DIABETES/METABOLISM RESEARCH AND REVIEWS
Diabetes Metab Res Rev 2009; 25(Suppl 1): S29–S33.
Published online in Wiley InterScience (www.interscience.wiley.com) DOI: 10.1002/dmrr.985
Physical activity/exercise training in type 2
diabetes. The role of the Italian Diabetes
and Exercise Study
S. Balducci1,2 *
S. Zanuso3
F. Fernando4
S. Fallucca1
F. Fallucca1
G. Pugliese2 for the Italian
Diabetes Exercise Study
(IDES) Group
1
Metabolic Fitness Association,
Monterotondo, Rome, Italy
2
Diabetes Division, S. Andrea
Hospital and Department of Clinical
Sciences, 2nd Medical School, ‘La
Sapienza’ University, Rome, Italy
3
Department of Motor Science,
Faculty of Medicine, University of
Padua, Padua, Italy
4
Division of Sport Medicine, St.
Andrea Hospital, Rome, Italy
*Correspondence to: S. Balducci,
Metabolic Fitness Association, Via
Nomentana, 27 - 00015
Monterotondo (Rome), Italy.
E-mail: sbalducci@esinet.it
Received:
Copyright  2009 John Wiley & Sons, Ltd.
REVIEW ARTICLE
Summary
Cardiorespiratory fitness is inversely related to the development of type 2
diabetes and cardiovascular morbidity and mortality. Trials in individuals
with impaired glucose tolerance have highlighted the role of physical
activity/exercise in the prevention of type 2 diabetes. Moreover, physical
activity and exercise training have been recognized as treatment options for
patients with type 2 diabetes. Both aerobic and resistance training were shown
to produce beneficial effects by reducing HbA1c , inducing weight loss and
improving fat distribution, lipid profile and blood pressure in patients with
type 2 diabetes. Mixed aerobic and resistance training was recently shown
to be more effective than either one alone in ameliorating HbA1c . However,
further research is needed to establish the volume, intensity and type of
exercise that are required to reduce cardiovascular burden and particularly
to define the best strategy for promoting long-term compliance and durable
lifestyle changes in individuals with type 2 diabetes.
The Italian Diabetes Exercise Study (IDES) is a prospective Italian
multicentre randomized controlled trial, of larger size and longer duration
than previously published trials. It has been designed to assess the combined
effect of structured counselling and supervised mixed (aerobic plus resistance)
exercise training, as compared with counselling alone, on HbA1c and other
cardiovascular risk factors as well as fitness parameters in individuals with
type 2 diabetes and the metabolic syndrome. This study was also aimed at
testing a sustainable strategy for promoting and maintaining a sufficient level
of physical activity among individuals with type 2 diabetes to be implemented
at the population level. Copyright  2009 John Wiley & Sons, Ltd.
Keywords type 2 diabetes; metabolic syndrome; physical activity; exercise;
exercise counselling
It has been shown that cardiorespiratory fitness is inversely related to
the development of type 2 diabetes [1] and cardiovascular morbidity and
mortality [2]. Therefore, physical activity has been proposed as a valuable
approach for the prevention and treatment of type 2 diabetes by ameliorating
insulin sensitivity and the modifiable cardiovascular risk factors.
The 1996 report of the US Surgeon General on ‘Physical Activity and Health’
[3] distinguished the terms ‘physical activity’ and ‘exercise’ as two different
types of ‘movement’. Physical activity was defined as any bodily movement
produced by the contraction of skeletal muscle that requires energy expen-
diture in excess of resting energy expenditure; and exercise as a subset of
physical activity: planned, structured, and repetitive bodily movements per-
formed to improve or maintain one or more components of physical fitness.
S30 S. Balducci et al.

Table 1. Summary of the three major randomized controlled trials on the effects of lifestyle modification programs on the incidence
of type 2 diabetes

Study population Mean BMI Arms Diabetes incidencea RRR NNT

Diabetes Prevention Program (a 34 Control 11.0 Baseline Baseline

total of 3234 primary care
patients, both sexes, mixed
ethnic backgrounds, various
ages)
Finnish Diabetes Prevention 31 Metformin 7.8 31% 14 (over 7 years)
Study (a total of 522 patients)
Intensive lifestyle 4.8 58% 7 (over 7 years)
modification
Da Qing IGT and Diabetes Study 25.8 Control 23 Baseline Baseline
(a total of 577 primary care
patients, men and women aged
<25 years).
Intensive lifestyle 11 58% 5 (over 5 years)
modification
Control 15 Baseline Baseline
Diet 10 31% 17
Exercise 8 46% 14
Diet + exercise 9.5 42% 16

a Incidence
of diabetes per 100 person-year.
BMI, body mass index; IGT, impaired glucose tolerance; NNT, number needed to treat; RRR, relative risk reduction.

Table 2. Summary of the effects of aerobic, resistance and mixed exercise training in type 2 diabetic patients

Exercise type Effects Higlights

Aerobic exercise Improves glycemic control; assists in
lipoproteins/lipids control; helps in body
weight control; increases insulin sensitivity
Resistance exercise Improves glycemic control; increases insulin
sensitivity; increases lean body mass;
increases overall functionality
Mixed aerobic and resistance exercise Improves glycemic control more than
aerobic or resistance alone
More vigorous aerobic exercise programs
are better than those of low-to-moderate
intensity
Resistance exercise offers the same benefits
as aerobic exercise
Mixed training offers incremental
advantages

Even though these terms are properly utilized in
the context of exercise science, they are not always
operationally well defined and often used interchangeably
in studies involving patients with impaired glucose
tolerance (IGT) or diabetes.
Physical activity and exercise in the
prevention of type 2 diabetes
In recent years, clinical trials and cohort studies have
highlighted the role of physical activity in the prevention
of type 2 diabetes. Most of the studies focused on
individuals at high risk for developing type 2 diabetes,
such as those with IGT, who were received a ‘lifestyle
intervention’ consisting of diet, physical activity and
exercise, either separately or in combination.
The most relevant randomized clinical trials published
in the literature are the ‘Da Qing IGT and Diabetes Study’
[4], the ‘Diabetes Prevention Study’ [5] and the ‘Diabetes
Prevention Program’ [6], which evaluated the effect of
diet and/or physical activity/exercise in IGT subjects. In
the ‘Da Qing IGT and Diabetes Study’, diet, exercise, and
diet plus exercise interventions were associated with 31%,
46%, and 42% decreases in risk of developing diabetes,
respectively, [4] whereas, in the other two trials, risk
reduction was 58% with combined intervention [5,6]
(Table 1).
In a meta-analysis and systematic review of pharmaco-
logical and lifestyle interventions to prevent or delay type
2 diabetes in IGT subjects [7], the authors concluded that
lifestyle interventions seem to be at least as effective as
drug treatment, but wondered whether lifestyle should
really be treated as a lifelong course of medication. Thus,
as compliance is the key to the success of lifestyle interven-
tions, strategies to assist compliance need to be carefully
considered and implemented.
Current actions to implement
diabetes prevention programs into
clinical practice
Currently, numerous prevention management concepts
exist in the various European countries which can be
implemented into clinical practice. Finland is the pioneer
and has started with the Program for the Prevention
of Type 2 Diabetes [8] and is testing in practice the

Copyright  2009 John Wiley & Sons, Ltd. Diabetes Metab Res Rev 2009; 25(Suppl 1): S29–S33.
DOI: 10.1002/dmrr
Physical Activity/Exercise in Type 2 Diabetes
translation of the findings of the Diabetes Prevention
Study into strategies, facilitating and supporting the
implementation of preventive activities in primary health
care centres and occupational (employer-provided) health
care units in Finland.
In Germany, an intensive implementation process has
started and it is currently the largest and most practical
implementation concept. It is a standardized structured
concept considering scientific evidence and application to
practical requirements during implementation [9].
In Europe, some strategic focused actions are going
on, funded by the European Union in the public health
sector. One European Union public health research project
‘Diabetes in Europe – Prevention using Lifestyle, Physical
Activity and Nutritional intervention’ [10] is developing
structures of a European prevention management concept
and is testing it in pilot projects funded by the Commission
of the European Communities.
In addition, the European Union currently started a
project for the ‘Development and Implementation of a
European Guideline and Training Standards for Diabetes
Prevention’ [11]. The ‘Development and Implementation
of a European Guideline and Training Standards for
Diabetes Prevention’ project will develop a European
practice-orientated guidelines for the primary prevention
of type 2 diabetes.
Physical activity and exercise in the
management of type 2 diabetes
A consensus statement from the American Diabetes
Association summarizes the most clinically relevant recent
advances related to individuals with type 2 diabetes and
formulates the recommendations that follow from these
findings [12].
Aerobic training
Available data indicate that aerobic exercise is effective in
reducing blood glucose and body weight and improving
cardiovascular risk profile in patients with type 2 diabetes.
These results have been analysed in three recent meta-
analyses [13–15], which confirmed the beneficial effect of
aerobic exercise on HbA1c , the best indicator of glycaemic
control (Table 2).
Two of these meta-analyses [13,14] also addressed
the issue of exercise intensity, showing that it was a
better predictor than exercise volume of the difference
in HbA1c and VO2 max between the intervention and the
control groups. Recently, three randomized controlled
trials [16–18] and a review article [19] analysed the effect
of exercise intensity on insulin sensitivity and found that
intensity of aerobic training, independent of total energy
expenditure, is a major determinant of the improvement
in insulin action induced by exercise.
Copyright  2009 John Wiley & Sons, Ltd.
S31
Resistance training
Resistance training has been shown to be beneficial in
type 2 diabetic patients in a number of studies. Eriksson
et al. showed that 3 months of moderate intensity circuit
resistance training significantly decreases HbA1c [20].
The randomized controlled trials by Dunstan et al. [21]
and Ishii et al. [22] reported a reduced plasma insulin
response to glucose ingestion and an increased glucose
disposal rate during the hyperinsulinemic–euglycaemic
clamp, respectively. However, these studies failed to
detect a significant change in HbA1c , which most likely
depended on the small sample size and short training
duration (8 and 6 weeks, respectively) or lack of sufficient
intensity and/or volume of exercise.
More recent trials by Castaneda et al. [23], Dunstan
et al. [24], and particularly Baldi et al. [25], which were
of larger size and longer duration and utilized a resistance
training of higher intensity than previous studies, did in
fact show a significant reduction in HbA1c in the resistance
training group, as compared with control. In these three
studies, a significant relationship was observed between
reduction in HbA1c and increase in skeletal muscle mass
[23–25], thus supporting the hypothesis that resistance
training improves glycaemic control by increasing muscle
glucose uptake. However, the increased glucose rate of
disappearance might also be dependent on qualitative
changes in certain muscle functions. In addition, the
extent of HbA1c reduction in these studies was comparable
to that reported in the meta-analysis by Boulè et al. [13],
thus indicating that resistance training is as effective as
aerobic exercise in improving glycaemic control.
Mixed aerobic and resistance training
A number of studies in individuals with type 2 diabetes
have showed that mixed aerobic and resistance training
is effective in reducing HbA1c, inducing weight loss and
improving fat distribution, lipid profile and blood pressure
[26–28].
The question whether combination of aerobic and
resistance training induces additive or synergistic effects
as compared with either one alone has been addressed by
Cuff et al. [29] and, more recently, by Sigal et al. [30]. In
the first report, a mixed aerobic and resistance training
group was compared with an aerobic-only training group
and a non-exercising control group. However, the results
of this study did not show any significant difference
among groups, probably due to the low baseline HbA1c
values (6.7% on average) and particularly by the small
sample size (nine to ten persons per group) [29]. The
second, much larger trial, called the Diabetes Aerobic
and Resistance Exercise Study, compared three groups of
subjects performing supervised training (mixed aerobic
and resistance, aerobic alone and resistance alone) and
a sedentary control group. At variance with the previous
study, mixed aerobic and resistance exercise was found
Diabetes Metab Res Rev 2009; 25(Suppl 1): S29–S33.
DOI: 10.1002/dmrr
S32
to be more effective than either one alone in ameliorating
HbA1c , but not on other cardiovascular risk factors [30].
Based on these results, resistance training is now
recommended by the American Diabetes Association in
combination with aerobic exercise, or as an alternative
when the latter is limited or contraindicated, [12] and
also in subjects with the metabolic syndrome [31].
The role of the Italian Diabetes
and Exercise Study (IDES)
As previously mentioned, a major issue in lifestyle
interventions comprising physical activity/exercise is
compliance and strategies aimed at promoting compliance
include structured conselling and supervised exercise
training sessions. Both approaches have been shown to be
effective in promoting leisure-time physical activity and
exercise, respectively [14,32].
The IDES is a prospective multicentre, randomized
controlled trial, of larger size (606 subjects) and longer
duration (12 months) than previously published trials in
diabetic patients, conducted in 22 outpatients diabetes
clinics, connected with 20 metabolic fitness centres
nationwide. This study, the design and methods of
which were published in detail elsewhere [33], has been
designed to assess the combined effect of structured
counselling and supervised mixed exercise training, as
compared with counselling alone, in subjects with type
2 diabetes and the metabolic syndrome. Thus, the
IDES allowed to compare the combination of leisure-
time physical activity, mainly aerobic, and a mixed
(aerobic + resistance) training program with leisure-time
aerobic physical activity alone.
Moreover, this study has been designed not only to
answer a scientific question, but also to test a practical,
sustainable and viable strategy for the promotion
and maintenance of a sufficient amount of physical
activity/exercise among subjects with type 2 diabetes to
be implemented at the population level. In fact, supervised
sessions were not individual, were held in standard fitness
facilities and were limited to two per week, leaving time
for practising leisure-time physical activity.
Finally, end points were HbA1c (primary outcome),
other modifiable cardiovascular risk factors and global
cardiovascular risk (secondary outcomes), in keeping
with the concept that increased cardiovascular burden
in diabetic patients is attributable not only to hyper-
glycaemia, but also to other cardiovascular risk factors
clustering with impaired glucose metabolism in the set-
ting of the metabolic syndrome. Secondary end points
included also physical fitness, comprising cardiorespira-
tory fitness, strength and flexibility, due to the well-known
inverse relationship of fitness with cardiovascular morbid-
ity and mortality in the general population [2] as well as
in diabetic patients [34].
Because adherence is a crucial point in a long-term
trial such as the IDES, 2 years prior to initiating the
Copyright  2009 John Wiley & Sons, Ltd.
S. Balducci et al.
study, physicians and exercise specialists participating
in the study received a specific training to provide
structured counselling and prescribe exercise and to
supervise exercise sessions, respectively. This strategy was
also aimed at increasing awareness of the importance of
exercise in type 2 diabetic subjects among physicians and
trainers.
Conclusions
Physical activity/exercise has been shown to be effective
in preventing type 2 diabetes in IGT subjects and to
improve both glycaemic control and other cardiovascular
risk factors in patients with type 2 diabetes. Both aerobic
and resistance training were shown to produce beneficial
effects, though combination of the two seems to be
synergistic. However, a major issue for the success of
lifestyle interventions is adherence, especially in the
long-term period, and strategies based on structured
counselling or supervised exercise sessions have been
designed to improve compliance.
The IDES is a prospective Italian multicentre, random-
ized controlled trial, of larger size and longer duration
than previously published trials, designed to assess the
combined effect of these two strategies versus counselling
alone on HbA1c and other cardiovascular risk factors as
well as fitness parameters in subjects with type 2 diabetes
and the metabolic syndrome. It was also aimed at testing
a sustainable strategy for promoting and maintaining a
sufficient level of physical activity among subjects with
type 2 diabetes.
Conflict of interest
None declared.
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DOI: 10.1002/dmrr