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Physical Activity and Type 2 Diabetes

Physical Activity and type 2 Diabetes

Introduction

Benefits of regular physical activity

Physical activity recommendations for people with type 2 diabetes

Exercise prescription details

Minimising the risk of exercise related adverse events

General

Exercise in the presence of specific long-term complications

Hypoglycaemia

Physical activity counselling and motivation

 

SEMDSA 2017 Recommendations
Optimising physical activity is an integral part of the management of type 2 diabetes
 
Physical activity lowers morbidity and mortality in type 2 diabetes
 
Both aerobic and resistance exercise confer benefit in type 2 diabetes
 
All people with type 2 diabetes should be encouraged to perform 150 minutes of aerobic exercise, at 50 to 70% of maximal heart rate, per week, as well as resistance training three (3) times per week
 
Flexibility and balance training are recommended 2–3 times per week for older adults with diabetes
 
Co-morbidities and cardiovascular risk need careful assessment before advising on a physical exercise regimen
 
Patients using insulin and/or sulphonylureas should be counselled about the symptoms and risks of hypoglycaemia before starting with a physical exercise regimen
 


INTRODUCTION

Randomised controlled trials have demonstrated that physical activity can delay the progression of impaired glucose tolerance to type 2 diabetes, when combined with dietary changes.1 

For inpatients with type 2 diabetes, regular physical activity significantly improves glycaemic control, reduces cardiovascular risk factors and may reduce chronic medication dosages.2 Regular physical activity may also improve symptoms of depression and improve health-related quality of life. These guidelines are adapted from the Canadian and American Diabetes Association’s guidelines.

BENEFITS OF REGULAR PHYSICAL ACTIVITY

Moderate to high levels of physical activity and cardiorespiratory fitness are associated with substantial reductions in morbidity and mortality in both type 13 and type 2 diabetes mellitus.4 

Large cohort studies have demonstrated that in people with type 2 diabetes, regular physical activity and moderate to high levels of cardiorespiratory fitness are associated with reductions in cardiovascular and overall mortality of 39-70% over a 15 to 20 year period.5,6,7

People with type 2 diabetes will derive the following benefits from regular physical activity:8,9,10

  • Increased cardiorespiratory fitness
  • Improved glycaemic control
  • Decreased insulin resistance
  • Improved blood lipid profile
  • Improved blood pressure
  • Maintenance of weight loss
  • Reduced abdominal and overall fat percentage
  • Improved well-being
  • Decreased stress and anxiety
  • Improved mobility in overweight people

PHYSICAL ACTIVITY RECOMMENDATIONS FOR PEOPLE WITH TYPE 2 DIABETES

People with type 2 diabetes should be advised to perform at least 150 minutes per week of moderate-intensity aerobic physical activity, with the aim of achieving and maintaining a heart rate that is 50-70% of the maximum heart rate. 

In the absence of contraindications, people with type 2 diabetes should also be encouraged to perform resistance training three times per week.11 Table I and Table II summarises these recommendations. The maximum heart rate is calculated by subtracting the chronological age from 220.12

EXERCISE PRESCRIPTION DETAILS

Both aerobic and resistance exercise are recommended for most people with diabetes (See: Table I and Table II). 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), semi-recumbent cycling may provide an alternative. For most middle-aged individuals, moderately brisk walking on level ground or semi-recumbent 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 and increased resting metabolic rate).13,14,15 The studies reporting the greatest impact of resistance exercise on HbA1C 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), three times per week16,17 or more.18,19 

However, significant reductions in HbA1C and body fat have been achieved with twice-weekly resistance exercise in combination with regular aerobic exercise.10,20 The effects of resistance exercise and aerobic exercise on glycaemic control are additive.21

Individuals who wish to begin resistance exercise, should receive initial instruction and periodic supervision by a qualified exercise specialist where possible, to maximise benefits while minimising risk of injury. A meta-analysis of trials evaluating resistance exercise with less supervision reported less beneficial impact on glycaemic control, insulin resistance and body composition than studies with greater supervision.14 

Individuals with diabetes should be encouraged to increase the amount of activities of daily living, such as housework, gardening and walking around shopping centres and the office at regular intervals. All people with diabetes, should be encouraged to reduce sedentary time, particularly by breaking up extended amounts of time ( >90 mins) spent sitting.22

Table I: Aerobic exercise recommended for individuals with type 2 diabetes23

Definition Intensity Frequency Examples
Activities that consist of rhythmic, repetitive and continuous movement of the same large muscle groups, for at least 10 minutes at a time
Moderate: 50-70% of maximum heart rate
Minimum 150 minutes per week
Cycling, brisk walking, continuous swimming, dancing, water aerobics, raking leaves
Or
Vigorous: > 70% of maximum heart rate
Minimum 75 minutes per week
Brisk walking up an incline, jogging, aerobics, hockey, basketball, fast swimming, fast dancing
Or
Equivalent combination of moderate and vigorous aerobic exercise


Table II: Resistance exercise recommended for individuals with type 2 diabetes 23

Definition Recommended Frequency Examples
Activities of brief duration involving the use of
weights, weight machines or resistance bands
to increase muscle strength and endurance
Two to three times per week: 
  • Start with one set, using a weight, and perform 15-20 repetitions while maintaining proper form
  • Progress to two 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 three sets of 8 repetitions performed, using an increased weight, ensuring proper form is maintained
Exercise with weight machines



 
Free weight lifting
 

Thera-Band® exercises

a Resistance exercise should only be attempted if there are no contraindications to this kind of activity

MINIMISING THE RISK OF EXERCISE RELATED ADVERSE EVENTS

General

Patients with multiple cardiovascular risk factors, should be assessed before an exercise programme is recommended.8 .Certain conditions might be contraindications to specific types of exercise, or predispose to injury:

  • Uncontrolled hypertension
  • Severe autonomic neuropathy
  • Severe peripheral neuropathy or history of foot ulcers 
  • Unstable proliferative retinopathy
  • Orthopaedic injuries

The patient’s age and previous physical activity level should also be taken into account.

In general, ECG stress testing may be indicated for individuals matching one or more of these criteria24:

  • Age > 40 years, with or without CVD risk factors other than diabetes
  • Age > 30 years and type 2 diabetes of >10 years duration
  • Hypertension
  • Cigarette smoking
  • Dyslipidaemia
  • Proliferative or pre-proliferative retinopathy
  • Nephropathy, including microalbuminuria
  • Any of the following, regardless of age
    • Known or suspected coronary artery disease (CAD, cerebrovascular disease, and/or peripheral arterial disease)
    • Autonomic neuropathy
    • Advanced nephropathy with renal failure

EXERCISE IN THE PRESENCE OF SPECIFIC LONG TERM COMPLICATIONS

Diabetic Retinopathy
In the presence of proliferative diabetic retinopathy (PDR) or severe non-PDR (NPDR), vigorous aerobic or resistance exercise may be contraindicated because of the risk of triggering vitreous haemorrhage or retinal detachment.25 These include jumping, jarring and head-down activities.11

Peripheral Neuropathy
Decreased pain sensation and a higher pain threshold in the extremities result in increased risk of skin breakdown and infection and of Charcot joint destruction with some forms of exercise. However, studies have shown that moderate-intensity walking may not lead to increased risk of foot ulcers or re-ulceration in those with peripheral neuropathy.26 

In addition, 150 min per week of moderate exercise was reported to improve outcomes in patients with milder forms of neuropathy.27 

All individuals with peripheral neuropathy should wear proper footwear and examine their feet daily to detect lesions early. Anyone with a foot injury or open wound should be restricted to non–weight-bearing activities.

Autonomic Neuropathy
Autonomic neuropathy can increase the risk of exercise-induced injury or adverse event through decreased cardiac responsiveness to exercise, postural hypotension, impaired thermoregulation, impaired night vision due to impaired papillary reaction, and higher susceptibility to hypoglycaemia.28 

Cardiovascular autonomic neuropathy (CAN) is also an independent risk factor for cardiovascular death and silent myocardial ischemia.29 Therefore, individuals with diabetic autonomic neuropathy should undergo cardiac investigation before beginning physical activity more intense than that to which they are accustomed.

Albuminuria and Nephropathy
Physical activity can acutely increase urinary protein excretion. However, there is no evidence that vigorous exercise increases the rate of progression of diabetic kidney disease. Furthermore, there is no need for any specific exercise restrictions for people with diabetic kidney disease, unless there are other complications.30

HYPOGLYCAEMIA

In individuals taking insulin and/or insulin secretagogues, physical activity can cause hypoglycaemia if the medication dose is not reduced or carbohydrate consumption is not increased.8 In these individuals, if pre-exercise blood glucose levels are below 5.5 mmol/L, approximately 15-30 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).23

In individuals whose diabetes is controlled by lifestyle or oral hypoglycaemic agents that do not increase insulin levels, the risk of developing hypoglycaemia 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.23

PHYSICAL ACTIVITY COUNSELLING AND MOTIVATION

Studies have found that structured physical activity counselling by a physician,36,skilled healthcare personnel or case managers31,32 increased physical activity levels, improved glycaemic control33,reduced the need for oral anti-hyperglycaemic agents and insulin, and produced modest but sustained weight loss.33

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.34 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).35 

Self-efficacy is a very strong cognitive predictor of both aerobic and resistance exercise participation in people with diabetes.35 However, the impact of physical activity counselling on glycaemic control, fitness, body composition and lipids is not as significant as that achieved through a supervised aerobic and resistance exercise programme.36 Having social support (e.g. exercising with a friend or partner) facilitates and aids in motivating regular physical activity.37

Author: Andrew Heilbrunn
Editors: Aslam Amod and Fraser J Pirie

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NeoHealth® ID 19126 · updated 10/26/2021