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Type 2 diabetes: Treatment guidelines explained


The American Diabetes Association provides several guidelines for treating type 2 diabetes, involving lifestyle modifications, medication, surgery, and more.

No single treatment course works for everyone with type 2 diabetes, but the American Diabetes Association (ADA) does have a series of guidelines. Members of the ADA Professional Practice Committee update the association’s standards of care each year or more often, as needed. Physicians and other experts in diabetes care and education serve on this committee.

Their guidelines recommend approaches to choosing appropriate treatments based on a person’s specific situation.

This article explains the ADA’s type 2 diabetes treatment recommendations.

According to the ADA, “Lifestyle management is a fundamental aspect of diabetes care.” These techniques include:

The education and support help people manage diabetes and adapt to new challenges and advances in treatment. Nutrition therapy can help a person follow a healthy eating plan.

Learn which foods people with type 2 diabetes should choose and avoid here.

Carbohydrate management

The ADA recommends various dietary changes, including carbohydrate management. Because research into the ideal amount of carbohydrates for people with type 2 diabetes has been inconclusive, there are no concrete guidelines.

However, the association recommends avoiding sweetened beverages and processed low fat or nonfat foods. It also suggests replacing foods containing refined carbohydrates and sugar with:

  • whole grains
  • vegetables
  • legumes
  • fruit

They recommend a variety of approaches to managing the intake of carbohydrates based on what might work for different people.

Learn more about the relationship between carbohydrates and diabetes here.

Protein and fat

The ADA recommends personalizing protein goals while having protein make up 15–20% of the total daily intake of calories.

It notes that specifying an ideal fat intake for people with diabetes is “controversial” and that focusing on the type of fat is more important than the total amount of fat.

The ADA reports that a Mediterranean eating plan rich in monounsaturated fats can help blood glucose control.

See our guide to the Mediterranean diet here.

Exercise

Getting enough exercise is another key part of diabetes self-care and management. The ADA has the following suggestions about physical activity:

  • Children and adolescents with type 2 diabetes should have at least 60 minutes of moderate-intensity or vigorous aerobic activity per day, plus vigorous strengthening activities on at least 3 days per week.
  • Most adults with type 2 diabetes should do at least 2–3 resistance exercise sessions and at least 150 minutes of moderate-to-vigorous activity per week, while younger and more physically fit people should do at leat 75 minutes of vigorous activity or interval training per week.
  • All adults with type 2 diabetes should spend less time being sedentary and break up long periods of sitting with some activity every 30 minutes.
  • Older adults with type 2 diabetes should take part in flexibility and balance training 2–3 times per week.

Learn more about the benefits of exercise for type 2 diabetes here.

Insulin is a hormone that the pancreas creates. Its role is to help the body use or store glucose in the blood. A person with type 2 diabetes produces insulin but does not respond well to it.

Metformin is a prescription drug that can help reduce high blood glucose levels caused by type 2 diabetes. A doctor may recommend taking metformin with a synthetic version of insulin for a combined effect.

According to the ADA, “Metformin should be continued, as long as it is tolerated and not contraindicated; other agents, including insulin, should be added to metformin.”

The ADA goes on to explain that a doctor should consider its use when a person has blood glucose levels of at least 300 milligrams per deciliter (mg/dl) or A1C levels of greater than 10%. Doctors should also consider prescribing it for people who have lost weight or have symptoms of high blood sugar levels, such as frequent urges to urinate or excessive thirst.

Types

They describe several different types of insulin, including:

  • Basal insulin: A person may take this alongside metformin.
  • Prandial insulin: A person typically takes this before a meal.
  • Concentrated insulins: These typically act faster.
  • Inhaled insulin: These also act rapidly.

Peaking

How long the effects of insulin last and when levels peak in the body can differ, depending on the type of insulin. Some examples include:

Injecting

A person may use a prefilled syringe for their injection, or they may need to mix a solution first. A person can inject the drug in several areas, including:

  • in the abdomen
  • in the back of the upper arm
  • in the buttocks
  • in the thigh

Rotate the injection sites and keep these areas clean. Take care to inject insulin into subcutaneous tissue, not muscle tissue.

Learn about the best insulin injection sites here.

The ADA recommends using metformin with insulin, noting, “Once initiated, metformin should be continued as long as it is tolerated and not contraindicated; other agents, including insulin, should be added to metformin.”

In other words, a doctor should prescribe insulin in addition to the original treatment, not instead of it. They recommend prescribing insulin early on if:

However, the ADA states that “Glucagon-like peptide 1 receptor agonist is preferred to insulin when possible.” In other words, insulin is not typically even the secondary treatment if glucagon-like peptide 1 receptor agonist is an option for the person.

Learn how to mix insulin here.

People with type 2 diabetes may benefit from surgery. According to the American Society for Metabolic and Bariatric Surgery, people with this type of diabetes who have metabolic or bariatric surgery may see their diabetes symptoms improve within a few days, and nearly 78% find that their symptoms go into remission, so they no longer need diabetes medication afterward.

A common example of bariatric surgery is a gastric bypass.

Learn more about bariatric surgery and type 2 diabetes here.

Medical treatment might start with metformin combined with lifestyle changes. Over time, a person may find it more difficult to manage their blood sugar levels, and if this happens, the ADA recommends combination therapy. This refers to any combination of medications.

The ADA recommends that, in many cases, people with the following health conditions should take a combination of metformin and glucagon-like peptide 1 receptor agonist or sodium-glucose transport protein 2 inhibitor:

Learn more about combination therapy for type 2 diabetes here.

According to the ADA guidelines, a person should start taking metformin from the time of their diabetes diagnosis, unless there are medical reasons why this is unsuitable. For most people, the first approach to treatment is metformin plus lifestyle modifications.

Second therapy

The ADA goes on to say that if metformin is suitable, a doctor may introduce a second therapy. However, “Early combination therapy can be considered in some patients at treatment initiation to extend the time to treatment failure.”

In other words, a doctor may consider prescribing an additional drug shortly after the diagnosis to help prevent one treatment from failing.

Additional therapies

As time goes on, the ADA recommends adding treatments based on the person’s risk factors. They specify, “Sodium–glucose cotransporter 2 inhibitor or glucagon-like peptide 1 receptor agonist with demonstrated cardiovascular disease benefit is recommended” for managing glucose levels in people with kidney disease or heart failure or a risk of one of these illnesses.

The ADA also recommends that doctors continually follow up to monitor how the treatment is going.

Individual treatment plans

Finally, the ADA says: “A patient-centered approach should be used to guide the choice of pharmacologic agents. Considerations include effect on cardiovascular and renal comorbidities, efficacy, hypoglycemia risk, impact on weight, cost, risk for side effects, and patient preferences.”

In other words, the treatment should progress based on the person’s needs and wishes, not necessarily on the guidelines.

This encourages people to suggest adjustments to their treatment plans and doctors to make adjustments that are likely to be beneficial.

The ADA continually updates its recommendations for the treatment and management of type 2 diabetes. These recommendations cover various combinations of lifestyle changes and medical interventions.

Still, the ADA highlights the importance of each person working with their doctor to tailor and personalize their treatment plan.



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