IJSM/5290/16.5.

2016/MPS Clinical Sciences

Low-Volume High-Intensity Interval Training as a

Therapy for Type 2 Diabetes

Authors C. Alvarez1, R. Ramirez-Campillo2, C. Martinez-Salazar3, R. Mancilla4, M. Flores-Opazo5, J. Cano-Montoya6,

E. G. Ciolac7

Affiliations Affiliation addresses are listed at the end of the article

Key words Abstract blood pressure (3.7 ± 0.5 mmHg), HDL-cholesterol

●
▶ blood pressure
▼ (21.1 ± 2.8 %), triglycerides (17.7 ± 2.8 %), endur-

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●
▶ body composition
Our purpose was to investigate the effects of low- ance performance (9.8  ± 
1.0 %), body weight
●
▶ endurance performance
volume, high-intensity interval training (HIT) on (2.2 ± 0.3 %), BMI (2.1 ± 0.3 %), waist circumference
●
▶ glycemic control
cardiometabolic risk and exercise capacity in (4.0 ± 0.5 %) and subcutaneous fat (18.6 ± 1.4 %)
●
▶ high-intensity interval

­exercise women with type 2 diabetes mellitus (T2DM).
●
▶ type 2 diabetes mellitus Sedentary overweight/obese T2DM women
(age = 44.5 ± 1.8 years; BMI = 30.5 ± 0.6 kg/m2) were
randomly assigned to a tri-weekly running-based
HIT program (n = 13) or non-exercise control fol-
low-up (CON; n = 10). Glycemic control, lipid and
blood pressure levels, endurance performance,
and anthropometry were measured before and
after the follow-up (16 weeks) in both groups.
Medication intake was also assessed throughout
the follow-up. Improvements (P < 0.05) on fasting
glucose (14.3 ± 1.4 %), HbA1c (12.8 ± 1.1 %), systolic
were found after HIT intervention. Patients of
HIT group also showed reductions in daily dos-
age of antihyperglycemic and antihypertensive
medication during follow-up. No changes were
found in any variable of CON group. The HIT-
induced improvements occurred with a weekly
time commitment 56–25 % lower than the mini-
mal recommended in current guidelines. These
findings suggest that low-volume HIT may be a
time-efficient intervention to treat T2DM
women.

Introduction intensity interval training (HIT), which consist of

accepted after revision
March 01, 2016
Bibliography
DOI  http://dx.doi.org/
10.1055/s-0042-104935
Published online: 2016
Int J Sports Med
© Georg Thieme
Verlag KG Stuttgart · New York
ISSN 0172-4622
Correspondence
Prof. Dr. Emmanuel Gomes
Ciolac
Departamento de Educação
Física
Faculdade de Ciências
Universidade Estadual Paulista
– UNESP
Av. Engenheiro Luiz Edmundo
Carrijo Coube 14-06
17033-360 Bauru
Brazil
ciolac@fc.unesp.br
▼ several bouts of high-intensity exercise inter-
Type 2 diabetes mellitus (T2DM) is a highly prev-
alent disease associated with increased levels of
morbidity, mortality and health care expendi-
ture [28, 39]. Regular physical activity has been
recognized as an important tool for preventing
and managing T2DM and its complications,
including glycemic control, cardiometabolic risk
and psychological well-being [9]. In this context,
physical activity is a first-line treatment for
T2DM patients, and a minimum of 150 min/wk
(30 min, 5 d/wk) of moderate to vigorous aerobic
exercise, in association with 2–3 sessions per
week of resistance training, has been recom-
mended in the current American Diabetes Asso-
ciation and American College of Sports Medicine
guidelines [9].
Continuous activities that causes a sustained
heart rate (HR) increase (i. e., walking, cycling or
jogging at ~55–70 % of maximal HR) has been
commonly recommended to meet this aerobic
exercise recommendation [9]. However, high-
spersed with intervals of rest or active recovery
[8], may have superior effects for improving gly-
cemic control [10] and other health-related
markers [5,  8, 
37]. For example, HIT showed
greater improvements on cardiorespiratory fit-
ness [6, 7, 25, 31, 38], endothelial function and its
markers [6,  31], blood lipoprotein and glucose
[31], insulin sensitivity and fasting insulin [31, 32],
markers of sympathetic activity [6, 7] and arterial
stiffness [6, 13] compared to energy-expenditure-
matched continuous moderate exercise.
It is noteworthy that only 2 weeks (6 exercise
sessions) of low-volume HIT has shown improve-
ments in glycemic control of T2DM patients
[20, 27]. Low-volume HIT is also time-efficient,
with a weekly time commitment (including
warm-up, cool-down and rest periods) markedly
lower [10,  12, 
20, 27] than current guidelines
re­commendation [9]. Given that most T2DM
patients are sedentary or insufficiently active
[24], and lack of time is the most frequently cited

Alvarez C et al. High-Intensity Exercise and Diabetes …  Int J Sports Med

 Clinical Sciences IJSM/5290/16.5.2016/MPS

barrier to regular exercise participation [33], these findings may
have important implications from a public health perspective.
However, low-volume HIT studies with T2DM patients are of
short-duration (only 2 weeks), small sample size, and lack an
appropriate control group [10, 27]. Studies analyzing the effects
of longer periods of low-volume HIT on glycemic control and
others treatments goals in T2DM are lacking (i. e., lipid and blood
pressure levels, drug therapy optimization) [9]. Thus, the aim of
the present study was to investigate the effects of 4 months of
low-volume HIT on glycemic control, lipid and blood pressure
levels, endurance performance, medication intake and anthro-
pometry of T2DM women.
Methods
▼ random assignment. Fasting glucose, HbA1c and lipids levels,
Population and study design
We studied adult overweight or obese (BMI between 25 and
35 kg/m2) adult women with established diagnosis of T2DM for
at least 12 months. Eligibility criteria included fasting hypergly-
cemia > 126 mg · dL − 1 and glycated hemoglobin (HbA1c) ≥ 6.5 %
mum of 70 % of exercise program compliance was required in
order for the intervention group patients to be included in the
final statistical analyses.
84 T2DM women (age 35–55 years), with less than 5 years of
diagnosis, patients of the Family Healthcare Center Tomas Rojas
of Los Lagos (Chile) that answered a telephone call with explana-
tions about the study protocol, agreed to participate in the pre-
sent investigation. A structured medical records review and
physical examination by a physician were performed in all
patients for eligibility criteria assessment. 28 T2DM patients who
met all of the inclusion criteria were included in the present study
▶  Fig. 1). Subjects were then randomly assigned in a 1:1 ratio to
( ●
16-week HIT (n = 14, age = 46.0 ± 3.0 years, BMI = 30.8 ± 1.0 kg/m2)
or non-exercise control (CON; n = 14, age = 43.0 ± 2.4 years,
BMI = 30.6 ± 1.0 kg/m2) intervention, using a computer generated
resting blood pressure, endurance performance and anthropom-
etry were assessed before and after the 16-week follow-up in
both groups. All assessments were performed by examiner who
were blinded to the patients’ intervention group. Hypoglycemic
medication intake was controlled throughout the follow-up and,

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[9], unchanged drug therapy during the previous 6 months, sed-
entary or insufficiently active life style (according to the Interna-
tional Physical Activity Questionnaire previously validated in
Chilean population) [26], non-involvement in regular physical
activity or exercise program during the previous 6 months, and
family history of T2DM (mother and/or father). Patients with
musculoskeletal disorders, cardiovascular contraindications to
exercise, history of stroke, asthma and chronic obstructive pul-
monary disease, long-term diabetic complications (history of
foot injury, retinopathy, nephropathy, and diabetic peripheral
neuropathy), or smokers were not included in the study. A mini-
if necessary, changes were performed following the recommen-
dations to continue preventing hypoglycemia events in T2DM
patients under regular exercise [1]. Patients in HIT group per-
formed a tri-weekly progressive exercise program, which con-
sisted of jogging/running intervals interspersed with recovery
periods of low-intensity walking. Patients in CON group were
advised not to engage in any exercise/physical activity programs
during the study. All patients (HIT and CON) were oriented to
maintain their daily living physical activity and dietary patterns
throughout the 16-week study period. The present study is in
accordance with the ethical standards of the International Jour-

Fig. 1  Study design.

Enrollment Assessed for eligibility (n = 84)

Not included (n = 56)

Without T2DM family history (n = 22)
Musculoskeletal disorders (n = 2)
History of stroke (n = 1)
Asthma (n = 2)
Foot injury or history of foot injury (n = 7)
Altered electrocardiography (n = 4)
Nephropathy (n = 3)
Regular Physical Activity (n = 3)
Age ≥ 60 years (n = 5)
Address in rural areas (n = 7)

Randomization (n = 28)

Allocation
Allocated to HIT (n = 14) Allocated to CON (n = 14)

Follow-Up
Lost to follow-up (n = 4)
Lost to follow-up (n = 1)
Change of residence address (n = 2)
Exercise training compliance < 70 %
Change from health center (n = 2)

Analysis
Analyzed (n = 13) Analyzed (n = 10)

Alvarez C et al. High-Intensity Exercise and Diabetes …  Int J Sports Med

IJSM/5290/16.5.2016/MPS
nal of Sports Medicine [14], and was approved by the ethics
committees of the Department of Physical Activity Sciences of
the University of Los Lagos and of the Family Healthcare Center
Tomás Rojas of Los Lagos. All volunteers read a detailed descrip-
tion of the study protocol and provided their written informed
consent.
Blood analyses
Blood samples (nearly 3.5 ml) were collected before and after the
16-week of follow-up, at morning and after a 10 h overnight fast-
ing. The post-training blood sampling of HIT patients were per-
formed at least 48 h after the last exercise session to avoid an
acute effect of exercise. Samples were immediately placed in ice
and centrifuged at 4 000 rpm (1 700 × g) for 5 min at  − 4 °C. Plasma
samples were immediately transferred to pre-chilled microtubes
and stored at  − 20 °C for later analysis. HbA1c was analyzed by
high performance liquid chromatography (Variant™ II Turbo
Hemoglobin Testing System, Bio-Rad Inc., Hercules, CA, USA).
Plasma glucose, total cholesterol and triglycerides were ana-
lyzed by enzymatic methods using standard kits (Wiener Lab
Inc., Rosario, Argentina) on an automatic analyzer (Metrolab
2 300 Plus™, Metrolab Biomed Inc., Buenos Aires, Argentina).
Plasma HDL cholesterol was measured by the same enzymatic
method after phosphotungstate precipitation. LDL cholesterol
levels were calculated using the Friedewald formula [11].
Blood pressure and anthropometric measurements
Blood pressure measurements were performed one week before
and after the 16-week follow-up, with an automatic monitor
(Omron HEM 7114™, Omron Healthcare Inc., Lake Forest, IL,
USA), in triplicate (2 min of interval between measurements),
after 15 min of resting, and with the patients in seated position.
The blood pressure measurements were repeated in 3 non-con-
secutive days, at the same time of morning (between 8:00 and
11:00 a.m.). The mean of the 9 blood pressure measurements,
performed both before and after the follow-up, were registered
and used for inter- and intra-group analyses [4].
Anthropometric measurements were also performed one week
before and after the 16-week follow-up in all patients. Body
mass (kg) was measured (to the nearest of 0.1 kg) by a digital
scale (Omron HBF-INT™, Omron Healthcare Inc., Lake Forest, IL,
USA), with minimum of clothes and no shoes. Height (m) was
measured without shoes, using a standard stadiometer (Health o
Meter™ Professional, Sunbeam Products Inc., Chicago, IL, USA),
to the nearest of 0.1 m. Body mass index (BMI) was calculated as
body mass divided by height squared (kg/m2). Waist circumfer-
ence (cm) was measured to the nearest of 0.1 cm, using a flexible
and inextensible measuring tape (Hoechstmass™, Sulzbach,
Germany). Assessment of skinfolds thickness was performed
using a Langue™ skinfold caliper (Beta Technology Inc., Santa
Cruz, California, USA), according to the International Society for
the Advance of Kinanthropometry [21], in 4 sites (tricipital, sub-
scapular, suprailiac and mid-leg).
Endurance performance assessment
Endurance performance was assessed one week before and after
the 16-week follow-up by the 2 km walking test (2KWT) [19]. In
brief, the test was performed in an indoor sports court (100 m
track), after a 10 min warm-up (low-intensity walking and slow
movements involving the knee and ankle joints). Patients were
then instructed to walk as fast as possible with a steady pace.
Heart rate was continuously monitored (ProTrainer 5™, Polar
Clinical Sciences
Electro Inc., Kempele, Finland). In order to warrant an accurate
test [19], patients were encouraged to walk faster if their heart
rate was lower than 75 % of maximum age-predicted heart rate.
The time spent in walking the 2 km was measured and used for
analysis. All tests were carried out between 8:00 and 10:00 a.m.
Exercise training intervention
Participants of HIT group performed a tri-weekly progressive
HIT program for 16 weeks. All exercise sessions were performed
on a flat surface (indoor sports court), and supervised by an
exercise specialist. The progressive HIT program was based on
high-intensity exercise intervals (jogging/running) interspersed
with low-intensity active recovery (walking). Patients’ heart rate
was continuously monitored (ProTrainer 5™, Polar Electro Inc.,
Kempele, Finland). During all HIT sessions, patients were
instructed by the exercise specialist to jog/run and walk using a
steady pace, which should be controlled by maintaining a per-
ceived exertion between 15–17 (jogging/running) and < 9 (walk-
ing) in the 15-point rating of perceived exertion scale [2]. The
goal was to reach 90–100 % and less than 70 % of their age pre-
dicted reserve heart rate [18] at the end of each jogging/running
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and walking interval, respectively. Thus, all patients were con-
tinuously oriented to adjust their jogging/running or walking
pace, if their heart rate was not in the goal at the end of the pre-
vious interval. The progressive HIT program started (week 1–2)
with 8 jogging/running intervals of ~30 s interspersed with
~120 s of low-intensity walking. To promote sufficient workload
for eliciting improvements throughout the follow-up, there was
a 7–10 % increase in the high-intensity interval duration and a
4 % decrease in the recovery interval duration every 2 weeks.
There was also an increase of 2 exercise intervals every 4 weeks
of follow-up. With the exercise intensity/volume progression,
total working duration ranged from 4 to 13.5 min (week 1–16),
total recovery duration ranged from 18 to 24 min (week 1–16)
and number of intervals ranged from 8 to 14 (week 1–16). Thus,
the exercise session duration ranged from 22 min to 37.5 min
(week 1–16), totalizing 66 min/wk (week 1) to 112.6 min/wk
(week 16) of exercise. A detailed description of the HIT volume and
intensity progression during follow-up is showed in ●  ▶  Table 1.
Statistical analyses
Data are reported as mean ± standard error of the mean (SEM) or
median and interquartile ranges. Statistical analyses were per-
formed using SPSS™ statistical software version 18.0 (SPSS Inc.,
Chicago, IL, USA). Normality and homoscedasticity of variables
were determined using the Shapiro-Wilk and Levene tests,
respectively. Two-way ANOVA with repeated measures (group
vs. time) was used to indicate inter- and intra-interventions dif-
ferences in the data presenting Gaussian distribution. The Bon-
ferroni’s post hoc test was performed to identify significant
differences indicated by ANOVA.
Results
▼
Four patients of CON group were lost to follow-up because of
failure to communicate a change in residence address (N = 2) or
in health center of treatment (N = 2). One patient of HIT group
was excluded from final analysis because she did not have the
minimal exercise training compliance of 70 %. Thus, 23 over-
weight or obese T2DM patients completed the 16-week follow-
up and were included in the final analysis ( ● ▶  Fig. 1). No
Alvarez C et al. High-Intensity Exercise and Diabetes …  Int J Sports Med
 Clinical Sciences IJSM/5290/16.5.2016/MPS

Variable Weeks Weeks Weeks Weeks Table 1  Characteristics of low-

volume, high-intensity interval
0–4 5–9 10–13 14–16
training during follow-up.
Exercise intensity (% HRRESERVE) 90–100 90–100 90–100 90–100
Exercise duration (s) 30–34 38–44 46–50 52–58
Number of exercise bouts 8 10 12 14
Exercise time commitment/day (min) 4–4.5 6.3–7.3 9.2–10 12.1–13.5
Exercise time commitment/week (min) 12–13.5 19–21,9 27.6–30 36.4–40.6
Exercise method jogging/running jogging/running jogging/running jogging/running
Recovery intensity (% HRRESERVE)  ≤ 70 %  ≤ 70 %  ≤ 70 %  ≤ 70 %
Recovery duration (s) 120 108 100 96
Number of recovery bouts *  9 11 13 15
Recovery method walking walking walking walking
Total time commitment/day (min) 22–22.5 26.1–27.1 30.9–31.7 36.1–37.5
Total time commitment/week (min) 66–67.5 78.3–81.3 92.6–95 108.4–112.6
 * All sessions started and ended with a recovery bout

Variable HIT (N = 13) CON (N = 10) Table 2  Subjects’ characteristics

before and after the experimental
Pre Post Pre Post
protocol.
Age (y) 45.6 ± 3.1 43.1 ± 1.5

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Time elapsed from diagnosis (y) 3.4 ± 1.1 3.6 ± 1.1
Height (cm) 1.56 ± 0.02 1.58 ± 0.02
Body mass (kg) 73.8 ± 2 72.2 ± 1.9 *  75.3 ± 1.6 75.3 ± 1.7
Body mass index (kg/m2) 30.6 ± 1.1 29.9 ± 1.1 *  30.4 ± 0.4 30.4 ± 0.4
Waist circumference (cm) 101.1 ± 2.4 97.0 ± 2.1 **  98.7 ± 1.5 99.3 ± 1.5 †
∑ 4 Skin-folds (mm) 147 ± 6 119 ± 4 ***  144 ± 5 147 ± 5 †††
Endurance performance (min) • 23.2 ± 0.2 21.0 ± 0.3 ***  22.3 ± 0.3 22.4 ± 0.2 †
Blood pressure
  Systolic (mmHg) 132 ± 1 129 ± 1 *  130 ± 1 131 ± 1
  Diastolic (mmHg) 77 ± 1 77 ± 1 78 ± 1 79 ± 1
Current medication
  Metformin (N) (mg/day) 13 (1 700 ± 0) 13 (1 242 ± 122) 10 (1 700 ± 0) 10 (1 700 ± 0)
  Glibenclamide (N) (mg/day) 12 (5 ± 0) 12 (3.7 ± 0.4) 8 (5 ± 0) 8 (5 ± 0)
  ACE inhibitor (N) (mg/day) 3 (10 ± 0) 0 3 (10 ± 0) 3 (10 ± 0)
  Levothyroxine (N) (mg/day) 1 (100 ± 0) 1 (100 ± 0) 1 (100 ± 0) 1 (100 ± 0)
ACE: angiotensin converting enzyme; HIT: high-intensity interval training group. CON: non-exercise control group. T2DM: type 2
diabetes mellitus. • Endurance performance was measured by the time to complete the 2-km walking test. Asterisks denote significant
difference from pre follow-up in the same group (* = P < 0.05; ** = P < 0.01; *** = P < 0.001). Daggers denotes significant difference from
HIT during the same period († =  P < 0.05; ††† =  P < 0.001)

The exercise program was well tolerated by all patients, and

Table 3  Lipid profile before and after the experimental protocol.
there were no injuries during the training program. The exercise
Variables HIT (N = 13) CON (N = 10) compliance was 89  ± 5 % during the 16-week follow-up. 7
Pre Post Pre Post patients of HIT group reduced their daily dosage of metformin
Fasting total cholesterol 187 ± 4 183 ± 4 197 ± 6 199 ± 6 and glibenclamide during the follow-up. First, the dosage was
(mg/dL) reduced only in the exercise training days (tri-weekly) due to
Fasting HDL cholesterol 50 ± 2 60 ± 1 *  44 ± 2 43 ± 2 † episodes of post-exercise hypoglycemia that started 1 h after the
(mg/dL) exercise session (from the 1st week of follow-up). Then, the dos-
Fasting LDL cholesterol 128 ± 4 126 ± 5 129 ± 5 132 ± 5 age was reduced in all days of week (from the 11th week of fol-
(mg/dL)
low-up) due to increasing episodes of hypoglycemia in the
Fasting triglycerides 129 ± 6 106 ± 6 *  130 ± 10 139 ± 7 †
non-exercise days. The 3 HIT patients under antihypertensive
(mg/dL)
drug therapy before follow-up stopped taking the medication
HIT: high-intensity interval training group. CON: non-exercise control group. 
* denotes significant difference from pre follow-up in the same group (P < 0.05).
after physician recommendation at a routine medical consulta-
†
 denotes significant difference from HIT during the same period (P < 0.05) tion (from the 11th week of follow-up). There were no changes in
any medication dosage intake in the CON group during follow-
up ( ●▶  Table 2).

significant baseline differences between HIT and CON patients The 2-way ANOVA indicated significant interactions between
▶  Table 2, 3 and ●
were found in any variable ( ●  ▶  Fig. 2). There was inter- and intra-intervention in fasting glucose (F1,9 = 87.78,
also no significant differences in baseline characteristics P < 0.001), HbA1c (F1,9 = 128.29, P < 0.001), HDL cholesterol
between patients who completed the follow-up and those who (F1,9 = 57.81, P < 0.001), triglycerides (F1,9 = 20.27, P = 0.001), sys-
did not (data not shown). tolic (F1,9 = 37.29, P  < 0.001) and diastolic blood pressure

Alvarez C et al. High-Intensity Exercise and Diabetes …  Int J Sports Med

IJSM/5290/16.5.2016/MPS Clinical Sciences

group during follow-up (  ▶  Table 2). HIT group also showed a

●
a reduced body mass (1.6 ± 0.2 kg, P < 0.05), BMI (2.1 ± 0.3 %,
150
P < 0.05), waist circumference (4.1 ± 0.6 cm, P < 0.01) and skinfold
thickness (18.6 ± 1.4 %, P < 0.001) during follow-up (  ●
▶  Table 2).

Finally, the HIT group improved its endurance performance as

140
shown by a reduced time (9.8 ± 1.0 %, P < 0.001) to complete the
2KWT. The CON group did not change any variable during fol-
Fasting Glucose (mg/dL)

low-up. With these results, the HIT group displayed improved

130 levels of fasting glucose, HbA1c, HDL cholesterol, triglycerides,
endurance performance, waist circumference and skinfold
thickness compared to the CON group after the experimental
120 protocol.

Discussion
110
▼
The present study investigated the effects of a low-volume HIT
program in T2DM women. The primary finding was that the HIT
100 program was effective for reducing fasting glucose and HbA1c
HIT CON levels during 16 weeks of follow-up, which occurred even with a
b
8.5 reduction in the daily dosage of antihyperglycemic medication.

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In addition, the HIT program was also effective for improving
lipid profile, blood pressure levels, endurance performance and
8.0
body composition of T2DM women. To the best of our knowl-
edge, this is the first randomized controlled study that evaluated
7.5 the effects of a long-term (> 12 weeks) low-volume HIT program
in T2DM women.
7.0 Aerobic and resistance exercise training have shown improve-
HbA1c (%)

ments over the glycemic control in T2DM patients [3, 29, 35, 36].

6.5
6.0
5.5
5.0
HIT CON
Pre Post
Fig. 2  Fasting glucose a and HbA1c b before and after the experimental
protocol. HIT: high-intensity interval training group. CON: non-exercise
control group. *** denotes significant difference from pre follow-up in the
same group (P < 0.001). †denotes significant difference from HIT during
the same period (P < 0.05).
(F1,9 = 18.25, P = 0.002), body mass (F1,9 = 31.98, P < 0.001), waist
circumference (F1,9 = 38.88, P < 0.001), BMI (F1,9 = 35.05, P < 0.001),
skinfold thickness (F1,9 = 64.81, P < 0.001) and endurance perfor-
mance (F1,9 = 104.5, P < 0.001).
Post hoc analysis showed that there were significant improve-
ments in biochemical, hemodynamic, anthropometric and
endurance performance variables of HIT group during follow-
up. Fasting glucose and HbA1c were reduced (P < 0.001)
19.8 ± 1.9 mg/dL and 0.9 ± 0.1 % (9.9 ± 1.0 mmol/mol) after the HIT
program, respectively ( ● ▶  Fig. 2). Although total and LDL choles-
terol did not change significantly, the HIT group showed an
increase in HDL cholesterol (10.1  ± 
1.1 
mg/dL, P < 0.05) and
decrease in triglycerides (22.9 ± 3.4 mg/dL, P < 0.05) during fol-
low-up (  ▶  Table 3). Systolic blood pressure, but not diastolic
● betes medication. These results confirm the time-efficiency of
blood pressure, was reduced 3.7 ± 0.5 mmHg (P < 0.05) in HIT
Although a pioneer meta-analysis showed that exercise inten-
sity was a stronger predictor for HbA1c improvements than exer-
cise volume [3], recent meta-analyses did not confirm this
association [35,  36]. For example, an absolute 0.89  % (95 %
CI, − 1.26 % to − 0.51 %) reduction in HbA1c levels has been found
after exercise programs with volume > 150 min/wk, which were
greater than the absolute 0.36 % (95 % CI, − 0.50 % to  − 0.23 %)
reduction observed after exercise programs with vol-
ume < 150 min/wk [35]. Accordingly, a minimum of 150 min/wk
(30 min, 5 d/wk) of moderate to vigorous aerobic exercise, in
association with 2–3 sessions per week of resistance training,
has been recommended in the current American Diabetes Asso-
ciation and American College of Sports Medicine guidelines [9].
However, recent studies with HIT programs have suggested that
exercise intensity may have a key role in T2DM management.
When compared to energy expenditure-matched continuous
moderate exercise, HIT programs have shown greater improve-
ments in HbA1c [23], fasting insulin [17, 23], glucose control
assessed by continuous glucose monitoring [17] and others car-
diovascular risk factors [17, 23] in T2DM patients. In the present
study, it was shown for the first time that a 16-week progressive
low-volume HIT program, with a weekly time commitment
56–25 % (66–112.6 min/wk divided in 3 exercise sessions) lower
than the minimum recommended by current guidelines [9],
resulted in improvements of glycemic control (HbA1c and fasting
glucose levels), lipid profile, blood pressure, endurance perfor-
mance and body composition (BMI, waist circumference and sub-
cutaneous fat) in T2DM women. It is noteworthy that the mean
absolute reduction of 0.9 % on HbA1c levels was similar to the
reductions found in exercise programs with volume > 150 min/wk
[35], and occurred even with a reduction in daily dosage of dia-
low-volume HIT to T2DM management, which has been sug-

Alvarez C et al. High-Intensity Exercise and Diabetes …  Int J Sports Med

 Clinical Sciences
gested by uncontrolled studies with short-duration (only 2
weeks) and small sample size [20, 27].
The mechanism involved in the superior effects of HIT on glyce-
mic control of T2DM patients is not completely understood. One
might speculate that the ~1.6 kg reduction on body mass, which
was probably due to the reductions on visceral (~4.1 cm reduc-
tion on waist circumference) and subcutaneous fat (~28.0 mm
reduction on sum of 4 skinfold thickness), may be involved in
the glycemic control improvements found after the low-volume
HIT program. However, a previous study showed that a greater
HIT-induced reduction on body mass (~4.2 kg), which was due to
reduction on fat mass (no changes on fat free mass was found),
accounted for maximally 25 % of the glycemic control improve-
ments found after a HIT program [16]. Therefore, improvements
on skeletal muscle insulin sensitivity, explained by increased
peripheral glucose disposal probably due to increased GLUT4
protein content and mitochondrial capacity [16, 20], appears to
be involved in the low-volume HIT-induced improvements on
glycemic control found in the present study. In addition, the
~14.3 mg/dL reduction on plasma fasting glucose observed after
low-volume HIT, but not after CON intervention, does not allow
to rule out a training-induced improvement on hepatic glucose
output.
The present low-volume HIT program also resulted in significant
reduction of systolic (but not diastolic) blood pressure
(~3.7 mmHg), which occurred even after the 3 patients who
were under antihypertensive drug therapy prior to the interven-
tion stopped taking the medication during the follow-up.
Although there is a study showing a greater HIT-induced systolic
blood pressure reduction (~13 mmHg) compared to the one
found in the present study [23], others HIT intervention studies
in T2DM patients have shown no training-induced improve-
ments on blood pressure [15, 17]. HIT-induced improvements on
lipid profile in T2DM patients has also been inconsistent in the
literature. There are studies showing improvements only in LDL
cholesterol [17], in both LDL and HDL cholesterol [23], or no
improvements [30]. The same studies also showed no HIT-
induced improvements on triglycerides in T2DM patients
[17, 23, 30]. In the present study, we showed improvements on
HDL cholesterol and triglycerides levels, but not in LDL cholesterol
levels, after the 16-week low-volume HIT. Differences in exercise
intensity and volume of HIT protocol, as well as in intervention
duration may explain discrepancies between studies on training-
induced improvements in blood pressure and lipid profile.
The training-induced improvements observed in the present
study occurred after a HIT protocol of jogging/running and walk-
ing over ground that was prescribed using an easy and inexpen-
sive method [18]. This is an unique strength of the present study,
because most of intervention studies in T2DM patients have
based HIT prescription on cardiopulmonary exercise testing
[17, 20, 23, 27] and using ergometers for training [20, 23, 27],
which are expensive and may reduce HIT access to general pop-
ulation [8]. However, the present study investigated only over-
weight or obese women with less than 5 years of diagnosis and
with no disease-related complications. This limitation makes it
difficult to extrapolate present findings for other populations,
mainly long-standing T2DM patients with complications. We
did not provide any control for dietary changes during the study
and for physical activity during daily life after the intervention.
However, both HIT and CON groups were instructed to maintain
their dietary and daily physical activity patterns throughout the
16-week study period.
Alvarez C et al. High-Intensity Exercise and Diabetes …  Int J Sports Med
IJSM/5290/16.5.2016/MPS
Clinical implications
It is well known that T2DM is becoming increasingly prevalent
worldwide; it is also known that not only an improvement in
glycemic control but a reduction in cardiovascular risk factors
can positively affect disease morbidity, mortality and health
care expenditures [22, 28, 34, 39]. For example, decreases of
2.1/0.9  mmHg on systolic/diastolic blood pressure reduced
major cardiovascular events by 10 % in T2DM patients [34].
Decreases of 2–3 % in the risk for developing coronary artery dis-
ease has been suggested for each 1 mg/dL increase in HDL cho-
lesterol [22]. In this context, the HIT-induced improvements in
systolic blood pressure ( − 3.7 mmHg) and HDL cholesterol
( + 10.1 mg/dL) may have important clinical implications. More­
over, the low-volume HIT program resulted in low daily dosage
of diabetes medication in 54 % (7 patients) of the trained popula-
tion, and the 3 HIT patients taking anti-hypertensive medication
before training stopped taking it during follow-up. Thus, the
present low-volume HIT program also has important implica-
tions for reducing health care expenditures for medication.
Finally, the current low-volume HIT program resulted in glyce-
mic control improvements similar to those observed with
Downloaded by: Serials Unit - Periodicals. Copyrighted material.
greater volumes of exercise ( > 150 min/wk) [35]. Given that
most T2DM patients are sedentary or insufficiently active [24],
and lack of time is the most frequently cited barrier to regular
exercise participation [33], these findings may have important
implications for a public health perspective.
In summary, the low-volume HIT program was effective to
improve glycemic control, lipid and blood pressure levels, endur-
ance performance, medication dosage used and anthropometry
in T2DM women with a weekly time commitment 56–25 %
lower than the minimal recommended in current guidelines [9].
These findings suggest that low-volume HIT may be a time-effi-
cient intervention to treat T2DM women.
Acknowledgements
▼
The present research project was funded primarily by the Family
Healthcare Center Tomas Rojas (2014 Annual Grant), and by the
2014 Health Promotion Program of Los Ríos Health Service.
Conflict of interest: There are no conflicts of interest to declare.
Affiliations
1
 Cardiovascular Health Program, Centro de Salud Familiar, Los Lagos, Chile
2
 Department of Physical Activity Sciences, Universidad de Los Lagos, Osorno,
Chile
3
 Department of Physical Education and Recreation, Faculty of Education,
Social Sciences and Humanities, Universidad de la ­Frontera, Temuco, Chile
4
 Department of Human Movement Science, Faculty of Health, Medicine and
Life Sciences, Maastricht University, Maastricht, Netherlands
5
 Department of Physiology, Faculty of Medicine, Dentistry and Health
­Sciences, University of Melbourne, Victoria, Australia
6
 Rehabilitation, Public Hospital of Los Lagos, Los Lagos, Chile
7
 Exercise and Chronic Disease Research Laboratory, Physical Education
Department, School of Sciences, São Paulo State Univiersity - UNESP,
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