Purpose of review: Protein anabolism is abnormal in human type 2 diabetes (T2DM). We review studies of anabolic stimuli that identify potential causes. If uncorrected, and combined with aging effects, they will compromise muscle function and mass. Knowing causes can guide studies of preventive and treatment measures.
Recent findings: T2DM accelerates age-related decreases in muscle mass. This could be related to insulin resistance of whole-body protein anabolism demonstrated in hyperglycemic obese men. In contrast, their protein anabolic response to hyperaminoacidemia suggested that ample amino acid administration, especially branched chain amino acids might overcome such insulin resistance. One study of chronic leucine supplementation in elderly T2DM patients did not increase muscle mass. However, they lacked sarcopenia and had adequate dietary protein intake, so may be atypical. Exercise induced similar increases in muscle protein synthesis, mass and strength in healthy and T2DM patients suggesting that physical activity might also overcome insulin resistance of protein anabolism.
Summary: Muscle protein anabolism in T2DM is resistant to the action of insulin but perhaps not to amino acid supply or exercise. Whether leucine supplementation improves muscle mass and function in persons with T2DM (especially elderly) with reduced protein intake or muscle mass needs to be determined.
aSchool of Arts and Sciences, Natural Science Division, Lebanese American University, Beirut, Lebanon
bMcGill Nutrition and Food Science Centre, McGill University Health Centre/Royal Victoria Hospital, Montreal, Quebec, Canada
Correspondence to Dr Réjeanne Gougeon, McGill Nutrition and Food Science Centre, MUHC/Royal Victoria Hospital, 687 Pine Avenue West, H6.61, Montreal, QC H3A 1A1, Canada. Tel: +1 514 843 1665; fax: +1 514 843 1706; e-mail: firstname.lastname@example.org.
Type 2 diabetes mellitus (T2DM) is characterized by insulin resistance. This is classically defined as blunted insulin-induced suppression of hepatic glucose production and uptake into peripheral tissues, including muscle, and of lipolysis in adipose tissue. As insulin also modulates protein metabolism by stimulating synthesis and suppressing breakdown, derangement in muscle protein anabolism in T2DM is expected, albeit not found using some experimental protocols. In this review we explore the potential clinical manifestations of altered muscle protein anabolism in T2DM and discuss recent studies of whole body and muscle protein anabolism in response to insulin, amino acids, and exercise.
MUSCLE MASS AND STRENGTH
Clinically, obese people with T2DM are not perceived to have muscle loss, a reason for protein metabolism abnormalities not having been considered until recently as significant. Despite usually having greater muscle mass than lean controls due to larger body size and obesity [1▪], T2DM appears to cause poorer muscle performance, a factor contributing to increased disabilities in older age. Lower leg and arm muscle strength have been reported in a cross-section of older men with T2DM compared with healthy controls . Similarly, older patients with T2DM had a 30% greater decline over 3 years in leg muscle strength and quality than healthy age-matched controls . Impairments in muscle strength in T2DM have been strongly correlated with intramuscular fat storage which is twice that found in controls . However, intramyocellular triglyceride content is not an independent biomarker of insulin resistance, as its increase in chronic exercise and obesity has opposing effects on insulin sensitivity .
T2DM also aggravates the loss of muscle mass even to the point of sarcopenia associated with aging. Older adults with T2DM followed for 6 years had accelerated loss of appendicular muscle mass compared with controls, interestingly, with more pronounced loss in newly diagnosed diabetes . In agreement with this, the Korean Sarcopenic Obesity Study showed that sarcopenia was more prevalent among older people with T2DM (15.7 versus 6.9%) . The Third National Health and Nutrition Survey revealed an inverse relationship between skeletal muscle index (ratio of skeletal muscle mass to total body weight), and insulin resistance [using the Homeostatic Model Assessment (HOMA-IR)], glycated haemoglobin (A1C), and prevalence of prediabetes and diabetes [8▪▪]. Consistent with this, muscle of patients with T2DM has increased expression of myostatin mRNA, a peptide hormone known to negatively regulate skeletal muscle mass [9▪].
RESPONSE TO INSULIN
Insulin stimulates protein anabolism in muscle fibers from healthy individuals by increasing protein synthesis and suppressing breakdown . Thus, insulin resistance in T2DM should impair protein metabolism concurrent with that proven to occur for that of glucose and lipids. Under in-vivo physiological conditions, insulin increases postprandially, but meal studies cannot distinguish its effect on protein anabolism from that of absorbed nutrients. To isolate the effect of insulin, the hyperinsulinemic, euglycemic clamp has been used, with serum concentrations maintained at typical postprandial concentrations (500–600 pmol/l) and glucose is infused to maintain glycemia at 5.5 mmol/l. Amino acid tracers (13C or 14C leucine, L-ring 2H5-phenylalanine) are infused to assess whole body and/or muscle protein kinetics. Ideally, a mixture of amino acids is also infused to maintain basal fasting plasma concentrations (isoaminoacidemia). This prevents plasma amino acids from falling below fasting levels due to suppression of protein breakdown by insulin, and thus creating a nonphysiological limitation of amino acid availability for synthesis . Using hyperinsulinemic, euglycemic, isoaminoacidemic clamps, we found insulin resistance of whole body net protein anabolism, mostly due to blunted stimulation of synthesis, in overweight and obese men with poorly controlled T2DM compared with weight matched nondiabetic men (Fig. 1) . Women studied in the same manner did not show this added diabetes effect possibly because the obese women have more insulin resistance of protein anabolism versus lean patients . Similar results were found in obese, hyperglycemic men with T2DM with glycemia clamped at 8 mmol/l to simulate the more typical postabsorptive milieu of T2DM, instead of being lowered to 5.5 mmol/l to begin the clamp [1▪]. This hyperglycemia was associated with a more accelerated turnover rate (higher protein synthesis and breakdown) than during euglycemia. These whole body protein data suggest that most of the impairments exist in muscles, as they account for most of the insulin-induced protein anabolism , and thus wherein most insulin resistance takes place.
Our findings contrast with those of others reporting normal whole body  and muscle  protein anabolism in T2DM in response to insulin. This discrepancy might be due to the lack of controlling for sex, body composition, previous protein and energy intake differences, or especially the absence of concurrent amino acid infusion to maintain fasting levels during these clamps. Inconsistent findings might also stem from differences in prior glucose control as hyperglycemia was normalized by insulin infusion for 11 days  or overnight  before assessing insulin-induced protein anabolism in some protocols, but not others [1▪,12]. It remains to be determined with well designed clamp studies that control for these confounding variables, whether good prior glycemic control improves muscle insulin resistance of protein metabolism.
RESPONSES TO AMINO ACIDS
Amino acids not only stimulate muscle protein anabolism by serving as substrates for protein synthesis but also as nutritional signals in the mRNA translation initiation pathway leading to protein synthesis. Among amino acids, the essential branched-chain, leucine, is the most potent by activating the mammalian target of rapamycin-complex 1 (mTORC1), which then triggers signal transduction events that promote protein synthesis in skeletal muscle . The exact mechanisms of leucine action are still not clear but appear to involve Rag proteins, a family of guanosine triphosphatases that interact with mTORC1. This promotes its intracellular perinuclear localization, which favors its activation by Rheb . Furthermore, leucine may also contribute to anabolism by suppressing muscle protein breakdown via inhibition of the ubiquitin–proteasome pathway  and possibly autophagy, through mTORC1 activation or independently .
Amino acids stimulate muscle protein anabolism in an independent and synergistic fashion with insulin . This is why under normal physiological conditions, the greatest protein anabolism occurs in the fed state, during which concentrations of insulin and amino acids are elevated. Thus, one might anticipate that insulin resistance of protein anabolism in T2DM would be predicted to be maximal in this state. However, postprandial muscle protein synthesis was found to be normal in hyperglycemic T2DM men after the consumption of carbohydrate and protein hydrolysate taken in repeated boluses . We have also recently reported ‘normalized’ whole body protein anabolism in T2DM during clamp simulating fed state concentrations of insulin and amino acids [1▪]. Obese men with T2DM had a whole-body protein anabolic response comparable to that found in lean men during the hyperinsulinemic, hyperglycemic, hyperaminoacidemic clamp. This was supported by signaling data from muscle biopsies collected during the clamps [23▪▪], in which the magnitude of increase in phosphorylation of mTOR and its downstream substrate, ribosomal protein S6 (rpS6) in response to hyperinsulinemia and hyperaminocidemia (Fig. 2a and b) was comparable to that of lean men studied under similar conditions . Thus, we concluded that postprandial hyperaminoacidemia can overcome insulin resistance of protein anabolism in T2DM.
One possible explanation for these findings is the ample amino acid or protein administered, which if extrapolated over one day exceeds the recommended daily adult protein intake. Although the total amount of amino acid infused during the clamp study (30 g) [1▪] corresponds to a typical adult meal, the total amount of protein consumed during the study by Manders et al. was very high (134 g protein hydrolysate taken in 12 repeated boluses over 6 h). Thus, it remains to be determined at what levels and durations of hyperaminoacidemia muscle protein anabolism become normalized in T2DM, as there could be a shift in dose-response to the right, requiring larger amounts of exogenous protein than recommended requirements. This could explain the clinical signs of abnormal muscle protein anabolism in T2DM that start to become apparent in old age concurrent with a decrease in protein intake  and specifically in serum branched-chain amino acids (BCAA).
THE DILEMMA OF AMINO ACIDS/PROTEIN IMPROVING VERSUS IMPAIRING METABOLIC CONTROL
Increasing dietary protein/amino acid intake has been recommended as part of the dietary management to improve insulin sensitivity and blood glucose control in T2DM . High protein, hypoenergetic diets can cause weight loss with maintenance of lean body mass. Furthermore, certain individual amino acids including leucine augment insulin secretion, despite the blunted glucose insulinotropic response in T2DM . This is likely to be a factor in low carbohydrate, high protein diets improving glycemic control in untreated T2DM . Increasing protein and amino acid intake, leucine in particular, has been suggested as a nutritional strategy to improve muscle protein anabolism in T2DM, especially in the elderly with decreased muscle mass [28,29]. This is thought to increase muscle protein anabolism both directly by activating protein synthesis and by stimulating insulin secretion. Amino acid composition and digestibility of specific protein sources may also play roles. Muscle protein synthesis was stimulated significantly more in response to 20 g whey versus casein in prediabetic older men [30▪]. This was partly attributed to whey's higher leucine content. A high protein (30% of energy mostly from animal food sources), low carbohydrate (30%), weight maintaining diet for 5 weeks in men with untreated T2DM was associated with improved nitrogen balance with no change in body composition [31▪]. Notable is that integrated 24 h plasma concentrations of leucine and the other BCAA, tyrosine, and phenylalanine were increased up to 12-fold for leucine. In contrast, long-term leucine supplementation (7.5 g per day) did not affect muscle mass in older men with T2DM. However, these patients did not have compromised muscle mass at baseline, and their diet composition was not controlled, though protein intake was ‘adequate’ (∼1.0 g per day) [32▪▪]. It remains to be established whether persons with T2DM with reduced protein intake and/or muscle mass would benefit from leucine supplementation, as was recently demonstrated in the healthy elderly consuming protein at the RDA level (0.8 g/kg body weight per day) .
In contrast, several lines of evidence have been published that have been interpreted as protein, especially leucine, worsening glucoregulation. A plethora of recent metabolomic studies have all come up with serum BCAA as a signal of diabetes risk, including prediction of later T2DM . Epidemiological studies have revealed a strong positive association between increased intake of animal protein rich in BCAA and the risk of insulin resistance and T2DM . Furthermore, raising serum amino acids to postprandial concentrations blunts glucose uptake in healthy humans [21,36]. At the molecular level, this was attributed to leucine-induced overactivation of ribosomal protein (rp) S6 kinase 1 (S6K1), a substrate of the mTORC1 signaling pathway , which phosphorylates the insulin receptor substrate (IRS)-1 at specific serine residues . This, in turn, inhibits IRS-1 and deactivates Akt signaling resulting in attenuated translocation of GLUT4 to the plasma membrane, and hence, reduced glucose uptake.
These mechanisms were extrapolated to insulin resistant states to postulate that increased protein intake in T2DM could further contribute to peripheral insulin resistance of glucose metabolism . However, we have recently demonstrated in hyperglycemic men with T2DM during hyperisulinemic clamps that whole-body glucose uptake was not further impaired by hyperaminoacidemia. This was supported by unchanged IRS-1 serine phosphorylation during hyperaminoacidemia despite increased mTORC1 phosphorylation (Fig. 2c and d) [23▪▪]. We suggest that in such hyperglycemic T2DM, insulin-stimulated glucose uptake is already highly attenuated, as is hyperphosphorylation of IRS-1 serine residues, such that hyperaminoacidemia does not aggravate it. Another key metabolic abnormality of T2DM that is thought to be worsened by excess leucine intake is pancreatic β cell apoptosis. Leucine-induced mTORC1 phosphorylation in cultured β cells, concurrent with high levels of glucose, insulin, and insulin-like growth factor (IGF)-1 in T2DM might ‘overstimulate’ β cell proliferation and precipitate β cell senescence . However, there exists no evidence to support this hypothesis in humans. In summary, inconsistent findings arise among those with unambiguous clinical benefits favoring higher protein/amino acid intakes with negative associations derived from epidemiologic/metabolomic and some more fundamental studies. Reconciliation of these findings requires highly targeted whole-body and organ/tissue studies at a mechanistic level, in persons with T2DM.
RESPONSES TO EXERCISE
Resistance exercise generates anabolic signals that stimulate muscle protein synthesis and is also known to improve insulin sensitivity independently of any effect it might have on weight loss. Physical activity has been recommended to prevent age-related loss of muscle mass. In a recent report, Wall et al.[40▪] demonstrated that electrical stimulation of leg muscle contraction was sufficient to increase muscle protein synthesis in older T2DM men during a 4 h recovery period. Exercise prior to ingestion of a protein bolus (20 g) led to higher muscle protein synthesis versus no exercise in prediabetic aged men , at a magnitude that was comparable to that observed in young men. Longer term exercise regimens over 3–4 months have also been proven to increase muscle mass  and strength [43▪,44▪] in T2DM and improvements were comparable with those of healthy controls [44▪].
Age-related loss of muscle mass and function is accelerated with T2DM that might be due to insulin resistance of protein anabolism with concurrent insufficient protein intake and physical activity. Indeed, in T2DM, muscle protein anabolism is normal in response to ample supply of BCAA, especially leucine, or to exercise. More research is required on the human muscle cellular and molecular mechanisms that reveal strategies for intervention to concurrently correct glucose and protein metabolic abnormalities. The dilemma is to identify the right balance, that is, optimal protein intake combined with exercise prescription to protect from muscle loss, while not aggravating good glycemic control.
We thank Dr Errol B. Marliss, Dr Stéphanie Chevalier, and Dr Terry P. Combs for their valuable edits and additions based on the critical reading of the manuscript.
Conflicts of interest
There are no conflicts of interest.
REFERENCES AND RECOMMENDED READING
Papers of particular interest, published within the annual period of review, have been highlighted as:
▪ of special interest
▪▪ of outstanding interest
Additional references related to this topic can also be found in the Current World Literature section in this issue (pp. 116–117).
1▪. Bassil M, Marliss EB, Morais JA, et al. Postprandial hyperaminoacidaemia overcomes insulin resistance of protein anabolism in men with type 2 diabetes. Diabetologia 2011; 54:648–656.
Normal protein anabolism in response to postprandial insulin and amino acids.
2. Park SW, Goodpaster BH, Strotmeyer ES, et al. Decreased muscle strength and quality in older adults with type 2 diabetes: the health, aging, and body composition study. Diabetes 2006; 55:1813–1818.
3. Park SW, Goodpaster BH, Strotmeyer ES, et al. Accelerated loss of skeletal muscle strength in older adults with type 2 diabetes: the health, aging, and body composition study. Diabetes Care 2007; 30:1507–1512.
4. Hilton TN, Tuttle LJ, Bohnert KL, et al. Excessive adipose tissue infiltration in skeletal muscle in individuals with obesity diabetes mellitus, and peripheral neuropathy: association with performance and function. Phys Ther 2008; 88:1336–1344.
5. Amati F, Dubé JJ, Alvarez-Carnero E, et al. Skeletal muscle triglycerides, diacylglycerols, and ceramides in insulin resistance. Diabetes 2011; 60:2588–2597.
6. Park SW, Goodpaster BH, Lee JS, et al. Excessive loss of skeletal muscle mass in older adults with type 2 diabetes. Diabetes Care 2009; 32:1993–1997.
7. Kim TN, Park MS, Yang SJ, et al. Prevalence and determinant factors of sarcopenia in patients with type 2 diabetes: The Korean Sarcopenic Obesity Study (KSOS). Diabetes Care 2010; 33:1497–1499.
8▪▪. Srikanthan P, Karlamangla AS. Relative muscle mass is inversely associated with insulin resistance and prediabetes. findings from The Third National Health And Nutrition Examination Survey. J Clin Endocrinol Metab 2011; 96:2898–2903.
Data from Third National Health and Nutrition Examination Survey showing inverse relationship between muscle mass and risk of type 2 diabetes.
9▪. Brandt C, Nielsen AR, Fischer CP, et al. Plasma and muscle myostatin in relation to type 2 diabetes. PLoS One 2012; 7:e37236.
Increased expression of myostatin known to downregulate muscle mass in diabetic muscle.
10. Chow LS, Albright RC, Bigelow ML, et al. Mechanism of insulin's anabolic effect on muscle: measurements of muscle protein synthesis and breakdown using aminoacyl-tRNA and other surrogate measures. Am J Physiol 2006; 291:E729–E736.
11. Chevalier S, Gougeon R, Kreisman SH, et al. The hyperinsulinemic amino acid clamp increases whole-body protein synthesis in young subjects. Metabolism 2004; 53:388–396.
12. Pereira S, Marliss EB, Morais JA, et al. Insulin resistance of protein metabolism in type 2 diabetes. Diabetes 2008; 57:56–63.
13. Chevalier S, Marliss EB, Morais JA, et al. Whole-body protein anabolic response is resistant to the action of insulin in obese women. Am J Clin Nutr 2005; 82:355–365.
14. Nygren J, Nair KS. Differential regulation of protein dynamics in splanchnic and skeletal muscle beds by insulin and amino acids in healthy human subjects. Diabetes 2003; 52:1377–1385.
15. Halvatsiotis PG, Turk D, Alzaid A, et al. Insulin effect on leucine kinetics in type 2 diabetes mellitus. Diabetes Nutr Metab 2002; 15:136–142.
16. Halvatsiotis P, Short KR, Bigelow M, Nair KS. Synthesis rate of muscle proteins, muscle functions, and amino acid kinetics in type 2 diabetes. Diabetes 2002; 51:2395–2404.
17. Dodd KM, Tee AR. Leucine and mTORC1: a complex relationship. Am J Physiol Endocrinol Metab 2012; 302:E1329–E1342.
18. Sancak Y, Peterson TR, Shaul YD, et al. The Rag GTPases bind raptor and mediate amino acid signaling to mTORC1. Science 2008; 320:1496–1501.
19. Nakashima K, Ishida A, Yamazaki M, Abe H. Leucine suppresses myofibrillar proteolysis by down-regulating ubiquitin–proteasome pathway in chick skeletal muscles. Biochem Biophys Res Commun 2005; 336:660–666.
20. Sandri M. Autophagy in health and disease. 3. Involvement of autophagy in muscle atrophy. Am J Physiol Cell Physiol 2010; 298:C1291–C1297.
21. Adegoke OAJ, Chevalier S, Morais JA, et al. Fed-state clamp stimulates cellular mechanisms of muscle protein anabolism and modulates glucose disposal in normal men. Am J Physiol Endocrinol Metab 2009; 296:E105–113.
22. Manders RJ, Koopman R, Beelen M, et al. The Muscle protein synthetic response to carbohydrate and protein ingestion is not impaired in men with longstanding type 2 diabetes. J Nutr 2008; 138:1079–1085.
23▪▪. Bassil M, Burgos S, Marliss EB, et al. Hyperaminoacidaemia at postprandial levels does not modulate glucose metabolism in type 2 diabetes mellitus. Diabetologia 2011; 54:1810–1818.
Molecular data from muscle biopsies showing normal phosphorylation of mTORC1 pathway in response to hyperaminoacidemia in T2DM supporting previous data of normal whole-body leucine kinetics in T2DM.
24. Evans WJ. Protein nutrition, exercise and aging. J Am Coll Nutr 2004; 23:601S–609S.
25. Hamdy O, Horton E. Protein content in diabetes nutrition plan. Curr Diab Rep 2011; 11:111–119.
26. Yang J, Chi Y, Burkhardt BR, et al. Leucine metabolism in regulation of insulin secretion from pancreatic beta cells. Nutr Rev 2010; 68:270–279.
27. Gannon MC, Nuttall FQ. Control of blood glucose in type 2 diabetes without weight loss by modification of diet composition. Nutr Metab (Lond) 2006; 3:16.
28. Leenders M, van Loon LJC. Leucine as a pharmaconutrient to prevent and treat sarcopenia and type 2 diabetes. Nutr Rev 2011; 69:675–689.
29. Keller U. Dietary proteins in obesity and in diabetes. Int J Vitam Nutr Res 2011; 81:125–133.
30▪. Pennings B, Boirie Y, Senden JM, et al. Whey protein stimulates postprandial muscle protein accretion more effectively than do casein and casein hydrolysate in older men. Am J Clin Nutr 2011; 93:997–1005.
Leucine rich whey protein versus casein results in higher stimulation of muscle protein synthesis in prediabetic men.
31▪. Nuttall F, Gannon M. Effect of a LoBAG30 diet on protein metabolism in men with type 2 diabetes. Nutr Metab (Lond) 2012; 9:43.
High protein, low carbohydrate diet for 5 weeks induces a positive nitrogen balance in type 2 diabetes compared with control diet.
32▪▪. Leenders M, Verdijk LB, van der Hoeven L, et al. Prolonged leucine supplementation does not augment muscle mass or affect glycemic control in elderly type 2 diabetic men. J Nutr 2011; 141:1070–1107.
First long-term (6 months) leucine supplementation studies in T2DM that showed no change in muscle mass.
33. Casperson SL, Sheffield-Moore M, Hewlings SJ, Paddon-Jones D. Leucine supplementation chronically improves muscle protein synthesis in older adults consuming the RDA for protein. Clin Nutr 2012; 31:512–519.
34. Newgard CB, An J, Bain JR, et al. A branched-chain amino acid-related metabolic signature that differentiates obese and lean humans and contributes to insulin resistance. Cell Metab 2009; 9:311–326.
35. Wang TJ, Larson MG, Vasan RS, et al. Metabolite profiles and the risk of developing diabetes. Nat Med 2011; 17:448–453.
36. Krebs M, Brunmair B, Brehm A, et al. The mammalian target of rapamycin pathway regulates nutrient-sensitive glucose uptake in man. Diabetes 2007; 56:1600–1607.
37. Tremblay F, BrÛlé S, Hee Um S, et al. Identification of IRS-1 Ser-1101 as a target of S6K1 in nutrient- and obesity-induced insulin resistance. Proc Natl Acad Sci 2007; 104:14056–14061.
38. Krebs M, Krssak M, Bernroider E, et al. Mechanism of amino acid-induced skeletal muscle insulin resistance in humans. Diabetes 2002; 51:599–605.
39. Melnik BC. Leucine signaling in the pathogenesis of type 2 diabetes and obesity. World J Diabetes 2012; 3:38–53.
40▪. Wall BT, Dirks ML, Verdijk LB, et al.
Neuromuscular electrical stimulation increases muscle protein synthesis in elderly, type 2 diabetic men. Am J Physiol Endocrinol Metab 2012; 303:E614–E623.
First study on effective muscle protein synthesis stimulation in elderly T2DM by electrical stimulation.
41. Pennings B, Koopman R, Beelen M, et al. Exercising before protein intake allows for greater use of dietary protein-derived amino acids for de novo muscle protein synthesis in both young and elderly men. Am J Clin Nutr 2011; 93:322–331.
42. Cauza E, Strehblow C, Metz-Schimmerl S, et al. Effects of progressive strength training on muscle mass in type 2 diabetes mellitus patients determined by computed tomography. Wien Med Wochenschr 2009; 159:141–147.
43▪. Otterman NM, van Schie CHM, van der Schaaf M, et al. An exercise programme for patients with diabetic complications: a study on feasibility and preliminary effectiveness. Diabet Med 2011; 28:212–217.
Improvement in muscle strength after 3 months exercise regimen in T2DM.
44▪. Geirsdottir OG, Arnarson A, Briem K, et al.
Effect of 12-Week Resistance Exercise Program on Body Composition, Muscle Strength, Physical Function, and Glucose Metabolism in Healthy, Insulin-Resistant, and Diabetic Elderly Icelanders. J Gerontol A Biol Sci Med Sci 2012; 67:1259–1265.
Similar Improvements in muscle strength in elderly T2DM and healthy controls after 4-month exercise regimen.