Maximizing lifestyle changes to manage type 2 diabetes
Four dietary plans can reduce A1C levels but may differ in long-term outcomes. Intensive lifestyle interventions may even make remission possible.
PRACTICE RECOMMENDATIONS
› Recommend a reduced-calorie diet that is generally plant based and low in carbohydrates as part of the treatment plan for type 2 diabetes. B
› Counsel all patients with type 2 diabetes to engage in physical activity for at least 150 minutes per week at moderate intensity and to add resistance training on at least 2 days to improve glycemic control. B
› Teach patients techniques to reduce stress and improve sleep quality. C
Strength of recommendation (SOR)
A Good-quality patient-oriented evidence
B Inconsistent or limited-quality patient-oriented evidence
C Consensus, usual practice, opinion, disease-oriented evidence, case series
H ow can I get my patient to change?
The AACE recommends using motivational interviewing, behavioral therapy consultation, and wearable feedback devices (eg, accelerometers/pedometers) to stimulate behavioral change in patients.3 Motivational interviewing is the principal counseling strategy and is supported by multiple studies showing the benefits of using this technique in a clinical encounter to induce behavioral changes.34 In general, offer receptive patients intensive behavioral interventions and provide them with resources to accomplish their goals.35 For example, a 7-step yearly intensive behavioral counseling intervention over 3 years showed significant improvements in activity of any intensity, reduced sedentary time, and led to favorable metabolic outcomes.36 Wearable devices result in up to a 1 hour increase in physical activity per week for the wearers vs control, although there was no appreciable effect on A1C.37
One systematic review showed a 0.5% reduction in A1C (95% CI, –0.65 to –0.34) by focusing on environmental changes related to the diet, with the most effective intervention being full meal replacement for calorie control (ie, each meal was pre-made and provided to the patients based on macronutrient and caloric goals).38 Additionally, diabetes self-management education includes coping strategies, problem solving, self-advocacy, and health care system navigation, which have been shown to reduce A1C by an average of 0.6%.21 Patient resources are available for further assistance with lifestyle modifications (TABLE 3).
C an your patient achieve remission?
Emerging evidence suggests that patients may achieve remission from type 2 diabetes with intensive lifestyle interventions.39 This is supported by the American College of Lifestyle Medicine.5 Although there is no consensus definition for remission, in general it is reasonable to presume remission if a patient achieves normo-glycemia (A1C < 5.7%) for at least 1 year without any medication therapy.5 These intensive lifestyle interventions would include a mostly plant-based diet with moderate calorie restriction, appropriate and sustained physical activity, adequate sleep, and stress-reduction techniques.5 One study found that 46% of patients in a weight-management program across multiple primary care clinics achieved remission at 12 months.40 A meta-analysis showed that a low-carbohydrate diet induced remission at 6 months in 32% of patients (although the result was not controlled for weight loss as a possible confounding factor and an A1C cutoff of 6.5% was used).11 Thus far, most studies have focused on short-term follow-up intervals, but evidence is emerging that with intensive lifestyle interventions the effects are sustained at the 2-year mark.41
This evidence could reframe our understanding of type 2 diabetes therapy and could change the conversations we have with patients regarding their treatment. Instead of focusing on an A1C goal that is adequate for control of type 2 diabetes, we would instead focus on achieving remission.
CORRESPONDENCE
Stephen McMullan, MD, Mayo Clinic College of Medicine and Science, 4500 San Pablo Road, Jacksonville, FL 32224; mcmullan.stephen@mayo.edu
