Last updated March 14, 2022

Exercise and Physical Activity in Individuals with Type 2 Diabetes

Consensus Statements and Recommendations

  • Regular aerobic exercise training improves glycemic management in adults with type 2 diabetes, with less daily time in hyperglycemia and 0.5%–0.7% reductions in overall glycemia (as measured by A1C).
  • High-intensity resistance exercise training has greater beneficial effects than low-to-moderate-intensity resistance training in terms of overall glucose management and attenuation of insulin levels.
  • Greater energy expenditure postprandially reduces glucose levels regardless of exercise intensity or type, and durations ≥45 min provide the most consistent benefits.
  • Small “doses” of PA throughout the day to break up sitting modestly attenuate postprandial glucose and insulin levels, particularly in individuals with insulin resistance and a higher body mass index.
  • Weight loss (accomplished through lifestyle changes in diet and PA) of >5% seems to be necessary for beneficial effects on A1C, blood lipids, and blood pressure.
  • For reductions in visceral fat in individuals with type 2 diabetes, a moderately high volume of exercise (~500 kcal) done 4–5 d·wk−1 is needed.
  • In youth with type 2 diabetes, intensive lifestyle interventions plus metformin have not been superior to metformin alone in managing glycemia.
  • Despite the limited data, it is still recommended that youth and adolescents with type 2 diabetes meet the same PA goals set for youth in the general population.
  • Pregnant women with and without diabetes should participate in at least 20–30 min of moderate-intensity exercise most days of the week.
  • Individuals with type 2 diabetes using insulin or insulin secretagogues are advised to supplement with carbohydrate (or reduce insulin, if possible) as needed to prevent hypoglycemia during and after exercise.
  • Participation in an exercise program before bariatric surgery may enhance surgical outcomes, and after surgery, participation confers additional benefits.

Recommended types of exercise training for all adults with T2D

 
Type of Training
Type Intensity Frequency Duration Progression
Aerobic Walking, jogging, cycling, swimming, aquatic activities, rowing, dancing, interval training 40%–59% of V˙O2R or HRR (moderate), RPE 11–12; or 60%–89% of V˙O2R or HRR (vigorous), RPE 14–17 3–7 d·wk−1, with no more than 2 consecutive days between bouts of activity Minimum of 150–300 min·wk−1 of moderate activity or 75–150 min of vigorous activity, or an equivalent combination thereof Rate of progression depends on baseline fitness, age, weight, health status, and individual goals; gradual progression of both intensity and volume is recommended
Resistance Free weights, machines, elastic bands, or body weight as resistance; undertake 8–10 exercises involving the major muscle groups Moderate at 50%–69% of 1RM, or vigorous at 70%–85% of 1RM 2–3 d·wk−1, but never on consecutive days 10–15 repetitions per set, 1–3 sets per type of specific exercise As tolerated; increase resistance first, followed by a greater number of sets, and then increased training frequency
Flexibility Static, dynamic, or PNF stretching; balance exercises; yoga and tai chi increase range of motion Stretch to the point of tightness or slight discomfort ≥2–3 d·wk−1 or more; usually done with when muscles and joints are warmed up 10–30 s per stretch (static or dynamic)group; 2–4 repetitions of each As tolerated; may increase range of stretch as long as not painful
Balance Balance exercises: lower body and core resistance exercises, yoga, and tai chi also improve balance No set intensity ≥2–3 d·wk−1 or more No set duration As tolerated; balance training should be done carefully to minimize the risk of falls
1RM, 1-repetition maximum; HRR, heart rate reserve; PNF, proprioceptive neuromotor facilitation; RPE, rating of perceived exertion; V˙O2R, V˙O2 reserve.

Indications for preparticipation exercise stress testing

In general, maximal graded exercise stress testing may be indicated for adults matching one or more of these criteria:
• Age >40 yr, with or without CVD risk factors other than diabetes
• Age >30 yr and
 ○ Type 1 or T2D >10 yr duration
 ○ Hypertension
 ○ Cigarette smoking
 ○ Dyslipidemia
 ○ Proliferative or preproliferative retinopathy
 ○ Nephropathy including microalbuminuria
• Any of the following, regardless of age
 ○ Known of suspected cardiovascular, coronary artery, or peripheral artery disease
 ○ Autonomic neuropathy
 ○ Advanced nephropathy with renal failure
 

General exercise training considerations and precautions

  • Medical clearance (and exercise testing) before starting activities more vigorous than brisk walking is recommended for adults with signs or symptoms of CVD, longer diabetes duration, older age, or other diabetes-related complications.
  • Individuals should not begin exercise with a blood glucose >250 mg·dL−1 (13.9 mmol·L−1) if moderate or high levels of blood or urinary ketones are present. Use caution during PA with a blood glucose >300 mg·dL−1 (16.7 mmol·L−1) without excessive ketones, stay hydrated, and only begin if feeling well.
  • Individuals are advised to hydrate properly by drinking adequate fluids before, during, and after exercise, as well as avoid exercising during the peak heat of the day or in direct sunlight to prevent overheating.
  • Particularly for anyone using insulin or taking sulfonylureas (and possibly meglitinides within 2–3 h of PA), it is important to carry rapid-acting carbohydrate sources during PA to treat hypoglycemia and have glucagon available to treat severe hypoglycemia (if prone to developing it).

PA precautions for common comorbid health complications

 
 
Health Complication
Precaution
Autonomic neuropathy • Be aware of an increased likelihood of hypoglycemia, abnormal blood pressure responses, and impaired thermoregulation, as well as elevated resting and blunted maximal heart rate.
• Use of ratings of perceived exertion (RPE) is suggested to monitor exercise intensity.
• Take steps to prevent dehydration and hyperthermia or hypothermia.
Peripheral neuropathy • Limit exercise participation that may cause foot trauma, such as prolonged hiking, jogging, or walking on uneven surfaces.
• Non–weight-bearing exercises (e.g., cycling, chair exercises, swimming) may be more appropriate, but avoid aquatic exercise with unhealed plantar surface ulcers.
• Check feet daily for signs of trauma and redness.
• Choose shoes and socks carefully for proper fit and wear socks that keep feet dry.
• Avoid activities requiring excessive balance ability.
Diabetic retinopathy • With unstable proliferative and severe retinopathy, avoid vigorous, high-intensity activities that involve breath holding (e.g., weight lifting and isometrics) or overhead lifting.
• Avoid activities that lower the head (e.g., yoga, gymnastics) or that jar the head.
• In the absence of a stress test measured maximal heart rate, use RPE to monitor exercise intensity (10 to 12 on a 6–20 scale).
• Exercise is contraindicated for anyone with unstable or untreated proliferative retinopathy, recent panretinal photocoagulation, or other recent surgical eye treatment.
• Consult an ophthalmologist for specific restrictions and limitations.
Diabetic kidney disease • Avoid exercise that causes excessive increases in blood pressure (e.g., weight lifting, high-intensity aerobic exercise) and refrain from breath holding during activities.
• High blood pressure is common, and lower-intensity exercise may be necessary to manage blood pressure responses and fatigue.
• Light to moderate exercise is possible during dialysis treatments if electrolytes are managed.
Hypertension • Avoid heavy weight lifting or breath holding.
• Perform dynamic exercises using large muscle groups, such as walking and cycling at a low to moderate intensity.
• Follow blood pressure guidelines for activity levels.
• In the absence of a measured maximal heart rate, use of RPE is recommended (10 to 12 on a 6–20 scale).

Recommendation Grading

Overview

Title

Exercise and Physical Activity in Individuals with Type 2 Diabetes

Authoring Organization

Publication Month/Year

January 24, 2022

Document Type

Consensus

Country of Publication

US

Document Objectives

The objective of this consensus statement is to provide readers with a summary of the current evidence and extend and update the prior recommendations from 2010. The writing group used a consensus approach to synthesize available evidence from clinical trials and case reports, narrative and systematic reviews, and meta-analyses, and the recommendations represent the consensus of the writing panel and ACSM and incorporate guidance from other professional organizations with expertise in this area, such as the ADA.

Target Patient Population

Children and adults with type 2 diabetes

Target Provider Population

All providers and caregivers who care for individuals with type 2 diabetes, and those individuals themselves

Inclusion Criteria

Male, Female, Adolescent, Adult, Child, Older adult

Health Care Settings

Ambulatory, Childcare center, Long term care, School

Intended Users

Athletics coaching, physical therapist

Scope

Counseling, Management

Diseases/Conditions (MeSH)

D003924 - Diabetes Mellitus, Type 2, D010809 - Physical Fitness, D015444 - Exercise

Keywords

diabetes, nutrition, exercise, physical activity, type 2 diabetes mellitus, Type 2 Diabetes

Source Citation

Kanaley JA, Colberg SR, Corcoran MH, Malin SK, Rodriguez NR, Crespo CJ, Kirwan JP, Zierath JR. Exercise/Physical Activity in Individuals with Type 2 Diabetes: A Consensus Statement from the American College of Sports Medicine. Med Sci Sports Exerc. 2022 Feb 1;54(2):353-368. doi: 10.1249/MSS.0000000000002800. PMID: 35029593.