Review Article| Volume 197, 110575, March 2023

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Aquatic training improves HbA1c, blood pressure and functional outcomes of patients with type 2 diabetes: A systematic review with meta-analysis

Published:February 11, 2023DOI:



      This study aimed to summarize the effects of aquatic training on the health outcomes of type 2 diabetes (T2D) patients.


      This is a systematic review with meta-analysis that followed the PRISMA recommendations. Searches were performed in four databases in April 2021. The following eligibility criteria were adopted: adults with T2D; aquatic training (AT) intervention in an upright position; pre- and post-intervention assessments of the following outcomes: HbA1c, SBP and DBP, functional capacity, VO2peak. The random-effects meta-analysis results are presented as mean differences and 95% confidence intervals.


      Of the 375 studies, 12 studies were eligible and included in the meta-analysis. Favorable effects of AT post-intervention were observed in HbA1c (-0.62 %), VO2peak (2.16 mL.Kg−1.min−1), SBP (-5.55 mmHg), DBP (-4.99 mmHg), and the 6-minute walk test (76.64 m). AT also revealed superior effects when compared to the control group (CG) and similar effects to land training (LT) in HbA1c (AT vs CG = -0.67 % and AT vs LT = -0.40 %), VO2peak (AT vs CG = 3.78 mL.Kg−1.min−1; AT vs LT = -0.12 mL/Kg-1.min−1), SBP (AT vs LT = -0.85 mmHg), and DBP (AT vs LT = 2.12 mmHg).


      AT improves HbA1c, VO2peak, SBP, DBP, and functional capacity in T2D patients. Beneficial effects favored AT over CG, while similar effects were verified between AT and LT on HbA1c, VO2peak, and blood pressure.


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      1. American Diabetes Association. Standards of Medical Care in Diabetes. Diabetes Care. 2021.

        • Sampath Kumar A.
        • Maiya A.G.
        • Shastry B.A.
        • et al.
        Exercise and insulin resistance in type 2 diabetes mellitus: A systematic review and meta-analysis.
        Ann Phys Rehabil Med. 2019; 62: 98-103
        • Pan B.
        • Ge L.
        • Xun Y.-Q.
        • et al.
        Exercise training modalities in patients with type 2 diabetes mellitus: a systematic review and network meta-analysis.
        Int J Behav Nutr Phys Act. 2018; 15: 72
        • Mogre V.
        • Johnson N.A.
        • Tzelepis F.
        • et al.
        A systematic review of adherence to diabetes self-care behaviours: Evidence from low- and middle-income countries.
        J Adv Nurs. 2019; 75: 3374-3389
        • Burgess E.
        • Hassmén P.
        • Pumpa K.L.
        Determinants of adherence to lifestyle intervention in adults with obesity: a systematic review.
        Clin Obes. 2017; 7: 123-135
        • Jenkins D.W.
        • Jenks A.
        Exercise and Diabetes: A Narrative Review.
        J Foot Ankle Surg Off Publ Am Coll Foot Ankle Surg. 2017; 56: 968-974
        • Epstein M.
        Cardiovascular and renal effects of head-out water immersion in man: application of the model in the assessment of volume homeostasis.
        Circ Res. 1976; 39: 619-628
        • Coruzzi P.
        • Novarini A.
        • Musiari L.
        • et al.
        Effects of ‘Central Hypervolemia’by Water Immersion on Renin-Aldosterone System and ACTH-Cortisol Axis in Hemodialyzed Patients.
        Nephron. 1984; 36: 238-241
        • Delevatti R.
        • Marson E.
        • Kruel L.
        Effect of aquatic exercise training on lipids profile and glycaemia: A systematic review.
        Rev Andal Med Deporte. 2015; 8: 163-170
        • Delevatti R.
        • Alberton C.L.
        • Kanitz A.C.
        • et al.
        Vertical ground reaction force during land- and water-based exercise performed by patients with type 2 diabetes.
        Med Sport. 2016; : 8
        • Delevatti R.
        • Kanitz A.C.
        • Alberton C.L.
        • et al.
        Glucose control can be similarly improved after aquatic or dry-land aerobic training in patients with type 2 diabetes: A randomized clinical trial.
        J Sci Med Sport. 2016; 19: 688-693
        • Pendergast D.R.
        • Moon R.E.
        • Krasney J.J.
        • et al.
        Human Physiology in an Aquatic Environment.
        Compr Physiol. 2015; 5: 1705-1750
        • Rees J.L.
        • Johnson S.T.
        • Boulé N.G.
        Aquatic exercise for adults with type 2 diabetes: a meta-analysis.
        Acta Diabetol. 2017; 54: 895-904
        • Delevatti R.
        • Kanitz A.C.
        • Bracht C.G.
        • et al.
        Effects of 2 Models of Aquatic Exercise Training on Cardiorespiratory Responses of Patients With Type 2 Diabetes: The Diabetes and Aquatic Training Study-A Randomized Controlled Trial.
        J Phys Act Health. 2020; 17: 1091-1099
        • Häfele M.S.
        • Alberton C.L.
        • Häfele V.
        • et al.
        Water-based Training Programs Improve Functional Capacity, Cognitive and Hemodynamic Outcomes? The ACTIVE Randomized Clinical Trial.
        Res Q Exerc Sport. 2022; : 1-11
        • Reichert T.
        • Costa R.R.
        • Barroso B.M.
        • et al.
        Aquatic Training in Upright Position as an Alternative to Improve Blood Pressure in Adults and Elderly: A Systematic Review and Meta-Analysis.
        Sports Med. 2018; 48: 1727-1737
        • Andrade L.S.
        • Pinto S.S.
        • Silva M.R.
        • et al.
        Randomized Clinical Trial of Water-Based Aerobic Training in Older Women (WATER Study): Functional Capacity and Quality of Life Outcomes.
        J Phys Act Health. 2020; : 1-9
        • Prado A.K.G.
        • Reichert T.
        • Conceição M.O.
        • et al.
        Effects of aquatic exercise on muscle strength in young and elderly adults: a systematic review and meta-analysis of randomized trials.
        J Strength Cond Res. 26 August 2016; (Publish Ahead of Print Epub ahead of print)
        • Waller B.
        • Ogonowska-Słodownik A.
        • Vitor M.
        • et al.
        The effect of aquatic exercise on physical functioning in the older adult: a systematic review with meta-analysis.
        Age Ageing. 2016; 45: 594-602
      2. Higgins J, Thomas J, Chandler J, et al. Cochrane Handbook for Systematic Reviews of Interventions version 6.2. Cochrane Training, (2021, accessed 19 September 2021).

      3. Moher D, Liberati A, Tetzlaff J, et al. Preferred Reporting Items for Systematic Reviews and Meta-Analyses: The PRISMA Statement, (2009, accessed 23 April 2022).

        • Page M.J.
        • McKenzie J.E.
        • Bossuyt P.M.
        • et al.
        The PRISMA 2020 statement: an updated guideline for reporting systematic reviews.
        BMJ. 2021; 372n71
        • Liberati A.
        • Altman D.G.
        • Tetzlaff J.
        • et al.
        The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate healthcare interventions: explanation and elaboration.
        BMJ. 2009; 339: b2700-b
        • Smart N.A.
        • Waldron M.
        • Ismail H.
        • et al.
        Validation of a new tool for the assessment of study quality and reporting in exercise training studies: TESTEX.
        Int J Evid Based Healthc. 2015; 13: 9-18
      4. Wallace B, Dahabreh I, Trikalinos T, et al. Closing the gap between methodologists and end-users: R as a computational back-end. American Statical Association.

        • Asa C.
        • Maria S.
        • Katharina S.S.
        • et al.
        Aquatic exercise is effective in improving exercise performance in patients with heart failure and type 2 diabetes mellitus.
        Evid-Based Complement Altern Med ECAM. 2012; 2012349209
        • Chagas E.F.B.
        • Cruz A.C.
        • Rodrigues P.H.
        • et al.
        Aquatic exercise and cardiac autonomic modulation of postmenopausal women with type 2 diabetes.
        Rev Bras Fisiol Exerc. 2020; 19: 82
      5. Conners RT, Morgan DW, Fuller DK, et al. Underwater Treadmill Training, Glycemic Control, and Health-Related Fitness in Adults with Type 2 Diabetes. Int J Aquat Res Educ; 8. Epub ahead of print November 2014. DOI: 10.25035/ijare.08.04.08.

        • Conners R.T.
        • Caputo J.L.
        • Coons J.M.
        • et al.
        Impact of Underwater Treadmill Training on Glycemic Control, Blood Lipids, and Health-Related Fitness in Adults With Type 2 Diabetes.
        Clin Diabetes. 2019; 37: 36-43
        • Cugusi L.
        • Cadeddu C.
        • Nocco S.
        • et al.
        Effects of an aquatic-based exercise program to improve cardiometabolic profile, quality of life, and physical activity levels in men with type 2 diabetes mellitus.
        PM R. 2015; 7 (quiz 148): 141-148
        • da Silva M.G.
        • Dias C.L.C.
        • Roso C.Z.V.
        • et al.
        Comportamento da glicemia, pressão arterial sistêmica e frequência cardíaca em indivíduos com diabetes mellitus tipo 2 praticantes de fisioterapia aquática.
        Fisioter Bras. 2015; 16: 256-260
        • Johnson S.T.
        • Mundt C.
        • Qiu W.
        • et al.
        Changes in Functional Status After Aquatic Exercise in Adults with Type 2 Diabetes and Arthritis: A Pilot Study.
        Act Adapt Aging. 2019; 43: 65-75
        • Nuttamonwarakul A.
        • Amatyakul S.
        • Suksom D.
        Effects of water-based versus land-based exercise training on cutaneous microvascular reactivity and c-reactive protein in older women with type 2 diabetes mellitus.
        J Exerc Physiol Online. 2014; 17: 27-33
        • Scheer A.S.
        • Naylor L.H.
        • Gan S.K.
        • et al.
        The Effects of Water-based Exercise Training in People with Type 2 Diabetes.
        Med Sci Sports Exerc. 2020; 52: 417-424
        • Suntraluck S.
        • Tanaka H.
        • Suksom D.
        The Relative Efficacy of Land-Based and Water-Based Exercise Training on Macro- and Microvascular Functions in Older Patients With Type 2 Diabetes.
        J Aging Phys Act. 2017; 25: 446-452
        • Boulé N.G.
        • Kenny G.P.
        • Haddad E.
        • et al.
        Meta-analysis of the effect of structured exercise training on cardiorespiratory fitness in Type 2 diabetes mellitus.
        Diabetologia. 2003; 46: 1071-1081
        • Heberle I.
        • de Barcelos G.T.
        • Silveira L.M.P.
        • et al.
        Effects of aerobic training with and without progression on blood pressure in patients with type 2 diabetes: A systematic review with meta-analyses and meta-regressions.
        Diabetes Res Clin Pract. 2021; 171108581
        • Nery C.
        • Moraes S.R.A.D.
        • Novaes K.A.
        • et al.
        Effectiveness of resistance exercise compared to aerobic exercise without insulin therapy in patients with type 2 diabetes mellitus: a meta-analysis.
        Braz J Phys Ther. 2017; 21: 400-415
        • Klein K.R.
        • Buse J.B.
        The trials and tribulations of determining HbA1c targets for diabetes mellitus.
        Nat Rev Endocrinol. 2020; 16: 717-730
        • Laiteerapong N.
        • Ham S.A.
        • Gao Y.
        • et al.
        The Legacy Effect in Type 2 Diabetes: Impact of Early Glycemic Control on Future Complications (The Diabetes & Aging Study) |.
        Diabetes Care. 2019; 42: 416-426
      6. American College of Sports Medicine. ACSM’s guidelines for exercise testing and prescription. Lippincott Williams & Wilkins, 2013.

        • Umpierre D.
        • Ribeiro P.A.B.
        • Kramer C.K.
        • et al.
        Physical activity advice only or structured exercise training and association with HbA1c levels in type 2 diabetes: a systematic review and meta-analysis.
        JAMA. 2011; 305: 1790-1799
        • Al-Mallah M.H.
        • Sakr S.
        • Al-Qunaibet A.
        Cardiorespiratory Fitness and Cardiovascular Disease Prevention: an Update.
        Curr Atheroscler Rep. 2018; 20: 1
        • Alberton C.L.
        • Fonseca B.A.
        • Nunes G.N.
        • et al.
        Magnitude of vertical ground reaction force during water-based exercises in women with obesity.
        Sports Biomech. 2021; : 1-14
        • Nogueira M.
        • Otuyama L.J.
        • Rocha P.A.
        • et al.
        Pharmaceutical care-based interventions in type 2 diabetes mellitus : a systematic review and meta-analysis of randomized clinical trials.
        Einstein. 2020; 18: eRW4686
        • Laffin L.J.
        • Bakris G.L.
        Update on blood pressure goals in diabetes mellitus.
        Curr Cardiol Rep. 2015; 17: 37
        • Stergiou G.S.
        • Palatini P.
        • Parati G.
        • et al.
        2021 European Society of Hypertension practice guidelines for office and out-of-office blood pressure measurement.
        J Hypertens. 2021; 39: 1293-1302
        • Unger T.
        • Borghi C.
        • Charchar F.
        • et al.
        2020 International Society of Hypertension global hypertension practice guidelines.
        J Hypertens. 2020; 38: 982-1004
        • Gonela J.T.
        • de Castro V.
        • Zanetti M.L.
        Rev Bras Med Esporte. 2020; 26: 53-57
        • Studenski S.
        • Perera S.
        • Patel K.
        • et al.
        Gait speed and survival in older adults.
        JAMA. 2011; 305: 50-58
        • Jor’dan A.J.
        • Manor B.
        • Novak V.
        Slow gait speed - an indicator of lower cerebral vasoreactivity in type 2 diabetes mellitus.
        Front Aging Neurosci. 2014; 6: 135
        • Dipietro L.
        • Campbell W.W.
        • Buchner D.M.
        • et al.
        Physical Activity, Injurious Falls, and Physical Function in Aging: An Umbrella Review.
        Med Sci Sports Exerc. 2019; 51: 1303-1313
        • Distefano G.
        • Goodpaster B.H.
        Effects of Exercise and Aging on Skeletal Muscle.
        Cold Spring Harb Perspect Med. 2018; 8a029785
        • Liu C.
        • Feng X.
        • Li Q.
        • et al.
        Adiponectin, TNF-α and inflammatory cytokines and risk of type 2 diabetes: A systematic review and meta-analysis.
        Cytokine. 2016; 86: 100-109
        • Pedersen B.K.
        Anti-inflammatory effects of exercise: role in diabetes and cardiovascular disease.
        Eur J Clin Invest. 2017; 47: 600-611
        • Melo L.C.
        • Dativo-Medeiros J.
        • Menezes-Silva C.E.
        • et al.
        Physical Exercise on Inflammatory Markers in Type 2 Diabetes Patients: A Systematic Review of Randomized Controlled Trials.
        Oxid Med Cell Longev. 2017; 2017: 8523728