What is a safe and effective resistance training regimen for a patient with type 2 diabetes taking tirzepatide (glucagon-like peptide-1 (GLP-1) and glucose-dependent insulinotropic polypeptide (GIP) receptor agonist)?

Resistance Training for Patients with Type 2 Diabetes on Tirzepatide

Patients with type 2 diabetes taking tirzepatide should perform resistance training 2-3 times per week on non-consecutive days, starting with 1 set of 10-15 repetitions at 50% of 1-repetition maximum (1-RM) across 8-10 exercises targeting major muscle groups, progressing over 6 months to 3 sets of 8-10 repetitions at 75-80% of 1-RM. 1

Frequency and Timing

• Perform resistance training at least 2-3 days per week on non-consecutive days to optimize insulin action and glucose control 1, 2
• Never allow more than 2 consecutive days without any exercise (aerobic or resistance), as insulin resistance returns within 48-72 hours of the last exercise session 2, 3
• Allow at least 48 hours between resistance training sessions for adequate muscle recovery 3

Exercise Selection and Volume

• Include 5-10 exercises involving major muscle groups in the upper body, lower body, and core (examples: chest press, rows, squats, leg press, shoulder press, lat pulldown, leg curls, leg extensions, core exercises) 1, 3
• Use multi-joint compound movements that engage multiple muscle groups to maximize whole-body insulin sensitivity improvements 3
• Both resistance machines and free weights produce equivalent gains in strength and targeted muscle mass 1

Intensity Progression

Starting Phase (Weeks 1-8):

• Begin at moderate intensity: 50% of 1-RM 1
• Perform 10-15 repetitions to near fatigue per set 1, 3
• Complete 1 set minimum (up to 2 sets if tolerated) 1, 3

Progression Phase (Months 2-6):

• Progress to vigorous intensity: 75-80% of 1-RM for optimal gains in strength and insulin action 1
• Reduce repetitions to 8-10 per set with heavier weights 1
• Increase to 3 sets per exercise as the optimal goal 1

Rate of Progression

• Increase weight/resistance first, only after consistently exceeding the target number of repetitions per set 1, 3
• Then increase the number of sets 1
• Finally increase training frequency if needed 1
• Progress slowly over 6 months to avoid injury 1

Combination with Aerobic Exercise

• Combine resistance training with at least 150 minutes per week of moderate-intensity aerobic exercise spread over at least 3 days 2, 4
• Combined aerobic and resistance training produces twice the improvement in glycemic control (A1C reduction) compared to either modality alone 2, 4, 5
• The combined approach in the landmark trial by Church et al. showed an additional A1C reduction of -0.46 percentage points compared to aerobic training alone and -0.59 percentage points compared to resistance training alone 5

Supervision and Safety

• Initial instruction and periodic supervision by a qualified exercise trainer is recommended, particularly for resistance training, to ensure optimal benefits to glucose control, blood pressure, lipids, cardiovascular risk, and to minimize injury risk 1
• Supervised training produces greater compliance and blood glucose control than unsupervised exercise 2

Special Considerations for Tirzepatide Users

• Tirzepatide produces marked reductions in A1C (-1.87 to -2.59%) and body weight (-6.2 to -12.9 kg) 6, 7
• The primary adverse events are gastrointestinal in nature 6, 7, 8
• Hypoglycemia risk is low with tirzepatide when used without insulin or insulin secretagogues, so patients generally do not need to postpone exercise due to elevated blood glucose (up to 300 mg/dL) provided they feel well and are adequately hydrated 1
• The combination of tirzepatide's weight loss effects with resistance training is particularly important to preserve muscle mass during weight reduction 2

Common Pitfalls to Avoid

• Do not skip resistance training in favor of aerobic exercise alone - the combination provides superior metabolic benefits 2, 4, 5
• Do not use excessively light weights - heavier weights or resistance may be needed for optimization of insulin action and glucose control 1
• Do not progress too rapidly - slow progression over 6 months minimizes injury risk and maximizes adherence 1
• Do not allow prolonged sitting periods exceeding 30 minutes - break up sedentary time with brief standing or walking for additional glycemic benefits 2, 4