New clinical practice guideline puts lifestyle interventions at forefront of diabetes care

The first-ever clinical guideline published by the American College of Lifestyle Medicine offers a comprehensive and evidence-based roadmap for clinicians to effectively incorporate therapeutic lifestyle behavior interventions as a mainstay of type 2 diabetes treatment. 

A supplement in the American Journal of Lifestyle Medicine features a series of articles with the potential to revolutionize how type 2 diabetes (T2D) and prediabetes are managed in adults. The supplement includes a clinical practice guideline (CPG), “Lifestyle Interventions for Treatment and Prevention of Type 2 Diabetes and Prediabetes in Adults,” an executive summary and plain language summary (for patients and the public) of the guideline, and several editorials.  

The CPG, a first-ever for ACLM, was developed with trustworthy methods for using current, best evidence to make recommendations for improving the quality and consistency of medical care. These recommendations, also called key action statements (KASs), were crafted by a 20-member guideline development group (including consumer advocates) representing advanced practice nursing, cardiology, clinical pharmacology, behavioral medicine, endocrinology, family medicine, lifestyle medicine, nutrition and dietetics, health education, health and wellness coaching, sleep medicine, sports medicine, and obesity medicine. 

Why diabetes and prediabetes? 

ACLM chose T2D and prediabetes as topics for its first CPG to build upon prior work that included a position statement and an expert consensus statement. Diabetes is a defining disease of the 21st century because of rising prevalence, a relationship with obesity, and an enormous health impact: 

• Over 38 million people in the U.S. have diabetes, and it is the eighth leading cause of death. Of all people with diabetes, 90% to 95% have T2D. 

• Just under 15% of U.S. adults have diabetes and another 38% have prediabetes, meaning that over half the U.S. adult population has either condition. 

• $413 billion is spent annually in the U.S. on health care for diabetes and $43 billion for prediabetes, accounting for over 25% of all healthcare dollars spent. 

• About 1.3 billion people worldwide are expected to be living with diabetes by the year 2050, with an annual health care cost of over $1 trillion. 

Why is this new guideline important? 

Although there are nearly 1,000 guiding documents for diabetes in the medical literature, and more than 350 pages of standards from the American Diabetes Association, they may not offer details and practice advice on lifestyle change. Our CPG not only makes the case for lifestyle changes as the starting point in managing T2D, but also offers clear, practical, evidence-based advice on how people can change behavior, sustain these changes, and enjoy the healthiest lifestyle possible.  

The CPG is not a comprehensive summary of how to manage prediabetes or T2D, nor is it intended to replace other guidelines. Instead, we focus explicitly on lifestyle changes while excluding other information (such as diagnosis, prevention, medical treatment, dealing with complications) that is extensively dealt with by other guidelines. We hope to enhance existing guidelines by empowering individuals, clinicians, and health care professionals to achieve positive and sustained behavior changes. 

Key action statements in the guideline 

KAS 1: Advocacy for Lifestyle Interventions

The clinician or health care professional (HCP) should be an advocate for lifestyle interventions as first-line management for prediabetes andT2D, including restorative sleep, stress management, adequate physical activity, connectedness, a whole-food, plant-predominant eating pattern, and avoidance of risky substances.  

KAS 2: Assessment of Baseline Lifestyle Habits

The clinician or HCP should assess the baseline lifestyle habits, in adults with prediabetes, T2D or a history of gestational diabetes mellitus (GDM) with regards to the six pillars of lifestyle medicine (See Table 3), educate the individual regarding opportunities to improve their lifestyle behaviors, and evaluate the individual’s readiness to change. 

KAS 3: Establishing Priorities for Lifestyle Change

For an adult with prediabetes, T2D, or a history of GDM, the clinician or HCP should establish priorities for lifestyle change with regards to the six pillars of lifestyle medicine (See Table 3) through shared decision-making and should discuss the role of using SMART (Specific, Measurable, Achievable, Relevant, And Time-Bound) goals in supporting positive lifestyle change. 

KAS 4: Prescribing Aerobic and Muscle Strengthening Physical Activity

The clinician or HCP should prescribe physical activity, with an emphasis on aerobic and muscle strength training, by establishing SMART goals and using the FITT (frequency, intensity, time, type) framework for implementation for adults with prediabetes, T2D, or a history of GDM.  

KAS 5: Reducing Sedentary Time

The clinician or HCP should prescribe physical activity to reduce sedentary time, using SMART goals, for adults with prediabetes, T2D, or a history of GDM. 

KAS 6: Identifying Sleep Disorders

In adults with prediabetes, T2D, or a history of GDM, the clinician or HCP should ask about sleep quality, quantity, and patterns, determine if a sleep disorder is present, and refer, as indicated, for further evaluation and management. Sleep disorders associated with prediabetes, T2D, and a history of GDM include, but are not limited to, obstructive sleep apnea, shift work sleep disorder, chronic insomnia, and short or long sleep duration. 

KAS 7: Prescribing a Nutrition Plan for Prevention

In adults with prediabetes, or a history of GDM, the clinician, HCP, or their designee, should prescribe a nutrition plan using SMART goals that is consistent with the individual’s cultural background and is framed in food-based advice regarding caloric intake, nutrient needs, and the importance of a whole-food, plant-predominant eating plan. 

KAS 8: Prescribing a Nutrition Plan for Treatment

The clinician, HCP, or their designee, should clarify with the person with T2D if their goal is to achieve remission or improvement and should prescribe a nutrition plan using SMART goals that is consistent with the person’s desired outcome(s), cultural background, and is framed in food-based guidance promoting appropriate energy intake, nutrient needs, and the benefits of a whole-food, plant-predominant eating plan. 

KAS 9: Peer/Familial Support and Social Connections

The clinician or HCP should counsel adults with prediabetes, T2D, or a history of GDM regarding the importance of cultivating positive social connections provided by peers, family members, and/or other professionals trained in lifestyle change methods to achieve SMART goals and optimize glucose management. 

KAS 10: Identifying Need for Psychological Interventions

In adults with prediabetes, T2D, or a history of GDM, the clinician or HCP should identify or refer to someone who can identify serious mental illness such as severe mood/affective disorders, anxiety disorders, or psychotic disorders. For individuals experiencing stress or symptoms of depression or anxiety, prescribe mindfulness-based cognitive behavioral therapy (CBT), or CBT-based interventions to improve diabetes clinical outcomes.  

KAS 11: Tobacco, Alcohol, and Recreational Drugs

The clinician or HCP should assess adults with T2D for use of tobacco, alcohol, and other recreational drugs and should counsel them on how using these substances can adversely impact management of T2D.  

KAS 12: Achieving Person-Driven, Sustained Positive Behavior Change

For adults with prediabetes, T2D, or a history of GDM, the clinician, HCP, or their designee, should help individuals achieve sustained, person-centered, positive behavior change using evidence-based approaches including, but not limited to, coaching, motivational interviewing, and cognitive behavioral therapy. 

KAS 13: Establishing a Plan for Continuity of Care

For adults with prediabetes, T2D, or a history of GDM, the clinician or HCP should establish a plan for continuity of care that prescribes lifestyle interventions and specifies the frequency of visits, anticipated duration of care, potential need for adjustments of pharmacologic therapy, and expectations regarding the individual’s engagement. 

KAS 14: Adjusting Pharmacologic Therapy

For adults with prediabetes, T2D, or a history of GDM, the clinician or HCP should adjust the type and dosing of an individual’s pharmacologic therapy based on the impact of lifestyle intervention on their medication needs.  

Putting lifestyle medicine at the center of care 

As reflected in the KASs listed above, this new CPG is unique in emphasizing all six pillars of lifestyle intervention, distinguishing three nutrition intervention goals (prevention, management, and remission), explicitly addressing behavior change, and dealing with medication adjustment (de-prescribing). Also unique are the approximately 30 figures and 30 tables that facilitate understanding and implementation.  

We hope that you are as excited as we are about the novelty and potential impact of this CPG in helping shift the paradigm of managing T2D and prediabetes to a lifestyle intervention focus.