From the Guidelines
For patients at risk of developing Type 2 Diabetes Mellitus (DM2), I strongly recommend a comprehensive approach combining intensive lifestyle modifications and, when appropriate, metformin therapy, as this has been shown to significantly reduce the risk of developing DM2 by 40-70%. This approach should include a structured weight loss program targeting 5-7% of body weight through a reduced-calorie diet and regular physical activity, such as at least 150 minutes of moderate-intensity exercise weekly 1. Dietary changes should focus on reducing refined carbohydrates and increasing fiber intake through vegetables, whole grains, and legumes.
Key Recommendations
- Intensive lifestyle modification programs have been shown to be very effective, with a 58% reduction in diabetes onset after 3 years, and sustained reduction in the rate of conversion to type 2 diabetes, such as a 43% reduction at 20 years in the Da Qing study 1.
- Metformin therapy may be considered for prevention of type 2 diabetes in those with impaired glucose tolerance (IGT), impaired fasting glucose (IFG), or an A1C 5.7–6.4%, especially for those with BMI > 35 kg/m2, aged < 60 years, and women with prior gestational diabetes mellitus (GDM) 1.
- Regular monitoring is essential, including at least annual monitoring for the development of diabetes in those with prediabetes, and screening for and treatment of modifiable risk factors for cardiovascular disease 1.
Lifestyle Modifications
The lifestyle modifications should be tailored to the individual's needs and preferences, and may include:
- A reduced-calorie diet with a focus on whole, unprocessed foods
- Regular physical activity, such as brisk walking, for at least 150 minutes per week
- Stress management techniques, such as meditation or yoga
- Adequate sleep and relaxation
Medication
Metformin is the primary pharmacological option for those with BMI ≥35 kg/m², age <60 years, or women with history of gestational diabetes, and should be started at a dose of 500-850 mg once daily, increased to twice daily if tolerated 1. However, the most recent and highest quality study 1 suggests that medication plan and medication-taking behavior should be reevaluated at regular intervals and adjusted as needed to incorporate specific factors that impact choice of treatment.
Monitoring and Follow-up
Regular monitoring is essential to assess the effectiveness of the lifestyle modifications and medication, and to detect any potential complications early. This should include:
- At least annual monitoring for the development of diabetes in those with prediabetes
- Regular HbA1c testing to assess glycemic control
- Screening for and treatment of modifiable risk factors for cardiovascular disease
- Regular follow-up with a healthcare provider to adjust the treatment plan as needed.
From the Research
Effective Treatments for Type 2 Diabetes Mellitus (DM2)
The American Diabetes Association (ADA) recommends an A1c goal of less than 7% for most patients with type 2 diabetes, although this goal may be adjusted depending on certain patient factors 2.
First-Line Treatment
- Metformin should be used as a first-line treatment in all patients with type 2 diabetes unless contraindicated 2, 3.
- Metformin is the most commonly used oral antihyperglycemic agent in the U.S. due to its affordability and tolerability 3.
Add-on Treatments
- Add-on treatment with a sodium-dependent glucose cotransporter 2 inhibitor or glucagon-like peptide 1 receptor agonist should be considered in patients who have or are at high risk of cardiovascular disease and in patients with kidney disease 2.
- The MGI (metformin, glucagon-like peptide-1 receptor agonist, and insulin) approach is recommended, starting with metformin and progressing to the early addition of glucagon-like peptide-1 receptor agonists due to their weight loss potential and ability to target multiple pathophysiologic defects in patients with type 2 diabetes 4.
Other Treatment Options
- Insulins, sulfonylureas, thiazolidinediones, and dipeptidyl-peptidase 4 inhibitors also have roles in management 2.
- Sulfonylureas are potent glucose lowering drugs and can be used as a second-line treatment for type 2 diabetes, especially in patients who cannot tolerate metformin therapy 5, 6.
- Thiazolidinediones work by activating the peroxisome proliferator-activated receptor gamma (PPARγ), decreasing insulin resistance, and increasing the response of β-cells towards the glucose level, but may increase the risk of cardiovascular disease, weight gain, water retention, and edema 6.
Lifestyle Interventions
- A healthy, plant-based diet that is low in saturated fat and refined carbohydrates but high in whole grains, vegetables, legumes, and fruits, coupled with resistance and aerobic exercise regimens, are recommended for patients with type 2 diabetes 4.
Monitoring and Management
- Patients taking metformin, sulfonylureas, and thiazolidinediones should be closely monitored for adverse effects, such as hypoglycemia, weight gain, and cardiovascular events 6.