Review Article Open Access
Diabetes and Physical Activity
Jameela Banu*
Coordinated Program in Dietetics, Department of Health and Biomedical Sciences, College of Health Affairs and Department of Biology, College of Sciences, University of Texas Rio Grande Valley, 1201 W University Dr, Edinburg, TX 78539-2999, USA
*Corresponding author: Jameela Banu, Coordinated Program in Dietetics, Department of Health and Biomedical Sciences, College of Health Affairs and Department of Biology, College of Sciences, University of Texas Rio Grande Valley, 1201 W University Dr, Edinburg, TX 78539-2999, USA, Tel: +956-665-3222; Fax: +956-665-5253; E-mail: @
Received: August 31, 2015; Accepted: February 20, 2016; Published: February 24, 2016
Citation: Banu J (2016) Diabetes and Physical Activity. J Endocrinol Diab 3(1): 1-12.
Diabetes has been on the rise globally. Although many factors contribute to the increasing risk and manifestation of this disease lack and decreased physical activity/ exercise stands out as one of the major factors. Treatment interventions for prediabetic and diabetic patients include diet and lifestyle changes with enhanced physical activity/ exercise. Several types of physical activity are available for these patients but, recommendations have to be made on an individual basis after giving due consideration to the co morbidities and other risks and barriers. Implementation of progressive resistance therapy may be successful in maintaining glucose homeostasis in diabetic patients.

Keywords: Diabetes; Aerobic exercise; Resistance exercise; Myostatin; miRNA; Osteocalcin
Recently, there is an increase in the number of individuals diagnosed with diabetes- A medical disorder associated with an imbalance in glucose homeostasis. Many factors contribute to this condition and one of the most important factors, in addition to diet, is a lack of Physical Activity (PA)/ Exercise (EX) and adoption of partial or complete sedentary lifestyle. PA is the daily activities an individual performs in addition to planned EX regimens. Interventions that include increased physical activity/ exercise along with medications are highly recommended. However, with several different options available for EX regimens, it is important to select the most beneficial form of EX for individuals, considering the existing lifestyle and co-morbidities. This review focuses on the various factors and mechanisms that are affected by diabetes and physical activity. PubMed and Medline were the databases used to collect relevant literature, and they are compiled and discussed. In addition, the risks and barriers associated with the different types of PA are also discussed.
Diabetes is a medical condition that affects 347 million people around the world. In 2014, the global prevalence of diabetes was estimated to be 9% among adults aged 18 and above [1]. In the United States, in 2012, 29.1 million people (9.3% of the population) had diabetes [2] and diabetes remained the 7th leading cause of death in the US, in 2010. The total cost of diagnosed diabetes is $245 billion in 2012. This included $176 billion in direct medical expenses for emergency care, hospitalization, office visits and medications and $69 billion as indirect costs such as days absent from work, reduced productivity, unemployment due to diabetesrelated disability and lost productivity due to early mortality [3].

There are two major types of chronic diabetic conditions identified – Type I Diabetes Mellitus (T1DM) and Type II Diabetes Mellitus (T2DM). A temporary diabetic condition is also seen during pregnancy in some women and is termed gestational diabetes mellitus. Diabetes, in general, is characterized by increased circulating blood sugar and uncontrolled diabetes. These adverse effects lead to many complications that affect several organs like skin, eye, kidney, heart, nerves, bone, etc. resulting in ketoacidosis, high blood pressure, stroke and severe Diabetic Neuropathy (DPN) of the extremities [4-7]. DPN affects predominantly the distal segments of the lower limbs impairing walking and daily activities [4,7]. In addition, diabetic patients have decreased skin thickness, increased skin hardness, thickened tendons, muscle atrophy, impairment and activation delays, and decreased bone mineral density, limited mobility at joints, less thick fat pad and gait changes [8-14]. The severity of the complications advances with age and adds to the complications of the normal aging process.

Muscle strength of the upper and lower body correlated with measures of diabetic complications especially with sensory and autonomic functions [6]. Loss of muscle strength is associated with atrophy of ankle and foot muscles due to denervation caused by loss of motor axons combined with insufficient innervations [15]. Also, Peripheral Arterial Disease (PAD), due to diabetes, may aggravate muscle weakness and atrophy of limbs including the upper limbs [16] where handgrip strength decreased with age [8].

T1DM is usually diagnosed in children and is characterized by a lack of insulin due to non-functional or destroyed pancreatic β cells. The auto-destruction of β cells [17] is controlled genetically. In addition, T1DM patients have greater utilization of fatty acid and oxidation as well as, decreased glucose utilization [18]. The kidneys are overworked in T1DM patients, as these patients have higher hyperfiltration rate due to increasing glomerular hypertension in the kidneys [19] and undergo diabetic nephropathy [20]. However, only 5% of all the individuals diagnosed with diabetes are diagnosed with T1DM, which is about 1.25 millions of Americans [21].

T2DM, on the other hand, is seen in adults and older individuals. These patients usually develop insulin resistance (IR) as underutilization of insulin leads to increased circulation in the blood resulting in decreased production of insulin, and eventual failure of β cells [2]. A Majority of the total number of patients diagnosed with diabetes 90-95% is T2DM [2].

Actually, IR starts before β cell damage and shut down of the pancreas [22-27]. For insulin-dependent glucose transport, insulin first binds to the insulin receptor on the plasma membrane and triggers the signaling pathway to mobilize glucose from the cells. After insulin binds to its receptor, Insulin Receptor Substrate-I (IRS-I) is phosphorylated and this activates Phosphoinositide-3 Kinase (PI3K) and protein kinase B (Akt), leading to translocation of glucose transporter 4 (GLUT4) to the membrane and subsequent transportation of glucose into the cells. In the case of IR, IRS-1 phosphorylation is defective so is the activation of PI3K and Akt [2], therefore, GLUT4 is not translocated to the membrane, thus, decreasing the uptake of glucose into the cells. This leads to dysfunction in skeletal muscle with (a) IR in the muscles [28]; (b) buildup of intramuscular triglycerides [29,30]; (c) impaired mitochondrial function [2,31]; (d) impaired glycogen synthesis; and (e) lipid accumulation around and within the muscles [2]. Several factors cause IR, such as inflammation, reduced mitochondrial content or dysfunction mainly by accumulation of lipid intermediates in skeletal muscle [32]; reduced insulin signaling leading to decreased insulinstimulated GLUT4 translocation and aging [33].

In diabetic individuals, muscle function is compromised. Muscles are influenced greatly, by the levels of Myostatin, a protein that inhibits muscle differentiation and growth [34-37] and attenuates muscle fiber protein accretion [38-40]. Myostatin has direct metabolic effects on other tissues like adipose and liver as well [41]. In T2DM, there is an increase in the mRNA levels of Myostatin [42], and this is inversely related to insulin sensitivity which directly influences glucose uptake and utilization in a cell-specific manner [41]. Myostatin also affects glucose uptake indirectly, through Tumor Necrosis Factor-α (TNF-α) expression, which antagonizes insulin-mediated glucose uptake [43]. In addition, mutations in Myostatin gene and impaired Myostatin protein leads to increase in muscle mass in animals and humans [39, 44-46].

Diet plays an important role in manifestation, establishment, and progression of diabetes. As glucose metabolism is affected, it is very logical to focus on carbohydrate intake in diabetic patients and has been the practice for a long time. Interventions on regulating carbohydrate intake reduced circulating glucose levels. However, there is increasing evidence pointing towards the role of excessive intake of fats also leading to IR. T2DM patients show increased levels of fat uptake soon after meals [47]. Lipid accumulates in adipocytes within muscle tissues and fibers [48] which are one more factor that can cause IR [30,49]. In addition, chronic overload of calories with increased adiposity also leads to IR [50] and hypocaloric diet reduces both fat and lean mass [51]. IR, in the skeletal muscles, also develops when there is increased H2O2 production in the mitochondria as a result of acute and chronic intake of high-fat diet [52]. Moreover, high-fat diet-induced IR and glucose intolerance was decreased in mice that had mutated Myostatin along with decreased TNF-α level in muscle and adipose tissue [53]. Therefore, myostatin down-regulation may be beneficial to diabetic patients.

Diabetic patients also exhibit a faulty energy balance. This is attributed to decreased mitochondrial density, size and ultrastructure [54], and impairment of the oxidative capacity of mitochondria in the skeletal muscle [55]. The Electron Transport System (ETS) housed in the mitochondria, and responsible for producing most of the energy molecules-Adenosine Triphosphate (ATP), is also impaired [56]. The hydrogen molecules that are necessary for ATP production enter the ETS from the TCA cycle and β oxidation through Nicotinamide Adenine Dinucleotide (NAD). Higher levels of reduced Nicotinamide Adenine Dinucleotide (NADH) production from the Tricarboxylic Cycle (TCA) and β oxidation are reported from muscle cells of T2DM patients [57]. This results in a buildup of high reducing equivalents in energy metabolism, leading to the accumulation of acetyl-CoA, ceramides, and diacylglycerols which correlate with IR and altered insulin cascades [58].

Oxidative stress is one more factor that may play a role in the development of diabetes [59,60]. Oxidative stress increases with aging [61] and a combination of low intake of antioxidants with decreased PA contributed to the escalation of oxidative stress [52,62]. One of the molecules that contribute to oxidative stress is nitric oxide (NO). Many metabolic reactions in the body are mediated by NO, which is produced with the help of the enzyme Nitric Oxide Synthase (NOS). NOS are produced in several different organs of the body including pancreatic β cells [63]. In T1DM, β cell degradation is associated with NOS, which is associated with increased pro-inflammatory cytokines that induce apoptosis of cells [64]. However, dual effects of NO have been reported. Depending on the NO concentration, anti-apoptotic or pro-apoptotic effects may occur [65]. At high concentrations, excessive NO is detrimental to the β cells and at low concentrations NO protects these cells. It is also important to note that under IR and T2DM conditions, there is increased circulation of NOS inhibitor in the plasma which results in decreased NO production – a natural adaptation of the body to reduce NO production. On the other hand, when there is impaired glucose-stimulated insulin secretion (GSIS), NO production is enhanced [66]. Therefore, normal functioning of the GSIS is necessary, to avoid the deleterious effects of NO. Moreover, insulin can also increase NOS activity [67].

During the last decade, the importance of microRNA (miRNA) in the regulation of metabolism had been brought to light. miRNA are small molecules that play an important role in the eventual expression and translation of mRNA and proteins. They have been implicated in glucose homeostasis and IR as well. Interestingly, miRNAs' are associated with changes in fat mass and IR in children [68]. Silencing certain miRNA's like miR103 and miR107 improved glucose homeostasis and insulin sensitivity while other miRNA's like miR103 and miR107 impaired glucose homeostasis [69]. Glucose tolerance and IR is also modulated by Let-7. Overexpression of Let-7 led to IR [70] and has been found at higher levels in T2DM patients [71]. miRNA's such as miR133a and miR206 were downregulated in T2DM patients and an inverse relationship between IR and miR133a exists [72].

Recently, Osteocalcin (OC), a protein secreted by bone cells and important for bone formation has been shown to play an endocrine role in influencing insulin secretion and sensitivity. Undercarboxylated OC (UnOC) fraction increased insulin secretion and sensitivity and decreased visceral fat in males and females [73]. Increase in serum OC and UnOC levels, improved insulin secretion and/or sensitivity in humans [74,75]. Lack of OC led to glucose intolerance in muscles [76]. Mice, genetically modified to increase UnOC are protected from T2DM and obesity [76]. Injection of OC improved glucose tolerance and insulin sensitivity in high fat fed mice [76]. Mice treated with intermittent OC injections displayed more mitochondria in their skeletal muscles and increased energy utilization. In addition, they were protected from diet-induced obesity, improved glucose handling, prevented the development of T2DM, and liver steatosis [76]. Interestingly, mice lacking OC have decreased β cell proliferation [75]. Therefore, OC may be used as treatment option along with medications, diet modifications, and PA interventions.
Physical activity/ Exercise
Global industrialization is responsible for drastic lifestyle changes in humans. One major drawback is the lack and/or reduction of PA, which is essential for maintaining health and healthy aging. Lack of sufficient daily PA is an underappreciated primary cause of most chronic conditions [77]. Therefore, there is increasing emphasis on maintaining PA and EX regimen throughout an individual's lifetime. PA/EX during childhood influences many organ systems in the body to function and develop normally, in addition to reducing obesity and complications that arise from diabetes. In adults, also PA/ EX is encouraged to reduce the risk of developing several health issues that may arise, during and after middle age. The elderly are more susceptible to frailty, and a daily EX regimen is emphasized to maintain better health, thereby, improving the quality of their life [78]. There are reports of age-related decreases in muscle mass, and EX regimen increased muscle mass and strength as one age [79]. Convincing evidence suggests that sedentary lifestyle increased the risk of cardiovascular disease (CVD) in T1DM patients [80]. In addition, inactive muscles are not capable of removing oxidative intermediates due to insufficient electron transport and results in lipid toxicity [81,82]. Moreover, continued longterm reductions in PA/EX and inactivity are the primary causes of IR [52,83]. Daily PA reversed the risk of development of diabetes in prediabetic patients [52]. Furthermore, muscle loss occurs with aging and there is a decline in aerobic capacity with a dramatic decrease in PA/EX [51,84]. A Normal function of an individual is dependent on sufficient aerobic capacity and muscle strength [51]. Therefore, an increase daily PA and a continuous EX regimen are important to avoid several medical complications including diabetes.

There are several benefits of EX-(a) decreased mortality up to 40%and lower utilization of health care services [85-94]; (b) prevention of Coronary Heart Disease (CHD) [95,96]; (c) decreased lipid levels [97,98]; and (d) body composition [99]. With regular EX, primary and secondary prevention of several chronic conditions including diabetes has been reported [51]. Regular EX also decreased glucose levels and increased insulin receptors effectiveness [100].

EX can be of different types-aerobic EX-involves a large group of muscles. This EX regimen is for extended periods of time and includes multiple repetitions. It also includes endurance EX for both the muscles and heart and is reported to increase mitochondrial abundance and aerobic capacity [101]. On the other hand, resistance EX (REX) involves a movement of high loads using machines or weights or both and the number of repetitions is relatively less [102,103]. This is reported to increase muscle mass in middle-aged and elderly [101]. Both aerobic EX and REX are associated with decreased risk of T2DM. Even a single bout of muscle contraction increased insulin sensitivity in animals and humans [104-113].

Another important fact is that EX can also induce non-insulin dependent uptake of glucose. For example, IR patients show contraction mediated uptake of glucose through calcium and adenosine monophosphate-activated protein kinase (AMPK) [114,115] with an increase in AMPK α 2 mediated glucose uptake after EX [116]. The intensity of EX controls the uptake of glucose and sometimes both pathways may be involved in this. Whole body strength training for 16 weeks shows improved homeostatic model assessment-IR (HOMA-IR) in T2DM Hispanic adults [117] and increased hepatic insulin sensitivity [28].

EX influences NOS, a membrane protein found in the muscle fibers, and is increased in many disease conditions [118,119]. There are three kinds of NOS-eNOS which is co-localized with mitochondrial markers in muscle fibers [118]; iNOS that increased under conditions of inflammation and the presence of pro-inflammatory cytokines [120,121]; and nNOS that is found in the outer membrane of muscle fibers and neuromuscular junctions [119]. During EX, NO production is increased initially due to a burst of the NOS activity [122]. NO production is induced by an increase in pro-inflammatory cytokines due to EX, which supplies oxygen during vigorous EX [123]. Prolonged treadmill EX, also increased protein expression of nNOS and eNOS and the contractile activity of skeletal muscles [122,124,125].

EX is also influenced by miRNA's as they control muscle proliferation, differentiation and apoptosis [126] and regulate the aging process and changes in skeletal muscles [127-129]. During aging, in mice, the quadriceps muscles expressed upregulated miR7, miR206; miR468, miR542, and miR698 while miR124a, miR181a, miR221, miR382, miR434, miR455 were downregulated [130]. In Rhesus monkeys, miR15a, miR18a, miR144, and miR451 were up-regulated and miR181a/b was downregulated with aging [131]. Both aerobic EX and REX influenced the expression of different miRNAs. During aerobic EX miR181, miR1 and miR107 are up-regulated and miR23 is downregulated in mice [132]. But in humans, miR1 and miR133 increased before EX, rather than after EX [133] in several muscles. REX down regulated muscle specific miR-1 and miR133a, in mice [134]. In humans, miRNA up-regulation and downregulation was reported based on responders with reference to hypertrophy of vastus lateralis muscles [135]. Downregulation of miR26a, miR29a and miR378 was reported in low responders with upregulation of miR451. There were 15 other miRNAs' that were not affected by REX. These miRNA's may modulate yet another pathway-the mammalian target of rapamycin (mTOR) signaling pathway, which is activated during muscle protein anabolism and REX [135]. REX also increased insulin-like growth factor-I (IGF-I) and decreased miR1 which may result in increased muscle cross-sectional area, in elderly men and women after EX [136]. In addition, EX also increased UnOC this had potentially positive effects on glucose tolerance [73].
Impact of exercise on diabetes
T1DM: In T1DM individuals, aerobic EX maintained glycemic control and decreased the amount of insulin required to maintain circulating glucose levels, although HbA1cdid not change [17]. After EX, insulin in pancreatic β cells increased and insulin secretion by the pancreas also enhanced. It also stimulated the uptake of glucose by muscles and supported muscle contraction. In addition, muscle cells were protected from oxidative damage [137-142]. Short term and long term aerobic EX also increased GLUT4 [142,143] which is required for glucose transport into the cells.

NOS is highly influenced by EX. Interestingly, although GLUT4 mediated transport of glucose is independent of NO, NOS activity enhanced glucose transport and the NOS inhibitor-LNG- Monomethyl Arginine (L-NMMA) attenuated glucose uptake [124]. At low concentrations, NOS can positively influence insulin secretions while at high concentrations it may have a negative influence on pancreatic β cells and inhibit insulin secretion [63]. Therefore, TIDM patients may have to increase the intake of the diet containing anti-oxidants, before EX, to counter the production of NO.

EX is an indispensable component of treatment for patients with T1DM [144]. Even low-intensity EX helps [17] and Stretching EX decreased T1DM neuropathy and pain [145]. However, it has been reported that moderate EX helped in declining glucose levels rapidly during the exercise and slowly reversed back after the exercise when compared to high-intensity EX and REX [146]. High-intensity EX programs showed great improvements in insulin response to oral glucose load compared to lower intensity aerobic EX [147]. Therefore, the overall impact on circulating glucose levels were attained more with intermittent moderate EX and some high-intensity EX.

T2DM: In insulin resistant middle-aged men, aerobic EX decreased muscle and plasma myostatin and this strongly correlated with insulin sensitivity and diabetic patients [148]. In mice, there was decreased the circulation of myostatin, insulin and glucose levels [148] after EX, which decreased IR. Aerobic training increased insulin sensitivity in T2DM patients [149,150]. In addition, aerobic EX in T2DM patients reversed advanced glycation in kidney and ameliorated the early signs of diabetic nephropathy [151]. Kidney function is also influenced by EX. There are reports that there is reduced glomerular mesangial volume and decreased albumin excretion, a level of lipid peroxidation and fibrogenesis in glomerular mesangium [152-154]. Moreover, improved cardiac function may also protect kidney function after EX [155]. Aerobic EX showed increased glucose disposal rate in these patients [156]. In addition, treadmill EX in rats increased insulin sensitivity, improved insulin-mediated capillary recruitment in combination with augmented muscle glucose uptake [137].

Endurance training in T2DM individuals increased the expression of GLUT4 protein and mRNA [157,158]. EX also decreased glucose-stimulated insulin levels [159] and myostatin [41]; especially high bouts of Endurance EX decreased myostatin mRNA levels [160,161]. Furthermore, myostatin null mice displayed decreased endurance performance and energy is regulated by increased mitochondrial enzymes such as citric synthase and succinate dehydrogenase [162,163]. An important fact is that levels of myostatin mRNA is different depending on the time after EX [164]. Another way REX can influence muscle maybe by decreasing skeletal muscle myostatin mRNA expression and plasma protein levels [165-170]. However, some reports on REX did not show the same benefits [171,172] and this may be due to differences in the experimental protocols such as - terms of rest, repetition, a number of contractions, intensity, training state and biopsy sampling time.

Many benefits of REX have been reported in T2DM patients. In addition, to decreasing neuropathy and pain, REX improved the glycemic index, HbA1C, adiposity and muscle strength [145,173,174], it also reduced fasting insulin, increased insulin sensitivity, glucose disposal rates and improved glucose tolerance [175-179]. REX increased glucose uptake in muscles by increasing and translocating GLUT4 to the plasma membrane [180]. In addition, REX also increased skeletal muscle crosssectional area, muscle cell mitochondria [181] and improved mitochondrial function [182-184].

Risks and barriers of EX: Many patients have reported several difficulties in fulfilling the EX regimens recommended to them. Some of the problems they face may include allocation of time; work schedule, weather, proximity and access to facilities, lack of motivation [185]. Among those who have low economic status, several psychological factors, like embarrassment and fear of failure, negative body image and chronic disease stigma that needs vigilance during PA/EX (especially among T1DM patients with fear of hypoglycemia) [186] are also barriers that contribute to non-compliance. Other obstacles include numerous intrapersonal reasons like lack of energy, lack of time due to other leisure activities and perceived competencies, as well as interpersonal reasons such as family, friend peer support, environmental/organizational factors, opportunity, resources, etc. [77,187-189].

Although PA/EX is recommended for healthy living, it is associated with several risks as well. Usually high intensity, as well as rapid increase in intensity is detrimental for the patients. One very dangerous side-effect is the late onset of hypoglycemia after EX, especially in T1DM individuals. Aerobic EX caused acute risk of hypoglycemia [190], while intermittent and REX had the lowest likelihood of hypoglycemia [185,191]. Another important physiological change is that moderate and exhaustive EX may generate oxidative stress, which can enhance IR [192]. Therefore, when interventional methods are recommended, a combination of several factors such as intensity of EX and co-morbidities including CVD, stroke, etc. should be taken into consideration.
In order to successfully reduce the risks of diabetes in humans and maintain a healthy life with diabetes, significant multiple lifestyle changes seems to be the best approach [193-199]. These changes include diet modifications and PA/EX with medicines [200,201]. Consumption of decreased carbohydrates and fats, with the inclusion of moderate to high amounts of fiber, will be the major dietary changes for prediabetic and diabetic patients.

Diet adjustments should accompany changes in PA/EX as well. Both T1DM and T2DM will benefit from these changes. Although T1DM patients may have to continue taking insulin, the amount of insulin can be reduced significantly. Regular EX is important as it reduced HbA1C in T1DM [185], however, moderate caloric restriction intake with PA reduced fat mass [202] can be beneficial too.

T2DM patients may benefit more extensively with diet and lifestyle changes. Non-diabetic children of T2DM and IR T2DM patients showed decreased insulin sensitivity, muscle mitochondrial density, mitochondrial electron transport and insulin-mediated skeletal muscle glucose uptake [22,23,56,203], putting them at high risk of developing diabetes. Such individuals can delay the onset of diabetes by increasing their PA/ EX. Independent of the type of EX, both prediabetic and diabetic patients showed benefits with increased PA by improving insulin sensitivity and maintaining glucose homeostasis. Moreover, the habitual physical activity may prevent and postpone non-insulin dependent diabetes [100]. Aerobic EX is good, so is repetitive EX [204]. The overall an increase in PA, increased post-receptor insulin signaling increase in GLUT4 mRNA and protein levels [63,157], glucose synthase [205], hexokinase [206], β cell function [146], An influx of glucose to muscles, enhanced muscle capillarization and blood flow [207,208]. Increased blood flow, stimulated NO which induced smooth muscle relaxation and vasodilation [209]. However, REX may be better than aerobic EX, and may result in program retention and success of the interventional objectives [185].

As mentioned earlier, EX can affect several pathways to maintain glucose homeostasis. Apart from increasing insulin sensitivity and mobilizing glucose into the cells, it can influence the insulin signaling pathway through miRNAs' to stimulate glucose uptake. Another protein that is impacted due to EX is OC, which increased insulin secretion, sensitivity, and mitochondria in the muscles, thereby, affecting the energy balance which is disrupted in diabetes [75].
In conclusion, it is established that people with moderate to high levels of EX have lower mortality rate and utilization of health care services. However, physical fitness is dependent on nutritional status, dietary and smoking, genetics, socio-economic factors and PA. In addition, it also depends on pulmonary and muscle function health status of other organ systems, medications, and orthopedic limitations [77,210]. To have attainable goals, which may be more pleasant and an inspiring experience [211], graduated physical activity with small increments and long term goals on the health is recommended [61]. Therefore, progressive resistant therapy (PRT) is safe and an effective EX regimen, which [212] promotes favorable energy balance and decreased visceral fat deposition with an increase in basal metabolism and activity will be more beneficial. It also improved insulin sensitivity and glycemic control. More importantly, it is safe for frail elderly individuals and patients with co-morbidities like CVD and obesity. Moreover, PRT increased glucose disposal rates, glycogen storage capacity, GLUT4 receptors in skeletal muscle and insulin sensitivity [212]. However, it is important to have good glycemic control for EX to benefit [17].
The author thanks, Ms. Vaijayanthi Rajendran for collecting the literature and Mr. Robert Salazar for critically reading the manuscript.
The author does not have any conflict of interest. This is a review and did not involve animals or humans.

Disclaimers: The author discloses the views expressed in the article are her own and not an official position of the institution or funding agency.
  1. Fact sheet N'312 2015 [7/25/2015]. Available from:
  2. Wood RJ, O'Neill EC. Resistance Training in Type II Diabetes Mellitus: Impact on Areas of Metabolic Dysfunction in Skeletal Muscle and Potential Impact on Bone. J Nutr Metab. 2012;2012:268197. doi: 10.1155/2012/268197.
  3. Economic costs of diabetes in the US in 2012-2013 [06/25/2015]. Available from:
  4. Andersen H, Nielsen S, Mogensen CE, Jakobsen J. Muscle strength in type 2 diabetes. Diabetes. 2004;53(6):1543-1548.
  5. Andreassen CS, Jakobsen J, Andersen H. Muscle weakness: a progressive late complication in diabetic distal symmetric polyneuropathy. Diabetes. 2006;55(3):806-812.
  6. Balducci S, Sacchetti M, Orlando G, Salvi L, Pugliese L, Salerno G, et al. Correlates of muscle strength in diabetes: The study on the assessment of determinants of muscle and bone strength abnormalities in diabetes (SAMBA). Nutr Metab Cardiovasc Dis. 2014;24(1):18-26. doi: 10.1016/j.numecd.2013.04.010.
  7. Andersen H, Poulsen PL, Mogensen CE, Jakobsen J. Isokinetic muscle strength in long-term IDDM patients in relation to diabetic complications. Diabetes. 1996;45(4):440-445.
  8. Stenholm S, Harkanen T, Sainio P, Heliovaara M, Koskinen S. Long-term changes in handgrip strength in men and women--accounting the effect of right censoring due to death. J Gerontol A Biol Sci Med Sci. 2012;67(10):1068-1074. doi: 10.1093/gerona/ gls064. 
  9. Park SW, Goodpaster BH, Strotmeyer ES, de Rekeneire N, Harris TB, Schwartz AV, et al. Decreased muscle strength and quality in older adults with type 2 diabetes: the health, aging, and body composition study. Diabetes. 2006;55(6):1813-1818.
  10. TH IJ, Schaper NC, Melai T, Meijer K, Willems PJ, Savelberg HH. Lower extremity muscle strength is reduced in people with type 2 diabetes, with and without polyneuropathy, and is associated with impaired mobility and reduced quality of life. Diabetes Res Clin Pract. 2012;95(3):345-351. doi: 10.1016/ j.diabres.2011.10.026. 
  11. Sacchetti M, Balducci S, Bazzucchi I, Carlucci F, Scotto di Palumbo A, Haxhi J, et al. Neuromuscular dysfunction in diabetes: role of nerve impairment and training status. Med Sci Sports Exerc. 2013;45(1):52-59. doi: 10.1249/ MSS.0b013e318269f9bb.
  12. Ijzerman TH, Schaper NC, Melai T, Blijham P, Meijer K, Willems PJ, et al. Motor nerve decline does not underlie muscle weakness in type 2 diabetic neuropathy. Muscle Nerve. 2011;44(2):241-5. doi: 10.1002/mus.22039.
  13. Park SW, Goodpaster BH, Strotmeyer ES, Kuller LH, Broudeau R, Kammerer C, et al. Accelerated loss of skeletal muscle strength in older adults with type 2 diabetes: the health, aging, and body composition study. Diabetes Care. 2007;30(6):1507-1512.
  14. Wrobel JS, Najafi B. Diabetic foot biomechanics and gait dysfunction. Journal J Diabetes Sci Technol. 2010 ;4(4):833-845.
  15. Andreassen CS, Jakobsen J, Ringgaard S, Ejskjaer N, Andersen H. Accelerated atrophy of lower leg and foot muscles--a follow-up study of long-term diabetic polyneuropathy using magnetic resonance imaging (MRI). Diabetologia. 2009;52(6):1182-91. doi: 10.1007/ s00125-009-1320-0.
  16. Dolan NC, Liu K, Criqui MH, Greenland P, Guralnik JM, Chan C, et al. Peripheral artery disease, diabetes, and reduced lower extremity functioning. Diabetes Care. 25(1):113-120.
  17. Stehno-Bittel L. Organ-based response to exercise in type 1 diabetes. ISRN Endocrinol. 2012;2012:318194. doi: 10.5402/2012/318194.
  18. Herrero P, Marin R, Fernandez Vega F, Gorostidi M, Riesgo A, Vazquez J, et al. Renal function and cardiovascular risk in patients with essential hypertension. The "FRESHA" study. Nefrologia. 2006;26(3):330-338.
  19. Zatz R, Meyer TW, Rennke HG, Brenner BM. Predominance of hemodynamic rather than metabolic factors in the pathogenesis of diabetic glomerulopathy. Proc Natl Acad Sci USA. 1985;82(17):5963-5967.
  20. Evans N, Forsyth E. End-stage renal disease in people with type 2 diabetes: systemic manifestations and exercise implications. Phys Ther. 2004;84(5):454-463.
  21. American Diabetes Association  [7/22/2015]. Available from: 1.
  22. Warram JH, Martin BC, Krolewski AS, Soeldner JS, Kahn CR. Slow glucose removal rate and hyper insulinemia precede the development of type II diabetes in the offspring of diabetic parents. Ann Intern Med. 1990;113(12):909-915.
  23. Perseghin G, Ghosh S, Gerow K, Shulman GI. Metabolic defects in lean nondiabetic offspring of NIDDM parents: a cross-sectional study. Diabetes. 1997;46(6):1001-1009.
  24. Jallut D, Golay A, Munger R, Frascarolo P, Schutz Y, Jequier E, et al. Impaired glucose tolerance and diabetes in obesity: a 6-year follow-up study of glucose metabolism. Metabolism. 1990;39(10):1068-1075.
  25. Ferrannini E, Gastaldelli A, Matsuda M, Miyazaki Y, Pettiti M, Glass L, et al. Influence of ethnicity and familial diabetes on glucose tolerance and insulin action: a physiological analysis. J Clin Endocrinol Metab. 2003;88(7):3251-3257.
  26. Gulli G, Ferrannini E, Stern M, Haffner S, DeFronzo RA. The metabolic profile of NIDDM is fully established in glucose-tolerant offspring of two Mexican-American NIDDM parents. Diabetes. 1992;41(12):1575-1586.
  27. Kashyap SR, Belfort R, Berria R, Suraamornkul S, Pratipranawatr T, Finlayson J, et al. Discordant effects of a chronic physiological increase in plasma FFA on insulin signaling in healthy subjects with or without a family history of type 2 diabetes. Am J Physiol Endocrinol Metab. 2004;287(3):E537-546.
  28. DeFronzo RA, Tripathy D. Skeletal muscle insulin resistance is the primary defect in type 2 diabetes. Diabetes Care. 2009;32 Suppl 2:S157-163. doi: 10.2337/ dc09-S302.
  29. Goodpaster BH, Kelley DE, Thaete FL, He J, Ross R. Skeletal muscle attenuation determined by computed tomography is associated with skeletal muscle lipid content. J Appl Physiol (1985). 2000;89(1):104-110.
  30. Cree MG, Newcomer BR, Katsanos CS, Sheffield-Moore M, Chinkes D, Aarsland A, et al. Intramuscular and liver triglycerides are increased in the elderly. J Clin Endocrinol Metab. 2004;89(8):3864-3871.
  31. Garcia-Roves PM. Mitochondrial pathophysiology and type 2 diabetes mellitus. Arch Physiol Biochem. 2011;117(3):177-187. doi: 10.3109/ 13813455.2011.584538.
  32. Samuel VT, Petersen KF, Shulman GI. Lipid-induced insulin resistance: unravelling the mechanism. Lancet. 2010 26;375(9733):2267-277. doi: 10.1016/ S0140-6736(10)60408-4.
  33. Evans WJ. Exercise, nutrition and aging. J Nutr. 1992;122(3 Suppl):796-801.
  34. Langley B, Thomas M, Bishop A, Sharma M, Gilmour S, Kambadur R. Myostatin inhibits myoblast differentiation by down-regulating MyoD expression. J Biol Chem. 2002;277(51):49831-49840.
  35. McPherron AC, Lawler AM, Lee SJ. Regulation of skeletal muscle mass in mice by a new TGF-beta superfamily member. Nature. 1997;387(6628):83-90.
  36. Taylor WE, Bhasin S, Artaza J, Byhower F, Azam M, Willard DH, Jr, et al. Myostatin inhibits cell proliferation and protein synthesis in C2C12 muscle cells. Am J Physiol Endocrinol Metab. 2001;280(2):E221-228.
  37. Thomas M, Langley B, Berry C, Sharma M, Kirk S, Bass J, et al. Myostatin, a negative regulator of muscle growth, functions by inhibiting myoblast proliferation. J Biol Chem. 2000;275(51):40235-40243.
  38. Trendelenburg AU, Meyer A, Rohner D, Boyle J, Hatakeyama S, Glass DJ. Myostatin reduces Akt/TORC1/p70S6K signaling, inhibiting myoblast differentiation and myotube size. Am J Physiol Cell Physiol. 2009;296(6):C1258-1270. doi: 10.1152/ ajpcell.00105.2009.
  39. Matsakas A, Foster K, Otto A, Macharia R, Elashry MI, Feist S, et al. Molecular, cellular and physiological investigation of myostatin propeptide-mediated muscle growth in adult mice. Neuromuscul Disord. 2009;19(7):489-499. doi: 10.1016/ j.nmd.2009.06.367.
  40. Welle S, Bhatt K, Pinkert CA. Myofibrillar protein synthesis in myostatin-deficient mice. Am J Physiol Endocrinol Metab. 2006;290(3):E409-415.
  41. Allen DL, Hittel DS, McPherron AC. Expression and function of myostatin in obesity, diabetes, and exercise adaptation. Med Sci Sports Exerc. 2011;43(10):1828-835. doi: 10.1249/ MSS.0b013e3182178bb4.
  42. Palsgaard J, Brons C, Friedrichsen M, Dominguez H, Jensen M, Storgaard H, et al. Gene expression in skeletal muscle biopsies from people with type 2 diabetes and relatives: differential regulation of insulin signaling pathways. PLoS One. 2009;4(8):e6575. doi: 10.1371/ journal.pone.0006575.
  43. Moller DE. Potential role of TNF-alpha in the pathogenesis of insulin resistance and type 2 diabetes. Trends Endocrinol Metab. 2000;11(6):212-217.
  44. Schuelke M, Wagner KR, Stolz LE, Hubner C, Riebel T, Komen W, et al. Myostatin mutation associated with gross muscle hypertrophy in a child. N Engl J Med. 2004;350(26):2682-2688.
  45. Yang J, Ratovitski T, Brady JP, Solomon MB, Wells KD, Wall RJ. Expression of myostatin pro domain results in muscular transgenic mice. Mol Reprod Dev. 2001;60(3):351-361.
  46. Zhu X, Hadhazy M, Wehling M, Tidball JG, McNally EM. Dominant negative myostatin produces hypertrophy without hyperplasia in muscle. FEBS Lett. 2000;474(1):71-75.
  47. Kelley DE, Simoneau JA. Impaired free fatty acid utilization by skeletal muscle in non-insulin-dependent diabetes mellitus. J Clin Invest. 1994;94(6):2349-2356.
  48. Malenfant P, Joanisse DR, Theriault R, Goodpaster BH, Kelley DE, Simoneau JA. Fat content in individual muscle fibers of lean and obese subjects. Int J Obes Relat Metab Disord. 2001;25(9):1316-1321.
  49. Goodpaster BH, Thaete FL, Kelley DE. Thigh adipose tissue distribution is associated with insulin resistance in obesity and in type 2 diabetes mellitus. Am J Clin Nutr. 2000;71(4):885-892.
  50. Rector RS, Uptergrove GM, Borengasser SJ, Mikus CR, Morris EM, Naples SP, et al. Changes in skeletal muscle mitochondria in response to the development of type 2 diabetes or prevention by daily wheel running in hyperphagic OLETF rats. Am J Physiol Endocrinol Metab. 2010;298(6):E1179-1187. doi: 10.1152/ ajpendo.00703.2009.
  51. Vogel T, Brechat PH, Lepretre PM, Kaltenbach G, Berthel M, Lonsdorfer J. Health benefits of physical activity in older patients: a review. Int J Clin Pract. 2009;63(2):303-20. doi: 10.1111/ j.1742-1241.2008.01957.x.
  52. Booth FW, Roberts CK, Laye MJ. Lack of exercise is a major cause of chronic diseases. Compr Physiol. 2012 ;2(2):1143-211. doi: 10.1002/ cphy.c110025.
  53. Wilkes JJ, Lloyd DJ, Gekakis N. Loss-of-function mutation in myostatin reduces tumor necrosis factor alpha production and protects liver against obesity-induced insulin resistance. Diabetes. 2009;58(5):1133-1143. doi: 10.2337/ db08-0245.
  54. Smith GL, Doherty AP, Banks LM, Dutton J, Hanham LW, Christmas TJ, et al. Dual X-ray absorptiometry detects disease- and treatment-related alterations of bone density in prostate cancer patients. Clin Exp Metastasis. 2000;18(5):385-390.
  55. Kelley DE, He J, Menshikova EV, Ritov VB. Dysfunction of mitochondria in human skeletal muscle in type 2 diabetes. Diabetes. 2002;51(10):2944-2950.
  56. Larsen S, Ara I, Rabol R, Andersen JL, Boushel R, Dela F, et al. Are substrate use during exercise and mitochondrial respiratory capacity decreased in arm and leg muscle in type 2 diabetes? Diabetologia. 2009;52(7):1400-8. doi: 10.1007/ s00125-009-1353-4.
  57. Ritov VB, Menshikova EV, Azuma K, Wood R, Toledo FG, Goodpaster BH, et al. Deficiency of electron transport chain in human skeletal muscle mitochondria in type 2 diabetes mellitus and obesity. Am J Physiol Endocrinol Metab. 2010;298(1):E49-58. doi: 10.1152/ ajpendo.00317.2009.
  58. Schmitz-Peiffer C. Protein kinase C and lipid-induced insulin resistance in skeletal muscle. Ann N Y Acad Sci. 2002;967:146-157.
  59. Ashok BT, Ali R. The aging paradox: free radical theory of aging. Exp Gerontol. 1999;34(3):293-303.
  60. Valko M, Leibfritz D, Moncol J, Cronin MT, Mazur M, Telser J. Free radicals and antioxidants in normal physiological functions and human disease. Int J Biochem Cell Biol. 2007;39(1):44-84.
  61. Nobili V, de Ville de Goyet J. Pediatric post-transplant metabolic syndrome: new clouds on the horizon. Pediatr Transplant. 2013;17(3):216-223. doi: 10.1111/ petr.12065.
  62. Vincent HK, Innes KE, Vincent KR. Oxidative stress and potential interventions to reduce oxidative stress in overweight and obesity. Diabetes Obes Metab. 2007;9(6):813-839.
  63. Kurohane Kaneko Y, Ishikawa T. Dual role of nitric oxide in pancreatic beta-cells. J Pharmacol Sci. 2013;123(4):295-300.
  64. Cnop M, Welsh N, Jonas JC, Jorns A, Lenzen S, Eizirik DL. Mechanisms of pancreatic beta-cell death in type 1 and type 2 diabetes: many differences, few similarities. Diabetes. 2005;54 Suppl 2:S97-107.
  65. Noguchi A, Takada M, Nakayama K, Ishikawa T. cGMP-independent anti-apoptotic effect of nitric oxide on thapsigargin-induced apoptosis in the pancreatic beta-cell line INS-1. Life Sci. 2008;83(25-26):865-70. doi: 10.1016/ j.lfs.2008.10.002.
  66. Mosen H, Ostenson CG, Lundquist I, Alm P, Henningsson R, Jimenez-Feltstrom J, et al. Impaired glucose-stimulated insulin secretion in the GK rat is associated with abnormalities in islet nitric oxide production. Regul Pept. 2008;151(1-3):139-146. doi: 10.1016/ j.regpep.2008.07.002.
  67. Kaliman P, Canicio J, Testar X, Palacin M, Zorzano A. Insulin-like growth factor-II, phosphatidylinositol 3-kinase, nuclear factor-kappaB and inducible nitric-oxide synthase define a common myogenic signaling pathway. J Biol Chem. 1999;274(25):17437-17444.
  68. Prats-Puig A, Ortega FJ, Mercader JM, Moreno-Navarrete JM, Moreno M, Bonet N, et al. Changes in circulating microRNAs are associated with childhood obesity. J Clin Endocrinol Metab. 2013;98(10):E1655-1660. doi: 10.1210/ jc.2013-1496.
  69. Trajkovski M, Hausser J, Soutschek J, Bhat B, Akin A, Zavolan M, et al. MicroRNAs 103 and 107 regulate insulin sensitivity. Nature. 2011;474(7353):649-653. doi: 10.1038/ nature10112.
  70. Zhu H, Shyh-Chang N, Segre AV, Shinoda G, Shah SP, Einhorn WS, et al. The Lin28/let-7 axis regulates glucose metabolism. Cell. 2011;147(1):81-94. doi: 10.1016/ j.cell.2011.08.033.
  71. Jiang LQ, Franck N, Egan B, Sjögren RJ, Katayama M, Duque-Guimaraes D, et al. Autocrine role of interleukin-13 on skeletal muscle glucose metabolism in type 2 diabetic patients involves microRNA let-7. Am J Physiol Endocrinol Metab. 2013;305(11):E1359-66. doi: 10.1152/ajpendo.00236.2013.
  72. Gallagher IJ, Scheele C, Keller P, Nielsen AR, Remenyi J, Fischer CP, et al. Integration of microRNA changes in vivo identifies novel molecular features of muscle insulin resistance in type 2 diabetes. Genome Med. 2010;2(2):9. doi: 10.1186/gm130.
  73. Patti A, Gennari L, Merlotti D, Dotta F, Nuti R. Endocrine actions of osteocalcin. Int J Endocrinol. 2013;2013:846480. doi: 10.1155/2013/846480.
  74. Bulló M, Moreno-Navarrete JM, Fernández-Real JM, Salas-Salvadó J. Total and undercarboxylated osteocalcin predict changes in insulin sensitivity and β cell function in elderly men at high cardiovascular risk. Am J Clin Nutr. 2012;95(1):249-55. doi: 10.3945/ajcn.111.016642.
  75. Fernández-Real JM, Izquierdo M, Ortega F, Gorostiaga E, Gómez-Ambrosi J, Moreno-Navarrete JM, et al. The relationship of serum osteocalcin concentration to insulin secretion, sensitivity, and disposal with hypocaloric diet and resistance training. J Clin Endocrinol Metab. 2009;94(1):237-45. doi: 10.1210/jc.2008-0270.
  76. Ferron M, McKee MD, Levine RL, Ducy P, Karsenty G. Intermittent injections of osteocalcin improve glucose metabolism and prevent type 2 diabetes in mice. Bone. 2012;50(2):568-75. doi: 10.1016/j.bone.2011.04.017.
  77. Brazeau AS, Rabasa-Lhoret R, Strychar I, Mircescu H. Barriers to physical activity among patients with type 1 diabetes. Diabetes Care. 2008;31(11):2108-9. doi: 10.2337/dc08-0720.
  78. Vagetti GC, Barbosa Filho VC, Moreira NB, Oliveira Vd, Mazzardo O, Campos Wd. Association between physical activity and quality of life in the elderly: a systematic review, 2000-2012. Rev Bras Psiquiatr. 2014;36(1):76-88.
  79. LeBrasseur NK, Schelhorn TM, Bernardo BL, Cosgrove PG, Loria PM, Brown TA. Myostatin inhibition enhances the effects of exercise on performance and metabolic outcomes in aged mice. J Gerontol A Biol Sci Med Sci. 2009;64(9):940-8. doi: 10.1093/gerona/glp068.
  80. Bishop FK, Maahs DM, Snell-Bergeon JK, Ogden LG, Kinney GL, Rewers M. Lifestyle risk factors for atherosclerosis in adults with type 1 diabetes. Diab Vasc Dis Res. 2009;6(4):269-75. doi: 10.1177/1479164109346359.
  81. Koves TR, Ussher JR, Noland RC, Slentz D, Mosedale M, Ilkayeva O, et al. Mitochondrial overload and incomplete fatty acid oxidation contribute to skeletal muscle insulin resistance. Cell Metab. 2008;7(1):45-56. doi: 10.1016/j.cmet.2007.10.013.
  82. Thyfault JP, Cree MG, Tapscott EB, Bell JA, Koves TR, Ilkayeva O, et al. Metabolic profiling of muscle contraction in lean compared with obese rodents. Am J Physiol Regul Integr Comp Physiol. 2010;299(3):R926-34. doi: 10.1152/ajpregu.00093.2010.
  83. Alibegovic AC, Sonne MP, Højbjerre L, Bork-Jensen J, Jacobsen S, Nilsson E, et al. Insulin resistance induced by physical inactivity is associated with multiple transcriptional changes in skeletal muscle in young men. Am J Physiol Endocrinol Metab. 2010;299(5):E752-63. doi: 10.1152/ajpendo.00590.2009.
  84. Fleg JL, Morrell CH, Bos AG, Brant LJ, Talbot LA, Wright JG, et al. Accelerated longitudinal decline of aerobic capacity in healthy older adults. Circulation. 2005;112(5):674-82.
  85. Fried LP, Kronmal RA, Newman AB, Bild DE, Mittelmark MB, Polak JF, et al. Risk factors for 5-year mortality in older adults: the Cardiovascular Health Study. JAMA. 1998;279(8):585-92.
  86. Knoops KT, de Groot LC, Kromhout D, Perrin AE, Moreiras-Varela O, Menotti A, et al. Mediterranean diet, lifestyle factors, and 10-year mortality in elderly European men and women: the HALE project. JAMA. 2004;292(12):1433-9.
  87. Sundquist K, Qvist J, Sundquist J, Johansson SE. Frequent and occasional physical activity in the elderly: a 12-year follow-up study of mortality. Am J Prev Med. 2004;27(1):22-7.
  88. Hakim AA, Petrovitch H, Burchfiel CM, Ross GW, Rodriguez BL, White LR, et al. Effects of walking on mortality among nonsmoking retired men. N Engl J Med. 1998;338(2):94-9.
  89. Bijnen FC, Caspersen CJ, Feskens EJ, Saris WH, Mosterd WL, Kromhout D. Physical activity and 10-year mortality from cardiovascular diseases and all causes: The Zutphen Elderly Study. Arch Intern Med. 1998;158(14):1499-505.
  90. Franco OH, de Laet C, Peeters A, Jonker J, Mackenbach J, Nusselder W. Effects of physical activity on life expectancy with cardiovascular disease. Arch Intern Med. 2005;165(20):2355-60.
  91. Rolland Y, Lauwers-Cances V, Cesari M, Vellas B, Pahor M, Grandjean H. Physical performance measures as predictors of mortality in a cohort of community-dwelling older French women. Eur J Epidemiol. 2006;21(2):113-22.
  92. Benetos A, Thomas F, Bean KE, Pannier B, Guize L. Role of modifiable risk factors in life expectancy in the elderly. J Hypertens. 2005;23(10):1803-8.
  93. Landi F, Cesari M, Onder G, Lattanzio F, Gravina EM, Bernabei R. Physical activity and mortality in frail, community-living elderly patients. J Gerontol A Biol Sci Med Sci. 2004;59(8):833-7.
  94. Chakravarty EF, Hubert HB, Lingala VB, Fries JF. Reduced disability and mortality among aging runners: a 21-year longitudinal study. Arch Intern Med. 2008;168(15):1638-46. doi: 10.1001/archinte.168.15.1638.
  95. Wannamethee SG, Shaper AG, Walker M. Physical activity and mortality in older men with diagnosed coronary heart disease. Circulation. 2000;102(12):1358-63.
  96. Hakim AA, Curb JD, Petrovitch H, Rodriguez BL, Yano K, Ross GW, et al. Effects of walking on coronary heart disease in elderly men: the Honolulu Heart Program. Circulation. 1999;100(1):9-13.
  97. Petrella RJ, Lattanzio CN, Demeray A, Varallo V, Blore R. Can adoption of regular exercise later in life prevent metabolic risk for cardiovascular disease? Diabetes Care. 2005;28(3):694-701.
  98. Halverstadt A, Phares DA, Wilund KR, Goldberg AP, Hagberg JM. Endurance exercise training raises high-density lipoprotein cholesterol and lowers small low-density lipoprotein and very low-density lipoprotein independent of body fat phenotypes in older men and women. Metabolism. 2007;56(4):444-50.
  99. Brooks GA, Fahey TD, White TP. Exercise physiology: Human bioenergetics and its application. Mountain View, CA: Mayfield Publishing Co; 1995.
  100. Siscovick DS, LaPorte RE, Newman JM. The disease-specific benefits and risks of physical activity and exercise. Public Health Rep. 1985;100(2):180-8.
  101. McGregor RA, Poppitt SD, Cameron-Smith D. Role of microRNAs in the age-related changes in skeletal muscle and diet or exercise interventions to promote healthy aging in humans. Ageing Res Rev. 2014;17:25-33. doi: 10.1016/j.arr.2014.05.001.
  102. Wang Q, Jin T. The role of insulin signaling in the development of β-cell dysfunction and diabetes. Islets. 2009;1(2):95-101. doi: 10.4161/isl.1.2.9263.
  103. Haskell WL, Lee IM, Pate RR, Powell KE, Blair SN, Franklin BA, et al. Physical activity and public health: updated recommendation for adults from the American College of Sports Medicine and the American Heart Association. Med Sci Sports Exerc. 2007;39(8):1423-34.
  104. Holloszy JO. Adaptations of muscular tissue to training. Prog Cardiovasc Dis. 1976;18(6):445-58.
  105. Holloszy JO, Booth FW. Biochemical adaptations to endurance exercise in muscle. Annu Rev Physiol. 1976;38:273-91.
  106. Ivy JL, Holloszy JO. Persistent increase in glucose uptake by rat skeletal muscle following exercise. Am J Physiol. 1981;241(5):C200-3.
  107. Heath GW, Gavin JR 3rd, Hinderliter JM, Hagberg JM, Bloomfield SA, Holloszy JO. Effects of exercise and lack of exercise on glucose tolerance and insulin sensitivity. J Appl Physiol Respir Environ Exerc Physiol. 1983;55(2):512-7.
  108. Mikines KJ, Sonne B, Farrell PA, Tronier B, Galbo H. Effect of physical exercise on sensitivity and responsiveness to insulin in humans. Am J Physiol. 1988;254(3 Pt 1):E248-59.
  109. Richter EA, Garetto LP, Goodman MN, Ruderman NB. Muscle glucose metabolism following exercise in the rat: increased sensitivity to insulin. J Clin Invest. 1982;69(4):785-93.
  110. Cox JH, Cortright RN, Dohm GL, Houmard JA. Effect of aging on response to exercise training in humans: skeletal muscle GLUT-4 and insulin sensitivity. J Appl Physiol (1985). 1999;86(6):2019-25.
  111. Evans EM, Racette SB, Peterson LR, Villareal DT, Greiwe JS, Holloszy JO. Aerobic power and insulin action improve in response to endurance exercise training in healthy 77-87 yr olds. J Appl Physiol (1985). 2005;98(1):40-5.
  112. DiPietro L, Dziura J, Yeckel CW, Neufer PD. Exercise and improved insulin sensitivity in older women: evidence of the enduring benefits of higher intensity training. J Appl Physiol (1985). 2006;100(1):142-9.
  113. Yki-Järvinen H, DeFronzo RA, Koivisto VA. Normalization of insulin sensitivity in type I diabetic subjects by physical training during insulin pump therapy. Diabetes Care. 1984;7(6):520-7.
  114. Richter EA, Nielsen JN, Jørgensen SB, Frøsig C, Birk JB, Wojtaszewski JF. Exercise signalling to glucose transport in skeletal muscle. Proc Nutr Soc. 2004;63(2):211-6.
  115. Rose AJ, Richter EA. Skeletal muscle glucose uptake during exercise: how is it regulated? Physiology (Bethesda). 2005;20:260-70.
  116. Musi N, Fujii N, Hirshman MF, Ekberg I, Fröberg S, Ljungqvist O, et al. AMP-activated protein kinase (AMPK) is activated in muscle of subjects with type 2 diabetes during exercise. Diabetes. 2001;50(5):921-7.
  117. Brooks N, Layne JE, Gordon PL, Roubenoff R, Nelson ME, Castaneda-Sceppa C. Strength training improves muscle quality and insulin sensitivity in Hispanic older adults with type 2 diabetes. Int J Med Sci. 2006;4(1):19-27.
  118. Kobzik L, Stringer B, Balligand JL, Reid MB, Stamler JS. Endothelial type nitric oxide synthase in skeletal muscle fibers: mitochondrial relationships. Biochem Biophys Res Commun. 1995;211(2):375-81.
  119. Stamler JS, Meissner G. Physiology of nitric oxide in skeletal muscle. Physiol Rev. 2001;81(1):209-237.
  120. Boczkowski J, Lanone S, Ungureanu-Longrois D, Danialou G, Fournier T, Aubier M. Induction of diaphragmatic nitric oxide synthase after endotoxin administration in rats: role on diaphragmatic contractile dysfunction. J Clin Invest. 1996;98(7):1550-9.
  121. El Dwairi Q, Guo Y, Comtois A, Zhu E, Greenwood MT, Bredt DS, et al. Ontogenesis of nitric oxide synthases in the ventilatory muscles. Am J Respir Cell Mol Biol. 1998;18(6):844-52.
  122. Tidball JG, Lavergne E, Lau KS, Spencer MJ, Stull JT, Wehling M. Mechanical loading regulates NOS expression and activity in developing and adult skeletal muscle. Am J Physiol. 1998;275(1 Pt 1):C260-6.
  123. Wehling M, Stull JT, McCabe TJ, Tidball JG. Sparing of mdx extraocular muscles from dystrophic pathology is not attributable to normalized concentration or distribution of neuronal nitric oxide synthase. Neuromuscul Disord. 1998;8(1):22-9.
  124. Balon TW, Nadler JL. Evidence that nitric oxide increases glucose transport in skeletal muscle. J Appl Physiol (1985). 1997;82(1):359-63.
  125. Sessa WC, Pritchard K, Seyedi N, Wang J, Hintze TH. Chronic exercise in dogs increases coronary vascular nitric oxide production and endothelial cell nitric oxide synthase gene expression. Circ Res. 1994;74(2):349-53.
  126. Wang XH. MicroRNA in myogenesis and muscle atrophy. Curr Opin Clin Nutr Metab Care. 2013;16(3):258-66. doi: 10.1097/MCO.0b013e32835f81b9.
  127. Drummond MJ, McCarthy JJ, Sinha M, Spratt HM, Volpi E, Esser KA, et al. Aging and microRNA expression in human skeletal muscle: a microarray and bioinformatics analysis. Physiol Genomics. 2011;43(10):595-603. doi: 10.1152/physiolgenomics.00148.2010.
  128. Drummond MJ, McCarthy JJ, Fry CS, Esser KA, Rasmussen BB. Aging differentially affects human skeletal muscle microRNA expression at rest and after an anabolic stimulus of resistance exercise and essential amino acids. Am J Physiol Endocrinol Metab. 2008;295(6):E1333-40. doi: 10.1152/ajpendo.90562.2008.
  129. Olivieri F, Spazzafumo L, Santini G, Lazzarini R, Albertini MC, Rippo MR, et al. Age-related differences in the expression of circulating microRNAs: miR-21 as a new circulating marker of inflammaging. Mech Ageing Dev. 2012;133(11-12):675-85. doi: 10.1016/j.mad.2012.09.004.
  130. Hamrick MW, Herberg S, Arounleut P, He HZ, Shiver A, Qi RQ, et al. The adipokine leptin increases skeletal muscle mass and significantly alters skeletal muscle miRNA expression profile in aged mice. Biochem Biophys Res Commun. 2010;400(3):379-83. doi: 10.1016/j.bbrc.2010.08.079.
  131. Mercken EM, Majounie E, Ding J, Guo R, Kim J, Bernier M, et al. Age-associated miRNA alterations in skeletal muscle from rhesus monkeys reversed by caloric restriction. Aging (Albany NY). 2013;5(9):692-703.
  132. Safdar A, Abadi A, Akhtar M, Hettinga BP, Tarnopolsky MA. miRNA in the regulation of skeletal muscle adaptation to acute endurance exercise in C57Bl/6J male mice. PLoS One. 2009;4(5):e5610. doi: 10.1371/journal.pone.0005610 .
  133. Nielsen S, Scheele C, Yfanti C, Akerström T, Nielsen AR, Pedersen BK, et al. Muscle specific microRNAs are regulated by endurance exercise in human skeletal muscle. J Physiol. 2010;588(Pt 20):4029-37. doi: 10.1113/jphysiol.2010.189860.
  134. McCarthy JJ, Esser KA, Andrade FH. MicroRNA-206 is overexpressed in the diaphragm but not the hindlimb muscle of mdx mouse. Am J Physiol Cell Physiol. 2007;293(1):C451-7.
  135. Davidsen PK, Gallagher IJ, Hartman JW, Tarnopolsky MA, Dela F, Helge JW, et al. High responders to resistance exercise training demonstrate differential regulation of skeletal muscle microRNA expression. J Appl Physiol (1985). 2011;110(2):309-17. doi: 10.1152/japplphysiol.00901.2010.
  136. Mueller M, Breil FA, Lurman G, Klossner S, Flück M, Billeter R, et al. Different molecular and structural adaptations with eccentric and conventional strength training in elderly men and women. Gerontology. 2011;57(6):528-38. doi: 10.1159/000323267.
  137. Rattigan S, Wallis MG, Youd JM, Clark MG. Exercise training improves insulin-mediated capillary recruitment in association with glucose uptake in rat hindlimb. Diabetes. 2001;50(12):2659-65.
  138. Gulve EA. Exercise and glycemic control in diabetes: benefits, challenges, and adjustments to pharmacotherapy. Phys Ther. 2008;88(11):1297-321. doi: 10.2522/ptj.20080114.
  139. Huang HH, Farmer K, Windscheffel J, Yost K, Power M, Wright DE, et al. Exercise increases insulin content and basal secretion in pancreatic islets in type 1 diabetic mice. Exp Diabetes Res. 2011;2011:481427. doi: 10.1155/2011/481427.
  140. Coskun O, Ocakci A, Bayraktaroglu T, Kanter M. Exercise training prevents and protects streptozotocin-induced oxidative stress and beta-cell damage in rat pancreas. Tohoku J Exp Med. 2004;203(3):145-54.
  141. Krause Mda S, de Bittencourt PI Jr. Type 1 diabetes: can exercise impair the autoimmune event? The L-arginine/glutamine coupling hypothesis. Cell Biochem Funct. 2008;26(4):406-33. doi: 10.1002/cbf.1470.
  142. Frosig C, Richter EA. Improved insulin sensitivity after exercise: focus on insulin signaling. Obesity (Silver Spring). 2009;S15-20. doi: 10.1038/oby.2009.383.
  143. Holmes B, Dohm GL. Regulation of GLUT4 gene expression during exercise. Med Sci Sports Exerc. 2004;36(7):1202-6.
  144. Salem MA, Aboelasrar MA, Elbarbary NS, Elhilaly RA, Refaat YM. Is exercise a therapeutic tool for improvement of cardiovascular risk factors in adolescents with type 1 diabetes mellitus? A randomised controlled trial. Diabetol Metab Syndr. 2010;2(1):47. doi: 10.1186/1758-5996-2-47.
  145. Kluding PM, Pasnoor M, Singh R, Jernigan S, Farmer K, Rucker J, et al. The effect of exercise on neuropathic symptoms, nerve function, and cutaneous innervation in people with diabetic peripheral neuropathy. J Diabetes Complications. 2012;26(5):424-9. doi: 10.1016/j.jdiacomp.2012.05.007.
  146. Garcia-Garcia F, Kumareswaran K, Hovorka R, Hernando ME. Quantifying the acute changes in glucose with exercise in type 1 diabetes: a systematic review and meta-analysis. Sports Med. 2015;45(4):587-99. doi: 10.1007/s40279-015-0302-2.
  147. Seals DR, Hagberg JM, Hurley BF, Ehsani AA, Holloszy JO. Effects of endurance training on glucose tolerance and plasma lipid levels in older men and women. JAMA. 1984;252(5):645-9.
  148. Hittel DS, Axelson M, Sarna N, Shearer J, Huffman KM, Kraus WE. Myostatin decreases with aerobic exercise and associates with insulin resistance. Med Sci Sports Exerc. 2010;42(11):2023-9. doi: 10.1249/MSS.0b013e3181e0b9a8.
  149. Rogers MA, King DS, Hagberg JM, Ehsani AA, Holloszy JO. Effect of 10 days of physical inactivity on glucose tolerance in master athletes. J Appl Physiol (1985). 1990;68(5):1833-7.
  150. Kirwan JP, Solomon TP, Wojta DM, Staten MA, Holloszy JO. Effects of 7 days of exercise training on insulin sensitivity and responsiveness in type 2 diabetes mellitus. Am J Physiol Endocrinol Metab. 2009;297(1):E151-6. doi: 10.1152/ajpendo.00210.2009.
  151. Boor P, Celec P, Behuliak M, Grancic P, Kebis A, Kukan M, et al. Regular moderate exercise reduces advanced glycation and ameliorates early diabetic nephropathy in obese Zucker rats. Metabolism. 200;58(11):1669-77. doi: 10.1016/j.metabol.2009.05.025.
  152. Albright AL, Mahan JD, Ward KM, Sherman WM, Roehrig KL, Kirby TE. Diabetic nephropathy in an aerobically trained rat model of diabetes. Med Sci Sports Exerc. 1995;27(9):1270-7.
  153. Kutlu M, Naziroglu M, Simsek H, Yilmaz T, Sahap Kukner A. Moderate exercise combined with dietary vitamins C and E counteracts oxidative stress in the kidney and lens of streptozotocin-induced diabetic-rat. Int J Vitam Nutr Res. 2005;75(1):71-80.
  154. Peng CC, Chen KC, Hsieh CL, Peng RY. Swimming exercise prevents fibrogenesis in chronic kidney disease by inhibiting the myofibroblast transdifferentiation. PLoS One. 2012;7(6):e37388. doi: 10.1371/journal.pone.0037388.
  155. Loganathan R, Bilgen M, Al-Hafez B, Zhero SV, Alenezy MD, Smirnova IV. Exercise training improves cardiac performance in diabetes: in vivo demonstration with quantitative cine-MRI analyses. J Appl Physiol (1985). 2007;102(2):665-72.
  156. Boulé NG, Haddad E, Kenny GP, Wells GA, Sigal RJ. Effects of exercise on glycemic control and body mass in type 2 diabetes mellitus: a meta-analysis of controlled clinical trials. JAMA. 2001;286(10):1218-27.
  157. Dela F, Ploug T, Handberg A, Petersen LN, Larsen JJ, Mikines KJ, et al. Physical training increases muscle GLUT4 protein and mRNA in patients with NIDDM. Diabetes. 1994;43(7):862-5.
  158. Hughes VA, Fiatarone MA, Fielding RA, Kahn BB, Ferrara CM, Shepherd P, et al. Exercise increases muscle GLUT-4 levels and insulin action in subjects with impaired glucose tolerance. Am J Physiol. 1993;264(6 Pt 1):E855-62.
  159. Kirwan JP, Kohrt WM, Wojta DM, Bourey RE, Holloszy JO. Endurance exercise training reduces glucose-stimulated insulin levels in 60- to 70-year-old men and women. J Gerontol. 1993;48(3):M84-90.
  160. Harber MP, Crane JD, Dickinson JM, Jemiolo B, Raue U, Trappe TA, et al. Protein synthesis and the expression of growth-related genes are altered by running in human vastus lateralis and soleus muscles. Am J Physiol Regul Integr Comp Physiol. 2009;296(3):R708-14. doi: 10.1152/ajpregu.90906.2008.
  161. Louis E, Raue U, Yang Y, Jemiolo B, Trappe S. Time course of proteolytic, cytokine, and myostatin gene expression after acute exercise in human skeletal muscle. J Appl Physiol (1985). 2007;103(5):1744-51.
  162. Hennebry A, Berry C, Siriett V, O'Callaghan P, Chau L, Watson T, et al. Myostatin regulates fiber-type composition of skeletal muscle by regulating MEF2 and MyoD gene expression. Am J Physiol Cell Physiol. 2009;296(3):C525-34. doi: 10.1152/ajpcell.00259.2007.
  163. Girgenrath S, Song K, Whittemore LA. Loss of myostatin expression alters fiber-type distribution and expression of myosin heavy chain isoforms in slow- and fast-type skeletal muscle. Muscle Nerve. 2005;31(1):34-40.
  164. Hulmi JJ, Ahtiainen JP, Kaasalainen T, Pollanen E, Hakkinen K, Alen M, et al. Postexercise myostatin and activin IIb mRNA levels: effects of strength training. Med Sci Sports Exerc. 2007;39(2):289-97.
  165. Raue U, Slivka D, Jemiolo B, Hollon C, Trappe S. Myogenic gene expression at rest and after a bout of resistance exercise in young (18-30 yr) and old (80-89 yr) women. J Appl Physiol (1985). 2006;101(1):53-9.
  166. Roth SM, Martel GF, Ferrell RE, Metter EJ, Hurley BF, Rogers MA. Myostatin gene expression is reduced in humans with heavy-resistance strength training: a brief communication. Exp Biol Med (Maywood). 2003;228(6):706-9.
  167. Kim JS, Cross JM, Bamman MM. Impact of resistance loading on myostatin expression and cell cycle regulation in young and older men and women. Am J Physiol Endocrinol Metab. 2005;288(6):E1110-9.
  168. Kim JS, Petrella JK, Cross JM, Bamman MM. Load-mediated downregulation of myostatin mRNA is not sufficient to promote myofiber hypertrophy in humans: a cluster analysis. J Appl Physiol (1985). 2007;103(5):1488-95.
  169. Saremi A, Gharakhanloo R, Sharghi S, Gharaati MR, Larijani B, Omidfar K. Effects of oral creatine and resistance training on serum myostatin and GASP-1. Mol Cell Endocrinol. 2010;317(1-2):25-30. doi: 10.1016/j.mce.2009.12.019.
  170. Walker KS, Kambadur R, Sharma M, Smith HK. Resistance training alters plasma myostatin but not IGF-1 in healthy men. Med Sci Sports Exerc. 2004;36(5):787-93.
  171. Coffey VG, Shield A, Canny BJ, Carey KA, Cameron-Smith D, Hawley JA. Interaction of contractile activity and training history on mRNA abundance in skeletal muscle from trained athletes. Am J Physiol Endocrinol Metab. 2006;290(5):E849-55.
  172. Willoughby DS. Effects of heavy resistance training on myostatin mRNA and protein expression. Med Sci Sports Exerc. 2004;36(4):574-82.
  173. Irvine C, Taylor NF. Progressive resistance exercise improves glycaemic control in people with type 2 diabetes mellitus: a systematic review. Aust J Physiother. 2009;55(4):237-46.
  174. Herriott MT, Colberg SR, Parson HK, Nunnold T, Vinik AI. Effects of 8 weeks of flexibility and resistance training in older adults with type 2 diabetes. Diabetes Care. 2004;27(12):2988-9.
  175. Ibanez J, Izquierdo M, Arguelles I, Forga L, Larrion JL, Garcia-Unciti M, et al. Twice-weekly progressive resistance training decreases abdominal fat and improves insulin sensitivity in older men with type 2 diabetes. Diabetes Care. 2005;28(3):662-7.
  176. Gordon BA, Benson AC, Bird SR, Fraser SF. Resistance training improves metabolic health in type 2 diabetes: a systematic review. Diabetes Res Clin Pract. 2009;83(2):157-75. doi: 10.1016/j.diabres.2008.11.024.
  177. Tresierras MA, Balady GJ. Resistance training in the treatment of diabetes and obesity: mechanisms and outcomes. J Cardiopulm Rehabil Prev. 2009;29(2):67-75. doi: 10.1097/HCR.0b013e318199ff69.
  178. Ishii T, Yamakita T, Sato T, Tanaka S, Fujii S. Resistance training improves insulin sensitivity in NIDDM subjects without altering maximal oxygen uptake. Diabetes Care. 1998;21(8):1353-5.
  179. Holten MK, Zacho M, Gaster M, Juel C, Wojtaszewski JF, Dela F. Strength training increases insulin-mediated glucose uptake, GLUT4 content, and insulin signaling in skeletal muscle in patients with type 2 diabetes. Diabetes. 2004;53(2):294-305.
  180. Praet SF, Jonkers RA, Schep G, Stehouwer CD, Kuipers H, Keizer HA, et al. Longstanding, insulin-treated type 2 diabetes patients with complications respond well to short-term resistance and interval exercise training. Eur J Endocrinol. 2008;158(2):163-72. doi: 10.1530/EJE-07-0169.
  181. Balakrishnan VS, Rao M, Menon V, Gordon PL, Pilichowska M, Castaneda F, et al. Resistance training increases muscle mitochondrial biogenesis in patients with chronic kidney disease. Clin J Am Soc Nephrol. 2010;5(6):996-1002. doi: 10.2215/CJN.09141209.
  182. Tarnopolsky MA. Mitochondrial DNA shifting in older adults following resistance exercise training. Appl Physiol Nutr Metab. 2009;34(3):348-54. doi: 10.1139/H09-022.
  183. Luthi JM, Howald H, Claassen H, Rosler K, Vock P, Hoppeler H. Structural changes in skeletal muscle tissue with heavy-resistance exercise. Int J Sports Med. 1986;7(3):123-7.
  184. MacDougall JD, Sale DG, Moroz JR, Elder GC, Sutton JR, Howald H. Mitochondrial volume density in human skeletal muscle following heavy resistance training. Med Sci Sports. 1979;11(2):164-6.
  185. Pivovarov JA, Taplin CE, Riddell MC. Current perspectives on physical activity and exercise for youth with diabetes. Pediatr Diabetes. 2015;16(4):242-55. doi: 10.1111/pedi.12272.
  186. Mulvaney SA, Hood KK, Schlundt DG, Osborn CY, Johnson KB, Rothman RL, et al. Development and initial validation of the barriers to diabetes adherence measure for adolescents. Diabetes Res Clin Pract. 2011;94(1):77-83. doi: 10.1016/j.diabres.2011.06.010.
  187. Zabinski MF, Saelens BE, Stein RI, Hayden-Wade HA, Wilfley DE. Overweight children's barriers to and support for physical activity. Obes Res. 2003;11(2):238-46.
  188. Robertson K AP, Riddell MC, Scheiner G, Hanas R. Exercise in children and adolescents with diabetes. Pediatr Diabetes. 2009;10 Suppl 12:154-68. doi: 10.1111/j.1399-5448.2009.00567.x.
  189. Patton SR, Dolan LM, Henry R, Powers SW. Parental fear of hypoglycemia: young children treated with continuous subcutaneous insulin infusion. Pediatr Diabetes. 2007;8(6):362-8.
  190. Francescato MP, Geat M, Fusi S, Stupar G, Noacco C, Cattin L. Carbohydrate requirement and insulin concentration during moderate exercise in type 1 diabetic patients. Metabolism. 2004;53(9):1126-30.
  191. Adolfsson P, Nilsson S, Albertsson-Wikland K, Lindblad B. Hormonal response during physical exercise of different intensities in adolescents with type 1 diabetes and healthy controls. Pediatr Diabetes. 2012;13(8):587-96. doi: 10.1111/j.1399-5448.2012.00889.x.
  192. Na HK, Oliynyk S. Effects of physical activity on cancer prevention. Ann N Y Acad Sci. 2011;1229:176-83. doi: 10.1111/j.1749-6632.2011.06105.x.
  193. Jeon CY, Lokken RP, Hu FB, van Dam RM. Physical activity of moderate intensity and risk of type 2 diabetes: a systematic review. Diabetes Care. 2007;30(3):744-52.
  194. Knowler WC, Barrett-Connor E, Fowler SE, Hamman RF, Lachin JM, Walker EA, et al. Reduction in the incidence of type 2 diabetes with lifestyle intervention or metformin. N Engl J Med. 2002;346(6):393-403.
  195. Hu FB, Sigal RJ, Rich-Edwards JW, Colditz GA, Solomon CG, Willett WC, et al. Walking compared with vigorous physical activity and risk of type 2 diabetes in women: a prospective study. JAMA. 1999;282(15):1433-9.
  196. Hsia J, Wu L, Allen C, Oberman A, Lawson WE, Torrens J, et al. Physical activity and diabetes risk in postmenopausal women. Am J Prev Med. 2005;28(1):19-25.
  197. Folsom AR, Kushi LH, Hong CP. Physical activity and incident diabetes mellitus in postmenopausal women. Am J Public Health. 2000;90(1):134-8.
  198. Laaksonen DE, Lindstrom J, Lakka TA, Eriksson JG, Niskanen L, Wikstrom K, et al. Physical activity in the prevention of type 2 diabetes: the Finnish diabetes prevention study. Diabetes. 2005;54(1):158-65.
  199. Van Dam RM, Schuit AJ, Feskens EJ, Seidell JC, Kromhout D. Physical activity and glucose tolerance in elderly men: the Zutphen Elderly study. Med Sci Sports Exerc. 2002;34(7):1132-6.
  200. Albright A, Franz M, Hornsby G, Kriska A, Marrero D, Ullrich I, et al. American College of Sports Medicine position stand. Exercise and type 2 diabetes. Med Sci Sports Exerc. 2000;32(7):1345-60.
  201. Joslin P. The treatment of diabetes mellitus. Febiger La, editor. Philadelphia: 1959.
  202. Christmas C, Andersen RA. Exercise and older patients: guidelines for the clinician. J Am Geriatr Soc. 2000;48(3):318-24.
  203. Morino K, Petersen KF, Dufour S, Befroy D, Frattini J, Shatzkes N, et al. Reduced mitochondrial density and increased IRS-1 serine phosphorylation in muscle of insulin-resistant offspring of type 2 diabetic parents. J Clin Invest. 2005;115(12):3587-93.
  204. Pedersen BK, Saltin B. Evidence for prescribing exercise as therapy in chronic disease. Scand J Med Sci Sports. 2006;16 Suppl 1:3-63.
  205. Ebeling P, Bourey R, Koranyi L, Tuominen JA, Groop LC, Henriksson J, et al. Mechanism of enhanced insulin sensitivity in athletes. Increased blood flow, muscle glucose transport protein (GLUT-4) concentration, and glycogen synthase activity. J Clin Invest. 1993;92(4):1623-31.
  206. Coggan AR, Spina RJ, Kohrt WM, Holloszy JO. Effect of prolonged exercise on muscle citrate concentration before and after endurance training in men. Am J Physiol. 1993;264(2 Pt 1):E215-20.
  207. Mandroukas K, Krotkiewski M, Hedberg M, Wroblewski Z, Bjorntorp P, Grimby G. Physical training in obese women. Effects of muscle morphology, biochemistry and function. Eur J Appl Physiol Occup Physiol. 1984;52(4):355-61.
  208. Saltin B, Henriksson J, Nygaard E, Andersen P, Jansson E. Fiber types and metabolic potentials of skeletal muscles in sedentary man and endurance runners Ann N Y Acad Sci. 1977;301:3-29.
  209. McAllister RM, Hirai T, Musch TI. Contribution of endothelium-derived nitric oxide (EDNO) to the skeletal muscle blood flow response to exercise. Med Sci Sports Exerc. 1995;27(8):1145-51.
  210. Morris CK, Ueshima K, Kawaguchi T, Hideg A, Froelicher VF. The prognostic value of exercise capacity: a review of the literature. Am Heart J. 1991;122(5):1423-31.
  211. Phillips EM, Schneider JC, Mercer GR. Motivating elders to initiate and maintain exercise. Arch Phys Med Rehabil. 2004;85(7 Suppl 3):S52-7.
  212. Willey KA, Singh MA. Battling insulin resistance in elderly obese people with type 2 diabetes: bring on the heavy weights. Diabetes Care. 2003;26(5):1580-8.
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