EXERCISE CONSIDERATIONS FOR TYPE 1
AND TYPE 2 DIABETES
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by Joel E. Williams, M.P.H., Ph.D.; Brian Helsel, M.S., CSCS, EIM1;
Bryce Nelson, M.D., Ph.D.; and Ransome Eke, M.D., M.P.H., Ph.D.
Apply It!
By reading this article, the health
and fitness professional will learn
more about the contraindications
when working with clients who
have type 1 or type 2 diabetes.
10 ACSM’s Health & Fitness Journal ®
Copyright © 2018 American College of Sports Medicine. Unauthorized reproduction of this article is prohibited.
INTRODUCTION
D
iabetes is a group of metabolic diseases where the pancreas either does
not produce adequate insulin or the body does not properly respond to
the insulin, resulting in high blood glucose levels over a prolonged period.
Diabetes is a global epidemic, and racial/ethnic minorities are affected
disproportionately. In 2011, 365 million people worldwide had a diagno-
sis of diabetes (1). The West Pacific region had the highest number of individuals (131.9
million) diagnosed with diabetes. The Middle East and North Africa regions had the
highest prevalence rates of diabetes at 11.0%. The North America/Caribbean region
had the second highest prevalence rate of diabetes at 10.7%. South-Central America and
Southeast Asia had similar diabetes prevalence rates of 9.2%, whereas Europe had a
6.7% prevalence rate. Africa has the lowest prevalence rate of diabetes at 4.5%; however,
Africa also had the highest proportion of undiagnosed diabetes, with at least 78% of
affected individuals being undiagnosed (2). It is estimated that 9.3% of the U.S. popula-
tion, or 29.1 million (21.0 million diagnosed, 8.1 million undiagnosed), are affected by dia-
betes. Among those aged 20 or older, 7.6% of individuals with diabetes are non-Hispanic
white, 9.0% are Asian American, 12.8% are Hispanic, 13.2% are non-Hispanic black,
and 15.0% are American Indian/Alaska Native (3).
It is widely known that prevention of a disease before it is diagnosed is preferred and
can reduce costs associated with health care (4). Furthermore, a person’s lifestyle, includ-
ing physical activity and dietary patterns, can influence the onset and progression of
chronic disease. Increased physical activity and improved nutrition also is a practical strat-
egy for reducing the risk of diabetes, and even those individuals already diagnosed with
type 2 diabetes (T2D) could benefit from a lifestyle modification program (5). Individuals
with diabetes can realize the same benefits of physical activity as those without diabetes,
including increased energy, normalization of blood glucose, and a reduction of chronic
disease risk factors. However, persons with diabetes, and those who supervise clients who
January/February 2018
have diabetes, should be aware of exercise recommendations and
contraindications. This article outlines special physical activity
and nutritional considerations for those with type 1 diabetes
(T1D) and T2D.
TYPE 1 DIABETES
Cause
T1D can occur at any age but is most commonly diagnosed be-
tween infancy and the late 30s. T1D results when the pancreas
produces little to no insulin, due to the body’s immune system’s
destruction of the insulin-producing cells in the pancreas. This
process results in lifelong dependence on exogenous insulin (6).
In the SEARCH for Diabetes in Youth study, it was estimated
that 18,436 U.S. youths were newly diagnosed with T1D in
2009 (Figure 1) (7). Worldwide, approximately 78,000 youths
are diagnosed with T1D annually. Incidence varies among
countries: East Asians and American Indians have the lowest
incidence rates (0.1–8 per 100,000/year) as compared with the
Finnish, who have the highest rates (>64.2 per 100,000/year)
(8). In the United States, the number of youth with T1D was
estimated to be 166,984 (9).
Exercise and Nutrition
Benefits of Exercise
Many benefits can be gained from regular exercise or physical ac-
tivity, such as better mood, higher quality sleep, and improving var-
ious cardiovascular risk factors such as cholesterol and triglycerides.
There are some other specific advantages for people with T1D:
• Exercise can improve overall and disease-specific quality
of life (10).
• Regular activity may enhance or improve insulin sensi-
tivity (6).
• Exercise contributes to an increased metabolism, which
plays a role in the regulation of body weight.
• Physical activity lowers blood pressure and heart rate at
rest and during submaximal exercise.
Volume 22 | Number 1
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Figure 1. Youth T1D prevalence by race/ethnicity.
• Increases self-efficacy for maintaining normal blood glu-
cose levels by learning about the short- and long-term
benefits of optimal control and how to manage blood glu-
cose before, during, and after exercise (6).
Individuals with T1D should follow general recommendations
for aerobic and resistance training while ensuring that he or she
manages his or her blood glucose levels before, during, and after
the exercise session. Practical recommendations for frequency,
intensity, duration, mode, and rate of progression for exercise
are listed in the T2D section. Any patient with T1D should seek
help from his or her health care team if problems managing
blood glucose levels occur.
Nutritional Considerations
Hydration is essential for thermoregulation and cardiovascular
function in active individuals but is particularly important for
people with T1D to help maintain optimal blood sugar levels
(11). Dehydration slows down food absorption and raises blood
glucose rapidly. In addition to regular fluid consumption during
the day, we recommend your clients drink 20 oz of extra fluid an
hour or two before starting exercise and 28 to 40 oz of fluid for
every 1 hour of exercise or activity. Both male and female ado-
lescent athletes who engage in sports that require muscular strength
(e.g., football, wrestling) may consider increasing protein intake
or taking performance-related nutritional supplements. We rec-
ommend lean meats (e.g., chicken breast, fish) as primary sources
of protein. The long-term and short-term effects of creatine, a
popular supplement taken to improve strength in adults, are still
an understudied area in children and adolescents. The American
College of Sports Medicine and the American Academy of Pedi-
atrics both recommend against the use of creatine supplements in
those younger than 18 years, and we adhere to that recommen-
dation among our patients (12). Poorly controlled T1D increases
the risk for renal complications with resulting proteinuria. Al-
though physical activity can acutely increase urinary protein fil-
tration, there is currently no evidence that vigorous activity
increases the progression rate of diabetes-related kidney disease
www.acsm-healthfitness.org 11
EXERCISE AND DIABETES
and no specific contraindication to exercise per se in diabetes-
related kidney disease. However, those patients with diabetes
and microalbuminuria (mild to moderate levels of albumin in
the urine), macroalbuminuria (severe levels of albumin in the
urine), renal failure, or other risk for renal problems should
NOT markedly increase protein supplementation without con-
sulting with his or her health care provider and should maintain
the recommended dietary allowance of 0.8 g of protein per kilo-
gram of body weight (13).
Hydration is essential for thermoregulation and
cardiovascular function in active individuals but
is particularly important for people with T1D to
help maintain optimal blood sugar levels (11).
Treatment — Controlling Blood Glucose Levels
Preventing hypoglycemia is of primary importance with the ac-
tive T1D client. Because he or she is on insulin, he or she is at
greater risk for hypoglycemia during exercise and for delayed
onset hypoglycemia after prolonged aerobic (≥60 minutes) or
anaerobic exercise. These individuals should check blood glu-
cose before, during, and after exercise. Blood glucose levels be-
fore activity should not be 100 mg/dL or less or 250 mg/dL or
greater. Blood glucose management varies depending on age
and type of activity. A recommendation from the American Di-
abetes Association (ADA), which is similar to most organiza-
tions, includes checking blood glucose at least 30 minutes
before exercise. If preexercise blood glucose is 100 mg/dL or
less, the client would benefit from a 15- to 30-g high glycemic in-
dex carbohydrate snack like fruit juice, fruit, or even glucose tab-
lets. If preexercise blood glucose is 250 mg/dL or greater,
caution is recommended, and the client should be checked for
the presence of ketones. If ketones are present, exercise is contra-
indicated until ketone levels are no longer present to prevent the
development of diabetic ketoacidosis. Premeal insulin doses also
may need to be adjusted depending on the duration and mode
of exercise to prevent exercise-induced hypoglycemia. For mod-
erate level of exercise (e.g., walking, bicycling leisurely, shooting
basketball, mowing the lawn), your client should be careful to
avoid acute hypoglycemia that can occur during or after exer-
cise. For more intensive and longer activities (e.g., jogging, bicycle
race, basketball game), increased carbohydrates may be necessary
and more care taken to prevent delayed hypoglycemia, which can
occur later in the night or the next day. Blood glucose should be
monitored immediately after exercise and one to two times for 2
to 3 hours after exercise, especially if the exercise bout is 60 minutes
or more. In these situations, your clients may benefit from reduc-
tion in basal insulin of 20% to 25% and a lower glycemic index
snack like yogurt, peanut butter, or dark chocolate before bedtime.
Clients with diabetes should determine the appropriate food intake
12 ACSM’s Health & Fitness Journal ®
Copyright © 2018 American College of Sports Medicine. Unauthorized reproduction of this article is prohibited.
based on blood glucose levels before, during, and after exercise by
keeping records of activities and blood glucose levels.
Practical Strategies — Sprinting to
Reduce Hypoglycemia
To prevent delayed hypoglycemia, a practical strategy for your
clients may be to perform a hard sprint for 10 seconds after exer-
cising. This strategy may be physiologically explained through an in-
crease in catecholamine and lactate levels. Elevated catecholamine
levels stimulate hepatic glucose production through glycogenol-
ysis, which inhibits insulin-mediated glucose uptake by the skel-
etal muscle and stabilizes blood glucose levels in patients with
T1D. Likewise, elevated lactate levels caused by sprinting can help
stabilize blood glucose through gluconeogenesis via the Cori Cycle
(14). Furthermore, sprinting before a moderate intensity exer-
cise session could have some benefit in the stabilization of glyce-
mia (15), but care should be taken when engaging in a sprint
before moderate intensity exercise unless a proper warm-up is
completed. Sprinting should only be considered an option for
clients who are in good health and do not have any contrain-
dications to high-intensity exercise. Each individual with T1D
should continue to monitor glycemia levels and make adjust-
ments as needed. If your client with diabetes is having chronic
lows or highs, he or she may need to alter his or her insulin dose
or make changes to his or her meal plan in consultation with his
or her physician or endocrinologist. The health care team can
use blood glucose and activity information to suggest adjust-
ments and refine the care plan.
Health Impact and Other Important Considerations
Individuals with T1D can exercise safely and effectively and
gain the same benefits from exercise as anyone else. However,
he or she should pay more attention to how his or her body re-
sponds to exercise; learn to balance insulin, food, and physical
activity; and use evidence-based strategies to minimize the risk
of hypoglycemia during and after exercise. Lastly, there are sev-
eral important considerations for the active client with T1D who
is vigilant about blood glucose control. These individuals should
always carry the following items with him or her, especially
when he or she exercises:
• Fast-acting carbohydrate to treat low blood glucose level
• Additional snacks such as cheese and crackers or a sandwich
• A bottle of water to maintain adequate hydration
• Glucose meter and supplies
• Medical alert identification (e.g., medical bracelet)
It is recommended that your client always has a friend, coach, or
some other adult nearby who is able to identify and respond to
low blood glucose levels. If your client’s blood glucose levels are
high before exercise, remind him or her to check his or her blood
or urine for ketones. If your client tests positive for ketones, avoid
activity and treat the elevated blood glucose and ketones as
instructed by your health care team. A child or adult should
January/February 2018
NEVER exercise if his or her blood glucose is 250 mg/dL or
higher and ketones are present. This puts him or her at risk
for developing diabetic ketoacidosis.
TYPE 2 DIABETES
Cause
With an estimated 22 million Americans living with diabetes
and an even greater number with prediabetes, it is essential that
researchers and clinicians make prevention and treatment of
T2D a priority. T2D is caused by the inability of muscle and other
tissue cells to properly respond to insulin, called insulin resistance,
and/or inadequate compensatory insulin secretion. T2D is more
prevalent than T1D and represents 90% to 95% of all diabetes
cases. The risk for developing T2D increases with age, obesity,
and physical inactivity (16). Diabetes can be diagnosed from any
one of four criteria (Figure 2) including a glycated hemoglobin
(A1c) value higher than 6.5%, fasting plasma glucose 126 mg/dL
or higher, 2-hour plasma glucose 200 mg/dL or higher during
an oral glucose test, or symptoms of hyperglycemia (16).
Exercise and Nutrition
Benefits of Exercise
Similar benefits found in T1D also can be seen for those individ-
uals with T2D. In addition to the benefits mentioned earlier,
such as better mood, higher quality sleep, and improving cardio-
vascular risk factors, patients with type 2 diabetes also experi-
ence better control of blood glucose and modest weight loss,
two factors that can help reverse the signs, symptoms, and even
diagnosis of T2D. Benefits of physical activity in T2D can be
achieved through a few basic exercise guidelines that establish
the frequency, intensity, duration, mode, and rate of progression
for aerobic and resistance training (6,10).
Aerobic Exercise
• Frequency: Start with a minimum of 3 d/wk of moderate
intensity exercise and no more than 2 consecutive days be-
tween exercise sessions because of the short duration of
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Figure 2. Diabetes diagnostic criteria.
improvements in insulin function. The recommended
amount of aerobic exercise for the general population is
5 d/wk of moderate intensity or 3 d/wk of vigorous inten-
sity (6,10).
• Intensity: Moderate intensity is between 40% and 60%
Heart Rate Reserve, which is similar to brisk walking in
most clients with T2D. Additional benefits can be seen
by engaging in vigorous intensity exercise of greater than
60% Heart Rate Reserve.
• Duration: Moderate intensity exercise for at least 150 min/wk.
This exercise does not need to be continuous and can be
accumulated in 10-minute bouts.
• Mode: A variety of types of aerobic exercise that use large
muscle groups (i.e., swimming, cycling, walking, running,
rowing).
• Rate of Progression: A gradual progression of not more
than a 10% increase per week in exercise intensity or du-
ration to minimize the risk of injury and to promote exer-
cise adherence is recommended (6,10).
Resistance Exercise
• Frequency: 2 or 3 nonconsecutive days each week with a
minimum of 48 to 72 hours of rest in between each resis-
tance training session targeting a given muscle group.
• Intensity: Training should be moderate or vigorous for op-
timal improvements in strength and insulin action. Moder-
ate intensity begins at 50% of an individual’s one repetition
maximum (1RM) and vigorous intensity at 75% to 80% of
the 1RM.
• Duration: The training session should consist of 5 to 10 ex-
ercises and 10 to 15 repetitions that use all the large mus-
cle groups in the upper body, lower body, and core. It is
recommended to complete 1 to 4 sets for each exercise.
• Mode: Resistance machines and free weights should be the
primary mode of resistance training. Other types of resis-
tance training using bands, cables, body weight, etc., may
be used. In addition, functional movement exercises that
allow the client to simulate activities of daily living (e.g., walk-
ing, climbing stairs) and instrumental activities of daily liv-
ing (e.g., cooking, doing housework) should be a focus to
improve disease-specific and overall quality of life.
www.acsm-healthfitness.org 13
EXERCISE AND DIABETES
• Rate of Progression: Rate of progression should be slow
and only take place when the number of repetitions per
set can consistently be exceeded. A common rule is the
2-for-2 rule, stating that weight increases should occur if
the individual can perform 2 more repetitions on his or
her final set in 2 consecutive resistance training sessions.
Progression of resistance training to three weekly sessions
using three sets of 8 to 12 repetitions at 75% to 80% 1RM
should be the optimal goal for strength gains. Recovery
periods between strength sets will vary based on individ-
ual resistance training goals (i.e., hypertrophy, maximal
strength or power, and endurance), usually ranging from
30 seconds for endurance to 3 or more minutes for max-
imal strength and power (6,10).
Children with either T1D or T2D should be encouraged to en-
gage in at least 60 min/d of moderate to vigorous aerobic physi-
cal activity and at least 3 d/wk of muscle and bone strengthening
activities (17). Vigorous intensity aerobic and resistance training
in children and adults should be used with caution, and the clini-
cian should ensure that the client has no contraindications to vig-
orous intensity exercise.
Nutritional Considerations
Although there is not a one-size-fits-all food plan that is suitable
for each individual with diabetes, it is important that each per-
son works with a registered dietitian and health care team to es-
tablish eating patterns that will manage both glycemic levels and
weight. Diets in overweight or obese persons with T2D should
focus on modest weight loss ranging from 5% to 7% of initial
body weight. These diets should primarily consist of nutrient-
dense foods (i.e., fruits, vegetables, whole grains, and lean meats)
while achieving the desired energy deficit. Average protein intake
should be 0.8 g/kg of body weight per day and may increase
slightly if higher levels of physical activity are being achieved.
Supplements for Omega-3 fatty acids, vitamins, or minerals have
little supporting evidence for outcome improvement in patients
with T2D who do not have a dietary deficiency. It is recom-
mended that a registered dietitian be consulted before supple-
mentation is added (10). Furthermore, patients with T2D and
hyperglycemic hyperosmolar state (HHS), a complication of di-
abetes in which high blood sugars cause severe dehydration,
need to pay particular attention to water intake and fluid man-
agement. HHS, characterized by a serum glucose greater than
600 mg/dL, a serum osmolality greater than 330 mOsm/kg,
and no significant ketosis or acidosis can be avoided through
proper blood glucose management (6). The classical symptoms
for hyperglycemia may include polyuria (frequent urination),
polydipsia (increased thirst), polyphagia (increased hunger),
and weight loss (16).
Treatment — Controlling Blood Glucose Levels
Several agencies have published clinical guidelines reviewing rec-
ommendations for exercise in patients with diabetes including
14 ACSM’s Health & Fitness Journal ®
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the ADA, the American Association of Clinical Endocrinologists,
and the American Association of Diabetes Educators. In general,
it is recommended that persons with diabetes should receive
medical care from a multidisciplinary, collaborative team with
expertise in diabetes management to include physicians, phy-
sician assistants, nurse practitioners, dietitians, exercise specialists,
mental health providers, dentists, podiatrists, and pharmacists.
The patient should work with his or her team to develop an indi-
vidualized treatment plan for diabetes self-management and set
treatment goals for all aspects of his or her diabetes care. Physical
activity and exercise have been shown to improve glycemic control,
lower cardiovascular risk factors, promote weight loss, and improve
overall health, but its role in reducing diabetes-related complica-
tions is not fully understood (10,16). Patients may see a clinically
significant reduction in A1c with regular exercise independent
of changes in body mass index (BMI).
Practical Strategies — Prevention Before Diagnosis
Although there may be some drug treatments that have been
successful in reducing the risk of diabetes, lifestyle intervention
and behavior change have been shown to be among the most ef-
fective methods for reducing T2D risk. An article published in
the New England Journal of Medicine compared drug treatment,
specifically metformin, and lifestyle intervention in a group of
3,234 adults who had prediabetes and had an average BMI
of 34 ± 6.7 kg/m2. Researchers found that participants assigned
to the lifestyle modification group had greater body weight loss
and physical activity increases than those who were assigned to
the drug treatment or placebo groups. The incidence of diabetes
was 58% and 31% lower in the lifestyle intervention and drug
treatment group, respectively, when compared with the placebo
(5). In addition, the incidence of diabetes was reduced by 39%
in the lifestyle intervention when compared with the drug
treatment group.
Supplementary practical strategies can be seen in Figure 3
and can be used as a guide to developing individualized plans
for your client. Lifestyle interventions should include a combina-
tion of diet, physical activity, and behavioral therapy techniques
with the main goals of increasing physical activity and reducing
body weight. Using dietary restriction of fat often is a successful
strategy for weight loss in patients with T2D because of the
higher caloric density of fat (9 kcal/g) when compared with car-
bohydrates or protein (4 kcal/g) (10). A reduction in dietary fat
intake also decreases low-density lipoprotein cholesterol, which
is associated with a higher risk for future cardiovascular events.
A complete assessment of your client’s exercise history and
motivational level also are necessary steps to facilitating behav-
ior change through lifestyle modification. Through an assess-
ment of exercise history and motivational levels, you may
learn potential barriers that will limit your client’s ability or
readiness to make changes. These barriers could include, but
are not limited to, a physical injury that required surgery, an
emotional or social limitation such as lack of support from family
and friends, financial and work-related stress, or problems with
January/February 2018
Figure 3. Diet, physical activity, and behavioral therapy suggestions for health fitness professionals working with clients who
have T2D.
time management. Being aware of roadblocks will help you in-
dividualize a plan for your client that works on moving past
these barriers and shifting his or her focus to the benefits that
may come from these lifestyle changes. Working past these bar-
riers may be challenging, which is why we recommend treating
each client individually and offering encouragement in ways
that fit his or her motivational level and readiness to change. Be-
havior change theories, such as the health belief model and
transtheoretical model (also called stages of change), offer con-
structs that may directly or indirectly influence how successful
your client will be in his or her weight loss journey and lifestyle
modification program (18,19). We recommend you familiarize
yourself with various behavior change theories, although appli-
cation of those theories and specific recommendations for
adapting the theories to fit an intervention for your client are be-
yond the scope of this article.
Health Impact and Other Important Considerations
Exercise and healthy eating have both acute and long-term ef-
fects on the management of diabetes. A combination of resis-
tance and aerobic training generally is best for patients with
diabetes and should be an individualized and progressive pro-
gram. Although using both aerobic and resistance exercise train-
ing is recommended and more likely to cause improvements in
blood glucose control, additional research is needed to determine
Volume 22 | Number 1
Copyright © 2018 American College of Sports Medicine. Unauthorized reproduction of this article is prohibited.
whether caloric expenditure, exercise duration, or mode is most
responsible (16). Health and fitness professionals should use these
recommendations as a guide for working with clients who have
diabetes, while paying careful attention to monitoring how the cli-
ent is feeling and where his or her blood glucose levels are before,
during, and after exercise.
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BRIDGING THE GAP
Disclosure: The authors declare no conflict of interest and do not have any Diabetes is a worldwide epidemic. Persons with diabetes
financial disclosures. should regularly engage in physical activity and healthy
nutritional practices so he or she can gain the same
Joel E. Williams, M.P.H., Ph.D., is an associate profes- health benefits as those without the diagnosis. It is
sor of graduate studies in the Department of Public important for those with diabetes and those who
Health Sciences and faculty scholar with the Clemson supervise individuals with diabetes to be aware of
University School of Health Research. He has been disease-specific recommendations and
an ACSM member since his undergraduate days contraindications. In this article, we provide
and is past cochair and a current member of the Ex- evidence-based recommendations for those with T1D
ercise is MedicineW Community Health Committee. and T2D.

16 ACSM’s Health & Fitness Journal ® January/February 2018

Copyright © 2018 American College of Sports Medicine. Unauthorized reproduction of this article is prohibited.