Managing Diabetes with Lifestyle Modifications and Pharmacologic Therapy

Initial Management Approach

The American Diabetes Association recommends that all patients with diabetes should receive comprehensive diabetes self-management education focusing on healthy eating patterns and physical activity 2
Structured programs emphasizing lifestyle changes can produce long-term weight loss of 5-7% of starting weight, according to the American Heart Association 3
Physical activity recommendations include at least 150 minutes of moderate-intensity aerobic activity per week, reduced sedentary time, and resistance training at least twice per week, as suggested by the American College of Sports Medicine 4, 2
Nutrition therapy should focus on healthy eating patterns emphasizing nutrient-dense, high-quality foods and decreased consumption of calorie-dense, nutrient-poor foods, as recommended by the Academy of Nutrition and Dietetics 2

Metformin should be initiated at or soon after diagnosis if not contraindicated, starting at a low dose of 500 mg daily, increasing by 500 mg every 1-2 weeks, up to an ideal maximum dose of 2000 mg daily in divided doses, according to the American College of Clinical Endocrinologists 1, 2

Insulin therapy should be initiated instead of metformin as first-line treatment in patients with ketosis or diabetic ketoacidosis, random blood glucose ≥250 mg/dL, HbA1c >9% (>75 mmol/mol), severe hyperglycemia with catabolism, or symptomatic diabetes with polyuria, polydipsia, and weight loss, as recommended by the American Association of Clinical Endocrinologists 1

When monotherapy with metformin at the maximum tolerated dose does not achieve or maintain the HbA1c target over 3 months, a second agent should be added, such as SGLT-2 inhibitors, GLP-1 receptor agonists, sulfonylureas, thiazolidinediones, DPP-4 inhibitors, or basal insulin, according to the American Diabetes Association 5, 2

A reasonable HbA1c goal for most adults with diabetes is <7%, with more stringent targets (such as <6.5%) for selected individuals, as recommended by the American College of Endocrinology 2
HbA1c should be monitored every 3 months until target is reached, then at least twice yearly, according to the American Association of Clinical Endocrinologists 1

Hypoglycemia may be reversed with administration of 15-20g of rapid-acting glucose, and patients should be educated on situations that increase their risk for hypoglycemia, such as fasting for tests or procedures, during or after exercise, and during sleep, as recommended by the American Diabetes Association 4

For elderly patients, energy requirements are less than for younger adults, and physical activity should be encouraged, but caution should be exercised when prescribing weight-loss diets, according to the American Geriatrics Society 3
For patients with comorbidities, such as elevated LDL cholesterol, saturated fatty acids and trans-saturated fatty acids should be limited to <10% and perhaps to <7% of energy, and sodium intake should be reduced to 2,400 mg (100 mmol) or sodium chloride to 6,000 mg per day, as recommended by the American Heart Association 3