What are the best practices for managing diabetes?

Comprehensive Diabetes Management

All individuals with diabetes should immediately begin diabetes self-management education and support (DSMES) at diagnosis, combined with structured lifestyle modifications including at least 150 minutes of moderate-intensity aerobic exercise weekly, medical nutrition therapy, and regular glucose monitoring, with pharmacologic therapy initiated concurrently for type 2 diabetes. 1

Core Management Framework

Diabetes Self-Management Education and Support (DSMES)

• DSMES is as critical as medication selection and must be offered at four specific timepoints: at diagnosis, annually, when complications arise, and during care transitions 1
• Education should be delivered by trained diabetes care and education specialists using individual, group, or technology-based formats 1
• Focus on empowering patients to make informed decisions rather than passive information delivery—this improves A1C, reduces mortality risk, and enhances quality of life 1
• Essential content includes hypoglycemia/hyperglycemia recognition and treatment, medication administration, blood glucose monitoring, and nutritional management 2

Medical Nutrition Therapy (MNT)

• All patients require MNT with a personalized food plan developed at diagnosis and re-evaluated regularly 1
• No single dietary pattern is superior—Mediterranean, DASH, plant-based, lower-fat, and lower-carbohydrate patterns are all effective based on individual preferences and context 1, 2
• For overweight/obese patients, prescribe a 500-750 kcal/day energy deficit targeting at least 5-7% weight loss, which can induce diabetes remission when achieved early in disease course 1, 3
• Weight loss ≥10% substantially increases remission probability 1

Physical Activity Requirements

Adults with diabetes must engage in:

• 150 minutes minimum of moderate-to-vigorous aerobic activity weekly, spread over at least 3 days with no more than 2 consecutive inactive days 1
• Shorter durations of 75 minutes weekly are acceptable only for younger, physically fit individuals performing vigorous-intensity or interval training 1
• 2-3 resistance exercise sessions weekly on nonconsecutive days 1
• Flexibility and balance training 2-3 times weekly for older adults, including yoga or tai chi 1
• Interrupt prolonged sitting every 30 minutes for blood glucose benefits 1

Youth with diabetes require:

• 60 minutes daily of moderate-to-vigorous aerobic activity 1
• Vigorous muscle-strengthening and bone-strengthening activities at least 3 days weekly 1

Glycemic Monitoring and Targets

• Perform HbA1c testing every 3 months when therapy changes or goals are unmet, and at least twice yearly when stable 1, 2
• Target HbA1c <7.0% for most adults, with preprandial glucose 90-130 mg/dL and peak postprandial glucose <180 mg/dL 1
• Individualize targets based on age, comorbidities, hypoglycemia risk, and life expectancy—less stringent goals are appropriate for those with severe/frequent hypoglycemia 1, 2
• For insulin users or those on insulin secretagogues, perform self-monitoring of blood glucose (SMBG) at least 3 times daily 1

Team-Based Care Structure

• Assemble a physician-coordinated multidisciplinary team including nurse practitioners, nurses, dietitians, pharmacists, and mental health professionals 1, 2
• The patient must assume an active role with shared decision-making to improve adherence, satisfaction, and outcomes 2
• Develop a written management plan with input from patient, family, and all team members 2

Pharmacologic Therapy for Type 2 Diabetes

• Initiate pharmacologic therapy at diagnosis concurrently with lifestyle modifications 2
• Metformin is first-line for metabolically stable patients with adequate renal function 2
• For prediabetes (HbA1c 5.7-6.4%), consider metformin particularly for BMI ≥35 kg/m², age <60 years, prior gestational diabetes, or rising HbA1c despite lifestyle intervention 3
• Start metformin at 500 mg daily and titrate gradually to minimize gastrointestinal side effects 3
• For patients with overweight/obesity not meeting goals, use GLP-1 receptor agonists with high weight loss efficacy 1

Cardiovascular Risk Management

• Target blood pressure <140/90 mmHg (or <130/80 mmHg with chronic kidney disease) 2
• Initiate beta blockers and/or ACE inhibitors as tolerated 2
• Aggressively manage lipid abnormalities, particularly in patients with cardiovascular disease 2
• Only 23% of patients achieve all three targets (A1C, blood pressure, LDL cholesterol) while avoiding smoking—systematic attention to all risk factors is essential 2

Complication Screening

• Annual comprehensive dilated eye examination by an ophthalmologist or optometrist experienced in diabetic retinopathy 1
• Annual screening for diabetic kidney disease with urine albumin measurement 1
• Comprehensive foot examination regularly 2
• Screen for and address social determinants of health, particularly in those not achieving goals 1

Exercise-Specific Precautions

Pre-exercise evaluation is critical for:

• Uncontrolled hypertension, untreated proliferative retinopathy, autonomic neuropathy, peripheral neuropathy, or history of foot ulcers/Charcot foot 1
• Cardiovascular autonomic neuropathy increases risk of cardiac events, postural hypotension, impaired thermoregulation, and hypoglycemia—these patients require cardiac investigation before intensifying activity 1
• Diabetic kidney disease does not require exercise restriction, as vigorous activity does not accelerate progression 1

Hypoglycemia prevention:

• Educate on risks of immediate and delayed hypoglycemia, particularly with insulin or insulin secretagogues 1
• Monitor glucose frequently after exercise 1
• Adjust insulin dose and carbohydrate intake based on exercise type and duration 4
• Moderate alcohol intake with food does not significantly affect long-term glucose control, but increases hypoglycemia risk—frequent post-drinking glucose monitoring is mandatory 1

Smoking Cessation

• All patients must be advised to avoid cigarettes, tobacco products, and e-cigarettes 1
• Smoking cessation counseling should be routine in diabetes care 1
• Brief counseling combined with pharmacologic therapy is more effective than either alone 1
• Weight gain after cessation does not diminish substantial cardiovascular benefits 1
• E-cigarettes lack rigorous evidence for safety or efficacy in smoking cessation 1

Common Pitfalls to Avoid

• Do not delay pharmacologic therapy while attempting lifestyle modification alone in type 2 diabetes—initiate both simultaneously 2
• Do not overlook DSMES by focusing solely on medication—it is equally important and improves outcomes while reducing costs 1
• Do not allow more than 2 consecutive days without exercise—this increases insulin resistance regardless of diabetes type 1
• Do not neglect cardiovascular risk factor management—comprehensive care addressing blood pressure, lipids, and smoking is essential 2
• Do not use HbA1c for diagnosis in patients with hemoglobinopathies—use glucose-based criteria instead 3
• Do not assume diabetic kidney disease requires exercise restriction—vigorous activity is safe 1