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RESEARCH Review Role of Physical Activity in Diabetes Management and Prevention CHARLOTTE HAYES, MMSc, MS, RD; ANDREA KRISKA, PhD ABSTRACT During recent years, evidence supporting the vital role of physical activity in the prevention and treatment of diabe- tes has been accumulating. Physical activity is recognized to produce multiple general and diabetes-specific health ben- efits. Yet despite the multitude of benefits, many people are physically inactive. As the prevalence of overweight and obesity, prediabetes, and type 2 diabetes has continued to rise at an alarming rate, physical inactivity has become an urgent public health concern. The purpose of this article is to review the physical activity/exercise research in diabetes and summarize the current exercise recommendations. This information can be used by clinicians to make safe and effective recommendations for integrating physical activity/ exercise into self-management plans for individuals with diabetes or at risk for its development. J Am Diet Assoc. 2008;108:S19-S23. A physically active lifestyle is important in the pre- vention and treatment of many chronic diseases and conditions. Mounting evidence about the health benefits of a physically active lifestyle is convincing and has far exceeded that reported in the 1996 US Surgeon General’s Report on Physical Activity and Health (1). Physiological benefits of physical activity include a posi- tive impact on the prevention of type 2 diabetes and management of type 1 and 2 diabetes (1-4). Although physical activity is known to produce multi- ple health benefits, many people are considered to be relatively physically inactive. Fewer than half of Ameri- can adults achieve activity levels recommended by the US Surgeon General (5). Of greater concern is that despite national educational efforts to decrease sedentary behav- ior in the United States, a recent estimate (2005) sug- gests that 24% of adults still do not partake in leisure- time activity (6). Inadequate participation in physical activity extends to those individuals with diabetes, as demonstrated by findings of the Third National Health and Nutrition Examination Survey. In this effort, 31% of individuals with type 2 diabetes reported not regularly participating in physical activity (7). Physical inactivity is a pressing national health concern and is relevant to many patients who are counseled by registered dietitians (RDs). Therefore, advising individuals, with or at risk for developing diabetes, about physical ac- tivity is imperative. When providing diabetes medical nu- trition therapy, RDs can positively influence individuals who are inactive to integrate physical activity/exercise into a management plan that supports optimal health. A basic understanding of the benefits and risks of physical activity and exercise for individuals with diabetes or prediabetes is essential prior to offering specific exercise advice. HEALTH BENEFITS OF PHYSICAL ACTIVITY Regular physical activity leads to a number of beneficial physiological changes that favorably affect muscle and liver insulin sensitivity, muscle glucose uptake and utili- zation, and overall glycemic control (2,8-14). However, the benefits of a physically active lifestyle extend beyond improvements in insulin action and glycemic control. Consistently performed activity can improve lipid profile, decrease body weight and percentage of body fat, lower blood pressure, and positively affect thromboembolic state and thus reduce overall cardiovascular disease risk (6,15-17). This reduction in cardiovascular disease risk is of primary importance for individuals with diabetes who are twice as likely to experience serious cardiovascular disease events and are two to four times as likely to die from complications of cardiovascular events compared to the general population (18,19). Adoption and mainte- nance of an active lifestyle can reduce this risk by an estimated 35% to 55 % (19,20). In addition, physical activity can contribute to the pre- vention or delay in development of other long-term diabetes complications, such as neuropathy, retinopathy, and ne- phropathy, and may slow progression of existing complica- tions (21). Physical activity can also reduce stress and feel- ings of anxiety, heighten sense of well-being (17,22), reduce risk of other chronic diseases (17,23), and reduce the func- tional decline that occurs with aging (24). The multiple metabolic adaptations that occur in re- sponse to physical activity can improve glycemic control for individuals with type 2 diabetes (16,21). However, the impact on glucose control, as measured by hemogloblin C. Hayes is a certified diabetes educator and Director of Nutrition Services, Open Hand/Atlanta, Atlanta, GA. A. Kriska is an associate professor, Department of Epide- miology, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA. STATEMENT OF CONFLICT OF INTEREST: See page S22. Address correspondence to: Charlotte Hayes, MMSc, MS, RD, Nutrition Services, Open Hand/Atlanta, 176 Ottley Dr NE, Atlanta, GA 30324. E-mail: chayes@ projectopenhand.org Manuscript accepted: December 13, 2007. Copyright © 2008 by the American Dietetic Association. 0002-8223/08/10804-1007$34.00/0 doi: 10.1016/j.jada.2008.01.016 © 2008 by the American Dietetic Association Supplement to the Journal of the AMERICAN DIETETIC ASSOCIATION S19

Role of Physical Activity in Diabetes Management and Prevention

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Page 1: Role of Physical Activity in Diabetes Management and Prevention

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HARLOTTE HAYES, MMSc, MS, RD; ANDREA KRISKA, PhD

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BSTRACTuring recent years, evidence supporting the vital role ofhysical activity in the prevention and treatment of diabe-es has been accumulating. Physical activity is recognized toroduce multiple general and diabetes-specific health ben-fits. Yet despite the multitude of benefits, many people arehysically inactive. As the prevalence of overweight andbesity, prediabetes, and type 2 diabetes has continued toise at an alarming rate, physical inactivity has become anrgent public health concern. The purpose of this article iso review the physical activity/exercise research in diabetesnd summarize the current exercise recommendations. Thisnformation can be used by clinicians to make safe andffective recommendations for integrating physical activity/xercise into self-management plans for individuals withiabetes or at risk for its development.Am Diet Assoc. 2008;108:S19-S23.

physically active lifestyle is important in the pre-vention and treatment of many chronic diseases andconditions. Mounting evidence about the health

enefits of a physically active lifestyle is convincing andas far exceeded that reported in the 1996 US Surgeoneneral’s Report on Physical Activity and Health (1).hysiological benefits of physical activity include a posi-ive impact on the prevention of type 2 diabetes andanagement of type 1 and 2 diabetes (1-4).Although physical activity is known to produce multi-

le health benefits, many people are considered to beelatively physically inactive. Fewer than half of Ameri-an adults achieve activity levels recommended by the USurgeon General (5). Of greater concern is that despiteational educational efforts to decrease sedentary behav-

. Hayes is a certified diabetes educator and Director ofutrition Services, Open Hand/Atlanta, Atlanta, GA. A.riska is an associate professor, Department of Epide-iology, Graduate School of Public Health, University

f Pittsburgh, Pittsburgh, PA.STATEMENT OF CONFLICT OF INTEREST: See

age S22.Address correspondence to: Charlotte Hayes, MMSc,S, RD, Nutrition Services, Open Hand/Atlanta, 176ttley Dr NE, Atlanta, GA 30324. E-mail: [email protected] accepted: December 13, 2007.Copyright © 2008 by the American Dietetic

ssociation.0002-8223/08/10804-1007$34.00/0

idoi: 10.1016/j.jada.2008.01.016

2008 by the American Dietetic Association

or in the United States, a recent estimate (2005) sug-ests that 24% of adults still do not partake in leisure-ime activity (6). Inadequate participation in physicalctivity extends to those individuals with diabetes, asemonstrated by findings of the Third National Healthnd Nutrition Examination Survey. In this effort, 31% ofndividuals with type 2 diabetes reported not regularlyarticipating in physical activity (7).Physical inactivity is a pressing national health concern

nd is relevant to many patients who are counseled byegistered dietitians (RDs). Therefore, advising individuals,ith or at risk for developing diabetes, about physical ac-

ivity is imperative. When providing diabetes medical nu-rition therapy, RDs can positively influence individualsho are inactive to integrate physical activity/exercise intomanagement plan that supports optimal health. A basic

nderstanding of the benefits and risks of physical activitynd exercise for individuals with diabetes or prediabetes isssential prior to offering specific exercise advice.

EALTH BENEFITS OF PHYSICAL ACTIVITYegular physical activity leads to a number of beneficialhysiological changes that favorably affect muscle andiver insulin sensitivity, muscle glucose uptake and utili-ation, and overall glycemic control (2,8-14). However,he benefits of a physically active lifestyle extend beyondmprovements in insulin action and glycemic control.onsistently performed activity can improve lipid profile,ecrease body weight and percentage of body fat, lowerlood pressure, and positively affect thromboembolictate and thus reduce overall cardiovascular disease risk6,15-17). This reduction in cardiovascular disease risk isf primary importance for individuals with diabetes whore twice as likely to experience serious cardiovascularisease events and are two to four times as likely to dierom complications of cardiovascular events compared tohe general population (18,19). Adoption and mainte-ance of an active lifestyle can reduce this risk by anstimated 35% to 55 % (19,20).In addition, physical activity can contribute to the pre-

ention or delay in development of other long-term diabetesomplications, such as neuropathy, retinopathy, and ne-hropathy, and may slow progression of existing complica-ions (21). Physical activity can also reduce stress and feel-ngs of anxiety, heighten sense of well-being (17,22), reduceisk of other chronic diseases (17,23), and reduce the func-ional decline that occurs with aging (24).

The multiple metabolic adaptations that occur in re-ponse to physical activity can improve glycemic controlor individuals with type 2 diabetes (16,21). However, the

mpact on glucose control, as measured by hemogloblin

Supplement to the Journal of the AMERICAN DIETETIC ASSOCIATION S19

Page 2: Role of Physical Activity in Diabetes Management and Prevention

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1c, is not as consistent in those with type 1 diabetes16,25) relative to those with type 2 diabetes. Althoughxercise can lead to substantial blood glucose variationnd management challenges for those who require insu-in, self-management training can reduce potential forxcessive glucose variability related to exercise. Given itsany benefits, routine physical activity participation is of

ey importance and should be encouraged for all individ-als, especially those with type 1, type 2, or prediabetes.

REPARTICIPATION SCREENINGany inactive adults can safely begin a program of light-

o-moderate physical activity, such as brisk walking, with-ut extensive preexercise screening (6,26). This holds trueor individuals with diabetes as well (27). However, becauseiabetes is associated with higher cardiovascular and over-ll exercise risk, individuals with diabetes should consultheir health care provider before increasing their currenthysical activity level, especially if planning to initiate vig-rous exercise (6,27). Thorough preexercise screening andisk stratification can improve the safety and effectivenessf exercise recommendations and help determine whethern individual should undergo additional medical evaluationr exercise testing prior to beginning exercise; should re-rain from certain types of activity; should participate in a

edically supervised exercise program, or should initiaten exercise program with professional guidance (1,6,26).he other reason to involve an individual’s health carerovider is that it brings him or her into an active role as aember of a team, which includes the dietitian, that is

ommitted to helping the individual achieve and maintain aealthful lifestyle comprised of physical activity, healthfuliet, and weight management. See Whaley and colleagues26) for detailed guidelines regarding preexercise healthcreening and risk stratification.

Ideally, psychosocial evaluations to assess factors suchs exercise self-efficacy, readiness/stage of change, andotivation/decisional balance will be performed to iden-

ify variables that may preclude successful initiation andaintenance of a physical activity routine. Based on

hese evaluations, counseling strategies that support suc-ess with participation in activity can be identified beforepecific exercise advice is offered (6,22,26).

IABETES PREVENTIONn recent years, four clinical trials (three of them random-zed), which included physical activity as an integral partf lifestyle interventions, suggested that onset of type 2iabetes can be prevented or delayed (28,29) as a result ofhe intervention. In these studies, progression of predia-etes to type 2 diabetes was decreased by 31% to 63% indults with impaired glucose tolerance at baseline3,4,30,31), as a result of successful lifestyle interventionshat included physical activity.

Physical activity plays an important role in delaying orreventing development of type 2 diabetes in those atisk, both directly by improving insulin sensitivity andndirectly by producing beneficial changes in body massnd body composition (21,32-34). However, it is not en-irely clear whether physical activity alone can prevent

iabetes. With the exception of the Da Qing Study (31), l

20 April 2008 Suppl 1 Volume 108 Number 4

hich was randomized by clinic, the trials already men-ioned combined physical activity with diet and weightoss in their intervention schemes. However, the Da Qingtudy (31) demonstrated that the decrease in diabetesevelopment in the physical activity intervention armccurred without a substantial change in body mass in-ex (calculated as kg/m2) and was evident in both initiallyean (body mass index �23) and overweight (body massndex�23) participants. Likewise, in the Diabetes Pre-ention Program, achievement of the physical activityoal of 150 minutes per week was substantially and in-ependently related to development of diabetes amonghe 495 Diabetes Prevention Program lifestyle partici-ants who did not meet the weight loss goal at year 1,esulting in a 46% reduction in diabetes incidence (34).lthough both of these findings suggest an independentffect of activity, that is yet to be proven.The physical activity goals of these trials were similar to

he public health recommendations described in the USurgeon General’s Report (1), which calls for achievement offoundation of physical activity comprised of an average of0 minutes of moderate intensity activity, similar to briskalking, on most days of the week. These 30 minute do notave to be accomplished in one continuous exercise session,ut can be accrued in short exercise bouts, each lasting 10inutes or longer, performed throughout the day, and can

nclude a variety of activities beyond structured exercise orports (1,6). Greater benefits are likely to be achieved ifore than the minimum recommend amount of activity is

ccumulated (6,35). Most importantly, in order to maintainhe benefits of an active lifestyle, the activity must be con-istently maintained over the years.

IABETES MANAGEMENTn addition to impacting development of type 2 diabetes36), regular physical activity participation is associatedith numerous health benefits for the individual withiabetes. Physical activity appears to have an indepen-ent, beneficial effect on insulin action, glycemic control,nd metabolic abnormalities associated with type 2 dia-etes (2,8,26). However, beneficial metabolic effects pro-uced by physical activity appear to be greatest early inhe progression of the disease (15).

For individuals with type 1 diabetes, the typical hormonalesponse to exercise, characterized by a decrease in insulinnd increase in counterregulatory hormone release, is defi-ient. This can result in a mismatch between liver glucoseroduction and muscle glucose uptake and utilization andailure to maintain glucose stability during and after exer-ise (11,16,24,37-40). Numerous variables, including exer-ise duration and intensity; timing of exercise in relation toeals/snacks and nutrient mix of preexercise meals; insulin

osages; and timing of exercise in relation to injections,xercise climate, stress, and hydration can influence bloodlucose response to exercise (11,16, 24). Of these variables,nsulin dosages and carbohydrate intake can most readilye modified. Insulin adjustments (11,16,24,41-44) and car-ohydrate supplementation (16,24,45,46) can be used inde-endently and in combination to maintain optimal glucose

evels during and after exercise (Figure).
Page 3: Role of Physical Activity in Diabetes Management and Prevention

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XERCISE RECOMMENDATIONS FOR DIABETES MANAGEMENTost types of physical activity, including leisure time

ctivities; recreational games; and high-performance,ompetitive sports are appropriate for individuals withiabetes (47). However, exercise initiation should be pre-eded with appropriate medical guidance and preexercisecreening, as described previously, and must be carefullyntegrated into the diabetes management plan so thatptimal glucose levels can be maintained (11,16,24). For aist of exercise guidelines appropriate for most individu-ls with type 1 and type 2 diabetes, visit www.dce.org/

Guiding statement MNTa Me

PrediabetesAmerican Diabetes

Association, 2007(47)

Reduced calorie, low-fat diet plus regularphysical activity can lead to improvementsin glucose tolerance, blood pressure, andlipid profile

Modest weight loss (5-7% of starting weight)and prevention of weight gain is animportant therapeutic objective

Physical activity plays an important role inweight maintenance and prevention ofweight-regain

Insut

Type 2 diabetesSigal and colleagues,

2004 (2)Albright and

colleagues, 2000(22)

American DiabetesAssociation, 2007(47)

Meal planning, physical activity, plusglucose-lowering medication(s) lead tooptimal glucose-lowering as well asimprovements in blood pressure and lipidprofile

Modest weight loss (5-7% of starting weight)and prevention of weight gain is animportant therapeutic objective

Physical activity plays an important role inweight maintenance and prevention ofweight-regain

Extra food for increased activity should beused judiciously if weight loss is a goaland is generally unnecessary forindividuals on medications that do notincrease hypoglycemia risk

For individuals on insulin or insulinsecretagogues: additional carbohydrateshould be consumed if the BG is �100mg/dL (5.6 mmol/L); 15 g rapidlyabsorbable carbohydrate should beavailable for treatment and prevention ofhypoglycemia (BG �70 mg/dL) (3.9 mmol/L) during prolonged activity

Meir

Insuwh

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Type 1 diabetesWasserman and

colleagues, 1994(25)

Franz, 2002 (45)American Diabetes

Association, 2007(47)

Carbohydrate supplementation is oftennecessary for maintaining target-rangeglucose levels with exercise, especially ifactivity is spontaneous or unplanned, longduration, or high intensity

Intake of additional carbohydrate is indicatedwhen the preexercise BG is �100 mg/dL(5.6 mmol/L); 15 g rapidly absorbablecarbohydrate should be available fortreatment of hypoglycemia [BG �70 mg/dL (3.9 mmol/L)]

As a starting guideline: 15-30 g carbohydrateconsumed every 30-60 min of exercise;depending on exercise intensity* reduceshypoglycemia risk and supplies fuel forexercise; 1.5 g carbohydrate/kg bodyweight consumed 30 minutes afterintense/competitive exercise and again1-2 h later may prevent postexercisehypoglycemia and replenish glycogenstores

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igure. Guidelines for integrating physical activity into diabetes managlucose. cSMBG�self-monitoring of blood glucose. *Based on increas

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April 2008 ●

ent activity that includes aerobic exercise supplementedith resistance exercise as part of a healthful lifestyle is

mportant (2,21,26,49,50).Heightened insulin sensitivity lasts 24 to 72 hours after

n activity session, depending on the intensity and durationf the activity (2,26). Therefore, for optimal glucose-lower-ng, activity should be performed regularly throughout theeek (2,26). Individuals who experience excessive postmeallucose elevations can benefit from performing moderatectivity 1 to 2 hours postmeal as a strategy for reducinglood glucose elevations (51,52), as well as triglyceride con-

ns Monitoring

t evidence to support use of drug Follow-up monitoring every 1 to 2years

Ongoing monitoring of weightstatus

, thiazolidinediones or �-glucosidasers alone do not increase hypoglycemia

cretagogues and insulin are associatedgher risk of exercise-relatedcemia

of insulin or secretagogues can bed preexercise to reduce likelihood ofnt hypoglycemia in those at risk

BGb monitoring before and afterexercise supportsunderstanding of glycemicresponse to activity

Pre- and postexercise monitoringis advised for individuals oninsulin or secretagogues

nsitivity and responsiveness are alteredrcise, therefore, skill in adjusting insulins can increase exercise safety andance

insulin therapy allows optimal flexibilitycuracy of insulin dose adjustments

with the time course of insulin actionlivery methods is necessary before

advice about insulin adjustments50% reduction in the dosage of insulin

during the time of exercise is generallyd as a safe starting guidelinep to 80%) reductions may be needed fored or extreme exercises in insulin dosages may be necessaryextended time (up to 36 hours) afteror prolonged exercise

ntal insulin may be indicated to correctrcise hyperglycemia [BG�240 mg/dLmol/L)] prior to initiation of exercise.

ntal insulin to correct transient BGns following intense, short- duratione is not generally indicated

Frequent SMBGc before, during,and after exercise helpsdetermine glycemic responsesto exercise, appropriate self-management decisions, andthe effectiveness of thesedecisions

SMBG should be performed every1 to 2 hours postexercise toassess the BG response toactivity and support decisionsabout adjustments in foodintake and insulin dosages

Frequent postexercise monitoring,including during the night (eg,at 3:00 AM), is an advisableprecautionary measure forpreventing delayed-onsethypoglycemia

t and prevention plans. aMNT�medical nutrition therapy. bBG�bloodlucose uptake by 8.4 to 12.6 g/h during moderate exercise.

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emen

entrations (53) and appetite postprandially (54). Exercis-

Supplement to the Journal of the AMERICAN DIETETIC ASSOCIATION S21

Page 4: Role of Physical Activity in Diabetes Management and Prevention

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ng postprandially can also lower risk of exercise-relatedypoglycemia for those at risk for this complication.

IABETES MEDICAL NUTRITION THERAPY AND EXERCISE FORPTIMAL GLYCEMIC CONTROLhen advising individuals with diabetes, it is important

o emphasize that meal planning plus physical activity,hen combined with glucose-lowering medications, can

ead to an optimal glucose-lowering effect in addition tother health benefits (55). The Figure summarizes guide-ines to consider when advising individuals with type 1 orype 2 diabetes about integrating physical activity into anndividualized plan for optimal diabetes management.

LUCOSE MONITORING AND PATTERN MANAGEMENTelf-monitoring of blood glucose, careful record-keeping,nd recognition of glucose patterns with exercise are im-ortant skills that enhance the ability of the individualith diabetes to self-adjust his or her management forptimal exercise safety and peak performance (8,11,16).onitoring should be done regularly preexercise, and

uring and after prolonged or “unusual” activity. Fre-uent monitoring helps to identify the possibility of hy-oglycemia or hyperglycemia occurring during or afterxercise and thus reduces risk of these acute complica-ions. Frequent monitoring also provides useful informa-ion about glycemic response to activity and guides sub-equent adjustment decisions.Introduction of continuous glucose-monitoring technol-

gy as a tool to support diabetes management may im-rove understanding of glucose patterns in varying exer-ise situations (56,57). Because sensors identifyownward or upward glucose trends and rate of change inlucose levels, and have alarm features that signal pre-icted hypo- or hyperglycemia, they potentially havenique utility when information gathered from sensorse augments data gathered by self-monitoring of bloodlucose and is applied to improve an individual’s self-anagement decisions with exercise. Perhaps of greatest

mportance, continuous glucose monitoring can enablendividuals with diabetes to take early action to preventr reduce the severity and length of an episode of exer-ise-related hypo- or hyperglycemia (56,57).

ONCLUSIONphysically active lifestyle plays a vital role in both

anagement of type 1 diabetes and prevention and man-gement of type 2 diabetes. Benefits of physical activityre numerous and include aiding weight loss and weightaintenance and improving the insulin/glucose profile

or people with prediabetes, glycemic control in individu-ls with type 2 diabetes, and quality of life for all indi-iduals. Of particular importance for people with diabe-es or at risk is a reduction of cardiovascular risk factorsnd all-cause mortality (18,19,35). Although the indepen-ent effect of physical activity in diabetes prevention isot known, its role as a key component of a lifestyle

ntervention that also includes dietary modification andeight loss has been well-documented.Regarding diabetes treatment, more work is needed to

erfect the integration of exercise and insulin therapy.

22 April 2008 Suppl 1 Volume 108 Number 4

urrent guidelines for insulin adjustment are based onmall-scale studies, many that were done prior to devel-pment of the rapid and long-acting insulin types nowidely used. Short-term studies tend to focus on specificetabolic mechanisms by which physical activity im-

roves glycemic control or contributes to development ofypoglycemia, and findings may not necessarily translate

nto recommendations for practice.The RD plays an important role in informing, motivating,

nd supporting all individuals, including those with diabe-es and prediabetes, in their efforts to make positive life-tyle changes for improved health. Offering advice abouthysical activity is an essential part of lifestyle recommen-ations and should be offered at an appropriate level basedn careful preexercise evaluation. Exercise guidelines andesources established by recognized sources, including theS Surgeon General (1), American College of Sports Medi-

ine (6,22,24,48), American Heart Association (15,18), andhe American Diabetes Association (2,16,25,47), should berawn upon to assure appropriateness, accuracy, and safetyf physical activity recommendations.

TATEMENT OF CONFLICT OF INTEREST: The au-hors have no conflict of interest to report with the spon-or of this supplement article or products discussed inhis article.

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