What are the primary recommendations for managing diabetes in a patient with diabetes?

Diabetes Management: Evidence-Based Recommendations

Diabetes management requires individualized nutrition therapy, regular physical activity (30-60 minutes daily), and pharmacologic therapy when indicated, with metformin as first-line medication for type 2 diabetes and multiple-dose insulin for type 1 diabetes. 1, 2

Initial Assessment and Care Structure

Adopt a patient-centered, team-based approach that includes physicians, nurses, dietitians, pharmacists, and mental health professionals to optimize outcomes. 3, 4 Treatment decisions must be timely, evidence-based, and tailored to patient preferences, prognoses, and comorbidities. 3

Lifestyle Management: The Foundation

Diabetes Self-Management Education and Support (DSMES)

All patients with diabetes must participate in DSMES at four critical times: at diagnosis, annually, when complications arise, and during care transitions. 3, 1 This education should be patient-centered and can be delivered individually, in groups, or through technology. 3 DSMES improves outcomes and reduces costs, making adequate third-party reimbursement essential. 3

Nutrition Therapy

There is no single "one-size-fits-all" eating pattern for diabetes. 3 However, specific evidence-based recommendations include:

• Emphasize nutrient-dense, high-quality foods while decreasing calorie-dense, nutrient-poor options. 1
• For overweight/obese patients with type 2 diabetes, reduce energy intake by 500-750 kcal/day to achieve 5-7% weight loss, which provides clinical benefits including improved glycemia, blood pressure, and lipids. 1, 4
• Consume meals at similar times daily and never skip meals to reduce hypoglycemia risk. 3
• Limit daily fat intake to ≤30% of calories, with <7% from saturated fat. 2
• Low glycemic index dietary patterns, whole-grain products, cereal high-fiber foods, and non-oil-seed pulses are beneficial, while frequent meat consumption increases risk. 5

Physical Activity

Exercise 30-60 minutes daily at an intensity of at least a brisk walk. 3 More specifically:

• Complete at least 150 minutes of moderate-intensity aerobic activity per week, spread across at least 5 days. 1, 4
• Add resistance training at least twice weekly to improve insulin sensitivity and reduce cardiovascular risk. 1, 2
• Before exercise, reduce insulin dose or consume extra carbohydrates proportionate to intensity and duration. 3
• Always carry rapid-acting carbohydrates during physical activity as exercise may result in low blood glucose. 3

Critical pitfall: Insulin is absorbed and peaks faster during exercise, especially when injected into the leg. 3

Weight Management

Men should maintain waist size ≤40 inches (102 cm) and women ≤35 inches (88.9 cm). 3 Weight gain from tight glycemic control increases blood pressure, LDL cholesterol, triglycerides, and decreases HDL cholesterol, potentially leading to insulin resistance. 3

Pharmacologic Management

Type 2 Diabetes

First-line therapy: Metformin at a low dose, increasing gradually to maximum 2000 mg daily in divided doses when not contraindicated. 1 Metformin is preferred due to efficacy, safety, low cost, and potential cardiovascular benefits. 1

Exception - Start insulin instead of metformin when:

• Ketosis or diabetic ketoacidosis present 1
• Random blood glucose ≥250 mg/dL 1
• HbA1c >8.5% 1
• Symptomatic diabetes with polyuria, polydipsia, and weight loss 1

Treatment intensification: When metformin at maximum tolerated dose fails to achieve HbA1c target over 3 months, add a second agent: SGLT-2 inhibitors, GLP-1 receptor agonists, thiazolidinediones, DPP-4 inhibitors, or basal insulin. 1

Type 1 Diabetes

Use multiple-dose insulin injections (≥3 injections daily) or continuous subcutaneous insulin infusion with insulin analogs. 1, 2

Specific insulin regimen:

• Start with 0.5 units/kg/day total daily dose in metabolically stable patients, split approximately 50% basal and 50% prandial. 2
• Higher doses (up to 1.0 units/kg/day) required during puberty, pregnancy, or acute illness. 2
• Use rapid-acting insulin analogs (aspart, lispro, or glulisine) for prandial coverage to reduce hypoglycemia risk by 20% and nocturnal hypoglycemia by 45%. 2
• Basal insulin analogs reduce severe hypoglycemia by 27% and nocturnal hypoglycemia by 31% compared to NPH insulin. 2

Patients must match prandial insulin doses to carbohydrate intake, preprandial blood glucose levels, and anticipated activity level. 1, 2

Glucose Monitoring

For Type 1 Diabetes:

• Test fingertip blood glucose at least 3 times daily, plus before/after exercise, before driving, and when uncertain of glucose level. 3
• Bedtime testing is especially important as nocturnal symptoms may go unnoticed, causing severe hypoglycemia. 3
• If blood glucose drops below 100 mg/dL (5.6 mmol/L), eat a small snack. 3
• Fingertip remains the recommended test site, as nonfingertip testing 60 minutes after meals and after exercise is less reliable. 3
• Consider continuous glucose monitoring for all patients, particularly those with hypoglycemia unawareness, as it significantly reduces severe hypoglycemia risk. 1, 2

Equipment accuracy: Use control solution to check meter accuracy if readings seem inconsistent with symptoms or HbA1c testing. 3

Glycemic Targets

Target HbA1c <7% for most nonpregnant adults, with more stringent targets (such as <6.5%) for selected individuals. 1, 2 Monitor HbA1c every 3 months until target reached, then at least twice yearly. 1

Individualize targets based on:

• Age 1, 4
• Comorbidities 1, 4
• Risk of hypoglycemia 1, 4
• Life expectancy 4

Critical pitfall: Avoid aggressively targeting near-normal HbA1c levels in patients with advanced disease where such targets cannot be safely reached. 1

Hypoglycemia Management

Treat hypoglycemia (glucose <70 mg/dL or <3.9 mmol/L) with 15-20 grams of rapid-acting glucose (glucose tablets, fruit juice, sports drinks, regular soda, or hard candy). 3, 1, 2

Management algorithm:

1. Consume 15-20g glucose 3, 1
2. Check blood glucose after 15 minutes 3
3. Repeat treatment if hypoglycemia persists 3
4. Prescribe glucagon to all insulin-taking patients and train family members/caregivers on administration 2

For patients with hypoglycemia unawareness: Temporarily increase glycemic targets to partially reverse this condition and reduce future risk. 1

Cardiovascular Risk Management

Blood pressure control:

• Target <140/90 mmHg (or <130/80 mmHg for chronic kidney disease) 4
• Start ACE inhibitors or angiotensin receptor blockers for confirmed hypertension 1
• Treat initially with beta blockers and/or ACE inhibitors as tolerated 4

Lipid management:

• Initiate at least moderate-intensity statin therapy for most patients aged 40 years or older 2
• Target LDL cholesterol <100 mg/dL (2.60 mmol/L), with therapeutic option of <70 mg/dL (1.80 mmol/L) for high-risk patients with known cardiovascular disease 2

Smoking cessation: Advise every tobacco user to quit and provide assistance with counseling/referral. 3

Complication Screening

Annual screening requirements:

• Comprehensive dilated eye examination by ophthalmologist or optometrist starting 3-5 years after type 1 diabetes onset 2
• Screening for diabetic kidney disease 4
• Comprehensive foot examination 4
• Assessment of cardiovascular risk factors 4, 2

Special Populations

Children and Adolescents with Type 2 Diabetes

Initial management includes lifestyle modifications and diabetes education, with metformin as initial therapy for A1C <8.5% without acidosis or ketosis. 1 For A1C ≥8.5% or with ketosis, initiate insulin therapy until acidosis resolves. 1