New Guidelines Shift Diabetes Care Toward Behavior

New guidelines for the management of type 2 diabetes and prediabetes include tools clinicians can use to help patients stick to lifestyle interventions.

The guidelines, released on June 1src by the American College of Lifestyle Medicine (ACLM), largely mirror lifestyle guidelines by the American Diabetes Association (ADA) but add specifics about how clinicians can help patients achieve their goals.

A panel of practitioners working in lifestyle medicine, including primary care physicians, cardiologists, endocrinologists, sleep experts, dietitians, and exercise medicine specialists, laid out six areas clinicians should help patients manage. These include sleep and stress, nutrition, physical activity, tobacco and alcohol, and social connection.

The new guidelines are intended to “enhance some of the health behaviors that are recommended by all of the leading authorities and medical societies,” said Mahima Gulati, MD, an endocrinologist and visiting associate professor of medicine at the University of Connecticut in Farmington, Connecticut.

Each patient should still receive tailored counseling, which may include medication, Gulati said.

“Lifestyle interventions are the foundation of diabetes and prediabetes no matter what,” said Nestoras Mathioudakis, MD, co-medical director of the Diabetes Prevention & Education Program at Johns Hopkins Medicine in Baltimore, who was not involved with the new guidelines. “Whether we jump to medications depends on how far off from the goal they are, but doctors should never diagnose someone with diabetes or prediabetes and say, ‘Keep doing what you’re doing, and just here’s some medication.’”

Mathioudakis said the recommendation of using SMART (specific, measurable, achievable, relevant, and time-bound) goals allows patients to work with their care providers to set achievable milestones that can be reevaluated during visits.

“We have to be careful not to overwhelm people,” Mathioudakis said. “I have found with my patients that when I do this counseling, setting small achievable goals at each visit and building as we go is more effective than bombarding them with everything.”

Gulati and her team broke their recommendations into two groups. “Strong” recommendations were backed by high-quality scientific evidence, while other recommendations lacked the same level of robust supportive data.

The strong recommendations include:

• Identify and refer patients with suspected sleep disorders such as sleep apnea or insomnia for further evaluation, potentially by a sleep specialist.
• Prescribe aerobic and muscle-strengthening physical activity tailored to a patient’s baseline. The body recommends using the FITT (frequency, intensity, time, and type) to set expectations of what that activity should look like while also helping patients reduce sedentary time.
• Implement a nutrition plan using SMART goals that are tailored to a patient’s current eating habits and cultural background, with the goal to eat whole and plant-based foods.
• Clinicians should counsel patients on the importance of fostering familial support and social connections that can help people stay on track for their goals.
• Counsel patients on using alcohol, tobacco, and recreational drugs, making sure they understand how using these substances can hinder their diabetes management.
• Utilize coaching, motivational interviewing, and cognitive-behavioral therapy to help patients sustain behavioral changes related to type 2 diabetes and prediabetes.
• Establish a continuity of care plan that lays out the frequency and duration of care visits, expectations for how the patient should be involved with setting and working toward lifestyle intervention goals, and whether the patient needs pharmacologic therapies.

They also make the following other recommendations:

• Evaluating patients for any psychological care needs, which can include depression or anxiety, stress, or mood and affective or psychotic disorders. Treatment for these conditions ranges from medication to mindfulness-based exercises and cognitive-behavioral therapy.
• Adjust pharmacologic therapy, which will depend on the progress they make through lifestyle interventions alone.

Meeting Patients Where They Are

Particularly with exercise and nutrition goals, clinicians need to be mindful of a patient’s baseline instead of implementing drastic diet or movement changes at the start.

“If you have someone who is drinking 1src cans of soda per day, we aren’t going to get into the nitty-gritty details of a Mediterranean diet right away; we need to start with reducing or eliminating these sugary beverages,” he said.

On the other hand, a patient who is well-versed in nutrition may need more sophisticated education about what parts of their diet may unknowingly be contributing to mismanaged blood sugars, he said.

The guidelines also recommend prescribing aerobic and muscle strength exercises using the SMART goal framework. Rather than simply telling patients to get more exercise, Gulati and her team recommend giving people examples of specific exercises that count as aerobic or strength training that are suited to each patient.

“One thing I thought was really good about these guidelines is they give links to YouTube videos on exercises for older people or those with limitations,” Mathioudakis said.

Shift Work and Social Connection

While exercise and nutrition are mainstays of lifestyle interventions for diabetes management, sleep and social connection are newer recommendations that began appearing in official ADA guidelines within the past 5 years.

“I think things are changing a bit now, but not every healthcare provider may understand the vital role sleep plays in patients with diabetes,” Gulati said. “Especially shift work, if someone is working shift work, their risk of diabetes goes up significantly. Same with obstructive sleep apnea.”

Social connection is another domain that can help or harm a patient’s ability to stick to lifestyle interventions.

“How can a patient change their own way of eating if their spouse doesn’t want to eat that way?” Gulati said. “If the patient isn’t able to drive, do they have a support network to ensure they always have a ride to doctor’s appointments?”

Even with strong social support, people may backtrack on progress, Gulati said. In these cases, she said, never guilt or shame patients, and always include them in decision-making about what their next goals should be.

“They may do good on nutrition for a while, but then they fall off, or they had some disruptions in their sleep routine, and now they want to focus on that,” she said. “Priorities may change as time goes on.”

This study was supported by the ACLM. The panel members received no financial support for the research, authorship, and/or publication of the guidelines. Various guideline authors reported financial disclosures including receiving consulting fees from Sanofi and LifeScan Diabetes and serving as an advisor to Medtronic, among others.

Kaitlin Sullivan is a freelance journalist living in Colorado.