Diabetes Standards of Care and Resources for Clinicians and Educators

Recommendations for Physical Activity

• Assess Current Level of Physical Activity
  • Document each person’s current level of daily movement (including structured exercise and unstructured physical activity) at each clinic visit.
    • Assess type of exercise, exercise intensity (light, moderate, vigorous), duration (minutes), and frequency (days/week) at follow up visits.
      • Consider advising a daily step count as a self-assessment tool. Track Your Steps may be a helpful teaching resource.
• Perform Assessment of Health Status
  • Assess individuals for medical conditions that might affect the type, frequency, duration, and intensity of the physical activity (PA) in which they engage at initial visit and as needed, but at least annually thereafter. The Physical Activity Readiness Questionnaire (PAR-Q+) Exit Disclaimer: You Are Leaving www.ihs.gov  is one resource that can be useful in completing an initial assessment.²
  • Evaluate the need for provider consultation or medical clearance. Specific guidance on pre-exercise evaluation is available in the ACSM Consensus Statement on Exercise/Physical Activity in Type 2 Diabetes.³ Exit Disclaimer: You Are Leaving www.ihs.gov 
    • Medical clearance is not needed for most individuals planning to participate in a low-to-moderate intensity PA like brisk walking. However, evaluation by a provider is needed for individuals diagnosed with cardiovascular disease (CVD), retinopathy, chronic kidney disease, and/or peripheral neuropathy.3 Special precautions may be necessary for these individuals.
    • Further evaluation and medical clearance are recommended for exercise participation for:
      • Individuals who report signs and symptoms suggestive of CVD (e.g. chest discomfort, lightheadedness, shortness of breath);
      • Middle-aged and older individuals with diabetes who are not regularly exercising and want to begin a supervised high-intensity exercise program.
• Provide General Recommendations for Physical Activity
  • Address physical activity (PA) at every diabetes visit.
  • Assess level of motivational readiness and encourage people to set activity goals.
  • Advise to begin slowly and increase gradually. Specific recommendations for increasing PA will vary by age, activity, and presence of diabetes-related complications.
  • Develop person-centered recommendations based on consensus guidelines, see below.

  American Diabetes Association (ADA) and American College of Sports Medicine (ACSM) Physical Activity/Exercise Recommendations^3,4

  Components of PA/Exercise Plan	ADA and ACSM Guidance
  Reducing Sedentary Time	ADA: Evaluate and address sedentary time. Encourage increased daily PA (e.g. walking, household chores and gardening). Counsel that prolonged sitting should be interrupted every 30 minutes for health and fitness benefits. ACSM: Move More and Sit Less. Some PA is better than none.
  General Recommendations	ADA: 150 minutes or more of moderate-to-vigorous activity per week, spread over at least 3 days/week, with no more than 2 consecutive days without activity. Shorter durations of vigorous activity or interval training (minimum 75 minutes/week) may be sufficient for more physically fit individuals. ACSM: 150-300 minutes/week of moderate-intensity, or 75-150 minutes of vigorous-intensity aerobic PA, or an equivalent combination of moderate and vigorous-intensity aerobic activity, spread over 3-7 days.
  Muscular Strength	ADA: 2-3 sessions/week of resistance exercise on non-consecutive days. ACSM: Muscle strengthening activities that involve all major muscle groups on 2-3 days/week, but not on consecutive days.
  Flexibility and Balance	ADA: Flexibility and balance training 2-3 times/week for older individuals (e.g. yoga, tai chi). ACSM: Flexibility and balance exercises 2-3 days/week or more (e.g. yoga, tai chi).

  Note: When appropriate and available, referral to a certified fitness or exercise specialist for supervision and coaching is highly recommended. For high-intensity training, participation in supervised exercise training is recommended over non-supervised programs.

• Provide Guidance for Staying Safe/Healthy During Physical Activity
  • Provide general guidance on safety considerations for physical activity (PA) and address important safety issues more specific to people with diabetes. Important safety tips for people with diabetes include:
    • Exercise at a safe intensity level.
    • Take steps to avoid low blood glucose.
    • Avoid high blood glucose and ketoacidosis.
    • Stay hydrated.
    • Use caution when exercising in hot and humid environments.
    • Use caution when exercising in cold environments.
    • Take care of feet.
    • Be alert to personal safety.

  See Additional Information: Safety Guidance for Counseling Individuals with Diabetes

• Provide Guidance and Support for Success in Incorporating Lifestyle Changes
  • Share strategies for implementing and sustaining lifestyle changes that promote and increase physical activity (PA) such as:
    • Look for ways to incorporate PA into your day.
    • Find physical activities you enjoy.
    • Make PA social (asking a friend or family member to accompany you).
    • Walk your dog for regular PA.
    • Interrupt prolonged sitting with activity breaks, such as walking or simple resistance activities, for 3-5 minutes every 30-60 minutes. View Move More Sit Less.
  • Encourage goal setting and plans for overcoming barriers to PA.
  • Leverage technology to promote, measure, or facilitate PA. Resources include cell phones, smart watches, fitness trackers, pedometers, step counters, and internet-based exercise programs.

References

1. Armstrong, M, Colberg, SR, and Sigal, RJ. Where to Start? Physical Assessment, Readiness, and Exercise Recommendations for People With Type 1 or Type 2 Diabetes, Exit Disclaimer: You Are Leaving www.ihs.gov  Diabetes Spectrum 2023; 36(2):105-113; doi: 10.2337/dsi22-0016
2. ACSM’s Guidelines for Exercise Testing and Prescription, 12th Edition. Ozemek, C, editor. Wolter’s Kluwer Health, 2025 (Chapter 9, pp 348-389).
3. Kanaley J, Colberg S, Corcoran M, et.al. Exercise/Physical Activity in Individuals with Type 2 Diabetes: A Consensus Statement from the American College of Sports Medicine. Exit Disclaimer: You Are Leaving www.ihs.gov  Medicine & Science in Sports & Exercise 2022; 54(2): 353-368; doi: 10.1249/MSS.0000000000002800
4. American Diabetes Association. 5. Facilitating Positive Health Behaviors and Well-being to Improve Health Outcomes: Standards of Care in Diabetes 2025 Exit Disclaimer: You Are Leaving www.ihs.gov  Diabetes Care 2025;48(Supplement_1):S100-S104; doi: 10.2337/dc25-S005
5. Centers for Disease Control. (December 2023). Talk Test. Measuring Physical Activity Intensity. https://www.cdc.gov/physical-activity-basics/measuring/index.html Exit Disclaimer: You Are Leaving www.ihs.gov 
6. Rowe W, Welk D., Heil D., et.al. Stride Rate Recommendations for Moderate-Intensity Walking. Exit Disclaimer: You Are Leaving www.ihs.gov  Medicine & Science in Sports & Exercise 2011; 43(2): 312–318; doi: 10.1249/MSS.0b013e3181e9d99a
7. Robertson RJ, Goss F, Rutkowski J, et.al. Concurrent validation of the OMNI perceived exertion scale for resistance exercise. Exit Disclaimer: You Are Leaving www.ihs.gov  Medicine & Science in Sports & Exercise 2003; 35(2): 333–341; doi: 10.1249/01.MSS.0000048831.15016.2A

Featured Physical Activity Resources

Physical Activity Patient Education Resources