Download PDF
Exp Clin Endocrinol Diabetes
DOI: 10.1055/a-2500-1026
German Diabetes Associaton: Clinical Practice Guidelines

Diabetes, Sports and Exercise

Katrin Esefeld
1   Preventive and Rehabilitative Sports Medicine, Technical University of Munich, Klinikum rechts der Isar, Munich, Germany
2   German Center for Cardiovascular Research (Deutsches Zentrum für Herzkreislaufforschung – DZHK), partner site Munich Heart Alliance (MHA), Munich, Germany
,
Stephan Kress
3   Diabetes, Sport and Exercise Working Group of the DDG, Berlin, Germany
4   Department of Internal Medicine I, Vinzentius Hospital Landau, Landau, Germany
,
Meinolf Behrens
3   Diabetes, Sport and Exercise Working Group of the DDG, Berlin, Germany
5   Diabetes Center Minden, Minden, Germany
,
Peter Zimmer
3   Diabetes, Sport and Exercise Working Group of the DDG, Berlin, Germany
,
Michael Stumvoll
6   Department of Internal Medicine III, University Hospital Leipzig, Leipzig, Germany
,
Ulrike Thurm
3   Diabetes, Sport and Exercise Working Group of the DDG, Berlin, Germany
,
Bernhard Gehr
3   Diabetes, Sport and Exercise Working Group of the DDG, Berlin, Germany
7   m&i Specialist Hospital Bad Heilbrunn, Bad Heilbrunn, Germany
,
Martin Halle‡
1   Preventive and Rehabilitative Sports Medicine, Technical University of Munich, Klinikum rechts der Isar, Munich, Germany
2   German Center for Cardiovascular Research (Deutsches Zentrum für Herzkreislaufforschung – DZHK), partner site Munich Heart Alliance (MHA), Munich, Germany
3   Diabetes, Sport and Exercise Working Group of the DDG, Berlin, Germany
,
Christian Brinkmann‡
3   Diabetes, Sport and Exercise Working Group of the DDG, Berlin, Germany
8   Institute of Cardiovascular Research and Sports Medicine, German Sport University Cologne, Cologne, Germany
9   IST University of Applied Sciences Düsseldorf, Düsseldorf, Germany
› Author Affiliations
› Further Information
Also available at
   Permissions and Reprints

Notice of update

The DDG clinical practice guidelines are updated regularly during the second half of the calendar year. Please ensure that you read and cite the respective current version.

UPDATES TO CONTENT AND DIFFERENT RECOMMENDATIONS COMPARED TO THE PREVIOUS YEAR’S VERSION

Change 1:

Update of exercise recommendations for an optimum amount of exercise according to the recommendations of the American Diabetes Association (ADA) for the year 2024

Reason:

Recommendations of the newly-published ADA 2024 guidelines are now being considered.

Supporting reference:

[1]

Change 2:

Note that menstrual cycle phases should be taken into account as an additional factor when considering insulin dose/supplemental carbohydrate adjustments in the context of exercise.

Reason:

Studies suggest that glucose dynamics can vary depending on the menstrual cycle in the context of exercise.

Supporting reference:

[2]

Change 3:

Reference to the possibility of using digital health applications (DIGA) for lifestyle modifications

Reason:

Prescription of DIGAs can help people with diabetes make lifestyle changes to improve clinical outcomes. Proof of efficacy has already been provided for some DIGAs.

Supporting reference:

[3]

Change 4:

Update of recommendations for electromyostimulation (EMS) training for people with diabetes mellitus

Reason:

According to the recommendation of a revised consensus report (based on recent studies on the effectiveness and safety of EMS training), diabetes mellitus is no longer considered an absolute, but a relative contraindication for EMS training in a commercial setting.

Supporting reference:

[4]

Change 5:

Advice on the use of “exercise snacks” (movement units of short duration)

Reason:

Some studies suggest that “exercise snacks”, which can be easily integrated into everyday life, can be useful in counteracting the harmful effects of long periods of inactivity and improving the glucose profile.

Supporting reference:

[5] [6]

Change 6:

Advice on the optimum timing of sport and exercise in people with type 2 diabetes mellitus

Reason:

A recent meta-study shows that to reduce postprandial glucose peaks, sport and exercise immediately after eating are more effective than before eating.

Supporting reference:

[7]

For all forms of diabetes mellitus, exercise is one of the most important measures for maintaining good health. Sport and exercise trigger adaptation and repair mechanisms in various organ systems and cells, such as the muscles, nerves, vessels, immune system or brain, which can help ward off diseases [8] [9] [10] [11].

There is no need for maximum physical exercise. Exertion according to the motto “running/walking without panting” already results in good health benefits. In addition to 30 minutes of exercise per day, increasing the opportunities for being active in the context of everyday activities has also been proven to be effective. In addition to the recommendations of the American Diabetes Association (ADA) from 2024, adults with diabetes should exercise for 150 minutes/week or more at moderate intensity. Younger and physically fit patients can also exercise more intensively (minimum recommendation: 75 minutes/week). Exercise should be performed on at least 3 days, with no more than 2 consecutive days of inactivity. In addition, it is recommended to do strength training 2 to 3 times a week, but not on consecutive days. Periods of sitting should be interrupted every 30 minutes. For older people, flexibility and balance training is also recommended 2–3 times a week. Alternative sports such as yoga and tai-chi may also be suitable. For the treatment of obesity, 200–300 minutes of exercise per week and an energy deficit of about 500–750 kcal/day should be aimed for [1]. For children and adolescents, moderate to strenuous exercise of at least 60 minutes duration/day is recommended [1].

This clinical practice guideline is intended to outline therapeutic options for physical activity in the treatment of diabetes mellitus and to provide practical recommendations for implementing these options for type 1 and type 2 patients.



Publication History

Article published online:
10 June 2025

© 2025. Thieme. All rights reserved.

Georg Thieme Verlag KG
Oswald-Hesse-Straße 50, 70469 Stuttgart, Germany

 

  • References

  • 1 American Diabetes Association Standards in medical care in diabetes 2024. Diabetes Care. 2023 47. S77-S110
    CrossrefPubMedSearch in Google Scholar
  • 2 Toor S, Yardley JE, Momeni Z. Type 1 Diabetes and the Menstrual Cycle: Where/How Does Exercise Fit in?. Int J Environ Res Public Health 2023; 20: 2772
    CrossrefPubMedSearch in Google Scholar
  • 3 Bretschneider MP, Schwarz PEH. Digitale Gesundheitsanwendungen – digitale Diabetestherapie mit CGM. Diabetes aktuell 2024; 22: 96-97
    Thieme ConnectPubMedSearch in Google Scholar
  • 4 Von Stengel S, Fröhlich M, Ludwig O. et al. Recommended contraindications for the use of non-medical WB-electromyostimulation. Front Sports Act Living 2024; 16: 6
    CrossrefPubMedSearch in Google Scholar
  • 5 Wang T, Laher I, Li S. Exercise snacks and physical fitness in sedentary populations. Sports Med Health Sci 2024;
    CrossrefPubMedSearch in Google Scholar
  • 6 Krouwel M, Greenfield SM, Chalkley A. et al. Promoting participation in physical activity through Snacktivity: A qualitative mixed methods study. PLoS One 2023; 18: e0291040
    CrossrefPubMedSearch in Google Scholar
  • 7 Engeroff T, Groneberg DA, Wilke J. After Dinner Rest a While, After Supper Walk a Mile? A Systematic Review with Meta-analysis on the Acute Postprandial Glycemic Response to Exercise Before and After Meal Ingestion in Healthy Subjects and Patients with Impaired Glucose Tolerance. Sports Med 2023; 53: 849-869
    CrossrefPubMedSearch in Google Scholar
  • 8 Pedersen BK, Saltin B. Exercise as medicine – evidence for prescribing exercise as therapy in 26 different chronic diseases. Scand J Med Sci Sports 2015; 25: 1-72
    CrossrefPubMedSearch in Google Scholar
  • 9 Kirchner H, Osler ME, Krook A. et al. Epigenetic flexibility in metabolic regulation: disease cause and prevention?. Trends Cell Biol 2013; 23: 203-209
    CrossrefPubMedSearch in Google Scholar
  • 10 Benatti FB, Pedersen BK. Exercise as an anti-inflammatory therapy for rheumatic diseases-myokine regulation. Nat Rev Rheumatol 2015; 11: 86-97
    CrossrefPubMedSearch in Google Scholar
  • 11 Fiuza-Luces C, Garatachea N, Berger NA. et al. Exercise is the real polypill. Physiology 2013; 28: 330-358
    CrossrefPubMedSearch in Google Scholar
  • 12 Stanford KI, Goodyear LJ. Exercise and type 2 diabetes: molecular mechanisms regulating glucose uptake in skeletal muscle. Adv Physiol Educ 2014; 38: 308-314
    CrossrefPubMedSearch in Google Scholar
  • 13 Herbst A, Kordonouri O, Schwab KO. et al. Impact of physical activity on cardiovascular risk factors in children with type 1 diabetes: a multicenter study of 23251 patients. Diabetes Care 2007; 30: 2098-2100
    CrossrefPubMedSearch in Google Scholar
  • 14 Tonoli C, Heyman E, Roelands B. et al. Effects of different types of acute and chronic (training) exercise on glycaemic control in type 1 diabetes mellitus: a meta-analysis. Sports Med 2012; 42: 1059-1080
    CrossrefPubMedSearch in Google Scholar
  • 15 Riddell MC, Li Z, Gal RL. et al. Examining the acute glycemic effects of different types of structured exercise sessions in type 1 diabetes in a real-world setting: The type 1 diabetes and exercise initiative (T1DEXI). Diabetes Care 2023; 46: 704-713
    CrossrefPubMedSearch in Google Scholar
  • 16 Riddell MC, Peters AL. Exercise in adults with type 1 diabetes mellitus. Nat Rev Endocrinol 2023; 19: 98-111
    CrossrefPubMedSearch in Google Scholar
  • 17 Riddell MC, Gallen IW, Smart CE. et al. Exercise management in type 1 diabetes: a consensus statement. Lancet Diabetes Endocrinol 2017; 5: 377-390
    CrossrefPubMedSearch in Google Scholar
  • 18 Moser O, Riddell MC, Eckstein ML. et al. Glucose management for exercise using continuous glucose monitoring (CGM) and intermittently scanned CGM (isCGM) systems in type 1 diabetes: position statement of the European Association for the Study of Diabetes (EASD) and of the International Society for Pediatric and Adolescent Diabetes (ISPAD) endorsed by JDRF and supported by the American Diabetes Association (ADA). Diabetologia 2020; 63: 2501-2520
    CrossrefPubMedSearch in Google Scholar
  • 19 Roberts AJ, Taplin CE. Exercise in Youth with Type 1 Diabetes. Curr Pediatr Rev 2015; 11: 120-125
    CrossrefPubMedSearch in Google Scholar
  • 20 Pivovarov JA, Taplin CE, Riddell MC. Current perspectives on physical activity and exercise for youth with diabetes. Pediatr Diabetes 2015; 16: 242-255
    CrossrefPubMedSearch in Google Scholar
  • 21 Bally L, Laimer M, Stettler C. Exercise-associated glucose metabolism in individuals with type 1 diabetes mellitus. Curr Opin Clin Nutr Metab Care 2015; 18: 428-433
    CrossrefPubMedSearch in Google Scholar
  • 22 Garcia-Garcia F, Kumareswaran K, Hovorka R. et al. Quantifying the acute changes in glucose with exercise in type 1 diabetes: a systematic review and meta-analysis. Sports Med 2015; 45: 587-599
    CrossrefPubMedSearch in Google Scholar
  • 23 Riddell MC, Scott SN, Fournier PA. et al. The competitive athlete with type 1 diabetes. Diabetologia 2020; 63: 1475-1490
    CrossrefPubMedSearch in Google Scholar
  • 24 Toghi-Eshghi SR, Yardley JE. Morning (fasting) vs afternoon resistance exercise in individuals with type 1 diabetes: a randomized crossover study. J Clin Endocrinol Metab 2019; 104: 5217-5224
    CrossrefPubMedSearch in Google Scholar
  • 25 Aronson R, Brown RE, Li A. et al. Optimal insulin correction factor in post high-intensity exercise hyperglycemia in adults with type 1 diabetes: the FIT study. Diabetes Care 2019; 42: 10-16
    CrossrefPubMedSearch in Google Scholar
  • 26 Lean ME, Leslie WS, Barnes AC. Primary care-led weight management for remission of type 2 diabetes (DiRECT): an open-label, cluster randomised trial. Lancet 2018; 391: 541-551
    CrossrefPubMedSearch in Google Scholar
  • 27 Lean MEJ, Leslie WS, Barnes AC. Durability of a primary care-led weight management intervention for remission of type 2 diabetes: 2 year results of the DiRECT open-label, cluster randomised trial. Lancet Diabetes Endocrinol 2019; 7: 344-355
    CrossrefPubMedSearch in Google Scholar
  • 28 Röhling M, Herder C, Roden M. et al. Effects of Long-Term Exercise Interventions on Glycaemic Control in Type 1 and Type 2 Diabetes: a Systematic Review. Exp Clin Endocrinol Diabetes 2016; 124: 487-494
    Thieme ConnectPubMedSearch in Google Scholar
  • 29 Umpierre D, Ribeiro PA, Kramer CK. et al. Physical activity advice only or structured exercise training and association with HbA1c levels in type 2 diabetes: a systematic review and meta-analysis. JAMA 2011; 305: 1790-1799
    CrossrefPubMedSearch in Google Scholar
  • 30 Wing RR, Bolin P, Brancati FL. et al. Cardiovascular effects of intensive lifestyle intervention in type 2 diabetes. N Engl J Med 2013; 369: 145-154
    CrossrefPubMedSearch in Google Scholar
  • 31 Goldberg RB, Orchard TJ, Crandall JP. et al. Effects of long-term metformin and lifestyle interventions on cardiovascular events in the diabetes prevention program and its outcome study. Circulation 2022; 145: 1632-1641
    CrossrefPubMedSearch in Google Scholar
  • 32 Rietz M, Lehr A, Mino E. et al. Physical activity and risk of major diabetesrelated complications in individuals with diabetes: a systematic review and meta-analysis of observational studies. Diabetes Care 2022; 45: 3101-3111
    CrossrefPubMedSearch in Google Scholar
  • 33 Banach M, Lewek J, Surma S. et al. The association between daily step count and all-cause and cardiovascular mortality: a meta-analysis. Eur J Prev Cardiol 2023; 30: 1975-1985
    CrossrefPubMedSearch in Google Scholar
  • 34 Colberg SR, Laan R, Dassau E. et al. Physical activity and type 1 diabetes: time for a rewire. J Diabetes Sci Technol 2015; 9: 609-618
    CrossrefPubMedSearch in Google Scholar
  • 35 Jayawardene DC, McAuley SA, Horsburgh JC. et al. Closed-loop insulin delivery for adults with type 1 diabetes undertaking high-intensity interval exercise versus moderate-intensity exercise: a randomized, crossover study. Diabetes Technol Ther 2017; 19: 340-348
    CrossrefPubMedSearch in Google Scholar
  • 36 Breton MD, Chernavvsky DR, Forlenza GP. et al. Closed-loop control during intense prolonged outdoor exercise in adolescents with type 1 diabetes: the artificial pancreas ski study. Diabetes Care 2017; 40: 1644-1650
    CrossrefPubMedSearch in Google Scholar
  • 37 Dovc K, Macedoni M, Bratina N. et al. Closed-loop glucose control in young people with type 1 diabetes during and after unannounced physical activity: a randomised controlled crossover trial. Diabetologia 2017; 60: 2157-2167
    CrossrefPubMedSearch in Google Scholar
  • 38 Porter M, Fonda S, Swigert T. et al. Real-time continuous glucose monitoring to support self-care: results from a pilot study of patients with type 2 diabetes. J Diabetes Sci Technol 2022; 16: 578-580
    CrossrefPubMedSearch in Google Scholar
  • 39 Taylor PJ, Thompson CH, Luscombe-Marsh ND. et al. Tolerability and acceptability of real-time continuous glucose monitoring and its impact on diabetes management behaviours in individuals with type 2 diabetes – A pilot study. Diabetes Res Clin Pract 2019; 155: 107814
    CrossrefPubMedSearch in Google Scholar
  • 40 Vallis M, Ryan H, Berard L. et al. How continuous glucose monitoring can motivate self-management: Can motivation follow behaviour. ? Can J Diabetes 2023; S1499-S2671: 00064-3
    CrossrefPubMedSearch in Google Scholar
  • 41 Ding S, Schumacher M. Sensor monitoring of physical activity to improve glucose management in diabetic patients: a review. Sensors 2016; 16: 589
    CrossrefPubMedSearch in Google Scholar
  • 42 Lunde P, Blakstad Nilsson B, Bergland A. et al. The effectiveness of smartphone apps for lifestyle improvement in noncommunicable diseases: systematic review and meta-analyses. J Med Internet Res 2018; 20: 1-12
    CrossrefPubMedSearch in Google Scholar
  • 43 Wu X, Guo X, Zhang Z. The efficacy of mobile phone apps for lifestyle modification in diabetes: systematic review and meta-analysis. JMIR mHealth uHealth 2019; 7: e12297
    CrossrefPubMedSearch in Google Scholar
  • 44 Yom-Tov E, Feraru G, Kozdoba M. et al. Encouraging physical activity in patients with diabetes: intervention using a reinforcement learning system. J Med Internet Res 2017; 19: e338
    CrossrefPubMedSearch in Google Scholar
  • 45 Jimenez G, Lum E, Car J. Examining diabetes management apps recommended from a Google search: content analysis. JMIR mHealth uHealth 2019; 7: e11848
    CrossrefPubMedSearch in Google Scholar
  • 46 Pais S, Parry D, Petrova K. et al. Acceptance of using an ecosystem of mobile apps for use in diabetes clinic for self-management of gestational diabetes mellitus. Stud Health Technol Inform 2017; 245: 188-192
    PubMedSearch in Google Scholar
  • 47 Kordonouri O, Riddell MC. Use of apps for physical activity in type 1 diabetes: current status and requirements for future development. Ther Adv Endocrinol Metab 2019; 10: 1-7
    CrossrefPubMedSearch in Google Scholar
  • 48 Thomas JG, Bond DS, Raynor HA. et al. Comparison of smartphone-based behavioral obesity treatment with gold standard group treatment and control: a randomized trial. Obesity (Silver Spring) 2019; 27: 572-580
    CrossrefPubMedSearch in Google Scholar
  • 49 Schütte L. Digitale Selbsthilfe. Digitalisierungs- und Technologiereport Diabetes. 2019. Accessed: 26.05.2019 Retrieved from: https://www.dutreport.de/wp-content/uploads/2019/01/Selbsthilfe_Schuette.pdf
    PubMed
  • 50 Staiano AE, Beyl RA, Guan W. et al. Home-based exergaming among children with overweight/obesity: a randomized clinical trial. Pediatr Obes 2018; 13: 724-733
    CrossrefPubMedSearch in Google Scholar
  • 51 Cooper AR, Tibbitts B, England C. et al. Potential of electric bicycles to improve the health of people with type 2 diabetes: a feasibility study. Diabet Med 2018; 35: 1279-1282
    CrossrefPubMedSearch in Google Scholar
  • 52 van der Berg JD, Stehouwer CD, Bosma H. et al. Associations of total amount and patterns of sedentary behaviour with type 2 diabetes and the metabolic syndrome: The Maastricht Study. Diabetologia 2016; 59: 709-718
    CrossrefPubMedSearch in Google Scholar
  • 53 Dunstan DW, Dogra S, Carter SE. et al. Sit less and move more for cardiovascular health: emerging insights and opportunities. Nat Rev Cardiol 2021; 18: 637-648
    CrossrefPubMedSearch in Google Scholar
  • 54 Duvivier BM, Schaper NC, Hesselink MK. et al. Breaking sitting with light activities vs structured exercise: a randomised crossover study demonstrating benefits for glycaemic control and insulin sensitivity in type 2 diabetes. Diabetologia 2017; 60: 490-498
    CrossrefPubMedSearch in Google Scholar
  • 55 Han HO, Lim J, Viskochil R. et al. Pilot study of impact of a pedal desk on postprandial responses in sedentary workers. Med Sci Sports Exerc 2018; 50: 2156-2163
    CrossrefPubMedSearch in Google Scholar
  • 56 Karstoft K, Winding K, Knudsen SH. et al. The effects of free-living interval walking training on glycemic control, body composition, and physical fitness in type 2 diabetic patients: a randomized, controlled trial. Diabetes Care 2013; 36: 228-236
    CrossrefPubMedSearch in Google Scholar
  • 57 Yang Z, Scott AC, Mao C. et al. Resistance exercise versus aerobic exercise for type 2 diabetes: a systematic review and meta-analysis. Sports Med 2014; 44: 487-499
    CrossrefPubMedSearch in Google Scholar
  • 58 van Buuren F, Horstkotte D, Mellwig KP. et al. Electrical myostimulation (EMS) improves glucose metabolism and oxygen uptake in type 2 diabetes mellitus patients – results from the EMS study. Diabetes Technol Ther 2015; 17: 413-419
    CrossrefPubMedSearch in Google Scholar
  • 59 Robinson CC, Barreto RP, Sbruzzi G. et al. The effects of whole body vibration in patients with type 2 diabetes: a systematic review and metaanalysis of randomized controlled trials. Braz J Phys Ther 2016; 20: 4-14
    CrossrefPubMedSearch in Google Scholar
  • 60 Kempf K, Martin S. Autonomous exercise game use improves metabolic control and quality of life in type 2 diabetes patients – a randomized controlled trial. BMC Endocr Disord 2013; 13: 57
    CrossrefPubMedSearch in Google Scholar
  • 61 Baskerville R, Ricci-Cabello I, Roberts N. et al. Impact of accelerometer and pedometer use on physical activity and glycaemic control in people with type 2 diabetes: a systematic review and meta-analysis. Diabet Med 2017; 5: 612-620
    CrossrefPubMedSearch in Google Scholar