Ten Commandments of Type2 Diabetes Management
Management of diabetes does not mean just blood sugar control. Optimum control of diabetes can only be achieved by ensuring good overall health, with multifactorial interventions. The following 10 commandments are an attempt to achieve diabetes management using a more holistic approach.
Potential Obesity Complications:
- Type2 Diabetes, Obstructive Sleep Apnea
- Cardiovascular Risk - ASCVD, Heart Failure
- Liver-NAFLD, NASH, Cirrhosis, Malignancy
- Osteoarthritis, Polycystic Ovarian Syndrome,
- Cancers of Liver, Pancreas, Endometrium, Colon/Rectum, Breast & Bladder
Obesity Complications:
- Type2 Diabetes, Obstructive Sleep Apnea
- Liver-NAFLD, NASH, Cirrhosis, Malignancy
- Cancers of Liver, Pancreas, Endometrium, Colon/Rectum, Breast & Bladder
- Osteoarthritis, Polycystic Ovarian Syndrome,
- Cardiovascular Risk - ASCVD, Heart Failure
Risk Factor Evaluation
- Type2 Diabetes, Obstructive Sleep Apnea
- Cardiovascular Risk - ASCVD, Heart Failure
- Liver-NAFLD, NASH, Cirrhosis, Malignancy
- Osteoarthritis, Polycystic Ovarian Syndrome
- Cancers of Liver, Pancreas, Endometrium, Colon/Rectum, Breast & Bladder
Diabetic Kidney Disease
- Type2 Diabetes, Obstructive Sleep Apnea
- Cardiovascular Risk - ASCVD, Heart Failure
- Liver-NAFLD, NASH, Cirrhosis, Malignancy
- Osteoarthritis, Polycystic Ovarian Syndrome
- Cancers of Liver, Pancreas, Endometrium, Colon/Rectum, Breast & Bladder
Ten Commandments of Type2 Diabetes Management
1. AVERAGE GLUCOSE (A1c) CONTROL
DCCT in T1DM and KUMAMOTO, UKPDS in T2DM have proven that intensive glycemic control (A1c <7%) can significantly reduce the risk of microvascular complications. Lowering of A1c from 7 to 6% is associated with further lowering of microvascular diseases. Intensive treatment of glycemia in newly diagnosed patients may also reduce long term CVD rates. TIR, TBR & TAR as measured by CGM are emerging as beneficial parameters for the evaluation of the treatment regimen. Agents with cardiorenal metabolic benefits & low risk of hypoglycaemia are preferred.
2. BLOOD PRESSURE CONTROL
Hypertension, defined as sustained BP ≥130/80 mmHg, is a major risk factor for both ASCVD & microvascular complications. Numerous studies have shown that antihypertensive therapy reduces ASCVD events, heart failure & microvascular complications. Patients with sustained office-based BP ≥130/80 in addition to lifestyle therapy should be initiated with one drug and ≥160/100 should have prompt initiation of two drugs with drug classes demonstrated to reduce CV events in PwD.
3. CHOLESTEROL REDUCTION
PwD have increased prevalence of lipid abnormalities. Several trials have shown benefit of Statin therapy on ASCVD outcomes both for primary & secondary prevention. Fasting/Nonfasting lipid profile should be performed at diagnosis & repeat at 4-12 weeks of therapy initiation & atleast annually thereafter. Use high Intensity Statin for people with established/high risk of ASCVD & Moderate Intensity Statin for others, regardless of baseline LDL. CV benefit is linearly related to LDL levels. People with extreme risk may need addition of Ezetimibe/PCSK9i. Fasting TG ≥500 mg/dl should be treated with Fibrates to reduce the risk of Pancreatitis. Statins are contraindicated in pregnancy.
4. DIETARY MODIFICATION
Nutrition therapy plays an integral role in diabetes management. A healthy diet should include vegetables, legumes, dairy, lean sources of protein, nuts, seeds, whole grains & fruits. Ideal diabetic plate should be half (50%) filled with non starchy vegetables, 1/4th (25%) with proteins and remaining 1/4th (25%) with carbohydrates. Complex carbohydrates should be preferred and direct sugars, sweetened beverages, fruit juices are to be avoided.
5. EXERCISE COUNSELING
Exercise has been shown to improve blood glucose levels, reduce CV risks, contribute to weight loss & improve well being. Moderate to high volumes of aerobic activity is associated with lower CV & overall mortality both in T1D & T2D. PwD should engage in ≥150 minutes of moderate to vigorous intensity aerobic activity/week spread over atleast 3 days/week & 2 to 3 sessions of resistance exercises. Yoga & tai chi may be included to increase flexibility & muscular strength. Sedentary behaviour & prolonged sitting should be avoided. Pre-exercise evaluation should be done if vigorous exercise is planned.
6. FOLLOW UP ENCOURAGEMENT
Follow up for PwD should be every 3-4 months, i.e 3-4 visits/year. Low frequency follow-up is associated with poor glycemic control and metabolic outcomes & hence is associated with increased diabetes complications. Every clinic visit of diabetes patient should include an assessment of lifestyle, diet, behavioral changes, medication errors /adherence and hypoglycemia frequency. Regular follow up also gives opportunity for Diabetes education & understanding patient's socioeconomics.
7. GENERAL HEALTH IMPROVEMENT
Anemia is common in PwD due to several reasons including CKD. It affects QoL & is associated with increased CV risk, hypertension, Retinopathy, Neuropathy & foot ulcers. PwD are at increased risk of Bone abnormalities & fractures especially Hip. Risk of Liver, Pancreas, Endometrial, Colon/Rectum, Breast & Bladder Cancers is also increased in PwD. Diabetes Distress is common in PwD & can affect their control, follow ups, check ups & QoL. Endocrine diseases esp. Hypo & Hyperthyroidism are common in PwD. FIB-4 score should be calculated for NAFLD as it increases risk of both CLD & CVD.
8. HABITS AVOIDANCE
PwD should not use cigarettes and other tobacco products or e-cigarettes. Smoking cessation counseling and other forms of treatment should be addressed as a routine component of diabetes care. Alcohol use should be discouraged or allowed only in moderation ( ≤ 1 drink /day for women & ≤ 2 drinks/day for men). Educating the PwD about the signs, symptoms, monitoring and self-management of hypoglycemia after drinking alcohol, especially when using insulin or insulin secretagogues, is recommended
9. INFECTION PREVENTION
Diabetes increases the risk of systemic infections most of which can be prevented with optimal glycemic control. Gum infections & Periodontal disease are more prevalent & severe in PwD. It is associated with higher A1c levels & increases the risk of Diabetes outcomes. Respiratory infections i.e.Pneumococcal, Influenza & Tuberculosis are also common. Vaccination against Influenza, Pneumococci, Hepatitis B & COVID-19 is highly recommended. Genitourinary infections can be prevented by proper hygiene & counselling.
10. JEOPARDY (ADVERSE DRUG EVENT) EDUCATION
Hypoglycemia is the most common jeopardy faced by PwD especially on Insulin or secretagogues (SU/Glinides). Patient education can help prevent & treat this adverse complication in most cases. People on insulin therapy should be watched for lipodystrophy. Genital infections associated with SGLT2i can be prevented by hygiene & counseling. Patients taking Pioglitazone should be informed about possible weight gain & fluid retention. Patients on Metformin should be watched for B12 deficiency & GI side effects.