As of this posting, the new American Diabetes Association/European Association for the Study of Diabetes (ADA/EASD) position statement on management of type 2 diabetes mellitus (T2DM) is just 4 days old and the ink is yet drying. While there are a number of changes put forth in this revision (including many that will certainly generate further discussion), what is left unchallenged is that lifestyle modification remains the foundation from which all other diabetes therapies are launched.1 No matter what strategy the clinician selects, it must build on top of lifestyle changes. And the new position statement stresses recurrent emphasis with every patient on the benefits of persistent lifestyle changes.
Lifestyle change is an old message that grows stronger with frequent refreshing. The Diabetes Prevention Program study2 first taught us that intensive lifestyle modification in patients with “pre-diabetes” promises a significant reduction-approximately 58%-in the risk of progression to T2DM. This reduction in risk was much more than that achieved by medical means alone.2 The only drawback to relying on lifestyle changes alone to reduce the likelihood of diabetes is that few patients will actually achieve their lifestyle modification goals. The new ADA/EASD position statement addresses this issue, suggesting that lifestyle modification be supplemented with metformin initially, with the prospect of metformin withdrawal if lifestyle goals are met and sustained.1
Goals for Lifestyle Change
So what are the lifestyle goals to be attained? The new position statement calls for standardized diabetes education (preferably using an approved curriculum) with a specific focus on dietary change, regular exercise, and weight control.1 Participation in an ongoing structured program of diabetes education is proved to improve A1C values3 and is recommended in an individual or group setting. Periodic individual counseling also is stressed.
Weight reduction, whether through dietary, medical, or surgical means, is encouraged. Even a modest 5% to 10% weight loss can result in significant improvement of glycemic control. The new guidelines urge establishing goals for weight loss or maintenance.1
Dietary advice should be personalized. Eating a healthy diet is important, but that diet must be adjusted for personal and cultural preferences. High fiber, low fat, and fresh fish should be encouraged, while “high-energy” foods should be limited. The statement stresses the importance of clinicians being understanding and repetitively encouraging during this process.1
Exercise goals are not particularly stringent. Ideally, the target is 150 minutes per week of aerobic, resistance, and/or flexibility training. For older patients, any increase in activity helps.1
Almost all of our patients, diabetic or not, would profit from these recommendations. Who would not see positive results from following a healthy diet, maintaining a reasonable weight, and practicing modest exercise? In my practice, you never get out of the door without me addressing these 3 essential elements of lifestyle change. In fact, they really are the foundation for good health. While I suspect the new ADA/EASD position statement on management of T2DM may invoke many debates, it is very unlikely anyone will challenge the benefits of ongoing lifestyle modification as the starting point for good diabetes care.
1. Inzucchi SE, Bergenstahl RM, Buse JB, et al. Management of hyperglycemia in type 2 diabetes: a patient centered approach. Diabetes Care. Published online ahead of print, April 19, 2012. Available at: http://care.diabetesjournals.org/content/early/2012/04/19/dc12-0413.full.pdf. Accessed April 24, 2012.
2. Diabetes Prevention Program Research Group. Reduction in the incidence of type 2 diabetes with lifestyle intervention or metformin. N Engl J Med. 2002;346:393-403.
3. Norris SL, Lau J, Smith SJ, et al. Self-management education for adults with type 2 diabetes: a meta-analysis of the effect on glycemic control. Diabetes Care. 2002;25:1159-1171.