Knowledge, physical activity, and control of type 2 diabetes mellitus at Lansot Primary Health Center Tomohon, Indonesia

INTRODUCTION

In Indonesia, the leading cause of fatalities is attributed to non-communicable diseases. This health issue remains a significant focal point, while the occurrence and fatality rates related to non-communicable diseases persist in their ascent. Diabetes mellitus stands as a prominent non-communicable disease afflicting a substantial number of individuals in contemporary society. According to data from the World Health Organization (WHO), diabetes mellitus alone accounted for 1.5 million deaths in the year 2019. What’s of concern is that 48% of these fatalities transpired before reaching the age of 70.¹

Drawing from the data furnished by the International Diabetes Federation (IDF), it is anticipated that the worldwide populace grappling with diabetes mellitus will reach an astounding 783.2 million by the year 2045. Within Indonesia, the count of adults aged 20-79 afflicted with diabetes mellitus is forecasted to surge by 28.6 million within the same timeframe. This constitutes a significant uptick of 47%, as compared to the 19.5 million documented cases in the year 2021. On a global scale, Indonesia secures the fifth position among nations with the highest prevalence of diabetes mellitus patients, trailing behind China, India, Pakistan, and the United States.²

As per data from the National Basic Health Research (Riskesdas), approximately 2% of the population has been diagnosed with diabetes mellitus. Notably, there has been a 1.5% surge in the prevalence of diabetes mellitus among individuals aged 15 years and older. When considering the provinces, five regions within Indonesia display a notably elevated prevalence of diabetes mellitus. Among these, North Sulawesi ranks fourth with a prevalence rate of 2.3%.³ The prevalence of diabetes mellitus tends to escalate with advancing age, and a significant upswing is evident within the 55 to 64 year-old category. Within this specific age bracket, the prevalence surges from 3.88% in the 45-54-year-old group to 6.29.⁴

The prevalence of diabetes mellitus in North Sulawesi Province is established by considering doctors’ diagnoses across all age groups within each district and city. Among the cities within this province, Manado City has the highest prevalence of diabetes mellitus at 3.45%. On the other hand, the city of Tomohon is the fourth highest position in North Sulawesi province, with prevalence rate of 2.91%.³ Derived from an initial study carried out at the Lansot Primary Health Center in January 2023, it has been consistently observed that diabetes mellitus ranks among the ten most prevalent diseases from the years 2019 to 2022.⁵ This study underscores the continuous upward trajectory in the occurrence of diabetes mellitus within the jurisdiction of the Lansot Primary Health Center throughout year 2019 to 2022.

In 2022, Lansot Primary Health Center reported a cumulative count of 453 new cases of diabetes mellitus. Among the different classifications of diabetes mellitus, type 2 diabetes mellitus stands out as the predominant form, constituting a staggering 95% of all cases. This specific variant of diabetes mellitus is notably prevalent within the demographic of individuals aged 45 years and above. It is noteworthy that this age group, ranging from 45 to 64 years old, aligns with the age range ascertained in data from the ministry of health, indicating heightened vulnerability to the onset of diabetes mellitus.³

The escalation in the number of individuals with diabetes mellitus can be attributed to inadequate management of blood sugar levels. When left unaddressed, this condition can result in persistent hyperglycemia, presenting substantial health hazards and potentially giving rise to severe complications.⁶ These complications encompass a spectrum of issues spanning both macrovascular and microvascular domains, including peripheral vascular disease, nerve impairment, cardiovascular ailments, stroke, kidney dysfunction, diabetic retinopathy, and even the potential for blindness.⁷ Previous research found that resident living with diabetes mellitus in the Lanjas subdistrict, highlights that the absence of a healthy lifestyle also poses a significant health challenge for those with diabetes mellitus. Factors such as insufficient physical activity, irregular blood sugar monitoring, and an unhealthy diet are identified as contributing elements to this issue.⁸

It is crucial for individuals who have diabetes to meticulously manage their blood sugar levels as a means to prevent or alleviate potentialcomplications.⁷ Attaining effective diabetes control is intricately linked to the foundational aspects of diabetes management, which encompass diabetes education, dietary choices, engagement in physical activity, and the formulation of a suitable treatment regimen.⁹ Insufficient diabetes knowledge is influenced by several factors, including educational attainment, occupation, income, and accessibility to public health information. A higher level of education generally corresponds to increased access to diverse information concerning diabetes.¹⁰ Nevertheless, it's important to clarify that a lower level of education doesn’t necessarily equate to a lower level of knowledge.¹¹ Lack of physical activity is one of the leading causes of death in non-communicable diseases such as diabetes.¹² Physical activity and history of diabetes also influence the incidence of diabetes.¹³ Physical activity is how people with type 2 diabetes regulate and control blood sugar levels.¹⁴

METHODS

An analytical observation using a cross-sectional design was conducted at Lansot Primary Health Center, Tomohon, Indonesia, from March to June 2023. The population of the study were type 2 diabetes mellitus cases at Lansot Primary Health Center. Sample size was calculated with Lemeshow formula, and then the sample were selected through purposive sampling technique.¹⁵

Inclusion criteria

The inclusion criteria were patients diagnosed with type 2 diabetes mellitus at Lansot Primary Health Center, aged between 45-64 years, residing within Lansot Primary Health Center’s catchment area, and willing to participate by providing informed consent.

Exclusion criteria

Exclusion criteria were patients with communication difficulties, those undergoing insulin therapy, and individuals experiencing cognitive impairment (dementia).

The sample size for this study was 100 respondents.

The study used questionnaires as the research instrument for evaluating the variables. Level of knowledge was evaluated using the diabetes knowledge questionnaire (DKQ)-24, which classifies comprehension as poor (<56%), enough (56-75%), and good (76-100%) according to measurement outcomes.^16-18 Physical activity levels were assessed using the international physical activity questionnaire-short form (IPAQ-SF), which categorizes activity intensity as intense (>1500 MET-minutes/week), moderate (≥600-1500 MET-minutes/week), or light (<600 MET-minutes/week) based on the measurements obtained.¹⁹ The control of type 2 diabetes mellitus management was conducted through the diabetes self management questionnaire-revised (DSMQ-R), which determines control levels as good (76%-100%) and poor (<76%) according to the measurement outcomes..^16,20

The research employed univariate analysis to describe each variable of interest and bivariate analysis to examine the relationship between the level of knowledge and physical activity with control of type 2 diabetes mellitus. Data analysis was conducted using SPSS software version 29.0.

RESULTS

Univariate analysis

Respondents in the age group of 45-54 years were 32 respondents (32%) and respondents in the age group 55-64 years were 68 respondents (68%) (Table 1).

The breakdown of participants by gender indicated that there were more female respondents than male respondents (Table 2).

In Table 3, the most frequently performed jobs by respondents were housewives (38%), then followed by farmers (21%), retirees (15%), entrepreneurs (14%), and civil servants (12%) (Table 3).

The study found that most respondents were high school graduates (40%), then followed by junior high school graduates (28%), degree/bachelor (22%), and the least was primary school graduates (10%) (Table 4).

Based on the three categories of knowledge, 16 respondents (16%) had good knowledge, 51 respondents (51%) had enough knowledge and 33 respondents (33%) had poor knowledge (Table 5).

Distribution of physical activity in Table 6, shows that there were 36 (36%) respondents with high physical activity, 43 respondents (43%) with moderate level, and 21 respondents (21%) with low (Table 6).

Table 7, shows that out of 100 respondents, 56 respondents (56%) had poor type 2 diabetes mellitus control and 44 respondents (46%) had good control (Table 7).

Bivariate analysis

In Table 8, respondents with good knowledge and good diabetes control were 11 (11%), while those with good knowledge but poor control were 5 (5%). Good knowledge and good control were found in 23 respondents (23%), but 28 respondents (28%) with sufficient knowledge showed poor diabetes control. Limited knowledge with good control was seen in 10 respondents (10%), and 23 (23%) had poor knowledge with inadequate diabetes control. The Chi-Square test yielded a significant p value of 0.038 (<α=0.05), indicating a relationship between knowledge level and type 2 diabetes control at the Lansot Primary Health Center in Tomohon (Table 8).

In Table 9, high physical activity was associated with good control for 24 respondents (24%) and poor control for 36 respondents (36%). Moderate physical activity showed good control for 14 respondents (14%) and poor control for 29 respondents (29%). Low physical activity correlated with good control for 6 respondents (6%) and poor control for 15 respondents (15%). The chi-square test revealed a significant relationship between physical activity and type 2 diabetes control at the Lansot Primary Health Center in Tomohon, indicated by a p value of 0.003 (<α=0.05) (Table 9).

DISCUSSION

This study involved 100 respondents between the ages of 45 and 64 years. The aim is to identify the prevalence of diabetes mellitus in this age group. Distribution of age groups based on the Republic of Indonesia in late adulthood a range of age 45-54 years and early elderly with an age range of 55-64 years.³ This is following the basic health research data which shows a high prevalence of diabetes mellitus in this age group. The findings indicated that the majority of those suffering with type 2 diabetes were between the group age of 55-64 years with an average age of 57 years.²¹ In that study also stated that the majority of individuals with type 2 diabetes in developing countries were in the age range of 45-64 years. These findings are consistent with existing theory and knowledge regarding diabetes mellitus prevalence and general features in this age group.

The results of this study shows more female (61%) than male (39%) respondents. Females were also more susceptible to type 2 diabetes mellitus than males.^22,23 Research shows that there are more females than males. The concept of sex is used to differentiate males and females based on existing biological and anatomical factors.²⁴ Females are more at risk of experiencing weight gain and obesity. In 2013, the proportion of overweight females increased to 38% compared to 37% for males. Females have a higher risk of weight gain and obesity, especially after the age of 45. One of the contributing factors is the problem of obesity due to the lack of physical activity in females.²² This leads to overproduction of insulin and insulin resistance, which can eventually lead to type 2 diabetes mellitus. These findings support the existing theory.

The most common occupation of the respondents was homemakers with 38 respondents (38%) and the most uncommon was government employees with 12 respondents (12%). Type of work affects the risk of developing type 2 diabetes mellitus. Work with low physical activity can cause a lack of burning energy which can lead to weight gain. In this condition, the glucose level in the blood becomes too high and there is a great risk of developing type 2 diabetes mellitus.

Treatment for type 2 diabetes mellitus can be done in several ways, such as managing a healthy diet with exercise, controlling blood sugar levels regularly, and avoiding excessive stress.²⁵

The majority of respondents were high school graduates (40%) and education with the lowest frequency was primary school graduates (10%). Knowledge is a person’s attitude related to an object at different levels, it can be said that the higher a person’s education level, the better the knowledge that person has.²⁶ Other research also shows that there is a relationship between education and diabetes mellitus.²⁷ The study findings indicate a positive correlation between higher education and good knowledge about diabetes mellitus. As education level increases, there is an increased likelihood of accessing diverse information related to diabetes mellitus.¹⁰

In this study, the majority of the respondents had adequate knowledge about diabetes mellitus, specifically 51%. Sufficient knowledge about diabetes mellitus enables the implementation of appropriate measures in preventing and managing the associated complications. Knowledge is acquired through observing objects using the senses such as vision, audition, scent, taste, and tactile perception. The level of individual comprehension of these objects varies.²⁶ Accessible information and support from healthcare professionals contribute to the enhancement of knowledge about diabetes mellitus in the community.²⁸

The findings revealed that most respondents with type 2 diabetes mellitus had a moderate level of physical activity, specifically 43 respondents (43%). Physical activity is one of the primary factors in managing type 2 diabetes mellitus. Physical activity pertains to bodily movements that involve the contraction of skeletal muscles and the burning of calories.²⁹ The level of physical activity can vary among individuals depending on their lifestyle and other factors. Physical engagement encompasses work, sleep, and recreation, including planned and structured exercise. Insufficient physical activity can lead to an increase in body fat, weight gain, and type 2 diabetes mellitus risk. Excess fat in the body can be converted into glucose, resulting in an 8.333 times higher risk of developing diabetes mellitus for individuals who are obese.³⁰

Most of the respondents still lack control over type 2 diabetes mellitus, specifically 56 respondents (56%). This is primarily due to insufficient physical activity (47%) and uncontrolled eating habits (63.3%). Insufficient physical activity and uncontrolled eating habits are common obstacles in achieving control over type 2 diabetes mellitus. Adhering to dietary recommendations and engaging in type 2 diabetes mellitus can be much better controlled with the use of proper physical activity. Effective control of diabetes mellitus necessitates active management and regulation by individuals, with the goal of achieving optimal blood glucose levels. This entails various aspects such as dietary adjustments, physical activity, monitoring of blood sugar levels, adherence to medication, and regular consultations with healthcare professionals. By effectively controlling diabetes mellitus, individuals can reduce the risk of complications and maintain their overall health.³¹

Research outcomes were deemed significant when the p value was <0.05. In this study, the chi-square test yielded a p value of 0.038, indicating a value <0.05. This suggests a strong association between the knowledge level variable and the control of type 2 diabetes mellitus among type 2 diabetes patients at Lansot Primary Health Center in Tomohon. The results underscore the impact of knowledge on the control of type 2 diabetes mellitus.

Other studies also found a positive relationship with a correlation coefficient of 0.326 between knowledge and self-management in type 2 diabetes mellitus patients, p value 0.013 <α (0.05) which means between expertise in type 2 self-management for diabetes mellitus patients.³² Other research showed the degree of knowledge and patients’ ability to control themselves are related. with diabetes mellitus. The statistical results show strong significance with a p value of 0.000 and a correlation coefficient of 0.799, also shows a significant relationship with a p value of 0.000 confirms that to what extent knowledge affects the control of diabetes mellitus.^25,26,33 The overall results of this study indicate that good knowledge plays an important role in effective self-management of diabetes mellitus. Confirms that the level of knowledge affects the control of diabetes mellitus. Adequate knowledge enables patients to take appropriate actions in managing diabetes mellitus, including in terms of diet, use of drugs, and a healthy lifestyle.³⁴ The importance of the level of knowledge in controlling diabetes mellitus. the greater one’s level of knowledge of diabetes mellitus, the better the control of this condition. Good knowledge provides an in-depth understanding of the disease, risk factors, and effective management strategies. Increasing the amount of knowledge among people with type 2 diabetes is important to improve control of their condition and quality of life.³⁵

Physical activity contributes significantly to maintaining health and managing blood glucose levels, especially in individuals with diabetes mellitus. Lack of exercise is a risk factor for chronic disease and can have serious health impacts. Emphasizes the importance of physical activity by increasing muscle glucose recovery and helping to improve blood glucose control.³⁶

The findings of the research involving 100 participants revealed that participants with high levels of effective type 2 diabetes control and physical exercise were 24 participants (24%), while participants with low levels of physical activity and poor control of type 2 diabetes were 15 participants (15%). Chi-square analysis yielded a significant p-value of 0.003, highlighting the strong link between physical activity variables and type 2 diabetes control at Lansot Primary Health Center in Tomohon City. The significance of physical activity in controlling blood sugar levels includes increasing how well muscles use glucose to lower blood sugar levels, decreasing insulin resistance, and improving insulin sensitivity.³⁷ Additionally, physical activity also positively impacts heart health, physical fitness, and weight management. It is important for people with type 2 diabetes to do physical activity regularly, about 3-4 times a week, with a duration of about 30 minutes, and follow the principles of CRIPE (continuous, rhythmical, interval, progressive, endurance training).³⁸ It is important to achieve 75-85% of maximal heart rate during exercise. This factor becomes crucial especially when the patient does physical exercise when insulin has reached its maximum level. By setting the right time for physical exercise, patients can improve their glucose control.³⁶ Therefore, physical activity is an important component in managing diabetes mellitus and controlling blood glucose.

The consistent practice of physical exercise is linked to a 45-70% decrease in mortality rates among individuals with type 2 diabetes mellitus. Additionally, it helps to reduce HbA1c levels to a point where complications are prevented. Engaging in a minimum of 150 minutes per week of both aerobic and strength training exercises can contribute to a decrease in HbA1c levels in individuals with type 2 diabetes mellitus.³⁹

Based on the findings of this research, it can be argued that having a sufficient level of knowledge and engaging in physical activity are vital for controlling, treating, and preventing type 2 diabetes mellitus. This research demonstrates the significance of having a sufficient level of knowledge and engaging in physical activity when it comes to controlling, treating, and preventing type 2 diabetes mellitus.

The limitations of this study includes using a purposive sampling method and the lower representation of men. Generalization should be done with caution. The nature of the cross-sectional design also limits the potential to ascertain the causal relationship with the determinants.

CONCLUSION

There is a notable correlation between the level of knowledge and the control of type 2 diabetes mellitus at Lansot Primary Health Center, Tomohon. Similarly, there is a significant association between physical exercise and the control of type 2 diabetes mellitus at Lansot Primary Health Center, Tomohon.

ACKNOWLEDGEMENTS

The author expresses his gratitude to all the patients and staff in Lansot Primary Health Centre for their involvement in the completion of the research. The writer acknowledges all staff and teachers at faculty of public health, Sam Ratulangi University for the guidance and support for this research.

Funding: No funding sources

Conflict of interest: None declared

Ethical approval: The study was approved by the Institutional Ethics Committee of Faculty of Public Health, Sam Ratulangi University, with the reference number 1243/UN12.11.1/LL/2023, and also obtained approval from the Tomohon City Health Office with the reference number 440/Dinkes/VI/647

REFERENCES

1. 1. World Health Organization (WHO). Diabetes. who.int. 2022. Available from: https://www.who.int/health-topics/diabetes#tab=tab_1. Accessed on 12 June 2023.
2. 2. Boyko EJ, Magliano DJ, Karuranga S, Piemonte L, Pouya PR, Saeedi HS, et al eds. International Diabetes Federation (IDF). IDF Diabetes Atlas. 10th edn. Brussels, Belgium; 2021.
3. 3. Basic Health Research. Publishing Institutions Agency for Health Research and Development. Jakarta; 2018. Available from: http://repository.bkpk.kemkes.go.id/3514/1/LaporanRiskesdas2018Nasional.pdf. Accessed on 12 June 2023.
4. 4. Ministry of Health. Diabetes mellitus. kemkes.go.id. 2020. Available from: https://www.kemkes.go.id/downloads/resources/download/pusdatin/infodatin/Infodatin 2020 Diabetes Melitus.pdf. Accessed on 12 June 2023.
5. 5. Tomohon City Central Statistics Agency. The highest number of cases of the 10 diseases in the city of Tomohon. bps.go.id. 2019. Available from: https://tomohonkota.bps.go.id/statictable/2019/06/13/562/jumlah-kasus-10-penyakit-terbanyak-di-kota-tomohon-2018.html. Accessed on 12 June 2023.
6. 6. Kandou GD, Ratag BT, Kalesaran AFC, Kandou PC. Obesity and lifestyle factors as determinants of type 2 diabetes mellitus in Manado City, Indonesia. Malay J Public Health Med. 2019;19(2):54-60.
7. 7. Anani S, Ari U, Praba G. The relationship between diabetes mellitus control behavior and blood glucose levels of diabetes mellitus outpatients (case study at Arjawinangun Hospital, Cirebon Regency). J Health. 2012;2:466-78.
8. 8. Zuliana J, Jatmika SED. Education on prevention and control of diabetes mellitus for Posyandu Cadres in RT. 18 RWs. 05 Lanjas Village, Teweh Tengah District. Aptekmas J Serv Community. 2022;5(2):117-22.
9. 9. Ramadhan N, Marissa N, Fitria E, Wilya V. Control of type 2 diabetes mellitus in patients at the Jayabaru Community Health Center, Banda Aceh City. Health Res Develop Media. 2018;28(4):239-46.
10. 10. Asmamaw A. Knowledge and attitude about diabetes mellitus and its associated factors among people in DebreTabor Town, Northwest Ethiopia: cross sectional study. Sci J Public Health. 2015;3(2):199.
11. 11. Kosasih, Setiawan Y. The relationship between the level of knowledge and diabetes self-management with the stress level of diabetes mellitus patients who are on a diet. J Nursing Indonesia. 2022.
12. 12. Palit ID, Kandou GD, Kaunang WJP. The Relationship Between Physical Activity and Quality of Life in the Elderly in Channelg Village, Tabukan Selatan Tengah District, Sangihe Islands Regency. J Health. 2021;10(6):93100.
13. 13. Mongkau L, Langi FLFG, Kalesaran AFC. Ecological study of the prevalence of diabetes mellitus with stroke in Indonesia. Prepotif J Community Health. 2022;6(2):1156-62.
14. 14. Rustini SA, Maulidia N. The relationship between physical activity levels and blood sugar nucleus in type 2 diabetes mellitus patients. J Nurs. 2018;11(2):5-5.
15. 15. Lwanga SK, Lemeshow S. Sample size determination in health studies: a practical manual. Geneva: WHO; 1991:15.
16. 16. Notoatmodjo S. Health Research Methodology. Jakarta: Rineka Cipta; 2010.
17. 17. Umah CI. The Relationship between Knowledge Level and Self-Management in Diabetes Mellitus Patients at the RSI Sultan Agung Semarang Polyclinic. Universitas Islam Sultan Agung. 2019.
18. 18. Alvionia AZ. The relationship between the 4 pillars of management of type 2 diabetes mellitus (T2DM) and blood pressure control in T2DM patients with hypertension (study at Bina Sehat Hospital and Kaliwates Hospital, Jember). 2019.
19. 19. IPAQ-SF. International Physical Activity Questionnaire- Short Form. Metiers la Petite Enfance. 2014;20(212-213):41.
20. 20. Schmitt A, Kulzer B, Ehrmann D, Haak T, Hermanns N. A self-report measure of diabetes self-management for type 1 and type 2 diabetes: revised diabetes self-management questionnaire (DSMQ-R)- clinimetric evidence from five studies. Front Clin Diabetes Health. 2022;2:823046.
21. 21. Wild S, Roglic G, Green A, Sicree R, King H. Global prevalence of diabetes: estimates for the year 2000 and projections for 2030. Diabetes Care. 2004;27(5):1047-53.
22. 22. Fitri R. Yekti W. Energy intake, carbohydrates, fiber, glycemic load, physical exercise and blood sugar levels in type 2 diabetes mellitus patients. Media Med Indonesia. 2012;46:121-31b.
23. 23. Paseki JA, Kaunang WJ, Kandou GD. The relationship between type II diabetes mellitus and the quality of life of patients at Pancaran Kasih Hospital, Manado. Health. 2021;10(8).
24. 24. Komariah K, Rahayu S. The relationship between age, gender and body mass index with fasting blood sugar levels in patients with type 2 diabetes mellitus at the Pratama outpatient clinic, Depok, West Java. J Health Kusuma Husada. 2020;41-50.
25. 25. Arania R, Triwahyuni T, Prasetya T, Cahyani SD. The relationship between work and physical activity and the incidence of diabetes mellitus at the Mardi Waluyo Clinic, Central Lampung Regency. J Med Malahayati. 2021;5(3):163-9.
26. 26. Notoatmodjo S. Health Promotion and Behavioral Science. Jakarta: Rineka Cipta; 2012.
27. 27. Damayanti M, Sofyan O. Relationship between education level and community knowledge level in Sumberan Sedayu Hamlet, Bantul regarding COVID-19 prevention in January 2021. Maj Farm. 2022;18(2):220-6.
28. 28. Indonesia PE. Management and prevention of type 2 diabetes mellitus in Indonesia. pbperkeni.or.id. 2015.
29. 29. Wicaksono A, Handoko W. Physical activity and health. Pontianak: IAIN Pontianak Press; 2020.
30. 30. Sari NN. The relationship between central obesity and the incidence of type II diabetes mellitus. J Sci Nurs Sai Betik. 2019;14(2):157-61.
31. 31. Mulyani NS. Relationship between self management of type II diabetes mellitus patients and blood sugar levels in Banda Aceh City Hospitals. J Health Res. 2019;62.
32. 32. Saqila RL, Muftahuin SK. The relationship between knowledge and self-management in type II diabetes mellitus sufferers in the working area of the Palaran Community Health Center, Samarinda City. Borneo Student Res. 2021;2(2):872-8.
33. 33. Ningrum TP, Siliapantur HO. Factors that influence self-management of type 2 dm patients. J BSI Nurs. 2019;7(2):114-26.
34. 34. Kusnanto K, Sundari PM, Asmoro CP, Arifin H. The relationship between the level of knowledge and diabetes self-management with the stress level of diabetes mellitus patients who are on a diet. J Nurs Indonesia. 2019;22(1):31-42.
35. 35. Gharaibeh B, Tawalbeh LI. Diabetes self-care management practices among insulin-taking patients. J Res Nurs. 2018;23(7):553-65.
36. 36. Wahid RAN. The effect of diabetes self management education (DSME) health education on blood sugar levels of type ii diabetes patients at Prolanis Gajahan Community Health Center, Surakarta. Universitas Pahlawan Tuanku Tambusai. 2016.
37. 37. Barnes DE. Diabetes Exercise Program. Yogyakarta: Citra Aji Parama; 2011.
38. 38. Cicilia L, Kaunang WP, Langi FL. The relationship between physical activity and the incidence of diabetes mellitus in outpatients at the Bitung City Regional General Hospital. Health. 2019;7(5).
39. 39. Astuti DYAH. The effect of aerobic exercise on fasting blood sugar levels in type 2 diabetes mellitus sufferers in the Prolanis Group UPT Wonogiri I Health Center. Surakarta: Stikes Kusuma Husada; 2016.