AbstractType 2 diabetes mellitus is highly prevalent among the elderly Age-associated changes in body composition obesity and sedentary behavior are some of the main fac-tors responsible for the increased prevalence of diabetes in this population Elderly patients experience important and specific issues including the association of comor-bidities and geriatric syndromes use of many medica-tions the presence of dependencies and frailty Physical activity has been shown to be as effective for the treat-ment of diabetes in the elderly as in younger patients so that its practice must be strongly encouraged Resistive activities are preferable for the frail and vulnerable dia-betic elderly Aerobic activities should be prescribed whenever possible and the association of both modali-ties is the best choice Moderate- to high-intensity exer-cises are more effective for glycemic control and unlike previously thought are generally safe for the elderly pop-ulation The frequency of exercising should be at least 3 daysweek for aerobic and 2 daysweek for resistance activities Balance exercises may be beneficial in special situations In the elderly patient special care must be tak-

en for the presence of contraindications for the practice of each exercise modality the interactions and limita-tions imposed by medications chronic comorbidities and geriatric syndromes the higher possibility of devel-oping hypoglycemia especially if insulin is used for treat-ment and the prevention of orthostatic hypotension that may be worsened by dehydration The prescription of ex-ercises tailored for each patientrsquos preferences and limita-tions is highly effective not only for glycemic control but also for improving independence self-esteem and qual-ity of life copy 2014 S Karger AG Basel

Epidemiology of Diabetes in the Elderly

Diabetes mellitus (DM) is a disease with increas-ing worldwide prevalence due to population ag-ing high levels of urbanization high prevalence of obesity and low levels of physical activity that affect all age groups [1 2] The World Health Or-ganization predicts the trebling of the elderly population in the next few decades from 524 mil-

Goedecke JH Ojuka EO (eds) Diabetes and Physical ActivityMed Sport Sci Basel Karger 2014 vol 60 pp 122ndash129 (DOI 101159000357342)

Diabetes and Exercise in the Elderly

Eduardo Ferriolli Fernanda Pinheiro Amador S Pessanha Juliana Cristina Lemos S Marchesi Division of General Internal and Geriatric Medicine Department of Medicine School of Medicine of Ribeiratildeo Preto University of Satildeo Paulo Ribeiratildeo Preto Brasil

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Diabetes and Exercise in the Elderly 123

lion people in 2010 to more than 15 billion in 2050 [3] Recent forecasts suggest that the num-ber of people diagnosed with DM will reach 522 million in 2030 [4] with DM becoming the sev-enth cause of death [3] These numbers are even more worrying for elderly people as the preva-lence of DM increases with increasing age [5] Es-timates show that presently half of the new diag-noses of DM are made in people aged 60 years or over [6]

The epidemic rise in the number of elderly people diagnosed with DM may be seen as one of the main problems for the healthcare of this pop-ulation in the near future Besides being one of the most expensive health conditions [7] DM is as-sociated with the main geriatric syndromes [5] and their complications [8] World estimates in-dicate that the health costs related exclusively to DM and its complications exceeded USD 376 bil-lion in 2010 and will reach USD 490 billion in 2030 [9] More than 75 of this amount will be expended in the healthcare of people aged be-tween 50 and 80 years [10]

One of the best policies to reduce costs in healthcare and minimize the effect of ageing and age-associated disorders is to promote healthy and active ageing Promoting physical activity is one of the main strategies for reaching this goal and physical activity programs for diabetic elderly also seem to have a good cost-benefit ratio [11] be-sides being effective in the reduction of the inci-dence of complications related to this disease [12]

Pathophysiology of Diabetes in the Elderly

Type 2 diabetes (DM2) is the most common form of diabetes in the general population and in the elderly population being the type pre-sented by 90 of the diabetic elderly DM2 is characterized by hyperglycemia and changes in lipid metabolism It is caused by the inability of pancreatic β-cells to secrete insulin adequately in response to high caloric intake or resistance

of body tissues to the action of insulin (insulin resistance) Persistent hyperglycemia the main characteristic of DM causes lesions in different organs and systems of the body especially the heart eyes kidneys and the nervous system [13]

During the aging process changes in body composition are important for the development of glucose intolerance and diabetes There is loss of lean mass the target for the action of insulin in the uptake of glucose and increase in visceral fat mass which secrete inflammatory cytokines and hormones that induce insulin resistance [14] These changes in body composition although partly associated with the natural aging process are potentiated by the frequent reduction in phys-ical activity during the aging process along with a history of bad alimentary habits including a high caloric intake despite decreasing energy needs [15]

Diabetes in the elderly has distinct metabolic aspects In younger patients there is increased production of glucose in the liver during fasting and this response is absent in the elderly increas-ing the risk of hypoglycemia [16] Furthermore elderly patients frequently have higher levels of inflammation and multiple comorbidities and use a number of medications (polypharmacy) that may affect glucose metabolism including be-ta-blockers diuretics and others

Diabetic elderly patients have higher rates of lower limb amputations myocardial infarction visual impairment and end-stage renal failure than patients of any other age group Patients aged 75 years or over have higher rates of compli-cations than those aged 65ndash74 years Deaths due to hyperglycemic crises are also significantly more frequent among the elderly although the incidence of this complication has decreased sharply over the last two decades [8] Those aged 75 years and over also use emergency services for hypoglycemia twice as much as the general popu-lation with DM [8] Recent studies have shown that elderly diabetics also have increased risk for

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124 Ferriolli middot Pessanha middot Marchesi

the development of cognitive impairment and de-pression [17 18] as well as the loss of muscle mass with women being at higher risk [19]

Finally geriatric syndromes such as functional impairment postural instability and falls urinary and fecal incontinence pain depression homeo-static instability and dementia are also highly prevalent in the diabetic elderly population Symptoms caused by these syndromes lead to frailty loss of independence and quality of life which themselves constitute important obstacles for the treatment and care of the elderly with DM

Diabetes and Physical Activity in the Elderly

It is well established in the literature that one of the best ways to preventing and treating DM2 is the regular practice of physical activity [20 21] Moreover sedentary behavior is described as one of the main factors related to the development of the disease [22] The same remains true for el-derly people although the number of studies in this specific age group is limited In fact the el-derly population is theoretically one of the groups that should benefit most from physical activity as the main age-related changes related to insulin resistance are the development of changes in body composition obesity and physi-cal inactivity all modifiable by physical activity [23]

Previous research has shown that in people who increased their physical activity as part of a lifestyle intervention the incidence of DM was 39 lower compared to those that received met-formin only This effect was more evident among those of older age [24] In addition the age-relat-ed increase in insulin resistance initially consid-ered physiological has been shown to be at least partially reversible by lifestyle changes especially increased physical activity levels [25]

Although physical activity may be seen as an essential part of the treatment of DM2 in the el-derly [26] the prescription of exercise to this age

group may present a great challenge Age-related and DM-associated disorders such as cognitive deficit visual impairment postural instability autonomic neuropathy and reduced functional-ity in addition to the presence of osteoarthritis depression and lower tolerance to exercising must all be taken into consideration [27] These conditions are often seen as barriers to the prac-tice of physical activity [28] starting a vicious cy-cle in which less activity leads to worsening of clinical condition and so on However the bene-fits obtained by physical activity in the control of DM and general health are clearly superior to these limitations and beyond preconceived be-liefs these limitations are often less limiting than they may seem

Therefore exercises tailored to the challeng-es of each patient should be encouraged when-ever possible Finally physical activity pro-grams should be seen as a good option to be-sides controlling DM promoting an increased functional independence in the elderly with DM2 [29]

Mechanisms of Action of Physical Activity in the Diabetic Elderly

Many of the positive metabolic effects that have been described with the practice of physical activ-ity by diabetic adults described in detail in the previous chapters have been confirmed in the di-abetic elderly [21 29 30]

The action of physical activity is not restricted only to the prevention and control of DM by di-rectly improving glucose metabolism It also im-proves body composition lipid profile and pre-vents by many different pathways cardiovascu-lar diseases [31]

The reduction of central obesity seems to exert primordial function in glycemic control Adult and elderly women with higher body mass index and waist-to-hip index had a relative risk of de-veloping DM 29 times higher compared to those

Goedecke JH Ojuka EO (eds) Diabetes and Physical ActivityMed Sport Sci Basel Karger 2014 vol 60 pp 122ndash129 (DOI 101159000357342) D

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Diabetes and Exercise in the Elderly 125

with lower anthropometric values [32] Further a study performed in obese adults and elderly peo-ple (63 plusmn 1 year) showed that the loss of visceral fat was one of the main factors favoring glucose metabolism and was associated with the decrease in insulin resistance after an aerobic training (AT) program [33]

Modalities Intensity and Frequency of Physical Activity

First of all it is important to mention that not only programmed physical activity but also any general increases in physical activity level which may be stimulated in many different ways benefit the elderly population In this chapter however we will look at programmed physical activity it-self and at the effects of two main physical train-ing modalities that have been investigated in ran-domized and well-controlled clinical studies re-sistive training (RT) and AT

The effects of AT are essentially reduction of fat mass and increase in lipolysis and VO2max [28 33] and a better muscle glucose uptake due to the use of big muscle groups [34] AT improves gly-cemic control in both the short and long term Seven-day consecutive AT was shown to increase GLUT-4 concentrations increasing insulin sensi-tivity in young and elderly people in similar pro-portions [35] In another study 16-week AT also increased the number of GLUT-4 carriers and improved muscle mitochondrial response in all age groups [25]

However the implementation of an AT pro-gram including all safety recommendations may be very difficult in frail elderly populations and in the presence of comorbidities which as men-tioned before are very frequent in the diabetic el-derly AT may be beneficial and a good modality choice for conditions such as cognitive deficit and depression but for others such as foot problems osteoarthritis balance impairment and postural hypotension AT may not be feasible or even rec-

ommended Therefore in practice AT may not be the most viable option

Isolated RT also seems to be a good option for the diabetic elderly Besides improving energy balance due to an increase in fat-free mass and a reduction of fat deposits RT has also been shown to increase the control of glucose levels insulin sensitivity and the number of GLUT-4 receptors in muscle [36] RT also has the potential to im-prove sarcopenia [37] an important factor in the development of DM2 in the elderly RT unlike previously thought is safe and highly tolerable in the elderly even in frailer populations [38] It may also be a good option for obese elderly that may not tolerate AT [39]

Studies that compared AT and RT concluded that the combination of the two exercise modali-ties whenever possible seems to exert the best ef-fect in diabetic elderly [40] as the mechanisms of action are distinct and complementary A pro-gram that included both AT and RT [21] led to a reduction in fat mass blood glucose insulin and glycated hemoglobin improved lipid profile and increased lower limb strength

Balance exercises although not favoring gly-cemic control are beneficial for postural stabil-ity reaction time and reduction in the number of falls which are frequently present in diabetic elderly [41] Therefore they may also be consid-ered for the treatment of this population in spe-cial situations although always associated with one of the previously discussed modalities Benefits of this modality of exercise have been particularly shown in elderly with diabetic neu-ropathy [42]

Regarding exercise intensity moderate-to-high intensity is considered the most efficacious in preventing and treating DM High-intensity exercises have been shown as the most favorable for the elderly with DM2 although presenting somewhat higher risks for lesions and being con-traindicated in some situations in the elderly group (including unstable angina severe coro-nary disease severe cardiac arrhythmias and val-

Goedecke JH Ojuka EO (eds) Diabetes and Physical ActivityMed Sport Sci Basel Karger 2014 vol 60 pp 122ndash129 (DOI 101159000357342) D

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126 Ferriolli middot Pessanha middot Marchesi

vular disease aortic or cerebral aneurism some ophthalmologic diseases advanced dementia and severe behavioral disturbances) [43] High-inten-sity AT has been shown to be more effective for improving insulin sensitivity in comparison with low and moderate intensity AT in obese elderly women with DM2 [44] Also a program of high-intensity RT performed by 62 high-risk elderly men with DM2 (66 plusmn 8 years) was shown to be ef-fective in controlling glycemic levels in this study the prescription of medications was reduced by up to 72 [45]

The duration of exercise may also influence the changes in insulin sensitivity A study performed with adults and elderly people showed that inde-pendent of the intensity and modality of physical activity a program with 170 minweek of exercise was superior for improving insulin sensitivity compared to a program with 115 minweek [46]

As a note of caution it is important to mention that although the literature supports the benefits of physical activity in the elderly most of the stud-ies were performed in lsquoyoung-oldrsquo patients (those aged less than 75 years) The number of old-old people is increasing sharply and the results ob-tained so far may not be applicable to this particu-lar population

Recommendations for the Diabetic Elderly

As mentioned before combined exercise pro-grams seem to be the best indication for the elderly population with DM2 However per-sonal characteristics must be taken into consid-eration for the choice of the best modality for each patient

Resistance exercises are more highly recom-mended for frail and vulnerable people that are not fit for AT In the absence of contraindications (see above) all elderly people with DM2 should be en-couraged to perform RT at least twice a week [47 48] Regarding intensity although extra care must be taken for the prevention of lesions and complica-

tions in this population moderate-to-high inten-sity should be the goal whenever possible [44 45]

AT should be prescribed in association with RT whenever possible again respecting limita-tions and preferences The lsquoPhysical Activity Guidelines for Americansrsquo of the United States Department of Health and Human Services [47] suggest that people aged 65 years or over should follow the same guidelines for the practice of AT as younger adults that is to practice at least 150 minweek of aerobic physical activity with mod-erate intensity (50ndash70 of maximum heart rate) distributed over at least 3 daysweek and spend no more than 2 consecutive days without exercising

The prescription of exercises for diabetic el-derly people must take into consideration the higher risk of hypoglycemia especially when in-sulin is used for treatment Careful attention must also be given to the possible exacerbation of pre-existing cardiovascular diseases and other chron-ic conditions [16] Also during the practice of ex-ercises orthostatic hypotension due to diabetic autonomic neuropathy may be exacerbated by dehydration so that the intake of fluids and ade-quacy of the environment must be carefully ob-served [49]

Frailty syndrome cognitive deficit and func-tional limitations must also be considered in the prescription of exercises for the elderly [50] As some 50 of the elderly patients present three or more chronic conditions [51] and consequently use a number of medications the interaction be-tween them and physical exercise must be care-fully considered before activity is started

Finally it is highly recommended that before starting any exercise programs diabetic elderly patients are assessed by an inter-disciplinary team with experience and knowledge on the physiology of ageing and pathophysiology of dia-betes their complications and interactions [52]

Table 1 shows a compilation of the recom-mendations for the practice of physical activity by diabetic elderly patients

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Diabetes and Exercise in the Elderly 127

Conclusions

In conclusion the practice of physical activity is important and highly recommended for the treatment of the elderly with DM2 Although the association of RT and AT (as well as balance and flexibility training when needed) is the best option due to their complementary effects spe-

cial care must be taken with age-associated dis-eases and conditions that may restrain the prac-tice of one or the other modality Challenges of DM in the elderly including the presence of co-morbidities dependences and frailty as well as a higher risk of hypoglycemia and postural hy-potension must also be carefully considered and monitored

Table 1 Recommendations for the practice of physical activity by diabetic elderly patients

Modality Aerobic and resistance exercises are effective however the combination of both modalities seems to be the best option

Intensity Moderate 50ndash70 of maximum heart rate or 40ndash60 of RMIntense gt70 of maximum heart rate or gt60 of RMPreferably whenever possible intense exercises

Duration At least 150 minweek preferably 300 minweek

Frequency AT at least 3 daysweek with no more than 2 consecutive days without trainingRT at least 2 daysweek

Muscle groups Train big muscle groups

Special care Consider the interaction between DM2 and other geriatric conditions such as frailty cognitive deficit functional impairment and others

Progress slowly define modality according to patientrsquos aptitude and choices

Encourage the intake of liquids during the activity provide guidelines for adequate diet and environment in order to avoid orthostatic hypotension and hypoglycemia during exercising

Diabetic peripheral neuropathy affects walking and balance attempt to avoid falls during exercising

Consider interactions between the medications in use and the practice of exercises

Assess clinically before exercising and carefully monitor before during and after exercise higher risk of hypoglycemia after activity

RM = Repetition maximum

References

1 World Health Organization Global Health and Aging Geneva World Health Organization 2004

2 Wild S Roglic G Green A Sicree R King H Global prevalence of diabetes estimates for the year 2000 and projec-tions for 2030 Diabetes Care 2004 27

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3 World Health Organization Global Sta-tus Report on Noncommunicable Dis-eases 2010 Geneva World Health Orga-nization 2011

4 Whiting D Guariguata RL Weil C Shaw J IDF diabetes atlas global estimates of the prevalence of diabetes for 2011 and 2030 Diabetes Res Clin Pract 2011 94

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128 Ferriolli middot Pessanha middot Marchesi

5 Mollentze WF Management of diabetes in the elderly The care of diabetes in the elderly may be different from that in younger patients CME 2010 28 480ndash483

6 Steven R Gamber T Pinkstaff S Emerg-ing epidemic diabetes in older adults demography economic impact and pathophysiology Diabetes Spectrum 2006 19 221ndash228

7 Lipscombe LL Hux JE Trends in diabe-tes prevalence incidence and mortality in Ontario Canada 1995ndash2005 a popu-lation-based study Lancet 2007 369

750ndash756 8 Kirkman MS Briscoe VJ Clark N Florez

H Haas LB Halter JB Huang ES Koryt-kowski MT Munshi MN Odegard PS Pratley RE Swift CS Diabetes in older adults Diabetes Care 2012 35 2650ndash2664

9 Zhang P Zhang X Brown J Vistisen D Sicree R Shaw R Nichols G Global healthcare expenditure on diabetes for 2010 and 2030 Diabetes Res Clin Pract 2010 87 293ndash301

10 Hodge AM Flicker L Orsquodea K English DR Giles GG Diabetes and ageing in the Melbourne Collaborative Cohort Study (MCCS) Diabetes Res Clin Pract 2013 100 398ndash403

11 Coyle D Coyle K Kenny GP Boule NG Wells GA Fortier M Reid RD Phillips P Sigal RJ Cost-effectiveness of exercise programs in type 2 diabetes Int J Tech-nol Assess Health Care 2012 28 228ndash234

12 Otterman NM Van Schie CH Van Der Schaaf M Van Bon AC Busch-West-broek TE Nollet F An exercise pro-gramme for patients with diabetic com-plications a study on feasibility and preliminary effectiveness Diabet Med 2011 28 212ndash217

13 Ribeiro J Rocha P Alves S Popim RC Compreendendo o significado de quali-dade de vida segundo idosos portadores de diabetes mellitus tipo II Esc Anna Nery 2010 14 765ndash771

14 Howthorne G Diabetes the glycaemic index and older people Age Ageing 2011 40 655ndash656

15 Tessier D Age related insulin resistance and predisposition to diabetes Geriatr Aging 2004 7 53ndash56

16 Meneilly GS Diabetes in the elderly Can J Diabetes 2011 35 13ndash16

17 Umegaki H Pathophysiology of cogni-tive dysfunction in older people with type 2 diabetes vascular changes or neurodegeneration Age Ageing 2010

39 8ndash10

18 Chau PH Woo J Lee CH Cheung WL Chen J Chan WM Hui L McGhee SM Older people with diabetes have higher risk of depression cognitive and func-tional impairments implications for diabetes services J Nutr Health Aging 2011 15 751ndash755

19 Park SW Goodpaster BH Lee JS Kuller LH Boudreau R Rekeneire N Harris TB Kritchevsky S Tylavisky FA Nevitt M Cho YW Newman AB Excessive loss of skeletal muscle mass in older adults with type 2 diabetes Diabetes Care 2009 32 1993ndash1997

20 Tuomilehto J Lindstrom J Eriksson JG Valle TT Hamalainen H Ilanne-Parikka P Keinanen-Kiukaanniemi S Laakso M Louheranta A Rastas M Salminen V Uusitupa M Prevention of type 2 diabe-tes mellitus by changes in lifestyle among subjects with impaired glucose tolerance N Engl J Med 2001 344 1343ndash1350

21 Tan S Li W Wang J Effects of six months of combined aerobic and resis-tance training for elderly patients with a long history of type 2 diabetes J Sports Sci Med 2012 11 495ndash501

22 Wilmot EG Edwardson CL Achana FA Davies MJ Gorely T Gray LJ Khunti K Yates T Biddle SJ Sedentary time in adults and the association with diabetes cardiovascular disease and death sys-tematic review and meta-analysis Dia-betologia 2012 55 2895ndash2905

23 Amati F Dube JJ Coen PM Stefanovic-Racic M Toledo FG Goodpaster BH Physical inactivity and obesity underlie the insulin resistance of aging Diabetes Care 2009 328 1547ndash1549

24 Diabetes Prevention Research Group Reduction in the incidence of type 2 diabetes with lifestyle intervention or metformin New Engl J Med 2002 346

393ndash40325 Short KR Vittone JL Bigelow ML Proc-

tor DN Rizza RA Coenen-Schimke JM Nair KS Impact of aerobic exercise training on age-related changes in insu-lin sensitivity and muscle oxidative ca-pacity Diabetes 2003 52 1888ndash1896

26 Tessier D Menard J Fulop T Ardilouze J Roy M Dubuc N Dubois M Gauthier P Effects of aerobic physical exercise in the elderly with type 2 diabetes mellitus Arch Gerontol Geriatr 2000 31 121ndash132

27 Morley JE The elderly Type 2 diabetic patient special considerations Diabet Med 1998 15S41ndashS46

28 Constans T Lecomte P Non pharmaco-logical treatments in elderly diabetics Diabetes Metab 2007 33S79ndashS86

29 Davidson L Hudson ER Kilpatrick K Kuk JL Mcmillan K Janiszewski PM Lee S Lam M Ross R Effects of exercise modality on insulin resistance and func-tional limitation in older adults a ran-domized controlled trial Arch Intern Med 2009 169 122ndash131

30 Ferrer-Garcia JC Sanchez Lopez P Pab-los-Abella C Albalat-Galera R Elvira-Macagno L Sanchez-Juan C Pablos-Monzo A Benefits of a home-based physical exercise program in elderly subjects with type 2 diabetes mellitus Endocrinol Nutr 2011 58 387ndash394

31 American Diabetes Association Diabe-tes mellitus and exercise Diabetes Care 2002 25 564ndash568

32 Folsom AR Kushi LH Anderson KE Mink PJ Olson JE Hong CP Sellers TA Lazovich D Prineas RJ Associations of general and abdominal obesity with multiple health outcomes in older wom-en the Iowa Womenrsquos Health Study Arch Intern Med 2000 160 2117ndash2128

33 OrsquoLeary VB Marchetti CM Krishnan RK Stetzer BP Gonzalez F Kirwan JP Exercise-induced reversal of insulin re-sistance in obese elderly is associated with reduced visceral fat J Appl Physiol 2006 100 1584ndash1589

34 Fenicchia LM Kanaley JA Azevedo JL Jr Miller CS Weinstock RS Carhart RL Ploutz-Snyder LL Influence of resis-tance exercise training on glucose con-trol in women with type 2 diabetes Me-tabolism 2004 53 284ndash289

35 Cox JH Cortright RN Dohm GL Hou-mard JA Effect of aging on response to exercise training in humans skeletal muscle GLUT-4 and insulin sensitivity J Appl Physiol 1999 86 2019ndash2025

36 Willey KA Singh MA Battling insulin resistance in elderly obese people with type 2 diabetes bring on the heavy weights Diabetes Care 2003 26 1580ndash1588

37 Hovanec N Sawant A Overend TJ Petrella RJ Vandervoort AA Resis-tance training and older adults with type 2 diabetes mellitus strength of the evidence J Aging Res 2012 2012

28463538 Sundell J Resistance training is an effec-

tive tool against metabolic and frailty syndromes Adv Prev Med 2011 2011

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Diabetes and Exercise in the Elderly 129

39 Ibantildeez J Izquierdo M Arguumlelles I Forga L Garcia-Unciti M Idoate F Gorostiaga EM Twice-weekly progressive resis-tance training decreases abdominal fat and improves insulin sensitivity in older men with type 2 diabetes Diabetes Care 2005 28 662ndash667

40 Maiorana A Orsquodriscoll G Goodman C Taylor R Green D Combined aerobic and resistance exercise improves glyce-mic control and fitness in type 2 diabe-tes Diabetes Res Clin Pract 2002 56

115ndash12341 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 748ndash750

42 Song CH Petrofsky JS Lee SW Lee KJ Yim JE Effects of an exercise program on balance and trunk proprioception in older adults with diabetic neuropathies Diabetes Technol Ther 2011 13 803ndash811

43 Frankel JE Bean JF Frontera WR Exer-cise in the elderly research and clinical practice Clin Geriatr Med 2006 22 239ndash256

44 Dipietro L Dziura J Yeckel CW Neufer PD Exercise and improved insulin sen-sitivity in older women evidence of the enduring benefits of higher intensity training J Appl Physiol 2006 100 142ndash149

45 Castaneda C Layne JE Munoz-Orians L Gordon PL Walsmith J Foldvari M Roubenoff R Tucker KL Nelson ME A randomized controlled trial of resistance exercise training to improve glycemic control in older adults with type 2 dia-betes Diabetes Care 2002 25 2335ndash2341

46 Houmard JA Tanner CJ Slentz CA Duscha BD Mccartney JS Kraus WE Effect of the volume and intensity of exercise training on insulin sensitivity J Appl Physiol 2004 96 101ndash106

47 US Department of Health and Human Services Physical Activity Guidelines for Americans 2008 httpwwwhealthgovpaguidelinesguidelinesdefaultaspx

48 American Diabetics Association Stan-dards of Medical Care in Diabetes Dia-betes Care 2012 35 11ndash63

49 Robert S Schwartz MD Exercise train-ing in treatment of diabetes mellitus in elderly patients Diabetes Care 1990 13

77ndash8550 Abbatecola AM Paolisso G Diabetes

care targets in older persons Diabetes Res Clin Pract 2009 86S35ndashS40

51 Durso SC Using clinical guidelines de-signed for older adults with diabetes mellitus and complex health status JAMA 2006 295 1935ndash1940

52 Chau D Edelman SV Clinical manage-ment of diabetes in the elderly Clin Dia-betes 2001 19 172ndash175

Prof Eduardo FerriolliDepartamento de Cliacutenica MeacutedicaFaculdade de Medicina de Ribeirao Preto ndash USPAv Bandeirantes 3900 14049-900 Ribeiratildeo Preto SP (Brasil)E-Mail eferriolfmrpuspbr

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