Comprehensive Management of Type 2 Diabetes Mellitus
For effective control of Type 2 Diabetes Mellitus (T2DM), implement a combination of lifestyle modifications and pharmacotherapy, starting with metformin as first-line therapy along with a tailored nutrition plan and regular physical activity. 1, 2
Lifestyle Modifications
Dietary Recommendations
- Adopt a heart-healthy dietary pattern such as Mediterranean, DASH, or vegetarian/vegan diet 1, 2
- Focus on fiber-rich whole grains and avoid refined carbohydrates 1
- Reduce intake of red meat, which has been shown to increase risk of T2DM 1
- Limit saturated and trans fatty acids, cholesterol, and sodium 2
- For overweight/obese patients, adjust dietary recommendations to achieve meaningful weight loss 1
- Consider consulting a registered dietitian-nutritionist or diabetes education program for personalized nutrition planning 1
Physical Activity
- Perform at least 150 minutes per week of moderate-intensity aerobic activity or 75 minutes of vigorous-intensity physical activity 1, 2
- Include 2-3 sessions of resistance exercise on non-consecutive days weekly 2
- Combine aerobic and resistance training for better glycemic control and weight loss than either type alone 1
- Break up prolonged sedentary time with brief activity throughout the day 2
- For older individuals with comorbidities, consider a simple walking program 1
Other Lifestyle Modifications
- Quit smoking and reduce second-hand smoke exposure 1
- Limit alcohol intake to one drink per day for women and two for men 2
- Reduce sedentary time throughout the day 1, 2
- Aim for weight loss of ≥5% in overweight/obese patients 2
Pharmacological Management
First-Line Therapy
- Initiate metformin at diagnosis along with lifestyle therapies 1, 2, 3
- Benefits of metformin include:
- Start with a low dose and gradually increase to reduce gastrointestinal side effects 1
- Monitor for vitamin B12 deficiency in patients on long-term metformin therapy 2
- Use with caution in patients with renal impairment (eGFR < 45 mL/min/1.73m²) 1, 2
Second-Line Therapy
- For patients requiring additional glucose-lowering therapy despite lifestyle modifications and metformin, consider adding:
- When adding these medications with adequate glycemic control, consider reducing or discontinuing sulfonylureas or long-acting insulins to reduce hypoglycemia risk 2
Monitoring and Follow-up
- Assess glycemic response with HbA1c every 3-6 months 2
- Target HbA1c < 7% for most patients, though goals may be individualized 2
- Monitor blood pressure (target <130/80 mmHg) and lipids regularly 2
- Regularly assess renal function, especially with SGLT-2 inhibitors and metformin 2
- Provide diabetes self-management education at diagnosis, annually, and during transitions of care 2
Common Pitfalls and Caveats
- Hypoglycemia risk: Particularly high with insulin and sulfonylureas; use insulin analogs when possible to reduce this risk 2
- Medication adherence: Address cost barriers when selecting treatments, as currently no generic SGLT-2 inhibitors or GLP-1 agonists are available 2
- Metformin side effects: Gastrointestinal issues are common; start with low dose and gradually increase 1
- SGLT-2 inhibitor risks: Include rare diabetic ketoacidosis, genital mycotic infections, urinary tract infections, and volume depletion 2
- Comprehensive approach: Don't rely solely on medications; integrate dietary improvement, weight management, physical activity, and stress management 2
- Special populations: Adjust treatment for patients with renal impairment, cardiovascular disease, or other comorbidities 2
By implementing this comprehensive approach to T2DM management, focusing on both lifestyle modifications and appropriate pharmacotherapy, patients can achieve improved glycemic control, reduced risk of complications, and better overall health outcomes.