P O S I T I O N S T A T E M E N T Physical Activity/Exercise and

Physical Activity/Exercise and Diabetes

AMERICAN DIABETES ASSOCIATION

D
uring physical activity, whole-body of glucose and other substrates induced by an exercise program, the individual with
oxygen consumption may increase physical activity, and hypoglycemia may diabetes mellitus should undergo a de-
by as much as 20-fold, and even ensue. Similar concerns exist in patients tailed medical evaluation with appropri-
greater increases may occur in the work- with type 2 diabetes on insulin or ate diagnostic studies. This examination
ing muscles. To meet its energy needs sulfonyl- urea therapy; however, in should carefully screen for the presence
un- der these circumstances, skeletal general, hypogly- cemia during physical of macro- and microvascular

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muscle uses, at a greatly increased rate, activity tends to be less of a problem in complications that may be worsened by
its own stores of glycogen and this population. Indeed, in patients with the exercise pro- gram. Identification of
triglycerides, as well as free fatty acids type 2 diabetes, physical activity may areas of concern will allow the design of
(FFAs) derived from the breakdown of improve insulin sensitivity and assist in an individualized exercise prescription
adipose tissue triglycerides and glucose diminishing elevated blood glucose levels that can minimize risk to the patient.
released from the liver. To preserve into the normal range. Most of the following recommendations
central nervous sys- tem function, blood The purpose of this position state- are excerpts from The Health
glucose levels are re- markably well ment is to update and crystallize current Professional’s Guide to Diabetes and
maintained during physical activity. thinking on the role of physical activity in Exercise (3).
Hypoglycemia during physical activity patients with types 1 and 2 diabetes. A careful medical history and physi-
rarely occurs in nondia- betic With the publication of new clinical cal examination should focus on the
individuals. The metabolic adjust- ments reviews, it is becoming increasingly clear symptoms and signs of disease affecting
that preserve normoglycemia during that phys- ical activity may be a the heart and blood vessels, eyes,
physical activity are in large part therapeutic tool in a variety of patients kidneys, feet, and nervous system.
hormonally mediated. A decrease in with, or at risk for dia- betes, but that
plasma insulin and the presence of gluca- like any therapy its effects must be Cardiovascular system
gon appear to be necessary for the early thoroughly understood (1–3). From a A graded exercise test may be helpful if a
increase in hepatic glucose production practical point of view, this means that patient, about to embark on a moderate-
during physical activity, and during pro- the diabetes health care team will be to high-intensity physical activity pro-
longed exercise, increases in plasma required to understand how to analyze gram (Table 1) (4 – 6), is at high risk for
gluca- gon and catecholamines appear to the risks and benefits of physical activity underlying cardiovascular disease, based
play a key role. These hormonal in a given patient. Furthermore, the team, on one of the following criteria:
adaptations are essentially lost in insulin- consisting of but not limited to the
deficient patients with type 1 diabetes. physi- cian, nurse, dietitian, mental ● Age 35 years
As a consequence, when such individuals health pro- fessional, and patient, will ● Age 25 years and
have too little insulin in their circulation benefit from working with an individual Type 2 diabetes of 10 years’ dura-
due to inadequate ther- apy, an excessive with knowl- edge and training in tion
release of counterinsulin hormones during exercise physiology. Finally, it has also Type 1 diabetes of 15 years’ dura-
physical activity may in- become clear that it will be the role of tion
crease already high levels of glucose and this team to educate primary care ● Presence of any additional risk factor
ke- tone bodies and can even physicians and others involved in the for coronary artery disease
precipitate diabetic ketoacidosis. care of a given patient. ● Presence of microvascular disease (pro-
Conversely, the pres- ence of high levels of liferative retinopathy or nephropathy,
insulin, due to exoge- nous insulin including microalbuminuria)
administration, can attenuate or even EVALUATION OF THE PATIENT ● Peripheral vascular disease
prevent the increased mobilization BEFORE EXERCISE — Before increas-
ing usual patterns of physical activity or
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● © 2004 by the American Diabetes Association.
The recommendations in this paper are based on the evidence reviewed in the following publications:
Exercise and NIDDM (Technical Review). Diabetes Care 13:785–789, 1990; and Exercise in individuals with
IDDM (Technical Review). Diabetes Care 17:924 –937, 1994.
Originally approved February 1990. Most recent review/revision, 2002.
The initial draft of this revision was prepared by Bernard Zinman, MD (co-chair); Neil Ruderman,
MD, DPhil (co-chair); Barbara N. Campaigne, PhD; John T. Devlin, MD; and Stephen H. Schneider,
MD. The paper was peer-reviewed, modified, and approved by the Professional Practice Committee and the
Executive Committee, June 1997, as well as by the American College of Sports Medicine’s Pronouncements
Committee and Board of Trustees, July 1997.
Guidelines of the American Diabetes Association and the American College of Sports Medicine.
Abbreviations: CAN, cardiac autonomic neuropathy; ECG, electrocardiogram; FFA, free fatty acid;
PAD, peripheral arterial disease; PDR, proliferative diabetic retinopathy; PN, peripheral neuropathy.
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● Autonomic neuropathy
Physical Activity/Exercise and
In some patients who exhibit nonspe- cific electrocardiogram (ECG) changes in
response to exercise, or who have nonspe- cific ST and T wave changes on the resting
ECG, alternative tests such as radionu- clide stress testing may be performed. In
patients planning to participate in low- intensity forms of physical activity
( 60% of maximal heart rate) such as walking, the physician should use clinical

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 Physical Activity/Exercise and
judgment in deciding whether to recom- Table 1—Classification of physical activity intensity, based on physical activity lasting up to
mend an exercise stress test. Patients 60 min
with known coronary artery disease
should undergo a supervised evaluation
Relative intensity
of the ischemic response to exercise,
ischemic threshold, and the propensity Intensity Vo2max (%) Maximal heart rate (%)* RPE†
to arrhyth- mia during exercise. In
many cases, left ventricular systolic Very light 20 35
function at rest and during its response Light 20–39
10 35–54 10–11
to exercise should be assessed. Moderate 40–59 55–69 12–13
Hard 60–84 70–89 14–16
Peripheral arterial disease Very hard 85 90 17–19
Maximal‡ 100 100 20
Evaluation of peripheral arterial disease
Modified by Haskell and Pollock from Physical Activity and Health: A Report of the Surgeon General (4).
(PAD) is based on signs and symptoms, *Maximal heart rate (HRmax) 220 age (Note: It is preferable and recommended that HRmaxbe measured
including intermittent claudication, cold during a maximal graded exercise test when possible); †Borg rating of relative perceived exertion (RPE) 6 –
feet, decreased or absent pulses, atrophy 20 scale; ‡maximal values are mean values achieved during maximal exercise by healthy adults.

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of subcutaneous tissues, and hair loss. The
ba- sic treatment for intermittent
claudication is
nonsmoking and a supervised physical ac- of activity, high-intensity or strenuous ical activity should probably be discour-
tivity program. The presence of a dorsalis phys- aged in these individuals unless blood
pedis and posterior tibial pulse does not pressure is carefully monitored during
rule out ischemic changes in the forefoot. exercise.
If there is any question about blood flow
to the forefoot and toes on physical Neuropathy: peripheral
examina- tion, toe pressures as well as Peripheral neuropathy (PN) may result in
Doppler pres- sures at the ankle should be loss of protective sensation in the feet. Sig-
carried out. nificant PN is an indication to limit weight-
bearing exercise. Repetitive exercise on
Retinopathy insensitive feet can ultimately lead to ulcer-
The eye examination schedule should ation and fractures. Evaluation of PN can be
fol- low the American Diabetes made by checking the deep tendon reflexes,
Association’s Clinical Practice vibratory sense, and position sense. Touch
Recommendations. For patients who sensation can best be evaluated by using
have proliferative diabetic retinopathy monofilaments. The inability to detect sen-
(PDR) that is active, strenu- ous activity sation using the 5.07 (10 g) monofilament is
may precipitate vitreous hem- orrhage or indicative of the loss of protective sensation.
traction retinal detachment. These Table 3 lists contraindicated and recom-
individuals should avoid anaerobic mended physical activity for patients with
exercise and physical activity that in- loss of protective sensation in the feet.
volves straining, jarring, or Valsalva-like
maneuvers. Neuropathy: autonomic
On the basis of the Joslin Clinic The presence of autonomic neuropathy
experi- ence, the degree of diabetic may limit an individual’s physical activity
retinopathy has been used to stratify the capacity and increase the risk of an ad-
risk of physical ac- tivity and to verse cardiovascular event during physi-
individually tailor the physical activity cal activity. Cardiac autonomic neuropathy
prescription. Table 2 is reproduced, with (CAN) may be indicated by resting tachy-
minor modifications, from The Health cardia ( 100 beats per minute), orthos-
Professional’s Guide to Diabetes and tasis (a fall in systolic blood pressure 20
Exercise (3). mmHg upon standing), or other distur-
bances in autonomic nervous system
Nephropathy function involving the skin, pupils, gas-
Specific physical activity recommenda- trointestinal, or genitourinary systems.
tions have not been developed for pa- Sudden death and silent myocardial isch-
tients with incipient (microalbuminuria emia have been attributed to CAN in
20 mg/min albumin excretion) or overt diabetes. Resting or stress thallium myo-
nephropathy ( 200 mg/min). Patients cardial scintigraphy is an appropriate
with overt nephropathy often have a re- noninvasive test for the presence and ex-
duced capacity for physical activity, tent of macrovascular coronary artery dis-
which leads to self-limitation in activity ease in these individuals. Hypotension
level. Although there is no clear reason
to limit low- to moderate-intensity forms
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 Physical Activity/Exercise and
and hypertension after vigorous physical
activity are more likely to develop in
pa- tients with autonomic neuropathy,
par- ticularly when starting a physical
activity program. Because these
individuals may have difficulty with
thermoregulation, they should be
advised to avoid physical activity in hot
or cold environments and to be vigilant
about adequate hydration.

PREPARING FOR EXERCISE —

Preparing the individual with diabetes
for a safe and enjoyable physical activity
pro- gram is as important as physical
activity itself. The young individual in
good met- abolic control can safely
participate in most activities. The
middle-aged and older individual with
diabetes should be encouraged to be
physically active. The aging process
leads to a degeneration of muscles,
ligaments, bones, and joints, and
disuse and diabetes may exacerbate the
problem. Before beginning any phys-
ical activity program, the individual with
diabetes should be screened thoroughly
for any underlying complications as de-
scribed above.
A standard recommendation for dia-
betic patients, as for nondiabetic
individu- als, is that physical activity
includes a proper warm-up and cool-
down period. A warm-up should consist
of 5–10 min of aer- obic activity (walking,
cycling, etc.) at a low- intensity level. The
warm-up session is to prepare the
skeletal muscles, heart, and lungs for a
progressive increase in exercise intensity.
After a short warm-up, muscles should
be gently stretched for another 5–10 min.
Primarily, the muscles used during the
active physical activity session should be
stretched, but warming up all muscle
groups is optimal. The active warm-up
can

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 Position Physical Activity/Exercise and

Table 2—Considerations for activity limitation in diabetic retinopathy (3)

Level of DR Acceptable activities Discouraged activities Ocular reevaluation

No DR Dictated by medical status Dictated by medical status 12 months

Mild NPDR Dictated by medical status Dictated by medical status 6–12 months
Moderate NPDR Dictated by medical status Activities that dramatically elevate blood 4–6 months
pressure
Power lifting
Heavy Valsalva
Severe NPDR Dictated by medical status Activities that substantially increase 2–4 months
systolic blood pressure, Valsalva (may require
maneuvers, and active jarring laser surgery)
Boxing
Heavy competitive sports

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PDR Low-impact, cardiovascular Strenuous activities, Valsalva 1–2 months
conditioning maneuvers, pounding or jarring (may require
Swimming Weight lifting laser surgery)
Walking Jogging
Low-impact aerobics High-impact aerobics
Stationary cycling Racquet sports
Endurance exercises Strenuous trumpet playing
DR, diabetic retinopathy; NPDR, nonproliferative diabetic retinopathy.

either take place before or after stretching. maximal amount of fluid tolerated. and were most marked in patients with
After the activity session, a cool-down Precau- tions should be taken when mild type 2 diabetes and in those who
should be structured similarly to the exercising in extremely hot or cold are likely to be the most insulin
warm- up. The cool-down should last environments. High- resistance exercise resistant. It remains true, unfortunately,
about 5–10 min and gradually bring the using weights may be ac- ceptable for that most of these studies suffer from
heart rate down to its pre-exercise level. young individuals with diabetes, but inadequate ran- domization and
There are several considerations that not for older individuals or those with controls, and are con- founded by
are particularly important and specific for long-standing diabetes. Moder- ate weight associated lifestyle changes. Data on the
the individual with diabetes. Aerobic phys- training programs that utilize light effects of resistance exercise are not
ical activity should be recommended, but weights and high repetitions can be used available for type 2 diabetes al- though
taking precautionary measures for for maintaining or enhancing upper body early results in normal individuals and
physical activity involving the feet is strength in nearly all patients with di- patients with type 1 disease suggest a
essential for many patients with diabetes. abetes. beneficial effect.
The use of sil- ica gel or air midsoles as It now appears that long-term pro-
well as polyester or blend (cotton- EXERCISE AND TYPE 2 grams of regular physical activity are indeed
polyester) socks to prevent blisters and DIABETES — The possible benefits of feasible for patients with impaired glucose
keep the feet dry is important for physical activity for the patient with type tolerance or uncomplicated type 2
minimizing trauma to the feet. Proper 2 diabetes are substantial, and recent diabetes with acceptable adherence
footwear is essential and must be empha- studies strengthen the importance of rates. Those studies with the best
sized for individuals with PN. Individuals long-term physical activity programs for adherence have used an initial period of
must be taught to monitor closely for the treatment and prevention of this supervision, followed by relatively
blis- ters and other potential damage to common metabolic abnormality and its informal home physical activity
their feet, both before and after physical complications. Specific metabolic effects
activity. A di- abetes identification can be highlighted as fol- lows.
bracelet or shoe tag should be clearly Table 3—Exercises for diabetic patients
visible when exercising. Proper hydration Glycemic control with loss of protective sensation
is also essential, as dehy-
dration can affect blood glucose levels and Several long-term studies have demon- Contraindicated Recommended
heart function adversely. Physical activity strated a consistent beneficial effect of exercise exercise
in heat requires special attention to regular physical activity training on car-
maintain-
ing hydration. Adequate hydration prior to compensate for losses in sweat reflected bohydrate metabolism and insulin sensi-
physical activity is recommended (e.g., 17 in body weight loss, or the tivity, which can be maintained for at least
ounces of fluid consumed 2 h before 5 years. These studies used physical activ-
phys- ical activity). During physical ity regimens at an intensity of 50 – 80%
activity, fluid should be taken early and Vo2max three to four times a week for
frequently in an amount sufficient to 30 – 60 min a session. Improvements in
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 Position Treadmill Swimming Physical Activity/Exercise and
HbA1c were generally 10 –20% of baseline
Prolonged walking Bicycling
Jogging Rowing
Step exercises Chair exercises
Arm exercises
Other non-weight-bearing
exercise

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 Position Physical Activity/Exercise and
programs with regular, frequent follow-up Obesity flexibility to make appropriate insulin
assessments. A number of such programs Data have accumulated suggesting that dose adjustments for various activities.
have demonstrated sustained relative im- physical activity may enhance weight loss The rigid recommendation to use carbo-
provements in Vo2max over many years and, in particular, weight maintenance hydrate supplementation, calculated
with little in the way of significant when used along with an appropriate from the planned intensity and duration
complications. calorie- controlled meal plan. There are of physical activity, without regard to gly-
few studies specifically dealing with this cemic level at the start of physical
Prevention of cardiovascular disease issue in type 2 diabetes, and much of the activity, the previously measured
In patients with type 2 diabetes, the available data is complicated by the metabolic re- sponse to physical
insulin resistance syndrome continues to simultaneous use of un- usual diets and activity, and the pa- tient’s insulin
gain sup- port as an important risk factor other behavioral interven- tions. Of therapy, is no longer appropriate.
for prema- ture coronary disease, particular interest are studies suggesting Such an approach not infre- quently
particularly with concomitant a disproportionate effect of physical neutralizes the beneficial glyce- mic
hypertension, hyperinsulin- emia, central activity on loss of intra-abdominal fat, the lowering effects of physical activity in
obesity, and the overlap of metabolic presence of which has been associ- ated patients with type 1 diabetes.
abnormalities of hypertriglyceri- demia, most closely with metabolic abnormal- General guidelines that may prove

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low HDL, altered LDL, and elevated FFA. ities. Data on the use of resistance exercise helpful in regulating the glycemic response
Most studies show that these patients have in weight reduction are promising, but to physical activity can be summarized as
a low level of fitness compared with studies in patients with type 2 diabetes, in follows:
control patients, even when matched for particu- lar, are lacking.
levels of ambient activity, and that poor 1. Metabolic control before physical ac-
aer- obic fitness is associated with many Prevention of type 2 diabetes tivity
of the cardiovascular risk factors. A great deal of evidence has been
Improvement in many of these risk factors accumu- lated supporting the ● Avoid physical activity if fasting glucose
has been linked to a decrease in plasma hypothesis that physical activity, levels are 250 mg/dl and ketosis is
insulin levels, and it is likely that many of among other therapies, may be useful in present, and use caution if glucose
the beneficial effects of physical activity preventing or delaying the onset of type lev- els are 300 mg/dl and no
on cardiovascular risk are related to 2 diabetes. There are now three ketosis is present.
improvements in insulin sensitiv- ity. published trials documenting that with ● Ingest added carbohydrate if glucose
lifestyle modification (weight loss, levels are 100 mg/dl.
Hyperlipidemia regular moderate physical activity),
Regular physical activity has consistently diabetes can be delayed or prevented (7– 2. Blood glucose monitoring before and
been shown to be effective in reducing 9). after physical activity
lev- els of triglyceride-rich VLDL.
However, ef- fects of regular physical EXERCISE AND TYPE 1 ● Identify when changes in insulin or
activity on levels of LDL cholesterol have DIABETES — All levels of physical ac- food intake are necessary.
not been consistently documented. With tivity, including leisure activities, recre- ● Learn the glycemic response to differ-
one major exception, most studies have ational sports, and competitive ent physical activity conditions.
failed to demonstrate a significant professional performance, can be
improvement in levels of HDL in patients performed by people with type 1 diabetes 3. Food intake
with type 2 diabetes, perhaps be- cause of who do not have com- plications and are
the relatively modest exercise in- tensities in good blood glucose control (note ● Consume added carbohydrate as
used. previous section). The ability to adjust the needed to avoid hypoglycemia.
therapeutic regimen (insulin and medical ● Carbohydrate-based foods should be
Hypertension nutrition therapy) to allow safe readily available during and after phys-
There is evidence linking insulin resis- participation and high performance has re- ical activity.
tance to hypertension in patients. Effects cently been recognized as an important
of physical activity on reducing blood management strategy in these individuals. Because diabetes is associated with an in-
pressure levels have been demonstrated In particular, the important role played by creased risk of macrovascular disease,
most consistently in hyperinsulinemic the patient in collecting self-monitored the benefit of physical activity in
subjects. blood glucose data of the response to improving known risk factors for
physical ac- tivity and then using these atherosclerosis is to be highly valued.
Fibrinolysis data to improve performance and This is particularly true in that physical
Many patients with type 2 diabetes have enhance safety is now fully accepted. activity can improve the lipoprotein
im- paired fibrinolytic activity associated Hypoglycemia, which can occur dur- profile, reduce blood pres- sure, and
with elevated levels of plasminogen ing, immediately after, or many hours improve cardiovascular fitness. However,
activator in- hibitor-1 (PAI-1), the major af- ter physical activity, can be avoided. it must also be appreciated that several
naturally oc- curring inhibitor of tissue This requires that the patient has both an studies have failed to show an in-
plasminogen activator (t-PA). Studies have ade- quate knowledge of the metabolic dependent effect of physical activity train-
demonstrated an association of aerobic and hormonal responses to physical ing on improving glycemic control as
fitness and fibrino- lysis. There is still no activity and well-tuned self- measured by the A1C test in patients
clear consensus on whether physical management skills. The increasing use with type 1 diabetes. Indeed, these
training results in im- proved fibrinolytic of intensive insulin therapy has studies
activity in these patients. provided patients with the
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 Position Physical Activity/Exercise and
have been valuable in changing the eral population, and an acceptable Care 13:785–789, 1990
focus for physical activity in diabetes incidence of complications. It is likely 2. Wasserman DH, Zinman B: Exercise in
from glu- cose control to that of an that maintaining better levels of fitness in individuals with IDDM (Technical Re-
important life behavior with multiple this population will lead to less chronic view). Diabetes Care 17:924 –937, 1994
benefits. The chal- lenge is to develop 3. Devlin JT, Ruderman N. Diabetes and ex-
vascular disease and an improved quality
strategies that allow individuals with ercise: the risk-benefit profile revisited. In
of life. Handbook of Exercise in Diabetes. Ruder-
type 1 diabetes to partic- ipate in
man N, Devlin JT, Schneider SH, Krisra
activities that are consistent with their A, Eds. Alexandria, VA, American
lifestyle and culture in a safe and CONCLUSIONS — The recent Sur- Diabetes Association, 2002
enjoyable manner. geon General’s Report on Physical 4. U.S. Department of Health and Human
In general, the principles recom- Activity and Health (4) underscores the Services: Physical Activity and Health: A
mended for dealing with physical pivotal role physical activity plays in Re- port of the Surgeon General. Centers
activity in adults with type 1 diabetes, health promotion and disease prevention. for Disease Control and Prevention,
free of com- plications, apply to children, It recommends that individuals National Center for Chronic Disease
with the ca- veat that children may be Prevention and Health Promotion,
accumulate 30 min of moderate physical
prone to greater variability in blood Washington, DC, U.S. Govt. Printing
activity on most days of the week. In the

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Office, 1996
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the gen-

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