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Engaging in Other Physical Activities with Diabetes

by Dr. Sheri Colberg, Ph.D., FACSM

The potential health benefits of other types of physical activities frequently are overlooked.

For instance, as individuals age it is important for them to work on maintaining balance, agility, and coordination to lower the risk of falling. Current guidelines from the American College of Sports Medicine (ACSM) recommend that adults perform resistance exercises for each of the major muscle groups and neuromotor exercise involving balance, agility, and coordination 2–3 days/week1. It is critical for all adults, but particularly those with diabetes, to maintain their range of movement around all joints by completing a series of flexibility exercises for each the major muscle-tendon groups on ≥2 days/week1,2. For youth with any type of diabetes, focusing on maintaining greater daily energy expenditure through various physical activities (including active video gaming) is important to prevent weight gain and cardiovascular complications3,4,5.

Flexibility Training

Flexibility is defined as the ability to move a joint though a complete range of motion and is considered an important part of physical fitness1. Limited joint mobility is frequently observed in elderly people and in individuals with all types of diabetes, a contributor likely being formation of advanced glycation end-products that accumulate during the process of normal aging in the plasma and tissues, but to an accelerated degree in patients with diabetes6. People with diabetes are more prone to developing structural changes to joints that can limit movement, such as shoulder adhesive capsulitis ("frozen shoulder"), carpal tunnel syndrome (wrist pain), metatarsal fractures (of the foot bones), and neuropathy-related joint disorders (e.g., Charcot foot) in people with peripheral neuropathy, among others. Aging itself also results in a reduction in flexibility and joint movement6.

Flexibility programs are low intensity and easy to perform, thus providing the perfect introduction toward a more physically active lifestyle for deconditioned individuals while bestowing health benefits. Adults should complete a series of flexibility exercises for each the major muscle-tendon groups, done for a total of 60 sec/exercise, on ≥2 days/week1. The American Diabetes Association recommends that flexibility training be included as part of a physical activity program, but not as a substitute for other training2. Both dynamic and static stretching exercises are effective in increasing flexibility and allow individuals with diabetes to more easily do activities that require greater movement around joints.

Tai Chi and Yoga

Both tai chi and yoga include basic stretching movements as part of the instruction. Gentle movement, such as that undertaken during both of these exercise modalities, can benefit flexibility in doing specific movements, and both activities assist adults in meeting the recommended levels of participation in flexibility exercise1. Mild-intensity exercises like tai chi and yoga have been investigated for their potential to improve blood glucose management in individuals with type 2 diabetes, with mixed results. A meta-analysis of yoga studies stated that the limitations characterizing most studies, such as small sample size and varying forms of yoga, preclude drawing firm conclusions about benefits to diabetes management7, and recent systematic reviews also failed to show any overall glycemic benefit of tai chi participation in diabetic individuals8. In their position statement, the American Diabetes Association was unable to conclusively support the inclusion of these types of activities due to the variable results with regard to glycemic benefits2.

While such exercises can be included based on individual preferences to increase flexibility, muscular strength, and balance and to gain other potential health benefits, their effects on aerobic fitness are likely minimal and their impact on glycemic control are variable. Of note, one study demonstrated the effectiveness of 6 months of weekly tai chi training in improving plantar sensation and balance in elderly adults with and without diabetes with a large plantar sensation loss9. Some have argued that yoga’s benefits on fasting blood glucose, lipids, oxidative stress markers, and antioxidant status are at least equivalent to more conventional forms of physical activity10

Active Video Gaming Activities

Active video games (exergames) increase energy expenditure and physical activity compared with sedentary video gaming. Exergaming also has the potential to increase overall physical activity and favorably influence energy balance, making it a viable alternative to some types of traditional fitness activities. It can reduce sedentary screen time in children while facilitating slight increases in vigorous physical activity in that population3 along with improving flow-mediated dilation, aerobic fitness, and mean arterial pressure in overweight children with endothelial dysfunction4. Energy expenditure in overweight youth ages 10–13 years playing exergames also has been found comparable to moderate-intensity walking5.

Simply increasing physical activity with exergaming during leisure time can be beneficial. Wii Fit is a viable exergame for adolescents and adults that replaces sedentary leisure behavior with light- to moderate-intensity activity11. Engaging in Wii Fit games also has been hown to be a feasible alternative to more traditional aerobic exercise in middle-age and older adults for improving and maintaining cardiorespiratory fitness12. In older adults doing Wii Fit games, 20 min sessions result in an exercise intensity of 43.4±16.7% heart rate reserve (HRR), or ~3.5 METs, along with net energy expenditure of 116.2±40.9 kilocalories. Wii video games can count toward the daily amount of exercise based on the latest guidelines for moderate-intensity physical activity1.

Balance Training

All older adults are advised to undertake exercises that maintain or improve balance1, especially individuals with T2D or peripheral neuropathy with a higher risk of falling13. Any type of balance training can be beneficial. Even engaging in a 10-week traditional Greek dance program improves performance on static and dynamic balance indices in healthy elderly adults14. Use of Wii Fit for limited supervised balance training in the home has also been shown to be safe and feasible for older adults15.

A balance training program can be effective, even if simple like the following one: Complete a series of stretches of the lower limb muscles followed by a lower limb, abdominal, and lower back exercises on 3 nonconsecutive days per week. The lower limb exercises include bilateral calf raises (two sets, 20 repetitions) and bilateral or single-leg calf raises (two sets, 10–15 repetitions). Abdominal crunches (one to three sets), lower back extension exercises, and bilateral single leg extensions (two to three repetitions) are performed while lying prone on a floor mat. Standing balance exercises include standing on a single-leg with eyes closed on a firm surface (two sets, 15 sec), followed by a forward leaning activity that involves standing on one leg with hands on hips and leaning forward (two sets, 15 sec each exercise, 10 repetitions)13.

Table 10.2. Recommended Other Physical Activities for All Types of Diabetes
 Participation Recommendations

Flexibility Training (Stretching)

Include a series of flexibility exercises (static or dynamic) for each the major muscle-tendon groups, done for a total of ~60 seconds per exercise, on two or more days per week

Tai Chi and Yoga

Do as part of or in place of flexibility training on two or more days per week (with tai chi being more dynamic, yoga more static in nature)
Active Video Gaming (Exergames)
Use to replace sedentary leisure time with more physical activity; one-third of Wii video game activities can count toward the daily amounts of moderate-intensity physical activity

Balance Training

All older adults are advised to undertake exercises that maintain or improve balance at least three days per week

In summary, many other physical activities are possible and beneficial for individuals with diabetes. Doing both regular stretching and balance training is increasingly important as people age, and tai chi and yoga are acceptable alternative activities for both of those types of training. Active video gaming activities can be used to work on cardiovascular fitness and balance, and they can be used to reduce leisure time sedentary activities in individuals of all ages.

References Cited:
  1. Garber, C. E., B. Blissmer, M. R. Deschenes, et al.: American College of Sports Medicine position stand. Quantity and quality of exercise for developing and maintaining cardiorespiratory, musculoskeletal, and neuromotor fitness in apparently healthy adults: guidance for prescribing exercise. Med Sci Sports Exerc 43 (7):1334–1359, 2011
  2. Colberg, S. R., R. J. Sigal, B. Fernhall, et al.: American College of Sports Medicine, and Association American Diabetes: Exercise and type 2 diabetes: the American College of Sports Medicine and the American Diabetes Association: joint position statement." Diabetes Care 33 (12):e147–e167, 2010
  3. Maloney, A. E., T. C. Bethea, K. S. Kelsey, et al.: A pilot of a video game (DDR) to promote physical activity and decrease sedentary screen time. Obesity (Silver Spring) 16 (9):2074–2080, 2008
  4. Murphy, E. C., L. Carson, W. Neal, et al.: Effects of an exercise intervention using Dance Dance Revolution on endothelial function and other risk factors in overweight children. Int J Pediatr Obes 4 (4):205–214, 2009
  5. Graf, D. L., L. V. Pratt, C. N. Hester, and K. R. Short: Playing active video games increases energy expenditure in children. Pediatrics 124 (2):534–540, 2009
  6. Abate, M., C. Schiavone, P. Pelotti, and V. Salini: Limited joint mobility in diabetes and ageing: recent advances in pathogenesis and therapy. Int J Immunopathol Pharmacol 23 (4):997–1003, 2011
  7. Innes, K. E., and H. K. Vincent: The influence of yoga-based programs on risk profiles in adults with type 2 diabetes mellitus: a systematic review. Evid Based Complement Alternat Med 4 (4):469–486, 2007
  8. Lee, M. S., T. Y. Choi, H. J. Lim, and E. Ernst: Tai chi for management of type 2 diabetes mellitus: A systematic review. Chin J Integr Med, 2011
  9. Richerson, S., and K. Rosendale: Does tai chi improve plantar sensory ability? A pilot study. Diabetes Technol Ther 9 (3):276–286, 2007
  10. Gordon, L. A., E. Y. Morrison, D. A. McGrowder, et al.: Effect of exercise therapy on lipid profile and oxidative stress indicators in patients with type 2 diabetes. BMC Complement Altern Med 8:21, 2008
  11. Graves, L. E., N. D. Ridgers, K. Williams, et al.: The physiological cost and enjoyment of Wii Fit in adolescents, young adults, and older adults. J Phys Act Health 7 (3):393–401, 2010
  12. Guderian, B., L. A. Borreson, L. E. Sletten, et al.: The cardiovascular and metabolic responses to Wii Fit video game playing in middle-aged and older adults. J Sports Med Phys Fitness 50 (4):436–442, 2010
  13. Morrison, S., S. R. Colberg, M. Mariano, et al.: Balance training reduces falls risk in older individuals with type 2 diabetes. Diabetes Care 33 (4):748–750, 2010
  14. Sofianidis, G., V. Hatzitaki, S. Douka, and G. Grouios: Effect of a 10-week traditional dance program on static and dynamic balance control in elderly adults. J Aging Phys Act 17 (2):167–180, 2009
  15. Agmon, M., C. K. Perry, E. Phelan, G. Demiris, and H. Q. Nguyen: A pilot study of wii fit exergames to improve balance in older adults. J Geriatr Phys Ther 34 (4):161–167, 2011

This article is excerpted from Chapter 10 of Exercise and Diabetes: A Clinician’s Guide to Prescribing Physical Activity, a case-study based book available through the American Diabetes Association in June 2013 and written by Dr. Sheri Colberg (find more information about the book online at

In addition, anyone wishing to earn free CME credits through the ADA for completing a new self-assessment program on exercise and diabetes may do so now through the ADA’s web site at