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Physical activity and exercise in the management of type 2 diabetes: where to start?

Corresponding Author

Deirdre Harrington PhD

[email protected]

Diabetes Research Centre, University of Leicester, UK

Psychological Sciences and Health, University of Strathclyde, Glasgow, UK

Correspondence to: Deirdre Harrington, PhD, Room 676 Graham Hills Building, 40 George Street, Glasgow G1 1QE, UK; email: [email protected]Search for more papers by this author

Joe Henson PhD,

Joe Henson PhD

Diabetes Research Centre, University of Leicester, UK

NIHR Leicester Biomedical Research Centre, Leicester, UK

Search for more papers by this author

Deirdre Harrington PhD,

Corresponding Author

Deirdre Harrington PhD

[email protected]

Diabetes Research Centre, University of Leicester, UK

Psychological Sciences and Health, University of Strathclyde, Glasgow, UK

Correspondence to: Deirdre Harrington, PhD, Room 676 Graham Hills Building, 40 George Street, Glasgow G1 1QE, UK; email: [email protected]Search for more papers by this author

Joe Henson PhD,

Joe Henson PhD

Diabetes Research Centre, University of Leicester, UK

NIHR Leicester Biomedical Research Centre, Leicester, UK

Search for more papers by this author

First published: 04 October 2021

https://doi.org/10.1002/pdi.2361

Citations: 4

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Abstract

Physical activity is a fundamental therapeutic aid in the management of type 2 diabetes (T2D). Regular engagement elicits a plethora of adaptations which leads to improvements in clinical outcomes, such as HbA_1c, lipids and blood pressure as well as whole body health and physical function benefits. Those with T2D are encouraged to engage in a minimum of 150 minutes/week of moderate-intensity physical activity (or 75 minutes/week of vigorous activity). Current recommendations also suggest that this should be supplemented with two-to-three resistance, flexibility and/or balance training sessions/week. The latter is particularly encouraged for older individuals or those with limited mobility/poor physical function. Those with T2D are also encouraged to break up prolonged bouts of sitting.

However, a large proportion of the general population do not meet current physical activity guidelines, with the figure even lower in those with T2D. Getting started and sustaining a physically active lifestyle is challenging. Therefore, this article aims to provide health care professionals with the information required to tailor guidance to individuals with T2D by: presenting an overview of current guidelines, terminology and benefits; discussing the risk of adverse events; precautions when exercising with complications; practical options for getting started and how to tailor advice in primary care.

Where appropriate, individual preferences and motivations should inform decision making regarding exercise modality in order to maximise compliance. That said, the overarching message is that any physical activity is better that none, but more is better especially when combined with a reduction in sitting. Copyright © 2021 John Wiley & Sons.

Introduction

Physical activity is at the cornerstone of the lifestyle management of type 2 diabetes (T2D).¹ Regular physical activity is associated with substantially lower cardiovascular and overall mortality risk.^{2, 3} Getting started and sustaining a physically active lifestyle is challenging, particularly for those with established T2D.⁴ Data from England show that in the general population 37% of adults are not meeting current guidelines.⁵ For those with long-term conditions⁵ and established T2D physical activity is lower.^{6, 7} The COVID-19 pandemic has reminded us of the ongoing physical inactivity pandemic that should not be ignored.⁸ There is evidence of an unprecedented drop in physical activity during lockdown in the general population⁹ and those with T2D.¹⁰ We believe that physical activity will be focused on more than ever due to links between obesity and COVID-19,¹¹ motivated by the UK Prime Minister's ‘war against fat’¹² and will predominantly be looking to solve the negative fall outs from COVID-19.

This paper aims to present accessible information for health care professionals (HCPs) on concepts related to physical activity including the physiological benefits, safety considerations and practical options for supporting those wishing to bring regular physical activity into their lives.

Commonly used terms

The movement of the body in space is a simple concept yet the variety of terms related to physical activity has the potential to confuse or alienate those wishing to get active. Physical activity in its most basic definition is any substantial movement produced by skeletal muscles¹³ with movements done during daily household chores, occupation and active transport falling under this umbrella. Exercise is a sub-category of physical activity and is typically planned, repetitive and structured, with the purpose of improving or maintaining fitness.¹⁴ Most physical activity that will be recommended to those with T2D will be aerobic in nature with a view to building cardiorespiratory fitness. This is a measure of the functional capabilities of the heart, lungs and muscles relative to the demands of specific exercise routines. It allows us to carry out daily tasks and routine physical activities without undue fatigue or getting out of breath. At the other end of the movement continuum are sedentary behaviours which are any waking behaviours with a low energy expenditure done while in a sitting, reclining or lying posture.¹⁵ In order to aid interpretation, examples of the commonly used terms are presented in Table 1.

Table 1. A summary of the different modes of activity, examples and their desirable intensity. (Adapted from Garber et al., 2011)⁷⁴

		Sedentary behaviours	Light intensity	Moderate intensity	Vigorous intensity	Resistance activities	Flexibility/balance activities
Intensity (ranging from initial introduction to optimal intensity)	% VO₂ peak	–	37–40	46–63	64–90	–	–
	% HR max	–	57–63	64–76	77–95	–	–
	Borg RPE	6–8	9–11	12–13	14–17	9–15	9–13
	METs	≤1.5	>1.5–2.9	3.0–5.9	≥6.0	2.0 to ≥6.0	2.0–4.0
	1-RM	≤1.5	30–49	50–69	≥70	40–60	20–50
	Definition	Any waking behaviour characterised by any low energy expenditure ≤1.5 METs, while in a sitting, reclining or lying posture⁴⁷	Activities that require standing up and moving around, either in the home, workplace or community. Can also include activities of daily living	This level of activity can be defined by the ‘talk test’: being able to talk but not sing indicates moderate intensity activity. Conversely, having difficulty talking without pausing is a sign of vigorous activity	An activity that requires a large amount of effort and causes rapid breathing and substantial increases in heart rate. This category also includes high intensity interval exercise – a very vigorous intensity activity performed in short bouts interspersed with breaks	Any activity that makes your muscles work harder than usual. The activities involve using your body weight or working against a resistance	Flexibility and balance exercises are activities that improve the ability of a joint to maintain the movement necessary for carrying out daily tasks and physical activity
		• Sitting or lying while watching TV • Sitting at a desk or computer	• Standing • Light housework • ‘Pottering’	• Brisk walking • Water aerobics • Heavier housework	• Running, sprinting • Fast cycling • Swimming	• Lifting weights • Squats • Lifting/carrying children or groceries	• Yoga • Pilates • Heel to toe walking • One leg stand
% VO₂ peak: peak oxygen consumption. % HR max: percentage of maximal heart rate. RPE: rating of perceived exertion.⁴⁸ METs: metabolic equivalents of task. One MET is defined as the energy used when at rest. Therefore, an activity with a MET value of 3 means exerting 3 times the energy than you would if you were sitting still. 1-RM: 1-repetition maximum is the heaviest weight that can be successfully lifted once through the complete range of motion and using the correct technique. 1-RM should be determined for each exercise that is contained within a resistance training programme.

T2D-related physical activity recommendations

Regular physical activity and structured exercise are recommended for individuals with T2D, unless otherwise contraindicated (see ‘safety considerations’ section below).² Those with T2D are encouraged to undertake a minimum of 150 minutes/week of moderate intensity physical activity³ in bouts of at least 10 minutes and spread over ≥ three days/week.^{2, 16} Vigorous intensity can be substituted in for moderate intensity in those who are already physically active, with a minimum of 75 minutes/week suggested.^{2, 16} This should be supplemented with two-to-three resistance, flexibility and/or balance training sessions/week. The latter is particularly encouraged for older individuals or those with limited mobility/poor physical function. Indeed, some 29% of 635 adults (median age 66 years) with T2D have impaired physical function with their ability to carry out functional tasks of daily living similar to those without diabetes who are over a decade older.¹⁷ Sarcopenia and frailty risk is greater in individuals with T2D via impaired balance, reduced flexibility, decreased muscle mass and muscle quality compared to healthy age-matched controls.^18-20 This in turn reduces quality of life and the ability to perform activities of daily living.

These recommendations are similar to the UK Chief Medical Officers’ guidelines for the general population (18–64 years) and older adults (65 years+).²¹ The recently published World Health Organisation (WHO) guidelines state that those with chronic disease (e.g. T2D) may increase moderate intensity aerobic activity to >300 minutes (or >150 minutes of vigorous intensity physical activity per week,²² for additional health benefits). Sedentary behaviours should also be limited with the American Diabetes Association (ADA) guidelines suggesting that prolonged periods of sitting should be interrupted at least every 30 minutes.² This specific recommendation may serve as an effective behavioural goal in those wishing to reduce prolonged periods of sedentary behaviour. Conversely, the WHO and UK guidelines around sedentary behaviour are more conservative, with no recommendations made regarding sedentary duration and frequency. However, they do suggest that limiting sedentary behaviour and simultaneously increasing moderate-to-vigorous physical activity is important.²³ A summary of these guidelines can be found in Table 2.

Table 2. Summary of physical activity recommendations for those with type 2 diabetes and for the general population

	American Diabetes Association guidelines (type 2 diabetes)²	WHO guidelines (those living with chronic conditions)²²	UK – Chief Medical Officers’ guidelines²¹
Sedentary behaviour	All patients should reduce their daily levels of sedentary behaviour. In particular, prolonged sitting should be interrupted at least every 30 minutes with either light or moderate activity	Limit the amount of time spent being sedentary. In parallel, all adults should also aim for the recommended levels of moderate to vigorous intensity physical activity	Adults should aim to minimise the amount of time spent being sedentary
Light intensity exercise	Increasing active tasks of daily living should be recommended to all. This intensity of exercise may also be used as the initial focus or as an introduction to exercise in previously inactive individuals	No specific recommendations, although it is promulgated as a viable form of activity to break up sedentary behaviour	No specific recommendations, although it can be used to break up prolonged periods of inactivity/sedentary behaviour
Moderate intensity exercise	A minimum of 150 minutes per week, not allowing more than 2 days to elapse between exercise sessions	At least 150–300 minutes per week. Potential to increase moderate intensity aerobic physical activity to >300 minutes per week	Each week, adults should accumulate at least 150 minutes of moderate intensity activity
Vigorous intensity exercise	Potential to be used as an alternative to moderate intensity aerobic exercise provided a minimum of 75 minutes per week is undertaken	At least 75–150 minutes OR an equivalent combination of moderate and vigorous intensity exercise	75 minutes of vigorous intensity activity; or even shorter durations of very vigorous intensity activity OR a combination of moderate, vigorous and very vigorous intensity activity
Resistance exercise	2–3 sessions per week performed on non-consecutive days, with 8–10 exercises per session. 1–3 sets of each exercise should be performed, reaching ‘near-fatigue’ by the end of each set	Muscle-strengthening activities at moderate or greater intensity (involving all major muscle groups) on 2 or more days a week	Adults should do activities to develop or maintain strength in the major muscle groups. Muscle strengthening activities should be done at least 2 days a week, but any strengthening activity is better than none
Flexibility	2–3 sessions per week focusing on major muscle-tendon groups. Strongly recommended for patients aged 50 years or more, or those with peripheral neuropathy	Older adults should undertake multicomponent physical activity with a specific focus on ≥3 days a week. Functional balance and strength training should be performed at a moderate intensity (as a minimum) in order to enhance physical function	Older adults (>65). Older adults should maintain or improve their physical function by undertaking activities aimed at improving or maintaining muscle strength, balance and flexibility on at least 2 days a week

Benefits of physical activity in those with established T2D

A summary of the modes of exercise, examples and optimal intensities can be found in Table 1.

Aerobic activities

Regular engagement in moderate intensity aerobic activity induces a plethora of physiological adaptations including (but not limited to): increased mitochondrial density; improvements in peak oxygen uptake; insulin sensitivity; cardiac output; and an increase in oxidative enzymes.^{2, 16} In turn, this leads to improvements in clinical outcomes, such as reductions in HbA_1c, lipids, blood pressure, and insulin resistance.^{24, 25} A dose-response relationship exists, whereby higher intensity activities provide additional cardiorespiratory fitness and metabolic control benefits.^{26, 27} As little as a single session (~60 minutes) of moderate intensity exercise can improve glycaemic control for up to 48 hours, through both insulin- dependent and insulin-independent mechanisms.²⁸ At the other end of the activity spectrum, low intensity aerobic activities (lasting longer than 60 minutes) have been shown to enhance insulin action in obese, insulin-resistant adults for at least 24 hours.²⁹ Taken together, the observed glycaemic benefits may be largely attributed to the cumulative effects of each bout of exercise rather than the response to prolonged exercise training, per se.

Resistance exercise

T2D reflects a powerful physiological model of accelerated biological aging that impacts on whole body health and function.³⁰ Resistance exercises, or strength training, build muscular strength and are generally found to improve insulin sensitivity and glucose tolerance by upregulating the activity of key proteins in the insulin-signalling cascade, while also improving lean body mass.^{24, 31-33} Decreases in muscle mass with aging, inactivity and weight loss also have implications for glucose capacity, as ~80% of the body's glycogen is stored in skeletal muscles.³⁴ The building and maintenance of lean muscle mass via resistance training are now commonplace in the recommendations.

‘Sit less, move more and more often’³⁵

Although a higher intensity and duration of activity elicits a greater range and magnitude of physiological adaptations, any form of increased movement has beneficial effects on overall health. The overarching message is that any physical activity is better that none, but more is better especially when combined with a reduction in sitting.^{23, 35} Contemporary evidence shows that breaking up prolonged sitting time with light intensity physical activity (e.g. walking) and simple resistance exercises (i.e. calf raises and squats) elicits acute improvements in postprandial glucose metabolism.^{36, 37} The initiation of regular, light intensity activity also leads to longer-term benefits in obese T2D individuals. In some instances, it can be as effective as continuous moderate to high intensity training (when matched for energy cost) in lowering HbA_1c and increasing the body's ability to utilise oxygen.³⁸ Similarly, flexibility exercises such as yoga or Tai Chi induce improvements in balance and gait, thus reducing the falls risk.²

Safety considerations

While exercise is a valuable therapeutic aid to optimise health, it may carry additional risk of cardiac events or hypo/hyperglycaemia.² Although the risk of cardiovascular events is transiently increased during vigorous intensity exercise, the overall absolute and relative risks still remain low.³⁹ Therefore, the benefits of regular activity outweigh the risks, which are arguably even lower when engaging in light- or moderate-intensity activity, the likely prescription for previously sedentary and/or inactive individuals.

ADA guidelines suggest that mandatory medical clearance for all individuals with T2D may be unnecessary.² Indeed, initiating any screening protocol beyond usual T2D care does not necessarily reduce the risk of exercise-induced adverse events in asymptomatic individuals.⁴⁰ However, clinical assessment beyond ongoing T2D management may be warranted for individuals wishing to engage in activities above the demands of brisk walking (who were previously sedentary and/or inactive), when adverse symptoms are experienced at lower intensities,² or in those who meet certain high risk criteria. For example, poor cardiorespiratory fitness, diabetic retinopathy, and aged >60 years represent good predictors for the likelihood of a cardiac event, particularly when considered in combination with traditional cardiac risk factors.^41-43 The clinical evaluation may include symptom-limited exercise testing in the first instance or more sensitive diagnostic tests should silent myocardial ischaemia be suspected.⁴⁴ Importantly, screening should be appropriate for the intensity of activity prescribed, with the latter often reserved for vigorous intensities.

By initiating certain safety precautions under the guidance of an HCP along with regular monitoring of blood glucose before, during and after exercise, the risk of hypo- or hyperglycaemia should also reduce. This may be particularly pertinent for those individuals taking insulin and/or insulin secretagogues.⁴⁵

Considerations include changes to/potential interactions with medication regimens and the timing and macronutrient composition of food (in particular carbohydrate intake). Engagement in moderate-to-vigorous activities (in particular high-intensity interval training) will involve switching from a predominantly catabolic state to an anabolic state, which may cause glucose levels to remain elevated after exercise due to glycogen repletion.^{34, 46} Similarly, the risk of nocturnal hypoglycaemia following exercise may be reduced by lowering basal insulin doses, consuming bedtime snacks, and/or use of continuous glucose monitoring.²

Given the potential risks, where possible, HCPs should monitor the individual response to exercise and be prepared to make necessary adjustments to medications or exercise prescriptions accordingly. It should also be ensured that previously inactive individuals start by performing short sessions of low intensity exercise before the duration and intensity of exercise are increased progressively, towards desired targets.⁴⁷ Sedentary and/or inactive individuals may benefit most from a graded approach whereby the first aim is to reduce sitting time through increasing standing, light ambulation or simple resistance exercises (e.g. calf raises). Light ambulation (i.e. slow walking) may then progress to continuous bouts of exercise.

Activity or exercise in the presence of complications

When considering physical activity or exercise interventions, special and serious considerations are required for those with T2D complications¹ with the ADA making a series of recommendations on how to manage exercise in specific situations.²

Diabetic retinopathy

In the case of mild non-proliferative retinopathy no alterations are required, although individuals should be encouraged to have yearly eye scans to monitor progression.² However, in moderate to severe non-proliferative/unstable proliferative retinopathy, activities that dramatically increase blood pressure (such as power-lifting) or any activities involving jumping, jarring or breath holding should be avoided.² No exercise should be undertaken during a vitreous haemorrhage.²

Diabetic nephropathy

Exercise is generally safe in all stages of kidney disease, when appropriate to the individual's condition.⁴⁸ For example, in those with end-stage or dialysis dependent renal disease, exercise should be limited to low intensity and regular monitoring of renal function is essential.⁴⁹ Individuals should not undertake exercise within the three months following initiation of haemodialysis.⁵⁰ In those individuals with microalbuminuria, exercise acutely increases protein excretion (so falsely elevated readings are possible if urine protein tests are performed within 24 hours of exercise cessation).⁴⁵

Peripheral neuropathy

This debilitating complication of T2D causes alterations in sensation, balance, and walking ability, increasing the risk for foot ulceration and falls.⁵¹ This may be a barrier to initiating or maintaining an active lifestyle, but exercise can be used to prevent or manage peripheral neuropathy.⁵² Understandably, those who suffer from severe foot pain, numbness or other foot complaints may remain hesitant about engaging in physical activity/exercise. Although previous guidelines have advised against weight-bearing physical activity to reduce the risk of ulceration, moderate walking does not appear to increase this risk.⁵³ However, those with active ulcers, amputations or foot deformities should avoid any weight-bearing exercises (particularly if their gait has altered) and opt for swimming, cycling or arm exercises.² Indeed, arm ergometry (‘arm crank’ machine) is proposed as a non-weight bearing activity to allow those with diabetic foot ulceration to meet aerobic physical activity guidelines (and yield the aforementioned benefits) at home via a commercially available lightweight table-top arm ergometer.⁵⁴ Other temporary but significant contraindications should also be noted.⁵⁵

Overall, when prescribing, encouraging or monitoring aerobic and resistance activities, it is necessary to consider the T2D stage, the presence of comorbidities and other lifestyle behaviours. For example, an analysis of 233,110 UK Biobank participants showed a clustering of unhealthy behaviours in those with T2D with and without complications⁷ so it is likely that multiple health-related behaviours can be intervened on. Similarly, although the combination of weight loss and improved glycaemic control associated with novel dietary interventions (e.g. meal replacement plans⁵⁶) and newer pharmacological therapies yield promising results on markers of cardiometabolic health, it is also important to understand the impact of these therapies on physical function and body composition. For example, diet or medication induced weight loss results in the loss of lean mass so an adjunct of physical activity may attenuate this loss and maximise the benefits of the treatment.⁵⁷ When aerobic and resistance activities are combined, they provide a powerful stimulus that improves muscle quality and muscle strength, increases muscle mass and enhances cardiorespiratory fitness and function.⁵⁸ This combination may be particularly pertinent in those with sarcopenia/frailty/poor physical function, given their higher risk of falling and the limited ability of the exercising muscle to extract and utilise oxygen.^{20, 59} The subsequent improvements in physical function and enhanced performance in tasks of daily living may also mediate improvements in quality of life.⁶⁰

The role of health care professionals

Guidelines alone are unlikely to increase population levels of physical activity.⁶¹ A systems approach is needed. Advice from an HCP, mass media campaigns (see the Sport England ‘We are Undefeatable’⁶² social media campaign aiming to inspire, assure and support those with long-term conditions to build physical activity into their lives) and changes to the environment such as increased walkability and bikeability and improved community design⁶³ can all work synchronously. That said, contacts with HCPs are thought to be a cost-effective and viable approach to physical activity promotion.⁶⁴ While 73% of 1013 GPs in England said they would discuss and recommend physical activity to people with T2D, ~50% of them had not completed or received any training in physical activity advising themselves.⁶⁵ Communication methods and channels to reach HCPs with physical activity promotion opportunities are not clear.⁶¹ The ambition to consistently embed effective physical activity counselling into routine undergraduate, postgraduate and continuing professional development clinical training and ultimately everyday clinical practice in England may be a good step.⁶⁴

Getting started: primary care brief advice

NICE recommends brief advice be offered to T2D patients in primary care through:⁶⁶

Establishing patient needs (screening).
Tailoring advice to patient motivations and goals, current level of activity and ability, circumstances, preferences and barriers and health status.
Signposting to good information and local opportunities.
Recording advice and goals and follow-up with reinforcement.

Action planning (goal setting) is typically done as part of T2D self-management education⁶⁷ and is one key behaviour change technique used in interventions that see an HbA_1c reduction of >0.3%.⁶⁸ Any action plans previously developed could be shared with the individual's own HCP and be used as a starting point for further behaviour change conversations during a brief contact.⁶⁷ Asking people with T2D whether they made any physical activity or exercise changes or goals during the COVID-19 lockdown could open the conversation about beginning and sustaining activity behaviour change. Perhaps it was a short daily walk outdoors or living room-based activities led by online trainers. Many free websites, phone apps and online resources are available to support goal setting and action planning. Self-monitoring of activity goals can be done using an inexpensive pedometer or capitalising on the fact that people with T2D likely already own a smartphone with an in-built movement sensor and app, and the trends for wearable technology (for a review see⁶⁹) make self-monitoring cheaper, easier and even fashionable.

As physical activity and exercise counselling should be tailored to meet the needs of individuals,² identifying the myriad of real and perceived barriers faced when engaging in physical activity is crucial.⁷⁰ Some of these barriers may be physical (e.g. joint pain), or psychological (e.g. not being comfortable being active in public). Other barriers, however, can be more systemic in nature and are beyond the scope of what can be solved within primary care or a brief behaviour change contact. We should be aware of the barriers to being active that, for example, those juggling two jobs and childcare may face or someone not feeling safe being outside in their own neighbourhood due to anti- social behaviour. The availability of local appropriate and tailored activity opportunities is just one way to overcome some barriers. Collaborative locally developed and driven programmes such as ‘Walking Cricket’ (a culturally appealing activity for men with or at risk of T2D) or ‘Healthy Goals’ (an education programme for South Asian women)⁷¹ have sought to overcome the barriers reported in BME groups in the UK.⁷² These programmes seek to address individual level barriers by including social support⁷³ and providing instruction⁶⁸ as evidence for better clinical outcomes, and behaviour change exists when these are featured.

The COVID-19 pandemic has shone a spotlight on our nation's health. Physical activity will predominantly be looking to solve the negative fall outs from COVID-19 including social isolation, mental health difficulties and obesity while capitalising on the beneficial effects of the outdoors, social support and community-driven solutions.

Conclusions

Health care professionals must individualise their approach when advising and supporting physical activity engagement in those with T2D with or without complications. After considering the existence of comorbidities and complications, where possible, individual preferences and motivations should primarily inform decision making regarding modality (aerobic and resistance). Although recommending a single mode of activity (e.g. aerobic) is unlikely to address the multi-domain deficits often present in those with T2D, the HCP should also be pragmatic regarding realistic targets, particularly if the individual is sedentary/inactive. An approach combining both aerobic and resistance activity yields the greatest benefit but, in truth, the kind of activity is far less important than the decision of whether to be active at all.

While guidelines promote minimum targets, patients should be encouraged to know that more physical activity is better. Conversely, in individuals where 150 minutes/week of moderate exercise seems daunting they should be encouraged that any increase in movement and reduction in time spent sedentary is of benefit. The provision of, and sign-posting to, appropriate local opportunities as well as changes to the environment in which people live will together influence whether the brief advice offered in primary care has an impact on an individual's physical activity.

This article is based upon a presentation given at the virtual Trends Diabetes Conference, October 2020.

Acknowledgements

This paper was supported by the NIHR Leicester Biomedical Research Centre (which is a partnership between University Hospitals of Leicester NHS Trust, Loughborough University and the University of Leicester). The views expressed are those of the author(s) and not necessarily those of the NHS, the NIHR or the Department of Health.

Declaration of interests

There are no conflicts of interest declared.

References

References are available online at https://wchh.onlinelibrary.wiley.com.

KEY POINTS

Physical activity is at the cornerstone of the lifestyle management of type 2 diabetes. Getting started and sustaining a physically active lifestyle is challenging for patients
Health care professionals should individualise their approach when advising and supporting physical activity engagement in those with type 2 diabetes with or without complications
Where possible, individual preferences and motivations should primarily inform decision making regarding modality (aerobic, resistance and balance/flexibility)
Any physical activity is better that none, but more is better especially when combined with a reduction in sitting

References

1Davies MJ, et al. Management of hyperglycaemia in type 2 diabetes, 2018. A consensus report by the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD). Diabetologia 2018; 61: 2461–98.
10.1007/s00125-018-4729-5
PubMedWeb of Science®Google Scholar
2Colberg SR, et al. Physical activity/exercise and diabetes: a position statement of the American Diabetes Association. Diabetes Care 2016; 39: 2065–79.
10.2337/dc16-1728
PubMedWeb of Science®Google Scholar
3Inzucchi SE, et al. Management of hyperglycaemia in type 2 diabetes: a patient-centered approach. Position statement of the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD). Diabetologia 2012; 55: 1577–96.
10.1007/s00125-012-2534-0
CASPubMedWeb of Science®Google Scholar
4Kirwan JP, et al. The essential role of exercise in the management of type 2 diabetes. Cleve Clin J Med 2017; 84: S15.
10.3949/ccjm.84.s1.03
PubMedWeb of Science®Google Scholar
5Sport England. Active Lives Adult Survey May 2019/20 Report. https://sportengland-production-files.s3.eu- west-2.amazonaws.com/s3fs-public/2020-10/Active%20Lives%20Adult%20May%2019-20%20Report.pdf?AYzBswpBmlh9cNcH8TFctPI38v4Ok2JD.
Google Scholar
6Kennerly AM, Kirk A. Physical activity and sedentary behaviour of adults with type 2 diabetes: a systematic review. Pract Diabetes 2018;35:86–9g.
Google Scholar
7Cassidy S, et al. Cross-sectional study of diet, physical activity, television viewing and sleep duration in 233 110 adults from the UK Biobank; the behavioural phenotype of cardiovascular disease and type 2 diabetes. BMJ Open 2016; 6(3):e010038.
10.1136/bmjopen-2015-010038
PubMedWeb of Science®Google Scholar
8Hall G, et al. A tale of two pandemics: How will COVID-19 and global trends in physical inactivity and sedentary behavior affect one another? Prog Cardiovasc Dis 2021; 64: 108–10.
10.1016/j.pcad.2020.04.005
PubMedWeb of Science®Google Scholar
9Sport England. Active Lives Adult Survey Coronavirus (Covid-19) Report 2020. https://sportengland-produc tion-files.s3.eu-west-2.amazonaws.com/s3fs-public/ 2020-10/Active%20Lives%20Adult%20May%2019-20%20Coronavirus%20Report.pdf?2L6TBVV5U vCGXb_VxZcWHcfFX0_wRal7.
Google Scholar
10Rowlands AV, et al. The impact of COVID-19 restrictions on accelerometer-assessed physical activity and sleep in individuals with type 2 diabetes. Diabet Med 2021; 38(10):e14549.
10.1111/dme.14549
CASPubMedWeb of Science®Google Scholar
11 ICNARC (Intensive Care National Audit & Research Centre). COVID-19 Report 2020. https://www.icnarc.org/Our-Audit/Audits/Cmp/Reports.
Google Scholar
12Swinford S. Boris Johnson to launch war on fat after coronavirus scare. The Times, May 15 2020.
Google Scholar
13Caspersen CJ, et al. Physical activity, exercise, and physical fitness: definitions and distinctions for health-related research. Public Health Rep 1985; 100: 126–31.
CASPubMedWeb of Science®Google Scholar
14Sigal RJ, et al. Physical activity/exercise and type 2 diabetes. Diabetes Care 2004; 27: 2518–39.
10.2337/diacare.27.10.2518
PubMedWeb of Science®Google Scholar
15Tremblay MS, et al. Sedentary behavior research network (SBRN) – terminology consensus project process and outcome. Int J Behav Nutr Phys Act 2017; 14: 75.
10.1186/s12966-017-0525-8
PubMedWeb of Science®Google Scholar
16American Diabetes Association. 4. Lifestyle Management: Standards of Medical Care in Diabetes – 2018. Diabetes Care 2018; 41: S38–S50.
10.2337/dc18-S004
PubMedWeb of Science®Google Scholar
17Mickute M, et al. Device-measured physical activity and its association with physical function in adults with type 2 diabetes mellitus. Diabet Med 2021; 38:e14393.
10.1111/dme.14393
CASPubMedWeb of Science®Google Scholar
18Mesinovic J, et al. Sarcopenia and type 2 diabetes mellitus: a bidirectional relationship. Diabetes Metab Syndr Obes 2019; 12: 1057–72.
10.2147/DMSO.S186600
PubMedWeb of Science®Google Scholar
19Morley JE, et al. Frailty, sarcopenia and diabetes. J Am Med Dir Assoc 2014; 15: 853–9.
10.1016/j.jamda.2014.10.001
PubMedWeb of Science®Google Scholar
20Sinclair AJ, et al. An international position statement on the management of frailty in diabetes mellitus: Summary of recommendations 2017. J Frailty Aging 2018; 7: 10–20.
CASPubMedWeb of Science®Google Scholar
21Department of Health and Social Care. UK Chief Medical Officers Physical Activity Guidelines 2019. https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/832868/uk-chief-medical-officers-physical-activity- guidelines.pdf.
Google Scholar
22Bull FC, et al. World Health Organization 2020 guidelines on physical activity and sedentary behaviour. Br J Sports Med 2020; 54: 1451–62.
10.1136/bjsports-2020-102955
PubMedWeb of Science®Google Scholar
23Dempsey PC, et al. New global guidelines on sedentary behaviour and health for adults: broadening the behavioural targets. Int J Behav Nutr Phys Act 2020; 17: 1–12.
10.1186/s12966-020-01044-0
PubMedWeb of Science®Google Scholar
24Snowling 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: 2518–27.
10.2337/dc06-1317
PubMedWeb of Science®Google Scholar
25Boule NG, et al. Effects of exercise on glycemic control and body mass in type 2 diabetes mellitus: a meta-analysis of controlled clinical trials. JAMA 2001; 286: 1218–27.
10.1001/jama.286.10.1218
CASPubMedWeb of Science®Google Scholar
26Jelleyman C, et al. The effects of high-intensity interval training on glucose regulation and insulin resistance: a meta-analysis. Obes Rev 2015; 16: 942–61.
10.1111/obr.12317
CASPubMedWeb of Science®Google Scholar
27Liubaoerjijin Y, et al. Effect of aerobic exercise intensity on glycemic control in type 2 diabetes: a meta-analysis of head-to-head randomized trials. Acta Diabetol 2016; 53: 769–81.
10.1007/s00592-016-0870-0
CASPubMedWeb of Science®Google Scholar
28Sylow L, et al. Exercise-stimulated glucose uptake – regulation and implications for glycaemic control. Nat Rev Endocrinol 2017; 13: 133–48.
10.1038/nrendo.2016.162
CASPubMedWeb of Science®Google Scholar
29Newsom SA, et al. A Single Session of Low-Intensity Exercise Is Sufficient to Enhance Insulin Sensitivity Into the Next Day in Obese Adults. Diabetes Care 2013; 36: 2516–22.
10.2337/dc12-2606
CASPubMedWeb of Science®Google Scholar
30Bianchi L, Volpato S. Muscle dysfunction in type 2 diabetes: a major threat to patient's mobility and independence. Acta Diabetol 2016; 53: 879–89.
10.1007/s00592-016-0880-y
CASPubMedWeb of Science®Google Scholar
31Zanuso S, et al. Exercise in type 2 diabetes: genetic, metabolic and neuromuscular adaptations. A review of the evidence. Br J Sports Med 2017; 51: 1533–8.
10.1136/bjsports-2016-096724
PubMedWeb of Science®Google Scholar
32Strasser B, Pesta D. Resistance training for diabetes prevention and therapy: experimental findings and molecular mechanisms. Biomed Res Int 2013; 2013: 805217.
10.1155/2013/805217
CASPubMedWeb of Science®Google Scholar
33Holten MK, et al. Strength training increases insulin-mediated glucose uptake, GLUT4 content, and insulin signaling in skeletal muscle in patients with type 2 diabetes. Diabetes 2004; 53: 294–305.
10.2337/diabetes.53.2.294
CASPubMedWeb of Science®Google Scholar
34Jensen J, et al. The role of skeletal muscle glycogen breakdown for regulation of insulin sensitivity by exercise. Front Physiol 2011; 2: 112.
10.3389/fphys.2011.00112
PubMedWeb of Science®Google Scholar
35Ekelund U, et al. Dose-response associations between accelerometry measured physical activity and sedentary time and all cause mortality: systematic review and harmonised meta-analysis. BMJ 2019; 366: l4570.
10.1136/bmj.l4570
PubMedGoogle Scholar
36Dempsey PC, 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: 964–72.
10.2337/dc15-2336
CASPubMedWeb of Science®Google Scholar
37Chastin SFM, et al. How does light-intensity physical activity associate with adult cardiometabolic health and mortality? Systematic review with meta-analysis of experimental and observational studies. Br J Sports Med 2019; 53: 370–6.
10.1136/bjsports-2017-097563
PubMedWeb of Science®Google Scholar
38Hansen D, 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: 1789–97.
10.1007/s00125-009-1354-3
CASPubMedWeb of Science®Google Scholar
39Franklin BA, et al. Exercise-related acute cardiovascular events and potential deleterious adaptations following long-term exercise training: placing the risks into perspective – an update: a scientific statement from the American Heart Association. Circulation 2020; 141: e705–e736.
10.1161/CIR.0000000000000749
PubMedWeb of Science®Google Scholar
40Young LH, 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: 1547–55.
10.1001/jama.2009.476
CASPubMedWeb of Science®Google Scholar
41Faglia E, et al. Cardiac events in 735 type 2 diabetic patients who underwent screening for unknown asymptomatic coronary heart disease: 5-year follow-up report from the Milan Study on Atherosclerosis and Diabetes (MiSAD). Diabetes Care 2002; 25: 2032–6.
10.2337/diacare.25.11.2032
PubMedWeb of Science®Google Scholar
42McAuley PA, et al. Exercise capacity and body mass as predictors of mortality among male veterans with type 2 diabetes. Diabetes Care 2007; 30: 1539–43.
10.2337/dc06-2397
PubMedWeb of Science®Google Scholar
43Valensi P, et al. Predictive value of silent myocardial ischemia for cardiac events in diabetic patients: influence of age in a French multicenter study. Diabetes Care 2005; 28: 2722–7.
10.2337/diacare.28.11.2722
PubMedWeb of Science®Google Scholar
44Praet SF, van Loon LJ. Optimizing the therapeutic benefits of exercise in type 2 diabetes. J Appl Physiol (1985) 2007;103:1113–20.
Google Scholar
45American Diabetes Association. 5. Facilitating behavior change and well-being to improve health outcomes: Standards of medical care in diabetes – 2021. Diabetes Care 2021; 44: S53–S72.
PubMedWeb of Science®Google Scholar
46Wojtaszewski JF, Richter EA. Effects of acute exercise and training on insulin action and sensitivity: focus on molecular mechanisms in muscle. Essays Biochem 2006; 42: 31–46.
10.1042/bse0420031
CASPubMedWeb of Science®Google Scholar
47 American College of Sports Medicine, et al. Exercise and acute cardiovascular events: placing the risks into perspective: a scientific statement from the American Heart Association Council on Nutrition, Physical Activity, and Metabolism and the Council on Clinical Cardiology. Circulation 2007; 115: 2358–68.
10.1161/CIRCULATIONAHA.107.181485
PubMedWeb of Science®Google Scholar
48National Institute for Health and Care Excellence. Clinical Practice Guideline Exercise and Lifestyle in Chronic Kidney Disease 2021. https://www.evidence.nhs.uk/document?id=2360428&returnUrl=search% 3Fom%3D%5B%7B%22srn%22%3A%5B%22Renal +Association%22%5D%7D%5D%26q%3Daudit% 2Btopics%26s%3DDate%26sp%3Don.
Google Scholar
49Johansen KL, Painter P. Exercise in individuals with CKD. Am J Kidney Dis 2012; 59: 126–34.
10.1053/j.ajkd.2011.10.008
PubMedWeb of Science®Google Scholar
50Ashby D, et al. Renal Association clinical practice guideline on haemodialysis. BMC Nephrol 2019; 20: 379.
10.1186/s12882-019-1527-3
PubMedWeb of Science®Google Scholar
51Brown MJ, Asbury AK. Diabetic neuropathy. Ann Neurol 1984; 15: 2–12.
10.1002/ana.410150103
CASPubMedWeb of Science®Google Scholar
52Balducci S, et al. Exercise training can modify the natural history of diabetic peripheral neuropathy. J Diabetes Complications 2006; 20: 216–23.
10.1016/j.jdiacomp.2005.07.005
PubMedWeb of Science®Google Scholar
53Lemaster JW, et al. Effect of weight-bearing activity on foot ulcer incidence in people with diabetic peripheral neuropathy: feet first randomized controlled trial. Phys Ther 2008; 88: 1385–98.
10.2522/ptj.20080019
PubMedWeb of Science®Google Scholar
54McCarthy M, et al. Health impacts of seated arm ergometry training in patients with a diabetic foot ulcer: protocol for a randomised controlled trial. BMJ Open 2020; 10:e039062.
10.1136/bmjopen-2020-039062
PubMedWeb of Science®Google Scholar
55Hordern MD, et al. Exercise prescription for patients with type 2 diabetes and pre-diabetes: a position statement from Exercise and Sport Science Australia. J Sci Med Sport 2012; 15: 25–31.
10.1016/j.jsams.2011.04.005
PubMedWeb of Science®Google Scholar
56Lean MEJ, et al. Durability of a primary care-led weight-management intervention for remission of type 2 diabetes: 2-year results of the DiRECT open- label, cluster-randomised trial. Lancet Diabetes Endocrinol 2019; 7: 344–55.
10.1016/S2213-8587(19)30068-3
PubMedWeb of Science®Google Scholar
57Sargeant JA, et al. A Review of the Effects of Glucagon-Like Peptide-1 Receptor Agonists and Sodium-Glucose Cotransporter 2 Inhibitors on Lean Body Mass in Humans. Endocrinol Metab (Seoul) 2019; 34: 247–62.
10.3803/EnM.2019.34.3.247
CASPubMedGoogle Scholar
58Booth FW, Thomason DB. Molecular and cellular adaptation of muscle in response to exercise: perspectives of various models. Physiol Rev 1991; 71: 541–85.
10.1152/physrev.1991.71.2.541
CASPubMedWeb of Science®Google Scholar
59Chao CT, et al. Both pre-frailty and frailty increase healthcare utilization and adverse health outcomes in patients with type 2 diabetes mellitus. Cardiovasc Diabetol 2018; 17: 130.
10.1186/s12933-018-0772-2
CASPubMedWeb of Science®Google Scholar
60Villareal DT, et al. Weight loss, exercise, or both and physical function in obese older adults. N Engl J Med 2011; 364: 1218–29.
10.1056/NEJMoa1008234
CASPubMedWeb of Science®Google Scholar
61Milton K, et al. Maximising the impact of global and national physical activity guidelines: the critical role of communication strategies. Br J Sports Med 2020; 54: 1463–7.
10.1136/bjsports-2020-102324
PubMedWeb of Science®Google Scholar
62Sport England. We are Undefeatable. 2019. Available from: https://weareundefeatable.co.uk/.
Google Scholar
63Hill JO, et al. Scientific statement: socioecological determinants of prediabetes and type 2 diabetes. Diabetes Care 2013; 36: 2430–9.
10.2337/dc13-1161
PubMedWeb of Science®Google Scholar
64Brannan M, et al. Moving healthcare professionals – a whole system approach to embed physical activity in clinical practice. BMC Med Educ 2019; 19: 84.
10.1186/s12909-019-1517-y
PubMedWeb of Science®Google Scholar
65Chatterjee R, et al. GPs’ knowledge, use, and confidence in national physical activity and health guidelines and tools: a questionnaire-based survey of general practice in England. Br J Gen Pract 2017; 67: e668–e675.
10.3399/bjgp17X692513
PubMedWeb of Science®Google Scholar
66National Institute for Health and Care Excellence. Physical activity: brief advice for adults in primary care Public Health guideline [PH44] 2013. https://www.nice.org.uk/guidance/ph44/chapter/ 1-recommendations.
Google Scholar
67O'Donnell M, et al. Assessing the effectiveness of a goal-setting session as part of a structured group self-management education programme for people with type 2 diabetes. Patient Educ Couns 2018; 101: 2125–33.
10.1016/j.pec.2018.07.009
PubMedWeb of Science®Google Scholar
68Cradock KA, et al. Behaviour change techniques targeting both diet and physical activity in type 2 diabetes:A systematic review and meta-analysis. Int J Behav Nutr Phys Act 2017; 14: 18.
10.1186/s12966-016-0436-0
PubMedWeb of Science®Google Scholar
69Coughlin SS, Stewart J. Use of consumer wearable devices to promote physical activity: a review of health intervention studies. J Environ Health Sci 2016; 2(6): 10.15436/2378-6841.16.1123.
10.15436/2378-6841.16.1123
Google Scholar
70Jenkins DW, Jenks A. Exercise and diabetes: a narrative review. J Foot Ankle Surg 2017; 56: 968–74.
10.1053/j.jfas.2017.06.019
PubMedWeb of Science®Google Scholar
71Harrington D, et al. Type 2 diabetes prevention for “at risk” populations: Cities Changing Diabetes in Leicester. osf.io pre-prints.
Google Scholar
72Ige-Elegbede J, et al. Barriers and facilitators of physical activity among adults and older adults from Black and Minority Ethnic groups in the UK: A systematic review of qualitative studies. Prev Med Rep 2019; 15: 100952.
10.1016/j.pmedr.2019.100952
PubMedGoogle Scholar
73Strom JL, Egede LE. The impact of social support on outcomes in adult patients with type 2 diabetes: a systematic review. Curr Diab Rep 2012; 12: 769–81.
10.1007/s11892-012-0317-0
PubMedWeb of Science®Google Scholar
74Garber CE, et al. American College of Sports Medicine position stand. Quantity and quality of exercise for developing and maintaining cardiorespiratory, musculoskeletal, and neuromotor fitness in apparently healthy adults: guidance for prescribing exercise. Med Sci Sports Exerc 2011; 43: 1334–59.
10.1249/MSS.0b013e318213fefb
PubMedWeb of Science®Google Scholar

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Volume38, Issue5

September/October 2021

Pages 35-40b

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Physical activity and exercise in the management of type 2 diabetes: where to start?

Abstract

Introduction

Commonly used terms

T2D-related physical activity recommendations

Benefits of physical activity in those with established T2D

Aerobic activities

Resistance exercise

‘Sit less, move more and more often’³⁵

Safety considerations

Activity or exercise in the presence of complications

Diabetic retinopathy

Diabetic nephropathy

Peripheral neuropathy

The role of health care professionals

Getting started: primary care brief advice

Conclusions

Acknowledgements

Declaration of interests

References

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References

Citing Literature

References

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Physical activity and exercise in the management of type 2 diabetes: where to start?

Abstract

Introduction

Commonly used terms

T2D-related physical activity recommendations

Benefits of physical activity in those with established T2D

Aerobic activities

Resistance exercise

‘Sit less, move more and more often’35

Safety considerations

Activity or exercise in the presence of complications

Diabetic retinopathy

Diabetic nephropathy

Peripheral neuropathy

The role of health care professionals

Getting started: primary care brief advice

Conclusions

Acknowledgements

Declaration of interests

References

KEY POINTS

References

Citing Literature

References

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‘Sit less, move more and more often’³⁵