Q: What are the latest evidence-based recommendations for lifestyle management for patients with type 2 diabetes?

In the 2017 Standards for Diabetes Care, lifestyle management includes diabetes self-management education, diabetes self-management support, nutrition therapy, physical activity, smoking cessation counseling, and psychosocial care (American Diabetes Association [ADA], 2017). This should take place between the patient and the provider in a patient-centered, collaborative, ongoing approach. The standards review and evaluate the most current studies to determine recommendations.

Diabetes self-management education and diabetes self-management "support informed decision making, self-care behaviors, problem solving, and active collaboration with the health care team to improve clinical outcomes, health status, and quality of life in a cost-effective manner" (ADA, 2017, p. S33). There is a great deal of evidence that supports the benefits of diabetes self-management education, which include improved diabetes knowledge and self-care behaviors, lower A1c, lower self-reported weight, improved quality of life, healthy coping, and reduced healthcare costs. There is also an increase in use of primary care and preventive services, with less frequent acute care/inpatient services. For these reasons, diabetes self-management education is recommended for all patients with diabetes.

However, only 5% to 7% of those who are eligible receive these services, perhaps due to lack of referral, costs, timing, or lack of perceived benefit. For this reason, innovative models of diabetes self-management education delivery should be explored and reimbursement for new models is recommended. Currently, diabetes self-management education is reimbursed for in-person visits for those with Medicare and other insurances for programs that meet national standards and are recognized by the American Diabetes Association or American Association of Diabetes Educators. The need for diabetes self-management education should be assessed at diagnosis and annually.

It is recommended that all individuals with diabetes receive individual medical nutrition therapy by a registered dietician with skill in providing diabetes-specific nutrition education. The main goal of nutrition therapy is to improve health by maintaining a healthy weight as well as individualized glycemic, blood pressure, and lipid goals. For those who are overweight, a reduction of 7% of body weight can produce beneficial outcomes. Diet choice should be based on patient health status and preference that achieve a 500 to 750 kcal/day energy deficit or provide 1,200 to 1,500 kcal/day for women and 1,500 to 1,800 kcal/day for men. Monitoring carbohydrate intake and response to it are important for improving postprandial control. Replacing refined carbohydrates with whole grains, legumes, vegetables, and fruits is important. Education is best achieved when the level of education matches the needs of the patient.

Aerobic activity suggested is 150 minutes of moderate to vigorous activity spread over at least 3 days/week, with no more than 2 days without activity. Resistance exercise should occur 2 to 3 days/week on nonconsecutive days. Patients should be reminded to interrupt prolonged sitting every 30 minutes. Flexibility and balance training are also recommended especially for older patients.

Other areas of lifestyle management include not smoking, alcohol moderation, and psychosocial components, which will be explored in a future column.

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