Lifestyle modification must be the cornerstone of any management plan for type 2 diabetes.
Effectively attending to basic problems – obesity, nutrition, and exercise – will dramatically increase the success of any long-term treatment plan for patients with type 2 diabetes (T2DM), and help prevent or delay disease development in those with prediabetes, according to a new treatment algorithm.
The document , published by the American Association of Clinical Endocrinology, is an annual update to its unique strategy of clarifying T2DM management.
The 2016 AACE/ACE Comprehensive Diabetes Management Algorithm presents an easy-to-follow stepwise decision model for diagnosis, blood glucose management, and medical management – including all of the currently approved oral diabetes medications and insulins ( Endocr Pract. 2016 Jan;22[1]:84-113 ). The original algorithm was launched 10 years ago and was last updated in 2013.
This new iteration is the first to place lifestyle intervention as a foundation for the most effective medical management.
“Obviously, this is very important,” said Dr. Paul S. Jellinger, a member of the algorithm writing committee, and an endocrinologist in Fort Lauderdale, Fla. “Weight loss, fitness training, and nutritional management play important roles in the management of blood glucose, lipids, and blood pressure. Appropriate focus in this direction may reduce medication dosage and at times eliminate the need for pharmaceutical intervention. We have all experienced improved therapeutic results in patients who are engaged in effective lifestyle therapy.”
As well as being a text document replete with data-driven details, the algorithm is presented in a colorful poster format that is very helpful for both doctors and patients alike, said Dr. George Grunberger , AACE president. It’s an especially effective tool when considering treatment decisions in the 12 different drug classes used in T2DM management.
“It’s one thing to talk about risk and benefits but to see it graphically displayed is very helpful,” he said in an interview. “I have the poster in every exam room, and every time I am with a patient, I can point out where we are and where we are heading. Rather than me just talking, I can show exactly where we are and where we want to go.”
It is especially helpful for primary care physicians, who care for the vast majority of patients with T2DM, Dr. Grunberger said in an interview.
“We are trying to get better management information into primary care. Most people with diabetes will never see a specialist in their entire life. They need help with glycemic control, obesity, prediabetes, dyslipidemia, and these are the bread and butter of primary care. But there are so many new things going on in this field, and primary care doctors are already in over their heads with the amount of things they deal with. So we have sorted it out and provide practical, practice-oriented guidelines about how to get from A to B.”
Dr. Grunberger noted that most of the recommendations in the document are based on expert opinion. “There are no randomized, controlled trials for most of this stuff. Many of the medications are relatively new, and with 12 drug classes, there’s no way you can ever do a trial with every permutation.”
The new document is similar to the 2013 algorithm with regard to medical management, Dr. Grunberger said. Its focus on lifestyle modification as an integral part of treatment is new, however. “The initial algorithm 10 years ago was solely based on glycemic control. Now we’ve decided to look at more than blood sugar – at obesity, overweight, hypertension and dyslipidemia. You cannot ignore these things in a disease where the major morbidity and mortality are cardiovascular.”
The algorithm stresses that “lifestyle optimization” is essential for all patients with diabetes. “[It] is multifaceted, ongoing, and should engage the entire diabetes team.”
There are several key components to lifestyle modification. All of these should be addressed early.
Medical nutrition therapy
This is a fundamental issue that must be addressed. A primarily plant-based diet high in poly- and monounsaturated fats is recommended, with the goal of a 5%-10% reduction in body weight for overweight or obese patients. In addition to discussing foods that damage and promote metabolic health, patients may need help with carbohydrate and sugar intake. Structured counseling is an excellent way to achieve consistent results.
Physical activity
Regular exercise improves glucose control and lowers lipid and blood pressure levels. It decreases the chance of falls and fractures, promotes functional capacity, and reduces the risk of depression. The goal should be at least 150 minutes of moderate-intense exercise each week. Every patient – and particularly those with complications of diabetes and/or obesity – should have a thorough physical exam before embarking on an exercise program.
Adequate rest
Emerging data continue to confirm the importance of sleep in health and disease. Getting 6-9 hours each night is associated with a reduction in cardiometabolic risk factors. Sleep deprivation aggravates insulin resistance, hypertension, hyperglycemia, and dyslipidemia and increases proinflammatory cytokines. An evaluation for obstructive sleep apnea may be in order, especially for obese patients.
Behavioral support
It’s impossible to overstate the importance of support in a successful lifestyle modification program. Patients should be encouraged to join community groups that facilitate and teach healthy behaviors. Not only will doing so help improve compliance, but being part of a structured group also reaps social and cognitive benefits.
Smoking cessation
The final component of the program, smoking cessation, is critical. All forms of tobacco should be eliminated.
While lifestyle modification is crucial, it should not obviate prompt medical therapy. “Such efforts should not delay needed pharmacotherapy, which can be initiated simultaneously and adjusted based on patient response to lifestyle efforts,” the document notes. “The need for medical therapy should not be interpreted as a failure of lifestyle management but as an adjunct to it.”
Aggressive medical therapy really accelerates effective diabetes treatment, Dr. Jellinger said.
“Clinical inertia has been and remains a huge problem. Some studies demonstrate as much as a 2-year delay in advancing therapy while the patient still remains far from hemoglobin A1c goal. For decades a ‘treat to failure’ concept dominated, i.e., that we should advance therapy only after a prolonged period of failure on existing therapy. One of the major contributions of the earlier AACE algorithms as well as the current version has been the strong therapeutic mandate to re-evaluate the patient and make a therapeutic change in no longer than 3 months. This is a direct attempt to eliminate clinical inertia.”
Dr. Grunberger agreed.
“Why do we wait until people are sick and experiencing complications before we take them seriously? Preventing and dealing with overweight and obesity is complicated, but if you treat obesity, you are treating diabetes. We emphasize starting medical therapy early, going to combination therapy quickly because no one drug usually achieves the target, and trying to be aggressive. Get people on the right treatment as quickly as possible and sustain success – don’t go from one failure to another.”
Dr. Jellinger has received support from Amarin, Boehringer Ingelheim, Bristol-Myers Squibb/AstraZeneca, Janssen Pharmaceuticals, and Novo Nordisk.
Dr. Grunberger has received remuneration and research funding from Eli Lilly, BI-Lilly, Novo Nordisk, Sanofi, Janssen, AstraZeneca, Merck, Medtronic, and GlaxoSmithKline.
