Journal of Environmental Treatment Techniques  
2020, Volume 8, Issue 4, Pages: 1420-1424  
J. Environ. Treat. Tech.  
ISSN: 2309-1185  
Journal web link:  
Effect of Aerobic and Arm Exercises on HbA1c and  
Immunological Properties of Breast Milk in  
Diabetic Lactating Women  
Magda Sayed Morsi *, Adel Farouk El Begawy , Reham Hamed Saad Hamza  
Department of Physical Therapy for Woman’s Health, Faculty of Physical Therapy, Cairo University, Egypt  
Department of Gynecology and Obstetrics, Faculty of Medicine, Cairo University, Egypt  
Objective: To assess the therapeutic efficacy of aerobic and arm exercises on glycated hemoglobin (HbA1c) and immunological  
properties of breast milk in diabetic lactating women. Material and Methods: This study was carried out on thirty breast feeding  
diabetic lactating women. They were randomly divided into two groups. Group (A) received aerobic and arm exercises, diet program  
and medications for 8 weeks (n=15), while group (B) received diet program and medications for 8 weeks (n=15). HbA1c and  
immunological properties of breast milk (IgA, lactoferrin and lysozyme) were evaluated before and after treatment for both groups.  
Results: Comparing both groups post-treatment showed that there were a statistically significant reduction in HbA1c (p<0.05) and  
statistically significant increases in all immunological properties of breast milk (p<0.05) in favor of group (A). Conclusion: Aerobic  
and arm exercises have a significant positive effect on HbA1c and immunological properties of breast milk in diabetic lactating  
Keywords: Diabetic lactating women, Aerobic and arm exercises, HbA1c, Breast milk, Immunological properties  
synthesis and secretion of immunoglobulins [3]. Hence,  
physical therapy programs for improving glycemic control  
and breast milk immunological properties in diabetic lactating  
women are desirable.  
Lactation gives immunological support for the infant  
against infections during the first months of life and over the  
long-term. Accordingly, the American Academy of Pediatrics  
reaffirms its recommendation of exclusive breast feeding for  
six months followed by continued breast feeding with  
introducing complementary foods for at least one year [1].  
Immunoglobulin A (IgA), lactoferrin and lysozyme represent  
three proteins that are found in relatively high levels in breast  
milk and provide beneficial immunological impact. IgA  
prevents bacterial adherence to mucosal surfaces and  
neutralizes toxins from microorganisms. Lactoferrin works at  
the mucosal sites and has antimicrobial and anti-inflammatory  
activities. It competes with bacteria for ferric iron and  
prevents the growth of microorganisms. Lysozyme is a  
protein that provides bacterial lysis and works synergistically  
with IgA and lactoferrin in antibacterial functions [2].  
Diabetic lactating women have decreased concentrations of  
immunological factors in their breast milk. The total IgA  
concentration in diabetic breast milk was 63.6% lower than in  
those without gestational diabetes [3]. The reduced  
immunoglobulins in breast milk of diabetic women could be a  
result of reduced function of B-cell lymphocyte associated  
with hyperglycemia in diabetes [4-6]. Another mechanism  
explaining the reduction in milk immunoglobulins in diabetic  
women could stem from the reduced circulating levels of  
prolactin associated with obesity and diabetes as demonstrated  
in insulin-dependent diabetes mellitus [7]. Prolactin regulates  
humoral immunity by binding to prolactin receptors on B  
lymphocytes and stimulating ornithine decarboxylase, the  
rate-limiting enzyme in polyamine biosynthesis required for  
Regular exercise is a cornerstone of treatment for  
diabetes. In the 2018 Diabetes Standards of Care publication,  
the American Diabetes Association recommended most  
patients with diabetes should engage in 150ꢀminutes or more  
of moderate intensity physical activity per week [8]. Aerobic  
exercise increases work capacity, improves cardio respiratory  
fitness, improves insulin sensitivity, improves glycemic  
control as reflected in HbA1c, enhances the immune function  
and brings favourable changes in body mass, body  
composition and lipid profile, even without dietary restriction  
9-11]. Previous studies investigated the effect of maternal  
exercise on immunological properties of breast milk in  
healthy lactating women [2, 12]. Additionally, other studies  
examined the effect of exercise training on glycemic control  
in diabetic patients [13, 14]. However, none of them had  
examined the effect of maternal exercise on glycemic control  
and immunological properties of breast milk in diabetic  
lactating women. Therefore, this study was the first one which  
aimed to investigate the effect of aerobic and arm exercises on  
HbA1c and immunological properties of breast milk in  
diabetic lactating women.  
2 Materials and methods  
2.1 Study Design  
The study was designed as a prospective, pre- and post-  
test, randomized, controlled trial. Ethical approval was  
obtained from the institutional review board at Faculty of  
Physical Therapy, Cairo University. The study followed the  
Guidelines of Declaration of Helsinki on the conduct of  
human research. It was conducted between May 2019 and  
February 2020.  
Corresponding author: Magda Sayed Morsi, Department of  
Physical Therapy for Woman’s Health, Faculty of Physical Therapy,  
Cairo University, Egypt. E-mail:  
Journal of Environmental Treatment Techniques  
2020, Volume 8, Issue 4, Pages: 1420-1424  
.2 Participants  
Thirty sedentary, nonsmoking, diabetic lactating women  
2.5 Outcome Measures  
were selected, from the Outpatient Clinic of Gynecology and  
Obstetrics, Imbaba General Hospital and Kasr Al- Ainy  
Hospital, to engage in this study. They had delivered a single,  
full-term, healthy infant without any complications. Their  
HbA1c was greater than or equal to 6.5%, their ages ranged  
from 25 to 35 years old and their body mass index (BMI)  
2.5.1 Plasma blood HbA1c  
Blood samples were collected from all diabetic lactating  
women in both groups to measure plasma levels of HbA1c, a  
weighted average of blood glucose levels during the preceding  
120 days [17], pre- and post-treatment. Samples were  
collected into serum separating tubes and allowed to clot at  
room temperature for 30 minutes. Then, centrifugation of  
blood clot was done at 3000 g for 15 minutes. Aliquots of the  
serum samples were stored at −20 °C for further use. HbA1c  
was measured by using high performance Elisa kit (Bionic  
Company, China) [18].  
ranged from 25 to 30 Kg/m . Lactating women were excluded  
if they had poor lactation, nipple problems (retracted, cracked,  
inflamed or inverted nipples), breast cancer, previous  
surgeries in breast or chest, any cardiorespiratory disease,  
anemia, immune dysfunction, infectious diseases or  
psychiatric disorders. Additionally, lactating women that had  
received contraceptive pills or corticosteroid medications  
were excluded from this study.  
2.5.2 Analyses of immunological properties of breast milk  
A sample of 10 mL of breast milk was collected from  
each diabetic lactating woman in both groups to check the  
concentrations of IgA, lactoferrin and lysozyme pre- and post-  
treatment. Samples were collected into sterile sample bottles  
and transported on ice to the laboratory for analysis through  
an enzyme-linked immunosorbent assay procedure. IgA was  
analyzed by Human IgA ELISA core kit (KOMA BIOTECH),  
while both lactoferrin and lysozyme were analyzed by  
AssayMax Human ELISA kit (ASSAYPRO, USA) [19].  
.3 Randomization  
Informed consent was obtained from all participants  
following the detailed explanation of the study. The privacy of  
all received data and the right to refuse or leave at any  
moment were also provided to all participants. The diabetic  
lactating women were randomly assigned into two groups (A  
and B) using a computer-generated randomization cards saved  
in sealed envelopes. After randomization, there was no  
dropping out of subjects.  
2.6 Statistical analysis  
Statistical Package for Social Science (SPSS) computer  
program (version 23 windows) was used for data analysis.  
Results were expressed as mean and standard deviation (SD).  
The KolmogorovSmirnov distribution test was used for  
examining normal distribution of data. In comparing  
quantitative data, the unpaired samples t-test was used in  
intergroup comparison of parameters, while the Paired  
samples t-test was used for intragroup comparisons. The level  
of significance was set at P value of less than or equal to 0.05.  
.4 Interventions  
Group (A) included 15 diabetic lactating women who  
received aerobic and arm exercises plus diet program for 8  
weeks, while group (B) included 15 diabetic lactating women  
who received medications plus diet program for 8 weeks.  
.4.1 Aerobic and arm exercises  
Each diabetic lactating woman in group (A) received  
aerobic exercise for 30 minutes using treadmill and received  
arm exercise for 15 minutes using multi gym machine for 8  
weeks. For aerobic exercise performance, participants were  
asked to walk on treadmill for 30 minutes (five minutes of  
warm up, 20 minutes of moderate aerobic exercise at 60 to  
Both groups were similar at baseline (P>0.05) regarding  
age, weight, height, BMI and all outcome measures (tables 1-  
). The HbA1c showed a statistically significant reduction  
0% of maximal heart rate (HRmax) and 5 minutes of cooling  
down). HRmax was calculated by subtracting the age from  
20 [15]. Then, participants were asked to perform arm  
within both groups (A and B) (P<0.05). Also, the post-  
treatment comparison of both groups revealed a statistically  
significant reduction in HbA1c (P<0.05) in favour of group  
exercise for 15 minutes using multi gym machine to train  
upper limb muscles including chest and arms muscles. The  
duration of the treatment session was 45 minutes, 3 times per  
week, for 8 weeks.  
A) (Table 2). The immunological properties of breast milk  
IgA, lactoferrin and lysozyme) showed statistically  
significant increases within both groups (A and B) (P<0.05).  
Also, the post-treatment comparison of both groups revealed a  
statistically significant increases in all immunological  
properties of breast milk (P<0.05) in favour of group (A)  
.4.2 Diet program  
All diabetic lactating women in both groups (A and B)  
(Table 2).  
received diet program to follow it during treatment course.  
They were instructed to eat every day 2-3 servings of protein  
foods (e.g. meat, poultry, fish, eggs, beans, nuts and seeds), 4-  
Diabetic lactating women have higher levels of HbA1c in  
servings of dairy products (e.g. milk and yoghurt), 2-4  
their blood and lower levels of immunological factors in their  
breast milk [3, 20]. Therefore, the present study aimed to  
investigate the effect of aerobic and arm exercises on HbA1c  
and immunological properties of breast milk in diabetic  
lactating women. The results of the present study revealed that  
there were a statistically significant reduction in HbA1c and  
statistically significant increases in all immunological  
properties of breast milk (IgA, lactoferrin and lysozyme) post-  
treatment in favor of group (A). These results indicated the  
effectiveness of aerobic and arm exercises in improving  
glycemic control and immunological properties of breast milk  
in diabetic lactating women.  
servings of vegetables per day (including dark green and  
yellow vegetables), 2-3 servings of fruit per day, and 4-5  
servings of whole grains (e.g. whole wheat breads, pasta,  
cereal and oatmeal), as well as drink plenty of water (6-8  
glasses) and fluids daily [16].  
.4.3 Medications  
All diabetic lactating women in both groups (A and B)  
were instructed to follow medications prescribed by physician  
for diabetes during treatment course.  
Journal of Environmental Treatment Techniques  
2020, Volume 8, Issue 4, Pages: 1420-1424  
Table 1: Demographic features of women in both groups  
Group (A)  
n = 15)  
Group (B)  
(n = 15)  
P value  
Age (years)  
Weight (Kg)  
Height (cm)  
29.93 ± 2.46  
71.27 ± 3.39  
159.33 ± 3.90  
28.06 ± 0.76  
29.47 ± 3.07  
73.27 ± 3.31  
160.40 ± 3.91  
28.47 ± 0.67  
0.649 NS  
0.113 NS  
0.461 NS  
0.131 NS  
BMI (Kg/m²)  
P > 0.05 = non-significant, P = Probability.  
Table 2: HbA1c and immunological properties of breast milk for both groups  
Group (A)  
n = 15)  
Group (B)  
(n = 15)  
P value*  
HbA1c (%)  
P value**  
7.33 ± 0.67  
6.43 ± 0.50  
7.37 ± 0.55  
6.90 ± 0.51  
IgA (μg/ml)  
P value**  
174.43 ± 13.70  
240.06 ± 18.02  
180.61 ± 7.40  
220.69 ± 22.82  
Lactoferrin (μg/ml)  
Lysozyme (μg/ml)