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

Recommended Treatments and Lifestyle Modifications for Diabetes Management

The optimal approach to diabetes management includes metformin as first-line therapy, followed by SGLT2 inhibitors or GLP-1 receptor agonists as second-line options, combined with at least 150 minutes of weekly moderate-to-vigorous aerobic activity, resistance training, and a personalized nutrition plan emphasizing fiber-rich foods and limited refined carbohydrates. 1

Pharmacological Management

First-Line Treatment

• Metformin is the recommended first-line medication for most patients with type 2 diabetes 1
  • Start at a low dose and gradually titrate to minimize gastrointestinal side effects
  • Appropriate for patients with eGFR ≥30 ml/min per 1.73 m²
  • Monitor for vitamin B12 deficiency with periodic testing
  • May cause metallic taste initially, but this typically resolves quickly 2
  • Rarely causes hypoglycemia when used as monotherapy 2

Second-Line Treatment Options

• SGLT2 inhibitors or GLP-1 receptor agonists are preferred second-line agents due to their proven cardiorenal benefits 1
  • GLP-1 receptor agonists offer additional benefits of weight reduction
  • These agents are preferred over sulfonylureas due to their cardiovascular benefits

Combination Therapy Considerations

• When combining medications, monitor for potential interactions:
  • Adding sulfonylureas to metformin and SGLT2 inhibitors increases hypoglycemia risk 1
  • Insulin can be effectively combined with GLP-1 receptor agonists for greater efficacy with reduced hypoglycemia risk 1
  • Reassess insulin dosing when adding GLP-1 receptor agonists (may need to reduce insulin by 10-25% if hypoglycemia occurs) 1, 3

Lifestyle Modifications

Physical Activity Recommendations

• Aerobic Exercise:

  • At least 150 minutes of moderate-to-vigorous intensity aerobic activity weekly 1
  • Spread over at least 3 days per week
  • Avoid more than 2 consecutive days without activity

• 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

• Reducing Sedentary Behavior:

  • Break up prolonged sitting every 30 minutes with brief activity 1
  • This provides significant blood glucose benefits

• Exercise Timing Strategies:

  • Moderate exercise 30-60 minutes before anticipated glucose peaks can blunt postmeal glucose surges 4
  • Short-duration, high-intensity exercise can also be effective
  • Be cautious with high-intensity premeal exercise as it may cause delayed hypoglycemia in some individuals 4

Nutritional Recommendations

• Macronutrient Distribution:

  • No single ideal macronutrient distribution exists for all people with diabetes 1
  • Prioritize carbohydrates from vegetables, fruits, legumes, whole grains, and dairy products
  • Emphasize foods higher in fiber and lower in glycemic load

• Meal Composition and Timing:

  • Consider consuming protein and vegetables first, followed by carbohydrates 30 minutes later to moderate glucose levels 4
  • Eat most carbohydrates earlier in the day
  • Avoid sugar-sweetened beverages

• Other Dietary Considerations:

  • Limit sodium consumption to <2,300 mg/day (further restriction may be indicated for those with hypertension) 1
  • If consuming alcohol, limit to one drink per day for women and two drinks per day for men 1
  • Be aware of increased hypoglycemia risk with alcohol, especially when using insulin or insulin secretagogues

• Weight Management:

  • For overweight or obese individuals, aim for weight loss of ≥5% through calorie reduction and lifestyle modification 1

Monitoring and Follow-Up

• Glycemic Control:

  • Use HbA1c as the primary indicator of long-term glycemic control 1, 3
  • Individualize targets ranging from <6.5% to <8.0% based on age, disease duration, comorbidities, and hypoglycemia risk
  • Check HbA1c quarterly when therapy changes or targets are not met

• Medication Review:

  • Reevaluate medication regimen every 3-6 months 1
  • Adjust based on glycemic control, side effects, and development of comorbidities

• Regular Screening:

  • Comprehensive foot examination annually
  • Dilated eye examination annually
  • Nephropathy screening annually with urine albumin-to-creatinine ratio
  • Blood pressure check at every routine visit

Common Pitfalls and Caveats

• Hypoglycemia Risk:

  • Metformin rarely causes hypoglycemia by itself, but risk increases when combined with sulfonylureas or insulin 2
  • Alcohol consumption increases hypoglycemia risk 1

• Medication Storage:

  • Store metformin at 68ºF to 77ºF (20ºC to 25ºC) 2
  • Keep medications out of reach of children

• Specialized Support:

  • Refer patients for individualized Medical Nutrition Therapy (MNT), preferably provided by a registered dietitian 1
  • Consider additional precautions for patients with diabetic complications such as retinopathy or peripheral neuropathy 5