Comprehensive Management of Diabetes
The best approach to diabetes management is a holistic strategy that combines diabetes self-management education and support (DSMES), medical nutrition therapy, regular physical activity, smoking cessation, and psychosocial care, with all components being equally important for improving morbidity, mortality, and quality of life outcomes. 1
Diabetes Self-Management Education and Support (DSMES)
- DSMES is as critical to diabetes management as medication selection and should be provided to all people with diabetes to facilitate knowledge, skills, and abilities necessary for optimal self-care 1
- Four critical times to evaluate the need for DSMES: at diagnosis, annually, when complicating factors arise, and during transitions in care 1
- DSMES should be patient-centered and can be delivered in group or individual settings, or using technology 1
- Clinical outcomes, health status, and quality of life are key goals of DSMES that should be measured as part of routine care 1
Physical Activity Recommendations
- Adults with diabetes should engage in at least 150 minutes of moderate- to vigorous-intensity aerobic activity weekly, spread over at least 3 days with no more than 2 consecutive days without activity 1, 2
- Resistance exercise should be performed 2-3 sessions per week on non-consecutive days 1, 3
- For older adults, flexibility and balance training 2-3 times per week is recommended; yoga and tai chi may be included based on individual preferences 1
- Youth with diabetes should engage in 60 minutes or more of moderate- to vigorous-intensity aerobic activity daily, with muscle and bone-strengthening activities at least 3 days per week 1
- Prolonged sitting should be interrupted every 30 minutes for blood glucose benefits 1, 3
Nutrition Management
- There is no single ideal percentage of calories from carbohydrate, protein, or fat for people with diabetes 1
- Key nutritional recommendations include:
- Emphasizing non-starchy vegetables 1
- Minimizing added sugars and refined grains 1
- Choosing whole foods over highly processed foods 1
- Incorporating more plant-based protein sources (nuts, seeds, legumes) 1
- Considering elements of a Mediterranean eating pattern rich in monounsaturated and polyunsaturated fats 1
- Limiting intake of foods high in saturated fat 1
- For those using insulin, education on the glycemic impact of carbohydrates, fat, and protein is essential for optimizing mealtime insulin dosing 1
Weight Management
- For people with diabetes and overweight/obesity, weight management should be a central focus 1
- A target of at least 5% weight loss is reasonable and can provide clinical benefits 1
- Substantial weight loss (>10%) early in the course of type 2 diabetes increases the chance of disease remission 1
Alcohol and Substance Use
- Adults with diabetes who drink alcohol should do so in moderation (no more than one drink per day for women, no more than two drinks per day for men) 1
- Alcohol intake with food does not have major detrimental effects on long-term blood glucose management, but risks include hypoglycemia, weight gain, and hyperglycemia (with excessive amounts) 1
- Education about signs, symptoms, and self-management of delayed hypoglycemia after drinking alcohol is essential, especially for those using insulin or insulin secretagogues 1
Smoking Cessation
- All patients should be advised not to use cigarettes, other tobacco products, or e-cigarettes 1
- Smoking cessation counseling and treatment should be a routine component of diabetes care 1
- Smoking may have a role in the development of type 2 diabetes and increases risk of cardiovascular disease and premature death 1
Glycemic Targets and Monitoring
- Recommended targets include:
- A1C: 7.0%
- Preprandial plasma glucose: 90-130 mg/dL
- Peak postprandial plasma glucose: <180 mg/dL 1
- Blood glucose monitoring should be performed for those taking insulin or oral glucose-lowering agents 1
- The frequency and timing of glucose monitoring should be dictated by individual needs and goals 1
- A1C testing should be performed initially and at least twice yearly in patients meeting treatment goals with stable glycemic control, and quarterly in patients whose therapy has changed or who are not meeting glycemic goals 1
Medication Management
- For patients with type 2 diabetes not currently on insulin, the recommended starting dosage of insulin glargine is 0.2 units/kg or up to 10 units once daily 4
- For patients with type 1 diabetes, the recommended starting dosage of insulin glargine is approximately one-third of total daily insulin requirements, with short-acting premeal insulin for the remainder 4
- When switching from other insulin therapies to insulin glargine, dosage adjustments are recommended to lower hypoglycemia risk 4
Special Considerations
- Pre-exercise evaluation should assess for conditions that might contraindicate certain types of exercise or predispose to injury, such as uncontrolled hypertension, untreated proliferative retinopathy, autonomic neuropathy, peripheral neuropathy, and history of foot ulcers 1
- High-risk patients should start with short periods of low-intensity exercise and slowly increase intensity and duration 1
- For patients with diabetes complications (retinopathy, nephropathy, neuropathy), exercise regimens may require modifications 5
- Mental health should be addressed as part of comprehensive diabetes care, as mental illness can complicate diabetes management 1
Monitoring Progress
- Regular assessment of glycemic control, cardiovascular risk factors, and diabetes complications is essential 1, 6
- Urine albumin should be measured annually 1
- A dilated retinal examination by an ophthalmologist or optometrist knowledgeable in diabetic retinopathy management should be performed regularly 1
By implementing this comprehensive approach to diabetes management, focusing on lifestyle modifications alongside appropriate medication management, patients can achieve improved glycemic control, reduced risk of complications, and enhanced quality of life.