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

Diabetes Management: A Structured Approach

All patients with diabetes must immediately begin comprehensive lifestyle modifications alongside pharmacologic therapy, as these interventions reduce mortality, improve glycemic control, and prevent complications regardless of diabetes type. 1, 2

Universal Foundation: Lifestyle Modifications (Required for ALL Patients)

Every patient with diabetes must receive the following interventions at diagnosis and continuously throughout care:

Diabetes Self-Management Education and Support

• Provide comprehensive diabetes self-management education immediately at diagnosis, as this intervention reduces mortality risk and healthcare costs with high-quality evidence. 1, 2, 3
• Education must cover hypoglycemia/hyperglycemia recognition and treatment, medication administration, blood glucose monitoring, nutritional management, and matching insulin doses to carbohydrate intake. 3
• Use patient-centered communication that incorporates patient preferences, assesses literacy and numeracy, and addresses cultural barriers. 3

Medical Nutrition Therapy

• Medical nutrition therapy delivered by a registered dietitian reduces A1C by 0.3-2% in type 2 diabetes and 1.0-1.9% in type 1 diabetes. 2
• No single eating pattern works universally; individualize based on patient preferences, but emphasize nutrient-dense, high-quality foods while decreasing calorie-dense, nutrient-poor foods. 4, 1
• Effective eating patterns include Mediterranean-style, DASH, plant-based, lower-fat, and lower-carbohydrate approaches. 3
• Reduce intake of saturated fat, trans fat, and cholesterol while increasing omega-3 fatty acids, viscous fiber, and plant stanols or sterols. 3
• Consume meals at similar times daily and never skip meals to reduce hypoglycemia risk. 4

Physical Activity (Mandatory Prescription)

• Prescribe at least 150 minutes per week of moderate-intensity aerobic exercise (minimum brisk walking intensity) spread over at least 3 days with no more than 2 consecutive days without activity. 1, 2, 3
• Add resistance training 2-3 sessions per week on nonconsecutive days. 1, 2
• Exercise for 30-60 minutes daily at minimum brisk walk intensity. 4
• Before exercise, patients can reduce insulin dose or consume extra carbohydrates proportionate to intensity and duration of physical activity. 4
• Insulin is absorbed and peaks faster during exercise, especially when injected into the leg. 4

Weight Management

• For overweight/obese patients with type 2 diabetes, achieving minimum 5% body weight reduction is mandatory before or concurrent with pharmacotherapy. 1, 2
• Prescribe 500-750 kcal/day energy deficit through high-intensity diet, physical activity, and behavioral therapy. 3
• Men should maintain waist size ≤40 inches (102 cm); women should maintain waist size ≤35 inches (88.9 cm). 4
• Weight management should use a family-centered, behavioral management approach involving all overweight family members. 4

Type 2 Diabetes: Pharmacologic Algorithm

First-Line Therapy

• Metformin is the mandatory first-line agent at diagnosis due to efficacy, safety, low cost, cardiovascular benefits, and mortality reduction. 1, 2, 3
• Start at low dose and increase gradually to ideal maximum dose of 2000 mg daily in divided doses. 1

Special Circumstances Requiring Insulin First

• Initiate insulin therapy instead of metformin as first-line treatment in patients with ketosis or diabetic ketoacidosis, random blood glucose ≥250 mg/dL, HbA1c >8.5%, or symptomatic diabetes with polyuria, polydipsia, and weight loss. 1

Immediate Add-On Therapy for High-Risk Patients

• For patients with established atherosclerotic cardiovascular disease, heart failure, or chronic kidney disease at diagnosis, immediately add an SGLT2 inhibitor or GLP-1 receptor agonist with proven cardiovascular benefit alongside metformin. 1, 2
• For heart failure: Add SGLT2 inhibitor for glycemic management and prevention of heart failure hospitalizations. 2
• For chronic kidney disease: Add SGLT2 inhibitor to minimize CKD progression, reduce cardiovascular events, and reduce heart failure hospitalizations. 2
• For advanced CKD: Add GLP-1 receptor agonist (preferred over SGLT2 inhibitor) for glycemic management due to lower hypoglycemia risk and cardiovascular event reduction. 2

Treatment Intensification

• When monotherapy with metformin at maximum tolerated dose does not achieve or maintain HbA1c target over 3 months, add a second agent including SGLT-2 inhibitors, GLP-1 receptor agonists, thiazolidinediones, DPP-4 inhibitors, or basal insulin. 1, 3

Type 1 Diabetes: Insulin-Based Management

Insulin Regimen (Mandatory from Diagnosis)

• Multiple daily insulin injections (≥3 injections daily) or continuous subcutaneous insulin infusion are mandatory from diagnosis. 1, 2, 3
• Use insulin analogues instead of regular human insulin to significantly reduce hypoglycemia risk. 1, 2
• Patients should use an insulin bolus at mealtime plus a long-acting insulin to mimic normal physiologic insulin levels. 4, 3
• Consider automated insulin delivery systems for all adults with type 1 diabetes. 2

Insulin Administration

• Inject rapid-acting insulin within 5-10 minutes before meals into the abdominal area, thigh, buttocks, or upper arm. 5
• Rotate injection sites within the same region from one injection to the next to reduce risk of lipodystrophy and localized cutaneous amyloidosis. 5
• Never inject into areas of lipodystrophy or localized cutaneous amyloidosis, as this causes hyperglycemia; sudden change to unaffected area can cause hypoglycemia. 5
• Always carry rapid-acting insulin syringes or pens to accommodate flexible meal times or additional doses. 4
• Never mix rapid-acting insulin with any other insulin. 5

Patient Education Requirements

• Educate patients on matching mealtime insulin doses to carbohydrate intake, fat, and protein intake. 2, 3
• Teach modification of insulin dose based on concurrent glycemia and glycemic trends, sick-day management, and anticipated physical activity adjustments. 2

Glycemic Targets and Monitoring

Target Goals

• A reasonable HbA1c goal for most adults with diabetes is <7%, with more stringent targets (such as <6.5%) for selected individuals. 1
• Monitor HbA1c every 3 months until target is reached, then at least twice yearly. 1
• Treatment goals should be individualized based on patient factors including age, comorbidities, and risk of hypoglycemia. 1, 3

Blood Glucose Monitoring

• Patients with type 1 diabetes should assess fingertip blood glucose levels at least three times daily. 4
• Test blood glucose levels before and after exercising, before driving, when uncertain if blood glucose is at appropriate level, and at bedtime. 4
• Bedtime testing is especially important because nocturnal symptoms may go unnoticed, causing severe hypoglycemia. 4
• If blood glucose level drops below 100 mg/dL (5.6 mmol/L), eat a small snack. 4
• Fingertip remains the recommended test site; nonfingertip testing 60 minutes after meals and after exercise is less reliable. 4
• Continuous glucose monitoring systems can detect frequency and severity of unrecognized hypoglycemic episodes and significantly reduce severe hypoglycemia risk. 4, 2

Monitoring Equipment Accuracy

• Patients should be aware that inaccurate blood glucose readings can occur because of faulty equipment or improper testing techniques. 4
• Use control solution to check meter accuracy if equipment malfunction is suspected. 4
• Suspect inaccurate reading if home blood glucose test is inconsistent with A1C testing. 4

Hypoglycemia Management (Critical Safety Priority)

Recognition and Treatment

• Hypoglycemia (plasma glucose <70 mg/dL or <3.9 mmol/L) must be treated with 15-20 grams of rapid-acting glucose, preferably pure glucose tablets or carbohydrate-containing foods (fruit juice, sports drinks, regular soda, or hard candy). 4, 1, 2
• Confirm blood glucose after 15 minutes; if hypoglycemia persists, repeat treatment. 4
• When blood glucose levels are 50-60 mg/dL, treatment with 15g glucose can be expected to raise blood glucose levels approximately 50 mg/dL. 4

Prevention Strategies

• Glucagon must be prescribed for all individuals taking insulin or at high risk for hypoglycemia; family and caregivers must know its location and administration. 2
• Educate patients on situations that increase hypoglycemia risk: fasting for tests or procedures, during or after exercise, and during sleep. 1, 3
• Severe or frequent hypoglycemia is an absolute indication for treatment regimen modification. 1, 2
• Patients with hypoglycemia unawareness should increase glycemic targets temporarily to partially reverse this condition and reduce future risk. 1
• Increase frequency of blood glucose monitoring in patients at higher risk for hypoglycemia and those with reduced symptomatic awareness. 5

Medication Error Prevention

• Always instruct patients to check the insulin label before each injection to avoid accidental mix-ups between insulin products. 5
• Make any changes to insulin regimen under close medical supervision with increased frequency of blood glucose monitoring. 5

Cardiovascular Risk Factor Management

Lipid Management

• Initiate at least moderate-intensity statin therapy for most patients aged 40 years or older to reduce cardiovascular mortality. 2, 3
• Maintain LDL cholesterol level <100 mg/dL (2.60 mmol/L), with therapeutic option of <70 mg/dL (1.80 mmol/L) for high-risk patients with known CVD. 4

Blood Pressure Control

• Target blood pressure <140/90 mm Hg for patients with diabetes and hypertension. 2, 3
• Maintain blood pressure levels <130/80 mm Hg. 4
• Lifestyle therapy should consist of weight loss, reduced-sodium diet, moderate alcohol intake, and increased physical activity. 3
• Initiate ACE inhibitor or ARB (but not both) as first-line antihypertensive for renal protection. 2, 3

Additional Risk Reduction

• Daily aspirin regimen lowers coronary heart disease risk by 20-25%. 4
• Patients who smoke should quit to reduce risk of CVD and microvascular complications. 4

Complication Screening

Annual Screening Requirements

• Annual comprehensive dilated eye examination by ophthalmologist or optometrist starting immediately at diagnosis. 2
• Diabetic retinopathy can be treated, and tight glycemic control reduces its progression; start dilated eye examinations three to five years after onset of type 1 diabetes. 4
• Annual comprehensive foot examination including visual inspection for skin integrity, callous formation, deformities, or ulcers. 2
• Annual laboratory monitoring: lipid profile, spot urinary albumin-to-creatinine ratio, serum creatinine and eGFR, liver function tests, thyroid-stimulating hormone, vitamin B12 levels, and serum potassium. 2
• Early nephropathy can be detected by screening for microalbuminuria. 4

Critical Pitfalls to Avoid

• Never delay adding SGLT2 inhibitor or GLP-1 receptor agonist in patients with established cardiovascular disease, heart failure, or chronic kidney disease. 2
• Never continue aggressive glycemic targets in patients experiencing severe or frequent hypoglycemia. 2
• Never neglect ongoing lifestyle modifications throughout the entire treatment course regardless of medication regimen. 2
• Never share insulin pens between patients, even if needle is changed; never share needles or syringes. 5
• Never aggressively lower blood pressure below 130/70 mm Hg in older adults due to increased mortality risk. 2
• Avoid aggressively targeting near-normal HbA1c levels in patients with advanced disease where such targets cannot be safely reached. 1