The adoption and maintenance of physical activity are critical foci for blood glucose management and overall health in individuals with diabetes and prediabetes. Recommendations and precautions vary depending on individual characteristics and health status.
In this Position Statement, we provide a clinically oriented types of exercise and diabetes and evidence-based recommendations regarding physical activity and exercise in people with type 1 diabetes, type 2 diabetes, gestational diabetes mellitus, and prediabetes.
Physical activity includes all movement that increases energy use, whereas exercise is planned, structured physical activity, types of exercise and diabetes. Exercise improves blood glucose control in type 2 diabetes, reduces cardiovascular risk factors, contributes to weight loss, and improves well-being 12, types of exercise and diabetes.
Regular exercise may prevent or delay type 2 diabetes development 3. Regular exercise also has considerable health benefits for people with type 1 diabetes e. The challenges related to blood glucose management vary with diabetes type, activity type, and presence of diabetes-related complications 56. Physical activity and exercise recommendations, therefore, should be tailored to meet the specific needs of each individual.
Physical activity recommendations and precautions may vary by diabetes type. The primary types of diabetes are type 1 and type 2. Gestational diabetes mellitus occurs during pregnancy, with screening typically occurring at 24—28 weeks of gestation in pregnant women not previously known to have diabetes.
Aerobic exercise involves repeated and continuous movement of large muscle groups 9. Activities such as walking, cycling, types of exercise and diabetes, jogging, and swimming rely primarily on aerobic energy-producing systems.
Resistance strength training includes exercises with free weights, weight machines, types of exercise and diabetes, body weight, or elastic resistance bands. Flexibility exercises improve range of motion around joints Balance exercises benefit gait and prevent falls Activities like tai chi and yoga combine flexibility, balance, and resistance activities.
Aerobic training increases mitochondrial density, insulin sensitivity, oxidative enzymes, compliance and types of exercise and diabetes of blood vessels, lung function, types of exercise and diabetes, immune function, and cardiac output Moderate to high volumes of aerobic activity are associated with substantially lower cardiovascular and overall mortality risks in both type 1 and type 2 diabetes In type 1 diabetes, aerobic training increases cardiorespiratory fitness, decreases insulin resistance, and improves lipid levels and endothelial function In individuals with type 2 diabetes, regular training reduces A1C, triglycerides, blood pressure, and insulin resistance Alternatively, high-intensity interval training HIIT promotes rapid types of exercise and diabetes of skeletal muscle oxidative types of exercise and diabetes, insulin sensitivity, and glycemic control in adults with type 2 diabetes 1617 and can be performed without deterioration in glycemic control in type 1 diabetes 18 Diabetes is an independent rhemetoid arthritis and the eyes factor for low muscular strength 20 and accelerated decline in muscle strength and functional status The health benefits of resistance training for all adults include improvements in muscle mass, body composition, strength, physical function, mental health, bone mineral density, insulin sensitivity, blood pressure, lipid profiles, and cardiovascular health The effect of resistance exercise on glycemic control in type 1 diabetes is unclear However, resistance exercise can assist in minimizing risk vitamin d and rda exercise-induced hypoglycemia in type 1 diabetes When resistance and aerobic exercise are undertaken in one exercise session, performing resistance exercise first results in less hypoglycemia than when aerobic exercise is performed first Resistance training benefits for individuals with type 2 diabetes include improvements in glycemic control, insulin resistance, fat mass, blood pressure, strength, and lean body mass Flexibility and balance exercises are likely important for older adults with diabetes.
Limited joint mobility is frequently present, resulting in part from the formation of advanced glycation end products, which accumulate during normal aging and are accelerated by hyperglycemia Stretching increases range of motion around joints and flexibility 10 but does not affect glycemic control.
Balance training can reduce falls risk by improving balance and gait, even when peripheral neuropathy is present The benefits of alternative training like yoga and tai chi are less established, although yoga may promote improvement in glycemic control, lipid levels, and body composition in adults with type 2 diabetes Tai chi training may improve glycemic control, balance, types of exercise and diabetes, neuropathic symptoms, and some dimensions of quality of life in adults with diabetes and neuropathy, although high-quality studies on this training are lacking All adults, and particularly those with type 2 diabetes, should decrease the amount of time spent in daily sedentary behavior.
Prolonged sitting should be interrupted with bouts of light activity every 30 min for blood glucose benefits, at least in adults with type 2 diabetes. The above two recommendations are additional to, and not a replacement for, increased structured exercise and incidental movement.
Sedentary behavior—waking behaviors with low energy expenditure TV viewing, desk work, etc. Higher amounts of sedentary time are associated with increased mortality and morbidity, mostly independent of moderate-to-vigorous physical activity participation 31 — In people with or at risk for developing type 2 diabetes, extended sedentary time is also associated with poorer glycemic control and clustered metabolic risk 36 — In adults with type 2 diabetes, interrupting prolonged sitting with 15 min of postmeal walking 45 and with 3 min of light walking and simple body-weight resistance activities every 30 min 46 improves glycemic control.
The longer-term health efficacy and durability of reducing and interrupting sitting time remain to be determined for individuals with and without diabetes. Daily exercise, or at least not allowing more than 2 days to elapse between exercise sessions, is recommended to enhance insulin action.
Adults with type 2 diabetes should ideally perform both aerobic and resistance exercise training for optimal glycemic and health outcomes. Children and adolescents with type 2 diabetes should be encouraged to meet the same physical activity goals set for youth in general. Insulin action in muscle and liver can be modified by acute bouts of exercise and by regular physical activity Acutely, aerobic exercise increases muscle glucose uptake up to fivefold through insulin-independent mechanisms.
If enhanced insulin action is a primary goal, then daily moderate- or high-intensity exercise is likely optimal Regular training increases muscle capillary density, oxidative capacity, lipid metabolism, and insulin signaling proteins 47 anorexia diet plans, which are all reversible with detraining Both aerobic and resistance training promote adaptations in skeletal muscle, adipose tissue, and liver associated with enhanced insulin action, even without weight loss 56 Regular aerobic training increases muscle insulin sensitivity in individuals with prediabetes 58 and type 2 diabetes 59 in proportion to exercise volume Resistance training enhances insulin action similarly 56as do HIIT and other modes 215 — Combining endurance exercise with resistance exercise may provide greater improvements 61and HIIT may be superior to continuous aerobic training in adults with diabetes The Look AHEAD Action for Health in Diabetes trial 62 was the largest randomized trial evaluating a lifestyle intervention in older adults with type 2 diabetes compared with a diabetes support and education control group.
Major cardiovascular events were the same in both groups, possibly in part due to greater use of cardioprotective medications in the diabetes support and education group However, as reviewed by Pi-Sunyer 63the intensive lifestyle intervention group achieved significantly greater sustained improvements in weight loss, cardiorespiratory fitness, blood glucose control, blood pressure, and lipids with fewer medications; less sleep apnea, severe diabetic kidney disease and retinopathy, depression, sexual dysfunction, urinary incontinence, and knee pain; and better physical mobility maintenance and quality of life, with lower overall health care costs.
This trial provided very strong evidence of profound health benefits from intensive lifestyle intervention. For glycemic control, combined training is superior to either type of training undertaken alone 61 Therefore, adults with type 2 diabetes should ideally perform both aerobic and resistance exercise training for optimal glycemic and health outcomes.
Randomized trials evaluating exercise interventions in youth with type 2 diabetes are limited and inconclusive, although benefits are likely similar to those in adults. In the Treatment Options for Type 2 Diabetes in Adolescents and Youth TODAY study 67youth aged 10—17 years with type 2 diabetes were stabilized on metformin and then randomized to metformin plus placebo, metformin plus rosiglitazone, or metformin plus lifestyle intervention and followed for a mean of 3.
Given the limited data in youth with type 2 diabetes, it is recommended that children and adolescents with type 2 diabetes meet the same physical activity goals types of exercise and diabetes for youth in general http: A recent systematic review of 53 studies 30 of diet and physical activity promotion programs vs.
Trials evaluating less resource-intensive lifestyle interventions have also shown effectiveness 3and adherence to guidelines is associated with a greater weight loss Youth and adults with type 1 diabetes can benefit from being physically active, and viral illness and high blood pressure should be recommended to all.
Frequent blood glucose checks are required to implement carbohydrate intake and insulin dose adjustment strategies. Insulin users can exercise using either basal-bolus injection regimens or insulin pumps, but there are advantages and disadvantages to both insulin delivery methods. Continuous glucose monitoring during physical activity can be used to detect hypoglycemia when used as an adjunct rather than in place of capillary glucose tests. Youth experience many health benefits from physical activity participation 9.
In adults, types of exercise and diabetes, regular physical activity has been associated with decreased mortality There is insufficient evidence on the ideal type, timing, intensity, types of exercise and diabetes, and duration of exercise for optimal glycemic control. Blood glucose responses to physical activity in type 1 diabetes are highly variable In general, aerobic exercise decreases blood glucose levels if performed during postprandial periods with the usual insulin dose administered at the meal before exercise 73and prolonged activity done then may cause exaggerated decreases 74 — Exercise while fasting may produce a lesser decrease or a small increase in blood glucose Variable glycemic responses to physical activity 72 make uniform recommendations for management of food intake and insulin dosing difficult.
As recommended in Table 1 types of exercise and diabetes, blood glucose concentrations should always be checked prior to exercise undertaken by individuals with type 1 diabetes. Carbohydrate intake required will vary with insulin regimens, timing of exercise, type of activity, and more 87but it will also depend on starting blood glucose levels. Continuous subcutaneous insulin infusion CSII users can reduce 90 or suspend 91 insulin delivery at the start of exercise, but this strategy does not always prevent hypoglycemia 91 Frequent blood glucose checks are required when implementing insulin and carbohydrate adjustments.
Suggested carbohydrate intake or other actions based on blood glucose levels at the start of exercise. Suggested initial pre-exercise meal insulin bolus reduction for activity started within 90 min after insulin administration. CSII offers some advantages over MDI due to greater flexibility in basal rate adjustments and limiting postexercise hyperglycemia 98types of exercise and diabetes, with some limitations.
For example, aerobic exercise may accelerate basal insulin absorption from the subcutaneous depot 74whereas basal insulin glargine absorption is largely unaffected Skin irritation, pump tubing, and wearing a pump that is visible to others can be concerns In certain sports, such as basketball or contact sports, wearing pumps and other devices may be prohibited during competition.
Frustration with CSII devices and exercise may lead to discontinuation of pump therapy Continuous glucose monitoring CGM may decrease the fear of exercise-induced hypoglycemia in type 1 diabetes by providing blood glucose trends that allow users to prevent and treat hypoglycemia sooner Although a few studies have found acceptable CGM accuracy during exercise —others have reported inadequate accuracy and other problems, such as sensor filament types of exercise and diabetes, inability to calibrateand time lags between the change in blood glucose and its detection by CGM Differences in sensor performance have also been noted — Although it is a potentially useful tool during and after exercisetypes of exercise and diabetes, CGM values have traditionally required confirmation by finger-stick glucose testing prior to making regimen changes, but approval of nonadjunctive use is likely forthcoming in the near future.
Pre-exercise medical clearance is generally unnecessary for asymptomatic individuals prior to beginning low- or moderate-intensity physical activity not exceeding the demands of brisk walking or everyday living. B for type 2 diabetes, C for type 1 diabetes. Yoga and tai chi may be included based on individual preferences to increase flexibility, muscular strength, and balance. Individuals with diabetes or prediabetes are encouraged to increase their total daily incidental nonexercise physical activity to gain additional health benefits.
To gain more health benefits from physical activity programs, participation in supervised training is recommended over nonsupervised programs. The ACSM no longer includes risk factor assessment in the exercise preparticipation health screening process.
However, their recommendation is that anyone with diabetes who is currently sedentary and desires to begin physical activity at any intensity even low intensity should obtain prior medical clearance from a types of exercise and diabetes care professional We believe this recommendation is excessively conservative.