EXERCISE TIPS FOR
PEOPLE WITH DIABETES
Ron Sigal, MD, MPH, FRCPC rsigal@ucalgary.ca
Professor of Medicine, Cardiac Sciences, Kinesiology &
Community Health Sciences,
Cumming School of Medicine, University of Calgary
Health Senior Scholar, Alberta Innovates-Health Solutions
Outline
How much exercise should people
with diabetes perform? Why?
 What are some new strategies to
reduce risk of exercise-induced
hypoglycemia (low blood sugar) in
people with type 1 diabetes?
 Why should people with diabetes
do strength training (resistance
exercise)?

I have no conflicts of interest to
declare
Acknowledgments
Operating support:



Canadian Institutes of Health Research
Canadian Diabetes Association
The Lawson Foundation
Salary support:



R. Sigal: Health Senior Scholar, Alberta
Innovates-Health Solutions
G. Kenny: University Research Chair,
University of Ottawa
B. Perkins and Jane Yardley: Canadian
Diabetes Association
Marni Armstrong, PhD Candidate
Author of slides with black background
Exercise

Planned, structured physical
activity.
Types of exercise
Aerobic exercise
 Exercise involving continuous, repeated
movements of large muscle groups.
 E.g. brisk walking, running, bicycling
Resistance exercise (strength training)
 Exercise involving weight lifting or
movement of muscles against
resistance
 E.g. exercise with free weights, weight
machines
Current Canadian Diabetes
Association (CDA) guidelines


At least 150 min/week of moderate to
vigorous aerobic exercise spread out
during at least 3 days during the week,
with no more than 2 consecutive days
between bouts of aerobic activity.
Resistance training at least twice per
week, and ideally 3 times per week, in
addition to aerobic training. Initial
instruction and periodic supervision by an
exercise specialist are recommended.
Sigal RJ et al, Can J Diabetes 2013; 37(Suppl 1):S40-S44.
Why 150 minutes of aerobic
exercise?
Why 150 minutes?
• 2008 US Physical Activity Guidelines Advisory Committee Report:
• For studies classifying subjects by energy expended, it appears that some
1,000 kilocalories per week or 10 to 12 MET-hours per week
(approximately equivalent to 2.5 hours per week of moderate-intensity
activity) or more is needed to significantly lower the risk of:
•
all-cause mortality
•
coronary heart disease
•
stroke
•
hypertension
•
type 2 diabetes
Evidence from trials in type 2 diabetes
Absolute changes in HbA1C of individual studies – structured exercise training vs. no
intervention, according to weekly amount of exercise
Umpierre, JAMA, 2011;
305, (17); 1790-99
Reduction of 0.89% in
HbA1C
Reduction of
0.36% in
HbA1C
Are resistance training and
strength clinically important?
Strength is clinically important
Biological aging: lose strength and
lean body mass
 Older patients with type 2 diabetes
have an accelerated decline in
muscle mass and strength when
compared with age-matched nondiabetic controls
 Strategies to maintain muscular
strength enhance mobility and
functional independence further
into old age are important

Strength is clinically important

Large long-term cohort study: bottom
tertile of strength was associated with:
 23% higher all-cause mortality
 32% higher cancer mortality
 29% higher heart disease mortality
Ruiz JR. BMJ 2008; 337:a439.
Ruiz JR. Cancer Epidemiol Biomarkers
Prev Med 2009;18(5):1468-1476.
Resistance training is
clinically important
Large long-term cohort study:
 Regular resistance training was
independently associated with
23% reduction in heart disease
risk…
 even after adjustment for age,
smoking, alcohol, diet, and all
other physical activity.
Tanasescu M. JAMA 2002; 288(16):1994-2000.
Tanasescu M. Circulation 2003;107(19):2435-2439.
Combined aerobic and resistance
exercise is probably best
The Diabetes Aerobic and
Resistance Exercise (DARE) Trial
RJ Sigal, GP Kenny, NG Boulé, RD
Reid, D. Prud’homme, M. Fortier, D.
Coyle, GA Wells
Funding:
Canadian Institutes of Health Research
Canadian Diabetes Association
Sigal RJ et al. Ann Intern Med 2007; 147:357-369.
DARE trial: Design
Randomized, controlled trial
 4-week pre-randomization run-in
period to assess compliance

Randomization to
 Aerobic Training only
 Resistance Training only
 Both Aerobic and Resistance
Training
 Waiting-list Control
Results: A1c (%)—changes over
time
Change from 0-6 mo.
Baselin 3 mo.
e
Combined
n=64
(40M,24F)
Aerobic
n=60
(39M,21F)
Resistanc
e
n=64
(40M,24F)
Control
n=63
(41M,22F)
6 mo.
Adj mean
(95% CI)
P-value
<0.001
7.46
6.99
6.56
-0.90
(1.48)
(1.56)
(0.88)
(-1.15 to -0.64)
7.41
7.00
6.98
-0.43
(1.50)
(1.59)
(1.50)
(-0.70 to -0.17)
7.48
7.35
7.18
-0.30
(1.47)
(1.57)
(1.52)
(-0.56 to -0.05)
7.44
7.33
7.51
+0.07
(1.38)
(1.49)
(1.47)
(-0.18 to +0.32)
0.002
0.018
0.57
HART-D: Health Benefits of Aerobic & Resistance
Training in Individuals with Diabetes Church T, JAMA. Nov 24
2010;304(20):2253-2262.
Intention-toTreat Analysis (n=262)
7.80
Control
7.70
HbA1c , %
7.60
Resistance
7.50
Aerobic
7.40
Combo
7.30
7.20
0
1
2
3
4
5
Month
6
7
8
9
Italian Diabetes and
Exercise Study
•606 patients with type 2 diabetes
and metabolic syndrome
•All received exercise counseling
•Randomized to control group
(usual care plus exercise
counseling) or intervention group
(prescribed and supervised
aerobic and resistance exercise
training) for 12 months
Balducci S et al, Arch Intern Med 2010
IDES: Supervised exercise was
superior for
HbA1c
 Systolic and diastolic blood
pressure
 BMI
 Waist circumference
 Aerobic fitness
 Muscle strength
 HDL cholesterol
 Estimated 10-year cardiac risk

What strategies can reduce
exercise-induced hypoglycemia in
type 1 diabetes?
Strategies to reduce risk of
hypoglycemia from exercise in T1DM
Adjust insulin.
 Adjust carbohydrate intake.
 Short (10-second) sprints before,
during or at the end of exercise.
 Perform resistance exercise
before aerobic exercise.

Short sprints

Interventions involving anaerobic
activity (short sprints) have shown
some promise for avoidance of
hypoglycemia
http://www.sevenseeds.org
3
Acute effects of short
sprints
10-sec sprint at end of
exercise
4-sec sprint every 2 minutes
Intermittent sprint
group
10-sec sprint
group
From Bussau, VA et al. Diabetes Care 2006; 29: 601-6.
4
From Guelfi, KJ et al., Diabetes Care 2005; 28(6):1289-94.
10-second sprint at
beginning of exercise
10-sec sprint group
Bussau VA et al, Diabetologia 2007
Strategies to reduce risk of
hypoglycemia from exercise in T1DM
Adjust insulin.
 Adjust carbohydrate intake.
 Short (10-second) sprints before,
during or at the end of exercise.
 Perform resistance exercise
before aerobic exercise.

Jane Yardley, PhD
Design
• Participants performed five exercise sessions in
random order followed by 1 hour of monitored
recovery separated by at least 5 days:
1) No exercise (45 minutes seated resting)
2) Aerobic exercise (45 minutes treadmill running at
60% VO2peak)
3) Resistance exercise (3 sets of 8 repetitions (8RM))
4) Aerobic then resistance exercise
5) Resistance then aerobic exercise
7
Participants
N
Age (yrs)
Ht (m)
Wt (kg)
BMI (kg/m2)
VO2peak (L/kg · min)
10
12 (10 male, 2 female)
31.8 15.3
1.77 0.07
79.2 10.4
25.3 3.0
51.2 10.8
Hemoglobin A1c (%) 7.13
1.1
Diabetes Duration
12.5
10.0
Insulin delivery
MDI = 5, insulin pump = 7
Aerobic exercise vs. resistance exercise vs.
control
Yardley JE, Kenny GP, Perkins BA, Riddell MC, Balaa N, Khandwala F,
Malcolm J, Boulay P, Sigal RJ. Resistance versus aerobic exercise:
acute effects on glycemia in type 1 diabetes. Diabetes Care 2013
Mar;36(3):537-542.
11
Aerobic vs. resistance exercise
Control
Resistance
Aerobic
◊ - control
● - aerobic exercise
Δ - resistance exercise
12
a – significant change from baseline (aerobic)
b - significant change from baseline (resistance)
c – significant difference between aerobic & control
d – significant change throughout recovery (aerobic)
Resistance-then-aerobic (RA)
vs. aerobic alone (A)
Presented as an oral abstract at the 2011
CDA/CSEM National Conference:
Yardley JE, Kenny GP, Perkins BA, Riddell M,
Malcolm JS, Sigal, RJ. Declines in Blood
Glucose During Aerobic Exercise are
Attenuated by Prior Resistance Exercise. Can
J Diabetes (Suppl.), 2011.
16
Resistance-then-Aerobic
vs. Aerobic only
● - resistance then aerobic exercise
○ - aerobic exercise alone
17
* - significant change from baseline
† - significant change throughout recovery
Resistance then Aerobic (RA) vs.
Aerobic then Resistance (AR)
Yardley JE, Kenny GP, Perkins BA, Riddell MC,
Malcolm J, Boulay P, Khandwala F, Sigal RJ.
Effects of performing resistance exercise
before versus after aerobic exercise on
glycemia in type 1 diabetes. Diabetes Care.
2012 Apr;35(4):669-75.
20
Resistance then Aerobic (RA) vs.
Aerobic then Resistance (AR)
RA
AR
● - resistance then aerobic exercise
○ - aerobic then resistance exercise
21
* - significant change from baseline
† - significant difference between treatments
§ - significant change throughout recovery
Summary: acute effects of aerobic and
resistance exercise in T1DM
In physically-fit individuals with type 1 diabetes
with good glycemic control:
• Resistance exercise on its own was
associated with less acute glucose-lowering
and a lower need for supplemental glucose
than aerobic exercise on its own
• In sessions combining aerobic and resistance
exercise, performing resistance exercise prior
to aerobic exercise decreases the need for
carbohydrate intake during exercise and may
reduce the risk of exercise-induced
hypoglycemia during aerobic exercise.
How important is it to avoid
sedentary behaviour?
Sedentary Behavior
Canada Fitness Survey of 1981: 7278 men and 9735 women,
aged 18–90 yr
Cumulative Survival, %
Daily Sitting Time
Katzmarzyk, MSSE,
2009 41(5):998-1005
Follow-up years
Age Adjusted All Cause Death Rate per 10,000 person years
Canada Fitness Survey of 1981: 7278 men and 9735
women, aged 18–90 yr
Katzmarzyk, MSSE,
2009 41(5):998-1005
Back to strength training…

Resistance training (strength
training) is recommended for
people with diabetes, but
participation rates are low.
Cost of gym membership.
 Travel to gym.
 Discomfort with gym
environment.

Could training with resistance
bands be the solution?
Resistance bands training
(vs. gym-based training)
Much lower costs.
 Greater feasibility of home-based
training.
 Greater ease of supervising
multiple participants at the same
time.
 However, clinical trial data on
resistance bands training are
limited.

DARE-Bands trial:
Main research questions
To compare the effects of 24 weeks of
 Aerobic training only
 Aerobic training plus resistance bands
training
…on strength, hemoglobin A1c (A1C), and
other outcomes, in men and women aged
> 35 years with type 2 diabetes.
Supported by the Lawson Foundation
DARE-Bands study: other
outcomes
BMI, waist and hip circumferences
 Lipids
 Blood pressure
 Quality of life: SF-36, EuroQOL
EQ-5D-5L, Diabetes Distress Scale
 Changes in medications
 Satisfaction with the exercise
program

Aerobic training
Same in both groups. All
participants have an exercise
program.
 Progress to 150 minutes/week of
walking.
 Activity monitored by
downloadable MyWellness Key
accelerometers (Technogym,
Cesena Italy).

Resistance Band Training
(RBT)
12 resistance bands exercises.
 Photographs and YouTube videos of each
exercise are available.
 Use of 8 progressive colour-coded
resistance bands, in combination when
necessary, to achieve required intensity.
 Training 3 times per week

Resistance Bands Training
(continued)


Gradual increase in intensity (colour of band,
multiple bands when necessary) and volume
(number of sets)
Group sessions weekly in weeks 1-4, every 2
weeks in weeks 5-8, every 2-4 weeks thereafter.
Who qualifies?
Type 2 diabetes, age 35-75.
 Not taking insulin.
 Not already exercising 150
minutes or more per week.
 No recent resistance exercise
training.

Are you potentially interested in
participating in the DARE-Bands
trial?
Samantha McGinley, MSc,
Research Coordinator.
exercise@ucalgary.ca
403-955-8117