healthcare

Review
Intensity Differences of Resistance Training for Type 2 Diabetic
Patients: A Systematic Review and Meta-Analysis
Tenglong Fan 1 , Man-Hsu Lin 2 and Kijin Kim 1, *

1 Department of Physical Education, Keimyung University, Daegu 42601, Republic of Korea

2 Department of Sport Marketing, Keimyung University, Daegu 42601, Republic of Korea
* Correspondence: [email protected]

Abstract: Resistance training is used as adjunctive therapy for type 2 diabetes (T2DM), and the aim
of this study was to investigate the differences in the treatment effects of different intensities of
resistance training in terms of glycemia, lipids, blood pressure, adaptations, and body measurements.
A comprehensive search was conducted in the PubMed, EMBASE (Excerpta Medica dataBASE),
EBSCO (Elton B. Stephens Company) host, Cochrane Library, WOS (Web of Science), and Scopus
databases with a cut-off date of April 2022, and reference lists of relevant reviews were also consulted.
The literature screening and data extraction were performed independently by two researchers.
RoB2 (Risk of bias 2) tools were used for the literature quality assessment, the exercise intensity
was categorized as medium-low intensity and high intensity, and the meta subgroup analysis was
performed using R Version. A fixed or random effects model was selected for within-group analysis
based on the heterogeneity test, and a random effects model was used for the analysis of differences
between subgroups. A total of 36 randomized controlled trials were included, with a total of
1491 participants. It was found that resistance training significantly improved HbA1c (glycated
hemoglobin), fasting blood glucose, TG (triglycerides), TC (total cholesterol), and LDL (low-density
lipoprotein cholesterol) levels in patients with T2DM and caused a significant reduction in systolic
blood pressure, percent of fat mass, and HOMA-IR (homeostatic model assessment for insulin
resistance) indexes. The effects of high and medium-low intensity resistance training on T2DM
patients were different in terms of HOMA-IR, maximal oxygen consumption, weight, waist-to-hip
ratio, and body mass indexes. Only medium-low intensity resistance training resulted in a decrease
Citation: Fan, T.; Lin, M.-H.; Kim, K.
in HOMA-IR. In addition to weight (MD = 4.25, 95% CI: [0.27, 8.22], I2 = 0%, p = 0.04; MD = −0.33,
Intensity Differences of Resistance
95% CI: [−2.05, 1.39], I2 = 0%, p = 0.76; between groups p = 0.03) and HOMA-IR (MD = 0.11, 95% CI:
Training for Type 2 Diabetic Patients:
[−0.40, −0.63], I2 = 0%, p = 0.85; MD = −1.09, 95% CI: [−1.83, −0.36], I2 = 87%, p = < 0.01; between
A Systematic Review and Meta-
groups p = 0.0085), other indicators did not reach statistical significance in the level of difference
Analysis. Healthcare 2023, 11, 440.
https://doi.org/10.3390/
within the two subgroups of high intensity and medium-low intensity. The treatment effects (merger
healthcare11030440 effect values) of high intensity resistance training were superior to those of medium-low intensity
resistance training in terms of HbA1c, TG, TC, LDL levels and diastolic blood pressure, resting heart
Academic Editor: João Paulo Brito
rate, waist circumference, fat mass, and percentage of fat mass. Therefore, high intensity resistance
Received: 17 December 2022 training can be considered to be a better option to assist in the treatment of T2DM and reduce the
Revised: 27 January 2023 risk of diabetic complications compared to medium-low intensity resistance training. Only one study
Accepted: 2 February 2023 reported an adverse event (skeletal muscle injury) associated with resistance training. Although
Published: 3 February 2023 results reflecting the difference in treatment effect between intensity levels reached no statistical
significance, the practical importance of the study cannot be ignored.

Keywords: resistance training; type 2 diabetes; blood glucose; lipids

Copyright: © 2023 by the authors.
Licensee MDPI, Basel, Switzerland.
This article is an open access article
distributed under the terms and
conditions of the Creative Commons
1. Introduction
Attribution (CC BY) license (https:// Previous studies have shown that mortality from diabetes is declining in high-
creativecommons.org/licenses/by/ income countries; however, due to differences in demographics and lifestyles, the impact
4.0/). of diabetes on society is still expected to increase, especially in developing countries [1].

Healthcare 2023, 11, 440. https://doi.org/10.3390/healthcare11030440 https://www.mdpi.com/journal/healthcare

Healthcare 2023, 11, 440 2 of 22

Additionally, the coronavirus pandemic has been ongoing for more than two years; until
28 June 2022, cases have found from more than 200 countries, more than 540 million
people have been found to be infected, and more than 6.3 million have died [2]. A
survey in the United States showed that diabetic comorbidities patients accounted for
one-third of hospitalized patients who were infected by coronavirus [3]. A survey in
China showed that diabetic comorbidities patients accounted for 19% of hospitalized
coronavirus-infected patients [4]. Clinical investigations have shown that patients with
type 2 diabetes and diabetic comorbidities are at high risk of admission to intensive care
units and death after infection [5,6]. Thus, the impacts of type 2 diabetes on human
health in the post-pandemic era cannot be ignored.
Exercise can be an adjunctive therapy of type 2 diabetes, and its effectiveness in
improving blood glucose, blood lipids, and other physiological indicators has been
demonstrated [7–9]. A meta-analysis demonstrated significant differences in glycemic
and insulin reductions between different intensity subgroups in patients with type 2
diabetes after a period of resistance training [10]. Ishiguro et al. [11] also found that
resistance training can be recommended to patients who are in the early stage of type 2
diabetes for glycemic control and that patients with lower levels of obesity gained more
benefits in this process.
However, thanks to these two meta-analysis studies, we found that: (i) the included
literature differed largely in these two studies; (ii) only glycemic indicators was included
in these two meta-analyses, while lipid indicators, obesity level, and blood pressure were
not studied. The blood lipid indicators total cholesterol, HDL (high-intensity lipoprotein)
cholesterol, and LDL cholesterol, offer better prediction on atherosclerotic cardiovascular
disease comorbidity than glycated hemoglobin [12,13]. Moreover, since obese people are
considered to be a high-risk group in coronavirus-infected patients, indicators of blood
lipids and obesity (i.e., body weight, BMI) need to be studied more thoroughly. Even
though Yang et al. [14] found statistically significant effects in terms of resistance training
on glycated hemoglobin, body mass index, peak oxygen consumption, and maximal heart
rate in a group of patients with type 2 diabetes, research related to the therapeutic effects of
different levels of intensity on various physiological indicators of type 2 diabetic patients
was not conducted.
In general, in the previous meta-analysis studies considered resistance training as an
effective treatment for type 2 diabetes patients, there was a lack of study of the intensity
of exercise and the effectiveness to those indicators mentioned above. The criteria for
selecting an optimum exercise intensity in the process of performing resistance training as
an effective treatment for type 2 diabetes patients still needs to be discovered. The purpose
of this study was therefore to understand the effectiveness of exercise at different intensity
levels in terms of the critical indicators for type 2 diabetes patients.

2. Materials and Methods

2.1. Data Sources and Retrieval Strategies
The PRISMA statement guided the study, which involved searching the PubMed,
EMBASE, EBSCO host, Cochrane Library, WOS, and Scopus databases with a search dead-
line of 5 April 2022. The search strategy used a combination of medicine subject heading
terms and test words provided by the databases (see Appendix A: Search strategies). The
literature retrieved from the six databases was downloaded and imported into Endnote x9,
and the overlapped studies were automatically and manually deleted in it. Two personnel
sorted the remaining studies into five categories, which were (i) not strongly associated
with resistance training and type 2 diabetes, (ii) interventions disqualified, (iii) no random-
ized controlled trials conducted, (iv) experimental subjects not type 2 diabetic patients, and
(v) full text (including conference literature) not available. This study was registered with
PROSPERO (International Prospective Register of Systematic Reviews), under registration
number: CRD42022326530.
Healthcare 2023, 11, 440 3 of 22

2.2. Inclusion and Exclusion Criteria

2.2.1. Inclusion Criteria
The included studies (i) were randomized controlled trials conducted, written in
English, (ii) had type 2 diabetic patients aged ≥17 years as subjects, (iii) arranged only
resistance training intervention to the experimental group, no exercise or only stretching to
the control group, and (iv) included at least one indicators below in the results: glycated
hemoglobin, insulin, HOMA (homeostasis model assessment), fasting glucose, TG (triglyc-
eride), TC (total cholesterol), HDL, LDL, systolic blood pressure, diastolic blood pressure,
BMI, body weight, waist circumference, and waist-hip ratio.

2.2.2. Exclusion Criteria

Studies were excluded which (i) conducted randomized controlled trials with an
intervention period of <4 weeks, (ii) included non-type 2 diabetic patients as subjects,
(iii) obtained no mean ± standard deviation at experimental result data, and (iv) replicated
experimental results in publications.

2.3. Data Extraction and Literature Quality Assessment

Two researchers used Microsoft Excel to extract data from the included studies and
organized them using same sample tables. According to the collected results, the abnor-
mal data were reviewed, and the difference from two tables was verified by rechecking
the studies. The extracted data were as followed: (i) basic information from the study
(e.g., author, country, year of publication, the number of intervention and control groups,
and the characteristics of the participating population, etc.), (ii) resistance training plan
(i.e., training duration, training intensity, and training frequency, etc.), and (iii) randomized
controlled trials-related physiological indicators.
RoB2 tools were used to evaluate the quality of the literature according to five aspects,
which were the randomization process, deviation from the intended intervention, missing
outcome data, measurement of the outcome, and selection of the reported result. The
quality assessment results were classified to low risk, some problems, and high risk. Any
study evaluated as high risk in any one of the five aspects were considered as high risk.

2.4. Subgroup Division

The subgroup was divided by the intensity level of the exercise. The included studies
were classified according to the classifications of resistance training intensity provided
by the American College of Sports Medicine (ACSM), which are medium-low intensity
resistance training (20-less than 75% of 1RM; repetition maximum) and high intensity
resistance training (75–100% of 1RM) [15]. The repetition of exercise was converted to
intensity level according to the “Repetition Percentages of 1RM” developed by Michael
Clark, and the converted intensity values (%; based on 1RM) were substituted into the
corresponding study [16]. This method was also used in the classification of resistance
training intensity in Liu’s study [10]. For progressive resistance training, the training
intensity was taken as the middle value between the lowest and highest intensity value.

2.5. Data Analysis

The meta-analysis was performed using R Version 4.1.3, and the collated data were in
the format of continuous data with the same units. The weighted mean difference (MD) and
95% confidence interval (CI) were used as effect size indicators, and the heterogeneity of the
studies was evaluated by the I2 and p-value of the Q-test. If I2 ≥ 50% or p ≤ 0.1, the study
was said to have heterogeneity among the included experiments. A random effects model
was also used; if I2 ≥ 75%, the difference was significant, requiring careful consideration
of whether to use meta-analysis. A fixed effects model combined the weighted mean
differences for I2 ≤ 50, and a random effects model was used for I2 > 50%. The study
conducted subgroup analyses for each of the included physiological indicators according
 model was also used; if I2 ≥ 75%, the difference was significant, requiring careful consid-
eration of whether to use meta-analysis. A fixed effects model combined the weighted
mean differences for I2 ≤ 50, and a random effects model was used for I2 > 50%. The study
conducted subgroup analyses for each of the included physiological indicators according
Healthcare 2023, 11, 440 4 of 22
to the intensity of resistance training. The differences between subgroups were analyzed
using a random effects model combined values for independent sample t-test.
to the intensity of resistance training. The differences between subgroups were analyzed
3. Results
using a random effects model combined values for independent sample t-test.
3.1. Literature Screening and Quality Assessment
3. Results
Searching for studies published up until 5 April 2022 by medicine subject heading
3.1. Literature Screening and Quality Assessment
terms and test words retrieved a total of 19,812 studies, 1359 of the screened studies re-
lated toSearching
randomizedfor studies published up until 5 April 2022 by medicine subject heading
controlled trials, and 18 references were added from the published
terms and test words retrieved a total of 19,812 studies, 1359 of the screened studies related
literature during manual screening for a total of 1377. A total of 1377 articles were manu-
to randomized controlled trials, and 18 references were added from the published literature
ally screened,
during manualand 464 overlapped
screening for a total ofarticles
1377. Awere excluded,
total of leaving
1377 articles 873 articles.
were manually A total of
screened,
251and
articles were screened
464 overlapped articles out
wereby reviewing
excluded, the 873
leaving titlearticles.
and abstract,
A total ofand
251 211 articles
articles were were
excluded
screenedafter thereviewing
out by full textsthewere reviewed.
title and abstract,Inand
all,211
41articles
articleswere
included
excludednotafter
only
thetype 2
diabetic patients
full texts but also In
were reviewed. non-type 2 diabetic
all, 41 articles patients
included as subjects,
not only 87 papers
type 2 diabetic determined
patients but
thealso non-type
control group2 diabetic patients
to include as subjects, 87
non-stretching papers determined
additional exercise, 69 thepapers
controlhad
groupno to
experi-
include non-stretching additional exercise, 69 papers had no experimental
mental group accepted resistance training as interventions, the trial periods of 6 papers group accepted
resistance training as interventions, the trial periods of 6 papers were too short, 3 papers
were too short, 3 papers were not written in English, and the data were unavailable for 5
were not written in English, and the data were unavailable for 5 papers. The final 40
papers. The final 40 publications were included in the meta-analysis for a literature quality
publications were included in the meta-analysis for a literature quality assessment. The
assessment. The detailed
detailed process is shownprocess
in Figureis1.shown in Figure 1.

Figure 1. 1.
Figure Flow
Flowchart
chartof
ofliterature screening.
literature screening.

The
The RoB2tool
RoB2 toolwas
was used
used to
to assess
assessthethequality
qualityof of
thethe
included studies,
included and and
studies, four four
high-high-
risk papers were excluded. The research of Johannsen et al. [17] was excluded because
risk papers were excluded. The research of Johannsen et al. [17] was excluded because of
of missing experimental results and the high risk of selective publication. Studies by
Plotnikoff et al. [18] and Mavros et al. [19] were excluded due to the high risk in terms of
result data loss. Church et al. [20] were excluded due to the high risk of randomization.
The details of the excluded literature from the literature quality assessment are shown in
Figure 2.
 Healthcare 2023, 11, 440 5 of 22

11, x 5 of 21
A total of 36 publications were included after quality assessment, and the specific
regions with type 2 diabetic subjects included in the literature numbered 1491. Classified
by region, the number of studies and subjects were: Asia (19, 540), Europe (5, 170), North
missing experimental results
America andOceania
(6, 618), the high(3,risk of selective
91), and publication.
South America (3, 72). Studies by Plot-
Four studies included only
male subjects, four studies included only female subjects, and four
nikoff et al. [18] and Mavros et al. [19] were excluded due to the high risk in terms of resultstudies did not give
data loss. Church et al. [20] were excluded due to the high risk of randomization. The with ages
a specific gender ratio. The other 24 studies included both males and females,
rangingliterature
details of the excluded from 19–73 years,
from thepre-experimental
literature qualityglycosylated
assessmenthemoglobin
are shown values ranging from
in Fig-
6.75% up and down to 9.51% up and down, and the duration of intervention for different
ure 2.
groups ranging from 6–52 weeks, with specific information shown in Table 1.

Figure 2. Specific information of theinformation

Figure 2. Specific excluded literature.
of the excluded literature.

3.2. Effect of Different Intensities of Resistance Training on the Adjunctive Therapy of Type 2
A total of 36Diabetes
publications
Patientswere included after quality assessment, and the specific
regions with type 2 diabetic subjects included in the literature numbered 1491. Classified
The therapeutic effects of different intensities of resistance training on blood glucose,
by region, the number
blood of studies
lipids, and
blood subjectscardiopulmonary
pressure, were: Asia (19, 540), Europe
function, and (5, 170), North indices
anthropometrical
America (6, 618), in
Oceania
type 2 diabetic patients are shown in Table 2. Supplementary Figureonly
(3, 91), and South America (3, 72). Four studies included S1 shows the
male subjects, four studies included
screenshots only
of subgroup femalefor
analysis subjects, and four
meta-analysis studies
(source didinnot
of data give
Table 2). a
specific gender ratio. The other 24 studies included both males and females, with ages
ranging from 19–733.2.1.years,
Blood Glucose Indicators glycosylated hemoglobin values ranging
pre-experimental
from 6.75% up and down The studies on HbA1c
to 9.51% (%)down,
up and included 30 randomized
and the duration controlled trials, withfor
of intervention 377 patients
different groups ranging from 6–52 weeks, with specific information shown in Table 1. and 239 in
in the high intensity experimental group and 377 patients in the control group
the medium-low intensity experimental group and 247 in the control group. The results
showed that resistance training had a positive adjunctive therapeutic effect on HbA1c in
Table 1. Characteristics of the literature included in the meta-analysis.
type 2 diabetic patients (MD = −0.41, 95% CI: [−0.64, −0.18], I2 = 67%, Test for overall effect
p < 0.01), and both high intensity
Repeti- resistance training
Fre-and medium-low
Dura- intensity resistance
Coun- RT Female Age training
HbA1Chad Intensity
a positive adjunctive therapeutic effect on HbA1c, with Outcome
the treatment effect
tion Set quency tion
try /CN % (Year) being (%)marginally%1RM Indicators
better in the case of high intensity compared to medium-low intensity
(Times) (t/wk) (k)
resistance training (MD = −0.49, 95% CI: [−0.73, −0.02], I2 = 75%, Test for overall effect
0.02;± MD = −0.33, 95% CI: [−0.75, −0.13], I2 = 56%, Test for overall effect p = 0.01), but
p =8.34
India 12/12 - 51.4 ± 2.2 the difference was
70–80↑ 12 significant
not statistically 2 (p = 30.5268). 12 a.e.g.h.
0.67
The studies on insulin (ng/mL) included 12 randomized controlled trials, with 60 pa-
tients in the high intensity experimental group and 59 in the control group and 120 in
n.s.m.k.i.j.d
the7.52 ±
medium-low intensity experimental group and 126 in the control group. The results
Iran 15/13 53.6 51.76 ± 3.92 80↑ 8 3 3 12 .b.c.a.e.f.g.
showed
0.88 that resistance training reduced the insulin value of type 2 diabetic patients. How-
ever, the difference between the experimental and control groups was h.not statistically
2
significant (MD = −1.27, 95% CI: [−2.79, 0.26], I = 77%, Test for d.a.b.c.e.f.g
overall effect p = 0.10).
Sri 8.27 ±
27/28 50 49.16 ± 8.13Insulin values in81↑ type 2 diabetic 8 patients 3 were lower
2 in the12
experimental group than in
.h.i.j.n.s.o.q
Lanka 1.7
the control group in both subgroups of outcome indicators after experiencing high inten-
.r.
sity and low-medium-intensity resistance training, but this difference was not significant
9.51 ±
Iran 15/14 0 63.48 ± 3 (MD = −1.05, 95% ≥50↓CI: [−3.14, 0.55], I2 1–3
10–15 = 0%, Test
2–3 a. MD = −1.30,
for overall12effect p = 0.35;
95%1.82
CI: [−3.14, 0.55], I2 = 83%, Test for overall effect p = 0.17). The difference between the
two subgroups was also not significant (p = 0.868).
d.b.c.m.s.r.
Iran 14/15 0 21.9 ± 1.97 ≥2 years 50–70↓ 8–15 ii 3 4 8
q.o.n.

Iran 15/13 - 44.33 ± 2.81 8.1 ± 0.8 40–80↓ 8–18 ii 3 3 12 n.s.m.r.c.a.

Healthcare 2023, 11, 440 6 of 22

Table 1. Characteristics of the literature included in the meta-analysis.

RT Female Age HbA1C Intensity Repetition Frequency Duration

Study Country Set Outcome Indicators
/CN % (Year) (%) %1RM (Times) (t/wk) (k)
Ramachandran
India 12/12 - 51.4 ± 2.2 8.34 ± 0.67 70–80↑ 12 2 3 12 a.e.g.h.
et al. [21]
Sabouri et al.
Iran 15/13 53.6 51.76 ± 3.92 7.52 ± 0.88 80↑ 8 3 3 12 n.s.m.k.i.j.d.b.c.a.e.f.g.h.
[22]
Ranasinghe 8.27 ±
Sri Lanka 27/28 50 49.16 ± 8.13 81↑ 8 3 2 12 d.a.b.c.e.f.g.h.i.j.n.s.o.q.r.
et al. [23] 1.7
Gholami
Iran 15/14 0 63.48 ± 3 9.51 ± 1.82 ≥50↓ 10–15 1–3 2–3 12 a.
et al. [24]
Rezaeeshirazi
Iran 14/15 0 21.9 ± 1.97 ≥2 years 50–70↓ 8–15 ii 3 4 8 d.b.c.m.s.r.q.o.n.
et al. [25]
Motahari
Iran 15/13 - 44.33 ± 2.81 8.1 ± 0.8 40–80↓ 8–18 ii 3 3 12 n.s.m.r.c.a.
et al. [26]
Yamamoto
Japan 18/17 45.7 73.25 ± 2.55 7.21 ± 0.81 Medium-low↓ 20 15 Min 7 48 a.s.
et al. [27]
Mogharnasi
Iran 10/8 100 48.52 ± 7.06 ≥3 years 30–80↓ 10–18 ii 3 3 10 n.s.p.r.m.d.b.c.
et al. [28]
Hsieh
China 14/15 63.3 71.2 ± 4.4 7.25 ± 0.76 40–75↓ 8–12 3 3 12 m.l.i.j.n.r.o.d.a.e.f.g.h.
et al. [29]
Botton
Brazil 13/13 40.9 69.6 ± 6.9 7.07 ± 0.67 67 i ↓ 12 3 3 12 a.d.e.f.g.h.
et al. [30]
AminiLari
Iran 12/15 100 45–60 ≥2 years 50–55↓ 8 3 3 12 n.s.r.d.b.
et al. [31]
Shabani
Iran 10/10 100 50.75 ± 5.83 7.45 ± 1.43 40–65↓ 8–12 1–3 iii 3 8 n.s.p.a.d.
et al. [32]
Mahdirejei
Iran 9/9 0 48.61 ± 7.88 7.96 ± 1.62 50–80↓ 8–15 ii 3 3 8 n.s.r.p.m.e.f.g.h.d.a.b.c
et al. [33]
Kadoglou
Greece 23/24 70.2 57 ± 6.3 7.9 ± 0.75 60–80↓ 8–10 2–3 4 24 s.p.i.j.m.d.a.e.f.g.h.b.c.r
et al. [34]
Oliveira
Brazil 10/12 63.6 53.7 ± 9.4 7.71 ± 1.73 ≥50↓ 8–12 4 3 12 d.a.e.f.g.h.n.q.o.p.m.i.j.r.
et al. [35]
Kadoglou
Greece 23/24 74.5 63.08 ± 4.87 7.45 ± 0.45 60–80↓ 6–8 2–3 3 12 s.p.i.j.a.d.e.f.g.h.b.c.m.r.
et al. [36]
Healthcare 2023, 11, 440 7 of 22

Table 1. Cont.

RT Female Age HbA1C Intensity Repetition Frequency Duration

Study Country Set Outcome Indicators
/CN % (Year) (%) %1RM (Times) (t/wk) (k)
Hameed
India 24/24 27.08 44.7 ± 4.9 8.4 ± 0.8 65–70↓ 10 3 2–3 8 a.n.o.e.f.g.h.i.j.
et al. [37]
Yavari
Iran 20/20 53.75 51.5 ± 7.48 7.5 ± 0.89 75–80↑ 8–10 3 3 52 a.d.e.f.g.h.n.s.r.i.j.l.m.
et al. [38]
Jorge
Brazil 12/12 62.5 53.8 ± 9.4 7.63 ± 1.79 89–94↑ 10 2 3 12 s.p.m.i.j.a.d.f.g.c.e.
et al. [39]
Larose
Canada 64/63 36.2 54.75 ± 58.6 7.69 ± 6.97 80 i ↑ 8 2 2–3 22 a.n.s.m.
et al. [40]
Kwon
Seoul, Korea 12/15 - 57.74 ± 5.88 7.23 ± 0.79 40–50↓ 10–15 ii 3 3 12 n.a.b.e.f.g.h.
et al. [41]
Hazley
Britain 6/6 41.7 54 ± 9 7.3 ± 0.95 50–60↓ 15 3 2 8 s.o.p.l.d.a.e.f.g.h.b.c.i.j.
et al. [42]
Ku et al. [43] Korea 13/16 100 56.86 ± 7.32 7.3 ± 0.8 40–50↓ 15–20 ii 3 5 12 n.s.o.a.d.
Gavin
Canada 64/63 34.6 54.75 ± 7.35 7.69 ± 0.88 80 i ↑ 8 2 2–3 22 e.a.g.h.
et.al. [44]
Wycherley
Australia 17/16 - 55.0 ± 8.4 7.45 ± 1.2 70–85↑ 12 2 3 16 n.s.q.o.i.j.d.a.b.e.f.g.h.
et al. [45]
Arora
India 9/10 50 54 ± 3.9 7.67 ± 1.18 70–80↑ 10 3 2 8 a.g.e.f.i.j.l.s.
et al. [46]
Cheung
Australia 20/17 67.6 60.38 ± 7.85 7.31 ± 1.36 67 i ↓ 12 2 5 16 a.s.o.
et al. [47]
Larose
Canada 64/63 36.2 54.75 ± 7.35 7.69 ± 0.88 80 i ↑ 8 2 2–3 22 k.
et al. [48]
Shenoy
India 10/10 40 54 ± 3.89 7.67 ± 0.41 60–100↑ 10 3 2 16 a.d.i.j.l.
et al. [49]
Sigal
Canada 56/59 37.5 54.75 ± 7.35 7.69 ± 0.88 81↑ 8 2–3 3 22 a.i.j.e.f.g.h.n.o.q.r.s.
et al. [50]
Baum
Germany 13/13 40 63.1 ± 6.64 - 70–80↑ 12 3 3 36 d.
et al. [51]
Healthcare 2023, 11, 440 8 of 22

Table 1. Cont.

RT Female Age HbA1C Intensity Repetition Frequency Duration

Study Country Set Outcome Indicators
/CN % (Year) (%) %1RM (Times) (t/wk) (k)
Brooks
USA 31/31 35.48 66 ± 1.58 8.55 ± 0.3 70–80↑ 8 3 3 16 a.
et al. [52]
Castaneda
USA 29/31 64.5 66 ± 1.58 8.55 ± 0.3 60–80↓ 8 3 3 16 a.d.f.g.h.i.j.l
et al. [53]
Dunstan
Australia 11/10 38 50.68 ± 6.79 4.8 years 50–55↓ 10–15 2–3 3 8 n.s.p.b.d.i.j.l.a.
et al. [54]
Ishii
Japan 9/8 0 49.2 ± 8.58 9.22 ± 2.5 40–50↓ 10–20 2 5 6 s.r.
et al. [55]
Honkola
Finland 18/20 55 64.63 ± 2 7.61 ± 1.31 medium↓ 12–15 2 2 20 i.j.e.f.g.h.n.a.
et al. [56]
“i” No specific exercise intensity is given in the text; intensity is defined by the number of single repetitions. “ii” The number of repetitions is the lowest number of repetitions—the
highest number of repetitions in all phases. “iii” The number of sets is the lowest number of sets—the highest number of sets in all phases. “-” indicates that the corresponding value is
not given in the literature and cannot be estimated. “↑” indicates that the intervention used high intensity resistance training or more than half high intensity training; “↓” indicates that
the intervention used medium-low intensity resistance training. The duration of type 2 diabetes was used instead of glycosylated hemoglobin levels in the intervention and control
groups where they were not given. Other ranges are taken as in the original text. a: HbA1c; b: insulin; c: HOMA-IR; d: fasting blood glucose; e: triglycerides; f: total cholesterol;
g: high-density lipoprotein cholesterol; h: low-density lipoprotein cholesterol; i: diastolic blood pressure; j: systolic blood pressure; k: maximum heart rate; l: resting heart rate; m:
maximum oxygen uptake; n: weight; o: waist circumference; p: waist-to-hip ratio; q: body Fat; r: percentage of body fat; s: BMI.
Healthcare 2023, 11, 440 9 of 22

Table 2. Effect of resistance training as an auxiliary to treatment in patients with type 2 diabetes.

Test for
Quantifying Between
Participants Merger Effect Value Overall
Outcome Heterogeneity Groups
RT/NT MD 95%CI Effect
I2 (%) p p p
HbA1c (%) (30) 616/624 −0.41 [−0.64, −0.18] 67 <0.01 <0.01
H 377/377 −0.49 [−0.73, −0.02] 75 <0.01 0.02
0.5268
L-M 239/247 −0.33 [−0.75, −0.13] 56 <0.01 0.01
Insulin (ng/mL) (12) 180/185 −1.27 [−2.79, 0.26] 77 <0.01 0.10
H 60/59 −1.05 [−3.26, 1.15] 0 0.68 0.35
0.8680
L-M 120/126 −1.30 [−3.14, 0.55] 83 <0.01 0.17
HOMA-IR (10) 155/154 −0.82 [−1.46, −0.18] 85 <0.01 0.01
H 55/55 0.11 [−0.40, −0.63] 0 0.85 0.66
0.0085
L-M 100/99 −1.09 [−1.83, −0.36] 87 <0.01 <0.01
FBG (mmol/L) (21) 307/317 −0.52 [−1.00, −0.04] 71 0.053 0.03
H 119/121 −0.23 [−1.37, 0.91] 76 <0.01 0.69
0.4958
L-M 188/196 −0.66 [−1.18, −0.15] 66 <0.01 0.01
TG (mmol/L) (19) 379/390 −0.20 [−0.32, −0.08] 30 0.10 <0.01
H 227/228 −0.28 [−0.44, −0.12] 0 0.88 <0.01
0.1917
L-M 152/162 −0.06 [−0.35, 0.22] 55 0.02 0.67
TC (mmol/L) (17) 274/286 −0.26 [−0.42, −0.09] 0 0.49 <0.01
H 108/107 −0.32 [−0.56, −0.08] 22 0.26 <0.01
0.5884
L-M 166/179 −0.20 [−0.43, 0.03] 0 0.62 0.09
HDL-c (mmol/L) (20) 406/420 −0.02 [−0.06, 0.02] 10 0.33 0.38
H 240/241 −0.01 [−0.06, 0.05] 34 0.14 0.81
0.5243
L-M 166/179 −0.03 [−0.09, 0.03] 0 0.63 0.30
LDL-c (mmol/L) (18) 386/399 −0.18 [−0.30, −0.05] 0 0.64 <0.01
H 206/206 −0.19 [−0.35, −0.03] 6 0.38 0.02
0.8697
L-M 180/193 −0.16 [−0.34, 0.03] 0 0.63 0.10
DBP (mmHg) (17) 320/331 −1.81 [−4.80, 1.19] 81 <0.01 0.24
H 161/165 −2.16 [−5.99, 1.66] 81 <0.01 0.27
0.7956
L-M 159/166 −1.33 [−6.39, 3.74] 83 <0.01 0.61
SBP (mmHg) (17) 320/331 −6.83 [−11.50, −2.61] 72 <0.01 <0.01
H 161/165 −4.36 [−9.74, 1.02] 71 <0.01 0.11
0.2350
L-M 159/166 −9.53 [−16.15, −2.91] 71 <0.01 <0.01
Rest HR (bpm) (6) 88/91 −3.42 [−8.92, 2.09] 71 <0.01 0.22
H 33/35 −3.42 [−8.92, 2.09] 87 <0.01 0.43
0.8661
L-M 55/56 −2.71 [−8.05, 2.63] 0 0.97 0.32
HRmax (bpm) (2) 79/76 −0.10 [−0.83, 0.63] 0 0.81 0.80
H 79/76 −0.10 [−0.83, 0.63] 0 0.81 0.80
L-M
VO2max (ml/kg) (12) 225/221 0.62 [−0.99, 2.23] 81 <0.01 0.45
H 121/116 −0.25 [−3.00, 2.49] 69 0.01 0.86
0.4154
L-M 104/105 1.13 [−0.77, 3.04] 83 <0.01 0.24
Weight (kg) (19) 368/380 0.39 [−1.19, 1.97] 0 0.64 0.63
H 195/196 4.25 [0.27, 8.22] 0 0.75 0.04
0.0382
L-M 173/184 −0.33 [−2.05, 1.39] 0 0.76 0.70
Healthcare 2023, 11, 440 10 of 22

Table 2. Cont.

Test for
Quantifying Between
Participants Merger Effect Value Overall
Outcome Heterogeneity Groups
RT/NT MD 95%CI Effect
I2 (%) p p p
WC (cm) (10) 202/208 −0.75 [−2.24, 0.75] 0 0.85 0.33
H 100/103 −1.49 [−5.55, 2.58] 0 0.82 0.47
0.7006
L-M 102/105 −0.63 [−2.24, 0.98] 0 0.64 0.44
WHR (9) 114/115 −0.02 [−0.03, 0.01] 0 0.43 0.21
H 12/12 0.01 [−0.06, 0.08]
0.4213
L-M 102/103 −0.02 [−0.04, 0.01] 5 0.39 0.14
FM (kg) (6) 147/152 −1.18 [−3.75, 1.39] 51 0.07 0.37
H 115/119 −2.12 [−7.25, 3.01] 64 0.04 0.42
0.7281
L-M 32/33 −1.57 [−3.03, −0.11] 43 0.18 0.03
PFM (%) (13) 243/251 −1.38 [−2.64, −0.12] 52 0.01 0.03
H 103/108 −2.61 [−7.98, 2.75] 76 0.02 0.34
0.6455
L-M 140/143 −0.94 [−1.52, −0.36] 46 0.05 <0.01
BMI (22) 409/410 −0.29 [−0.70, 0.11] 0 0.92 0.15
H 216/218 0.18 [−1.05, 1.41] 0 0.86 0.77
0.4223
L-M 193/192 −0.35 [−0.78, 0.08] 0 0.80 0.11
HbA1c: glycosylated hemoglobin; HOMA-IR: homeostatic model assessment for insulin resistance; FBG: fasting
blood glucose; TG: triglycerides; TC: total cholesterol; HDL-c: high-density lipoprotein cholesterol; LDL-c:
low-density lipoprotein cholesterol; DBP: diastolic blood pressure; SBP: systolic blood pressure; HR: heart rate;
VO2max: maximal oxygen consumption; WC: waist circumference; WHR: waist-to-hip ratio; FM: fat mass; PFM:
percentage of fat mass; BMI: body mass index. The number in parentheses is the number of included studies.

The studies on HOMA-IR included 10 randomized controlled trials, with 55 patients

in the high intensity experimental group and 55 in the control group and 100 participants
in the medium-low intensity experimental group and 99 in the control group. Resistance
training had a significant adjunctive therapeutic effect on reducing HOMA-IR in type
2 diabetic patients (MD = −0.82, 95% CI: [−1.46, −0.18], I 2 = 85%, Test for overall
effect p = 0.01) but only in the high intensity subgroup, with the mean of inter-group
difference of the experimental group being higher than the control group. However, this
difference was not significant. The mean of inter-group differences in the medium-low
intensity subgroup of the experimental group was lower than the control group, and
this difference was statistically significant (MD = −0.82, 95% CI: [−1.46, −0.18], I 2 = 0%,
Test for overall effect p = 0.66; MD = −1.09, 95% CI: [−1.83, −0.36], I 2 = 87%, Test for
overall effect p < 0.01). There was a significant difference between these two subgroups
(p = 0.0085).
The studies on fasting blood glucose (mmol/L) included 21 randomized controlled
trials, with 119 patients in the high intensity experimental group and 121 in the control
group and 188 in the medium-low intensity experimental group and 196 in the control
group. Resistance training had an adjunctive therapeutic effect on reducing fasting blood
glucose value in type 2 diabetic patients. After resistance training, the mean difference
between fasting blood glucose in the experimental and control groups was significant
(MD = −0.52, 95% CI: [−1.00, −0.04], I2 = 71%, Test for overall effect p = 0.03). High
intensity resistance training was not as effective as medium-low intensity training, and only
the mean difference between the experimental and control groups within the medium-low
intensity subgroup was significant (MD = −0.23, 95% CI: [−1.37, 0.91], I2 = 76%, Test
for overall effect p = 0.69; MD = −0.66, 95% CI: [−1.18, −0.15], I2 = 66%, Test for overall
effect p = 0.01). The mean difference between the high intensity and medium-low intensity
subgroups did not differ between groups (p = 0.4958).
Healthcare 2023, 11, 440 11 of 22

3.2.2. Blood Lipid Indicators

To understand the adjunctive therapeutic effect of triglycerides (mmol/L), 19 random-
ized controlled trials were included, with 227 patients in the high intensity experimental
group and 228 in the control group and 152 in the medium-low intensity experimental
group and 162 in the control group. After a certain period of resistance training, patients in
the experimental group had significantly lower triglyceride levels (MD = −0.20, 95% CI:
[−0.32, −0.08], I2 = 30%, Test for overall effect p < 0.01). The treatment effect was better
in the high intensity subgroup than in the medium-low intensity subgroups, and only the
mean values of the experimental and control groups within the high intensity subgroup
were significantly different (MD = −0.28, 95% CI: [−0.44, −0.12], I2 = 0%, Test for overall
effect p < 0.01; MD = −0.06, 95% CI: [−0.35, 0.22], I2 = 55%, Test for overall effect p = 0.67).
Furthermore, the difference between the means of the high intensity and medium-low
intensity subgroups was not significant between groups (p = 0.1917).
In terms of the adjunctive therapeutic effect of total cholesterol (mmol/L), 17 random-
ized controlled trials were included, including 108 patients in the high intensity experimen-
tal group and 107 in the control group and 166 in the medium-low intensity experimental
group and 179 in the control group. The total cholesterol index of the experimental group
was significantly lower than that of the control group after a period of resistance training
(MD = −0.26, 95% CI: [−0.42, −0.09], I2 = 0%, Test for overall effect p < 0.01). The treatment
effect was better in the high intensity group than in the medium-low intensity group,
and the difference between the means of the experimental and control groups was signif-
icant in the high intensity group and not significant in the medium-low intensity group
(MD = −0.32, 95% CI: [−0.56, −0.08], I2 = 22%, Test for overall effect p < 0.01; MD = −0.20,
95% CI: [−0.43, 0.03], I2 = 0%, Test for overall effect p = 0.09). Furthermore, the difference
in the means between the high intensity and medium-low intensity subgroups was not
significant between groups (p = 0.5884).
In the study of HDL cholesterol (mmol/L), 20 randomized controlled trials were
included, with 240 patients in the high intensity experimental group and 241 in the control
group and 166 in the medium-low intensity experimental group and 179 in the control
group. After a period of resistance training, the mean HDL cholesterol levels were lower
in the experimental group than in the control group (MD = −0.02. 95% CI: [−0.06, 0.02],
I2 = 10%), which went against the expectation of researchers. However, this difference was
not significant (p = 0.38). The mean value of the HDL cholesterol experimental group results
was slightly lower in the high intensity group than in the control group. The difference
between the experimental and control data was not significant (MD = −0.01, 95% CI: [−0.06,
0.05], I2 = 34%, Test for overall effect p = 0.81), and the HDL cholesterol experimental group
results in the medium-low intensity groups were lower than those of the control group,
but the difference was also not significant (MD = −0.03, 95% CI: [−0.09, 0.03], I2 = 0%,
Test for overall effect p = 0.30). The difference in means between the high intensity and
medium-low intensity subgroups was insignificant between groups (p = 0.5243).
In the study of LDL cholesterol (mmol/L), 18 randomized controlled trials were
included, including 206 patients in the high intensity experimental group and 206 in the
control group and 180 in the medium-low intensity experimental group and 193 in the
control group. After a period of resistance training, the results were significantly lower in
the experimental group than in the control group (MD = −0.18, 95% CI: [−0.30, −0.05],
I2 = 0%, Test for overall effect p < 0.01). The treatment effect was better in the high intensity
group than in the medium-low intensity group. There was a significant difference between
the mean values of the experimental and control groups in the high intensity group and
a difference which was not significant between the mean values of the experimental and
control groups in the medium-low intensity group (MD = −0.19, 95% CI: [−0.35, −0.03],
I2 = 6%, Test for overall effect p = 0.02; MD = −0.16, 95% CI: [−0.34, 0.03], I2 = 0%, Test for
overall effect p = 0.10). The mean difference between the high intensity and medium-low
intensity subgroups was not significantly different between groups (p = 0.8697).
Healthcare 2023, 11, 440 12 of 22

3.2.3. Blood Pressure

A total of 17 randomized controlled trials were included in terms of the study of
diastolic blood pressure (mmHg), with 161 patients in the high intensity experimental
group and 165 in the control group and 159 in the medium-low intensity experimental
group and 166 in the control group. After a period of resistance training, the mean blood
pressure in the experimental group was lower than the mean blood pressure in the control
group, but this difference was not significant (MD = −1.81, 95% CI: [−4.80, 1.19], I2 = 81%,
Test for overall effect p = 0.24). The difference between experimental and control group
means was slightly greater in the high intensity subgroup than in the medium-low intensity
subgroup. However, the differences between the experimental and control groups within
both subgroups were not significant (MD = −2.16, 95% CI: [−5.99, 1.66], I2 = 81%, Test for
overall effect p = 0.27; MD = −1.33, 95% CI: [−6.39, 3.74], I2 = 83%, Test for overall effect
p = 0.61). Furthermore, the difference in means between the high intensity and medium-low
intensity subgroups was not significant between groups (p = 0.7956).
A total of 17 randomized controlled trials were included in the study of systolic blood
pressure (mmHg), including 161 patients in the high intensity experimental group and
165 in the control group and 159 in the medium-low intensity experimental group and
166 in the control group. After a period of resistance training, the mean systolic blood
pressure in the experimental group was significantly lower than the mean value in the
control group (MD = −6.83, 95% CI: [−11.50, −2.61], I2 = 72%, Test for overall effect p < 0.01).
The reduction in the mean of systolic blood pressure in the high intensity group was not as
great as that in the medium-low intensity group. Only within the medium-low intensity
subgroup did the experimental results differ significantly between the experimental and
control groups (MD = −4.36, 95% CI: [−9.74, 1.02], I2 = 71%, Test for overall effect p = 0.11;
MD = −9.53, 95% CI: [- 16.15, −2.91], I2 = 71%, Test for overall effect p < 0.01). Furthermore,
the reduction in inter-group means in both groups was not significantly different between
groups (p = 0.2350).

3.2.4. Cardiopulmonary Function Indicators

A total of six randomized controlled trials were included in the study of the resting
heart rate (bpm), including 33 patients in the high intensity experimental group and 35 in
the control group and 55 in the medium-low intensity experimental group and 56 in the
control group. After a period of resistance training, the resting heart rate was significantly
lower in the experimental group than in the control group (MD = −3.42, 95% CI: [−8.92,
2.09], I2 = 71%, Test for overall effect p = 0.22). The mean difference in resting heart rate
between the experimental and control groups was slightly higher in the high intensity
subgroup than in the medium-low intensity subgroup. The inter-group differences were not
significant in both subgroups. (MD = −3.42, 95% CI: [−8.92, 2.09], I2 = 87%, Test for overall
effect p = 0.43; MD = −2.71, 95% CI: [−8.05, 2.63], I2 = 0%, Test for overall effect p = 0.32).
The mean difference between the high intensity and medium-low intensity subgroups was
not significantly different (p = 0.8661).
A total of two randomized controlled trials were included in the study of maximal
heart rate (bpm). The experimental group intervention was all high intensity resistance
training, with 79 patients in the experimental group and 76 in the control group. After a
period of high intensity resistance training, the mean maximal heart rate in the experimental
group was lower than that in the control group, but the difference was not significant
(MD = −0.10, 95% CI: [−0.83, 0.63], I2 = 0%. Test for overall effect p = 0.80).
A total of 12 randomized controlled trials were included in the study of maximal
oxygen uptake (ml/kg), with 121 patients in the high intensity experimental group and
116 in the control group and 104 in the medium-low intensity experimental group and 105 in
the control group. After a period of resistance training, the mean of maximal oxygen uptake
was higher in the experimental group than in the control group, but the difference was not
significant (MD = 0.62, 95% CI: [−0.99, 2.23], I2 = 81%, Test for overall effect p = 0.45). The
mean of maximum oxygen uptake in the experimental group of high intensity was lower
Healthcare 2023, 11, 440 13 of 22

than that of the control group, but the difference was not significant (MD = −0.25, 95%
CI: [−3.00, 2.49], I2 = 69%, Test for overall effect p = 0.86). The mean of maximum oxygen
uptake in the experimental group of medium and low intensity was higher than that of the
control group but was not significant (MD = 1.13, 95% CI: [−0.77, 3.0], I2 = 83%, Test for
overall effect p = 0.24), and the mean difference between the high intensity subgroup and
the medium-low intensity subgroup was not significant between groups (p = 0.4154).

3.2.5. Anthropometrical Indicators

A total of 19 randomized controlled trials were included in the body weight study,
with 195 patients in the high intensity experimental group and 196 in the control group and
173 in the medium-low intensity experimental group and 184 in the control group. After
a period of resistance training, the mean weight of the experimental group was higher
than that of the control group, with no significant difference (MD = 0.39, 95% CI: [−1.19,
1.97], I2 = 0%, Test for overall effect p = 0.63). Only the mean value of the experimental
group was lower than that of the control group within the medium-low intensity subgroup
groups. Only the experimental and control groups were statistically different within the
high intensity group (MD = 4.25, 95% CI: [0.27, 8.22], I2 = 0%, Test for overall effect p = 0.04;
MD = −0.33, 95% CI: [−2.05, 1.39], I2 = 0%, Test for overall effect p = 0.70). The difference
between the high intensity and low-medium-intensity subgroups was significant in terms
of the effect on body weight in patients with type 2 diabetes (p = 0.0382).
A total of 10 randomized controlled trials were included in the study of waist cir-
cumference (cm), including 100 patients in the high intensity experimental group and
103 in the control group and 102 in the medium-low intensity experimental group and
105 in the control group. After a period of resistance training, the mean reduction in waist
circumference was greater in the experimental group than in the control group, with a
non-significant difference (MD = −0.75, 95% CI: [−2.24, 0.75], I2 = 0%, Test for overall effect
p = 0.33). The within-group difference was greater in the high intensity subgroup than in
the medium-low intensity subgroup, and this within-group difference was not statistically
significant (MD = −1.49, 95% CI: [−5.55, 2.58], I2 = 0%, Test for overall effect p = 0.47;
MD = −0.63, 95% CI: [−2.24, 0.98], I2 = 0%, Test for (Test for overall effect p = 0.44). The
difference in means between the high intensity and medium-low intensity subgroups was
not significantly different between the two groups (p = 0.7006).
A total of 9 randomized controlled trials were included in the study of waist-to-
hip ratio, including 12 patients in the experimental group and 12 in the control group
in the high intensity group and 102 in the experimental group and 103 in the control
group in the medium-low intensity group. After a period of resistance training, the
mean waist circumference in the experimental group was smaller than the mean waist
circumference in the control group, and the difference was not significant (MD = −0.02,
95% CI: [−0.03, 0.01], I2 = 0.2%, Test for overall effect p = 0.21). The waist-to-hip ratio
was higher in the experimental group with high intensity than in the control group and
lower in the experimental group with medium-low intensity than in the control group,
with the difference not being significant in either group (MD = 0.01, 95% CI: [−0.06, 0.08];
MD = −0.02, 95% CI: [−0.04, 0.01], I2 = 5%, Test for overall effect p = 0.14). There was no
significant difference between groups in the mean difference between the high intensity
subgroup and the medium-low intensity subgroup (p = 0.4213).
A total of 6 randomized controlled trials were included in the study of fat mass (FM,
kg), including 115 patients in the experimental group and 119 in the control group in
high intensity group and 32 in the experimental group and 33 in the control group in the
medium-low intensity group. After a period of resistance training, the mean fat mass
value in the experimental group was lower than in the control group, and the difference
was not significant (MD = −1.18, 95% CI: [−3.75, 1.39], I2 = 51.1%, Test for overall effect
p = 0.37). The value of the difference between the experimental and control groups was
greater in the high intensity group than in the medium-low intensity groups, and only
the difference between the experimental and control groups in the medium-low intensity
Healthcare 2023, 11, 440 14 of 22

groups was significant (MD = −2.12, 95% CI: [−7.25, 3.01], I2 = 64%, Test for overall effect
p = 0.42; MD = −1.57, 95% CI: [−3.03, −0.11], I2 = 43%, Test for overall effect p = 0.03). The
mean difference between the high intensity and medium-low intensity subgroups was not
significantly different (p = 0.7281).
A total of 13 randomized controlled trials were included in the study of the percentage
of fat mass (PBF, %), with 103 patients in the experimental group and 108 in the control
group in high intensity group and 140 in the experimental group and 143 in the control
group in the medium-low intensity group. After a period of resistance training, the mean of
the experimental group was lower than the that of the control group, and this difference was
significant (MD = −1.38, 95% CI: [−2.64, −0.12], I2 = 52.4%, Test for overall effect p = 0.03).
The difference between the experimental and control groups was greater for the high
intensity groups than for the medium-low intensity groups. Only the difference between
the experimental and control groups was significant for the medium-low intensity groups
(MD = −2.69, 95% CI: [−7.98, 2.75], I2 = 76%, Test for overall effect p = 0.34; MD = −0.94,
95% CI: [−1.52, −0.36], I2 = 46%, Test for overall effect p < 0.01). The difference in means
between the high intensity and medium-low intensity subgroups was insignificant between
groups (p = 0.6455).
A total of 22 randomized controlled trials were included in the study of BMI, with
216 patients in the experimental group and 218 in the control group in the high intensity
group and 193 in the experimental group and 192 in control the medium-low intensity
group. After a period of resistance training, the mean of the experimental group was lower
than that of the control group, and the difference was not significant (MD = −0.29, 95% CI:
[−0.70, 0.11], I2 = 0%, Test for overall effect p = 0.15). The mean of the experimental group in
the high intensity group was higher than the control group. The mean of the experimental
group in the medium-low intensity group was lower than the control group, and none of
the differences was significant (MD = 0.18, 95% CI: [−1.05,1.41], I2 = 0%, Test for overall
effect p = 0.77; MD = −0.35, 95% CI: [−0.78, 0.08], I2 = 0%, Test for overall effect p = 0.11).
The mean difference between the experimental and control groups was not significantly
different between the high intensity and medium-low intensity subgroups (p = 0.4223).

3.2.6. Adverse Events

Adverse events were pooled for all studies included in the meta-analysis (including
high risk studies), and only a small number of studies reported hypoglycemic and other
events. The Yavari et al. [38] study reported that two patients withdrew from the trial in the
first month with recurrent hypoglycemia, Castaneda et al. [53] reported seven hypoglycemic
events in the control group, and Church et al. [20] reported 8 serious adverse events in the
resistance training group. However, no events were related to the intervention, including
diverticulitis, emergency hysterectomy, lung cancer, and 5 cardiovascular diseases; only one
adverse event was related to exercise, which was not specifically reported. Jorge et al. [39]
reported a similar incidence of hypoglycemic events in the control and exercise groups.
The Oliveira et al. [35] study reported two hypoglycemic events, and Plotnikoff et al. [18]
reported 8 cases of musculoskeletal muscle injury in the resistance training group, where
skeletal muscle injury affected the participants’ ability to perform resistance training, but
no serious adverse events occurred. Two trials by Reid et al. [57] and Sigal et al. [50] were
discussed the same randomized controlled trial, which reported one adverse event in the
control group. Yamamoto et al. [27] reported one case of hospitalization for depression in
the control group, one case of surgery for lumbar stenosis, and one case of hospitalization
for complete AV block.

4. Discussion
To address the effect of resistance training of different intensities on blood glucose
levels in patients with type 2 diabetes, Liu et al. [10] conducted a meta-analyses on HbA1c,
including 11 high intensity and 9 medium-low intensity trials, and a meta-analyses on
insulin, which had 5 high intensity and 5 medium-low intensity trials, for a total of 24 ran-
Healthcare 2023, 11, 440 15 of 22

domized controlled trials, and concluded that high intensity resistance training had greater
benefits relative to medium-low intensity in terms of HbA1c and insulin attenuation, with
significant differences between groups. However, our meta-analysis on glycemic control
and HbA1c included 15 high intensity randomized controlled trials and 15 medium-low
intensity trials; and on insulin, which included 3 high intensity and 9 medium-low intensity
trials. For a total of 31 trials, with the results showing that the differences in HbA1c and
insulin attenuation between high intensity and medium-low intensity groups were not
statistically significant.
Differing from the study of Liu et al. [10], this study discarded the Chinese Wanfang
database they selected, and added two internationally recognized databases, Cochrane
Library and WOS. In terms of subgroup classification, this study classified randomized
controlled trials with more than half of the duration being high intensity (≥75% 1RM) as
high intensity subgroups and the rest as medium-low intensity subgroups according to
ACSM guidelines. However, Liu et al.’s study [10] gave no specific subgroup classification
criteria. To sum up, our study was more recognized in terms of database selection, more
comprehensive in terms of search strategy, and clearer in terms of subgroup delineation
criteria. The study demonstrated again the role of resistance training in glycemic control
in type 2 diabetic patients, with a more significant effect on HbA1c, insulin, and fasting
glucose stabilization, with no significant difference between high intensity resistance train-
ing and medium-low intensity resistance training in these three aspects. In Liu et al.’s
study [10], Mahdirejei et al. [33] and Kadoglou et al. [36] were classified in the high intensity
subgroup; but, since the the duration of the experiment was less than half, these papers
were classified in the medium-low intensity subgroup. In Liu et al.’s study [10], the studies
by Ishii et al. [55] and Gordon et al. [58] did not find data related to HbA1c. Avros et al. [19],
Church et al. [20], and Plotnikoff et al. [18] were excluded from this study because of their
high risk. All other randomized controlled trials were included in our study, except those
in the Wanfang database.
Holten et al. [59] proved that resistance training increases the protein content of GLUT4
(glucose transporter 4), insulin receptor, protein kinase B-α/β, glycogen synthase (GS), and
GS total activity. This increase in glucose clearance efficiency caused by resistance training
exceeded the effect of increased muscle mass. A prospective study from the UK on the risk
of complications associated with diabetes and HbA1c levels concluded that a 1% decrease
in HbA1c decreased the risk of complications by 21%, and in our study, the difference in
HbA1c within the high intensity subgroup was 0.16% lower than the medium-low intensity
subgroups, which leads to the assumption that using high intensity resistance training as an
intervention would reduce 3.4% diabetes complications risk more than using medium-low
intensity resistance training; and it is also superior to medium-low intensity training in
terms of glycemic control. The study demonstrated for the first time by meta-analysis
that high intensity and medium-low intensity resistance training had a better adjunctive
therapeutic effect on HOMA-IR. This effect was mainly caused by medium-low intensity
resistance training. There was a significant difference in the therapeutic effect between
medium-low intensity and high intensity resistance training.
TG and LDL were also found to be more predictive of atherosclerotic cardiovascular
disease than HbA1c in type 2 diabetic patients. However, no meta-analysis on the effect
of resistance training on lipid levels in type 2 diabetes was found in the current research.
This study is the first research validated by meta-analysis to show that resistance training
is effective in reducing triglycerides, total cholesterol, and LDL cholesterol levels in type
2 diabetic patients, and high intensity resistance training causes a greater reduction in
triglycerides, total cholesterol, and LDL cholesterol levels than medium-low intensity
resistance training. High-density lipoprotein cholesterol is a protective factor for coronary
heart disease, and resistance training does not significantly increase HDL cholesterol levels
in the blood. However, relatively speaking, the reduction in HDL cholesterol concentration
caused by high intensity resistance training is smaller than that caused by medium-low
intensity resistance training [60]. Therefore, although there was no significant difference
Healthcare 2023, 11, 440 16 of 22

between high intensity and medium-low intensity resistance training in terms of blood
lipids, the treatment effect was slightly better in the case of high intensity than medium-low
intensity training.
This meta-analysis study proved that resistance training reduces diastolic and systolic
blood pressure in patients with type 2 diabetes. Due to the complexity of the association
between blood pressure and mortality, it would appear unsuitable to use it as a critical
indicator for making medical decisions. However, a cohort study by Pastor-Barriuso [61]
demonstrated that a reduction in systolic blood pressure reduced the risk of death from
cardiovascular disease of elderly patients aged ≥ 65 years, with a u-shaped correlation
between diastolic blood pressure and the risk of death from cardiovascular disease. In our
study, all type 2 diabetes patients aged ≥ 17 were included, hence it could not prove that the
reduction in systolic and diastolic blood pressure caused by high intensity and medium-low
intensity resistance training can be considered as a critical indicator for clinicians to make
treatment decision regarding intensity selection.
It is worth noting that this meta-analysis showed significant differences in the effects
of the two subgroups (high intensity and medium-low intensity) on both the HOMA-IR
and body weight. High intensity resistance training caused a slightly increase in HOMA-IR,
which was not the effect the researchers expected. In addition, high intensity resistance
training also caused an increase in body weight, while the corresponding FM (kg) and
PFM (%) did not increase. This result arose as result of high intensity exercise being more
effective in terms of FM increase than medium-low exercise, which explained the reason
for the slightly increased BMI value.
Based on the information in the literature included in the meta-analysis, the use of
resistance training as adjunctive therapy for type 2 diabetic patients has been recognized
by researchers. However, there is still a lack of certainty surrounding the question of
whether to use high or medium-low intensity exercise. In this research, there is generally no
significant difference in the adjunctive therapeutic effectiveness between high intensity and
medium-low intensity resistance training for type 2 diabetic patients. However, according
to the differences in experiment results between the experimental and control groups, high
intensity resistance training was found have a greater effect in terms of reducing the HbA1c,
triglyceride, total cholesterol, and LDL cholesterol levels of type 2 diabetic patients than
medium-low intensity resistance training, with it also having a greater effect on diastolic
blood pressure, resting mental, waist circumference, FM (kg), and PFM (%).
However, medium-low intensity resistance training had a greater effect on reducing
insulin, fasting glucose, HDL cholesterol levels, and a slightly greater effect on systolic
blood pressure than high intensity training. In addition, the effect of high and medium-low
intensity resistance training on HOMA-IR, maximal oxygen uptake, body weight, waist-to-
hip ratio, and BMI were opposite. These differences were not statistically significant except
in the cases of HOMA-IR and body weight.
The intervention group with high intensity resistance training had higher HOMA-IR,
body weight, waist-to-hip ratio, and BMI values and lower maximal oxygen uptake than
the control group, but the intervention group with medium-low intensity resistance training
had lower HOMA-IR, body weight, waist-to-hip ratio, BMI values and higher maximal
oxygen uptake than the control group.
Although this study could be the most comprehensive review by far, it is undeniable
that: first, there was high heterogeneity in a portion of the meta-analysis literature, and
this heterogeneity may suggest selecting resistance training in more intensity levels as
an intervention for randomized controlled trials to explore the optimal intensity of resis-
tance training; second, resistance training as an adjunctive therapy should be a long-term
procedure, but the trial periods of only two of the included randomized controlled trials
were longer than two years, demonstrating that this study cannot validate the adjunctive
therapeutic effect of long-term resistance training for type 2 diabetes.
Healthcare 2023, 11, 440 17 of 22

5. Conclusions
Resistance training is a treatment that is effective in patients with type 2 diabetes.
Although the p-value reflecting the difference in treatment effect between medium-low
and high intensity resistance training did not reach statistical significance, the practical
importance of treatment differences cannot be ignored. The weighted mean difference
between the experimental and control groups within the two subgroups indicated that high
intensity resistance training was slightly more effective than medium-low intensity training.
The therapeutic effectiveness in terms of HbA1c indicated that choosing high intensity
resistance training reduced the risk of diabetes complications 3.4% more comparing to
medium-low intensity resistance training.

Supplementary Materials: The following supporting information can be downloaded at: https:
//www.mdpi.com/article/10.3390/healthcare11030440/s1, Figure S1: Screenshots of subgroup
analysis for meta-analysis (source of data in Table 2).
Author Contributions: Conceptualization, T.F. and M.-H.L.; methodology, T.F.; formal analysis, T.F.;
investigation, T.F. and K.K.; resources, T.F.; data curation, T.F.; writing—original draft preparation,
T.F. and M.-H.L.; writing—review and editing, T.F. and M.-H.L.; visualization, T.F.; supervision,
K.K.; project administration, K.K.; funding acquisition, K.K. All authors have read and agreed to the
published version of the manuscript.
Funding: This work was supported by the Ministry of Education of the Republic of Korea and the
National Research Foundation of Korea (NRF-2020S1A5A2A01045037).
Institutional Review Board Statement: The study did not require ethical approval.
Informed Consent Statement: Not applicable.
Data Availability Statement: Data are contained within the article.
Conflicts of Interest: The authors declare no conflict of interest.

Appendix A. Search Strategy

PubMed Search Strategy:

Search Strategy Number

“Diabetes Mellitus, Type 2”[Mesh] OR (Diabetes Mellitus,
Noninsulin-Dependent[Title/Abstract]) OR (Diabetes Mellitus,
Ketosis-Resistant[Title/Abstract]) OR (Diabetes Mellitus, Ketosis
Resistant[Title/Abstract]) OR (Ketosis-Resistant Diabetes Mellitus[Title/Abstract]) OR
(Diabetes Mellitus, Non Insulin Dependent[Title/Abstract]) OR (Diabetes Mellitus,
Non-Insulin-Dependent[Title/Abstract]) OR (Non-Insulin-Dependent Diabetes
Mellitus[Title/Abstract]) OR (Diabetes Mellitus, Stable[Title/Abstract]) OR (Stable
Diabetes Mellitus[Title/Abstract]) OR (Diabetes Mellitus, Type II[Title/Abstract]) OR
(NIDDM[Title/Abstract]) OR (Diabetes Mellitus, Noninsulin
Dependent[Title/Abstract]) OR (Diabetes Mellitus, Maturity-Onset[Title/Abstract])
OR (Diabetes Mellitus, Maturity Onset[Title/Abstract]) OR (Maturity-Onset Diabetes
#1 212,413
Mellitus[Title/Abstract]) OR (Maturity Onset Diabetes Mellitus[Title/Abstract]) OR
(MODY[Title/Abstract]) OR (Diabetes Mellitus, Slow-Onset[Title/Abstract]) OR
(Diabetes Mellitus, Slow Onset[Title/Abstract]) OR (Slow-Onset Diabetes
Mellitus[Title/Abstract]) OR (Type 2 Diabetes Mellitus[Title/Abstract]) OR
(Noninsulin-Dependent Diabetes Mellitus[Title/Abstract]) OR (Noninsulin
Dependent Diabetes Mellitus[Title/Abstract]) OR (Maturity-Onset
Diabetes[Title/Abstract]) OR (Diabetes, Maturity-Onset[Title/Abstract]) OR (Maturity
Onset Diabetes[Title/Abstract]) OR (Type 2 Diabetes[Title/Abstract]) OR (Diabetes,
Type 2[Title/Abstract]) OR (Diabetes Mellitus, Adult-Onset[Title/Abstract]) OR
(Adult-Onset Diabetes Mellitus[Title/Abstract]) OR (Diabetes Mellitus, Adult
Onset[Title/Abstract])
Healthcare 2023, 11, 440 18 of 22

Search Strategy Number

(“Resistance Training”[Mesh] OR (Training, Resistance[Title/Abstract]) OR (Strength
Training[Title/Abstract]) OR (Training, Strength[Title/Abstract]) OR (Weight-Lifting
Strengthening Program[Title/Abstract]) OR (Strengthening Program,
Weight-Lifting[Title/Abstract]) OR (Strengthening Programs,
Weight-Lifting[Title/Abstract]) OR (Weight Lifting Strengthening
Program[Title/Abstract]) OR (Weight-Lifting Strengthening Programs[Title/Abstract])
OR (Weight-Lifting Exercise Program[Title/Abstract]) OR (Exercise Program,
Weight-Lifting[Title/Abstract]) OR (Exercise Programs,
Weight-Lifting[Title/Abstract]) OR (Weight Lifting Exercise Program[Title/Abstract])
#2 15,575
OR (Weight-Lifting Exercise Programs[Title/Abstract]) OR (Weight-Bearing
Strengthening Program[Title/Abstract]) OR (Strengthening Program,
Weight-Bearing[Title/Abstract]) OR (Strengthening Programs,
Weight-Bearing[Title/Abstract]) OR (Weight Bearing Strengthening
Program[Title/Abstract]) OR (Weight-Bearing Strengthening
Programs[Title/Abstract]) OR (Weight-Bearing Exercise Program[Title/Abstract]) OR
(Exercise Program, Weight-Bearing[Title/Abstract]) OR (Exercise Programs,
Weight-Bearing[Title/Abstract]) OR (Weight Bearing Exercise
Program[Title/Abstract]) OR (Weight-Bearing Exercise Programs[Title/Abstract])
#3 #1 AND #2 391
#4 #3 Filters: Randomized Controlled Trial 147

EMBASE Search Strategy:

‘non insulin dependent diabetes mellitus’/exp AND ‘resistance training’/exp

Search Strategy Number

‘non insulin dependent
#1 299,169
diabetes mellitus’/exp
#2 ‘resistance training’/exp 23,271
#3 #1 AND #2 994
#3 AND ‘randomized
#4 230
controlled trial’/de

EBSCO host Search Strategy:

Search Strategy Number

DE “Exercise” OR DE “Physical Activity” OR DE “Aerobic
Exercise” OR DE “Weightlifting” OR DE “Yoga” OR DE
“Exercise Dependence” OR DE “Health Behavior” OR DE
S1 “Kinesiology” OR DE “Movement Therapy” OR DE 1,021,010
“Physical Fitness” OR DE “Sport and Exercise Measures”
OR DE “Sport Psychology” OR DE “Wearable Devices” OR
DE “Weight Control”
S2 DE “Type 2 Diabetes” OR DE “Blood Sugar” 135,774
S3 S1 AND S2 7472
S4 randomized controlled trials→Update 185
Healthcare 2023, 11, 440 19 of 22

Automatic removal of duplicate exports : 145

Cochrane Library Search Strategy:

Search Strategy Number

#1 MeSH descriptor: [Resistance Training] explode all trees 4073
#2 MeSH descriptor: [Diabetes Mellitus, Type 2] explode all trees 19,666
#3 #1 AND #2 125
#4 Trials 125

WOS Search Strategy:

Search Strategy Number

TS = (non insulin dependent diabetes mellitus) OR TS =
(1) 16,147
(Diabetes Mellitus Type 2)
(2) TS = (resistance training)OR TS = (resistance exercise) 7122
(TS = (non insulin dependent diabetes mellitus) OR TS =
(Diabetes Mellitus Type 2)) AND (TS = (resistance training)OR
(3) 335
TS = (resistance exercise)) AND TS = (randomized controlled
trials)
(4) Refine:(Article) 224

Scopus Search Strategy:

Search Strategy Number

TITLE-ABS-KEY(‘non insulin dependent diabetes mellitus’ OR ‘Diabetes
174,313
Mellitus Type 2’)
TITLE-ABS-KEY(‘resistance training’ OR ‘resistance exercise’) 50,934
TITLE-ABS-KEY((‘resistance training’ OR ‘resistance exercise’) AND (‘non
3246
insulin dependent diabetes mellitus’ OR ‘diabetes mellitus type 2’))
TITLE-ABS-KEY((‘resistance training’ OR ‘resistance exercise’) AND (‘non
insulin dependent diabetes mellitus’ OR ‘Diabetes Mellitus Type 2’)) AND 448
(LIMIT-TO (EXACTKEYWORD,”Randomized Controlled Trial” ) )

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