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1. Role of Exercise in
Management of
Diabetes
Mohammad Hassabi MD
Assistant Professor
Sports and Exercise Medicine Dept. SBMU

2. Risk of Inactivity
• being overweight and having low physical activity
were associated with an increased risk of incident
type 2 diabetes
• Individuals who were both obese and had low
physical activity had 7.4-fold increased risk of type
2 diabetes compared with normal weight, high
physically active participants.
• Meta-analysis of 9 Studies, A total of 11,237 incident type 2
diabetes cases
Cloostermans, Laura, et al. "Independent and combined effects of physical activity
and body mass index on the development of Type 2 Diabetes–a meta-analysis of 9
prospective cohort studies." International Journal of Behavioral Nutrition and
Physical Activity 12.1 (2015): 147.

3. Preventive effect
in people with impaired glucose tolerance
Structured lifestyle intervention trials that include
• physical activity (at least 150–175 min/week) and
• dietary energy restriction (targeting weight loss of 5-7%)
have demonstrated reductions of 40–70% in the risk of developing DM2.

4. • Both high-level Leisure-time physical activity and moderate-level LTPA
were associated with decreased incidence of type 2 diabetes.
• High-level LTPA is more beneficial in decreasing the incidence of type
2 diabetes than moderate-level LTPA
• A Meta- analysis of total of eight studies, including 296,395 participants
Huai et al. Leisure-time physical activity and risk of type 2 diabetes: a meta-analysis of
prospective cohort studies. Endocrine, 52 (2016), pp. 226-230

5. Physical Activity
Exercise
(Defined Purpose, FITT)
Sports

6. TYPES OF EXERCISE
• Aerobic exercise involves repeated and continuous movement of large muscle
groups: walking, cycling, jogging, and swimming
• Resistance (strength) training includes exercises with free weights, weight
machines, body weight, or elastic resistance bands
• Flexibility exercises improve range of motion around joints
• Balance exercises benefit gait and prevent falls
Multi purpose workouts: Activities like
tai chi and yoga combine flexibility,
balance, and resistance activities.

7. BENEFITS OF EXERCISE (Aerobic training)
• insulin sensitivity
• increases mitochondrial density
• oxidative enzymes
• compliance and reactivity of blood vessels
• lung function
• immune function
• cardiac output
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

8. Benefits in young Type 1
• Meta-analyses of 10 randomized and 16 non-randomized studies of
subjects aged ≤18 years with Type 1 diabetes showed potential
benefits of physical activity on HbA1c; BMI and triglycerides
Quirk, Helen, et al. "Physical activity interventions in children and young people with type 1 diabetes mellitus:
A systematic review with meta‐analysis." Diabetic Medicine 31.10 (2014): 1163-1173.
• Another meta-analysis of 10 trials in youth <18 years of age with type
1 diabetes found significant improvements in A1C in exercisers
MacMillan, Freya, et al. "A systematic review of physical activity and sedentary behavior intervention studies in
youth with type 1 diabetes: study characteristics, intervention design, and efficacy." Pediatric diabetes 15.3
(2014): 175-189.

9. BENEFITS OF EXERCISE (resistance training)
• improvements in muscle mass, body composition,
• strength, physical function,
• bone mineral density,
• insulin sensitivity,
• Blood pressure
• lipid profiles
• cardiovascular health
Diabetes is an independent risk factor for low muscular strength and
accelerated decline in muscle strength and functional status

10. • The effect of resistance exercise on glycemic control in type 1
diabetes is unclear
Tonoli, Cajsa, et al. "Effects of different types of acute and chronic (training) exercise on glycaemic
control in type 1 diabetes mellitus." Sports medicine42.12 (2012): 1059-1080.
• Resistance training benefits for individuals with type 2 diabetes
include:
• improvements in glycemic control
• insulin resistance
• fat mass and lean body mass
• blood pressure
• Strength
Gordon, B. A., et al. "Resistance training improves metabolic health in type 2 diabetes: a systematic
review." Diabetes research and clinical practice 83.2 (2009): 157-175.

11. • Resistance exercise can assist in minimizing risk of exercise-induced
hypoglycaemia in type 1 diabetes
• Resistance exercise causes less initial decline in blood glucose during
the activity but is associated with more prolonged reductions in
postexercise glycemia than aerobic exercise
Yardley, Jane E., et al. "Resistance versus aerobic exercise." Diabetes care 36.3 (2013): 537-542.
• Performing resistance exercise before aerobic exercise improves
glycemic stability throughout exercise and reduces the duration and
severity of postexercise hypoglycemia for individuals with type 1
diabetes
• When resistance and aerobic exercise are undertaken in one exercise
session, performing resistance exercise first results in less
hypoglycaemia than when aerobic exercise is performed first
Yardley, Jane E., et al. "Effects of performing resistance exercise before versus after aerobic exercise
on glycemia in type 1 diabetes." Diabetes care35.4 (2012): 669-675.

12. BENEFITS OF EXERCISE (stretching, Balance)
• Stretching increases range of motion around joints and
flexibility but does not affect glycemic control.
Colberg, Sheri R., et al. "Physical activity/exercise and diabetes: a position statement
of the American Diabetes Association." Diabetes Care 39.11 (2016): 2065-2079.
• Balance training can reduce falls risk by improving balance
and gait, even when peripheral neuropathy is present
Morrison, Steven, et al. "Balance training reduces falls risk in older individuals with
type 2 diabetes." Diabetes care 33.4 (2010): 748-750.

13. Dose-response
• Higher levels of Leisure-time physical activity were
associated with substantially lower incidence of type 2
diabetes in the general population
• Risk reduction of 26% for type 2 diabetes among those who
achieved 11.25 MET h/week (equivalent to 150 min/week of
moderate activity) relative to inactive individuals
• The relationship between LTPA and type 2 diabetes was
curvilinear
• Achieving twice this amount of PA was associated with a risk
reduction of 36%
28 prospective studies
Smith AD, et al. Physical activity and incident type 2 diabetes mellitus: a systematic review and dose-response meta-
analysis of prospective cohort studies. Diabetologia. 2016;59:2527–45

14. Advice only vs. Structured exercise training
• structured exercise trainings are more effective than advice only in lowering BP in
diabetic patients
• Structured exercise => reductions in SBP -4.22 mmHg; and DBP -2.07 mmHg
• In structured exercise interventions ,Both Aerobic and Resistive were associated
with declines in BP
• PA advice only => reduction in SBP -2.97 mmHg; and DBP -1.41 mmHg
A total of 30 RCTs of structured training (2,217 patients) and 21 of PA advice (7,323 patients)
Figueira, Franciele R., et al. "Association between physical activity advice only or structured exercise training with
blood pressure levels in patients with type 2 diabetes: a systematic review and meta-analysis." Sports Medicine44.11
(2014): 1557-1572.

15. Advice only vs. Structured exercise training
Type HbA1c change as compared with control Sample Volume
overall of any structured exercise − 0.67% 23 studies; 1533 patients
Structured Aerobic − 0.73% 18 studies; 848 patients
Structured Resistance − 0.57% 4 studies; 261 patients
Structured combination − 0.51% 7 studies; 404 patients
Physical activity advice alone not associated with HbA1c changes 14 studies; 712 patients
physical activity associated with
dietary advice
− 0.58% 12 studies, 6313 patients
Umpierre, Daniel, et al. "Physical activity advice only or structured exercise training and association with HbA1c
levels in type 2 diabetes: a systematic review and meta-analysis." Jama 305.17 (2011): 1790-1799.
structured exercise duration of more than 150 minutes per week was associated with
greater benefit (0.89% reduction in HbA1c ) than structured exercise duration of 150
minutes or less per week (0.36% reduction in HbA1c)

16. Effects of Activity Type and Timing on Glycemic Balance
• Blood glucose responses to physical activity in type 1 diabetes are highly variable
• aerobic exercise decreases blood glucose levels if performed during postprandial
periods with the usual insulin dose administered at the meal before exercise, and
prolonged activity done then may cause exaggerated decreases
• Exercise while fasting may produce a lesser decrease or a small increase in blood
glucose
• Very intense activities may provide better glucose stability or a rise in blood
glucose if the relative intensity is high and done for a brief duration (≤10 min)
• Mixed activities, such as interval training or team/individual field sports, are
associated with better glucose stability than those that are predominantly
aerobic
Colberg, Sheri R., et al. "Physical activity/exercise and diabetes: a position statement of the American Diabetes
Association." Diabetes Care 39.11 (2016): 2065-2079.

17. ADA Recommendations

18. RECOMMENDED PA PARTICIPATION FOR PEOPLE WITH DM
• Most adults with diabetes should engage in
150 min/week or more of moderate-to-vigorous intensity
activity, spread over at least 3 days/week, with no more than
2 consecutive days without activity.
- Shorter durations (minimum 75 min/week) of vigorous-
intensity or interval training may be sufficient for younger
and more physically fit individuals
• Individuals with diabetes or prediabetes are encouraged to
increase their total daily incidental (nonexercise) physical
activity to gain additional health benefits.

19. RECOMMENDED PA PARTICIPATION FOR PEOPLE WITH DM
• Adults with diabetes should engage in 2–3 sessions/week of
resistance exercise on nonconsecutive days.

20. RECOMMENDED PA PARTICIPATION FOR PEOPLE WITH DM
• Flexibility training and balance training are recommended 2–3
times/week for older adults with diabetes.
• Yoga and tai chi may be included based on individual preferences to
increase flexibility, muscular strength, and balance.

21. RECOMMENDED PA PARTICIPATION FOR PEOPLE WITH DM
• to gain more health benefits from physical activity programs,
participation in supervised training is recommended over
nonsupervised programs

22. RECOMMENDED PA PARTICIPATION FOR PEOPLE WITH DM
• Children and adolescents with type 1 or type 2 diabetes should
engage in 60 min/day or more of moderate or vigorous intensity
aerobic activity, with vigorous, muscle-strengthening, and bone-
strengthening activities included at least 3 days/week.

23. Pre-exercise Health Evaluation
• Physical activity does carry some potential health risks for people with
diabetes, including acute complications like cardiac events,
hypoglycemia, and hyperglycemia.
• pre-exercise medical clearance is not necessary for asymptomatic
individuals receiving diabetes care consistent with guidelines who wish
to begin low- or moderate-intensity physical activity not exceeding the
demands of brisk walking or everyday living.
• some individuals who plan to increase their exercise intensity or who
meet certain higher-risk criteria may benefit from referral to a health
care provider for a checkup and possible exercise stress test before
starting such activities
Colberg, Sheri R., et al. "Physical activity/exercise and diabetes: a position statement of the ADA ."
Diabetes Care 39.11 (2016): 2065-2079.