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

Comprehensive Diabetes Management Strategies

The most effective diabetes management requires a combination of medication therapy with metformin as first-line pharmacological treatment, along with structured lifestyle modifications including 150 minutes of weekly physical activity (both aerobic and resistance training) and individualized medical nutrition therapy. 1

Lifestyle Modifications

Physical Activity Recommendations

• Aerobic Exercise:

  • At least 150 minutes of moderate-intensity aerobic activity weekly, spread over at least 3 days with no more than 2 consecutive days without activity 1
  • Activity bouts should last at least 10 minutes, with a goal of 30 minutes/day or more 1
  • For those capable of more vigorous exercise, 75 minutes/week of high-intensity activity can provide equivalent benefits 1

• Resistance Training:

  • 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
  • Benefits include improved glycemic control, strength, balance, and ability to perform daily activities 1

• Reducing Sedentary Behavior:

  • Break up prolonged sitting (≥30 minutes) with brief periods of standing, walking, or light activity 1
  • This helps prevent type 2 diabetes and aids glycemic control 1

Nutrition Therapy

• Dietary Pattern:

  • Emphasize carbohydrates from fruits, vegetables, whole grains, legumes, and low-fat milk 1
  • Monitor carbohydrate intake through counting, exchanges, or experience-based estimation 1
  • Consider glycemic index and load for modest additional benefit 1

• Weight Management:

  • For overweight/obese patients, aim for 5-10% weight reduction through calorie restriction and increased physical activity 1
  • Even modest weight loss can improve insulin resistance 1

• Alcohol Consumption:

  • Limit to moderate amounts (≤1 drink/day for women, ≤2 drinks/day for men) 1
  • Consume with food to reduce risk of nocturnal hypoglycemia, especially for those on insulin or insulin secretagogues 1

Pharmacological Management

Type 2 Diabetes

1. First-Line Therapy:

   • Metformin is the preferred initial pharmacologic agent 1
   • Benefits include:
     • Long-established efficacy and safety
     • Potential reduction in cardiovascular events and death
     • Low cost
     • Can be continued with declining renal function down to GFR of 30-45 mL/min (with dose reduction) 1

2. Combination Therapy (when monotherapy is insufficient):

   • Add a second agent if HbA1c target not achieved after 3 months on maximum tolerated metformin dose 1
   • Options include:
     • Sulfonylureas
     • Thiazolidinediones (e.g., pioglitazone)
     • DPP-4 inhibitors
     • SGLT2 inhibitors
     • GLP-1 agonists
     • Basal insulin 1

3. Medication Adjustments:

   • For patients on pioglitazone: Start at 15 or 30 mg once daily, can increase to maximum 45 mg daily 2
   • For patients on insulin: When adding pioglitazone, insulin dose may need to be reduced by 10-25% if hypoglycemia occurs 2

Type 1 Diabetes

• Multiple daily insulin injections or continuous subcutaneous insulin infusion (insulin pump) 1
• Match prandial insulin doses to carbohydrate intake, pre-meal glucose levels, and anticipated activity 1
• Use insulin analogs to reduce hypoglycemia risk 1

Special Considerations

Exercise Safety

• Hypoglycemia Prevention:

  • For those on insulin/insulin secretagogues: May need additional carbohydrate if pre-exercise glucose <100 mg/dL 1
  • Monitor for delayed hypoglycemia (can occur several hours post-exercise) 1
  • Consider insulin dose adjustments for planned exercise 1

• For Patients with Complications:

  • Those with peripheral neuropathy should wear proper footwear and examine feet daily 1
  • Restrict to non-weight-bearing activities if foot injury or open sore is present 1

Monitoring and Follow-up

• Use HbA1c to evaluate long-term glycemic control (every 3 months) 2
• Monitor blood glucose to determine if adjustments to food, activity, or medications are needed 1
• Assess for quality of life alongside metabolic parameters 3

Common Pitfalls to Avoid

1. Neglecting resistance training - Many providers focus only on aerobic exercise, but resistance training provides unique benefits for glycemic control 4

2. Overlooking hypoglycemia risk - Exercise can cause immediate or delayed hypoglycemia in patients on insulin or insulin secretagogues 1, 5

3. Failing to address sedentary behavior - Even with structured exercise, prolonged sitting periods can negatively impact glycemic control 1, 6

4. Not individualizing carbohydrate management - Patients need specific guidance on adjusting carbohydrate intake based on activity type, timing, and intensity 7

5. Focusing only on medication - Lifestyle modifications are fundamental and should be emphasized alongside pharmacotherapy 1, 3