Table 2.

Summary of ACSM evidence and ADA clinical practice recommendation statements

	ACSM evidence and ADA clinical practice recommendation statements	ACSM evidence category (A, highest; D, lowest)/ADA level of evidence (A, highest; E, lowest)
Acute effects of exercise	• 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.	A/*
	• Insulin-stimulated BG uptake into skeletal muscle predominates at rest and is impaired in type 2 diabetes, while muscular contractions stimulate BG transport via a separate, additive mechanism not impaired by insulin resistance or type 2 diabetes.	A/*
	• Although moderate aerobic exercise improves BG and insulin action acutely, the risk of exercise-induced hypoglycemia is minimal without use of exogenous insulin or insulin secretagogues. Transient hyperglycemia can follow intense PA.	C/*
	• The acute effects of resistance exercise in type 2 diabetes have not been reported, but result in lower fasting BG levels for at least 24 h postexercise in individuals with IFG.	C/*
	• A combination of aerobic and resistance exercise training may be more effective in improving BG control than either alone; however, more studies are needed to determine whether total caloric expenditure, exercise duration, or exercise mode is responsible.	B/*
	• Milder forms of exercise (e.g., tai chi, yoga) have shown mixed results.	C/*
	• PA can result in acute improvements in systemic insulin action lasting from 2 to 72 h.	A/*
Chronic effects of exercise training	• Both aerobic and resistance training improve insulin action, BG control, and fat oxidation and storage in muscle.	B/*
	• Resistance exercise enhances skeletal muscle mass.	A/*
	• Blood lipid responses to training are mixed but may result in a small reduction in LDL cholesterol with no change in HDL cholesterol or triglycerides. Combined weight loss and PA may be more effective than aerobic exercise training alone on lipids.	C/*
	• Aerobic training may slightly reduce systolic BP, but reductions in diastolic BP are less common, in individuals with type 2 diabetes.	C/*
	• Observational studies suggest that greater PA and fitness are associated with a lower risk of all-cause and CV mortality.	C/*
	• Recommended levels of PA may help produce weight loss. However, up to 60 min/day may be required when relying on exercise alone for weight loss.	C/*
	• Individuals with type 2 diabetes engaged in supervised training exhibit greater compliance and BG control than those undertaking exercise training without supervision.	B/*
	• Increased PA and physical fitness can reduce symptoms of depression and improve health-related QOL in those with type 2 diabetes.	B/*
PA and prevention of type 2 diabetes	• At least 2.5 h/week of moderate to vigorous PA should be undertaken as part of lifestyle changes to prevent type 2 diabetes onset in high-risk adults.	A/A
PA in prevention and control of GDM	• Epidemiological studies suggest that higher levels of PA may reduce risk of developing GDM during pregnancy.	C/*
	• RCTs suggest that moderate exercise may lower maternal BG levels in GDM.	B/*
Preexercise evaluation	• Before undertaking exercise more intense than brisk walking, sedentary persons with type 2 diabetes will likely benefit from an evaluation by a physician. ECG exercise stress testing for asymptomatic individuals at low risk of CAD is not recommended but may be indicated for higher risk.	C/C
Recommended PA participation for persons with type 2 diabetes	• Persons with type 2 diabetes should undertake 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.	B/B
	• In addition to aerobic training, persons with type 2 diabetes should undertake moderate to vigorous resistance training at least 2–3 days/week.	B/B
	• Supervised and combined aerobic and resistance training may confer additional health 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.	B/C
Exercise with nonoptimal BG control	• 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.	C/E
	• 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.	C/C
Medication effects on exercise responses	• 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.	C/C
Exercise with long-term complications of diabetes	• 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.	C/C
	• 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.	B/B
	• 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.	C/C
	• Individuals with uncontrolled proliferative retinopathy should avoid activities that greatly increase intraocular pressure and hemorrhage risk.	D/E
	• 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.	C/C
Adoption and maintenance of exercise by persons with diabetes	• 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.	B/B

*No recommendation given.