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Lifestyle and type 2 diabetes

The mainstay of type 2 diabetes treatment is permanent lifestyle changes: moderate weight loss, a balanced diet, smoking cessation, and a structured exercise programme.

The primary goal of these lifestyle changes is to assist the patient in maintaining a blood glucose level that’s as close to normal as possible (preprandial levels of 90-130 mg/dL and haemoglobin A1C levels less than 7%).

However, in most type 2 diabetics, even the correct lifestyle will eventually fail to control blood glucose levels, prompting the need for medication.

Weight loss and a balanced diet
Diabetes care is best provided by a multidisciplinary team of health-care providers that includes a clinical dietician. All type 2 diabetics should consult a dietician straight after diagnosis to work out an individualised diet plan suited to their lifestyle and needs. As adherence to meal-planning principles can be challenging, regular sessions are encouraged.

Overweight and obesity is a complicating factor of type 2 diabetes that has to be addressed over time. An estimated 80% of type 2 diabetics are obese or have a history of obesity, and moderate weight loss has been shown to reduce:

• Hyperglycaemia
• Insulin resistance
• Dyslipidaemia
• Hypertension

Calorie restriction and moderate exercise is encouraged to promote gradual weight loss. However, realistic body-weight goals should be set, as “normal” body weight might be difficult to achieve.

On a day-to-day level, the diabetic patient should focus on blood glucose control. To help achieve this, the patient should follow a diet rich in:

• Unrefined carbohydrates, like whole-grain bread, brown rice, whole-grain pasta and whole oats
• A variety of fruits and vegetables
• Pulses, such as beans and lentils

The diabetic patient should, wherever possible, avoid:

• Foods high in saturated fat and cholesterol
• Highly refined and processed food
• Foods with a high sugar or salt content

Alcohol consumption should be limited to a maximum of two drinks per day for men and one drink a day for women.

Furthermore, meals and nutrient intake should be spread out, so that the patient eats small, regular meals throughout the day.

Smoking cessation
Cigarette smoking can affect both insulin action and pancreatic cell function. Compared to non-smokers, a larger insulin dose is needed in smokers to achieve similar glycaemic control.

To facilitate proper control and to prevent macrovascular complications such as coronary, cerebrovascular and peripheral vascular difficulties, the diabetic patient should attempt to stop smoking. If this isn’t possible, the patient should reduce the habit to an absolute minimum.

Assist patients by encouraging them to gradually cut back over several weeks. Referral to a counsellor for individual or group therapy is recommended. Other alternatives include nicotine replacement therapy (NRT), medications such as bupropion or varenicline (unless medically contraindicated), or a combination of counselling, NRT and medication.

Exercise
Exercise is an integral part of type 2 diabetes management. It helps to lower blood glucose, blood pressure and cholesterol levels, it promotes weight loss and insulin sensitivity, and it reduces macrovascular complications.

Diabetic patients should aim to do some type of aerobic exercise (walking, swimming or cycling) at least 30 minutes most days, as enhanced insulin sensitivity is lost within 48 hours after exercise. Walking is encouraged in unfit patients, while all patients should aim to also do some strength-training activities twice a week.

Before prescribing an exercise regime, patients should undergo a physical activity assessment. The person’s medical history and clinical status should be carefully considered. Stress tests are advised as a precaution in patients over 35 years of age, in those who have had type 2 diabetes for more than 10 years, and in those who have been diagnosed with high blood pressure or cardiovascular complications.

Note that increased activity levels might require adjustments to the patient’s carbohydrate intake.

Patients should self-monitor their blood-glucose levels before and after exercise, and wear diabetes identification (e.g. MedicAlert) at all times. Remind patients to stop and rest if they experience any discomfort in the chest, abdomen, neck or arm area, and to contact a physician if these symptoms don’t settle in less than 10 minutes.
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