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Promoting Exercise as Medicine for Prediabetes and Prehypertension

Bushman, Barbara PhD, FACSM

doi: 10.1249/JSR.0000000000000066
Exercise is Medicine

Prediabetes and prehypertension are conditions that reflect higher-than-normal blood glucose level and elevated blood pressure. The use of the term “pre” helps highlight the potentially slippery slope toward fully realized diabetes or hypertension. In both situations, recommended lifestyle modifications include a focus on regular exercise, including cardiorespiratory (aerobic) activity and resistance training. In spite of strong evidence related to the benefits of exercise, the number of American adults meeting even minimal targets is low. Therefore medical and health professionals should utilize strategies (including goal setting, problem solving, and relapse prevention, feedback, self-monitoring, and modeling) to encourage behavior change.

Department of Kinesiology, Missouri State University, Springfield, MO

Address for correspondence: Barbara Bushman, PhD, FACSM, Department of Kinesiology, Missouri State University 901 S. National Ave., Springfield, MO; E-mail:

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The Exercise is Medicine® (EIM®) initiative was launched in 2007 with a focus “on encouraging primary care physicians and other health care providers to include exercise when designing treatment plans for patients” (14). To appreciate the reasoning behind this initiative, consider this EIM® guiding principle: “Exercise and physical activity are important to health and the prevention and treatment of many chronic diseases” (14). Although it is a seemingly simple statement, it reflects on the many ways in which exercise promotes health and the numerous lives that could be impacted if exercise is embraced as a lifestyle habit. When compared with common drugs, exercise “combines preventive, multisystem effects with little adverse consequences and at a lower cost” (16). With a focus on prevention, this article will explore the benefits of exercise that are related to prediabetes and prehypertension. These designations — with the use of the term “pre” — emphasize the health concern for individuals with higher blood glucose level and increased blood pressure by highlighting the risk of progressing toward fully realized diabetes or hypertension (Fig. 1).

Figure 1

Figure 1

Although health risks associated with higher-than-normal blood glucose level and elevated blood pressure have been known for some time, the more consumer-focused terms of prediabetes and prehypertension have been applied only within the past 12 years. In 2002, “pre-diabetes” was used to identify a “condition in which blood glucose levels are higher than normal but not yet diabetic” (38). Prediabetes was described as a “serious condition that can be reversed or alleviated with modest changes in [a person’s] daily routine,” and one of the changes mentioned was regular exercise (38). “Prehypertension” was defined initially in the Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure, as follows: “Individuals with a systolic blood pressure of 120 to 139 mm Hg or a diastolic blood pressure of 80 to 89 mm Hg should be considered prehypertensive and require health-promoting lifestyle modifications to prevent CVD [cardiovascular disease]” (39). In both situations, lifestyle modifications were noted within the introduction of the new terminology; exercise will be the focus of this article, recognizing the value of other lifestyle modifications (e.g., dietary changes) in promoting health (36).

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Individuals with glucose levels too high to be considered normal but whose glucose levels fall below the criterion for diabetes are considered to have impaired fasting glucose (IFG, 100 to 125 mg·dL−1 or 5.6 to 6.9 mmol) or impaired glucose tolerance (IGT, 2-h plasma glucose oral glucose tolerance test of 140 to 199 mg·dL−1 or 7.8 to 11.0 mmol) (2). Glycated hemoglobin (A1C) between 5.7% and 6.4% also reflects increased risk for diabetes and cardiovascular disease and thus can be used to identify prediabetes (2). Note that for IFG, IGT, and elevated A1C, the risk should be seen as continuous, “extending below the lower limit of the range and becoming disproportionately greater at the higher ends of the range” (2). Prediabetes reflects IFG or IGT, or both. Rather than being considered as clinical entities, IFG and IGT should be viewed as risk factors for diabetes and cardiovascular diseases (2). In addition to impacting mortality and morbidity related to cardiovascular diseases, poorly controlled type 2 diabetes is a significant cause of blindness, kidney and nerve diseases, and amputation (10).

The U.S. Centers for Disease Control and Prevention (CDC) estimates that 79 million Americans (35% of adults) have prediabetes and that 15% to 30% will develop type 2 diabetes within 5 years without lifestyle changes (8). Transitioning from either IFG or IGT to diabetes occurs eventually for most, with some estimates up to 70% (30). Lifestyle changes (modest weight loss and regular physical activity) can help prevent or delay type 2 diabetes in those with prediabetes (8). In particular, programs targeting weight loss of 7% body weight and increasing physical activity to at least 150 min·wk−1 of moderate-intensity activity have been recommended (2).

Many studies support the value of exercise for individuals with prediabetes, as demonstrated by the following examples. Moderate-intensity physical activities (e.g., brisk walking) have been found to substantially reduce the risk of type 2 diabetes (24). Individuals engaging in at least 2 d·wk−1 of muscle-strengthening activities were 29% less likely to have IFG compared with individuals reporting no engagement in muscle-strengthening activities (9). Regular participation in muscle-strengthening (resistance exercise) and muscle-conditioning (yoga, stretching, or toning) activities was associated with a reduced risk of type 2 diabetes in a study on nearly 100,000 women (Nurses’ Health Study I and II); women who included these activities for at least 60 min·wk−1 along with aerobic activity meeting current physical activity recommendations (i.e., at least 150 min·wk−1) were a third as likely to develop diabetes as inactive women (20). Similarly individuals with IGT who received individualized counseling focused on reducing weight, total fat intake, and saturated fat intake and on increasing fiber intake and physical activity (including aerobic activity and resistance training) realized a 58% reduction in diabetes risk; the effect was most pronounced for individuals who made more comprehensive changes in their lifestyle (37).

In a position statement from the American College of Sports Medicine (ACSM) and the American Diabetes Association (ADA), diet and physical activity are considered central to the management and prevention of diabetes (10). The position statement recommends at least 2.5 h·wk−1 of moderate-to-vigorous physical activity to prevent onset of type 2 diabetes in adults at high risk (10). For individuals with type 2 diabetes, physical activity is recommended, including the following (10):

  • Aerobic exercise training at least 3 d·wk−1 with no more than 2 consecutive days between bouts (in order to optimize the exercise-induced improvements in insulin action), at least moderate intensity (40% to 60% maximal aerobic capacity), minimum of 150 min·wk−1 (this can be done in 10-min bouts), including large muscle group activity resulting in sustained increases in heart rate (e.g., brisk walking);
  • Resistance training at least twice weekly (ideally 3 times per week) on nonconsecutive days, moderate (50% of one-repetition maximum) or vigorous intensity (75% to 80% of one-repetition maximum), 5 to 10 exercises involving the major muscle groups, progressing from a weight that can be lifted 10 to 15 times before fatigue to heavier weights or greater resistance that can be lifted only 8 to 10 times, at least 1 set but as many as 3 to 4 sets, resistance machines or free weights can be equally effective;
  • Flexibility training may be included also but should be in addition to, not in place of, aerobic exercise or resistance training.

Unfortunately according to one analysis, only about half of U.S. adults with prediabetes reported trying to control or lose weight, reduce the amount of fat or calories in the diet, or increase physical activity within the past year (17). Having physician advice regarding these behaviors did increase the proportion of adults with prediabetes who reported performing these risk-reducing behaviors; unfortunately only about one-third of adults with prediabetes received physician advice (17). To help promote physical activity, ACSM and ADA suggest focusing on increasing self-efficacy and nurturing social support from family, friends, and health care providers (10).

Optimizing safety and maximizing adherence are both keys to realizing the potential benefit of physical activity. A cross-sectional analysis of self-reported physical function limitations and comorbidities revealed highest prevalence among those with diabetes, followed by those with prediabetes and then those with normal glucose levels (27). With 32% reporting mobility limitations and 56% with lower extremity limitations, health professionals need to develop interventions that accommodate individual physical function limitations (27). Appropriate screening prior to beginning an exercise program can help maximize benefits while minimizing risks. For sedentary individuals with type 2 diabetes who desire to exercise more intensely, evaluation by a physician is beneficial; however exercise stress testing for asymptomatic individuals at low risk is not recommended, although such testing may be indicated for individuals at higher risk (10).

A recent meta-analysis found a reduction in progression from prediabetes to diabetes for both intensive lifestyle therapy and for drug treatments, although the lifestyle therapy was superior (22). Although beyond the scope of the current article, the impact of medications (i.e., metformin) on preventing or delaying type 2 diabetes has been examined. The ADA suggests that metformin therapy may be considered for prevention of type 2 diabetes in some situations (including in those with IGT, IFG, and elevated A1C and especially for those with body mass index >35 kg·m−2, less than 60 years of age, and women with prior gestational diabetes mellitus) (2). In a clinical trial involving individuals at high risk of diabetes at 27 centers (Diabetes Prevention Program), the incidence of diabetes was reduced by 31% with metformin compared with that in placebo; however the lifestyle intervention (healthy, low-calorie, low-fat diet and physical activity of moderate intensity for at least 150 min·wk−1) reduced incidence of diabetes by 58% (25). Metformin along with exercise training has been studied in individuals with prediabetes (28). Insulin sensitivity was increased after 12 wk of exercise training, metformin use, or combined exercise training and metformin; adding metformin to exercise training did not provide additional improvements (28). Given the benefits of exercise (i.e., impact on glucose in addition to the changes in lipids and blood pressure and the potential impact on weight loss and maintenance), any use of medications should be considered to augment, not replace, lifestyle improvements (10).

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Prehypertension is defined as systolic blood pressure of 120 to 139 mm Hg or diastolic blood pressure of 80 to 89 mm Hg (40). The prevalence of prehypertension for U.S. adults has been found to be 34% for men and 22% for women; this is in addition to the 29% of U.S. adults with hypertension (32). The relationship between blood pressure and cardiovascular risk is linear (23); beginning at a blood pressure of 115/75 mmHg, cardiovascular risk doubles for each increase of 20/10 (40). Individuals with prehypertension have an increased risk of stroke, myocardial infarction, and total cardiovascular events (21).

The lifetime risk (i.e., the probability of developing hypertension during one’s life) is approximately 90% for adults with nonhypertensive blood pressure at age 55 or 65 years who live to 80 to 85 years of age (40). For those with prehypertension, the 4-year rate of progression to hypertension is impacted by current blood pressure level: 26% for those 65 years age or older with blood pressure in the 120–129/80–84 range but 50% for those with blood pressure between 130–139/85–89 (40). Thus the designation of prehypertension is intended to “identify those individuals in whom early intervention by adoption of healthy lifestyles could reduce [blood pressure (BP)], decrease the rate of progression of BP to hypertensive levels with age, or prevent hypertension entirely” (40).

Within the past year, a number of organizations have provided guidance for controlling high blood pressure. For example, the American Heart Association (AHA), the American College of Cardiology (ACC), and the Centers for Disease Control and Prevention (CDC) released a science advisory for high blood pressure control (18); the Eighth Joint National Committee’s (JNC 8) 2014 Evidence-Based Guideline for Management of High Blood Pressure in Adults (23) became available; the European Society of Hypertension (ESH) and the European Society of Cardiology (ESC) provided guidelines for arterial hypertension management (29); and the American Society of Hypertension (ASH) and the International Society of Hypertension (ISH) published a statement on clinical practice guidelines for the management of hypertension in the community (42).

These resources include information on proposed effective use of pharmacological treatment of hypertension, with some differences in recommendations and guidelines related to medication use and timing; in general agreement, however, the guidelines and statements point out the value of including exercise, as follows:

  • AHA, ACC, CDC (18): Among the lifestyle changes recommended for all patients: “Exercise at a moderate pace to achieve 150 min/week (i.e.,30 min/5days/wk).”
  • JNC8 (23): “For all persons with hypertension, the potential benefits of a healthy diet, weight control, and regular exercise cannot be overemphasized. These lifestyle treatments have the potential to improve BP control and even reduce medication needs.”
  • ESC, ESH (29): One of the lifestyle recommendations is: “Regular exercise, i.e. at least 30 min of moderate dynamic exercise on 5 to 7 days per week is recommended.” In addition, the guidelines point out “...regular aerobic physical activity may be beneficial for both prevention and treatment of hypertension and to lower [cardiovascular] risk and mortality.”
  • ASH, ISH (42): For patients with prehypertension, “they should be encouraged to make lifestyle changes in the hope of delaying or even preventing progression to hypertension.” One of the lifestyle changes noted is regular exercise, including walking, cycling, climbing stairs and integrating physical activity into daily routines.

The focus of these recommendations is on aerobic-based activities. Resistance training also is included in the recommendations provided in the ACSM’s Guidelines for Exercise Testing and Prescription, Ninth Edition (1), for individuals with the following:

  • Aerobic exercise on most, preferably all, days of the week, including moderate intensity (40% to <60% oxygen uptake reserve or heart rate reserve, 11 to 13 on 6 to 20 RPE scale); 30 to 60 min of continuous or intermittent aerobic exercise (e.g., walking, jogging, cycling, swimming);
  • Resistance exercise 2 to 3 d·wk−1 at an intensity of 60% to 80% 1-RM, including at least 1 set of 8 to 12 repetitions of 8 to 10 different exercises targeting the major muscle groups; modalities include machine or free weights.

As with the previous recommendations by other organizations, ACSM places an emphasis on aerobic exercise but then goes on to state that aerobic exercise “may be supplemented with moderate-intensity resistance training” (1). As an example of a study supporting the inclusion of resistance training, individuals reporting at least 2 d·wk−1 of muscle-strengthening activities were 19% less likely to have prehypertension, an association that supports the potential value of resistance training in promoting health (9).

In a 2013 scientific statement from the AHA, aerobic physical activity at least 30 min·d−1 on most days of the week is recommended (7). Dynamic aerobic exercise had a high level of evidence for lowering blood pressure in addition to the other health parameters such as lipid and glucose levels. Thus aerobic exercise “should be considered the primary alternative modality to help reduce BP” and is in accord with the use of lifestyle modifications to treat prehypertension (7). Resistance exercise also is potentially beneficial and was recommended by the review. The statement acknowledges that the optimal mode, training frequency, intensity, and duration resulting in maximal blood pressure lowering are still areas for future study (7).

A recent meta-analysis including data from more than 5,000 participants demonstrated that endurance training, dynamic resistance training, combined (endurance and resistance training) training, and isometric resistance training significantly reduced diastolic and systolic blood pressure (although the decrease in systolic blood pressure for combined training was not significant) (12). Although the impact of endurance exercise was greatest for participants with hypertension (mean decrease of 8.3 mm Hg for systolic blood pressure and 5.2 mm Hg for diastolic blood pressure), participants with prehypertension also benefited (mean decrease of 4.3 mm Hg for systolic blood pressure and 1.7 mm Hg for diastolic blood pressure) (12). The AHA and ACC recommend that adults of all blood pressure levels, including those with hypertension, include aerobic activity, specifically noting that effective interventions typically include 40 min per session of moderate-to-vigorous activity (13). For participants with prehypertension, endurance training, dynamic resistance training, or combined training had a similar effect and thus the value of resistance training in addition to the typically recommended endurance training supported (12), although additional studies are needed to determine the impact fully (13).

Effectiveness of a physical activity program is foundational; in addition, to achieve potential health benefits, the practicality of incorporating physical activity within the routine of life must be considered. For example, use of 10-min sessions 3 times per day for 5 d·wk−1 was found to be effective for lowering the blood pressure of young, hypertension-prone African American women (reduction of 6.4 mm Hg for systolic blood pressure and decrease in diastolic blood pressure from 90.8 to 87.4 mm Hg) over an 8-wk period (35). A relatively high adherence (72% self-reported frequency and 87% self-reported duration) supports the feasibility of lifestyle physical activity (described as incorporating activity into daily living) (35). Supporting the effectiveness of multiple 10-min sessions, researchers compared individuals with prehypertension who accumulated physical activity (i.e., 4 10-min walking sessions per day) with individuals who engaged in a single session of continuous physical activity (i.e., 40 min of physical activity in a single continuous session). Both groups had reductions in blood pressure, but the accumulated sessions resulted in a greater reduction in blood pressure (33). Considering concerns related to adherence to physical activity, researchers suggest that several 10-min walking sessions may allow for easier incorporation into daily routines than long continuous sessions, although the chronic training effects will need to be examined (33).

The relationship between fitness and development of hypertension has been studied. High normal blood pressure increases the risk of developing hypertension; in a study on women over a 5-year period (Aerobics Center Longitudinal Study), 63% of those with prehypertension at baseline had hypertension at follow-up (5). However the incidence was lower in moderately and highly fit women compared with that in women at low levels of fitness. Researchers conclude that higher levels of fitness conferred substantial protection against development of hypertension in women at higher risk due to prehypertension (5). Similarly male veterans with higher exercise capacity exhibited a lower rate of progression from prehypertension to hypertension, with protective effects of fitness when exercise capacity exceeded 8.5 metabolic equivalents (15).

Combining multiple lifestyle modifications, including increased physical activity, has been effective in altering blood pressure. For individuals with hypertension, the impact of lifestyle recommendations over a 6-month period (including increased physical activity, weight loss, reduced sodium intake, and limited intake for those who drank alcohol) has been demonstrated (reduction of 12.5 mm Hg for systolic blood pressure and 5.8 mm Hg for diastolic blood pressure) (3). Improvements also have been found for nonhypertensive individuals (reduction of 9.4 mm Hg for systolic blood pressure and 5.3 mm Hg for diastolic blood pressure) (3). Similarly after 6 months, men and women with prehypertension in a community-based program of therapeutic lifestyle changes (including exercise training, nutrition, weight management, stress management, and smoking cessation interventions) experienced decreases in both systolic and diastolic blood pressure compared with those in baseline (mean decreases of 7 and 6 mm Hg, respectively, in those with elevated baseline values), with over 38% normalizing their blood pressure (6). Likewise a 12-wk program including dietary changes as well as an exercise program (3 d·wk−1 including aerobic and resistance training) resulted in a decrease in systolic blood pressure for women with prehypertension (resting reduction from 128.2 to 118 mm Hg) (34). The results of these studies support the value of lifestyle modifications even in those with elevated, although not hypertensive, blood pressure.

In a recent review, researchers point out that prehypertension does not typically occur in isolation; 90% of those with prehypertension have been found to have at least one other cardiovascular risk factor (11). This is underscored by the association between prehypertension and stroke as well as the association with risks for cardiovascular disease outcomes (19). A strong inverse association between exercise capacity and all-cause mortality has been observed in younger and older male veterans with prehypertension (26). Exercise is a valuable lifestyle behavior that is overlooked too often. One review article examining the internal and external factors associated with the prevalence of prehypertension concluded with the following: “Our goal is to use exercise as a daily medication that fits every individual worldwide. The challenge is to change the current school of thought that exercise, as a therapy, is only used for a short while until symptoms disappear” (11). Initiating and maintaining an exercise program should be the goal.

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Strategies to Promote Behavior Change

In spite of continued evidence regarding the benefits of physical activity and exercise, far too few adults are sufficiently active (Fig. 2) (31). Figure 2 shows the percentage of American adults who do not meet the 2008 Physical Activity Guidelines for Americans (41) minimum target levels for aerobic and muscle-strengthening activities (31). Optimally the percentage of adults lacking sufficient activity would be 0% (i.e., the intent is 100% of individuals meeting physical activity goals). The figure is not intended to be discouraging, but rather, it is intended to demonstrate opportunity and the need for continued efforts to encourage physical activity.

Figure 2

Figure 2

In a scientific statement from the AHA on cardiovascular risk factor reduction, strategies used to promote behavior change were reviewed and summarized (4). Recommendations for counseling individuals regarding behavior change (dietary and physical activity) include the following:

  • Goal setting
    • ○ Setting goals at the start of a program helps one achieve behavior change.
    • ○ The characteristics of more effective goals are as follows: specific outcomes (rather than vague or absent), focus on behavior rather than a physiological target, appropriately ambitious (not too difficult or too easy), and realistic in terms of an individual’s capacity.
  • Feedback about behavior performance
    • ○ Feedback is important at the initial screening as well as at follow-up assessments.
  • Self-monitoring
    • ○ The purpose of self-monitoring is to increase awareness of physical cues and behaviors and to identify barriers.
    • ○ Examples include paper-based log books and Internet-based programs.
  • Follow-up contacts
    • ○ Frequency and duration should be based on individual needs.
    • ○ Examples include face-to-face communication, telephone, e-mail, and Internet, which can be used along with group-based interventions.
  • Motivational interviewing
    • ○ Motivational interviewing is a style of counseling that involves helping individuals explore and resolve their perspective on behavior change.
  • Enhancement of perceived self-efficacy
    • ○ Sources of perceived self-efficacy include mastery experiences, vicarious experiences, verbal persuasion, and physiological feedback.

Using a combination of strategies is recommended (4). Other strategies of potential value in promoting physical activity changes include the following (4):

  • Incentives
    • ○ For example, a reduction in health premium for specific changes.
  • Modeling
    • ○ For example, personal physical activity training where a credible source provides a “how-to” for exercise.
  • Problem solving
    • ○ Steps in problem solving include identifying and defining the problem, brainstorming solutions, evaluating solutions, implementing the solution, and evaluating the outcome.
  • Relapse prevention
    • ○ With the understanding that lapses do occur, the focus is to recognize situations that will increase risk of lapses from physical activity program and to use behavioral and cognitive strategies to handle such situations.

To fully embrace the potential health-promoting benefits of exercise, a long-term commitment is required. Although knowledge of the value of exercise is foundational, action is the key. The full impact will be realized only when individual preferences and goals are personalized and put into meaningful action. The EIM® Web site provides various resources that health care providers can use (e.g., see the Health Care Providers’ Action Guide available at this link: Additional resources are listed at the end of the article.

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The value of exercise for individuals with prediabetes and prehypertension is supported strongly; future research will continue to provide insights into the optimal prescription and factors that may impact individual responses. Although the content of the current article focuses on the impact of exercise on blood pressure and blood glucose, the value of a complete exercise program for the whole individual, not only for a single condition, must be considered. This comprehensive view of exercise prescription is summarized by ACSM, as follows: “For most adults, an exercise program including aerobic, resistance, flexibility, and neuromotor exercise training is indispensable to improve and maintain physical fitness and health” (1). Medical and health professionals can provide encouragement and guidance related to complete exercise programs in order to potentially halt the progression of prediabetes or prehypertension into a diagnosis of type 2 diabetes or hypertension and to promote overall health and fitness.

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For Patients or Clients

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For Health Professionals

ACSM’s Complete Guide to Fitness & Health (Human Kinetics, 2011), a resource developed under the direction of the American College of Sports Medicine, is listed on the EIM Web site and is therefore noted as a potential client/patient resource. B Bushman served as a compensated editor of this book.

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