Holistic approach to prevention and management of type 2 diabetes mellitus in a family setting

Figures & data

Table 1 Professionals involved and recommended targets for lifestyle and medical risk factors

Professionals involved in the care

Recommended goals of therapy*

Short-term management Involved in core care, provide support and structured education for patients • Primary care physician • Diabetes specialist nurse • Certified diabetes educator • Dietitian • Physical activity specialist Long-term management • Endocrinologist • Ophthalmologist • Podiatrist • Renal and cardiac physicians • Mental health practitioners • Pharmacists • Social workers

Lifestyle goals^Citation62 Smoking cessation weight loss achieved with a) Diet  • Calorie restriction to 1,500 kcal/day  • Fat intake restricted to 30%–35% of total daily energy uptake, with saturated fat <10.7%  • 10% monounsaturated fatty acids, eg, olive oil  • Avoidance of trans-fats  • Fiber intake restricted to 30 g per day b) Physical activity  • 2.5–5 h/week moderate-intensity physical activity or1–2.5 h/week vigorous-intensity exercise • Limit total time spent being sedentary Pharmacotherapy^Citation11 Glycemic control (individualized) • HbA1c <7% • Fasting plasma glucose 3.9–7.2 mmol/L • Postprandial glucose < 10 mmol/L Lipids • Total cholesterol <4 mmol/L • LDL cholesterol <2.6 mmol/L (< 1.8 if CVD) • HDL cholesterol > 1.04 mmol/L (males), > 1.3 (females) • Triglycerides < 1.7 mmol/L • BP < 130/80 mmHg

Note:

* These targets should be individualized, as discussed in the text.

Abbreviations: BP, blood pressure; CVD, cardiovascular disease; HbA_1c, glycated hemoglobin; HDL, high-density lipoprotein; LDL, low-density lipoprotein.

Table 2 Effectiveness, advantages, and disadvantages of the various strategies employed in the management of DM

Intervention	Effectiveness (% Decrease in HbAIC)	Advantages	Disadvantages
Lifestyle changes to decrease weight and increase activity	1.0–2.0	Broad benefits, as outlined in the text	Transient GI and musculoskeletal discomfort
Insulin	1.5–3.5	No dose limit, rapidly effective, improves lipid profile	One to four injections daily, monitoring, weight gain, hypoglycemia, analogues are expensive
Metformin	1.0–2.0	Weight neutral, low hypoglycemia risk	GI side effects, lactic acidosis (rare), contraindicated with renal insufficiency
Sulfonylureas	1.0–2.0	Rapidly effective	Weight gain, hypoglycemia (especially with glibenclamide or chlorpropamide)
Thiazolidinediones	0.5–1.4	Improved lipid profile (pioglitazone)	Fluid retention, congestive heart failure, weight gain, bone fractures, expensive
DPP-4 inhibitors	0.5–0.8	Weight-neutral	Long-term safety not established, expensive
GLP-1 analogs	0.5–1.0	Weight loss	Given by injection, frequent GI side effects, long-term safety not established, expensive
α-glucosidase inhibitors	0.5–0.8	Weight-neutral	Frequent GI side effects, three times per day dosing, expensive
Glinides	0.5–1.5	Rapidly effective	Weight gain, three times per day dosing, hypoglycemia, expensive
Amylin analogs	0.5–1.0	Weight loss	Three injections daily, frequent GI side effects, long-term safety not established, expensive

Note: Copyright © 2012. American Diabetes Association. Reproduced from Inzucchi SE, Bergenstal RM, Buse JB et al. American Diabetes Association (ADA); European Association for the Study of Diabetes (EASD). Management of hyperglycemia in type 2 diabetes: a patient-centered approach: position statement of the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD). Diabetes Care. 2012;35(6):1364–1379.¹⁴

Abbreviations: DM, diabetes mellitus; DPP-4, dipeptidyl peptidase-4; GI, gastrointestinal; GLP-1, glucagon-like peptide-1; HbA_1c, glycated hemoglobin.

Table 3 Methods to monitor success of advice given

Self-regulation techniques

• Self-weighing, waist circumference measurements, or both

• The level of attendance to the clinic can be used as an indicator of commitment

Objective methods

• Changes in the amount of moderate to vigorous physical activity undertaken, assessed with exercise questionnaires

• Changes in dietary intake, monitored with food records

• Changes in weight, waist circumference, or BMI

• Changes in the fasting plasma glucose or HbA1c will be used to monitor glycemic control

Note: Data taken from the 2012 NICE guidelines.³⁰

Abbreviations: BMI, body mass index; HbA_1c, glycated hemoglobin; NICE, National Institute for Health and Care Excellence.

Rydén L Standl E Bartnik M Task Force on Diabetes and Cardiovascular Diseases of the European Society of Cardiology (ESC) European Association for the Study of Diabetes (EASD) Guidelines on diabetes, pre-diabetes, and cardiovascular diseases: executive summary. The Task Force on Diabetes and Cardiovascular Diseases of the European Society of Cardiology (ESC) and of the European Association for the Study of Diabetes (EASD) Eur Heart J 2007 28 1 88 136 17220161

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American Diabetes Association Standards of medical care in diabetes – 2012 Diabetes Care 2012 35 Suppl 1 S11 S63 22187469

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Inzucchi SE Bergenstal RM Buse JB American Diabetes Association (ADA) European Association for the Study of Diabetes (EASD) Management of hyperglycemia in type 2 diabetes: a patient-centered approach: position statement of the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD) Diabetes Care 2012 35 6 1364 1379 22517736

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National Institute for Health and Clinical Excellence (NICE) Preventing Type 2 Diabetes – Risk Identification and Interventions for Individuals at High Risk (PH38) London National Institute for Health and Care Excellence 2012 Available from: http://guidance.nice.org.uk/PH38 Accessed March 26, 2014

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