What are the primary recommendations for managing diabetes?

Primary Recommendations for Managing Diabetes

The primary recommendations for managing diabetes include individualized lifestyle modifications (diet, physical activity, weight management), medication therapy starting with metformin, regular blood glucose monitoring, and comprehensive cardiovascular risk reduction. 1

Lifestyle Management

Nutrition Therapy

• No single ideal dietary distribution of calories among carbohydrates, fats, and proteins exists for people with diabetes 1
• Preferred carbohydrate sources: vegetables, fruits, legumes, whole grains, and dairy products with emphasis on high-fiber and low-glycemic load foods 1
• For those with type 1 diabetes or type 2 diabetes on flexible insulin therapy, carbohydrate counting education is recommended 1
• For those on fixed insulin dosing, consistent carbohydrate intake timing and amount is beneficial 1
• Avoid sugar-sweetened beverages and minimize foods with added sugars 1

Physical Activity

• Regular physical activity improves blood glucose control and reduces cardiovascular risk factors
• Pre-exercise evaluation should include careful history and cardiovascular risk assessment 1
• Special considerations for patients with:
  • Retinopathy: Avoid activities that dramatically increase blood pressure
  • Neuropathy: Focus on non-weight-bearing activities
  • Cardiovascular autonomic neuropathy: Undergo cardiac investigation before beginning intense physical activity 1

Weight Management

• For overweight/obese individuals, weight loss of ≥5% through calorie reduction and lifestyle modification is recommended 1
• Structured weight loss programs are beneficial 1

Medication Therapy

First-line Therapy

• Metformin remains the primary first-line medication for type 2 diabetes due to its efficacy, safety, and cost-effectiveness 2, 3
• Start metformin at diagnosis unless contraindicated
• Metformin should be taken with meals to minimize gastrointestinal side effects 2

Additional Medication Options

• For type 1 diabetes: Multiple daily injections (MDI) of prandial and basal insulin or continuous subcutaneous insulin infusion (CSII) 4
• For type 2 diabetes requiring additional therapy beyond metformin:
  • GLP-1 receptor agonists offer benefits for HbA1c reduction, weight loss, and cardiovascular outcomes 3
  • SGLT-2 inhibitors provide glucose lowering with cardiovascular and renal benefits 3
  • Thiazolidinediones (like pioglitazone) may be used but require monitoring for fluid retention 5
  • Insulin therapy when other options fail to achieve glycemic targets 6

Blood Glucose Monitoring

• For patients on multiple-dose insulin or insulin pump therapy: Monitor before meals, occasionally after meals, at bedtime, before exercise, when hypoglycemia is suspected, and before critical tasks like driving 1
• For patients on less intensive insulin regimens or non-insulin therapies: Monitoring frequency should be dictated by individual needs 1
• HbA1c testing is recommended for long-term glycemic control assessment 1

Cardiovascular Risk Reduction

• Blood pressure target: <130/80 mmHg 1
• LDL cholesterol target: <100 mg/dL (2.60 mmol/L), with option for <70 mg/dL (1.80 mmol/L) in high-risk patients 1
• Daily aspirin regimen for appropriate candidates reduces coronary heart disease risk by 20-25% 1
• Smoking cessation is essential for all patients who use tobacco products 1

Screening for Complications

• Annual dilated eye examinations starting 3-5 years after onset of type 1 diabetes 1
• Regular screening for nephropathy through microalbuminuria testing 1
• Foot examinations to prevent complications

Special Considerations for Older Adults

• Goals should be individualized based on functional status, comorbidities, and life expectancy 1
• For stable older adults: Continue previous medication plan with focus on preventing hypoglycemia 1
• For those with organ failure: Preventing hypoglycemia becomes the primary goal 1

Common Pitfalls to Avoid

1. Relying solely on sliding-scale insulin as a treatment strategy 4
2. Failing to recognize atypical presentation of hypoglycemia in patients on beta-blockers or with long-standing diabetes 6
3. Not accounting for increased risk of hypoglycemia when combining alcohol with insulin or insulin secretagogues 1
4. Overlooking the importance of diabetes self-management education and support 1
5. Neglecting to adjust insulin doses for physical activity 4

By implementing these evidence-based recommendations, patients with diabetes can achieve better glycemic control, reduce complications, and maintain quality of life.