Substrate source utilisation in long-term diagnosed type 2 diabetes patients at rest, and during exercise and subsequent recovery

Cardiorespiratory fitness in individuals with type 2 diabetes mellitus: a systematic review and meta-analysis

Objective

To conduct a systematic review and meta-analysis assessing the cardiorespiratory fitness (CRF) among individuals with and without type 2 diabetes.

Materials and methods

The current review was registered in PROSPERO under the number CRD42018082718. MEDLINE, EMBASE, and Cochrane Library databases were searched from inception through February 2022. Eligibility criteria consisted of observational or interventional studies that evaluated CRF through cardiopulmonary exercise testing or six-minute walk test in individuals with type 2 diabetes compared with individuals without type 2 diabetes. For data extraction, we used baseline CRF assessments of randomized clinical trials or follow-up CRF assessments in observational studies. We performed a meta-analysis using maximal oxygen consumption (VO2 max), and distance walked in the 6MWT as primary outcomes. They were extracted and expressed as mean differences (MDs) and 95% CIs between treatment and comparator groups. The meta-analysis was conducted using Review Manager (RevMan) software.

Results

Out of 8,347 studies retrieved, 77 were included. Compared with individuals without type 2 diabetes, individuals with diabetes achieved a lower VO2 max (-5.84 mL.kg-1.min-1, 95% CI -6.93, -4.76 mL.kg-1.min-1, p = <0.0001; I2 = 91%, p for heterogeneity < 0.0001), and a smaller distance walked in 6MWT (-93.30 meters, 95% CI -141.2, -45.4 meters, p > 0.0001; I2: 94%, p for heterogeneity < 0.0001).

Conclusion

Type 2 diabetes was associated with lower cardiorespiratory fitness, as observed by lower VO2 max on maximal tests, and smaller distance walked in 6MWT, however the quality of studies was low.

Intramuscular lipid utilization during exercise: a systematic review, meta-analysis, and meta-regression

Intramuscular lipid (IMCL) utilization during exercise was controversial as numerous studies did not observe a decline in IMCL content post-exercise when assessed in muscle biopsies using biochemical techniques. Contemporary techniques including immunofluorescence microscopy and ¹H-magnetic resonance spectroscopy (¹H-MRS) offer advantages over biochemical techniques. The primary aim of this systematic review, meta-analysis, and meta-regression was to examine the net degradation of IMCL in response to an acute bout of cycling exercise in humans, as assessed with different analytical approaches. A secondary aim was to explore the factors influencing IMCL degradation including feeding status, exercise variables, and participant characteristics. A total of 44 studies met the inclusion criteria using biochemical, immunofluorescence, and ¹H-MRS techniques. A meta-analysis was completed using a random effects model and percentage change in IMCL content calculated from the standardized mean difference. Cycling exercise resulted in a net degradation of IMCL regardless of technique (total effect -23.7%, 95% CI = -28.7 to -18.7%) and there was no difference when comparing fasted versus fed-state exercise (P > 0.05). IMCL degradation using immunofluorescence techniques detected larger effects in type I fibers compared with whole muscle using biochemical techniques (P = 0.003) and in type I fibers compared with type II fibers (P < 0.001). Although IMCL degradation was associated with exercise duration, V̇o_2max, and BMI, none of these factors independently related to the change in IMCL content. These findings provide strong evidence that the analytical approach can influence the assessment of IMCL degradation in human skeletal muscle in response to exercise.

Chronic Statin Treatment Does Not Impair Exercise Lipolysis or Fat Oxidation in Exercise-Trained Individuals With Obesity and Dyslipidemia

OBJECTIVE

To determine whether statin medication in individuals with obesity, dyslipidemia, and metabolic syndrome affects their capacity to mobilize and oxidize fat during exercise.

METHODS

Twelve individuals with metabolic syndrome pedaled during 75 min at 54 ± 13% V˙O2max (5.7 ± 0.5 metabolic equivalents) while taking statins (STATs) or after 96-hr statin withdrawal (PLAC) in a randomized double-blind fashion.

RESULTS

At rest, PLAC increased low-density lipoprotein cholesterol (i.e., STAT 2.55 ± 0.96 vs. PLAC 3.16 ± 0.76 mmol/L; p = .004) and total cholesterol blood levels (i.e., STAT 4.39 ± 1.16 vs. PLAC 4.98 ± 0.97 mmol/L; p = .008). At rest, fat oxidation (0.99 ± 0.34 vs. 0.76 ± 0.37 μmol·kg-1·min-1 for STAT vs. PLAC; p = .068) and the rates of plasma appearance of glucose and glycerol (i.e., Ra glucose-glycerol) were not affected by PLAC. After 70 min of exercise, fat oxidation was similar between trials (2.94 ± 1.56 vs. 3.06 ± 1.94 μmol·kg-1·min-1, STA vs. PLAC; p = .875). PLAC did not alter the rates of disappearance of glucose in plasma during exercise (i.e., 23.9 ± 6.9 vs. 24.5 ± 8.2 μmol·kg-1·min-1 for STAT vs. PLAC; p = .611) or the rate of plasma appearance of glycerol (i.e., 8.5 ± 1.9 vs. 7.9 ± 1.8 μmol·kg-1·min-1 for STAT vs. PLAC; p = .262).

CONCLUSIONS

In patients with obesity, dyslipidemia, and metabolic syndrome, statins do not compromise their ability to mobilize and oxidize fat at rest or during prolonged, moderately intense exercise (i.e., equivalent to brisk walking). In these patients, the combination of statins and exercise could help to better manage their dyslipidemia.

Lipidome Alterations with Exercise Among People With and Without HIV: An Exploratory Study

Age-related comorbidities and physical function impairments in aging people with HIV (PWH) can be improved through exercise interventions. The mechanisms underlying these improvements, including lipidomic changes, are unknown. Sedentary adults (50-75 years old) with or without HIV participated in supervised endurance/resistance exercise for 24 weeks. Plasma lipid concentrations (∼1,200 lipid species from 13 lipid classes) at baseline and week 24 were measured by mass spectrometry. Given multiple comparisons, unadjusted and Benjamini-Hochberg corrected p values are reported. Analyses are considered exploratory. Twenty-five PWH and 24 controls had paired samples at baseline and week 24. The change in total triacylglycerol (TAG) concentrations after exercise intervention differed between groups (unadj-p = 0.006, adj-p = 0.078) with concentrations increasing among controls, but not among PWH. Changes in concentrations of TAG species composed of long-chain fatty acids differed between groups (unadj-p < 0.04) with increases among controls, but not among PWH. Changes in total diacylglycerol (DAG) concentration from baseline to week 24 differed between groups (unadj-p = 0.03, adj-p = 0.2) with an increase in PWH and a nonsignificant decrease in controls. Baseline to week 24 changes in DAGs composed of palmitic acid (16:0), palmitoleic acid (16:1), and stearic acid (18:0) differed by serostatus (unadj-p = 0.009-0.03; adj-p 0.10-0.12), with nonsignificant increases and decreases in concentrations in PWH and controls, respectively. Concentrations of individual lysophosphatidylcholine (LPC) and ceramide (CER) species also differed by HIV serostatus (unadj-p < = 0.05). Although exploratory, the effects of exercise on the lipidome may differ among people with and without HIV, potentially due to underlying alterations in lipid processing and fatty acid oxidation in PWH. Clinical Trials NCT02404792.

Effects of metabolic syndrome on fuel utilization during exercise on middle-aged moderately trained individuals

People with the metabolic syndrome (MetS) may have blunted exercise stimulation of metabolism explaining their resistance to lower blood glucose and triglycerides with exercise training. Glycerol and glucose rate of appearance (Ra) in plasma and substrate oxidation were determined at rest and during cycle ergometer exercise at three increasing intensities (55, 80 and 95% of maximal heart rate) in 9 middle-aged (61±7 yr) individuals with MetS. Data were compared to 8 healthy-younger (29±10 yr) individuals matched for habitual exercise training and fat free mass (Healthy-young). At rest, fasting plasma triglycerides (TG), blood glucose and insulin were higher in MetS than in Healthy-young (38%, 42% and 85%, respectively; all p<0.05). At rest, and during low intensity exercise (32-43% VO2MAX), plasma glycerol Ra (index of whole-body lipolysis) and glucose Ra and Rd (index of glucose appearance and disposal) were similar in MetS and Healthy-young. Fat oxidation peaked at low intensity exercise similarly in MetS and Healthy-young (0.273±0.082 vs 0.272±0.078 g·min-1, respectively; p = 0.961). Ra glycerol increased with exercise intensity but was lower in MetS at moderate and high exercise intensities (i.e., 60-100% VO2MAX; p<0.05). Metabolic clearance rate of glucose at high intensity (85-100% VO2MAX) was lower in MetS compared to Healthy-young (p = 0.029). The MetS that develops in middle adulthood, reduces exercise lipolysis and plasma glucose clearance at high exercise intensities, but does not blunt fat or carbohydrate metabolism at low exercise intensity.

Skeletal Muscle Hyperemia: A Potential Bridge Between Post-exercise Hypotension and Glucose Regulation

For both healthy individuals and patients with type 2 diabetes (T2D), the hemodynamic response to regular physical activity is important for regulating blood glucose, protecting vascular function, and reducing the risk of cardiovascular disease. In addition to these benefits of regular physical activity, evidence suggests even a single bout of dynamic exercise promotes increased insulin-mediated glucose uptake and insulin sensitivity during the acute recovery period. Importantly, post-exercise hypotension (PEH), which is defined as a sustained reduction in arterial pressure following a single bout of exercise, appears to be blunted in those with T2D compared to their non-diabetic counterparts. In this short review, we describe research that suggests the sustained post-exercise vasodilation often observed in PEH may sub-serve glycemic regulation following exercise in both healthy individuals and those with T2D. Furthermore, we discuss the interplay of enhanced perfusion, both macrovascular and microvascular, and glucose flux following exercise. Finally, we propose future research directions to enhance our understanding of the relationship between post-exercise hemodynamics and glucose regulation in healthy individuals and in those with T2D.

Impact of moderate exercise on fatty acid oxidation in pancreatic β-cells and skeletal muscle

Fatty acids (FA) play a crucial role in glycaemia regulation in healthy and metabolic disorders conditions through various mechanisms. FA oxidation is one of the processes involved in lipid metabolism and can be modulated by exercise. Nowadays, physical activity is known to be an effective strategy for the prevention and treatment of Type 2 Diabetes. Moreover, its intensity, its duration, the sex-gender, the prandial state, exerkines… are as many parameters that can influence glycaemic control. However, the widely debated question is to determine the best type of exercise for patients with metabolic disorders. In this review, we will discuss the impact of exercise intensity, especially moderate activity, on glycaemic control by focussing on FA oxidation in pancreatic β-cells and skeletal muscle. Finally, thanks to all the recent data, we will determine whether moderate physical activity is a good therapeutic strategy and if FA oxidation represents a target of interest to treat diabetic, obese and insulin-resistant patients.

Exercising your fat (metabolism) into shape: a muscle-centred view

Fatty acids are an important energy source during exercise. Training status and substrate availability are determinants of the relative and absolute contribution of fatty acids and glucose to total energy expenditure. Endurance-trained athletes have a high oxidative capacity, while, in insulin-resistant individuals, fat oxidation is compromised. Fatty acids that are oxidised during exercise originate from the circulation (white adipose tissue lipolysis), as well as from lipolysis of intramyocellular lipid droplets. Moreover, hepatic fat may contribute to fat oxidation during exercise. Nowadays, it is clear that myocellular lipid droplets are dynamic organelles and that number, size, subcellular distribution, lipid droplet coat proteins and mitochondrial tethering of lipid droplets are determinants of fat oxidation during exercise. This review summarises recent insights into exercise-mediated changes in lipid metabolism and insulin sensitivity in relation to lipid droplet characteristics in human liver and muscle. Graphical abstract.

Exercise as 'precision medicine' for insulin resistance and its progression to type 2 diabetes: a research review

Type 2 diabetes and obesity epidemics are in effect in the United States and the two pathologies are linked. In accordance with the growing appreciation that ‘exercise is medicine,’ it is intuitive to suggest that exercise can play an important role in the prevention and/or treatment of these conditions. However, if exercise is to truly be considered as a viable alternative to conventional healthcare prevention/treatment strategies involving pharmaceuticals, it must be prescribed with similar scrutiny. Indeed, it seems reasonable to posit that the recent initiative calling for ‘precision medicine’ in the US standard healthcare system should also be applied in the exercise setting. In this narrative review, we consider a number of explanations that have been forwarded regarding the pathological progression to type 2 diabetes both with and without the concurrent influence of overweight/obesity. Our goal is to provide insight regarding exercise strategies that might be useful as ‘precision medicine’ to prevent/treat this disease. Although the etiology of type 2 diabetes is complex and cause/consequence characteristics of associated dysfunctions have been debated, it is well established that impaired insulin action plays a critical early role. Consequently, an exercise strategy to prevent/treat this disease should be geared toward improving insulin sensitivity both from an acute and chronic standpoint. However, research suggests that a chronic improvement in insulin sensitivity only manifests when weight loss accompanies an exercise intervention. This has resonance because ectopic fat accumulation appears to represent a central component of disease progression regardless of whether obesity is also part of the equation. The cause/consequence characteristics of the relationship between insulin resistance, pathological fat deposition and/or mobilsation, elevated and/or poorly-distributed lipid within myocytes and an impaired capacity to use lipid as fuel remains to be clarified as does the role of muscle mitochondria in the metabolic decline. Until these issues are resolved, a multidimensional exercise strategy (e.g., aerobic exercise at a range of intensities and resistance training for muscular hypertrophy) could provide the best alternative for prevention/treatment.

Stimulation of white adipose tissue lipolysis by xenin, a neurotensin-related peptide

Xenin is a gastrointestinal hormone that belongs to the neurotensin family. Central administration of xenin to obese mice reduces food intake and body weight gain and causes alterations in the expression of lipid metabolism-related genes and proteins in white adipose tissue (WAT). However, it has not been tested whether or not xenin directly acts on adipose tissue and alters lipid metabolism. The present study was performed to address this possibility by examining the effect of xenin treatment on the levels of glycerol and free fatty acids (FFA) and expression levels of lipolysis marker proteins ex vivo in cultured mouse WAT. Xenin treatment significantly increased concentrations of glycerol and FFA in culture media and increased phosphorylation of hormone sensitive lipase (HSL) in ex vivo cultured WAT. These findings support the hypothesis that xenin directly acts on adipose tissues and stimulates lipolysis. Thus, enhancement of xenin action and its downstream signaling may offer a novel and effective therapy for obese patients by reducing the amount of stored fat in adipose tissue.

IFN-γ and TNF-α Pre-licensing Protects Mesenchymal Stromal Cells from the Pro-inflammatory Effects of Palmitate

The use of mesenchymal stromal cell (MSC) therapy for the treatment of type 2 diabetes (T2D) and T2D complications is promising; however, the investigation of MSC function in the setting of T2D has not been thoroughly explored. In our current study, we investigated the phenotype and function of MSCs in a simulated in vitro T2D environment. We show that palmitate, but not glucose, exposure impairs MSC metabolic activity with moderate increases in apoptosis, while drastically affecting proliferation and morphology. In co-culture with peripheral blood mononuclear cells (PBMCs), we found that MSCs not only lose their normal suppressive ability in high levels of palmitate, but actively support and enhance inflammation, resulting in elevated PBMC proliferation and pro-inflammatory cytokine release. The pro-inflammatory effect of MSCs in palmitate was partially reversed via palmitate removal and fully reversed through pre-licensing MSCs with interferon-gamma and tumor necrosis factor alpha. Thus, palmitate, a specific metabolic factor enriched within the T2D environment, is a potent modulator of MSC immunosuppressive function, which may in part explain the depressed potency observed in MSCs isolated from T2D patients. Importantly, we have also identified a robust and durable pre-licensing regimen that protects MSC immunosuppressive function in the setting of T2D.

The Flexibility of Ectopic Lipids

In addition to the subcutaneous and the visceral fat tissue, lipids can also be stored in non-adipose tissue such as in hepatocytes (intrahepatocellular lipids; IHCL), skeletal (intramyocellular lipids; IMCL) or cardiac muscle cells (intracardiomyocellular lipids; ICCL). Ectopic lipids are flexible fuel stores that can be depleted by physical exercise and repleted by diet. They are related to obesity and insulin resistance. Quantification of IMCL was initially performed invasively, using muscle biopsies with biochemical and/or histological analysis. ¹H-magnetic resonance spectroscopy (¹H-MRS) is now a validated method that allows for not only quantifying IMCL non-invasively and repeatedly, but also assessing IHCL and ICCL. This review summarizes the current available knowledge on the flexibility of ectopic lipids. The available evidence suggests a complex interplay between quantitative and qualitative diet, fat availability (fat mass), insulin action, and physical exercise, all important factors that influence the flexibility of ectopic lipids. Furthermore, the time frame of the intervention on these parameters (short-term vs. long-term) appears to be critical. Consequently, standardization of physical activity and diet are critical when assessing ectopic lipids in predefined clinical situations.

The effects of interval- vs. continuous exercise on excess post-exercise oxygen consumption and substrate oxidation rates in subjects with type 2 diabetes

BACKGROUND

For unknown reasons, interval training often reduces body weight more than energy-expenditure matched continuous training. We compared the acute effects of time-duration and oxygen-consumption matched interval- vs. continuous exercise on excess post-exercise oxygen consumption (EPOC), substrate oxidation rates and lipid metabolism in the hours following exercise in subjects with type 2 diabetes (T2D).

METHODS

Following an overnight fast, ten T2D subjects (M/F: 7/3; age=60.3±2.3years; body mass index (BMI)=28.3±1.1kg/m(2)) completed three 60-min interventions in a counterbalanced, randomized order: 1) control (CON), 2) continuous walking (CW), 3) interval-walking (IW - repeated cycles of 3min of fast and 3min of slow walking). Indirect calorimetry was applied during each intervention and repeatedly for 30min per hour during the following 5h. A liquid mixed meal tolerance test (MMTT, 450kcal) was consumed by the subjects 45min after completion of the intervention with blood samples taken regularly.

RESULTS

Exercise interventions were successfully matched for total oxygen consumption (CW=1641±133mL/min; IW=1634±126mL/min, P>0.05). EPOC was higher after IW (8.4±1.3l) compared to CW (3.7±1.4l, P<0.05). Lipid oxidation rates were increased during the MMTT in IW (1.03±0.12mg/kg per min) and CW (0.87±0.04mg/kg per min) compared with CON (0.73±0.04mg/kg per min, P<0.01 and P<0.05, respectively), with no difference between IW and CW. Moreover, free fatty acids and glycerol concentrations, and glycerol kinetics were increased comparably during and after IW and CW compared to CON.

CONCLUSIONS

Interval exercise results in greater EPOC than oxygen-consumption matched continuous exercise during a post-exercise MMTT in subjects with T2D, whereas effects on substrate oxidation and lipid metabolism are comparable.

Mitochondrial involvement in skeletal muscle insulin resistance: A case of imbalanced bioenergetics

Skeletal muscle insulin resistance in obesity associates with mitochondrial dysfunction, but the causality of this association is controversial. This review evaluates mitochondrial models of nutrient-induced muscle insulin resistance. It transpires that all models predict that insulin resistance arises as a result of imbalanced cellular bioenergetics. The nature and precise origin of the proposed insulin-numbing molecules differ between models but all species only accumulate when metabolic fuel supply outweighs energy demand. This observation suggests that mitochondrial deficiency in muscle insulin resistance is not merely owing to intrinsic functional defects, but could instead be an adaptation to nutrient-induced changes in energy expenditure. Such adaptive effects are likely because muscle ATP supply is fully driven by energy demand. This market-economic control of myocellular bioenergetics offers a mechanism by which insulin-signalling deficiency can cause apparent mitochondrial dysfunction, as insulin resistance lowers skeletal muscle anabolism and thus dampens ATP demand and, consequently, oxidative ATP synthesis.

A longitudinal study to assess the impact of exercise on clinical, biochemical, and anthropometric parameters among the type 2 diabetes patients of South India

Aim:

Aim of the study isto assess the scope of physical activity among type 2 diabetes mellitus (T2DM) patients residing in an urban area of SouthIndia.

Materials and Methods:

A longitudinal interventional study was conducted for a period of 8months (January 2014–August 2014) among patients of T2DM accessing the healthcare services at an Urban Health and Training Center (UHTC) of a Medical College located in Kancheepuram district, Tamil Nadu. Universal sampling method was employed and all diagnosed T2DM patients attending UHTC during the month of January were enrolled in the study provided they satisfied the inclusion and exclusion criteria. Overall 151 participants were considered for final analysis and all of them were subjected to indulge in moderate type of aerobic exercise in the form of brisk walking for 2.5 h spread over a period of 1 week, for the next 6months. Before and after the exercise regimen, cases were subjected to clinical evaluation, measurement of weight and waist circumference, and estimation of fasting and postprandial blood sugar; and the results were compared with the baseline estimates. The associations were tested using paired t-test for continuous (mean ± standard deviation ( SD)) variables.

Results:

Majority (86, 57%) of the diabetics were from the age group of 40–60 years with a definite female preponderance (82/151) in contrast to males (69/151). A significant reduction in both fasting and postprandial sugar was observed before and after the exercise. However, from the perspective of the weight and waist circumference, although a reduction was observed, the association was not statistically significant.

Conclusion:

The findings of the present longitudinal study suggest that compliance with moderate type of physical activity can significantly improve the fasting and postprandial blood sugar, apart from reduction in weight of T2DM patients.

The effects of aerobic exercise training at two different intensities in obesity and type 2 diabetes: implications for oxidative stress, low-grade inflammation and nitric oxide production

AIMS

To investigate the effect of 16 weeks of aerobic training performed at two different intensities on nitric oxide (tNOx) availability and iNOS/nNOS expression, oxidative stress (OS) and inflammation in obese humans with or without type 2 diabetes mellitus (T2DM).

METHODS

Twenty-five sedentary, obese (BMI > 30 kg/m2) males (52.8 ± 7.2 years); 12 controls versus 13 T2DM were randomly allocated to four groups that exercised for 30 min, three times per week either at low (Fat-Max; 30-40% VO(2max)) or moderate (T(vent); 55-65 % VO(2max)) intensity. Before and after training, blood and muscle samples (v. lateralis) were collected.

RESULTS

Baseline erythrocyte glutathione was lower (21.8 ± 2.8 vs. 32.7 ± 4.4 nmol/ml) and plasma protein oxidative damage and IL-6 were higher in T2DM (141.7 ± 52.1 vs. 75.5 ± 41.6 nmol/ml). Plasma catalase increased in T2DM after T(vent) training (from 0.98 ± 0.22 to 1.96 ± 0.3 nmol/min/ml). T2DM groups demonstrated evidence of oxidative damage in response to training (elevated protein carbonyls). Baseline serum tNOx were higher in controls than T2DM (18.68 ± 2.78 vs. 12.34 ± 3.56 μmol/l). Training at T(vent) increased muscle nNOS and tNOx in the control group only. Pre-training muscle nNOS was higher in controls than in T2DMs, while the opposite was found for iNOS. No differences were found after training for plasma inflammatory markers.

CONCLUSION

Exercise training did not change body composition or aerobic fitness, but improved OS markers, especially when performed at T(vent). Non-diabetics responded to T(vent) training by increasing muscle nNOS expression and tNOx levels in skeletal muscle while these parameters did not change in T2DM, perhaps due to higher insulin resistance (unchanged after intervention).

Exercise and 24-h glycemic control: equal effects for all type 2 diabetes patients?

PURPOSE

We assessed the effect of a single bout of moderate-intensity exercise on subsequent 24-h glycemic control in 60 type 2 diabetes patients. Moreover, we examined whether individual responses to exercise were related to subjects' baseline characteristics, including age, body mass index, diabetes duration, exercise performance, medication, and HbA1c content.

METHODS

Sixty type 2 diabetes patients (insulin-treated, n = 23) participated in a randomized crossover experiment. Patients were studied on two occasions for 3 d under strict dietary standardization but otherwise free-living conditions. Parameters of glycemic control (means [95% confidence interval]) were assessed by continuous glucose monitoring over the 24-h period after a single bout of moderate-intensity endurance-type exercise or no exercise at all (control).

RESULTS

Type 2 diabetes patients experienced hyperglycemia (blood glucose >10 mmol·L) for as much as 8:16 h:min (6:44 to 9:48 h:min) per day. The prevalence of hyperglycemia was reduced by 31% to 5:38 h:min (3:17 to 7:00 h:min) over the 24-h period after the exercise bout (P < 0.001). Moreover, exercise lowered average blood glucose concentrations by 0.9 mmol·L (0.7 to 1.2) and reduced glycemic variability (P < 0.05). The response to exercise showed considerable variation between subjects and correlated positively with HbA1c levels (r = 0.38, P < 0.01). Nevertheless, even well-controlled patients with an HbA1c level below 7.0% (n = 28) achieved a 28% reduction in the daily prevalence hyperglycemia after exercise (P < 0.01).

CONCLUSIONS

A single bout of moderate-intensity exercise substantially improves glycemic control throughout the subsequent day in insulin- and non-insulin-treated type 2 diabetes patients. Of all baseline characteristics, only subjects' HbA1c level is related to the magnitude of response to exercise. Nevertheless, the present study demonstrates that even well-controlled patients benefit considerably from the blood glucose-lowering properties of daily exercise.

Insulin-mediated suppression of lipolysis in adipose tissue and skeletal muscle of obese type 2 diabetic men and men with normal glucose tolerance

AIMS/HYPOTHESIS

Impaired regulation of lipolysis and accumulation of lipid intermediates may contribute to obesity-related insulin resistance and type 2 diabetes mellitus. We investigated insulin-mediated suppression of lipolysis in abdominal subcutaneous adipose tissue (AT) and skeletal muscle (SM) of obese men with normal glucose tolerance (NGT) and obese type 2 diabetic men.

METHODS

Eleven NGT men and nine long-term diagnosed type 2 diabetic men (7 ± 1 years), matched for age (58 ± 2 vs 62 ± 2 years), BMI (31.4 ± 0.6 vs 30.5 ± 0.6 kg/m(2)) and [Formula: see text] (28.9 ± 1.5 vs 29.5 ± 2.4 ml kg(-1) min(-1)) participated in this study. Interstitial glycerol concentrations in AT and SM were assessed using microdialysis during a 1 h basal period and a 6 h stepwise hyperinsulinaemic-euglycaemic clamp (8, 20 and 40 mU m(-2) min(-1)). AT and SM biopsies were collected to investigate underlying mechanisms.

RESULTS

Hyperinsulinaemia suppressed interstitial SM glycerol concentrations less in men with type 2 diabetes (-7 ± 6%, -13 ± 9% and -27 ± 9%) compared with men with NGT (-21 ± 7%, -38 ± 8% and -53 ± 8%) (p = 0.014). This was accompanied by increased circulating fatty acid and glycerol concentrations, a lower glucose infusion rate (21.8 ± 3.1 vs 30.5 ± 2.0 μmol kg body weight(-1) min(-1); p < 0.05), higher hormone-sensitive lipase (HSL) serine 660 phosphorylation, increased saturated diacylglycerol (DAG) lipid species in the muscle membrane and increased protein kinase C (PKC) activation in type 2 diabetic men vs men with NGT. No significant differences in insulin-mediated reduction in AT interstitial glycerol were observed between groups.

CONCLUSIONS/INTERPRETATION

Our results suggest that a blunted insulin-mediated suppression of SM lipolysis may promote the accumulation of membrane saturated DAG, aggravating insulin resistance, at least partly mediated by PKC. This may represent an important mechanism involved in the progression of insulin resistance towards type 2 diabetes.

TRIAL REGISTRATION

ClinicalTrials.gov NCT01680133.

Exercise prescription in the treatment of type 2 diabetes mellitus : current practices, existing guidelines and future directions

Exercise is an effective treatment for type 2 diabetes mellitus, resulting in stabilization of plasma glucose in the acute phase and improvements in body composition, insulin resistance and glycosylated haemoglobin with chronic exercise training. However, the most appropriate exercise prescription for type 2 diabetes has not yet been established, resulting from insufficient evidence to determine the optimum type, intensity, duration or frequency of exercise training. Furthermore, patient engagement in exercise is suboptimal. There are many likely reasons for low engagement in exercise; one possible contributory factor may be a tendency for expert bodies to prioritize the roles of diet and medication over exercise in their treatment guidelines. Published treatment guidelines vary in their approach to exercise training, but most agencies suggest that people with type 2 diabetes engage in 150 min of moderate to vigorous aerobic exercise per week. This prescription is similar to the established guidelines for cardiovascular health in the general population. Future possibilities in this area include investigation of the physiological effects and practical benefits of exercise training of different intensities in type 2 diabetes, and the use of individualized prescription to maximize the health benefits of training.

"Deficiency" of mitochondria in muscle does not cause insulin resistance

Based on evidence that patients with type 2 diabetes (T2DM), obese insulin-resistant individuals, and lean insulin-resistant offspring of parents with T2DM have ~30% less mitochondria in their muscles than lean control subjects, it appears to be widely accepted that mitochondrial "deficiency" is responsible for insulin resistance. The proposed mechanism for this effect is an impaired ability to oxidize fat, resulting in lipid accumulation in muscle. The purpose of this counterpoint article is to review the evidence against the mitochondrial deficiency concept. This evidence includes the findings that 1) development of insulin resistance in laboratory rodents fed high-fat diets occurs despite a concomitant increase in muscle mitochondria; 2) mitochondrial deficiency severe enough to impair fat oxidation in resting muscle causes an increase, not a decrease, in insulin action; and 3) most of the studies comparing fat oxidation in insulin-sensitive and insulin-resistant individuals have shown that fat oxidation is higher in T2DM patients and obese insulin-resistant individuals than in insulin-sensitive control subjects. In conclusion, it seems clear, based on this evidence, that the 30% reduction in muscle content of mitochondria in patients with T2DM is not responsible for insulin resistance.

Exercise therapy in type 2 diabetes: is daily exercise required to optimize glycemic control?

OBJECTIVE

Given the transient nature of exercise-induced improvements in insulin sensitivity, it has been speculated that daily exercise is preferred to maximize the benefits of exercise for glycemic control. The current study investigates the impact of daily exercise versus exercise performed every other day on glycemic control in type 2 diabetic patients.

RESEARCH DESIGN AND METHODS

Thirty type 2 diabetic patients (age 60 ± 1 years, BMI 30.4 ± 0.7 kg/m(2), and HbA(1c) 7.2 ± 0.2%) participated in a randomized crossover experiment. Subjects were studied on three occasions for 3 days under strict dietary standardization but otherwise free-living conditions. Blood glucose homeostasis was assessed by continuous glucose monitoring over 48 h during which subjects performed no exercise (control) or 60 min of cycling exercise (50% maximal workload capacity) distributed either as a single session performed every other day or as 30 min of exercise performed daily.

RESULTS

The prevalence of hyperglycemia (blood glucose >10 mmol/L) was reduced from 7:40 ± 1:00 h:min per day (32 ± 4% of the time) to 5:46 ± 0:58 and 5:51 ± 0:47 h:min per day, representing 24 ± 4 and 24 ± 3% of the time, when exercise was performed either daily or every other day, respectively (P < 0.001 for both treatments). No differences were observed between the impact of daily exercise and exercise performed every other day.

CONCLUSIONS

A short 30-min session of moderate-intensity endurance-type exercise substantially reduces the prevalence of hyperglycemia throughout the subsequent day in type 2 diabetic patients. When total work is being matched, daily exercise does not further improve daily glycemia compared with exercise performed every other day.

Physical activity: the forgotten tool for type 2 diabetes management

Individuals who are currently sedentary, unfit, or overweight can benefit metabolically from simply taking breaks from sitting. Since avoidance of sedentary behavior appears to have a large impact on glycemic management, all individuals with type 2 diabetes should be encouraged to minimally engage in greater daily movement to better manage their diabetes and body weight. In addition, engaging in physical activity of any intensity (including low-intensity ones) likely positively impacts insulin action and blood glucose control acutely. Moreover, as long as total caloric expenditure during exercise is matched (i.e., total exercise dose), daily exercise may be done every other day instead with the same glycemic results, although at least 150 min of weekly physical activity is recommended. Both aerobic and resistance training are important for individuals with diabetes, and ideally a program that combines the two types of training should be undertaken to achieve maximal glycemic and other benefits. Once individuals have successfully implemented more daily movement into their lifestyle, they will be more likely to participate in structured forms of physical activity to gain additional benefits. All clinicians working with individuals with either type 2 diabetes or prediabetes should consider incorporating these suggestions into care plans to improve their patients' glycemic management.

Exercise and type 2 diabetes: American College of Sports Medicine and the American Diabetes Association: joint position statement. Exercise and type 2 diabetes

Although physical activity (PA) is a key element in the prevention and management of type 2 diabetes mellitus (T2DM), many with this chronic disease do not become or remain regularly active. High-quality studies establishing the importance of exercise and fitness in diabetes were lacking until recently, but it is now well established that participation in regular PA improves blood glucose control and can prevent or delay T2DM, along with positively affecting lipids, blood pressure, cardiovascular events, mortality, and quality of life. Structured interventions combining PA and modest weight loss have been shown to lower T2DM risk by up to 58% in high-risk populations. Most benefits of PA on diabetes management are realized through acute and chronic improvements in insulin action, accomplished with both aerobic and resistance training. The benefits of physical training are discussed, along with recommendations for varying activities, PA-associated blood glucose management, diabetes prevention, gestational diabetes, and safe and effective practices for PA with diabetes-related complications.

Exercise and type 2 diabetes: the American College of Sports Medicine and the American Diabetes Association: joint position statement

Although physical activity (PA) is a key element in the prevention and management of type 2 diabetes, many with this chronic disease do not become or remain regularly active. High-quality studies establishing the importance of exercise and fitness in diabetes were lacking until recently, but it is now well established that participation in regular PA improves blood glucose control and can prevent or delay type 2 diabetes, along with positively affecting lipids, blood pressure, cardiovascular events, mortality, and quality of life. Structured interventions combining PA and modest weight loss have been shown to lower type 2 diabetes risk by up to 58% in high-risk populations. Most benefits of PA on diabetes management are realized through acute and chronic improvements in insulin action, accomplished with both aerobic and resistance training. The benefits of physical training are discussed, along with recommendations for varying activities, PA-associated blood glucose management, diabetes prevention, gestational diabetes mellitus, and safe and effective practices for PA with diabetes-related complications.

Effect of kinin B2 receptor ablation on skeletal muscle development and myostatin gene expression

Bradykinin (BK) is an active peptide that binds to the kinin B(2) receptor and induces biological events during the development and adult life. In this study we aimed to investigate the effect of kinin B(2) receptor ablation in the postnatal skeletal muscle development and body composition in adult life. For studies of skeletal muscle development, control (C57Bl6 - WT) and B(2) receptor knockout mice (B(2)(-/-)) were sacrificed at 15, 30 and 90days after birth, the gastrocnemius skeletal muscle was weighed and myostatin gene expression evaluated by real time PCR. For energy balance determination, data from control and B(2)(-/-) at 90 and 120days were collected by calorimetric method. Body composition at 120days was determined by chloroform-methanol (total body fat) and Lowry-modified method (total body protein). The results show that B(2)(-/-) have significantly increased total body weight at 15, 30 and 90days of life, when compared to WT. The weight of the gastrocnemius skeletal muscle was also significantly increased at 30 and 90days of life. Body composition analyses revealed that B(2)(-/-) mice exhibit more total corporal protein and less total corporal fat. Energy balance revealed that B(2)(-/-) have increased metabolizable energy intake and energy expenditure when compared to control mice, resulting in a lower energy gain. Interestingly, myostatin mRNA expression was significantly decreased in 15 and 30days old B(2)(-/-) mice and after icatibant treatment of WT adult mice for 5days. In conclusion, together our results show that kinin B(2) receptor deletion increases lean mass, reduces fat mass and improves metabolism efficiency in mice. The mechanism involved in this phenotype could be related to the reduction of myostatin gene expression during postnatal life.

Lipid oxidation in overweight men after exercise and food intake

Fat oxidation (FO) is optimized during low- to moderate-intensity exercise in lean and obese subjects, whereas high-intensity exercise induces preferential FO during the recovery period. After food intake during the postexercise period, it is unknown if FO differs according to the intensity exercise in overweight subjects. Fat oxidation was thus evaluated in overweight men after low- and high-intensity exercise during the recovery period before and after food intake as well as during a control session. Ten healthy, sedentary, overweight men (age, 27.9 +/- 5.6 years; body mass index, 27.8 +/- 1.3 kg m(-2); maximal oxygen consumption, 37 +/- 3.9 mL min(-1) kg(-1)) exercised on a cycloergometer (energy expenditure = 300 kcal) at 35% (E35) or 70% (E70) maximal oxygen consumption or rested (Cont). The subjects were fed 30 minutes after the exercise with 300 kcal (1256 kJ) more energy in the exercise sessions than in the Cont session. Respiratory quotient and FO were calculated by indirect calorimetry. Blood samples were analyzed to measure plasma glycerol, nonesterified fatty acid, glucose, and insulin. During exercise, mean respiratory quotient was lower (P < .05) and FO was higher (P < .01) in the E35 than in the E70 session (FO [in mg min(-1)]: E35 = 290 +/- 12, E70 = 256 +/- 38, and Cont = 131 +/- 7). Conversely, FO was higher in the E70 than in both the E35 session and the Cont session during the immediate recovery as well as during the postprandial recovery period (P = .005 for all; FO from the end of the exercise to the end of the session [in grams]: E70 = 45.7 +/- 8.9, E35 = 38.2 +/- 6.8, and Cont = 36.0 +/- 4.3). Blood parameters did not differ between the 3 sessions but changed according to the absorption of the nutrients. In overweight subjects, high-intensity exercise increased FO during the postexercise period even after food intake compared with the low-intensity exercise and the control session.

Exercise therapy in type 2 diabetes

Structured exercise is considered an important cornerstone to achieve good glycemic control and improve cardiovascular risk profile in Type 2 diabetes. Current clinical guidelines acknowledge the therapeutic strength of exercise intervention. This paper reviews the wide pathophysiological problems associated with Type 2 diabetes and discusses the benefits of exercise therapy on phenotype characteristics, glycemic control and cardiovascular risk profile in Type 2 diabetes patients. Based on the currently available literature, it is concluded that Type 2 diabetes patients should be stimulated to participate in specifically designed exercise intervention programs. More attention should be paid to cardiovascular and musculoskeletal deconditioning as well as motivational factors to improve long-term treatment adherence and clinical efficacy. More clinical research is warranted to establish the efficacy of exercise intervention in a more differentiated approach for Type 2 diabetes subpopulations within different stages of the disease and various levels of co-morbidity.

Maximal lipid oxidation in patients with type 2 diabetes is normal and shows an adequate increase in response to aerobic training

AIM

Insulin resistance in subjects with type 2 diabetes (T2D) and obesity is associated with an imbalance between the availability and the oxidation of lipids. We hypothesized that maximal whole-body lipid oxidation during exercise (FATmax) is reduced and that training-induced metabolic adaptation is attenuated in T2D.

METHODS

Obese T2D (n = 12) and control (n = 11) subjects matched for age, sex, physical activity and body mass index completed 10 weeks of aerobic training. Subjects were investigated before and after training with maximal and submaximal exercise tests and euglycaemic-hyperinsulinaemic clamps combined with muscle biopsies.

RESULTS

Training increased maximal oxygen consumption (VO(2max)) and muscle citrate synthase activity and decreased blood lactate concentrations during submaximal exercise in both groups (all p < 0.01). FATmax increased markedly (40-50%) in both T2D and control subjects after training (all p < 0.001). There were no significant differences in these variables and lactate threshold (%VO(2max)) between groups before or after training. Insulin-stimulated glucose disappearance rate (Rd) was lower in T2D vs. control subjects both before and after training. Rd increased in response to training in both groups (all p < 0.01). There was no correlation between Rd and measures of oxidative capacity or lipid oxidation during exercise or the training-induced changes in these parameters.

CONCLUSIONS

FATmax was not reduced in T2D, and muscle oxidative capacity increased adequately in response to aerobic training in obese subjects with and without T2D. These metabolic adaptations to training seem to be unrelated to changes in insulin sensitivity and indicate that an impaired capacity for lipid oxidation is not a major cause of insulin resistance in T2D.

Are substrate use during exercise and mitochondrial respiratory capacity decreased in arm and leg muscle in type 2 diabetes?

AIM/HYPOTHESIS

The aim of the study was to investigate mitochondrial function, fibre type distribution and substrate oxidation in arm and leg muscle during exercise in patients with type 2 diabetes and in obese and lean controls.

METHODS

Indirect calorimetry was used to calculate fat and carbohydrate oxidation during both progressive arm-cranking and leg-cycling exercises. Muscle biopsies from arm and leg were obtained. Fibre type, as well as O(2) flux capacity of saponin-permeabilised muscle fibres were measured, the latter by high resolution respirometry, in patients with type 2 diabetes, age- and BMI-matched obese controls, and age-matched lean controls.

RESULTS

Fat oxidation was similar in the groups during either arm or leg exercise. During leg exercise at higher intensities, but not during arm exercise, carbohydrate oxidation was lower in patients with type 2 diabetes compared with the other groups. In patients with type 2 diabetes, ADP-stimulated state 3 respiration per mg muscle with parallel electron input from complex I+II was lower in m. vastus lateralis compared with obese and lean controls, whereas no differences between groups were present in m. deltoideus. A higher percentage of type IIX fibres was seen in m. vastus lateralis in patients with type 2 diabetes compared with obese and lean controls, whereas no difference was found in the deltoid muscle.

CONCLUSIONS/INTERPRETATION

This study demonstrates similar O(2) flux capacity, fibre type distribution and carbohydrate oxidation in arm muscle in the groups despite the presence of attenuated values in leg muscle in patients with type 2 diabetes compared with obese and lean controls.

Metabolic flexibility in the development of insulin resistance and type 2 diabetes: effects of lifestyle

Lipotoxicity in skeletal muscle plays a critical role in the aetiology of insulin resistance and type 2 diabetes mellitus by interference of lipid metabolites with insulin signalling and action. The dynamics of lipid oxidation and fine tuning with fatty acid uptake and intramyocellular triacylglycerol turnover may be very important to limit the accumulation of lipid intermediates. The use of metabolic inflexibility, defined as the impaired capacity to increase fat oxidation upon increased fatty acid availability and to switch between fat and glucose as the primary fuel source after a meal, does more justice to the complexity of changes in fuel oxidation during the day. Fatty acid availability, uptake and oxidation all play a role in metabolic flexibility and insulin resistance. During high fatty acid availability, fatty acid transporters may limit cellular and mitochondrial fatty acid uptake and thus limit fat oxidation. After a meal, when the demand for fatty acids as fuel is low, an increased fractional extraction of lipids from plasma may promote intramyocellular lipid accumulation and insulin resistance. Furthermore, defects in fuel switching cluster together with impaired mitochondrial content and/or function. Lifestyle changes in dietary fat intake, physical activity and weight loss may improve metabolic flexibility in skeletal muscle, and thereby contribute to the prevention of type 2 diabetes.

Glucoregulation is more precise in women than in men during postexercise recovery

BACKGROUND

The regulation of glycemia is challenged in healthy men and women after exercise bouts of substantial energy expenditure.

OBJECTIVE

We determined rates of glucose appearance (Ra), disappearance (Rd), and metabolic clearance (MCR) before, during, and after isoenergetic moderate and hard-intensity exercise.

DESIGN

Ten men and 8 women received primed-continuous infusion of [6,6-(2)H(2)]glucose tracer to measure glucose kinetics. Participants were studied under 3 different conditions with diet unchanged between trials: 1) before, during, and 3 h after 90 min of exercise at 45% of peak oxygen consumption (VO(2)peak; E45); 2) before, during, and 3 h after 60 min of exercise at 65% VO(2)peak (E65), and 3) in a time-matched sedentary control trial.

RESULTS

In men and women, Ra, Rd, and MCR increased above the control trial during exercise and were higher in E65 than in E45 (P < 0.05). Average Ra, Rd, and MCR remained elevated above the control over 3 h of postexercise recovery in men after exercise in E45 and E65 (P < 0.05), and blood glucose concentrations were depressed below the control during recovery (P < 0.05). Glucose concentrations were not depressed in women during 3 h of postexercise recovery, and in contrast with that in men, average Ra and Rd did not remain significantly elevated during postexercise recovery in women, although MCR did remain elevated in E65 (P < 0.05).

CONCLUSIONS

After exercise bouts, women are better able to maintain glucose concentrations at sedentary control levels, thus not requiring the counter-regulation of glucose production that is seen in men and requiring less accentuation of lipid metabolism.

Determinants of intramyocellular triglyceride turnover: implications for insulin sensitivity

Increased intramyocellular triglyceride (IMTG) content is found in both insulin-sensitive endurance-trained subjects and insulin-resistant obese/type 2 diabetic subjects. A high turnover rate of the IMTG pool in athletes is proposed to reduce accumulation of lipotoxic intermediates interfering with insulin signaling. IMTG turnover is a composite measure of the dynamic balance between lipolysis and lipid synthesis; both are influenced by mitochondrial fat oxidation and plasma free fatty acid availability. Therefore, more attention should be given to the factors controlling the rate of turnover of IMTG. In this review, particular attention has been given to muscle oxidative capacity, plasma free fatty acid availability, and IMTG hydrolysis (lipolysis) and synthesis. A higher oxidative, lipolytic, and lipid storage capacity in the muscle of endurance-trained subjects reflects a higher fractional turnover of the IMTG pool. Thus the co-localization of intermyofibrillar lipid droplets and mitochondria allows for a fine coupling of lipolysis of the IMTG pool to mitochondrial beta-oxidation. Conversely, reduced oxidative capacity and a mismatch between IMTG lipolysis and beta-oxidation might be detrimental to insulin sensitivity by generating several lipotoxic intermediates in sedentary populations including obese/type 2 diabetic subjects. Further studies are clearly required to better understand the relationship between the rate of turnover of IMTG and the accumulation of lipotoxic intermediates in the pathophysiology of insulin resistance.

Lipolysis and fatty acid metabolism in men and women during the postexercise recovery period

We sought to determine whether lipolysis, fatty acid (FA) mobilization, and plasma FA oxidation would remain elevated for hours following isoenergetic exercise bouts of different intensities. Ten men and eight women received a primed-continuous infusion of [1,1,2,3,3-(2)H(5)]glycerol and continuous infusion of [1-(13)C]palmitate to measure glycerol and plasma FA kinetics. On Day 1 (D1), participants were studied under one of three different conditions, assigned in random order: (1) before, during and 3 h after 90 min of exercise at 45% V(O2)peak (E45), (2) before, during and 3 h after 60 min of exercise at 65% V(O2)peak (E65), and (3) in a time-matched sedentary control trial (C). For each condition, participants were studied by indirect calorimetry the following morning as well (D2). Rate of appearance (Ra) of glycerol (Ra(GL)) increased above C during exercise in men and women (P < 0.05), was higher in E45 than E65 in men (P < 0.05), and was not different between exercise intensities in women. During 3 h of postexercise recovery, Ra(GL) remained significantly elevated in men (P < 0.05), but not women. FA Ra (Ra(FA)) increased during exercise in men and women and was higher in E45 than E65 (P < 0.05), and remained elevated during 3 h of postexercise recovery in both sexes (P < 0.05), but with a greater relative increase in men than women (P < 0.05). Plasma FA oxidation (Rox) increased during exercise with no difference between intensities, and it remained elevated during 3 h of postexercise recovery in both sexes (P < 0.05). Total lipid oxidation (Lox) was elevated in both sexes (P < 0.05), but more in men during 3 h of postexercise recovery on D1 (P < 0.05) and remained elevated on D2 in men (P < 0.05), but not in women. There were no differences between E45 and E65 for postexercise energy substrate turnover or oxidation in men and women as energy expenditure of exercise (EEE) was matched between bouts. We conclude that the impact of exercise upon lipid metabolism persists into recovery, but that women depend more on lipid during exercise whereas, during recovery, lipid metabolism is accentuated to a greater extent in men.

Responses to acute exercise in type 2 diabetes, with an emphasis on metabolism and interaction with oral hypoglycemic agents and food intake

In people with type 1 diabetes mellitis (DM), insulin administration, food intake, and exercise have to be carefully matched to avoid either hypo- or hyperglycemia. People with type 2 DM have some insulin secretion, which changes with needs. Accordingly, during exercise, these people do not run the same metabolic risks as people with type 1 DM. However, a contraction-mediated increase in glucose clearance in muscle is intact in type 2 DM. Therefore, , in the postabsorptive state in diet-treated type 2 DM, a marked reduction in hyperglycemia can occur during prolonged moderate exercise. Sulfonylurea drugs augment the rate of decline in plasma glucose, because stimulation of insulin secretion reduces hepatic glucose production. After abstention from sulfonylurea for 5 days, the rate of decrease in plasma glucose with exercise is also enhanced, but from a higher glucose level. In the postabsorptive state, brief vigourous exercise elicits an increase in plasma glucose concentration, reflecting an exaggerated counterregulatory hormone response and glucose production. Moreover, insulin sensitivity is reduced in the early postexercise period. In the postprandial state, both prolonged moderate exercise and intermittent high-intensity exercise markedly decrease meal-induced increases in glucose, insulin, and C-peptide concentrations, whereas glucose appearance in plasma is unchanged. When exercise bouts are isocaloric, responses are identical, indicating that overall energy expenditure, and not peak exercise intensity, is the major determinant of exercise-induced changes in overall glucose homeostasis and insulin secretion in type 2 DM. Neither prolonged moderate nor intermittent high-intensity exercise performed in the postprandial state influences glucose or insulin responses to a subsequent meal. Finally, in people with type 2 DM, after a high-fat meal, prolonged moderate exercise reduces the exaggerated increases in plasma concentrations of triglycerides contained in chylomicrons and very low-density lipoproteins.