Physical Activity and Diabetes

Canadian Diabetes Association Clinical Practice Guidelines Expert Committee

Ronald J. Sigal MD, MPH, FRCPC Marni J. Armstrong CEP, PhD candidate Pam Colby BSc, RD Glen P. Kenny PhD Ronald C. Plotnikoff PhD Sonja M. Reichert MD, MSc, CCFP Michael C. Riddell PhD

  • Key Messages
  • Recommendations
  • Figures
  • Full Text
  • References

Key Messages

  • Moderate to high levels of physical activity and cardiorespiratory fitness are associated with substantially lower morbidity and mortality in men and women with and without diabetes.
  • For most people, being sedentary has far greater adverse health consequences than exercise would. However, before beginning a program of physical activity more vigorous than walking, people with diabetes should be assessed for conditions that might place the individual at increased risk for an adverse event associated with certain types of exercise.
  • For people with type 2 diabetes, supervised exercise programs have been particularly effective in improving glycemic control, reducing the need for antihyperglycemic agents and insulin, and producing modest but sustained weight loss.
  • Both aerobic and resistance exercise are beneficial for patients with diabetes, and it is optimal to do both types of exercise. At least 150 minutes per week of aerobic exercise, plus at least two sessions per week of resistance exercise, is recommended.

Types of Exercise

Aerobic exercise is physical activity, such as walking, bicycling or jogging, that involves continuous, rhythmic movements of large muscle groups lasting for at least 10 minutes at a time. Resistance exercise is physical activity involving brief repetitive exercises with weights, weight machines, resistance bands or one's own body weight (e.g. pushups) to increase muscle strength and/or endurance. Flexibility exercise is a form of activity, such as lower back or hamstring stretching, that enhances the ability of joints to move through their full range of motion. Some types of exercise, such as yoga, can incorporate elements of both resistance and flexibility exercise.

Benefits of Physical Activity

Physical activity can help people with diabetes achieve a variety of goals, including increased cardiorespiratory fitness, increased vigour, improved glycemic control, decreased insulin resistance, improved lipid profile, blood pressure reduction and maintenance of weight loss (1–4). The terms “physical activity” and “exercise” are used interchangeably in this chapter.

Benefits of Aerobic Exercise

Moderate to high levels of aerobic physical activity and higher levels of cardiorespiratory fitness are associated with substantial reductions in morbidity and mortality in both men and women and in both type 1 and type 2 diabetes. Large cohort studies have demonstrated that, in people with type 2 diabetes, regular physical activity (5–7) and/or moderate to high cardiorespiratory fitness (8) are associated with reductions in cardiovascular and overall mortality of 39% to 70% over 15 to 20 years of follow-up. Similarly, a cohort study in people with type 1 diabetes found that 7-year mortality was 50% lower in those reporting more than 2000 kcal of weekly exercise (equivalent to about 7 hours per week of brisk walking) compared to those reporting <1000 kcal of physical activity per week (9). Additional benefits of aerobic exercise include increased cardiorespiratory fitness in both type 1 and type 2 diabetes (10) and slowing of the development of peripheral neuropathy (11). In contrast to trials in type 2 diabetes, most clinical trials evaluating exercise interventions in people with type 1 diabetes have not demonstrated a beneficial effect of exercise on glycemic control (12).

Benefits of Resistance Exercise

A systematic review of randomized trials found that resistance training improves glycemic control (as reflected by reduced glycated hemoglobin [A1C]), decreases insulin resistance and increases muscular strength in adults with type 2 diabetes (13). Additionally, resistance training has been shown to increase lean muscle mass (14) and bone mineral density (15,16), leading to enhanced functional status and prevention of sarcopenia and osteoporosis. Resistance exercise in these studies was carried out using weight machines and/or free weights, and cannot necessarily be generalized to other types of resistance exercise, such as resistance bands or exercises utilizing only one's own body weight.

Benefits of Other Types of Exercise

To date, evidence for the beneficial effects of other types of exercise is not as extensive or as supportive as the evidence for aerobic and resistance exercise. For example, we found no study demonstrating any impact of a pure flexibility program on metabolic control, injury risk or any diabetes-related outcome. A systematic review found that tai chi had no significant effects on glycemic control or quality of life (17). In one trial, 40 people with type 2 diabetes were randomized to whole-body vibration, strength training or flexibility training (18). A1C decreased nonsignificantly in the vibration group while it increased nonsignificantly in the strength and flexibility training groups. Baseline A1Cs were 7.3%, 6.8%, and 6.7% in vibration, strength and flexibility groups, respectively. This study's sample size was small (n=13 to 14 per group) so statistical power was limited; therefore, further studies would be needed before we can be confident regarding the degree of effectiveness of vibration therapy. A systematic review of trials evaluating yoga as an intervention for type 2 diabetes found modest reductions in A1C, fasting glucose and total cholesterol, as well as modest increases in high-density lipoprotein cholesterol (HDL-C) (19). The quality of the included studies was low, results were highly heterogenous and there was evidence of significant publication bias. A trial published after this systematic review's search date found that Hatha yoga reduced A1C, fasting glucose, total cholesterol, body mass index and blood pressure to the same extent as aerobic exercise, with fewer self-reported symptoms of hypoglycemia (20,21). It is important to note that the Hatha yoga program in this trial incorporated elements of both strength training (where the resistance load was the individual's body weight) and aerobic exercise (repeated movements, done in a flowing manner, resulting in increased heart rate), and that it involved three 2-hour exercise sessions per week. This study's findings cannot necessarily be extrapolated to all Hatha Yoga programs or to other forms of yoga.

Supervised vs. Unsupervised Exercise

A systematic review and meta-analysis found that supervised programs involving aerobic or resistance exercise improved glycemic control in adults with type 2 diabetes, whether or not they included dietary co-intervention (22). The same meta-analysis found that unsupervised exercise only improved glycemic control if there was concomitant dietary intervention. A 1-year randomized trial compared exercise counselling plus twice-weekly supervised aerobic and resistance exercise vs. exercise counselling alone in patients with type 2 diabetes and the metabolic syndrome (23). Although self-reported total physical activity increased substantially in both groups, the group receiving the supervised aerobic and resistance exercise training had significantly better results: greater reductions in A1C, blood pressure, body mass index, waist circumference and estimated 10-year cardiac risk, and greater increases in aerobic fitness, muscle strength and HDL-C.

Minimizing Risk of Exercise-Related Adverse Events

People with diabetes should be prescribed and encouraged to incorporate regular exercise as a key part of their treatment plan. For most people with and without diabetes, being sedentary is associated with far greater health risks than exercise would be. However, before beginning a program of vigorous physical activity, people with diabetes should be assessed for conditions that might increase risks associated with certain types of exercise or predispose them to injury (2,24). Examples of such conditions include severe autonomic neuropathy, severe peripheral neuropathy, preproliferative or proliferative retinopathy and unstable angina. Preproliferative or proliferative retinopathy should be treated and stabilized prior to commencement of vigorous exercise. People with severe peripheral neuropathy should be instructed to inspect their feet daily, especially on days they are physically active, and to wear appropriate footwear. Although previous guidelines stated that persons with severe peripheral neuropathy should avoid weight-bearing activity, recent studies indicate that individuals with peripheral neuropathy may safely participate in moderate weight-bearing exercise provided they do not have active foot ulcers (25). Studies also suggest that patients with peripheral neuropathy in the feet, who participate in daily weight-bearing activity, are at decreased risk of foot ulceration compared with those who are less active (26).

A resting electrocardiogram (ECG) should be performed, and an exercise ECG stress test should be considered, for individuals with possible cardiovascular disease who wish to undertake exercise more intense than brisk walking, especially if they are considering intense, prolonged endurance exercise, such as marathon running. Maximal exercise testing can be useful for exercise prescription. Exercise intensity can be prescribed and assessed more accurately when the actual maximum heart rate or maximum oxygen consumption (VO 2max ) is known from exercise testing, as opposed to estimating target heart rate or work rate from age-predicted calculations. In addition, in cases where ischemia or arrhythmias are induced at higher exercise intensities, exercise test results could be used to keep exercise intensity below the ischemic threshold. Exercise testing also can be useful for risk stratification, given that lower aerobic capacity (27) and the presence of ischemic changes on ECG (28) are each associated with higher risks of cardiovascular and overall morbidity and mortality. Exercise testing can also sometimes detect previously unsuspected coronary disease. However, no trial has specifically assessed whether exercise stress testing before beginning an exercise program reduces coronary morbidity or mortality. Furthermore, a recent randomized trial found that screening of asymptomatic people with diabetes and additional cardiac risk factors using exercise ECG stress testing (or dipyridamole single photon emission computed tomography for those unable to exercise) did not reduce the risk of major cardiovascular events in the subsequent 3.5 years compared to a no-screening strategy (29). Another trial, in which 1123 asymptomatic people aged 50 to 75 years with type 2 diabetes were randomized to screening adenosine-stress radionuclide myocardial perfusion imaging or usual care found that screening had no impact on major cardiovascular events over the subsequent 5 years (30). Subjects in these 2 screening trials were not necessarily planning to begin exercise programs. Nevertheless, the evidence for exercise ECG stress testing of asymptomatic individuals with type 2 diabetes before beginning an exercise program is neither strong nor clear-cut.

The risk of hypoglycemia during exercise is of concern for people with diabetes, particularly those with type 1 diabetes, and to a lesser extent in those with type 2 diabetes using insulin or insulin secretagogues (sulfonylureas and meglitinides). In these individuals, if pre-exercise blood glucose levels are <5.5 mmol/L, approximately 15 to 30 g carbohydrate should be ingested before exercise. (The actual amount will be dependent on injected insulin dose, exercise duration and intensity, and results of blood glucose monitoring). In individuals whose diabetes is controlled by lifestyle or oral hypoglycemic agents that do not increase insulin levels, the risk of developing hypoglycemia during exercise is minimal, and most individuals will not need to monitor their blood glucose levels or be required to supplement with carbohydrate for exercise lasting <1 hour.

Hyperglycemia prior to exercise also may be of concern in people with diabetes. In individuals with type 1 diabetes who are severely insulin deficient (e.g. due to insulin omission or illness), hyperglycemia can be worsened by exercise. In patients with type 1 diabetes, if capillary glucose is >16.7 and the patient does not feel well, blood or urine ketones should be tested. If ketone levels are elevated, it is suggested that vigorous exercise be postponed and the patient take additional insulin. If ketones are negative and the patient feels well, it is not necessary to defer exercise due to hyperglycemia. Individuals with type 2 diabetes generally do not need to postpone exercise because of high blood glucose, provided they feel well. If capillary glucose levels are elevated >16.7 mmol/L, it is important to ensure proper hydration and monitor for signs and symptoms (e.g. increased thirst, nausea, severe fatigue, blurred vision or headache), especially for exercise to be performed in the heat.

Minimizing Risk of Heat-Related Illness

People with diabetes may have greater susceptibility to adverse effects from heat than those without diabetes (31). Metabolic, cardiovascular and neurological dysfunctions associated with diabetes, along with associated health issues and advanced age, reduce the body's ability to detect heat and impair its capacity to dissipate heat (32–34). Reductions in sweating (32,33) and skin blood flow (35–37) decrease the body's ability to maintain core temperature at safe levels, especially during extended heat exposure and/or exercise in the heat. Patients with diabetes, especially those who are elderly and/or have autonomic neuropathy, cardiac or pulmonary disease, should be aware that they are at higher risk for heat illness. Whenever possible, exercise should be performed in a cool environment, such as an air-conditioned training centre. When weather is hot, exercise outdoors should be performed in the early or later hours of the day when the temperatures are cooler and the sun is not at its peak.

Acute Effects of Exercise on Blood Glucose

During and after all but the most intense exercise, blood glucose tends to decline due to increased glucose disposal and insulin sensitivity (38). However, during, and especially after, brief, very intense exercise (e.g. competitive track and field, hockey, basketball, intense resistance training), blood glucose often increases as a result of increases in glucose production that exceed increases in glucose disposal (39). These diverging effects of exercise on blood glucose concentrations can make management challenging, particularly for patients with type 1 diabetes, although some strategies are provided below.

Exercise Prescription Details

Both aerobic and resistance exercise are recommended for most people with diabetes ( Tables 1 and 2 ). Walking is often the most popular and most feasible type of aerobic exercise in overweight, middle-aged, and elderly people with diabetes. For those who struggle with pain upon walking (e.g. due to osteoarthritis), semirecumbent cycling may provide an alternative. For most middle-aged individuals, moderately brisk walking on level ground or semirecumbent cycling would be an example of moderate aerobic exercise, while brisk walking up an incline or jogging would be vigorous aerobic exercise. Resistance exercise performed 2 or 3 times per week may provide benefits that complement those of aerobic training (e.g. increased strength and vigour, reduced body fat, increased resting metabolic rate) (3,13,40). The studies reporting the greatest impact of resistance exercise on A1C had subjects progress to 3 sets (with approximately 8 repetitions per set) of resistance-type exercises at moderate to high intensity (i.e. the maximum weight that can be lifted 8 times while maintaining proper form), 3 times per week (41,42) or more (43,44). However, significant reductions in A1C and body fat have been achieved with twice-weekly resistance exercise in combination with regular aerobic exercise (23,45). The effects of resistance exercise and aerobic exercise on glycemic control are additive (46). Individuals who wish to begin resistance exercise should receive initial instruction and periodic supervision by a qualified exercise specialist to maximize benefits while minimizing risk of injury. A meta-analysis found that trials evaluating resistance exercise with less supervision showed less beneficial impact on glycemic control, insulin resistance and body composition than studies with greater supervision (13). Individuals with diabetes should also be recommended to reduce the amount of time spent doing sedentary activities.

Table 1
Aerobic exercise
Definition and recommended frequency Intensity Examples
Rhythmic, repeated Moderate:
  • Biking
and continuous 50%–70%
  • Brisk walking
movements of the of person's
  • Continuous swimming
same large muscle maximum
  • Dancing
groups for at least heart rate
  • Raking leaves
10 minutes at a time  
  • Water aerobics
     
Recommended for Vigorous:
  • Brisk walking up
a minimum of 150 >70% of
  • an incline
minutes per week person's
  • Jogging
(moderate intensity) maximum heart rate
  • Aerobics
  • Hockey
   
  • Basketball
   
  • Fast swimming
   
  • Fast dancing

Physical Activity in Children with Type 2 Diabetes

The pathophysiology of type 2 diabetes in children is similar to that of type 2 diabetes in adults; therefore, it seems logical to expect similar benefits from physical activity in children with type 2 diabetes as has been achieved in adults. A recent systematic review found no good-quality studies directly assessing the effects of physical activity in youth with type 2 diabetes (47). In the absence of direct evidence in this population, it is reasonable to recommend that children with type 2 diabetes strive to achieve the same activity level recommended for children in general: 60 minutes daily of moderate to vigorous physical activity and limit sedentary screen time to no more than 2 hours per day. Canadian physical activity guidelines for children and youth are available from the Canadian Society for Exercise Physiology ( www.csep.ca ).

Table 2
Resistance exercise
Initial instruction and periodic supervision are recommended.
Note: The evidence supporting exercise with resistance bands is not as strong as the evidence for free weights or weight machines.
Definition Recommended frequency Examples
Activities of brief duration involving the use of weights, weight machines or resistance bands to increase muscle strength and endurance Three times per week
  • Start with 1 set using a weight with which you can perform 15 to 20 repetitions while maintaining proper form.
  • Progress to 2 sets and decrease the number of repetitions to 10–15 while increasing the weight slightly. If you cannot complete the required repetitions while maintaining proper form, reduce the weight.
  • Progress to 3 sets of 8 repetitions performed using an increased weight, ensuring proper form is maintained.
  • Exercise with weight machines
  • Exercise with free weights

Beginning Exercise in People with Low Baseline Fitness Levels

Previously sedentary individuals with limited exercise tolerance may have to gradually build up their amount of exercise, starting with as little as 5 to 10 minutes per day. Multiple, shorter exercise sessions (each lasting at least 10 minutes) in the course of a day should be considered as this regimen is as effective as a single longer session of equivalent length and intensity (48).

Exercise in Type 1 Diabetes

Moderate intensity aerobic exercise causes increased insulin sensitivity during, and for many hours after, the activity in people with and without diabetes. In type 1 diabetes, there is little or no endogenous insulin secretion and no physiological regulation of insulin levels. Therefore, if exogenous insulin and/or carbohydrate ingestion is not adjusted, hypoglycemia often occurs. Fear of hypoglycemia is an important barrier to exercise in people with type 1 diabetes (49) and advice on physical activity to patients with type 1 diabetes should include strategies to reduce risk of hypoglycemia. Small studies have explored several types of strategies for the prevention of hypoglycemia in type 1 diabetes. These strategies include the consumption of extra carbohydrates for exercise (50), limiting preprandial bolus insulin doses (51) and altering basal insulin for insulin pump users (52). These strategies can be used alone or in combination (53,54). Another strategy to avoid hypoglycemia is to perform intermittent, very brief (10 seconds), maximal-intensity sprints either at the beginning (55) or end (56) of an otherwise moderate-intensity exercise session, or intermittently during an exercise session (57). The attenuation of hypoglycemia is due to transiently reduced glucose disposal (58). Another strategy is to perform resistance exercise immediately prior to aerobic exercise (59). Exercise performed late in the day or in the evening can be associated with increased risk of overnight hypoglycemia in people with type 1 diabetes (50). To reduce this risk, one can reduce bedtime intermediate or long-acting injected insulin dose, or reduce overnight basal insulin infusion rates by approximately 20% from bedtime to 3  am for insulin pump users (60). For more detailed, case-based discussions of insulin and carbohydrate adjustment for exercise in type 1 diabetes, see references 53 and 54.

Hyperglycemia can occur after very intense exercise. If it occurs, it can be addressed by giving a small bolus of a short-acting insulin analogue or, in insulin pump users, by temporarily increasing the basal insulin infusion until euglycemia is restored.

Motivating People with Diabetes to Be Physically Active

Physicians and other healthcare professionals can heighten awareness of the importance of physical activity by promoting regular exercise as a key component of therapy and identifying resources in the community (61). Patients should be encouraged to set specific physical activity goals, anticipate likely barriers to physical activity (e.g. weather, competing time commitments) and develop strategies to overcome these barriers (62). Having patients record their daily physical activity has been shown to increase physical activity levels and improve self-efficacy (confidence in one's own ability to successfully carry out a behaviour) (63). Self-efficacy is a very strong cognitive predictor of both aerobic and resistance exercise participation in people with diabetes (64). Some studies have found that structured physical activity counselling by a physician (65), skilled healthcare personnel or case managers (66,67) increases physical activity levels, improves glycemic control (66), reduces the need for oral antihyperglycemic agents and insulin (67), and produces modest but sustained weight loss (68). However, the impact of physical activity counselling on glycemic control, fitness, body composition and lipids is not as great as can be achieved through a supervised aerobic and resistance exercise program (23). Having social support (e.g. exercising with a friend or partner) facilitates regular physical activity, especially for women (69).

In youth with type 1 diabetes, physical activity adherence levels can be increased through structured programs involving pedometers, text messaging, social media and exercise trainers (70–72).

Recommendations

  1. People with diabetes should accumulate a minimum of 150 minutes of moderate- to vigorous-intensity aerobic exercise each week, spread over at least 3 days of the week, with no more than 2 consecutive days without exercise [Grade B, Level 2, for type 2 diabetes (1,3,22) ; Grade C, Level 3, for type 1 diabetes (9)].
  2. People with diabetes (including elderly people) should perform resistance exercise at least twice a week (23) and preferably 3 times per week [Grade B, Level 2 (13)] in addition to aerobic exercise [Grade B, Level 2 (23,45,46)]. Initial instruction and periodic supervision by an exercise specialist are recommended [Grade C, Level 3 (13)].
  3. People with diabetes should set specific physical activity goals, anticipate likely barriers to physical activity (e.g. weather, competing commitments), develop strategies to overcome these barriers [Grade B, Level 2 (61)] and keep records of their physical activity [Grade B, Level 2 (62)].
  4. Structured exercise programs supervised by qualified trainers should be implemented when feasible for people with type 2 diabetes to improve glycemic control, CVD risk factors and physical fitness [Grade B, Level 2 (22,23)].
  5. People with diabetes with possible CVD or microvascular complications of diabetes who wish to undertake exercise that is substantially more vigorous than brisk walking should have medical evaluation for conditions that might increase exercise-associated risk. The evaluation would include history, physical examination (including funduscopic exam, foot exam, and neuropathy screening), resting ECG and, possibly, exercise ECG stress testing [Grade D, Consensus].

Abbreviations:
CVD, cardiovascular disease; ECG, electrocardiogram.

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