Management of Type 2 Diabetes

Initial Assessment and Diagnosis

• Complete a thorough evaluation to classify diabetes, detect complications, review previous treatment, and formulate a management plan, as recommended by the American Diabetes Association 1
• Screen for autoimmune conditions in Type 1 diabetes patients, as suggested by the American Diabetes Association 1

Lifestyle Modifications

• Recommend 150 minutes or more of moderate-to-vigorous intensity aerobic activity per week, spread over at least 3 days with no more than 2 consecutive days without activity, as recommended by the American Diabetes Association 2
• Include 2-3 sessions of resistance exercise per week on non-consecutive days, as suggested by the American Diabetes Association 2, 4
• Break up prolonged sitting every 30 minutes for blood glucose benefits, as recommended by the American Diabetes Association 2
• For children and adolescents, recommend 60 minutes/day of moderate or vigorous-intensity aerobic activity, as suggested by the American Diabetes Association 2
• Refer to a registered dietitian for individualized Medical Nutrition Therapy (MNT), as recommended by the American Diabetes Association 4
• Focus on portion control and healthy food choices for those with limited health literacy, as suggested by the American Diabetes Association 4
• Emphasize carbohydrate intake from vegetables, fruits, legumes, whole grains, and dairy products with higher fiber and lower glycemic load, as recommended by the American Diabetes Association 4
• Reduce intake of refined carbohydrates, added sugars, and sugar-containing beverages, as suggested by the American Diabetes Association 4, 3
• Limit sodium consumption to <2,300 mg/day, as recommended by the American Diabetes Association 2
• For those who consume alcohol, limit to one drink per day for women and two drinks per day for men, as suggested by the American Diabetes Association 2

Pharmacological Management

• Start metformin as first-line therapy at the time of diagnosis along with lifestyle modifications, as recommended by the American Academy of Pediatrics 5
• Begin with a low dose (500 mg once or twice daily) and gradually increase to minimize gastrointestinal side effects, as suggested by the American Diabetes Association 4
• Monitor vitamin B12 levels in patients taking metformin due to risk of deficiency, as recommended by the American Diabetes Association 2, 3
• Add a second agent based on patient-specific factors, such as DPP-4 inhibitors if hypoglycemia is a concern, as suggested by the American College of Physicians 6
• Consider initiating insulin therapy if patient presents with random blood glucose ≥250 mg/dL, HbA1c >9%, or is ketotic or in diabetic ketoacidosis, as recommended by the American Academy of Pediatrics 5
• Consider continuous glucose monitoring (CGM) for patients requiring frequent blood glucose monitoring, as suggested by the American Diabetes Association 7

Monitoring and Follow-up

• Monitor HbA1c every 3 months and intensify treatment if targets are not met, as recommended by the American Academy of Pediatrics 5 and the American College of Physicians 6
• Recommend finger-stick blood glucose monitoring for patients taking insulin or medications with risk of hypoglycemia, as suggested by the American Academy of Pediatrics 5

Special Considerations

• Recognize that T2DM in India often presents at a younger age compared to Western populations, as noted by the American College of Physicians 6
• Consider more stringent glycemic targets (HbA1c <6.5%) for younger patients without comorbidities, as suggested by the American College of Physicians 6
• Overlooking vitamin B12 deficiency in patients on long-term metformin therapy, as warned by the American Diabetes Association 2