Nearly 26 million US adults are estimated to have type 2 diabetes, including at least eight million who are unaware they have the disease.1 An additional 80 million adults are affected by prediabetes, with above-average glucose levels that do not yet meet American Diabetes Association (ADA) criteria for type 2 diabetes.1,2
In this context, the primary care provider is likely to encounter patients with a diagnosis of type 2 diabetes in its early stages. Which patients can be considered candidates for conservative management—that is, lifestyle modification—before antidiabetic medications are initiated?
Case Patient
A black woman, age 44, presented for a routine physical examination. She said she had been in good health until three months earlier, when she began to experience weakness and fatigue. She complained of increased thirst and frequent urination, requiring her to get up three or four times each night. She had increased her average fluid intake to nine glasses a day from the usual four. Despite a good appetite, she had lost about 7 lb over the previous three months.
The patient’s previous medical history was significant for four cesarean deliveries, gestational diabetes during all four pregnancies, hemorrhoids, constipation, keloid formation, and hyperlipidemia. Her family history was significant for diabetes (paternal side) and hyperlipidemia.
Findings from the patient’s physical exam included weight, 217 lb; height, 5’11”; BMI, 30.3; pulse, 80 beats/min and regular; and blood pressure, 138/78 mm Hg. With the exception of obesity and elevated systolic blood pressure, her physical exam findings were within normal limits.
Laboratory testing yielded the following results: urinalysis, 3+ glucose, negative for ketones and protein; fasting blood glucose, 145 mg/dL; hemoglobin A1C, 6.9%; total cholesterol, 230 mg/dL; HDL cholesterol (HDL-C), 21 mg/dL; LDL cholesterol (LDL-C), 144 mg/dL; and triglycerides, 400 mg/dL.
The patient’s history of gestational diabetes, her acknowledged sedentary lifestyle, body weight currently exceeding her ideal weight by 50 lb, and family history positive for diabetes put her at increased risk for diabetes. Also of concern was her elevated systolic blood pressure.
The patient’s A1C of 6.9% indicated that during the previous two months, her average blood glucose had been in excess of 125 mg/dL. A diagnosis of type 2 diabetes was made, based on the patient’s elevated fasting blood glucose and A1C, and the aforementioned symptoms of weight loss, fatigue, polydypsia, and polyuria.
Because the patient was perceived as self-reliant and responsible, it was recommended that she be treated conservatively with a broad lifestyle modification regimen. Goals were to reduce all of her diabetes indicators, including weight,3,4 blood pressure,5 and A1C, with an improved lipids profile—all, if possible, without the use of medication. The regimen comprised a low–glycemic index (GI) diet6,7 to reduce her glucose level, and aerobic exercise and strength training8 to improve her cardiovascular health. With resulting weight loss and reduced salt intake,3-5 it was expected that the patient would see reductions in her total cholesterol, LDL-C, and systolic blood pressure.
The patient’s management team recommended a daily plan of four small meals and one or two small snacks. She was advised to control portions by visually dividing her plate: Non-starchy (low-GI) vegetables should fill half of the plate, with the remaining half divided into equal sections for a small serving of protein and a small serving of carbohydrates with a GI of 55 or less (see figure7,9).
Her exercise program was based on recommendations from the American Association of Clinical Endocrinologists (AACE)10 and the US Department of Health and Human Services11: cardiovascular/aerobic exercise (five 30-minute sessions per week), ranging in intensity from moderate (eg, brisk walking, bicycling, doubles tennis) to vigorous (jogging or running, swimming laps, singles tennis); and strength training (two 30-minute sessions per week), such as weight-lifting, push-ups, and sit-ups.
Discussion
Type 2 diabetes mellitus affects an estimated 25.8 million residents of the United States, including an estimated 8.3 million who have not yet been diagnosed.1 According to the CDC,12 prevalence of diabetes is greatest in black and Hispanic women and men.
The sixth leading cause of death in the US, diabetes is also the leading cause of blindness (ie, diabetic retinopathy), kidney disease requiring dialysis, and lower-limb amputation. Diabetes is closely associated with cardiovascular disease (CVD), the leading cause of death in the US.12 Other diabetes-related health concerns include hypertension, peripheral diabetic neuropathy, dental disease, depression, delayed wound healing, and increased risk for infection.12
The standard criteria for a diagnosis of diabetes, according to the 2012 ADA Standards of Medical Care in Diabetes,13 are:
• A1C exceeding 6.5%, or
• A fasting blood glucose level at or exceeding 126 mg/dL, or