Therapeutic Lifestyle Changes
ÎMedical 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.
ÎRegular 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 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
ÎThe 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).
ÎInsulin 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).
ÎPhysiologic 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).
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