KEY FIGURE

Highlights

• Rising diabetes prevalence and heterogeneity in older adults require tailored care.

• Aging induces sarcopenia, visceral adiposity, and impaired metabolic homeostasis.

• Individualized exercise strategies tailored to functional status optimize outcomes in older adults with diabetes.

INTRODUCTION

The prevalence of diabetes among older adults has been increasing worldwide [1-3]. In the 2014 United States, diabetes prevalence among older adults aged 65 and older was 19.8% [4], while in 2020 Korea, the prevalence among this age group reached 30.1% [5]. With the progression of population aging [6], this trend is leading to a growing socioeconomic burden. More specifically, the International Diabetes Federation estimated the global economic burden of diabetes in 2015 at $1.3 trillion, and that this burden would exceed $2.1 trillion by 2025 [7]. The need for effective management strategies to relieve this burden is becoming increasingly apparent.

Importantly, diabetes management in older adults is challenged by several characteristics distinct to this population. With aging, muscle mass progressively decreases while fat mass increases [8]; this often leads to sarcopenic obesity, one of the major phenotypes of frailty, which increases risk of falls and mortality and contributes to insulin resistance and persistent hyperglycemia. Among those with diabetes, muscle mass loss progresses more rapidly due to hyperglycemia, diabetesrelated complications, obesity, and elevation of inflammatory cytokines [8]. These patients are also at higher risk of frailty compared to healthy older adults and tend to have greater glycemic variability, increasing vulnerability to both hyperglycemia and hypoglycemia [9,10] and hence to downstream harm through increased oxidative stress and chronic low-grade inflammation [10]. Finally, high blood glucose and diabetes have been shown to contribute to dementia risk [11], which can also complicate diabetes management.

Beyond these intrinsic factors, the low level of physical activity (PA) among older adults contributes to decline in physical function due to reduced muscle mass, increased insulin resistance, and poor glycemic control. This ultimately creates a vicious cycle of decreased PA. In 2020, only 33.2% of Korean adults aged 65 and older met the current guidelines for aerobic training (AT); the proportion meeting the guidelines for resistance training (RT) was even lower, at 22.5% [12]. Furthermore, those with diabetes tend to have lower levels of PA compared to those without diabetes [13]. Exercise is well-established to have positive effects on glycemic control, insulin sensitivity, muscle mass, physical function, and mobility, and as such is crucial in mitigating problems associated with aging and diabetes alike. However, there is still a lack of research on the effects of exercise specifically in older patients, and the optimal duration, type, and combination of exercise for this population remains unclear. In addition, effective strategies have yet to be developed for older adults who are unable to engage in PA regularly.

This review aims to provide an overview of the effects and pathophysiological mechanisms of exercise in older adults with diabetes, to examine the factors contributing to their low levels of PA, and to propose alternative strategies for addressing these issues.

PATHOPHYSIOLOGIC CHARACTERISTICS OF OLDER ADULTS WITH DIABETES

Aging induces multiple pathophysiologic changes relevant to diabetes management, which can be categorized as metabolic, body compositional, and functional alterations.

Metabolic changes

Glycemic control progressively deteriorates with advancing age. In a study using the 2-hour oral glucose tolerance test, healthy adults aged 60 to 92 years exhibited significantly greater glucose intolerance than younger individuals, a difference partly attributable to variations in body composition and PA levels, but also reflecting intrinsic metabolic alterations associated with aging itself [14]. Age-related impairments in glucose metabolism are primarily characterized by diminished insulin secretion and increased insulin resistance. The reduction in insulin secretion is linked to decreased pancreatic β-cell sensitivity to incretin hormones that stimulate insulin release following glucose ingestion. Several studies have demonstrated markedly blunted β-cell responsiveness to both endogenous and exogenous glucose-dependent insulinotropic polypeptide (GIP) among older adults [15,16]. Conversely, heightened insulin resistance predominantly arises from visceral adipose tissue accumulation and loss of skeletal muscle mass, both hallmark consequences of aging [14,16]. These alterations in body composition and their consequent metabolic imbalance are elaborated in the following section.

Body compositional changes

Aging is accompanied by a progressive decline in skeletal muscle mass and concomitant increases in visceral and intermuscular fat [14]. Skeletal muscle mass decreases by approximately 1%–2% per year, with an accelerated rate after the age of 60 years [8]. In men with obesity and diabetes, declining testosterone levels impair muscle protein synthesis and promote visceral fat accumulation [8]. In women, post-menopausal estrogen deficiency drives a redistribution of adipose tissue from peripheral to central depots, resulting in greater visceral adiposity and heightened metabolic risk [17]. Decreased anabolic hormone levels and reduced PA further exacerbate muscle loss, collectively predisposing to sarcopenic obesity and insulin resistance. At the molecular level, reduced activation of AMP-active protein kinase (AMPK) and peroxisome proliferator-activated receptor gamma coactivator-1α (PGC-1α), together with enhanced dynamic related protein 1 (DRP-1) signaling, contributes to mitochondrial dysfunction and muscle atrophy [18]. Ultimately, these alterations in body composition aggravate insulin resistance and chronic hyperglycemia, thereby increasing the complexity of diabetes management [19].

Functional changes

Aging is characterized by the progressive accumulation of molecular and cellular damage, leading to diminished physiological reserve and functional decline across multiple organ systems, including the endocrine and immune systems [20]. Frail older adults exhibit impaired recovery of homeostasis following physiological stress and display concomitant reductions in insulin-like growth factor-1 (IGF-1) levels and chronic elevations in cortisol [20]. Elevated cortisol promotes proteolysis and contributes to loss of muscle mass and body weight, while reflecting dysregulation of the hypothalamic–pituitary–adrenal axis and associating with cognitive decline [21]. From an immunological perspective, aging is accompanied by a chronic low-grade inflammatory state driven by elevated circulating cytokines, which underlies many age-related diseases [22]. This persistent inflammation disrupts muscle homeostasis and accelerates muscle atrophy, ultimately resulting in deterioration of physical function [20]. Collectively, these age-related alterations interact to aggravate insulin resistance and β-cell dysfunction, sustain chronic inflammation and muscle wasting, and perpetuate the vicious cycle linking frailty and diabetes.

POTENTIAL MECHANISMS UNDERLYING THE HEALTH BENEFITS OF EXERCISES IN OLDER ADULTS WITH DIABETES

Exercise plays a pivotal role in mitigating age-related pathophysiological changes that complicate diabetes management in older adults.

Metabolic improvements

Exercise has been consistently shown to improve glycemic homeostasis and insulin sensitivity [23-26]. For instance, in men aged 40 to 55 years with prediabetes or diabetes, 2 weeks of exercise significantly enhanced insulin sensitivity, suggesting partial normalization of incretin-mediated signaling pathways [24]. Similarly, in adults aged 55 years and older with type 2 diabetes mellitus (T2DM), 16 weeks of vigorous-intensity RT reduced plasma free fatty acid concentrations and homeostatic model assessment of insulin resistance indices, indicating improved insulin action [26]. Exercise also induces favorable alterations in body composition, including reduction of visceral fat and increases in skeletal muscle mass, both of which are key determinants of metabolic health. Because visceral adiposity is a primary driver of insulin resistance [14,16], improving body composition through regular PA represents a fundamental strategy to enhance insulin sensitivity and overall metabolic function.

Body compositional improvements

Both aerobic and RT have been shown to increase skeletal muscle mass and strength while reducing fat mass [18]. Exercise promotes muscle hypertrophy by activating AMPK and PGC-1α and suppressing DRP-1, thereby enhancing mitochondrial biogenesis and metabolic efficiency [18,22]. In older men (mean age 62±2 years), 6 weeks of high-intensity interval training (HIIT) significantly increased circulating testosterone and sex hormone-binding globulin (SHBG) levels, reflecting improved anabolic hormone profiles [27]. Furthermore, RT stimulates IGF-1 production, which contributes to sustained gains in both muscle mass and strength [28].

Functional improvements

Exercise elicits favorable physiological adaptations that mitigate functional decline associated with aging and diabetes [29]. In a study of older adults residing in long-term care facilities, programs incorporating resistance and balance training were shown to be safe and effective, contributing to reduced frailty risk and improved physical function [30]. Chronic low-grade inflammation, a hallmark of aging, disrupts muscle homeostasis and accelerates muscle atrophy, yet regular exercise can attenuate these effects. Through the activation of PGC-1α, exercise suppresses inflammatory signaling, thereby improving muscle quality and insulin sensitivity [22,25,26]. In adults aged ≥55 years with T2DM, 16 weeks of vigorous-intensity RT significantly reduced circulating C-reactive protein levels, demonstrating the anti-inflammatory benefits of exercise [26]. Moreover, exercise modulates endocrine factors related to functional capacity by lowering cortisol levels and enhancing IGF-1 production, which supports muscle maintenance and overall physical performance. A meta-analysis of adults aged ≥65 years reported a significant reduction in cortisol following 12 weeks of exercise [31], while another study found that 8 weeks of training increased IGF-1 levels in adults over 60 years, correlating with improved functional performance [32].

Collectively, the age-related pathophysiological changes and their modulation through exercise are summarized in Fig. 1.

EVIDENCE FROM CLINICAL RESEARCH ON THE HEALTH BENEFITS OF EXERCISE IN OLDER ADULTS WITH DIABETES

Among adults with diabetes, exercise has been demonstrated to provide numerous benefits [33]. While it is likely that older adult patients experience similar benefits from exercise, there remains a lack of research centering on this population. This review will provide an overview of the currently known health benefits of exercise in older adults with diabetes, based on findings from clinical studies.

Metabolic improvements

Aerobic, resistance, and combination training (CT) have all been shown to improve glycemic control in older adults with diabetes. For AT, a 6-month walking program, with three sessions per week at 50 minutes each, produced significant improvements in fasting blood glucose (FBG) and glycosylated hemoglobin (HbA1c) among adults aged 65 years and older with diabetes [34]. For RT, a 24-week program, with three sessions per week at 55 minutes each, likewise reduced HbA1c in adults aged 60 years and older with diabetes [35]. Another study showed RT-induced increase in muscle mass to associate with improved HbA1c level and further confirmed a significant correlation between muscle gain and improved insulin sensitivity [36]. Finally, for CT, an 8-week program consisting of 70 minutes AT and 50 minutes RT per week resulted in significant improvements in FBG among 32 patients with an average age of 65 [37]. Notably, in adult patients with diabetes, CT reportedly produces greater improvement in glycemic control compared to either AT or RT alone [38]. In older adults with diabetes, given that AT reduces HbA1c level [34] and RT both increases muscle mass and decreases fat mass [39], it is reasonable to expect that CT may provide additional glycemic benefits beyond those achieved by AT or RT alone.

There is conflicting evidence regarding the effects of exercise on lipid profiles in older adults with diabetes. While some studies have shown no significant changes following exercise interventions [22,39-42], others have reported significant reductions in triglyceride levels [34,37,43,44]. Further research is needed to clarify the effects of exercise on lipid profiles in this population.

Physical function improvements

The most effective intervention for preventing and treating frailty is a lifestyle intervention involving PA. Exercise can be implemented by patients with physical limitations without increasing the risk of harm compared to usual activity levels, and can improve physical function [45]. Moreover, a meta-analysis in 2019 determined that the most effective intervention for frailty is RT with protein supplementation, which can be easily implemented in primary clinical settings [46]. Whereas calorie constriction without exercise may increase the risk of falls and fractures, combining RT with protein supplementation can minimize adverse effects and lead to significant physical improvements [47]. RT increases both muscle mass and strength, improves mobility [48,49], and in older adults with sarcopenia also effectively improves physical function [50]. In addition, in older adults with diabetes, RT has been shown to produce improvements in muscle function [29,49], while multimodal exercise can improve overall physical function [51].

Cognitive improvements

Exercise is suggested to have several potential benefits on cognitive function in older adults with diabetes. In the finnish geriatric intervention study to prevent cognitive impairment and disability (FINGER) study [52] and lifestyle interventions and independence for elders (LIFE) trial [51], multimodal exercise by older adults was found to result in partial cognitive improvements. In particular, during the LIFE trial, only participants with diabetes showed cognitive improvements, indicating that exercise-mediated improvement of glycemic control may contribute to cognitive function [51]. A meta-analysis in 2020 similarly found that in patients aged 18 and older with diabetes, exercise interventions exert a small to moderate effect on some domains of cognitive function; however, the results did not achieve significance due to the small sample size [53].

Improvement of depressive symptoms

Exercise may also reduce the risk of depression in older adults with diabetes [54-56]. In the action for health in diabetes (Look AHEAD) trial study, lifestyle intervention participants were 15% less likely to develop symptoms of mild or greater depression, and this effect was not attributable to differential use of antidepressant medication [54]. Similarly, a study using data from the Korea National Health and Nutritional Examination Survey found PA to have a positive effect on patient health questionnaire-9 (PHQ-9) scores [55], and a cross-sectional study using the U.S. National Health and Nutritional Examination Survey (NHANES) data determined non-exercising participants to have significantly higher risk of experiencing depressive symptoms compared to those who did exercise [56].

Improvement of health-related quality of life

In addition to the above benefits, exercise may contribute to improvements in health-related quality of life in older adults with diabetes. A cross-sectional study using NHANES data found non-exercising participants to have significantly higher rates of total healthcare visits, overnight hospitalizations, and emergency department visits. Moreover, their findings indicated that physical inactivity is one of the major contributors to vulnerability related to frailty [56].

GUIDELINES ON PHYSICAL ACTIVITY FOR OLDER ADULTS

Guidelines on PA have been developed and disseminated in many countries. Most provide similar recommendations for older adults aged 65 and over, as well as for adults aged 18 and older, and some include additional recommendations for individuals with chronic diseases. Among the following guidelines, only the position statement of the American Diabetes Association (ADA) specifically targets individuals with diabetes, whereas the others apply to the general population.

Physical activity guidelines for Americans, 2nd edition, 2018

Guidelines from the United States recommend 150 to 300 minutes of moderate-intensity AT or 75 to 150 minutes of vigorous-intensity AT per week for older adults aged 65 and over, along with muscle-strengthening activities on 2 or more days per week. In addition, balance training is recommended to prevent falls. For individuals with diabetes, the same guidelines are recommended, but with additional emphasis on foot injury prevention and blood glucose monitoring [47].

World Health Organization guidelines on physical activity and sedentary behavior, 2020

The World Health Organization guidelines recommend similar levels of AT and RT for older adults, with additional emphasis on balance training. They suggest that going above and beyond the recommended levels may bring additional health benefits, and encourage gradually increasing activity frequency, intensity, and duration over time. For individuals with diabetes, it is suggested that AT, RT, and CT may help improve glycemic control. Reducing sedentary behavior is also emphasized; however, the certainty of evidence remains low for older adults and individuals with chronic diseases [57].

Physical activity guidelines for Korean revised edition, 2023

Korea also provides similar guidelines, including recommendations for balance training more than three times per week and for reducing sedentary behavior. For patients with diabetes, blood glucose monitoring before exercise is recommended, along with warnings about the risk of hypoglycemic events during exercise [12].

Systematic review of physical activity guidelines

According to a systematic review of 18 national guidelines on PA for older adults aged 65 and over, most guidelines provide similar recommendations. The certainty of evidence for AT and RT was rated as moderate to high, whereas the certainty of evidence for balance and flexibility training was low due to a lack of supporting studies. Among the 18 guidelines, 10 included recommendations on sedentary behavior, but these recommendations were inconsistent and rated as having low certainty of evidence due to being mainly based on cohort studies and expert opinion [58].

Physical activity/exercise and diabetes: a position statement of the American Diabetes Association, 2016

In their position statement, the ADA recommends individuals with diabetes undertake more than 150 minutes of moderate-to vigorous-intensity AT per week, performed on at least 3 nonconsecutive days, along with RT two to three times per week. For older people, additional flexibility and balance training are also recommended. For individuals with type 1 diabetes mellitus (T1DM), the guideline recommends blood glucose monitoring before exercise and provides detailed recommendations for adjusting insulin dose based on blood glucose level [59].

Suggestions for guidelines

Although current guidelines are similar in their recommendations, they do not fully account for the complex characteristics of older adults with diabetes. Therefore, the following suggestions are proposed for future guidelines.

First, while recommendations are provided for older adults and individuals with chronic diseases generally, current guidelines lack recommendations specifically targeting older adults with diabetes. Older adults with diabetes are highly heterogenous in terms of age, comorbidities, and functional status, making it difficult to apply uniform recommendations across this population. However, extant literature includes few studies with the high level of evidence needed for establishing detailed classifications, and individualized strategies that account for these characteristics are likewise scarce. Consequently, detailed clinical guidelines based on such studies are required.

Second, while the ADA position statement provides specific recommendations regarding blood glucose monitoring before and after exercise and strategies for patients with diabetes, they are limited to patients with T1DM. Since older adults with T2DM also have high risk of hypoglycemia and may experience serious adverse effects from hypoglycemic events, additional detailed recommendations for preventing hypoglycemia during exercise in that population are needed.

Third, while current guidelines emphasize the importance of reducing sedentary behavior, recommendations for alternative activities or implementation plans remain insufficient. Efficient strategies for breaking up sedentary behavior, including intensity and intervals, should be incorporated in future guidelines. The recommendations of the PA guidelines are summarized in Table 1, while the common recommendations across several guidelines and areas where further recommendations are need are summarized in Fig. 2.

BARRIERS TO PHYSICAL ACTIVITY AND STRATEGIES IN OLDER ADULTS WITH DIABETES

Despite the well-recognized importance of PA, the proportion of people that perform exercise is smaller among older adults than in other age groups, and lower still among those with diabetes [13,60]. A number of barriers impede older adults in engaging in exercise. Some experience physical disabilities such as sarcopenia, muscle weakness, and joint diseases, which often lead to concerns about the safety of initiating exercise. Especially, they may fear exercising without an instructor, or fear falling due to impaired balance and reduced gait speed. Additionally, some older adults believe that exercise is unnecessary or even harmful for them. Other barriers can include environmental factors such as financial burden and a lack of exercise facilities [61].

Physiological and medical factors may also present barriers to exercise among older adults with diabetes. High glycemic variability may increase overall physical fatigue by increasing oxidative stress [10], which can impair recovery from post-exercise fatigue. Complications of diabetes such as neuropathy and retinopathy may also act as barriers to PA [62]. Some older adults with diabetes do not recognize the necessity of exercise for diabetes management [63], while others report fear of exercise due to lack of information regarding the types and intensities of exercise appropriate to their physical abilities [64].

Suggestions for solutions

The following strategies are suggested to promote safe and sustained exercise participation in older adults with diabetes.

Training methods

It has been reported that faddish forms of exercise tend to be unsustainable, whereas exercises that can be easily implemented in daily life, such as walking, tend to be more sustainable [63]. Accordingly, exercises without restrictions on place or time may be more effective among older adults with diabetes. Providing patients with information about the preventive effects of lower-extremity strengthening exercise and balance training for falls, and starting with activities for which risk of falling is low, can help reduce psychological burdens that act as barriers [65]. For multimodal exercise, which is especially recommended for older adults with diabetes, sustained adherence can be promoted by beginning with one type of exercise and adding another only after adaptation, or by starting at a low intensity and gradually ramping up [66].

Motivation

Motivation is crucial to sustaining adherence to any regimen, including exercise. For example, in a systematic review, an unsupervised walking program alone was found to have no significant effect, whereas an unsupervised walking program with motivational strategies produced effects comparable to supervised walking programs [67]. Numerous strategies exist for enhancing motivation. Advice and continuous interventions from exercise therapists or healthcare professionals can be effective, as supported by several studies [68-70]. Even without supervision, setting individualized goals and having healthcare professionals conduct regular reviews helps increase PA level [71,72]. Various digital health devices are also expected to support motivation.

Education

In a study that investigated barriers to engaging in exercise among older adults with diabetes, some patients reported being unaware that exercise can help manage their disease; in addition, contrary to researcher expectations, participants did not perceive the risk of hypoglycemia as a significant barrier [64]. This suggests that public education on PA in this population is still insufficient. Providing regular education on how to exercise safely, including considerations related to diabetes complications and medications, can help reduce exercise-related risks and enhance the sustainability of exercise.

ALTERNATIVE STRATEGIES FOR PHYSICALLY LIMITED OLDER ADULTS WITH DIABETES

Physically limited individuals may perceive the recommended levels of PA as unrealistic for them to achieve. Given that participating in a lower level of PA can still provide health benefits [73], the following approaches can be beneficial for this population.

Walking

Walking is associated with a low psychological burden, as it can be performed without restrictions of place or time. Among older adults with diabetes, several studies have reported positive results for walking, but others have reported conflicting results. Walking has been associated with improvements in weight loss [74], glycemic control [34], triglyceride levels [34], and both all-cause and cardiovascular mortality [75]. Likewise, walking and lowered FBG level has demonstrated a significant association with reduced abdominal fat [74], and walking was shown to have a greater reducing effect on mortality in older adults with diabetes compared to those without diabetes [75]. However, in a meta-analysis of seven pedometer-based walking studies, only two studies showed improvement in HbA1c; the others observed no significant change, possibly due to the short duration of intervention being insufficient to affect HbA1c [76]. Recent studies have suggested that timing may matter, with postprandial walking potentially offering greater benefits compared to walking at other times. In particular, greater improvement in glycemic control was observed with postmeal walking compared to pre-dinner walking [77], and three 10-minute walks, one after each meal, were reported to produce greater glycemic benefits than a single 30-minute walking session [78]. Notably, although the average age of participants in these studies was relatively high at 61.4 years, they did not specifically target older adults with diabetes, and the durations of interventions were too short to confirm long-term effects. Future research is needed to clarify these findings.

Breaking up sedentary behavior

Sedentary behavior is a substantial concern in modern society. Several studies have reported association of sedentary behavior with adverse outcomes, such as increased mortality risk in adults with and without diabetes. In particular, a meta-analysis conducted in adults found that sedentary time exceeding 8 or 9.5 hours per day significantly increased mortality risk [79-81], and screen time exceeding 3.5, 4, or 5 hours was also significantly associated with increased mortality risk [79,80,82]. This association between sedentary time and mortality risk has also been observed specifically in older adults aged 65 years and over [83] and also adults with diabetes [84]. Although the association of sedentary behavior with mortality risk has been consistently observed across multiple studies, the specific threshold of harmful sedentary time and optimal strategies for mitigating the risk have not yet been clearly established.

The harmful effects of sedentary behavior are expected to be mitigated by engaging in light physical activities, including periodic walking. Especially, breaking up sedentary behavior can serve as a feasible alternative to structured exercise for older adults who experience difficulties in sustaining the latter; however, the optimal frequency and methods for such behavioral interventions have not yet been clearly established. In older adults, walking at a self-selected pace for a 5-minute period every 30 minutes significantly improved postprandial insulin, glucose levels, and blood pressure [85]. In patients with diabetes generally, one study suggested that compared to structured exercise, breaking up sedentary behavior may lead to greater improvement in insulin sensitivity and lower risk of hypoglycemia, resulting in more stable blood glucose levels [86]. Another study found a 3-minute session of walking or simple resistance activity every 30 minutes to lead to improvements in blood glucose, lipid profiles, and blood pressure [87-90]. However, these studies did not specifically target older adults with diabetes, and differed in their intervention methods and results, making it difficult to establish optimal strategies or specific thresholds. Additionally, they employed short-duration interventions; long-term effects yet remain to be evaluated. Nevertheless, given that the average ages of participants were relatively high, at 62 and 63 years [85,87-90], and that benefits were observed among older adults, it can be proposed that performing light physical activities every 30 minutes may have positive effects in older adults with diabetes.

Integration of balance and strength training into daily life activity

Another potential alternative to structured exercise is integrating balance and strength training into daily life, embedding these activities into habitual daily routines. The LIFE study [91] included 317 participants aged 70 years and older who were assigned to one of three home-based intervention groups: Lifestyle integrated Functional Exercise (LiFE) group, structured program group, and sham control program group. The study investigated the effects of simple actions such as shifting weight between feet while doing the dishes, reducing the base of support like a tandem stand, bending at the knees instead of the waist, and standing on tiptoes while brushing teeth. The adherence rate in the LiFE group was higher than that in the structured exercise group immediately after the education program and remained above the other two groups even at 6 months of follow-up. Improvements in fall outcomes, balance, ankle strength, and functional outcomes involving activities of daily living (ADL) and PA level were also observed [91].

Aquatic exercise

Aquatic exercise can be performed at high intensity with reduced risk of musculoskeletal injuries [92], making it an attractive option for older adults. In a meta-analysis involving adults with diabetes, aquatic exercise was found to result in similar improvements in glucose level, blood pressure, and functional capacity compared to land training, while also exhibiting greater adherence [93]. In another study on adults with diabetes, land training and aquatic exercise for 12 weeks produced comparable improvements, with no hypoglycemic events observed in the aquatic exercise group, suggesting it may be an effective and safer alternative [92]. In older adults with diabetes aged 60 to 75 years, aquatic Nordic walking was found to significantly improve blood glucose levels, physical fitness, and vascular function [94]. Although evidence regarding the effects of aquatic exercise remains limited due to the paucity of studies, and the intervention has notable environmental restrictions, it is expected to provide similar benefits to land training and may be especially helpful for patients who need to avoid weight-bearing exercise.

Digital health devices

A number of digital health devices have recently seen wide adoption. While it is common for older adults to face difficulties in using digital devices, the convenience and visual features afforded by these technologies are nonetheless expected to help motivate older adults in PA. Among these devices are continuous glucose monitoring (CGM) systems, which continuously measure blood glucose level and can provide warnings of hypoglycemia during exercise [95]. Since older adults with diabetes often experience age-related impairment in hypoglycemia awareness independent of altered neuroendocrine counter-regulation [96], CGM can be particularly effective for this population. Additionally, CGM systems allow for visualization of glucose fluctuations, which can aid patients in recognizing the importance of PA, enhance their motivation, and improve self-efficacy [97].

Pedometers have been reported to increase PA levels [67,72], but conflicting results have also been observed [98]. A study conducted in 1,650 older adults with diabetes found subjects who received a videoconference with a diabetes educator every 4–6 weeks to exhibit significantly lower rate of decline in PA and less physical impairment, and pedometer use was significantly associated with these outcomes [72]. Similarly, a meta-analysis found an unsupervised walking program with motivational strategies that included pedometer use to produce effects comparable to a supervised walking program [67]. Although the effects of pedometers have yet to be fully elucidated, they may be effective when combined with routine reviews by healthcare professionals.

More broadly, a study in older adults aged 65 and over found participants who used wearable devices long-term to exhibit improved health outcomes in terms of nutrition, fall prevention, and frailty index scores. However, during the self-management phase, in which participants continued device use voluntarily, adherence declined to 37% [99]. Thus, while wearable devices are expected to improve health outcomes and PA levels, complementary strategies are needed to promote their sustained use. In addition, user-friendly design and convenience are particularly important for older adults, such as lightweight design, long batteries, and convenient features such as waterproofing; conversely, device inaccuracies such as underestimation of steps may lead to decreased motivation [100].

CONSIDERATIONS FOR EXERCISE PRESCRIBING IN OLDER ADULTS WITH DIABETES

Older patients often present with multiple comorbidities, complications, and diverse types of medications. When prescribing exercise, it is important to consider potential interactions with medications as well as the possibility of exacerbating diabetes-related complications.

Medication interactions with exercise

Hypoglycemic agents

Insulin and insulin secretagogues are associated with a high risk of hypoglycemia because they increase insulin level [101]. Exercise also has a glucose-lowering effect, which can compound with the risk posed by these medications. Accordingly, it is recommended that patients monitor their blood glucose level before and after exercise and eat a snack when hypoglycemia risk is elevated [59].

Metformin is relatively safe for older adults with diabetes, and therefore widely used in this population [101]. However, studies conducted in adults with T2DM [102-104] and in healthy older adults [105,106] suggest that metformin may attenuate the improvements in insulin sensitivity and exercise capacity induced by exercise. No study examining the effects of metformin on exercise outcomes has yet targeted older adults with diabetes. Therefore, further research is needed in this area.

Sodium-glucose cotransporter 2 (SGLT-2) inhibitors are being prescribed more frequently due to their having both hypoglycemic and nephroprotective effects. However, among their adverse effects, one of the most common is volume depletion, with individuals aged 75 and older being more susceptible [107,108]. Volume depletion is dangerous in itself, and can increase the risk of ketoacidosis by elevating stress hormone secretion [109]; moreover, exercise can exacerbate volume depletion due to sweating [109]. Given these considerations, patients taking SGLT-2 inhibitors should undertake electrolyte monitoring during exercise, and stop the intake of SGLT-2 inhibitors at least 24 hours prior to vigorous-intensity exercise [109]. Additionally, SGLT-2 inhibitors and glucagon-like peptide 1 agonists have weight loss effects mediated through calorie restriction, which by itself may lead to declines in muscle mass and bone density. As described above, concomitant RT and protein supplementation are recommended to minimize these adverse effects of weight loss [48].

Antihypertensive agents

Orthostatic hypotension is relatively common in older adults and can be exacerbated by antihypertensive medications, increasing the risk of falls during exercise. In particular, diuretics can lead to volume depletion, so monitoring for dehydration is necessary. Additionally, alpha-blockers can cause post-exercise orthostatic hypotension due to their vasodilatory effects, requiring caution even after exercise [110]. However, it merits mention that angiotensin-converting enzyme inhibitors, a class of antihypertensive agents that regulate the renin-angiotensin system, have been suggested to promote additional functional improvements when combined with exercise [111-113].

Lipid-lowering agents

Statins may cause muscle-related adverse effects such as muscle weakness, discomfort, and cramp, which can negatively impact engagement in PA among older adults with musculoskeletal impairments. Consequently, monitoring for muscle-related symptoms during exercise is recommended for this population [59].

These interactions between exercise and medications are summarized in Table 2.

Diabetes-related complications and exercise

Diabetes is a chronic disease characterized by impaired glucose metabolism, and it induces complications that affect multiple systems, including the cardiovascular system, kidney, nerves, and retina [114]. As older adults are at higher risk of diabetes-related complications than younger patients [115], comprehensive considerations including complications are necessary.

Cardiovascular disease

Patients with diabetes are at high risk of ischemic heart disease, and this risk is particularly elevated in older adults [116]. For individuals with coronary artery disease, such as myocardial infarction, participation in a supervised cardiac rehabilitation program is recommended, particularly during the early phase after onset. Exercise should be immediately discontinued if chest pain, radiating pain, or other symptoms suggestive of myocardial infarction occur [59]. Vigorous-intensity exercise should be avoided because it may excessively increase blood flow across the coronary arteries [117]. Additionally, individuals with cardiovascular disease should avoid activities involving the Valsalva maneuver, such as squatting, and bench pressing, due to the risk of excessive blood pressure elevation [59]. Heart failure is another major cardiovascular complication in older adults with diabetes. Regular low-to-moderate intensity aerobic exercise has been shown to improve exercise tolerance, functional capacity, and quality of life in stable heart failure patients [118]. However, exercise should be initiated under medical supervision, with gradual progression and close monitoring for symptoms such as dyspnea, fatigue, or peripheral edema. RT may be incorporated to improve muscle strength and peripheral circulation, provided that volume overload and abrupt increases in intrathoracic pressure are avoided.

Nerve disease

Exercise may help relieve neuropathic pain [119] and delay disease progression in patients with peripheral neuropathy. In particular, non-weight-bearing exercises are reported to improve wound healing in diabetic foot ulcers [120], while moderate- intensity walking may not increase the risk of developing ulcers. However, activities with a risk of foot injury, such as jogging, should be avoided [59]. In addition, individuals with autonomic neuropathy exhibit impaired exercise capacity due to decreased heart rate and blood pressure responses, and may develop complications such as gastroparesis, postural hypotension, and dehydration during exercise. Therefore, a thorough evaluation including cardiac stress testing by healthcare professionals is recommended before initiating exercise [59,117].

Eye disease

Retinopathy is the most common eye disease among patients with diabetes, in which context it is classified into non-proliferative and proliferative forms. Patients having either proliferative or severe non-proliferative retinopathy are at increased risk for retinal hemorrhage and detachment, and should avoid vigorous-intensity exercise as it can rapidly elevate blood pressure [59,117].

Kidney disease

Since exercise does not accelerate the progression of kidney disease, engaging in moderate-intensity AT is recommended even for patients with end-stage kidney disease. However, those undergoing hemodialysis must undertake electrolyte monitoring [59].

SUGGESTION FOR INDIVIDUALIZED STRATEGIES BASED ON FUNCTIONAL STATUS

Older adults with diabetes can be classified by functional status into the following three groups [121]: (1) individuals in good health with little or no cognitive or functional impairment and long life expectancy; (2) those with some comorbidities and mild disability; and (3) those with high comorbidity and/or disability, and correspondingly shorter life expectancy.

For group (1), multimodal exercise is recommended, including AT, RT, and balance training, in the manner also recommended for healthy older adults. Specifically, AT should begin at 40%–50% of maximum heart rate (HRmax) and gradually increase to 70%–80% of HRmax. RT should start at 50%–80% of the one-repetition maximum and gradually increase over the course of 8–15 repetitions per set and 2–3 sets per session [49]. Since older adults with diabetes may adapt to exercise at a slower pace, it is recommended to initiate with one type of exercise, then add another after adaptation [66]. Exercise should be performed within a range that does not overstrain the joints [59]. For overweight patients, combining exercise with a weight loss strategy through calorie restriction alongside protein supplementation a further improve glycemic control [122].

Meanwhile, the exercise strategy for group (2) should focus on prevention of frailty. The most effective strategy is to prevent functional decline before its onset rather than try to recover after impairments have developed [68]. In the early stages of frailty management among patients with diabetes, it is recommended to focus on prevention of sarcopenia [48]. Although RT is effective for sarcopenia in preventing sarcopenia and improving muscle strength, multimodal exercise including AT, RT, and balance training have shown the greatest benefits in enhancing physical function, including ADL. Therefore, engaging in multimodal exercise is recommended [123-125]. For individuals who have difficulty performing AT, light activities such as walking, or daily household tasks may provide benefit. As such, individualized strategies based on each person’s exercise capacity are necessary. The Vivifrail program offers an individualized multicomponent exercise program, with patients classified into five groups based on physical function. In a 12-week study involving 188 patients aged 75 years and older with mild physical and cognitive impairments, this program led to significant functional improvements, with even greater affects observed in the frail group [126]. Using such an individualized program may be effective. Other potentially effective approaches include undertaking slow-paced walking, breaking up sedentary behavior, and integrating balance and strength training into daily life [91].

Finally, even among group (3), older adults with high comorbidities and/or disability, exercise is essential [29], with priority given to improvement of functional capacity over glycemic control [49]. Moderate- to vigorous-intensity RT can be safely implemented without major adverse effects, even in advanced-aged adults with frailty [29]. Additionally, low-speed walking, breaking up sedentary behavior, and integrating exercise into daily life may also provide benefits [91]. Given that seated exercise has shown large positive effects on cognition, with smaller effects on strength, spinal flexibility, and quality of life [127], seated RT can be a safer option for individuals who are non-ambulatory. Although seated exercise is less effective for improving overall physical function, performing range-of-motion activities alone may improve ADL [128]. Since weight-bearing exercises offer greater benefits for balance and mobility, these functional exercises are recommended for individuals who can perform them with the support of others. Given the high risk of impaired hypoglycemic awareness in this population [96], use of a CGM device is also recommended. Notably, long-term adherence to exercise may be low due to a number of physical barriers; improving adherence may require continuous intervention or motivational strategies from healthcare professionals or caregivers [46,68].

Alternatives for physically limited individuals and proposed strategies based on functional status are summarized in Fig. 3.

CONCLUSIONS

PA is a critical role element of diabetes management, and older adults account for a significant proportion of the overall diabetic population, yet there is a deficit of studies specifically examining activity in older adults with diabetes. Additionally, the proportion of older adults engaging in PA remains low, and especially among those with diabetes. Several kinds of barriers may contribute to this low engagement; potential avenues for overcoming these barriers include pursuing activities such as aquatic exercise and integrating walking, breaking up sedentary behavior, and balance and strength training into daily life. Notably, integrating exercise into daily life has demonstrated greater adherence compared to structured exercise. Combining these activities with the use of digital health devices such as pedometers may further increase their impact. As digital health devices have become increasingly available, research on their effects among older adults with diabetes has likewise grown; however, adherence to their use remains low among older adults, highlighting the need for strategies to promote sustained usage.

Current guidelines do not provide recommendations specifically for older adults with diabetes; moreover, this population is highly heterogenous, precluding a single set of commonly effective recommendations. This review proposes a classification into three groups based on physical function, along with strategies to promote engagement in PA. For individuals in good health with little or no cognitive or functional impairment, exercise at the normally recommended level is recommended, beginning with just one type of exercise and then adding another after adaptation. For those with some comorbidities and mild disability, exercise strategies should focus on the prevention of frailty. For those with high comorbidity and/or disability, seated exercise can serve as an alternative, with active use of devices such as a CGM to detect hypoglycemia. Ultimately, such tailored approaches based on individual functional status are essential to promote safe, effective, and sustainable participation in PA among older adults with diabetes.

NOTES

CONFLICTS OF INTEREST

No potential conflict of interest relevant to this article was reported.

FUNDING

This research was supported by the Korea National Institute of Health (KNIH) research project (project No.#2024-ER1101-00 and #2025-ER1102-00).

ACKNOWLEDGMENTS

We would like to express our gratitude to Seoin Choi for her invaluable assistance with the creation of the figures and the graphical abstract.

Fig. 1.

Age-related pathophysiological changes and the effects of exercise. AMPK, AMP-active protein kinase; PGC-1α, peroxisome proliferator-activated receptor gamma coactivator-1α; DRP-1, dynamic related protein 1; IGF-1, insulin-like growth factor-1.

Fig. 2.

Current guidelines on physical activity and suggested improvements.

Fig. 3.

Alternatives for physically limited individuals and proposed strategies based on functional status. CGM,continuous glucose monitoring; ADL, activities of daily living.

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Yu HJ, Hong D, Kim K, Heo JH, Cho DH, Hashimoto Y, Yun JS. Optimizing Physical Activity Strategies for Older Adults with Diabetes. Diabetes Metab J. 2025;49(6):1178-1197.

Received: Sep 29, 2025; Accepted: Oct 30, 2025

DOI: https://doi.org/10.4093/dmj.2025.0967.

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