Optimizing Physical Activity Strategies for Older Adults with Diabetes

The increasing prevalence of diabetes among older adults has emerged as a major socioeconomic burden. This population is highly heterogeneous, ranging from functionally independent to severely impaired individuals, making it difficult to establish standardized recommendations. Physical activity (PA) is a cornerstone of diabetes management; however, current exercise guidelines do not adequately address the wide spectrum of functional capacities observed in older adults. For those with physical limitations, relatively simple activities such as walking, breaking up sedentary time, incorporating movement into daily routines, and aquatic exercise have been proposed, yet supporting evidence remains limited. This review summarizes the pathophysiologic mechanisms of metabolic and functional changes associated with aging and diabetes-including sarcopenia, altered body composition, and cardiovascular decline-and comprehensively discusses the benefits and precautions of various exercise modalities, tailored recommendations according to diabetes-related complications, and key clinical considerations. We further classified older adults with diabetes into three functional levels, individuals in good health, those with some comorbidities or mild disabilities, and those with high comorbidities and/or functional impairment, and proposed corresponding physical activity strategies for each level. Finally, we highlight practical and feasible approaches, including walking, interrupting sedentary behavior, daily functional movements, and aquatic exercise, to enhance clinical applicability for individuals with reduced physical capacity. These tailored, function-based strategies may help older adults with diabetes achieve safer, more effective, and sustainable improvements in glycemic control and overall health.