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symptoms of type 2 diabetes include
Diabetes Care. 2010 Dec; 33(12): e147–e167.
PMCID: PMC2992225
PMID: 21115758
The American College of Sports Medicine and the American Diabetes Association: joint position statement
Sheri R. Colberg, PHD, FACSM,1 Ronald J. Sigal, MD, MPH, FRCP(C),2 Bo Fernhall, PHD, FACSM,3 Judith G. Regensteiner, PHD,4 Bryan J. Blissmer, PHD,5 Richard R. Rubin, PHD,6 Lisa Chasan-Taber, SCD, FACSM,7 Ann L. Albright, PHD, RD,8 and Barry Braun, PHD, FACSM9

Sheri R. Colberg

are bananas bad for pre diabetics long term effects (πŸ”₯ oral medications) | are bananas bad for pre diabetics diet plan lose weighthow to are bananas bad for pre diabetics for 1Human Movement Sciences Department, Old Dominion University, Norfolk, Virginia;

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Ronald J. Sigal

2Departments of Medicine, Cardiac Sciences, and Community Health Sciences, Faculties of Medicine and Kinesiology, University of Calgary, Calgary, Alberta, Canada;

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are bananas bad for pre diabetics and coronavirus (β˜‘ youth) | are bananas bad for pre diabetics statisticshow to are bananas bad for pre diabetics for Bo Fernhall

3Department of Kinesiology and Community Health, University of Illinois at Urbana-Champaign, Urbana, Illinois;

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Judith G. Regensteiner

4Divisions of General Internal Medicine and Cardiology and Center for Women''s Health Research, University of Colorado School of Medicine, Aurora, Colorado;

5Department of Kinesiology and Cancer Prevention Research Center, University of Rhode Island, Kingston, Rhode Island;
6Departments of Medicine and Pediatrics, The Johns Hopkins University School of Medicine, Baltimore, Maryland;
7Division of Biostatistics and Epidemiology, University of Massachusetts, Amherst, Massachusetts;
8Division of Diabetes Translation, Centers for Disease Control and Prevention, Atlanta, Georgia;
9Department of Kinesiology, University of Massachusetts, Amherst, Massachusetts.
Corresponding author: Sheri R. Colberg, [email protected].
Copyright © 2010 by the American Diabetes Association.
Readers may use this article as long as the work is properly cited, the use is educational and not for profit, and the work is not altered. See http://creativecommons.org/licenses/by-nc-nd/3.0/ for details.
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Abstract

Although physical activity (PA) is a key element in the prevention and management of type 2 diabetes, many with this chronic disease do not become or remain regularly active. High-quality studies establishing the importance of exercise and fitness in diabetes were lacking until recently, but it is now well established that participation in regular PA improves blood glucose control and can prevent or delay type 2 diabetes, 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 type 2 diabetes 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. The benefits of physical training are discussed, along with recommendations for varying activities, PA-associated blood glucose management, diabetes prevention, gestational diabetes mellitus, and safe and effective practices for PA with diabetes-related complications.

Introduction

Diabetes has become a widespread epidemic, primarily because of the increasing prevalence and incidence of type 2 diabetes. According to the Centers for Disease Control and Prevention, in 2007, almost 24 million Americans had diabetes, with one-quarter of those, or six million, undiagnosed (261). Currently, it is estimated that almost 60 million U.S. residents also have prediabetes, a condition in which blood glucose (BG) levels are above normal, thus greatly increasing their risk for type 2 diabetes (261). Lifetime risk estimates suggest that one in three Americans born in 2000 or later will develop diabetes, but in high-risk ethnic populations, closer to 50% may develop it (200). Type 2 diabetes is a significant cause of premature mortality and morbidity related to cardiovascular disease (CVD), blindness, kidney and nerve disease, and amputation (261). Although regular physical activity (PA) may prevent or delay diabetes and its complications (10,46,89,112,176,208,259,294), most people with type 2 diabetes are not active (193).

In this article, the broader term “physical activity” (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 [CV], 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.

Diagnosis, classification, and etiology of diabetes

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The major forms of diabetes can be categorized as type 1 or type 2 (4). In type 1 diabetes, which accounts for 5–10% of cases, the cause is an absolute deficiency of insulin secretion resulting from autoimmune destruction of the insulin-producing cells in the pancreas. Type 2 diabetes (90–95% of cases) results from a combination of the inability of muscle cells to respond to insulin properly (insulin resistance) and inadequate compensatory insulin secretion. Less common forms include gestational diabetes mellitus (GDM), which is associated with a 40–60% chance of developing type 2 diabetes in the next 5–10 years (261). Diabetes can also result from genetic defects in insulin action, pancreatic disease, surgery, infections, and drugs or chemicals (4,261).

Genetic and environmental factors are strongly implicated in the development of type 2 diabetes. The exact genetic defects are complex and not clearly defined (4), but risk increases with age, obesity, and physical inactivity. Type 2 diabetes occurs more frequently in populations with hypertension or dyslipidemia, women with previous GDM, and non-Caucasian people including Native Americans, African Americans, Hispanic/Latinos, Asians, and Pacific Islanders.

Treatment goals in type 2 diabetes

The goal of treatment in type 2 diabetes is to achieve and maintain optimal BG, lipid, and blood pressure (BP) levels to prevent or delay chronic complications of diabetes (5). Many people with type 2 diabetes can achieve BG control by following a nutritious meal plan and exercise program, losing excess weight, implementing necessary self-care behaviors, and taking oral medications, although others may need supplemental insulin (261). Diet and PA are central to the management and prevention of type 2 diabetes because they help treat the associated glucose, lipid, BP control abnormalities, as well as aid in weight loss and maintenance. When medications are used to control type 2 diabetes, they should augment lifestyle improvements, not replace them.

ACUTE EFFECTS OF EXERCISE

Fuel metabolism during exercise

Fuel mobilization, glucose production, and muscle glycogenolysis.

are bananas bad for pre diabetics jokes (πŸ”₯ reddit) | are bananas bad for pre diabetics for dummieshow to are bananas bad for pre diabetics for The maintenance of normal BG at rest and during exercise depends largely on the coordination and integration of the sympathetic nervous and endocrine systems (250). Contracting muscles increase uptake of BG, although BG levels are usually maintained by glucose production via liver glycogenolysis and gluconeogenesis and mobilization of alternate fuels, such as free fatty acids (FFAs) (250,268).

Several factors influence exercise fuel use, but the most important are the intensity and duration of PA (9,29,47,83,111, 133,160,181,241). Any activity causes a shift from predominant reliance on FFA at rest to a blend of fat, glucose, and muscle glycogen, with a small contribution from amino acids (15,31). With increasing exercise intensity, there is a greater reliance on carbohydrate as long as sufficient amounts are available in muscle or blood (21,23,47,133). Early in exercise, glycogen provides the bulk of the fuel for working muscles. As glycogen stores become depleted, muscles increase their uptake and use of circulating BG, along with FFA released from adipose tissue (15,132, 271). Intramuscular lipid stores are more readily used during longer-duration activities and recovery (23,223,270). Glucose production also shifts from hepatic glycogenolysis to enhanced gluconeogenesis as duration increases (250,268).

Evidence statement.

PA causes increased glucose uptake into active muscles balanced by hepatic glucose production, with a greater reliance for 1 last update 06 Jun 2020 on carbohydrate to fuel muscular activity as intensity increases. The American College of Sports Medicine (ACSM) evidence category A (see Tables 1 and and22 for explanation).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. The American College of Sports Medicine (ACSM) evidence category A (see Tables 1 and and22 for explanation).

Table 1

Evidence categories for ACSM and evidence-grading system for clinical practice recommendations for ADA

I. ACSM evidence categories
Evidence categorySource of evidenceDefinition
ARandomized, controlled trials (overwhelming data)Provides a consistent pattern of findings with substantial studies
BRandomized, controlled trials (limited data)Few randomized trials exist, which are small in size, and results are inconsistent
CNonrandomized trials, observational studiesOutcomes are from uncontrolled, nonrandomized, and/or observational studies
DPanel consensus judgmentPanel''s intrinsic capacity to respond to insulin, whereas aerobic exercise enhances its uptake via a greater insulin action, independent of changes in muscle mass or aerobic capacity (51). However, all reported combination training had a greater total duration of exercise and caloric use than when each type of training was undertaken alone (51,183,238). Mild-intensity exercises such as tai chi and yoga have also been investigated for their potential to improve BG management, with mixed results (98,117,159, 257,269,286,291). Although tai chi may lead to short-term improvements in BG levels, effects from long-term training (i.e., 16 weeks) do not seem to last 72 h after the last session (257). Some studies have shown lower overall BG levels with extended participation in such activities (286,291), although others have not (159,257). One study suggested that yoga''s ability to process glucose.

Increases in liver fat content common in obesity and type 2 diabetes are strongly associated with reduced hepatic and peripheral insulin action. Enhanced whole-body insulin action after aerobic training seems to be related to gains in peripheral, not hepatic, insulin action (146,282). Such training not resulting in overall weight loss may still reduce hepatic lipid content and alter fat partitioning and use in the liver (128).

Evidence statement.

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.

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An individual'' greater activity came from walks of short duration (<15 min) and low velocity (∼1 mph) (168).

Moreover, use of objective measures such as step counters may enhance reaching daily goals. A meta-analysis of 26 studies with a total of 2,767 (primarily nondiabetic) participants (8 RCTs and 18 observational studies) found that pedometer users increased PA by 26.9% over baseline in studies having an average intervention of 18 weeks (30). An important predictor of increased PA was the use of a goal, such as to take 10,000 steps per day (30).

Flexibility training

Flexibility training may be included as part of a PA program, although it should not substitute for other training. Older adults are advised to undertake exercises that maintain or improve balance (202,217), which may include some flexibility training, particularly for many older individuals with type 2 diabetes with a higher risk of falling (194). Although flexibility exercise (stretching) has frequently been recommended as a means of increasing joint range of motion (ROM) and reducing risk of injury, two systematic reviews found that flexibility exercise does not reduce risk of exercise-induced injury (237,287). A small RCT found that ROM exercises modestly decreased peak plantar pressures (94), but no study has directly evaluated whether such training reduces risk of ulceration or injury in type 2 diabetes. However, flexibility exercise combined with resistance training can increase ROM in individuals with type 2 diabetes (109) and allow individuals to more easily engage in activities that require greater ROM around joints.

Evidence statement.

Supervised and combined aerobic and resistance training may confer health additional benefits, although milder forms of PA (such as yoga) have shown mixed results. Persons with type 2 diabetes 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

Hyperglycemia.

While hyperglycemia can be worsened by exercise in type 1 diabetic individuals who are insulin deficient and ketotic (due to missed or insufficient insulin), very few persons with type 2 diabetes develop such a profound degree of insulin deficiency. Therefore, individuals with type 2 diabetes generally do not need to postpone exercise because of high BG, provided that they are feeling well. If they undertake strenuous physical activities with elevated glucose levels (>300 mg/dl or 16.7 mmol/l), it is prudent to ensure that they are adequately hydrated (3). If hyperglycemic after a meal, individuals with type 2 diabetes will still likely experience a reduction in BG during aerobic work because endogenous insulin levels will likely be higher at that time (221).

Evidence statement.

Individuals with type 2 diabetes may engage in PA, using caution when exercising with BG levels exceeding 300 mg/dl (16.7 mmol/l) without ketosis, provided they are feeling well and are adequately hydrated. ACSM evidence category C. ADA E level recommendation.

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Of greatest concern to many exercisers is the risk of hypoglycemia. In individuals whose diabetes is being controlled by lifestyle alone, the risk of developing hypoglycemia during exercise is minimal, making stringent measures unnecessary to maintain BG (239). Glucose monitoring can be performed before and after PA to assess its unique effect. Activities of longer duration and lower intensity generally cause a decline in BG levels but not to the level of hypoglycemia (9,29,75,111,160). While very intense activities can cause transient elevations in BG (156,252,253), intermittent high-intensity exercise done immediately after breakfast in individuals treated with diet only reduces BG levels and insulin secretion (160).

In insulin or insulin secretagogue users, who frequently have the effects of both exercise and insulin to increase glucose uptake, PA can complicate diabetes management (138,198,230,293). For preexercise BG levels of less than 100 mg/dl (5.5 mmol/l), ADA recommends that carbohydrate be ingested before any PA (3), but this applies only to individuals taking insulin or the secretagogues more likely to cause hypoglycemia (e.g., sulfonylureas such as glyburide, glipizide, and glimepiride, as well as nateglinide and repaglinide) (161,230). If controlled with diet or other oral medications, most individuals will not need carbohydrate supplements for exercise lasting less than an hour. Insulin users should likely consume up to 15 g of carbohydrate before exercise for an initial BG level of 100 mg/dl or lower, with the actual amount dependent on injected insulin doses, exercise duration and intensity, and results of BG monitoring. Intense, short exercise requires lesser or no carbohydrate intake (156).

Later-onset hypoglycemia is a greater concern when carbohydrate stores (i.e., muscle and liver glycogen) are depleted during an acute bout of exercise. In particular, high-intensity exercise (e.g., repeated interval or intense resistance training) can result in substantial depletion of muscle glycogen, thereby increasing risk for postexercise hypoglycemia in users of insulin or insulin secretagogues (161). In such cases, the consumption of 5–30 g for 1 last update 06 Jun 2020 of carbohydrate during and within 30 min after exhaustive, glycogen-depleting exercise will lower hypoglycemia risk and allow for more efficient restoration of muscle glycogen (31,247).Later-onset hypoglycemia is a greater concern when carbohydrate stores (i.e., muscle and liver glycogen) are depleted during an acute bout of exercise. In particular, high-intensity exercise (e.g., repeated interval or intense resistance training) can result in substantial depletion of muscle glycogen, thereby increasing risk for postexercise hypoglycemia in users of insulin or insulin secretagogues (161). In such cases, the consumption of 5–30 g of carbohydrate during and within 30 min after exhaustive, glycogen-depleting exercise will lower hypoglycemia risk and allow for more efficient restoration of muscle glycogen (31,247).

Evidence statement.

Persons with type 2 diabetes 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

Current treatment strategies promote combination therapies to address the three major defects in type 2 diabetes: impaired peripheral glucose uptake (liver, fat, and muscle), excessive hepatic glucose release (with glucagon excess), and insufficient insulin secretion. Medication adjustments for PA are generally necessary only with use of insulin and other insulin secretagogues (161,230). To prevent hypoglycemia, individuals may need to reduce their oral medications or insulin dosing before (and possibly after) exercise (83,161). Before planned exercise, short-acting insulin doses the 1 last update 06 Jun 2020 will likely have to be reduced to prevent hypoglycemia. Newer, synthetic, rapid-acting insulin analogs (i.e., lispro, aspart, and glulisine) induce more rapid decreases in BG than regular human insulin. Individuals will need to monitor BG levels before, occasionally during, and after exercise and compensate with appropriate dietary and/or medication regimen changes, particularly when exercising at insulin peak times. If only longer-acting insulins such as glargine, detemir, and NPH are being absorbed from subcutaneous depots during PA, exercise-induced hypoglycemia is not as likely (219), although doses may need to be reduced to accommodate regular participation in PA. Doses of select oral hypoglycemic agents (glyburide, glipizide, glimepiride, nateglinide, and repaglinide) may also need to be lowered in response to regular exercise training if the frequency of hypoglycemia increases (161,230).Current treatment strategies promote combination therapies to address the three major defects in type 2 diabetes: impaired peripheral glucose uptake (liver, fat, and muscle), excessive hepatic glucose release (with glucagon excess), and insufficient insulin secretion. Medication adjustments for PA are generally necessary only with use of insulin and other insulin secretagogues (161,230). To prevent hypoglycemia, individuals may need to reduce their oral medications or insulin dosing before (and possibly after) exercise (83,161). Before planned exercise, short-acting insulin doses will likely have to be reduced to prevent hypoglycemia. Newer, synthetic, rapid-acting insulin analogs (i.e., lispro, aspart, and glulisine) induce more rapid decreases in BG than regular human insulin. Individuals will need to monitor BG levels before, occasionally during, and after exercise and compensate with appropriate dietary and/or medication regimen changes, particularly when exercising at insulin peak times. If only longer-acting insulins such as glargine, detemir, and NPH are being absorbed from subcutaneous depots during PA, exercise-induced hypoglycemia is not as likely (219), although doses may need to be reduced to accommodate regular participation in PA. Doses of select oral hypoglycemic agents (glyburide, glipizide, glimepiride, nateglinide, and repaglinide) may also need to be lowered in response to regular exercise training if the frequency of hypoglycemia increases (161,230).

Diabetic individuals are often prescribed a variety of medications for comorbid conditions, including diuretics, β-blockers, ACE inhibitors, aspirin, lipid-lowering agents, and more. These medications generally do not affect exercise responses, with some notable exceptions. β-Blockers are known to blunt HR responses to exercise and lower maximal exercise capacity to ∼87% of expected via negative inotropic and chronotropic effects (241). They may also block adrenergic symptoms of hypoglycemia, increasing the risk of undetected hypoglycemia during exercise. However, β-blockers may increase exercise capacity in those with CAD, rather than lowering it, by reducing coronary ischemia during activity (53). Diuretics, however, may lower overall blood and fluid volumes resulting in dehydration and electrolyte imbalances, particularly during exercise in the heat. Statin use has been associated with an elevated risk of myopathies (myalgia and myositis), particularly when combined with use of fibrates and niacin (203). An extended discussion on medications can be found in the Handbook of Exercise in Diabetes (2002) (84).

Evidence statement.

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 β-blockers, some diuretics, and statins. ACSM evidence category C. ADA C level recommendation.

EXERCISE WITH LONG-TERM COMPLICATIONS OF DIABETES

Vascular disease.

Individuals with angina and type 2 diabetes classified as moderate or high risk should preferably exercise in a supervised cardiac rehabilitation program, at least initially (245). Diabetes accelerates the development of atherosclerosis and is a major risk factor for CVD and PAD. Individuals with type 2 diabetes have a lifetime risk of CAD that includes 67% of women and 78% of men and is exacerbated by obesity (22,80,165). Moreover, some individuals who have an acute myocardial infarction may for 1 last update 06 Jun 2020 not experience chest pain, and up to a third may have silent myocardial ischemia (45,180).Individuals with angina and type 2 diabetes classified as moderate or high risk should preferably exercise in a supervised cardiac rehabilitation program, at least initially (245). Diabetes accelerates the development of atherosclerosis and is a major risk factor for CVD and PAD. Individuals with type 2 diabetes have a lifetime risk of CAD that includes 67% of women and 78% of men and is exacerbated by obesity (22,80,165). Moreover, some individuals who have an acute myocardial infarction may not experience chest pain, and up to a third may have silent myocardial ischemia (45,180).

For individuals with PAD, with and without intermittent claudication and pain in the extremities during PA, low-to-moderate walking, arm-crank, and cycling exercise have all been shown to enhance mobility, functional capacity, exercise pain tolerance, and QOL (214,295). Lower extremity resistance training also improves functional performance measured by treadmill walking, stair climbing ability, and QOL measures (187).

Vascular alterations are common in diabetes, even in the absence of overt vascular disease. Endothelial dysfunction may be an underlying cause of many associated vascular problems (45,54). In addition to traditional risk factors, hyperglycemia, hyperinsulinemia, and oxidative stress contribute to endothelial damage, leading to poor arterial function and greater susceptibility to atherogenesis (45,82,289). Both aerobic and resistance training can improve endothelial function (46,294), but not all studies have shown posttraining improvement (283).

the 1 last update 06 Jun 2020

Evidence statement.

Known 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 PAD. ACSM evidence category C. ADA C level recommendation.

Peripheral neuropathy.

Mild to moderate exercise may help prevent the onset of peripheral neuropathy (10). Individuals without acute foot ulcers can undertake moderate weight-bearing exercise, although anyone with a foot injury or open sore or ulcer should be restricted to non–weight-bearing PA. All individuals should closely examine their feet on a daily basis to prevent and detect sores or ulcers early and follow recommendations for use of proper footwear. Previous guidelines stated that persons with severe peripheral neuropathy should avoid weight-bearing activities to reduce risk of foot ulcerations (102,264). However, recent studies indicated that moderate walking does not increase risk of foot ulcers or reulceration in those with peripheral neuropathy (166,167).

Peripheral neuropathy affects the extremities, particularly the lower legs and feet. Hyperglycemia causes nerve toxicity, leading to nerve damage and apoptosis (242,244), which causes microvascular damage and loss of perfusion. Symptoms manifest as neuropathic pain and/or loss of sensation that, coupled with poor blood flow, increase the risk of foot injuries and ulcerations (45,244). Up to 40% of diabetic individuals may experience peripheral neuropathy, and 60% of lower extremity amputations in Americans are related to diabetes (166,199,216).

Evidence statement.

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.

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Moderate-intensity aerobic training can improve autonomic function in individuals with and without CV autonomic neuropathy (CAN) (112,176,208); however, improvements may only be evident after an acute submaximal exercise (78). Screening for CAN should include a battery of autonomic tests (including HR variability) that evaluate both branches of the autonomic nervous system. Given the likelihood of silent ischemia, HR, and BP abnormalities, individuals with CAN should have physician approval and possibly undergo stress testing to screen for CV abnormalities before commencing exercise (265). Exercise intensity may be accurately prescribed using the HR reserve method (a percentage of the difference between maximal and resting HR, added to the resting value) to approximate oxygen consumption during submaximal exercise with maximal HR directly measured, rather than estimated, for better accuracy (48,265).

Approximately 22% of those with type 2 diabetes have CAN, but most exhibit alterations in autonomic function (292). The presence of CAN doubles the risk of mortality (48,265) and indicates more frequency of silent myocardial ischemia (265), orthostatic hypotension, or resting tachycardia (76,177). CAN also impairs exercise tolerance and lowers maximal HR (131,265). Although both sympathetic and parasympathetic dysfunctions can be present, vagal dysfunction usually occurs earlier. Slower HR recovery after PA is associated with mortality risk (38,265).

Evidence statement.

Individuals with CAN should be screened and receive physician approval and for 1 last update 06 Jun 2020 possibly an exercise stress test before exercise initiation. Exercise intensity is best prescribed using the HR reserve method with direct measurement of maximal HR. ACSM evidence category C. ADA C level recommendation.Individuals with CAN should be screened and receive physician approval and possibly an exercise stress test before exercise initiation. Exercise intensity is best prescribed using the HR reserve method with direct measurement of maximal HR. ACSM evidence category C. ADA C level recommendation.

Retinopathy.

In diabetic individuals with proliferative or preproliferative retinopathy or macular degeneration, careful screening and physician approval are recommended before initiating an exercise program. Activities that greatly increase intraocular pressure, such as high-intensity aerobic or resistance training (with large increases in systolic BP) and head-down activities, are not advised with uncontrolled proliferative disease, nor are jumping or jarring activities, all of which increase hemorrhage risk (1). Diabetic retinopathy is the main cause of blindness in developed countries and is associated with increased CV mortality (129,147). Individuals with retinopathy may receive some benefits, such as improved work capacity, after low- to moderate-intensity exercise training (16,17). While PA has been shown to be protective against development of age-related macular degeneration (150), very little research exists in type 2 diabetes.

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Nephropathy and microalbuminuria.

Both aerobic and resistance training improve physical function and QOL in individuals with kidney disease (126,209, 210), although BP increases during PA may transiently elevate levels of microalbumin in urine. Resistance exercise training is especially effective in improving muscle function and activities of daily living, which are normally severely affected by later-stage kidney disease (126). Before initiation of PA, individuals with overt nephropathy should be carefully screened, have physician approval, and possibly undergo stress testing to detect CAD and abnormal HR and BP responses (1,27). Exercise should be begun at a low intensity and volume because aerobic capacity and muscle function are substantially reduced, and avoidance of the Valsava maneuver or high-intensity exercise to prevent excessive increases in BP is advised (1). Supervised, moderate aerobic exercise undertaken during dialysis sessions, however, has been shown to be effective as home-based exercise and may improve compliance (126,151).

Diabetic nephropathy develops in ∼30% of individuals with diabetes and is a major risk factor for death in those with diabetes (20,45). Microalbuminuria, or minute amounts of albumin in the urine, is common and a risk factor for overt nephropathy (45) and CV mortality (91). Tight BG and BP control may delay progression of microalbuminuria (127,148), along with exercise and dietary changes (81,162). Exercise training delays the progression of diabetic nephropathy in animals (89,259), but few evidence is available in humans.

Evidence statement.

Exercise training increases physical function and QOL 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

Most American adults with type 2 diabetes or at highest risk for developing it do not engage in regular PA; their rate of participation is significantly below national norms (193). Additional strategies are needed to increase the adoption and maintenance of PA.

One of the most consistent predictors of greater levels of activity has been higher levels of self-efficacy (2,55,68), which reflect confidence in the ability to exercise (185). Social support has also been associated with greater levels of PA (93,190,215), supporting the role of social networks in the spread of obesity (41). Fortunately, those same social dynamics may be exploited to increase the effects of interventions beyond the “target” individual (8,99) and potentially can help spread PA behavior. Counseling delivered by health care professionals may be a meaningful source of support and effective source for delivery (7,144). Physicians vary in counseling their patients to exercise: on average, advice or referral related to exercise occurred at 18% of office visits among diabetic patients (213), and 73% of patients reported receiving advice at some point to exercise more (192). The availability of facilities or pleasant and safe places to walk may also be important predictors of regular PA (59).

are bananas bad for pre diabetics etiology (πŸ”΄ treatment side effect) | are bananas bad for pre diabetics genetic linkhow to are bananas bad for pre diabetics for When prescribing PA for the prevention or control of type 2 diabetes, the effects of the dose of the prescription on adherence are small (225). Therefore, practitioners are encouraged to use factors such as choice and enjoyment in helping determine specifically how an individual would meet recommended participation. Affective responses to exercise may be important predictors of adoption and maintenance, and encouraging activity at intensities below the ventilatory threshold may be most beneficial (172,277,278). Many individuals with, or at risk of developing, type 2 diabetes prefer walking as an aerobic activity (190), and pedometer-based interventions can be effective for increasing aerobic activity (30,205,258). Finally, the emerging importance of sedentary behaviors in determining metabolic risk (106,107) suggests that future interventions may also benefit from attempting to decrease sitting time and periods of extended sedentary activity.

Large-scale trials such as the DPP and Look AHEAD provide some insight into successful lifestyle interventions that help promote PA by incorporating goal setting, self-monitoring, frequent contact, and stepped-care protocols (56,60,71,266). Delivering these programs requires extensive access to resources, staff, and space, although they are cost-effective overall (121,122).

These large studies are multifactorial, targeting several behaviors that include PA, but include multiple behavior interventions that also require changes in diet and focusing on weight loss or management (179). Therefore, strategies for PA intervention in weight management are highly relevant to this population (62). Fewer RCTs solely targeted PA behavior in individuals with or at risk of developing type 2 diabetes (279,284,285). The results have been mixed, with some showing increased PA (67,120,145,171) and others showing no effect (142,143,189). Effective short-term programs have used print (67), phone (44,144,233), in-person (120,139), or Internet (92,171) delivery. Long-term effectiveness of such interventions has not been assessed (197).

Evidence statement.

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.

CONCLUSIONS

Exercise plays a major role in the prevention and control of insulin resistance, prediabetes, GDM, type 2 diabetes, and diabetes-related health complications. Both aerobic and resistance training improve insulin action, at least acutely, and can assist with the management of BG levels, lipids, BP, CV risk, mortality, and QOL, but exercise must be undertaken regularly to have continued benefits and likely include regular training of varying types. Most persons with type 2 diabetes can perform exercise safely as long as certain precautions are taken. The inclusion of an exercise program or other means of increasing overall PA is critical for optimal health in individuals with type 2 diabetes.

Acknowledgments

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