Current Diabetes Reports

, 17:110 | Cite as

Physical Exercise Improves Heart Rate Variability in Patients with Type 2 Diabetes: A Systematic Review

  • Santos Villafaina
  • Daniel Collado-Mateo
  • Juan Pedro Fuentes
  • Eugenio Merellano-Navarro
  • Narcis Gusi
Macrovascular Complications in Diabetes (VR Aroda and A Getaneh, Section Editors)
Part of the following topical collections:
  1. Topical Collection on Macrovascular Complications in Diabetes


Purpose of Review

The aim of the present systematic review is to provide an up-to-date analysis of the research on the effects of exercise programs on heart rate variability (HRV) in individuals with type 2 diabetes mellitus (T2DM). An electronic search of the literature (PubMed, PEDro and Web of Science) was performed. “HRV”, “heart rate variability”, “exercise”, “physical” and “diabetes” were the terms used for article retrieval. Lastly, 15 articles were selected. PRISMA methodology was employed and data were extracted according to the PICOS approach.

Recent Findings

Although HRV is not routinely measured in the management of T2DM, it is an important measure due to its relation with mortality and diabetic neuropathy. Physical exercise has become a therapy for T2DM, because it improves physical fitness and functional capacity, enhances metabolic control and insulin sensitivity, reduces inflammatory markers and neuropathy symptoms and can increase the regenerative capacity of cutaneous axons, slowing or preventing neuropathy progression. However, it is not clear to what extent physical exercise can improve HRV in this population.


Participation in the 15 selected studies was similar in men and women (48.01% men and 51.99% women). All the intervention programs included aerobic training, and it was complemented by strength training in four studies. Duration of physical exercise sessions ranged between 30 and 75 min, the frequency being between 2 and 7 days/week. Statistically significant improvements in groups with diabetes, relative to baseline, were observed in nine studies. More than 3 days per week of aerobic training, complemented by strength training, during at least 3 months seems to improve HRV in T2DM. Weekly frequency might be the most important factor to improve HRV. These aspects could help to design better programs based in scientific evidence, incorporating HRV as an important variable associated with diabetic neuropathy and mortality.


Heart rate variability Type 2 diabetes Autonomic function Physical exercise 



The author DCM is supported by a grant from the Spanish Ministry of Education, Culture and Sport (FPU14/01283). Also, the author SV is supported by a grant from the regional Department of Economy and Infrastructure of the Government of Extremadura and European Social Fund (PD16008). The funders had no role in the study design, data collection and analysis, decision to publish or preparation of the manuscript.

Funding Sources

This research did not receive any specific grant from funding agencies in the public, commercial or not-for-profit sectors.

Compliance with Ethical Standards

Conflict of Interest

Santos Villafaina, Daniel Collado-Mateo, Juan Pedro Fuentes, Eugenio Merellano-Navarro and Narcis Gusi declare that they have no conflicts of interest.

Human and Animal Rights and Informed Consent

This article does not contain any studies with human or animal subjects performed by any of the authors.

Supplementary material

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ESM 1 (DOCX 24 kb)
11892_2017_941_MOESM2_ESM.docx (36 kb)
ESM 2 (DOCX 36 kb)


Papers of particular interest, published recently, have been highlighted as: • Of importance

  1. 1.
    Henson J, Dunstan DW, Davies MJ, Yates T. Sedentary behaviour as a new behavioural target in the prevention and treatment of type 2 diabetes. Diabetes Metab Res Rev. 2016;32:213–20.CrossRefPubMedGoogle Scholar
  2. 2.
    Maser RE, Mitchell BD, Vinik AI, Freeman R. The association between cardiovascular autonomic neuropathy and mortality in individuals with diabetes - A meta-analysis. Diabetes Care. 2003;26(6):1895–901.CrossRefPubMedGoogle Scholar
  3. 3.
    Pop-Busui R, Lu J, Lopes N, Jones TLZ, Investigators BD. Prevalence of diabetic peripheral neuropathy and relation to glycemic control therapies at baseline in the BARI 2D cohort. J Peripher Nerv Syst. 2009;14(1):1–13.CrossRefPubMedPubMedCentralGoogle Scholar
  4. 4.
    Thomas PK. Classification, differential diagnosis, and staging of diabetic peripheral neuropathy. Diabetes. 1997;46:S54–S7.CrossRefPubMedGoogle Scholar
  5. 5.
    Olafsdottir E, Andersson DK, Dedorsson I, Svardsudd K, Jansson SP, Stefansson E. Early detection of type 2 diabetes mellitus and screening for retinopathy are associated with reduced prevalence and severity of retinopathy. Acta Ophthalmol. 2016;94(3):232–9.CrossRefPubMedGoogle Scholar
  6. 6.
    Freeman JV, Dewey FE, Hadley DM, Myers J, Froelicher VF. Autonomic nervous system interaction with the cardiovascular system during exercise. Prog Cardiovasc Dis. 2006;48(5):342–62.CrossRefPubMedGoogle Scholar
  7. 7.
    Dekker JM, Crow RS, Folsom AR, Hannan PJ, Liao D, Swenne CA, et al. Low heart rate variability in a 2-minute rhythm strip predicts risk of coronary heart disease and mortality from several causes - The ARIC study. Circulation. 2000;102(11):1239–44.CrossRefPubMedGoogle Scholar
  8. 8.
    Velcheva I, Damianov P, Mantarova S, Antonova N. Hemorheology and heart rate variability in patients with diabetes mellitus type 2. Clin Hemorheol Microcirc. 2011;49(1–4):513–8.PubMedGoogle Scholar
  9. 9.
    Perin PC, Maule S, Quadri R. Sympathetic nervous system, diabetes, and hypertension. Clin Exp Hypertens. 2001;23(1–2):45–55.CrossRefPubMedGoogle Scholar
  10. 10.
    Osterhues HH, Grossmann G, Kochs M, Hombach V. Heart-rate variability for discrimination of different types of neuropathy in patients with insulin-dependent diabetes mellitus. J Endocrinol Investig. 1998;21(1):24–30.CrossRefGoogle Scholar
  11. 11.
    • Chessa M, Butera G, Lanza GA, Bossone E, Delogu A, De Rosa G, et al. Role of heart rate variability in the early diagnosis of diabetic autonomic neuropathy in children. Herz. 2002;27(8):785–90. This study shows how autonomic dysfunction in individuals with type 1 diabetes is associated with the severity of retinopathy, nephropathy, and peripheral neuropathy. Thus, HRV may be a future risk marker of diabetes complication. Google Scholar
  12. 12.
    Khandoker AH, Al-Angari HM, Khalaf K, Lee S, Almahmeed W, Al Safar HS, et al. Association of Diabetes Related Complications with Heart Rate Variability among a Diabetic Population in the UAE. PloS One. 2017;12(1).Google Scholar
  13. 13.
    Jelinek HF, Tarvainen MP, Cornforth DJ. Renyi Entropy in Identification of Cardiac Autonomic Neuropathy in Diabetes. 2012 Comput Cardiol (Cinc), 39. 2012:909–911.Google Scholar
  14. 14.
    Yun WH, Min SW, Huh J, Ro YJ, Kim CS. Autonomic Changes in Preoperative Uncomplicated Diabetic Patients with Postural Changes. J Int Med Res. 2010;38(5):1764–71.CrossRefPubMedGoogle Scholar
  15. 15.
    Fleischer J, Cichosz SL, Jakobsen PE, Yderstraede K, Gulichsen E, Nygaard H, et al. The degree of autonomic modulation is associated with the severity of microvascular complications in patients with type 1 diabetes. J Diab Sci Technol. 2015;9(3):681–6.CrossRefGoogle Scholar
  16. 16.
    • Singleton JR, Smith AG, Marcus RL. Exercise as Therapy for Diabetic and Prediabetic Neuropathy. Curr Diab Rep. 2015;15(12). This study proves how supervised exercise increased cutaneous regenerative capacity. Google Scholar
  17. 17.
    Balducci S, Iacobellis G, Parisi L, Di Biase N, Calandriello E, Leonetti F, et al. Exercise training can modify the natural history of diabetic peripheral neuropathy. J Diabetes Complicat. 2006;20(4):216–23.CrossRefPubMedGoogle Scholar
  18. 18.
    Allet L, Armand S, de Bie RA, Golay A, Monnin D, Aminian K, et al. The gait and balance of patients with diabetes can be improved: a randomised controlled trial. Diabetologia 2010;53(3):458–66.Google Scholar
  19. 19.
    van der Heijden MMP, van Dooren FEP, Pop VJM, Pouwer F. Effects of exercise training on quality of life, symptoms of depression, symptoms of anxiety and emotional well-being in type 2 diabetes mellitus: a systematic review. Diabetologia. 2013;56(6):1210–25.CrossRefPubMedGoogle Scholar
  20. 20.
    Mann S, Beedie C, Balducci S, Zanuso S, Allgrove J, Bertiato F, et al. Changes in insulin sensitivity in response to different modalities of exercise: a review of the evidence. Diabetes Metab Res Rev. 2014;30(4):257–68.CrossRefPubMedGoogle Scholar
  21. 21.
    Karstoft K, Pedersen BK. Exercise and type 2 diabetes: focus on metabolism and inflammation. Immunol Cell Biol. 2016;94(2):146–50.CrossRefPubMedGoogle Scholar
  22. 22.
    Kluding PM, Pasnoor M, Singh R, Jernigan S, Farmer K, Rucker J, et al. The effect of exercise on neuropathic symptoms, nerve function, and cutaneous innervation in people with diabetic peripheral neuropathy. J Diabetes Complicat. 2012;26(5):424–9.CrossRefPubMedPubMedCentralGoogle Scholar
  23. 23.
    Singleton JR, Marcus RL, Lessard MK, Jackson JE, Smith AG. Supervised Exercise Improves Cutaneous Reinnervation Capacity in Metabolic Syndrome Patients. Ann Neurol. 2015;77(1):146–53.CrossRefPubMedGoogle Scholar
  24. 24.
    Huikuri HV, Stein PK. Clinical application of heart rate variability after acute myocardial infarction. Front Physiol. 2012;3:UNSP 41-UNSPGoogle Scholar
  25. 25.
    Oliveira NL, Ribeiro F, Alves AJ, Teixeira M, Miranda F, Oliveira J. Heart rate variability in myocardial infarction patients: Effects of exercise training. Rev Port Cardiol. 2013;32(9):687–700.PubMedGoogle Scholar
  26. 26.
    Fong SSM, Wong JYH, Chung LMY, Yam TTT, Chung JWY, Lee YM, et al. Changes in heart-rate variability of survivors of nasopharyngeal cancer during Tai Chi Qigong practice. J Phys Ther Sci. 2015;27(5):1577–9.CrossRefPubMedPubMedCentralGoogle Scholar
  27. 27.
    Sridhar B, Haleagrahara N, Bhat R, Kulur AB, Avabratha S, Adhikary P. Increase in the Heart Rate Variability with Deep Breathing in Diabetic Patients after 12-Month Exercise Training. Tohoku J Exp Med. 2010;220(2):107–13.CrossRefPubMedGoogle Scholar
  28. 28.
    Kanaley JA, Goulopoulou S, Franklin RM, Baynard T, Holmstrup ME, Carhart R Jr, et al. Plasticity of heart rate signalling and complexity with exercise training in obese individuals with and without type 2 diabetes. Int J Obes. 2009;33(10):1198–206.CrossRefGoogle Scholar
  29. 29.
    Stuckey MI, Petrella RJ. Heart rate variability in type 2 diabetes mellitus. Crit Rev Biomed Eng. 2013;41(2)(0278-940X (Print)):137–47.Google Scholar
  30. 30.
    Voulgari C, Pagoni S, Vinik A, Poirier P. Exercise improves cardiac autonomic function in obesity and diabetes. Metab Clin Exp. 2013;62(5):609–21.CrossRefPubMedGoogle Scholar
  31. 31.
    Liberati A, Altman DG, Tetzlaff J, Mulrow C, Gotzsche PC, Ioannidis JPA, et al. The PRISMA Statement for Reporting Systematic Reviews and Meta-Analyses of Studies That Evaluate Health Care Interventions: Explanation and Elaboration. PLoS Med. 2009;6(7).Google Scholar
  32. 32.
    Maher CG, Sherrington C, Herbert RD, Moseley AM, Elkins M. Reliability of the PEDro scale for rating quality of randomized controlled trials. Phys Ther. 2003;83(8):713–21.PubMedGoogle Scholar
  33. 33.
    Rosenbrand K, Van Croonenborg J, Wittenberg J. Guideline development. Stud Health Technol Inform. 2008;139:3–21.PubMedGoogle Scholar
  34. 34.
    Camm AJ, Malik M, Bigger JT, Breithardt G, Cerutti S, Cohen RJ, et al. Heart rate variability. Standards of measurement, physiological interpretation, and clinical use. Eur Heart J. 1996;17(3):354–81.CrossRefGoogle Scholar
  35. 35.
    Simmonds MJ, Minahan CL, Serre KR, Gass GC, Marshall-Gradisnik SM, Haseler LJ, et al. Preliminary findings in the heart rate variability and haemorheology response to varied frequency and duration of walking in women 65-74 yr with type 2 diabetes. Clin Hemorheol Microcirc. 2012;51(2):87–99.PubMedGoogle Scholar
  36. 36.
    Pagkalos M, Koutlianos N, Kouidi E, Pagkalos E, Mandroukas K, Deligiannis A. Heart rate variability modifications following exercise training in type 2 diabetic patients with definite cardiac autonomic neuropathy. Br J Sports Med. 2008;42(1).Google Scholar
  37. 37.
    Loimaala A, Huikuri HV, Koobi T, Rinne M, Nenonen A, Vuori I. Exercise training improves baroreflex sensitivity in type 2 diabetes. Diabetes. 2003;52(7):1837–42.CrossRefPubMedGoogle Scholar
  38. 38.
    Kang S-J, Ko K-J, Baek U-H. Effects of 12 weeks combined aerobic and resistance exercise on heart rate variability in type 2 diabetes mellitus patients. J Phys Ther Sci. 2016;28(7):2088–93.CrossRefPubMedPubMedCentralGoogle Scholar
  39. 39.
    Sacre JW, Jellis CL, Jenkins C, Haluska BA, Baumert M, Coombes JS, et al. A six-month exercise intervention in subclinical diabetic heart disease: Effects on exercise capacity, autonomic and myocardial function. Metab Clin Exp. 2014;63(9):1104–14.CrossRefPubMedGoogle Scholar
  40. 40.
    Baynard T, Goulopoulou S, Sosnoff RF, Fernhall B, Kanaley JA. Cardiovagal Modulation and Efficacy of Aerobic Exercise Training in Obese Individuals. Med Sci Sports Exerc. 2014;46(2):369–75.CrossRefPubMedPubMedCentralGoogle Scholar
  41. 41.
    Faulkner MS, Michaliszyn SF, Hepworth JT, Wheeler MD. Personalized Exercise for Adolescents With Diabetes or Obesity. Biol Res Nurs. 2014;16(1):46–54.CrossRefPubMedGoogle Scholar
  42. 42.
    Goit RK, Paudel BH, Khadka R, Roy RK, Shrewastwa MK. Mild-to-moderate intensity exercise improves cardiac autonomic drive in type 2 diabetes. J Diab Investig. 2014;5(6):722–7.CrossRefGoogle Scholar
  43. 43.
    Goulopoulou S, Baynard T, Franklin RM, Fernhall B, Carhart R Jr, Weinstock R, et al. Exercise training improves cardiovascular autonomic modulation in response to glucose ingestion in obese adults with and without type 2 diabetes mellitus. Metab Clin Exp. 2010;59(6):901–10.CrossRefPubMedGoogle Scholar
  44. 44.
    Zoppini G, Cacciatori V, Gemma ML, Moghetti P, Targher G, Zamboni C, et al. Effect of moderate aerobic exercise on sympatho-vagal balance in Type 2 diabetic patients. Diabet Med. 2007;24(4):370–6.CrossRefPubMedGoogle Scholar
  45. 45.
    Figueroa A, Baynard T, Fernhall B, Carhart R, Kanaley JA. Endurance training improves post-exercise cardiac autonomic modulation in obese women with and without type 2 diabetes. Eur J Appl Physiol. 2007;100(4):437–44.CrossRefPubMedGoogle Scholar
  46. 46.
    Howorka K, Pumprla J, Haber P, KollerStrametz J, Mondrzyk J, Schabmann A. Effects of physical training on heart rate variability in diabetic patients with various degrees of cardiovascular autonomic neuropathy. Cardiovasc Res. 1997;34(1):206–14.CrossRefPubMedGoogle Scholar
  47. 47.
    Bhagyalakshmi S, Nagaraja H, Anupama BK, Ramesh B, Prabha A, Niranjan M, et al. Effect of supervised integrated exercise on heart rate variability in type 2 diabetes mellitus. Kardiol Pol. 2007;65(4):363–9.PubMedGoogle Scholar
  48. 48.
    Routledge FS, Campbell TS, McFetridge-Durdle JA, Bacon SL. Improvements in heart rate variability with exercise therapy. Can J Cardiol. 2010;26(6):303–12.CrossRefPubMedPubMedCentralGoogle Scholar
  49. 49.
    Ferriolli E, Pessanha FPAS, Marchesi JCLS. Diabetes and exercise in the elderly. Med Sport Sci. 2014;60:122–9.CrossRefPubMedGoogle Scholar
  50. 50.
    Jelleyman C, Yates T, O'Donovan G, Gray LJ, King JA, Khunti K, et al. The effects of high-intensity interval training on glucose regulation and insulin resistance: a meta-analysis. Obes Rev. 2015;16(11):942–61.CrossRefPubMedGoogle Scholar
  51. 51.
    Hottenrott K, Hoos O, Esperer HD. Heart rate variability and physical exercise. Curr Status Herz. 2006;31(6):544–52.CrossRefGoogle Scholar
  52. 52.
    Achten J, Jeukendrup AE. Heart rate monitoring - Applications and limitations. Sports Med. 2003;33(7):517–38.CrossRefPubMedGoogle Scholar
  53. 53.
    Schwartz AR, Gerin W, Davidson KW, Pickering TG, Brosschot JF, Thayer JF, et al. Toward a causal model of cardiovascular responses to stress and the development of cardiovascular disease. Psychosom Med. 2003;65(1):22–35.CrossRefPubMedGoogle Scholar
  54. 54.
    Higgins JPT, Green S. Cochrane handbook for systematic reviews of interventions: Wiley Online Library; 2008.Google Scholar

Copyright information

© Springer Science+Business Media, LLC 2017

Authors and Affiliations

  • Santos Villafaina
    • 1
  • Daniel Collado-Mateo
    • 1
  • Juan Pedro Fuentes
    • 1
  • Eugenio Merellano-Navarro
    • 2
  • Narcis Gusi
    • 1
  1. 1.Faculty of Sport ScienceUniversity of ExtremaduraCaceresSpain
  2. 2.Facultad de EducaciónUniversidad Autónoma de ChileTalcaChile

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