KANALEY-2022-EXERCISE & PA in T2D - ACSM Consensus Statement

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Med Sci Sports Exerc. Author manuscript; available in PMC 2023 February 01.
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Published in final edited form as:

Med Sci Sports Exerc. 2022 February 01; 54(2): 353–368. doi:10.1249/MSS.0000000000002800.
Exercise/Physical Activity in Individuals with Type 2 Diabetes:

A Consensus Statement from the American College of Sports
Medicine
Jill A. Kanaley1, Sheri R. Colberg2, Matthew H. Corcoran3, Steven K. Malin4, Nancy R.
Rodriguez5, Carlos J. Crespo6, John P. Kirwan7, Juleen R. Zierath8
1Department of Nutrition and Exercise Physiology, University of Missouri, Columbia, MO
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2Human Movement Sciences Department, Old Dominion University, Norfolk, VA

3Shore Physicians Group, Northfield, NJ
4Department of Kinesiology and Health, Rutgers University, New Brunswick, NJ
5Department of Nutritional Sciences, University of Connecticut, Storrs, CT
6Oregon Health and Science University-Portland State University School of Public Health,
Portland, OR
7Pennington Biomedical Research Center, Baton Rouge, LA
8Department of Molecular Medicine and Surgery, Karolinska Institute, Stockholm, Sweden
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Abstract
This consensus statement is an update of the 2010 ACSM position stand on exercise and type 2
diabetes. Since then, a substantial amount of research on select topics in exercise in individuals
of various ages with type 2 diabetes has been published while diabetes prevalence has continued
to expand worldwide. This consensus statement provides a brief summary of the current evidence
and extends and updates the prior recommendations. The document has been expanded to include
physical activity, a broader, more comprehensive definition of human movement than planned
exercise, and reducing sedentary time. Various types of physical activity enhance health and
glycemic management in people with type 2 diabetes, including flexibility and balance exercise,
and the importance of each recommended type or mode is discussed. In general, the 2018
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Corresponding author: Corresponding author name, Jill Kanaley, PhD, University of Missouri, 204 Gwynn Hall, Columbia, MO.
This article is being published as an official pronouncement of the American College of Sports Medicine. This pronouncement was
reviewed for the American College of Sports Medicine by members-at-large and the Pronouncements Committee.
Care has been taken to confirm the accuracy of the information present and to describe generally accepted practices. However,
the authors, editors, and publisher are not responsible for errors or omissions or for any consequences from the application of the
information in this publication and make no warranty, expressed or implied, with respect to the currency, completeness, or accuracy of
the contents of the publication. The application of this information in a particular situation remains the professional responsibility of
the practitioner; the clinical treatments described and recommended may not be considered absolute and universal recommendations.
Click here (***include URL) to download a slide deck that summarizes this ACSM Expert Consensus Statement on Exercise/Physical
Activity and Type 2 Diabetes
COI Disclosures
MC is part of the Speakers Bureau for: Novo Nordisk, Boerhinger Ingelheim, Eli Lilly, and Medtronic. He has an affiliation with
Diabetes Training Camp Foundation.
Kanaley et al. Page 2
Physical Activity Guidelines for Americans apply to all individuals with type 2 diabetes, with
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a few exceptions and modifications. People with type 2 diabetes should engage in physical
activity regularly and be encouraged to reduce sedentary time and break up sitting time with
frequent activity breaks. Any activities undertaken with acute and chronic health complications
related to diabetes may require accommodations to ensure safe and effective participation. Other
topics addressed are exercise timing to maximize its glucose-lowering effects and barriers to and
inequities in physical activity adoption and maintenance.
Synopsis
This consensus statement is an update of the 2010 position stand on exercise and type 2 diabetes
(T2D) published jointly by the American College of Sports Medicine (ACSM) and the American
Diabetes Association (ADA) (1, 2). In the ensuing decade, a considerable amount of research
on select topics in exercise in individuals of varying ages with T2D has been published while
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diabetes prevalence has continued to expand worldwide. 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 (1,
2). Current science, new topics for discussion, and clinical experience in making recommendations
for participation by people with T2D of all ages are highlighted. In addition, the title of the
consensus statement and the text itself have been expanded to include physical activity, a broader,
more comprehensive definition of human movement of which structured or planned exercise is a
subset.
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Keywords
exercise; physical activity; type 2 diabetes
Introduction
Currently diabetes affects over 463 million people worldwide (3), and its prevalence in
the United States is 10.5% (4). T2D accounts for 90-95% of all cases (5). The goal of
treatment for T2D is to facilitate an individualized treatment plan, one that may include
education, glycemic management, reduction of cardiovascular disease (CVD) risk, and
ongoing screening for microvascular complications, in order to achieve and maintain optimal
blood glucose, lipid, and blood pressure levels that prevent or delay chronic complications.
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Lifestyle interventions and/or medications are usually prescribed for treatment of T2D, and
more recently, bariatric surgery has also become part of a possible treatment plan.
During any type of physical activity (PA), glucose uptake into active skeletal muscles
increases via insulin-independent pathways. Blood glucose levels are maintained by
glucoregulatory hormone-derived increases in hepatic glucose production and mobilization
of free fatty acids (6, 7), which may be impaired by insulin resistance or diabetes (7).
Improvements in systemic, and possibly hepatic, insulin sensitivity following any PA can
last from 2 to 72 h, with reductions in blood glucose closely associated with PA duration and
intensity (8–10). Additionally, regular PA enhances β-cell function (11), insulin sensitivity
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(12), vascular function (13, 14), and gut microbiota (15), all of which may lead to better
diabetes and health management as well as disease risk reduction.
Impact of Exercise/PA on Diabetes Management and Health Risks

Multiple types of PA enhance health and glycemic management in people with T2D,
although structured exercise training has been studied most frequently. Many of the proven
benefits result from improved insulin sensitivity, postprandial hyperglycemia, and CVD risk.
Aerobic exercise training

Short-term aerobic exercise training improves insulin sensitivity in adults with T2D,
paralleling improved mitochondrial function (16). Vigorous aerobic exercise training for
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7 d may improve glycemia without lowering body weight via increased insulin-stimulated
glucose disposal and suppression of hepatic glucose production (12). Short-term aerobic
exercise in individuals with obesity and T2D improves whole body insulin action through
gains in peripheral insulin sensitivity more so than hepatic insulin sensitivity (17). Meta-
analyses and systematic reviews have confirmed that regular aerobic exercise training
improves glycemia in adults with T2D, with fewer daily hyperglycemic excursions and
0.5-0.7% reductions in hemoglobin A1C (A1C) (18–22). Regular training also improves
insulin sensitivity, lipids, blood pressure, other metabolic parameters, and fitness levels, even
without weight loss (23, 24).
Resistance exercise training

Resistance exercise training in adults with T2D typically results in 10-15% improvements
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in strength, bone mineral density, blood pressure, lipid profiles, skeletal muscle mass,
and insulin sensitivity (25). Combined with modest weight loss, resistance training may
increase lean skeletal muscle mass and reduce A1C three-fold more in older adults with
T2D compared to a calorie-restricted, non-exercising group that lost skeletal muscle mass
(26). A recent meta-analysis of resistance exercise suggests that high-intensity training is
more beneficial than low-to-moderate-intensity training for overall glucose management and
attenuation of insulin levels in adults with T2D (27).
Combined exercise training

Interventions with combined aerobic and resistance exercise training may be superior
to either mode alone. A greater reduction in A1C has been noted in adults with T2D
undertaking a combined training program compared with either type alone (28); however,
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combined training group participants had a greater exercise volume. In another trial,
combined training significantly improved A1C levels over non-exercising controls, although
neither resistance nor aerobic training alone resulted in significant changes (29). Moreover,
the combined group lost more weight and improved aerobic fitness more so than controls. A
meta-analysis (21) showed that all three exercise modalities favorably impact glycemia and
insulin sensitivity, and combined training may produce greater reductions in A1C than either
training modality alone (30).
High-Intensity Interval Exercise (HIIE).

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Higher intensities of aerobic training are generally considered superior to low-intensity

training (31). HIIE training is a regimen that involves aerobic training done between 65-90%
VO2peak or 75-95% heart rate peak (HRpeak) for 10 sec to 4 min with 12 sec to 5 min of
active or passive recovery. HIIE has gained attention as a potentially time-efficient modality
that can elicit significant physiological and metabolic adaptations. One session of HIIE
(10 × 60 s cycling at ~90% HRmax) reduced postprandial hyperglycemia in adults with
T2D (32). Two wks of afternoon HIIE training were shown to improve continuous glucose
monitor (CGM)-monitored glycemia while morning training may increase glucose levels
on exercise days, particularly if undertaken fasted (33). HIIE training also significantly
improves fitness levels and reduces A1C and body mass index (BMI) in adults with T2D.
Compared with continuous walking matched for energy expenditure, HIIE training resulted
in greater fitness, better body composition, and improved CGM-monitored glycemia (34), as
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well as enhanced insulin sensitivity and pancreatic β-cell function in adults with T2D (35).
Individuals with T2D who seek to improve glycemia with HIIE should closely monitor their
responses to training, as chronic intense training may have negative effects such as transient
post-exercise hyperglycemia.
The maximal activity of citrate synthase and skeletal muscle mitochondrial protein content
in adults with T2D are improved following just 6 sessions of low-volume HIIE (36). Further
changes observed with HIIE training include greater reduction in A1C and CVD risk factors
with less exercise time (37), as well as enhanced diastolic function (38), increased left
ventricular wall mass, greater end-diastolic blood volume due to increased stroke volume
and left ventricular ejection fraction (39), and improved endothelial function (40).
Types of Exercise Training Compared.

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Glycemia and insulin sensitivity in adults with overweight/obesity and with insulin
resistance, prediabetes, or T2D are improved similarly with different modes of structured
exercise training when energy expenditure is matched (41–44). Adverse events have been
reported in 34% of studies included in a meta-analysis, with a majority attributable to
musculoskeletal injuries during HIIE rather than moderate training (45). The benefits of
other types of PA are less well established and have mixed glycemic outcomes. Yoga may
improve A1C, blood lipids, and body composition in adults with T2D (46); whereas, tai chi
may improve glycemic management, balance, neuropathic symptoms, and some dimensions
of quality of life (47). Further studies are required to fully establish the potential benefits of
yoga and tai chi in populations with T2D.
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Exercise/PA with and without Weight Loss

Dietary restriction and increased PA are the cornerstones of intensive lifestyle (ILS)
interventions that are typically used to induce weight loss. Such interventions may prevent or
delay onset of T2D in at-risk populations and reduce CVD risk in individuals with T2D. In
many cases PA has been shown to be as important as, if not more so than, weight loss.
T2D Prevention.
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The U.S. Diabetes Prevention Program (DPP) multicenter trial utilized ILS with a goal of
achieving modest (5-7%) weight loss and led to the important observation that for every
1 kg of body weight lost, T2D risk was reduced by 16% (48). Even among those failing
to meet the weight loss goal of 7% during the first year, individuals meeting the PA goal
had a 44% reduction in diabetes incidence, independent of the small weight loss (−2.9 kg)
(48). The DPP outcomes study (DPPOS) has shown a higher incidence of T2D onset in
those who gained weight at 10 and 15 years after participating in the original ILS arm
(49, 50). More recent follow-up data from DPPOS shows that cumulative T2D incidence
remained lower in the ILS group, a finding not explained by differences in body weight
among groups (51); rather, PA was inversely related to incident of T2D for all participants.
Importantly prevention of T2D was enhanced in active participants with lower baseline PA,
and moderate-intensity walking (about 18.2 km/wk) improved oral glucose tolerance with
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only 2 kg of weight loss (52). Overall, individuals at high risk for developing T2D who have
initially low PA levels benefit the most from moderate-intensity walking and other exercise
with minimal weight loss.
CVD Risk Reduction.

Most ILS interventions in adults with T2D have also led to a reduction in CVD risk
factors. In the Look AHEAD trial (53), ILS participants with T2D lowered triglycerides and
increased HDL-C levels. More weight loss led to greater improvements in A1C, systolic
blood pressure, HDL-C, and triglyceride levels. Most ILS trials (focused primarily on
dietary changes and increased PA) with weight reduction as a goal in adults with T2D have
resulted in <5% weight loss and few beneficial metabolic outcomes (54, 55). A weight
loss of >5% appears to be necessary for beneficial effects on A1C, blood lipids, and blood
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pressure in most individuals (54, 55). During the first year of the trial, ILS participants
experienced greater reductions in A1C, initial improvements in fitness and attenuation of
all CVD risk factors except for LDL-C levels. Further, ILS did not reduce the occurrence
of a composite CVD outcome score over 9.6 y despite the greater, sustained weight loss
in participants (56), but the participants had fewer hospitalizations, medications, and health
care costs over 10 y (57). Thus, lifestyle interventions that include PA in recommended
amounts and possible weight loss remain important approaches in the management of T2D
and CVD risks.
Weight Loss and Regional Fat Distribution.

Weight loss from PA alone is generally small, although possible with 1 or more hours of
daily moderate-or high-intensity exercise (58–60). In men and women with obesity, 1 h of
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daily moderate-intensity aerobic exercise induced weight loss similar to dietary restrictions
alone, with similar reductions in abdominal subcutaneous and visceral fat observed in
both groups. Regular exercise without weight loss also reduced subcutaneous and visceral
fat and prevented further weight gain (58). In postmenopausal women with T2D, modest
weight loss with either dietary restriction alone or diet plus exercise similarly reduced total
abdominal fat, subcutaneous adipose tissue, and glycemia, but the addition of exercise was
necessary for visceral adipose tissue loss (61), which leads to lesser metabolic dysfunction
and CVD risk. Thus, moderate-to high-intensity exercise (~500 kcal) done 4-5 d/wk appears
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to reduce abdominal, but particularly visceral, fat in adults with T2D and may lower their
metabolic risk.
Prevention of Gestational Diabetes.

Women with gestational diabetes mellitus (GDM) may have a nearly 10-fold higher risk of
developing T2D at some point (62). PA is a preventative tool for GDM and subsequent
development of T2D (63, 64). Prepregnancy exercise training has been consistently
associated with a reduced risk of GDM (65–68). Moderate aerobic exercise performed 3
d/wk (50-55 min/session) for 8-10 wk through the third trimester reduces the prevalence
of GDM (2.6% vs. 6.8% with standard care) and minimizes excessive weight gain
during pregnancy (69). Cycling exercise (30 min, 3x/wk) initiated early in pregnancy
has been shown to reduce the frequency of GDM in women with overweight/obesity
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and lowered gestational weight gain before the mid-second trimester (70). A recent meta-
analysis concluded that prenatal exercise alone, including 140 min of moderate-intensity
exercise weekly, results in a 25% reduction in risk of GDM, preeclampsia, and gestational
hypertension (71). Regular PA of any type during pregnancy decreases the incidence
of GDM and maternal weight gain without serious adverse events (72). It is widely
recommended that pregnant women participate in ~20-30 min of moderate-intensity aerobic
exercise most days of the week, but the total amount of PA needed to achieve these diabetes
risk reductions may be greater (73, 74).
Mental Health and Cognition Benefits of PA

Regular PA potentially has psychological and cognitive function benefits for people with
T2D. Both are important for the long-term health of this population.
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Mental Health.
Participation in both short-and long-term exercise training has been shown to substantially
decrease symptoms of depression and anxiety in individuals across all age groups diagnosed
with clinical depression (75). Exercise increases certain brain hormones that modulate
hippocampal plasticity to improve both cognition and mental health (76). In the Look
AHEAD trial, participants following ILS had improved health-related quality of life and
reduced symptoms of depression after 12 m (77), and the benefit extended as long as 8 y
(78). In the U-TURN study (79), participants with T2D who undertook ILS experienced
improvements in the physical component of quality-of-life scores but with no change in
the mental component at 1 y. Collectively, these studies suggest that regular exercise may
improve psychological well-being, including health-related quality of life and depressive
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symptoms, in individuals with T2D.
Memory and Cognitive Function.

T2D is associated with cognitive dysfunction, including poor attention and concentration,
visual and verbal memory, processing speed, and executive function (80). Young and
older adults have experienced increases in basal glucose uptake in brain regions critical to
cognitive function following 12 wk of aerobic interval exercise (4 × 4 min >90% VO2peak
for 3 d/wk) combined with moderate-intensity treadmill walking (70% VO2peak for 2d/wk)
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(81). Similarly, 2 wk of sprint interval training lowered insulin-stimulated glucose uptake in

the temporal cortex, cingulate gyrus, cerebellum as well as global regions when compared
with other moderate-intensity continuous exercise training in sedentary, middle-aged adults
with insulin resistance (82). When PA is combined with a low-fat diet, brain insulin
sensitivity is increased in adults with obesity (83). Surprisingly, there is a paucity of research
on the effects of exercise on memory and cognitive function in people with T2D (84–87).
Although the Look AHEAD trial reported no cognitive benefit after 8-9 y of lifestyle
treatment in people with T2D (88), a recent meta-analysis suggested a favorable, albeit small
to moderate, effect of exercise on executive function and memory (89), similar to reported
associations between exercise and cognitive function in adults with T2D (90, 91). There is a
paucity of data on the physiological mechanisms related to memory, cognitive function, and
cerebral blood flow.
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PA Recommendations for Individuals with T2D

The 2018 update of the Physical Activity Guidelines for Americans (Table 1) included
recommendations for youth, adults, and older adults (92, 93). In general, these
recommendations apply to individuals with T2D as well, with a few exceptions and
modifications (Table 2). In most instances, the recommendations for adults of all ages are
the same unless comorbid health conditions or older age impact their ability to be active and
modifications are needed (92).
Adults and Older Adults

Aerobic Exercise.—All adults with T2D should follow the same recommendations, with
no more than two consecutive days between bouts due to the transient nature of exercise-
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induced improvements in insulin action (94, 95). Adults with comorbid health conditions
and compromised older adults with T2D should aim to get as much aerobic activity as their
physical and mental health allows.
Resistance Exercise.—Resistance exercise training in older adults with T2D results in

10-15% improvement in strength, bone mineral density, lean mass, blood pressure, blood
lipids, and insulin sensitivity (25, 96), along with 3-fold greater reductions in A1C (26).
Notably, interventions that combine aerobic and resistance training may be superior to either
one alone (21, 29, 30). Adults unable to meet current recommendations should focus on
improving on functional fitness and balance.
Flexibility Exercise.—Exercises that enhance joint flexibility are highly beneficial for
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health and well-being in older adults with T2D. Limitations to joint mobility, resulting in
part from glycation occurring with normal aging, may be accelerated by hyperglycemia (97).
While stretching exercises increase range of motion and flexibility (98), they generally do
not impact glycemia unless undertaken as part of another PA such as yoga (99). Flexibility
exercises, alone or in combination with resistance training, has been shown to improve
joint range-of-motion in individuals with T2D and facilitates participation in activities that
require flexibility (98). Moreover, flexibility training is generally low-intensity and easier to
perform, thereby providing one possible entry into a more physically active lifestyle for less
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fit and older adults (1).
Balance Exercise.—Many lower body and core resistance exercises double as balance
training (100). Power training undertaken by adults with T2D can improve overall body
balance (101). Balance exercises may reduce the risk of falls by improving balance and gait,
even in adults with peripheral neuropathy (102, 103). At-home balance exercises may reduce
risk of falls even without significant changes in leg strength in older adults with T2D at
increased risk for falls (103).
Other Types of Exercise and PA.—Along with traditional static and dynamic
stretching, yoga, tai chi, and other types of PA may also provide health and glycemic
benefits. Inclusive of basic stretching and strengthening activities, yoga may improve overall
glycemia, lipid levels, and body composition in adults with T2D (46, 99, 104, 105). Tai chi
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training incorporates some balance, stretching, and resistance elements and may improve
glycemia, reduce BMI and neuropathic symptoms, and increase balance and quality of life
in adults with T2D and neuropathy (106, 107). Various forms of qigong may improve A1C
levels and other health and fitness parameters including balance (106, 108, 109). Pilates may
improve blood glucose management, along with functional capacity, in older adults with
T2D (110). Thus, many alternate types of exercise and PA may be appropriate and beneficial
for adults with T2D, especially individuals with lower initial fitness and poorer balance.
Sedentary Time and Activity Breaks.—Physical inactivity (i.e., sitting or lying while
awake) increases the risk of T2D across all racial and ethnic groups (111). In sedentary
adults with 9 h of sedentary behavior per day, 1 h extra of sedentary time daily over an 8-d
period is associated with a 22% increase in the odds of developing T2D (112). Furthermore,
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greater sedentary time is related to hyperglycemia independent of aerobic fitness (113),

although high levels of fitness can attenuate CVD risk factor clustering (114).
In adults with T2D, the interruption of prolonged sitting with activity breaks, such as
light-intensity walking or simple resistance activities for 3 min every 30 min over 8 h,
decreases postprandial glucose, insulin, C-peptide, and triglyceride levels (115). Replacing
sitting time with standing (2.5 h/d) and light-intensity walking (totaling 2.2 h/d) every 30
min may improve 24-h glucose levels and insulin sensitivity more than structured exercise
(116). Bouts of stair climbing also have been effective at reducing postprandial glycemia
(117, 118), but not necessarily A1C (119). Short 5-min breaks every h over 12 h more
effectively lowered glucose and insulin levels than 1 h of moderate-intensity continuous
exercise at the beginning of the day in people with impaired glucose tolerance (120), and
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short bouts of exercise (HIIE consisting of 6 × 1 min walking at 90% max HR) 30 min
before meals reduces glucose levels more than a single 30-min bout of moderate walking
(121). Small “doses” of PA to break up sitting moderately attenuate postprandial glucose
and insulin levels, somewhat more than moderate continuous exercise, with greater effects
in people with insulin resistance and a higher BMI (122). However, breaks from sitting
have not been shown to lower hyperglycemia in free-living environments (123). Whether
long-term use of breaks in sedentary time has clinically relevant glycemic benefits remains
unclear.
Adolescents and Youth

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PA goals recommended for youth and adolescents with T2D are the same as for youth in the
general population (92, 93). Childhood obesity and T2D occur in complex psychosocial
and cultural environments making successful implementation of lifestyle interventions
difficult (124). Youth with T2D manifest both insulin resistance and non-autoimmune β-cell
failure similar to adults; however, youth-onset is associated with a more rapid decline
in β-cell function and acceleration of diabetes complications. The Bright Bodies Weight
Management Program for Children, a year-long 2x/wk exercise and nutrition/behavior
modification program in youth with obesity without diabetes, reduced insulin resistance and
T2D risk (125). In a multicenter study in youth with T2D (the TODAY Study), metformin
therapy managed glycemia in half of participants, and the addition of rosiglitazone, but
not lifestyle changes including PA, was superior to metformin alone (126, 127). A 12-wk
gym-based, supervised program in adolescents with T2D improved endothelial function and
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health, independent of changes in insulin sensitivity (14). Thus, home-based and gym-based
exercise and weight management programs should be encouraged for youth with T2D
to enhance insulin sensitivity and cardiometabolic function and manage overweight and
obesity.
Pre-exercise Evaluation and Testing

For most individuals planning to participate in a low- to moderate-intensity PA like
brisk walking, no pre-exercise medical evaluation is needed unless symptoms of CVD or
microvascular complications are present (1, 96). In adults who are currently sedentary,
medical clearance is recommended prior to participation in moderate-to high-intensity
PA. Although suggested by practice guidelines (Table 3), pre-exercise stress testing
in asymptomatic adults with T2D remains controversial. One study reported that all
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participants with T2D had lower rates of major CVD outcomes (< 1%), with no differences
between those who underwent stress testing (sedentary with 1 or more cardiac risk factors)
and those who did not over 3.4 y, and pre-exercise stress testing did not reduce CVD events
(128). In the Look AHEAD trial, only older age was associated with increased prevalence
of all abnormalities during maximal exercise stress testing (129), and in the DIAD trial,
more intensive testing did not alter event rates (130). Moreover, no evidence is available to
determine whether pre-exercise evaluation involving stress testing is necessary or beneficial
before participation in anaerobic or resistance training. Coronary ischemia is less likely to
occur during resistance compared with aerobic exercise eliciting the same heart rate, and
some doubt exists that resistance exercise induces ischemia (131–133).
Management of Acute and Chronic Health Complications with PA

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Numerous acute and chronic health issues may arise around PA initiated by individuals
with T2D. Of primary concern are exercise-related hypoglycemia and hyperglycemia. In
addition, exercising with chronic health complications related to diabetes may require
accommodations to ensure safe and effective PA participation.
Hypoglycemia.
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Individuals managing glycemia with lifestyle improvement alone have minimal risk for
hypoglycemia (134). Use of select medications for T2D may increase the risk of exercise-
related hypoglycemia, including insulin and insulin secretagogues (i.e., sulfonylureas and
meglitinides) (7, 135–137). For example, pre-exercise insulin administration increases
the risk of hypoglycemia during exercise, and both insulin dosing and timing must be
considered. Carbohydrates may be needed if pre-exercise blood glucose levels are likely to
lead to hypoglycemia during or following activities and medication doses are not lowered
to compensate. No medication dose adjustments or carbohydrate intake is necessary for
other oral diabetes medications or non-insulin injectables, such as GLP-1 agonists (96).
Later-onset hypoglycemia is a greater concern when carbohydrate stores (i.e., skeletal
muscle and liver glycogen) are depleted, but usually is not an issue for most recreational
exercisers who are non-insulin users. While high-intensity exercise may be problematic for
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those taking insulin, finishing an exercise session with a short, high-intensity bout has been
shown to be beneficial in preventing hypoglycemia in those not on insulin. Longer duration,
high-intensity PA increases the risk for post-exercise hypoglycemia with use of insulin or its
secretagogues (138).
Hyperglycemia.
Clinical consensus recommendations state that if blood glucose is >300 mg/dL−1 (16.7
mmol/L−1), caution should be advised when exercising without or with minimal levels
of blood or urinary ketones, but ketones are seldom measured or excessively elevated in
individuals with T2D. Regardless, if blood glucose is elevated, individuals are advised to
only begin light activity if they are asymptomatic and properly hydrated (96, 139). Activities
that are short and intense (such as HIIE) may cause a transient increase in blood glucose that
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remains elevated afterward for a period of time (140, 141). Extra insulin (in users) and/or a
lower intensity cool-down following intense activities may be used to reduce post-exercise
glucose elevations, although no treatment is needed in most cases (140). Importantly,
diabetic ketoacidosis, which normally is the result of hyperglycemia and elevated ketones,
may occur with euglycemia or only moderate hyperglycemia in adults with T2D taking oral
SGLT-2 inhibitors to manage blood glucose (142). Given these potential confounders, PA
should only be undertaken when individuals with elevated blood glucose, even without overt
ketosis, are feeling well.
Heat Stress.
Aging alone negatively affects heat loss in both dry and humid environments (143), but T2D
also appears to increase the risk of heat stress during PA, but not during passive rest (144).
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Impairments in whole-body heat loss are related to abnormal cutaneous vasodilation and
decreased sweating (145), which can lead to increases in body temperature and heart rate.
Consequently, many adults with T2D have a reduced ability to do PA, especially in warm
environments, due to an impaired ability to thermoregulate, and with dehydration, their risk
of chronic hyperglycemia increases (146). Moreover, certain diabetes-related comorbidities
and medications may increase the risk of heat-related illness (147). Heat acclimation has
been shown to be possible in adults with T2D engaging in aerobic or resistance training,
though, with some improvements in exercise-generated heat dissipation and other factors
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after adaptation (148, 149). Nevertheless, individuals with T2D should be cautious when
exercising in hot environments, although they may acclimatize to hotter conditions with
regular PA.
Chronic Health Complications.

Recurrent hyperglycemia increases the risk for chronic complications of diabetes, including
macrovascular complications (CVD, PVD and lower limb amputations) and microvascular
complications (e.g. retinopathy, nephropathy, and peripheral and autonomic neuropathy
(150–152). Prolonged daily sedentary time also increases the risk of T2D, CVD, and
premature mortality, even when adjusted for PA levels (153, 154). Most individuals can
engage in various types of PA safely and effectively despite having health complications.
With regular training, they can anticipate significant and meaningful improvements
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when following general exercise training precautions (Table 4). Certain activities may
be contraindicated due to existing health conditions, and special testing or pre-exercise
preparation may be required (Table 5). In individuals with macrovascular diseases or cardiac
autonomic neuropathy, pre-exercise screening should follow the guidelines set by ACSM
(155) and ADA (96).
Exercise Timing and Dietary Considerations

Some studies have addressed optimal timing of exercise around meals and in general to
maximize blood glucose management and other health benefits in T2D. In addition, while
dietary eating patterns may be used to enhance blood glucose management, their impact on
exercise remains equivocal.
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Exercise timing
Most acute exercise studies have examined effects on glycemia around breakfast,
demonstrating better management with light-or moderate-intensity aerobic exercise
undertaken postprandially in individuals with T2D (156–158), but this glycemic benefit
does not necessarily carry over to lunch (156, 157). Only one study found better glycemic
management with exercise prior to breakfast (159). A comparison of 2 wks of morning or
afternoon HIIE (3x/wk) training in men with T2D showed that afternoon sessions reduced
blood glucose more than morning sessions, which actually increased glycemia (33). A 12-
wk multimodal exercise training program found that either morning and afternoon sessions
in men and women with T2D improved A1C, fasting glucose, and HOMA2-IR but not
fructosamine, and postprandial glucose and insulin levels were similarly lowered following
a mixed meal (160). When exercise was undertaken around dinner, better blood glucose
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responses occurred with self-selected-pace walking post-meal (161), and blood glucose and
triglyceride levels were attenuated by post-meal resistance exercise (162). Overall, most
studies have shown that postprandial exercise provides better glucose control by attenuating
acute glycemic spikes, and greater energy expenditure postprandially reduces glycemia
regardless of exercise intensity or type, with a longer duration (≥45 min) providing the most
consistent benefits (61).
Dietary Intake and eating patterns

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Prevention or delay of T2D can be achieved with regular PA and maintenance of a healthy
body weight, and individuals with T2D should focus on sustainable eating plans that
consider the amount and timing of carbohydrate intake in combination with an active
lifestyle to manage glycemia, insulin sensitivity, body weight, and CVD risk. According to
the 2020-2025 US Dietary Guidelines for Americans (163), a healthy eating plan provides
appropriate daily calories; highlights fruits, vegetables, and whole grains; includes reduced
or non-fat dairy products, lean meats, poultry, fish, beans, eggs, and nuts; and is low
in saturated and trans fats, cholesterol, salt, and added sugar. Whole foods-based eating
is micronutrient dense, antioxidant rich, and beneficial in preventing and managing T2D
(164). Carbohydrate restriction reduces body weight and improves glycemia (165–168),
and use of popular diet options (i.e., low carbohydrate, ketogenic diet) and other eating
patterns (i.e., Mediterranean, vegan) are frequently followed for T2D management (169,
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170). Time-restricted feeding and intermittent fasting which have multiple definitions have
become popular in recent years, but there are limited studies to date in individuals with
T2D and the benefits to glycemic management are unknown. Caution is recommended when
implementing a ketogenic diet that chronically restricts carbohydrate to ≤50 g/d to induce
ketosis (170) as insufficient trials in individuals with T2D support this approach (165, 169,
170) and its impact on PA participation and exercise performance remains equivocal (167,
168, 171–173).
Medical Interventions and Exercise Effectiveness

Anti-diabetes medications are often co-prescribed with exercise for management of T2D.
Some of these, as well as others taken for comorbid conditions, may impact the effectiveness
of exercise participation. In addition, adults undergoing bariatric surgery to manage obesity
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and T2D may also be impacted by pre- and post-surgery exercise participation.
Diabetes Medications.
Somewhat surprisingly, pilot studies on adults with insulin resistance have found that
metformin, the most commonly prescribed medication for pre-diabetes and diabetes, may
attenuate exercise-enhanced peripheral insulin sensitivity benefits following acute (174) and
chronic exercise (175) training. In adults with T2D, the normal reduction in postprandial
glycemia with metformin use also may be somewhat attenuated by exercise (176). Although
it augments skeletal muscle glucose uptake during any PA (177) and improves glycemia in
individuals with T2D (178), metformin has been found to potentially blunt AMP-activated
protein kinase activity (174) and mitochondrial adaptations to aerobic exercise (179) and
attenuate skeletal muscle hypertrophy after weight lifting (180) in healthy adults. Thus,
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metformin may be contributing to the inter-individual variability observed in exercise-

induced improvements in insulin sensitivity and cardiometabolic health (181), but more
research is needed in this area.
As for other medications, both GLP-1 agonists and SGLT-2 inhibitors have glucose-
lowering mechanisms and downstream metabolic impacts that may impact exercise-induced
adaptations. GLP-1 agonists may improve A1C levels and fasting glycemia following
aerobic exercise training in adults with T2D, but these findings have been confounded
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by significant weight loss (182). More research is needed on the interaction of all these
medications and exercise. Insulin therapy is often a last option in T2D, but in men with T2D,
similar reductions in time spent in hyperglycemia and reduced glycemic variations over 24
h were observed following a 45-60 min bout of exercise with and without insulin use (183).
Individuals with T2D using insulin or insulin secretagogues are advised to supplement with
carbohydrate (or reduce insulin, if possible) as needed to prevent hypoglycemia before
and/or after exercise.
Non-Diabetes Medications.
β-blockers blunt the heart rate responses to exercise and lower maximal aerobic exercise
capacity to ~87% of expected via negative inotropic and chronotropic effects (184). While
their use may increase risk of hypoglycemia unawareness with PA by blunting adrenergic
responses, β-blockers can increase exercise capacity in people with T2D and CVD by
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reducing ischemia during PA (185). In adults using β-blockers, ratings of perceived exertion
(RPE) should be utilized to monitor exercise intensity rather than heart rate (186). In
a small number of individuals, statin use has been associated with an elevated risk of
myopathies (myalgia and myositis), particularly when combined with fibrates and niacin and
hyperglycemia (187).
Bariatric Surgery.
Bariatric surgery is now considered the most effective way to improve glycemic
management and achieve diabetes remission over the long term (188, 189); however, less
than 10% of adults undergoing bariatric procedures meet PA recommendations pre-surgery,
despite the nearly 40% of adults saying they feel ready to exercise 14 d before surgery (190).
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Preoperative exercise may benefit these individuals by lowering surgical risk and enhancing
recovery, as well as reducing the length of hospital stays (191). Increases in VO2peak
are also associated with reduced operating time and improved quality of life despite no
additional effect on blood glucose levels or insulin sensitivity (192, 193). Others have
suggested increased exercise pre-surgery increases the propensity for being active afterward
(194). Aerobic exercise training following surgery may further enhance weight maintenance,
glycemic management, and insulin sensitivity (195–197), lower risk of CVD, enhance
endothelial function (198), and improve cardiac autonomic regulation (199). Resistance
exercise training may reverse muscle strength deficits frequently observed after bariatric
surgery (200). Exercise training is also effective in ameliorating surgery-related bone loss
(201, 202), which is common following bariatric surgery (203–205).
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Barriers to Adoption of PA and Inequities

Barriers to PA participation are similar among people with and without diabetes and include
lower self-efficacy (206), inappropriate goal-setting (207), lack of access to facilities (208),
lack of supervision or social support (209–211), and inattention to cultural nuances (212).
Health issues like obesity and knee and hip osteoarthritis may also be barriers as they
negatively impact self-efficacy related to PA participation (213). The built environment, or
human-made surroundings, may also impact the ability and willingness to be regularly active
(208), and may include availability of facilities, having pleasant and safe places to walk, and
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access to green spaces (214, 215). Focusing on creating more exercise-friendly environments
is likely to promote greater participation. Setting realistic goals with appropriate activities,
slower progression, and supportive feedback can increase success and confidence (216–218).
Counseling by health care professionals may also be a meaningful and effective source of
support (219). Likewise, supervision of exercise sessions improves compliance and glycemia
(220).
The prevalence of physical inactivity, obesity, and T2D are significantly higher among
non-Hispanic Blacks, American Indian/Alaskan Natives, and Hispanics than among non-
Hispanic Whites (4, 221–224). The disproportionate burden of these conditions is likely
more attributable to social and environmental determinants in these racial and ethnic
minorities than biological differences (225, 226). Physical education in schools, limited
open spaces for outdoor activities, inadequate infrastructure for active transportation, unsafe
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environments, and hypercaloric diets are dominant environmental factors that contribute to
T2D development (225–232). Community environments that promote PA are associated with
a lower incidence of T2D (227, 233–235); therefore, efforts that promote long-term health
outcomes and target environmental factors may reduce T2D (235, 236). Neighborhood
walkability, PA resources, and access to green spaces may reduce T2D risk (215, 235), while
living in urban settings may raise it.
Expert Interpretation and Key Future Directions

• Large scale clinical trials in T2D are needed to understand optimal treatment
regimens and importance of PA and exercise, other lifestyle changes, and
medications on glycemia.
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• Further work is warranted to elucidate the cognitive domains that are most
responsive to PA and dietary improvements in adults with T2D, as well
as exercise effects on memory and cognitive function related to glycemic
management.
• More research on the effect of exercise training on vascular function and the
microbiome needs to be conducted in individuals with obesity and with and
without T2D.
• Longer duration training is needed to establish whether exercise timing modifies

the glycemic response to meals as well as overnight levels and if specific time of
day of planned exercise should be prescribed.
• While prolonged sitting has been found deleterious in research settings, studies
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on PA breaks in daily life are necessary to determine whether long-term use has
clinically relevant glycemic benefits in populations with T2D.
• Potential interactions between diabetes medications like metformin and exercise

training need to be further investigated with respect to their impact on glycemic
management.
• Social and environmental factors have also been associated with physical
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inactivity and the incidence of T2D and these factors need to be explored further.
• Targeted research is needed to better define the health disparities that exist across
racial, ethnic, and potentially socioeconomic populations and how their impact
on PA participation for T2D and prediabetes prevention and management can be
mitigated.
• Larger clinical trials examining the impact of chronic high-intensity exercise on

mitochondrial function and glucose tolerance in a population with obesity and
with and without T2D are needed.
Conclusions
Various types of physical activity, inclusive of but not limited to planned exercise, can
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greatly enhance the health and glycemic management of individuals of all ages with T2D,
including flexibility and balance exercise in adults. The latest Physical Activity Guidelines
for Americans are applicable to most individuals with diabetes, including youth, with a few
exceptions and modifications. All individuals should engage in regular physical activity,
reduce sedentary time, and break up sitting time with frequent activity breaks. Physical
activity undertaken with health complications can be made safe and efficacious, and exercise
training undertaken before and after bariatric surgery is warranted and may enhances its
health benefits. Finally, barriers to, and inequities in, physical activity and exercise adoption
and maintenance need to be addressed to maximize participation.
Supplementary Material
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Refer to Web version on PubMed Central for supplementary material.
Funding
C.C. is supported by the National Institute of Health grants: 1T34GM141989-01, 5UL1GM118964-07,
5TL4GM118965-07, 5RL5GM118963-07
J.A.K. is supported by the National Institute of Health R01 DK101513.
J.P.K. is supported by National Institute of Health grants: U54 GM104940, U54 GM104940-S2, U54 GM104940-
S3, U01 DK114156, P01 HL103453, R01 HD088061, R01 DK114156.
S.K.M. is supported by National Institutes of Health R01-HL130296.
J.R.Z. was supported by the Swedish Research Council (Vetenskapsrådet) (2015-00165), the Strategic Research
Program in Diabetes at Karolinska Institutet (2009-1068), the Swedish Research Council for Sport Science
(P2018-0097), and Novo Nordisk Foundation (NNF17OC0030088).
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References
1. Colberg SR, Albright AL, Blissmer BJ, Braun B, Chasan-Taber L, Fernhall B, et al. Exercise and
type 2 diabetes: American College of Sports Medicine and the American Diabetes Association: joint
position statement. Exercise and type 2 diabetes. Med Sci Sports Exerc. 2010;42(12):2282–303. doi:
10.1249/MSS.0b013e3181eeb61c. [PubMed: 21084931]
2. Colberg SR, Sigal RJ, Fernhall B, Regensteiner JG, Blissmer BJ, Rubin RR, et al. Exercise and
type 2 diabetes: the American College of Sports Medicine and the American Diabetes Association:
joint position statement. Diabetes Care. 2010;33(12):e147–67. doi: 10.2337/dc10-9990. [PubMed:

21115758]
Author Manuscript
3. Saeedi P, Petersohn I, Salpea P, Malanda B, Karuranga S, Unwin N, et al. Global and

regional diabetes prevalence estimates for 2019 and projections for 2030 and 2045: Results
from the International Diabetes Federation Diabetes Atlas, 9(th) edition. Diabetes Res Clin Pract.
2019;157:107843. Epub 2019/09/14. doi: 10.1016/j.diabres.2019.107843. [PubMed: 31518657]
4. Centers for Disease Control and Prevention. National Diabetes Statistics Report, 2020. https://
www.cdc.gov/diabetes/library/features/diabetes-stat-report.html.
5. 2. Classification and Diagnosis of Diabetes: Standards of Medical Care in Diabetes-2021. Diabetes
Care. 2021;44(Suppl 1):S15–s33. Epub 2020/12/11. doi: 10.2337/dc21-S002. [PubMed: 33298413]
6. Suh SH, Paik IY, Jacobs K. Regulation of blood glucose homeostasis during prolonged exercise.
Mol Cells. 2007;23(3):272–9. Epub 2007/07/25. [PubMed: 17646701]
7. Zierath JR, He L, Guma A, Odegoard Wahlstrom E, Klip A, Wallberg-Henriksson H. Insulin
action on glucose transport and plasma membrane GLUT4 content in skeletal muscle from patients
with NIDDM. Diabetologia. 1996;39(10):1180–9. Epub 1996/10/01. doi: 10.1007/BF02658504.
[PubMed: 8897005]
Author Manuscript
8. Bajpeyi S, Tanner CJ, Slentz CA, Duscha BD, McCartney JS, Hickner RC, et al.
Effect of exercise intensity and volume on persistence of insulin sensitivity during training
cessation. Journal of applied physiology. 2009;106(4):1079–85. Epub 2009/02/07. doi: 10.1152/
japplphysiol.91262.2008. [PubMed: 19196913]
9. Houmard JA, Tanner CJ, Slentz CA, Duscha BD, McCartney JS, Kraus WE. Effect of the
volume and intensity of exercise training on insulin sensitivity. Journal of applied physiology.
2004;96(1):101–6. doi: 10.1152/japplphysiol.00707.2003. [PubMed: 12972442]
10. Kang J, Robertson RJ, Hagberg JM, Kelley DE, Goss FL, DaSilva SG, et al. Effect of exercise
intensity on glucose and insulin metabolism in obese individuals and obese NIDDM patients.
Diabetes Care. 1996;19(4):341–9. Epub 1996/04/01. doi: 10.2337/diacare.19.4.341. [PubMed:
8729157]
11. Heiskanen MA, Motiani KK, Mari A, Saunavaara V, Eskelinen JJ, Virtanen KA, et al.
Exercise training decreases pancreatic fat content and improves beta cell function regardless of
baseline glucose tolerance: a randomised controlled trial. Diabetologia. 2018;61(8):1817–28. Epub
2018/05/03. doi: 10.1007/s00125-018-4627-x. [PubMed: 29717337]
Author Manuscript
12. Kirwan JP, Solomon TP, Wojta DM, Staten MA, Holloszy JO. Effects of 7 days of exercise training
on insulin sensitivity and responsiveness in type 2 diabetes mellitus. Am J Physiol Endocrinol
Metab. 2009;297(1):E151–6. doi: 10.1152/ajpendo.00210.2009. [PubMed: 19383872]
13. Magalhaes JP, Melo X, Correia IR, Ribeiro RT, Raposo J, Dores H, et al. Effects of combined
training with different intensities on vascular health in patients with type 2 diabetes: a 1-year
randomized controlled trial. Cardiovasc Diabetol. 2019;18(1):34. Epub 2019/03/20. doi: 10.1186/
s12933-019-0840-2. [PubMed: 30885194]
14. Naylor LH, Davis EA, Kalic RJ, Paramalingam N, Abraham MB, Jones TW, et al. Exercise
training improves vascular function in adolescents with type 2 diabetes. Physiol Rep. 2016;4(4).
Epub 2016/02/19. doi: 10.14814/phy2.12713.
15. Motiani KK, Collado MC, Eskelinen JJ, Virtanen KA, E LO, Salminen S, et al. Exercise
Training Modulates Gut Microbiota Profile and Improves Endotoxemia. Med Sci Sports
Exerc. 2020;52(1):94–104. Epub 2019/08/20. doi: 10.1249/MSS.0000000000002112. [PubMed:
31425383]
Author Manuscript
16. Phielix E, Meex R, Moonen-Kornips E, Hesselink MK, Schrauwen P. Exercise training increases
mitochondrial content and ex vivo mitochondrial function similarly in patients with type 2 diabetes
and in control individuals. Diabetologia. 2010;53(8):1714–21. Epub 2010/04/28. doi: 10.1007/
s00125-010-1764-2.. [PubMed: 20422397]
17. Winnick JJ, Sherman WM, Habash DL, Stout MB, Failla ML, Belury MA, et al. Short-term
aerobic exercise training in obese humans with type 2 diabetes mellitus improves whole-body
insulin sensitivity through gains in peripheral, not hepatic insulin sensitivity. J Clin Endocrinol
Metab. 2008;93(3):771–8. Epub 2007/12/13. doi: jc.2007-1524 [pii] 10.1210/jc.2007-1524 [doi].
[PubMed: 18073312]
18. Boulé NG, Haddad E, Kenny GP, Wells GA, Sigal RJ. Effects of exercise on glycemic control
and body mass in type 2 diabetes mellitus: a meta-analysis of controlled clinical trials. JAMA.
Author Manuscript
2001;286(10):1218–27. [PubMed: 11559268]

19. Umpierre D, Ribeiro PA, Kramer CK, Leitao CB, Zucatti AT, Azevedo MJ, 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. 2011;305(17):1790–9. doi: 10.1001/jama.2011.576.
[PubMed: 21540423]
20. Chudyk A, Petrella RJ. Effects of exercise on cardiovascular risk factors in type 2 diabetes: a meta-
analysis. Diabetes Care. 2011;34(5):1228–37. Epub 2011/04/29. doi: 34/5/1228 [pii] 10.2337/
dc10-1881 [doi]. [PubMed: 21525503]
21. Snowling NJ, Hopkins WG. Effects of different modes of exercise training on glucose control
and risk factors for complications in type 2 diabetic patients: a meta-analysis. Diabetes
Care. 2006;29(11):2518–27. Epub 2006/10/27. doi: 29/11/2518 [pii] 10.2337/dc06-1317 [doi].
[PubMed: 17065697]
22. Borror A, Zieff G, Battaglini C, Stoner L. The Effects of Postprandial Exercise on Glucose Control
in Individuals with Type 2 Diabetes: A Systematic Review. Sports Med. 2018;2(10):018–0864.
Author Manuscript
23. Kadoglou NP, Iliadis F, Angelopoulou N, Perrea D, Ampatzidis G, Liapis CD, et

al. The anti-inflammatory effects of exercise training in patients with type 2 diabetes
mellitus. Eur J Cardiovasc Prev Rehabil. 2007;14(6):837–43. Epub 2007/11/29. doi: 10.1097/
HJR.0b013e3282efaf50 [doi] 00149831-200712000-00019 [pii]. [PubMed: 18043308]
24. Boulé NG, Kenny GP, Haddad E, Wells GA, Sigal RJ. Meta-analysis of the effect of
structured exercise training on cardiorespiratory fitness in Type 2 diabetes mellitus. Diabetologia.
2003;46(8):1071–81. [PubMed: 12856082]
25. Gordon BA, Benson AC, Bird SR, Fraser SF. Resistance training improves metabolic health in type
2 diabetes: a systematic review. Diabetes Res Clin Pract. 2009;83(2):157–75. Epub 2009/01/13.
doi: S0168-8227(08)00587-1 [pii] 10.1016/j.diabres.2008.11.024 [doi]. [PubMed: 19135754]
26. Dunstan DW, Daly RM, Owen N, Jolley D, De Courten M, Shaw J, et al. High-intensity
resistance training improves glycemic control in older patients with type 2 diabetes. Diabetes
Care. 2002;25(10):1729–36. Epub 2002/09/28. [PubMed: 12351469]
27. Liu Y, Ye W, Chen Q, Zhang Y, Kuo CH, Korivi M. Resistance Exercise Intensity is Correlated
with Attenuation of HbA1c and Insulin in Patients with Type 2 Diabetes: A Systematic Review
Author Manuscript
and Meta-Analysis. Int J Environ Res Public Health. 2019;16(1).(pii):ijerph16010140. doi:

10.3390/ijerph.
28. Sigal RJ, Kenny GP, Boule NG, Wells GA, Prud’homme D, Fortier M, et al. Effects of aerobic
training, resistance training, or both on glycemic control in type 2 diabetes: a randomized
trial. Ann Intern Med. 2007;147(6):357–69. Epub 2007/09/19. doi: 147/6/357 [pii]. [PubMed:
17876019]
29. Church TS, Blair SN, Cocreham S, Johannsen N, Johnson W, Kramer K, et al. Effects of aerobic
and resistance training on hemoglobin A1c levels in patients with type 2 diabetes: a randomized
controlled trial. JAMA. 2010;304(20):2253–62. Epub 2010/11/26. doi: 304/20/2253 [pii] 10.1001/
jama.2010.1710 [doi]. [PubMed: 21098771]
30. Schwingshackl L, Missbach B, Dias S, Konig J, Hoffmann G. Impact of different training
modalities on glycaemic control and blood lipids in patients with type 2 diabetes: a systematic
review and network meta-analysis. Diabetologia. 2014;57(9):1789–97. Epub 2014/07/06. doi:
10.1007/s00125-014-3303-z. [PubMed: 24996616]
Author Manuscript
31. Grace A, Chan E, Giallauria F, Graham PL, Smart NA. Clinical outcomes and glycaemic responses
to different aerobic exercise training intensities in type II diabetes: a systematic review and meta-
analysis. Cardiovasc Diabetol. 2017;16(1):37. Epub 2017/03/16. doi: 10.1186/s12933-017-0518-6.
[PubMed: 28292300]
32. Gillen JB, Little JP, Punthakee Z, Tarnopolsky MA, Riddell MC, Gibala MJ. Acute high-intensity
interval exercise reduces the postprandial glucose response and prevalence of hyperglycaemia
in patients with type 2 diabetes. Diabetes, obesity & metabolism. 2012;14(6):575–7. Epub
2012/01/25. doi: 10.1111/j.1463-1326.2012.01564.x.
33. Savikj M, Gabriel BM, Alm PS, Smith J, Caidahl K, Bjornholm M, et al. Afternoon exercise is
more efficacious than morning exercise at improving blood glucose levels in individuals with type
2 diabetes: a randomised crossover trial. Diabetologia. 2019;62(2):233–7. Epub 2018/11/15. doi:

10.1007/s00125-018-4767-z. [PubMed: 30426166]
Author Manuscript
34. Karstoft K, Winding K, Knudsen SH, Nielsen JS, Thomsen C, Pedersen BK, et al. The effects of
free-living interval-walking training on glycemic control, body composition, and physical fitness
in type 2 diabetic patients: a randomized, controlled trial. Diabetes Care. 2013;36(2):228–36. doi:
10.2337/dc12-0658. [PubMed: 23002086]
35. Nieuwoudt S, Fealy CE, Foucher JA, Scelsi AR, Malin SK, Pagadala M, et al. Functional high-
intensity training improves pancreatic β-cell function in adults with type 2 diabetes. Am J Physiol
Endocrinol Metab. 2017;313(3):E314–e20. Epub 2017/05/18. doi: 10.1152/ajpendo.00407.2016.
[PubMed: 28512155]
36. Little JP, Gillen JB, Percival ME, Safdar A, Tarnopolsky MA, Punthakee Z, et al. Low-
volume high-intensity interval training reduces hyperglycemia and increases muscle mitochondrial
capacity in patients with type 2 diabetes. J Appl Physiol. 2011;111(6):1554–60. Epub 2011/08/27.
doi: japplphysiol.00921.2011 [pii] 10.1152/japplphysiol.00921.2011 [doi]. [PubMed: 21868679]
37. Mitranun W, Deerochanawong C, Tanaka H, Suksom D. Continuous vs interval training on
glycemic control and macro-and microvascular reactivity in type 2 diabetic patients. Scand J Med
Author Manuscript
Sci Sports. 2014;24(2):e69–76. Epub 2013/10/10. doi: 10.1111/sms.12112. [PubMed: 24102912]

38. Hollekim-Strand SM, Bjorgaas MR, Albrektsen G, Tjonna AE, Wisloff U, Ingul CB. High-
intensity interval exercise effectively improves cardiac function in patients with type 2
diabetes mellitus and diastolic dysfunction: a randomized controlled trial. J Am Coll Cardiol.
2014;64(16):1758–60. Epub 2014/10/18. doi: 10.1016/j.jacc.2014.07.971. [PubMed: 25323267]
39. Revdal A, Hollekim-Strand SM, Ingul CB. Can Time Efficient Exercise Improve Cardiometabolic
Risk Factors in Type 2 Diabetes? A Pilot Study. J Sports Sci Med. 2016;15(2):308–13. Epub
2016/06/09. [PubMed: 27274669]
40. Ghardashi Afousi A, Izadi MR, Rakhshan K, Mafi F, Biglari S, Gandomkar Bagheri H. Improved
brachial artery shear patterns and increased flow-mediated dilatation after low-volume high-
intensity interval training in type 2 diabetes. Exp Physiol. 2018;103(9):1264–76. Epub 2018/06/23.
doi: 10.1113/ep087005. [PubMed: 29932275]
41. Braun B, Zimmermann MB, Kretchmer N. Effects of exercise intensity on insulin sensitivity in
women with non-insulin-dependent diabetes mellitus. J Appl Physiol. 1995;78(1):300–6. Epub
1995/01/01. [PubMed: 7713829]
Author Manuscript
42. Ryan BJ, Schleh MW, Ahn C, Ludzki AC, Gillen JB, Varshney P, et al. Moderate-Intensity
Exercise and High-Intensity Interval Training Affect Insulin Sensitivity Similarly in Obese Adults.
J Clin Endocrinol Metab. 2020;105(8):e2941–59. Epub 2020/06/04. doi: 10.1210/clinem/dgaa345.
43. Heiston EM, Eichner NZ, Gilbertson NM, Malin SK. Exercise improves adiposopathy,
insulin sensitivity and metabolic syndrome severity independent of intensity. Exp Physiol.
2020;105(4):632–40. Epub 2020/02/06. doi: 10.1113/ep088158. [PubMed: 32020676]
44. Hansen D, Dendale P, Jonkers RA, Beelen M, Manders RJ, Corluy L, et al. Continuous low-to
moderate-intensity exercise training is as effective as moderate- to high-intensity exercise training
at lowering blood HbA(1c) in obese type 2 diabetes patients. Diabetologia. 2009;52(9):1789–97.
Epub 2009/04/17. doi: 10.1007/s00125-009-1354-3 [doi]. [PubMed: 19370339]
45. Jelleyman C, Yates T, O’Donovan G, Gray LJ, King JA, Khunti K, et al. The effects of high-
intensity interval training on glucose regulation and insulin resistance: a meta-analysis. Obes Rev.
2015;16(11):942–61. Epub 2015/10/21. doi: 10.1111/obr.12317. [PubMed: 26481101]
46. Innes KE, Selfe TK. Yoga for adults with type 2 diabetes: A systematic review of controlled trials.
Author Manuscript
Journal of diabetes research. 2016;2016:6979370. Epub 2016/10/21. doi: 10.1155/2016/6979370.

[PubMed: 26788520]
47. Ahn S, Song R. Effects of Tai Chi Exercise on glucose control, neuropathy scores, balance,
and quality of life in patients with type 2 diabetes and neuropathy. J Altern Complement Med.
2012;18(12):1172–8. Epub 2012/09/19. doi: 10.1089/acm.2011.0690. [PubMed: 22985218]
48. Hamman RF, Wing RR, Edelstein SL, Lachin JM, Bray GA, Delahanty L, et al. Effect of weight
loss with lifestyle intervention on risk of diabetes. Diabetes Care. 2006;29(9):2102–7. Epub
2006/08/29. doi: 29/9/2102 [pii] 10.2337/dc06-0560 [doi]. [PubMed: 16936160]
49. Knowler WC, Fowler SE, Hamman RF, Christophi CA, Hoffman HJ, Brenneman AT, et al. 10-year
follow-up of diabetes incidence and weight loss in the Diabetes Prevention Program Outcomes
Author Manuscript
Study. Lancet. 2009;374(9702):1677–86. Epub 2009/11/03. doi: 10.1016/s0140-6736(09)61457-4.

[PubMed: 19878986]
50. Long-term effects of lifestyle intervention or metformin on diabetes development and
microvascular complications over 15-year follow-up: the Diabetes Prevention Program Outcomes
Study. Lancet Diabetes Endocrinol. 2015;3(11):866–75. doi: 10.1016/S2213-8587(15)00291-0.
Epub 2015 Sep 13. [PubMed: 26377054]
51. Kriska AM, Rockette-Wagner B, Edelstein SL, Bray GA, Delahanty LM, Hoskin MA, et al.
The Impact of Physical Activity on the Prevention of Type 2 Diabetes: Evidence and Lessons
Learned From the Diabetes Prevention Program, a Long-Standing Clinical Trial Incorporating
Subjective and Objective Activity Measures. Diabetes Care. 2021;44(1):43–9. Epub 2021/01/15.
doi: 10.2337/dc20-1129. [PubMed: 33444158]
52. Slentz CA, Bateman LA, Willis LH, Granville EO, Piner LW, Samsa GP, et al. Effects of exercise
training alone vs a combined exercise and nutritional lifestyle intervention on glucose homeostasis
in prediabetic individuals: a randomised controlled trial. Diabetologia. 2016;59(10):2088–98.
Epub 2016/07/17. doi: 10.1007/s00125-016-4051-z. [PubMed: 27421729]
Author Manuscript
53. Pi-Sunyer X, Blackburn G, Brancati FL, Bray GA, Bright R, Clark JM, et al. Reduction in weight
and cardiovascular disease risk factors in individuals with type 2 diabetes: one-year results of the
look AHEAD trial. Diabetes Care. 2007;30(6):1374–83. Epub 2007/03/17. doi: dc07-0048 [pii]
10.2337/dc07-0048. [PubMed: 17363746]
54. Franz MJ, Boucher JL, Rutten-Ramos S, VanWormer JJ. Lifestyle weight-loss intervention
outcomes in overweight and obese adults with type 2 diabetes: a systematic review and meta-
analysis of randomized clinical trials. J Acad Nutr Diet. 2015;115(9):1447–63. Epub 2015/05/04.
doi: 10.1016/j.jand.2015.02.031. [PubMed: 25935570]
55. Terranova CO, Brakenridge CL, Lawler SP, Eakin EG, Reeves MM. Effectiveness of lifestyle-
based weight loss interventions for adults with type 2 diabetes: a systematic review and meta-
analysis. Diabetes Obes Metab. 2015;17(4):371–8. Epub 2014/12/20. doi: 10.1111/dom.12430.
[PubMed: 25523815]
56. Look ARG, Wing RR, Bolin P, Brancati FL, Bray GA, Clark JM, et al. Cardiovascular effects
of intensive lifestyle intervention in type 2 diabetes. N Engl J Med. 2013;369(2):145–54. doi:
Author Manuscript
10.1056/NEJMoa1212914. [PubMed: 23796131]

57. Espeland MA, Glick HA, Bertoni A, Brancati FL, Bray GA, Clark JM, et al. Impact of an intensive
lifestyle intervention on use and cost of medical services among overweight and obese adults
with type 2 diabetes: the action for health in diabetes. Diabetes Care. 2014;37(9):2548–56. Epub
2014/08/26. doi: 10.2337/dc14-0093. [PubMed: 25147253]
58. Ross R, Dagnone D, Jones P, Smith H, Paddags A, Hudson R, et al. Reduction in obesity and
related comorbid conditions after diet-induced weight loss or exercise-induced weight loss in men:
a randomized controlled trial. Ann Intern Med. 2000;1333:92–103.
59. Ross R, Janssen I, Dawson J, Kungle A-M, Kuk J, Wong S, et al. Exercise-induced reduction
in obesity and insulin resistance in women: a randomized controlled trial. Obesity Research.
2004;12:789–98. [PubMed: 15166299]
60. Yassine HN, Marchetti CM, Krishnan RK, Vrobel TR, Gonzalez F, Kirwan JP. Effects of exercise
and caloric restriction on insulin resistance and cardiometabolic risk factors in older obese adults--
a randomized clinical trial. J Gerontol A Biol Sci Med Sci. 2009;64(1):90–5. Epub 2009/01/24.
doi: 10.1093/gerona/gln032. [PubMed: 19164269]
Author Manuscript
61. Giannopoulou I, Fernhall B, Carhart R, Weinstock R, Baynard T, Figueroa A, et al. Effects of diet
and/or exercise on the adipocytokine and inflammatory cytokine levels of postmenopausal women
with type 2 diabetes. Metabolism. 2005;54:866–75. [PubMed: 15988694]
62. Vounzoulaki E, Khunti K, Abner SC, Tan BK, Davies MJ, Gillies CL. Progression to type
2 diabetes in women with a known history of gestational diabetes: systematic review and
meta-analysis. BMJ. 2020;369:m1361. Epub 2020/05/15. doi: 10.1136/bmj.m1361. [PubMed:
32404325]
63. 14. Management of Diabetes in Pregnancy: Standards of Medical Care in Diabetes-2021.

Diabetes Care. 2021;44(Suppl 1):S200–s10. Epub 2020/12/11. doi: 10.2337/dc21-S014. [PubMed:
Author Manuscript
33298425]
64. Li Z, Cheng Y, Wang D, Chen H, Ming WK, Wang Z. Incidence Rate of Type 2 Diabetes Mellitus
after Gestational Diabetes Mellitus: A Systematic Review and Meta-Analysis of 170,139 Women.
J Diabetes Res. 2020;2020:3076463. Epub 2020/05/15. doi: 10.1155/2020/3076463. [PubMed:
32405502]
65. Dempsey JC, Butler CL, Sorensen TK, Lee IM, Thompson ML, Miller RS, et al. A case-control
study of maternal recreational physical activity and risk of gestational diabetes mellitus. Diabetes
Res Clin Pract. 2004;66(2):203–15. Epub 2004/11/10. doi: S0168822704001056 [pii] 10.1016/
j.diabres.2004.03.010 [doi]. [PubMed: 15533588]
66. Dempsey JC, Sorensen TK, Williams MA, Lee IM, Miller RS, Dashow EE, et al. Prospective study
of gestational diabetes mellitus risk in relation to maternal recreational physical activity before and
during pregnancy. Am J Epidemiol. 2004;159(7):663–70. Epub 2004/03/23. [PubMed: 15033644]
67. Oken E, Ning Y, Rifas-Shiman SL, Radesky JS, Rich-Edwards JW, Gillman MW.
Associations of physical activity and inactivity before and during pregnancy with glucose
Author Manuscript
tolerance. Obstet Gynecol. 2006;108(5):1200–7. Epub 2006/11/02. doi: 108/5/1200 [pii]

10.1097/01.AOG.0000241088.60745.70 [doi]. [PubMed: 17077243]
68. Zhang C, Solomon CG, Manson JE, Hu FB. A prospective study of pregravid physical activity
and sedentary behaviors in relation to the risk for gestational diabetes mellitus. Arch Intern
Med. 2006;166(5):543–8. Epub 2006/03/15. doi: 166/5/543 [pii] 10.1001/archinte.166.5.543 [doi].
[PubMed: 16534041]
69. Barakat R, Refoyo I, Coteron J, Franco E. Exercise during pregnancy has a preventative effect
on excessive maternal weight gain and gestational diabetes. A randomized controlled trial. Braz
J Phys Ther. 2019;23(2):148–55. Epub 2018/11/25. doi: 10.1016/j.bjpt.2018.11.005. [PubMed:
30470666]
70. Wang C, Wei Y, Zhang X, Zhang Y, Xu Q, Sun Y, et al. A randomized clinical trial of
exercise during pregnancy to prevent gestational diabetes mellitus and improve pregnancy outcome
in overweight and obese pregnant women. Am J Obstet Gynecol. 2017;216(4):340–51. Epub
2017/02/06. doi: 10.1016/j.ajog.2017.01.037. [PubMed: 28161306]
71. Davenport MH, Ruchat SM, Poitras VJ, Jaramillo Garcia A, Gray CE, Barrowman N, et al.
Author Manuscript
Prenatal exercise for the prevention of gestational diabetes mellitus and hypertensive disorders of
pregnancy: a systematic review and meta-analysis. Br J Sports Med. 2018;52(21):1367–75. Epub
2018/10/20. doi: 10.1136/bjsports-2018-099355. [PubMed: 30337463]
72. Sanabria-Martínez G, García-Hermoso A, Poyatos-León R, Álvarez-Bueno C, Sánchez-López M,
Martínez-Vizcaíno V. Effectiveness of physical activity interventions on preventing gestational
diabetes mellitus and excessive maternal weight gain: a meta-analysis. Bjog. 2015;122(9):1167–
74. Epub 2015/06/04. doi: 10.1111/1471-0528.13429. [PubMed: 26036300]
73. Mottola MF, Davenport MH, Ruchat SM, Davies GA, Poitras VJ, Gray CE, et al. 2019 Canadian
guideline for physical activity throughout pregnancy. Br J Sports Med. 2018;52(21):1339–46.
Epub 2018/10/20. doi: 10.1136/bjsports-2018-100056. [PubMed: 30337460]
74. Gynecology ACoOa. ACOG Committee Opinion No. 650: Physical Activity and Exercise During
Pregnancy and the Postpartum Period. Obstet Gynecol. 2015;126(6):e135–42. Epub 2015/11/26.
doi: 10.1097/aog.0000000000001214. [PubMed: 26595585]
75. Craft LL, Perna FM. The Benefits of Exercise for the Clinically Depressed. Prim Care Companion
J Clin Psychiatry. 2004;6(3):104–11. Epub 2004/09/14. [PubMed: 15361924]
Author Manuscript
76. Bettio LEB, Thacker JS, Rodgers SP, Brocardo PS, Christie BR, Gil-Mohapel J. Interplay between
hormones and exercise on hippocampal plasticity across the lifespan. Biochim Biophys Acta Mol
Basis Dis. 2020;1866(8):165821. Epub 2020/05/08. doi: 10.1016/j.bbadis.2020.165821. [PubMed:
32376385]
77. Williamson DA, Rejeski J, Lang W, Van Dorsten B, Fabricatore AN, Toledo K, et al. Impact of
a weight management program on health-related quality of life in overweight adults with type 2
diabetes. Arch Intern Med. 2009;169(2):163–71. Epub 2009/01/28. doi: 169/2/163 [pii] 10.1001/
archinternmed.2008.544 [doi]. [PubMed: 19171813]
78. Rubin RR, Wadden TA, Bahnson JL, Blackburn GL, Brancati FL, Bray GA, et al. Impact of
intensive lifestyle intervention on depression and health-related quality of life in type 2 diabetes:
Author Manuscript
the Look AHEAD Trial. Diabetes Care. 2014;37(6):1544–53. Epub 2014/05/24. doi: 10.2337/
dc13-1928. [PubMed: 24855155]
79. MacDonald CS, Nielsen SM, Bjørner J, Johansen MY, Christensen R, Vaag A, et al. One-year
intensive lifestyle intervention and improvements in health-related quality of life and mental health
in persons with type 2 diabetes: a secondary analysis of the U-TURN randomized controlled trial.
BMJ Open Diabetes Res Care. 2021;9(1). Epub 2021/01/15. doi: 10.1136/bmjdrc-2020-001840.
80. Palta P, Schneider AL, Biessels GJ, Touradji P, Hill-Briggs F. Magnitude of cognitive dysfunction
in adults with type 2 diabetes: a meta-analysis of six cognitive domains and the most frequently
reported neuropsychological tests within domains. J Int Neuropsychol Soc. 2014;20(3):278–91.
Epub 2014/02/22. doi: 10.1017/s1355617713001483. [PubMed: 24555960]
81. Robinson MM, Lowe VJ, Nair KS. Increased Brain Glucose Uptake After 12 Weeks of
Aerobic High-Intensity Interval Training in Young and Older Adults. J Clin Endocrinol Metab.
2018;103(1):221–7. Epub 2017/10/28. doi: 10.1210/jc.2017-01571. [PubMed: 29077855]
82. Honkala SM, Johansson J, Motiani KK, Eskelinen JJ, Virtanen KA, Löyttyniemi E, et al. Short-
Author Manuscript
term interval training alters brain glucose metabolism in subjects with insulin resistance. J Cereb
Blood Flow Metab. 2018;38(10):1828–38. Epub 2017/09/30. doi: 10.1177/0271678x17734998..
[PubMed: 28959911]
83. Kullmann S, Valenta V, Wagner R, Tschritter O, Machann J, Häring HU, et al. Brain insulin
sensitivity is linked to adiposity and body fat distribution. Nat Commun. 2020;11(1):1841. Epub
2020/04/17. doi: 10.1038/s41467-020-15686-y. [PubMed: 32296068]
84. Espeland MA, Lipska K, Miller ME, Rushing J, Cohen RA, Verghese J, et al. Effects of Physical
Activity Intervention on Physical and Cognitive Function in Sedentary Adults With and Without
Diabetes. J Gerontol A Biol Sci Med Sci. 2017;72(6):861–6. Epub 2016/09/04. doi: 10.1093/
gerona/glw179. [PubMed: 27590629]
85. Yanagawa M, Umegaki H, Uno T, Oyun K, Kawano N, Maeno H, et al. Association between
improvements in insulin resistance and changes in cognitive function in elderly diabetic patients
with normal cognitive function. Geriatr Gerontol Int. 2011;11(3):341–7. Epub 2011/03/18. doi:
10.1111/j.1447-0594.2011.00691.x. [PubMed: 21410855]
86. Shellington EM, Reichert SM, Heath M, Gill DP, Shigematsu R, Petrella RJ. Results From
Author Manuscript
a Feasibility Study of Square-Stepping Exercise in Older Adults With Type 2 Diabetes and
Self-Reported Cognitive Complaints to Improve Global Cognitive Functioning. Can J Diabetes.
2018;42(6):603–12.e1. Epub 2018/06/10. doi: 10.1016/j.jcjd.2018.02.003. [PubMed: 29884522]
87. Baker LD, Frank LL, Foster-Schubert K, Green PS, Wilkinson CW, McTiernan A, et al. Aerobic
exercise improves cognition for older adults with glucose intolerance, a risk factor for Alzheimer’s
disease. J Alzheimers Dis. 2010;22(2):569–79. Epub 2010/09/18. doi: 10.3233/jad-2010-100768.
[PubMed: 20847403]
88. Espeland MA, Rapp SR, Bray GA, Houston DK, Johnson KC, Kitabchi AE, et al. Long-term
impact of behavioral weight loss intervention on cognitive function. J Gerontol A Biol Sci Med
Sci. 2014;69(9):1101–8. Epub 2014/03/13. doi: 10.1093/gerona/glu031. [PubMed: 24619151]
89. Cooke S, Pennington K, Jones A, Bridle C, Smith MF, Curtis F. Effects of exercise, cognitive, and
dual-task interventions on cognition in type 2 diabetes mellitus: A systematic review and meta-
analysis. PLoS One. 2020;15(5):e0232958. Epub 2020/05/15. doi: 10.1371/journal.pone.0232958.
[PubMed: 32407347]
90. Colberg SR, Somma CT, Sechrist SR. Physical activity participation may offset some of the
Author Manuscript
negative impact of diabetes on cognitive function. J Am Med Dir Assoc. 2008;9(6):434–8. Epub
2008/07/01. doi: S1525-8610(08)00121-7 [pii] 10.1016/j.jamda.2008.03.014 [doi]. [PubMed:
18585646]
91. Devore EE, Kang JH, Okereke O, Grodstein F. Physical activity levels and cognition in women
with type 2 diabetes. Am J Epidemiol. 2009;170(8):1040–7. Epub 2009/09/05. doi: 10.1093/aje/
kwp224. [PubMed: 19729385]
92. Piercy KL, Troiano RP, Ballard RM, Carlson SA, Fulton JE, Galuska DA, et al. The Physical
Activity Guidelines for Americans. JAMA. 2018;320(19):2020–8. [PubMed: 30418471]
93. Powell KE, King AC, Buchner DM, Campbell WW, DiPietro L, Erickson KI, et al. The Scientific
Foundation for the Physical Activity Guidelines for Americans, 2nd Edition. J Phys Act Health.
Author Manuscript
2018;17:1–11.
94. Boulé NG, Weisnagel SJ, Lakka TA, Tremblay A, Bergman RN, Rankinen T, et al. Effects
of exercise training on glucose homeostasis: the HERITAGE Family Study. Diabetes Care.
2005;28(1):108–14. [PubMed: 15616242]
95. King DS, Baldus PJ, Sharp RL, Kesl LD, Feltmeyer TL, Riddle MS. Time course for exercise-
induced alterations in insulin action and glucose tolerance in middle-aged people. J Appl Physiol.
1995;78(1):17–22. Epub 1995/01/01. [PubMed: 7713807]
96. Colberg SR, Sigal RJ, Yardley JE, Riddell MC, Dunstan DW, Dempsey PC, et al. Physical
Activity/Exercise and Diabetes: A Position Statement of the American Diabetes Association.
Diabetes Care. 2016;39(11):2065–79. Epub 2016/12/08. doi: 10.2337/dc16-1728. [PubMed:
27926890]
97. Abate M, Schiavone C, Pelotti P, Salini V. Limited joint mobility in diabetes and ageing: recent
advances in pathogenesis and therapy. Int J Immunopathol Pharmacol. 2011;23(4):997–1003.
Epub 2011/01/20. doi: 4 [pii].
Author Manuscript
98. Herriott MT, Colberg SR, Parson HK, Nunnold T, Vinik AI. Effects of 8 weeks of flexibility and
resistance training in older adults with type 2 diabetes. Diabetes care. 2004;27(12):2988–9. Epub
2004/11/25. doi: 27/12/2988 [pii]. [PubMed: 15562222]
99. Jayawardena R, Ranasinghe P, Chathuranga T, Atapattu PM, Misra A. The benefits of yoga
practice compared to physical exercise in the management of type 2 Diabetes Mellitus: A
systematic review and meta-analysis. Diabetes Metab Syndr. 2018;12(5):795–805. doi: 10.1016/
j.dsx.2018.04.008. Epub Apr 18. [PubMed: 29685823]
100. Chapman A, Meyer C, Renehan E, Hill KD, Browning CJ. Exercise interventions for the
improvement of falls-related outcomes among older adults with diabetes mellitus: A systematic
review and meta-analyses. J Diabetes Complications. 2017;31(3):631–45. Epub 2016/10/22. doi:
10.1016/j.jdiacomp.2016.09.015. [PubMed: 27765575]
101. Pfeifer LO, Botton CE, Diefenthaeler F, Umpierre D, Pinto RS. Effects of a power training
program in the functional capacity, on body balance and lower limb muscle strength of elderly
with type 2 diabetes mellitus. J Sports Med Phys Fitness. 2021. Epub 2021/01/23. doi: 10.23736/
s0022-4707.21.11880-8.
Author Manuscript
102. Morrison S, Colberg SR, Mariano M, Parson HK, Vinik AI. Balance training reduces falls risk in
older individuals with type 2 diabetes. Diabetes care. 2010;33(4):748–50. Epub 2010/01/26. doi:
dc09-1699 [pii] 10.2337/dc09-1699 [doi]. [PubMed: 20097781]
103. Morrison S, Simmons R, Colberg SR, Parson HK, Vinik AI. Supervised Balance Training and
Wii Fit-Based Exercises Lower Falls Risk in Older Adults With Type 2 Diabetes. Journal of
the American Medical Directors Association. 2018;19(2):185.e7–.e13. Epub 2017/12/27. doi:
10.1016/j.jamda.2017.11.004.
104. Cui J, Yan JH, Yan LM, Pan L, Le JJ, Guo YZ. Effects of yoga in adults with type 2 diabetes
mellitus: A meta-analysis. J Diabetes Investig. 2017;8(2):201–9. Epub 2016/07/03. doi: 10.1111/
jdi.12548.
105. Thind H, Lantini R, Balletto BL, Donahue ML, Salmoirago-Blotcher E, Bock BC, et al. The
effects of yoga among adults with type 2 diabetes: A systematic review and meta-analysis.
Prev Med. 2017;105:116–26. Epub 2017/09/04. doi: 10.1016/j.ypmed.2017.08.017. [PubMed:
28882745]
Author Manuscript
106. Chao M, Wang C, Dong X, Ding M. The Effects of Tai Chi on Type 2 Diabetes Mellitus:
A Meta-Analysis. J Diabetes Res. 2018;2018:7350567.(doi):10.1155/2018/7350567. eCollection
2018. [PubMed: 30116744]
107. Qin J, Chen Y, Guo S, You Y, Xu Y, Wu J, et al. Effect of Tai Chi on Quality of Life, Body Mass
Index, and Waist-Hip Ratio in Patients With Type 2 Diabetes Mellitus: A Systematic Review and
Meta-Analysis. Front Endocrinol (Lausanne). 2020;11:543627. Epub 2021/02/06. doi: 10.3389/
fendo.2020.543627. [PubMed: 33542702]
108. Cai H, Li G, Jiang S, Yin H, Liu P, Chen L. Effect of Low-Intensity, Kinect™-Based Kaimai-
Style Qigong Exercise in Older Adults With Type 2 Diabetes. J Gerontol Nurs. 2019;45(2):42–
52. Epub 2019/01/29. doi: 10.3928/00989134-20190111-05. [PubMed: 30690653]
109. Meng D, Chunyan W, Xiaosheng D, Xiangren Y. The Effects of Qigong on Type 2 Diabetes
Mellitus: A Systematic Review and Meta-Analysis. Evid Based Complement Alternat Med.
Author Manuscript
2018;2018:8182938.(doi):10.1155/2018/8182938. eCollection 2018. [PubMed: 29507593]

110. Melo KCB, Araújo FS, Cordeiro Júnior CCM, de Andrade KTP, Moreira SR. Pilates Method
Training: Functional and Blood Glucose Responses of Older Women With Type 2 Diabetes. J
Strength Cond Res. 2020;34(4):1001–7. Epub 2018/07/10. doi: 10.1519/jsc.0000000000002704.
[PubMed: 29985228]
111. Larsen BA, Martin L, Strong DR. Sedentary behavior and prevalent diabetes in Non-Latino
Whites, Non-Latino Blacks and Latinos: findings from the National Health Interview Survey.
J Public Health (Oxf). 2015;37(4):634–40. Epub 2014/12/30. doi: 10.1093/pubmed/fdu103.
[PubMed: 25538143]
112. van der Berg JD, Stehouwer CD, Bosma H, van der Velde JH, Willems PJ, Savelberg HH, et al.
Associations of total amount and patterns of sedentary behaviour with type 2 diabetes and the
metabolic syndrome: The Maastricht Study. Diabetologia. 2016;59(4):709–18. Epub 2016/02/03.
doi: 10.1007/s00125-015-3861-8. [PubMed: 26831300]
113. Cooper AJ, Brage S, Ekelund U, Wareham NJ, Griffin SJ, Simmons RK. Association
Author Manuscript
between objectively assessed sedentary time and physical activity with metabolic risk factors
among people with recently diagnosed type 2 diabetes. Diabetologia. 2014;57(1):73–82. Epub
2013/11/08. doi: 10.1007/s00125-013-3069-8. [PubMed: 24196189]
114. Nauman J, Stensvold D, Coombes JS, Wisløff U. Cardiorespiratory Fitness, Sedentary Time,
and Cardiovascular Risk Factor Clustering. Med Sci Sports Exerc. 2016;48(4):625–32. Epub
2015/11/21. doi: 10.1249/mss.0000000000000819.. [PubMed: 26587846]
115. Dempsey PC, Larsen RN, Sethi P, Sacre JW, Straznicky NE, Cohen ND, et al. Benefits for
Type 2 Diabetes of Interrupting Prolonged Sitting With Brief Bouts of Light Walking or
Simple Resistance Activities. Diabetes Care. 2016;39(6):964–72. Epub 2016/05/22. doi: 10.2337/
dc15-2336. [PubMed: 27208318]
116. Duvivier BM, Schaper NC, Hesselink MK, van Kan L, Stienen N, Winkens B, et al. Breaking
sitting with light activities vs structured exercise: a randomised crossover study demonstrating
benefits for glycaemic control and insulin sensitivity in type 2 diabetes. Diabetologia.
2017;60(3):490–8. Epub 2016/12/03. doi: 10.1007/s00125-016-4161-7. [PubMed: 27904925]
117. Honda H, Igaki M, Hatanaka Y, Komatsu M, Tanaka S, Miki T, et al. Stair climbing/descending
Author Manuscript
exercise for a short time decreases blood glucose levels after a meal in people with type 2
diabetes. BMJ Open Diabetes Res Care. 2016;4(1):e000232. Epub 2016/08/23. doi: 10.1136/
bmjdrc-2016-000232.
118. Honda H, Igaki M, Hatanaka Y, Komatsu M, Tanaka SI, Miki T, et al. Repeated 3-minute stair
climbing-descending exercise after a meal over 2 weeks increases serum 1,5-anhydroglucitol
levels in people with type 2 diabetes. J Phys Ther Sci. 2017;29(1):75–8. Epub 2017/02/18. doi:
10.1589/jpts.29.75. [PubMed: 28210043]
119. Godkin FE, Jenkins EM, Little JP, Nazarali Z, Percival ME, Gibala MJ. The effect of brief
intermittent stair climbing on glycemic control in people with type 2 diabetes: a pilot study.
Appl Physiol Nutr Metab. 2018;43(9):969–72. Epub 2018/05/03. doi: 10.1139/apnm-2018-0135.
[PubMed: 29717900]
120. Holmstrup M, Fairchild T, Keslacy S, Weinstock R, Kanaley J. Multiple short bouts of exercise
over 12-h period reduce glucose excursions more than an energy-matched single bout of exercise.
Metabolism. 2014;63(4):510–9. doi: 10.1016/j.metabol.2013.12.006. [PubMed: 24439242]
121. Francois ME, Baldi JC, Manning PJ, Lucas SJ, Hawley JA, Williams MJ, et al. ‘Exercise
Author Manuscript
snacks’ before meals: a novel strategy to improve glycaemic control in individuals

with insulin resistance. Diabetologia. 2014;57(7):1437–45. Epub 2014/05/13. doi: 10.1007/
s00125-014-3244-6. [PubMed: 24817675]
122. Loh R, Stamatakis E, Folkerts D, Allgrove JE, Moir HJ. Effects of Interrupting Prolonged
Sitting with Physical Activity Breaks on Blood Glucose, Insulin and Triacylglycerol Measures: A
Systematic Review and Meta-analysis. Sports Med. 2020;50(2):295–330. Epub 2019/09/26. doi:
10.1007/s40279-019-01183-w. [PubMed: 31552570]
123. Blankenship JM, Chipkin SR, Freedson PS, Staudenmayer J, Lyden K, Braun B. Managing
free-living hyperglycemia with exercise or interrupted sitting in type 2 diabetes. J Appl Physiol
(1985). 2019;126(3):616–25. Epub 2018/12/21. doi: 10.1152/japplphysiol.00389.2018. [PubMed:

30571292]
Author Manuscript
124. Nadeau KJ, Anderson BJ, Berg EG, Chiang JL, Chou H, Copeland KC, et al. Youth-Onset
Type 2 Diabetes Consensus Report: Current Status, Challenges, and Priorities. Diabetes Care.
2016;39(9):1635–42. Epub 2016/08/04. doi: 10.2337/dc16-1066. [PubMed: 27486237]
125. Savoye M, Caprio S, Dziura J, Camp A, Germain G, Summers C, et al. Reversal of early
abnormalities in glucose metabolism in obese youth: results of an intensive lifestyle randomized
controlled trial. Diabetes Care. 2014;37(2):317–24. Epub 2013/09/26. doi: 10.2337/dc13-1571.
[PubMed: 24062325]
126. Group TS. Effects of metformin, metformin plus rosiglitazone, and metformin plus lifestyle on
insulin sensitivity and beta-cell function in TODAY. Diabetes Care. 2013;36(6):1749–57. Epub
2013/05/25. doi: 10.2337/dc12-2393. [PubMed: 23704674]
127. Group TS, Zeitler P, Hirst K, Pyle L, Linder B, Copeland K, et al. A clinical trial to maintain
glycemic control in youth with type 2 diabetes. N Engl J Med. 2012;366(24):2247–56. Epub
2012/05/01. doi: 10.1056/NEJMoa1109333. [PubMed: 22540912]
128. Armstrong MJ, Rabi DM, Southern DA, Nanji A, Ghali WA, Sigal RJ. Clinical Utility of
Author Manuscript
Pre-Exercise Stress Testing in People With Diabetes. Can J Cardiol. 2019;35(2):185–92. Epub
2019/02/15. doi: 10.1016/j.cjca.2018.11.007. [PubMed: 30760425]
129. Curtis JM, Horton ES, Bahnson J, Gregg EW, Jakicic JM, Regensteiner JG, et al. Prevalence
and predictors of abnormal cardiovascular responses to exercise testing among individuals with
type 2 diabetes: the Look AHEAD (Action for Health in Diabetes) study. Diabetes Care.
2010;33(4):901–7. Epub 2010/01/09. doi: 10.2337/dc09-1787. [PubMed: 20056948]
130. Young LH, Wackers FJ, Chyun DA, Davey JA, Barrett EJ, Taillefer R, et al. Cardiac outcomes
after screening for asymptomatic coronary artery disease in patients with type 2 diabetes: the
DIAD study: a randomized controlled trial. JAMA. 2009;301(15):1547–55. Epub 2009/04/16.
doi: 301/15/1547 [pii] 10.1001/jama.2009.476 [doi]. [PubMed: 19366774]
131. Featherstone JF, Holly RG, Amsterdam EA. Physiologic responses to weight lifting in coronary
artery disease. Am J Cardiol. 1993;71(4):287–92. Epub 1993/02/01. [PubMed: 8427169]
132. Ghilarducci LE, Holly RG, Amsterdam EA. Effects of high resistance training in coronary artery
disease. Am J Cardiol. 1989;64(14):866–70. Epub 1989/10/15. [PubMed: 2801553]
133. Wenger NK, Froelicher ES, Smith LK, Ades PA, Berra K, Blumenthal JA, et al. Cardiac
Author Manuscript
rehabilitation as secondary prevention. Agency for Health Care Policy and Research and National
Heart, Lung, and Blood Institute. Clin Pract Guidel Quick Ref Guide Clin. 1995(17):1–23. Epub
1995/10/01.
134. Sigal RJ, Kenny GP, Wasserman DH, Castaneda-Sceppa C. Physical activity/exercise
and type 2 diabetes. Diabetes Care. 2004;27(10):2518–39. Epub 2004/09/29. doi: 10.2337/
diacare.27.10.2518. [PubMed: 15451933]
135. Kennedy JW, Hirshman MF, Gervino EV, Ocel JV, Forse RA, Hoenig SJ, et al. Acute exercise
induces GLUT4 translocation in skeletal muscle of normal human subjects and subjects with type
2 diabetes. Diabetes. 1999;48(5):1192–7. Epub 1999/05/20. doi: 10.2337/diabetes.48.5.1192.
[PubMed: 10331428]
136. Musi N, Fujii N, Hirshman MF, Ekberg I, Froberg S, Ljungqvist O, et al. AMP-activated protein
kinase (AMPK) is activated in muscle of subjects with type 2 diabetes during exercise. Diabetes.
2001;50(5):921–7. Epub 2001/05/04. doi: 10.2337/diabetes.50.5.921. [PubMed: 11334434]
137. Rosenstock J, Hassman DR, Madder RD, Brazinsky SA, Farrell J, Khutoryansky N, et al.
Author Manuscript
Repaglinide versus nateglinide monotherapy: a randomized, multicenter study. Diabetes Care.

2004;27(6):1265–70. Epub 2004/05/27. doi: 10.2337/diacare.27.6.1265. [PubMed: 15161773]
138. Larsen JJ, Dela F, Madsbad S, Vibe-Petersen J, Galbo H. Interaction of sulfonylureas and exercise
on glucose homeostasis in type 2 diabetic patients. Diabetes Care. 1999;22(10):1647–54. Epub
1999/10/20. doi: 10.2337/diacare.22.10.1647. [PubMed: 10526729]
139. Riddell MC, Gallen IW, Smart CE, Taplin CE, Adolfsson P, Lumb AN, et al.
Exercise management in type 1 diabetes: a consensus statement. Lancet Diabetes
Endocrinol. 2017;5(5):377–90. Epub 2017/01/28. doi: 10.1016/S2213-8587(17)30014-1.
[PubMed: 28126459]
140. Gordon BA, Bird SR, MacIsaac RJ, Benson AC. Does a single bout of resistance or
aerobic exercise after insulin dose reduction modulate glycaemic control in type 2 diabetes?
Author Manuscript
A randomised cross-over trial. J Sci Med Sport. 2016. Epub 2016/02/26. doi: 10.1016/
j.jsams.2016.01.004.
141. Kjaer M, Hollenbeck CB, Frey-Hewitt B, Galbo H, Haskell W, Reaven GM. Glucoregulation
and hormonal responses to maximal exercise in non-insulin-dependent diabetes. J Appl Physiol.
1990;68(5):2067–74. Epub 1990/05/01. [PubMed: 2193907]
142. Hernandez-Quiles C, Ramirez-Duque N, Acosta-Delgado D. Ketoacidosis Due to Empagliflozin,
a Paradigm Shift: Case Report and Review of Literature. Curr Diabetes Rev. 2019;15(4):259–62.
Epub 2018/07/27. doi: 10.2174/1573399814666180726114044. [PubMed: 30047331]
143. Notley SR, Poirier MP, Hardcastle SG, Flouris AD, Boulay P, Sigal RJ, et al. Aging Impairs
Whole-Body Heat Loss in Women under Both Dry and Humid Heat Stress. Med Sci Sports
Exerc. 2017;49(11):2324–32. Epub 2017/10/19. doi: 10.1249/mss.0000000000001342. [PubMed:
29045327]
144. Poirier MP, Notley SR, Boulay P, Sigal RJ, Friesen BJ, Malcolm J, et al. Type 2
diabetes does not exacerbate body heat storage in older adults during brief, extreme
Author Manuscript
passive heat exposure. Temperature (Austin). 2020;7(3):263–9. Epub 2020/10/31. doi:

10.1080/23328940.2020.1736760. [PubMed: 33123619]
145. Notley SR, Poirier MP, Sigal RJ, D’Souza A, Flouris AD, Fujii N, et al. Exercise heat stress in
patients with and without Type 2 Diabetes. Jama. 2019;322(14):1409–11. Epub 2019/10/09. doi:
10.1001/jama.2019.10943. [PubMed: 31593261]
146. Kenny GP, Stapleton JM, Yardley JE, Boulay P, Sigal RJ. Older adults with type 2 diabetes store
more heat during exercise. Med Sci Sports Exerc. 2013;45(10):1906–14. Epub 2013/04/02. doi:
10.1249/MSS.0b013e3182940836. [PubMed: 23542894]
147. Layton JB, Li W, Yuan J, Gilman JP, Horton DB, Setoguchi S. Heatwaves, medications,
and heat-related hospitalization in older Medicare beneficiaries with chronic conditions. PLoS
One. 2020;15(12):e0243665. Epub 2020/12/11. doi: 10.1371/journal.pone.0243665. [PubMed:
33301532]
148. de Lemos Muller CH, Rech A, Botton CE, Schroeder HT, Bock PM, Farinha JB, et al. Heat-
induced extracellular HSP72 release is blunted in elderly diabetic people compared with healthy
middle-aged and older adults, but it is partially restored by resistance training. Exp Gerontol.
Author Manuscript
2018;111:180–7. Epub 2018/07/28. doi: 10.1016/j.exger.2018.07.014. [PubMed: 30053413]

149. Macartney MJ, Notley SR, Herry CL, Sigal RJ, Boulay P, Kenny GP. Effect of exercise-heat
acclimation on cardiac autonomic modulation in type 2 diabetes: a pilot study. Appl Physiol
Nutr Metab. 2021;46(3):284–7. Epub 2020/11/18. doi: 10.1139/apnm-2020-0785. [PubMed:
33201735]
150. 11. Microvascular Complications and Foot Care: Standards of Medical Care in Diabetes-2021.
Diabetes Care. 2021;44(Suppl 1):S151–s67. Epub 2020/12/11. doi: 10.2337/dc21-S011.
[PubMed: 33298422]
151. 10. Cardiovascular Disease and Risk Management: Standards of Medical Care in Diabetes-2021.
Diabetes Care. 2021;44(Suppl 1):S125–s50. Epub 2020/12/11. doi: 10.2337/dc21-S010.
[PubMed: 33298421]
152. Rossboth S, Lechleitner M, Oberaigner W. Risk factors for diabetic foot complications in type 2
diabetes-A systematic review. Endocrinol Diabetes Metab. 2021;4(1):e00175. Epub 2021/02/04.
doi: 10.1002/edm2.175. [PubMed: 33532615]
Author Manuscript
153. Biswas A, Oh PI, Faulkner GE, Bajaj RR, Silver MA, Mitchell MS, et al. Sedentary time and its
association with risk for disease incidence, mortality, and hospitalization in adults: a systematic
review and meta-analysis. Ann Intern Med. 2015;162(2):123–32. Epub 2015/01/20. doi: 10.7326/
m14-1651. [PubMed: 25599350]
154. Wilmot EG, Edwardson CL, Achana FA, Davies MJ, Gorely T, Gray LJ, et al. Sedentary
time in adults and the association with diabetes, cardiovascular disease and death: systematic
review and meta-analysis. Diabetologia. 2012;55(11):2895–905. Epub 2012/08/15. doi: 10.1007/
s00125-012-2677-z. [PubMed: 22890825]
155. Riebe D, Franklin BA, Thompson PD, Garber CE, Whitfield GP, Magal M, et al. Updating
ACSM’s Recommendations for Exercise Preparticipation Health Screening. Med Sci Sports
Exerc. 2015;47(11):2473–9. Epub 2015/10/17. doi: 10.1249/mss.0000000000000664. [PubMed:

26473759]
Author Manuscript
156. Derave W, Mertens A, Muls E, Pardaens K, Hespel P. Effects of post-absorptive and postprandial
exercise on glucoregulation in metabolic syndrome. Obesity (Silver Spring). 2007;15(3):704–11.
Epub 2007/03/21. doi: 10.1038/oby.2007.548. [PubMed: 17372321]
157. Larsen JJ, Dela F, Madsbad S, Galbo H. The effect of intense exercise on postprandial glucose
homeostasis in type II diabetic patients. Diabetologia. 1999;42(11):1282–92. doi: 10.1007/
s001250051440. [PubMed: 10550411]
158. Poirier P, Mawhinney S, Grondin L, Tremblay A, Broderick T, Cleroux J, et al. Prior meal
enhances the plasma glucose lowering effect of exercise in type 2 diabetes. Med Sci Sports
Exerc. 2001;33(8):1259–64. [PubMed: 11474324]
159. Terada T, Wilson BJ, Myette-Cote E, Kuzik N, Bell GJ, McCargar LJ, et al. Targeting
specific interstitial glycemic parameters with high-intensity interval exercise and fasted-state
exercise in type 2 diabetes. Metabolism. 2016;65(5):599–608. Epub 2016/04/18. doi: 10.1016/
j.metabol.2016.01.003. [PubMed: 27085769]
160. Teo SYM, Kanaley JA, Guelfi KJ, Marston KJ, Fairchild TJ. The Effect of Exercise Timing
Author Manuscript
on Glycemic Control: A Randomized Clinical Trial. Med Sci Sports Exerc. 2020;52(2):323–34.
Epub 2019/09/04. doi: 10.1249/MSS.0000000000002139. [PubMed: 31479004]
161. Colberg SR, Zarrabi L, Bennington L, Nakave A, Thomas Somma C, Swain DP, et al.
Postprandial walking is better for lowering the glycemic effect of dinner than pre-dinner
exercise in type 2 diabetic individuals. Journal of the American Medical Directors Association.
2009;10(6):394–7. doi: 10.1016/j.jamda.2009.03.015. [PubMed: 19560716]
162. Heden TD, Winn NC, Mari A, Booth FW, Rector RS, Thyfault JP, et al. Postdinner resistance
exercise improves postprandial risk factors more effectively than predinner resistance exercise
in patients with type 2 diabetes. Journal of applied physiology. 2015;118(5):624–34. Epub
2014/12/30. doi: 10.1152/japplphysiol.00917.2014. [PubMed: 25539939]
163. USDA, Services HaH. Dietary Guidelines for Americans, 2020–2025. 9th ed December 2020.
164. van der Schaft N, Schoufour JD, Nano J, Kiefte-de Jong JC, Muka T, Sijbrands EJG, et
al. Dietary antioxidant capacity and risk of type 2 diabetes mellitus, prediabetes and insulin
resistance: the Rotterdam Study. Eur J Epidemiol. 2019;34(9):853–61. Epub 2019/08/11. doi:
10.1007/s10654-019-00548-9. [PubMed: 31399939]
Author Manuscript
165. Feinman RD, Pogozelski WK, Astrup A, Bernstein RK, Fine EJ, Westman EC, et al.
Dietary carbohydrate restriction as the first approach in diabetes management: critical review
and evidence base. Nutrition (Burbank, Los Angeles County, Calif). 2015;31(1):1–13. Epub
2014/07/16. doi: 10.1016/j.nut.2014.06.011.
166. Lennerz BS, Koutnik AP, Azova S, Wolfsdorf JI, Ludwig DS. Carbohydrate restriction for
diabetes: rediscovering centuries-old wisdom. J Clin Invest. 2021;131(1). Epub 2021/01/05. doi:
10.1172/jci142246.
167. Kirk JK, Graves DE, Craven TE, Lipkin EW, Austin M, Margolis KL. Restricted-carbohydrate
diets in patients with type 2 diabetes: a meta-analysis. J Am Diet Assoc. 2008;108(1):91–100.
Epub 2007/12/25. doi: 10.1016/j.jada.2007.10.003. [PubMed: 18155993]
168. Powers MA, Bardsley J, Cypress M, Duker P, Funnell MM, Fischl AH, et al. Diabetes
Self-Management Education and Support in Type 2 Diabetes: A Joint Position Statement of
the American Diabetes Association, the American Association of Diabetes Educators, and the
Academy of Nutrition and Dietetics. J Acad Nutr Diet. 2015;115(8):1323–34. Epub 2015/06/10.
Author Manuscript
doi: 10.1016/j.jand.2015.05.012. [PubMed: 26054423]

169. Chester B, Babu JR, Greene MW, Geetha T. The effects of popular diets on type 2 diabetes
management. Diabetes Metab Res Rev. 2019;35(8):e3188. Epub 2019/05/24. doi: 10.1002/
dmrr.3188. [PubMed: 31121637]
170. Paoli A, Rubini A, Volek JS, Grimaldi KA. Beyond weight loss: a review of the therapeutic
uses of very-low-carbohydrate (ketogenic) diets. Eur J Clin Nutr. 2013;67(8):789–96. Epub
2013/06/27. doi: 10.1038/ejcn.2013.116. [PubMed: 23801097]
171. Burke LM. Re-Examining High-Fat Diets for Sports Performance: Did We Call the ‘Nail in
the Coffin’ Too Soon? Sports Med. 2015;45 Suppl 1(Suppl 1):S33–49. Epub 2015/11/11. doi:
Author Manuscript
10.1007/s40279-015-0393-9. [PubMed: 26553488]

172. McSwiney FT, Wardrop B, Hyde PN, Lafountain RA, Volek JS, Doyle L. Keto-adaptation
enhances exercise performance and body composition responses to training in endurance
athletes. Metabolism: clinical and experimental. 2018;81:25–34. Epub 2017/11/03. doi: 10.1016/
j.metabol.2017.10.010. [PubMed: 29108901]
173. Wroble KA, Trott MN, Schweitzer GG, Rahman RS, Kelly PV, Weiss EP. Low-carbohydrate,
ketogenic diet impairs anaerobic exercise performance in exercise-trained women and men:
a randomized-sequence crossover trial. J Sports Med Phys Fitness. 2019;59(4):600–7. Epub
2018/04/06. doi: 10.23736/s0022-4707.18.08318-4. [PubMed: 29619799]
174. Sharoff CG, Hagobian TA, Malin SK, Chipkin SR, Yu H, Hirshman MF, et al. Combining
short-term metformin treatment and one bout of exercise does not increase insulin action
in insulin-resistant individuals. Am J Physiol Endocrinol Metab. 2010;298(4):E815–23. Epub
2010/01/15. doi: 10.1152/ajpendo.00517.2009. [PubMed: 20071560]
175. Malin SK, Gerber R, Chipkin SR, Braun B. Independent and combined effects of exercise
Author Manuscript
training and metformin on insulin sensitivity in individuals with prediabetes. Diabetes Care.
2012;35(1):131–6. Epub 2011/11/02. doi: dc11-0925 [pii] 10.2337/dc11-0925 [doi]. [PubMed:
22040838]
176. Boule NG, Robert C, Bell GJ, Johnson ST, Bell RC, Lewanczuk RZ, et al. Metformin
and exercise in type 2 diabetes: examining treatment modality interactions. Diabetes Care.
2011;34(7):1469–74. Epub 2011/05/24. doi: dc10-2207 [pii] 10.2337/dc10-2207 [doi]. [PubMed:
21602430]
177. Hällsten K, Virtanen KA, Lönnqvist F, Sipilä H, Oksanen A, Viljanen T, et al. Rosiglitazone
but not metformin enhances insulin-and exercise-stimulated skeletal muscle glucose uptake
in patients with newly diagnosed type 2 diabetes. Diabetes. 2002;51(12):3479–85. Epub
2002/11/28. doi: 10.2337/diabetes.51.12.3479. [PubMed: 12453903]
178. Ortega JF, Morales-Palomo F, Ramirez-Jimenez M, Moreno-Cabañas A, Mora-Rodríguez R.
Exercise improves metformin 72-h glucose control by reducing the frequency of hyperglycemic
peaks. Acta Diabetol. 2020;57(6):715–23. Epub 2020/02/06. doi: 10.1007/s00592-020-01488-7.
[PubMed: 32020414]
Author Manuscript
179. Konopka AR, Laurin JL, Schoenberg HM, Reid JJ, Castor WM, Wolff CA, et al. Metformin
inhibits mitochondrial adaptations to aerobic exercise training in older adults. Aging Cell.
2019;18(1):e12880. Epub 2018/12/15. doi: 10.1111/acel.12880. [PubMed: 30548390]
180. Walton RG, Dungan CM, Long DE, Tuggle SC, Kosmac K, Peck BD, et al. Metformin blunts
muscle hypertrophy in response to progressive resistance exercise training in older adults: A
randomized, double-blind, placebo-controlled, multicenter trial: The MASTERS trial. Aging
Cell. 2019;18(6):e13039. Epub 2019/09/27. doi: 10.1111/acel.13039. [PubMed: 31557380]
181. Malin SK, Stewart NR. Metformin may contribute to inter-individual variability for glycemic
responses to exercise. Front Endocrinol (Lausanne). 2020;11:519. Epub 2020/08/28. doi:
10.3389/fendo.2020.00519. [PubMed: 32849302]
182. Mensberg P, Nyby S, Jørgensen PG, Storgaard H, Jensen MT, Sivertsen J, et al. Near-
normalization of glycaemic control with glucagon-like peptide-1 receptor agonist treatment
combined with exercise in patients with type 2 diabetes. Diabetes Obes Metab. 2017;19(2):172–
80. Epub 2016/11/05. doi: 10.1111/dom.12797. [PubMed: 27717126]
183. van Dijk JW, Tummers K, Stehouwer CD, Hartgens F, van Loon LJ. Exercise therapy in
Author Manuscript
type 2 diabetes: is daily exercise required to optimize glycemic control? Diabetes Care.
2012;35(5):948–54. doi: 10.2337/dc11-2112. [PubMed: 22399700]
184. Sigal RJ, Fisher SJ, Halter JB, Vranic M, Marliss EB. Glucoregulation during and after intense
exercise: effects of beta-adrenergic blockade in subjects with type 1 diabetes mellitus. J Clin
Endocrinol Metab. 1999;84(11):3961–71. Epub 1999/11/24. [PubMed: 10566635]
185. de Muinck ED, Lie KI. Safety and efficacy of beta-blockers in the treatment of stable angina
pectoris. J Cardiovasc Pharmacol. 1990;16 Suppl 5:S123–8. Epub 1990/01/01.
186. Colberg SR, Swain DP, Vinik AI. Use of heart rate reserve and rating of perceived exertion to
prescribe exercise intensity in diabetic autonomic neuropathy. Diabetes Care. 2003;26(4):986–90.
Author Manuscript
[PubMed: 12663561]
187. Nichols GA, Koro CE. Does statin therapy initiation increase the risk for myopathy? An
observational study of 32,225 diabetic and nondiabetic patients. Clin Ther. 2007;29(8):1761–
70. Epub 2007/10/09. doi: S0149-2918(07)00257-3 [pii] 10.1016/j.clinthera.2007.08.022 [doi].
[PubMed: 17919557]
188. Mingrone G, Panunzi S, De Gaetano A, Guidone C, Iaconelli A, Capristo E, et al. Metabolic
surgery versus conventional medical therapy in patients with type 2 diabetes: 10-year follow-
up of an open-label, single-centre, randomised controlled trial. Lancet. 2021;397:293–304.
[PubMed: 33485454]
189. Schauer PR, Bhatt DL, Kirwan JP, Wolski K, Aminian A, Brethauer SA, et al. Bariatric
Surgery versus Intensive Medical Therapy for Diabetes - 5-Year Outcomes. N Engl J Med.
2017;376(7):641–51. Epub 2017/02/16. doi: 10.1056/NEJMoa1600869. [PubMed: 28199805]
190. Bond DS, Jakicic JM, Unick JL, Vithiananthan S, Pohl D, Roye GD, et al. Pre- to postoperative
physical activity changes in bariatric surgery patients: self report vs. objective measures. Obesity
Author Manuscript
(Silver Spring). 2010;18(12):2395–7. Epub 2010/04/10. doi: 10.1038/oby.2010.88. [PubMed:

20379143]
191. Gilbertson NM, Gaitán JM, Osinski V, Rexrode EA, Garmey JC, Mehaffey JH, et al. Pre-
operative aerobic exercise on metabolic health and surgical outcomes in patients receiving
bariatric surgery: A pilot trial. PLoS One. 2020;15(10):e0239130. Epub 2020/10/03. doi:
10.1371/journal.pone.0239130. [PubMed: 33006980]
192. Gilbertson NM, Eichner NZM, Khurshid M, Rexrode EA, Kranz S, Weltman A, et al. Impact
of pre-operative aerobic exercise on cardiometabolic health and quality of life in patients
undergoing bariatric surgery. Front Physiol. 2020;11:1018. Epub 2020/09/29. doi: 10.3389/
fphys.2020.01018. [PubMed: 32982777]
193. Baillot A, Mampuya WM, Dionne IJ, Comeau E, Méziat-Burdin A, Langlois MF. Impacts of
supervised exercise training in addition to interdisciplinary lifestyle management in subjects
awaiting bariatric surgery: a randomized controlled study. Obes Surg. 2016;26(11):2602–10.
Epub 2016/10/21. doi: 10.1007/s11695-016-2153-9. [PubMed: 27038045]
194. Berglind D, Willmer M, Eriksson U, Thorell A, Sundbom M, Uddén J, et al. Longitudinal
Author Manuscript
assessment of physical activity in women undergoing Roux-en-Y gastric bypass. Obes Surg.
2015;25(1):119–25. Epub 2014/06/18. doi: 10.1007/s11695-014-1331-x. [PubMed: 24934315]
195. Coen PM, Tanner CJ, Helbling NL, Dubis GS, Hames KC, Xie H, et al. Clinical trial
demonstrates exercise following bariatric surgery improves insulin sensitivity. J Clin Invest.
2015;125(1):248–57. Epub 2014/12/02. doi: 10.1172/JCI78016. [PubMed: 25437877]
196. Dantas WS, Roschel H, Murai IH, Gil S, Davuluri G, Axelrod CL, et al. Exercise-induced
increases in insulin sensitivity after bariatric surgery are mediated by muscle extracellular
matrix remodeling. Diabetes. 2020;69(8):1675–91. Epub 2020/05/16. doi: 10.2337/db19-1180.
[PubMed: 32409493]
197. Mundbjerg LH, Stolberg CR, Cecere S, Bladbjerg EM, Funch-Jensen P, Gram B, et al. Supervised
physical training improves weight loss after Roux-en-Y gastric bypass surgery: a randomized
controlled trial. Obesity (Silver Spring). 2018;26(5):828–37. Epub 2018/03/23. doi: 10.1002/
oby.22143.. [PubMed: 29566463]
198. Dantas W, Gil S, Hisashi Murai I, Costa-Hong V, Peçanha T, Abujabra Merege-Filho C, et al.
Reversal of improved endothelial function after bariatric surgery is mitigated by exercise training.
Author Manuscript
Journal of the American College of Cardiology 2018;72:2278–9. [PubMed: 30360835]

199. Gil S, Pecanha T, Dantas WS, Murai IH, Merege-Filho CAA, de Sa-Pinto AL, et al. Exercise
enhances the effect of bariatric surgery in markers of cardiac autonomic function. Obes Surg.
2021;31(3):1381–6. Epub 2020/10/29. doi: 10.1007/s11695-020-05053-7. [PubMed: 33111247]
200. Oppert JM, Bellicha A, Roda C, Bouillot JL, Torcivia A, Clement K, et al. Resistance training
and protein supplementation increase strength after bariatric surgery: a randomized controlled
trial. Obesity (Silver Spring). 2018;26(11):1709–20. Epub 2018/10/26. doi: 10.1002/oby.22317.
[PubMed: 30358153]
201. Diniz-Sousa F, Veras L, Boppre G, Sa-Couto P, Devezas V, Santos-Sousa H, et al. The effect of an
exercise intervention program on bone health after bariatric Surgery: a randomized controlled
Author Manuscript
trial. J Bone Miner Res. 2021;36(3):489–99. Epub 2020/12/10. doi: 10.1002/jbmr.4213.

[PubMed: 33295063]
202. Murai IH, Roschel H, Dantas WS, Gil S, Merege-Filho C, de Cleva R, et al. Exercise
mitigates bone loss in women with severe obesity after Roux-en-Y gastric bypass: a randomized
controlled trial. J Clin Endocrinol Metab. 2019;104(10):4639–50. Epub 2019/07/20. doi:
10.1210/jc.2019-00074. [PubMed: 31322672]
203. Coates PS, Fernstrom JD, Fernstrom MH, Schauer PR, Greenspan SL. Gastric bypass surgery
for morbid obesity leads to an increase in bone turnover and a decrease in bone mass. J
Clin Endocrinol Metab. 2004;89(3):1061–5. Epub 2004/03/06. doi: 10.1210/jc.2003-031756.
[PubMed: 15001587]
204. Yu EW. Bone metabolism after bariatric surgery. J Bone Miner Res. 2014;29(7):1507–18. Epub
2014/03/29. doi: 10.1002/jbmr.2226. [PubMed: 24677277]
205. Ott MT, Fanti P, Malluche HH, Ryo UY, Whaley FS, Strodel WE, et al. Biochemical Evidence
of metabolic bone disease in women following Roux-Y gastric bypass for morbid Obesity.
Author Manuscript
Obes Surg. 1992;2(4):341–8. Epub 1992/11/01. doi: 10.1381/096089292765559936. [PubMed:

10765194]
206. Tang MY, Smith DM, Mc Sharry J, Hann M, French DP. Behavior change techniques associated
with changes in postintervention and maintained changes in self-efficacy for physical activity: A
Systematic Review With Meta-analysis. Ann Behav Med. 2019;53(9):801–15. Epub 2018/12/12.
doi: 10.1093/abm/kay090. [PubMed: 30534971]
207. Takahashi PY, Quigg SM, Croghan IT, Schroeder DR, Ebbert JO. SMART goals setting
and biometric changes in obese adults with multimorbidity: Secondary analysis of a
randomized controlled trial. SAGE Open Med. 2019;7:2050312119858042. Epub 2019/07/02.
doi: 10.1177/2050312119858042. [PubMed: 31258905]
208. Karmeniemi M, Lankila T, Ikaheimo T, Koivumaa-Honkanen H, Korpelainen R. The built
environment as a determinant of physical activity: a systematic review of longitudinal studies and
natural experiments. Ann Behav Med. 2018;52(3):239–51. doi: 10.1093/abm/kax043. [PubMed:
29538664]
209. Morowatisharifabad MA, Abdolkarimi M, Asadpour M, Fathollahi MS, Balaee P. Study on
Author Manuscript
social support for exercise and its impact on the level of physical activity of patients with Type
2 Diabetes. Open Access Maced J Med Sci. 2019;7(1):143–7. Epub 2019/02/12. doi: 10.3889/
oamjms.2019.016. [PubMed: 30740179]
210. Schmidt SK, Hemmestad L, MacDonald CS, Langberg H, Valentiner LS. Motivation and barriers
to maintaining lifestyle changes in patients with Type 2 Diabetes after an intensive lifestyle
intervention (The U-TURN Trial): a longitudinal qualitative study. Int J Environ Res Public
Health. 2020;17(20). Epub 2020/10/18. doi: 10.3390/ijerph17207454.
211. Wycherley TP, Mohr P, Noakes M, Clifton PM, Brinkworth GD. Self-reported facilitators
of, and impediments to maintenance of healthy lifestyle behaviours following a supervised
research-based lifestyle intervention programme in patients with type 2 diabetes. Diabet
Med. 2012;29(5):632–9. Epub 2011/09/16. doi: 10.1111/j.1464-5491.2011.03451.x. [PubMed:
21916973]
212. Whitfield GP, Carlson SA, Ussery EN, Fulton JE, Galuska DA, Petersen R. Trends in
meeting physical activity guidelines among urban and rural dwelling adults - United States,
2008-2017. MMWR Morb Mortal Wkly Rep. 2019;68(23):513–8. Epub 2019/06/14. doi:
Author Manuscript
10.15585/mmwr.mm6823a1. [PubMed: 31194722]

213. Hammer NM, Bieler T, Beyer N, Midtgaard J. The impact of self-efficacy on physical activity
maintenance in patients with hip osteoarthritis - a mixed methods study. Disabil Rehabil.
2016;38(17):1691–704. Epub 2015/12/19. doi: 10.3109/09638288.2015.1107642. [PubMed:
26677724]
214. Cerin E, Nathan A, van Cauwenberg J, Barnett DW, Barnett A. The neighbourhood physical
environment and active travel in older adults: a systematic review and meta-analysis. Int J Behav
Nutr Phys Act. 2017;14(1):15. doi: 0.1186/s12966-017-0471-5. [PubMed: 28166790]
215. den Braver NR, Lakerveld J, Rutters F, Schoonmade LJ, Brug J, Beulens JWJ. Built
environmental characteristics and diabetes: a systematic review and meta-analysis. BMC Med.
Author Manuscript
2018;16(1):12. doi: 0.1186/s12916-017-0997-z. [PubMed: 29382337]

216. Aljasem LI, Peyrot M, Wissow L, Rubin RR. The impact of barriers and self-efficacy on self-care
behaviors in type 2 diabetes. Diabetes Educator. 2001;27(3):393–404. Epub 2002/03/27.
217. Dutton GR, Tan F, Provost BC, Sorenson JL, Allen B, Smith D. Relationship between self-
efficacy and physical activity among patients with type 2 diabetes. Journal of Behavioral
Medicine. 2009;32(3):270–7. Epub 2009/01/22. doi: 10.1007/s10865-009-9200-0. [PubMed:
19156510]
218. McAuley E, Blissmer B. Self-efficacy determinants and consequences of physical activity. Exerc
Sport Sci Rev. 2000;28(2):85–8. [PubMed: 10902091]
219. Armit CM, Brown WJ, Marshall AL, Ritchie CB, Trost SG, Green A, et al. Randomized
trial of three strategies to promote physical activity in general practice. Preventive
Medicine. 2009;48(2):156–63. Epub 2008/12/23. doi: S0091-7435(08)00620-8 [pii] 10.1016/
j.ypmed.2008.11.009. [PubMed: 19100282]
220. Balducci S, Zanuso S, Fernando F, Nicolucci A, Cardelli P, Cavallo S, et al. The Italian diabetes
Author Manuscript
and exercise study. Diabetes. 2008;57(Suppl. 1):A306–A7.

221. Statistics NCfH. Health, United States, 2018. Hyattsville, MD 2019.
222. Saffer H, Dave D, Grossman M, Leung LA. Racial, ethnic, and gender differences in physical
activity. J Hum Cap. 2013;7(4):378–410. Epub 2013/01/01. doi: 10.1086/671200. [PubMed:
25632311]
223. Moore LV, Harris CD, Carlson SA, Kruger J, Fulton JE. Trends in no leisure-time physical
activity--United States, 1988–2010. Res Q Exerc Sport. 2012;83(4):587–91. Epub 2013/02/02.
doi: 10.1080/02701367.2012.10599884. [PubMed: 23367822]
224. QuickStats: Percentage of Adults Who Met Federal Guidelines for Aerobic Physical Activity
Through Leisure-Time Activity,* by Race/Ethnicity - National Health Interview Survey,(†)
2008-2017. MMWR Morb Mortal Wkly Rep. 2019;68(12):292. Epub 2019/03/29. doi: 10.15585/
mmwr.mm6812a6. [PubMed: 30921300]
225. Gray CL, Messer LC, Rappazzo KM, Jagai JS, Grabich SC, Lobdell DT. The association
between physical inactivity and obesity is modified by five domains of environmental quality
in U.S. adults: A cross-sectional study. PLoS One. 2018;13(8):e0203301. Epub 2018/08/31. doi:
Author Manuscript
10.1371/journal.pone.0203301. [PubMed: 30161196]

226. Hawes AM, Smith GS, McGinty E, Bell C, Bower K, LaVeist TA, et al. Disentangling race,
poverty, and place in disparities in physical activity. Int J Environ Res Public Health. 2019;16(7).
Epub 2019/04/17. doi: 10.3390/ijerph16071193.
227. Chien LC, Li X, Staudt A. Physical inactivity displays a mediator role in the association
of diabetes and poverty: A spatiotemporal analysis. Geospat Health. 2017;12(2):528. Epub
2017/12/15. doi: 10.4081/gh.2017.528. . [PubMed: 29239550]
228. Hunter RF, Christian H, Veitch J, Astell-Burt T, Hipp JA, Schipperijn J. The impact of
interventions to promote physical activity in urban green space: a systematic review and
recommendations for future research. Soc Sci Med. 2015;124:246–56. Epub 2014/12/03. doi:
10.1016/j.socscimed.2014.11.051. [PubMed: 25462429]
229. Kershaw KN, Pender AE. Racial/ethnic residential segregation, obesity, and diabetes mellitus.
Current diabetes reports. 2016;16(11):108. Epub 2016/09/25. doi: 10.1007/s11892-016-0800-0.
[PubMed: 27664041]
Author Manuscript
230. Kuo M How might contact with nature promote human health? Promising mechanisms
and a possible central pathway. Front Psychol. 2015;6:1093. Epub 2015/09/18. doi: 10.3389/
fpsyg.2015.01093. [PubMed: 26379564]
231. Prevention CfDCa. Status Report for Step It Up! The Surgeon General’s Call to Action to
Promote Walking and Walkable Communities. US Dept of Health and Human Services; 2017.
232. Thornton PL, Kumanyika SK, Gregg EW, Araneta MR, Baskin ML, Chin MH, et al.
New research directions on disparities in obesity and type 2 diabetes. Annals of the New
York Academy of Sciences. 2020;1461(1):5–24. Epub 2019/12/04. doi: 10.1111/nyas.14270.
[PubMed: 31793006]
233. Drewnowski A, Arterburn D, Zane J, Aggarwal A, Gupta S, Hurvitz PM, et al. The Moving to
Health (M2H) approach to natural experiment research: A paradigm shift for studies on built
Author Manuscript
environment and health. SSM Popul Health. 2019;7:100345. Epub 2019/01/19. doi: 10.1016/
j.ssmph.2018.100345. [PubMed: 30656207]
234. Auchincloss AH, Diez Roux AV, Mujahid MS, Shen M, Bertoni AG, Carnethon MR.
Neighborhood resources for physical activity and healthy foods and incidence of type 2 diabetes
mellitus: the Multi-Ethnic study of Atherosclerosis. Arch Intern Med. 2009;169(18):1698–704.
Epub 2009/10/14. doi: 10.1001/archinternmed.2009.302. [PubMed: 19822827]
235. Ludwig J, Sanbonmatsu L, Gennetian L, Adam E, Duncan GJ, Katz LF, et al. Neighborhoods,
obesity, and diabetes--a randomized social experiment. N Engl J Med. 2011;365(16):1509–19.
Epub 2011/10/21. doi: 10.1056/NEJMsa1103216. [PubMed: 22010917]
236. Diabetes Canada. The Built Environment and Diabetes: A Position Statement. Ottawa,
2020. https://www.diabetes.ca/advocacy---policies/our-policy-positions/the-built-environment-
and-diabetes
Author Manuscript
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Box:
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 physical activity 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% appears 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 days a week is needed.
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• 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 physical activity goals set for youth in the general population.
• Pregnant women with and without diabetes should participate in at least 20–30 minutes 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 prior to bariatric surgery may enhance surgical outcomes, and after
surgery participation confers additional benefits.
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Table 1:
Physical Activity Guidelines for All Americans (2018) (91, 92)

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Adults Move more and sit less throughout the day. Some physical activity is better than none.
For substantial health benefits, do at least 150 min (2 h, 30 min) to 300 min (5 h) a week of moderate-intensity, or
75 min (1 h, 15 min) to 150 min (2 h, 30 min) a week of vigorous-intensity aerobic physical activity, or an equivalent
combination of moderate- and vigorous-intensity aerobic activity, preferably spread throughout the week.
Additional health benefits are gained by engaging beyond the equivalent of 300 min (5 h) of moderate-intensity physical
activity weekly.
Perform muscle-strengthening activities of moderate or greater intensity and that involve all major muscle groups on 2 or
more days/week.
Older Adults The guidelines for healthy older adults are the same as those for all adults.
In addition, as part of weekly physical activity, do multicomponent physical activity that includes balance training as
well as aerobic and muscle-strengthening activities.
Determine level of effort for physical activity relative to the level of fitness.
With chronic conditions, understand whether and how the conditions affect the ability to do regular physical activity
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safely.
If an individual cannot do 150 min of moderate-intensity aerobic activity a week because of chronic conditions, engage
in as much physical activity as abilities and conditions allow.
Children and Preschool-aged children (ages 3 through 5 y) should be physically active throughout the day to enhance growth and
Adolescents development.
Adult caregivers of preschool-aged children should encourage active play that includes a variety of activity types.
Provide young people opportunities and encouragement to participate in physical activity appropriate for their age, that
are enjoyable, and that offer variety.
Children and adolescents ages 6 through 17

years should engage in 60 min (1 h) or more of moderate-to-vigorous
physical activity daily:
• Aerobic: Most of the 60
min or more per day should be either moderate-or vigorous-intensity
aerobic physical activity and should include vigorous-intensity physical
activity on at least 3 d/wk.
•
Muscle-strengthening: As part of 60 min or more of daily physical
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activity, include muscle-strengthening activities on at least 3

d/wk.
• Bone-strengthening: As part of 60 min or
more of daily physical activity, include weight-bearing exercise to
strengthen bones at least 3 d/wk.
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Table 2.
Recommended Types of Exercise Training for All Adults with Type 2 Diabetes
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Type of
Training Type Intensity Frequency Duration Progression
Aerobic Walking, jogging, 40%-59% of VO2R 3-7 d/wk, with no Minimum of 150 to Rate of progression
cycling, swimming, or HRR more than 2 300 min/wk of moderate depends on baseline
aquatic activities, (moderate), RPE consecutive days activity or 75 to fitness, age, weight, health
rowing, dancing, 11-12; or between bouts of 150 min of vigorous status, and individual
interval training 60%-89% of VO2R activity activity, or an equivalent goals; gradual progression
or HRR (vigorous), combination thereof of both intensity and
RPE 14-17 volume is recommended
Resistance Free weights, Moderate at 2-3 d/wk, but never 10-15 repetitions per set, As tolerated; increase
machines, elastic 50%-69% of 1- on consecutive 1-3 sets per type of resistance first, followed
bands, or body RM, or vigorous at days specific exercise by a greater number of
weight as resistance; 70%-85% of 1-RM sets, and then increased
undertake 8-10 training frequency
exercises involving
the major muscle
groups
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Flexibility Static, dynamic, Stretch to the point ≥2-3 d/wk or more; 10-30 s per As tolerated; may increase
or PNF stretching; of tightness or usually done with stretch (static or range of stretch as long as
balance exercises; slight discomfort when muscles and dynamic)group; 2-4 not painful
yoga and tai chi joints are warmed repetitions of each
increase range of up
motion
Balance Balance exercises: No set intensity ≥2-3 d/wk or more No set duration As tolerated; balance
lower body and core training should be done
resistance exercises, carefully to minimize the
yoga, and tai chi also risk of falls
improve balance
Note: VO2R, VO2 reserve; HRR, heart rate reserve; 1-RM, 1-repetition maximum; RPE, rating of perceived exertion; PNF, proprioceptive
neuromotor facilitation.
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Table 3:
Indications for Pre-Participation Exercise Stress Testing

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In general, maximal graded exercise stress testing may be indicated for adults matching one or more of these criteria:
• Age > 40 y, with or without cardiovascular disease risk factors other than diabetes
• Age > 30 y
and
○ Type 1 or type 2 diabetes
>10 y duration
○
Hypertension
○ Cigarette
smoking
○
Dyslipidemia
○ Proliferative or
preproliferative retinopathy
○
Nephropathy including microalbuminuria
• Any of the following,
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regardless of age
○ Known of
suspected cardiovascular, coronary artery, or peripheral artery
disease
○Autonomic
neuropathy
○ Advanced nephropathy
with renal failure
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Table 4:
General Exercise Training Considerations and Precautions

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Medical clearance (and exercise testing) prior to starting activities more vigorous than brisk walking is recommended for adults with signs or
symptoms of cardiovascular disease, longer diabetes duration, older age, or other diabetes-related complications (95).
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 (95, 139).
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 physical activity), 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).
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Table 5.
Physical Activity Precautions for Common Comorbid Health Complications

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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
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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
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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
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maximal heart rate, use of RPE is recommended (10 to 12 on a 6-20

scale).

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Exercise/Physical Activity in Individuals with Type 2 Diabetes:

2Human Movement Sciences Department, Old Dominion University, Norfolk, VA

Impact of Exercise/PA on Diabetes Management and Health Risks

Aerobic exercise training

Resistance exercise training

Combined exercise training

High-Intensity Interval Exercise (HIIE).

Higher intensities of aerobic training are generally considered superior to low-intensity

Types of Exercise Training Compared.

Exercise/PA with and without Weight Loss

CVD Risk Reduction.

Weight Loss and Regional Fat Distribution.

Prevention of Gestational Diabetes.

Mental Health and Cognition Benefits of PA

symptoms, in individuals with T2D.

Memory and Cognitive Function.

(81). Similarly, 2 wk of sprint interval training lowered insulin-stimulated glucose uptake in

PA Recommendations for Individuals with T2D

Adults and Older Adults

Resistance Exercise.—Resistance exercise training in older adults with T2D results in

fit and older adults (1).

greater sedentary time is related to hyperglycemia independent of aerobic fitness (113),

Adolescents and Youth

Pre-exercise Evaluation and Testing

Management of Acute and Chronic Health Complications with PA

Chronic Health Complications.

Exercise Timing and Dietary Considerations

Dietary Intake and eating patterns

Medical Interventions and Exercise Effectiveness

metformin may be contributing to the inter-individual variability observed in exercise-

Barriers to Adoption of PA and Inequities

Expert Interpretation and Key Future Directions

• Longer duration training is needed to establish whether exercise timing modifies

• Potential interactions between diabetes medications like metformin and exercise

• Larger clinical trials examining the impact of chronic high-intensity exercise on

Refer to Web version on PubMed Central for supplementary material.

J.A.K. is supported by the National Institute of Health R01 DK101513.

S.K.M. is supported by National Institutes of Health R01-HL130296.

joint position statement. Diabetes Care. 2010;33(12):e147–67. doi: 10.2337/dc10-9990. [PubMed:

3. Saeedi P, Petersohn I, Salpea P, Malanda B, Karuranga S, Unwin N, et al. Global and

2001;286(10):1218–27. [PubMed: 11559268]

23. Kadoglou NP, Iliadis F, Angelopoulou N, Perrea D, Ampatzidis G, Liapis CD, et

and Meta-Analysis. Int J Environ Res Public Health. 2019;16(1).(pii):ijerph16010140. doi:

2 diabetes: a randomised crossover trial. Diabetologia. 2019;62(2):233–7. Epub 2018/11/15. doi:

Sci Sports. 2014;24(2):e69–76. Epub 2013/10/10. doi: 10.1111/sms.12112. [PubMed: 24102912]

Journal of diabetes research. 2016;2016:6979370. Epub 2016/10/21. doi: 10.1155/2016/6979370.

Study. Lancet. 2009;374(9702):1677–86. Epub 2009/11/03. doi: 10.1016/s0140-6736(09)61457-4.

10.1056/NEJMoa1212914. [PubMed: 23796131]

63. 14. Management of Diabetes in Pregnancy: Standards of Medical Care in Diabetes-2021.

tolerance. Obstet Gynecol. 2006;108(5):1200–7. Epub 2006/11/02. doi: 108/5/1200 [pii]

2018;2018:8182938.(doi):10.1155/2018/8182938. eCollection 2018. [PubMed: 29507593]

snacks’ before meals: a novel strategy to improve glycaemic control in individuals

(1985). 2019;126(3):616–25. Epub 2018/12/21. doi: 10.1152/japplphysiol.00389.2018. [PubMed:

Repaglinide versus nateglinide monotherapy: a randomized, multicenter study. Diabetes Care.

passive heat exposure. Temperature (Austin). 2020;7(3):263–9. Epub 2020/10/31. doi:

2018;111:180–7. Epub 2018/07/28. doi: 10.1016/j.exger.2018.07.014. [PubMed: 30053413]

Exerc. 2015;47(11):2473–9. Epub 2015/10/17. doi: 10.1249/mss.0000000000000664. [PubMed:

doi: 10.1016/j.jand.2015.05.012. [PubMed: 26054423]