Therapeutic Lifestyle Changes
ÎÎMedical nutritional therapy must be individualized; this generally
means evaluation and teaching by a trained nutritionist/registered
dietitian or knowledgeable physician (D-4). Insulin dosage adjustments
to match carbohydrate intake (eg, use of carbohydrate counting),
sucrose-containing or high glycemic index food limitations, adequate
protein intake, "heart healthy" diet, weight management, and sufficient
physical activity are recommended.
ÎÎRegular physical activity, both aerobic and strength training, are
important to improve a variety of CVD risk factors, decrease risk of falls
and fractures, improve functional capacity and sense of well-being, and
improve glucose control in persons with T2DM.
ÎIncreased physical activity is also a major component in weight loss and
Î
weight maintenance programs. The current recommendations of at least
150 minutes per week of moderate-intensity exercise, such as brisk
walking or its equivalent, are now well accepted and part of the nationally
recommended guidelines. For persons with T2DM, it is also recommended
to incorporate flexibility and strength-training exercises. Patients must
be evaluated initially for contraindications and/or limitations to physical
activity, and then an exercise prescription should be developed for each
patient according to both their goals and exercise limitations. Physical
activity programs should begin slowly and build up gradually (D-4).
Antihyperglycemic Pharmacotherapy
ÎÎThe choice of therapeutic agents should be based on their differing
metabolic actions and adverse effect profiles as described in the 2009
AACE/ACE Diabetes Algorithm for Glycemic Control (D-4). The initial
choice of an agent targeting FPG or PPG involves comprehensive patient
assessment with emphasis given to the glycemic profile obtained by
self-monitoring of blood glucose (SMBG).
ÎÎInsulin is required in all patients with T1DM, and it should be
considered for patients with T2DM when noninsulin antihyperglycemic
therapy fails to achieve target glycemic control or when a patient,
whether drug naïve or not, has symptomatic hyperglycemia (A-1).
ÎÎPhysiologic insulin regimens, which provide both basal and prandial
insulin, are recommended for most patients with T1DM (A-1).
>> These regimens include:
▶▶ use of multiple daily injections (MDI), which usually provide 1 or 2 injections
daily of basal insulin to control glycemia between meals and overnight and
injections of prandial insulin before each meal to control meal-related glycemia;
▶▶ the use of continuous subcutaneous insulin infusion (CSII) to provide a more
physiologic way to deliver insulin, which may improve glucose control while
reducing risks of hypoglycemia; and
▶▶ for other patients (especially if hypoglycemia is a problem), the use of insulin
analogues (A-1).
7
