Picture a Monday morning in your local leisure centre. A GP has just referred one of your gym members to you. The referral form says type 2 diabetes, diagnosed eighteen months ago, currently on metformin, HbA1c of 58 mmol/mol. The client is 47, hasn’t exercised regularly in years and is understandably nervous. They’ve been told that structured exercise could help them reduce their medication, possibly even put their diagnosis into remission. They’re looking at you and they need you to know exactly what to do.
This is the kind of referral that exercise referral specialists across the country are seeing more and more of. In April 2024 NHS England scaled up one of the most ambitious diabetes remission programmes in the world, and the first real-world evaluation has confirmed that remission is achievable at scale, outside of a research lab. For qualified exercise professionals, this is a career-defining opportunity, but only if you understand what the evidence actually says and how to translate it into effective programming.
The NHS Path to Remission Programme
In April 2024 NHS England rolled out the Type 2 Diabetes Path to Remission Programme across the whole of England (NHS England, 2024). The programme had been piloted since 2020 and the decision to take it national was based on early data that was, by any standard, hugely encouraging.
The first formal evaluation, published in The Lancet Diabetes & Endocrinology, followed 7,540 people referred to the programme between September 2020 and December 2022. Among completers who had two follow-up HbA1c measurements recorded, 32 per cent achieved remission at 12 months, with an average weight loss of 15.9 kg (Valabhji et al., 2024). This was not a tightly controlled clinical trial. It was routine NHS delivery, and it was the first time remission of type 2 diabetes had been demonstrated through a nationally scaled service.
The programme centres on a total diet replacement phase (a specially formulated low-calorie diet of around 800 to 850 kcal per day for roughly three months), followed by structured food reintroduction and long-term lifestyle maintenance support. Exercise is not the centrepiece of the initial weight-loss phase, but it becomes increasingly important during maintenance and is a central pillar of sustained remission.
This is where exercise referral specialists come in. Many patients who complete the Path to Remission programme, or who are identified as suitable for structured exercise alongside it, will be referred to local exercise referral schemes. An even larger group of people living with type 2 diabetes who don’t meet the Path to Remission criteria (or who choose not to go through total diet replacement) still need structured exercise support to manage their condition. The evidence for what that exercise should look like is now very clear.
What the Evidence Says About Exercise and Glycaemic Control
The most current evidence on exercise interventions for type 2 diabetes comes from a series of meta-analyses and systematic reviews published over the last couple of years. The headline finding is that structured exercise of almost any type improves glycaemic control, but the size of the effect depends on the type of exercise prescribed, the intensity and how consistently it is performed.
A 2024 systematic review and meta-analysis of 46 randomised controlled trials involving 2,130 participants found that resistance training alone reduced HbA1c by an average of 0.50 percentage points (Wan and Su, 2024). That might sound modest in isolation, but in clinical terms a 0.50 per cent reduction in HbA1c is enough to shift a patient’s risk profile and in many cases reduce or delay the need for additional medication. The same analysis found that higher-intensity resistance training produced a significantly larger effect (a reduction of 0.61 percentage points) compared with low-to-moderate intensity protocols (0.23 percentage points), and that only the high-intensity protocols produced a statistically significant reduction in fasting insulin.
A large-scale systematic review and meta-analysis published in Diabetes Care, covering 126 randomised controlled trials and 6,718 participants, compared the effects of different exercise modalities on HbA1c. Combined aerobic and resistance training ranked among the most effective approaches, alongside high-intensity interval training. Aerobic exercise alone and resistance training alone were both beneficial, but combining the two produced a greater overall improvement in glycaemic control (Gallardo-Gómez et al., 2024). The same review identified an optimal dose of around 1,100 MET-minutes per week, roughly equivalent to five hours of moderate-intensity activity or a combination of resistance and aerobic sessions spread across the week.
A review by Astbury (2024), published in Diabetes, Obesity and Metabolism, reinforced the position that exercise interventions sit alongside dietary and pharmacological strategies as a core approach for improving glycaemic control in people living with, and at risk of developing, type 2 diabetes.
The practical message for us is that a programme that combines resistance training at a moderate-to-high intensity with regular aerobic conditioning represents the evidence-based gold standard for this population.
Why Resistance Training Is So Important
It is worth taking a minute to contemplate on why resistance training is so important for this client group, because many referrals still arrive with a default expectation that the programme will be built around walking, cycling or other steady-state aerobic work.
Resistance training improves insulin sensitivity through a mechanism that aerobic exercise alone does not fully replicate. When you load a muscle against resistance, you increase the number and activity of GLUT4 transporters (the proteins responsible for moving glucose out of the bloodstream and into muscle tissue) on the surface of muscle cells. Their increased activity means the muscle can absorb more glucose without needing as much insulin to make it happen. Over time, regular resistance training also increases lean muscle mass, which means there is a larger metabolic sink available to absorb circulating glucose both at rest and after meals.
A recent meta-analysis of resistance training in middle-aged and older adults with type 2 diabetes found significant reductions in HOMA-IR (a widely used measure of insulin resistance), fasting glucose and HbA1c, alongside improvements in systemic inflammation markers. The improvements were most pronounced when sessions were performed at least twice a week and included compound multi-joint movements at a challenging intensity.
The main point here is that resistance training is not an optional extra in a type 2 diabetes programme. It is the single most effective modality for improving the body’s ability to handle glucose and it should form the foundation of every programme designed for this client group.
Weight Loss and the Remission Threshold
Another important finding from the diabetes remission research is how strongly weight loss predicts whether someone achieves remission. The landmark DiRECT trial, which provided the evidence base for the NHS Path to Remission programme, showed a clear dose-response relationship. Among participants who lost 15 kg or more, 86 per cent achieved remission. Among those who lost 10 to 15 kg, 57 per cent achieved it. And among those who lost 5 to 10 kg, 34 per cent did (Lean et al., 2018).
The mechanism behind this is thought to involve the removal of excess fat from the liver and pancreas, which allows the insulin-producing beta cells to recover their function. The weight-loss threshold is not a magic number that works for everyone, but the evidence makes it pretty clear that for most people with type 2 diabetes diagnosed within the past six years, substantial weight reduction in the region of 10 to 15 kg gives the body the best chance of restoring normal glucose regulation.
Exercise fits into this bigger picture in two critical ways. First, it helps preserve lean muscle mass during the calorie deficit, which protects the metabolic rate and supports long-term weight maintenance. Second, it is the single strongest predictor of whether someone keeps their weight off over the following two to five years. The five-year follow-up of the DiRECT trial showed that remission rates dropped from 46 per cent at 12 months to around 13 per cent at five years, and the primary driver was weight regain. Structured exercise support during and beyond the weight-loss phase is the most evidence-based strategy available for preventing that.
Programming for Type 2 Diabetes Clients
Putting all of this evidence together, a well-structured exercise referral programme for someone living with type 2 diabetes should include the following components.
Resistance training at least twice a week, ideally three times. Each session should include compound multi-joint exercises (squat variations, deadlift or hip-hinge variations, pressing and rowing movements) at a moderate-to-high intensity relative to the client’s current ability. Two to three sets of eight to twelve repetitions is a solid starting framework, with load progressed once the client can comfortably complete twelve reps with good form. For deconditioned clients this might begin with bodyweight or very light resistance and build from there. Because the insulin sensitivity improvements are driven by training intensity, the programme needs to be genuinely progressive rather than staying at the same comfortable level week after week.
Aerobic conditioning at least three times per week, building towards a total of at least 150 minutes of moderate-intensity activity. This can include brisk walking, cycling, swimming or gym-based cardio at an RPE of around 5 to 6 out of 10. Where possible, include one or two sessions per week of higher-intensity interval work (RPE 7 to 8), as the meta-analysis evidence suggests HIIT produces the largest single-modality improvements in HbA1c. A simple format such as four to six intervals of 60 to 90 seconds at a high effort followed by two to three minutes of active recovery works well for most clients once they have a baseline of aerobic fitness.
Careful attention to energy balance. If the client’s goal includes weight loss (and for most type 2 diabetes referrals it will), the exercise programme needs to sit alongside a dietary approach that creates a sustained energy deficit. Exercise alone rarely generates the kind of energy expenditure needed to produce the 10 to 15 kg of weight loss associated with remission-level outcomes. The exercise referral specialist’s role is to deliver and progress the exercise component while ensuring the client is connected with appropriate dietary support, whether through the Path to Remission programme, a registered dietitian or another NHS-commissioned pathway.
Blood glucose monitoring. Clients taking insulin or sulfonylureas are at risk of exercise-induced hypoglycaemia, which is something every exercise referral specialist should be trained to recognise and manage. Pre-exercise blood glucose checks, timing sessions in relation to meals and medication and having fast-acting carbohydrate available are all standard protocols that should be part of your working practice.
Session structure and progression. There is growing evidence that splitting aerobic and resistance components across separate days, rather than combining them in a single long session, may improve adherence in deconditioned populations. For clients who are new to structured exercise, a realistic starting point might be two shorter sessions per week (20 to 30 minutes of resistance work plus a warm-up and cool-down) before introducing additional aerobic sessions as fitness and confidence build. The goal is to get the client moving consistently and progressing steadily, not to overwhelm them in the first fortnight.
The Role of the Exercise Referral Specialist
A 2025 scoping review published in the Journal of Public Health looked at how healthcare professionals and exercise specialists work together within exercise referral pathways (Journal of Public Health, 2025). The review, which included 39 studies, identified three themes that determine whether referral schemes succeed: the confidence of the referring healthcare professional in the exercise specialist, whether the programme takes a person-centred approach and whether there are joined-up systems connecting primary care with exercise providers.
Many of us working in exercise referral know that the quality of the referral relationship is everything. A GP who trusts that the exercise referral specialist understands the clinical picture, can manage risk and will communicate back about the client’s progress is far more likely to refer regularly. Building that trust means demonstrating clinical knowledge, not just fitness knowledge. Understanding HbA1c targets, knowing the medication classes your clients are taking and being able to explain in clinical language what your programme is designed to achieve are all part of the job.
The national rollout of the NHS Path to Remission programme has created growing demand for exercise professionals who can work confidently with this population. Whether you are supporting clients alongside the programme, receiving referrals from GPs independently or working within a community exercise referral scheme, the opportunity to make a genuine difference to people’s health and quality of life has never been bigger. And for the profession as a whole, the message from the NHS is that exercise referral is not a niche specialism any more. It is a frontline service.
Reference
- Astbury, N.M. (2024). Interventions to improve glycaemic control in people living with, and at risk of developing, type 2 diabetes. Diabetes, Obesity and Metabolism, 26(Suppl. 4), 39–49. Click here to review the full research article.
- Gallardo-Gómez, D., Del Pozo-Cruz, J., Noetel, M., Álvarez-Barbosa, F., Alfonso-Rosa, R.M. and Del Pozo Cruz, B. (2024). Optimal dose and type of physical activity to improve glycemic control in people diagnosed with type 2 diabetes: a systematic review and meta-analysis. Diabetes Care, 47(2), 295–306. Click here to review the full research article.
- Healthcare professionals and physical activity, working together for exercise referral: a scoping review (2025). Journal of Public Health. Click here to review the full research article.
- Lean, M.E.J., Leslie, W.S., Barnes, A.C., Brosnahan, N., Thom, G., McCombie, L., Peters, C., Zhyzhneuskaya, S., Al-Mrabeh, A., Hollingsworth, K.G., Rodrigues, A.M., Rehackova, L., Adamson, A.J., Sniehotta, F.F., Mathers, J.C., Ross, H.M., McIlvenna, Y., Stefanetti, R., Sheriffe, T. and Taylor, R. (2018). Primary care-led weight management for remission of type 2 diabetes (DiRECT): an open-label, cluster-randomised trial. The Lancet, 391(10120), 541–551. Click here to review the full research article.
- NHS England (2024). Successful NHS Type 2 Diabetes Path to Remission Programme to be rolled out across the whole of England from April 2024. Click here to review the full research article.
- Valabhji, J. et al. (2024). Early findings from the NHS Type 2 Diabetes Path to Remission Programme: a prospective evaluation of real-world implementation. The Lancet Diabetes & Endocrinology. Click here to review the full research article.
- Wan, Y. and Su, Z. (2024). The impact of resistance exercise training on glycemic control among adults with type 2 diabetes: a systematic review and meta-analysis of randomized controlled trials. Biological Research for Nursing, 26(4). Click here to review the full research article.
Ready to Work With Referred Clients?
If this article has got you thinking about specialising in exercise referral, our Exercise Referral qualification is designed to give you exactly the clinical knowledge and practical confidence the research points to. You’ll learn how to work with clients referred by GPs and other healthcare professionals, manage conditions including type 2 diabetes, cardiovascular disease and obesity, and design structured exercise programmes that are both evidence-based and person-centred.
If you want to go deeper into the diabetes and weight management side, our Obesity and Diabetes Management course pairs perfectly with Exercise Referral and gives you a specialism that is in growing demand across the NHS and private sector.
Exercise Referral Course – Distance Study
Level 4 Obesity & Diabetes Management Course – Distance Study
