DOI: 10.

1113/EP086844

Functional High Intensity Exercise Training Ameliorates Insulin Resistance and

Cardiometabolic Risk Factors in Type 2 Diabetes

Ciarán E Fealy1,2, Stephan Nieuwoudt1,3, Julie A Foucher1, Amanda R Scelsi1, Steve K

Malin1, Mangesh Pagadala1,4, Lauren A Cruz1, Miranda Li1, Michael Rocco5, Bartolome
Burguera6, John P Kirwan1,3

1
Department of Pathobiology, Lerner Research Institute, Cleveland Clinic, Cleveland, OH
2
Department of Biomedical Sciences, Kent State University, Kent, OH
3
Department of Physiology and Biophysics, Case Western Reserve University, Cleveland,
OH
4
Department of Gastroenterology and Hepatology, Cleveland Clinic, Cleveland, OH
5
Department of Cardiology, Cleveland Clinic, Cleveland, OH
6
Endocrinology and Metabolism Institute, Cleveland Clinic, Cleveland, OH

Address for Correspondence:

John P. Kirwan, Ph.D.

Department of Pathobiology

Lerner Research Institute

Cleveland Clinic

9500 Euclid Ave/NE40

Cleveland, OH 44195

Phone: 216 444 3412

Fax: 216 636 1493

[email protected]

This is an Accepted Article that has been peer-reviewed and approved for publication in the
Experimental Physiology, but has yet to undergo copy-editing and proof correction. Please cite this
article as an Accepted Article; doi: 10.1113/EP086844.

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 2

Word Count: 3721

References: 61

Subject Area: Exercise Physiology

Short Title: Crossfit™ Exercise in Type 2 Diabetes

ABSTRACT

Aim

Functional high intensity training (F-HIT) is a novel fitness paradigm that integrates
simultaneous aerobic and resistance training in sets of constantly varied movements, based
on real-world situational exercises, performed at high intensity in workouts that range from
~8-20 min/session. We hypothesized that F-HIT would be an effective exercise mode for
reducing insulin resistance in type 2 diabetes (T2D).

Methods

We recruited 13 overweight/obese adults (5 males, 8 females; 53±7 years; BMI 34.5±3.6

kg•m-2, Mean±SD) with T2D to participate in a 6 week (3d/wk) supervised F-HIT program. An
oral glucose tolerance test was used to derive measures of insulin sensitivity.

Results

F-HIT significantly reduced fat mass (43.8±83.8 vs 41.6±7.9 kg; P<0.01), diastolic blood
pressure (80.2±7.1 vs 74.5±5.8; P<0.01), blood lipids (triglyceride and VLDL, both P<0.05)
and metabolic syndrome z-score (6.4±4.5 vs -0.2±5.2 AU; P<0.001), and increased basal fat
oxidation (FOX: 0.08±0.03 vs 0.10±0.04 g•min-1; P=0.05), and HMW adiponectin
(214.4±88.9 vs 288.8±127.4 ng•mL-1; P<0.01). Importantly, F-HIT also increased insulin
sensitivity (0.037±0.010 vs 0.042±0.010 AU; P<0.05). Increases in HMW adiponectin and
FOX correlated with the change in insulin sensitivity (rho: 0.75; P<0.05, rho: 0.81; P<0.01,
respectively). Compliance with the training program was >95% and no injuries or adverse
events were reported.

Conclusion

These data suggest that F-HIT may be an effective exercise mode for managing T2D. The
increase in insulin sensitivity addresses a key defect in T2D and is consistent with
improvements observed after more traditional aerobic exercise programs in
overweight/obese adults with T2D.

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NEW FINDINGS

What is the central question of this study?

The goal of this study was to examine whether short-duration, high-intensity exercise training
that it combines functional aerobic and resistance exercises into training sessions lasting 8-
20 minute could benefit individuals with type 2 diabetes.

What is the main finding and its importance?

Here we show that Functional High Intensity Training improves insulin sensitivity and
reduces cardiometabolic risk in individuals with type 2 diabetes. These data suggest that this
type of exercise training may be an effective exercise mode for managing T2D. The increase
in insulin sensitivity addresses a key defect in T2D.

Key Words: Crossfit™, diabetes, insulin resistance, insulin sensitivity, obesity

INTRODUCTION

Physical activity remains central to the treatment and prevention of type 2 diabetes
(T2D) and cardiovascular disease, yet empirical evidence for durable exercise training-
induced improvements in insulin sensitivity and cardiovascular health in diabetes is scarce.
Current physical activity recommendations for T2D include at least moderate intensity (40-
60% VO2max), aerobic exercise, 3-5 times per week. In addition to aerobic exercise,
resistance training 2-3 times per week is also recommended, recognising greater benefits
from this combined training than either aerobic or resistance training alone (Colberg et al.,
2016). Such programs typically take more than 5 hours per week to complete. Despite these
recommendations, compliance and adherence to exercise advice continues to remain
disappointingly low. Although patients with prediabetes and T2D report awareness that diet
and physical activity can improve their condition, these patients have not applied this advice
to their own health (Green et al., 2007). In fact, only 42% of US patients with T2D are
reported to have met the guidelines for physical activity (Zhao et al., 2008). One of the most
cited barriers to regular physical activity is lack of time (Korkiakangas et al., 2009).

In order to mitigate this perceived barrier to physical activity, high-intensity exercise

has been proposed as a time-efficient method for achieving cardio-metabolic health
outcomes equivalent to traditional aerobic training programs (Gibala, 2007; Gibala et al.,
2012). Such has been the increased popularity of high-intensity training amongst exercise
specialists and the general public that programs like “boot camp’ – a military-styled fitness
approach (Thompson, 2014) - and high-intensity interval training (HIIT) have become
mainstays in the top 20 worldwide fitness trends since 2010, with HIIT featured in the top 5
in each year since its initial appearance in 2014 (Thompson, 2014). Moreover, Crossfit™,

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which provides a form of Functional High Intensity Training (F-HIT), has established
remarkable participation rates worldwide (Butcher et al., 2015).

HIIT typically involves repeated, short intervals of running or cycling performed at 85-
95% of peak heart rate interspersed with periods of rest or low intensity exercise, while sprint
interval training (SIT) refers to similar modes of exercise performed at ≥100% peak heart
rate (Weston et al., 2013). While these modes of high intensity training may be adequate, or
perhaps superior, alternatives to moderate intensity aerobic exercise for metabolic health
(Boule et al., 2001; Snowling & Hopkins, 2006; Weston et al., 2014; Jelleyman et al., 2015),
they typically lack a resistance exercise component (Weston et al., 2013). Crossfit™, on the
other hand, involves functional high intensity training (F-HIT) that incorporate 2-3 different
exercises per workout including weightlifting, gymnastics, body weight, and endurance type
exercises. The workouts are performed either in the shortest amount of time, for as many
rounds as possible in a given time, or for maximal loads. Despite its growing popularity, few
studies have examined the efficacy of such interventions in the general population (McRae
et al., 2012; Heinrich et al., 2014; Butcher et al., 2015; Murawska-Cialowicz et al., 2015),
and none to our knowledge in individuals with T2D. We therefore examined the effectiveness
of a 6 week CrossFit™ F-HIT intervention in individuals with T2D. We hypothesized that,
given the combined aerobic and resistance components, F-HIT would reduce body fat while
maintaining lean tissue mass, and ameliorate insulin resistance and cardio-metabolic risk in
individuals with T2D.

METHODS

Ethical Approval

The study was approved by the Cleveland Clinic Institutional Review Board (IRB#: 12-436)
and all subjects provided signed informed consent in accordance with guidelines for the
protection of human subjects and the Declaration of Helsinki, except for registration in a
database (clause 35).

Subject Population

We recruited 13 overweight/obese, sedentary adults (5 males, 8 females; age 53±7

years; BMI 34.5±3.6 kg•m-2; mean±SD) with clinically diagnosed non-insulin dependent T2D
from the local community. This dataset includes 12 participants that were described in a
previous publication examining the effect of F-HIT on pancreatic β-cell function in individuals
with T2D (Nieuwoudt et al., 2017). All participants were screened with a medical history and
physical examination, blood and urine chemistry analyses, and a resting and exercise stress
test with 12-lead electrocardiogram. Individuals were excluded from participation if they, 1)
were smokers in the past 5 years, 2) had greater than 5 kg weight change in the previous 6
months, 3) undertook regular exercise (>30 min/day, >3 days/week), 4) had
contraindications to elevated levels of physical activity as indicated by an electrocardiogram,
5) demonstrated any evidence of current or previous hematological, renal, hepatic,
cardiovascular, or pulmonary disease, or 6) patients taking insulin, or thyroid medications.
4

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Female subjects were either, postmenopausal and not using any hormone replacement
therapy, or premenopausal and in the follicular phase of the menstrual cycle during the
testing period. Thus, premenopausal women had baseline testing ~2 weeks prior to the
commencement of the exercise intervention.

Medications & Supplements

All but one participant was taking one (n=5) or more (2 drugs, n=4; >2 drugs, n=3)
oral hypoglycemic agents. These included metformin (n=12), sulfonylureas (n=5), and GLP-1
agonists (n=3). In addition, 5 participants were taking one blood pressure medication and 4
were taking two blood pressure medications. These included thiazide diuretics (n=6), ACE
inhibitors (n=4), ANGII inhibitors (n=3). In addition, seven participants were taking statins. All
participants were instructed under medical supervision to withhold medications for 48 hours
prior to metabolic testing.

Four participants reported taking a daily multivitamin and four also reported taking
vitamin D daily. In addition, aspirin and ibuprofen was taken daily by four participants and
tramadol by one. One participant also reported taking L-Lysine, zinc, cinnamon, and Naftifine
HCl. Additionally two participants were taking fish oil supplements. Medications and
supplement dosages were maintained constant throughout the duration of the study.

Exercise Intervention

Subjects participated in a 6-week F-HIT training program at an established

CrossFit™ gym. An experienced CrossFit™ coach led groups of 2-6 subjects in three
exercise training sessions per week. Training sessions included a warm-up, skill practice,
and one high-intensity workout, performed at >85% HR maximum, ranging in duration from
~8-20 minutes. Over the course of 6-weeks, subjects were exposed to an array of functional
weightlifting, gymnastics, and endurance movements in various combinations such as
deadlifts, clean and snatch, overhead press, gymnastic style ring exercises, box jumps, and
body weight exercises. All subjects completed the same workouts, however, no individual
sessions were replicated - with the exception of session 2 and 18 which was used as a
measure of functional improvement (Nieuwoudt et al., 2017). Examples of specific workouts
are described in table 1. In addition, sample relative heart rate responses from 5 individuals
during a session are presented in Figure 1. Three-day diet records were obtained prior to,
and in the last week of, the exercise intervention to monitor any changes in dietary intake.
Furthermore, subjects were instructed to avoid caffeine consumption for 12- and alcohol for
48-hours prior to testing and to consume the same diet containing 250 g carbohydrate on the
day prior to the pre- and post-study testing days. Post-intervention testing commenced ~24-
36 hours following the last exercise bout.

Body Composition

Height and weight were obtained with participants wearing a standard hospital gown and by
use of a wall-mounted stadiometer and a calibrated scale. BMI was calculated as body mass
(kilograms) divided by the square of height (meters). Body fat distribution, and fat-free mass
5

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were assessed using dual-energy x-ray absorptiometry (iDXA, Lunar Prodigy; GE

Healthcare). Waist circumference was measured up to 3 times with the use of a plastic tape
measure ∼2 cm above the umbilicus. Measurements within 0.5 cm were averaged and used
for analysis.

Blood Pressure.

Blood pressure was measured using an automated platform (DINAMAPProcare 400; GE

Medical Systems) to obtain morning brachial SBP and DBP measurements. Measurements
were performed on the left arm in a lowly lighted room while participants lay semisupine after
10 min of awake rest. Reported data were based on the mean of 3 measurements. Mean
arterial pressure was calculated as 2/3(DBP) + 1/3(SBP). Pulse pressure was estimated by
subtracting DBP from SBP.

Insulin Sensitivity and Substrate Metabolism

Subjects arrived at the Clinical Research Unit following an overnight fast, and lay
supine in bed for 30 minutes followed by assessment of non-protein corrected, whole body
fat oxidation (FOX) by indirect calorimetry using the following equation; (FOX = 1.695(VO2) –
1.701(VCO2) (Peronnet & Massicotte, 1991). Subsequently, a 75 gram OGTT was
administered. Baseline blood draws were obtained from an antecubital vein prior to ingestion
of the glucose drink. Blood samples were drawn in EDTA tubes at 30, 60, 90, 120 and 180
minutes after ingestion. Total and incremental metabolite responses (area under the curve,
tAUC and iAUC, respectively) during the OGTT were calculated using the trapezoidal rule.
Insulin sensitivity during the OGTT was calculated using the modified Stumvoll equation
(Solomon et al., 2014).

Biochemical Analysis and Cardiometabolic Risk Score

Plasma analyses were performed on samples that had been stored at -80°C
immediately following post-draw processing. Glucose was determined using the YSI 2300
STAT Plus analyser (Yellow Springs, OH), and insulin was determined via
radioimmunoassay (Millipore, Billerica, MA). Triglycerides and cholesterol were analysed
using enzymatic methods with an automated platform (Roche Modular Diagnostics,
Indianapolis, IN). Fasting plasma high molecular weight (HMW) adiponectin and resistin
were measured at baseline and following the exercise intervention by ELISA (Millipore,
Billerica, MA). Plasma creatine kinase (CK) was measured using an enzymatic activity assay
(Sigma-Aldrich, St. Louis, MO). Sex-specific z-scores were calculated to determine the
efficacy of the intervention on decreasing the severity of the metabolic syndrome (Malin et
al., 2014)

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Statistical Analyses

Statistical analysis was performed using GraphPad Prism 6.0 (Graphpad Software
Inc., San Diego CA). Values were tested for normality using the D’Agostino & Pearson
omnibus normality test. Pre- to post-intervention changes were assessed using a repeated
measures analysis of variance for normally distributed samples. Pre- to post-changes that
were not normally distributed were assessed using the non-parametric Wilcoxon signed rank
test. Pearson’s correlation was used to examine associations between normally distributed
data. In addition, Spearman’s rank correlation analyses were used to identify relationships
between variables that failed the normality test. Statistical significance was accepted when
P<0.05 and all data are expressed as mean±SD.

RESULTS

Body Composition and Blood Pressure

Anthropometric data for the group are summarised in Table 2. Six-weeks of F-HIT
training did not produce significant changes in body weight or BMI (P=0.11). Regional
changes to body composition are reported in Table 3. Notably, android fat (P<0.05), gynoid
fat (P<0.01), trunk fat (P<0.05), and leg fat (P<0.0001) were all decreased, while lean tissue
remained unchanged. Aerobic fitness (VO2max) was increased after the F-HIT training
program (Nieuwoudt et al., 2017). The 6-week exercise intervention also resulted in a
decrease in diastolic blood pressure (DBP; P<0.01), mean arterial pressure (MAP; P<0.05).

Insulin Sensitivity and Metabolic Syndrome Severity

ISIOGTT was increased in all but one individual following training (Figure 2A). Even
though there was a downward shift in the overall glucose response during the post-
intervention OGTT, total (tAUC; P=0.20) and incremental (iAUC; P=0.85) glucose area under
the curve (Table 4) were not significantly altered. Insulin areas under the curve (tAUC
P=0.16 and iAUC; P=0.88) were unchanged after the intervention (Table 4). Metabolic
syndrome severity was also reduced following the intervention (P<0.001; Figure 2B).

Substrate Metabolism and Blood Biochemistry

F-HIT resulted in significant increases in fat oxidation (P<0.05; Figure 3A) and HMW
adiponectin (P<0.01; Figure 3B) along with reductions in plasma triglycerides (P<0.05) and
VLDL cholesterol (P<0.05) (Table 3). There were also reductions in total cholesterol
(P=0.11) and LDL cholesterol (P=0.15); however, these changes did not reach statistical
significance. Plasma resistin was reduced (P<0.05) after the exercise program (Table 3).
Plasma CK was increased (P<0.05), following 6-weeks of training (Table 3).

Correlation Analysis

The increase in HMW adiponectin and FOX both correlated with the change in
ISIOGTT (P<0.01, Figure 4A and B). Moreover, ISIOGTT changes were correlated with

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decreases in both fasting glucose (Nieuwoudt et al., 2017) (rho -0.26; P<0.05) and tAUC
glucose (rho -0.27; P<0.05). Changes in HMW adiponectin were also associated with
alterations in total fat mass (rho -0.67; P<0.05), while differences in glucose iAUC were
correlated with increases in CK (r=0.61; P<0.05).

DISCUSSION

Exercise training has long been recognised as a key component in the clinical
management of patients with T2D (American Diabetes Association, 2014). Despite this,
adherence to traditional exercise programs is low (Ary et al., 1986; Clark, 1997), with one of
the main barriers to adherence cited as a lack of time (Korkiakangas et al., 2009). Here, we
demonstrate for the first time in patients with T2D, the effectiveness of a novel high intensity
training modality for increasing insulin sensitivity, FOX, and HMW-adiponectin, while
reducing fat mass, plasma triglycerides and cholesterol, metabolic syndrome severity,
diastolic blood pressure, and plasma concentration of the pro-inflammatory adipokine
resistin over the course of a 6-week intervention using short 8-20 minute workouts, 3-days
per week. It is important to note that this was achieved with no injuries reported, and greater
than 95% compliance with the exercise program. This is significant due to the widespread,
and legitimate, concerns expressed within the fitness and scientific community regarding the
safety and efficacy of Crossfit-style F-HIT training programs for individuals with pre-existing
chronic illness (Karstoft et al., 2013; Mitranun et al., 2014; Thompson, 2014). The data
presented herein, however, indicate that F-HIT, performed in a controlled setting, and under
appropriate supervision, is effective for individuals with T2D. Our data also adds to the
growing body of literature which suggests that high intensity exercise interventions may offer
a time efficient approach to achieve outcomes comparable to traditional aerobic exercise
programs.

Glucose lowering is the major focus in the management of patients with T2D
(Inzucchi et al., 2012). Traditional, long duration, moderate intensity aerobic exercise
programs have proven extremely effective at improving insulin sensitivity (Mourier et al.,
1997), reducing HbA1c (Umpierre et al., 2011), and regulating plasma glucose levels
(Holloszy et al., 1986). Indeed, we have observed improvements of ~25% in clamp and
OGTT derived measures of insulin sensitivity with as little as 7-days of moderate intensity
aerobic exercise (Kirwan et al., 2009). However, these interventions lack a resistance
training component, and this is particularly important where weight loss is accompanied by a
loss of lean tissue (Baba et al., 1999; Saris et al., 2000; Brehm et al., 2005; Solomon et al.,
2010). Increasing recognition of the role of lean mass in the regulation of blood glucose in
T2D (Srikanthan & Karlamangla, 2011; Kirwan et al., 2017) has prompted the ADA to add 2-
3 days of resistance training per week to their physical activity recommendations (Colberg et
al., 2016). Nonetheless, while the addition of resistance exercise training to physical activity
recommendations is a welcome step, the added exercise burden is unlikely to increase
adherence to exercise recommendations. We were therefore interested to understand
whether the combination of aerobic and resistance training performed at high intensity would
result in similar improvements in insulin sensitivity to those we have previously observed in

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individuals with T2D (Fenicchia et al., 2004; Kirwan et al., 2009; Ryan, 2010) while
preserving the lean mass sparing benefits of resistance training. The 15% improvement in
insulin sensitivity observed in this study reflects a consistent and positive outcome. This was
achieved while maintaining total and regional lean mass coincident with reductions in total
and regional fat mass.

Despite the improvements insulin sensitivity, we did not observe significant

reductions in glucose area under the curve following the exercise intervention. Several
recent interventional studies have suggested that high intensity exercise programs may
result in improvements in HbA1c (Dunstan et al., 2002; Hansen et al., 2009), and
improvements in glucose homeostasis measured by continuous glucose monitoring (Karstoft
et al., 2014) without apparent differences in glucose AUC during an OGTT. Previous
research indicates that muscle damage from eccentric exercise transiently reduces insulin
sensitivity (Kirwan et al., 1992) and there have been isolated reports of rhabdomyolysis
associated with CrossFit-style exercise (Larsen & Jensen, 2014). However, while eccentric
exercise induced muscle damage is an expected, acute response, training adaptations
rapidly result in a resistance to exercise induced muscle damage (Howatson et al., 2007).
Nonetheless, we considered whether transient impairments in glucose uptake induced by
muscle damage might have contributed to this anomaly and we did observe a modest
increase in circulating CK after the 6-week training intervention. In the absence of a control
group it is unclear whether this change was related to the intervention or just a normal
fluctuation associated with T2D, and although the increases in CK are well below the levels
reported in rhabdomyolysis, we did observe a positive correlation between changes in
plasma CK and glucose iAUC which suggests that a longer intervention may be required to
allow the skeletal musculature to fully adapt to the demands of F-HIT. Moreover, the ISIOGTT
response observed in the current study may, as a result, underestimate the magnitude of
change in glucose homeostasis achievable with F-HIT exercise.

Individuals with T2D are at significantly higher risk for cardiovascular disease, which
can manifest as increased metabolic syndrome severity. This elevated risk persists when
compared to non-diabetic individuals similar in age and body fat distribution (Malin et al.,
2014). Wijndaele et al. (Wijndaele et al., 2006) developed a metabolic syndrome risk score
(z-score) that provides a continuous metric of metabolic syndrome severity. Here we
observed a ~110% decrease in the metabolic syndrome z-score following the exercise
intervention. There are currently few interventional studies that we are aware of that have
examined metabolic syndrome z-score responses to exercise interventions in individuals
with T2D. Nonetheless, the decreased risk observed in the current study appears superior to
a recent study examining z-score risk in individuals with T2D undergoing 16 weeks of either
moderate intensity continuous training 5 days per week (41% reduction), or HIIT 3 days per
week (51% or 1% protocol dependent reduction) (Ramos et al., 2017). This may be due to
the fact that the participants started with higher average baseline z-score values. However, it
should also be noted that the post-intervention average z-score in the current study was
lower compared to the Ramos et al. study, despite a markedly reduced duration of
intervention.

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Components of the metabolic syndrome z-score include fasting plasma glucose,

triglycerides, waist circumference, mean arterial pressure, and high density lipoprotein
content. We observed significant improvements in triglycerides and mean arterial pressure,
while fasting glucose and waist circumference tended towards a significant reduction. The
improvement in MAP was provoked by a significant reduction in diastolic blood pressure of
~5.5 mmHg following the intervention. Notably, this was achieved in a cohort where
significant hypertension was not present. We did not observe changes in systolic blood
pressure or heart rate, however, the duration of the intervention may have been too short to
achieve significant improvements in these outcomes. Nonetheless, the reduction in diastolic
blood pressure represents a significant reduction in mortality risk, especially stroke risk
(Lindenstrom et al., 1995). The reduction in diastolic blood pressure may represent a novel
early adaptation to F-HIT style exercise, compared to HIIT/SIT, in T2D or metabolic
syndrome as several recent reports utilizing 12- and 15 week HIIT or SIT interventions
showed no change in diastolic blood pressure (Stensvold et al., 2010; Mitranun et al., 2014;
Mohr et al., 2014), though notably systolic pressure was reduced in a 12 week intervention
(Mohr et al., 2014). In a 6-week aerobic conditioning and HIIT intervention, diastolic blood
pressure was reduced in older, healthy sedentary men, however, the reduction was
observed in the conditioning component and no further reduction was observed following
HIIT (Grace et al., 2017).

Similar to previous HIIT interventions in participants with T2D or metabolic syndrome

reductions in fat mass (Stensvold et al., 2010; Terada et al., 2013; Mitranun et al., 2014;
Mohr et al., 2014) and plasma triglycerides (Freese et al., 2015) also contributed to the
lowering of cardio-metabolic risk and this was associated with reductions in VLDL
cholesterol. The mechanism for decreased plasma lipids is unclear, though improved
adipose tissue health is likely to be a factor. Our observation of altered adipokines -
increased HMW adiponectin and reduced plasma resistin - support the possible contribution
of improved adipose tissue function leading to improved lipid profiles and overall metabolic
health. Enhanced whole body fat oxidation may also have contributed to reductions in
cardiometabolic risk. Increased fat oxidation is a common adaptation to endurance exercise
(Holloszy & Booth, 1976; Henriksson, 1977; Calles-Escandon et al., 1996; Lund et al., 2017)
and our data suggests that this adaptation is preserved after F-HIT. This increase in fat
oxidation may be attributable, at least in part, to the increases in HMW adiponectin. HMW
adiponectin is a known insulin sensitizer and increases oxidative capacity by signaling
through Sirt1 and AMPK, key cell mediators of mitochondrial biogenesis in muscle that
contribute to increased mitochondrial mass (Iwabu et al., 2010). Indeed the consistent
relationship between HMW-adiponectin, fat oxidation, and insulin resistance, both in cross-
sectional studies (Cnop et al., 2003) and following exercise training programs (Kelly et al.,
2012; Navaneethan et al., 2015), a relationship that is replicated in the current study, support
the hypothesis that mitochondrial adaptations are central to the reductions in insulin
resistance and cardio-metabolic risk in individuals with and without T2D, though the exact
mechanism remains elusive (Holloszy, 2009; Dela & Helge, 2013).

10

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 11

In summary, this proof of principle study suggests that F-HIT, performed under
controlled supervised conditions, is an effective means of improving insulin sensitivity and
reducing cardiometabolic risk in individuals with T2D. Moreover, F-HIT may provide a time
efficient method for reducing the metabolic burden of T2D.

GRANTS

This research was supported by an investigator-initiated grant from CrossFit, Inc.™ (JPK),
Cleveland Clinic research support award RPC 2013-1010, and National Institutes of Health,
National Center for Research Resources Grant UL1RR024989.

Competing Interests

Julie Foucher is an elite CrossFit athlete and has received consulting fees from CrossFit. S
Nieuwoudt, CE Fealy, AR Scelsi, SK Malin, M Pagadala, L Cruz, M Li, M Rocco, B
Burguera, and JP Kirwan have no conflicts of interest relative to this work. CrossFit, Inc™
provided no input to the study design, data analysis, interpretation, or writing of this article.

AUTHOR CONTRIBUTIONS

Author contributions: C.E.F., J.A.F., A.R.S., S.K.M., and J.P.K. conception and design of
research; C.E.F., S.N., A.R.S, M.P., L.C., and M.L. performed experiments; C.E.F., M.R.,
B.B., and J.P.K. analyzed data; C.E.F. and J.P.K. interpreted results of experiments; C.E.F.
prepared figures; C.E.F. drafted manuscript; All authors edited and revised manuscript; All
authors approved final version of manuscript.

ACKNOWLEDGEMENTS

We thank the research volunteers for outstanding dedication and effort, the staff of the
Clinical Research Unit, and the technical staff and students who helped with the
implementation of the study and assisted with data collection. The staff and coaches at
Great Lakes CrossFit in Bedford Heights, Ohio, particularly Patrick Flannery, for the
outstanding work in coaching the research participants through the exercise program.

REFERENCES

American Diabetes Association (2014). Standards of medical care in diabetes--2014.

Diabetes Care 37 Suppl 1, S14-80.

Ary DV, Toobert D, Wilson W & Glasgow RE (1986). Patient perspective on factors
contributing to nonadherence to diabetes regimen. Diabetes Care 9, 168-172.

Baba NH, Sawaya S, Torbay N, Habbal Z, Azar S & Hashim SA (1999). High protein vs high
carbohydrate hypoenergetic diet for the treatment of obese hyperinsulinemic
subjects. Int J Obes Relat Metab Disord 23, 1202-1206.
11

This article is protected by copyright. All rights reserved.

 12

Boule NG, Haddad E, Kenny GP, Wells GA & Sigal RJ (2001). Effects of exercise on
glycemic control and body mass in type 2 diabetes mellitus: a meta-analysis of
controlled clinical trials. JAMA 286, 1218-1227.

Brehm BJ, Spang SE, Lattin BL, Seeley RJ, Daniels SR & D'Alessio DA (2005). The role of
energy expenditure in the differential weight loss in obese women on low-fat and low-
carbohydrate diets. J Clin Endocrinol Metab 90, 1475-1482.

Butcher SJ, Neyedly TJ, Horvey KJ & Benko CR (2015). Do physiological measures predict
selected CrossFit((R)) benchmark performance? Open Access J Sports Med 6, 241-
247.

Calles-Escandon J, Gordan MI, O'Connell M, Sreekumaran Nair K & Danforth Jr. E (1996).
Exercise increases fat oxidation at rest unrelated to changes in energy balance or
lipolysis. Am J Physiology 270, E1009-E1014.

Clark DO (1997). Physical activity efficacy and effectiveness among older adults and
minorities. Diabetes Care 20, 1176-1182.

Cnop M, Havel PJ, Utzschneider KM, Carr DB, Sinha MK, Boyko EJ, Retzlaff BM, Knopp
RH, Brunzell JD & Kahn SE (2003). Relationship of adiponectin to body fat
distribution, insulin sensitivity and plasma lipoproteins: evidence for independent
roles of age and sex. Diabetologia 46, 459-469.

Colberg SR, Sigal RJ, Yardley JE, Riddell MC, Dunstan DW, Dempsey PC, Horton ES,
Castorino K & Tate DF (2016). Physical Activity/Exercise and Diabetes: A Position
Statement of the American Diabetes Association. Diabetes Care 39, 2065-2079.

Dela F & Helge JW (2013). Insulin resistance and mitochondrial function in skeletal muscle.
Int J Biochem Cell Biol 45, 11-15.

Dunstan DW, Daly RM, Owen N, Jolley D, De Courten M, Shaw J & Zimmet P (2002). High-
intensity resistance training improves glycemic control in older patients with type 2
diabetes. Diabetes Care 25, 1729-1736.

12

This article is protected by copyright. All rights reserved.

 13

Fenicchia LM, Kanaley JA, Azevedo JL, Jr., Miller CS, Weinstock RS, Carhart RL & Ploutz-
Snyder LL (2004). Influence of resistance exercise training on glucose control in
women with type 2 diabetes. Metabolism 53, 284-289.

Freese EC, Gist NH, Acitelli RM, McConnell WJ, Beck CD, Hausman DB, Murrow JR,
Cureton KJ & Evans EM (2015). Acute and chronic effects of sprint interval exercise
on postprandial lipemia in women at-risk for the metabolic syndrome. J Appl Physiol
(1985) 118, 872-879.

Gibala MJ (2007). High-intensity interval training: a time-efficient strategy for health

promotion? Curr Sports Med Rep 6, 211-213.

Gibala MJ, Little JP, Macdonald MJ & Hawley JA (2012). Physiological adaptations to low-
volume, high-intensity interval training in health and disease. J Physiol 590, 1077-
1084.

Grace F, Herbert P, Elliott AD, Richards J, Beaumont A & Sculthorpe NF (2017). High
intensity interval training (HIIT) improves resting blood pressure, metabolic (MET)
capacity and heart rate reserve without compromising cardiac function in sedentary
aging men. Exp Gerontol.

Green AJ, Bazata DD, Fox KM & Grandy S (2007). Health-related behaviours of people with
diabetes and those with cardiometabolic risk factors: results from SHIELD. Int J Clin
Pract 61, 1791-1797.

Hansen D, Dendale P, Jonkers RA, Beelen M, Manders RJ, Corluy L, Mullens A, Berger J,
Meeusen R & van Loon LJ (2009). Continuous low- to moderate-intensity exercise
training is as effective as moderate- to high-intensity exercise training at lowering
blood HbA(1c) in obese type 2 diabetes patients. Diabetologia 52, 1789-1797.

Heinrich KM, Patel PM, O'Neal JL & Heinrich BS (2014). High-intensity compared to
moderate-intensity training for exercise initiation, enjoyment, adherence, and
intentions: an intervention study. BMC Public Health 14, 789.

Henriksson J (1977). Training induced adaptation of skeletal muscle and metabolism during
submaximal exercise. J Physiol 270, 661-675.

13

This article is protected by copyright. All rights reserved.

 14

Holloszy JO (2009). Skeletal muscle "mitochondrial deficiency" does not mediate insulin
resistance. Am J Clin Nutr 89, 463S-466S.

Holloszy JO & Booth FW (1976). Biochemical adaptations to endurance exercise in muscle.

Ann Rev Physiol 38, 273-291.

Holloszy JO, Schultz J, Kusnierkiewicz J, Hagberg JM & Ehsani AA (1986). Effects of

exercise on glucose tolerance and insulin resistance. Acta Med Scand (Suppl) 711,
55-65.

Howatson G, Van Someren K & Hortobagyi T (2007). Repeated bout effect after maximal
eccentric exercise. Int J Sports Med 28, 557-563.

Inzucchi SE, Bergenstal RM, Buse JB, Diamant M, Ferrannini E, Nauck M, Peters AL,
Tsapas A, Wender R & Matthews DR (2012). Management of hyperglycaemia in type
2 diabetes: a patient-centered approach. Position statement of the American
Diabetes Association (ADA) and the European Association for the Study of Diabetes
(EASD). Diabetologia 55, 1577-1596.

Iwabu M, Yamauchi T, Okada-Iwabu M, Sato K, Nakagawa T, Funata M, Yamaguchi M,

Namiki S, Nakayama R, Tabata M, Ogata H, Kubota N, Takamoto I, Hayashi YK,
Yamauchi N, Waki H, Fukayama M, Nishino I, Tokuyama K, Ueki K, Oike Y, Ishii S,
Hirose K, Shimizu T, Touhara K & Kadowaki T (2010). Adiponectin and AdipoR1
regulate PGC-1alpha and mitochondria by Ca(2+) and AMPK/SIRT1. Nature 464,
1313-1319.

Jelleyman C, Yates T, O'Donovan G, Gray LJ, King JA, Khunti K & Davies MJ (2015). The
effects of high-intensity interval training on glucose regulation and insulin resistance:
a meta-analysis. Obes Rev 16, 942-961.

Karstoft K, Christensen CS, Pedersen BK & Solomon TP (2014). The acute effects of
interval- Vs continuous-walking exercise on glycemic control in subjects with type 2
diabetes: a crossover, controlled study. J Clin Endocrinol Metab 99, 3334-3342.

Karstoft K, Winding K, Knudsen SH, Nielsen JS, Thomsen C, Pedersen BK & Solomon TP
(2013). The effects of free-living interval-walking training on glycemic control, body

14

This article is protected by copyright. All rights reserved.

 15

composition, and physical fitness in type 2 diabetic patients: a randomized, controlled

trial. Diabetes Care 36, 228-236.

Kelly KR, Blaszczak A, Haus JM, Patrick-Melin A, Fealy CE, Solomon TP, Kalinski MI &
Kirwan JP (2012). A 7-d exercise program increases high-molecular weight
adiponectin in obese adults. Med Sci Sports Exerc 44, 69-74.

Kirwan J, Sacks J & Nieuwoudt S (2017). The essential role of Exercise in the management
of type 2 diabetes. Cleveland Clinic Journal of Medicine 84.

Kirwan JP, Hickner RC, Yarasheski KE, Kohrt WM, Wiethop BV & Holloszy JO (1992).
Eccentric exercise induces transient insulin resistance in healthy individuals. J Appl
Physiol 72, 2197-2202.

Kirwan JP, Solomon TP, Wojta DM, Staten MA & Holloszy JO (2009). Effects of 7 days of
exercise training on insulin sensitivity and responsiveness in type 2 diabetes mellitus.
Am J Physiol Endocrinol Metab 297, E151-156.

Korkiakangas EE, Alahuhta MA & Laitinen JH (2009). Barriers to regular exercise among
adults at high risk or diagnosed with type 2 diabetes: a systematic review. Health
Promot Int 24, 416-427.

Larsen C & Jensen MP (2014). [Rhabdomyolysis in a well-trained woman after unusually

intense exercise.]. Ugeskr Laeger 176.

Lindenstrom E, Boysen G & Nyboe J (1995). Influence of systolic and diastolic blood
pressure on stroke risk: a prospective observational study. Am J Epidemiol 142,
1279-1290.

Lund J, Rustan AC, Lovsletten NG, Mudry JM, Langleite TM, Feng YZ, Stensrud C, Brubak
MG, Drevon CA, Birkeland KI, Kolnes KJ, Johansen EI, Tangen DS, Stadheim HK,
Gulseth HL, Krook A, Kase ET, Jensen J & Thoresen GH (2017). Exercise in vivo
marks human myotubes in vitro: Training-induced increase in lipid metabolism. PLoS
One 12, e0175441.

15

This article is protected by copyright. All rights reserved.

 16

Malin SK, Finnegan S, Fealy CE, Filion J, Rocco MB & Kirwan JP (2014). beta-Cell
dysfunction is associated with metabolic syndrome severity in adults. Metab Syndr
Relat Disord 12, 79-85.

McRae G, Payne A, Zelt JG, Scribbans TD, Jung ME, Little JP & Gurd BJ (2012). Extremely
low volume, whole-body aerobic-resistance training improves aerobic fitness and
muscular endurance in females. Appl Physiol Nutr Metab 37, 1124-1131.

Mitranun W, Deerochanawong C, Tanaka H & Suksom D (2014). Continuous vs interval

training on glycemic control and macro- and microvascular reactivity in type 2
diabetic patients. Scand J Med Sci Sports 24, e69-76.

Mohr M, Nordsborg NB, Lindenskov A, Steinholm H, Nielsen HP, Mortensen J, Weihe P &
Krustrup P (2014). High-intensity intermittent swimming improves cardiovascular
health status for women with mild hypertension. Biomed Res Int 2014, 728289.

Mourier A, Gautier JF, De Kerviler E, Bigard AX, Villette JM, Garnier JP, Duvallet A,
Guezennec CY & Cathelineau G (1997). Mobilization of visceral adipose tissue
related to the improvement in insulin sensitivity in response to physical training in
NIDDM. Effects of branched-chain amino acid supplements. Diabetes Care 20, 385-
391.

Murawska-Cialowicz E, Wojna J & Zuwala-Jagiello J (2015). Crossfit training changes brain-

derived neurotrophic factor and irisin levels at rest, after wingate and progressive
tests, and improves aerobic capacity and body composition of young physically
active men and women. J Physiol Pharmacol 66, 811-821.

Navaneethan SD, Fealy CE, Scelsi AC, Arrigain S, Malin SK & Kirwan JP (2015). A Trial of
Lifestyle Modification on Cardiopulmonary, Inflammatory, and Metabolic Effects
among Obese with Chronic Kidney Disease. Am J Nephrol 42, 274-281.

Nieuwoudt S, Fealy CE, Foucher JA, Scelsi AR, Malin SK, Pagadala MR, Rocco M,
Burguera B & Kirwan JP (2017). Functional High Intensity Training Improves
Pancreatic beta-cell Function in Adults with Type 2 Diabetes. Am J Physiol
Endocrinol Metab, ajpendo 00407 02016.

16

This article is protected by copyright. All rights reserved.

 17

Peronnet F & Massicotte D (1991). Table of nonprotein respiratory quotient: an update. Can
J Sport Sci 16, 23-29.

Ramos JS, Dalleck LC, Borrani F, Beetham KS, Wallen MP, Mallard AR, Clark B, Gomersall
S, Keating SE, Fassett RG & Coombes JS (2017). Low-Volume High-Intensity
Interval Training Is Sufficient to Ameliorate the Severity of Metabolic Syndrome.
Metab Syndr Relat Disord 15, 319-328.

Ryan AS (2010). Exercise in aging: its important role in mortality, obesity and insulin
resistance. Aging health 6, 551-563.

Saris WH, Astrup A, Prentice AM, Zunft HJ, Formiguera X, Verboeket-van de Venne WP,
Raben A, Poppitt SD, Seppelt B, Johnston S, Vasilaras TH & Keogh GF (2000).
Randomized controlled trial of changes in dietary carbohydrate/fat ratio and simple vs
complex carbohydrates on body weight and blood lipids: the CARMEN study. The
Carbohydrate Ratio Management in European National diets. Int J Obes Relat Metab
Disord 24, 1310-1318.

Snowling NJ & Hopkins WG (2006). Effects of different modes of exercise training on

glucose control and risk factors for complications in type 2 diabetic patients: a meta-
analysis. Diabetes Care 29, 2518-2527.

Solomon TP, Haus JM, Kelly KR, Cook MD, Filion J, Rocco M, Kashyap SR, Watanabe RM,
Barkoukis H & Kirwan JP (2010). A low-glycemic index diet combined with exercise
reduces insulin resistance, postprandial hyperinsulinemia, and glucose-dependent
insulinotropic polypeptide responses in obese, prediabetic humans. Am J Clin Nutr
92, 1359-1368.

Solomon TP, Malin SK, Karstoft K, Knudsen SH, Haus JM, Laye MJ, Pedersen M, Pedersen
BK & Kirwan JP (2014). Determining pancreatic beta-cell compensation for changing
insulin sensitivity using an oral glucose tolerance test. Am J Physiol Endocrinol
Metab 307, E822-829.

Srikanthan P & Karlamangla AS (2011). 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 96, 2898-2903.

17

This article is protected by copyright. All rights reserved.

 18

Stensvold D, Tjonna AE, Skaug EA, Aspenes S, Stolen T, Wisloff U & Slordahl SA (2010).
Strength training versus aerobic interval training to modify risk factors of metabolic
syndrome. J Appl Physiol (1985) 108, 804-810.

Terada T, Friesen A, Chahal BS, Bell GJ, McCargar LJ & Boule NG (2013). Feasibility and
preliminary efficacy of high intensity interval training in type 2 diabetes. Diabetes Res
Clin Pract 99, 120-129.

Thompson WR (2014). Worldwide Survey of Fitness Trends for 2015 What's Driving the
Market. Acsms Health & Fitness Journal 18, 8-17.

Umpierre D, Ribeiro PA, Kramer CK, Leitao CB, Zucatti AT, Azevedo MJ, Gross JL, Ribeiro
JP & Schaan BD (2011). Physical activity advice only or structured exercise training
and association with HbA1c levels in type 2 diabetes: a systematic review and meta-
analysis. JAMA 305, 1790-1799.

Weston KS, Wisloff U & Coombes JS (2014). High-intensity interval training in patients with
lifestyle-induced cardiometabolic disease: a systematic review and meta-analysis. Br
J Sports Med 48, 1227-1234.

Wijndaele K, Beunen G, Duvigneaud N, Matton L, Duquet W, Thomis M, Lefevre J &

Philippaerts RM (2006). A continuous metabolic syndrome risk score: utility for
epidemiological analyses. Diabetes Care 29, 2329.

Zhao G, Ford ES, Li C & Mokdad AH (2008). Compliance with physical activity
recommendations in US adults with diabetes. Diabet Med 25, 221-227.

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FIGURE LEGENDS
Figure 1. Relative heart rates for 5 individuals during the “deck of cards” workout (Session
12). During this workout participants performed a set of exercises determined by deck of
cards. In this example, ♣ = Kettlebell Swings; ♠ = Squats; ♥ = Push Ups; ♦ = Sit Ups; Joker =
10 Burpees, and the number of reps performed was determined by the value of the card, ie.
8♦ = 8 Sit Ups. Participants alternated between flipping a card and performing the exercise
with a partner until the deck was finished.

110

105

100
H e a rt R a te (% o f M a x )

95

90

85

80

75

70

65

60
-2 0 2 4 6 8 10 12 14 16 18 20 22 24 26 28 30

T im e ( m in )

Figure 2. A) ISIOGTT was significantly increased and B) metabolic syndrome severity was
reduced following the 6-week intervention. Data are Mean±SD. *P<0.05

A. B.
0.08 15
* *
10
Metabolic Syndrome
(µmol•kg •min •p M )

Severity (z-score)

0.06
Insulin Sensitivity
-1 -1

5
0.04
-1

0.02
-5

0.00 -10
PRE POST PRE POST

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Figure 3. A) Fat oxidation and B) HMW adiponectin are significantly increased following the
intervention. Data are Mean±SD. *P<0.05

A. B.
0.20 * 500 *

HMW Adiponectin (ng mL)

Fat Oxidation (g min-1)


400
0.15


300
0.10
200

0.05 100

0.00 0
PRE POST PRE POST

Figure 4. Correlation between pre- to post- intervention changes in ISIOGTT and A. plasma
HMW adiponectin (rho = 0.70; P<0.05) and, B. whole body fat oxidation (rho = 0.86;
P<0.05). Data were analysed using a Spearman’s rank correlation.

A B

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Table 1. Example workouts performed by participants during the 6-week F-HIT intervention

Day 2 Day 11 Day 16

Warm Up: 3 sets; 15 reps Warmup
 5 Rollouts  Wall ball sit up 3 sets; 10 reps
 5 Dumbbell Press  Overhead Squat  Sampson Stretch
 5 Dumbbell Push  KB swing  Overhead Squats
Press  GHD Sit-Ups
 Hip Extension
 Pull Ups
 Dips
WOD:  Fight Gone Bad  Grace
5 sets; 1 min per 1 min/exercise; 3 sets Clean and jerk
exercise: Row for calories  30 reps; ground to
 Row for calories Wall ball overhead; for time
 Sit ups Sumo deadlift
 Squats high pull
Push Press
Box Jump
Cool 3 sets:  Wall ball (25) 30 reps each:
down:  Maximum Plank hold   Sit up
 Squat
 Flutter kick
Mountain Climbers

Table 2. Participant demographic and anthropometric characteristics, and blood pressure

responses before and after six weeks of F-HIT training. Data are Mean±SD.

Variable PRE POST P-value

Sex (M/F) 5/8 - -
Age (years) 53±7 - -
Height (cm) 168.7±10.1 - -
Weight (kg) 98.2±11.8 96.5±9.2 0.09
BMI (kg•m-2) 34.5±3.6 34.0±3.1 0.11
Waist circumference (cm) 110.7±12.3 108.7±11.7 0.11
SBP (mmHg) 133.8±7.7 132.8±12.3 0.73
DBP (mmHg) 81.0±5.1 75.4±7.1 <0.01
MAP (mmHg) 98.6±5.1 94.6±7.8 <0.05
Pulse Pressure (mmHg) 52.8±6.9 57.4±10.3 0.06

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Table 3. Total and regional fat and lean mass distribution before and after 6-weeks of F-HIT
training. Data are Mean±SD.

Variable PRE POST P-value

Total Fat Mass (kg) 43.0±8.8 40.7±7.9 <0.001
Android Fat (kg) 4.8±1.1 4.4±0.9 <0.05
Gynoid Fat (kg) 6.8±2.1 6.4±2.0 <0.01
Arms Fat (kg) 4.6±1.2 4.4±1.3 0.09
Legs Fat (kg) 11.7±1.9 11.0±1.7 <0.0001
Trunk Fat (kg) 24.4±5.0 23.1±4.5 <0.05
Total Fat-Free Mass (kg) 55.2±7.8 55.5±6.8 0.63
Android Lean (kg) 3.8±0.7 3.7±0.9 0.68
Gynoid Lean (kg) 7.6±1.5 7.7±1.3 0.68
Arms Lean (kg) 6.4±1.3 6.4±1.3 1.00
Legs Lean (kg) 18.3±1.4 18.6±1.7 0.41
Trunk Lean (kg) 25.4±3.6 25.6±3.2 0.58

Table 4. Blood biochemistry changes before and after a 6-week F-HIT intervention. AUC
values were determined from a 3-hour OGTT. All other measures were taken in the morning
following an overnight fast. Data are Mean±SD. ᵜdenotes that data was analyzed using the
non-parametric Wilcoxon signed rank test.

Variable PRE POST P-value

tAUC Glucoseᵜ (mmol•L-1•3h) 2783.7±706.6 2578.4±619.8 0.20
-1
iAUC Glucose (mmol•L •3h) 1049.8±216.9 1038±210.4 0.85
-1
tAUC Insulinᵜ (µU•mL •3h) 10859±8031 12355±10850 0.16
iAUC Insulinᵜ (µU•mL-1•3h) 8464±7403 8555±8763 0.88
-1
Triglycerides (mg•dL )ᵜ 146.7±88.3 110.8±64.9 <0.05
-1
Cholesterol (mg•dL ) 176.9±30.3 160.4±32.7 0.11
VLDL cholesterol (mg•dL-1)ᵜ 29.3±17.6 22.2±13.0 <0.05
-1
LDL cholesterol (mg•dL )ᵜ 96.7±26.1 87.1±29.9 0.15
Resistin (ng•mL-1) 6.4±4.9 5.6±4.4 <0.05
Creatine Kinase (U•L-1) 83.4±17.3 116.2±67.9 <0.05

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