2022: Position of Brazilian Diabetes Society on exercise recommendations for people with type 1 and type 2 diabetes
Authors: Pereira William Valadares Campos , Vancea Denise Maria Martins , de Andrade Oliveira Ricardo , de Freitas Yuri Galeno Pinheiro Chaves , Lamounier Rodrigo Nunes , Silva Júnior Wellington S. , Fioretti Andrea Messias Britto , Macedo Clayton Luiz Dornelles , Bertoluci Marcello Casaccia , Zagury Roberto Luis 
Published: January 2023

Abstract
Introduction
For individuals diagnosed with diabetes mellitus, the practice of properly oriented physical exercises brings significant benefits to the individual's health and is considered an indispensable tool for metabolic management. The individualization of exercise routines is an essential aspect for therapeutic success, despite the need to consider some general recommendations. This review is an authorized literal translation of the Brazilian Society of Diabetes (SBD) Guidelines 2021–2022, which is based on scientific evidence and provides guidance on physical activities and exercises aimed at individuals with type 1 and 2 diabetes.

Methods
SBD designated 9 specialists from its “Department of Diabetes, Exercise & Sports” to author chapters on physical activities and exercises directed to individuals with type 1 and 2 diabetes. The aim of these chapters was to highlight recommendations in accordance with Evidence Levels, based on what is described in the literature. These chapters were analyzed by the SBD Central Committee, which is also responsible for the SBD 2021–2022 guidelines. Main clinical inquiries were selected to perform a narrated review by using MEDLINE via PubMed. Top available evidence, such as high-quality clinical trials, large observational studies and meta-analyses related to physical activity and exercise advisory, were analyzed. The adopted MeSh terms were [diabetes], [type 1 diabetes], [type 2 diabetes], [physical activity] [physical exercise].

Results
17 recommendations were defined by the members. For this review, it was considered different Evidence Levels, as well as different Classes of Recommendations. As to Evidence Levels, the following levels were contemplated: Level A) More than one randomized clinical trial or a randomized clinical trial meta-analysis with low heterogeneity. Level B) Meta analysis with observational studies, one randomized clinical trial, sizeable observational studies and sub-groups analysis. Level C) Small non-randomized studies, cross-sectional studies, case control studies, guidelines or experts’ opinions. In respect to Recommendation Classes, the following criteria were adopted: I. “Recommended”: Meaning there was a consent of more than 90% of the panel; IIa. “Must be considered”: meaning there is a general preference of the panel which 70–90% agrees; IIb. “Can be considered”. 50–70% agrees; III Not recommended: There is a consensus that the intervention should not be performed.

Conclusion
Physical exercise aids on the glycemic control of type 2 diabetes individuals while also decreasing cardiovascular risk in individuals with type 1 and 2 diabetes. Individuals diagnosed with diabetes should perform combined aerobic and resistance exercises in order to manage the disease. In addition, exercises focusing on flexibility and balance should be specially addressed on elderly individuals. Diabetes individuals using insulin as therapeutic treatment should properly monitor glycemia levels before, during and after exercise sessions to minimize health incidents, such as hypoglycemia.