Diabetes management

Lifestyle Modification

Diet

Dietary changes have been shown to significantly help people manage diabetes. There are many diets that are effective at managing diabetes however, it is important that patients understand that there is no one diet that all patients should use. Some diets that have strong evidence and have commonly been used successfully in diabetes management and assist with weight loss include Mediterranean diet, Dietary Approaches to Stop Hypertension (DASH), Alternative Healthy Eating Index (AHEI), vegetarian, low carb, or carb-controlled. In addition, it is recommended that individuals choose a diet that can be adhered to long-term. Even in the most ideal diet becomes impractical if the patient has difficulty following it.

While not advocating for a particular diet, the American Diabetes Association does recommend using the "Diabetes Plate Method" as a way to balance food groups. In this method, a 9 inch plate is divided into thirds, with 50% containing non-starchy vegetables, 25% protein, and 25% carbohydrates. Patients should avoid excess simple carbs or added fat (such as butter, salad dressing) and instead eat complex carbohydrates such as whole grains. In addition, patients should also avoid consumption of processed meat and foods and sugar-sweetened beverages. In the long term, it is helpful to eat a consistent diet and amount of carbohydrate to make blood sugar management easier. It is important for patients to eat 3 meals a day in order to reduce the chances of hypoglycemia, especially with patients that take insulin.

There is a lack of evidence of the usefulness of low-carbohydrate dieting for people with type 1 diabetes (T1D). Although for certain individuals it may be feasible to follow a low-carbohydrate regime combined with carefully managed insulin dosing, this is hard to maintain and there are concerns about potential adverse health effects caused by the diet. In general people with T1D are advised to follow an individualized eating plan rather than a pre-decided one.

Physical Activity/Exercise

Along with diet, physical activity is also important for the management of diabetes. Not only does exercising regularly help manage blood sugar levels and weight, it helps reduce the risk of heart attack and stroke, reduces cholesterol and blood pressure levels, reduces risk of diabetes related complications, increases the effect of insulin, provides a boost in energy levels, helps reduce stress, and contributes to positive self-esteem. By exercising, the body becomes more sensitive to insulin, allowing for better absorption of glucose by the muscle cells, for up to 24 hours after exercise. In addition, studies have shown that physical activity, even below recommended amounts, has the ability to reduce risk of diabetic-related complications.

In people with type 2 diabetes, the combination of aerobic ("cardio") exercise and strength training is effective. Aerobic exercise has been shown to largely improve HbA1c, and contributes to weight loss and the enhanced regulation of cholesterol and lipoproteins. This may be any form of continuous exercise that elevates breathing and heart rate, such as walking, swimming, or dancing. During the last 20 years, resistance training has gained recognition as an effective form of exercise for people with type 2 diabetes. A light walk after a meal (postprandial walking) is also recognized as effective in reducing postprandial glucose spikes in people with or at risk for type 2 diabetes.

In youths with type 1 diabetes, there is an association between exercise and lower HBA1c. Furthermore, studies have shown that the longer the length of the exercise program, the better the reduction in HBA1c and insulin requirements.

Weight Loss

In addition to diet and exercise, weight loss is an important tool to help with diabetes management. Type 2 diabetes (T2D) is often associated with obesity and increased abdominal circumference. Often patients who are at risk of diabetes may be able to reverse their progression to T2D with weight loss as well. Weight loss can help improve metabolic control, reduce the risk of further complications, other health related problems, and helps improve the effects of insulin on the body. Weight loss helps reduce the destruction of the beta cells, which produce insulin in the body, as well.

It is recommended for patients who have been diagnosed with T2D who are overweight or obese to lose at least 5% of their weight and maintain the weight loss. There have been studies that have demonstrated that by losing about 5 to 10% of their weight at diagnosis, there is a reduction in heart disease risk factors, lowered Hb A1c, less diabetes medications, lower cholesterol and improved fitness.

Common strategies to help reduce weight many include lifestyle measures such as diet and exercise, behavioral therapy, pharmacologic interventions, and surgery. The goal of weight loss and method for achievement should be individualized based on the patient's desires and motivation. It is important for providers to help maintain patient motivation and provide education to assist individuals in their weight journey. Additionally, some medications that reduce blood sugars such as insulin may initially cause weight gain due to the increased conversion of blood sugar to stored forms such as fat. Therefore, in patients with diabetes, providers may try other medications that lower blood sugar but not cause as much weight gain.

Medications

There are several medications classes that are commonly used to control blood sugar levels in patients with diabetes. Most of the medications used are either oral or injected. In patients with T1D, insulin is required because the body no longer produces insulin. In patients with T2D, management is largely more variable as lifestyle changes can have a significant impact. However, medications may be added to further help control blood glucose levels if the lifestyle changes are not effectively controlling the condition. Unlike patients with type 1 diabetes, patients with T2D can still produce insulin, so usually oral medications are recommended as first line treatment before requiring insulin for diabetic control. Patient education and adherence with treatment is very important in managing the disease. Improper use of medications and insulin can be very dangerous causing hypo- or hyper-glycemic episodes.

Insulin

Insulin is the hormone that is made by the body that controls the cell intake of glucose. Normally, the pancreas produces insulin in response to high glucose levels in the body to bring the blood glucose levels down. For those with type 1 diabetes, there will always be a need for insulin injections throughout their life, as the pancreatic beta cells are not capable of producing sufficient insulin. Insulin can not be taken orally because insulin is a hormone and is destroyed by the digestive tract. Insulin can be injected by several methods, including a hypodermic needle, jet injector, or insulin pump. There is also inhaled insulin that can be used in adults with diabetes.

There are several types of insulin that are commonly used in medical practice, with varying times of onset and duration of action. These include:

• Rapid acting (i.e. insulin lispro) with onset in 15 minutes and duration of about 4 hrs
• Short acting (i.e. regular insulin) with onset in 30 minutes and duration of about 6 hrs
• Intermediate acting (i.e NPH insulin) with onset in 2 hours and duration of about 14 hrs
• Long acting (i.e. detemir) with onset in 1 hour and duration of about 24 hrs
• Premixed which are usually combinations of short and long acting insulin

Insulin is usually taken several times per day in patients who require it to control their diabetes. Patients usually take long acting insulin once per day and then take insulin before meals. The time of onset of the insulin determines how far in advance patients should take the insulin before they eat.

Insulin therapy requires close monitoring and a great deal of patient education, as improper administration is quite dangerous. Insulin can easily cause hypoglycemia if the patient does not eat after administering insulin or accidentally took too much insulin. A previously satisfactory dosing may be too much if less food is consumed causing hypoglycemia. Exercise decreases insulin requirements as exercise increases glucose uptake by body cells whose glucose is controlled by the insulin.

Insulin therapy creates risk because of the inability to continuously know a person's blood glucose level and adjust insulin infusion appropriately. However, new advances in technology have significantly alleviated many of these risks, although they can still occur. Small, portable insulin infusion pumps are available from several manufacturers. They allow a continuous infusion of small amounts of insulin to be delivered through the skin around the clock. They also have the ability to give bolus doses when a person eats or has elevated blood glucose levels. They are also capable to being used in conjunction with continuous glucose monitors for optimal glucose management. This is very similar to how the pancreas works, but these pumps lack a continuous "feed-back" mechanism. Thus, the user is still at risk of giving too much or too little insulin unless blood glucose measurements are made.

Oral Medications

Metformin

One of the most common drugs used in T2D, metformin is the drug of choice to help patients lower their blood sugar levels. Metformin is an example of a class of medicine called biguanides. The medication works by reducing the new creation of glucose from the liver and by reducing absorption of sugar from food. In addition, the medication also works to help increase the effects of insulin on muscle cells, which take in glucose. The medicine is not used for T1D as these patients do not produce any insulin and metformin relies on some insulin production in order to be effective. There are several preparations of the medication such as tablets, extend release tablets, and liquid suspensions. Metformin is usually started as 500 to 1000 mg tablets twice a day by mouth (PO), usually with meals. If taking the extended release tablets, they should be always swallowed whole as cutting the tablet will cause faster release of the medication. The medication most commonly may cause side effects such as stomach upset and diarrhea, but in general is well tolerated and has a relatively low chance of causing hypoglycemia. One rare (about 1% chance) but serious side effect of metformin is that it can cause lactic acidosis, usually in patients with poor kidney function. To assist in tolerance of the metformin, practitioners may recommend gradual increase of the dose of the medication.

Sulfonylureas

Another commonly used class of medications to treat T2D are sulfonylureas. This class of medicine increases the release of insulin from the beta cells in the pancreas. The medication can not be used in patients with T1D, as they do not have functioning beta cells and can not produce insulin. Some common examples of a sulfonylurea is glipizide, glyburide, glimepiride and gliclazide. Depending on the medication, there are different size tablets but in general, the sizes range from about 1 mg to 10 mg. Usually, the tablet is taken about 30 minutes before a meal and can be either once or twice a day. The most common adverse effects of the medication are lightheadedness and stomach irritation. Sulfonylureas have a greater risk of hypoglycemia but the risk is still only around 3% of patients who use them. In patients who have a greater risk of low sugar, such as in the elderly and patients with kidney disease, the starting dose can be as low as 0.5 mg.

GLP-1 agonists

Another popular medication that is used in T2D management are glucagon like peptide 1 (GLP-1) agonists. This class of medication works by mimicking a hormone called glucagon-like peptide which has many effects in the body. One effect of the hormone is that it helps time the release of insulin when patients eat and the blood glucose rises. In addition, it can significantly increase the amount of insulin release. Lastly, the medication also slows down the movement of food through the digestive tract and can increase feeling of fullness while eating, decreasing appetite and weight. These drugs are very effective at controlling T2D and reducing risk of heart attacks, strokes, and other complications due to diabetes. In addition, patients usually lose weight and have improved blood pressure and cholesterol. Common names of these medications include semaglutide (Ozempic and Wegovy), liraglutide (Victoza, Saxenda), and dulaglutide (Trulicity). These medications must be injected and are usually injected in the upper arm, thighs or stomach areas. They are usually given once a week but some of the medication can be as frequent as twice daily. The dose is usually started low and tapered gradually. Some of the common side effects of the medication is nausea, vomiting, and diarrhea. Patients with a family history of medullary thyroid cancer or Multiple Endocrine Neoplasia type 2 should not be prescribed the drug as it may increase the risk of developing cancer.

Surgery

While weight loss is beneficial in improving glycemic control in patients with T2D, maintaining significant weight loss can be challenging. People with diabetes who have a body mass index (BMI) of 35 or higher, and who have been unable to lose weight otherwise, bariatric surgery offers a viable option to help achieve that goal. In 2018, a Patient-Centered Outcomes Research Institute funded study was published which analyzed the effects of three common types of bariatric surgery on sustained weight loss and long-lasting glycemic control in patients with T2D. The results of this study demonstrated that five years after bariatric surgery, there was significant weight loss in a large majority of patients. In addition, and more importantly, this study showed that, in patients with type 2 diabetes with a BMI of 35 or higher, bariatric surgery has the potential to lead to complete remission of diabetes in as many as 40% of those people who have the procedure. Like any operation, bariatric surgery is not without risks and complications, and those risks need to weighed against the potential benefits in anyone considering the procedure.

Additional Monitoring

Foot Care

Foot monitoring can help in predicting the likelihood of developing diabetic foot ulcers, a common complication in persistent uncontrolled diabetes. A common method for this is using a special thermometer to look for spots on the foot that have higher temperature which indicate the possibility of an ulcer developing. At the same time there is no strong scientific evidence supporting the effectiveness of at-home foot temperature monitoring. The current guideline in the United Kingdom recommends collecting 8-10 pieces of information for predicting the development of foot ulcers. A simpler method proposed by researchers provides a more detailed risk score based on three pieces of information (insensitivity, foot pulse, previous history of ulcers or amputation). This method is not meant to replace individuals regularly checking their own feet but complement it.

Dental Care

High blood glucose levels in individuals with diabetes is a risk factor for developing gum and tooth problems. For patients with diabetes, there are increased risk of developing oral health problems such as tooth decay, saliva production dysfunction, fungal infections, and periodontal disease Diabetes lowers the ability to resist infection and also slows healing and therefore individuals may experience more severe periodontitis. In turn, the chronic infection from periodontal disease can cause difficulties in controlling diabetes, leading to worsening of diabetic complications. The oral problems in persons with diabetes can be prevented with a good control of the blood sugar levels, regular check-ups with their dental provider, and good oral hygiene. Looking for early signs of gum disease (redness, swelling, bleeding gums) and informing the dentist about them is also helpful in preventing further complications. Quitting smoking is recommended to avoid serious diabetes complications and oral diseases. By maintaining a good oral status, diabetic persons prevent losing their teeth as a result of various periodontal conditions.

Eye Care

Any individual with diabetes is at risk for diabetes-related eye conditions and it is recommended to have an initial diabetic eye exam screening and subsequent annual comprehensive dilated eye exam with either an optometrist or ophthalmologist. Diabetic retinopathy is the most common complication of diabetes and one of the leading causes of blindness worldwide. Individuals with diabetes are at greater risk for developing eye conditions such as glaucoma and cataracts earlier or more frequently. Blood sugar control continues to be the most effective way to decrease the risk or slow the progression of diabetic retinopathy.

Digital Tools

Audio-based interventions, primarily telephone consultations, have shown promise as supplements to usual diabetes care. A 2025 systematic review found moderate certainty evidence for modest improvements in glycemic control (A1c reduction of 0.20%), with greater effectiveness when interventions included at least monthly contact and remote monitoring tools.

Electronic Health Records

Sharing their electronic health records with people who have T2D helps them to reduce their blood sugar levels. It is a way of helping people understand their own health condition and involving them actively in its management.

m-health Monitoring Applications

The widespread use of smartphones has turned mobile applications (apps) into a popular means of the usage of all forms of software. The number of health-related apps accessible in the App Store and Google Play is approximately 100,000, and among these apps, the ones related to diabetes are the highest in number. Conducting regular self-management tasks such as medication and insulin intake, blood sugar checkup, diet observance, and physical exercise are demanding. This is why the use of diabetes-related apps for the purposes of recording diet and medication intake or blood glucose level may improve the health condition for diabetic people.

Complexities

The main complexities stem from the nature of the feedback loop of glucose in the blood stream.

• The glucose cycle is a system which is affected by two factors: entry of glucose into the bloodstream and also blood levels of insulin to control its transport out of the bloodstream
• As a system, it is sensitive to diet and exercise
• It is affected by the need for patient anticipation due to the complicating effects of time delays between any activity and the respective impact on the glucose
• Management is highly intrusive, and compliance is an issue, since it relies upon user lifestyle change and often upon regular sampling and measuring of blood glucose levels, multiple times a day in many cases
• It changes as people grow and develop
• It is highly individual

As diabetes is a prime risk factor for cardiovascular disease, controlling other risk factors which may give rise to secondary conditions, as well as the diabetes itself, is one of the facets of diabetes management. Checking cholesterol, LDL, HDL and triglyceride levels may indicate hyperlipoproteinemia, which may warrant treatment with hypolipidemic drugs. Checking the blood pressure and keeping it within strict limits (using diet and antihypertensive treatment) protects against the retinal, renal and cardiovascular complications of diabetes. Regular follow-up by a podiatrist or other foot health specialists is encouraged to prevent the development of diabetic foot. Annual eye exams are suggested to monitor for progression of diabetic retinopathy.

Hypoglycemia

A level of <70 mg/dL (<3.8 mmol/L) is described as a hypoglycemic attack (low blood sugar). Most diabetics know when they are hypoglycemic and seek food or a sweet drink to raise their glucose levels. Intensive efforts to achieve blood sugar levels close to normal have been shown to triple the risk of the most severe form of hypoglycemia, in which the person requires assistance from by-standers in order to treat the episode. Among intensively controlled type 1 diabetics, 55% of episodes of severe hypoglycemia occur during sleep, and 6% of all deaths in diabetics under the age of 40 are from hypoglycemia at night.

Hypoglycemia can be problematic if it occurs while driving as it can affect a person's thinking process, coordination, and state of consciousness. Some people are more prone to hypoglycemia as they have reported fewer warning symptoms, and their body released less epinephrine (a hormone that helps raise blood glucose). Additionally, individuals with a history of hypoglycemia-related driving mishaps appear to use sugar at a faster rate.

Drivers with diabetes susceptible to driving mishaps should monitor their blood sugar to be not less than 70 mg/dL (3.9 mmol/L). Instead, these drivers are advised to treat hypoglycemia and delay driving until their blood glucose is above 90 mg/dL (5 mmol/L).

Hyperglycemia

A patient is considered to have hyperglycemia (high glucose) if the patient has a sugar level of greater than 230–270 mg/dL (13–15 mmol/L). Sometimes the patient may be temporarily hyperglycemic under certain conditions (e.g. not eating regularly, or after strenuous exercise). Patients should closely monitor their sugar levels to ensure that they reduce rather than continue to remain high. High blood sugar levels are not as easy to detect as hypoglycemia and usually happens over a period of days rather than hours or minutes. If left untreated, this can result in diabetic coma and death.

Prolonged and elevated levels of glucose in the blood, which is left unchecked and untreated, will, over time, result in serious diabetic complications in those susceptible and sometimes even death. There is currently no way of testing for susceptibility to complications. Diabetics are therefore recommended to check their blood sugar levels either daily or every few days. There is also diabetes management software available from blood testing manufacturers which can display results and trends over time.

Medication nonadherence

Because many patients with diabetes have two or more comorbidities, they often require multiple medications. The prevalence of medication nonadherence is high among patients with chronic conditions, such as diabetes, and nonadherence is associated with public health issues and higher health care costs. One reason for nonadherence is the cost of medications. Being able to detect cost-related nonadherence is important for health care professionals, because this can lead to strategies to assist patients with problems paying for their medications. Some of these strategies are use of generic drugs or therapeutic alternatives, substituting a prescription drug with an over-the-counter medication, and pill-splitting. Interventions to improve adherence can achieve reductions in diabetes morbidity and mortality, as well as significant cost savings to the health care system. Smartphone apps have been found to improve self-management and health outcomes in people with diabetes through functions such as specific reminder alarms, while working with mental health professionals has also been found to help people with diabetes develop the skills to manage their medications and challenges of self-management effectively.

Psychological mechanisms and adherence

As self-management of diabetes typically involves lifestyle modifications, adherence may pose a significant self-management burden on many individuals. For example, individuals with diabetes may find themselves faced with the need to self-monitor their blood glucose levels, adhere to healthier diets and maintain exercise regimens regularly in order to maintain metabolic control and reduce the risk of developing cardiovascular problems. Barriers to adherence have been associated with key psychological mechanisms: knowledge of self-management, beliefs about the efficacy of treatment and self-efficacy/perceived control. Such mechanisms are inter-related, as one's thoughts (e.g. one's perception of diabetes, or one's appraisal of how helpful self-management is) is likely to relate to one's emotions (e.g. motivation to change), which in turn, affects one's self-efficacy (one's confidence in their ability to engage in a behaviour to achieve a desired outcome).

As diabetes management is affected by an individual's emotional and cognitive state, there has been evidence suggesting the self-management of diabetes is negatively affected by diabetes-related distress and depression. There is growing evidence that there is higher levels of clinical depression in patients with diabetes compared to the non-diabetic population. Depression in individuals with diabetes has been found to be associated with poorer self-management of symptoms. This suggests that it may be important to target mood in treatment. In the case of children and young people, especially if they are socially disadvantaged, research suggests that it is important that healthcare providers listen to and discuss their feelings and life situation to help them engage with diabetes services and self-management.

To this end, treatment programs such as the Cognitive Behavioural Therapy - Adherence and Depression program (CBT-AD) have been developed to target the psychological mechanisms underpinning adherence.