Jerry Batschi, Talon Allen, Emily Crapse, Blaine Gustafson, Kelly Johnson

ESS 465
M-F 12:45
Acute effects of exercise on blood glucose levels in type 2 diabetics

The glucose regulatory system in the human body is a sensitive yet highly effective system. In a
normal non-diabetic, the system is regulated mainly by hormonal changes in the body. As plasma
glucose levels rise above the normal, the pancreas is stimulated to release insulin which, in the
average individual, will effectively lower the levels of glucose in the blood by causing glucose
receptors to come to the cell wall. Conversely as blood glucose levels drop below normal the
pancreas will secrete glucagon which in turn will cause the liver to produce glucose. The main
tissue that is responsible for regulating the glucose levels in the body is skeletal-muscle.
However, in people who have type 2 diabetes, the body does not adequately respond to the
insulin. As the body builds intolerance to insulin it will begin adapting to fulfill its need for fuel.
With the understanding that skeletal muscles are the tissue in the body that helps decrease blood
glucose levels the most, it would be beneficial to look at what changes glucose uptake into these
cells. Because glucose cannot diffuse freely across the plasma membrane it must be transported
across. Of the transporters that move glucose the GLUT 4 protein is the most common. The
GLUT 4 glucose transporters are located intracellular and need to be brought to the plasma
membrane. Insulin binds to receptors on the cell wall and starts a chain reaction that causes this
relocation to occur. Another method for this relocation is through exercise, although the
mechanism for how this occurs is still uncertain (1, 2). As mentioned earlier, type 2 diabetics
have a reduced sensitivity to insulin, therefore, they also have impaired glucose uptake into the
muscles. Thus they must rely on other means, mainly exercise, diet, or medication to regulate
their plasma glucose levels. This paper will look at the acute effects of different intensities,
frequencies, duration, and types of exercises to find which would be most beneficial in the short
term for improved glycolytic regulation in type 2 diabetics.

Intensity
Low Intensity (LI), Moderate Intensity (MI), Vigorous or High Intensity (HI). Refer to table 1.1 above for the
definition of intensities:

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On average, considering the overall fitness level, type 2 diabetics tend to be overweight and
sedentary. It has also been shown that individuals with non-insulin-dependent diabetes have a
significantly lower VO2 maximum than matched individuals (3).This would make it difficult or
unlikely for them desire to do very vigorous exercise for a very long time. As exercise intensity
increases, muscle glucose stores become depleted more rapidly within activated skeletal muscles
cells.
In a 2 week study done with 12 men, (6 obese within the control group; 6 obese non-insulin
dependent diabetes mellitus NIDDM within the treatment group) a significant increase in muscle
glycogen utilization was found with a higher intensity of 70% VO2max for 50 minutes when
compared to moderate intensity of 50% VO2max for 70 minutes regardless of equal caloric
expenditure. Both exercise regimens showed an increase in muscle glycogen utilization for both
the obese subjects (59 9 g (HI) vs. 30 7 g (LI)) and the obese NIDDM subjects (48 5 g (HI)
vs. 24 5 g (LI)). One day before and after the exercise intervention oral glucose tolerance test
(OGTT) was administered with samples being taken every 30 minutes. There was a significant
(p<.05) decrease in insulin concentrations and insulin response 60 minutes into the OGTT after
the 70% exercise intervention. With the decrease in insulin also came a decrease in the insulin
response area from 9605+/-1783 to 7538+/-1522 which is a 22 percent drop. This study showed
results that a HI exercise produced greater benefits that a MI exercise even when caloric
expenditure was equal. (4).
In another study done nine sedentary male type 2 diabetic patients (57 2 yr, body mass index =
29.0 1.0 kg*m^-2, Wmax = 2.2 0.2 W*kg^-1 body weight) showed a prevalence in a
decrease in hyperglycemia (50% 4% (P < 0.05) and 19% 9% (P = 0.13)) in the LI and HI
exercise trials, respectively (5). Subjects of this study performed a single bout of endurance-type
exercise for 60 minutes at 35% Wmax (LI) one day and for 30 min at 70% Wmax (HI) on
another day; glucose concentrations were reduced within 24 hours after the LI exercise bouts
(7.8 T 0.9 mmol*L^-1; P < 0.05) as opposed to the HI exercise bouts in which no significance
was found in decreased glucose concentrations (8.7 T 0.7 mmol*L^-1; P = 0.14), (5). These
results are caused by an excess hepatic glycogen breakdown in response to excess glucose
depletion in HI exercise bouts with an inability for cells to uptake glucose because of
dysfunctional mechanistic steps within the insulin-mediated pathway single HI bouts
counterbalancing the bodys attempt towards glucose homeostasis. Isolated LI bouts prove to be
the healthiest approach towards glucose control and homeostasis according to the studies and
statistical data provided previously, when compared to isolated HI bouts.
As HI exercise bouts are performed consistently and on consecutive days for more than one day
in a row, an increase in hepatic glycogen resynthesis rates are found to clear the excess glucose
concentration within the blood by suppression of hepatic glucose production and distribution, as
is supported by a one week study done on 14 overweight or obese, diabetic volunteers (11 men, 3
women, age 64 2 yr, BMI 31.9 2.2 kg/m^2). The 14 patients performed 30 minutes of
cycling and 30 minutes of walking on the treadmill daily, for seven consecutive days, resulting in
a significant hepatic glucose production suppression, both after training and during resting
conditions (Glucose concentrations after training, before and after study: 1.15 0.41 vs. 0.46

0.20 mgkg1min1, P = 0.03; Glucose concentrations at rest, before and after study: 3.17
0.43 vs. 2.54 0.26 mgkg1min1, P = 0.05), respectively; proposing improvements with both
an increase in insulin sensitivity and responsiveness and hepatic glucose production suppression
(6). Type 2 Diabetic patients generally experience muscle weakness, cardiovascular
complications, and reduced exercise tolerance making it difficult in their ability to cooperate,
engage and dependably maintain higher-intensity exercise programs for the treatment and control
of Type 2 Diabetes, resulting in lower adherence and higher dropout rates. (5, 7). For this reason
alone, many studies available today suggest moderate to lower intensity exercises performed
daily on more than 1 consecutive days as a preferred source of therapeutic treatment for Type 2
Diabetes Mellitus.
In a 9 week done with 9 postmenopausal women (55 7 years), a combination of both aerobic
and strength training together were determined to be the most potent in the treatment of Type 2
Diabetes. In this study, aerobic exercise was performed at 60% VO2max for 75 minutes every
Monday and Thursday, while resistance training was performed at 70% VO2max for 60 min,
resulting in signicant improvements of glucose regulation, tolerance and concentration (8.1%
p<0.01), increase in endurance capabilities, increase in muscular strength, and an increase in
insulin sensitivity (20.7% p<0.05), (8). In a similar study with 20 men and 20 women (40-70
years), half of the participants performed aerobic training at 60-65% MHR, while the other half
performed 30 minutes of resistance training (3 sets of 10 beginning at 30-50%) at 70-80% MHR;
training was performed 3 days out of the week for 9 weeks. The study resulted in a significant
increase in insulin sensitivity of 30% for the aerobic MI group and only 15% in the resistance HI
group, (P= 0.004), (9).
Although MI aerobic training has been shown to significantly increase insulin sensitivity, it is by
resistance training performed at a HI where molecular changes, overall, are determined to be
more potent in glucose control and regulation and insulin sensitivity in a more substantial and
permanent, long lasting way, as was found in a 9 week study on the effects of exercise on GLUT
4 receptors in Type 2 Diabetic patients. For 6 days per week, 30 minutes a day, at 75% VO2
max, a significant increase was found in GLUT4 protein and GLUT4 mRNA content (to 0.43
0.03, and 0.57 0.08 arbitrary units; (P < 0.05)), respectively, (10). Another 2 week study
further explored the difference between a 60 minute isolated HI exercise bout compared to 7
consecutive 60 minutes/day HI exercise bout and its therapeutic effect on Type 2 Diabetes. The
results of this study concluded with an increase in Hexokinase production (After 1 day, 1.2 3;
After 7 days, 1.4 3, arbitrary units; (P=<0.05)), an increase in a Hexokinase Phosphorylation
activity (After 1 day, 1.2 1; After 7 Days, 1.3 3, arbitrary units; (P=<0.05)) and an increase in
GLUT 4 protein production (After 1 day, 1.0 1; After 7 days, 1.7 1, arbitrary units; (P=
<0.05)), (11).
It has been shown that bouts of LI to MI exercise allows for even, healthy blood flow, for an
increase in personal health condition and benefits, an increase in weight loss, a decrease in
cardiovascular complications, an increase in glucose delivery to peripheral muscles cells, and an
increase in glucose uptake through an increase in insulin-induced translocation of GLUT4 to the
cell surface (P = <0.05), allowing for greater glucose entry into the cell for a healthier body as a
whole, (7, 11, 9). For the greatest health benefits, adding HI exercise at least 2 times per week,
in between days of LI to MI exercise bouts performed, will increase hexokinase production and
activity, will increase GLUT4 production,and will increase strength capabilities, (P = <0.05), (8,

5, 5, 11, and 12), proving the greatest therapeutic response towards recovering from Type 2
Diabetes Mellitus and its unstable glycemic properties.

Frequency
In an attempt to better understand the use of exercise in controlling type 2 diabetes frequency has
been studied to determine the role it plays in controlling blood glucose levels. In the studies
looked at, the frequency of exercise varied anywhere from 1 bout to 7 consecutive days of
exercise in a week period. Some studies evaluated the effect of exercise over a 24 hour time
period while others evaluated a frequency of 3 days/week. In a study that evaluated the effect of
progressive resistance training on older Latino adults exercising 3-days/week, the baseline
fasting plasma glucose concentrations of the progressive resistance training group (PRT) and
control group started out at 8.8 mmol/L and 9.7mmol/L respectively, while the final glucose
concentration for the PRT and control group was 7.9 mmol/L and 8.9 mmol respectively with a P
value of > 0.34. The results of the study showed that exercise three days a week did show
significant benefits to those with type 2 diabetes. (13)
In another study the effects of weight training was evaluated on subjects that exercised 3
days/week for 50 min per session for about 6 weeks. The subjects performed 8 different
resistance exercises involving the abdominal region and 3 sets of crunches. The subjects started
out at 80% of their 3-RM, then did 12 reps with an incremental increase of 5 lbs. Pre exercise
fasting blood glucose levels were 9.5+/-2.3 and 9.4+/-2.1 for the Resistance training and the
weight loss control group. Post exercise fasting glucose levels were 9.0+/-2.3 and 10.3 +/-2.5 for
the resistance and the control groups respectively. Insulin sensitivity also changed slightly, but
like the change in fasting glucose levels they did not reach significance (p>.05) Again this study
also showed that 3 days a week did not produce significant benefits to glycemic control. (14)
In contrary to the first to study of three days a week, IL.M. Fenicchia et al. found significant
benefits in their study. During the study that looked at blood glucose levels in women with type 2
diabetes the subjects did resistance training for 3 nonconsecutive days/week for a period of 6
weeks. The pretraining area under the curve was 3,355.0 324.6 mmol/L*min and after an acute
bout of exercise it decreased to 2,868 324.0 mmol/L*min. However the pretaining did not
improve in chronic training with a decrease of only 149 mmol/L*min. The study had a
significance of <0.01. (15)
In a study where the subjects did aerobic exercises for 7 days, the subjects exercised at 60-75%
HR reserve with alternating sessions on a walking treadmill and stationary cycle for 20 min. The
minimum blood glucose for the control was 3.6 0.3 mmol/L for the control and 4.0 0.2
mmol/L for the diabetic group. The maximum blood glucose for the control was 13.6 1.2
mmol/L and 10.9 0.8 mmol/L for the diabetic group. In comparing measured fasting blood
glucose levels between resistance training and weight loss (RT and WL) vs just weight loss
(WL) there was a -0.6 mmol/L difference for RT and WL in 3 months and a -0.8 mmol/L
difference for WL. (16)

Stephan F. Praet et al. (4) conducted a study in which during a 48 hour time period subjects did a
5 min warm up on a bicycle ergometer, 10 reps were then done with exercises that targeted the
upper body followed by 2 sets of 20 alternating lunges. After the warmup the participants did leg
press and knee extension exercises. All exercises were done at 50% of their 1-RM and were
performed for about 45 min. The mean glucose levels over a 24 hour period did not differ
between a pre exercise test and a post exercise test with levels being 8.5+/- .4 and 8.1+/-.4
(mmol/L) respectively. One benefit to this exercise was it decreased the length of hyperglycemic
episodes significantly (7.6+/-1.4hours pre vs. 4.6+/-1.1hours post) (17)
In a walking study, it was evaluated on how walking affects blood glucose levels. In a single
bout of exercise the subjects walked a total of 1.6 miles without gradients. The walking exercise
caused a decrease in blood glucose levels by -2.2 mmol/L from 10.5 mmol/L with a p value of <
0.001. (18).
In another study the subjects were divided into normal and offspring, they exercised 4
times/week over a period of 6 weeks. The subjects used a stair-climbing machine at 65% of their
maximum aerobic capacity with a 5 min warmup and cool down. The rates of whole-body
glucose metabolism increased by 22 percent in the offspring and 27 percent in the normal
subjects after the first exercise session. The total increase from baseline, after six weeks of
exercise training, was 42 percent in the group of offspring and 38 percent in the normal group.
It found significance by having a p-value of <0.001. (19)
In an article 7 NIDDM men and 7 healthy men exercised on a one-legged ergometer bicycle for
9 weeks, 6 days/week, and 30 min/day. The GLUT 4 mRNA was always lower in the NIDDM,
but increased in both groups. The fasting blood glucose levels did not change throughout the
study, but was always higher in the NIDDM group. The study concluded that exercising at this
intensity and frequency can increase the GLUT4 mRNA content of both groups however, acute
exercise does not increase GLUT4 mRNA. A p-value of < 0.05 was determined. (20)
In the studies looked at there were differences in the blood glucose levels after exercise, but the
differences were not large, usually 2-3 mmol/L at most. Frequency is important in an exercise
program, but the total amount of time exercising in the week is more important than the
frequency of the exercises. In a single bout the glucose levels often decrease, but returns within a
24 hour time period. Single bouts arent as effective as 4-5 days/week because a single bout isnt
consistent or over a longer period of time.

Duration
While doing research on duration there were many times that correlations were found between
the length of time exercised, the intensity, and how many times per week exercise was
performed. The majority of the studies chose to do a duration of 60 minutes, others had durations
of: 50 minutes, 70 minutes, 45 minutes, 30 minutes, and 25 minutes.

Rogers et al. performed a 1 week study in which the participants exercised for 60 minutes at
moderate intensity (60-68% VO2 max). During exercise, the participants either walked at 60%
VO2max, or biked at 68% VO2 max. The study found that exercising for 60 minutes showed a
significant decrease in their oral blood glucose test, with the before values at 227 +/- 23 mg/dL
and 170 +/- 18 mg/dL after [p < 0.001]. The study also showed that there was a decrease of 36%
in the area under the glucose tolerance curve. Rogers also did testing after a single bout of
exercise and showed it did not have any improvement in glucose tolerance. (21)
Dijk et al. conducted a study which compared the differences in 30 minutes every day to 60
minutes every other day. Each bout of exercise was performed at 60 percent of the participants
VO2 max. This study found that the subjects who performed the daily 30 minute and 60 minute
exercises showed decreases in hyperglycemia the next day from 7:40+/-1:00 h:min to 5:46+/0:58 and 5:51+/-0:47 respectively [p<0.01] and showed that the total work done between the two
groups was equal in improving the glycemic control. (22)
Holten did a study that consisted of 17 total patients who trained one leg 3 times a week, for only
30 minutes each training session. The workloads varied as time increased, going from 50% of
1RM to allowing failure between reps 8-12 during the last two weeks. The results of this study
showed an increase in blood glucose clearance in the trained legs of both the control group and
the diabetes group [ P < 0.05 ]. The glucose clearance rates between clamp step 1 and 2 in the
trained legs decreased in type 2 diabetics compared to the control group [ P = 0.041 and 0.002
respectively stage 1, and P = 0.002 and P < 0.001 stage 2 clamp]. (23)
Dela performed a study to determine if exercise would cause an increase in GLUT4 transport
protein. The exercise consisted of one legged bicycle ergometer training that was performed six
days per week, for 30 minutes each day. Before the study, the GLUT4 content was measured and
found to be 0.43+/- 0.03, 0.40+/- 0.03, and 0.41+/- 0.03 arbitrary units in the NIDDM, control,
and young group respectively, and it increased to 0.43+/- 0.03, 0.40+/- 0.03, and 0.57+/- 0.08
[P< 0.05]. This study showed that training would cause in increase in GLUT4 protein in both
subjects with non-insulin-dependent diabetes mellitus and those in the control group due to
exercise. (24)
Another study published by Winnick et al. showed that performing two 25 minute bouts of
aerobic exercise with a 10 minute break in between had a significant effect on insulin sensitivity
if the dosage was high. During exercise training, the subjects performed the two 25 minute bouts
of exercise on a treadmill walking at 70% of the subjects VO2 max. They performed this on days
1-3, and 5-7 over a one week period. On day 4, the subjects exercised for 60 minutes at 60% of
their age predicted heart rate max. This results of this study showed that performing 25 minute
bouts of exercise with a break in between did not increase blood glucose sensitivity. It did cause
in increase in whole body insulin sensitivity when high doses of insulin was used after exercise
with pre intervention values at 0.12 +/- 0.02 mg/kg*min and 0.09 +/- 0.03 mg/kg*min, compared
to 0.16 +/- 0.03 mg/kg*min after exercise [P < 0.05] (25)
Although there are some studies that have shown changes in blood glucose and sensitivity by
performing 30 minutes of exercise three times each week, the recommendation that is most
evident based on the articles reviewed is exercising for a duration longer than 150 minutes each

week, preferable at least 50-60 minutes for each exercise period, at any intensity seems to have
the greatest impact and gives the greatest result in causing an increase in glucose and insulin
sensitivity in Type 2 diabetics.

Mode of exercise (type)

There are many different type or modes of exercise with each type having its own strengths and
weaknesses. Types of exercises have the greatest benefits for a type 2 diabetic. Ishii, T. et al. (26)
conducted a study in which there were two groups in which the participants were divided:
resistance with machine or free weights and a control which was sedentary. The resistance group
exercised 5 times a week with free weights doing push ups, sit ups, military press, heel raises,
knee extensions, back extensions, squats, and upright rows. A mix of these exercises were
performed at 40-50 percent of their one repetition maximum. Test were taken before the study
and 2 days after the last bout of exercise. To test for insulin sensitivity a hyperinsulinemiceuglycemic clamp was used. After the exercise intervention the glucose disposal rate increased
48 percent from 10.12+/-3.15 mg kg-I lean body mass x min^sup -1 to 6.85+/- 1.86 mg x kg^sup
-1^ lean body mass x min^sup -1. This change was significant with a p value less than 0.05. The
results of this article show that resistance training can improve the glucoregulatory system.
In 2005 Ibanez, Javier et al. (27) conducted a study which showed resistance training to be an
effective method for improving glycemic control while increasing insulin sensitivity and
decreasing fasting glucose levels. Nine men with an average age of 66 years with type 2 diabetes
participated in a 16 week progressive resistance training program. Each participant exercised
twice a week with two days in between each session. Each session included two exercises for leg
muscles, one exercise for arm muscles and four or five exercises for the other main muscle
groups. Only resistance machines were used. For the first eight weeks, participants trained at 5070% of their 1-RM and 10-15 repetitions per set with four sets of each exercise. The second eight
weeks modified 20% of the leg exercises to range from 30-50% of the maximum load.
Repetitions now ranged from 6-8 for 3-4 sets of each exercise. As total abdominal fat decreased
with a p value of .01, insulin sensitivity increased with a p value .001. There seems to be a
correlation between abdominal fat with insulin sensitivity and resistance training
Most increases with insulin sensitivity and glucose disposal rate came from participants who
exercised aerobically and those who combined aerobic training with resistance training. In 2004
a study (28) set to analyze the effects of resistance and aerobic training programs on insulin
sensitivity compared with aerobic training alone. This study was conducted on 28
postmenopausal women with type 2 diabetes over the course of 16 weeks. Between the
combined exercise group and the control group there was a significant difference in raising the
steady-state plasma glucose levels (P<0.05).
A study comparing aerobic training and resistance training by Elisabetta Bacchi (29) assessed the
differences in the effects of each type of exercise. 40 type 2 diabetic participants were randomly
assigned to either training group. Before and after 4 months of training, oral glucose tolerance
tests were given, body composition via dual-energy X-ray absorptiometry, adipose tissue by
means of magnetic resonance imaging and glucose clamp-measured insulin sensitivity were
measured. Both groups exercised for 4 months, 60 mins per week three times a week at a fitness

center. After the learning period for the AER group the workload was gradually increased to 6065% of RH. The RES group exercised on free weights and weight machines alternating from
lower body, upper body, and core exercises using nine different exercises. Participants exercised
with three series of 10 repetitions on each machine at roughly 45% 1-RM and gradually
increased to roughly 75% 1-RM. Glucose disposal rate went from 0.22 and 0.01 to 2.07 and 1.05
for aerobic and resistance respectively. This was statistically significant having a p value of
0.006. Aerobic training versus resistance training alone had a much greater effect on Glucose
disposal rate.
Ronald J. Sigal, in 2007 assigned 251 type 2 diabetic participants from 39 to 70 years of age to
one of four exercise groups: resistance training, aerobic training, combined resistance and
aerobic training or a control group that reverted to prestudy exercise levels (30). For the course
of 26 weeks participants exercised 3 times a week. Aerobic training progressed from 15-20
minutes at 60% of maximum heart rate to 45 minutes at 75% of maximum heart rate. Resistance
training performed seven different exercises on weight machines beginning with 2-3 sets at
maximum weight 7-9 times. The combined aerobic and resistance group completed the full
aerobic training program and the full resistance training program. Dietary and medicinal
recommendations were given to prevent other variables influencing results. Hemoglobin A1c
percentages were compared within groups: Aerobic training vs. control P Value .007, resistance
training vs control P Value 0.038, combined exercise vs. aerobic training P Value 0.014, and
combined exercise vs. resistance training P Value 0.001. Aerobic training had a statistically
significant effect on HbA1c and when combined exercise was compared to aerobic training the
effect was even greater.
Exercise in general has a great impact on improving levels of glucose disposal rate, insulin
sensitivity and Hba1c. The mode of exercise that was most effective in improving the health of a
type 2 diabetic is a combination of both resistance training and aerobic training.

Conclusion
In the case for type 2 diabetes the keys to help treat it are the same keys to help prevent it.
Exercise is one of the main factors to stay healthy and to regain health. The recommendations for
treatments are more demanding than what would be needed to prevent diabetes. Diabetes is a
disease that is closely correlated with obesity, therefore it is important to keep weight at a
reasonable level. The ACSM (31) guidelines suggest that an individual does moderate exercise 5
days a week, vigorous exercise 3 days a week or a combination of the two. They suggest that it is
done between 75-150 minutes a week. There are many important tools to help improve the health
of an individual with type 2 diabetes. As shown in this paper exercise is a great tool, but not the
only tool needed to help with this disease. Some of the studies that saw the greatest benefits
controlled the diets of the participants as well as the different exercises. Other studies not
mentioned here have shown the benefits of medications in providing assistance to type 2
diabetics. This paper discusses the different exercise routines that would be most beneficial in an
acute sense for improving glycemic. For the health benefits that are the most reasonable, exercise
should be performed 4-5 days per week, adding HI exercises at least 2 times per week, in
between days of LI to MI exercise bouts. The duration of bouts of exercise should last from
between 50 and 60 minutes per day for optimal benefits. Many modes of exercise are great for
improving glycemic control as long as the requirements for intensity duration and frequency are
met. That being said a mixture of aerobic and resistance training would be most beneficial.

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