Sequences of Aerobic and Resistance Exercise in Training and Their Effects on Cardio-metabolic Functions Among Type 2 Diabetes Patients - a Randomized Study
Phase: NA
Conditions: Type 2 Diabetes
Sponsor: Zhejiang University

Sequences of Aerobic and Resistance Exercise and Cardio-metabolic 
Functions in T2D (ARRA)  
NCT06145542 
January 25, 2025 
Study Protocol and Statistical Analysis Plan 
 

Participants 
Fifty-six T2D patients aged 50 years to 70 years, with a duration of T2D of at 
least one year. T2D is diagnosed by physicians according to the following 
criteria: random blood glucose ≥11.1 mmol·L-1 (200 mg·dL-1), fasting plasma 
glucose ≥7.0 mmol·L-1 (126 mg·L-1), oral glucose tolerance test ≥11.1 mmol·L-
1 (200 mg·dL-1), or HbA1c ≥6.5% (48 mmol/mol).  
Exclusion criteria are patients with T1D, diseases diagnosed by physicians that 
are unsuitable for exercise intervention, patients who have regular physical 
activity habits (90min moderate intensity exercise or 75min high intensity 
exercise), and currently under dietary program for weight loss. 
Randomization 
Participants are randomized in a 1:1 ratio into aerobic-then-resistance exercise 
group (AR, n=28) and resistance-then-aerobic exercise group (RA, n=28). 
Randomization is stratified by age and HbA1c (≤ or >medians) with a block size 
of 4.  
Continuous glucose monitoring 
Participants undergo a 14-day continuous glucose monitoring (CGM, FreeStyle 
libre Pro, Abbott Diabetes Care Ltd, Witney, UK) started at two time points: one 
week before initializing the exercise intervention and at the 8th week of the 
intervention. An ambulatory glucose monitoring sensor is attached to the 
posterior aspect of the participants' non-dominant arm, with a guide needle 
implanted into the subcutaneous tissues. Sensor attachment is manipulated by 
a research assistant at the study site, between 8:00 to 10:30 on the same day 
of blood sample collection. Participants do not have access to their own CGM 
data during the monitoring periods. Following the monitoring period, data are 
exported and saved from the sensor using scanner of the CGM system by a 
research assistant at the study site. CGM data collected starting from 00:00 on 
the second day following the sensor attachment until 00:00 on the day of sensor 
detachment are included in the analyses. 
Assessments of regular glycemic outcomes and covariates 
Baseline information included age, sex, duration of T2D, and medication are 
obtained by the specialist physician during the recruitment procedure. Prior to 
the exercise intervention, participants’ body mass index (BMI) and blood 
pressure were measured at the study site. Measurements of participants' 
fasting plasma glucose, fasting insulin, and hemoglobin A1c (HbA1c) are taken 
within the week before and after an 8-week exercise intervention. Following an 
overnight fasting period of ≥8 hours, 10 ml of venous blood is collected before 
breakfast (7:00-8:00), and tested by the Laboratory Department of the 
Community Health Service Center.  
Exercises intervention program 
Exercise intervention is implemented in the gym room at the Community Health 
Service Center. The room was equipped with multiple devices for both aerobic 
and resistance training, which allowed a maximum of six participants to perform 
exercise at the same time. Room temperature is between 18-22 °C, controlled 

by air conditioning. The training program is designed to take place three times 
a week for a total of eight weeks. Exercise intervention is scheduled for 
approximately 70 minutes per session (30 minutes of aerobic and 30 minutes 
of resistance, no break between two types, 5-min of preparation and 5-min 
relaxation stretching movements before and after each intervention), performed 
between 8:00 to 11:00 or between 14:00 to 16:30, Monday through Saturday. 
Exercise sessions starts at least 30 minutes after meals.  
The target heart rate during aerobic exercise is set as resting heart rate (HR) + 
40%-70% of heart rate reserve (HRR). Participants’ HRR was calculated based 
on their resting HR and maximum heart rate (HRmax=208-0.7×age) as HRmax 
- HR. Heart rate monitors (OH1, Polar Oy, Oulu, Finland) are used during all 
exercise sessions to track exercise intensity and ensure that it remained within 
the specified range. Aerobic exercise is performed on bicycle ergometers 
(Ergoselect 100K, Ergoline GmbH, Bitz, Germany) for a continuous 30 minutes 
with a progressive intensity of 40%-70% HRR. Resistance level is set according 
to an adaptive training prior to the first intervention, pedal cadences are 50-
60r/min.  
Resistance exercise is conducted using a set of equipment (Nanjing Kuanyue 
Health Technology Co., Ltd, Nanjing, China) including chest press/ row, leg 
extension/ curl, abdominal/ back, biceps/ triceps, inner/ outer thigh, and push/ 
pull machines. Prior to conducting the 1 repetition maximum (RM) testing for 
the major muscles of the upper and lower limbs, all participants receive proper 
instructions on how to use the equipment. The Brzycki 1-RM prediction 
equation is used to estimate the 1RM based on the recorded resistance and 
repetitions. All participants performed resistance exercise with a weight of 60%-
80% 1RM. Movements on each machine are repeated 10-12 times per unit for 
a total of 4 units, with a-30 second break between units. Resistance training 
involves progressive overload over an 8-week period.  
In all intervention sessions, participants in AR group complete aerobic exercise 
before starting resistance exercise, while participants in RA group performe two 
types of exercise in a reversed order. Participants are instructed to maintain 
their usual lifestyle but refrain from engaging in other forms of regular exercise 
throughout the intervention period. Prior to enrollment and during the 
intervention period, weekly dietary guidance on diabetes management is 
delivered by a dietitian from the Community Health Service Center to minimize 
the possibility of dietary changes during the intervention. 
Statistical analysis plan 
A sample size of 54 participants is considered adequate to achieve 95% power 
for detecting within-between interactions, using measures taken at pre- and 
post-intervention time points, based on a medium effect size (f = 0.25, G*Power, 
version 3.0.10). Analyses are carried out following the intention-to-treat 
principle. The personnel who conduct the analyses are blinded about 
participants’ randomization group. Data are checked for normality by using the 
Shapiro-Wilk test. Between group comparisons of the outcome variables are 

conducted using analysis of covariance (ANCOVA), controlling for the baseline 
value of the variable of interest, while within-group pre-post-intervention 
comparisons are performed using paired samples t-tests. Between-group 
comparisons of non-normally distributed outcome variables are conducted 
using the Mann-Whitney U test, and within-group comparisons are conducted 
using the Wilcoxon signed-rank test. Repeated measures analysis of variance 
(ANOVA) is used to analyze blood glucose levels at various time points during 
exercise and recovery periods (90 minutes post-exercise), including the main 
effects of time and group, as well as interaction between time × group. 
Additionally, the change rates of overnight blood glucose levels recorded by 
CGM on non-exercise days are analyzed for the main effect of group. Between 
group comparisons of baseline values are analyzed using independent 
samples t-tests, Mann-Whitney U test, or chi-square test. All tests are two-tailed, 
P values < 0.05 are considered statistically significant. All analyses are 
performed using SPSS statistical software version 26 (IBM Corp., Armonk, NY, 
USA).