So what should we recommend to people with diabetes about lifestyle? Updated ADA/EASD advice

Weight loss of 5–15% as an important goal¹

• 5–10% provides metabolic improvement.

• 10–15% has disease-modifying effect and can lead to type 2 diabetes remission.

• Medications and/or metabolic surgery are effective additions to lifestyle and can improve glycaemia, remission and weight loss.

In the Look AHEAD study,² intensive lifestyle intervention improved:

• Diabetes control and complications.

• Depression.

• Physical function.

• Health-related quality of life.

• Sleep apnoea.

• Incontinence.

• Brain structure.

• Measurements of multimorbidity, geriatric syndromes/frailty and disability-free life-years.

• >10% weight loss may be required for benefits in terms of cardiovascular disease, mortality and complications such as NASH.

Nutrition

• No single ratio of carbohydrates, proteins and fat that is optimal for everyone with type 2 diabetes. Aim for a net energy deficit that can be sustained for weight loss.

• Encourage individually selected eating patterns that include foods with health benefits, while minimising foods known to be harmful.

• Network meta-analysis compared nine dietary approaches and demonstrated HbA_1c reductions of 5.1–9.0 mmol/mol with all approaches compared to control diets.³

• Greater glycaemic benefits with Mediterranean diet and low-carbohydrate diet (<26% energy from carbs), but low-carb benefits only demonstrated up to 6 months.⁴

• Systematic review of trials >6 months:⁵ compared to a low-fat diet, a Mediterranean diet showed greater reductions in weight and HbA_1c levels, delayed requirements for diabetes medication and provided benefits for cardiovascular health. Similar benefits seen with vegan and vegetarian diets.

• 12-month study of intermittent fasting (5:2 diet) and continuous energy restriction (1200–1500 kcal diet) demonstrated similar glycaemic effects, and at 24 months both groups achieved ­3.9 kg weight loss.⁶

24-hour physical behaviours recommended for type 2 diabetes

Sleep

• Over 50% people with type 2 diabetes have obstructive sleep apnoea; increase severity associated with worsening glucose levels.

• U-shaped curve of sleep and health outcomes: 6–8 hours optimal for HbA_1c – improves insulin sensitivity and reduces energy intake.⁷

• Irregular sleep associated with poorer glycaemic control; catch-up weekend sleep does not reverse impact of insufficient sleep.⁸

• “Night owls”/evening chronotypes may be more prone to inactivity and poorer control than “early birds”/morning chronotypes.

Aerobic exercise (“Sweating”)

• Regular aerobic exercise can decrease HbA_1c by 7 mmol/mol (0.6%) and improves cardiorespiratory fitness significantly; optimise with ≥45 minutes per session and especially post-prandial.⁹

• Encourage ≥150 minutes moderate to vigorous or ≥75 min vigorous, over ≥3 days per week; 30 min moderate/vigorous per week has metabolic benefit.

Stepping

• Additional 500 steps per day associated with 2–9% decreased risk cardiovascular disease morbidity and all-cause mortality.¹⁰

• 5–6 min brisk-intensity walk daily equates to/associated with around 4 years’ greater life expectancy.

Strengthening

• Resistance exercise improves insulin sensitivity and glucose levels.

• Encourage 2–3 resistance, balance, flexibility sessions per week.

• Physical function/frailty/sarcopenia can deteriorate faster in those with type 2 diabetes.

Sitting/breaking up prolonged sitting

• Limit sitting.

• Break up with walking or simple resistance exercise every 30 minutes.