Effects of exercise in adults with diabetes mellitus
- David K McCulloch, MD
David K McCulloch, MD
- Washington Permanente Medical Group
Exercise is being increasingly promoted as part of the therapeutic regimen for diabetes mellitus. In addition to its cardiovascular benefits, exercise can also improve glycemic control. The beneficial effect on glycemic control largely results from increased tissue sensitivity to insulin.
To understand how these changes occur, it is helpful to begin by briefly reviewing the short- and long-term effects of exercise in normal individuals. Subsequently, the benefits of exercise in patients with type 1 and 2 diabetes and a program for physical activity are reviewed here.
The glycemic benefits of combined diet and exercise interventions in patients with diabetes, exercise for the prevention of type 2 diabetes, and sample cases illustrating problems that can occur when exercise is performed in patients treated with an intensive insulin regimen are discussed separately. (See "Cases illustrating the effects of exercise in intensive insulin therapy for diabetes mellitus" and "Initial management of blood glucose in adults with type 2 diabetes mellitus", section on 'Intensive lifestyle modification' and "Prevention of type 2 diabetes mellitus".)
EXERCISE AND MUSCLE METABOLISM
Exercise has both short- and long-term effects on metabolism in nondiabetic subjects .
Short-term effects — As a person exercises, the muscles initially use glucose in the muscle and later convert muscle glycogen to glucose to provide energy. An average, 70-kg adult man has approximately 1100 kcal stored as muscle glycogen and another 400 to 500 kcal stored as liver glycogen. Skeletal muscle differs from liver in that it lacks the enzyme glucose-6-phosphatase, which converts glucose-6-phosphate (derived from glycogen) to glucose; as a result, muscle glycogen can only be used as an energy source for muscle via the metabolism of glucose-6-phosphate to pyruvate. Glucose cannot be transferred out of muscle to prevent hypoglycemia (figure 1).
- Colberg SR, Sigal RJ, Fernhall B, et al. Exercise and type 2 diabetes: the American College of Sports Medicine and the American Diabetes Association: joint position statement. Diabetes Care 2010; 33:e147.
- Abernethy PJ, Thayer R, Taylor AW. Acute and chronic responses of skeletal muscle to endurance and sprint exercise. A review. Sports Med 1990; 10:365.
- Jensen TE, Richter EA. Regulation of glucose and glycogen metabolism during and after exercise. J Physiol 2012; 590:1069.
- McAuley KA, Williams SM, Mann JI, et al. Intensive lifestyle changes are necessary to improve insulin sensitivity: a randomized controlled trial. Diabetes Care 2002; 25:445.
- Gibala MJ, Little JP, Macdonald MJ, Hawley JA. Physiological adaptations to low-volume, high-intensity interval training in health and disease. J Physiol 2012; 590:1077.
- Burgomaster KA, Howarth KR, Phillips SM, et al. Similar metabolic adaptations during exercise after low volume sprint interval and traditional endurance training in humans. J Physiol 2008; 586:151.
- Little JP, Safdar A, Wilkin GP, et al. A practical model of low-volume high-intensity interval training induces mitochondrial biogenesis in human skeletal muscle: potential mechanisms. J Physiol 2010; 588:1011.
- Richards JC, Johnson TK, Kuzma JN, et al. Short-term sprint interval training increases insulin sensitivity in healthy adults but does not affect the thermogenic response to beta-adrenergic stimulation. J Physiol 2010; 588:2961.
- Duncan GE, Perri MG, Theriaque DW, et al. Exercise training, without weight loss, increases insulin sensitivity and postheparin plasma lipase activity in previously sedentary adults. Diabetes Care 2003; 26:557.
- Kraus WE, Houmard JA, Duscha BD, et al. Effects of the amount and intensity of exercise on plasma lipoproteins. N Engl J Med 2002; 347:1483.
- Phielix E, Meex R, Moonen-Kornips E, et al. Exercise training increases mitochondrial content and ex vivo mitochondrial function similarly in patients with type 2 diabetes and in control individuals. Diabetologia 2010; 53:1714.
- Winnick JJ, Sherman WM, Habash DL, et al. Short-term aerobic exercise training in obese humans with type 2 diabetes mellitus improves whole-body insulin sensitivity through gains in peripheral, not hepatic insulin sensitivity. J Clin Endocrinol Metab 2008; 93:771.
- Kirwan JP, Solomon TP, Wojta DM, et al. Effects of 7 days of exercise training on insulin sensitivity and responsiveness in type 2 diabetes mellitus. Am J Physiol Endocrinol Metab 2009; 297:E151.
- Poirier P, Tremblay A, Catellier C, et al. Impact of time interval from the last meal on glucose response to exercise in subjects with type 2 diabetes. J Clin Endocrinol Metab 2000; 85:2860.
- Berger M, Berchtold P, Cüppers HJ, et al. Metabolic and hormonal effects of muscular exercise in juvenile type diabetics. Diabetologia 1977; 13:355.
- Koivisto VA, Felig P. Effects of leg exercise on insulin absorption in diabetic patients. N Engl J Med 1978; 298:79.
- Frid A, Ostman J, Linde B. Hypoglycemia risk during exercise after intramuscular injection of insulin in thigh in IDDM. Diabetes Care 1990; 13:473.
- Fang ZY, Sharman J, Prins JB, Marwick TH. Determinants of exercise capacity in patients with type 2 diabetes. Diabetes Care 2005; 28:1643.
- Ritov VB, Menshikova EV, Azuma K, et al. Deficiency of electron transport chain in human skeletal muscle mitochondria in type 2 diabetes mellitus and obesity. Am J Physiol Endocrinol Metab 2010; 298:E49.
- Kelley DE, He J, Menshikova EV, Ritov VB. Dysfunction of mitochondria in human skeletal muscle in type 2 diabetes. Diabetes 2002; 51:2944.
- Devlin JT. Effects of exercise on insulin sensitivity in humans. Diabetes Care 1992; 15:1690.
- Schneider SH, Amorosa LF, Khachadurian AK, Ruderman NB. Studies on the mechanism of improved glucose control during regular exercise in type 2 (non-insulin-dependent) diabetes. Diabetologia 1984; 26:355.
- Henriksson J. Effects of physical training on the metabolism of skeletal muscle. Diabetes Care 1992; 15:1701.
- Little JP, Gillen JB, Percival ME, et al. Low-volume high-intensity interval training reduces hyperglycemia and increases muscle mitochondrial capacity in patients with type 2 diabetes. J Appl Physiol (1985) 2011; 111:1554.
- Womack L, Peters D, Barrett EJ, et al. Abnormal skeletal muscle capillary recruitment during exercise in patients with type 2 diabetes mellitus and microvascular complications. J Am Coll Cardiol 2009; 53:2175.
- Cuff DJ, Meneilly GS, Martin A, et al. Effective exercise modality to reduce insulin resistance in women with type 2 diabetes. Diabetes Care 2003; 26:2977.
- Boulé NG, Haddad E, Kenny GP, 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.
- Snowling NJ, Hopkins WG. Effects of different modes of exercise training on glucose control and risk factors for complications in type 2 diabetic patients: a meta-analysis. Diabetes Care 2006; 29:2518.
- Chudyk A, Petrella RJ. Effects of exercise on cardiovascular risk factors in type 2 diabetes: a meta-analysis. Diabetes Care 2011; 34:1228.
- Umpierre D, Ribeiro PA, Kramer CK, et al. Physical activity advice only or structured exercise training and association with HbA1c levels in type 2 diabetes: a systematic review and meta-analysis. JAMA 2011; 305:1790.
- Sigal RJ, Kenny GP, Boulé NG, et al. Effects of aerobic training, resistance training, or both on glycemic control in type 2 diabetes: a randomized trial. Ann Intern Med 2007; 147:357.
- Church TS, Blair SN, Cocreham S, et al. Effects of aerobic and resistance training on hemoglobin A1c levels in patients with type 2 diabetes: a randomized controlled trial. JAMA 2010; 304:2253.
- Gillen JB, Little JP, Punthakee Z, et al. Acute high-intensity interval exercise reduces the postprandial glucose response and prevalence of hyperglycaemia in patients with type 2 diabetes. Diabetes Obes Metab 2012; 14:575.
- Gordon BA, Benson AC, Bird SR, Fraser SF. Resistance training improves metabolic health in type 2 diabetes: a systematic review. Diabetes Res Clin Pract 2009; 83:157.
- American Diabetes Association. Standards of medical care in diabetes--2013. Diabetes Care 2013; 36 Suppl 1:S11.
- Gregg EW, Gerzoff RB, Caspersen CJ, et al. Relationship of walking to mortality among US adults with diabetes. Arch Intern Med 2003; 163:1440.
- Tanasescu M, Leitzmann MF, Rimm EB, Hu FB. Physical activity in relation to cardiovascular disease and total mortality among men with type 2 diabetes. Circulation 2003; 107:2435.
- Hu FB, Stampfer MJ, Solomon C, et al. Physical activity and risk for cardiovascular events in diabetic women. Ann Intern Med 2001; 134:96.
- Sluik D, Buijsse B, Muckelbauer R, et al. Physical Activity and Mortality in Individuals With Diabetes Mellitus: A Prospective Study and Meta-analysis. Arch Intern Med 2012; 172:1285.
- Kodama S, Tanaka S, Heianza Y, et al. Association between physical activity and risk of all-cause mortality and cardiovascular disease in patients with diabetes: a meta-analysis. Diabetes Care 2013; 36:471.
- Yates T, Haffner SM, Schulte PJ, et al. Association between change in daily ambulatory activity and cardiovascular events in people with impaired glucose tolerance (NAVIGATOR trial): a cohort analysis. Lancet 2014; 383:1059.
- Schneider SH, Khachadurian AK, Amorosa LF, et al. Ten-year experience with an exercise-based outpatient life-style modification program in the treatment of diabetes mellitus. Diabetes Care 1992; 15:1800.
- Skarfors ET, Wegener TA, Lithell H, Selinus I. Physical training as treatment for type 2 (non-insulin-dependent) diabetes in elderly men. A feasibility study over 2 years. Diabetologia 1987; 30:930.
- Long BJ, Calfas KJ, Wooten W, et al. A multisite field test of the acceptability of physical activity counseling in primary care: project PACE. Am J Prev Med 1996; 12:73.
- Calfas KJ, Long BJ, Sallis JF, et al. A controlled trial of physician counseling to promote the adoption of physical activity. Prev Med 1996; 25:225.
- Nelson KM, Reiber G, Boyko EJ, NHANES III. Diet and exercise among adults with type 2 diabetes: findings from the third national health and nutrition examination survey (NHANES III). Diabetes Care 2002; 25:1722.
- Tonoli C, Heyman E, Roelands B, et al. Effects of different types of acute and chronic (training) exercise on glycaemic control in type 1 diabetes mellitus: a meta-analysis. Sports Med 2012; 42:1059.
- Murillo S, Brugnara L, Novials A. One year follow-up in a group of half-marathon runners with type-1 diabetes treated with insulin analogues. J Sports Med Phys Fitness 2010; 50:506.
- Boehncke S, Poettgen K, Maser-Gluth C, et al. [Endurance capabilities of triathlon competitors with type 1 diabetes mellitus]. Dtsch Med Wochenschr 2009; 134:677.
- Temple MY, Bar-Or O, Riddell MC. The reliability and repeatability of the blood glucose response to prolonged exercise in adolescent boys with IDDM. Diabetes Care 1995; 18:326.
- Buse JB, Ginsberg HN, Bakris GL, et al. Primary prevention of cardiovascular diseases in people with diabetes mellitus: a scientific statement from the American Heart Association and the American Diabetes Association. Circulation 2007; 115:114.
- Mittleman MA, Maclure M, Tofler GH, et al. Triggering of acute myocardial infarction by heavy physical exertion. Protection against triggering by regular exertion. Determinants of Myocardial Infarction Onset Study Investigators. N Engl J Med 1993; 329:1677.
- Willich SN, Lewis M, Löwel H, et al. Physical exertion as a trigger of acute myocardial infarction. Triggers and Mechanisms of Myocardial Infarction Study Group. N Engl J Med 1993; 329:1684.
- Curfman GD. Is exercise beneficial--or hazardous--to your heart? N Engl J Med 1993; 329:1730.
- Bird SR, Hawley JA. Exercise and type 2 diabetes: new prescription for an old problem. Maturitas 2012; 72:311.
- US Department of Health and Human Services. Physical Activity Guidelines for Americans: Summary. http://www.health.gov/paguidelines/guidelines/summary.aspx (Accessed on February 15, 2013).
- Soo K, Furler SM, Samaras K, et al. Glycemic responses to exercise in IDDM after simple and complex carbohydrate supplementation. Diabetes Care 1996; 19:575.
- Grimm JJ, Ybarra J, Berné C, et al. A new table for prevention of hypoglycaemia during physical activity in type 1 diabetic patients. Diabetes Metab 2004; 30:465.
- Koivisto VA, Felig P. Alterations in insulin absorption and in blood glucose control associated with varying insulin injection sites in diabetic patients. Ann Intern Med 1980; 92:59.
- EXERCISE AND MUSCLE METABOLISM
- Short-term effects
- Long-term training effects
- EXERCISE IN DIABETIC ADULTS
- Short-term effects in type 1 and 2 diabetes
- Long-term effects in type 2 diabetes
- - Glycemic control
- - Cardiovascular disease and mortality
- - Long-term compliance
- Long-term effects in type 1 diabetes
- PREVENTION OF TYPE 2 DIABETES
- A PROGRAM FOR PHYSICAL ACTIVITY
- Evaluation prior to recommending an exercise regimen
- Type and frequency of exercise
- Managing blood glucose during exercise
- SOCIETY GUIDELINE LINKS
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS