Physical exercise

updated by Dr M Falter and Prof. D Hansen, 17 August 2021

Exercise training recommendations [4-12], further refined by the EAPC EXPERT working group [13] for:

Obesity

The greatest reductions in body weight occur in subjects with a higher BMI and when exercise training is combined with dietary intervention. A minimum of 150 min/week of moderate-intensity endurance exercise training should be combined with three weekly sessions of resistance exercise. 

It is recommended to increase the weekly endurance exercise volume >250 minutes (or >1,500 kcal) and to aim for a permanently increased physical activity level. A minimum exercise program duration of 6 months is recommended, followed by a permanently increased daily physical activity level. To maximize the total number of calories burned during exercise training (which is the key factor to successfully reduce the fat mass), moderate-intense (40-60% heart rate reserve (HRR)) endurance exercises involving large muscle groups (e.g. walking, stepping, rowing, cross-training) are recommended, 3 up to 5 days/week. There is a positive influence on long-term maintenance of weight reduction, general well-being and self-esteem, and reduction in anxiety and depression.

Resistance exercise training is not recommended for fat mass loss, although the addition of resistance exercise training leads to increased resting caloric expenditure, improved blood HDL cholesterol concentrations, and increased muscle strength and lean tissue mass (60-70% of 1 repetition maximum (RM), 12-15 repetitions for 3 series each exercise targeting large muscle groups). There is no compelling evidence that resistance training, when executed properly, will increase the risk for musculoskeletal injuries, or provoke musculoskeletal symptoms in obese individuals.

Arterial hypertension

Primarily reductions in systolic blood pressure (BP) may be expected, and especially in hypertensive patients. It is recommended to perform endurance exercise training at moderate intensity (40-60% HRR) for at least 30 minutes per day, 5 days/week (high frequency exercising is key to successful BP reduction). Vigorous exercise training intensities (60-80% HRR) may be considered in patients with a low CVD risk, and may sometimes be more effective. Dynamic resistance exercise training at moderate intensity (50-70% 1RM, 8-10 exercises for large muscle groups, with gradual build up to 2-3 sets per exercise), can be added 2-3 days per week (on non-consecutive days) as dynamic resistance exercise training may lower BP by itself. Resistance training is highly effective in reducing BP further.

Isometric handgrip exercise training at low intensity (<40% of one maximal volitional contraction), performed as several intermittent bouts of handgrip contractions lasting 2 minutes each for a total of 12-15 minutes per session may assist in decreasing BP. The BP-lowering effect of resistance and isometric exercise may be comparable to, or even greater than, that of aerobic exercise.

Dyslipidaemia

Different changes in blood lipid profiles occur in patients with obesity, diabetes or cardiovascular disease.

The impact of the intake of blood lipid-lowering drugs (such as statins), but also dietary intervention, is greater on blood lipid profile as opposed to exercise training alone, and thus may overrule the impact of different exercise training modalities.

The greatest improvements in blood lipid profile may be anticipated in patients with the worst blood lipid profile.

Continuous exercise training with moderate-or high intensity (40-60% HRR) may be preferred in which the caloric expenditure >900 kcal/week (the key target) should be achieved to maximise changes in the blood lipid profile (especially blood HDL cholesterol concentration).

Therefore, extend the exercise sessions (>40 minutes/session) as well as the total training programme duration (>40 weeks) and select exercise modes with the highest caloric expenditure/time unit (see section on exercise training in obesity). Higher intensity of exercise is recommended, as this may improve the lipid profile and reduce CV risk. 

The addition of resistance training exercises may positively affect the blood HDL cholesterol concentrations: 8-10 repetitions of each series, 70-85% of 1RM, for 3 series/exercise, which should be progressively reached and adapted.

Type 2 diabetes (T2DM)

Greater reductions in blood HbA1c concentrations are anticipated in T2DM patients with higher baseline blood HbA1c concentrations.

Both aerobic and resistance training are effective for glycaemic control, BP reduction, weight loss, peak exercise capacity, and dyslipidaemia in T2DM patients. T2DM patients are advised to become or remain physically active by walking >30 minutes on at least 5 days/week, ideally every day and every week. In addition, T2DM patients should follow a supervised exercise training intervention ≥150 minutes per week of moderate-intense (40-60% HRR) endurance exercise and/or 90 minutes per week of vigorous-intense endurance exercise (60-80% HRR), ideally 3–4 hours/week. T2DM patients should try to exercise at least 5 days per week (key factor to success) and energy expenditure should be between 1000–2000 kcal per week, for at least six months, preferably followed by a sustained increase in physical activity thereafter. Resistance exercise training (another key factor to success) should be performed at least 2-3 times per week: major muscle groups should be targeted, 2 sets per muscle group with 8-12 repetitions at 70-80% 1RM, or 25-30 repetitions at 40-55% 1RM, respectively. Electro muscle stimulation (EMS) twice weekly for 20 minutes can improve blood HbA1c concentration in T2DM patients and is particularly relevant for patients with limited mobilisation or rehabilitation capacity.

Type 1 diabetes (T1DM)

Although recommended by treatment guidelines, exercise training may increase the risk of (late onset) hypoglycaemia and bears the risk of deteriorating diabetes control due to complex interaction with the regulation of glucose transport into the working muscles, nutrition and insulin therapy. Therefore, exercise training for T1DM should be an integral part of the treatment. Endurance exercise training leads to improvements in chronic glycaemic control. Adding a single bout of high-intense exercise (near maximal efforts or sprint interval training up to 10 seconds/bout) to moderate-intense continuous exercises training (40-60% HRR) may stabilize the fall in glucose concentrations during and after exercise training. Resistance exercise can cause similar hormonal and metabolic responses to those of anaerobic exercise such as HIE, especially when only 1 or 2 sets are performed. Patients with T1DM are encouraged to perform at least 150 minutes of moderate-intense (40-60% HRR) endurance exercise training per week, and, in the absence of contraindications such as moderate or severe proliferative retinopathy, resistance exercise training at least twice per week is recommended (3 sets, 10 repetitions/set, 60-70 %1RM). Chronic glycaemic control may improve in patients with T1DM when exercise training is performed for more than 3 months, training up to 3 times a week, and the patients receive dietary or insulin administration advice from a healthcare professional.