Sports Med (2013) 43:39–49
DOI 10.1007/s40279-012-0004-y
REVIEW ARTICLE
Exercise Prescription in the Treatment
of Type 2 Diabetes Mellitus
Current Practices, Existing Guidelines and Future Directions
Ciara O’Hagan • Giuseppe De Vito •
Colin A. G. Boreham
Published online: 28 November 2012
Ó Springer International Publishing Switzerland 2012
Abstract Exercise is an effective treatment for type 2
diabetes mellitus, resulting in stabilization of plasma glu-
cose in the acute phase and improvements in body com-
position, insulin resistance and glycosylated haemoglobin
with chronic exercise training. However, the most appro-
priate exercise prescription for type 2 diabetes has not yet
been established, resulting from insufficient evidence to
determine the optimum type, intensity, duration or fre-
quency of exercise training. Furthermore, patient engage-
ment in exercise is suboptimal. There are many likely
reasons for low engagement in exercise; one possible
contributory factor may be a tendency for expert bodies to
prioritize the roles of diet and medication over exercise in
their treatment guidelines. Published treatment guidelines
vary in their approach to exercise training, but most
agencies suggest that people with type 2 diabetes engage in
150 min of moderate to vigorous aerobic exercise per
week. This prescription is similar to the established
guidelines for cardiovascular health in the general popu-
lation. Future possibilities in this area include investigation
of the physiological effects and practical benefits of exer-
cise training of different intensities in type 2 diabetes, and
the use of individualized prescription to maximize the
health benefits of training.
C. O’Hagan (&)
Academy of Sport and Physical Activity, Sheffield Hallam
University, Collegiate Crescent, Sheffield S10 2BP, UK
e-mail: c.ohagan@shu.ac.uk
C. O’Hagan
G. De Vito
C. A. G. Boreham
Institute for Sport and Health, University College Dublin,
Dublin, Ireland
1 Introduction
Diabetes mellitus is a chronic disease affecting 171 million
adults globally (2.8%); this is estimated to increase to 366
million (4.4%) by 2030 [1]. Between 90 and 95% of
patients have type 2 diabetes, the form of the disease
previously known as ‘adult onset diabetes’ or ‘non-insulin
dependent diabetes mellitus’ [2].
The aim of treatment for type 2 diabetes is to prevent or
slow progression of the disease and the development of
micro- and macro-vascular complications including car-
diovascular disease, retinopathy, neuropathy and kidney
disease. This is typically approached with a combination of
medication, dietary modification and exercise prescription
to reduce blood glucose concentrations and blood pressure,
induce weight loss and modify blood lipid levels.
However, while most patients and practitioners under-
stand the benefits of medication and dietary control in the
treatment of type 2 diabetes, the specific benefits of exer-
cise may be less well understood and, as such, the potential
of exercise prescription may not be fully exploited [3]. In
this review we briefly outline current understanding of the
beneficial effects of exercise training for people with type 2
diabetes, discuss trends for patient participation in exercise
training, review the available guidelines for exercise pre-
scription, and suggest some future directions for research
and practice in this area.
Articles for inclusion in Sect. 4, ‘Existing guidelines for
prescription of exercise in type 2 diabetes’, were selected
using a search of the MEDLINE database. The search was
restricted to articles published between 1998 and 2011, and
which were categorized as one of the following article
types: guideline, practice guideline, consensus develop-
ment conference, government publication or patient edu-
cation handout. The search terms ‘type 2 diabetes’,
40
‘physical activity’, ‘exercise’, ‘guidelines’ and ‘consensus
statement’ were used, and the resulting articles were then
screened to remove guidelines relating solely or primarily
to pharmacological or dietary treatments, diagnosis of type
2 diabetes, diagnosis or management of secondary com-
plications of type 2 diabetes or management of type 2
diabetes in children. Lastly, the reference lists of the
selected articles were hand searched to identify any addi-
tional relevant publications. This search process resulted in
the 13 guidelines listed in Table 1.
2 Effects of Exercise Training in Type 2 Diabetes
Mellitus
Exercise induces glucose uptake in skeletal muscle by an
insulin-independent pathway and enhances glucose uptake
by the insulin-dependent pathway, and this exercise-
induced increase is maintained in the insulin resistant state
of type 2 diabetes [4]. A single bout of exercise has been
shown to induce an increased glucose uptake (and conse-
quent reduction in blood glucose) in people with type 2
diabetes that persists for at least 24 h post exercise [4].
Furthermore, the single bout stabilizes plasma glucose
response for the subsequent 24 h, reducing the appearance
of postprandial hyperglycaemic ‘spikes’ that are known to
be a significant precursor in the development of diabetic
complications [5].
The cumulative effect of repeated exercise bouts (i.e. the
training effect), can thus be exploited for disease therapy.
Exercise training programmes for people with type 2 dia-
betes have been shown to have beneficial effects on body
weight [6], fasting glucose [7], fasting insulin and insulin
resistance [8], rate of fat oxidation [9], blood cholesterol
[10] and blood pressure [11]. Importantly, several long-
term exercise training studies have shown a reduction in gly-
cosylated haemoglobin (HbA1c), used clinically as a key marker
of long-term glycaemic control, and therefore frequently con-
sidered as an indicator of treatment efficacy [12–14].
However, there are still relatively few well controlled,
large-group exercise intervention studies in this area, and
those that have been published display considerable variety
in group sizes, intervention duration, exercise training
parameters (mode, intensity and volume [bout duration and
frequency]) and reported outcome measures. To address
this issue, several authors have conducted meta-analyses on
the available data, concluding that there is sufficient evi-
dence to support the use of exercise as a treatment
modality. A 2001 meta-analysis of 14 exercise intervention
studies involving a total of 504 subjects confirmed that
exercise training periods longer than 8 weeks had a sta-
tistically significant effect on HbA1c (mean HbA1c 0.66%
lower post-exercise intervention compared with control;
C. O’Hagan et al.
[15]). A later meta-analysis included a larger number of
studies, (27 studies, including all 14 included in the Boule
et al. meta-analysis [15]) with training studies being sub-
divided into aerobic training (17 studies, 622 subjects)
resistance training (6 studies, 202 subjects) and combined
training (5 studies, 251 subjects; [16]). The authors
reported that all three forms of training resulted in small
but clear improvements in HbA1c, and small to moderate
improvements in fasting glucose, postprandial glucose,
fasting insulin and insulin sensitivity. A 2008 Cochrane
review of exercise training studies involving people with
type 2 diabetes drew similar conclusions [17]. Employing
stringent inclusion criteria, this latter meta-analysis of 14
studies (377 subjects) supported the findings of the two
previous meta-analyses. A 2011 meta-analysis confined to
studies with HbA1c as an outcome measure confirmed
earlier findings, reporting a 0.67% decrease in HbA1c from
23 studies of structured exercise interventions [14]. A 1%
reduction in HbA1c has been associated with a 21%
reduction in risk of diabetic complications (microvascular
disease, stroke and myocardial infarction), and thus a
training-induced reduction of 0.66% can be considered
clinically significant [18]. Importantly, in three of the four
meta-analyses, the reduction in HbA1c was independent of
body weight changes, indicating that exercise can have
beneficial effects for people with type 2 diabetes without
concomitant weight loss [15–17]. The meta-analyses of
Snowling and Hopkins [16], and of Thomas and co-
workers [17] also sought to examine the moderating effects
of some study characteristics on outcome measures. A key
finding of the Snowling and Hopkins [16] review was that
there is a substantial influence of training programme
duration on HbA1c changes, with programmes longer than
12 weeks resulting in a mean HbA1c reduction of 0.8%,
compared with only 0.4% for those studies shorter than
12 weeks. In contrast, Thomas et al. reported a greater
change in HbA1c after shorter training studies (-0.8% for
periods shorter than 3 months, -0.5% for 3–12 month
studies). While Thomas and co-workers suggest that this
discrepancy may be accounted for by differences in exer-
cise intensity, training volume and patient compliance [17],
it is also important to note that the methods used in the two
meta-analyses differ with respect to pooling of aerobic,
resistance and mixed-exercise training programmes and, as
such, any comparisons must be made with caution. Such
variation in analytical approaches and results has important
implications for researchers designing studies in this area,
but also for clinicians, as it illustrates the difficulty of
prescribing exercise programmes based on currently
available literature. Most recently, Hansen and co-workers
[19] concluded in their review that the impact of training
frequency, duration or volume on clinical outcomes in type
2 diabetes is not yet clear.
 Prescription of Exercise Training in T2DM
Table I Published guidelines for the prescription of exercise in the treatment of type 2 diabetes mellitus
Guideline Prescription guidelines Specific recommendations
Type Intensity Frequency Duration Volume Progression

General treatment guidelines, no exercise recommendations

American Association of Clinical – – – – – – Aggressively implement all
Endocrinologists Medical Guidelines appropriate components of care
for Clinical Practice for the (medical nutrition therapy,
Management of Diabetes Mellitus [37] physical activity, weight
management regimen,
pharmacological interventions,
diabetes self-management
education) at the time of
diagnosis
American Association of Clinical – – – – – – Advise lifestyle modification
Endocrinologists Road Maps to
Achieve Glycaemic Control in Type 2
Diabetes Mellitus [35]
The Royal College of General – – – – – – Encourage increased physical
Practitioners and Diabetes UK; activity
Clinical Guidelines for Type 2
Diabetes [36]
General treatment guidelines, including exercise recommendations
International Diabetes Federation; – – 3–5 days/ 30–45 150 minutes/ – Introduce physical activity
Global Guidelines for Type 2 Diabetes week minutes week gradually. Advanced care could
[38] include exercise testing and
individualized testing and
education by exercise specialists
Diabetes Australia; Diabetes Aerobic 60–70% MHR, 3–4 days/ 30 minutes 150 minutes/ – Exercise professional included in
Management in General Practice [41] moderate week week care team
Institute for Clinical Systems Aerobic 50–70% MHR, 3 days/week – 150 minutes/ Start by incorporating
Improvement; Diagnosis and moderate week 10 min into each day
Management of Type 2 Diabetes and then progress to
Mellitus in Adults [42] meet guidelines

41
 42
Table I continued
Guideline Prescription guidelines Specific recommendations
Type Intensity Frequency Duration Volume Progression

Canadian Diabetes Association; 2008 Aerobic Moderate to 3 days/week – 150 minutes/ – Initial instruction and periodic
Clinical Practice Guidelines for the vigorous (50 % to week supervision by an exercise
Prevention and Management of [70% MHR) specialist are recommended
Diabetes in Canada [40] (resistance training). An exercise
electrocardiogram stress test
should be considered for
previously sedentary individuals
with diabetes at high risk for
cardiovascular disease who wish
to undertake exercise more
vigorous than brisk walking
Resistance Moderate 3 days/week – 1 set of 10–15 Start with one set of
progressing to repetitions 10–15 repetitions at
heavier weights moderate weight
Progress to 2 sets of
10–15 repetitions
Progress to 3 sets of 8
repetitions at heavier
weight
American Diabetes Association; Aerobic Moderate (50–70% – – 150 minutes/ –
Standards of Medical Care in Diabetes MHR) week
2011 [39] Resistance – 3 days/week – – –
Specific exercise guidelines
American College of Sports Medicine Aerobic Moderate (40–60% 3 days/week C10 min 150 min/week Gradual No more than two consecutive
and American Diabetes Association; (large _ 2max) to
VO days between bouts of activity
Joint Position Statement: Exercise and muscle vigorous
Type 2 Diabetes [43] group)
Resistance Moderate (50–80% 2–3 days/ – 5–10 Progressing to 4 sets of
1RM) to vigorous week (non- exercises, 1 8–10 repetitions
consecutive) set of 10–15
repetitions
American Diabetes Association; Aerobic Moderate to 3 days/week – 150 min or –
Consensus Statement: Physical vigorous (40-60%
Activity/Exercise and Type 2 Diabetes _ 2max or 50-70%
VO
[46] MHR) or
Vigorous ([60% 90 min

C. O’Hagan et al.
_ 2max or [70%
VO
MHR)
Prescription of Exercise Training in T2DM 43

3 Current Trends in Patient Engagement in Exercise

and periodic reassessments by a

Recommend initial supervision
Programmes

qualified exercise specialist

Specific recommendations

Despite the substantial body of evidence supporting the

beneficial role of exercise in the treatment of type 2 dia-
betes, it appears that patients are still not engaging in
sufficient physical activity. Between 1988 and 1994, the
Third National Health and Nutrition Examination Survey
(NHANES III) examined physical activity habits of 1,480
adults with type 2 diabetes in the US [20]. Only 31% of
respondents reported engaging in sufficient physical

Progress intensity and

activity to meet the minimum recommendations of the US
volume over initial
Surgeon General’s report, with a further 38% reporting
2–3 weeks of some physical activity but not enough to meet the recom-
programme
Progression

mendations and 31% self-reporting as inactive. In contrast,

among all adults surveyed, the corresponding figure for
self-reported inactivity was only 23% [21]. More recently,
–

similarly low levels of engagement in physical activity

rest 1–2 min

among people with type 2 diabetes were reported in two

_ 2max maximal oxygen consumption
repetitions,
150 min or

2–4 sets of

further large-scale studies that also reported lower physical

Volume

90 min

8–10

activity in people with type 2 diabetes compared with non-

diabetics. In the 2003 Scottish Health Survey of 8,148
–

adults, 58% of male and 74% of female people with type 2

repetitions

diabetes reported engaging in less than 30 minutes per

C10 min
Duration

3 sets of

30 min
8–10

week of physical activity but in the general population,

participation rates were significantly higher with only 36%
–

of men and 41% of women in this category [22]. Similarly,

3 days/week

3 days/week

3 days/week

of the 481,251 respondents surveyed between 2001 and

Frequency

3–7 days/

MAP maximal aerobic power, MHR maximum heart rate, RM repetitions maximum, VO

2005 for the Behavioural Risk Factor Surveillance System

week

survey from the Centers for Disease Control and Preven-

tion in the US, 5.9% self-reported as diabetic and only
39.7% of these people with type 2 diabetes met the
American Diabetes Association recommendations for
_ 2max
progressing to

physical activity. In contrast, 48% of the non-diabetic

40–50% VO

70% MAP
Moderate or
Prescription guidelines

population met the guidelines. Furthermore, while there

Vigorous
8–10RM

8–10RM
Intensity

was a significant trend for an increase in physical activity

among non-diabetics from 2001 to 2005, the same was not
seen in people with type 2 diabetes, with physical activity
Resistance

Resistance

participation remaining unchanged [23].

Aerobic

Aerobic
Type

Engagement in physical activity also appears to be lower

than adherence to other self-care behaviours in type 2
diabetes. The US-based TRIAD (Translating Research Into
l’Association de Langue Française pour
Training for Type 2 Diabetes Mellitus
American Heart Association; Exercise

l’Etude du Diabète et des Maladies

Métaboliques; Activité Physique et

Action for Diabetes) study analysed a range of self-repor-

ted health behaviours in 8,763 people with type 2 diabetes.
Only 46% of respondents reported taking part in regular
physical activity, but compliance with other health pro-
moting behaviours was significantly higher, with 68%
performing daily foot examination and 75% reporting daily
Table I continued

blood glucose self-monitoring [24]. The Diabetes Atti-

Diabète [44]

tudes, Wishes and Needs study of 5,104 patients across 13

Guideline

countries used a self-reported 1–4 scale to assess adherence

[45]

to ‘lifestyle recommendations’ (result: 3.06) and medica-

tion schedules (result: 3.48) [25]. While it is not possible to
44
interpret the clinical significance of this difference as no
supporting data is provided, the results are suggestive of a
similar trend to that observed in the TRIAD study. An
earlier WHO review of available data also suggested lower
adherence to physical activity recommendations than die-
tary advice or medication prescriptions [26].
As a result of this suboptimal engagement with exercise
in people with type 2 diabetes, the role of the physician in
advising or prescribing exercise has been examined. Of the
26,878 US adults surveyed for the 2002 Medical Expen-
diture Panel Survey, 1,972 self-reported as diabetic [27,
28]. While only 38% of diabetic respondents reported
taking part in moderate or vigorous physical activity three
or more times per week, 73% reported that they had been
advised by their healthcare professional to exercise more.
In the non-diabetic population, just 31% had received this
advice, yet 58% took part in regular physical activity.
Furthermore, no significant association was seen between
engagement in physical activity and physician advice to
take part. The trend for type 2 diabetic patients to receive
more physical activity advice than other adults was sup-
ported by the findings of the US National Health Interview
Survey and a survey of a sample population of Medicare
members in California [20, 29].
These large scale studies show that although healthcare
professionals do advise exercise for people with type 2 dia-
betes, often patients do not comply with this advice and par-
ticipation rates are low. The reasons for these discrepancies
are unclear, with several possibilities suggested: financial and
environmental barriers, time limitations, the physical limita-
tions imposed by secondary complications of type 2 diabetes
and co-morbidities, low self-efficacy and motivation, low
levels of family support and lack of patient understanding of
the benefits of exercise [26, 30, 31]. The role of healthcare
professionals’ support in promoting adherence has also been
examined. A review authored by Kirk and colleagues suggests
that specific physical activity consultations improve adher-
ence [32], while mixed-method studies of barriers to exercise
among people with type 2 diabetes highlighted a lack of
specificity in exercise advice given, and a perception of a low
priority of exercise as treatment [33, 34].
4 Existing Guidelines for Prescription of Exercise
in Type 2 Diabetes
Published guidelines for the management of type 2 diabetes
all include the common triad of medication, medical
nutrition therapy and engagement in physical activity.
These guidelines generally provide extensive discussion of
the evidence bases, mechanisms of action and recom-
mended dosage regimens for pharmacological therapies as
well as comprehensive recommendations for medical
C. O’Hagan et al.
nutritional therapy, but physical activity recommendations
are seldom afforded the same degree of promotion.
Table 1 outlines the range of published guidelines that
are currently available to practitioners. These guidelines
can be categorized into three groups: general management
guidelines with no specific exercise recommendations [35–
37], general management guidelines that do include exer-
cise recommendations [38–42] and statements or guide-
lines that specifically relate to physical activity or exercise
recommendations for type 2 diabetes [43–46].
While there are some differences in specific elements of the
prescription guidelines, most statements recommend that
patients accumulate 150 min of moderate to vigorous inten-
sity aerobic exercise each week [38–43, 45, 46]. Selected
guidelines provide detail on recommended session duration
[38, 43–45], frequency [38, 43–46], distribution [43] and
progression [43, 44], and several agencies also recommend a
programme of resistance training [39, 43, 45, 46].
It appears that the 150-min recommendation is drawn from
the traditional guidelines for health in the general population
(US Department of Health and Human Services Physical
Activity Guidelines for Americans [47] and the US Surgeon
General’s report [48]). The American Diabetes Association
and American College of Sports Medicine report that their
adoption of the US Surgeon General’s ‘150 minutes, moder-
ate intensity’ guidelines is based on the evidence presented in
the meta-analysis performed by Boule and colleagues [15],
which indicated that interventions which matched these
guidelines had beneficial effects on HbA1c [15, 39, 43].
These guidelines and statements provide a template for
the physician to suggest exercise training programmes to
the type 2 diabetic patient and, in many cases, adherence to
these recommendations may successfully ameliorate the
patient’s disease state. This traditional approach is gener-
ally aimed at producing improvements in cardiovascular
and muscular fitness and, thus, prevention of the develop-
ment of cardiovascular and other chronic diseases [47].
These changes are undoubtedly of benefit to the diabetic
patient, and may be accompanied by improvements in
HbA1c, the traditional marker of blood glucose control and
thus of the disease state. However, in many patients, HbA1c
targets are achieved through medication regimens and
therefore the beneficial effects of exercise on glucose
control may be masked. Furthermore, as type 2 diabetes is
characterized by disorders in overall substrate metabolism
and not only glucose control, it is likely that further ben-
efits could be gained from exercise programmes targeting
the pathogenic mechanisms at the origin of the disease.
Secondly, and perhaps critically, just as pharmacological
therapies and dietary modifications are individualized to
the patient, the same approach could be adopted for exer-
cise treatment, with the prescription of an individualized
programme for physical activity.
Prescription of Exercise Training in T2DM
5 Future Possibilities in Exercise Prescription
The current guidelines for the prescription of exercise in
type 2 diabetes discussed above are based on analysis of
the clinical outcomes of exercise intervention research
studies. However, it is important also to ensure the prac-
ticality of the prescribed programmes, particularly with
respect to patient compliance. As such, a parameter of
interest is exercise training intensity, as it has previously
been suggested that training intensity is inversely related to
adherence to prescribed programmes in sedentary [49] and
clinical populations [50, 51].
A comparison of low-to-moderate intensity (50% peak
oxygen uptake [VO _ 2peak]) and moderate-to-high intensity
(75% VO _ 2peak) training programmes in people with type 2
diabetes showed similar improvements in clinical out-
comes of low-density lipoprotein cholesterol, cardiovas-
cular fitness and skeletal muscle oxidative capacity from
both regimens, with no difference between groups [52].
Importantly, there was also no difference in improvements
in HbA1c, suggesting that the beneficial effects of exercise
training on glucose metabolism are not intensity dependent.
However, one recent study of acute exercise effects in
people with type 2 diabetes proposed a greater benefit of
low-intensity exercise; the authors found that a single low-
intensity exercise bout (35% maximal workload capacity)
reduced subsequent 24-h blood glucose more than a high-
intensity bout (75% maximal workload capacity), and also
decreased the prevalence of hyperglycaemic spikes [5].
As well as changes in glucose metabolism, people with
type 2 diabetes exhibit disturbances in lipid metabolism
during exercise relative to healthy, sedentary people [53,
54]. It has been suggested that in treating type 2 diabetes,
continuous exercise training at the intensity corresponding
to an individual’s maximal rate of fat oxidation (so-called
‘FATmax’ training), may result in greater improvements in
substrate utilization compared with traditional higher
intensities, where the principal benefits seen are in blood
pressure reduction and weight loss [55]. Programmes of
‘FATmax’ training for 4 weeks in obese healthy people
[56], 12 weeks in obese healthy males [57] and 10 weeks
in middle-aged men with type 2 diabetes [9] resulted in
improvements in lipid oxidation rates during exercise,
compared with higher-intensity training programmes. The
authors suggest that this may specifically relate to
increased oxidation of intramuscular triglycerides [9, 56],
the excess accumulation of which contributes to the
development of insulin resistance [58].
In parallel with this recent interest in low-intensity
continuous exercise, there has been an increased focus on
the use of low-volume, high-intensity interval training
(HIIT). While HIIT training was originally proposed as a
45
time-efficient method of cardiorespiratory training in
young healthy people, more recently it has also been pro-
posed for use in clinical populations [59–61]. While data
relating to the use of HIIT in people with type 2 diabetes is
limited, two recently published studies show beneficial
effects on glycaemic control after a single bout [62] and 6
bouts [63] of HIIT, suggesting that this may be a promising
line of investigation.
However, perhaps as important as consideration of
clinical benefits of differing exercise intensities in type 2
diabetes is the need to improve patient adherence. The
suggested inverse relationship between intensity and
adherence [49–51] could be used to support a shift towards
lower intensities of continuous aerobic training. Never-
theless, in a study involving young, healthy adults, HIIT
was reported to be more enjoyable than continuous aerobic
training, a finding which the authors postulate may result in
improved adherence [64]. ‘Lack of time’ is frequently cited
as a barrier to engagement in exercise in sedentary popu-
lations [65], and as it is likely that both time constraints and
low enjoyment of exercise contribute to low adherence in
people with type 2 diabetes, the benefits of low-volume,
high-intensity exercise programmes for this population
warrant further investigation.
Coupled with the need to develop exercise training
programmes that target specific metabolic outcomes in type
2 diabetes are the potential benefits of individualizing the
exercise prescription based on exercise test results. The
‘FATmax’ training protocols mentioned above rely on
matching prescribed training intensity (walking speed or
cycling power) for each patient to their optimal substrate
use; in contrast, traditional exercise prescription relies on
generalized heart rate zones or subjective ratings. While
this ‘one size fits all’ approach is suitable for large-scale
disease prevention programmes and health guidelines for
the general population, it is likely that patients will benefit
more from exercise programmes tailored to their own
disease status. Individualized prescription of exercise pro-
grammes based on laboratory exercise testing has long
been advocated in cardiac disease populations [66] and,
more recently, in chronic low back pain [67], fall-preven-
tion exercise programmes in the elderly [68], chronic heart
failure [69], spinal cord injured patients [70], hypertension
[71], chronic fatigue syndrome [72], fibromyalgia [73],
coronary artery disease [74] and cancer-related fatigue
[75], and has be shown to be effective in increasing aerobic
capacity in cancer patients [76], and exercise capacity in
cardiac rehabilitation [77]. In type 2 diabetes, individual-
ized prescription has been recommended [78–81] but the
proposed benefits have not yet been thoroughly investi-
gated. A small number of studies have investigated the
efficacy of this approach. Five months of individualized
46
mixed resistance and aerobic (high-intensity interval
training) training induced improvements in fasting blood
glucose, HbA1c and body composition in 11 people with
type 2 diabetes, although no control group (non-exercise or
non-individualized exercise prescription) was included in
this study [82]. In a 1-year study of obese, middle-aged
males with type 2 diabetes, twice weekly aerobic exercise
at the intensity of ventilatory threshold improved exercise
capacity and insulin resistance compared with non-exer-
cising controls [8]. However, in a study comparing an
individualized medical fitness prescription with generic
brisk walking, similar results were obtained in the two
groups [83], although high dropout figures for both arms of
the study suggest that a key element of any exercise pre-
scription may be continued supervision. This proposal was
substantiated by the results of a 2-year intervention from
the same researchers, who showed that prescribed but
unsupervised exercise programmes did not significantly
improve markers of disease state [84]. However, in this
study, the exercise prescription was ‘personalized’ based
on patient habits, preferences, motivation and ‘tolerance’
rather than a specific prescription describing exercise
duration, intensity and frequency based on clinical testing.
Thus, the initial evidence in this area is mixed, and further
work is required to establish whether individualized pre-
scription of exercise is more beneficial than prescription of
training based on general guidelines and, furthermore,
whether supervision of exercise is required.
If individualized exercise prescription is to be promoted,
due consideration must be given to the associated costs.
Successful exercise interventions in type 2 diabetes tend to
require intensive counselling and supervision from medical
or exercise professionals, with some of the success of these
programmes related to higher patient compliance than non-
supervised programmes. Regarding the implementation of
generalized or individualized prescriptions, the latter
requires initial and repeated laboratory testing that is
expensive and time consuming. However, current treat-
ment of diabetes and its associated complications is a
significant global economic burden. Previous studies have
estimated the daily healthcare cost for each diabetic patient
in France was $US15 in 2000, and $US36 in the US in
2002 [85–87]. Recently published estimates from the
International Diabetes Federation for 2010 are that the
international average annual expenditure for diabetes-
related healthcare costs is $US1,330 per patient; with
values of $US3,574 and $US7,382 for the UK and US,
respectively [88]. The estimated average percentage of
healthcare budget spend on the treatment of type 2 diabetes
and its complications is 12%, increasing to 21% in coun-
tries with a high prevalence of the disease [88]. While
evidence supporting the long-term cost-saving effects of
exercise interventions is sparse, a 1-year exercise
C. O’Hagan et al.
intervention of Brun and co-workers reduced hospital
admissions and medication use in people with type 2 dia-
betes, leading to estimated healthcare cost savings of 50%
[8]. Thus, while implementation of exercise programmes
may be expensive in the short term, the resultant delay of
disease progression and development of complications may
more than offset this initial outlay. An area of some current
attention is the use of financial incentives to leverage
greater adherence to treatment schedules in people with
chronic diseases. This approach has been successfully
implemented in smoking cessation programmes [89], and
has mixed results in weight loss programmes in obese
populations [90–92]. While research investigating the
possible health benefits and long-term financial viability of
incentive-based programmes in type 2 diabetes would be
welcome, due consideration must be given to the need to
promote adherence to guidelines for sustainable, long-term
lifestyle change, rather than short-term intensive exercise
programmes.
6 Conclusions
The benefits of exercise training in the treatment of type 2
diabetes are well established, but physician implementation
and patient engagement are low. Current guidelines for the
prescription of exercise as treatment in type 2 diabetics are
generic in nature, and most do not specifically target the
metabolic disturbances that contribute to disease progres-
sion and development of secondary complications. The
development of prescription guidelines that both target the
specific metabolic disturbances of the type 2 diabetes and
incorporate individualization of prescription for the
patients may improve adherence, improve clinical out-
comes and contribute to reducing the economic burden of
the disease.
Acknowledgements Funding sources, previous publication and
conflicts of interest: This review was supported by a grant from the
Irish Research Council for Science, Engineering and Technology.
This review has not been previously published and the authors have
no conflicts of interest that are directly relevant to the content of this
review.
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