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

Diabetes Management

All patients with diabetes should receive comprehensive diabetes self-management education at diagnosis, focusing on individualized nutrition therapy, at least 150 minutes of moderate-intensity physical activity weekly, and appropriate pharmacologic therapy—with metformin as first-line for type 2 diabetes and multiple-dose insulin regimens for type 1 diabetes. 1, 2, 3

Initial Assessment and Team-Based Care

• Diabetes care requires a multidisciplinary team including physicians, nurses, dietitians, pharmacists, and mental health professionals to optimize outcomes 3
• Complete medical evaluation should classify diabetes type, detect existing complications, and establish baseline laboratory values including HbA1c, lipid profile, kidney function, and urine tests 3
• Screen for autoimmune conditions in type 1 diabetes, particularly thyroid dysfunction and celiac disease 3

Lifestyle Management: The Foundation

Diabetes Self-Management Education and Support (DSMES)

• Provide DSMES at four critical times: at diagnosis, annually, when complications arise, and during care transitions 4
• Education must focus on carbohydrate counting, hypoglycemia recognition and treatment, medication administration, and blood glucose monitoring 3
• Immediate diabetes education reduces HbA1c by 0.72% compared to delayed education 2

Medical Nutrition Therapy

• All patients should receive medical nutrition therapy from a registered dietitian, which is mandatory for optimal diabetes management 2, 3
• No single eating pattern works universally—effective options include Mediterranean-style, DASH, plant-based, lower-fat, and lower-carbohydrate patterns 4, 3
• For overweight/obese patients with type 2 diabetes, prescribe a 500-750 kcal/day energy deficit to achieve 5-7% weight loss, which improves glycemia, blood pressure, and lipids 1, 3
• Limit daily fat intake to ≤30% of calories with <7% from saturated fat 2
• Meals should be consumed at similar times daily, and patients should never skip meals to reduce hypoglycemia risk 4

Physical Activity Requirements

• Prescribe at least 150 minutes of moderate-intensity aerobic activity per week (equivalent to brisk walking), spread over at least 3 days with no more than 2 consecutive days without activity 4, 1, 3
• Add resistance training at least twice weekly to improve insulin sensitivity and reduce cardiovascular risk 2, 3
• Patients should exercise for 30-60 minutes daily at minimum brisk-walking intensity 4
• Before exercise, patients can reduce insulin dose or consume extra carbohydrates proportionate to intensity and duration of activity 4

Weight Management Targets

• Men should maintain waist circumference ≤40 inches (102 cm) and women ≤35 inches (88.9 cm) 4
• For overweight/obese patients, prescribe high-intensity diet, physical activity, and behavioral therapy designed to achieve ≥5% weight loss 3

Pharmacologic Management

Type 1 Diabetes

• Initiate multiple-dose insulin injections (≥3 injections daily) or continuous subcutaneous insulin infusion using rapid-acting insulin analogs (aspart, lispro, or glulisine) for prandial coverage 1, 2
• Start with 0.5 units/kg/day total daily insulin dose in metabolically stable patients, split approximately 50% basal and 50% prandial 2
• Higher doses (up to 1.0 units/kg/day) are required during puberty, pregnancy, or acute illness 2
• Rapid-acting insulin analogs reduce hypoglycemia risk by 20% and nocturnal hypoglycemia by 45% compared to regular human insulin 2
• Basal insulin analogs reduce severe hypoglycemia by 27% and nocturnal hypoglycemia by 31% compared to NPH insulin 2
• Inject rapid-acting insulin within 5-10 minutes before meals into the abdomen, thigh, buttocks, or upper arm, rotating sites within the same region 5
• Consider automated insulin delivery systems for all adults with type 1 diabetes to improve glycemic control 2
• Continuous subcutaneous insulin infusion provides a fourfold reduction in severe hypoglycemia and 0.6% improvement in HbA1c compared to multiple daily injections 2
• Educate patients on matching prandial insulin doses to carbohydrate intake, premeal blood glucose levels, and anticipated physical activity 4, 1, 2

Type 2 Diabetes

• Initiate metformin as first-line pharmacologic therapy at diagnosis (in addition to lifestyle therapy) when not contraindicated, starting at low dose and increasing gradually to maximum dose of 2000 mg daily in divided doses 1, 3
• 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 is present 1
• Random blood glucose ≥250 mg/dL 1
• HbA1c >8.5% 1
• Symptomatic diabetes with polyuria, polydipsia, and weight loss 1

Treatment Intensification Algorithm:

• When metformin monotherapy at maximum tolerated dose fails to achieve HbA1c target over 3 months, add a second agent 1, 3
• Second-line options include SGLT-2 inhibitors, GLP-1 receptor agonists, thiazolidinediones, DPP-4 inhibitors, or basal insulin 1
• Selection should consider patient factors including cardiovascular disease, kidney disease, weight, hypoglycemia risk, and cost 3

Glycemic Targets and Monitoring

HbA1c Goals

• Target HbA1c <7% for most nonpregnant adults to reduce microvascular complications 1, 2
• More stringent targets (such as <6.5%) may be appropriate for selected individuals if achievable without significant hypoglycemia 1
• Monitor HbA1c every 3 months until target is reached, then at least twice yearly 1

Blood Glucose Monitoring

• Type 1 diabetes patients should test fingertip blood glucose at least 3 times daily, plus before and after exercise, before driving, at bedtime, and when uncertain about glucose levels 4
• If blood glucose drops below 100 mg/dL (5.6 mmol/L) at bedtime, patient should eat a small snack 4
• Fingertip testing remains the gold standard—nonfingertip testing 60 minutes after meals and after exercise is less reliable 4
• Consider continuous glucose monitoring for all patients with type 1 diabetes, particularly those with hypoglycemia unawareness or frequent hypoglycemic episodes 2
• Continuous glucose monitoring significantly reduces severe hypoglycemia risk and lowers HbA1c by 0.39% compared to standard monitoring 4

Equipment Accuracy

• Patients should use control solution to check meter accuracy if readings seem inconsistent with symptoms or HbA1c results 4
• Suspect inaccurate readings when home blood glucose tests are inconsistent with HbA1c testing 4

Hypoglycemia Management

Recognition and Treatment

• Treat hypoglycemia (glucose <70 mg/dL or <3.9 mmol/L) with 15-20 grams of rapid-acting glucose, preferably pure glucose tablets 4, 1, 2, 3
• Confirm blood glucose after 15 minutes and repeat treatment if hypoglycemia persists 4, 3
• Alternative treatments include fruit juice, sports drinks, regular soda, or hard candy 4
• Prescribe glucagon to all insulin-treated patients and train family members/caregivers on administration 2

Risk Factors and Prevention

• Hypoglycemia risk increases with fasting, exercise, sleep, changes in meal patterns, changes in physical activity level, and concomitant medications 3, 5
• Patients with renal or hepatic impairment are at higher risk 5
• Symptomatic awareness may be reduced in longstanding diabetes, diabetic nerve disease, or when taking beta-blockers 5
• Patients should always carry rapid-acting glucose and insulin syringes or pens 4
• Before exercise, patients should test blood glucose and adjust insulin or consume extra carbohydrates accordingly 4
• Insulin is absorbed and peaks faster during exercise, especially when injected into the leg 4

Hypoglycemia Unawareness

• Patients with hypoglycemia unawareness should temporarily increase glycemic targets to partially reverse this condition 1
• Structured education programs reduce severe hypoglycemia from 8.9 to 0.8 episodes per patient annually 2

Cardiovascular Risk Factor Management

Blood Pressure Control

• Target blood pressure <140/90 mm Hg to reduce cardiovascular mortality 2, 3
• Initiate lifestyle therapy including weight loss, reduced-sodium diet, moderate alcohol intake, and increased physical activity 3
• Start ACE inhibitor or ARB (but not both) for confirmed hypertension 1, 3

Lipid Management

• Initiate at least moderate-intensity statin therapy for most patients aged 40 years or older to reduce cardiovascular mortality 2, 3
• 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
• Lifestyle modification should include reducing saturated fat, trans fat, and cholesterol while increasing ω-3 fatty acids, viscous fiber, and plant stanols or sterols 3

Screening for Complications

• Arrange annual comprehensive dilated eye examination by an ophthalmologist or optometrist starting 3-5 years after type 1 diabetes onset 2
• Screen annually for diabetic kidney disease with urine albumin and serum creatinine 2, 3
• Perform comprehensive foot examination at least annually to assess for neuropathy and vascular disease 3
• Assess cardiovascular risk factors annually for all patients 2

Common Pitfalls and Caveats

Insulin Injection Site Rotation

• Rotate injection sites within the same region to reduce risk of lipodystrophy and localized cutaneous amyloidosis 5
• Repeated injections into areas of lipodystrophy can cause hyperglycemia 5
• Sudden change from lipodystrophic area to unaffected area can cause hypoglycemia—monitor closely during transition 5

Medication Errors

• Instruct patients to always check insulin label before each injection to avoid accidental mix-ups between insulin products 5
• Never share insulin pens between patients, even if needle is changed, due to blood-borne pathogen transmission risk 5

Regimen Changes

• Make any changes to insulin regimen under close medical supervision with increased frequency of blood glucose monitoring 5
• Changes in insulin strength, manufacturer, type, injection site, or method of administration may affect glycemic control 5

Weight Gain with Tight Control

• Tight glycemic control can cause weight gain and obesity, leading to increased blood pressure, LDL cholesterol, triglycerides, and decreased HDL cholesterol 4
• Weight gain can lead to insulin resistance and make glycemic control more difficult 4
• Emphasize food portion control, lower caloric intake, and regular physical activity to prevent weight gain 4

Avoiding Overly Aggressive Targets

• Do not aggressively target near-normal HbA1c levels in patients with advanced disease where such targets cannot be safely reached 1
• Treatment goals should account for patient age, comorbidities, life expectancy, and hypoglycemia risk 3