Diabetes Care Volume 37, August 2014
e175
Resistance and Aerobic Exercise Among Adults With Diabetes in the U.S.
Lin Mu,1 Aaron J. Cohen,2 and Kenneth J. Mukamal1,2
Diabetes Care 2014;37:e175–e176 | DOI: 10.2337/dc14-0619
considered respondents who reported $150 min of moderate intensity or $90 min of vigorous intensity aerobic physical activity per week as meeting ADA aerobic guidelines and those who reported resistance training $3 times/week as meeting ADA resistance guidelines (4). In 40 U.S. states and the District of Columbia (DC) (excluding Colorado, Idaho, Illinois, Maryland, Mississippi, New York, South Dakota, Vermont, Virginia, and Washington), the BRFSS also incorporated an additional series of questions for respondents with self-reported diabetes, including age at diagnosis, insulin use, home blood glucose testing, physician visits, complications, and other diabetesrelated behaviors. Throughout, we incorporated poststratification weights to appropriately represent the U.S. population, which we analyzed with logistic regression. Among 497,967 respondents nationwide, 55,234 reported a diagnosis of diabetes, corresponding to a weighted prevalence of 9.8% (95% CI 9.6–9.9). Among those with diabetes, 41.1% (40.2–41.9) met ADA aerobic exercise guidelines, compared with 51.5% (51.2–51.8) in the general U.S. adult population (odds ratio [OR] 0.63; 95% CI 0.60–0.65; P , 0.001). However, only 12.4% (11.9–13.0) met ADA resistance exercise guidelines, compared with 21.0% (20.8–21.3) in the general population (OR 0.51; 95% CI 0.48–0.53; P , 0.001).
Table 1 reports weighted proportions and ORs of diabetic Americans meeting aerobic and resistance exercise guidelines by selected characteristics that were significant predictors of adjusted prevalence, including sex (P , 0.001 for both), age (P 5 0.05 for aerobic; P 5 0.003 for resistance), race/ethnicity (P 5 0.006 for both), education level (P , 0.001 for both), BMI (P , 0.001 for both), and U.S. census region (P , 0.001 for aerobic; P 5 0.01 for resistance). Among 36,622 respondents with diabetes in 40 states and DC, significant predictors of meeting resistance exercise guidelines included previous education in diabetes management (adjusted OR 1.33; 95% CI 1.13–1.57; P 5 0.001), insulin use (adjusted OR for noninsulin users 1.30; 95% CI 1.05– 1.59; P 5 0.01), and frequency of home blood glucose testing (e.g., adjusted OR for $3 times a day vs. never 1.62; 95% CI 1.18–2.23; P 5 0.003). Years with diabetes, retinopathy, and frequency of clinical examinations and HbA1c testing were not related to resistance exercise. In summary, only 12% of U.S. adults with diabetes meet ADA resistance exercise guidelines, lower than the 21% in the general public and the 41% who meet aerobic exercise guidelines. In addition, adherence to resistance exercise guidelines is low across a broad range of different demographic subgroups. This represents an enormous opportunity
1
Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA Harvard Medical School, Boston, MA
2
Corresponding author: Kenneth J. Mukamal, [email protected]. © 2014 by the American Diabetes Association. Readers may use this article as long as the work is properly cited, the use is educational and not for profit, and the work is not altered.
e-LETTERS – OBSERVATIONS
Diabetes affects muscle and bone health and is characterized by osteoporosis and reduced bone quality (1). Resistance training improves insulin sensitivity, HbA 1c , lipid profile, blood pressure, bone development, physical performance, and quality of life (2,3), and serves as a promising intervention for diabetes management. Indeed, the American Diabetes Association (ADA) has published specific guidelines on resistance exercise for adults with diabetes that exceed those for the general public (4). To ascertain adherence to guidelines for resistance training and aerobic exercise, we examined the proportion of diabetic Americans who meet these guidelines. We used the 2011 administration of the Behavioral Risk Factor Surveillance System (BRFSS) conducted by the Centers for Disease Control and Prevention (CDC). In this large, anonymous telephone survey, respondents reported, during the past month, 1) the frequency and duration of the two leisure-time aerobic activities on which they spent the most time and 2) the frequency of physical activities or exercises to strengthen their muscles (excluding aerobic activities but including yoga, sit-ups, push-ups, and exercises using weights or elastic bands). The CDC classifies aerobic activities as moderate or vigorous based upon their estimated metabolic equivalents and respondents’ aerobic capacity (5). We
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Diabetes Care Volume 37, August 2014
Exercise Among Diabetic Adults
Table 1—Proportions of U.S. adults with diabetes meeting the ADA exercise guidelines by selected characteristics Meet aerobic exercise guidelines* Weighted prevalence Characteristic
Adjusted OR‡
Meet resistance exercise guidelines† Weighted prevalence
Adjusted OR‡
%
95% CI
OR
95% CI
%
95% CI
OR
95% CI
Sex Male Female
45.5 36.5
(44.2–46.8) (35.5–37.6)
1 0.73
d (0.68–0.78)
14.3 10.5
(13.5–15.3) (9.8–11.2)
1 0.72
d (0.65–0.80)
Age (years) 18–24 25–34 35–44 45–54 55–64 .65
50.1 42.0 41.6 39.0 39.7 42.6
(39.5–60.7) (36.3–47.9) (38.2–45.1) (36.9–41.1) (38.2–41.3) (41.4–43.7)
1.35 1.04 1.03 0.91 0.90 1
(0.89–2.07) (0.81–1.35) (0.88–1.20) (0.82–1.01) (0.83–0.98) d
22.9 15.7 14.1 11.7 11.5 12.4
(15.2–32.9) (12.0–20.2) (11.6–17.0) (10.4–13.2) (10.6–12.5) (11.7–13.1)
2.12 1.32 1.17 0.95 0.91 1
(1.29–3.47) (0.96–1.82) (0.93–1.49) (0.82–1.11) (0.81–1.02) d
Race/ethnicity White, non-Hispanic Black, non-Hispanic Hispanic Other
42.7 35.8 37.4 46.8
(41.8–43.6) (33.5–38.1) (34.5–40.5) (42.7–51.0)
1 0.87 0.91 0.95
d (0.77–0.97) (0.79–1.05) (0.80–1.13)
12.0 13.8 11.8 15.6
(11.4–12.6) (12.3–15.5) (9.8–14.0) (13.1–18.4)
1 1.32 1.06 1.16
d (1.13–1.53) (0.84–1.32) (0.93–1.44)
Education level Less than high school High school Some college College degree
31.4 39.0 43.8 53.3
(29.4–33.5) (37.6–40.5) (42.3–45.3) (51.6–55.1)
0.43 0.60 0.73 1
(0.38–0.49) (0.55–0.66) (0.66–0.80) d
10.1 10.7 13.7 16.7
(8.7–11.6) (9.9–11.7) (12.7–14.7) (15.5–18.0)
0.58 0.62 0.83 1
(0.48–0.69) (0.55–0.71) (0.73–0.94) d
BMI (kg/m2) Underweight/normal (,25) Overweight (25–30) Obese (.30)
50.2 46.3 36.2
(47.8–52.5) (44.7–47.9) (35.1–37.3)
1 0.86 0.59
d (0.76–0.96) (0.53–0.66)
15.8 14.0 10.9
(14.2–17.5) (12.9–15.1) (10.1–11.6)
1 0.88 0.68
d (0.75–1.03) (0.59–0.79)
U.S. census region Midwest Northeast South West
41.3 41.5 37.6 47.4
(39.6–43.0) (39.5–43.6) (36.3–38.9) (45.5–49.4)
1 1.00 0.89 1.24
d (0.90–1.12) (0.81–0.97) (1.11–1.38)
13.1 11.8 11.4 14.2
(11.9–14.4) (10.5–13.1) (10.6–12.3) (12.9–15.7)
1 0.86 0.83 1.02
d (0.73–1.02) (0.72–0.96) (0.86–1.21)
*To meet the ADA aerobic exercise guidelines (4), respondents had to report engaging at least 150 min per week in moderate intensity aerobic physical activity and/or at least 90 min per week in vigorous-intensity aerobic physical activity. †To meet the ADA resistance exercise guidelines (4), respondents had to report engaging in resistance exercise at least three times a week. ‡Adjusted OR accounted for sex, age-group, race/ethnicity, education level, BMI, and U.S. census region.
for improvement in diabetes management nationwide.
Duality of Interest. No potential conflicts of
interest relevant to this article were reported. Author Contributions. L.M. researched the
data and wrote the manuscript. A.J.C. researched the data and reviewed and edited the manuscript. K.J.M. provided supervision and reviewed and edited the manuscript. L.M. and K.J.M. are the guarantors of this work and, as such, had full access to all the data in the
study and take responsibility for the integrity of the data and the accuracy of the data analysis.
References 1. 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 2. Westcott WL. Resistance training is medicine: effects of strength training on health. Curr Sports Med Rep 2012;11:209–216
3. Eves ND, Plotnikoff RC. Resistance training and type 2 diabetes: Considerations for implementation at the population level. Diabetes Care 2006;29:1933–1941 4. Sigal RJ, Kenny GP, Wasserman DH, CastanedaSceppa C. Physical activity/exercise and type 2 diabetes. Diabetes Care 2004;27: 2518–2539 5. Centers for Disease Control and Prevention (CDC). Adult participation in aerobic and musclestrengthening physical activitiesdUnited States, 2011. MMWR Morb Mortal Wkly Rep 2013;62: 326–330
e175
Resistance and Aerobic Exercise Among Adults With Diabetes in the U.S.
Lin Mu,1 Aaron J. Cohen,2 and Kenneth J. Mukamal1,2
Diabetes Care 2014;37:e175–e176 | DOI: 10.2337/dc14-0619
considered respondents who reported $150 min of moderate intensity or $90 min of vigorous intensity aerobic physical activity per week as meeting ADA aerobic guidelines and those who reported resistance training $3 times/week as meeting ADA resistance guidelines (4). In 40 U.S. states and the District of Columbia (DC) (excluding Colorado, Idaho, Illinois, Maryland, Mississippi, New York, South Dakota, Vermont, Virginia, and Washington), the BRFSS also incorporated an additional series of questions for respondents with self-reported diabetes, including age at diagnosis, insulin use, home blood glucose testing, physician visits, complications, and other diabetesrelated behaviors. Throughout, we incorporated poststratification weights to appropriately represent the U.S. population, which we analyzed with logistic regression. Among 497,967 respondents nationwide, 55,234 reported a diagnosis of diabetes, corresponding to a weighted prevalence of 9.8% (95% CI 9.6–9.9). Among those with diabetes, 41.1% (40.2–41.9) met ADA aerobic exercise guidelines, compared with 51.5% (51.2–51.8) in the general U.S. adult population (odds ratio [OR] 0.63; 95% CI 0.60–0.65; P , 0.001). However, only 12.4% (11.9–13.0) met ADA resistance exercise guidelines, compared with 21.0% (20.8–21.3) in the general population (OR 0.51; 95% CI 0.48–0.53; P , 0.001).
Table 1 reports weighted proportions and ORs of diabetic Americans meeting aerobic and resistance exercise guidelines by selected characteristics that were significant predictors of adjusted prevalence, including sex (P , 0.001 for both), age (P 5 0.05 for aerobic; P 5 0.003 for resistance), race/ethnicity (P 5 0.006 for both), education level (P , 0.001 for both), BMI (P , 0.001 for both), and U.S. census region (P , 0.001 for aerobic; P 5 0.01 for resistance). Among 36,622 respondents with diabetes in 40 states and DC, significant predictors of meeting resistance exercise guidelines included previous education in diabetes management (adjusted OR 1.33; 95% CI 1.13–1.57; P 5 0.001), insulin use (adjusted OR for noninsulin users 1.30; 95% CI 1.05– 1.59; P 5 0.01), and frequency of home blood glucose testing (e.g., adjusted OR for $3 times a day vs. never 1.62; 95% CI 1.18–2.23; P 5 0.003). Years with diabetes, retinopathy, and frequency of clinical examinations and HbA1c testing were not related to resistance exercise. In summary, only 12% of U.S. adults with diabetes meet ADA resistance exercise guidelines, lower than the 21% in the general public and the 41% who meet aerobic exercise guidelines. In addition, adherence to resistance exercise guidelines is low across a broad range of different demographic subgroups. This represents an enormous opportunity
1
Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA Harvard Medical School, Boston, MA
2
Corresponding author: Kenneth J. Mukamal, [email protected]. © 2014 by the American Diabetes Association. Readers may use this article as long as the work is properly cited, the use is educational and not for profit, and the work is not altered.
e-LETTERS – OBSERVATIONS
Diabetes affects muscle and bone health and is characterized by osteoporosis and reduced bone quality (1). Resistance training improves insulin sensitivity, HbA 1c , lipid profile, blood pressure, bone development, physical performance, and quality of life (2,3), and serves as a promising intervention for diabetes management. Indeed, the American Diabetes Association (ADA) has published specific guidelines on resistance exercise for adults with diabetes that exceed those for the general public (4). To ascertain adherence to guidelines for resistance training and aerobic exercise, we examined the proportion of diabetic Americans who meet these guidelines. We used the 2011 administration of the Behavioral Risk Factor Surveillance System (BRFSS) conducted by the Centers for Disease Control and Prevention (CDC). In this large, anonymous telephone survey, respondents reported, during the past month, 1) the frequency and duration of the two leisure-time aerobic activities on which they spent the most time and 2) the frequency of physical activities or exercises to strengthen their muscles (excluding aerobic activities but including yoga, sit-ups, push-ups, and exercises using weights or elastic bands). The CDC classifies aerobic activities as moderate or vigorous based upon their estimated metabolic equivalents and respondents’ aerobic capacity (5). We
e176
Diabetes Care Volume 37, August 2014
Exercise Among Diabetic Adults
Table 1—Proportions of U.S. adults with diabetes meeting the ADA exercise guidelines by selected characteristics Meet aerobic exercise guidelines* Weighted prevalence Characteristic
Adjusted OR‡
Meet resistance exercise guidelines† Weighted prevalence
Adjusted OR‡
%
95% CI
OR
95% CI
%
95% CI
OR
95% CI
Sex Male Female
45.5 36.5
(44.2–46.8) (35.5–37.6)
1 0.73
d (0.68–0.78)
14.3 10.5
(13.5–15.3) (9.8–11.2)
1 0.72
d (0.65–0.80)
Age (years) 18–24 25–34 35–44 45–54 55–64 .65
50.1 42.0 41.6 39.0 39.7 42.6
(39.5–60.7) (36.3–47.9) (38.2–45.1) (36.9–41.1) (38.2–41.3) (41.4–43.7)
1.35 1.04 1.03 0.91 0.90 1
(0.89–2.07) (0.81–1.35) (0.88–1.20) (0.82–1.01) (0.83–0.98) d
22.9 15.7 14.1 11.7 11.5 12.4
(15.2–32.9) (12.0–20.2) (11.6–17.0) (10.4–13.2) (10.6–12.5) (11.7–13.1)
2.12 1.32 1.17 0.95 0.91 1
(1.29–3.47) (0.96–1.82) (0.93–1.49) (0.82–1.11) (0.81–1.02) d
Race/ethnicity White, non-Hispanic Black, non-Hispanic Hispanic Other
42.7 35.8 37.4 46.8
(41.8–43.6) (33.5–38.1) (34.5–40.5) (42.7–51.0)
1 0.87 0.91 0.95
d (0.77–0.97) (0.79–1.05) (0.80–1.13)
12.0 13.8 11.8 15.6
(11.4–12.6) (12.3–15.5) (9.8–14.0) (13.1–18.4)
1 1.32 1.06 1.16
d (1.13–1.53) (0.84–1.32) (0.93–1.44)
Education level Less than high school High school Some college College degree
31.4 39.0 43.8 53.3
(29.4–33.5) (37.6–40.5) (42.3–45.3) (51.6–55.1)
0.43 0.60 0.73 1
(0.38–0.49) (0.55–0.66) (0.66–0.80) d
10.1 10.7 13.7 16.7
(8.7–11.6) (9.9–11.7) (12.7–14.7) (15.5–18.0)
0.58 0.62 0.83 1
(0.48–0.69) (0.55–0.71) (0.73–0.94) d
BMI (kg/m2) Underweight/normal (,25) Overweight (25–30) Obese (.30)
50.2 46.3 36.2
(47.8–52.5) (44.7–47.9) (35.1–37.3)
1 0.86 0.59
d (0.76–0.96) (0.53–0.66)
15.8 14.0 10.9
(14.2–17.5) (12.9–15.1) (10.1–11.6)
1 0.88 0.68
d (0.75–1.03) (0.59–0.79)
U.S. census region Midwest Northeast South West
41.3 41.5 37.6 47.4
(39.6–43.0) (39.5–43.6) (36.3–38.9) (45.5–49.4)
1 1.00 0.89 1.24
d (0.90–1.12) (0.81–0.97) (1.11–1.38)
13.1 11.8 11.4 14.2
(11.9–14.4) (10.5–13.1) (10.6–12.3) (12.9–15.7)
1 0.86 0.83 1.02
d (0.73–1.02) (0.72–0.96) (0.86–1.21)
*To meet the ADA aerobic exercise guidelines (4), respondents had to report engaging at least 150 min per week in moderate intensity aerobic physical activity and/or at least 90 min per week in vigorous-intensity aerobic physical activity. †To meet the ADA resistance exercise guidelines (4), respondents had to report engaging in resistance exercise at least three times a week. ‡Adjusted OR accounted for sex, age-group, race/ethnicity, education level, BMI, and U.S. census region.
for improvement in diabetes management nationwide.
Duality of Interest. No potential conflicts of
interest relevant to this article were reported. Author Contributions. L.M. researched the
data and wrote the manuscript. A.J.C. researched the data and reviewed and edited the manuscript. K.J.M. provided supervision and reviewed and edited the manuscript. L.M. and K.J.M. are the guarantors of this work and, as such, had full access to all the data in the
study and take responsibility for the integrity of the data and the accuracy of the data analysis.
References 1. 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 2. Westcott WL. Resistance training is medicine: effects of strength training on health. Curr Sports Med Rep 2012;11:209–216
3. Eves ND, Plotnikoff RC. Resistance training and type 2 diabetes: Considerations for implementation at the population level. Diabetes Care 2006;29:1933–1941 4. Sigal RJ, Kenny GP, Wasserman DH, CastanedaSceppa C. Physical activity/exercise and type 2 diabetes. Diabetes Care 2004;27: 2518–2539 5. Centers for Disease Control and Prevention (CDC). Adult participation in aerobic and musclestrengthening physical activitiesdUnited States, 2011. MMWR Morb Mortal Wkly Rep 2013;62: 326–330
