What type of physical activity is recommended for an adult with type 2 diabetes?

Physical Activity Recommendations for Adults with Type 2 Diabetes

Adults with type 2 diabetes should perform both aerobic exercise (at least 150 minutes per week of moderate-intensity activity spread over ≥3 days) and resistance training (2–3 sessions per week on non-consecutive days), while breaking up prolonged sitting every 30 minutes. 1

Aerobic Exercise Requirements

The cornerstone is ≥150 minutes per week of moderate-intensity aerobic activity, distributed across at least 3 days with no more than 2 consecutive days without exercise. 1 This frequency is critical because the acute insulin-sensitizing effect of exercise wanes within 48–72 hours after each session. 2, 3

Practical Implementation:

• Start each aerobic bout at ≥10 minutes duration, progressing toward 30 minutes per session on most days of the week. 1
• Acceptable activities include walking, cycling, swimming, dancing, yoga, housework, and gardening—any activity that engages large muscle groups. 1, 2
• Moderate intensity corresponds to 40–60% VO₂max (brisk walking for most individuals). 2, 4
• For those capable of vigorous exercise (running at 6 mph for ≥25 minutes), 75 minutes per week of high-intensity interval training (HIIT) provides comparable benefits to 150 minutes of moderate exercise. 1, 2

Why the ≤2-Day Gap Matters:

The insulin-sensitizing benefit disappears after 48–72 hours of inactivity, making frequent exercise sessions non-negotiable for sustained glycemic control. 2, 3, 5 Daily exercise is ideal, but at minimum, avoid gaps exceeding 2 days. 1, 3

Resistance Training Requirements

Perform 2–3 resistance training sessions per week on non-consecutive days to allow 48 hours for muscle recovery. 1, 2 Clinical trials demonstrate strong evidence that resistance training lowers A1C in older adults with type 2 diabetes, and combined aerobic plus resistance exercise provides additive glycemic benefits. 1

Practical Implementation:

• Each session should include ≥1 set of 5 or more different exercises targeting large muscle groups (chest press, rows, squats, leg press, shoulder press, lat pulldown, leg curls, leg extensions, core exercises). 1, 2
• Any intensity of resistance training is beneficial—even light resistance with elastic bands or body weight improves strength, balance, and glycemic control when heavier loads are not tolerated. 1, 2
• Use free weights, machines, elastic bands, or body weight as resistance. 1

Breaking Sedentary Behavior

Interrupt prolonged sitting every 30 minutes with brief standing, walking, or light activity. 1, 2 This provides independent glycemic benefits beyond structured exercise sessions—reducing sedentary time is as important as adding structured exercise for glycemic control. 1, 2, 3

High-Intensity Interval Training (HIIT) Option

For patients able to tolerate vigorous effort, HIIT involves aerobic training at 65–90% VO₂peak or 75–95% heart rate peak for 10 seconds to 4 minutes, with 12 seconds to 5 minutes of recovery. 1 HIIT requires only ≈75 minutes per week to achieve benefits comparable to 150 minutes of moderate exercise and elicits significant physiologic and metabolic adaptations. 1, 2

Pre-Exercise Safety Assessment

Before initiating an exercise program, assess for conditions that may contraindicate certain activities or require modifications:

• Cardiovascular screening: Evaluate for uncontrolled hypertension, known coronary artery disease, or atypical chest symptoms. 1, 2 However, routine cardiac stress testing is not recommended for asymptomatic individuals—a thorough history and risk assessment suffice. 1, 2
• Proliferative or severe non-proliferative retinopathy: Contraindicates vigorous activity due to risk of vitreous hemorrhage or retinal detachment. 2
• Autonomic neuropathy: May alter cardiovascular responses to exercise and should be considered in program design. 1, 2
• Peripheral neuropathy or history of foot ulcers/Charcot foot: Requires modified exercise selection (consider non-weight-bearing activities like swimming or cycling), appropriate footwear, and daily foot inspection. 1, 2, 3, 5

Hypoglycemia Prevention (for Insulin or Secretagogue Users)

Check glucose before, during, and after exercise. 2, 3 If pre-exercise glucose is low (≈90 mg/dL or 5.0 mmol/L), ingest carbohydrates unless insulin dose can be reduced. 2, 3

• Adjust medication timing and dosing around exercise sessions to avoid hypoglycemia. 2
• Post-exercise hypoglycemia can persist for several hours due to heightened insulin sensitivity. 2, 3
• High-intensity activities may actually increase blood glucose levels, particularly when pre-exercise glucose is elevated. 2
• In patients not using insulin or secretagogues, hypoglycemia is uncommon and routine preventive measures are generally unnecessary. 2

Progression Strategy

• Start with short, low-intensity activity for previously sedentary individuals, then gradually increase intensity and duration as tolerated. 1, 2
• Progress stepwise toward the target of ≥150 minutes per week of aerobic exercise. 1, 2
• Medical monitoring may be indicated as exercise intensity escalates to ensure safety and evaluate effects on glucose management. 1, 2

Expected Metabolic Benefits

Regular exercise improves A1C (average reduction of 0.5–0.8%), blood pressure, lipid profile (triglycerides, LDL, HDL), waist circumference, cardiovascular fitness, and overall well-being in adults with type 2 diabetes. 1, 2, 6 Structured exercise interventions of ≥8 weeks can reduce A1C by an average of 0.66%, even without significant BMI change. 1, 2 Moderate to high volumes of aerobic activity substantially lower cardiovascular and overall mortality risks. 2

Common Pitfalls to Avoid

• Allowing >2 consecutive days without exercise: This eliminates the acute insulin-sensitizing effect. 1, 2, 3
• Omitting resistance training: Resistance exercise provides substantial metabolic benefits and is not optional. 1, 2
• Underestimating exercise intensity: Walking must be "brisk" to qualify as moderate intensity. 4
• Neglecting foot care in patients with neuropathy: Proper footwear and daily foot inspection are essential to prevent injury. 2, 3, 5
• Failing to adjust insulin or carbohydrate intake around exercise: This leads to hypoglycemia in insulin/secretagogue users. 2, 3