Physical Activity/Exercise andDiabetes: A Position Statement ofthe American Diabetes AssociationDiabetes Care 2016;39:2065–2079 | DOI: 10.2337/dc16-1728

The adoption and maintenance of physical activity are critical foci for blood glucosemanagement and overall health in individuals with diabetes and prediabetes. Recom-mendations and precautions vary depending on individual characteristics and healthstatus. In this Position Statement, we provide a clinically oriented review and evidence-based recommendations regarding physical activity and exercise in people with type 1diabetes, type 2 diabetes, gestational diabetes mellitus, and prediabetes.Physical activity includes all movement that increases energy use, whereas exer-

cise is planned, structured physical activity. Exercise improves blood glucose controlin type 2 diabetes, reduces cardiovascular risk factors, contributes to weight loss,and improves well-being (1,2). Regular exercise may prevent or delay type 2 di-abetes development (3). Regular exercise also has considerable health benefits forpeople with type 1 diabetes (e.g., improved cardiovascular fitness, muscle strength,insulin sensitivity, etc.) (4). The challenges related to blood glucose managementvary with diabetes type, activity type, and presence of diabetes-related complica-tions (5,6). Physical activity and exercise recommendations, therefore, should betailored to meet the specific needs of each individual.

TYPES AND CLASSIFICATIONS OF DIABETES AND PREDIABETES

Physical activity recommendations and precautions may vary by diabetes type. Theprimary types of diabetes are type 1 and type 2. Type 1 diabetes (5%–10% of cases)results from cellular-mediated autoimmune destruction of the pancreatic b-cells,producing insulin deficiency (7). Although it can occur at any age, b-cell destructionrates vary, typically occurring more rapidly in youth than in adults. Type 2 diabetes(90%–95% of cases) results from a progressive loss of insulin secretion, usually alsowith insulin resistance. Gestational diabetes mellitus occurs during pregnancy, withscreening typically occurring at 24–28 weeks of gestation in pregnant women notpreviously known to have diabetes. Prediabetes is diagnosed when blood glucoselevels are above the normal range but not high enough to be classified as diabetes;affected individuals have a heightened risk of developing type 2 diabetes (7) butmayprevent/delay its onset with physical activity and other lifestyle changes (8).

TYPES OF EXERCISE AND PHYSICAL ACTIVITY

Aerobic exercise involves repeated and continuous movement of large musclegroups (9). Activities such as walking, cycling, jogging, and swimming rely primarilyon aerobic energy-producing systems. Resistance (strength) training includes exer-cises with free weights, weight machines, body weight, or elastic resistance bands.Flexibility exercises improve range of motion around joints (10). Balance exercisesbenefit gait and prevent falls (11). Activities like tai chi and yoga combine flexibility,balance, and resistance activities.

1Department of HumanMovement Sciences, OldDominion University, Norfolk, VA2Departments of Medicine, Cardiac Sciences, andCommunity Health Sciences, Faculties of Medi-cine and Kinesiology, University of Calgary, Cal-gary, Alberta, Canada3Department of Social Sciences, AugustanaCampus, University of Alberta, Camrose, Alberta,Canada4School of Kinesiology and Health Science, YorkUniversity, Toronto, Ontario, Canada5Baker IDI Heart & Diabetes Institute, Mel-bourne, Victoria, Australia6Harvard Medical School and Joslin DiabetesCenter, Boston, MA7William Sansum Diabetes Center, Santa Bar-bara, CA8Department of Health Behavior, Gillings School ofGlobal Public Health, University of North Carolina,Chapel Hill, NC

Corresponding author: Sheri R. Colberg, scolberg@odu.edu.

This position statement was reviewed and ap-proved by the American Diabetes AssociationProfessional Practice Committee in June 2016and ratified by the American Diabetes Associa-tion Board of Directors in September 2016.

© 2016 by the American Diabetes Association.Readers may use this article as long as the workis properly cited, the use is educational and notfor profit, and the work is not altered. More infor-mation is available at http://www.diabetesjournals.org/content/license.

Sheri R. Colberg,1 Ronald J. Sigal,2

Jane E. Yardley,3 Michael C. Riddell,4

David W. Dunstan,5 Paddy C. Dempsey,5

Edward S. Horton,6 Kristin Castorino,7 and

Deborah F. Tate8

Diabetes Care Volume 39, November 2016 2065

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BENEFITS OF EXERCISE ANDPHYSICAL ACTIVITY

Aerobic Exercise BenefitsAerobic training increases mitochondri-al density, insulin sensitivity, oxidativeenzymes, compliance and reactivity ofblood vessels, lung function, immunefunction, and cardiac output (12). Mod-erate to high volumes of aerobic activityare associated with substantially lowercardiovascular and overall mortalityrisks in both type 1 and type 2 diabetes(13). In type 1 diabetes, aerobic trainingincreases cardiorespiratory fitness, de-creases insulin resistance, and improveslipid levels and endothelial function(14). In individuals with type 2 diabetes,regular training reducesA1C, triglycerides,blood pressure, and insulin resistance(15). Alternatively, high-intensity intervaltraining (HIIT) promotes rapid enhance-ment of skeletal muscle oxidative capac-ity, insulin sensitivity, and glycemiccontrol in adults with type 2 diabetes(16,17) and can be performed withoutdeterioration in glycemic control intype 1 diabetes (18,19).

Resistance Exercise BenefitsDiabetes is an independent risk factorfor low muscular strength (20) andaccelerated decline in muscle strengthand functional status (21). The healthbenefits of resistance training for alladults include improvements in musclemass, body composition, strength, phys-ical function, mental health, bone min-eral density, insulin sensitivity, bloodpressure, lipid profiles, and cardiovascu-lar health (12). The effect of resistanceexercise on glycemic control in type 1diabetes is unclear (19). However, resis-tance exercise can assist in minimizingrisk of exercise-induced hypoglycemiain type 1 diabetes (22). When resistanceand aerobic exercise are undertaken inone exercise session, performing resis-tance exercise first results in less hypo-glycemia than when aerobic exercise isperformed first (23). Resistance trainingbenefits for individuals with type 2 di-abetes include improvements in glyce-mic control, insulin resistance, fat mass,blood pressure, strength, and lean bodymass (24).

Benefits of Other Types of PhysicalActivityFlexibility and balance exercises arelikely important for older adults with di-abetes. Limited joint mobility is frequently

present, resulting in part from the forma-tion of advanced glycation end products,which accumulate during normal agingand are accelerated by hyperglyce-mia (25). Stretching increases rangeof motion around joints and flexibility(10) but does not affect glycemic con-trol. Balance training can reduce falls riskby improving balance and gait, evenwhen peripheral neuropathy is present(11). Group exercise interventions (re-sistance and balance training, tai chiclasses) may reduce falls by 28%229%(26). The benefits of alternative traininglike yoga and tai chi are less established,although yoga may promote improve-ment in glycemic control, lipid levels,and body composition in adults withtype 2 diabetes (27). Tai chi trainingmay improve glycemic control, bal-ance, neuropathic symptoms, andsome dimensions of quality of life inadults with diabetes and neuropathy,although high-quality studies on thistraining are lacking (28).

BENEFITS OF ANDRECOMMENDATIONS FORREDUCED SEDENTARY TIME

Recommendations

c All adults, and particularly thosewith type 2 diabetes, should de-crease the amount of time spentin daily sedentary behavior. B

c Prolonged sitting should be inter-rupted with bouts of light activityevery 30 min for blood glucosebenefits, at least in adults withtype 2 diabetes. C

c The above two recommendationsare additional to, and not a re-placement for, increased struc-tured exercise and incidentalmovement. C

Sedentary behaviordwaking behaviorswith low energy expenditure (TV view-ing, desk work, etc.)dis a ubiquitousand significant population-wide influenceon cardiometabolic health (29,30). Higheramounts of sedentary time are associatedwith increased mortality and morbidity,mostly independent of moderate-to-vigorous physical activity participation(31–35). In people with or at risk fordeveloping type 2 diabetes, extendedsedentary time is also associated withpoorer glycemic control and clusteredmetabolic risk (36–39). Prolonged sitting

interrupted by brief (#5 min) bouts ofstanding (40–42) or light-intensity am-bulation (41,43,44) every 20–30 min im-proves glycemic control in sedentaryoverweight/obese populations and inwomen with impaired glucose regula-tion. In adults with type 2 diabetes, inter-rupting prolonged sitting with 15 minof postmeal walking (45) and with 3 minof light walking and simple body-weightresistance activities every 30 min (46)improves glycemic control. The longer-term health efficacy and durability ofreducing and interrupting sitting timeremain to be determined for individu-als with and without diabetes.

PHYSICAL ACTIVITY AND TYPE 2DIABETES

Recommendations

c Daily exercise, or at least not allowingmore than 2 days to elapse betweenexercise sessions, is recommended toenhance insulin action. B

c Adults with type 2 diabetes shouldideally perform both aerobic andresistance exercise training for op-timal glycemic and health out-comes. C

c Children and adolescents withtype 2 diabetes should be en-couraged to meet the same phys-ical activity goals set for youth ingeneral. C

c Structured lifestyle interventionsthat include at least 150 min/weekof physical activity and dietarychanges resulting in weight lossof 5%–7% are recommended toprevent or delay the onset oftype 2 diabetes in populations athigh risk and with prediabetes. A

Insulin Action and Physical ActivityInsulin action in muscle and liver can bemodified by acute bouts of exercise andby regular physical activity (47). Acutely,aerobic exercise increases muscle glu-cose uptake up to fivefold throughinsulin-independent mechanisms. Afterexercise, glucose uptake remains ele-vated by insulin-independent (;2 h)and insulin-dependent (up to 48 h)mechanisms if exercise is prolonged(48), which is linked with muscle glycogenrepletion (49,50). Improvements in insulinaction may last for 24 h following shorterduration activities (;20 min) if the inten-sity is elevated to near-maximal effort

2066 Position Statement Diabetes Care Volume 39, November 2016

intermittently (51,52). Even low-intensityaerobic exercise lasting$60min enhancesinsulin action in obese, insulin-resistantadults for at least 24 h (53). If enhancedinsulin action is a primary goal, then dailymoderate- or high-intensity exercise islikely optimal (54).Regular training increases muscle

capillary density, oxidative capacity,lipid metabolism, and insulin signalingproteins (47), which are all reversiblewith detraining (55). Both aerobic andresistance training promote adaptationsin skeletal muscle, adipose tissue, andliver associated with enhanced insulinaction, even without weight loss (56,57).Regular aerobic training increases muscleinsulin sensitivity in individuals with pre-diabetes (58) and type 2 diabetes (59) inproportion to exercise volume (60). Evenlow-volume training (expending just400 kcal/week) improves insulin actionin previously sedentary adults (60).Those with higher baseline insulin resis-tance have the largest improvements,and a dose response is observed upto about 2,500 kcal/week (60). Resis-tance training enhances insulin actionsimilarly (56), as do HIIT and othermodes (2,15–17). Combining endur-ance exercise with resistance exercisemay provide greater improvements(61), and HIIT may be superior to con-tinuous aerobic training in adults withdiabetes (16).

Physical Activity in Adults With Type 2DiabetesThe Look AHEAD (Action for Health inDiabetes) trial (62) was the largest ran-domized trial evaluating a lifestyle in-tervention in older adults with type 2diabetes compared with a diabetes sup-port and education control group. Theintensive lifestyle intervention grouptargeted weight loss of at least 7%through a modest dietary energy defi-cit and at least 175 min/week of unsu-pervised exercise. Major cardiovascularevents were the same in both groups,possibly in part due to greater use ofcardioprotective medications in the dia-betes support and education group (62).However, as reviewed by Pi-Sunyer (63),the intensive lifestyle intervention groupachieved significantly greater sustainedimprovements in weight loss, cardiore-spiratory fitness, blood glucose control,blood pressure, and lipids with fewermedications; less sleep apnea, severe

diabetic kidney disease and retinopathy,depression, sexual dysfunction, urinaryincontinence, and knee pain; and betterphysical mobility maintenance and qual-ity of life, with lower overall health carecosts. This trial provided very strong evi-dence of profound health benefits fromintensive lifestyle intervention. More-over, aerobic exercise clearly improvesglycemic control in type 2 diabetes, par-ticularly when at least 150 min/weekare undertaken (64). Resistance exer-cise (free weights or weight machines)increases strength in adults with type 2diabetes by about 50% (24) and improvesA1C by 0.57% (64). A meta-analysis of12 trials in adults with type 2 diabetesreported a greater reduction (differenceof 20.18%) in A1C following aerobiccompared with resistance training butno difference in cardiovascular riskmarker reduction (65). For glycemiccontrol, combined training is superiorto either type of training undertakenalone (61,66). Therefore, adults withtype 2 diabetes should ideally performboth aerobic and resistance exercisetraining for optimal glycemic and healthoutcomes.

Physical Activity in Youth With Type 2DiabetesRandomized trials evaluating exerciseinterventions in youth with type 2 dia-betes are limited and inconclusive,although benefits are likely similarto those in adults. In the Treatment Op-tions for Type 2 Diabetes in Adolescentsand Youth (TODAY) study (67), youthaged 10–17 years with type 2 diabeteswere stabilized on metformin and thenrandomized to metformin plus placebo,metformin plus rosiglitazone, or metfor-min plus lifestyle intervention and fol-lowed for a mean of 3.86 years. Thelifestyle intervention included modestweight loss achieved through dietary en-ergy restriction and increased physi-cal activity (minimum 200 min/weekof moderate to vigorous activity formost;.300 min/week for already activeyouth), along with metformin use. Therate of glycemic failure (A1C .8.0% orneed to initiate insulin)was not significantlyreduced in the lifestyle plus metformingroup compared with metformin only ormetforminplus rosiglitazone.Given the lim-ited data in youth with type 2 diabetes, it isrecommended that children and adoles-cents with type 2 diabetes meet the same

physical activity goals set for youth in gen-eral (http://www.cdc.gov/physicalactivity/basics/children): a minimum 60 min/dayof moderate-to-vigorous physical activity,including strength-related exercise at least3 days/week.

Prevention and Treatment of Type 2Diabetes With Lifestyle InterventionStructured lifestyle intervention trialsthat include physical activity at least150–175 min/week and dietary energyrestriction targeting weight loss of5%27% have demonstrated reductionsof 40%–70% in the risk of developingtype 2 diabetes in people with impairedglucose tolerance (66). A recent system-atic review of 53 studies (30 of diet andphysical activity promotion programs vs.usual care, 13 of more intensive vs. lessintensive programs, and 13 of singleprograms) that evaluated 66 lifestyleintervention programs reported that,compared with usual care, diet and phys-ical activity promotion programs reducedtype 2 diabetes incidence, body weight,and fasting blood glucose while improvingother cardiometabolic risk factors (68).Trials evaluating less resource-intensivelifestyle interventions have also shown ef-fectiveness (3), and adherence to guide-lines is associated with a greater weightloss (69).

PHYSICAL ACTIVITY AND TYPE 1DIABETES

Recommendations

c Youth and adults with type 1 dia-betes can benefit from being phys-ically active, and activity should berecommended to all. B

c Blood glucose responses to phys-ical activity in all people withtype 1 diabetes are highly vari-able based on activity type/timing and require different ad-justments. B

c Additional carbohydrate intakeand/or insulin reductions are typi-cally required to maintain glyce-mic balance during and afterphysical activity. Frequent bloodglucose checks are required toimplement carbohydrate intakeand insul in dose adjustmentstrategies. B

c Insulin users can exercise usingeither basal-bolus injection regi-mens or insulin pumps, but there

care.diabetesjournals.org Colberg and Associates 2067

are advantages and disadvantagesto both insulin delivery methods. C

c Continuous glucose monitoring dur-ing physical activity can be used todetect hypoglycemia when used asan adjunct rather than in place ofcapillary glucose tests. C

Physical Activity and Sports in Youthand Adults With Type 1 DiabetesYouth experience many health bene-fits from physical activity participa-tion (9). A meta-analysis of 10 trials inyouth ,18 years of age with type 1diabetes found significant improvementsin A1C in exercisers (70), and exercis-ing more than three sessions/weekfor longer (.1 h/session) and doing bothaerobic and resistance exercise maybe beneficial (70). In adults, regular phys-ical activity has been associated with de-creasedmortality (71). There is insufficientevidence on the ideal type, timing, inten-sity, and duration of exercise for optimalglycemic control.

Effects of Activity Type and Timing onGlycemic BalanceBlood glucose responses to physical ac-tivity in type 1 diabetes are highly vari-able (72). In general, aerobic exercisedecreases blood glucose levels if per-formed during postprandial periodswith the usual insulin dose adminis-tered at the meal before exercise (73),and prolonged activity done then maycause exaggerated decreases (74–76).Exercise while fasting may produce a

lesser decrease or a small increase inblood glucose (77). Very intense activitiesmay provide better glucose stability (22)or a rise in blood glucose if the relativeintensity is high and done for a brief du-ration (#10 min) (78). Mixed activities,such as interval training or team/individualfield sports, are associated with betterglucose stability than those that are pre-dominantly aerobic (18,79–82), althoughvariable results have been reported for in-termittent, high-intensity exercise (80).

Management of Food and Insulin WithPhysical ActivityVariable glycemic responses to physicalactivity (72) make uniform recommen-dations for management of food intakeand insulin dosing difficult. To preventhypoglycemia during prolonged ($30min),predominantly aerobic exercise, addi-tional carbohydrate intake and/or reduc-tions in insulin are typically required.For low- to moderate-intensity aerobicactivities lasting 30260 min under-taken when circulating insulin levels arelow (i.e., fasting or basal conditions),;10215 g of carbohydrate may preventhypoglycemia (83). For activities per-formed with relative hyperinsulinemia(after bolus insulin), 30260 g of carbo-hydrate per hour of exercise may beneeded (84), which is similar to carbohy-drate requirements to optimize perfor-mance in athletes with (85) or without(86) type 1 diabetes.

As recommended in Table 1, bloodglucose concentrations should alwaysbe checked prior to exercise undertaken

by individuals with type 1 diabetes. Thetarget range for blood glucose prior toexercise should ideally be between 90and 250 mg/dL (5.0 and 13.9 mmol/L).Carbohydrate intake required will varywith insulin regimens, timing of exer-cise, type of activity, and more (87),but it will also depend on starting bloodglucose levels. As an alternative or acomplement to carbohydrate intake, re-ductions in basal and/or bolus insulindose should be considered for exercise-induced hypoglycemia prevention;lowering insulin levels adequately dur-ing activity may reduce or eliminatethe need for carbohydrate intake. Forexample, a 20% reduction in basal insulinfor individuals on multiple daily injec-tions (MDI) can be made for doses bothbefore and after exercise, but this strat-egy may not fully attenuate the declinein glucose during the activity (89). Con-tinuous subcutaneous insulin infusion(CSII) users can reduce (90) or suspend(91) insulin delivery at the start ofexercise, but this strategy does notalways prevent hypoglycemia (91,92).Performing basal rate reductions30260 min before exercise may reducehypoglycemia due to pharmacokineticsof rapid-acting insulin analogs used inCSII (93). For exercise performed within223 h after bolus insulin via CSII orMDI, 25%275% reductions in insulinmay limit hypoglycemia (Table 2). Fre-quent blood glucose checks are re-quired when implementing insulin andcarbohydrate adjustments.

Table 1—Suggested carbohydrate intake or other actions based on blood glucose levels at the start of exercise

Pre-exercise blood glucose Carbohydrate intake or other action

,90 mg/dL (,5.0 mmol/L) c Ingest 15–30 g of fast-acting carbohydrate prior to the start of exercise, depending on the size of theindividual and intended activity; some activities that are brief in duration (,30 min) or at a very highintensity (weight training, interval training, etc.) may not require any additional carbohydrate intake.

c For prolonged activities at a moderate intensity, consume additional carbohydrate, as needed(0.5–1.0 g/kg body mass per h of exercise), based on blood glucose testing results.

90–150 mg/dL (5.0–8.3 mmol/L) c Start consuming carbohydrate at the onset of most exercise (;0.5–1.0 g/kg body mass per h ofexercise), depending on the type of exercise and the amount of active insulin.

150–250 mg/dL (8.3–13.9 mmol/L) c Initiate exercise and delay consumption of carbohydrate until blood glucose levels are,150 mg/dL(,8.3 mmol/L).

250–350 mg/dL (13.9–19.4 mmol/L) c Test for ketones. Do not perform any exercise if moderate-to-large amounts of ketones are present.c Initiate mild-to-moderate intensity exercise. Intense exercise should be delayed until glucose levelsare ,250 mg/dL because intense exercise may exaggerate the hyperglycemia.

$350 mg/dL ($19.4 mmol/L) c Test for ketones. Do not perform any exercise if moderate-to-large amounts of ketones are present.c If ketones are negative (or trace), consider conservative insulin correction (e.g., 50% correction)before exercise, depending on active insulin status.

c Initiate mild-to-moderate exercise and avoid intense exercise until glucose levels decrease.

Adapted from Zaharieva and Riddell (88).

2068 Position Statement Diabetes Care Volume 39, November 2016

Use of CSII and MDI for ActivityIndividuals using CSII or MDI as a basal-bolus regimen can exercise with few re-strictions. CSII offers some advantagesover MDI due to greater flexibility inbasal rate adjustments and limitingpostexercise hyperglycemia (98), withsome limitations. For example, aerobicexercise may accelerate basal insulin ab-sorption from the subcutaneous depot(74), whereas basal insulin glargine ab-sorption is largely unaffected (99). Skinirritation, pump tubing, and wearing apump that is visible to others can beconcerns (100). In certain sports, suchas basketball or contact sports, wear-ing pumps and other devices may beprohibited during competition. Frus-tration with CSII devices and exercisemay lead to discontinuation of pumptherapy (100).

Use of Continuous GlucoseMonitoring With ActivityContinuous glucose monitoring (CGM)may decrease the fear of exercise-induced hypoglycemia in type 1 diabetesby providing blood glucose trends thatallow users to prevent and treat hypo-glycemia sooner (83). Although a fewstudies have found acceptable CGMaccuracy during exercise (101–104),others have reported inadequate accu-racy (105) and other problems, such assensor filament breakage (103,104), in-ability to calibrate (102), and time lagsbetween the change in blood glucoseand its detection by CGM (106). Differ-ences in sensor performance have alsobeen noted (107–109). Although it is apotentially useful tool during and afterexercise (110), CGM values have tradi-tionally required confirmation by finger-stick glucose testing prior to makingregimen changes, but approval of non-adjunctive use is likely forthcoming inthe near future.

RECOMMENDED PHYSICALACTIVITY PARTICIPATION FORPEOPLE WITH DIABETES

Recommendations

c Pre-exercise medical clearance isgenerally unnecessary for asymp-tomatic individuals prior to begin-ning low- or moderate-intensityphysical activity not exceeding thedemands of brisk walking or everydayliving. B

c Most adults with diabetes shouldengage in 150 min or more ofmoderate-to-vigorous intensityactivity weekly, spread over atleast 3 days/week, with no morethan 2 consecutive days withoutactivity. Shorter durations (mini-mum 75 min/week) of vigorous-intensity or interval training maybe sufficient for younger andmore physically fit individuals. Bfor type 2 diabetes, C for type 1diabetes

c Children and adolescents withtype 1 or type 2 diabetes shouldengage in 60 min/day or more ofmoderate or vigorous intensityaerobic activity, with vigorous,muscle-strengthening, and bone-strengthening activities includedat least 3 days/week. C

c Adults with diabetes should engagein 2–3 sessions/week of resistanceexercise on nonconsecutive days.B for type 2 diabetes, C for type 1diabetes

c Flexibility training and balancetraining are recommended 2–3times/week for older adults withdiabetes. Yoga and tai chi maybe included based on individualpreferences to increase flexibility,muscular strength, and balance. C

c Individuals with diabetes or predi-abetes are encouraged to increase

their total daily incidental (non-exercise) physical activity to gainadditional health benefits. C

c To gain more health benefits fromphysical activity programs, partic-ipation in supervised training isrecommended over nonsupervisedprograms. B

Pre-exercise Health Screening andEvaluationThe American College of Sports Medi-cine (ACSM) recently proposed a newmodel for exercise preparticipationhealth screening on the basis of 1) theindividual’s current physical activitylevels; 2) the presence of signs or symp-toms and/or known cardiovascular,metabolic, or renal disease; and 3) thedesired exercise intensity, all of whichare risk modulators of exercise-relatedcardiovascular events (111). The ACSMno longer includes risk factor assess-ment in the exercise preparticipationhealth screening process. However,their recommendation is that anyonewith diabetes who is currently seden-tary and desires to begin physical activ-ity at any intensity (even low intensity)should obtain prior medical clearancefrom a health care professional (111).We believe this recommendation is ex-cessively conservative.

Physical activity does carry some po-tential health risks for people with dia-betes, including acute complications likecardiac events, hypoglycemia, and hy-perglycemia. In low- and moderate-intensity activity undertaken by adultswith type 2 diabetes, the risk of exercise-induced adverse events is low. In indi-viduals with type 1 diabetes (any age)the only common exercise-induced ad-verse event is hypoglycemia. No currentevidence suggests that any screeningprotocol beyond usual diabetes care re-duces risk of exercise-induced adverseevents in asymptomatic individuals withdiabetes (112,113). Thus, pre-exercisemedical clearance is not necessary forasymptomatic individuals receiving dia-betes care consistent with guidelineswho wish to begin low- or moderate-intensity physical activity not exceed-ing the demands of brisk walking oreveryday living.

However, some individuals who planto increase their exercise intensity orwho meet certain higher-risk criteria

Table 2—Suggested initial pre-exercise meal insulin bolus reduction for activitystarted within 90 min after insulin administration

Exercise intensity

Exercise duration

30 min 60 min

Mild aerobic (;25% VO2max) 225%* 250%

Moderate aerobic (;50% VO2max) 250% 275%

Heavy aerobic (70%275% VO2max) 275% N-A

Intense aerobic/anaerobic (.80% VO2max) No reduction recommended N-A

Recommendations compiled based on four studies (94–97). N-A, not assessed as exerciseintensity is too high to sustain for 60 min. *Estimated from study (95).

care.diabetesjournals.org Colberg and Associates 2069

may benefit from referral to a healthcare provider for a checkup and possibleexercise stress test before starting suchactivities (6). In addition, most adultswith diabetes may also benefit fromworking with a diabetes-knowledgeableexercise physiologist or certified fitnessprofessional to assist them in formulat-ing a safe and effective exercise pre-scription. A combination of carefulconsideration of multiple factors andsound clinical judgment based on theindividual’s medical history and physi-cal examination will determine their de-gree of risk of acute complications andidentify the most appropriate physicalactivities to avoid or limit.

Aerobic Exercise TrainingPeople with diabetes should performaerobic exercise regularly. Aerobic activ-ity bouts should ideally last at least10 min, with the goal of ;30 min/dayor more, most days of the week foradults with type 2 diabetes. Daily

exercise, or at least not allowing morethan 2 days to elapse between exercisesessions, is recommended to decreaseinsulin resistance, regardless of diabetestype (16,19). Over time, activities shouldprogress in intensity, frequency, and/orduration to at least 150 min/week ofmoderate-intensity exercise. Adultsable to run at 6 miles/h (9.7 km/h) for atleast 25 min can benefit sufficiently fromshorter-duration vigorous-intensity activ-ity (75 min/week). Many adults, includ-ing most with type 2 diabetes, would beunable or unwilling to participate in suchintense exercise and should engage inmoderate exercise for the recommendedduration (Table 3).

Youth with type 1 or type 2 diabetesshould follow general recommendationsfor children and adolescents. These in-clude 60 min/day or more of moderate-or vigorous-intensity aerobic activity,with vigorous, muscle-strengthening,and bone-strengthening activities atleast 3 days/week (9).

Low-volume HIIT, which involvesshort bursts of very intense activity in-terspersed with longer periods of recov-ery at low to moderate intensity, is analternative approach to continuous aer-obic activity (16,19). However, its safetyand efficacy remain unclear for someadults with diabetes (114,115). Thosewho wish to perform HIIT should beclinically stable, have been partici-pating at least in regular moderate-intensity exercise, and likely be supervisedat least initially (116). The risks withadvanced disease are unclear (116),and continuous, moderate-intensity ex-ercise may be safer (117). The optimalHIIT training protocol has yet to bedetermined.

Resistance Exercise TrainingAdults with diabetes should engage in223 sessions/week of resistance exer-cise on nonconsecutive days (Table 3)(9). Although heavier resistance train-ing with free weights and weight

Table 3—Exercise training recommendations: types of exercise, intensity, duration, frequency, and progression

Aerobic Resistance Flexibility and Balance

Type of exercise c Prolonged, rhythmic activities usinglarge muscle groups (e.g., walking,cycling, and swimming)

c May be done continuously or as HIIT

c Resistance machines, free weights,resistance bands, and/or bodyweight as resistance exercises

c Stretching: static, dynamic, andother stretching; yoga

c Balance (for older adults): practicestanding on one leg, exercises usingbalance equipment, lower-body andcore resistance exercises, tai chi

Intensity c Moderate to vigorous (subjectivelyexperienced as “moderate” to “veryhard”)

c Moderate (e.g., 15 repetitions of anexercise that can be repeated nomore than 15 times) to vigorous (e.g.,6–8 repetitions of an exercise thatcan be repeated no more than 6–8times)

c Stretch to the point of tightness orslight discomfort

c Balance exercises of light tomoderate intensity

Duration c At least 150 min/week at moderateto vigorous intensity for most adultswith diabetes

c For adults able to run steadily at6 miles per h (9.7 km/h) for 25 min,75min/week of vigorous activity mayprovide similar cardioprotectiveand metabolic benefits

c At least 8–10 exercises withcompletion of 1–3 sets of 10–15repetitions to near fatigue per set onevery exercise early in training

c Hold static or do dynamic stretch for10230 s; 224 repetitions of eachexercise

c Balance training can be any duration

Frequency c 3–7 days/week, with no more than2 consecutive days without exercise

c A minimum of 2 nonconsecutivedays/week, but preferably 3

c Flexibility: $223 days/weekc Balance: $223 days/week

Progression c A greater emphasis should be placedon vigorous intensity aerobicexercise if fitness is a primary goal ofexercise and not contraindicated bycomplications

c Both HIIT and continuous exercisetraining are appropriate activitiesfor most individuals with diabetes

c Beginning training intensity shouldbe moderate, involving 10215repetitions per set, with increases inweight or resistance undertakenwitha lower number of repetitions (8210)only after the target number ofrepetitions per set can consistentlybe exceeded

c Increase in resistance can befollowed by a greater number of setsand finally by increased trainingfrequency

c Continue to work on flexibility andbalance training, increasing durationand/or frequency to progress overtime

2070 Position Statement Diabetes Care Volume 39, November 2016

machines may improve glycemic con-trol and strength more (118), doing re-sistance training of any intensity isrecommended to improve strength, bal-ance, and ability to engage in activities ofdaily living throughout the life span.

Flexibility, Balance, and OtherTrainingCompleting flexibility exercises for eachof the major muscle-tendon groups on2 or more days/week maintains jointrange of movement (Table 3) (12). Al-though flexibility training may be desir-able for individuals with all types ofdiabetes, it should not substitute forother recommended activities (i.e.,aerobic and resistance training), asflexibility training does not affect glu-cose control, body composition, or in-sulin action (6). Adults with diabetes(ages 50 years and older) should doexercises that maintain/improve balance223 times/week (Table 3) (11,12), par-ticularly if they have peripheral neu-ropathy (11). Many lower-body andcore-strengthening exercises conco-mitantly improve balance and may beincluded. Yoga and tai chi can be in-cluded based on individual prefer-ences to increase flexibility, strength,and balance.

Daily MovementIncreasing unstructured physical activ-ity (e.g., errands, household tasks, dogwalking, or gardening) increases dailyenergy expenditure and assists withweight management (119–121). Un-structured activity also reduces totaldaily sitting time. Increasing nonexer-cise activity, even in brief (3215 min)bouts, is effective in acutely reducingpostprandial hyperglycemia and im-proving glycemic control in those withprediabetes and type 1 and type 2 dia-betes, most prominently after meals(41,43–46,75,122–124). Increasing un-structured physical activity should beencouraged as part of a whole-day ap-proach, or at least initially as a steppingstone for individuals who are sedentaryand unable/reluctant to participate inmore structured exercise.

Supervised Versus NonsupervisedTrainingSupervised aerobic or resistance train-ing reduces A1C in adults withtype 2 diabetes whether or not theyinclude dietary cointervention, but

unsupervised exercise only reduces A1Cwith a concomitant dietary intervention(64). Similarly, individuals undertakingsupervised aerobic and resistance exer-cise achieve greater improvements inA1C, BMI, waist circumference, bloodpressure, fitness, muscular strength,and HDL cholesterol (125). Thus, super-vised training is recommended whenfeasible, at least for adults with type 2diabetes.

PHYSICAL ACTIVITY ANDPREGNANCY WITH DIABETES

Recommendations

c Women with preexisting diabe-tes of any type should be advisedto engage in regular physical ac-tivity prior to and during preg-nancy. C

c Pregnant women with or at riskfor gestational diabetes mellitusshould be advised to engage in20–30 min of moderate-intensityexercise on most or all days ofthe week. B

Physical activity and exercise duringpregnancy have been shown to benefitmost women by improving cardiovascu-lar health and general fitness while re-ducing the risk of complications likepreeclampsia and cesarean delivery(126). Regular physical activity duringpregnancy also lowers the risk of devel-oping gestational diabetes mellitus(127,128). Exercise programs includingat least 20230min ofmoderate-intensityexercise on most or all days of the weekare recommended (126). Once gesta-tional diabetes mellitus is diagnosed,either aerobic or resistance training canimprove insulin action and glycemic con-trol (129). In women with gestationaldiabetes mellitus, particularly thosewho are overweight and obese, vigorous-intensity exercise during pregnancymay reduce the odds of excess gesta-tional weight gain (130). Ideally, thebest time to start physical activity is priorto pregnancy to reduce gestational dia-betes mellitus risk (131), but it is safe toinitiate during pregnancy with very fewcontraindications (126). Any pregnantwomen using insulin should be awareof the insulin-sensitizing effects ofexercise and increased risk of hypogly-cemia, particularly during the first tri-mester (129).

MINIMIZING EXERCISE-RELATEDADVERSE EVENTS IN PEOPLE WITHDIABETES

Recommendations

c Insulin regimen and carbohydrateintake changes should be used toprevent exercise-related hypogly-cemia. Other strategies involve in-cluding short sprints, performingresistance exercise before aerobicexercise in the same session, andactivity timing. B

c Risk of nocturnal hypoglycemiafollowing physical activity may bemitigated with reductions in basalinsulin doses, inclusion of bedtimesnacks, and/or use of continuousglucose monitoring. C

c Exercise-induced hyperglycemiais more common in type 1 diabe-tes but may be modulated withinsulin administration or a lower-intensity aerobic cooldown. Exer-cising with hyperglycemia andelevated blood ketones is not rec-ommended. C

c Some medications besides insulinmay increase the risks of exercise-related hypoglycemia and dosesmay need to be adjusted basedon exercise training. C

c Older adults with diabetes or any-one with autonomic neuropathy,cardiovascular complications, orpulmonary disease should avoidexercising outdoors on very hotand/or humid days to preventheat-related illnesses. C

c Exercise training should progressappropriately to minimize risk ofinjury. C

HypoglycemiaExercise-induced hypoglycemia is com-mon in people with type 1 diabetes and,to a lesser extent, people with type 2diabetes using insulin or insulin secreta-gogues. In addition to insulin regimenand carbohydrate intake changes, abrief (10 s) maximal intensity sprintperformed before (132) or after (133)a moderate-intensity exercise sessionmay protect against hypoglycemia(134). Performing high-intensity boutsintermittently during moderate aerobicexercise also slows blood glucose de-clines (81,135,136), as can resistanceexercise done immediately prior toaerobic (23).

care.diabetesjournals.org Colberg and Associates 2071

Exercise-induced nocturnal hypogly-cemia is a major concern (137). Hypo-glycemic events occur typically within6215 h postexercise (138), althoughrisk can extend out to 48 h (139). Therisk of nocturnal hypoglycemia may beminimized through;20% reductions ofdaily basal insulin dose with reducedprandial bolus insulin and low glycemicindex carbohydrate feeding followingevening exercise for those on MDI (89).For CSII users, basal rate reductions of20% at bedtime for 6 h after afternoonexercise may limit nocturnal hypoglyce-mia (140). Inclusion of a bedtime snack,glucose checks overnight, and/or useof CGM with alarms and automaticpump suspensionmay also bewarranted(141,142).

HyperglycemiaExercise-induced hyperglycemia is morecommon in type 1 diabetes. Purposefulinsulin omission before exercise canpromote a rise in glycemia, as can mal-functioning infusion sets (143). Individ-uals with type 2 diabetes may alsoexperience increases in blood glucoseafter aerobic or resistance exercise, par-ticularly if they are insulin users and

administer too little insulin for mealsbefore activity (144). Overconsumptionof carbohydrates before or during exer-cise, alongwith aggressive insulin reduc-tion, can promote hyperglycemia duringany exercise (89).

Very intense exercise such as sprinting(134), brief but intense aerobic exercise(145), and heavy powerlifting (146,147)may promote hyperglycemia, especially ifstarting blood glucose levels are elevated(145). Hyperglycemia risk is mitigated ifintense activities are interspersed be-tween moderate-intensity aerobic ones(82,148). Similarly, combining resistancetraining (done first) with aerobic train-ing (second) optimizes glucose stabilityin type 1 diabetes (23). To correct post-exercise hyperglycemia, a conservative(50% of usual) correction can be admin-istered (77) or an aerobic cooldown maybe done to lower it (I.S. Millan, personalcommunication). Excessive insulin cor-rections after exercise increase noctur-nal hypoglycemia risk, which can resultin mortality (149).

Individuals with type 1 diabetes shouldtest for blood ketones if they have unex-plained hyperglycemia ($250 mg/dL).Exercise shouldbepostponedor suspended

if blood ketone levels are elevated($1.5 mmol/L), as blood glucose levelsand ketones may rise further with evenmild activity.

Medication EffectsAdults with diabetes are frequentlytreated with multiple medications fordiabetes and other comorbid conditions.Some medications (other than insulin)may increase exercise risk and dosesmay need to be adjusted (150,151).Although appropriate changes shouldbe individualized, Table 4 lists gen-eral considerations and guidelines formedications.

Heat-Related Illness During PhysicalActivityPhysical activity increases bodily heatproduction and core temperature, lead-ing to greater skin blood flow and sweat-ing. In relatively young adults withtype 1 diabetes, temperature regulationis only impaired during high-intensityexercise (152,153). With increasingage, poor blood glucose control, andneuropathy, skin blood flow and sweat-ing may be impaired in adults withtype 1 (152,154) and type 2 (155) diabe-tes, increasing the risk of heat-related

Table 4—Exercise considerations for diabetes, hypertension, and cholesterol medications and recommended safety and doseadjustments

Type/class of medication Exercise considerations Safety/dose adjustments

DiabetesInsulin c Deficiency: hyperglycemia, ketoacidosis

c Excess: hypoglycemia during and after exercisec Increase insulin dose pre- and postexercise fordeficiency

c Decrease prandial and/or basal doses for excess insulin

Insulin secretagogues c Exercise-induced hypoglycemia c If exercise-induced hypoglycemia has occurred,decrease dose on exercise days to reducehypoglycemia risk

Metformin c None c Generally safe; no dose adjustment for exercise

Thiazolidinediones c Fluid retention c Generally safe; no dose adjustment for exercise

Dipeptidyl peptidase 4inhibitors

c Slight risk of congestive heart failure withsaxagliptin and alogliptin

c Generally safe; no dose adjustment for exercise

Glucagon-like peptide1 receptor agonists

c May increase risk of hypoglycemia when used withinsulin or sulfonylureas but not when used alone

c Generally safe; no dose adjustment for exercise butmay need to lower insulin or sulfonylurea dose

Sodium–glucosecotransporter 2 inhibitors

c May increase risk of hypoglycemia when used withinsulin or sulfonylureas but not when used alone

c Generally safe; no dose adjustment for exercise

Hypertensionb-Blockers c Hypoglycemia unawareness and unresponsiveness;

may reduce maximal exercise capacityc Check blood glucose before and after exercise;treat hypoglycemia with glucose

Other agents c Regular exercise training may lower blood pressure;some agents increase risk of dehydration

c Doses may need to be adjusted to accommodate theimprovements from training and avoid dehydration

CholesterolStatins c Muscle weakness, discomfort, and cramping in a

minority of usersc Generally safe; no dose adjustment for exercise

Fibric acid derivatives c Rare myositis or rhabdomyolysis; risk increasedwith gemfibrozil and statin combination

c Avoid exercise if these muscle conditions arepresent

2072 Position Statement Diabetes Care Volume 39, November 2016

Table 5—Physical activity consideration, precautions, and recommended activities for exercising with health-relatedcomplications

Health complication Exercise considerations Physical activity recommendations/precautions

Cardiovascular diseasesCoronary artery disease c Coronary perfusion may actually be enhanced

during higher-intensity aerobic or resistanceexercise.

c All activities okay.c Consider exercising in a supervised cardiacrehabilitation program, at least initially.

Exertional angina c Onset of chest pain on exertion, but exercise-induced ischemia may be silent in some withdiabetes.

c All activities okay, but heart rate should bekept $10 bpm below onset of exercise-relatedangina.

Hypertension c Both aerobic and resistance training may lowerresting blood pressure and should beencouraged.

c Some blood pressure medications can causeexercise-related hypotension.

c Ensure adequate hydration during exercise.c Avoid Valsalva maneuver during resistancetraining.

Myocardial infarction c Stop exercise immediately should symptoms ofmyocardial infarction (such as chest pain,radiating pain, shortness of breath, and others)occur during physical activity and seek medicalattention.

c Restart exercise after myocardial infarction in asupervised cardiac rehabilitation program.

c Start at a low intensity and progress as able tomore moderate activities.

c Both aerobic and resistance exercise are okay.

Stroke c Diabetes increases the risk of ischemic stroke.c Stop exercise immediately if symptoms of astroke (occurring suddenly and often affectingonly one side of the body) happen duringexercise.

c Restart exercise after stroke in a supervisedcardiac rehabilitation program.

c Start at a low intensity and progress as able tomore moderate activities.

c Both aerobic and resistance exercise are okay.

Congestive heart failure c Most common cause is coronary artery diseaseand frequently follows a myocardial infarction.

c Avoid activities that cause an excessive rise inheart rate.

c Focus more on doing low- or moderate-intensityactivities.

Peripheral artery disease c Lower-extremity resistance training improvesfunctional performance (161).

c Low- or moderate-intensity walking, armergometer, and leg ergometer preferred asaerobic activities (162).

c All other activities okay.

Nerve diseasePeripheral neuropathy c Regular aerobic exercise may also prevent the

onset or delay the progression of peripheralneuropathy in both type 1 and type 2 diabetes(163).

c Proper care of the feet is needed to prevent footulcers and lower the risk of amputation (6).

c Keep feet dry and use appropriate footwear, silicagel or air midsoles, and polyester or blend socks(not pure cotton).

c Consider inclusion of more non–weight-bearingactivities, particularly if gait altered.

Local foot deformity c Manage with appropriate footwear and choice ofactivities to reduce plantar pressure and ulcerrisk (164).

c Focus more on non–weight-bearing activities toreduce undue plantar pressures.

c Examine feet daily to detect and treat blisters,sores, or ulcers early.

Foot ulcers/amputations c Moderate walking is not likely to increase risk offoot ulcers or reulceration with peripheralneuropathy (165).

c Weight-bearing activity should be avoided withunhealed ulcers.

c Examine feet daily to detect and treat blisters,sores, or ulcers early.

c Amputation sites should be properly cared for daily.c Avoid jogging.

Autonomic neuropathy c May cause postural hypotension, chronotropicincompetence, delayed gastric emptying, alteredthermoregulation, and dehydration duringexercise (6).

c Exercise-related hypoglycemia may be harder totreat in those with gastroparesis.

c With postural hypotension, avoid activities withrapid postural or directional changes to avoidfainting or falling.

c With cardiac autonomic neuropathy, obtainphysician approval and possibly undergosymptom-limited exercise testing beforecommencing exercise (166).

c With blunted heart rate response, use heart ratereserve and ratings of perceived exertion tomonitor exercise intensity (167).

c With autonomic neuropathy, avoid exercise inhot environments and hydrate well.

Continued on p. 2074

care.diabetesjournals.org Colberg and Associates 2073

illness. Chronic hyperglycemia also in-creases risk through dehydration causedby osmotic diuresis, and some medica-tions that lower blood pressure mayalso impact hydration and electrolytebalance. Older adults with diabetes oranyone with autonomic neuropathy,cardiovascular complications, or pul-monary disease should avoid exercising

outdoors on very hot and/or humiddays.

Orthopedic and Overuse InjuriesActive individuals with type 1 diabetesare not at increased risk of tendon injury(156), but this may not apply to sed-entary or older individuals with diabe-tes. Given that diabetes may lead to

exercise-related overuse injuries dueto changes in joint structures relatedto glycemic excursions (157), exer-cise training for anyone with diabetesshould progress appropriately to avoidexcessive aggravation to joint surfacesand structures, particularly when tak-ing statin medications for lipid control(158).

Table 5—Continued

Health complication Exercise considerations Physical activity recommendations/precautions

Eye diseasesMild to moderate

nonproliferative retinopathyc Individuals with mild to moderatenonproliferative changes have limited or no riskfor eye damage from physical activity.

c All activities okay with mild, but annual eye examshould be performed to monitor progression.

c With moderate nonproliferative retinopathy,avoid activities that dramatically elevate bloodpressure, such as powerlifting.

Severe nonproliferative andunstable proliferativeretinopathy

c Individuals with unstable diabetic retinopathyare at risk for vitreous hemorrhage and retinaldetachment.

c Avoid activities that dramatically elevate bloodpressure, such as vigorous activity of any type.

c Avoid vigorous exercise; jumping, jarring, andhead-down activities; and breath holding (6).

c No exercise should be undertaken during avitreous hemorrhage.

Cataracts c Cataracts do not impact the ability to exercise,only the safety of doing so due to loss of visualacuity.

c Avoid activities that are more dangerous due tolimited vision, such as outdoor cycling.

c Consider supervision for certain activities.

Kidney diseasesMicroalbuminuria c Exercise does not accelerate progression of

kidney disease even though protein excretionacutely increases afterward (6,159).

c Greater participation in moderate-to-vigorousleisure time activity and higher physical activitylevels may actually moderate the initiation andprogression of diabetic nephropathy (168–170).

c All activities okay, but vigorous exercise shouldbe avoided the day before urine protein tests areperformed to prevent false positive readings.

Overt nephropathy c Both aerobic and resistance training improvephysical function and quality of life in individualswith kidney disease.

c Individuals should be encouraged to be active.

c All activities okay, but exercise should begin at alow intensity and volume if aerobic capacity andmuscle function are substantially reduced.

End-stage renal disease c Doing supervised, moderate aerobic physicalactivity undertaken during dialysis sessions maybe beneficial and increase compliance (171).

c Exercise should begin at a low intensity andvolume if aerobic capacity and muscle functionare substantially reduced.

c Electrolytes should be monitored when activitydone during dialysis sessions.

Orthopedic limitationsStructural changes to joints c Individuals with diabetes are more prone to

structural changes to joints that can limitmovement, including shoulder adhesivecapsulitis, carpal tunnel syndrome, metatarsalfractures, and neuropathy-related joint disorders(Charcot foot) (25).

c In addition to engaging in other activities (asable), do regular flexibility training to maintaingreater joint range of motion (10,12).

c Stretch within warm-ups or after an activity toincrease joint range of motion best (172).

c Strengthen muscles around affected joints withresistance training.

c Avoid activities that increase plantar pressureswith Charcot foot changes.

Arthritis c Common in lower-extremity joints, particularly inolder adults who are overweight or obese.

c Participation in regular physical activity ispossible and should be encouraged.

c Moderate activity may improve joint symptomsand alleviate pain.

c Most low-andmoderate-intensity activitiesokay, butmore non–weight-bearing or low-impact exercisemay be undertaken to reduce stress on joints.

cDo range-of-motion activities and light resistanceexercise to increase strength of musclessurrounding affected joints.

c Avoid activities with high risk of joint trauma,such as contact sports and ones with rapiddirectional changes.

2074 Position Statement Diabetes Care Volume 39, November 2016

MANAGING PHYSICAL ACTIVITYWITH HEALTH COMPLICATIONS

Recommendations

c Physical activity with vascular dis-eases can be undertaken safely butwith appropriate precautions. B

c Physical activity done with pe-ripheral neuropathy necessitatesproper foot care to prevent,detect, and prevent problemsearly to avoid ulceration and am-putation. B

c The presence of autonomic neu-ropathy may complicate beingactive; certain precautions arewarranted to prevent problemsduring activity. C

c Vigorous aerobic or resistanceexercise; jumping, jarring, head-down activities; and breath hold-ing should be avoided in anyonewith severe nonproliferative andunstable proliferative diabetic ret-inopathy. E

c Exercise does not accelerate pro-gression of kidney disease and canbe undertaken safely, even duringdialysis sessions. C

c Regular stretching and appropri-ate progression of activities shouldbe done to manage joint changesand diabetes-related orthopediclimitations. C

Macrovascular and microvascular diabetes-related complications can develop andworsen with inadequate blood glucosecontrol (159,160). Vascular and neuralcomplications of diabetes often causephysical limitation and varying levels ofdisability requiring precautions during ex-ercise, as recommended in Table 5.

PROMOTING THE ADOPTION ANDMAINTENANCE OF PHYSICALACTIVITY

Recommendations

c Targeted behavior-change strate-gies should be used to increasephysical activity in adults withtype 2 diabetes. B

c When using step counters, adultswith type 2 diabetes should ini-tially set tolerable targets forsteps/day before progressing to-ward higher goals. C

c For adults with type 2 diabetes,Internet-delivered interventions

for physical activity promotionmay be used to improve out-comes. C

Behavior-Change StrategiesBehavioral interventions can signifi-cantly increase physical activity in adultswith type 2 diabetes (173), and A1Creductions produced by such interven-tions have been sustained to 24 months(174). Five key techniques have beenidentified: 1) prompt focus on past suc-cess, 2) barrier identification/problem-solving, 3) use of follow-up prompts,4) provision of information on where/when to perform the behavior, and5) prompt review of behavioral goals(175). However, motivational inter-viewing is not significantly better thanusual care (176), andother intervention fac-tors associated with weight loss, such asnumber and duration of contacts, havebeen inconsistent or not associated withgreater participation (177).

Step counters/pedometers have beenwidely studied as a behavior-changetool. Wearing the device may promptactivity, and it provides feedback forself-monitoring. Pedometer use inadults with type 2 diabetes increasedtheir daily steps by 1,822, but did notimprove A1C (178). Using a daily stepsgoal (e.g., 10,000) was predictive of in-creased participation, even using self-selected step goals (178). Thus, adultswith type 2 diabetes should initially setfeasible/achievable targets for steps/daybefore progressing toward higher goals.Adults should avoid taking ,5,000 steps/day (179–181) and to strive for $7,500steps/day (182). The positive findingsfor pedometers are not universal (175),however, and some individuals may re-quire greater support to realize benefits.Longer-term efficacy and determina-tion of which populations can benefitfrom pedometers and other wearableactivity trackers (183) require furtherevaluation.

Technology-Based StrategiesGiven that the majority of individualswith type 2 diabetes have access to theInternet, technology-based support isappealing for extending clinical inter-vention reach. For adults with type 2diabetes, Internet-delivered physicalactivity promotion interventions maybe more effective than usual care (184).Effective Internet-based programs

included monitoring of physical activity,feedback, goal setting, and supportfrom a coach via phone/e-mail (184).More evidence is needed regarding socialmedia approaches, given the importanceof social andpeer support in diabetes self-management (185).

CONCLUSIONS

Physical activity and exercise should berecommended and prescribed to all in-dividuals with diabetes as part of man-agement of glycemic control and overallhealth. Specific recommendations andprecautions will vary by the type of di-abetes, age, activity done, and presenceof diabetes-related health complica-tions. Recommendations should be tai-lored to meet the specific needs of eachindividual. In addition to engaging in reg-ular physical activity, all adults should beencouraged to decrease the total amountof daily sedentary time and to break upsitting timewith frequent bouts of activity.Finally, behavior-change strategies can beused to promote the adoption and main-tenance of lifetime physical activity.

Duality of Interest. No potential conflicts ofinterest relevant to this article were reported.

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54. Hawley JA, Lessard SJ. Exercise training-induced improvements in insulin action. ActaPhysiol (Oxf) 2008;192:127–13555. Olsen RH, Krogh-Madsen R, Thomsen C,Booth FW, Pedersen BK. Metabolic responsesto reduced daily steps in healthy nonexercisingmen. JAMA 2008;299:1261–126356. Bacchi E, Negri C, Targher G, et al. Both re-sistance training and aerobic training reducehepatic fat content in type 2 diabetic subjectswith nonalcoholic fatty liver disease (the RAED2Randomized Trial). Hepatology 2013;58:1287–129557. Hallsworth K, Fattakhova G, HollingsworthKG, et al. Resistance exercise reduces liver fatand its mediators in non-alcoholic fatty liver dis-ease independent of weight loss. Gut 2011;60:1278–128358. Dube JJ, Amati F, Toledo FG, et al. Effects ofweight loss and exercise on insulin resistance,and intramyocellular triacylglycerol, diacylgly-cerol and ceramide. Diabetologia 2011;54:1147–115659. Kirwan JP, Solomon TP, Wojta DM, StatenMA, Holloszy JO. Effects of 7 days of exercisetraining on insulin sensitivity and responsive-ness in type 2 diabetes mellitus. Am J PhysiolEndocrinol Metab 2009;297:E151–E15660. Dube JJ, Allison KF, Rousson V, GoodpasterBH, Amati F. Exercise dose and insulin sensitiv-ity: relevance for diabetes prevention. Med SciSports Exerc 2012;44:793–79961. Sigal RJ, Kenny GP, Boule NG, et al. Effectsof aerobic training, resistance training, or bothon glycemic control in type 2 diabetes: a random-ized trial. Ann Intern Med 2007;147:357–36962. Wing RR, Bolin P, Brancati FL, et al.; LookAHEAD Research Group. Cardiovascular effectsof intensive lifestyle intervention in type 2 di-abetes. N Engl J Med 2013;369:145–15463. Pi-Sunyer X. The Look AHEAD trial: a reviewand discussion of its outcomes. Curr Nutr Rep2014;3:387–39164. Umpierre D, Ribeiro PA, Kramer CK, et al.Physical activity advice only or structured exer-cise training and association with HbA1c levelsin type 2 diabetes: a systematic review andmeta-analysis. JAMA 2011;305:1790–179965. Yang Z, Scott CA, Mao C, Tang J, Farmer AJ.Resistance exercise versus aerobic exercise fortype 2 diabetes: a systematic review and meta-analysis. Sports Med 2014;44:487–49966. Church TS, Blair SN, Cocreham S, et al. Ef-fects of aerobic and resistance training on he-moglobin A1c levels in patients with type 2diabetes: a randomized controlled trial. JAMA2010;304:2253–226267. Zeitler P, Hirst K, Pyle L, et al.; TODAY StudyGroup. A clinical trial to maintain glycemic con-trol in youth with type 2 diabetes. N Engl J Med2012;366:2247–225668. Balk EM, Earley A, Raman G, Avendano EA,Pittas AG, Remington PL. Combined diet andphysical activity promotion programs to preventtype 2 diabetes among persons at increased risk: asystematic review for the community preventiveservices task force. Ann Intern Med 2015;163:437–45169. Dunkley AJ, Bodicoat DH, Greaves CJ, et al.Diabetes prevention in the real world: effective-ness of pragmatic lifestyle interventions for theprevention of type 2 diabetes and of the impact

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2078 Position Statement Diabetes Care Volume 39, November 2016

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