Optimal Dose and Type of Physical Activity to Improve Glycemic Control in People Diagnosed With Type 2 Diabetes: A Systematic Review and Meta-analysis
Open accessAbstract
BACKGROUND: The optimal dose or type of physical activity to control glycosylated hemoglobin (HbA1c) in people with diabetes remains unknown. Current guidelines do not include consideration of baseline HbA1c for activity prescription. PURPOSE: To examine the dose-response relationship between physical activity and HbA1c (%) in individuals with type 2 diabetes. DATA SOURCES: A systematic search was performed in Embase, MEDLINE, Scopus, CINAHL, SPORTDiscus, and Web of Science. STUDY SELECTION: We included trials that involved participants diagnosed with type 2 diabetes that included any type of physical activity as intervention. DATA EXTRACTION: Pre- and postintervention HbA1c data, population and interventions characteristics, and descriptive statistics were collected to calculate change scores for each study arm. DATA SYNTHESIS: We used Bayesian random-effects meta-analyses to summarize high-quality evidence from 126 studies (6,718 participants). The optimal physical activity dose was 1,100 MET min/week, resulting in HbA1c reductions, ranging from −1.02% to −0.66% in severe uncontrolled diabetes, from −0.64% to −0.49% in uncontrolled diabetes, from −0.47% to −0.40% in controlled diabetes, and from −0.38% to −0.24% in prediabetes. LIMITATIONS: The time required to achieve these HbA1c reductions could not be estimated due to the heterogeneity between interventions’ duration and protocols and the interpersonal variability of this outcome. CONCLUSIONS: The result of this meta-analysis provide key information about the optimal weekly dose of physical activity for people with diabetes with consideration of baseline HbA1c level, and the effectiveness of different types of active interventions. These results enable clinicians to prescribe tailored physical activity programs for this population.
AI snapshot
Written from the paper’s full text.
TL;DR
This systematic review and Bayesian dose-response meta-analysis found a nonlinear J-shaped relationship between physical activity and HbA1c in people with type 2 diabetes, with an optimal dose of 1,100 MET min/week across ADA glycemic categories. Multicomponent, strength, and walking interventions were ranked most effective, but dose appeared potentially more relevant than activity type.
Key findings
- Across 126 studies (285 change scores; 6,718 participants), the optimal physical activity dose was 1,100 MET min/week in all ADA categories, producing HbA1c changes ranging from −1.02% to −0.66% for severe uncontrolled diabetes, −0.64% to −0.49% for uncontrolled diabetes, −0.47% to −0.40% for controlled diabetes, and −0.38% to −0.24% for prediabetes.
- Minimal doses needed to move across ADA categories ranged from 150 to 810 MET min/week for severe uncontrolled to uncontrolled diabetes, 330 to 990 MET min/week for uncontrolled to controlled diabetes, and 570 to 900 MET min/week for controlled diabetes to prediabetes; no maximal tolerated dose was observed.
- Between-study heterogeneity was low (τ = 0.23; 95% CrI 0.19–0.28). At the intervention-specific level, the optimal dose was also 1,100 MET min/week, and multicomponent, strength, and walking were ranked as the most effective interventions.
- The optimal dose corresponds on average to ∼244 min/week of moderate-intensity aerobic activity or ∼157 min/week of vigorous-intensity aerobic activity, which is above current guideline ranges; GRADE certainty of evidence was high.
Methods
- Preregistered systematic review and meta-analysis (PROSPERO CRD42022313034) reported per PRISMA; searched Embase, MEDLINE/PubMed, Scopus, CINAHL, SPORTDiscus, and Web of Science, with last search in September 2022.
- Included randomized controlled trials of participants diagnosed with type 2 diabetes according to ADA criteria, using any physical activity intervention versus usual care or another physical activity intervention, and reporting HbA1c (%); excluded combined treatments where physical activity effects could not be isolated, severe associated conditions, and interventions <4 weeks.
- Used Bayesian random-effects dose-response meta-analysis models with natural splines (4 knots), adjusting for weekly physical activity dose and baseline HbA1c; analyses in R with brms, tidybayes, and ggplot2. Risk of bias assessed with RoB 2, publication bias by funnel plot, sensitivity analysis excluding high-risk studies, and GRADE for quality of evidence.
Limitations
- The authors state that certainty may decrease due to heterogeneity between trial protocols, some poorly reported physical activity type and parameters (e.g., intensity, duration, frequency); many studies were high risk of bias, mostly due to per-protocol analysis.
- The authors state that diabetes categorization was based on study-level mean/median data because participant-level data were lacking, and that data points above 1,100 MET min/week were scarce, so effects beyond that dose were extrapolated.
- The authors state that interpersonal variability and physiological mechanisms made it impossible to establish how long it would take to achieve the predicted HbA1c changes.
Model-written summary. Check it against the paper before relying on it.
Integrity signals
Registry
Cites
Statistics
Claims the paper makes
14 of 19 cited sources checked · 6 supported · 1 flagged · accuracy not yet measured
- Premisecitation
Bayesian dose-response meta-analysis models have demonstrated efficiency in determining the optimal type and dose of physical activity in specific health outcomes like cognitive function.
“Bayesian dose-response meta-analysis models have demonstrated efficiency in determining the optimal type and dose of physical activity in specific health outcomes like cognitive function (15).”
Quote in the paperSubstantial claim1 of 1 sources checked- cites [15] Gallardo-Gómez, 2022, Optimal dose and type of exercise to improve cognitive function in older adults: a systematic review and bayesian model-based network meta-analysis of RCTs, Ageing Res Rev source
- Premisecitation
No previous meta-analysis has found the optimal type or dose of physical activity to control HbA1c in type 2 diabetes.
“none found the optimal type or dose of physical activity to verify the validity and reliability of these recommendations”
Quote in the paperSubstantial claim2 of 3 sources checked- cites [11] Liu, 2019, Resistance exercise intensity is correlated with attenuation of HbA1c and insulin in patients with type 2 diabetes: a systematic review and meta-Analysis, Int J Environ Res Public Health source
The Introduction says no previous meta-analysis had compared resistance-exercise intensities for glycemic control in patients with type 2 diabetes. That supports a narrower point than the claim: the paper does not say that no meta-analysis had found the optimal type or dose of physical activity generally, or address verification of the recommendations’ validity and reliability. Page numbers were not available in our copy. (LLM, conf=0.86)
Experimental — accuracy not yet measured - cites [12] Grace, 2017, Clinical outcomes and glycaemic responses to different aerobic exercise training intensities in type II diabetes: a systematic review and meta-analysis, Cardiovasc Diabetol source
The Background says prior research found combined aerobic and resistance exercise most beneficial for glycaemic control, but it does not say whether previous meta-analyses established an optimal type or dose. The Study limitations section describes gaps in this review’s analyses, not whether earlier meta-analyses validated exercise recommendations. No page numbers are available in our copy. (LLM, conf=0.72)
Experimental — accuracy not yet measured - cites [13] Mannucci, 2021, Comparison between different types of exercise training in patients with type 2 diabetes mellitus: a systematic review and network metanalysis of randomized controlled trials, Nutr Metab Cardiovasc Dis source
- Interpretationown data
The predicted optimal physical activity dose differs from current guidelines' recommendations.
“In this dose-response meta-analysis we found important differences between our predicted optimal physical activity dose and the current guidelines' recommendations (5,10).”
Quote in the paperSubstantial claim2 of 2 sources checked - Findingown data
A nonlinear J-shaped dose-response relationship between physical activity dose and HbA1c reduction was observed across all ADA categories.
“We observed a nonlinear J-shaped doseresponse relationship between physical activity dose and HbA 1c reduction across all ADA categories (Fig. 2).”
Quote in the paperSubstantial claim - Findingown data
When 1,100 MET min/week of multicomponent interventions were accumulated, clinically important HbA1c reductions were achieved for severe uncontrolled (-1.06% to -0.67%) and uncontrolled (-0.65% to -0.50%) diabetes.
“When 1,100 MET min/week (i.e., the optimal dose) corresponding to multicomponent interventions were accu- mulated, clinically important ranges of HbA 1c change were achieved for severe uncontrolled (À1.06% to À0.67%) and uncontrolled (À0.65% to À0.50%) diabe- tes.”
Quote in the paperSubstantial claim
- Findingown data
Multicomponent, strength, and walking were ranked as the most effective interventions.
“Multicomponent, strength, and walking were ranked as the most effective interventions.”
Quote in the paperSubstantial claim - Findingown data
Between-study heterogeneity was low (τ = 0.23; 95% CrI 0.19-0.28).
“We found low between-study heterogeneity (t = 0.23; 95% CrI 0.19-0.28).”
Quote in the paperNot a substantial claim - Findingown data
Minimal doses needed to move from severe uncontrolled to uncontrolled diabetes ranged from 150 to 810 MET min/week.
“Minimal doses of physical activity needed to move from se- vere uncontrolled to uncontrolled diabetes ranged from 150 MET min/week (for indi- viduals with HbA 1c 8.1% [65 mmol/mol]) to 810 MET min/week (HbA 1c 8.6% [70 mmol/mol]).”
Quote in the paperSubstantial claim - Findingown data
Minimal doses needed to move from controlled diabetes to prediabetes ranged from 570 to 900 MET min/week.
“doses needed to move from controlled diabetes to prediabetes ranged from 570 MET min/week (HbA 1c 6.6% [49 mmol/mol]) to 900 MET min/week (HbA 1c 6.8% [51 mmol/mol]).”
Quote in the paperSubstantial claim - Findingown data
At the optimal dose, HbA1c change ranged from -0.38% to -0.24% for prediabetes.
“from À0.38% to À0.24% for prediabetes”
Quote in the paperSubstantial claim - Findingown data
At the intervention-specific level, the optimal dose for all types of activities was also 1,100 MET min/week.
“At intervention-specific level, the optimal dose for all types of activities was also 1,100 MET min/week (Supplementary Fig. 2).”
Quote in the paperSubstantial claim - Findingown data
126 studies (285 change scores and 6,718 participants) were included in the review and meta-analysis.
“Finally, 126 studies (285 change scores and 6,718 participants) were included in the review and meta-analysis.”
Quote in the paperSubstantial claim - Findingown data
The optimal dose was 1,100 MET min/week in all ADA categories.
“The optimal dose was achieved at 1,100 MET min/ week in all categories”
Quote in the paperSubstantial claim - Findingown data
Minimal doses needed to move from uncontrolled to controlled diabetes ranged from 330 to 990 MET min/week.
“Doses needed to move from uncontrolled to controlled diabetes were estimated from 330 MET min/week (HbA 1c 7.1% [54 mmol/mol]) to 990 MET min/week (HbA 1c 7.5% [58 mmol/ mol])”
Quote in the paperSubstantial claim - Findingown data
At the optimal dose, HbA1c change ranged from -0.64% to -0.49% for uncontrolled diabetes.
“from À0.64% to À0.49% for uncontrolled diabetes”
Quote in the paperSubstantial claim - Findingown data
At the optimal dose, HbA1c change ranged from -0.47% to -0.40% for controlled diabetes.
“from À0.47% to À0.40% for controlled diabetes”
Quote in the paperSubstantial claim - Findingown data
No maximal tolerated dose was observed.
“No maxi-mal tolerated dose was observed.”
Quote in the paperSubstantial claim - Findingown data
At the optimal dose, HbA1c change ranged from -1.02% to -0.66% for severe uncontrolled diabetes.
“resulting in HbA 1c change ranging from À1.02% to À0.66% for severe uncontrolled diabetes”
Quote in the paperSubstantial claim - Findingown data
In this systematic review and meta-analysis, a new nonlinear dose-response relationship between physical activity and glucose control in people with type 2 diabetes was identified.
“In this systematic review and metaanalysis we have identified a new nonlinear dose-response relationship between physical activity and glucose control in people with type 2 diabetes.”
Quote in the paperSubstantial claim - Findingown data
The optimal physical activity dose to achieve the greatest reductions in HbA1c regardless of baseline HbA1c level was 1,100 MET min/week.
“The optimal physical activity dose to achieve the greatest reductions in HbA 1c regardless of baseline HbA 1c level was 1,100 MET min/week.”
Quote in the paperSubstantial claim - Study design and conductreasoning
The certainty of the evidence presented in this meta-analysis is high according to the GRADE approach.
“According to the GRADE approach the certainty of the evidence presented in this meta-analysis is high.”
Quote in the paperNot a substantial claim - Interpretationreasoning
1,100 MET min/week is equivalent on average to approximately 157 min/week of vigorous-intensity aerobic physical activity.
“Similarly, 1,100 MET min/ week is equivalent on average to $157 min/week of vigorous-intensity aerobic physical activity (assuming a vigorous intensity of 7 MET min)”
Quote in the paperSubstantial claim - Study design and conductown data
Bayesian-based dose-response meta-analysis models allowed precise prediction of the dose-response relationship between physical activity and glycemic control.
“Second, we pooled data from different trials using cutting-edge evidence synthesis methods (i.e., Bayesian-based doseresponse meta-analysis models), which allowed us to precisely predict the doseresponse relationship between physical activity and glycemic control.”
Quote in the paperSubstantial claim - Interpretationreasoning
1,100 MET min/week is equivalent on average to approximately 244 min/week of moderate-intensity aerobic physical activity (range approximately 183 to 367 min/week).
“we estimated that 1,100 MET min/week (i.e., the optimal dose) is equivalent on average to $244 min/week of moderateintensity aerobic physical activity (ranging from $183 to $367 min/week, depending on the intensity of the activity, from 3 to 6 MET min)”
Quote in the paperSubstantial claim - Study design and conductreasoning
Due to interpersonal variability and physiological mechanisms by which blood glucose decreases, it was not possible to establish how long it would take to achieve the predicted HbA1c changes.
“Finally, due to the interpersonal variability and physiological mechanisms by which blood glucose decreases, it was not possible to establish how long it would take to achieve the predicted HbA 1c changes (Supplementary Fig. 8).”
Quote in the paperNot a substantial claim - Interpretationreasoning
People with diabetes may need to be more physically active than recommended to optimize their health outcomes.
“In summary, our evidence suggests that people with diabetes may need to be more physically active than recommended to optimize their health outcomes.”
Quote in the paperSubstantial claim - Study design and conductreasoning
The novel method allowed determination of the optimal and minimal effective doses of physical activity for a wide range of HbA1c values (6% to 10% [42-86 mmol/mol]) that people with diabetes should accumulate to impact their glycemic control.
“This novel method allowed us to determine the optimal and minimal effective doses of physical activity for a wide range of HbA 1c values (i.e., 6% to 10% [42-86 mmol/mol]) that people with diabetes should accumulate to impact their glycemic control.”
Quote in the paperSubstantial claim - Interpretationcitation
The dose of physical activity may be more relevant for glycemic control than the activity type performed.
“However, in observing the effectiveness of different physical activity types, there was not a great between-intervention variation when the estimated optimal dose was applied, which leads us to consider that the dose of physical activity may be potentially more relevant for glycemic control than the activity type performed (28).”
Quote in the paperSubstantial claim0 of 1 sources checked- cites [28] Yang, 2014, Resistance exercise versus aerobic exercise for type 2 diabetes: a systematic review and meta-analysis, Sports Med source
- May combine two claims. 17
- Classified as probably not a substantial claim. 12
- The quote only partly states this claim. 1
May combine two claims.
PremisecitationPhysical activity is effective in reducing mortality, comorbidities, and clinical parameters such as HbA1c in people with diabetes.
“Physical activity has been shown to be effective in reducing mortality, comorbidities, and clinical parameters such as glycosylated hemoglobin (HbA 1c ) (6)(7)(8).”
Quote in the paperSubstantial claim2 of 3 sources checked- cites [6] Hemmingsen, 2017, Diet, physical activity or both for prevention or delay of type 2 diabetes mellitus and its associated complications in people at increased risk of developing type 2 diabetes mellitus, Cochrane Database Syst Rev source
The Description of the intervention (page unavailable) says a trial in people with type 2 diabetes found no substantial effect of intensive diet plus physical activity on mortality or cardiovascular outcomes. The review’s Main results concern people at risk of diabetes, not people already diagnosed, and report very low-quality mortality evidence for physical activity alone. Its HbA1c results for diet plus physical activity are uncertain in the random-effects analysis, so they do not establish the claimed benefit either. (LLM, conf=0.86)
Checked by a reasoning model — may be wrong.
Experimental — accuracy not yet measured - cites [7] Chang, 2021, Habitual physical activity and diabetes control in young and older adults with type II diabetes: a longitudinal correlational study, Int J Environ Res Public Health source
The Introduction reports studies in which exercise reduced HbA1c in people with type 2 diabetes, and the Conclusions associate moderate daily activity with better glycemic control. Neither section reports that physical activity reduces mortality or comorbidities in people with diabetes. The paper's own study is correlational, so it also does not establish that daily activity caused the improvement. (LLM, conf=0.88)
Experimental — accuracy not yet measured - cites [8] Hou, 2023, Exercise modalities for type 2 diabetes: a systematic review and network meta-analysis of randomized trials, Diabetes Metab Res Rev source
Probably not a substantial claim: may not pass S3 (load-bearing).
Study design and conductcitationThe GRADE system was used to rate the quality of the body of evidence presented in this meta-analysis.
“The Grading of Recommendations Assessment, Development and Evaluation (GRADE) system was used to rate the quality of the body of evidence presented in this meta-analysis (27).”
Quote in the paperNot a substantial claim1 of 1 sources checked- cites [27] Kavanagh, 2009, The GRADE system for rating clinical guidelines, PLoS Med source
Classified as probably not a substantial claim.
Study design and conductcitationRisk of bias was assessed by four reviewers independently using version 2 of the Cochrane risk-of-bias tool for randomized trials (RoB 2).
“Four reviewers (J.d.P.-C., B.d.P.-C., R.M.A.-R., and J.R.-M.) independently assessed the risk of bias of the included studies according to version 2 of the Cochrane riskof-bias tool for randomized trials (RoB 2) (26).”
Quote in the paperSubstantial claim1 of 1 sources checked- cites [26] Higgins, 2011, The Cochrane Collaboration’s tool for assessing risk of bias in randomised trials, BMJ source
The Evaluation of initial implementation section says the paper presents a revision of the 2008 Cochrane risk-of-bias tool for randomized trials. It does not identify that tool as version 2 (RoB 2), so the citation supports the general tool identification but not the specified version. The four-reviewer procedure describes the citing authors’ own methods, not a finding attributed to this source. (LLM, conf=0.88)
Experimental — accuracy not yet measured
Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.
Study design and conductcitationThe systematic review was preregistered (PROSPERO CRD42022313034) and reported according to the PRISMA checklist.
“This preregistered systematic review with meta-analysis (International prospective register of systematic reviews [PROSPERO], no.CRD42022313034) was reported in accord with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) checklist ( 16).”
Quote in the paperNot a substantial claim1 of 1 sources checked- cites [16] Page, 2021, Updating guidance for reporting systematic reviews: development of the PRISMA 2020 statement, J Clin Epidemiol source
Classified as probably not a substantial claim. May combine two claims.
PremisecitationCurrent guidelines recommend at least 150-300 min/week of moderate-intensity aerobic physical activity or 75-150 min/week of vigorous-intensity aerobic physical activity and muscle-strengthening activities two or more times a week for people with diabetes.
“The ADA and other institutions, such as the World Health Organization and the American College of Sports Medicine, recommend, in their physical activity guidelines for people living with diabetes, engaging in at least 150-300 min of moderate-intensity aerobic physical activity per week or 75-150 min of vigorous-intensity aerobic physical activity per week and in muscle-strengthening activities”
Quote in the paperSubstantial claim1 of 2 sources checked- cites [9] American College of Sports Medicine, 2013
Couldn’t be matched to a paper in Crossref, so it can’t be checked.
- cites [10] Bull, 2020, World Health Organization 2020 guidelines on physical activity and sedentary behaviour, Br J Sports Med source
May combine two claims.
InterpretationcitationThe optimal physical activity dose can achieve a decrease of up to >1% for patients with severe uncontrolled diabetes, attenuating the risk of microvascular complications, macrovascular complications, and diabetes all-cause mortality.
“The optimal physical activity dose here represents a more objective approach, use of which can achieve a decrease of up to >1% for patients with severe uncontrolled diabetes, attenuating the risk of microvascular complications, macrovascular complications, and diabetes all-cause mortality (30).”
Quote in the paperSubstantial claim1 of 1 sources checked- cites [30] Chen, 2015, The impact of diabetes mellitus and corresponding HbA1c levels on the future risks of cardiovascular disease and mortality: a representative cohort study in Taiwan, PLoS One source
The Results (page unavailable) associate higher HbA1c with greater cardiovascular and all-cause mortality risk, supporting the claim’s general link between glycemic control and those outcomes. The paper does not show that an optimal physical-activity dose lowers HbA1c by more than 1% in patients with severe uncontrolled diabetes, or that it reduces microvascular complications. Its observational associations do not establish the claimed effect of physical activity. (LLM, conf=0.88)
Experimental — accuracy not yet measured
Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.
PremisecitationHbA1c levels below the <7% threshold could reduce risk of ischemic stroke, coronary heart disease, and cardiovascular disease for patients with diabetes, metabolic disease, neuropathy, nephropathy, and peripheral vascular disease.
“HbA 1c levels below this threshold could reduce risk of ischemic stroke, coronary heart disease, and cardiovascular disease (30) for patients with diabetes, metabolic disease, neuropathy, nephropathy, and peripheral vascular disease (31).”
Quote in the paperNot a substantial claim2 of 2 sources checked- cites [30] Chen, 2015, The impact of diabetes mellitus and corresponding HbA1c levels on the future risks of cardiovascular disease and mortality: a representative cohort study in Taiwan, PLoS One source
The Results associate higher HbA1c with greater risks of ischemic stroke, coronary heart disease, and cardiovascular disease; the Discussion says these findings might support an HbA1c target below 7%. The study does not establish that lowering HbA1c below 7% reduces those risks: its significant comparison uses ≥7.5%, and the evidence is observational. The list of patient conditions is attached to a separate citation (31), not this source. Page numbers are unavailable in our copy. (LLM, conf=0.85)
Experimental — accuracy not yet measured - cites [31] Boye, 2022, The association between sustained HbA1c control and long-term complications among individuals with type 2 diabetes: a retrospective study, Adv Ther source
The Results report that, among individuals with type 2 diabetes, sustained HbA1c <7% was associated with lower odds of subsequent cardiovascular disease, metabolic disease, neuropathy, nephropathy, and peripheral vascular disease diagnoses. The citing sentence instead describes these conditions as characteristics of patients for whom risk was reduced; the paper studied them as outcomes, not as patient subgroups. The ischemic-stroke and coronary-heart-disease clause is attached to citation (30), not this source. (LLM, conf=0.86)
Experimental — accuracy not yet measured
May combine two claims.
Findingown dataSensitivity analysis including only low-risk-of-bias studies showed similar dose-response curves and the optimal dose hardly differed from the base-case model.
“A sensitivity analysis that included only studies classified as low risk of bias presented greater effect fluctuations in the physical activity dosage tails (i.e., <600 and >1,400 MET min/week) (Supplementary Table 5). However, the estimated dose-response curves were similar, and thus the optimal dose hardly differed from that of our base-case model”
Quote in the paperNot a substantial claimMay combine two claims. The quote only partly states this claim.
Findingown dataStatistically significant HbA1c reductions were observed in controlled diabetes (range -0.48% to -0.37%) and prediabetes (-0.38% to -0.23%) with multicomponent interventions at 1,100 MET min/week.
“Statistically significant HbA 1c reduc- tions were also observed in controlled diabetes (range À0.48% to À0.37%) and prediabetes (À0.38% to À0.23%).”
Quote in the paperSubstantial claimMay combine two claims.
Findingown dataAt the overall level, 28 studies had low risk of bias, 34 unclear risk of bias, and 64 high risk of bias.
“At overall level, 28 studies were classified to have low risk of bias, 34 studies unclear risk of bias, and 64 studies high risk of bias.”
Quote in the paperNot a substantial claimMay combine two claims.
Findingown dataThe optimal dose of 1,100 MET min/week achieved a clinically significant decrease for participants with HbA1c baseline level ≥7.5% and a statistically significant HbA1c reduction for those with lower baseline levels.
“The optimal dose of physical activity (1,100 MET min/week) achieved a clinically significant decrease for participants with HbA 1c baseline level $7.5% (59 mmol/mol) and a statistically significant HbA 1c reduction for those with lower baseline levels.”
Quote in the paperSubstantial claimMay combine two claims.
Study design and conductown dataThe funnel plot did not show a clear pattern of asymmetry, indicating that small-study effects are unlikely.
“The funnel plot did not show a clear pattern of asymmetry, indicating it is unlikely that these are smallstudies effects (Supplementary Fig. 5).”
Quote in the paperNot a substantial claimClassified as probably not a substantial claim.
Study design and conductown dataA sensitivity analysis excluding high-risk-of-bias studies was conducted to determine whether these studies could influence the overall dose-response relationship.
“We conducted a sensitivity analysis excluding from the meta-analyses the studies rated as high-risk bias to determine whether these studies could influence the overall dose-response relationship”
Quote in the paperSubstantial claimProbably not a substantial claim: may not pass S3 (load-bearing).
Study design and conductnone givenPublication bias was assessed by funnel plot asymmetry visualization.
“Publication bias was assessed by funnel plot asymmetry visualization.”
Quote in the paperNot a substantial claimProbably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.
Study design and conductown dataTitle/abstract and full-text screening were performed by two investigators independently, with a third resolving discrepancies.
“Titles/abstract and full text screening were reviewed by two investigators (D.G.-G.and F.A.-B.) independently.In case of discrepancy, a third author resolved the disagreement (E.S.-M.).”
Quote in the paperNot a substantial claimProbably not a substantial claim: may not pass S3 (load-bearing).
Study design and conductnone givenLarge variations in baseline HbA1c levels were taken into account in the risk-of-bias analysis.
“However, large variations in baseline HbA 1c levels were taken into account in the risk-of-bias analysis.”
Quote in the paperNot a substantial claimProbably not a substantial claim: may not pass S3 (load-bearing).
Study design and conductreasoningThe diabetes categorization derived by the authors was based on the mean/median data provided for each of the studies due to the lack of participant-level data.
“Third, the diabetes categorization derived by the authors was based on the mean/median data provided for each of the studies due to the lack of participant-level data.”
Quote in the paperNot a substantial claimMay combine two claims.
InterpretationreasoningThe optimal dose of 1,100 MET min/week can be translated into ≥314 min/week moderate-intensity or ≥138 min/week vigorous-intensity multicomponent activities, ≥314 min/week moderate-intensity or ≥183 min/week vigorous-intensity strength activities, or ≥256 min/week moderate-paced or ≥157 min/week brisk walking.
“This dose of physical activity can be translated into minutes per week of some of the different types of interventions included in this review: $314 min/week moderate-intensity or $138 min/week vigorous-intensity multicomponent activities, $314 min/week moderate-intensity or $183 min/week vigorous-intensity strength activities, or $256 min/week moderate-paced or $157 min/week brisk walking.”
Quote in the paperSubstantial claim0 of 1 sources checked- cites [19] Ainsworth, 2011, 2011 compendium of physical activities: a second update of codes and MET values, Med Sci Sports Exerc source
Probably not a substantial claim: may not pass S3 (load-bearing).
Study design and conductnone givenThe transference of the predicted minimum effective doses to other health outcomes in this population has not been contrasted.
“but the transference to other health outcomes in this population has not been contrasted.”
Quote in the paperNot a substantial claimProbably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.
Study design and conductnone givenThe physical activity dose calculation process used allows reproducibility of the conducted analyses, making possible comparison of future research results with those presented in this meta-analysis.
“Third, we used a physical activity dose calculation process that allows the reproducibility of the conducted analyses, making possible the comparison of future research results with those presented in this metaanalysis.”
Quote in the paperNot a substantial claimMay combine two claims.
Study design and conductown dataThe detected dose-response gradient and the potential confounding adjustment upgraded this evidence.
“However, it is important to highlight the detected dose-response gradient and the potential confounding adjustment, which upgraded this evidence.”
Quote in the paperSubstantial claimMay combine two claims.
Study design and conductown dataSeveral studies were assessed to have high risk of bias according to RoB 2, most due to the per-protocol analysis performed, resulting in many being of some concern regarding risk of bias.
“Second, several studies were assessed to have high risk of bias according to RoB 2, most due to the perprotocol analysis performed, resulting in many being of some concern regarding risk of bias.”
Quote in the paperNot a substantial claimMay combine two claims.
Study design and conductown dataThe available number of data points >1,100 MET min/week (optimal dose) was scarce, so effects from this dose point were extrapolated using modeling techniques, with no clear evidence to contrast these predicted effects of very high physical activity doses.
“Fourth, the available number of data points >1,100 MET min/week (i.e., optimal dose) was scarce, which means that the effects from this dose point were extrapolated with use of modeling techniques, with no clear evidence to contrast these predicted effects of very high physical activity doses.”
Quote in the paperSubstantial claimMay combine two claims.
Study design and conductnone givenThe meta-analysis comprised a large sample size of people with type 2 diabetes, providing adequate statistical power for the study aims.
“First, this meta-analysis comprised a large sample size of people with type 2 diabetes, providing adequate statistical power for the study aims.”
Quote in the paperNot a substantial claim
The paper relies on this without support.
The impact of baseline HbA1c level on physical activity response has not been meta-analyzed.
“Additionally, the potential impact of important clinical characteristics such as baseline HbA 1c level at which participants enter into a physical activity program has not yet been meta-analyzed.”
Claims other papers make about this one
Each is checked against this paper’s own text: does it say what the citing paper says it does?
In meta-analyses of people with diabetes (type 1 and 2), clinically meaningful HbA1C reductions have been reported for Mediterranean-style vs control diets (difference in HbA1C, −0.39% [95% CI, −0.58% to −0.20%]), the Dietary Approaches to Stop Hypertension vs control diets (difference in HbA1C, −0.53% [95% CI, −0.62% to −0.43%]), and low- vs high-carbohydrate diets (difference in HbA1C at 6 mo, −
“In meta-analyses of people with diabetes (type 1 and 2), clinically meaningful HbA1C reductions have been reported for Mediterranean-style vs control diets (difference in HbA1C, −0.39% [95% CI, −0.58% to −0.20%]), the Dietary Approaches to Stop Hypertension vs control diets (difference in HbA1C, −0.53% [95% CI, −0.62% to −0.43%]), and low- vs high-carbohydrate diets (difference in HbA1C at 6 mo, −”
From Diagnosis and Treatment of Type 2 Diabetes in Adults (2025) · cites this paper as [27]
The Discussion reports HbA1c reductions associated with physical activity in people with type 2 diabetes, not dietary comparisons. Searches of our copy for Mediterranean-style, DASH, and low- versus high-carbohydrate diets found no passage reporting the attributed estimates or addressing outcomes in people with type 1 and type 2 diabetes together. Page numbers were not provided for the indexed passages. (LLM, conf=0.76)
Experimental — accuracy not yet measured
Self-check
Percentages, sums and reported differences re-computed from the paper’s own numbers.
Each contradiction between two passages listed here was confirmed by an independent check.
244 minutes is not above the 80th percentile of the stated range
MinorThe stated recommended moderate-intensity range is 150-300 minutes per week. Its 80th-percentile point is 270 minutes, so 244 minutes is below it.
“$244 min/week of moderateintensity aerobic physical activity (ranging from $183 to $367 min/week, depending on the intensity of the activity, from 3 to 6 MET min), which is above the 80th percentile of the recommended moderate-intensity physical activity per week range for this population.”
“engaging in at least 150-300 min of moderate-intensity aerobic physical activity per week”
An HbA1c level of 8.0% is placed in the wrong category
MinorThe methods define severe uncontrolled type 2 diabetes as HbA1c >8%, but Table 1 places an 8.0% baseline in that category.
“| | 8.0% (64 mmol/mol) | Optimal** | 1,100 | À0.655 (À0.733 to À0.576) |”
“and >8% (64 mmol/mol) as severe uncontrolled type 2 diabetes.”
Inconsistent mmol/mol equivalents for 7.5% HbA1c
MinorThe clinical implications give 59 mmol/mol for 7.5% HbA1c, while Table 1 and the discussion give 58 mmol/mol for the same percentage.
“HbA 1c baseline level $7.5% (59 mmol/mol)”
“| | 7.5% (58 mmol/mol) | Minimal** | 990 | À0.570 (À0.638 to À0.502) |”
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Diagnosis and Treatment of Type 2 Diabetes in Adults
Kalyani, R. R., Neumiller, J. J., Maruthur, N. M., & Wexler, D. J. (2025) · JAMA · doi:10.1001/jama.2025.5956 · Cited by 145 · see citing works
- Authors
- Gallardo-Gómez, D., Salazar-Martínez, E., Alfonso-Rosa, R. M., Ramos-Munell, J., del Pozo-Cruz, J., del Pozo Cruz, B., & Álvarez-Barbosa, F.
- Affiliations
- 1Department of Physical Education and Sport, University of Seville, Seville, Spain
- 2Epidemiology of Physical Activity and Fitness Across the Lifespan (EPAFit) Research Group, University of Seville, Spain
- Universidad de Sevilla (ES)
- Venue
- Diabetes Care
- Publisher
- American Diabetes Association
- Published
- 2024-01-19
- Volume
- 47
- Issue
- 2
- Pages
- 295-303
- ISSN
- 0149-5992 (ISSN-L)
- 1935-5548
- OpenAlex
- W4391017463
- Semantic Scholar
- d3a02ac4e6b42d695771e4db4433c5f810b058e6
- Cited by
- 111
- References
- 50
- Citations by year
- 2026: 44 · 2025: 44 · 2024: 23
- FWCI
- 8.59
- Type
- journal article
- Language
- en
- Open access
- bronze
- doi.org
- Locations
- Diabetes Care (publishedVersion)
- PubMed (publishedVersion)
- Deposito de Investigacion Universidad de Sevilla (University of Seville) (submittedVersion, public-domain)
- University of Southern Denmark Research Portal (University of Southern Denmark) (submittedVersion, other-oa)
- Funders
- Spanish Government (FPU20/0067)
- PAIDI (P20_1181)
- Development, and Innovation Program
- Research Program of the University of Seville, Spain
- Research Talent Recruitment Program (EMERGIA 2020/00158)
- Topics
- Health Sciences › Medicine › Physiology › Physical Activity and Health
- Health Sciences › Medicine › Endocrinology, Diabetes and Metabolism › Diabetes Management and Research
- Health Sciences › Medicine › Endocrinology, Diabetes and Metabolism › Diabetes Treatment and Management
- Keywords
- type 2 diabetes, physical activity, glycemic control, HbA1c, dose-response relationship, exercise prescription, prediabetes, uncontrolled diabetes
- MeSH terms
- Glycemic Control, Bayes Theorem, Diabetes Mellitus, Type 2, Glycated Hemoglobin, Humans, Exercise
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Registry, retraction, Cites and statistics results are computed, not judged, with one exception: a printed reference that no index lists is read once by a model before it counts as a citation error. Claims are extracted by a model and kept only when their quote appears verbatim in the text; each cited source is then checked, with a model’s help, for whether it says what the claim relies on. Those verdicts can be wrong — read the claim’s quote and the cited source before relying on one.
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