Journal of Diabetology

: 2021  |  Volume : 12  |  Issue : 3  |  Page : 257--262

Mechanism of physical activity in the prevention and management of type 2 diabetes mellitus: A short review

Jintu Kurian1, Ramesh Mavathur Nanjundaih2, Guru Deo3,  
1 Department of Life Sciences, Swami Vivekananda Yoga Anusandhana Samsthana, Bengaluru, Karnataka, India
2 Molecular Bioscience Research Lab, Swami Vivekananda Yoga Anusandhana Samsthana, Bengaluru, Karnataka, India
3 Department of Yoga Therapy, Morarji Desai National Institute of Yoga, New Delhi, India

Correspondence Address:
Dr. Guru Deo
Department of Yoga Therapy, Morarji Desai National Institute of Yoga, 68 Ashoka Road, New Delhi.


Background: Pre-diabetes (PDM) is a state with impaired glucose tolerance and/or impaired fasting glucose where people are at risk for diabetes. In less than 3 years, PDM gets converted to diabetes. Physical activity (PA) is a boon to PDM and diabetes to gain control over the glycemic variability and insulin secretion, reduction in cardiometabolic risk, and improvement in overall health. Increasing PA helps delay or prevent the conversion of PDM to diabetes mellitus (DM), as well as helps prevent complications of diabetes effectively. Materials and Methods: The aim of the review was to understand the mechanism by which PA can help to prevent and manage DM. Research papers, manuscripts, and review papers on PA and its mechanism of action on prevention and management of diabetes were searched and relevant contents were studied. One hundred and twelve papers were chosen from online sources like Google Scholar, Scopus, PubMed, Sci-Hub, and Library Genesis. Fifty-seven articles were shortlisted and out of them 54 included in this mini-review comprising of meta-analysis, systematic review, and randomized control trials. Fifty-seven articles were excluded due to irrelevant content in the contexts of diabetes and its mechanism. Result: The review resulted in getting a better understanding of the possible mechanisms by which PA works in prevention and management of DM and delaying the onset of diabetes in PDM. In addition to that, the highest known risk factors for diabetes in this current scenario are understood as physical inactivity among youngsters, along with low nutrition high-quality diet, stress, low-quality sleep, and associated fat and glucose metabolism. Conclusion: During pandemics like coronavirus disease 2019 (COVID-19), physically being active also has its role in reducing resistance power and metabolism of fat and glucose, thereby increasing the risk for diabetes. It is always better to keep oneself with some exercise daily to maintain surface immunity high and strong to avoid diseases. This is possible by modification of lifestyle with yoga, exercises, and proper diet. Periodic incorporation of indoor–outdoor activities aiming at cutting short period of inactivity will help prevent and manage diabetes and other metabolic endocrine disorders to a large extent.

How to cite this article:
Kurian J, Nanjundaih RM, Deo G. Mechanism of physical activity in the prevention and management of type 2 diabetes mellitus: A short review.J Diabetol 2021;12:257-262

How to cite this URL:
Kurian J, Nanjundaih RM, Deo G. Mechanism of physical activity in the prevention and management of type 2 diabetes mellitus: A short review. J Diabetol [serial online] 2021 [cited 2021 Nov 28 ];12:257-262
Available from:

Full Text


Pre-diabetes (PDM) is a warning stage for the onset of diabetes.[1],[2],[3] PDM is increasingly found in developed and developing countries and is linked to the rise in risk for cardiovascular disorders. Preventing diabetes at a pre-diabetic state is of high priority these days as the number of cases found with PDM is increasing.[4],[5] The prevalence of diabetes mellitus (DM) is found to be high as predicted in the previous study on Indian population.[6] Impaired secretion of insulin from pancreatic beta cells, increased resistance of body cells to insulin, increased glucagon release from pancreatic alpha cells, and increased conversion of hepatic glycogen to glucose are major causes for the increased glycemic variability leading to impaired glucose tolerance (IGT), in other words known as PDM. Ignorance, lack of care, and ineffective management of PDM and diabetes can result in ill-effects to different systems of the human body. Those system-wise complications include partial or complete loss of vision, retinopathy, peripheral vascular disease, neuropathy, cardiovascular disorders, nephropathy, and other kidney-related disorders. On the other hand, obesity, sedentary lifestyle, family history of diabetes, metabolic syndromes, lack of physical activity (PA), and imbalanced high calorie, high carbohydrate diet pattern are the predisposing factors for PDM and diabetes.[7]

India has the second highest prevalence rate of IGT.[8] Impaired fasting glucose (IFG) characterizing PDM is also experiencing a rise in prevalence in India.[9] The conversion rate of IGT to IFG is also alarming. Early stages of glucose intolerance not only carry out a high risk for complications in different systems of the body but it also increases the rate of conversion of PDM to diabetes. High insulin resistance and associated risk for other complications are increasingly found in younger age in Indians.[10] Nearly 347 million people around the world were found to be diagnosed as diabetic in 2008. A paper published in 2017 projected the prevalence of diabetes in India as 69.1 million (11.6%) and undiagnosed PDM as 36 million (6.7%).[11] Whereas a study published in 2019 shows that the prevalence of diabetes has risen to 72.96 million; 10.9% in urban and 14.2% in rural India.[8]

Risk factors associated with PDM and diabetes

The most commonly found risk factor associated with improper management of diagnosed PDM and diabetes are metabolic disorders, endocrine dysfunction, impaired sleep dynamics, fat, oxidative stress[12] and glucose metabolism abnormalities, and lack of PA.[13],[14] Eighty percent of obese people are found to be caught with increased risk for diabetes and PDM. Elevated free fatty acid, plasma triglycerides, dense low-density lipoprotein (LDL), and low catabolism of triglycerides precipitate Type 2 DM and increase the risk for cardiovascular complications[15],[16],[17] in diabetes. Factors impairing beta cell activity and intracellular insulin stores include elevated free fatty acid and prolonged lipid exposure.[18] In addition to that, visceral fat stores and central obesity mediate insulin resistance and glucose intolerance[19] and risk for cardiovascular disorders.[20] Insulin resistance of skeletal muscle glucose transport is one of the key defects in the development of IGT and Type 2 DM (T2DM).[21]

Fat metabolism, insulin release, and glucose homeostasis

Insulin is a peptide hormone secreted by β cells of the pancreas, playing as a gatekeeper for the cells to convert glucose into energy. Insulin acts as a regulator of lipoprotein lipase activity.[22] Glucose homeostasis is maintained in normal healthy subjects by first-phase insulin release (FPIR).[23] Proper fat metabolism, hepatic glucose production, and glycemic control are the main influencing factors in glucose homeostasis, which is an important factor required for the prevention and management of diabetes. Impaired FPIR inhibits hepatic glucose production and this results in postprandial hyperglycemia.[24] Hence, patients with IGT will have abnormal fat metabolism, lipoprotein level, and lipid profiles. Insulin acts as a regulator for lipoprotein lipase activity under physiological conditions by which the insulin resistance can be brought under control and glucose homeostasis can be achieved. Adiponectin, a protein hormone that regulates energy metabolism, fatty acid breakdown, and oxidation, has a significant role in glucose regulation. To link with, the level of adiponectin that is found to be deficient in case of obesity and diabetes can be an indicator for the development of T2DM.

PA and its vital role in a comforting life

The rise in the prevalence of diabetes highlights the need for complementary alternative therapies to reduce the increasing incidence. Increasing the level of PA can be of different forms such as Yoga[25] exercises, sports, occupational, or household work. Yoga and exercise are a subset of PA. Yoga asana improves glycemic balance, glucose and fat metabolism, and glucose homeostasis attaining physical and mental wellbeing.[26]Whereas outdoor exercises, gym, and other fitness training programs achieve the goal of calorie-burning, fat metabolism, and physical fitness.[27] Most importantly, Yoga asanas such as Ardhamatsyendra asana, Vakrasana, Hamsasana, Mayurasana, Bhujangansana, Dhanurasana, Mandukasana, and Suryanamaskar are reported to be very effective in the prevention and management of diabetes.[28] The impact of PAs on glycemic control, weight maintenance[29],[30], and reduction in cardiovascular risk[31] is pretty much evident.[32] The metabolism of fat and carbohydrate is better with moderate level of PA as compared to low and high intensity activity [Chart 1]. The major efficacy trials have shown that lifestyle interventions targeting PA, dietary changes, and weight loss are efficient and cost-effective in preventing T2DM among people with IGT.[33] High- and moderate-intensity training helps not only in the prevention of diabetes but also improves functional ability in people with diabetes.[34],[35]{Figure 1}

Mechanism by which PA works in PDM and Diabetes

PA is assumed to work in such a way that the insulin secretion and post heparin lipoprotein lipase activity can be improved and insulin-mediated glucose disposal and triglyceride concentration level can be found to be decreased.[36] Metabolic effects of aerobic endurance exercise[37] are found to be effective in subjects with PDM and improved glycemic control in people with diabetes. The neuro-endocrine system plays a major role in gluco-regulation during intensive PA.[38] Increasing muscle contraction improves glucose uptake by muscles and hence there will be no need for dependency on insulin or oral hypoglycemic drugs.[39] Fat oxidation also improves after a period of PA and being physically active improves muscle fuel utilization with a direct impact on blood glucose and lipid profile. Structuring the lifestyle with diet modifications and a minimum of 120–150min of PA per week is highly effective in PDM, preventing the onset of diabetes and reversing newly diagnosed diabetes.[40]

Prevention and management of DM

Regular PA not only ensures good health and wellbeing but also reduces the risk for mental disorders such as depression, anxiety, and emotional upsurges commonly found bothering people with DM.[41],[42] PA is found to help improve the quality of sleep and thereby help reverse insulin resistance.[43] Yoga and PAs are known to improve the oxygen flux through muscles by 90- to 100-folds, reduce the level of free radicals and oxidative stress, and thus upregulate defense mechanism with animproved antioxidant support.[44] PA is associated with improving fatty acid metabolism and lowering the level of pro-inflammatory cytokines, thereby helping achieving glycemic control in diabetes.[39] Increasing the duration of leisure-time PA in addition to household works would provide additional benefit for a diabetic patient to keep the control over the glycemic load.[45] The study found that a high participation rate in leisure-time PAs correlated with good control of HbA1c levels. Appropriate leisure-time PAs for patients with T2DM including hula hoop, jogging, walking, gardening, yoga, tai chi, qigong, swimming, dancing, and cycling found a positive association between regular walking exercises, lower HbA1c levels, body mass index, and diastolic blood pressure.

Categorizing priority along with PA

Priority should be given in the selection of a low glycemic index diet in adopting a well-balanced menu for a daily regime. Low glycemic index, low-fat diet, high fiber diet play a major role in the management of diabetes.[46] Awareness about the quality and quantity of diet and getting the nutrients absorbed through exercises and PA is to be given utmost importance in diabetes. Well-balanced diet including seasonal and less-processed food with low glycemic index diet can support glycemic control. Exercise has long been heralded as a cornerstone in the management of T2DM. Increased body mass index is another risk factor for PDM and diabetes. PA plays its role with its effects on body weight management and thus reducing risk for PDM and DM. However, it is strongly recommended that exercise should be an adjunct to a proper lifestyle and diet control.

 Materials and Methods

The aim of the review was to understand the mechanism by which PA works on the prevention and management of diabetes. Different online sources such as Sci-Hub, PubMed, Google Scholar, Library Genesis were searched to find relevant papers that can provide with information on the importance of PA and the mechanism by which PA works. Fifty-seven papers with systematic review, meta-analysis, randomized control trials, cross-sectional studies were shortlisted and 55 of them were included in the mini-review. The keywords used in the search for the articles were “pre-diabetes,” “diabetes,” “diabetes pre-diabetes prevalence,” “Physical activity,” “Mechanism of action of physical activity,” “mechanism of action of Yoga in diabetes,” “mechanism of action of exercise in diabetes,” “diet for diabetes management,” “diet to delay diabetes onset,” “sleep and pre-diabetes,” “sleep and diabetes,” “COVID-19 pandemic,” and “risk for diabetes and diabetes complications.” Retrospective studies and studies carried with subjective assessments alone and pilot studies were excluded. The studies that were not related to the concept sought out in the current study were excluded from the review. The review process resulted in getting a precise idea about the mechanism by which PA works in the prevention and management of DM. The results are summed up in a basic understanding that ample duration of PA can help achieve optimal glycemic outcomes through balancing the release of insulin, glucagon, and glycogen in people under risk and who are diagnosed with diabetes. People with diabetes can thus achieve physical, mental, and social harmony in a period of time.


The current review resulted in understanding the possible mechanism by which PA works in the prevention and management of diabetes as well as delaying of conversion of PDM to diabetes. The review could also bring up the risk factors for diabetes other than known nonmodifiable factors like age and family history and nonmodifiable factors like obesity and stress. This review altogether highlights PA as a top priority risk factor for the cause of diabetes. There are several risk factors in the current pandemic time including stress, fear, worry, anxiety, and increased hours with electronic devices that impair the fat and glucose metabolism resulting in shortening the conversion time from PDM to DM. This mini-review highlights the importance of PA, diet, and yoga, pranayama, meditation as a stress reduction approach to improve metabolism, wellbeing, and quality of life in people with PDM and diabetes.


PA defined as bodily movement involving skeletal muscles that in turn results in energy expenditure is claiming its impact on glucose and fat metabolism.[47] In the current scenario of COVID-19 pandemic outbreak, health and wellness are at risk. Work from home, increased duration of dependency on electronic devices, increasing stress, and anxiety are all the triggering factors for the increasing prevalence of metabolic disorders like DM. To prevent diabetes at this time and in future, it is essential to reduce economical, physical, and mental burden. Diet modifications, stress-relieving therapies like meditation, breathing practices, and pranayama, and outdoor games are the remedies to fight against crisis-induced triggers. Dietary modifications including avoiding processed and refined items and adding polyunsaturated fatty acids like omega-3, omega-6, and omega-9 in the daily menu have been very vital for insulin secretion.[48] Behavioral counseling helps to get awareness about the need for PA in young adults under various risks including diabetes.

Diabetes with higher enrollment in PA is observed with lower healthcare expenditures when compared to physically less and inactive cases.[48] Research shows that blood glucose level can drop drastically with aerobic exercises and shoot up with anaerobic exercises.[49],[50] Hence, consulting PA trainer or a physician before choosing the type of exercise and intensity is important. Certain factors like avoiding anti-diabetic medications before aerobic exercise is also to be noted down.[51] Medium intensity PA is recommended for diabetes under medication. On the other hand, intense PA is suggested for PDM and diabetes not under medication and with no associated complications. The mechanism by which PA works is by decreasing hepatic glucose production and oxidative stress[52] and by increasing peripheral glucose uptake[53] that in turn helps in glucose–insulin regulation thereby controlling the glycemic load and variability.

Yoga and pranayama are categorized under mild to moderate intensity PA and are of the best choice in retaining the balance of blood glucose level during and after the practice. Finding time for yoga[54] and exercise is always a matter of question among professionals and nonprofessionals. Foreseeing the risks for health will be a self-motivational factor for adopting therapies to keep individuals physically active. Regular practice of yoga for 30min to 1h can be the best of all PAs along with other stretching exercises. At long duration work, PA can be in the form of simple stretching exercises like sitting or standing at 30min interval, short 5-min walk at every hour of work, and occasional sit and stand exercise, and short 5–10min breath regulating mind-relaxing practice of pranayamas like Bhramari and Nadisuddhi can not only increase work productivity, but also enhance physical wellbeing and ease out the internal stress. Together with that, getting involved in household activities, outdoor games, jogging, running, swimming, cycling are the other best remedies for moderately being active after office hours. Accepting the facts and trying to secure the life ahead by a modified lifestyle with Yoga and PA will prevent diabetes and ensure a complication-free life ahead for people with diabetes.


Prolonged sitting, physical inactivity, and unhealthy diet are the highest known risk factors for PDM and diabetes in the current scenario. It is of utmost need to inculcate PAs even during medication for such disorders. PA in the form of Yoga, pranayama, and periodic scheduling of healthy break with stretching practices and other forms of exercises can guarantee fat and glucose metabolism and glucose homeostasis. Improved PA can thus prevent and manage DM. Along with this, discipline on diet, sleep hygiene, and stress reduction therapies can offer immense support for prevention and management of DM.

Financial support and sponsorship

There is no funding involved.

Conflict of interest

There is no conflict of interest among authors and others in carrying out this mini-review.


1Tabák AG, Herder C, Rathmann W, Brunner EJ, Kivimäki M. Prediabetes: A high-risk state for diabetes development. Lancet 2012;379:2279-90.
2Pai LW, Li TC, Hwu YJ, Chang SC, Chen LL, Chang PY. The effectiveness of regular leisure-time physical activities on long-term glycemic control in people with type 2 diabetes: A systematic review and meta-analysis. Diabetes Res Clin Pract 2016;113:77-85.
3Wang G, Liu X, Christoffel KK, Zhang S, Wang B, Liu R, et al. Prediabetes is not all about obesity: Association between plasma leptin and prediabetes in lean rural Chinese adults. Eur J Endocrinol 2010;163:243-9.
4Pandey U, Midha T, Rao YK, Katiyar P, Wal P, Kaur S, et al. Anthropometric indicators as predictor of pre-diabetes in Indian adolescents. Indian Heart J 2017;69:474-9.
5American Diabetes Association. Standards of medical care in diabetes—2013. Diabetes Care 2013;36(Suppl 1):S11-66.
6Malik R. India is the diabetes capital of the world! Times of India. 2016; Retrieved 2018 June 22, from
7Kolb H, Martin S. Environmental/lifestyle factors in the pathogenesis and prevention of type 2 diabetes. BMC Med 2017;15:1-11.
8Sharma NC. Government survey found 11.8% prevalence of diabetes in India [Internet]. Livemint 2019. Available from: [Last accessed on 2019 Feb 17].
9Vijayakumar G, Manghat S, Vijayakumar R, Simon L, Scaria LM, Vijayakumar A, et al. Incidence of type 2 diabetes mellitus and prediabetes in Kerala, India: Results from a 10-year prospective cohort. BMC Public Health 2019;19:140.
10Ramachandran A. Epidemiology of diabetes in India—three decades of research. JAPi 2005;53:34-8.
11Tripathy JP, Thakur JS, Jeet G, Chawla S, Jain S, Pal A, et al. Prevalence and risk factors of diabetes in a large community-based study in North India: Results from a STEPS survey in Punjab, India. Diabetol Metab Syndr 2017;9:8.
12Gómez-Sámano MÁ, Cuevas-Ramos D, Grajales-Gómez M, Escamilla-Márquez M, López-Estrada A, Guillén-Pineda LE, et al. Reduced first-phase insulin secretion increases postprandial lipidemia in subjects with impaired glucose tolerance. BMJ Open Diabetes Res Care 2017;5:e000344.
13Reis JP, Allen NB, Bancks MP, Carr JJ, Lewis CE, Lima JA, et al. Duration of diabetes and prediabetes during adulthood and subclinical atherosclerosis and cardiac dysfunction in middle age: The CARDIA study. Diabetes Care 2018;41:731-8.
14Jadhav RA, Hazari A, Monterio A, Kumar S, Maiya AG. Effect of physical activity intervention in prediabetes: A systematic review with meta-analysis. J Phys Activity Health 2017;14: 745-55.
15Mitra S, Goyal T, Mehta JL. Oxidized LDL, LOX-1 and atherosclerosis. Cardiovasc Drugs Ther 2011;25:419-29.
16Borén J, Matikainen N, Adiels M, Taskinen M-R. Postprandial hypertriglyceridemia as a coronary risk factor. Clin Chim Acta 2014;431:131-42.
17American Diabetes Association. 4. lifestyle management. Diabetes Care 2017;40(Suppl 1):S33-43.
18Lim EL, Hollingsworth KG, Aribisala BS, Chen MJ, Mathers JC, Taylor R. Reversal of type 2 diabetes: Normalisation of beta cell function in association with decreased pancreas and liver triacylglycerol. Diabetologia 2011;54:2506-14.
19López S, Bermúdez B, Abia R, Muriana FJG. The influence of major dietary fatty acids on insulin secretion and action. Curr Opin Lipidol 2010;21:15-20.
20Van der Merwe L. Prediabetes: A focus on the role of diabetes education in prevention of type 2 diabetes. J Endocrinol Metab Diabetes South Africa 2011;16:64-5.
21Jacqueminet S, Briaud I, Rouault C, Reach G, Poitout V. Inhibition of insulin gene expression by long-term exposure of pancreatic beta cells to palmitate is dependent on the presence of a stimulatory glucose concentration. Metab Clin Exp 2000;49:532-6.
22Colberg SR, Sigal RJ, Yardley JE, Riddell MC, Dunstan DW, Dempsey PC, et al. Physical activity/exercise and diabetes: A position statement of the American Diabetes Association. Diabetes Care 2016;39:2065-79.
23van Loon L, Greenhaff P, Constantin-Teodosiu D, Saris W, Wagenmakers A. The effects of increasing exercise intensity on muscle fuel utilisation in humans. J Physiol 2001;536:295-304.
24Weiss R, Dufour S, Taksali SE, Tamborlane WV, Petersen KF, Bonadonna RC, et al. Prediabetes in obese youth: A syndrome of impaired glucose tolerance, severe insulin resistance, and altered myocellular and abdominal fat partitioning. Lancet 2003;362:951-7.
25Ding D, Stamatakis E. (n.d.). Yoga practice in England 1997–2008: Prevalence, temporal trends, and correlates of participation. Available from [Last accessed on 2019 Jan 15].
26Sharma R, Gupta N, Bijlani RL. Effect of yoga based lifestyle intervention on subjective well-being. Indian J Physiol Pharmacol 2008;52:123-31.
27Caspersen CJ, Powell KE, Christenson GM. Physical activity, exercise, and physical fitness: Definitions and distinctions for health-related research. Public Health Reports (Washington, D.C. : 1974) 1985;100:126-31.
28Zuo H, Shi Z, Yuan B, Dai Y, Hu G, Wu G, et al. Interaction between physical activity and sleep duration in relation to insulin resistance among non-diabetic Chinese adults. BMC Public Health 2012;12:247.
29Hamasaki H, Noda M, Moriyama S, Yoshikawa R, Katsuyama H, Sako A, et al. Daily physical activity assessed by a triaxial accelerometer is beneficially associated with waist circumference, serum triglycerides, and insulin resistance in Japanese patients with prediabetes or untreated early type 2 diabetes. J Diabetes Res 2015;2015:526201.
30Hamasaki H. Physical activity and obesity in adults. Adiposity-epidemiology and treatment modalities [Internet]. Chiba: InTech; 2017. p. 129-47.
31Chow LS, Odegaard AO, Bosch TA, Bantle AE, Wang Q, Hughes J, et al. Twenty year fitness trends in young adults and incidence of prediabetes and diabetes: The CARDIA study. Diabetologia 2016;59:1659-65.
32Berlanga F, Eltringham-Cox A, Burr WA, Nagi DK. Physical activity in type 2 diabetes. Its role and the current care pattern: A survey of diabetes health care professionals in the UK keywords. Practical Diabetes Int 2000;17:60-1.
33Thankappan KR, Sathish T, Tapp RJ, Shaw JE, Lotfaliany M, Wolfe R, et al. A peer-support lifestyle intervention for preventing type 2 diabetes in India: A cluster-randomized controlled trial of the Kerala diabetes prevention program. PLoS Med 2018;15:e1002575.
34Lee M, Saver JL, Hong KS, Song S, Chang KH, Ovbiagele B. Effect of pre-diabetes on future risk of stroke: Meta-analysis. BMJ 2012;344:e3564.
35De Nardi AT, Tolves T, Lenzi TL, Signori LU, Silva AMVD. High-intensity interval training versus continuous training on physiological and metabolic variables in prediabetes and type 2 diabetes: A meta-analysis. Diabetes Res Clin Pract 2018;137:149-59.
36Maheux P, Azhar S, Kern PA, Chen YD, Reuven GM. Relationship between insulin-mediated glucose disposal and regulation of plasma and adipose tissue lipoprotein lipase. Diabetologia 1997;40:850-8.
37Henriksen EJ. Invited review: Effects of acute exercise and exercise training on insulin resistance. J Appl Physiol (Bethesda, MD: 1985) 2002;93:788-96.
38Coker R, Kjaer M. Glucoregulation during exercise : The role of the neuroendocrine system. Sports Med Auckl NZ 2005;35:575-83.
39Gillen JB, Little JP, Punthakee Z, Tarnopolsky MA, Riddell MC, Gibala MJ. Acute high-intensity interval exercise reduces the postprandial glucose response and prevalence of hyperglycaemia in patients with type 2 diabetes. Diabetes Obes Metab 2012;14:575-7.
40Venables M, Achten J, Jeukendrup A. Determinants of fat oxidation during exercise in healthy men and women: A cross-sectional study. J Appl Physiol 2005;98:160-7.
41Ruud J, Steculorum SM, Brüning JC. Neuronal control of peripheral insulin sensitivity and glucose metabolism. Nature Commun2017;8:1-2.
42Ohta S. Molecular hydrogen is a novel antioxidant to efficiently reduce oxidative stress with potential for the improvement of mitochondrial diseases. Biochim Biophys Acta 2012;1820:586-94.
43Dobson AJ. A test of new imagery-based intervention for increasing physical activity [Internet]. Queensland University of Technology; 2018. Available from: [Last accessed on 2021 Aug 10].
44Umpierre D, Ribeiro PAB, Kramer CK, Leitão CB, Zucatti ATN, Azevedo MJ, et al. Physical activity advice only or structured exercise training and association with HbA1c levels in type 2 diabetes: A systematic review and meta-analysis. JAMA 2011;305:1790-9.
45Gordon BA, Benson AC, Bird SR, Fraser SF. Resistance training improves metabolic health in type 2 diabetes: A systematic review. Diabetes Res Clin Pract 2009;83:157-75.
46Hu FB, Leitzmann MF, Stampfer MJ, Colditz GA, Willett WC, Rimm EB. Physical activity and television watching in relation to risk for type 2 diabetes mellitus in men. Arch Int Med 2001;161:1542.
47Talchai C, Xuan S, Lin HV, Sussel L, Accili D. Pancreatic β cell dedifferentiation as a mechanism of diabetic β cell failure. Cell 2012;150:1223-34.
48Boden G. Free fatty acids, insulin resistance, and type 2 diabetes mellitus. Proc Assoc Am Phys 1999;111:241-8.
49Lukács A, Barkai L. Effect of aerobic and anaerobic exercises on glycemic control in type 1 diabetic youths. World J Diabetes 2015;6:534-42.
50Campbell MD, Walker M, Trenell MI, Luzio S, Dunseath G, Tuner D, et al. Metabolic implications when employing heavy pre- and post-exercise rapid-acting insulin reductions to prevent hypoglycaemia in type 1 diabetes patients: A randomised clinical trial. PLoS One 2014;9:1-9.
51Riddell M, Perkins BA. Exercise and glucose metabolism in persons with diabetes mellitus: Perspectives on the role for continuous glucose monitoring. J Diabetes Sci Technol 2009;3:914-23.
52Robertson AP. Chronic oxidative stress as a central mechanism for glucose toxicity in pancreatic islet beta cells in diabetes. J Biol Chem 2004;279:42351-4.
53Sjöros TJ, Heiskanen MA, Motiani KK, Löyttyniemi E, Eskelinen JJ, Virtanen KA, et al. Increased insulin-stimulated glucose uptake in both leg and arm muscles after sprint interval and moderate-intensity training in subjects with type 2 diabetes or prediabetes. Scand J Med Sci Sports 2018;28:77-87.
54Venugopal V, Rathi A, Raghuram N. Effect of short-term yoga-based lifestyle intervention on plasma glucose levels in individuals with diabetes and pre-diabetes in the community. Diabetes Metab Syndr 2017;11(Suppl 2):597-9.