What are the recommended treatments and lifestyle modifications for diabetes management?

Comprehensive Diabetes Management: Treatments and Lifestyle Modifications

Effective diabetes management requires a combination of structured physical activity, dietary modifications, and appropriate pharmacological therapy, with metformin as the first-line medication for type 2 diabetes. 1

Physical Activity Recommendations

Aerobic Exercise

• Perform at least 150 minutes of moderate-intensity aerobic physical activity (50-70% of maximum heart rate) per week 1
• Spread activity over at least 3 days per week with no more than 2 consecutive days without exercise 1
• Daily exercise is recommended to decrease insulin resistance, regardless of diabetes type 1
• Break up prolonged sedentary periods (≥30 min) with brief standing, walking, or light activity 1

Resistance Training

• Engage in resistance training at least 2-3 sessions per week on non-consecutive days 1
• Include at least one set of five or more different resistance exercises involving large muscle groups 1
• All intensities of resistance training can improve strength and glycemic control 1

Dietary Management

General Nutrition Principles

• Individualized Medical Nutrition Therapy (MNT) provided by a registered dietitian is recommended for all persons with diabetes 1
• For overweight/obese individuals, weight loss of 5-7% of body weight is recommended 1
• Carbohydrate monitoring (counting, exchanges, or estimation) is key for glycemic control 1

Dietary Patterns

• Focus on carbohydrates from fruits, vegetables, whole grains, legumes, and low-fat milk 1
• For weight loss, low-carbohydrate, low-fat calorie-restricted, or Mediterranean diets may be effective in the short term (up to 2 years) 1
• Low-carbohydrate diets (restricting total carbohydrate to <130g/day) are not recommended for diabetes management 1
• Consider glycemic index/load as a modest additional benefit beyond total carbohydrate monitoring 1

Special Considerations

• Sucrose-containing foods can be substituted for other carbohydrates in the meal plan if covered with insulin or glucose-lowering medications 1
• If choosing to consume alcohol, limit intake to moderate amounts (≤1 drink/day for women, ≤2 drinks/day for men) and consume with food to prevent hypoglycemia 1
• Routine supplementation with antioxidants or vitamins is not advised due to lack of evidence 1

Pharmacological Management

Type 2 Diabetes

• Metformin is the preferred initial pharmacologic agent for type 2 diabetes 1, 2
  • Can be continued with declining renal function down to GFR of 30-45 mL/min (with dose reduction) 1
  • Common side effects include diarrhea, nausea, and upset stomach, which generally improve over time 2
  • Monitor for lactic acidosis, especially with alcohol consumption, dehydration, or kidney problems 2

Combination Therapy

• When monotherapy doesn't achieve HbA1c targets over 3 months, add a second agent 1
• Options include: sulfonylureas, thiazolidinediones, DPP-4 inhibitors, SGLT2 inhibitors, GLP-1 agonists, or basal insulin 1
• For thiazolidinediones like pioglitazone:
  • Starting dose is 15-30mg once daily (15mg for patients with heart failure) 3
  • Monitor for fluid retention and weight gain 3
  • Maximum dose with strong CYP2C8 inhibitors (e.g., gemfibrozil) is 15mg daily 3

Hypoglycemia Management

• Treat conscious patients with 15-20g glucose (preferred) or any carbohydrate containing glucose 1
• Recheck blood glucose after 15 minutes; repeat treatment if hypoglycemia persists 1
• After blood glucose normalizes, consume a meal or snack to prevent recurrence 1
• Prescribe glucagon for individuals at risk of severe hypoglycemia; educate caregivers on administration 1
• For those with hypoglycemia unawareness, temporarily raise glycemic targets to reverse the condition 1

Additional Interventions

Weight Management

• Consider bariatric surgery for adults with BMI >35 kg/m² and type 2 diabetes, especially with difficult-to-control diabetes 1
• Weight loss medications may be considered for some individuals with type 2 diabetes 1

Psychological Support

• Include assessment of psychological and social situation as part of diabetes management 1
• Screen for depression, diabetes-related distress, anxiety, eating disorders when self-management is poor 1
• Diabetes self-management education (DSME) should address psychosocial issues 1

Common Pitfalls and Caveats

1. Exercise-related hypoglycemia: Individuals on insulin or insulin secretagogues may need additional carbohydrates before exercise if pre-exercise glucose is <100 mg/dL 1

2. Peripheral neuropathy: Those with neuropathy should wear proper footwear, examine feet daily, and restrict to non-weight-bearing activities if foot injuries are present 1

3. Medication adjustments: When initiating exercise programs, medication doses may need adjustment to prevent hypoglycemia 1

4. Alcohol consumption: Can increase risk of hypoglycemia and lactic acidosis with metformin; requires extra precautions 1, 2

5. Post-exercise hypoglycemia: May occur several hours after activity due to increased insulin sensitivity 1