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The effects of resistance training on hemoglobin A1c, body mass index, and muscle strength in patients with diabetes mellitus based on age (middle-aged and older adults): a systematic review and meta-analysis

Awurabena Quayeba Dadzie1orcid, Priscilla Mary Ntim Babae1orcid, Denny Maurits Ruku2orcid
Osong Public Health and Research Perspectives 2025;16(6):534-551.
Published online: October 30, 2025

1Department of Public Health, Adventist University of the Philippines, Silang, Philippines

2Department of Nursing, Klabat University, Manado, Indonesia

Corresponding author: Denny Maurits Ruku Department of Nursing, Klabat University, Arnold Mononutu Street, Airmadidi, Minahasa Utara, Sulawesi Utara 95371, Indonesia E-mail: rukudenny28@gmail.com
• Received: July 11, 2025   • Revised: September 6, 2025   • Accepted: September 14, 2025

© 2025 Korea Disease Control and Prevention Agency.

This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

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  • Objectives
    This study aimed to examine the effectiveness of resistance training on hemoglobin A1c (HbA1c) levels and body mass index in patients with diabetes mellitus, categorized by age.
  • Methods
    A comprehensive search of English-language literature published between 1997 and 2025 was performed across 6 databases (Embase, CINAHL, Medline, Cochrane, PubMed, and PEDro). Standardized mean differences and 95% confidence intervals were calculated, and publication bias was assessed using funnel plots and Egger’s test. The Joanna Briggs Institute checklist was applied to evaluate study quality.
  • Results
    Thirty randomized controlled trials met the inclusion criteria, comprising 620 participants in the older (<60 years of age) subgroup and 1,389 in the middle-aged (40–59 years of age) subgroup. In both subgroups, resistance training significantly reduced HbA1c levels and body mass index, while increasing muscle strength (primary outcome). It also significantly increased high-density lipoprotein, improved VO₂ peak, and reduced low-density lipoprotein (secondary outcomes). However, the effects of resistance training were significant only in the older-adult subgroup for total cholesterol and only in the middle-aged subgroup for triglycerides.
  • Conclusion
    Resistance training is a recommended rehabilitation exercise for patients with diabetes mellitus. Routine resistance training has been shown to help maintain optimal HbA1c and body mass index levels and improve muscle strength. In addition, it does not pose a risk of adverse events in either middle-aged or older patients. Nonetheless, patients are advised to monitor blood glucose levels and adhere to a proper diet to achieve optimal outcomes.
  • Keywords: Body mass index; Diabetes mellitus; Hemoglobin A1c; Muscle strength; Resistance training
Diabetes mellitus (DM) is a global health problem caused by a chronic metabolic disorder characterized by elevated blood glucose (hyperglycemia) due to impaired insulin secretion [1,2]. Several complications of chronic hyperglycemia include elevated hemoglobin A1c (HbA1c) levels, increased body mass index (BMI), and reduced muscle strength (MS). These factors strongly influence quality of life, rehospitalization rates, and mortality in patients with DM [1]. Hyperglycemia also contributes to dyslipidemia, which increases the risk of atherosclerosis and cardiovascular disease [2,3]. Therefore, appropriate evidence-based interventions are urgently needed to address these issues.
Several strategies have been developed to optimize outcomes in patients with DM. Alongside standard medical therapy, resistance training (RT) is one such approach [4,5]. The American College of Sports Medicine recommends incorporating RT into rehabilitation programs for patients with DM in addition to pharmacological treatment [6]. Studies consistently demonstrate that RT improves glycemic control and insulin sensitivity [7,8], as well as lipid abnormalities in individuals with DM [9]. Previous research has also shown that RT exerts favorable effects in reducing HbA1c [8] and BMI [10,11]. Moreover, RT is hypothesized to help stabilize lipid profiles in patients with DM [9]. However, aging is associated with reduced insulin sensitivity, muscle loss (sarcopenia), weight gain (obesity) [12], and a more rapid decline in physiological function compared with younger individuals. These age-related factors may attenuate the beneficial effects of RT in individuals with diabetes.
Aging is also associated with declines in multiple organ functions [13]. In particular, older adults experience greater difficulty addressing muscle-related deficits through exercise regimens, partly because of impaired post-exercise muscle protein synthesis due to anabolic resistance [14]. Consequently, improvements in muscle mass among older patients with DM may be limited. In addition, the effects of RT on HbA1c, muscle mass, and glucose metabolism in older patients with DM are often less pronounced than in younger individuals. Previous studies have reported that RT did not significantly reduce HbA1c [10] or BMI in older patients [15]. Furthermore, RT showed no significant effect on upper-limb MS in this population [16]. Between 2016 and 2025, 6 meta-analyses examined RT in patients with DM [17–22], yet none specifically assessed its effects on HbA1c, BMI, and MS across different age groups. This gap is important, as diabetes complications vary with age. Accordingly, evaluating the effects of RT on HbA1c, BMI, and MS (both lower and upper limbs) in patients with DM by age group—including middle-aged and older adults—is essential. This study also provides insights into rehabilitation strategies for diabetes, offering practical implications for patients, families, and healthcare providers. The primary objective of this review was to compare the effectiveness of RT on HbA1c, BMI, and MS between middle-aged and older patients. Secondary outcomes included the effects of RT on VO₂ peak, lipid profiles (cholesterol, triglycerides, high-density lipoprotein [HDL], and low-density lipoprotein [LDL]), and the occurrence of serious adverse events in patients with DM.
Data Sources and Systematic Literature Review
This study adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines (Figure 1). Six databases—Embase, CINAHL, Medline, Cochrane, PubMed, and PEDro—were searched, and results were organized using the PICO framework. The population (P) included individuals with DM. The intervention (I) comprised RT alone or RT combined with aerobic exercise, vitamin D, or endurance training. The comparison (C) was standard care, and the outcomes (O) were HbA1c, BMI, and MS. The search strategy used Emtree/Medical Subject Headings (MeSH) terms and relevant keywords, including diabetes, diabetic, nonspecific DM, resistance exercise, resistance training, strength training, weight-bearing exercise, glycated hemoglobin A1c, glycosylated hemoglobin A1c, hemoglobin A1c, HbA1c, body mass index, Quetelet index, muscle strength, muscle force, muscle power, and dynamic muscular strength. This review was registered with PROSPERO (CRD420251063715).
This review included only English-language randomized controlled trials (RCTs) published between 1997 and 2025 that examined RT (alone or in combination with aerobic, vitamin D, or endurance training) in patients with DM. The search was conducted from April to June 2025. Exclusion criteria included systematic reviews or meta-analyses, RCTs without a control group, animal studies, studies not involving DM patients, and studies unrelated to HbA1c, BMI, or MS. After identification, duplicate articles were carefully removed. Screening involved abstract and title review, followed by full-text evaluation and reference list checks. The process concluded when all authors reviewed the reference lists of the included full texts and confirmed that no additional eligible studies were found.
Extracting Data and Assessment Quality of the Studies
All reviewers independently extracted data on study design, participant age (middle-aged: 40–59 years; older: ≥60 years), type of DM, intervention characteristics (RT type, frequency, and duration), and reported outcomes, as summarized in Table 1 [7,9–11,15,16,23–46]. Study quality was independently assessed by all reviewers using the Joanna Briggs Institute (JBI) checklist (Table 1). Publication bias was evaluated using the Egger test.
Statistical Analysis and Data Synthesis
Data synthesis was performed using RevMan 5.4 software (Cochrane). Baseline-to-follow-up changes were analyzed to assess intervention effects. Standardized mean differences (SMDs) and risk differences (RDs) were calculated, with 95% confidence intervals (CIs) used to determine statistical significance. Primary outcomes included HbA1c, BMI, and MS. Secondary outcomes included lipid profiles (cholesterol, HDL, LDL, triglycerides), VO₂ peak, and serious adverse events. Effect sizes were reported for both primary and secondary outcomes. Results from individual studies and the pooled meta-analysis were presented in forest plots. Study heterogeneity was evaluated using the I2 statistic. A random-effects model was applied when heterogeneity exceeded 50%, while a fixed-effects model was used when heterogeneity was below 50%.
Risk of Bias Assessment
Each study’s risk of bias was independently assessed by reviewers using the Cochrane Handbook for Systematic Reviews of Interventions criteria and the RoB 2 tool. Disagreements were resolved through discussion. Bias risk was categorized as high, low, or unclear, with justifications provided in a risk of bias summary and risk of bias graph (Figure S1). Publication bias was also assessed using funnel plots (Figure S2).
Study Description
The preliminary screening identified 1,957 studies from 6 databases: Embase (n=523), Medline (n=244), Cochrane (n=787), CINAHL (n=168), PubMed (n=181), and PEDro (n=54). Of these, 502 duplicates were removed, and 1,177 articles were excluded after title and abstract review. A total of 278 articles underwent full-text screening, but 248 were excluded for the following reasons: not RT studies (n=40), not RCT designs (n=40), absence of a control group (n=61), non-English language (n=13), review articles (systematic or meta-analyses) (n=49), animal studies (n=4), and outcomes unrelated to DM patients (n=30). Ultimately, 30 articles [7,9–11,15,16,23–46] met the inclusion criteria (Figure 1).
Characteristics of the Studies
Thirty RCTs published between 1997 and 2025 were included, comprising 620 older and 1,389 middle-aged participants with diagnosed DM. Participant mean ages ranged from 44.7±4.2 to 73.2±2.6 years. Among older participants, 316 were assigned to intervention groups and 304 to control groups. Among middle-aged participants, 739 were assigned to intervention groups and 650 to control groups. Study quality, assessed with the JBI checklist, ranged from 6 to 13 out of the maximum score (Table 1).
Table 1 provides a detailed overview of RT components across studies. Twenty-one studies used weight machines to deliver RT, while others employed elastic bands, progressive resistance programs, sandbag exercises, or isokinetic strength and endurance training. Training frequency ranged from 1 to 7 sessions per week, and intervention duration varied from 8 to 54 weeks. Many studies also incorporated structured warm-up and cool-down periods. Typically, these included a 5- to 10-minute warm-up before the main RT session, followed by a cool-down phase.
Methodological Quality and Potential for Bias
The methodological quality of included studies, as assessed by the JBI checklist, was moderate to high following consensus by the 3 reviewers (Table 1). Approximately 50% of studies demonstrated a low risk of bias in random sequence generation, and allocation concealment was satisfactory in over 60% of studies. Around 70% reported a low risk of bias in outcome assessment blinding. More than 75% showed a low risk of selective reporting and incomplete outcome data. However, fewer than 60% reported a low risk of bias regarding participant and personnel blinding (Figure S1). Evidence of potential publication bias was observed, as indicated by funnel plots. Heterogeneity was primarily attributable to the presence of 2 distinct study subgroups, particularly regarding the effects of RT on HbA1c, BMI, and MS (Figure S2).
Effect of RT on HbA1c, BMI, and MS in Patients with DM (Primary Outcome)

Effect of RT on HbA1c

Table 2 and Figure 2 summarize 15 trials including 699 participants in the older-adult subgroup. These analyses showed that RT significantly reduced HbA1c in the intervention group (SMD, –0.88; 95% CI, –1.66 to –0.10; I2=95%) compared with the control group. Similarly, 27 studies involving 1,457 middle-aged participants demonstrated that RT significantly reduced HbA1c in the intervention group (SMD, –0.86; 95% CI, –1.26 to –0.45; I2=92%) relative to the control group.

Effect of RT on BMI

Nine studies in the older-adult subgroup, with 182 participants in intervention groups and 192 in control groups, indicated that RT significantly reduced BMI among patients with DM (SMD, –1.21; 95% CI, –2.39 to –0.04; I2=96%) compared to controls. Sixteen studies in the middle-aged subgroup, comprising 260 intervention participants and 251 controls, also showed a significant BMI reduction in intervention groups (SMD, –0.36; 95% CI, –0.63 to –0.10; I2=53%). These findings are presented in Table 2 and Figure 3.

Effect of RT on MS

As shown in Figure 4 and Table 2, 7 RCTs with 242 older participants revealed that RT significantly improved lower-limb MS in the intervention group (SMD, 0.79; 95% CI, 0.44 to 1.14; I2=40%) compared with controls. Likewise, eleven studies involving 414 middle-aged participants demonstrated significant improvements in lower-limb MS in the intervention group (SMD, 1.54; 95% CI, 0.81 to 2.28, I2=90%).
RT also significantly improved upper-limb MS. In older participants, intervention groups showed an improvement (SMD, 0.37; 95% CI, 0.03 to 0.71; I2=0%) compared to controls. In middle-aged participants, RT similarly improved upper-limb MS (SMD, 0.91; 95% CI, 0.38 to 1.44; I2=80%) compared to control groups (Figure 5; Table 2).
Effect of RT on Lipid Profiles, VO2 Peak, and Serious Events in Patients with DM (Secondary Outcome)

Effect of RT on lipid profiles

Lipid profile outcomes are presented in Table 2 and Figures S3–S6. Among older participants, RT significantly reduced total cholesterol (SMD, –0.94; 95% CI, –1.62 to –0.26; I2=70%; n=132) and LDL (SMD, –0.98; 95% CI, –1.76 to –0.21; I2=76%; n=130), and significantly increased HDL (SMD, 0.40; 95% CI, –0.01 to 0.80; I2=40%; n=169). However, RT did not significantly reduce triglycerides (SMD, 0.41; 95% CI, –0.92 to 1.74; I2=94%; n=207). For middle-aged participants, RT significantly reduced triglycerides (SMD, –0.37; 95% CI, –0.59 to –0.14; I2=43%; n=654) and LDL (SMD, 0.18; 95% CI, 0.01 to 0.35; I2=0%; n=537), while also increasing HDL (SMD, 0.33; 95% CI, 0.05 to 0.61; I2=54%; n=583). However, RT did not significantly reduce total cholesterol (SMD, –0.16; 95% CI, –0.45 to 0.14; I2=70%; n=701).

Effect of RT on VO2 peak

Five studies in the older-adult subgroup, including 102 intervention participants and 99 controls, demonstrated that RT significantly improved VO₂ peak compared to controls (SMD, 2.80; 95% CI, 0.17 to 5.43; I2=98%). Similarly, 5 studies with 97 intervention participants and 91 controls in the middle-aged subgroup showed that RT significantly increased VO₂ peak (SMD, 1.21; 95% CI, 0.72 to 1.71; I2=59%). These results are shown in Table 2 and Figure S7.

Effect of RT on serious events

In older patients with DM, 423 participants were evaluated (224 in intervention groups and 199 in control groups). RT did not significantly influence the occurrence of adverse events (RD, 0.04; 95% CI, –0.01 to 0.10; I2=52%). Similarly, in middle-aged patients with DM (n=280; 146 intervention, 134 control), RT showed no significant effect on adverse events (RD, –0.01; 95% CI, –0.07 to 0.05; I2=0%). These findings are presented in Table 2 and Figure S8.
This study evaluated the effects of RT on HbA1c, BMI, and MS in patients with DM by comparing intervention and control groups (primary outcomes). The analysis also examined secondary outcomes, including lipid profile, VO₂ peak, and adverse events, in both middle-aged and older-adult subgroups. Overall, the evidence quality of the included studies was assessed as moderate to high (Table 1).
Effect of RT on HbA1c, BMI, and MS in Patients with DM (Primary Outcome)

Effect of RT on HbA1c

RT is widely recognized as an effective nonpharmacological intervention for glycemic control in patients with DM [20]. HbA1c serves as the primary clinical marker of long-term glycemic status, reflecting average blood glucose levels [20]. The present study demonstrated that RT significantly reduced HbA1c in both middle-aged and older patients with DM (Figure 2). Although no statistically significant differences were observed between subgroups, the reduction was more pronounced in middle-aged participants. This greater reduction may be attributed to higher metabolic flexibility in middle-aged individuals, enabling improved insulin sensitivity, enhanced skeletal muscle glucose uptake through glucose transporter type 4 (GLUT-4) translocation, and greater mitochondrial function following consistent RT compared with older adults [47]. The middle-aged group generally performed higher-intensity exercises—using weight machines, strength training, or endurance training—whereas the older adults more often engaged in progressive RT, elastic bands, isokinetic strength, or sandbag exercises. Training duration also differed slightly: middle-aged participants trained for 8 to 52 weeks, while older participants trained for 12 to 48 weeks. As supported by previous studies, higher-intensity RT produces greater improvements in insulin sensitivity and HbA1c [48]. Middle-aged adults typically tolerate higher-intensity training better than older adults, resulting in more substantial benefits. In addition, muscles in middle-aged individuals retain a stronger adaptive capacity, whereas older adults experience sarcopenia, which diminishes training responsiveness. These adaptations—greater insulin sensitivity and improved glucose metabolism—likely explain the more significant HbA1c reduction observed in middle-aged patients [49].

Effect of RT on BMI

This review also found that routine RT significantly reduced BMI in both middle-aged and older patients with DM (Figure 3). Defined as muscle-strengthening exercise, RT is increasingly recognized as an adjunctive strategy for regulating body composition and glycemic control [7,42,43]. In middle-aged patients, RT was particularly effective in decreasing BMI by reducing fat mass while increasing lean muscle [7]. Gains in muscle mass elevate resting metabolic rate, promoting higher energy expenditure even at rest [50]. RT further increases insulin sensitivity, which improves glucose and lipid metabolism, reduces fat storage, and supports long-term weight management [7,18]. Previous studies also reported that routine RT can lower BMI and waist circumference in overweight individuals with DM [38].
In older patients, RT significantly reduced BMI; however, the degree of reduction was smaller compared to middle-aged patients (Figure 3). This disparity may be explained by age-related anabolic resistance, reduced exercise tolerance, and the tendency toward sarcopenic obesity, characterized by excessive fat relative to muscle mass [44]. Moreover, the higher training intensity and longer exercise durations typically observed in middle-aged groups may account for the greater BMI reduction compared to older groups.

Effect of RT on MS

Patients with DM often experience accelerated muscle mass and strength loss, known as diabetic sarcopenia [4,12,20]. This condition contributes to impaired mobility, increased fall risk, and reduced quality of life [16]. The progression of metabolic syndrome in DM is linked to factors such as insulin resistance, chronic inflammation, oxidative stress, and impaired muscle protein synthesis [7]. Consequently, RT is increasingly recognized as a therapeutic approach for improving glycemic control and enhancing MS in this population [20]. This review found that RT significantly improved both lower- and upper-limb MS in middle-aged and older patients with DM, with greater effects observed in the middle-aged group (Figure 4). RT involves repeated muscle contractions against resistance, producing a mechanical stimulus that promotes protein synthesis and helps counteract sarcopenia. These adaptations are closely correlated with significant gains in MS among DM patients [28]. Furthermore, RT enhances skeletal muscle insulin sensitivity by increasing GLUT-4 expression and improving glucose utilization efficiency [47], leading to greater strength and contractility [51]. However, the magnitude of improvement differs with age: training intensity and duration exert a stronger influence on MS outcomes in middle-aged patients compared to older patients.
Effect of RT on Lipid Profiles, VO2 Peak, and Serious Events in Patients with DM (Secondary Outcome)

Effect of RT on lipid profiles

Patients with DM commonly exhibit dyslipidemia, typically characterized by elevated triglycerides, reduced HDL, and increased small dense LDL particles [52]. RT has long been recommended as a strategy to improve MS and glycemic control [53], and the present review confirms its benefits for lipid metabolism. Regular RT substantially increased HDL, reduced LDL, and lowered triglycerides, yielding clinically meaningful improvements in lipid profiles. However, total cholesterol was not significantly reduced in middle-aged patients (Figures S3–S6; Table 2). This may be explained by persistent insulin resistance during middle age, which can drive excessive hepatic very-low-density lipoprotein synthesis [54] and maintain overall cholesterol levels. In older patients, RT significantly reduced total cholesterol and LDL and increased HDL, but had no significant effect on triglycerides (Figures S3–S6; Table 2). The absence of triglyceride reduction may be linked to age-related declines in lipoprotein lipase activity in skeletal muscle [55], which limits the capacity of RT to influence triglyceride metabolism in this subgroup.

Effect of RT on VO2 peak

Patients with DM often present with reduced VO₂ peak due to mitochondrial dysfunction, insulin resistance, and impaired muscle capillarization [56]. These limitations increase the risk of cardiovascular complications and lower quality of life [40]. RT has been recommended as a rehabilitative intervention to improve muscle efficiency and mitochondrial capacity [56], thereby enhancing VO₂ peak. Consistent with this rationale, the present review showed that RT significantly increased VO₂ peak in both middle-aged and older patients, with greater improvements in the latter (Figure S7).

Effect of RT on serious events

Although RT involves physical exertion, this review found no evidence of serious adverse events among DM patients participating in RT programs (Figure S8). Nevertheless, caution is warranted. International guidelines recommend that exercise-based rehabilitation for DM be conducted either in facilities experienced with this patient population or in supervised home-based settings. In all cases, careful monitoring of blood glucose levels during RT is essential to ensure safety.
Limitations of the Study
This review has several limitations. First, publication bias may exist in some of the included studies, and the scope was restricted to English-language publications; therefore, both publication bias and limited generalizability are unavoidable. These biases were mitigated by involving 3 independent reviewers, conducting an extensive search across 6 databases, and applying strict inclusion criteria. Second, high heterogeneity was observed, particularly regarding the effects of RT on primary outcomes. To address this, a meta-regression stratified analyses by age group (middle-aged and older), and sensitivity analyses were conducted on studies with a high risk of bias, which yielded comparable pooled effect sizes. These findings suggest that the results are robust and reliable. Third, this review did not conduct subgroup analyses based on exercise intensity, which may have obscured variations in the effects of RT. Future research should stratify participants by exercise intensity to better evaluate the differential impact of RT in patients with DM. Additionally, comorbid conditions present in DM patients, which were not the primary focus of this review, may have influenced outcomes. Future studies should incorporate subgroup analyses categorized by DM type, sex, and RT modality to strengthen the evidence base on RT’s effectiveness in this population.
This meta-analysis demonstrated that RT provides substantial benefits for patients with DM. The analysis evaluated RT interventions in middle-aged and older adults with DM, including elastic bands, progressive exercises, sandbag exercises, isokinetic strength and endurance exercises, and weight-machine–based training. Interventions were performed either in facilities experienced in managing DM patients or in supervised home-based programs. The results revealed that RT significantly reduced HbA1c and BMI levels and improved MS in both upper and lower limbs. Importantly, RT was well tolerated, and no serious adverse events were reported. However, careful monitoring of blood glucose levels before and during RT remains essential for patient safety. Overall, RT is a recommended rehabilitation strategy for patients with DM, with demonstrated benefits in glycemic control, body composition, and MS.
• Resistance training is one of the rehabilitation recommendations for patients with diabetes mellitus.
• Regular resistance training helps maintain better hemoglobin A1c levels and body mass index in middle-aged and older adults with diabetes mellitus.
• Routine resistance training increases muscle strength in middle-aged or older adults with diabetes mellitus.
• Resistance training does not cause serious adverse events in middle-aged or older adults with diabetes mellitus.
Supplementary data are available at https://doi.org/10.24171/j.phrp.2025.0268.
Figure S1.
Risk of bias
j-phrp-2025-0268-Supplementary-Figure-S1.pdf
Figure S2.
Funnel plots.
j-phrp-2025-0268-Supplementary-Figure-S2.pdf
Figure S3.
Effect of resistance training on cholesterol.
j-phrp-2025-0268-Supplementary-Figure-S3.pdf
Figure S4.
Effect of resistance training on triglycerides.
j-phrp-2025-0268-Supplementary-Figure-S4.pdf
Figure S5.
Effect of resistance training on high-density lipoprotein.
j-phrp-2025-0268-Supplementary-Figure-S5.pdf
Figure S6.
Effect of resistance training on low-density lipoprotein.
j-phrp-2025-0268-Supplementary-Figure-S6.pdf
Figure S7.
Effect of resistance training on VO2 peak.
j-phrp-2025-0268-Supplementary-Figure-S7.pdf
Figure S8.
Effect of resistance training on serious events.
j-phrp-2025-0268-Supplementary-Figure-S8.pdf

Ethics Approval

This study was registered with PROSPERO (CRD420251063715).

Conflicts of Interest

The authors have no conflicts of interest to declare.

Funding

None.

Availability of Data

All data generated or analyzed during this study are included in this published article. For other data, these may be requested through the corresponding author.

Authors’ Contributions

Conceptualization: AQD, PMNB; Data curation: AQD, DMR; Formal analysis: all authors; Investigation: AQD, PMNB; Methodology: all authors; Project administration: AQD, DMR; Supervision: DMR; Writing–original draft: all authors; Writing–review & editing: all authors. All authors read and approved the final manuscript.

Figure 1.
Flow diagram of the study selection process.
RT, resistance training; RCT, randomized controlled trial; DM, diabetes mellitus.
Figure 1. Flow diagram of the study selection process.  
Figure 2.
Effect of resistance training on hemoglobin A1c.
SD, standard deviation; IV, inverse variance; CI, confidence interval; df, degrees of freedom.
Figure 2. Effect of resistance training on hemoglobin A1c.  
Figure 3.
Effect of resistance training on body mass index.
SD, standard deviation; IV, inverse variance; CI, confidence interval; df, degrees of freedom.
Figure 3. Effect of resistance training on body mass index.  
Figure 4.
Effect of resistance training on muscle strength (lower limbs).
SD, standard deviation; IV, inverse variance; CI, confidence interval; df, degrees of freedom.
Figure 4. Effect of resistance training on muscle strength (lower limbs).  
Figure 5.
Effect of resistance training on muscle strength (upper limbs).
SD, standard deviation; IV, inverse variance; CI, confidence interval; df, degrees of freedom.
Figure 5. Effect of resistance training on muscle strength (upper limbs).  
The effects of resistance training on hemoglobin A1c, body mass index, and muscle strength in patients with diabetes mellitus based on age (middle-aged and older adults): a systematic review and meta-analysis
Table 1.
Characteristics of the studies
Table 1.
No. Study Year Age(y, mean±SD) E/C Type of DM Components of RT Control Outcome JBI score
Type of intervention FE (time/wk) DE (wk)
1 Bacchi et al. [23] 2012 55.6±1.7 19/19 II Exercise using weight machines. Each session consists of 9 exercises. The workload was progressively increased to 70% to 80% of 1-RM after 10 repetitions at 30% to 50% of 1-RM on each piece of equipment. 3 12 Aerobic HbA1c, MS, BP, serious events 10/13
2 Bassi et al. [11] 2015 52.1±7.3 21/20 II Aerobic+RT, Exercise lasted one hour and 10 minutes and comprised a 5-minute warm-up, a 60-minute workout, and a 5-minute cool-down. 3 12 Aerobic HbA1c, BMI, VO2 peak, MS, BP 12/13
3 Banitalebi et al. [24] 2019 54.14±5.43 14/14 II 5 Minutes warm-up (cycling or treadmill), 10 minutes cool-down (cycling/treadmill), main exercise: aerobic+RT (weight stack machines) for 5 exercises (bilateral leg press, lateral pull down, bench press, bilateral biceps curl, and bilateral triceps push down) 3 10 Usual care HbA1c, BMI, VO2 peak 13/13
4 Cauza et al. [25] 2005 56.4±1.1 22/17 II 10 Minutes warm-up; RT exercise: Bench press, chest cross, shoulder press, pull-downs, biceps curls, triceps extensions, and abdominal exercises were among the upper-body strengthening exercises. Leg extensions, calf lifts, and leg presses were among the lower-body workouts. 3 12 Endurance training HbA1c. BMI, MS, BP 8/13
5 Celli et al. [26] 2022 72.3±4.0 50/50 II 15 Minutes warm-up, 30 minutes aerobic+30 minutes RT consisted of 9 upper-body and lower-body exercises (weight lifting machines), 15 minutes balance exercise - 16 Usual care HbA1c, BMI, VO2 peak, serious events 11/13
6 Cheung et al. [27] 2009 59±8.7 20/17 II 5 Minutes warm-up, 30 minutes RT (chest press, seated back rows, leg abductions, leg extension, seated leg press, triceps extensions, and biceps curls) 5 - Usual care HbA1c, BMI, MS 7/13
7 Chien et al. [28] 2022 67.6±7.7 19/18 II The RT equipment used was sandbags. 5 to 10 minutes for warm-up/cool-down. The RT included tiptoe (ankle flexion/extension), hip adduction/abduction, overhead press (shoulder), arm curl (elbow flexion/extension), and step (hip and knee flexion/extension). - - Usual care MS, HbA1c 12/13
8 Church et al. [29] 2010a 56.9±8.7 73/41 II RT comprising 2 sets of 4 upper-body exercises (bench press, seated row, shoulder press, and pull down), 3 sets of 3 leg exercises (leg press, extension, and flexion), and 2 sets each of abdominal crunches and back extensions. 3 36 Usual care MS 9/13
9 Church et al. [29] 2010b 55.4±8.3 76/41 II Aerobic+RT comprising 2 sets of 4 upper-body exercises (bench press, seated row, shoulder press, and pull down), 3 sets of 3 leg exercises (leg press, extension, and flexion), and 2 sets each of abdominal crunches and back extensions. 3 36 Usual care MS 9/13
10 Hameed et al. [30] 2012 44.7±4.2 24/24 II Weight machines (bench press, leg press, lateral pull, leg extension, seated biceps curls) 2–3 8 Cycling MS, HbA1c, BP 9/13
11 Hangping et al. [31] 2019 65.66±8.58 59/32 II RT; 4 exercises (chess press, leg press, core pull and vertical lift) 1 24 Usual care HbA1c, HDL, LDL, serious events 12/13/
12 Honkola et al. [32] 1997 62±2 18/20 II Progressive circuit-type RT 3 20 Usual care HbA1c, HDL, LDL, cholesterol, triglyceride, BP 8/13
13 Hsieh et al. [16] 2018 70.6±4.2 15/15 II RT used weight machine (chest press, shoulder press, biceps curl, hip abduction, standing hip flexion, leg press, standing calf raise, and abdominal crunch) 3 12 Aerobic HbA1c, MS, VO2 peak, BP 10/13
14 Kang et al. [33] 2016 56±7.4 8/8 II 10 Minutes (warm-up/cooling down), aerobic+resistance exercise using weight machines (chest press, lateral pull down, shoulder press, arm curl, leg press, leg extension, leg curl, calf raise, and curl-up) 3 12 Usual care HbA1c, HDL, LDL, cholesterol, triglyceride, BP 8/13
15 Khan et al. [15] 2022a 62±9 15/15 II 10 Bicycle ergometry, progressive RT (upper, and lower body) 2–3 Sessions/wk 12 Usual care HbA1c, BMI, MS, serious events 13/13
16 Khan et al. [15] 2022b 63±8 13/17 II 10 Bicycle ergometry, progressive RT (upper, and lower body) 2–3 Sessions/wk 12 Usual care HbA1c, BMI, MS, serious events 13/13
17 Kobayashi et al. [7] 2023a 60±53.66 38/38 II RT used weight machines (bench press, seated row, shoulder press and pull down, leg press/extension/flexion, abdominal crunches and back extensions) 3 12 Aerobic HbA1c, MS, serious events 13/13
18 Kobayashi et al. [7] 2023b 59±52.68 31/38 II Aerobic+treadmill and RT used weight machines (bench press, seated row, shoulder press and pull down, leg press/extension/flexion, abdominal crunches and back extensions) 3 12 Aerobic HbA1c, MS, serious events 13/13
19 Ku et al. [34] 2010 55.7±6.2 13/16 II RT using elastic band (biceps curl, triceps extension, upright row, shoulder chest press, trunk side-bending, seated row, leg press, hip flexion, leg flexion and leg extension) 5 12 Usual care HbA1c, BMI, MS 6/13
20 Lambers et al. [35] 2008a 55.8±9.66 17/11 II 10 Minutes warm-up/cool-down, ST (weight machines)+walking, cycling, knee flexion/extension, stepping - 12 Usual care HbA1c, BMI, MS 12/13
21 Lambers et al. [35] 2008b 52.2±8.26 18/11 II 10 Minutes warm-up/cool-down, ST (weight machines)+walking, cycling, knee flexion/extension, stepping, and endurance training (treadmills, stationary bicycles and steppers) - 12 Usual care HbA1c, BMI, MS 12/13
22 Liu et al. [36] 2015 52.9±11.43 22/20 II 10 Minutes warm-up, 15 minutes cool-down, aerobic+RT (elastic band) 2–3 12 Usual care HbA1c, HDL, LDL, Cholesterol, triglyceride 10/13
23 Loimaala et al. [37] 2009 53.6±6.2 24/24 II Aerobic+RT (weight machines) 2 8 Usual care HbA1c, MS, VO2 peak, BP 11/13
24 Magalhaes et al. [38] 2019a 59.7±6.5 28/27 II Moderate intensity+RT - 48 Usual care HbA1c, BMI, VO2 peak 13/13
25 Magalhaes et al. [38] 2019b 56.7±8.3 25/27 II High intensity+RT - 48 Usual care HbA1c, BMI, VO2 peak 13/13
26 Mavros et al. [39] 2013 - 36/48 II Progressive resistance training: concentric contraction (lifting), and eccentric contraction (lowering); workouts aimed at substantial symmetrical muscle groups of the arms, legs, and torso: seated row, chest press, leg press, knee extension, hip flexion, hip extension, and hip abduction. 3 16 Sham HbA1c, BMI 10/13
27 Plotnikoff et al. [40] 2010 55±12 27/21 II Weight machines (multigym and dumbbells) 3 16 Usual care MS, BMI, HbA1c, serious events 12/13
28 Rech et al. [41] 2019 70.5±7.4 18/21 II RT program comprised functional exercises like partial squats and bench stepping, while traditional resistance exercises encompassed the unilateral leg press, unilateral knee extension, knee flexion, plantar flexion, bench press, low row, biceps curl, elbow extension, hip abduction, and abdominal crunches. 3 12 Usual care HbA1c, cholesterol, triglyceride, HDL, LDL 13/13
29 Sigal et al. [42] 2007a 53.5±7.3 64/63 II Aerobic+RT (weight machine) 3 24 Usual care HbA1c, BMI, cholesterol, triglyceride, HDL, LDL, BP, serious events 13/13
30 Sigal et al. [42] 2007b 54.7±7.5 64/63 II RT (weight machine) 3 24 Usual care HbA1c, BMI, cholesterol, triglyceride, HDL, LDL, BP, serious events 13/13
31 Stubbs et al. [44] 2019a 64.2±9.5 11/12 II 10 Minutes warm-up, 10 minutes cool, RT (isokinetic strength) - 24 Usual care HbA1c, BMI. VO2 peak 13/13
32 Stubbs et al. [44] 2019b 63±6.6 11/12 II 10 Minutes warm-up, 10 minutes cool-down, aerobic+RT (isokinetic strength) - 24 Usual care HbA1c, BMI, VO2 peak 13/13
33 Sudarsono et al. [43] 2019 51.69±7.7 22/20 II RT (weight machine) 12 Usual care HbA1c 12/13
34 Sun et al. [9] 2023a 50.1±7.3 15/15 II RT (endurance cycling exercise) - 12 Usual care HbA1c, BMI, cholesterol, triglyceride, HDL, LDL 13/13
35 Sun et al. [9] 2023b 50.1±7.3 14/15 II Vit D+RT (endurance cycling exercise) - 12 Usual care HbA1c, BMI, cholesterol, triglyceride, HDL, LDL 13/13
36 Tan et al. [45] 2012 65.9±4.2 15/10 II 10 Minutes warm-up, 10 minutes cool-down, 30 minutes walking, 10 minutes RT (weight machine) 3 24 Usual care HbA1c, BMI, VO2 peak, cholesterol, triglyceride, HDL, LDL, BP 9/13
37 Yavari et al. [46] 2012a 51.5±6.3 20/20 II Weight machine (bench press, seated row, shoulder press, chest press, lateral pulldown, abdominal crunches, leg press, leg extension, triceps pushdown and seated bicep curls) 3 52 Usual care HbA1c, BMI, cholesterol, triglyceride, HDL, LDL, BP 8/13
38 Yavari et al. [46] 2012b 50.9±9.8 20/20 II Aerobic+weight machine (bench press, seated row, shoulder press, chest press, lateral pulldown, abdominal crunches, leg press, leg extension, triceps pushdown and seated bicep curls) 3 52 Usual care HbA1c, BMI, cholesterol, triglyceride, HDL, LDL, BP 8/13
39 Yamamoto et al. [10] 2021a 73.2±2.6 18/17 II RT used an elastic band 7 48 Usual care MS, BMI, HbA1c 12/13
40 Yamamoto et al. [10] 2021b 72.1±2.1 18/17 II RT used an elastic band+leucine-rich supplement 7 48 Usual care MS, BMI, HbA1c 12/13

SD, standard deviation; E/C, experiment/control; DM, diabetes mellitus; RT, resistance training; FE, frequency of exercise; DE, duration of exercise; JBI, Joanna Briggs Institute; RM, repetition maximum; HbA1c, hemoglobin A1c; MS, muscle strength; BP, blood pressure; BMI, body mass index; HDL, high-density lipoprotein; LDL, low-density lipoprotein; ST, strength training; -, not reported.

Table 2.
Summarized results for the intervention versus control
Table 2.
Outcome No. of studies No. of respondents Methods ES Overall effect Z (p)
Primary outcomes
 HbA1c (total)
  Elderly 15 699 SMD (IV, R, 95% CI) –0.88 (–1.66, –0.10) 2.20 (0.03)
  Middle age 27 1,457 SMD (IV, R, 95% CI) –0.86 (–1.26, –0.45) 4.16 (<0.00001)
 BMI (total)
  Elderly 9 374 SMD (IV, R, 95% CI) –1.21 (–2.39, –0.04) 2.02 (0.04)
  Middle age 15 511 SMD (IV, R, 95% CI) –0.36 (–0.63, –0.10) 2.72 (0.006)
 MS (lower limbs) (total)
  Elderly 7 242 SMD (IV, R, 95% CI) 0.79 (0.44, 1.14) 4.46 (<0.00001)
  Middle age 11 414 SMD (IV, R, 95% CI) 1.54 (0.81, 2,28) 4.14 (<0.00001)
 MS (upper limbs) (total)
  Elderly 4 137 SMD (IV, R, 95% CI) 0.37 (0.03, 0.71) 2.15 (0.03)
  Middle age 9 351 SMD (IV, R, 95% CI) 0.91 (0.38, 1.44) 3.35 (0.0008)
Secondary outcomes
 Cholesterol (total)
  Elderly 4 132 SDM (IV, R, 95% CI) –0.94 (–1.62, –0.26) 2.72 (0.006)
  Middle age 15 701 SDM (IV, R, 95% CI) –0.16 (–0.45, 0.14) 1.01 (0.31)
 Triglyceride (total)
  Elderly 6 207 SDM (IV, R, 95% CI) 0.41 (–0.92, 1.74) 0.60 (0.55)
  Middle age 14 654 SDM (IV, R, 95% CI) –0.37 (–0.59, –0.14) 3.24 (0.001)
 HDL (total)
  Elderly 5 169 SDM (IV, R, 95% CI) 0.40 (–0.01, 0.80) 1.93(0.05)
  Middle age 12 583 SDM (IV, R, 95% CI) 0.33 (0.05, 0.61) 2.28 (0.02)
 LDL (total)
  Elderly 5 130 SDM (IV, R, 95% CI) –0.98 (–1.76, –0.21) 2.48 (0.01)
  Middle age 10 537 SDM (IV, R, 95% CI) 0.18 (0.01, 0.35) 2.06 (0.04)
 VO2 peak (total)
  Elderly 5 201 SDM (IV, R, 95% CI) 2.80 (0.17, 5.43) 2.08 (0.04)
  Middle age 5 188 SDM (IV, R, 95% CI) 1.21 (0.72, 1.71) 4.79 (0.00001)
 Serious events
  Elderly 6 423 RD (M-H, F, 95% CI) 0.04 (0.01, 0.10) 1.52 (0.13)
  Middle age 4 280 RD (M-H, F, 95% CI) –0.01 (–0.07, 0.05) 0.28 (0.78)

ES, effect size; HbA1c, hemoglobin A1c; SMD, standard mean difference; IV, inverse variance; R, random; CI, confidence interval; BMI, body mass index; MS, muscle strength; HDL, high-density lipoprotein; LDL, low-density lipoprotein; RD, risk difference; M-H, Mantel-Haenszel; F, fixed.

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The effects of resistance training on hemoglobin A1c, body mass index, and muscle strength in patients with diabetes mellitus based on age (middle-aged and older adults): a systematic review and meta-analysis
Osong Public Health Res Perspect. 2025;16(6):534-551.   Published online October 30, 2025
DOI: https://doi.org/10.24171/j.phrp.2025.0268
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The effects of resistance training on hemoglobin A1c, body mass index, and muscle strength in patients with diabetes mellitus based on age (middle-aged and older adults): a systematic review and meta-analysis
Osong Public Health Res Perspect. 2025;16(6):534-551.   Published online October 30, 2025
DOI: https://doi.org/10.24171/j.phrp.2025.0268
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