European Journal of Internal Medicine 21 (2010) 404–408

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European Journal of Internal Medicine

j o u r n a l h o m e p a g e : w w w. e l s ev i e r. c o m / l o c a t e / e j i m

Original article

Impact of exercise intensity and duration on insulin sensitivity in women with T2D
Åsa B. Segerström a,⁎, Forouzan Glans b, Karl-Fredrik Eriksson b, Anna Maria Holmbäck a, Leif Groop b,
Ola Thorsson c, Per Wollmer c
a
Department of Health Sciences, Division of Physiotherapy, Lund University, Box 157, 221 00 Lund, Sweden
b
Department of Clinical Sciences, Malmö, Diabetes and Endocrinology, Lund University, University Hopsital Malmö, Malmö, Sweden
c
Department of Clinical Sciences, Malmö, Clinical Physiology and Nuclear Medicine Unit, Lund University, 221 05 Malmö, Sweden

a r t i c l e i n f o a b s t r a c t

Article history: Background: Clinical guidelines seldom provide in depth information about the most suitable type and
Received 4 February 2010 intensity of exercise to obtain optimal benefit in different subgroups of T2D individuals.
Received in revised form 28 April 2010 The aim of this study was to examine the effect of group exercise training on exercise capacity, insulin
Accepted 10 May 2010 sensitivity and HbA1c in women with diabetes.
Available online 8 June 2010
Methods: Twenty-two women with T2D participated in a supervised group exercise program for six months.
The program combined endurance and resistance exercise. The duration and intensity of exercise for each
Keywords:
subject was recorded. The volume of exercise was calculated as the product of exercise duration and
Exercise
Exercise tolerance
intensity. Exercise capacity, insulin sensitivity and HbA1c were measured at baseline and after six months of
Exercise therapy training. The subjects were dichotomized with respect to training volume in a high training volume group
Insulin resistance and a low training volume group.
Results: Exercise capacity did not change significantly during the training period. Insulin sensitivity increased
significantly and HbA1c decreased significantly from baseline in the high volume group but not in the low
volume group. The increase in insulin sensitivity was explained with the intensity of exercise by 30%. The
reduction in HbA1c was explained with exercise by 25%.
Conclusion: Improvement in insulin sensitivity after six months combined supervised group training in
female diabetic subjects is related to exercise intensity, whereas the reduction in HbA1c is related mainly to
training volume. Metabolic effects of training may be seen in the absence of improved exercise capacity.
© 2010 European Federation of Internal Medicine. Published by Elsevier B.V. All rights reserved.

1. Introduction
Exercise is one of the cornerstones of treatment of type 2 diabetes
(T2D) [1]. Aerobic endurance exercise has traditionally been seen as
the most suitable exercise mode [1–3]. Resistance exercise has lately
been shown to be beneficial to glucose metabolism [1,4,5]. Combined
endurance and resistance exercise has been shown to contribute to
both improved glucose control and fitness [6–8].
The current recommendation for endurance exercise of the
American College of Sports Medicine (ACSM) for patients with T2D
is to exercise at an intensity of 50 to 80% of heart rate ratio (HRR) or
peak oxygen uptake (VO2peak) [9]. The duration of each session is
recommended to be 20 to 60 min and should be repeated about three
to four times per week. Resistance exercise is recommended to engage
large muscle groups. Ten to fifteen repetitions of each muscle group
are recommended. The exercise program should be performed at a
minimum of two days per week with at least 48 h between sessions
[9]. Generally, clinical guidelines do not provide in depth information
⁎ Corresponding author. Tel.: +46 46 222 66 97; fax: +46 46 222 18 08.
E-mail address: asa.segerstrom@med.lu.se (Å.B. Segerström).
about the most suitable type and intensity of exercise to obtain
optimal benefit in different subgroups of T2D individuals [10].
Little is known about the impact of intensity and duration of
training on improvements in exercise capacity, insulin sensitivity and
HbA1c. Boulé et al. [11], performed a meta-analysis of the effect of
structured exercise training on fitness in subjects with T2D. Of the
seven controlled trials included in the analysis, none was primarily
designed to investigate the impact of exercise intensity and volume. A
wide range of modes of training was used. The meta-analysis showed
that exercise intensity, but not volume, was associated with improved
VO2peak. Improvement in HbA1c was related to relative exercise
intensity (expressed as % VO2peak) but not to absolute exercise
intensity (expressed as metabolic equivalents) or exercise duration. In
a previous meta-analysis including 12 studies [12], neither exercise
intensity nor volume was related to improvement in HbA1c.
A few studies have examined the effects of various combinations of
exercise intensity and duration in healthy, normal [13] or overweight/
obese [14,15] subjects. DiPietro found [13], in elderly women, that
high intensity exercise was more beneficial for insulin sensitivity than
moderate intensity exercise when energy expenditure was kept the
same. In contrast, Houmard et al. [14] found that for two exercise
regimens with the same energy expenditure, longer duration of

0953-6205/$ – see front matter © 2010 European Federation of Internal Medicine. Published by Elsevier B.V. All rights reserved.
doi:10.1016/j.ejim.2010.05.003
 Å.B. Segerström et al. / European Journal of Internal Medicine 21 (2010) 404–408 405

exercise at moderate intensity had better effects on insulin sensitivity were performed to music and led by certified instructors. During the
than shorter duration at high intensity. We are not aware of any study first three month the classes included a warm-up period (10 min),
specifically measuring the impact of exercise intensity and duration in rhythmic aerobic exercise training (15 min) including ergometric
diabetic subjects. The aim of this study was therefore to examine the cycling, resistance exercises modes for arm, leg, abdominal and back
impact of exercise intensity and duration on changes in exercise muscles (15 min), cool-down and stretching exercises (10 min).
capacity, insulin sensitivity and HbA1c in diabetic women taking part Resistance training was performed with the individuals own body
in a group training program. weight, rubber band and dumbbells as resistance, with modes such as
biceps/triceps curls, standing push-ups, crunches, sit ups and belly
2. Materials and methods backs. Each resistance exercise mode was performed 15–20 times.
During the last three month the classes included a warm-up period
2.1. Subjects (10 min), rhythmic aerobic exercise training (25 min) including step-
up, resistance exercises modes for arm, leg, abdominal and back
Twenty-two female patients with T2D living in Malmö, Sweden, muscles (10 min), cool-down and stretching exercises (10 min).
with a sedentary lifestyle, participated in the study. The patients were Resistance training was performed with the individuals own body
recruited from an endocrinology specialist clinic in Malmö for a study weight as resistance, with modes such as push-ups, crunches, sit ups
on ethnicities [16]. Approximately half of the patients were first and belly backs. Each resistance exercise mode was performed 15–20
generation immigrants from countries in the Middle East. No patient times. All subjects took part in all exercise modes but exercised at
took part in any organized physical activity before the study. different intensity.
Background data are presented in Table 1. Six of the patients had Heart rate was monitored continuously during each exercise
clinical signs of neuropathy and five patients were treated with beta session by a Polar belt (Polar Fitness F1, POLAR, Oulu, Finland). The
blockers for hypertension. Patient characteristics are fairly represen- certified instructor kept records of heart rate and exercise duration
tative for a specialist clinic treating T2D patients in Sweden. All throughout the training program. Exercise logs for each participant
subjects gave written informed consent prior to their inclusion. The were kept by the instructor. It proved to be impossible to monitor the
study was approved by the regional ethical review board at Lund individual walks in a reliable manner.
University, Sweden.
2.3. Exercise tests
2.2. Exercise protocol
An incremental exercise test was performed on an electrically
All patients were invited to take part in a six months exercise braked bicycle ergometer (Bosch EAG 551, Berlin, Germany) at baseline
training program, consisting of supervised combined group exercise and after 6 months of training. The subjects started to exercise at 30 W
training twice a week. The patients were also instructed to walk for and continued to exhaustion with the workload increasing by 15 W
1 h once a week at a level of 12–13 on Borg's 20 graded scale for rating every minute [18]. Pedalling rate was 60 rpm which was aided by both
of perceived exertion (RPE) [17]. visual feedback and verbal encouragement. Expired gas was sampled
The supervised combined group exercise training consisted of continuously via a mixing chamber and analysed for the concentration
aerobic exercise training and resistance exercise training. Aerobic of O2 and CO2 (Sensor medics 2900, Bilthoven, Netherlands). Measure-
exercise training includes rhythmic aerobic exercise modes involving ments were obtained every 20 s during 1 min at rest, continuously
large muscle groups to improve cardiovascular endurance. Resistance during exercise and for 1 min during recovery. VO2peak was determined
exercise training was performed with the individuals own body as the highest value recorded during the last minute of the exercise test.
weight, rubber band and dumbbells as resistance aimed to increase Heart rate was measured by means of electrocardiography. All patients
muscular strength and muscular endurance. Stretching routines were required to exercise until exhaustion, which was aided by verbal
aimed at improving flexibility were performed. The aerobics classes encouragement. A respiratory exchange ratio (RER) above 1.0 was
reached by all subjects. Work rate was determined as the peak value in
Table 1
Watt.
Subjects characteristics, exercise and metabolic variables at baseline and after six
months of training in the low volume (below 50th percentile of exercise volume) and
2.4. HbA1c
high volume groups. M-value and HbA1c were log-transformed before analysis due to
non-normal distribution.
HbA1c was measured by HPLC (mono S, Pharmica LKB No 17-
Low volume group High volume group
0547-01) and plasma glucose was analysed with hexokinase method
Baseline 6 months Baseline 6 months (Beckman Syncron CX System chemistry).
N 11 11 11 11
Age (years) 51.8 ± 6.5 49.8 ± 7.3
2.5. Insulin sensitivity
Height (cm) 156 ± 5 167 ± 5**
Body weight (kg) 78.7 ± 10.3 80.2 ± 10.3 93.5 ± 10.2** 91.5 ± 12.3*
BMI (kg m− 2) 32.1 ± 3.5 32.7 ± 3.5 33.5 ± 2.2 32.8 ± 3.2 A Hyperinsulinemic–euglycemic clamp was carried out at baseline
FFM (kg) 46.1 ± 4.0 45.9 ± 4.2 50.2 ± 3.9* 51.0 ± 4.6 and after 6 months of intervention. The clamp was performed after
Peak heart rate (min− 1) 173 ± 24 166 ± 19 158 ± 22 160 ± 18 10 h of overnight fast 24–72 h after the last supervised group exercise.
VO2 peak(l min− 1) 1.39 ± 0.30 1.26 ± 0.26 1.49 ± 0.27 1.49 ± 0.36
The subjects were requested not to smoke during the fast. An infusion
VO2/body weight 17.8 ± 3.6 15.6 ± 2.5 16.1 ± 3.4 16.6 ± 4.4
(ml min− 1 kg− 1) (infusion rate 45 mU/m2) of short acting human insulin (Actrapid,
Work rate (W) 102 ± 18 103 ± 17 121 ± 16* 127 ± 17* Novo Nordisk, Denmark) was started and continued for 120 min.
RER 1.11 ± 0.06 1.07 ± 0.03 1.20 ± 0.08 1.08 ± 0.08** Blood samples for the measurement of plasma glucose were obtained
HbA1c (%) 6.5 ± 1.4 6.8 ± 1.0 6.6 ± 1.2 6.1 ± 1.0†
at 5 min intervals throughout the clamp. A variable glucose infusion of
M-value 2.8 ± 1.6 2.7 ± 2.2 2.3 ± 1.5 3.1 ± 2.2†
(mg kg− 1 min− 1) 20% glucose was started to maintain plasma glucose concentration
unchanged at 5.5 mmol/l, with a coefficient of variance (CV) of 6%.
Values are means ± SD.
FFM = Fat free mass.
Insulin sensitivity was calculated from the glucose infusion rates
Significantly different between groups *p b 0.05, **p b 0.05. during the last 60 min of the euglycemic clamp (M-value) and
Significantly different within group †p b 0.05. expressed as glucose uptake per body weight [19].
406 Å.B. Segerström et al. / European Journal of Internal Medicine 21 (2010) 404–408
2.6. Fat free mass
The fat free mass (FFM) was measured using bioelectric imped-
ance analysis (Akern Srl, Florence, Italy) according to Segal et al. [20].
2.7. Calculations
2.7.1. Exercise intensity
The exercise intensity was expressed as a percentage of the heart
rate reserve (HHR%) calculated as
HRexercise −HRrest
HRR% = × 100
HRpeak −HRrest
where HRexercise is the mean heart rate during the exercise session and
HRrest is the heart rate recorded before the exercise test at baseline
[21].
2.7.2. Exercise duration
The exercise duration was defined has the mean duration (min/
week) of supervised group session attended during the six months.
One hour of walking per week was included for all subjects.
2.7.3. Exercise volume
Exercise volume (HRR% min/week) was calculated as the exercise
intensity (expressed as HRR%) multiplied with the exercise duration.
2.7.4. Group dividing process
When data were analysed in this study the participants were
retrospectively divided into two groups. One group had exercised
above the 50th percentile of the exercise volume (high volume group)
and one group had exercised below the 50th percentile of the exercise
volume (low volume group). There were four subjects with neuro-
pathy in the high volume group, two of whom were also treated with
betablockers. The low volume group contained three subjects treated
with betablockers, two of whom also had neuropathy.
2.7.5. Statistics
A paired Student's t-test was used when comparing changes with-
in groups. Unpaired Student's t-test was used when comparing
groups. Pearson's correlation was used to analyse interaction between
variables. SPSS (version 13.0, SPSS Inc, Chicago, Illinois, USA) was used
for the statistical analyses. HbA1c and M-value before and after
training as well as the changes in HbA1c and M-value after training
showed skewed distributions. They were therefore log-transformed
before statistical analysis. The p b 0.05 criterion was used for establishing
statistical significance.
3. Results
Twenty-two subjects completed six months of supervised group
training. Height and weight were significantly higher in the high
volume group, though there was no significant difference in BMI. In
the low volume group were three subjects treated with beta blocker of
whom two also had clinical signs of neuropathy. In the high volume
group had four subjects clinical signs of neuropathy of whom two also
were treated with beta blocker. There was no significant difference
in VO2peak between groups but WR was significantly higher in the
high volume group both at baseline and after training. There were no
significant differences in HbA1c or insulin sensitivity at baseline
(Table 1).
Information about the training performed is shown in Table 2.
When the material was dichotomized according to exercise volume,
there was approximately 50% difference between the two groups.
There was a spectrum of subjects training at low intensity and with
Table 2
Training characteristics in the low volume (below 50th percentile of exercise volume)
and high volume groups.
Below 50th percentile Above 50th percentile
Duration (min/week) 167 ± 16 198 ± 9**
Intensity (HRR%) 65 ± 4 72 ± 6**
Volume (HRR% min/week) 10861 ± 1500 14278 ± 1135**
Values are means ± SD.
Significantly different between groups **p b 0.005.
long duration and vice versa as supported by a lack of correlation
between exercise intensity and duration (r = 0.39, p = 0.07) (Table 2).
There were no significant changes in VO2peak, VO2peak/body weight,
or WR in either group after the training period. HbA1c decreased and
insulin sensitivity increased significantly after six months of training in
the high volume group (Table 1).
We correlated exercise intensity, duration and volume with insulin
sensitivity and HbA1c measured at six months and also with changes
in insulin sensitivity and HbA1c during the training period (Table 3).
The change in insulin sensitivity during training showed a significant
correlation to training intensity and volume but not to duration.
HbA1c at the end of the training period as well as change in HbA1c
showed significant negative correlations to duration and volume of
training, even if there was no correlation to intensity.
4. Discussion
The main findings of this study were that insulin sensitivity
increased and HbA1c decreased significantly after six months of
combined supervised group training in subjects achieving a relatively
high exercise volume, whereas no significant changes were seen in
subjects achieving a lower volume. Improved insulin sensitivity
appeared to be related to training intensity, whereas improved
HbA1c appeared to be related to training volume. Almost no cardio-
respiratory exercise effects were achieved independent of exercise
volume in this group of T2D women.
Increased physical activity is considered an important life-style
modification in subjects with T2D. Supervised group training is often
advocated as a means of maintaining adherence [22]. A meta-analysis
has shown that the effect of exercise on fitness is greater if exercise is
prescribed, supervised and performed in groups [23]. The training
program used in this study was designed so as to be varied and
promote adherence. It was not our intention to use a strictly
standardised program. As could be expected from this design, we
got a spectrum of training duration and intensity in the group. The
study should thus reflect a real life situation of supervised group
training, combining aerobic and resistance training.
The duration of exercise during the supervised sessions was
calculated from the records kept by the supervising instructor. The
subjects were also instructed to walk once a week during the
intervention. The adherence to this recommendation could not be
monitored in a reliable manner, which gives uncertainty about the
estimation of exercise duration. The intensity of exercise during the
Table 3
Pearson's correlation coefficients between exercise variables and insulin sensitivity and
HbA1c measured after the training period as well as the changes during the training
period (ΔM-value and ΔHbA1c). M-value and HbA1c were log-transformed before
analysis due to non-normal distribution.
Exercise M-value HbA1c ΔM-value ΔHbA1c
(mg kg− 1 min− 1) (%) (mg kg− 1 min− 1) (%)
Intensity 0.15 − 0.33 0.54* − 0.37
Duration 0.16 − 0.60** 0.19 − 0.46*
Volume 0.16 − 0.56** 0.53* − 0.50*
Significant correlation coefficients between variables *p b 0.05, **p b 0.005.
 Å.B. Segerström et al. / European Journal of Internal Medicine 21 (2010) 404–408
sessions was estimated from the heart rate recorded during each
session. Heart rate reserve has been shown to be an accurate method
to monitor exercise intensity in T2D patients with or without auto-
nomic neuropathy [24]. There were no substantial differences in the
number of subjects with neuropathy or treatment with betablockers
between the two groups, and these factors are unlikely to have
affected the results.
4.1. Exercise effects
The subjects in the high volume group were training at an intensity
of 72%, which is within the limits recommended for this group of
patients [1,11,23,25]. They also complied with more than 80% of the
exercise sessions which is generally considered satisfactory [9]. An
increase in exercise capacity might therefore have been expected in
these subjects. The subjects in the low volume group have, on the
other hand, exercised at an intensity lower than recommended [1,9].
Studies of fitness training in T2D have primarily been performed
with endurance exercise [5,26–40] but also with combined exercise
[8,41]. In studies where an increase in VO2peak has been demonstrated,
exercise has amounted to 90–280 min per week [5,8,27,29–36,38–
41]. In studies where no increase in VO2peak was achieved, exercise
amounted to 60–240 min weekly [26,28,37]. Most studies were
conducted at training intensities above 60% of VO2peak [5,8,27,29–
34,41]. Burns et al. [26] suggested that subjects with T2D respond less
to training than healthy subjects, but this has not been a consistent
finding [33,42,43].
4.2. Insulin sensitivity
Most previous studies of exercise effects on insulin sensitivity in
T2D have used primarily endurance exercise e.g. [5,26,27,29–
32,34,44,45]. Fewer studies have been performed on resistance
exercise [5,46,47] and combined exercise [7,8]. While most studies
using endurance exercise show increased insulin sensitivity, there are
exceptions [5,26,44]. The studies on resistance and combined exercise
show consistently an increase in insulin sensitivity [5,7,8,46,47]. Sigal
et al. [7] suggested that combined exercise results in greater increase
in insulin sensitivity than endurance or resistance exercise alone. It
has been suggested that a certain total energy expenditure is required
to enhance insulin sensitivity [27,48]. The impact of training intensity
and duration has, however, not previously been addressed in diabetic
subjects. The limited information available in non-diabetic subjects is,
as indicated above, conflicting [13,14]. Our finding that insulin
sensitivity increased only in the high volume group supports the
concept that a certain energy expenditure is required for this effect to
occur. The correlations analysis indicates that, for a given training
volume, intensity rather than duration is related to improved insulin
sensitivity.
4.3. HbA1c
It is well known that training can reduce HbA1c in subjects with
T2D [12,49]. A meta-analysis [12] including 14 trials showed that
HbA1c is reduced also in the absence of weight loss. The meta-analysis
did not find any relation between the effect on HbA1c and intensity
and duration of exercise. A larger meta-analysis including 103 studies
of interventions [49] aimed to modify self-management of T2D and
including exercise also showed reduction in HbA1c. In this meta-
analysis, the effect was weakly related to the duration of the
intervention, but inversely related to the duration of the exercise
session. It should be emphasised, however, that this analysis refers to
the duration of exercise recommended rather than to that accom-
plished. We found a reduction in the high volume group only and that
the reduction in HbA1c was best correlated with training volume.
Significant reduction in HbA1c was also found in some previous
407
studies with similar training volume (11600–18900 HRR% min/week)
as in our high volume group [8,29,31,32,39]. Other studies with lower
training volume (4800–9750 HRR% min/week) showed no effect on
HbA1c [5,28,30,36,38]. Our results are thus in agreement with
previous studies.
The reason why reduction in HbA1c is related to training volume is
probably that moderate as well as intense exercise causes a short-
lasting reduction in plasma glucose [50,51]. Regular exercise, even if
of moderate intensity, may therefore reduce HbA1c over time.
4.4. Limitations
One limitation of the present study is the relatively small number
of subjects. Exercise training studies with long duration are difficult to
perform, especially in sedentary subjects. The number of subjects in
our groups is similar to many previous studies. A further limitation is
that the analysis was done retrospectively. The findings therefore
need to be confirmed in prospective studies. Ideally, the spontaneous
physical activity of the subjects should also be monitored, e.g. by
accelerometry. We selected not to include a non-diabetic control
group in the study. There are several problems associated with a
control group in this type of study, e.g. matching with respect to body
weight. Furthermore, there is evidence suggesting that diabetic
subjects respond less to exercise training than non-diabetic subjects
[52]. The optimal training program may therefore be quite different in
diabetic and non-diabetic subjects.
In conclusion, this study suggests that the improvement in insulin
sensitivity after six months combined supervised group training in
female diabetic subjects is related to exercise intensity, whereas the
reduction in HbA1c is related mainly to training volume. Metabolic
effects of training may be seen in the absence of improved exercise
capacity. Further prospective studies are required to determine the
appropriate type, intensity, frequency and duration of training in
subjects with T2D.
5. Learning points
• Increase in insulin sensitivity is related to exercise intensity in
women with type 2 diabetes.
• Reduction in HbA1c is mainly related to training volume women
with type 2 diabetes.
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