Physical Activity/Exercise and Type 2DiabetesA consensus statement from the American Diabetes Association

RONALD J. SIGAL, MD, MPH1,2,3

GLEN P. KENNY, PHD2,3

DAVID H. WASSERMAN, PHD4

CARMEN CASTANEDA-SCEPPA, MD, PHD5

RUSSELL D. WHITE, MD6

For decades, exercise has been consid-ered a cornerstone of diabetes man-agement, along with diet and

medication. However, high-quality evi-dence on the importance of exercise andfitness in diabetes was lacking until recentyears. The present document summarizesthe most clinically relevant recent ad-vances related to people with type 2 dia-betes and the recommendations thatfollow from these. Our recently publishedtechnical review on physical activity/exercise and type 2 diabetes (1) includesgreater detail on individual studies, onprevention of diabetes, and on the physi-ology of exercise.

The present statement focuses ontype 2 diabetes. Issues primarily germaneto type 1 diabetes will be covered in asubsequent technical review and ADAStatement. The levels of evidence used aredefined by the ADA in ref. 2.

PHYSICAL ACTIVITY ANDPREVENTION OF TYPE 2DIABETES — Two randomized trialseach found that lifestyle interventions in-cluding �150 min/week of physical ac-tivity and diet-induced weight loss of5–7% reduced the risk of progressionfrom impaired glucose tolerance (IGT) totype 2 diabetes by 58% (3,4). A cluster-randomized trial found that diet alone,exercise alone, and combined diet and ex-ercise were equally effective in reducting

the progression from IGT to diabetes (5).Therefore, there is firm and consistent ev-idence that programs of increased physi-cal activity and modest weight loss reducethe incidence of type 2 diabetes in indi-viduals with IGT.

EFFECTS OF STRUCTUREDEXERCISE INTERVENTIONSON GLYCEMIC CONTROLAND BODY WEIGHT INTYPE 2 DIABETES — Boule et al.(6) undertook a systematic review andmeta-analysis on the effects of structuredexercise interventions in clinical trials of�8 weeks duration on HbA1c (A1C) andbody mass in people with type 2 diabetes.Postintervention A1C was significantlylower in exercise than control groups(7.65 vs. 8.31%, weighted mean differ-ence �0.66%; P � 0.001). In contrast,postintervention body weight did not dif-fer between the exercise and controlgroups. Meta-regression confirmed thatthe beneficial effect of exercise on A1Cwas independent of any effect on bodyweight. Therefore, structured exerciseprograms had a statistically and clinicallysignificant beneficial effect on glycemiccontrol, and this effect was not primarilymediated by weight loss. A subsequentmeta-analysis by the same authors (7)showed that exercise intensity predictedpostintervention weighted mean differ-ence in A1C (r � �0.91, P � 0.002) to a

larger extent than exercise volume (r ��0.46, P � 0.26). These results providesupport for encouraging type 2 diabeticindividuals who are already exercising atmoderate intensity to consider increasingthe intensity of their exercise in order toobtain additional benefits in both aerobicfitness and glycemic control.

PHYSICAL ACTIVITY,AEROBIC FITNESS, ANDRISK OF CARDIOVASCULARAND OVERALL MORTALITY —Large cohort studies have found thathigher levels of habitual aerobic fitnessand/or physical activity are associatedwith significantly lower subsequent car-diovascular and overall mortality (8–10),to a much greater extent than could beexplained by glucose lowering alone. Forexample, Church et al. (8) found that menin the lowest, second, and third quartilesof cardiorespiratory fitness had 4.5-, 2.8-,and 1.6-fold greater risk for overall mor-tality than men in the highest quartile ofcardiorespiratory fitness, even after ad-justment for age, examination year, base-line cardiovascular disease (CVD),hypercholesterolemia, hypertriglyceride-mia, BMI, hypertension, parental CVD,smoking, and baseline fasting glucose lev-els. Essentially all of the association be-tween higher BMI and higher mortalitywas explained by confounding with car-diorespiratory fitness; there was no differ-ence in mortality among normal-weight,overweight, and obese men after adjust-ment for cardiorespiratory fitness.

In the same cohort, it was shown thatamong moderately fit subjects (21st–60th percentile for age) whose only exer-cise was walking, the mean time spent perweek on exercise was 130 min for menand 148 min for women (11). These timesare consistent with recommendationsfrom the U.S. Surgeon General (12) andother respected bodies (13–15) statingthat 150 min/week of moderate-intensityexercise should be accumulated. Moder-ately fit subjects whose only exercise wasjogging or running reported a mean of 90min/week for men and 92 min/week forwomen. These times are consistent with

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From the 1Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada; the 2School of HumanKinetics, University of Ottawa, Ottawa, Ontario, Canada; the 3Clinical Epidemiology Program, OttawaHealth Research Institute, Ottawa, Ontario, Canada; the 4Department Of Molecular Physiology and Bio-physics, Vanderbilt University, Nashville, Tennessee; the 5Jean Mayer USDA Human Nutrition ResearchCenter on Aging, Tufts University, Boston, Massachusetts; and the 6Department of Community and FamilyMedicine, Truman Medical Center-Lakehead, University of Missouri-Kansas City School of Medicine, KansasCity, Missouri.

Address correspondence and reprint requests to Ronald J. Sigal, Clinical Epidemiology Program, OttawaHealth Research Institute, 1053 Carling Ave., Ottawa, Ontario, Canada K1Y 4E9. E-mail: rsigal@ohri.ca.

Abbreviations: CAD, coronary artery disease; CVD, cardiovascular disease; ECG, electrocardiogram;IGT, impaired glucose tolerance.

A table elsewhere in this issue shows conventional and Systeme International (SI) units and conversionfactors for many substances.

DOI: 10.2337/dc06-9910© 2006 by the American Diabetes Association.

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 sC O N S E N S U S S T A T E M E N T

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an alternative and equally valid recom-mendation for 30 min of vigorous activitythree times a week.

To our knowledge, no meta-analysisof the effects of exercise training on lipidsor blood pressure in people with diabeteshas been published. In the general, pre-dominantly nondiabetic population, theeffects of exercise training on blood pres-sure (16) and lipids (17) are relativelymodest. Greater increases in HDL choles-terol and decreases in plasma triglycerideshave been seen with exercise programsthat are more rigorous in terms of bothvolume and intensity than those that havebeen evaluated in diabetic subjects (18).Potential mechanisms through which ex-ercise could improve cardiovascularhealth were reviewed by Stewart (19).These include decreased systemic inflam-mation, improved early diastolic filling(reduced diastolic dysfunction), im-proved endothelial vasodilator function,and decreased abdominal visceral fataccumulation.

FREQUENCY OF EXERCISE —TheU.S. Surgeon General’s report (12) rec-ommended that most people accumulate�30 min of moderate-intensity activityon most, ideally all, days of the week.However, most clinical trials evaluatingexercise interventions in people with type2 diabetes have used a three-times-per-week frequency (6), and many peoplefind it easier to schedule fewer longer ses-sions rather than five or more weeklyshorter sessions. The effect of a singlebout of aerobic exercise on insulin sensi-tivity lasts 24–72 h depending on the du-ration and intensity of the activity (20).Because the duration of increased insulinsensitivity is generally not �72 h, we rec-ommend that there should not be morethan 2 consecutive days without aerobicphysical activity. The effect of resistanceexercise training on insulin sensitivitymay last somewhat longer (21), perhapsbecause some of its effects are mediatedby increases in muscle mass.

EXERCISE FOR WEIGHTLOSS AND WEIGHTMAINTENANCE — The most suc-cessful programs for long-term weightcontrol have involved combinations ofdiet, exercise, and behavior modification(22). Exercise alone, without concomi-tant dietary caloric restriction and behav-ior modification, tends to produce onlymodest weight loss of �2 kg. Weight lossis typically this small primarily because

obese people often have difficulty per-forming sufficient exercise to create alarge energy deficit, and it is relativelyeasy to counterbalance increased energyexpenditure through exercise by eatingmore or becoming less active outside ofexercise sessions (22). However, in a ran-domized trial, high-volume aerobic exer-cise (700 kcal/day, �1 h/day of moderate-intensity aerobic exercise) produced atleast as much fat loss as the equivalentdegree of caloric restriction and withgreater resulting improvements in insulinsensitivity (23).

The optimal volume of exercise toachieve sustained major weight loss isprobably much larger than needed toachieve improved glycemic control andcardiovascular health. In observationalstudies (24 –27), individuals who suc-cessfully maintain large weight loss overat least a year have typically performed�7 h/week of moderate- to vigorous-intensity exercise. Two randomized trialsfound that higher exercise volumes(2,000 and 2,500 kcal/week) producedgreater and more sustained weight lossthan lower exercise volumes (1,000 kcal/week) (28,29).

Because of the increased evidence forhealth benefits from resistance trainingduring the past 10–15 years, the Ameri-can College of Sports Medicine (ACSM)now recommends that resistance trainingbe included in fitness programs forhealthy young and middle-aged adults(13), older adults (30), and adults withtype 2 diabetes (15). With increased age,there is a tendency for progressive de-clines in muscle mass, leading to “sar-copenia,” decreased functional capacity,decreased resting metabolic rate, in-creased adiposity, and increased insulinresistance, and resistance training canhave a major positive impact on each ofthese (30). Resistance exercise improvesinsulin sensitivity to about the same ex-tent as aerobic exercise (31).

RESISTANCE TRAINING

Studies of resistance training in type2 diabetesTwo clinical trials provided the strongestevidence for the value of resistance train-ing in type 2 diabetes (32,33). In bothstudies, the average age of participantswas 66 years, and the resistance-trainingregimen involved multiple exercises athigh intensity (three sets, three times perweek), and absolute A1C declined 1.1–1.2% in resistance-training subjects ver-

sus no significant change in controlsubjects. One of these trials had a secondphase (months 7–12), where training washome based rather than facility based(34). Body composition changes weremaintained, but exercise intensity and ad-herence were lower than in the first 6months and the A1C difference betweengroups became statistically nonsignifi-cant. Other published studies ofresistance exercise in type 2 diabetic par-ticipants have used less intense exerciseregimens (35–40). All showed beneficialeffects of the resistance exercise programbut to a lesser extent than the Dunstan etal. (32) and Castaneda et al. (33) trials.

Safety of resistance trainingSome medical practitioners have con-cerns about the safety of higher-intensityresistance exercise in middle-aged andolder people who are at risk of CVD. Of-ten, the main concern is that the acuterises in blood pressure associated withhigher-intensity resistance exercise mightbe harmful, possibly provoking stroke,myocardial ischemia, or retinal hemor-rhage. We have found no evidence thatresistance training actually increasesthese risks. No serious adverse eventshave been reported in any research studyof resistance training in patients with type2 diabetes, although the total number ofsubjects enrolled in these studies wassmall (32,33,35–37,40). A review of 12resistance exercise studies in a total of 246male cardiac rehabilitation patients foundno angina, ST depression, abnormal he-modynamics, ventricular dysrhythmias,or other cardiovascular complications(41). A study of 12 men with known cor-onary ischemia and electrocardiogram(ECG) changes inducible by moderateaerobic exercise found that even maxi-mal-intensity resistance exercise did notinduce ECG changes (42). Therefore,moderate- to high-intensity resistancetraining was found to be safe even in menat significant risk of cardiac events.

While it is well known that bloodpressure rises while lifting a heavy weight,it is often not appreciated that blood pres-sure can also rise considerably in healthyolder people performing aerobic exercise.Benn et al. (43) demonstrated that inhealthy older men, the myocardialdemands of high-intensity resistance ex-ercise were comparable to those occasion-ally needed for activities of daily living,such as climbing stairs, walking up a hill,or carrying 20–30 lb of groceries.

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FLEXIBILITY EXERCISE — Flexi-bility exercise (stretching) has frequentlybeen recommended as a means of increas-ing range of motion and hopefullyreducing risk of injury. However, two sys-tematic reviews found that flexibility ex-ercise did not reduce risk of exercise-induced injury (44,45). Most studiesincluded in these systematic reviews eval-uated younger subjects undertaking veryvigorous activity programs, such as thosein military basic training; these resultsmay not be generalizable to older sub-jects. Flexibility exercise has been suc-cessfully used in clinical trials as a“placebo” exercise (32,46), since there isno evidence that flexibility exercise affectsmetabolic control or quality of life. Onesmall randomized trial (n � 19) foundthat range-of-motion exercises modestlydecreased peak plantar pressures (47).We found no studies that directly evalu-ated whether flexibility training reducedthe risk of ulceration or injury in peoplewith diabetes. Therefore, we feel thatthere is insufficient evidence to recom-mend for or against flexibility exercise as aroutine part of the exercise prescription.

EVALUATION OF THEDIABETIC PATIENT BEFORERECOMMENDING ANEXERCISE PROGRAM — For amore detailed review on this subject, seeref. 48. Before beginning a program ofphysical activity more vigorous than briskwalking, people with diabetes should beassessed for conditions that might be as-sociated with increased likelihood of CVDor that might contraindicate certain typesof exercise or predispose to injury, such assevere autonomic neuropathy, severe pe-ripheral neuropathy, and preproliferativeor proliferative retinopathy. The patient’sage and previous physical activity levelshould be considered.

The role of stress testing before begin-ning an exercise program is controversial.There is no evidence that such testing is rou-tinely necessary for those planning moder-ate-intensity activity such as walking, but itshould be considered for previously seden-tary individuals at moderate to high risk ofCVD who want to undertake vigorous aer-obic exercise exceeding the demands of ev-eryday living (49). The prevalence of bothsymptomatic and asymptomatic coronaryartery disease (CAD) is greater in diabeticindividuals compared with nondiabetic in-dividuals of the same age-group. However,many younger diabetic patients have rela-tively low absolute risk for a coronary event.

Ten-year CVD risk can be estimated usingthe UKPDS (U.K. Prosepctive DiabetesStudy) Risk Engine (50) (http://www.dtu.ox.ac.uk/index.html?maindoc%20�%20/riskengine/), while 30-year risk of a widevariety of outcomes, including CVD, can beestimated using the American Diabetes As-sociation’s Diabetes PHD (Personal HealthDecisions) (51) (http://diabetes.org/diabetesPHD). The lower the absolute CADrisk, the higher the likelihood of a false-positive test. A recent systematic review forthe U.S. Preventive Services Task Forcecame to the conclusion that stress testsshould usually not be recommended to de-tect ischemia in asymptomatic individualsat low CAD risk (�10% risk of a cardiacevent over 10 years) because the risks ofsubsequent invasive testing triggered byfalse-positive tests outweighed the expectedbenefits from detection of previously unsus-pected ischemia (52,53).

There is little or no evidence to guidepractitioners in terms of whether stresstesting before undertaking resistancetraining is necessary. One might askwhether such testing should use resis-tance exercise rather than the usual aero-bic exercise during a stress test in suchcircumstances. Very few test centerswould currently be equipped for suchtesting, and such tests have not been stan-dardized. In contrast, aerobic exercisestress testing is widely available, stan-dardized, and of proven prognostic value.

EXERCISE IN THE PRESENCEOF NONOPTIMALGLYCEMIC CONTROL

HyperglycemiaWhen people with type 1 diabetes are de-prived of insulin for 12–48 h and ketotic,exercise can worsen the hyperglycemia andketosis (54). Previous ADA exercise posi-tion statements suggested that physical ac-tivity be avoided if fasting glucose levels are�13.9 mmol/l (�250 mg/dl) and ketosis ispresent and that it be performed with cau-tion if glucose levels are �16.7 mmol/l (300mg/dl), even if no ketosis is present (55).We agree that vigorous activity shouldprobably be avoided in the presence of ke-tosis. However, the recommendation toavoid physical activity if plasma glucose is�300 mg/dl, even in the absence of ketosis,is probably more cautious than necessaryfor a person with type 2 diabetes, especiallyin a postprandial state. In the absence ofvery severe insulin deficiency, light- ormoderate-intensity exercise would tend todecrease plasma glucose. Therefore, pro-

vided the patient feels well, the patient isadequately hydrated, and urine and/orblood ketones are negative, it is not neces-sary to postpone exercise based solely onhyperglycemia.

HypoglycemiaIn individuals taking insulin and/or insu-lin secretagogues, physical activity cancause hypoglycemia if medication dose orcarbohydrate consumption is not altered.This is particularly so at times when ex-ogenous insulin levels are at their peaksand if physical activity is prolonged. Hy-poglycemia would be rare in diabetic in-dividuals who are not treated with insulinor insulin secretagogues. Previous ADAguidelines suggested that added carbohy-drate should be ingested if preexerciseglucose levels are �5.6 mmol/l (100 mg/dl) (55). We agree with this recommen-dation for individuals on insulin and/oran insulin secretagogue. However, therevised guidelines clarify that supple-mentary carbohydrate is generally notnecessary for individuals treated onlywith diet, metformin, �-glucosidase in-hibitors, and/or thiazolidinediones with-out insulin or a secretagogue. We foundno published studies examining re-sponses to exercise in subjects takingpramlintide (synthetic amylin analog) orexenatide (incretin analog). Neither islikely to cause hypoglycemia when usedas monotherapy or combined with onlymetformin or a thiazolidinedione. How-ever, patients taking either of these drugsin combination with insulin or a secreta-gogue may need to take additional carbo-hydrate before physical activity and/orreduce doses of insulin or secretagogue toavoid hypoglycemia. For a detailed dis-cussion of medication adjustments to re-duce risk of hypoglycemia, see ref. 56.Concomitant medications other thanhypoglycemic agents. Diabetic patientsfrequently take diuretics, �-blockers,ACE inhibitors, aspirin, and lipid-lowering agents. In most type 2 diabeticindividuals, medications will not interferewith the physical activities they choose toperform, but patients and health care pro-viders should be aware of potential prob-lems to minimize their impact. Diuretics,especially in higher doses, can interferewith fluid and electrolyte balance.�-Blockers can blunt the adrenergicsymptoms of hypoglycemia, possibly in-creasing risk of hypoglycemia unaware-ness. They can reduce maximal exercisecapacity to �87% of what it would bewithout � blockade (57) through their

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negative inotropic and chronotropic ef-fects. However, most people with type 2diabetes do not choose to exercise at veryhigh intensity, so this reduction of maxi-mum capacity is generally not problem-atic. In people with CAD, � blockadeactually increases exercise capacity by re-ducing coronary ischemia (58). For addi-tional discussion on the impact ofconcomitant medications on physical ac-tivity, see ref. 48.

EXERCISE IN THE PRESENCEOF SPECIFIC LONG-TERMCOMPLICATIONS OFDIABETES — There is a paucity of re-search on the risks and benefits of exercisein the presence of diabetes complications.Therefore, recommendations in this sec-tion are based largely on “expert opinion.”

RetinopathyExercise and physical activity are notknown to have any adverse effects on vi-sion or the progression of nonprolifera-tive diabetic retinopathy or macularedema (59). This applies to both resis-tance and aerobic training. However, inthe presence of proliferative or severenonproliferative diabetic retinopathy,vigorous aerobic or resistance exercisemay be contraindicated because of the po-tential risk of triggering vitreous hemor-rhage or retinal detachment (59). Wefound no research studies providing guid-ance as to an appropriate time interval be-tween successful laser photocoagulationand initiation or resumption of resistanceexercise. Ophthalmologists, with whomone of us (C.C.-S.) consulted, suggestedwaiting 3–6 months after laser photoco-agulation before initiating or resumingthis type of exercise.

Peripheral neuropathyWe are unaware of research studies assess-ing the risk of exercise-induced injury inpeople with peripheral sensory neuropathy.Common sense, however, would indicatethat decreased pain sensation in the extrem-ities would result in increased risk of skinbreakdown and infection and of Charcotjoint destruction. Therefore, in the presenceof severe peripheral neuropathy, it may bebest to encourage non–weight-bearing ac-tivities such as swimming, bicycling, or armexercises (60,61).

Autonomic neuropathyAutonomic neuropathy can increase therisk of exercise-induced injury by de-creasing cardiac responsiveness to exer-

cise, postural hypotension, impairedthermoregulation due to impaired skinblood flow and sweating, impaired nightvision due to impaired papillary reaction,and impaired thirst, which increases therisk of dehydration and gastroparesiswith unpredictable food delivery (60).Autonomic neuropathy is also stronglyassociated with CVD in people with dia-betes (62,63). Individuals with diabeticautonomic neuropathy should undergocardiac investigation before beginningphysical activity more intense than that towhich they are accustomed. Some expertsadvocate thallium scintigraphy as the pre-ferred screening technique for CVD inthis high-risk population (60).

Microalbuminuria and nephropathyPhysical activity can acutely increase uri-nary protein excretion. The magnitude ofthis increase is in proportion to the acuteincrease in blood pressure. This finding hasled some experts to recommend that peoplewith diabetic kidney disease perform onlylight or moderate exercise, such that bloodpressure during exercise would not rise tomore than 200 mmHg (64). However, thereis no evidence from clinical trials or cohortstudies demonstrating that vigorous exer-cise increases the rate of progression of dia-betic kidney disease. Several randomizedtrials in animals with diabetes and protein-uria showed that aerobic exercise trainingdecreased urine protein excretion (65,66),possibly in part due to improved glycemiccontrol, blood pressure, and insulin sensi-tivity. Resistance training also may be ofbenefit in terms of muscle mass, nutritionalstatus, functional capacity, and glomerularfiltration rate (67). Because of these encour-aging findings, we believe there may be noneed for any specific exercise restrictions forpeople with diabetic kidney disease. How-ever, because microalbuminuria and pro-teinuria are associated with increased riskfor CVD, it is important to perform an exer-cise ECG stress test in previously sedentaryindividuals with these conditions before be-ginning exercise significantly more intensethan the demands of everyday living.

RECOMMENDATIONS — Levelsof evidence used are those defined by theADA in ref. 2.

Lifestyle measures for prevention oftype 2 diabetesIn people with IGT, a program of weightcontrol is recommended, including atleast 150 min/week of moderate to vigor-ous physical activity and a healthful diet

with modest energy restriction. Level ofevidence: A (3,4,68,69).

Aerobic exerciseThe amount and intensity recommendedfor aerobic exercise vary according togoals.

● To improve glycemic control (6,7),assist with weight maintenance, andreduce risk of CVD (9,10), we recom-mend at least 150 min/week of moder-ate-intensity aerobic physical activity(40 – 60% of V� O2max or 50 –70% ofmaximum heart rate) and/or at least 90min/week of vigorous aerobic exercise(�60% of V� O2max or �70% of maxi-mum heart rate). The physical activityshould be distributed over at least 3days/week and with no more than 2consecutive days without physical ac-tivity. Level of evidence: A (6,7).

● Performing �4 h/week of moderate tovigorous aerobic and/or resistance ex-ercise physical activity is associatedwith greater CVD risk reduction com-pared with lower volumes of activity(10). Level of evidence: B (9,10).

● For long-term maintenance of majorweight loss (�13.6 kg/30 lb), largervolumes of exercise (7 h/week of mod-erate or vigorous aerobic physical activ-ity) may be helpful (24–27,70). Level ofevidence: B (24–27,70).

Resistance exerciseIn the absence of contraindications, peo-ple with type 2 diabetes should be en-couraged to perform resistance exercisethree times a week, targeting all majormuscle groups, progressing to three setsof 8–10 repetitions at a weight that can-not be lifted more than 8–10 times (8–10RM). Level of evidence: A (32,33). To en-sure resistance exercises are performedcorrectly, maximize health benefits, andminimize the risk of injury, we recom-mend initial supervision and periodic re-assessments by a qualified exercisespecialist, as was done in the clinical trials(32,33).

Prevention of hypoglycemiaThose who take insulin or secretagoguesshould check capillary blood glucose be-fore, after, and several hours after com-pleting a session of physical activity, atleast until they know their usual glycemicresponses to such activity. For those whoshow a tendency to hypoglycemia duringor after exercise, several strategies can beused. Doses of insulin or secretagogues

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can be reduced before sessions of physicalactivity, extra carbohydrate can be con-sumed before or during physical activity,or both strategies can be implemented.Level of evidence: E (consensus, clinicalexperience).

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