‘This is the foundation’: New guideline emphasizes lifestyle-first approach to diabetes
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Key takeaways:
- A new American College of Lifestyle Medicine guideline centers lifestyle treatments for people with type 2 diabetes and prediabetes.
- Key goals are sustained behavior changes, continuity of care and deprescribing.
ORLANDO — A first-ever clinical practice guideline from the American College of Lifestyle Medicine outlines practical recommendations for lifestyle interventions as first-line therapy for people with prediabetes or type 2 diabetes.
The multidisciplinary 228-page document, currently under peer review, highlights “just lifestyle, and not any other interventions,” according to Mahima Gulati, MD, MSc, ECNU, FACE, associate professor in the department of medical sciences at the Quinnipiac University Frank H. Netter School of Medicine and a member of the guideline writing committee. Lifestyle medicine should be the primary therapy employed for treating prediabetes and type 2 diabetes, Gulati said, as poor lifestyle habits are driving the surging prevalence of diabetes.
“According to CDC data, 90% of type 2 diabetes is preventable,” Gulati said during a presentation at the Lifestyle Medicine Conference. “If there was ever a preventable condition, it is type 2 diabetes. There are 529 million people across the globe living with type 2 diabetes today and that number is going to surpass 1 billion by 2050.”
Input from a range of specialties
The new guideline includes input from a wide range of specialists, including endocrinologists, cardiologists, diabetes care and education specialists, pharmacists, health and wellness coaches, psychologists and sleep and sports medicine experts, as well as consumer advocates. The guideline is intended for nonpregnant adults with type 2 diabetes, prediabetes or a history of gestational diabetes. It will include recommendations that reference the six pillars of active lifestyle intervention:
- Nutrition — extensive evidence supports a whole food, plant-predominant eating plan;
- Physical activity — movement combats the negative effects of sedentary behavior and builds mental health;
- Stress management — excess stress can lead to anxiety, depression, obesity and immune dysfunction;
- Sleep — inadequate or disordered sleep depresses mood, lowers daytime caloric burn, increases hunger and causes insulin resistance;
- Social connectedness — positive relationships enhance mental, physical and emotional health; and
- Avoiding risky substances — avoidance reduces risk for chronic diseases and death.
Lifestyle interventions can be “more effective than drug therapy” for preventing prediabetes from progressing to overt type 2 diabetes, according to Richard Rosenfeld, MD, MPH, MBA, DipABLM, distinguished professor and past chairman of otolaryngology at SUNY Downstate Health Science University and director of guidelines and quality for ACLM. However, only about 20% of U.S. adults report a healthy lifestyle that incorporates at least four of the six pillars, Rosenfeld said.
“When you look at the current diabetes guidelines — and we identified eight that were very relevant to us — there is not a lot of nuance in terms of nutrition [and] physical activity,” Rosenfeld said. “Even the American Diabetes Association Standards of Care is a bit lacking in some of the pragmatic emphasis on [these recommendations]. It is a good start, but we felt we needed to fill the void with this type of project.”
Use a ‘SMART’ goal structure
The first three key action statements of the guideline call for advocating for lifestyle management as first-line treatment, assessing a person’s baseline lifestyle habits with regard to the six pillars of lifestyle medicine, and establishing priorities for lifestyle change that also incorporate the six pillars. Rosenfeld said health care professionals should use a SMART goal structure — which stands for Specific, Measurable, Action-oriented, Realistic, Time-sensitive goals — to support positive lifestyle change.
“For a clinical practice guideline, this is very innovative and unusual, to have this be your first three key action statements,” Meagan L. Grega, MD, FACLM, DipABLM, co-founder and chief medical officer of the nonprofit Kellyn Foundation and ACLM conference chair, said during the presentation. “This is the foundation. If you do not know where you are starting from, how can you see where you are trying to go?”
The guideline recommends clinicians use the SMART goal structure to prescribe aerobic and muscle strength physical activity, with a detailed evidence profile, “because they align with the guidelines for Americans,” Rosenfeld said. There is also a separate key action statement that recommends prescribing physical activity specifically to reduce sedentary time.
‘Find a need and fill it’
Other recommendations include identifying sleep disorders and referring as needed for management and treatment; prescribing a nutrition plan for disease prevention and treatment that incorporates unprocessed or minimally processed foods; counseling patients about cultivating positive social connections; and identifying when a person may benefit from psychological interventions, using validated screening tools.
The final three key action statements, which Gulati said are the most important, focus on creating sustained behavior changes using coaching and motivational interviewing, ensuring continuity of care that prescribes lifestyle interventions and specifies the frequency of visits and adjusting therapy as needed, with a goal of deprescribing medications.
“The bottom line is: Find a need and fill it, and I think we are with this guideline,” Rosenfeld said. “This is different. This has been exciting and I have never seen a group as passionate and involved as this guideline development group. This [guideline] has the potential to have real impact on the field.”
Publication of the guideline is expected in 2025 and will also include an executive summary and a plain-language version for consumers, Rosenfeld said.
Healio is an official media partner of the Lifestyle Medicine Conference.
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Rosenfeld R, et al. Lifestyle interventions for treatment and remission of type 2 diabetes and prediabetes in adults: Presenting ACLM’s first clinical practice guideline. Presented at: Lifestyle Medicine Conference; Oct. 27-30, 2024; Orlando.
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