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Studies also suggest that people 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 A resting ECG should be performed, and an exercise ECG stress test should be considered, for individuals with typical or atypical chest discomfort, unexplained dyspnea, peripheral arterial disease, carotid bruits or history of angina, myocardial infarction MI , stroke or transient ischemic attacks see Screening for the Presence of Cardiovascular Disease chapter, p.
S who wish to undertake exercise more intense than brisk walking, especially if considering very intense, prolonged aerobic exercise. The value and utility of medical screening procedures prior to exercise, such as resting ECG and exercise stress testing in asymptomatic individuals has been the subject of much debate There is now an increased appreciation that exercise testing is a poor predictor of future cardiovascular disease CVD events because such testing detects flow-limiting coronary lesions while sudden cardiac arrest is usually produced by the rapid progression of a previously non-obstructive lesion Nevertheless, identifying individuals who are symptomatic remains very important.
People who are symptomatic, either before or during exercise, should be referred for ECG stress testing and further cardiac evaluation prior to participating or continuing in an exercise program see Screening for the Presence of Cardiovascular Disease chapter, p.
Performing physical activity, especially in the heat, places individuals at risk for heat-related injuries. The increase in metabolic heat production augments the rate at which heat must be dissipated to the environment to prevent dangerous increases in core temperature. Reduced physical fitness 70 and the presence of metabolic, CV and neurologic dysfunctions, which are often associated with diabetes 71 , further exacerbate an already compromised ability to dissipate heat.
People with diabetes should be aware that heat stress is associated with a reduction in exercise capacity and an increase in disease-related symptoms an air-conditioned training centre, room with fans if it is very hot outdoors. If activities e.
gardening, cycling, etc. must be performed outdoors when the weather is hot, the activities should be conducted in the early or later hours of the day when the temperatures are cooler and the sun is not at its peak. Middle-aged and older people with diabetes should try to avoid performing exercise in hot humid conditions as these conditions restrict the evaporation of sweat which is necessary to cool the body.
Staying well hydrated will help ensure that the body can maintain an adequate cooling capacity during exercise by maintaining sweat production at normal levels especially in the heat, and prevent fluctuations in blood glucose levels 71,72 , and is likely to reduce the risk for heat-related complications, such as heat exhaustion or heat stroke.
Prolonged aerobic exercise increases insulin sensitivity in recovery for up to 48 hours In type 1 diabetes, there is little or no endogenous insulin secretion, and achieving the appropriate balance of exogenous insulin and carbohydrate intake for the different forms and intensities of exercise can be challenging Fear of hypoglycemia is an important barrier to exercise in people with type 1 diabetes 75 and advice on physical activity to people with type 1 diabetes should include strategies to reduce risk of hypoglycemia.
Several small studies have explored several types of strategies for the prevention of hypoglycemia in type 1 diabetes, including the consumption of extra carbohydrates for exercise 76 , limiting preprandial bolus insulin doses 77—79 or reducing the basal insulin rate for continuous subcutaneous insulin infusion CSII insulin pump users These strategies can be used alone or in combination 81, Increasing carbohydrate intake just before, during and immediately after exercise is a simple and effective way to prevent hypoglycemia, although the optimal carbohydrate intake rate varies based on the duration and intensity of the activity and the amount of insulin in the circulation at the time of exercise 78,83, Basal insulin reduction before exercise may also offer some protection for children 86 and for those people on CSII 79, A more aggressive basal rate reduction, such as basal rate suspension at exercise onset is somewhat effective, although blood glucose levels may still drop markedly at the start of exercise As such, additional carbohydrates may still be needed even following basal rate reductions.
Another strategy to avoid hypoglycemia is to perform intermittent, brief 10 seconds , maximal-intensity sprints either at the beginning 90 or end 91 or intermittently during a moderate-intensity exercise session Performing resistance exercise immediately prior to aerobic exercise also helps reduce hypoglycemia risk, rather than performing aerobic exercise alone or aerobic exercise followed by resistance exercise 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 Glucose levels can rise with brief intense exercise, such as sprinting 90—92 , resistance training 93 , 10 to 15 minutes of maximal-intensity aerobic exercise to exhaustion 94,95 or high-intensity interval training 96 in individuals with type 1 diabetes.
If this occurs, it can be addressed by giving a small bolus of a rapid-acting insulin in exercise recovery 97 , or by temporarily increasing the basal insulin infusion in CSII users. Individuals with type 2 diabetes generally do not need to postpone exercise because of high blood glucose, provided they feel well.
increased thirst, nausea, severe fatigue, blurred vision or headache , especially for exercise to be performed in the heat. In individuals with type 1 diabetes who are severely insulin deficient e.
due to insulin omission or illness , hyperglycemia can worsen with exercise. Sedentary behaviours involve prolonged sitting or reclining while awake, including television viewing, working on a computer and driving.
Systematic reviews of observational studies 98,99 have demonstrated positive associations between the amount of sitting and the risk of premature mortality within the general population and in people with diabetes , even after adjusting for time spent in moderate-to-vigorous physical activity 98— Several recent studies in people with diabetes have documented harmful associations between objectively measured sedentary time and cardiometabolic risk factors, such as A1C, central adiposity, BMI, fasting TG, systolic BP, C-reactive protein, and hyperglycemia — Studies in people with and without type 2 diabetes have demonstrated that interrupting sitting by light walking or light resistance training can attenuate postprandial increases in BG, insulin and TG — Given the evidence that sedentary behaviour is associated with adverse health outcomes, even after statistically adjusting for levels of moderate-to-vigorous exercise, physical activity levels and sedentary behaviours should be considered distinct and potentially independent behaviours.
When discussing activity patterns with people with diabetes in clinical practice, it is reasonable, therefore, to promote both the reduction of prolonged sitting and the accumulation of moderate-to-vigorous physical activity in the person's daily routine.
There are a number of barriers and facilitators to physical activity in people with diabetes — Interventions targeting these barriers and facilitators are needed to initially engage people with diabetes in, and then maintain, sufficient physical activity.
Behaviour-change focused interventions added to exercise-based interventions have tended to focus on increasing physical activity self-efficacy i. an individual's desire or willingness to do physical activity For example, a recent meta-analysis suggested that the use of motivational interviewing-based interventions see description below not only improved physical activity but also decreased A1C by about 0.
However, it should be noted that some other studies found this kind of intervention did not reduce A1C , The vast majority of the studies have examined motivational interviewing or motivational communication as the behaviour change intervention.
Motivational interviewing is a goal-oriented, client-centred counselling style, which helps to explore and resolve ambivalence and increase intrinsic motivation in individuals in order to change behaviour Motivational communication represents a collection of evidence-based strategies drawn from motivational interviewing, cognitive-behavioural techniques and behaviour change theories e.
self-determination theory, social-cognitive theory, theory of planned behaviour and the transtheoretical model that are used as a communication strategy to engage individuals in changing their behaviour For people with type 2 diabetes, evidence suggests that goal setting, problem solving, providing information on where and when to exercise, and self-monitoring e.
use of objective monitoring with pedometers have some efficacy to increase physical activity and improve A1C ,— Newer evidence is starting to accumulate on the potential benefits of other motivational tools and techniques.
Examples of these include reinforcement, such as providing direct, instantaneous rewards monetary or token-based for goal completion , text-messaging , , mobile applications, social media and video games , However, further higher level evidence is needed to demonstrate their benefits for both physical activity and diabetes-related outcomes ,— A pedometer is a wearable device that detects and counts each step a person takes.
An accelerometer is a device that measures non-gravitational acceleration. Pedometers and accelerometers are well suited to measuring walking or jogging, but not bicycling or swimming.
Pedometers measure steps but not speed, whereas accelerometers can measure both steps and speed. Large-scale cohort studies consistently demonstrate an inverse relationship between higher self-reported walking with CV events and both CV and all-cause mortality in type 2 diabetes, even with adjustments for other CV risk factors.
In a randomized controlled trial examining the effect of a pedometer-based prescription in people with type 2 diabetes, the change in A1C at the end of the 1-year step count prescription intervention was 0.
Active arm participants reviewed step count logs with their physicians at each clinic visit over a 1-year period, set step targets and received a written step count prescription. Those in the control arm were encouraged to be active 30 to 60 minutes daily. Smarter Step Count Prescription. In these trials, the active arms engaged in pedometer-based interventions with monitoring and recording of daily step counts often complemented by support from a facilitator with or without peers in a group.
Physical Activity in Children with Type 2 Diabetes: see Type 2 Diabetes in Children and Adolescents chapter, p. A1C, glycated hemoglobin ; BG , blood glucose; BP , blood pressure; BMI , body mass index; CV , cardiovascular; CVD , cardiovascular disease; ECG , electrocardiogram; FPG , fasting plasma glucose; HDL-C ; high-density lipoprotein cholesterol; LDL-C , low-density lipoprotein cholesterol.
Literature Review Flow Diagram for Chapter Physical Activity and Diabetes. From: Moher D, Liberati A, Tetzlaff J, Altman DG, The PRISMA Group P referred R eporting I tems for S ystematic Reviews and M eta- A nalyses: The PRISMA Statement. PLoS Med 6 6 : e pmed For more information, visit www.
Sigal reports grants from Amilyn Pharmaceuticals, Boehringer Ingelheim, Prometic, Population Health Research Institute PHRI , and Sanofi; and personal fees from Novo Nordisk, outside the submitted work. Bacon reports personal fees from Kataka Medical Communications, Schering-Plough, Merck, and Sygesa; and grants from Abbive, outside the submitted work; also, he is Past-President of the Canadian Association of Cardiovascular Prevention and Rehabilitation.
Riddell reports personal fees from Medtronic, Lilly Innovation, Insulet, and Ascencia Diabetes Care; grants and personal fees from Sanofi; and non-financial support from Dexcom, outside the submitted work.
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Chapter Headings Types of Exercise Benefits of Physical Activity Benefits of Interval Training Benefits of Resistance Exercise Benefits of Other Types of Exercise Supervised vs. Unsupervised Exercise The Look-AHEAD Trial Minimizing Risk of Exercise-Related Adverse Events Reduction of Sedentary Behaviour The Use of Adjunct Motivational Interventions to Improve Physical Activity Uptake Objective Monitoring of Physical Activity Exercise Prescription Examples Other Relevant Guidelines Relevant Appendix Author Disclosures.
Key Messages Moderate to high levels of physical activity and cardiorespiratory fitness are associated with substantially lower morbidity and mortality in people with diabetes.
Key Messages for People with Diabetes Physical activity often improves glucose control and facilitates weight loss, but has multiple other health benefits even if weight and glucose control do not change.
Types of Exercise Physical activity is defined as any bodily movement produced by skeletal muscles that requires energy expenditure 1. 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 BP reduction and maintenance of weight loss 2—5.
Benefits of Interval Training High-intensity interval training involves alternating between short periods of higher and lower-intensity exercise see Exercise Prescription Examples. Benefits of Resistance Exercise Resistance training in adults with type 2 diabetes improves glycemic control as reflected by reduced A1C , decreases insulin resistance and increases muscular strength 30 , lean muscle mass 31 and bone mineral density 32,33 , leading to enhanced functional status and prevention of sarcopenia and osteoporosis.
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. 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 6.
Minimizing Risk of Exercise-Related Adverse Events Identifying individuals for whom medical evaluation should be considered prior to initiating an exercise program For most people with and without diabetes, being sedentary is associated with far greater health risks than exercise would be.
Minimizing risk of heat-related illness Performing physical activity, especially in the heat, places individuals at risk for heat-related injuries. Minimizing risk of exercise-induced hypoglycemia in type 1 diabetes Prolonged aerobic exercise increases insulin sensitivity in recovery for up to 48 hours Minimizing risks related to hyperglycemia Glucose levels can rise with brief intense exercise, such as sprinting 90—92 , resistance training 93 , 10 to 15 minutes of maximal-intensity aerobic exercise to exhaustion 94,95 or high-intensity interval training 96 in individuals with type 1 diabetes.
Reduction of Sedentary Behaviour Sedentary behaviours involve prolonged sitting or reclining while awake, including television viewing, working on a computer and driving. The Use of Adjunct Motivational Interventions to Improve Physical Activity Uptake There are a number of barriers and facilitators to physical activity in people with diabetes — Objective Monitoring of Physical Activity A pedometer is a wearable device that detects and counts each step a person takes.
Exercise Prescription Examples The following are practical examples illustrating how exercise can be prescribed: Aerobic exercise Start by walking at a comfortable pace for as little as 5 to 15 minutes at one time.
Gradually progress over 12 weeks to up to 50 minutes per session including warm-up and cool down of brisk walking. Alternatively, shorter exercise sessions in the course of a day, e.
Resistance exercise Choose approximately 6 to 8 exercises that target the major muscle groups in the body. Gradually increase the resistance until you can perform 3 sets of 8 to 12 repetitions for each exercise, with 1 to 2 minutes of rest between sets The best evidence supports strength training with weight machines or free weights.
Resistance bands may not be as effective to improve glycemic control, but they can help increase strength and can be a starting point to progress to other forms of resistance training.
If you wish to begin resistance exercise, you should receive initial instruction and periodic supervision by a qualified exercise specialist to maximize benefits, while minimizing risk of injury, at least for the initial sessions Table 3. Interval exercise Exercise performed in intervals, alternating between higher intensity and lower intensity, can be used by participants who have trouble sustaining continuous aerobic exercise, or can be used to shorten total exercise duration or increase variety.
Try alternating between 3 minutes of faster walking and 3 minutes of slower walking Another form of interval training, high-intensity interval training HIIT , can be performed through shorter intervals of higher-intensity exercise e.
Start with just a few intervals and progress to longer durations by adding additional intervals. Aquatic exercise can include walking briskly in the water, swimming or classes that include a variety of exercises. Other types of exercise or exercise classes, such as yoga, may be appealing for reasons, such as stress management.
Using pedometers or accelerometers Encourage people with diabetes to self-monitor physical activity with a pedometer or accelerometer.
Ask them to record values, review at visits, set step count targets and formalize recommendations with a written prescription see Appendix 4.
Breaking up sedentary time It is best to avoid prolonged sitting. Recommendations People with diabetes should ideally accumulate a minimum of 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, to improve glycemic control [Grade B, Level 2, for adults with type 2 diabetes 2,4,6 and children with type 1 diabetes 20 ]; and to reduce risk of CVD and overall mortality [Grade C, Level 3, for adults with type 1 diabetes 14 and type 2 diabetes 10 ].
Interval training short periods of vigorous exercise alternating with short recovery periods at low-to-moderate intensity or rest from 30 seconds to 3 minute each can be recommended to people willing and able to perform it to increase gains in cardiorespiratory fitness in type 2 diabetes [Grade B, Level 2 ] and to reduce risk of hypoglycemia during exercise in type 1 diabetes [Grade C, Level 3 28,29 ].
People with diabetes including elderly people should perform resistance exercise at least twice a week 39 and preferably 3 times per week [Grade B, Level 2 30 ] in addition to aerobic exercise [Grade B, Level 2 39—42 ].
Initial instruction and periodic supervision by an exercise specialist can be recommended [Grade C, Level 3 30 ]. In addition to achieving physical activity goals, people with diabetes should minimize the amount of time spent in sedentary activities and periodically break up long periods of sitting [Grade C, Level 3 ].
Setting specific exercise goals, problem solving potential barriers to physical activity, providing information on where and when to exercise, and self-monitoring should be performed collaboratively between the person with diabetes and the health-care provider to increase physical activity and improve A1C [Grade B, Level 2 , ].
Step count monitoring with a pedometer or accelerometer can be considered in combination with physical activity counselling, support and goal-setting to support and reinforce increased physical activity [Grade B, Level 2 , ].
Structured exercise programs supervised by qualified trainers should be implemented when feasible for people with type 2 diabetes to improve glycemic control, CV risk factors and physical fitness [Grade B, Level 2 6,39 ]. Abbreviations: A1C, glycated hemoglobin ; BG , blood glucose; BP , blood pressure; BMI , body mass index; CV , cardiovascular; CVD , cardiovascular disease; ECG , electrocardiogram; FPG , fasting plasma glucose; HDL-C ; high-density lipoprotein cholesterol; LDL-C , low-density lipoprotein cholesterol.
Other Relevant Guidelines Monitoring Glycemic Control, p. S47 Glycemic Management in Adults with Type 1 Diabetes, p. S80 Hypoglycemia, p. S Screening for the Presence of Cardiovascular Disease, p. S Type 2 Diabetes in Children and Adolescents, p.
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You may have to start slowly, with as little as five to 10 minutes of exercise per day, gradually building up to your goal. The good news is that multiple, shorter exercise sessions of at least 10 minutes each can be as useful as a single longer session of the same intensity.
Interval training involves short periods of vigorous aerobic exercise, such as running or cycling, alternating with short recovery periods at low-to-moderate intensity or rest from 30 seconds to 3 minutes each. Interval training is an effective way to increase your fitness level if you have type 2 diabetes, or to lower your risk of low blood sugar if you have type 1 diabetes.
Resistance exercise involves brief repetitive exercises with weights, weight machines, resistance bands or your own body weight to build muscle and strength.
Benefits of resistance exercise include:. Aim to do resistance exercises 2 to 3 times per week.
If you're living with diabetes—especially type 2 leevls physical activity is one syndromr the Ginseng tonic important Exercise and blood sugar levels in metabolic syndrome you bloof do to lower your blood sugar. Increased syndfome activity can Exercse just as effectively as some Almond varieties, with fewer side effects. If you're at risk of developing type 2 diabetes, regular exercise can help delay or even prevent diabetes from developing. Strive to complete at least minutes of moderate-to vigorous-intensity aerobic exercise each week e. Physical activity is any form of movement that causes your body to burn calories. This can be walking, gardening, cleaning and many other activities you already do. Daily physical activity is important. Syndroe is how exercise Healthy aging help lower blood glucose in Edercise short term. And Exercise and blood sugar levels in metabolic syndrome you are active on a regular basis, it sgar also lower your Almond varieties. Metaboloc effect physical activity has on your blood glucose will vary depending on how long you are active and many other factors. Physical activity can lower your blood glucose up to 24 hours or more after your workout by making your body more sensitive to insulin. Become familiar with how your blood glucose responds to exercise. Checking your blood glucose level more often before and after exercise can help you see the benefits of activity.
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