• A 2-hour plasma glucose at or exceeding 200 mg/dL during an oral glucose tolerance test, or
• A random blood glucose of 200 mg/dL or higher in a patient with classic symptoms of hyperglycemia or hyperglycemic crisis.13
Treatment Goals
Goals for diabetic patients advocated by the National Diabetes Education Program (NDEP)1 include maintaining blood pressure below 130/80 mm Hg, lowering LDL-C to below 100 mg/dL (and below 70 mg/dL in patients at risk for CVD), reducing triglyceride levels to below 150 mg/dL, and raising HDL-C above 40 mg/dL in women and above 50 mg/dL in men. Achieving these levels can reduce the diabetic patient’s risk for CVD and microvascular complications by 50%.1
Medical Nutrition Therapy
The NDEP and other entities1,14 refer to medical nutrition therapy as an integral component of diabetic management. This individualized meal plan, developed by a registered dietitian, is based on the patient’s nutritional status and preferences. To optimize the case patient’s glycemic control,10 a low-GI diet was selected.
As the ADA9 and Solomon et al15 have explained, this diet is based on foods that produce a reduced glucose response during the two hours after consumption. According to one literature review,16 use of a low-GI diet led a reduction in A1C of 0.43 percentage points. When combined with appropriate exercise, the low-GI diet can alleviate hypertension and postprandial hyperinsulinemia,15,17 as well as levels of C-reactive protein, an inflammatory marker that in high concentrations is associated with increased risk for CVD.18
The Role of Exercise
The ADA 2012 standards13 recommend a minimum of 150 minutes per week of moderate physical activity. The benefits of exercise in diabetic patients include improved control of blood glucose and reduction of risk for heart disease and other illnesses.3,11 Patients should be under the care of a provider who can help develop an appropriate, individualized plan.3,11
According to ADA recommendations,13 the patient’s lipid levels, blood pressure, and smoking status should be evaluated, with assessment for the presence of CVD in at-risk patients. For asymptomatic diabetic patients, the American College of Cardiology/American Heart Association recommend an ECG stress test before an exercise program is undertaken.19,20 Exercise is contraindicated in those with decompensated congestive heart failure, complex ventricular arrhythmias, unstable angina, significant aortic stenosis, or aortic aneurysm.19
Because initiating an exercise program incurs a slight risk for injury, patients should start gradually, warming up before each session and cooling down afterward.11,19 Diabetic patients should also wear proper shoes for maximum foot protection. They must also be instructed to watch for signs of hypoglycemia during physical activity and be prepared to treat it.11,13
Patient Outcome
After one year on her prescribed treatment regimen, the patient’s A1C was measured at 6.3%, and her LDL-C was 124 mg/dL. Another year later, her A1C was further reduced to 5.9%, and her LDL-C to 77.2 mg/dL. By then, she had lost 15 lb (BMI, 28.2) and perceived her current maintenance plan as enjoyable and manageable, long-term: She was exercising every day possible, with seven sessions of at least 30 minutes, and maintaining a diet of low-GI foods. The patient was committed to following up with her clinician for glucose monitoring every three months.
Conclusion
As illustrated in this patient’s case, the best plan for management of diabetes in its early stages is one that is realistic for the patient and that will prevent diabetic complications for as long as possible.
References
1. US Department of Health and Human Services, National Diabetes Education Program. Guiding Principles for Diabetes Care for Healthcare Professionals (2009). www.ndep.nih.gov/media/guid prin_hc_eng.pdf. Accessed January 24, 2013.
2. National Diabetes Information Clearinghouse, National Institute of Diabetes and Digestive and Kidney Diseases, NIH. Insulin resistance and prediabetes (2011). http://diabetes.niddk.nih.gov/dm/pubs/insulinresistance. Accessed January 25, 2013.
3. Hayes C, Kriska A. Role of physical activity in diabetes management and prevention. J Am Diet Assoc. 2008;108(4 suppl 1):S19-S23.
4. American Diabetes Association. Food and fitness: weight loss (2011). www.diabetes.org/food-and-fitness/fitness/weight-loss. Accessed January 25, 2013.
5. US Department of Health and Human Services, NIH. Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7 reference card, 2003). www.nhlbi.nih.gov/guidelines/hyper tension/phycard.pdf. Accessed January 24, 2013.
6. Ma Y, Olendzki BC, Merriam PA, et al. A randomized clinical trial comparing low-glycemic index versus ADA dietary education among individuals with type 2 diabetes. Nutrition. 2008;24(1):45-56.
7. American Diabetes Association. Glycemic index of foods (2013). www.diabetes.org/food-and-fit ness/food/planning-meals/the-glycemic-index-of-foods.html. Accessed January 25, 2013.
8. Pariser G, Ann Demeuro M, Gillette P, Stephen W. Outcomes of an education and exercise program for adults with type 2 diabetes, and comorbidities that limit their mobility: a preliminary project report. Cardiopulm Phys Ther J. 2010;21(2):5-12.