) there are significant differences between the population, comparisons, or outcomes of interest and those measured in the available evidence, the degree of certainty in the evidence will be decreased by one level.\u003c/p\u003e\u003cp\u003eImprecision: Results with wider confidence intervals and lower precision are usually obtained from research involving small numbers of patients, small numbers of events observed, or a high degree of variability in patient effects (17). A study is considered imprecise if its confidence interval is greater than the predefined threshold or if its dataset is not as large as it could be. These factors reduce the certainty of the evidence. However, the result may be imprecise if the confidence intervals overlap in clinically significant differences. Relative risks of 0.75 and 1.25 were used as benchmarks for assessing the precision of findings (17).\u003c/p\u003e\u003cp\u003ePublication bias: Reporting biases may occur when studies are not fully reported in the published literature(17), indicating that publication bias makes studies more eligible for guidelines or systematic reviews. Therefore, depending on the degree of bias, the existence of publications may lower the grade of evidence by one or two points (17).\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eThis systematic review protocol was developed in February 2025 to assess the efficacy of exercise interventions for HTN-T2DM comorbidity. To our knowledge, this will be the first systematic review focused specifically on exercise interventions for HTN-T2DM comorbidity. This review aims to synthesise evidence on the efficacy of exercise interventions for HTN-T2DM comorbidity via an integrated care approach. Upon completion (anticipated by April 2025), the outcome of this study will be submitted for publication in an academic journal that uses an expert peer-review process to evaluate research manuscripts.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cdiv id=\"Sec16\" class=\"Section2\"\u003e\u003ch2\u003eOverview\u003c/h2\u003e\u003cp\u003eIt was hypothesised that there would be enough literature for qualitative and quantitative synthesis and analysis showing the positive effects of exercise interventions for managing patients with HTN-T2DM. This systematic review protocol aims to identify, examine, and synthesise existing evidence regarding the efficacy of exercise interventions for HTN-T2DM comorbidity via an integrated care approach.\u003c/p\u003e\u003cp\u003eThis review will synthesise evidence on the efficacy of exercise interventions for HTN-T2DM comorbidity.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec17\" class=\"Section2\"\u003e\u003ch2\u003ePrincipal Findings\u003c/h2\u003e\u003cp\u003ePrevious RCTs and systematic reviews have demonstrated the effectiveness of exercise interventions in improving clinical outcomes in the general population with either diabetes or hypertension. This review will synthesise evidence on the efficacy of exercise interventions for HTN-T2DM comorbidity.\u003c/p\u003e\u003c/div\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eCI: Causality index\u003c/p\u003e\n\u003cp\u003eCINAHL: Cumulative index for nursing and allied health literature\u003c/p\u003e\n\u003cp\u003eCMID:\u0026nbsp;Clinical\u0026nbsp;minimum important\u0026nbsp;difference\u003c/p\u003e\n\u003cp\u003eHTN: Hypertension\u003c/p\u003e\n\u003cp\u003ePRISMA: Preferred items for reporting systematic\u0026nbsp;reviews\u0026nbsp;and meta-analyses\u003c/p\u003e\n\u003cp\u003eT2DM: Type 2 Diabetes\u003c/p\u003e\n\u003cp\u003eHTN-T2DM: Hypertension-Type 2 Diabetes Comorbidity.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e: Not applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e: Not applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials:\u003c/strong\u003e Study data will be available upon reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that there are no conflicts of interest.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe primary reviewer, Bridgette Opoku, is a PhD student with the Department of Physiotherapy, University of Pretoria, South Africa.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgement\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors thank the librarian who helped with setting keywords and the search strategy for the study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eClinical Trial Number\u003c/strong\u003e: Not Applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors' contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eBridgette Opoku (BO), Martins Nweke (MN), and Nombeko Mshunqane (NM) conceived and designed the study. Both BO and a trained research assistant will carry out the search and data screening. Data will be extracted by a trained research assistant and verified by BO. BO will carry out data curation and analysis. MN and NM contributed to the drafting of the review manuscript. Both authors approved the final manuscript for submission to the journal.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eMapa-Tassou C, Katte J-C, Mba Maadjhou C, Mbanya JC. The economic impact of diabetes in Africa. Current diabetes reports. 2019;19:1-8.\u003c/li\u003e\n\u003cli\u003eAl Dawish, MA, Robert, AA. Diabetes Mellitus in Saudi Arabia: challenges and possible solutions. Handbook of healthcare in the Arab world: Springer; 2021. p. 1083-100.\u003c/li\u003e\n\u003cli\u003eKazibwe J, Gad M, Abassah-Konadu E, Amankwah I, Owusu R, Gulbi G, et al. The epidemiological and economic burden of diabetes in Ghana: A scoping review to inform health technology assessment. PLOS global public health. 2024;4(3):e0001904.\u003c/li\u003e\n\u003cli\u003eSchutte AE, Srinivasapura Venkateshmurthy N, Mohan S, Prabhakaran D. Hypertension in low-and middle-income countries. Circulation research. 2021;128(7):808-26.\u003c/li\u003e\n\u003cli\u003ePetrie JR, Guzik TJ, Touyz RM. Diabetes, hypertension, and cardiovascular disease: clinical insights and vascular mechanisms. Canadian Journal of Cardiology. 2018;34(5):575-84.\u003c/li\u003e\n\u003cli\u003eLong AN, Dagogo‐Jack S. Comorbidities of diabetes and hypertension: mechanisms and approach to target organ protection. The journal of clinical hypertension. 2011;13(4):244-51.\u003c/li\u003e\n\u003cli\u003eSilva-Tinoco R, Cuatecontzi-Xochitiotzi T, Castillo-Mart\u0026iacute;nez L, de la Torre-Salda\u0026ntilde;a V, Guzman-Olvera E, Bernal-Ceballos F. Impact of a multicomponent integrated care delivery program on diabetes care goals achievement: a primary care quality improvement initiative. Primary Care Diabetes. 2023;17(6):568-74.\u003c/li\u003e\n\u003cli\u003eLiu L, Quang ND, Banu R, Kumar H, Tham Y-C, Cheng C-Y, et al. Hypertension, blood pressure control and diabetic retinopathy in a large population-based study. PLoS One. 2020;15(3):e0229665.\u003c/li\u003e\n\u003cli\u003eOpoku B, de Beer-Brandon CR, Quartey J, Mshunqane N. Effects of brisk walking on fasting blood glucose and blood pressure in diabetic patients. Journal of Metabolic Health. 2023;6(1):7.\u003c/li\u003e\n\u003cli\u003eLotsu E, Kwakye S, Mohammed T, Opoku B, Quartey J, Lawson H. Effects of aerobic exercise on fasting blood glucose and blood pressure levels of diabetic-hypertensive clients at a diabetes clinic in Accra, Ghana. Journal of Preventive and Rehabilitative Medicine. 2021;3(2):75-84.\u003c/li\u003e\n\u003cli\u003eVaidya A, Simkhada P, Lee A, Jones S, Mukumbang FC. Implementing a package of essential noncommunicable diseases interventions in low-and middle-income countries: a realist review protocol. BMJ Open. 2023;13(9):e074336.\u003c/li\u003e\n\u003cli\u003eDemaio AR, Nielsen KK, Tersb\u0026oslash;l BP, Kallestrup P, Meyrowitsch DW. Primary Health Care: a strategic framework for the prevention and control of chronic noncommunicable disease. Global health action. 2014;7(1):24504.\u003c/li\u003e\n\u003cli\u003eUwimana Nicol J, Rohwer A, Young T, Bavuma CM, Meerpohl JJ. Integrated models of care for diabetes and hypertension in low-and middle-income countries (LMICs): Protocol for a systematic review. Systematic reviews. 2018;7:1-9.\u003c/li\u003e\n\u003cli\u003eAli MK, Chwastiak L, Poongothai S, Emmert-Fees KM, Patel SA, Anjana RM, et al. Effect of a collaborative care model on depressive symptoms and glycated haemoglobin, blood pressure, and serum cholesterol among patients with depression and diabetes in India: the INDEPENDENT randomised clinical trial. Jama. 2020;324(7):651-62.\u003c/li\u003e\n\u003cli\u003eJpt H. Cochrane Handbook for systematic reviews of interventions. http://www cochrane-handbook org. 2008.\u003c/li\u003e\n\u003cli\u003eTadesse K, Amare H, Hailemariam T, Gebremariam T. Prevalence of hypertension among patients with type 2 diabetes mellitus and its sociodemographic factors in Nigist Ellen Mohamed Memorial Hospital, Hosanna, Southern Ethiopia. J Diabetes Metab. 2018;9(4):4-10.\u003c/li\u003e\n\u003cli\u003eGuyatt GH, Oxman AD, Vist G, Kunz R, Brozek J, Alonso-Coello P, et al. GRADE guidelines: 4. Rating the quality of evidence\u0026mdash;study limitations (risk of bias). Journal of Clinical Epidemiology. 2011;64(4):407-15.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":true,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"systematic-reviews","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"sysr","sideBox":"Learn more about [Systematic Reviews](http://systematicreviewsjournal.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/sysr/default.aspx","title":"Systematic Reviews","twitterHandle":"@MedicalEvidence","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"","lastPublishedDoi":"10.21203/rs.3.rs-6636610/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6636610/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eHypertension and diabetes often occur together, contributing to morbidity and mortality, particularly in environments with limited resources. Inadequate control of hypertension (HTN)-type 2 diabetes (T2DM) is a significant concern in Ghana because of the increasing burden of associated mortality. While medication and traditional therapies remain essential for the management of HTN-T2DM comorbidity, exercise interventions are glaringly lacking. Therefore, this systematic review aims to identify, examine, and synthesise existing evidence regarding the efficacy of exercise interventions for HTN-T2DM comorbidity via an integrated care approach.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA systematic review with meta-analysis will be performed. The PubMed, Medline, Cochrane Library, Academic Search Complete, SPORT Discus, and Cumulative Index for Allied Health Literature (CINAHL) databases were systematically searched. Terms related to type 2 diabetes, hypertension, and exercise interventions following the PICO framework. Interventional studies that are randomised and non-randomised controlled trials will be included. Two reviewers will independently screen the studies, extract data via EndNote 22, and assess the quality of the studies and the evidence via the PEDro scale of risk of bias tool and the GRADE approach, respectively. A third reviewer will be consulted to resolve possible conflicts. The analysis will be performed via RevMan (version 5.4; the Cochrane Collaboration).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study is currently at the proposal stage and in preparation for the search phase. We aim to start searching peer-reviewed articles in February 2025 and project to complete data extraction in June 2025.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis systematic review protocol outlines a rigorous methodology for evaluating the effects of exercise interventions for patients with type 2 diabetes and hypertension comorbidity. The findings will inform clinical practice and guide the development of a model of care via an integrated approach.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTrial registration\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eCRD420251016833\u003c/p\u003e","manuscriptTitle":"Efficacy of Exercise Interventions for Type 2 Diabetes and Hypertension Co-Morbidity: A Systematic Review Protocol","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-08-19 12:34:49","doi":"10.21203/rs.3.rs-6636610/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"reviewerAgreed","content":"","date":"2025-08-12T15:37:40+00:00","index":0,"fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-08-11T17:55:39+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-08-11T07:29:09+00:00","index":"","fulltext":""},{"type":"submitted","content":"Systematic Reviews","date":"2025-08-08T06:36:15+00:00","index":"","fulltext":""},{"type":"decision","content":"Major revision","date":"2025-07-19T05:07:03+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"systematic-reviews","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"sysr","sideBox":"Learn more about [Systematic Reviews](http://systematicreviewsjournal.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/sysr/default.aspx","title":"Systematic Reviews","twitterHandle":"@MedicalEvidence","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"6150ba56-eb42-474f-b4dd-8091b755877c","owner":[],"postedDate":"August 19th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2025-09-27T17:49:08+00:00","versionOfRecord":[],"versionCreatedAt":"2025-08-19 12:34:49","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6636610","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6636610","identity":"rs-6636610","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}