What is a recommended exercise regimen for diabetic patients?

Exercise Recommendations for Diabetic Patients

Adults with diabetes should engage in at least 150 minutes per week of moderate-to-vigorous intensity aerobic exercise spread over at least 3 days per week, with no more than 2 consecutive days without activity, combined with 2-3 sessions per week of resistance training on nonconsecutive days. 1

Aerobic Exercise Requirements

For Adults with Type 1 and Type 2 Diabetes

• Minimum target: 150 minutes per week of moderate-to-vigorous intensity aerobic activity 1
• Distribution: Spread across at least 3 days per week, with no more than 2 consecutive days between sessions 1
• Alternative for fit individuals: 75 minutes per week of vigorous-intensity exercise or interval training (equivalent to running at 6 miles/hour for 25 minutes) 1
• Session duration: Each aerobic bout should last at least 10 minutes, with a goal of 30 minutes per day on most days 1

The frequent exercise schedule (no more than 2 days between sessions) is critical because it directly decreases insulin resistance, regardless of diabetes type 1. Studies in type 1 diabetes demonstrate a dose-response relationship between physical activity frequency and improvements in A1C, BMI, blood pressure, lipids, and reduced diabetes complications including hypoglycemia, diabetic ketoacidosis, retinopathy, and microalbuminuria 1.

For Youth and Adolescents with Diabetes

• Daily requirement: 60 minutes or more of moderate-to-vigorous aerobic activity every day 1
• Muscle and bone strengthening: At least 3 days per week 1

Resistance Training Requirements

All adults with diabetes should perform resistance exercise 2-3 sessions per week on nonconsecutive days. 1

• Exercises: At least 5 different resistance exercises involving large muscle groups 1
• Sets and repetitions: Minimum of 1 set per exercise, progressing to 3-4 sets for optimal strength gains 1
• Intensity: Start with 10-15 repetitions to near fatigue, progressing to heavier weights allowing only 8-10 repetitions 1
• Modalities: Free weights, weight machines, elastic bands, or body weight resistance are all effective 1

Resistance training provides strong evidence for A1C reduction in older adults with type 2 diabetes, with additive benefits when combined with aerobic exercise 1. Any intensity of resistance training improves strength, balance, and ability to perform daily activities throughout the lifespan 1.

Additional Exercise Modalities

For Older Adults

• Flexibility training: 2-3 times per week 1
• Balance training: 2-3 times per week 1
• Options: Yoga and tai chi can be included based on individual preferences to increase flexibility, muscular strength, and balance 1

High-Intensity Interval Training (HIIT)

HIIT involves aerobic training at 65-90% VO2peak for 10 seconds to 4 minutes with recovery periods, showing reductions in A1C and BMI in type 2 diabetes 1. However, HIIT can cause transient post-exercise hyperglycemia, requiring glucose monitoring when starting 1.

Reducing Sedentary Behavior

Break up prolonged sitting every 30 minutes with brief standing, walking, or light physical activity. 1

• Evaluate baseline sedentary time (quiet sitting, lying, leaning) in all patients 1
• For those not meeting activity guidelines, encourage any increase in physical activity above baseline including walking, yoga, housework, gardening, swimming, and dancing 1
• Avoiding extended sedentary periods helps prevent type 2 diabetes and aids glycemic control 1

Critical Safety Considerations for Hypoglycemia

For Patients on Insulin or Insulin Secretagogues

These patients face significant hypoglycemia risk during and after exercise, requiring specific preventive measures. 1

• Pre-exercise glucose monitoring: Check blood glucose before exercise 1
• Carbohydrate supplementation: Ingest added carbohydrate if pre-exercise glucose is <90 mg/dL (5.0 mmol/L) 1
• Insulin dose adjustment: Reduce insulin doses during workouts (via pump adjustment or reduced pre-exercise dosing) 1
• Timing considerations: Time of day, exercise intensity, and duration all affect hypoglycemia risk 1
• Delayed hypoglycemia: Hypoglycemia can occur hours after exercise due to increased insulin sensitivity 1
• Post-exercise monitoring: Check blood glucose after exercise and monitor for prolonged effects 1

For Patients NOT on Insulin or Insulin Secretagogues

Hypoglycemia is uncommon, and routine preventive measures are not usually necessary 1.

Paradoxical Hyperglycemia

Intense activities may actually raise blood glucose levels, especially if pre-exercise glucose is already elevated 1. This requires patient education about variable glycemic responses to different exercise intensities 1.

Cardiovascular and Mortality Benefits

Moderate to high volumes of aerobic activity are associated with substantially lower cardiovascular and overall mortality risks in both type 1 and type 2 diabetes 1. A prospective study in type 1 diabetes showed higher physical activity levels reduced cardiovascular mortality after 11.4 years of follow-up, even in patients with chronic kidney disease 1.

Practical Implementation

• Progressive approach: Start with shorter durations of low-intensity exercise and gradually increase intensity, frequency, and duration to meet targets 1
• Individualized progression: Tailor exercise recommendations to individual capabilities, preferences, and presence of complications 1
• Stepwise goals: Set incremental goals toward meeting recommended exercise targets 1
• Medical monitoring: As patients intensify their exercise program, medical monitoring may be indicated for safety and glucose management evaluation 1