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Guideline Summary
Guideline Title
Exercise and type 2 diabetes: American College of Sports Medicine and the American Diabetes Association: joint position statement.
Bibliographic Source(s)
American College of Sports Medicine, American Diabetes Association. Exercise and type 2 diabetes: American College of Sports Medicine and the American Diabetes Association: joint position statement. Med Sci Sports Exerc. 2010 Dec;42(12):2282-303. [295 references] PubMed External Web Site Policy
Guideline Status

This is the current release of the guideline.

Scope

Disease/Condition(s)
  • Type 2 diabetes mellitus
  • Gestational diabetes
  • Prediabetes
  • Insulin resistance
  • Diabetes complications
Guideline Category
Counseling
Management
Prevention
Clinical Specialty
Endocrinology
Family Practice
Internal Medicine
Preventive Medicine
Sports Medicine
Intended Users
Advanced Practice Nurses
Dietitians
Health Care Providers
Nurses
Physician Assistants
Physicians
Guideline Objective(s)
  • To provide recommendations for the prevention and management of type 2 diabetes mellitus (T2DM) with physical activity
  • To discuss the benefits of physical training, along with recommendations for varying activities, physical activity-associated blood glucose management, diabetes prevention, gestational diabetes, and safe and effective practices for physical activity with diabetes-related complications
Target Population

Patients with type 2 diabetes mellitus, gestational diabetes, prediabetes, and/or diabetes complications

Interventions and Practices Considered
  1. Preexercise evaluation
  2. Aerobic exercise training
  3. Resistance exercise training
  4. Combined aerobic and resistance training
  5. Daily movement (unstructured activity)
  6. Flexibility training
  7. Medication dosage adjustments as required to prevent exercise-induced hypoglycemia
  8. Daily inspection of feet and use of proper footwear
Major Outcomes Considered
  • Blood glucose control
  • Rates of type 2 diabetes mellitus, high blood pressure, cardiovascular events, and mortality associated with type 2 diabetes mellitus
  • Blood lipids, insulin action, fat oxidation and storage, and blood pressure responses to physical activity
  • Body weight loss in response to physical activity
  • Patient compliance with exercise program
  • Quality of life

Methodology

Methods Used to Collect/Select the Evidence
Searches of Electronic Databases
Description of Methods Used to Collect/Select the Evidence

The main database searched for articles was PubMed. Literature searches were conducted from January through August 2009. Searches included all evidence-based studies from about 1990 to 2009, although most of what is cited in the position statement was published from 2000 onward.

Number of Source Documents

Not stated

Methods Used to Assess the Quality and Strength of the Evidence
Weighting According to a Rating Scheme (Scheme Given)
Rating Scheme for the Strength of the Evidence

American College of Sports Medicine (ACSM) Evidence Categories

Evidence Category Source of Evidence Definition
A Randomized, controlled trials (overwhelming data) Provides a consistent pattern of findings with substantial studies
B Randomized, controlled trials (limited data) Few randomized trials exist, which are small in size and results are inconsistent
C Nonrandomized trials, observational studies Outcomes are from uncontrolled, nonrandomized, and/or observational studies
D Panel consensus judgment Panel's expert opinion when the evidence is insufficient to place it in categories A–C

American Diabetes Association (ADA) Evidence-Grading System for Clinical Practice Recommendations

Level of Evidence Description
A Clear evidence from well-conducted, generalizable, randomized controlled trials that are adequately powered, including the following:
  • Evidence from a well-conducted multicenter trial
  • Evidence from a meta-analysis that incorporated quality ratings in the analysis
Compelling nonexperimental evidence, i.e., the "all-or-none" rule developed by the Centre for Evidence-Based Medicine at Oxford

Supportive evidence from well-conducted randomized controlled trials that are adequately powered, including the following:
  • Evidence from a well-conducted trial at one or more institutions
  • Evidence from a meta-analysis that incorporated quality ratings in the analysis
B Supportive evidence from well-conducted cohort studies, including the following:
  • Evidence from a well-conducted prospective cohort study or registry
  • Evidence from a well-conducted meta-analysis of cohort studies
Supportive evidence from a well-conducted case–control study
C Supportive evidence from poorly controlled or uncontrolled studies, including the following:
  • Evidence from randomized clinical trials with one or more major or three or more minor methodological flaws that could invalidate the results
  • Evidence from observational studies with high potential for bias (such as case series with comparison to historical controls)
  • Evidence from case series or case reports
Conflicting evidence with the weight of evidence supporting the recommendation
E Expert consensus or clinical experience
Methods Used to Analyze the Evidence
Review of Published Meta-Analyses
Systematic Review
Description of the Methods Used to Analyze the Evidence

Not stated

Methods Used to Formulate the Recommendations
Not stated
Rating Scheme for the Strength of the Recommendations

Not applicable

Cost Analysis

Published cost analyses were reviewed.

Method of Guideline Validation
Internal Peer Review
Description of Method of Guideline Validation

This joint position statement was written by the American College of Sports Medicine and the American Diabetes Association and was approved by the Executive Committee of the American Diabetes Association in July 2010. This pronouncement was reviewed by the American College of Sports Medicine Pronouncements Committee, American Diabetes Association Professional Practice Committee, and by Gregory D. Cartee, Ph.D., FACSM; Peter A. Farrell, Ph.D., FACSM; Laurie J. Goodyear, Ph.D., FACSM; and Andrea M. Kriska, Ph.D., FACSM.

Recommendations

Major Recommendations

The American College of Sports Medicine (ACSM) levels of evidence (A-D) and American Diabetes Association (ADA) levels of evidence (A-C, E) are defined at the end of the "Major Recommendations" field.

Acute Effects of Exercise

Fuel Metabolism during Exercise

Physical activity (PA) causes increased glucose uptake into active muscles balanced by hepatic glucose production, with a greater reliance on carbohydrate to fuel muscular activity as intensity increases. ACSM evidence category A.

Insulin-stimulated blood glucose (BG) uptake into skeletal muscle predominates at rest and is impaired in type 2 diabetes mellitus (T2DM), while muscular contractions stimulate BG transport via a separate additive mechanism not impaired by insulin resistance or T2DM. ACSM evidence category A.

Postexercise Glycemic Control/BG Levels

Although moderate aerobic exercise improves BG and insulin action acutely, the risk of exercise-induced hypoglycemia is minimal without use of exogenous insulin or insulin secretagogues. Transient hyperglycemia can follow intense PA. ACSM evidence category C.

The acute effects of resistance exercise in T2DM have not been reported, but result in lower fasting BG levels for at least 24 h after exercise in individuals with impaired fasting glucose (IFG). ACSM evidence category C.

A combination of aerobic and resistance exercise training may be more effective in improving BG control than either alone; however, more studies are needed to determine if total caloric expenditure, exercise duration, or exercise mode is responsible. ACSM evidence category B. Milder forms of exercise (e.g., tai chi, yoga) have shown mixed results. ACSM evidence category C.

Insulin Resistance

PA can result in acute improvements in systemic insulin action lasting from 2 to 72 h. ACSM evidence category A.

Chronic Effects of Exercise Training

Metabolic Control: BG Levels and Insulin Resistance

Both aerobic and resistance training improve insulin action, BG control, and fat oxidation and storage in muscle. ACSM evidence category B. Resistance exercise enhances skeletal muscle mass. ACSM evidence category A.

Lipids and Lipoproteins

Blood lipid responses to training are mixed but may result in a small reduction in low-density lipoprotein cholesterol (LDL-C) with no change in high-density lipoprotein cholesterol (HDL-C) or triglycerides. Combined weight loss and PA may be more effective than aerobic exercise training alone on lipids. ACSM evidence category C.

Hypertension

Aerobic training may slightly reduce systolic blood pressure (BP), but reductions in diastolic BP are less common in individuals with T2DM. ACSM evidence category C.

Mortality and Cardiovascular Risk

Observational studies suggest that greater PA and fitness are associated with a lower risk of all-cause and cardiovascular (CV) mortality. ACSM evidence category C.

Body Weight: Maintenance and Loss

Recommended levels of PA may help produce weight loss. However, up to 60 min·d-1 may be required when relying on exercise alone for weight loss. ACSM evidence category C.

Supervision of Training

Individuals with T2DM engaged in supervised training exhibit greater compliance and BG control than those undertaking exercise training without supervision. ACSM evidence category B.

Psychological Effects

Increased PA and physical fitness can reduce symptoms of depression and improve health-related quality of life (QOL) in those with T2DM. ACSM evidence category B.

PA and Prevention of T2DM

At least 2.5 h·wk-1 of moderate to vigorous PA should be undertaken as part of lifestyle changes to prevent T2DM onset in high-risk adults. ACSM evidence category A. ADA A level recommendation.

PA and Prevention and Control of Gestational Diabetes (GDM)

Epidemiologic studies suggest that higher levels of PA may reduce risk of developing GDM during pregnancy. ACSM evidence category C. Randomized controlled trials (RCTs) suggest that moderate exercise may lower maternal BG levels in GDM. ACSM evidence category B.

Preexercise Evaluation

Before undertaking exercise more intense than brisk walking, sedentary persons with T2DM will likely benefit from an evaluation by a physician. Electrocardiogram (ECG) exercise stress testing for asymptomatic individuals at low risk of coronary artery disease (CAD) is not recommended but may be indicated for higher risk. ACSM evidence category C. ADA C level recommendation.

Recommended PA Participation for Persons with T2DM

Aerobic Exercise Training

Persons with T2DM should undertake at least 150 min·wk-1 of moderate to vigorous aerobic exercise spread out during at least 3 d during the week, with no more than two consecutive days between bouts of aerobic activity. ACSM evidence category B. ADA B level recommendation.

Resistance Exercise Training

In addition to aerobic training, persons with T2DM should undertake moderate to vigorous resistance training at least 2–3 d.wk-1. ACSM evidence category B. ADA B level recommendation.

Flexibility Training

Supervised and combined aerobic and resistance training may confer additional health benefits, although milder forms of PA (like yoga) have shown mixed results. Persons with T2DM are encouraged to increase their total daily unstructured PA. Flexibility training may be included but should not be undertaken in place of other recommended types of PA. ACSM evidence category B. ADA C level recommendation.

Exercise with Nonoptimal BG Control

Individuals with T2DM may engage in PA, using caution when exercising with BG levels exceeding 300 mg·dL-1 (16.7 mmol·L-1) without ketosis, provided they are feeling well and are adequately hydrated. ACSM evidence category C. ADA E level recommendation.

Persons with T2DM not using insulin or insulin secretagogues are unlikely to experience hypoglycemia related to PA. Users of insulin and insulin secretagogues are advised to supplement with carbohydrate as needed to prevent hypoglycemia during and after exercise. ACSM evidence category C. ADA C level recommendation.

Medication Effects on Exercise Responses

Medication dosage adjustments to prevent exercise-associated hypoglycemia may be required by individuals using insulin or certain insulin secretagogues. Most other medications prescribed for concomitant health problems do not affect exercise, with the exception of beta-blockers, some diuretics, and statins. ACSM evidence category C. ADA C level recommendation.

Exercise with Long-Term Complications of Diabetes

Known cardiovascular disease (CVD) is not an absolute contraindication to exercise. Individuals with angina classified as moderate or high risk should likely begin exercise in a supervised cardiac rehabilitation program. PA is advised for anyone with peripheral artery disease (PAD). ACSM evidence category C. ADA C level recommendation.

Individuals with peripheral neuropathy and without acute ulceration may participate in moderate weight-bearing exercise. Comprehensive foot care including daily inspection of feet and use of proper footwear is recommended for prevention and early detection of sores or ulcers. Moderate walking likely does not increase risk of foot ulcers or reulceration with peripheral neuropathy. ACSM evidence category B. ADA B level recommendation.

Individuals with cardiovascular autonomic neuropathy (CAN) should be screened and receive physician approval and possibly an exercise stress test before exercise initiation. Exercise intensity is best prescribed using the heart rate (HR) reserve method with direct measurement of maximal HR. ACSM evidence category C. ADA C level recommendation.

Individuals with uncontrolled proliferative retinopathy should avoid activities that greatly increase intraocular pressure and hemorrhage risk. ACSM evidence category D. ADA E level recommendation.

Exercise training increases physical function and quality of life in individuals with kidney disease and may even be undertaken during dialysis sessions. The presence of microalbuminuria per se does not necessitate exercise restrictions. ACSM evidence category C. ADA C level recommendation.

Adoption and Maintenance of Exercise by Persons with Diabetes

Efforts to promote PA should focus on developing self-efficacy and fostering social support from family, friends, and health care providers. Encouraging mild or moderate PA may be most beneficial to adoption and maintenance of regular PA participation. Lifestyle interventions may have some efficacy in promoting PA behavior. ACSM evidence category B. ADA B level recommendation.

Definitions:

ACSM Evidence Categories

Evidence Category Source of Evidence Definition
A Randomized, controlled trials (overwhelming data) Provides a consistent pattern of findings with substantial studies
B Randomized, controlled trials (limited data) Few randomized trials exist, which are small in size and results are inconsistent
C Nonrandomized trials, observational studies Outcomes are from uncontrolled, nonrandomized, and/or observational studies
D Panel consensus judgment Panel's expert opinion when the evidence is insufficient to place it in categories A–C

American Diabetes Association (ADA) Evidence-Grading System for Clinical Practice Recommendations

Level of Evidence Description
A Clear evidence from well-conducted, generalizable, randomized controlled trials that are adequately powered, including the following:
  • Evidence from a well-conducted multicenter trial
  • Evidence from a meta-analysis that incorporated quality ratings in the analysis
Compelling nonexperimental evidence, i.e., the "all-or-none" rule developed by the Centre for Evidence-Based Medicine at Oxford

Supportive evidence from well-conducted randomized controlled trials that are adequately powered, including the following:
  • Evidence from a well-conducted trial at one or more institutions
  • Evidence from a meta-analysis that incorporated quality ratings in the analysis
B Supportive evidence from well-conducted cohort studies, including the following:
  • Evidence from a well-conducted prospective cohort study or registry
  • Evidence from a well-conducted meta-analysis of cohort studies
Supportive evidence from a well-conducted case–control study
C Supportive evidence from poorly controlled or uncontrolled studies, including the following:
  • Evidence from randomized clinical trials with one or more major or three or more minor methodological flaws that could invalidate the results
  • Evidence from observational studies with high potential for bias (such as case series with comparison to historical controls)
  • Evidence from case series or case reports
Conflicting evidence with the weight of evidence supporting the recommendation
E Expert consensus or clinical experience
Clinical Algorithm(s)

None provided

Evidence Supporting the Recommendations

Type of Evidence Supporting the Recommendations

The type of supporting evidence is identified and graded for each recommendation (see "Major Recommendations").

Benefits/Harms of Implementing the Guideline Recommendations

Potential Benefits

It is now well established that participation in regular physical activity (PA) improves blood glucose control and can prevent or delay type 2 diabetes mellitus (T2DM), along with positively affecting lipids, blood pressure, cardiovascular events, mortality, and quality of life. Structured interventions combining PA and modest weight loss have been shown to lower T2DM risk by up to 58% in high-risk populations. Most benefits of PA on diabetes management are realized through acute and chronic improvements in insulin action, accomplished with both aerobic and resistance training.

Potential Harms
  • Risk of injury
  • Exercise-associated hypoglycemia
  • For exercise more vigorous than brisk walking or exceeding the demands of everyday living, sedentary and older diabetic individuals will likely benefit from being assessed for conditions that might be associated with risk of cardiovascular disease (CVD), contraindicate certain activities, or predispose to injuries, including severe peripheral neuropathy, severe autonomic neuropathy, and preproliferative or proliferative retinopathy.
  • Individuals with uncontrolled proliferative retinopathy should avoid activities that greatly increase intraocular pressure and hemorrhage risk.
  • Individuals with angina classified as moderate or high risk should likely begin exercise in a supervised cardiac rehabilitation program.

Qualifying Statements

Qualifying Statements
  • In this article, the broader term "physical activity (PA)" (defined as "bodily movement produced by the contraction of skeletal muscle that substantially increases energy expenditure") is used interchangeably with "exercise," which is defined as "a subset of PA done with the intention of developing physical fitness (i.e., cardiovascular, strength, and flexibility training)." The intent is to recognize that many types of physical movement may have a positive effect on physical fitness, morbidity, and mortality in individuals with type 2 diabetes mellitus.
  • The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention.

Implementation of the Guideline

Description of Implementation Strategy

An implementation strategy was not provided.

Implementation Tools
Resources
For information about availability, see the Availability of Companion Documents and Patient Resources fields below.

Institute of Medicine (IOM) National Healthcare Quality Report Categories

IOM Care Need
Living with Illness
Staying Healthy
IOM Domain
Effectiveness
Patient-centeredness

Identifying Information and Availability

Bibliographic Source(s)
American College of Sports Medicine, American Diabetes Association. Exercise and type 2 diabetes: American College of Sports Medicine and the American Diabetes Association: joint position statement. Med Sci Sports Exerc. 2010 Dec;42(12):2282-303. [295 references] PubMed External Web Site Policy
Adaptation

Not applicable: The guideline was not adapted from another source.

Date Released
2010 Dec
Guideline Developer(s)
American College of Sports Medicine - Medical Specialty Society
American Diabetes Association - Professional Association
Source(s) of Funding

American College of Sports Medicine

American Diabetes Association

Guideline Committee

Not stated

Composition of Group That Authored the Guideline

Authors

American College of Sports Medicine (ACSM): Sheri R. Colberg, Ph.D., FACSM (Chair); Ann L. Albright, Ph.D., RD; Bryan J. Blissmer, Ph.D.; Barry Braun, Ph.D., FACSM; Lisa Chasan-Taber, Sc.D., FACSM; and Bo Fernhall, Ph.D., FACSM

American Diabetes Association (ADA): Judith G. Regensteiner, Ph.D.; Richard R. Rubin, Ph.D.; Ronald J. Sigal, M.D., M.P.H., FRCPC

Financial Disclosures/Conflicts of Interest

The authors have no financial support or professional conflicts of interest to disclose related to its content.

Guideline Status

This is the current release of the guideline.

Guideline Availability

Electronic copies: Available from the Medicine & Science in Sports & Exercise Web site External Web Site Policy and the Diabetes Care Web site External Web Site Policy.

Also available as an EPUB document from the Medicine & Science in Sports & Exercise Web site External Web Site Policy.

Availability of Companion Documents

None available

Patient Resources

None available

NGC Status

This NGC summary was completed by ECRI Institute on July 15, 2011. The information was verified by the guideline developer on July 21, 2011.

Copyright Statement

This NGC summary is based on the original guideline, which is subject to the guideline developer's copyright restrictions.

Disclaimer

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The National Guideline Clearinghouse™ (NGC) does not develop, produce, approve, or endorse the guidelines represented on this site.

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