Diabetes Research and Clinical Practice 72 (2006) 271–276

www.elsevier.com/locate/diabres

The effect of resistance versus aerobic training on metabolic control

in patients with type-1 diabetes mellitus
Ana Claudia Ramalho a,*, Maria de Lourdes Lima a, Fabiana Nunes b,
Zanine Cambuı́ b, Cynara Barbosa b, Aline Andrade b, Adriana Viana b,
Marlene Martins b, Valter Abrantes c, Crésio Aragão b, Marcos Temı́stocles c
a
Department of Endocrinology, Bahian School of Medicine, Salvador, Bahia, Brazil
b
Department of Endocrinology, Roberto Santos Hospital, Salvador, Bahia, Brazil
c
Department of Exercise Science, Bahia State University, Salvador, Bahia, Brazil
Received 25 April 2005; received in revised form 4 November 2005; accepted 11 November 2005
Available online 6 January 2006

Abstract
This study evaluated the effect of aerobic versus resistance training on metabolic control in type-1 diabetes patients. Thirteen
non-active patients, ranging in age from 13–30, were submitted to a 12-week aerobic exercise (Group A, n = 7) or resistance training
(Group B, n = 6) period. Group A training consisted of a 40 min walk or run and Group B training consisted of resistance exercises
three times a week. Blood samples were obtained before and after the 12-week training period. When these samples were compared,
results showed that in Group A there were no changes in glycated hemoglobin, lipid profile, fast glucose level or body mass index
(BMI). There was, however, a reduction in waist circumference and in average self-monitored blood glucose levels, measured after
each exercise session. In Group B, there were no changes in the parameters evaluated. In both groups the total insulin dosage was
reduced. As other authors have shown, resistance/aerobic training did not improve glycated hemoglobin in type-1 diabetes patients.
# 2005 Elsevier Ireland Ltd. All rights reserved.

Keywords: Diabetes; Aerobic exercise; Resistance exercise; Glycated hemoglobin

1. Introduction 12-week period of both aerobic exercise and resistance

Although physical activity has been associated with
a reduction in cardiovascular mortality in type-1
diabetes patients [1], contradictory data have been
reported regarding the benefits of physical activity on
metabolic control in these patients.
Mosher et al. showed beneficial effects on glycated
hemoglobin in eleven type-1 diabetes patients after a
* Corresponding author. Rua Altino Seberto de Barros 119 sala
1501, Itaigara, Salvador, Bahia, Brazil. Tel.: +55 71 33599831;
fax: +55 71 33599831.
E-mail address: acrramalho@superig.com.br (A.C. Ramalho).
training [2]. Similar beneficial results were also
demonstrated by Campaigne et al. in adolescents with
type-1 diabetes after 12 weeks of vigorous games and
recreational activities [3]. In contrast, no decrease in
glycated hemoglobin levels was reported by Laaksonen
et al. after a 12-week training program in twenty type-1
diabetes patients, compared to a control group [4].
Improvements in maximal oxygen uptake (VO2 max)
with no associated changes in glycemic control have
been reported by Rowland [5] and Zinman et al. [6] after
12 weeks of bicycle and treadmill exercise, respectively.
Apart from the controversy surrounding the bene-
ficial effects of exercise on glycemic control in type-1
diabetes patients, the question remains about which type

0168-8227/$ – see front matter # 2005 Elsevier Ireland Ltd. All rights reserved.
doi:10.1016/j.diabres.2005.11.011
272 A.C. Ramalho et al. / Diabetes Research and Clinical Practice 72 (2006) 271–276
of activity is better: aerobic exercise or resistance
training. Studies that evaluated the effect of exercise on
metabolic control in type-1 diabetes patients used
aerobic training or aerobic exercise associated with
resistance training [2–4]. Information is lacking about
the effect of resistance training without aerobic exercise
on metabolic control in type-1 diabetes. Taking into
account that today type-1 diabetes is more prevalent in
young people who frequent gyms for resistance
training, this evaluation becomes even more important.
The unanswered question as to whether exercise
should be encouraged in subjects with type-1 diabetes in
order to achieve better glycemic control has important
implications for these patients. Better glycemic control is
associated with a reduced risk of diabetic complications,
as shown in the DCCT trial [7]. At present, the
relationship between physical activity and glycemic
control in type-1 diabetes patients has yet to be fully
established. The aim of this study was to evaluate the
effect of 12 weeks of aerobic exercise and resistance
training on metabolic control in type-1 diabetes patients.
2. Materials and methods
2.1. Subjects
Sixteen patients with type-1 diabetes mellitus ranging
in ages from 13 to 30, who exercised less than twice a
week, were chosen from outpatients at a public hospital in
Salvador, Bahia, Brazil. Patients with ketosis, chronic
complications, such as proliferative retinopathy and
peripheral neuropathy, as determined by the monofila-
ment test (Semmes–Weinstein 5.07/10 g), were
excluded. At baseline, treatments were administered in
the morning and at bedtime using NPH insulin and
regular, lispro or aspart insulin, before meals. The study
was approved by the Hospital Ethics Committee and all
patients gave their informed written consent.
2.2. Anthropometric measurements
The anthropometric measurements consisted of
weight (calibrated scale-Filizola), height (nearest cm-
stadiometers-Standard), waist circumference measured
at the level of umbilicus and the waist/hip ratio was cal-
culated. The body mass index (BMI) was calculated as the
ratio of weight (kg) to the square of height (m) (kg/m2).
2.3. Exercise testing
Before and after 12 weeks of training, all subjects
underwent a maximal treadmill-graded exercise test to
estimate maximal oxygen consumption (VO2 max),
using the Bruce protocol [8].
2.4. Blood chemistry
Venous blood samples were collected after a 12 h
overnight fast. Samples were taken before and after the
12-week exercise program of: glycated hemoglobin
(HbA1c) (enzymatic colorimetry, Biorad, reference
range 4.0–6.3%), plasma glucose and lipid profile
(total cholesterol and fractions-HDL, VLDL, triglycer-
ide) (enzymatic colorimetry, Merck-selectra ll). LDL
was calculated according to Friedewald’s formula [9],
which has been validated in type-1 diabetes [10].
2.5. Pre- and post-exercise self-monitored blood
glucose levels
Self-monitored blood glucose levels were deter-
mined using a Roche glucometer (Active) before and
after each exercise session, using blood drawn from a
finger prick. Subjects with pre-exercise self-moni-
tored blood glucose levels higher than 250 mg/dl, had
their urine examined for the presence of ketosis, and if
positive, the exercise session was canceled as
recommended [11]. The session was also canceled
if self-monitored blood glucose levels were higher
than 300 mg/dl even without ketosis, if the subject had
measured this glucose level over the previous 2-day
period. When the subject began the exercise session
with a self-monitored blood glucose level of
>250 mg/dl, the level was monitored again after
20 min; if the level increased, the session was
interrupted.
Subjects consumed a carbohydrate supplement
based on pre-exercise self-monitored blood glucose
levels. If the level was between 70 and 140 mg/dl,
they consumed 15–20 g of carbohydrates before
exercising. If the level was between 140 and
180 mg/dl, no carbohydrates were consumed before
exercise. Subjects who had a self-monitored blood
glucose level of less than 70 mg/dl during or after
training, stopped the exercise and received 30 g of
carbohydrates, and the dose of regular, lispro or aspart
insulin for the pre-exercise meal was reduced by 2
units. If patients experienced hypoglycemia in the
evening after the exercise session, the insulin NPH
night dose was reduced by 20%. At the end of the
study, each patient’s final insulin dose was compared
to the dose used before the study began, and the
percentage change in NPH, regular, aspart and lispro
insulin was verified.
 A.C. Ramalho et al. / Diabetes Research and Clinical Practice 72 (2006) 271–276 273

2.6. Exercise training 3. Results

Patients were randomized into two groups: Group One patient in Group A and two in Group B did not
A patients participated in an aerobic exercise complete the study, the former because of an infectious
program (n = 8) and Group B patients in a resistance disease, and the latter two because of personal
training program (n = 8). Both groups trained three problems. Group A consisted of seven patients (five
times a week for 12 weeks, doing either aerobic women and two men), with an average age of
exercise or resistance training, supervised by a 19.8  5.1 years who had had diabetes for 7.0  5.9
physical trainer and an endocrinologist. Each exer- years. Group B consisted of six patients (five women
cise session began and finished with a 10 min and one man) with an average age of 20.8  4.7 who
warm-up or cool-down and stretching period. The had had diabetes for 7.8  4.8 years.
intensity and duration of the exercise program were After the exercise program, five in Group A (5/7) and
progressively increased throughout the 12-week five in Group B (5/6) showed a reduction in the NPH
period, according to the tolerance of each individual insulin dose. The rapid and ultra-rapid insulin dose was
patient. reduced in one patient (1/7) in Group A and in four (4/6)
in Group B. The average pre- and post-training program
2.7. Aerobic training total insulin doses are shown in Table 1.
There was a slight increase in cardio-respiratory
Patients in Group A were submitted to a 40 min endurance in both groups, based on VO2 max (ml/kg/
aerobic session on a treadmill, either walking or min): 34.5–36.5 in Group A and 31.7–36.8 in Group B.
running, based on heart rate, until the target heart rate A significant reduction in waist/hip ratio ( p = 0.017)
was reached, according to American College of Sport and in waist circumference ( p = 0.009) was observed in
Medicine guidelines [12]. The program began with Group A, while no difference was observed in these
10 min of stretching and was conducted using the parameters in Group B (Fig. 1). Nor was there any
maximal heart rate index (HRmax) estimated by: 220- alteration in BMI for either of the groups (22.2  2.3 to
age [13]. First 2 weeks = 60–70% of HRmax, 3rd to 6th 22.15  2.2 kg/m2 in Group A and 20.6  1.4 to
weeks = 70–80% of HRmax, 7th to 12th weeks = 70– 20.6  1.8 kg/m2 in Group B).
90% of HRmax. In Group A there was no difference in lipid profile or
fasting blood sugar before and after the exercise
2.8. Resistance training program, while the HbA1c increased. In Group B there
were no significant alterations in these parameters.
Patients in Group B were submitted to a 40 min (Table 2).
session of resistance training. The program began with
10 min of stretching and was conducted with exercises Table 1
done on nine resistance machines. The resistance Pre- and post-training daily insulin dosages in Groups A and B
machines used were: chest press, bicep curl, triceps
Daily insulin dosage (units/kg/day)
extension, lower back, abdominals, leg press, leg curl
and leg extension. Subjects performed three sets of 8–12 Pre-training Post-training
repetitions, with 60 s of rest between each set. Group A 0.84 0.65
Resistance was increased by five pounds after the 0.78 0.62
subject was able to complete three sets of eight 0.59 0.50
1.30 1.27
repetitions on three consecutive days. Subjects were 0.89 0.56
trained using between 60 and 80% of their one maximal 0.75 0.88
repetition weight (1-RM). 0.98 1.05
Group B 1.70 1.11
2.9. Statistical methodology 1.01 0.83
1.20 1.16
The Student’s t-test was used to compare means, and, 1.20 0.51
0.46 0.64
when necessary, Wilcoxon statistical significance was
0.60 0.48
defined at p < 0.05 with a 95% confidence interval.
SPSS/PC Windows software version 9.0 was used for Total mean 0.95  0.34 0.79  0.28*
*
statistical analyses. p < 0.05.
274 A.C. Ramalho et al. / Diabetes Research and Clinical Practice 72 (2006) 271–276

Fig. 2. Average self-monitored blood glucose levels in Groups A and

B, measured immediately before and after exercise training.

Fig. 1. Waist circumference measurements before and after 12 weeks

of exercise training.
Self-monitored blood glucose levels, measured
before and after each session, showed a significant
reduction in Group A and a less significant reduction in
Group B (Fig. 2). The average number of hypoglycemic
episodes during the 12-week training program was 3.4
in Group A and 3.8 in Group B.
4. Discussion
Evidence that regular exercise can improve metabolic
control in type-1 diabetes is lacking. As is the case with
non-diabetic subjects, the insulin sensitivity of type-1
diabetic patients improves [14], but this does not translate
into an improvement in long-term glucose control,
according to glycated hemoglobin levels [14–17].
Most studies that evaluated the effect of exercise on
metabolic control in type-1 diabetes used aerobic
exercise. Some of them showed an improvement in
metabolic control [2,6], but others did not [14–17]. Few
studies exist that evaluate the effect of resistance
training on metabolic control in type-1 diabetes, and
most of those that do exist evaluated resistance
associated with aerobic exercise in the same patient
[2]. In this study, no improvement in glycated
hemoglobin was found after either aerobic exercise
or resistance training programs. In fact, in the aerobic
exercise group there was a slight increase in glycated
hemoglobin.
The lack of improvement in glycated hemoglobin
can, in part, be explained by the reduction of insulin
doses related to the hypoglycemic episodes that
frequently occur in these patients. As no generally
accepted guidelines to adapt insulin and food intake to
exercise exist, the insulin dose was reduced based on
each patient’s response to exercise, as determined by
self monitoring blood glucose levels. The American

Table 2
Blood chemistry before and after 12 weeks of exercise training in Groups A and B
Group A Group B
Pre-training Post-training Pre-training Post-training
Fasting glycemia (mg/dl) 229.8  118.0 270.0  109.0 141.5  117.0 180.6  87.2
HbA1c (%) 8.7  1.6 9.8  1.8* 8.2  2.9 7.6  1.6
Frutosamine (mmol/L) 4.0  0.7 3.8  0.4 3.6  0.8 3.4  0.5
Total cholesterol (mg/dl) 176.4  35.0 181.0  36.1 156.6  29.9 165.0  44.2
HDL-c (mg/dl) 62.6  9.1 64.4  8.2 53.5  9.2 54.3  10.9
LDL-c (mg/dl) 98.1  33.4 100.7  31.8 89.3  23.1 94.8  40.6
Triglycerides (mg/dl) 81.4  26.2 75.8  17.5 69.2  15.9 79.0  23.2
*
p < 0.05.
 A.C. Ramalho et al. / Diabetes Research and Clinical Practice 72 (2006) 271–276
Diabetes Association [18], based on Wasserman and
Zima’s general recommendations [11], states that these
adaptations are based on blood glucose monitoring in
order to avoid hypoglycemia and does not provide
specific values.
After 12 weeks, patients in both aerobic exercise and
resistance training programs showed a reduction in their
NPH insulin dose, which was related to hypoglycemic
episodes. Probably, the 20% reduction in the NPH dose
was higher than necessary, and this could explain the
fact that there was no reduction in glycated hemoglobin
in either group, and that there was even a slight increase
in the aerobic group.
In patients with type-1 diabetes, as in individuals
without diabetes, exercise increases insulin sensitivity
and muscle glucose uptake [14]. This effect can last
more than 12 h after exercise, as shown by Mikines et al.
[19] and could explain the hypoglycemic episodes and
the subsequent reduction in insulin doses observed in
the patients in the present study.
Ligtenberg et al. [20] showed a significant decrease
in glycated hemoglobin in type-2 diabetes patients, but
only after 1 year of training, and not within 6 months.
This suggests that a longer period of regular activity is
necessary before any difference in glycemic control
can be observed. In the present study, a 3-month
training program was carried out, which may have
been too short to modify metabolic control, although
some authors found no improvement, even when
evaluating a long-term training program in type-1
women [16].
The effect of exercise on the lipid profile is
controversial. Mosher et al. showed a reduction of
LDLc in adolescents with type-1 diabetes, who
underwent endurance and resistance training [2].
Conversely, no alterations of lipoprotein profiles were
observed after 10 weeks of either running, weight
training or a combination of both in adolescent men
[21].
The lipid profile did not change in this type-1
diabetes group. In fact, they had normal pre-training
lipid levels, and the greatest improvement was observed
in individuals with the highest lipid levels [22]. A
tendency was observed for an increase in HDL-c levels
in both groups, which could be considered significant if
the number of subjects were higher. Furthermore, this
study did not evaluate other lipid parameters such as
LDL-a or Apo B levels, which may have changed as
shown by Laaksonen et al. [4].
The present study has some limitations. It is possible
that no significant difference in metabolic control was
detected because of the small sample size, the length of
275
the training program and the lack of guidelines to adapt
the insulin dose.
Although this study provides no evidence that
regular exercise improves glycemic control in type-1
diabetes patients, insulin sensitivity and muscle glucose
uptake are altered by exercise training [19]. Re-
assessment of the insulin dose, diet and prescriptive
exercise characteristics (frequency, duration, intensity
and mode) should be done to obtain more conclusive
results.
The lack of an improvement in glycemic control
shown in this and other studies should not discourage
type-1 diabetes patients from exercising. A reduction in
waist circumference in the aerobic exercise group
associated with a tendency for increased HDL-c levels
shown in this study may indicate a reduction of visceral
fat, with an improvement in insulin resistance, which
could have an impact on cardiovascular risk, thereby
reducing mortality.
Acknowledgements
We would like to thank the group who helped us with
the patients at the gym: Luciano Vidal, João Marcelo,
David Teixeira, Fábio Castro, Humberto Santos, João
Paulo, Marcos Paulo, Marli Batista, Paulo Cezar,
Tiago Neto, Vinicius David, Flávia Costa and Nixon
Fernandes.
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