Overview of management of type 2 diabetes mellitus

Treatment of this disease requires a multidisciplinary approach by physician, nurse, and dietitian.

Medical Care
The goals in caring for patients with diabetes mellitus include the elimination of symptoms; microvascular risk reduction through control of glycemia and blood pressure; macrovascular risk reduction through control of lipids and hypertension, smoking cessation, and utilizing aspirin therapy; and metabolic risk reduction through control of glycemia. Such care requires appropriate goal setting, regular complications monitoring, dietary and exercise modifications, medications, appropriate self-monitoring of blood glucose (SMBG), and laboratory assessment. Focus on glucose alone does not provide adequate treatment for patients with diabetes mellitus. Treatment involves multiple goals
Complications monitoring: The American Diabetes Association recommends initiation of complications monitoring at the time of diagnosis of diabetes mellitus. This regimen should include yearly dilated eye examinations, yearly microalbumin checks, and foot examinations at each visit.
Laboratory monitoring: Because diabetes mellitus is a multisystem disease, focusing solely on blood sugar is inadequate.
Intercurrent medical illness: Patients with intercurrent illness become more insulin resistant because of the effects of increased counter-regulatory (ie, anti-insulin) hormones. Therefore, despite decreased nutritional intake, glycemia may worsen. Patients on oral agents may need transient therapy with insulin to achieve adequate glycemic control. In patients requiring insulin, scheduled doses of insulin, as opposed to sliding scale insulin, are far more effective in achieving glycemic control.
Surgical Care
Bariatric surgery has been shown to improve diabetes control and, in some situations, normalize glucose tolerance in morbidly obese patients. It is certainly a reasonable alternative in carefully selected patients if an experienced team (providing appropriate preoperative evaluation as well as technical surgical expertise) is available.
Consultations
Primary care physicians can care for patients with type 2 diabetes mellitus adequately. The multiple facets of disease treatment (eg, nutrition, exercise, smoking cessation, medications, complications monitoring) and data management (eg, glucose levels, BP, lipids, complications monitoring) must be continually noted. Inability to achieve adequate glycemic (or BP or lipid) control usually should be a clear indication to consult a diabetes specialist. When a patient has developed advanced complications, a diabetes specialist cannot be expected to be able to lessen the burden of these complications.
Diet
For most patients, the best diet is of what they are currently eating. Time honored attachments to a precise macronutrient composition of the diet to control diabetes are generally not supported by the research. Caloric restriction is of first importance. After that, individual preference is reasonable. Modest restriction of saturated fats and simple sugars is reasonable. However, some patients have remarkable short-term success with high-fat low-carbohydrate diets of various sorts. Therefore, the author always stresses weight management in general and is flexible regarding the actual diet that the patient consumes. Also, the practitioner should advocate a diet using foods that are within the financial reach and cultural milieu of the patient.
Activity
In general, most patients with type 2 diabetes mellitus can benefit from increased activity. Aerobic exercise improves insulin sensitivity and may improve glycemia markedly in some patients.
• The patient should choose an activity that she or he is likely to continue. Walking is accessible to most patients in terms of time and financial expenditure.
• A previously sedentary patient should start activities slowly.
• Older patients, patients with long-standing disease, patients with multiple risk factors, and patients with previous evidence of atherosclerotic disease should have a cardiovascular evaluation, probably including an imaging study, prior to beginning a significant exercise regime.