exercise and type 2 diabetes · resistance exercise effects. the acute effects of a single bout of...

Exercise and Type 2 DiabetesThe American College of Sports Medicine and the American DiabetesAssociation: joint position statement

SHERI R. COLBERG, PHD, FACSM1

RONALD J. SIGAL, MD, MPH, FRCP(C)2

BO FERNHALL, PHD, FACSM3

JUDITH G. REGENSTEINER, PHD4

BRYAN J. BLISSMER, PHD5

RICHARD R. RUBIN, PHD6

LISA CHASAN-TABER, SCD, FACSM7

ANN L. ALBRIGHT, PHD, RD8

BARRY BRAUN, PHD, FACSM9

Although physical activity (PA) is a key element in the prevention and management of type 2diabetes, many with this chronic disease do not become or remain regularly active. High-qualitystudies establishing the importance of exercise and fitness in diabetes were lacking until recently,but it is now well established that participation in regular PA improves blood glucose control andcan prevent or delay type 2 diabetes, along with positively affecting lipids, blood pressure,cardiovascular events, mortality, and quality of life. Structured interventions combining PA andmodest weight loss have been shown to lower type 2 diabetes risk by up to 58% in high-riskpopulations. Most benefits of PA on diabetes management are realized through acute and chronicimprovements in insulin action, accomplished with both aerobic and resistance training. Thebenefits of physical training are discussed, along with recommendations for varying activities,PA-associated blood glucose management, diabetes prevention, gestational diabetes mellitus,and safe and effective practices for PA with diabetes-related complications.

Diabetes Care 33:e147–e167, 2010

INTRODUCTION

D iabetes has become a widespreadepidemic, primarily because of theincreasing prevalence and inci-

dence of type 2 diabetes. According to theCenters for Disease Control and Preven-tion, in 2007, almost 24 million Ameri-cans had diabetes, with one-quarter ofthose, or six million, undiagnosed (261).Currently, it is estimated that almost 60million U.S. residents also have prediabe-

tes, a condition in which blood glucose(BG) levels are above normal, thus greatlyincreasing their risk for type 2 diabetes(261). Lifetime risk estimates suggest thatone in three Americans born in 2000 orlater will develop diabetes, but in high-risk ethnic populations, closer to 50%may develop it (200). Type 2 diabetes is asignificant cause of premature mortalityand morbidity related to cardiovascular

disease (CVD), blindness, kidney andnerve disease, and amputation (261). Al-though regular physical activity (PA) mayprevent or delay diabetes and its compli-cations (10,46,89,112,176,208,259,294),most people with type 2 diabetes are notactive (193).

In this article, the broader term“physical activity” (defined as “bodilymovement produced by the contractionof skeletal muscle that substantially in-creases energy expenditure”) is used in-terchangeably with “exercise,” which isdefined as “a subset of PA done with theintention of developing physical fitness(i.e., cardiovascular [CV], strength, andflexibility training).” The intent is to rec-ognize that many types of physical move-ment may have a positive effect onphysical fitness, morbidity, and mortalityin individuals with type 2 diabetes.

Diagnosis, classification, andetiology of diabetesCurrently, the American Diabetes Associ-ation (ADA) recommends the use of anyof the following four criteria for diagnos-ing diabetes: 1) glycated hemoglobin(A1C) value of 6.5% or higher, 2) fastingplasma glucose �126 mg/dl (7.0 mmol/l), 3) 2-h plasma glucose �200 mg/dl(11.1 mmol/l) during an oral glucose tol-erance test using 75 g of glucose, and/or4) classic symptoms of hyperglycemia(e.g., polyuria, polydipsia, and unex-plained weight loss) or hyperglycemic cri-sis with a random plasma glucose of 200mg/dl (11.1 mmol/l) or higher. In the ab-sence of unequivocal hyperglycemia, thefirst three criteria should be confirmed byrepeat testing (4). Prediabetes is diag-nosed with an A1C of 5.7–6.4%, fastingplasma glucose of 100–125 mg/dl (5.6–6.9 mmol/l; i.e., impaired fasting glucose[IFG]), or 2-h postload glucose of 140–199 mg/dl (7.8–11.0 mmol/l; i.e., im-paired glucose tolerance [IGT]) (4).

The major forms of diabetes can becategorized as type 1 or type 2 (4). In type1 diabetes, which accounts for 5–10% ofcases, the cause is an absolute deficiencyof insulin secretion resulting from auto-immune destruction of the insulin-producing cells in the pancreas. Type 2

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From the 1Human Movement Sciences Department, Old Dominion University, Norfolk, Virginia; the 2De-partments of Medicine, Cardiac Sciences, and Community Health Sciences, Faculties of Medicine andKinesiology, University of Calgary, Calgary, Alberta, Canada; the 3Department of Kinesiology and Com-munity Health, University of Illinois at Urbana-Champaign, Urbana, Illinois; the 4Divisions of GeneralInternal Medicine and Cardiology and Center for Women’s Health Research, University of ColoradoSchool of Medicine, Aurora, Colorado; the 5Department of Kinesiology and Cancer Prevention ResearchCenter, University of Rhode Island, Kingston, Rhode Island; the 6Departments of Medicine and Pediatrics,The Johns Hopkins University School of Medicine, Baltimore, Maryland; the 7Division of Biostatistics andEpidemiology, University of Massachusetts, Amherst, Massachusetts; the 8Division of Diabetes Transla-tion, Centers for Disease Control and Prevention, Atlanta, Georgia; and the 9Department of Kinesiology,University of Massachusetts, Amherst, Massachusetts.

Corresponding author: Sheri R. Colberg, [email protected] joint position statement is written by the American College of Sports Medicine and the American

Diabetes Association and was approved by the Executive Committee of the American Diabetes Associationin July 2010. This statement is published concurrently in Medicine & Science in Sports & Exercise andDiabetes Care. Individual name recognition is stated in the ACKNOWLEDGMENTS at the end of thestatement.

The findings and conclusions in this report are those of the authors and do not necessarily represent theofficial position of the Centers for Disease Control and Prevention.

DOI: 10.2337/dc10-9990© 2010 by the American Diabetes Association. Readers may use this article as long as the work is properly

cited, the use is educational and not for profit, and the work is not altered. See http://creativecommons.org/licenses/by-nc-nd/3.0/ for details.

See accompanying article, p. 2692.

R e v i e w s / C o m m e n t a r i e s / A D A S t a t e m e n t sP O S I T I O N S T A T E M E N T

care.diabetesjournals.org DIABETES CARE, VOLUME 33, NUMBER 12, DECEMBER 2010 e147

diabetes (90–95% of cases) results from acombination of the inability of musclecells to respond to insulin properly (insu-lin resistance) and inadequate compensa-tory insulin secretion. Less commonforms include gestational diabetes melli-tus (GDM), which is associated with a40–60% chance of developing type 2 di-abetes in the next 5–10 years (261). Dia-betes can also result from genetic defectsin insulin action, pancreatic disease, sur-gery, infections, and drugs or chemicals(4,261).

Genetic and environmental factorsare strongly implicated in the develop-ment of type 2 diabetes. The exact geneticdefects are complex and not clearly de-fined (4), but risk increases with age, obe-sity, and physical inactivity. Type 2diabetes occurs more frequently in popu-lations with hypertension or dyslipide-mia, women with previous GDM, andnon-Caucasian people including NativeAmericans, African Americans, Hispanic/Latinos, Asians, and Pacific Islanders.

Treatment goals in type 2 diabetesThe goal of treatment in type 2 diabetes isto achieve and maintain optimal BG,lipid, and blood pressure (BP) levels toprevent or delay chronic complications ofdiabetes (5). Many people with type 2 di-abetes can achieve BG control by follow-ing a nutritious meal plan and exerciseprogram, losing excess weight, imple-menting necessary self-care behaviors,and taking oral medications, althoughothers may need supplemental insulin(261). Diet and PA are central to the man-agement and prevention of type 2 diabe-tes because they help treat the associatedglucose, lipid, BP control abnormalities,as well as aid in weight loss and mainte-nance. When medications are used tocontrol type 2 diabetes, they should aug-ment lifestyle improvements, not replacethem.

ACUTE EFFECTS OFEXERCISE

Fuel metabolism during exerciseFuel mobilization, glucose production,and muscle glycogenolysis. The main-tenance of normal BG at rest and duringexercise depends largely on the coordina-tion and integration of the sympatheticnervous and endocrine systems (250).Contracting muscles increase uptake ofBG, although BG levels are usually main-tained by glucose production via liver gly-cogenolysis and gluconeogenesis and

mobilization of alternate fuels, such asfree fatty acids (FFAs) (250,268).

Several factors influence exercise fueluse, but the most important are the inten-sity and duration of PA (9,29,47,83,111,133,160,181,241). Any activity causes ashift from predominant reliance on FFA atrest to a blend of fat, glucose, and muscleglycogen, with a small contributionfrom amino acids (15,31). With in-creasing exercise intensity, there is agreater reliance on carbohydrate as longas sufficient amounts are available inmuscle or blood (21,23,47,133). Earlyin exercise, glycogen provides the bulkof the fuel for working muscles. As gly-cogen stores become depleted, musclesincrease their uptake and use of circu-lating BG, along with FFA released fromadipose tissue (15,132, 271). Intramus-cular lipid stores are more readily usedduring longer-duration activities andrecovery (23,223,270). Glucose pro-duction also shifts from hepatic glyco-genolysis to enhanced gluconeogenesisas duration increases (250,268).Evidence statement. PA causes increasedglucose uptake into active muscles bal-anced by hepatic glucose production,with a greater reliance on carbohydrate tofuel muscular activity as intensity in-creases. The American College of SportsMedicine (ACSM) evidence category A (seeTables 1 and 2 for explanation).Insulin-independent and insulin-dependent muscle glucose uptake dur-ing exercise. There are two well-definedpathways that stimulate glucose uptakeby muscle (96). At rest and postprandi-ally, its uptake by muscle is insulin de-pendent and serves primarily to replenishmuscle glycogen stores. During exercise,contractions increase BG uptake to sup-plement intramuscular glycogenolysis(220,227). As the two pathways are dis-tinct, BG uptake into working muscle isnormal even when insulin-mediated up-take is impaired in type 2 diabetes(28,47,293). Muscular BG uptake re-mains elevated postexercise, with thecontraction-mediated pathway persist-ing for several hours (86,119) and insulin-mediated uptake for longer (9,33,141, 226).

Glucose transport into skeletal mus-cle is accomplished via GLUT proteins,with GLUT4 being the main isoform inmuscle modulated by both insulin andcontractions (110,138). Insulin activatesGLUT4 translocation through a complexsignaling cascade (256,293). Contrac-tions, however, trigger GLUT4 transloca-tion at least in part through activation of

5�-AMP–act ivated protein kinase(198,293). Insulin-stimulated GLUT4translocation is generally impaired in type2 diabetes (96). Both aerobic and resis-tance exercises increase GLUT4 abun-dance and BG uptake, even in the presenceof type 2 diabetes (39,51,204,270).Evidence statement. Insulin-stimulatedBG uptake into skeletal muscle predomi-nates at rest and is impaired in type 2diabetes, while muscular contractionsstimulate BG transport via a separate ad-ditive mechanism not impaired by insulinresistance or type 2 diabetes. ACSM evi-dence category A.

Postexercise glycemic control/BGlevelsAerobic exercise effects. During mod-erate-intensity exercise in nondiabeticpersons, the rise in peripheral glucose up-take is matched by an equal rise in hepaticglucose production, the result being thatBG does not change except during pro-longed, glycogen-depleting exercise. Inindividuals with type 2 diabetes perform-ing moderate exercise, BG utilization bymuscles usually rises more than hepaticglucose production, and BG levels tend todecline (191). Plasma insulin levels nor-mally fall, however, making the risk ofexercise-induced hypoglycemia in any-one not taking insulin or insulin secreta-gogues very minimal , even withprolonged PA (152). The effects of a sin-gle bout of aerobic exercise on insulin ac-tion vary with duration, intensity, andsubsequent diet; a single session in-creases insulin action and glucose toler-ance for more than 24 h but less than72 h (26,33,85,141). The effects ofmoderate aerobic exercise are similarwhether the PA is performed in a singlesession or multiple bouts with the sametotal duration (14).

During brief, intense aerobic exercise,plasma catecholamine levels rise mark-edly, driving a major increase in glucoseproduction (184). Hyperglycemia can re-sult from such activity and persist for upto 1–2 h, likely because plasma catechol-amine levels and glucose production donot return to normal immediately withcessation of the activity (184).Evidence statement. Although moderateaerobic exercise improves BG and insulin ac-tion acutely, the risk of exercise-induced hy-poglycemia is minimal without use ofexogenous insulin or insulin secretagogues.Transient hyperglycemia can follow intensePA. ACSM evidence category C.

Exercise and type 2 diabetes

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Resistance exercise effects. The acuteeffects of a single bout of resistance train-ing on BG levels and/or insulin action inindividuals with type 2 diabetes have notbeen reported. In individuals with IFG(BG levels of 100–125 mg/dl), resistanceexercise results in lower fasting BG levels24 h after exercise, with greater reduc-tions in response to both volume (multi-ple- vs. single-set sessions) and intensityof resistance exercise (vigorous comparedwith moderate) (18).Evidence statement. The acute effects ofresistance exercise in type 2 diabetes havenot been reported, but result in lower fast-ing BG levels for at least 24 h after exercisein individuals with IFG. ACSM evidencecategory C.Combined aerobic and resistance andother types of training. A combinationof aerobic and resistance training may bemore effective for BG management thaneither type of exercise alone (51,238).

Any increase in muscle mass that may re-sult from resistance training could con-tribute to BG uptake without altering themuscle’s intrinsic capacity to respond toinsulin, whereas aerobic exercise en-hances its uptake via a greater insulin ac-tion, independent of changes in musclemass or aerobic capacity (51). However,all reported combination training had agreater total duration of exercise and ca-loric use than when each type of trainingwas undertaken alone (51,183,238).Mild-intensity exercises such as tai chiand yoga have also been investigated fortheir potential to improve BG manage-ment, with mixed results (98,117,159,257,269,286,291). Although tai chi maylead to short-term improvements in BGlevels, effects from long-term training(i.e., 16 weeks) do not seem to last 72 hafter the last session (257). Some studieshave shown lower overall BG levels withextended participation in such activities

(286,291), although others have not(159,257). One study suggested that yo-ga’s benefits on fasting BG, lipids, oxida-tive stress markers, and antioxidant statusare at least equivalent to more conven-tional forms of PA (98). However, a meta-analysis of yoga studies stated that thelimitations characterizing most studies,such as small sample size and varyingforms of yoga, preclude drawing firmconclusions about benefits to diabetesmanagement (117).Evidence statement. A combination ofaerobic and resistance exercise trainingmay be more effective in improving BGcontrol than either alone; however, morestudies are needed to determine if totalcaloric expenditure, exercise duration, orexercise mode is responsible. ACSM evi-dence category B. Milder forms of exercise(e.g., tai chi, yoga) have shown mixed re-sults. ACSM evidence category C.

Table 1—Evidence categories for ACSM and evidence-grading system for clinical practice recommendations for ADA

I. ACSM evidence categories

Evidencecategory Source of evidence Definition

A Randomized, controlled trials (overwhelming data) Provides a consistent pattern of findings with substantial studiesB Randomized, controlled trials (limited data) Few randomized trials exist, which are small in size, and results are inconsistentC Nonrandomized trials, observational studies Outcomes are from uncontrolled, nonrandomized, and/or observational studiesD Panel consensus judgment Panel’s expert opinion when the evidence is insufficient to place it in categories

A–C

II. ADA evidence-grading system for clinical practice recommendations

Level ofevidence Description

A Clear evidence from well-conducted, generalizable, randomized, controlled trials that are adequately powered, including thefollowing:

• Evidence from a well-conducted multicenter trial• Evidence from a meta-analysis that incorporated quality ratings in the analysis

Compelling nonexperimental evidence, i.e., the “all-or-none” rule developed by the Centre for Evidence-Based Medicine atOxford

Supportive evidence from well-conducted, randomized, controlled trials that are adequately powered, including the following:• Evidence from a well-conducted trial at one or more institutions• Evidence from a meta-analysis that incorporated quality ratings in the analysis

B Supportive evidence from well-conducted cohort studies, including the following:• Evidence from a well-conducted prospective cohort study or registry• Evidence from a well-conducted meta-analysis of cohort studies

Supportive evidence from a well-conducted case-control studyC Supportive evidence from poorly controlled or uncontrolled studies, including the following:

• Evidence from randomized clinical trials with one or more major or three or more minor methodological flaws that couldinvalidate the results

• Evidence from observational studies with high potential for bias (such as case series with comparison to historical controls)• Evidence from case series or case reports

Conflicting evidence with the weight of evidence supporting the recommendationE Expert consensus or clinical experience

Colberg and Associates


Table 2—Summary of ACSM evidence and ADA clinical practice recommendation statements

ACSM evidence and ADA clinical practice recommendation statements

ACSM evidence category(A, highest; D, lowest)/ADA level of evidence(A, highest; E, lowest)

Acute effects of exercise • PA causes increased glucose uptake into active muscles balanced by hepatic glucoseproduction, with a greater reliance on carbohydrate to fuel muscular activity as intensityincreases.

A/*

• Insulin-stimulated BG uptake into skeletal muscle predominates at rest and is impairedin type 2 diabetes, while muscular contractions stimulate BG transport via a separate,additive mechanism not impaired by insulin resistance or type 2 diabetes.

A/*

• Although moderate aerobic exercise improves BG and insulin action acutely, the risk ofexercise-induced hypoglycemia is minimal without use of exogenous insulin or insulinsecretagogues. Transient hyperglycemia can follow intense PA.

C/*

• The acute effects of resistance exercise in type 2 diabetes have not been reported, butresult in lower fasting BG levels for at least 24 h postexercise in individuals with IFG.

C/*

• A combination of aerobic and resistance exercise training may be more effective inimproving BG control than either alone; however, more studies are needed todetermine whether total caloric expenditure, exercise duration, or exercise mode isresponsible.

B/*

• Milder forms of exercise (e.g., tai chi, yoga) have shown mixed results. C/*• PA can result in acute improvements in systemic insulin action lasting from 2 to 72 h. A/*

Chronic effects ofexercise training

• Both aerobic and resistance training improve insulin action, BG control, and fatoxidation and storage in muscle.

B/*

• Resistance exercise enhances skeletal muscle mass. A/*• Blood lipid responses to training are mixed but may result in a small reduction in LDL

cholesterol with no change in HDL cholesterol or triglycerides. Combined weight lossand PA may be more effective than aerobic exercise training alone on lipids.

C/*

• Aerobic training may slightly reduce systolic BP, but reductions in diastolic BP are lesscommon, in individuals with type 2 diabetes.

C/*

• Observational studies suggest that greater PA and fitness are associated with a lowerrisk of all-cause and CV mortality.

C/*

• Recommended levels of PA may help produce weight loss. However, up to 60 min/daymay be required when relying on exercise alone for weight loss.

C/*

• Individuals with type 2 diabetes engaged in supervised training exhibit greatercompliance and BG control than those undertaking exercise training withoutsupervision.

B/*

• Increased PA and physical fitness can reduce symptoms of depression and improvehealth-related QOL in those with type 2 diabetes.

B/*

PA and prevention oftype 2 diabetes

• At least 2.5 h/week of moderate to vigorous PA should be undertaken as part oflifestyle changes to prevent type 2 diabetes onset in high-risk adults.

A/A

PA in prevention andcontrol of GDM

• Epidemiological studies suggest that higher levels of PA may reduce risk of developingGDM during pregnancy.

C/*

• RCTs suggest that moderate exercise may lower maternal BG levels in GDM. B/*Preexercise evaluation • Before undertaking exercise more intense than brisk walking, sedentary persons with

type 2 diabetes will likely benefit from an evaluation by a physician. ECG exercisestress testing for asymptomatic individuals at low risk of CAD is not recommended butmay be indicated for higher risk.

C/C

Recommended PAparticipation forpersons with type 2diabetes

• Persons with type 2 diabetes should undertake at least 150 min/week of moderate tovigorous aerobic exercise spread out during at least 3 days during the week, with nomore than 2 consecutive days between bouts of aerobic activity.

B/B

• In addition to aerobic training, persons with type 2 diabetes should undertakemoderate to vigorous resistance training at least 2–3 days/week.

B/B

• Supervised and combined aerobic and resistance training may confer additional healthbenefits, although milder forms of PA (such as yoga) have shown mixed results.Persons with type 2 diabetes are encouraged to increase their total daily unstructuredPA. Flexibility training may be included but should not be undertaken in place ofother recommended types of PA.

B/C

(continued)



Insulin resistanceAcute changes in muscular insulin re-sistance. Most benefits of PA on type 2diabetes management and prevention arerealized through acute and chronic im-provements in insulin action (29,46,116,118,282). The acute effects of a re-cent bout of exercise account for most ofthe improvements in insulin action, withmost individuals experiencing a decreasein their BG levels during mild- and mod-erate-intensity exercise and for 2–72 h af-terward (24,83,204).

BG reductions are related to the dura-tion and intensity of the exercise, preex-ercise control, and state of physicaltraining (24,26,47,238). Although previ-ous PA of any intensity generally exerts itseffects by enhancing uptake of BG for gly-cogen synthesis (40,83) and by stimulat-ing fat oxidation and storage in muscle

(21,64,95), more prolonged or intense PAacutely enhances insulin action for longerperiods (9,29,75,111,160,238).

Acute improvements in insulin sensi-tivity in women with type 2 diabetes havebeen found for equivalent energy expen-ditures whether engaging in low-intensityor high-intensity walking (29) but may beaffected by age and training status(24,75,100,101,228). For example, mod-erate- to heavy-intensity aerobic trainingundertaken three times a week for 6months improved insulin action in bothyounger and older women but persistedonly in the younger group for 72–120 h.Acute changes in liver’s ability to pro-cess glucose. Increases in liver fat con-tent common in obesity and type 2 diabetesare strongly associated with reduced he-patic and peripheral insulin action. En-hanced whole-body insulin action after

aerobic training seems to be related to gainsin peripheral, not hepatic, insulin action(146,282). Such training not resulting inoverall weight loss may still reduce hepaticlipid content and alter fat partitioning anduse in the liver (128).Evidence statement. PA can result inacute improvements in systemic insulinaction lasting from 2 to 72 h. ACSM evi-dence category A.

CHRONIC EFFECTS OFEXERCISE TRAININGMetabolic control: BG levels and insu-lin resistance. Aerobic exercise has beenthe mode traditionally prescribed for dia-betes prevention and management. Even1 week of aerobic training can improvewhole-body insulin sensitivity in individ-uals with type 2 diabetes (282). Moderateand vigorous aerobic training improve in-

Table 2—Continued

ACSM evidence and ADA clinical practice recommendation statements

ACSM evidence category(A, highest; D, lowest)/ADA level of evidence(A, highest; E, lowest)

Exercise withnonoptimal BGcontrol

• Individuals with type 2 diabetes may engage in PA, using caution when exercising withBG levels exceeding 300 mg/dl (16.7 mmol/l) without ketosis, provided they arefeeling well and are adequately hydrated.

C/E

• Persons with type 2 diabetes not using insulin or insulin secretagogues are unlikely toexperience hypoglycemia related to PA. Users of insulin and insulin secretagogues areadvised to supplement with carbohydrate as needed to prevent hypoglycemia duringand after exercise.

C/C

Medication effects onexercise responses

• Medication dosage adjustments to prevent exercise-associated hypoglycemia may berequired by individuals using insulin or certain insulin secretagogues. Most othermedications prescribed for concomitant health problems do not affect exercise, withthe exception of �-blockers, some diuretics, and statins.

C/C

Exercise with long-termcomplications ofdiabetes

• Known CVD is not an absolute contraindication to exercise. Individuals with anginaclassified as moderate or high risk should likely begin exercise in a supervised cardiacrehabilitation program. PA is advised for anyone with PAD.

C/C

• Individuals with peripheral neuropathy and without acute ulceration may participatein moderate weight-bearing exercise. Comprehensive foot care including dailyinspection of feet and use of proper footwear is recommended for prevention and earlydetection of sores or ulcers. Moderate walking likely does not increase risk of footulcers or reulceration with peripheral neuropathy.

B/B

• Individuals with CAN should be screened and receive physician approval and possiblyan exercise stress test before exercise initiation. Exercise intensity is best prescribedusing the HR reserve method with direct measurement of maximal HR.

C/C

• Individuals with uncontrolled proliferative retinopathy should avoid activities thatgreatly increase intraocular pressure and hemorrhage risk.

D/E

• Exercise training increases physical function and QOL in individuals with kidneydisease and may even be undertaken during dialysis sessions. The presence ofmicroalbuminuria per se does not necessitate exercise restrictions.

C/C

Adoption andmaintenance ofexercise by personswith diabetes

• Efforts to promote PA should focus on developing self-efficacy and fostering socialsupport from family, friends, and health care providers. Encouraging mild or moderatePA may be most beneficial to adoption and maintenance of regular PA participation.Lifestyle interventions may have some efficacy in promoting PA behavior.

B/B

*No recommendation given.



sulin sensitivity (9,75,83,111), albeit foronly a period of hours to days (141), but alesser intensity may also improve insulinaction to some degree (111). Training canenhance the responsiveness of skeletalmuscles to insulin with increased expres-sion and/or activity of proteins involvedin glucose metabolism and insulin signal-ing (39,110,204,270). Moderate trainingmay increase glycogen synthase activityand GLUT4 protein expression but notinsulin signaling (39). Fat oxidation isalso a key aspect of improved insulin ac-tion, and training increases lipid storagein muscle and fat oxidation capacity(64,95,136,223).

An individual’s training status will af-fect the use of carbohydrate during an aer-obic activity. Aerobic training increasesfat utilization during a similar durationbout of low- or moderate-intensity activ-ity done after training, which spares mus-cle glycogen and BG and results in a lesseracute decrease in BG (28,83,223). Type 2diabetes may be associated with a de-crease in lipid oxidation and shift towardgreater carbohydrate oxidation at all exer-cise intensities (87).

Resistance exercise training also ben-efits BG control and insulin action in type2 diabetes (46,65,115,116,118,246). In arandomized controlled trial (RCT), twice-weekly progressive resistance training for16 weeks by older men with newly diag-nosed type 2 diabetes resulted in a 46.3%increase in insulin action, a 7.1% reduc-tion in fasting BG levels, and significantloss of visceral fat (116). An increase inmuscle mass from resistance training maycontribute to BG uptake from a mass ef-fect, and heavy weight training in partic-ular may reverse or prevent further loss ofskeletal muscle due to disuse and aging(34,276). In another RCT, all 20 menwith type 2 diabetes who participated ineither resistance or aerobic exercise thriceweekly for 10 weeks improved their over-all BG control, but those doing resistancetraining had significantly lower A1C val-ues (32). Diabetic women undergoing 12weeks of low-intensity training with resis-tance bands had gains in strength andmuscle mass and loss of fat mass but hadno change in insulin sensitivity (157).Evidence statement. Both aerobic andresistance training improve insulin ac-tion, BG control, and fat oxidation andstorage in muscle. ACSM evidence categoryB. Resistance exercise enhances skeletalmuscle mass. ACSM evidence category A.Lipids and lipoproteins. Small RCTsinvolving type 2 diabetes have reported

that aerobic training decreases total andLDL cholesterol and raises HDL choles-terol (130,229). One larger RCT founddecreases in total cholesterol with bothaerobic and yoga training but no changesin HDL cholesterol or LDL cholesterol(98), although most have found no effectof any form of exercise training on lipids(6,175,178,238,258,267). RCTs de-signed to increase PA also had no effect onthe cholesterol profile in type 2 diabetes,with most also finding no change in trig-lycerides (6,175,238,258,267). A meta-analysis of training effects on blood lipidsin adults with type 2 diabetes found, how-ever, that LDL cholesterol may be reducedby �5% (136).

Lipid profiles may benefit more fromconcomitant exercise training and weightreduction. Some studies using intensivediet and aerobic exercise interventions re-ported large reductions in total choles-terol and triglycerides but failed toinclude controls (12,13). In the LookAHEAD (Action for Health in Diabetes)study, intensive lifestyle participants ex-hibited greater decreases in triglyceridesand increases in HDL cholesterol than thecontrol group, while both the intensivelifestyle and usual care groups decreasedLDL cholesterol (218). Most lifestyle in-terventions have been accompanied by anapproximate 5-kg weight loss.Evidence statement. Blood lipid re-sponses to training are mixed but may resultin a small reduction in LDL cholesterol withno change in HDL cholesterol or triglycer-ides. Combined weight loss and PA may bemore effective than aerobic exercise trainingalone on lipids. ACSM evidence category C.Hypertension. Hypertension is a com-mon comorbidity affecting more than60% of individuals with type 2 diabetes(201,249). The risk of vascular complica-tions in hypertensive individuals withtype 2 diabetes is 66–100% higher thanwith either condition alone (103,195).Both aerobic and resistance training canlower BP in nondiabetic individuals, withslightly greater effects observed with theformer (49,134,135,137). Most observa-tional studies show that both exerciseslower BP in diabetic individuals (35,46,78,208,267). Several RCTs haveshown reductions in systolic BP (4 – 8mmHg), but only one reported a slightlylower diastolic BP (11,130,140,176). TheLook AHEAD trial found reductions inboth systolic and diastolic BP with exer-cise and weight loss (218), but severalstudies have reported no changes in BPwith training in type 2 diabetes

(175,238,283). Carefully designed RCTsusing increasing levels of PA also failed toshow any change in BP despite substan-tially increased PA (6,258).Evidence statement. Aerobic trainingmay slightly reduce systolic BP, but re-ductions in diastolic BP are less common,in individuals with type 2 diabetes. ACSMevidence category C.Mortality and CV risk. Higher levels ofphysical fitness and PA are associatedwith lower CV risk and mortality in bothhealthy and clinical populations (19,153,164,207). Increases in PA and phys-ical fitness are also associated with re-duced early mortality in both populationsas well (19,42,153,163,164,186,272).All-cause and CV mortality risk was 1.7–6.6 times higher in low-fit compared withhigh-fit men with type 2 diabetes, withthe fittest men exhibiting the lowest risk(42,43). A work capacity �10 METs(where 1 MET is defined as the equivalentof resting metabolic rate) carries the low-est r i sk, independent of obes i ty(42,153,186). No RCT data on the effectsof changes in physical fitness on mortalityin diabetes exist.Evidence statement. Observationalstudies suggest that greater PA and fitnessare associated with a lower risk of all-cause and CV mortality. ACSM evidencecategory C.Body weight: maintenance and loss.The most successful programs for long-term weight control have involved com-binations of diet, exercise, and behaviormodification (281). Exercise interven-tions undertaken with volumes typicallyrecommended to improve BG control andreduce CVD risk (e.g., 150 min/week ofbrisk walking) are usually insufficient formajor weight loss (24), likely becauseobese and older people frequently havedifficulty performing sufficient exercise tocreate a large energy deficit and can easilycounterbalance expenditures by eatingmore (281). However, in RCTs, about 1 hof daily moderate aerobic exercise pro-duces at least as much fat loss as equiva-lent caloric restriction, with resultantgreater insulin action (231,232).

The optimal volume of exercise toachieve sustained major weight loss isprobably much larger than the amountrequired to achieve improved BG controland CV health (24,217). In observationalstudies (234,235,274), individuals whosuccessfully maintained large weight lossduring at least a year typically engaged in�7 h/week of moderate- to vigorous-intensity exercise (62). Two RCTs found



that higher exercise volumes (2,000 and2,500 kcal/week) produced greater andmore sustained weight loss than 1,000kcal/week of exercise (123,124).Evidence statement. Recommended lev-els of PA may help produce weight loss.However, up to 60 min/day may be re-quired when relying on exercise alone forweight loss. ACSM evidence category C.Supervision of training. Exercise inter-vention studies showing the greatest ef-fect on BG control have all involvedsupervision of exercise sessions by quali-fied exercise trainers (34,65,196,238).The most direct test of the incrementalbenefits of supervised training was theItalian Diabetes and Exercise Study (11).In this 1-year trial, all 606 participants withtype 2 diabetes (both intervention and con-trol) received high-quality exercise counsel-ing that increased self-reported PAsubstantially. The intervention group alsoreceived supervised, facility-based com-bined aerobic and resistance exercisetraining twice weekly, resulting in greaterimprovements in overall BG control, BP,BMI, waist circumference, HDL choles-terol, and estimated 10-year CVD risk. Arecent systematic review of 20 resistancetraining studies on type 2 diabetes (97)found that supervised training of varyingvolume, frequency, and intensity im-proved BG control and insulin sensitivity,but that when supervision was removed,compliance and BG control bothdeteriorated.Evidence statement. Individuals withtype 2 diabetes engaged in supervisedtraining exhibit greater compliance andBG control than those undertaking exer-cise training without supervision. ACSMevidence category B.Psychological effects. Exercise likelyhas psychological benefits for personswith type 2 diabetes, although evidencefor acute and chronic psychological ben-efits is limited. In the Look AHEAD trial,participants in the intensive lifestyle inter-vention attempted to lose more than 7%of their initial weight and increase mod-erately intense PA to greater than 175min/week. They had improvements inhealth-related (SF-36 physical compo-nent scores) quality of life (QOL) and de-pression symptoms after 12 months thatwere mediated by enhanced physical fit-ness (280).

However, it seems that individualswho undertake exercise to prevent achronic disease fare better than those whoundertake it to manage an existing one. Arecent meta-analysis found that while

psychological well-being was signifi-cantly improved among individuals whoexercised for disease prevention, it dete-riorated significantly when undertakenfor management of CVD, end-stage renaldisease, pulmonary disease, neurologicaldisorders, and cancer (90). These find-ings suggest that benefits may vary, withthose with fewer existing complicationsbenefiting the most.

Meta-analyses of clinically depressedmen and women of all age-groups foundsubstantial decreases in depressive symp-toms after both short and long courses ofexercise (50) and clinical depression anddepressive symptoms among the aged(243). Potential mechanisms of exerciseinclude psychological factors, such as in-creased self-efficacy, a sense of mastery,distraction, and changes in self-concept,as well as physiological factors such as in-creased central norepinephrine transmis-sion, changes in the hypothalamicadrenocortical system (63), serotoninsynthesis and metabolism (61), and en-dorphins. Regular PA may improve psy-chological well-being, health-relatedQOL, and depression in individuals withtype 2 diabetes, among whom depressionis more common than in the general pop-ulation (73).Evidence statement. Increased PA andphysical fitness can reduce symptoms ofdepression and improve health-relatedQOL in those with type 2 diabetes. ACSMevidence category B.

PA AND PREVENTION OFTYPE 2 DIABETES — Participationin regular PA improves BG control andcan prevent or delay onset of type 2 dia-betes (64,104,149,158, 170,260). Pro-spective cohort and cross-sectionalobservational studies that assessed PAwith questionnaires showed that higherPA levels are associated with reduced riskfor type 2 diabetes, regardless of methodof activity assessment, ranges of activitycategories, and statistical methods(108,113,182). Both moderate walkingand vigorous activity have been associ-ated with a decreased risk, and greatervolumes of PA may provide the most pre-vention (113). Observational studies havereported that greater fitness is associatedwith a reduced risk of developing type 2diabetes (251,273), even if only moder-ate-intensity exercise is undertaken.

The Da Qing study in China (211)included an exercise-only treatment armand reported that even modest changes inexercise (20 min of mild or moderate, 10

min of strenuous, or 5 min of very stren-uous exercise one to two times a day) re-duced diabetes risk by 46% (comparedwith 42% for diet plus exercise and 31%for diet alone). The Finnish Diabetes Pre-vention Study (74,260) and the U.S. Dia-betes Prevention Program (DPP) (149)included intensive, lifestyle modificationswith both diet and increased PA. In theformer, 522 middle-aged, overweightadults with IGT completed either lifestylemodifications of at least 30 min of daily,moderate PA, or no change in behavior(74,260). The DPP randomized 3,234men and women with IGT or IFG intocontrol, medication (metformin), or life-style modification groups, composed ofdietary and weight loss goals and 150 minof weekly aerobic activity (149). Lifestylemodification in both studies reduced in-cident diabetes by 58% and, in the DPP,had a greater effect than metformin(31%). Weight loss was the dominantpredictor of a lower incidence, but in-creased PA reduced risk of type 2 diabeteseven when weight loss goals were notachieved (104,158,173). PA seems toplay a role in preventing type 2 diabetesacross ethnic groups and in both sexes(154,224).

Data show that moderate exercisesuch as brisk walking reduces risk of type2 diabetes (108,113,114,154,224), andall studies support the current recom-mendation of 2.5 h/week of a moderateaerobic activity or typically 30 min/dayfor 5 days/week for prevention. A meta-analysis of 10 cohort studies (125) thatassessed the preventive effects of moder-ate-intensity PA found that risk reductionfor type 2 diabetes was 0.70 (0.58–0.84)for walking on a regular basis (typicallybriskly for �2.5 h/week). The preventiveeffects of resistance training have not beenstudied.

Type 2 diabetes is also increasing inprevalence in children and adolescents,with increasingly sedentary behavior andobesity as key contributors. No RCTshave been completed that addresswhether PA or exercise prevents type 2diabetes in youth. However, limited stud-ies suggest that, to prevent and managetype 2 diabetes, goals for youth shouldinclude limiting daily screen time (televi-sion, computer, or video game) to lessthan 60 min/day and doing at least 60min/day of PA (188). A multicenter trial(the TODAY study) is currently underwayto assess the role of PA as part of a behav-ioral lifestyle intervention aimed at pre-venting type 2 diabetes in youth (254).



Evidence statement. At least 2.5 h/weekof moderate to vigorous PA should be un-dertaken as part of lifestyle changes toprevent type 2 diabetes onset in high-riskadults. ACSM evidence category A. ADA Alevel recommendation.

PA AND PREVENTION ANDCONTROL OF GDM — As the prev-alenceofdiabetescontinuestoriseworldwide,it becomes increasingly important to identifyhigh-risk populations and to implement strat-egies to delay or prevent diabetes onset.Women diagnosed with GDM are at substan-tially increased risk of developing type 2 dia-betes; therefore, PA may be considered a toolto prevent both GDM and possibly type 2 di-abetes at a later date (70). Prepregnancy PAhas been consistently associated with a re-duced risk of GDM (57,58,69,206, 290).Studies during pregnancy are sparse, withonly one case-control study (57), one retro-spective study (174), and one study of a co-hort of Hispanic women (37) observingsignificant protective effects of PA, while oth-ers have not (58,69,206).

Engaging in 30 min of moderate-intensity PA (e.g., brisk walking) duringmost days of the week (e.g., 2.5 h/week)has been adopted as a recommendationfor pregnant women without medical orobstetrical complications (222). How-ever, few primary prevention studies haveexamined whether making a change in PAreduces risk of developing GDM. In 2006,a meta-analysis reviewed four RCTs onGDM in which pregnant women in theirthird trimester exercised on a cycle or armergometer or performed resistance train-ing three times a week for 20–45 mincompared with doing no specific program(36). The women involved in exercise hadbetter BG control, lower fasting and post-prandial glucose concentrations, and im-proved cardiorespiratory fitness ,although frequency of prescription of in-sulin to control BG did not differ fromnonexercisers, and pregnancy outcomeswere unchanged.Evidence statement. Epidemiologicalstudies suggest that higher levels of PAmay reduce risk of developing GDM dur-ing pregnancy. ACSM evidence category C.RCTs suggest that moderate exercise maylower maternal BG levels in GDM. ACSMevidence category B.

PREEXERCISE EVALUATION —Safe exercise participation can be compli-cated by the presence of diabetes-relatedhealth complications such as CVD, hyper-tension, neuropathy, or microvascular

changes (239). For individuals desiring toparticipate in low-intensity PA such aswalking, health care providers should useclinical judgment in deciding whether torecommend preexercise testing (3). Con-ducting exercise stress testing beforewalking is unnecessary. No evidence sug-gests that it is routinely necessary as aCVD diagnostic tool, and requiring it maycreate barriers to participation.

For exercise more vigorous than briskwalking or exceeding the demands of ev-eryday living, sedentary and older dia-betic individuals will likely benefit frombeing assessed for conditions that mightbe associated with risk of CVD, contrain-dicate certain activities, or predispose toinjuries, including severe peripheral neu-ropathy, severe autonomic neuropathy,and preproliferative or proliferative reti-nopathy (240). Before undertaking newhigher-intensity PA, they are advised toundergo a detailed medical evaluationand screening for BG control, physicallimitations, medications, and macrovascu-lar and microvascular complications (3).

This assessment may include a gradedexercise test depending on the age of theperson, diabetes duration, and the pres-ence of additional CVD risk factors(3,240). The prevalence of symptomaticand asymptomatic coronary artery dis-ease (CAD) is greater in individuals withtype 2 diabetes (72,155), and maximalgraded exercise testing can identify asmall proportion of asymptomatic per-sons with severe coronary artery obstruc-tion (52).

Most young individuals with a lowCAD risk may not benefit from preexer-cise stress testing. In the Look AHEADtrial, although exercise-induced abnor-malities were present in 1,303 (22.5%)participants, only older age was associ-ated with increased prevalence of all ab-normalities during maximal testing (52).A systematic review of the U.S. PreventiveServices Task Force (USPSTF) concludedthat stress testing should not be routinelyrecommended to detect ischemia inasymptomatic individuals with a lowCAD risk (�10% risk of a cardiac eventmore than 10 years) because the risksfrom invasive testing done after a false-positive test outweigh the benefits of itsdetection (79,262). The lower the CADrisk, the higher the chance of a false pos-itive (79,248).

Current guidelines attempt to avoidautomatic inclusion of lower-risk individ-uals with type 2 diabetes, stating that ex-ercise stress testing is advised primarily

for previously sedentary individuals withdiabetes who want to undertake activitymore intense than brisk walking. The goalis to more effectively target individuals athigher risk for underlying CVD (239).The UKPDS Risk Engine (http://www.dtu.ox. ac.uk/riskengine/download.htm)(248) can also be used to calculate ex-pected 10-year CV risk based on age, sex,smoking, A1C, diabetes duration, lipids,BP, and race.

In general, electrocardiogram (ECG)stress testing may be indicated for indi-viduals matching one or more of thesecriteria:● Age �40 years, with or without CVD

risk factors other than diabetes● Age �30 years and

● Type 1 or type 2 diabetes of �10years in duration

● Hypertension● Cigarette smoking● Dyslipidemia● Proliferative or preproliferative reti-

nopathy● Nephropathy including microalbu-

minuria● Any of the following, regardless of age

● Known or suspected CAD, cerebro-vascular disease, and/or peripheralartery disease (PAD)

● Autonomic neuropathy● Advanced nephropathy with renal

failure

Use of these criteria does not excludethe possibility of conducting ECG stresstesting on individuals with a low CAD riskor those who planning to engage in lessintense exercise (248). In the absence ofcontraindications to maximal stress test-ing, it can still be considered for anyonewith type 2 diabetes. Although clinical ev-idence does not definitively determinewho should undergo such testing, poten-tial benefits should be weighed against therisk associated with unnecessary proce-dures for each individual (155,239).

In individuals with positive or non-specific ECG changes in response to exer-cise, or with nonspecific ST- and T-wavechanges at rest, follow-up testing may beperformed (236). However, the DIADtrial involving 1,123 individuals withtype 2 diabetes and no symptoms of CADfound that screening with adenosine-stress radionuclide myocardial perfusionimaging for myocardial ischemia morethan 4.8 years did not alter rates of cardiacevents (288); thus, the cost-effectivenessand diagnostic value of more intensivetesting remains in question.



There is no evidence available to de-termine whether preexercise evaluationinvolving stress testing is necessary orbeneficial before participation in anaero-bic or resistance training. At present, mosttesting centers are equipped for maximalstress testing but not for an alternate formof testing involving resistance exercise.Moreover, coronary ischemia is less likelyto occur during resistance compared withaerobic exercise eliciting the same heartrate (HR), and some doubt exists as towhether resistance exercise induces isch-emia (77,88). A review of 12 studies ofresistance exercise in men with knownCAD found no angina, ST depression, ab-normal hemodynamics, ventricular dys-rhythmias, or other complications duringsuch exercise (275).Evidence statement. Before undertakingexercise more intense than brisk walking,sedentary persons with type 2 diabeteswill likely benefit from an evaluation by aphysician. ECG exercise stress testing forasymptomatic individuals at low risk ofCAD is not recommended but may be in-dicated for higher risk. ACSM evidence cat-egory C . ADA C leve l recom-mendation.

RECOMMENDED PAPARTICIPATION FORPERSONS WITH TYPE 2DIABETES — Just 39% of adults withdiabetes are physically active comparedwith 58% of other American adults (193).However, for most people with type 2 di-abetes, exercise is recommended for dia-be tes management and can beundertaken safely and effectively.

Aerobic exercise trainingFrequency. Aerobic exercise should beperformed at least 3 days/week with nomore than 2 consecutive days betweenbouts of activity because of the transientnature of exercise-induced improvementsin insulin action (26,141). Most clinicaltrials evaluating exercise interventions intype 2 diabetes have used a frequency ofthree times per week (24,238,246,255),but current guidelines for adults generallyrecommend five sessions of moderate ac-tivity (105,202,217).Intensity. Aerobic exercise should be atleast at moderate intensity, correspond-ing approximately to 40–60% of VO2max(maximal aerobic capacity). For mostpeople with type 2 diabetes, brisk walkingis a moderate-intensity exercise. Addi-tional benefits may be gained from vigor-ous exercise (�60% of VO2max). A meta-

analysis (25) showed that exerciseintensity predicts improvements in over-all BG control to a greater extent than ex-ercise volume, suggesting that thosealready exercising at a moderate intensityshould consider undertaking some vigor-ous PA to obtain additional BG (and likelyCV) benefits.Duration. Individuals with type 2 diabe-tes should engage in a minimum of 150min/week of exercise undertaken at mod-erate intensity or greater. Aerobic activityshould be performed in bouts of at least10 min and be spread throughout theweek. Around 150 min/week of moder-ate-intensity exercise is associated withreduced morbidity and mortality in ob-servational studies in all populations(217). The average weekly duration inmeta-analyses of exercise interventions intype 2 diabetes (24,246,255), includinghigher-intensity aerobic exercise (196),has been in a similar range. Recent jointACSM/American Heart Associationguidelines (105,202) recommended 150min of moderate activity (30 min, 5 days/week) or 60 min of vigorous PA (20 minon 3 days) for all adults, whereas recentU.S. federal guidelines (217) recom-mended 150 min of moderate or 75 minof vigorous activity, or an equivalent com-bination, spread throughout each week.

The U.S. federal guidelines (217) sug-gest that an exercise volume of 500 –1,000 MET � min/week (MET equivalentof PA � number of minutes) is optimaland can be achieved, for example, with150 min/week of walking at 6.4 km/h (4mph; intensity of 5 METs) or 75 min ofjogging at 9.6 km/h (6 mph; 10 METs).Unfortunately, most people with type 2diabetes do not have sufficient aerobic ca-pacity to jog at 9.6 km/h for that weeklyduration, and they may have orthopedicor other limitations. In a meta-analysis,the mean maximal aerobic capacity in di-abetic individuals was only 22.4 ml/kg/min, or 6.4 METs (25), making 4.8 METs(75% of maximal) the highest sustainableintensity. Therefore, most diabetic indi-viduals will require at least 150 min ofmoderate to vigorous aerobic exercise perweek to achieve optimal CVD risk reduc-tion. Some CV and BG benefits may begained from lower exercise volumes (aminimum dose has not been established),whereas further benefit likely results fromengaging in durations beyond recom-mended amounts. Individuals withhigher aerobic capacities (�10 METs)may be able to exercise at a higher abso-

lute intensity for less time and achieve thesame benefits.Mode. Any form of aerobic exercise (in-cluding brisk walking) that uses largemuscle groups and causes sustained in-creases in HR is likely to be beneficial(114), and undertaking a variety of modesof PA is recommended (217).Rate of progression. At present, nostudy on individuals with type 2 diabeteshas compared rates of progression in ex-ercise intensity or volume. Gradual pro-gression of both is advisable to minimizethe risk of injury, particularly if healthcomplications are present, and to en-hance compliance.Body weight loss and maintenance.The most successful weight control pro-grams involve combinations of exercise,diet, and behavior modification. Peoplewho successfully maintain a large weightloss report exercising about 7 h/week(62,212,234,235,274).Evidence statement. Persons with type 2diabetes should undertake at least 150min/week of moderate to vigorous aero-bic exercise spread out during at least 3days during the week, with no more than2 consecutive days between bouts of aer-obic activity. ACSM evidence category B.ADA B level recommendation.

Resistance exercise trainingFrequency. Resistance exercise shouldbe undertaken at least twice weekly onnonconsecutive days (1,105,202,217,239,240), but more ideally three times aweek (65,246), as part of a PA programfor individuals with type 2 diabetes, alongwith regular aerobic activities.Intensity. Training should be moderate(50% of 1-repetition maximum [1-RM])or vigorous (75–80% of 1-RM) for opti-mal gains in strength and insulin action(1,97,239,240,263). Home-based resis-tance training following supervised, gym-based training may be less effective formaintaining BG control but adequate formaintaining muscle mass and strength(66).Duration. Each training session shouldminimally include 5–10 exercises involv-ing the major muscle groups (in the upperbody, lower body, and core) and involvecompletion of 10–15 repetitions to nearfatigue per set early in training (1,97,239,240,263), progressing over time toheavier weights (or resistance) that can belifted only 8–10 times. A minimum of one setof repetitions to near fatigue, but as many asthree to foursets, is recommendedforoptimalstrength gains.



Mode. Resistance machines and freeweights (e.g., dumbbells and barbells)can result in fairly equivalent gains instrength and mass of targeted muscles(66). Heavier weights or resistance maybe needed for optimization of insulin ac-tion and BG control (276).Rate of progression. To avoid injury,progression of intensity, frequency, andduration of training sessions should occurslowly. In most progressive training, in-creases in weight or resistance are under-taken first and only once when the targetnumber of repetitions per set can consis-tently be exceeded, followed by a greaternumber of sets and lastly by increasedtraining frequency. Progression for 6months to thrice-weekly sessions of threesets of 8–10 repetitions done at 75 to 80%of 1-RM on 8–10 exercises may be an op-timal goal (65).Evidence statement. In addition to aero-bic training, persons with type 2 diabetesshould undertake moderate to vigorousresistance training at least 2–3 days/week.ACSM evidence category B. ADA B levelrecommendation.

Supervised trainingInitial instruction and periodic supervi-sion by a qualified exercise trainer is rec-ommended for most persons with type 2diabetes, particularly if they undertake re-sistance exercise training, to ensure opti-mal benefits to BG control, BP, lipids, andCV risk and to minimize injury risk (11).

Combined aerobic and resistanceand other types of trainingInclusion of both aerobic and resistanceexercise training is recommended. Com-bined training thrice weekly in individu-als with type 2 diabetes may be of greaterbenefit to BG control than either aerobicor resistance exercise alone (238). How-ever, the total duration of exercise andcaloric expenditure was greatest withcombined training in all studies done todate (51,183,238), and both types oftraining were undertaken together on thesame days. No studies have yet reportedwhether daily, but alternating, training ismore effective or the BG effect of isoca-loric combinations of training. Milderforms of PA, such as yoga and tai chi, maybenefit control of BG (98,117,269,286,291), although their inclusion is notsupported conclusively at this time.

Daily movement (unstructuredactivity)Individuals with type 2 diabetes are en-couraged to increase their total daily, un-structured PA to gain additional healthbenefits. Nonexercise activity thermogen-esis (i.e., energy expending for activitiesof daily living) can create a large daily ca-loric deficit to prevent excessive weightgain (168,169). In an observationalstudy, obese individuals sat for about2.5 h more and walked an average of 3.5miles/day or less than their lean counter-parts do. Most of the lean subjects’ greateractivity came from walks of short dura-tion (�15 min) and low velocity (�1mph) (168).

Moreover, use of objective measuressuch as step counters may enhance reach-ing daily goals. A meta-analysis of 26studies with a total of 2,767 (primarilynondiabetic) participants (8 RCTs and 18observational studies) found that pedom-eter users increased PA by 26.9% overbaseline in studies having an average in-tervention of 18 weeks (30). An impor-tant predictor of increased PA was the useof a goal, such as to take 10,000 steps perday (30).

Flexibility trainingFlexibility training may be included aspart of a PA program, although it shouldnot substitute for other training. Olderadults are advised to undertake exercisesthat maintain or improve balance(202,217), which may include some flex-ibility training, particularly for manyolder individuals with type 2 diabeteswith a higher risk of falling (194). Al-though flexibility exercise (stretching)has frequently been recommended as ameans of increasing joint range of motion(ROM) and reducing risk of injury, twosystematic reviews found that flexibilityexercise does not reduce risk of exercise-induced injury (237,287). A small RCTfound that ROM exercises modestly de-creased peak plantar pressures (94), butno study has directly evaluated whethersuch training reduces risk of ulceration orinjury in type 2 diabetes. However, flexi-bility exercise combined with resistancetraining can increase ROM in individualswith type 2 diabetes (109) and allow in-dividuals to more easily engage in activi-ties that require greater ROM aroundjoints.Evidence statement. Supervised andcombined aerobic and resistance trainingmay confer health additional benefits, al-though milder forms of PA (such as yoga)

have shown mixed results. Persons withtype 2 diabetes are encouraged to increasetheir total daily unstructured PA. Flexibil-ity training may be included but shouldnot be undertaken in place of other rec-ommended types of PA. ACSM evidencecategory B. ADA C level recommendation.

EXERCISE WITHNONOPTIMAL BG CONTROLHyperglycemia. While hyperglycemiacan be worsened by exercise in type 1 di-abetic individuals who are insulin defi-cient and ketotic (due to missed orinsufficient insulin), very few personswith type 2 diabetes develop such a pro-found degree of insulin deficiency. There-fore, individuals with type 2 diabetesgenerally do not need to postpone exer-cise because of high BG, provided thatthey are feeling well. If they undertakestrenuous physical activities with elevatedglucose levels (�300 mg/dl or 16.7mmol/l), it is prudent to ensure that theyare adequately hydrated (3). If hypergly-cemic after a meal, individuals with type 2diabetes will still likely experience a re-duction in BG during aerobic work be-cause endogenous insulin levels willlikely be higher at that time (221).Evidence statement. Individuals withtype 2 diabetes may engage in PA, usingcaution when exercising with BG levelsexceeding 300 mg/dl (16.7 mmol/l) with-out ketosis, provided they are feeling welland are adequately hydrated. ACSMevidence category C . ADA E leve lrecommendation.Hypoglycemia: causes and prevention.Of greatest concern to many exercisers isthe risk of hypoglycemia. In individualswhose diabetes is being controlled by life-style alone, the risk of developing hypo-glycemia during exercise is minimal,making stringent measures unnecessaryto maintain BG (239). Glucose monitor-ing can be performed before and after PAto assess its unique effect. Activities oflonger duration and lower intensitygenerally cause a decline in BG levels butnot to the level of hypoglycemia(9,29,75,111,160). While very intenseactivities can cause transient elevations inBG (156,252,253), intermittent high-intensity exercise done immediately afterbreakfast in individuals treated with dietonly reduces BG levels and insulin secre-tion (160).

In insulin or insulin secretagogue us-ers, who frequently have the effects ofboth exercise and insulin to increase glu-cose uptake, PA can complicate diabetes



management (138,198,230,293). Forpreexercise BG levels of less than 100mg/dl (5.5 mmol/l), ADA recommendsthat carbohydrate be ingested before anyPA (3), but this applies only to individualstaking insulin or the secretagogues morelikely to cause hypoglycemia (e.g., sulfo-nylureas such as glyburide, glipizide, andglimepiride, as well as nateglinide and re-paglinide) (161,230). If controlled withdiet or other oral medications, most indi-viduals will not need carbohydrate sup-plements for exercise lasting less than anhour. Insulin users should likely consumeup to 15 g of carbohydrate before exercisefor an initial BG level of 100 mg/dl orlower, with the actual amount dependenton injected insulin doses, exercise dura-tion and intensity, and results of BG mon-itoring. Intense, short exercise requireslesser or no carbohydrate intake (156).

Later-onset hypoglycemia is a greaterconcern when carbohydrate stores (i.e.,muscle and liver glycogen) are depletedduring an acute bout of exercise. In par-ticular, high-intensity exercise (e.g., re-peated interval or intense resistancetraining) can result in substantial deple-tion of muscle glycogen, thereby increas-ing risk for postexercise hypoglycemia inusers of insulin or insulin secretagogues(161). In such cases, the consumption of5–30 g of carbohydrate during and within30 min after exhaustive, glycogen-depleting exercise will lower hypoglyce-mia risk and allow for more efficientrestoration of muscle glycogen (31,247).Evidence statement. Persons with type 2diabetes not using insulin or insulinsecretagogues are unlikely to experiencehypoglycemia related to PA. Users of in-sulin and insulin secretagogues are ad-vised to supplement with carbohydrate asneeded to prevent hypoglycemia duringand after exercise. ACSM evidence categoryC. ADA C level recommendation.

MEDICATION EFFECTS ONEXERCISE RESPONSES — Currenttreatment strategies promote combina-tion therapies to address the three majordefects in type 2 diabetes: impaired pe-ripheral glucose uptake (liver, fat, andmuscle), excessive hepatic glucose release(with glucagon excess), and insufficientinsulin secretion. Medication adjust-ments for PA are generally necessary onlywith use of insulin and other insulinsecretagogues (161,230). To prevent hy-poglycemia, individuals may need to re-duce their oral medications or insulin

dosing before (and possibly after) exercise(83,161). Before planned exercise, short-acting insulin doses will likely have to bereduced to prevent hypoglycemia.Newer, synthetic, rapid-acting insulin an-alogs (i.e., lispro, aspart, and glulisine) in-duce more rapid decreases in BG thanregular human insulin. Individuals willneed to monitor BG levels before, occa-sionally during, and after exercise andcompensate with appropriate dietaryand/or medication regimen changes, par-ticularly when exercising at insulin peaktimes. If only longer-acting insulins suchas glargine, detemir, and NPH are beingabsorbed from subcutaneous depots dur-ing PA, exercise-induced hypoglycemia isnot as likely (219), although doses mayneed to be reduced to accommodate reg-ular participation in PA. Doses of selectoral hypoglycemic agents (glyburide,glipizide, glimepiride, nateglinide, andrepaglinide) may also need to be loweredin response to regular exercise training ifthe frequency of hypoglycemia increases(161,230).

Diabetic individuals are often pre-scribed a variety of medications for co-morbid conditions, including diuretics,�-blockers, ACE inhibitors, aspirin, lipid-lowering agents, and more. These medi-cations generally do not affect exerciseresponses, with some notable exceptions.�-Blockers are known to blunt HR re-sponses to exercise and lower maximalexercise capacity to �87% of expected vianegative inotropic and chronotropiceffects (241). They may also block adren-ergic symptoms of hypoglycemia, in-c reas ing the r i sk o f undetec tedhypoglycemia during exercise. However,�-blockers may increase exercise capacityin those with CAD, rather than loweringit, by reducing coronary ischemia duringactivity (53). Diuretics, however, maylower overall blood and fluid volumes re-sulting in dehydration and electrolyte im-balances, particularly during exercise inthe heat. Statin use has been associatedwith an elevated risk of myopathies (my-algia and myositis), particularly whencombined with use of fibrates and niacin(203). An extended discussion on medi-cations can be found in the Handbook ofExercise in Diabetes (2002) (84).Evidence statement. Medication dosageadjustments to prevent exercise-associated hypoglycemia may be requiredby individuals using insulin or certain in-sulin secretagogues. Most other medica-tions prescribed for concomitant healthproblems do not affect exercise, with the

exception of �-blockers, some diuretics,and statins. ACSM evidence category C.ADA C level recommendation.

EXERCISE WITH LONG-TERM COMPLICATIONS OFDIABETESVascular disease. Individuals with an-gina and type 2 diabetes classified as mod-erate or high risk should preferablyexercise in a supervised cardiac rehabili-tation program, at least initially (245).Diabetes accelerates the development ofatherosclerosis and is a major risk factorfor CVD and PAD. Individuals with type2 diabetes have a lifetime risk of CADthat includes 67% of women and 78% ofmen and is exacerbated by obesity(22,80,165). Moreover, some individualswho have an acute myocardial infarctionmay not experience chest pain, and up toa third may have silent myocardial isch-emia (45,180).

For individuals with PAD, with andwithout intermittent claudication andpain in the extremities during PA, low-to-moderate walking, arm-crank, and cyclingexercise have all been shown to enhancemobility, functional capacity, exercise paintolerance, and QOL (214,295). Lower ex-tremity resistance training also improvesfunctional performance measured by tread-mill walking, stair climbing ability, andQOL measures (187).

Vascular alterations are common indiabetes, even in the absence of overt vas-cular disease. Endothelial dysfunctionmay be an underlying cause of many as-sociated vascular problems (45,54). Inaddition to traditional risk factors, hyper-glycemia, hyperinsulinemia, and oxida-tive stress contribute to endothelialdamage, leading to poor arterial functionand greater susceptibility to atherogenesis(45,82,289). Both aerobic and resistancetraining can improve endothelial function(46,294), but not all studies have shownposttraining improvement (283).Evidence statement. Known CVD is notan absolute contraindication to exercise. In-dividuals with angina classified as moderateor high risk should likely begin exercise in asupervised cardiac rehabilitation program.PA is advised for anyone with PAD. ACSMevidence category C . ADA C levelrecommendation.Peripheral neuropathy. Mild to moder-ate exercise may help prevent the onset ofperipheral neuropathy (10). Individualswithout acute foot ulcers can undertakemoderate weight-bearing exercise, al-though anyone with a foot injury or open



sore or ulcer should be restricted to non–weight-bearing PA. All individuals shouldclosely examine their feet on a daily basisto prevent and detect sores or ulcers earlyand follow recommendations for use ofproper footwear. Previous guidelinesstated that persons with severe peripheralneuropathy should avoid weight-bearingactivities to reduce risk of foot ulcerations(102,264). However, recent studies indi-cated that moderate walking does not in-crease risk of foot ulcers or reulceration inthose with peripheral neuropathy(166,167).

Peripheral neuropathy affects the ex-tremities, particularly the lower legs andfeet. Hyperglycemia causes nerve toxicity,leading to nerve damage and apoptosis(242,244), which causes microvasculardamage and loss of perfusion. Symptomsmanifest as neuropathic pain and/or lossof sensation that, coupled with poorblood flow, increase the risk of foot inju-ries and ulcerations (45,244). Up to 40%of diabetic individuals may experienceperipheral neuropathy, and 60% of lowerextremity amputations in Americans arerelated to diabetes (166,199,216).Evidence statement. Individuals withperipheral neuropathy and without acuteulceration may participate in moderateweight-bearing exercise. Comprehensivefoot care including daily inspection of feetand use of proper footwear is recom-mended for prevention and early detec-tion of sores or ulcers. Moderate walkinglikely does not increase risk of foot ulcersor reulceration with peripheral neuropa-thy. ACSM evidence category B. ADA B levelrecommendation.Autonomic neuropathy. Moderate-intensity aerobic training can improve au-tonomic function in individuals with andwithout CV autonomic neuropathy(CAN) (112,176,208); however, im-provements may only be evident after anacute submaximal exercise (78). Screen-ing for CAN should include a battery ofautonomic tests (including HR variabil-ity) that evaluate both branches of the au-tonomic nervous system. Given thelikelihood of silent ischemia, HR, and BPabnormalities, individuals with CANshould have physician approval and pos-sibly undergo stress testing to screen forCV abnormalities before commencing ex-ercise (265). Exercise intensity may be ac-curately prescribed using the HR reservemethod (a percentage of the difference be-tween maximal and resting HR, added tothe resting value) to approximate oxygenconsumption during submaximal exer-

cise with maximal HR directly measured,rather than estimated, for better accuracy(48,265).

Approximately 22% of those withtype 2 diabetes have CAN, but most ex-hibit alterations in autonomic function(292). The presence of CAN doubles therisk of mortality (48,265) and indicatesmore frequency of silent myocardial isch-emia (265), orthostatic hypotension, orresting tachycardia (76,177). CAN alsoimpairs exercise tolerance and lowersmaximal HR (131,265). Although bothsympathetic and parasympathetic dys-functions can be present, vagal dysfunc-tion usually occurs earlier. Slower HRrecovery after PA is associated with mor-tality risk (38,265).Evidence statement. Individuals withCAN should be screened and receive phy-sician approval and possibly an exercisestress test before exercise initiation. Exer-cise intensity is best prescribed using theHR reserve method with direct measure-ment of maximal HR. ACSM evidence cat-egory C. ADA C level recommendation.Retinopathy. In diabetic individualswith proliferative or preproliferative reti-nopathy or macular degeneration, carefulscreening and physician approval are rec-ommended before initiating an exerciseprogram. Activities that greatly increaseintraocular pressure, such as high-intensity aerobic or resistance training(with large increases in systolic BP) andhead-down activities, are not advisedwith uncontrolled proliferative disease,nor are jumping or jarring activities, all ofwhich increase hemorrhage risk (1). Dia-betic retinopathy is the main cause ofblindness in developed countries and isassociated with increased CV mortality(129,147). Individuals with retinopathymay receive some benefits, such as im-proved work capacity, after low- to mod-erate-intensity exercise training (16,17).While PA has been shown to be protectiveagainst development of age-related mac-ular degeneration (150), very little re-search exists in type 2 diabetes.Evidence statement. Individuals withuncontrolled proliferative retinopathyshould avoid activities that greatly in-crease intraocular pressure and hemor-rhage risk. ACSM evidence category D.ADA E level recommendation.Nephropathy and microalbuminuria.Both aerobic and resistance training im-prove physical function and QOL in indi-viduals with kidney disease (126,209,210), although BP increases during PAmay transiently elevate levels of mi-

croalbumin in urine. Resistance exercisetraining is especially effective in improv-ing muscle function and activities of dailyliving, which are normally severely af-fected by later-stage kidney disease (126).Before initiation of PA, individuals withovert nephropathy should be carefullyscreened, have physician approval, andpossibly undergo stress testing to detectCAD and abnormal HR and BP responses(1,27). Exercise should be begun at a lowintensity and volume because aerobic ca-pacity and muscle function are substan-tially reduced, and avoidance of theValsava maneuver or high-intensity exer-cise to prevent excessive increases in BP isadvised (1). Supervised, moderate aero-bic exercise undertaken during dialysissessions, however, has been shown to beeffective as home-based exercise and mayimprove compliance (126,151).

Diabetic nephropathy develops in�30% of individuals with diabetes and isa major risk factor for death in those withdiabetes (20,45). Microalbuminuria, orminute amounts of albumin in the urine,is common and a risk factor for overt ne-phropathy (45) and CV mortality (91).Tight BG and BP control may delay pro-gression of microalbuminuria (127,148),along with exercise and dietary changes(81,162). Exercise training delays theprogression of diabetic nephropathy inanimals (89,259), but few evidence isavailable in humans.Evidence statement. Exercise trainingincreases physical function and QOL inindividuals with kidney disease and mayeven be undertaken during dialysis ses-sions. The presence of microalbuminuriaper se does not necessitate exercise re-strictions. ACSM evidence category C. ADAC level recommendation.

ADOPTION ANDMAINTENANCE OFEXERCISE BY PERSONSWITH DIABETES — Most Americanadults with type 2 diabetes or at highest riskfor developing it do not engage in regularPA; their rate of participation is significantlybelow national norms (193). Additionalstrategies are needed to increase the adop-tion and maintenance of PA.

One of the most consistent predictorsof greater levels of activity has been higherlevels of self-efficacy (2,55,68), which re-flect confidence in the ability to exercise(185). Social support has also been asso-ciated with greater levels of PA (93,190,215), supporting the role of socialnetworks in the spread of obesity (41).



Fortunately, those same social dynamicsmay be exploited to increase the effects ofinterventions beyond the “target” individ-ual (8,99) and potentially can help spreadPA behavior. Counseling delivered byhealth care professionals may be a mean-ingful source of support and effectivesource for delivery (7,144). Physiciansvary in counseling their patients to exer-cise: on average, advice or referral relatedto exercise occurred at 18% of office visitsamong diabetic patients (213), and 73%of patients reported receiving advice atsome point to exercise more (192). Theavailability of facilities or pleasant andsafe places to walk may also be importantpredictors of regular PA (59).

When prescribing PA for the preven-tion or control of type 2 diabetes, the ef-fects of the dose of the prescription onadherence are small (225). Therefore,practitioners are encouraged to use fac-tors such as choice and enjoyment inhelping determine specifically how an in-dividual would meet recommended par-ticipation. Affective responses to exercisemay be important predictors of adoptionand maintenance, and encouraging activ-ity at intensities below the ventilatorythreshold may be most beneficial(172,277,278). Many individuals with, orat risk of developing, type 2 diabetes pre-fer walking as an aerobic activity (190),and pedometer-based interventions canbe effective for increasing aerobic activity(30,205,258). Finally, the emerging im-portance of sedentary behaviors in deter-mining metabolic risk (106,107) suggeststhat future interventions may also benefitfrom attempting to decrease sitting timeand periods of extended sedentaryactivity.

Large-scale trials such as the DPP andLook AHEAD provide some insight intosuccessful lifestyle interventions that helppromote PA by incorporating goal setting,self-monitoring, frequent contact, andstepped-care protocols (56,60,71,266).Delivering these programs requires exten-sive access to resources, staff, and space,although they are cost-effective overall(121,122).

These large studies are multifactorial,targeting several behaviors that includePA, but include multiple behavior inter-ventions that also require changes in dietand focusing on weight loss or manage-ment (179). Therefore, strategies for PAintervention in weight management arehighly relevant to this population (62).Fewer RCTs solely targeted PA behaviorin individuals with or at risk of develop-

ing type 2 diabetes (279,284,285). Theresults have been mixed, with someshowing increased PA (67,120,145,171)and others showing no e f f ec t(142,143,189). Effective short-term pro-grams have used print (67), phone(44,144,233), in-person (120,139), orInternet (92,171) delivery. Long-term ef-fectiveness of such interventions has notbeen assessed (197).Evidence statement. Efforts to promotePA should focus on developing self-efficacy and fostering social support fromfamily, friends, and health care providers.Encouraging mild or moderate PA may bemost beneficial to adoption and mainte-nance of regular PA participation. Life-style interventions may have someefficacy in promoting PA behavior. ACSMevidence category B . ADA B leve lrecommendation.

CONCLUSIONS — Exercise plays amajor role in the prevention and controlof insulin resistance, prediabetes, GDM,type 2 diabetes, and diabetes-relatedhealth complications. Both aerobic andresistance training improve insulin ac-tion, at least acutely, and can assist withthe management of BG levels, lipids, BP,CV risk, mortality, and QOL, but exercisemust be undertaken regularly to havecontinued benefits and likely include reg-ular training of varying types. Most per-sons with type 2 diabetes can performexercise safely as long as certain precau-tions are taken. The inclusion of an exer-cise program or other means of increasingoverall PA is critical for optimal health inindividuals with type 2 diabetes.

Acknowledgments— The authors have no fi-nancial support or professional conflicts of in-terest to disclose related to the article’scontent.

This joint position statement was written byACSM and ADA. ACSM: Sheri R. Colberg,PhD, FACSM (Chair); Ann L. Albright, PhD,RD; Bryan J. Blissmer, PhD; Barry Braun, PhD,FACSM; Lisa Chasan-Taber, ScD, FACSM;and Bo Fernhall, PhD, FACSM. ADA: Judith G.Regensteiner, PhD; Richard R. Rubin, PhD;and Ronald J. Sigal, MD, MPH, FRCP(C).

This pronouncement was reviewed by theACSM Pronouncements Committee, ADAProfessional Practice Committee, and by Greg-ory D. Cartee, PhD, FACSM; Peter A. Farrell,PhD, FACSM; Laurie J. Goodyear, PhD,FACSM; and Andrea M. Kriska, PhD, FACSM.

This joint position statement replaces the2000 ACSM Position Stand “Exercise and type2 Diabe tes ” (Med Sc i Spor t s Exerc2000;32:1345–1360).

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