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Effect of High- versus Low-Intensity Supervised Aerobic and Resistance Training on Modifiable Cardiovascular Risk Factors in Type 2 Diabetes; The Italian Diabetes and Exercise Study (IDES)
Open accessAbstract
BACKGROUND: While current recommendations on exercise type and volume have strong experimental bases, there is no clear evidence from large-sized studies indicating whether increasing training intensity provides additional benefits to subjects with type 2 diabetes. OBJECTIVE: To compare the effects of moderate-to-high intensity (HI) versus low-to-moderate intensity (LI) training of equal energy cost, i.e. exercise volume, on modifiable cardiovascular risk factors. DESIGN: Pre-specified sub-analysis of the Italian Diabetes and Exercise Study (IDES), a randomized multicenter prospective trial comparing a supervised exercise intervention with standard care for 12 months (2005-2006). SETTING: Twenty-two outpatient diabetes clinics across Italy. PATIENTS: Sedentary patients with type 2 diabetes assigned to twice-a-week supervised progressive aerobic and resistance training plus exercise counseling (n = 303). INTERVENTIONS: Subjects were randomized by center to LI (n = 142, 136 completed) or HI (n = 161, 152 completed) progressive aerobic and resistance training, i.e. at 55% or 70% of predicted maximal oxygen consumption and at 60% or 80% of predicted 1-Repetition Maximum, respectively, of equal volume. MAIN OUTCOME MEASURE(S): Hemoglobin (Hb) A(1c) and other cardiovascular risk factors; 10-year coronary heart disease (CHD) risk scores. RESULTS: Volume of physical activity, both supervised and non-supervised, was similar in LI and HI participants. Compared with LI training, HI training produced only clinically marginal, though statistically significant, improvements in HbA(1c) (mean difference -0.17% [95% confidence interval -0.44,0.10], P = 0.03), triglycerides (-0.12 mmol/l [-0.34,0.10], P = 0.02) and total cholesterol (-0.24 mmol/l [-0.46, -0.01], P = 0.04), but not in other risk factors and CHD risk scores. However, intensity was not an independent predictor of reduction of any of these parameters. Adverse event rate was similar in HI and LI subjects. CONCLUSIONS: Data from the large IDES cohort indicate that, in low-fitness individuals such as sedentary subjects with type 2 diabetes, increasing exercise intensity is not harmful, but does not provide additional benefits on cardiovascular risk factors. TRIAL REGISTRATION: www.ISRCTN.org ISRCTN-04252749.
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![Figure 2 Average monthly energy expenditure from supervised exercise. Energy expenditure data in LI (circles, dotted line; n = 136) and HI (squares, continuous line; n = 152) participants [mean values; means (SD) are reported below]. LI = low intensity; HI = high intensity.](/paper-figures/070e0a1ce5f3474eab3a3c783e8d1870/effect-of-high-versus-low-intensity-supervised-aerobic-and-resistance-training-figure-2.jpg)
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“Progressively increasing the duration and intensity of aerobic exercise can lead to further improvements in A1c.”
From The Impact of Physical Activity in Patients With Type 2 Diabetes (2025) · cites this paper as [41]
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“After 1 year, those in the highintensity training group had a 0.17% greater improvement in A1c compared to those in the lowintensity training group.”
From The Impact of Physical Activity in Patients With Type 2 Diabetes (2025) · cites this paper as [41]
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Diet and exercise in the prevention and treatment of type 2 diabetes mellitus
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“Randomized trials have found that supervised exercise interventions improve glycated hemoglobin (A1C) (6–8), triglycerides (TG) and cholesterol (9) in people with type 2 diabetes when compared to no exercise comparison groups (10).”
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“Evidence suggests that this type of physical activity can reduce mortality and morbidity both in sedentary people [6,7,8] and in people with Type 2 diabetes [7, 9, 10].”
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“The large Italian Diabetes and Exercise Study (IDES) [96] states that supervised exercise twice a week exceeds the physical fitness and CVD risk profile in patients with T2DM.”
BackgroundSarcopenia definition: Does it really matter? Implications for resistance training
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Management of diabesity: Current concepts
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“Increasing physical fitness in this population could enhance insulin sensitivity and glycemic control (Srikanthan & Karlamangla, 2011) and may attenuate declines in strength, endurance, and function (Balducci et al., 2012), all of which have been reported to be lower in this population when compared with those without…”
ResultKluding, P. M., Pasnoor, M., Singh, R., D’Silva, L. J., Yoo, M., Billinger, S. A., LeMaster, J. W., Dimachkie, M. M., Herbelin, L. L., & Wright, D. E. (2014) · Physical Therapy · doi:10.2522/ptj.20140108 · Cited by 66
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“PA/exercise are once again independent of weight loss [62], and in low-fitness, sedentary individuals with T2DM, increasing exercise intensity was not harmful, but did not provide additional benefits on cardiovascular risk factors [63].”
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“Balducci et al., 2012 [29] G1 (HIIT): aerobic training (70% VO2max) + resistance training (60% 1-Repetition Maximum).”
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“In this regard, combining RT and endurance training is an effective intervention to promote overall physical fitness in T2DM patients (Balducci et al., 2012).”
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“, lower intensity compensated by a longer duration) found no surplus benefit of high-intensity as opposed to moderate-intensity exercise training for A1C levels (55,56).”
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“Vigorous-intensity exercises are associated with higher benefits in glycemic control and cardiovascular risk factors in patients with T2D [39,40], and a HIIT program seems to induce greater benefits in HbA1c than a continuous training program of moderate intensity [41].”
BackgroundExercise and Type II Diabetes Mellitus: A Brief Guide for Exercise Professionals
Batrakoulis, A., Jamurtas, A. Z., & Fatouros, I. G. (2022) · Strength and conditioning journal · doi:10.1519/ssc.0000000000000731 · Cited by 33
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“Similarly, to ensure that the resistance of the isotonic strength exercises were prescribed appropriately according to the strength progressions of each participant, predicted 1RMs (48) were tested and calculated regularly (on the participants’ first and last training day and the Monday of Week 5 and 9).”
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“In addition, it should be considered that the extent of the beneficial effects—such as the improvement of glucose homeostasis and the reduction in cardiometabolic risk factors in people with diabetes—is dependent on the total energy expenditure of training rather than exercise duration or intensity [72,73].”
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Gut microbiota and Ma-Pi 2 macrobiotic diet in the treatment of type 2 diabetes
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Contemporary Lifestyle Modification Interventions to Improve Metabolic Comorbidities in HIV
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“These findings agree with other studies [57] that increasing exercise intensity does not appear to provide added benefit to improve CVD risk factors.”
ResultThe Impact of Physical Activity in Patients With Type 2 Diabetes
Bassin, S. R., & Srinath, R. (2025) · American Journal of Lifestyle Medicine · doi:10.1177/15598276231180541 · Cited by 17
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“Like exercise type, all three exercise intensities significantly improved executive function, with moderate-intensity showing the greatest effect [70, 100].”
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“46 47 However, a recent systematic review and meta-analysis found that high-intensity training was more effective in reducing HbA1c levels compared with moderate-intensity training.”
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Low-Force Muscle Activity Regulates Energy Expenditure after Spinal Cord Injury
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“Simple low-intensity activities such as standing throughout the day or engaging in very light-intensity activity to interrupt periods of sitting have improved the metabolic profiles of sedentary individuals (5,14,23,35).”
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“Physical activity is recommended as one first-line treatment in T2DM adults, but with widely varying even contrasting results non-resolved yet (Honkola et al. 1997; Dunstan et al. 2002, 2005; Cas-taneda et al. 2002; Kadoglou et al. 2012; Balducci et al. 2012; Krause et al. 2014; Amanat et al. 2020).”
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“[46,47] reported positive changes in VO2 max, upper- and lower-body strength, and flexibility.”
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“High-intensity interval training has also been compared with moderate-intensity exercise in patients with type 2 diabetes mellitus and has shown a reduction in hyperglycemia, although these data have been controversial in terms of clinical signi fi cance (20, 21).”
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Concurrent Aerobic and Strength Training for Body Composition and Health
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“In fact, meta-analysis studies showed that exercise under supervision is effective in improving cardio respiratory fitness and also in controlling blood sugar levels and other cardiovascular risk factors (16).”
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“The role of resistance training intensities on glycemic control have been approved [28, 29].”
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“HIIT involves short bursts of intense exercise followed by periods of rest or low-intensity exercise [10,11].”
Intervention effect of combined resistance and aerobic exercise on type 2 diabetes: A meta-analysis
Ma, J., Shu, S., Chen, T., Bai, H., Yang, Y., & Ding, X. (2025) · World Journal of Diabetes · doi:10.4239/wjd.v16.i7.108121 · Cited by 6
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Mancini, G. B. J., CHENG, A. Y. Y., Connelly, K. A., FITCHETT, D. H., Goldenberg, R., Goodman, S. G., Leiter, L. A., Lonn, E., Paty, B. W., Poirier, P., et al. (2018) · Canadian Journal of Cardiology · doi:10.1016/j.cjca.2018.07.010 · Cited by 5
Resistance and Aerobic Training in the Treatment of Type 2 Diabetes Mellitus
Nunes, R. B. (2017) · Journal of Diabetes Metabolic Disorders & Control · doi:10.15406/jdmdc.2017.04.00126 · Cited by 5
“303 patients (HI and LW intensities groups) improved exercise capacity (VO2MAX), insulin sensitivity (HOMA-IR), glycemic control (HbA1C), lipid profile (HDL-c) and strength (1RM), besides reducing systolic and diastolic blood pressure and becoming more physical active after 12 months of treatment [10].”
BackgroundBanitalebi, E., Ghahfarrokhi, M. M., Faramarzi, M., & Nasiri, S. (2018) · Journal of Shahrekord University of Medical Sciences · doi:10.34172/jsums.2019.01 · Cited by 5
“It was revealed that SIT and combined training programs that had been performed 3 days a week (for 10 weeks) were safe and well-tolerated by patients afflicted with T2D.”
BackgroundInfluentialSupervised Exercise Patterns among Diabetic and Non-diabetic Portuguese Adults
Esteves, M., Gouveia, A., Rodrigues, R. G., Pinheiro, P. G., Brás, R. M. M., O’Hara, K., & Duarte, P. (2019) · Annals of Applied Sport Science · doi:10.29252/aassjournal.2626 · Cited by 5
Weiler, A. A., & Alvar, B. A. (2013) · Strength and conditioning journal · doi:10.1519/ssc.0b013e31829a6ab7 · Cited by 5
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“In addition, some studies reported the effect of vigorous exercise training interventions in reducing fatty liver [18,19].”
BackgroundHelping people with diabetes to exercise 帮助糖尿病患者运动
Bloomgarden, Z. T., & Li, X. (2014) · Journal of Diabetes · doi:10.1111/1753-0407.12234 · Cited by 4
Lotfi, M., Behpoor, N., Rahimi, M., & Jafari, A. (2023) · Journal of Kermanshah University of Medical Sciences · doi:10.5812/jkums-137856 · Cited by 4
Agarwal, M., Singh, S., Sharma, P., & Saini, R. (2019) · The Journal of Sports Medicine and Physical Fitness · doi:10.23736/s0022-4707.17.08002-1 · Cited by 3
Gaesser, G. A., Angadi, S. S., Sawyer, B. J., Tucker, W. J., & Jarrett, C. L. (2014) · Elsevier eBooks · doi:10.1016/b978-0-12-800093-9.00029-6 · Cited by 3
THE INFLUENCE OF AEROBIC TRAINING ON THE BIOCHEMICAL AND PHYSICAL PARAMETERS OF OBESE WOMEN
Pelemiš, V. M., Macura, M., Andrevski-Krivokuća, N., Ujsasi, D., Pelemiš, M., & Lalić, S. (2016) · SCIndeks · Cited by 3
Pengaruh durasi senam diabetes pada penurunan glukosa darah penderita diabetes mellitus tipe II
Kurdanti, W., & Khasana, T. M. (2018) · Jurnal Gizi Klinik Indonesia · doi:10.22146/ijcn.45498 · Cited by 3
Ergotherapie, Kunst-, Musik-, Sport- und Bewegungstherapie bei psychischen Störungen
Reuster, T., von Spreti, F., Martius, P., Unterberger, J., & Broocks, A. (2017) · Springer eBooks · doi:10.1007/978-3-662-49295-6_51 · Cited by 2
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Bravo, G. M., Paramasivam, P., Bellissimo, G. F., Jacquez, Q., Zheng, H., Amorim, F. T., & Mota, R. I. (2024) · bioRxiv (Cold Spring Harbor Laboratory) · doi:10.1101/2024.08.21.608998 · Cited by 2
Matuk, A. L., Palacios, J. J., Hun, K. H. D., & Amador-Hernández, A. G. (2015) · European journal of health research · doi:10.30552/ejhr.v1i2.6 · Cited by 1
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Neurobiologische Effekte körperlicher Aktivität
Rieckmann, P., & Broocks, A. (2013) · Elsevier eBooks · doi:10.1016/b978-3-437-31610-4.00002-3 · Cited by 1
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Fathi, M., Rahmani, M., Rahmati, M., & Dehnou, V. V. (2018) · Qom Univ Med Sci J · doi:10.29252/qums.12.7.41 · Cited by 1
Exercise Intensities as Factors of Metabolic Outcomes in Type 2 Diabetes: A Systematic Review
Moxley, E., & Bugaieski, T. (2018) · Home Health Care Management & Practice · doi:10.1177/1084822318815446 · Cited by 2
de Souza, D. R., & Toigo, A. M. (2018) · Revista de Atenção à Saúde · doi:10.13037/ras.vol16n57.4161 · Cited by 1
Impact of Exercise on Cardiovascular Risk Factors: Diabetes Mellitus
Colberg, S. R., & Niederseer, D. (2020) · Springer eBooks · doi:10.1007/978-3-030-35374-2_38 · Cited by 1
Diabetes as a Metabolic Disease and Translational Exercise Medicine Informatics
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Ergotherapie, Kunst-, Musik-, Sport- und Bewegungstherapie bei psychischen Störungen
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Neurobiologische Effekte körperlicher Aktivität
Rieckmann, P., & Broocks, A. (2015) · Elsevier eBooks · doi:10.1016/b978-3-437-24255-7.00006-2 · Cited by 1
Exercise Prescription for Chronic Disease Management
Hovanec, N. (2015) · Scholarship@Western (Western University)
Neurobiologische Effekte körperlicher Aktivität
Rieckmann, P., & Broocks, A. (2015) · Elsevier eBooks · doi:10.1016/b978-3-437-24265-6.00001-9
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“adequate exercise volume improved metabolic control even with low intensity exercise [13].”
Background
Metadata
- Authors
- Balducci, S., Zanuso, S., Cardelli, P., Salvi, L., Bazuro, A., Pugliese, L., Maccora, C., Iacobini, C., Conti, F. G., Nicolucci, A., Pugliese, G., & for the Italian Diabetes Exercise Study (IDES) Investigators
- Affiliations
- Azienda Ospedaliera Sant'Andrea (IT)
- University of Greenwich (GB)
- Associazione Fitness Metabolica O.N.L.U.S. (IT)
- Mario Negri Sud Foundation (IT)
- Corresponding author
- Pugliese, Giuseppe
- ORCID
- Venue
- PLoS ONE
- Publisher
- Public Library of Science (PLoS)
- Published
- 2012-11-21
- Volume
- 7
- Issue
- 11
- Pages
- e49297
- ISSN
- 1932-6203 (ISSN-L)
- PMC
- PMC3504024
- OpenAlex
- W1985621733
- Cited by
- 123
- References
- 42
- Citations by year
- 2026: 3 · 2025: 4 · 2024: 10 · 2023: 11 · 2022: 8 · 2021: 3 · 2020: 8 · 2019: 6 · 2018: 14 · 2017: 11 · 2016: 10 · 2015: 15 · 2014: 10 · 2013: 10
- FWCI
- 7.51
- Type
- journal article
- Language
- en
- Open access
- gold
- doi.org
- Locations
- PLoS ONE (publishedVersion, cc-by)
- Europe PMC (PubMed Central) (publishedVersion, cc-by)
- PubMed Central (publishedVersion, cc-by)
- PubMed (publishedVersion)
- DOAJ (DOAJ: Directory of Open Access Journals) (submittedVersion, cc-by-sa)
- Figshare (submittedVersion, cc-by)
- IRIS Research product catalog (Sapienza University of Rome) (submittedVersion)
- Funders
- Bristol-Myers Squibb
- Novo Nordisk
- Topics
- Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Physical Activity and Health
- Health Sciences › Medicine › Physiology (medical) › Cardiovascular and exercise physiology
- Health Sciences › Medicine › Endocrinology, Diabetes and Metabolism › Diabetes, Cardiovascular Risks, and Lipoproteins
- Keywords
- type 2 diabetes, exercise intensity, high-intensity training, low-intensity training, supervised exercise, aerobic exercise, resistance training, cardiovascular risk factors, HbA1c, triglycerides, total cholesterol, coronary heart disease risk, sedentary patients, physical activity counseling, adverse events, exercise adherence, physical activity volume
- MeSH terms
- Cardiovascular Diseases, Diabetes Mellitus, Type 2, Energy Metabolism, Female, Humans, Italy, Male, Middle Aged, Physical Fitness, Risk Factors, Resistance Training
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