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

Pam Brown
Pam Brown summarises the latest lifestyle advice from the 2022 update of the ADA/EASD Consensus Report.

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 HbA1c 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 HbA1c 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 HbA1c – 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 HbA1c 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.

REFERENCES:

1. Lingvay I, Sumithran P, Cohen RV, le Roux CW (2022) Obesity management as a primary treatment goal for type 2 diabetes: time to reframe the conversation. Lancet 399: 394–405

2. Wing RR; Look AHEAD research group (2021) Does lifestyle intervention improve health of adults with overweight/obesity and type 2 diabetes? findings from the Look AHEAD randomized trial. Obesity (Silver Spring) 29: 1246–58

3. Schwingshackl L, Chaimani A, Hoffmann G et al (2018) A network meta-analysis on the comparative efficacy of different dietary approaches on glycaemic control in patients with type 2 diabetes mellitus. Eur J Epidemiol 33: 157–70

4. Snorgaard O, Poulsen GM, Andersen HK, Astrup A (2017) Systematic review and meta-analysis of dietary carbohydrate restriction in patients with type 2 diabetes. BMJ Open Diabetes Res Care 5: e000354

5. Martínez-González MA, Gea A, Ruiz-Canela M (2019) The Mediterranean diet and cardiovascular health. Circ Res 124: 779–98

6. Carter S, Clifton PM, Keogh JB (2019) The effect of intermittent compared with continuous energy restriction on glycaemic control in patients with type 2 diabetes: 24-month follow-up of a randomised noninferiority trial. Diabetes Res Clin Pract 151: 11–9

7. Lee SWH, Ng KY, Chin WK (2017) The impact of sleep amount and sleep quality on glycemic control in type 2 diabetes: a systematic review and meta-analysis. Sleep Med Rev 31: 91–101

8. Delevatti RS, Bracht CG, Lisboa SDC et al (2019) The role of aerobic training variables progression on glycemic control of patients with type 2 diabetes: a systematic review with meta-analysis. Sports Med Open 5: 22

9. Depner CM, Melanson EL, Eckel RH et al (2019) Ad libitum weekend recovery sleep fails to prevent metabolic dysregulation during a repeating pattern of insufficient sleep and weekend recovery sleep. Curr Biol 29: 957–67

10. Saint-Maurice PF, Troiano RP, Bassett DR Jr et al (2020) Association of daily step count and step intensity with mortality among US adults. JAMA 323: 1151–60

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