Exercise Must Be a Prescription for Those With Type 2 Diabetes, European Cardiologists Say

Keeping patients with diabetes motivated is the most challenging part of exercise, the authors say, as they call for psychologists and counselors to be part of the care team.

People with type 2 diabetes (T2D) need individual prescriptions for exercise, not finger-wagging from their doctors, according to a new position paper from the European Association of Preventive Cardiology.

The group is a branch of the European Society of Cardiology (ESC), which publishes the European Journal of Preventive Cardiology, where the paper appears Tuesday. “Just advising patients to exercise, which is what doctors typically do, is not enough,” first author Hareld Kemps, MD, a cardiologist with Maxima Medical Centre in the Netherlands, said in a statement. An actual prescription for exercise is needed, the authors say.

Kemps said that physicians must “take the lead” in calling for programs to be reimbursed by insurers.

Making movement a daily habit seriously lowers the risks associated with heart disease, which is the leading cause of death among people with T2D. It’s also the most cost-effective way to treat the disease, but it’s also the most difficult because so many people stumble when trying to stick with a fitness plan.

To address this, the paper encourages physicians to integrate exercise in a patient’s daily routine and increase their cardiorespiratory fitness over time. Showing the patient how measurable improvements are improving their health beyond what they see on the scale can keep patients motivated. The paper points out the need to work with a team of professionals, involving specialists such as psychologists and counselors, to help T2D patients achieve their goals.

Among the report’s recommendations and findings:

  1. A patient’s cardiorespiratory fitness should be assessed with cardiopulmonary testing before an exercise program begins. Getting low-density lipoprotein cholesterol under control is important for patients who have not been active.
  2. Each patient’s exercise plan should be customized, and doctors should increase goals as the patient hits fitness milestones.
  3. Where possible, combining aerobic training and resistance training is the best way to improve glycemic control and muscle mass and function.
  4. Both glycated hemoglobin (A1C) and cardiorespiratory fitness are important measures of the success of a training program.
  5. Current evidence does not support or refute that exercise that that exercise reduces death rates in T2D patients, but there is evidence that exercise reduces microvascular complications that lead to disability, such as the loss of kidney function or nerve damage.
  6. Improving vascular function is a good reason to exercise; it reduces the chance of a heart attack and eases symptoms such as erectile dysfunction, apart from the benefits for improving A1C.
  7. Exercise can help control of lipids, but it does not replace medication like statins.

What kind of exercise is best?

While the report generally recommends a combination of aerobic activity, such as running, cycling, or swimming, to improve cardiovascular fitness; along with resistance training to build muscle mass, how this happens will vary with each patient.

Keeping patients engaged is key. “Motivation and thus adherence might be improved by early achievement of certain exercise training goals,” the authors state.

The paper specifically recommends aerobic training 3 to 5 times per week, and it discusses the benefits of high intensity interval training (HIIT), which allows patients to maximize heart rate in short bursts from 1 to 4 minutes. But the paper cautions that HIIT “requires high levels of motivation and capability of the patient,” demands more supervision, and calls for a structured training plan.

A simpler strategy is telling the patient to break up long periods of sitting by walking around and stretching.


The paper discusses how to decide who can exercise, and which forms are safe for which patients. It calls for doctors to create “relevant and achievable targets,” including those that involve improving the quality of life. Some patients with T2D have serious health problems that would prevent certain types of exercise, or require them to slowly build up cardiorespiratory fitness over an extended period.

The paper spells out precautions and protocols for patients with arrhythmia, myocardial ischemia, cardiovascular autonomic neuropathy, and left ventricle dysfunction. Authors say those with peripheral artery disease should not perform high-intensity exercise. They recommend that patients be regularly checked for hypertension, glycemic status, and spell out when stress tests are required.

The main problem, however, is adherence, which the authors say “is severely affecting the outcome of many trials.”


Kemps H, Krankel N, Dorr M et al, on behalf of the European Association of Preventive Cardiology. Exercise training for patients with type 2 disease: what to pursue and how to do it. [published online January 15, 2019] Eur J Preven Cardiol. 2019. doi:10.1177/2047487318820420.