Fibrous foods keep you full and can aid in reducing bad cholesterol. Carbohydrates rich in fiber include fruits, vegetables, legumes beans , and whole grains.

The American Heart Association says that a diet rich in whole grains can help to reduce the risk of heart disease. Below are some examples of ideal breakfast options for people with diabetes, but be sure to consult with your Registered Dietitian or Physician before starting any new meal plan as individual needs do vary:.

Rabinovitz HR, Boaz M, Ganz T, et al. Big breakfast rich in protein and fat improves glycemic control in type 2 diabetics. Obesity Silver Spring. American Heart Association. Whole grains, refined grains and dietary Fiber. By Barbie Cervoni, RD Barbie Cervoni MS, RD, CDCES, CDN, is a New York-based registered dietitian and certified diabetes care and education specialist.

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DIABETES EDUCATION — Patients with newly diagnosed diabetes should participate in a comprehensive diabetes self-management education program, which includes individualized instruction on nutrition, physical activity, optimizing metabolic control, and preventing complications.

In clinical trials comparing diabetes education with usual care, there was a small but statistically significant reduction in A1C in patients receiving the diabetes education intervention [ 9 ].

In two meta-analyses, use of mobile phone interventions for diabetes education was successful in significantly reducing A1C Medical nutrition therapy — Medical nutrition therapy MNT is the process by which a dietary plan is tailored for people with diabetes, based on medical, lifestyle, and personal factors.

It is an integral component of diabetes management and diabetes self-management education. For all patients, the goals of MNT include avoidance of weight gain, consistency in day-to-day carbohydrate intake at meals and snacks, and balanced nutritional content.

MNT may be customized to achieve body weight reduction and is reviewed in detail elsewhere. See 'Diet' below and "Medical nutrition therapy for type 2 diabetes mellitus". Weight management — For patients with type 2 diabetes, body weight management should be considered as a therapeutic target in addition to glycemia.

Patients should receive counseling regarding changes in diet and physical activity to achieve weight loss or to prevent weight gain. Weight loss improves glycemia through mitigation of insulin resistance and impaired beta cell function, two major metabolic perturbations evident in type 2 diabetes [ 12,13 ].

For patients who have difficulty achieving weight loss, weight maintenance rather than gain is an alternative goal. Strategies for weight management include lifestyle change, pharmacologic therapy, and metabolic surgery.

Lifestyle change includes diet and physical activity, as well as behaviors that facilitate these changes, and is an essential component of any weight management plan. We emphasize lifestyle change as our initial approach to body weight reduction and reserve pharmacotherapy and metabolic surgery for patients who do not achieve targeted weight loss with lifestyle change alone.

We tailor our specific recommendations to patients' goals and preferences and encourage "intensive" lifestyle modification, where available, for highly motivated patients. Diet — Diagnosis of type 2 diabetes is often a powerful motivator for lifestyle change.

Dietary modification is a highly effective strategy for weight loss and for management of glycemia and hypertension in patients who are willing to commit to it, with metabolic benefit likely outlasting the effect of weight loss per se. The improvement in glycemia is related both to the degree of caloric restriction and weight reduction [ 12,14,15 ].

Body weight loss of 5 to 10 percent may also improve nonalcoholic steatohepatitis, sleep apnea, and other comorbidities of type 2 diabetes [ 16 ]. Consumption of sugar-sweetened beverages, including natural fruit juice, should be specifically queried and strongly discouraged in order to manage glycemia, weight, and reduce risk for CVD and fatty liver [ 17 ].

See "Medical nutrition therapy for type 2 diabetes mellitus", section on 'Designing a nutrition care plan' and "Management of nonalcoholic fatty liver disease in adults", section on 'Initial lifestyle interventions'.

In a two-year analysis of the DiRECT trial, only 11 percent of intervention participants had weight loss of 15 kg or more compared with 24 percent in the one-year analysis [ 18 ].

However, 36 percent of participants maintained diabetes remission, compared with 3 percent of control patients. Several studies have evaluated the long-term efficacy of diet alone or with exercise in patients with newly diagnosed type 2 diabetes see "Medical nutrition therapy for type 2 diabetes mellitus".

In the United Kingdom Prospective Diabetes Study UKPDS , for example, all patients were given a low-calorie, low-fat, high complex carbohydrate diet [ 21 ]. Furthermore, the mean glucose value was substantially higher with diet alone than with diet plus an oral hypoglycemic drug or insulin.

The likelihood of a successful glycemic response to diet is determined in large part by the initial fasting blood glucose. Pharmacologic therapy — Pharmacotherapy targeted solely for weight management is effective in patients with type 2 diabetes.

Although metformin is usually started for the management of hyperglycemia, it is also frequently an effective medication to promote modest weight loss. When additional body weight reduction is a primary goal of therapy, we choose medications that promote weight loss and lower glucose. Glucagon-like peptide 1 GLP-1 receptor and dual GLP-1 and glucose-dependent insulinotropic polypeptide GIP agonist therapies promote weight loss and help prevent weight gain due to other glucose-lowering pharmacotherapies.

We add these medications sequentially to metformin if additional glucose lowering or weight loss is a treatment goal. See "Glucagon-like peptide 1-based therapies for the treatment of type 2 diabetes mellitus" and "Obesity in adults: Drug therapy".

Surgical therapy — Weight loss surgery in patients with obesity and type 2 diabetes results in the largest degree of sustained weight loss and, in parallel, improvements in blood glucose management and the most frequent sustained remissions of diabetes.

Weight loss surgery is an option to treat poorly managed type 2 diabetes when other modalities have failed. This topic is reviewed in detail separately. See "Management of persistent hyperglycemia in type 2 diabetes mellitus", section on 'Bariatric metabolic surgery'.

Exercise — Regular exercise is beneficial in type 2 diabetes, independent of weight loss. It leads to improved glycemic management due to increased responsiveness to insulin; it can also delay the progression of impaired glucose tolerance to overt diabetes [ 22,23 ].

These beneficial effects are directly due to exercise, but concurrent weight reduction plays a contributory role. In one study, however, only 50 percent of patients with type 2 diabetes were able to maintain a regular exercise regimen [ 24 ].

See "Exercise guidance in adults with diabetes mellitus". Shorter-duration, intensive exercise may be appropriate for physically fit individuals [ 25 ]. Resistance training may be particularly important for individuals with type 2 diabetes who do not have overweight or obesity, in whom relative sarcopenia may contribute to diabetes pathophysiology [ 26 ].

Intensive lifestyle modification — In patients with established type 2 diabetes, intensive behavioral modification interventions focusing on weight reduction and increasing activity levels are successful in reducing weight and improving glycemic management while, at the same time, reducing the need for glucose-lowering and other medications [ 15,18, ].

The intensive intervention included caloric restriction maximum 30 percent calories from fat, minimum 15 percent protein, and the remainder from carbohydrates, in the form of liquid meal replacements, frozen food entrees, or structured meal plans , moderate-intensity physical activity goal minutes weekly , and weekly group or individual sessions with registered dietitians, behavioral psychologists, and exercise specialists.

The primary outcome was a composite of death from cardiovascular causes, nonfatal myocardial infarction, nonfatal stroke, and hospitalization for angina. Although the anticipated follow-up period was After a median follow-up of 9. The improvement in weight and glycemia did not reduce the occurrence of cardiovascular events.

Possible reasons for this finding include the lower-than-expected rates of cardiovascular events in both groups, improved overall cardiovascular risk factor treatment with medical therapy antihypertensives, statins in the standard diabetes education arm, enrollment of a relatively healthy patient population, gradual weight loss in the control group such that the differential weight loss between the two groups was only 2.

A sustained weight loss of greater than that achieved in the trial may be required to reduce the risk of CVD. In an observational post hoc analysis of the Look AHEAD trial, weight loss of 10 percent or greater in the first year was associated with a reduction in the primary outcome 1.

However, this post hoc analysis is problematic. Moreover, the degree of weight loss is difficult to achieve and maintain through lifestyle intervention alone. Weight loss, weight loss maintenance, and exercise remain important components of diabetes management due to overall health benefits.

The following summarizes several other major observations from the Look AHEAD trial [ 27,31, ]:. The difference was attenuated but remained significant throughout the trial 6 versus 3. Changes in waist circumference and physical fitness were also significantly better in the intervention group throughout the study.

By study end, mean A1C was significantly lower in the intervention group 7. Psychological interventions — Patients with type 2 diabetes often experience significant stress, a condition often called diabetes distress, related to the many self-care responsibilities required for glycemic management lifestyle modifications, medication, and blood glucose monitoring [BGM] [ 42 ].

Concurrent depression similarly may interfere with self-care. See "Overview of general medical care in nonpregnant adults with diabetes mellitus", section on 'Comorbid conditions'.

Psychotherapy reduces psychological distress and improves glycemic management in some [ 43,44 ], but not all [ 45 ], studies. In a meta-analysis of 12 trials of patients with type 2 diabetes randomly assigned to psychological intervention or usual care, mean A1C was lower in the intervention group pooled mean difference Measures of psychological distress were also significantly lower in the intervention group, but there were no differences in weight management.

Pregnancy planning — All women of childbearing age with diabetes should be counseled about the potential effects of diabetes and commonly used medications on maternal and fetal outcomes and the potential impact of pregnancy on their diabetes management and any existing complications.

See "Pregestational preexisting diabetes: Preconception counseling, evaluation, and management". When to start — Early institution of treatment for diabetes, at a time when the A1C is not substantially elevated, is associated with improved glycemic management over time and decreased long-term complications [ 46 ].

Pharmacologic therapy should be initiated along with consultation for lifestyle modification focusing on dietary and other lifestyle contributors to hyperglycemia. Weight loss and weight loss maintenance underpins all effective type 2 diabetes therapy, and lifestyle change reduces the risk of weight gain associated with sulfonylureas and insulin.

However, for those patients who have clear and modifiable contributors to hyperglycemia and who are motivated to change them eg, commitment to reduce consumption of sugar-sweetened beverages , a three-month trial of lifestyle modification prior to initiation of pharmacologic therapy is warranted.

Choice of initial therapy — Our suggestions are based upon clinical trial evidence and clinical experience in achieving glycemic targets and minimizing adverse effects table 1 , with the recognition that there is a paucity of high-quality, head-to-head drug comparison trials and long-duration trials or ones with important clinical endpoints, such as effects on complications.

The long-term benefits and risks of using one approach over another are unknown. In selecting initial therapy, we consider patient presentation eg, presence or absence of symptoms of hyperglycemia, comorbidities, baseline A1C level , individualized treatment goals and preferences, the glucose-lowering efficacy of individual drugs, and their adverse effect profile, tolerability, and cost [ 47 ].

We prefer initiating a single agent typically metformin and then sequentially adding additional glucose-lowering agents as needed, rather than starting with combination therapy [ 48 ].

Related Pathway s : Diabetes: Initial therapy for non-pregnant adults with type 2 DM. Asymptomatic, not catabolic — The majority of patients with newly diagnosed type 2 diabetes are asymptomatic, without symptoms of catabolism eg, without polyuria, polydipsia, or unintentional weight loss.

Hyperglycemia may be noted on routine laboratory examination or detected by screening. Metformin — In the absence of specific contraindications, we suggest metformin as initial therapy for patients with newly diagnosed type 2 diabetes who are asymptomatic.

We begin with mg once daily with the evening meal and, if tolerated, add a second mg dose with breakfast. The dose can be increased slowly one tablet every one to two weeks as tolerated to reach a total dose of mg per day. See 'When to start' above and "Metformin in the treatment of adults with type 2 diabetes mellitus", section on 'Dosing'.

Metformin is the preferred initial therapy because of glycemic efficacy see 'Glycemic efficacy' below , promotion of modest weight loss, very low incidence of hypoglycemia, general tolerability, and favorable cost [ 47 ]. Metformin does not have adverse cardiovascular effects, and it appears to decrease cardiovascular events [ ].

See "Metformin in the treatment of adults with type 2 diabetes mellitus", section on 'Cardiovascular effects'. Metformin is far less expensive and has more clinical practice experience than glucagon-like peptide 1 GLP-1 receptor agonists and sodium-glucose cotransporter 2 SGLT2 inhibitors.

Although some guidelines and experts endorse the initial use of these alternative agents as monotherapy or in combination with metformin [ 48,52 ], we prefer initiating a single agent typically metformin and then sequentially adding additional glucose-lowering agents as needed, rather than starting with combination therapy.

In the clinical trials that demonstrated the protective effects of GLP-1 receptor agonists and SGLT2 inhibitors, these agents were added to background metformin therapy in most participants.

Further, the cardiorenal benefits of GLP-1 receptor agonists and SGLT2 inhibitors have not been demonstrated in drug-naïve patients without established CVD or at low cardiovascular risk or without severely increased albuminuria.

Although each diabetes medication is associated with adverse events, metformin is associated with less weight gain and fewer episodes of hypoglycemia compared with sulfonylureas, and with less edema, heart failure HF , and weight gain compared with thiazolidinediones. See "Sodium-glucose cotransporter 2 inhibitors for the treatment of hyperglycemia in type 2 diabetes mellitus", section on 'Cardiovascular effects' and "Glucagon-like peptide 1-based therapies for the treatment of type 2 diabetes mellitus", section on 'Cardiovascular effects'.

Although virtually all recommendations for initial pharmacologic therapy outside of China, where alpha-glucosidase inhibitors are recommended as an alternate first-line monotherapy [ 53 ] endorse use of metformin , there are, in fact, relatively few relevant direct comparative effectiveness data available.

Contraindications to or intolerance of metformin — For patients who have gastrointestinal intolerance of metformin , slower titration, ensuring that the patient is taking the medication with food, or switching to an extended-release formulation may improve tolerability.

For patients who still cannot tolerate metformin or have contraindications to it, we choose an alternative glucose-lowering medication guided initially by patient comorbidities, and in particular, the presence of atherosclerotic CVD ASCVD or albuminuric chronic kidney disease.

See "Metformin in the treatment of adults with type 2 diabetes mellitus", section on 'Contraindications'. When compared with placebo, the GLP-1 receptor agonists liraglutide , semaglutide , and dulaglutide demonstrated favorable atherosclerotic cardiovascular and kidney outcomes [ ].

The SGLT2 inhibitors empagliflozin , canagliflozin , and dapagliflozin have also demonstrated benefit, especially for HF hospitalization, risk of kidney disease progression, and mortality [ ]. Patients at high CVD risk but without a prior event might benefit, but the data are less supportive.

Similarly, patients without severely increased albuminuria have some benefit, but the absolute benefits are greater among those with severely increased albuminuria. To select a medication, we use shared decision-making with a focus on beneficial and adverse effects within the context of the degree of hyperglycemia as well as a patient's comorbidities and preferences.

As examples:. SGLT2 inhibitors with cardiovascular benefit empagliflozin or canagliflozin are good alternatives, especially in the presence of HF. Given the high cost of these classes of medications, formulary coverage often determines the choice of the first medication within the class.

See "Glucagon-like peptide 1-based therapies for the treatment of type 2 diabetes mellitus", section on 'Cardiovascular effects' and "Glucagon-like peptide 1-based therapies for the treatment of type 2 diabetes mellitus", section on 'Microvascular outcomes'.

Choice of agent is primarily dictated by provider preference, insurance formulary restrictions, eGFR, and cost. In the setting of declining eGFR, the main reason to prescribe SGLT2 inhibitors is to reduce progression of DKD.

However, kidney and cardiac benefits have been shown in patients with eGFR below this threshold. Dosing in the setting of DKD is reviewed in detail elsewhere. See "Treatment of diabetic kidney disease", section on 'Type 2 diabetes: Treat with additional kidney-protective therapy'.

An alternative or an additional agent may be necessary to achieve glycemic goals. GLP-1 receptor agonists are an alternative in patients with DKD as their glycemic effect is not related to eGFR.

In addition, GLP-1 receptor agonists have been shown to slow the rate of decline in eGFR and prevent worsening of albuminuria. See 'Microvascular outcomes' below and "Sodium-glucose cotransporter 2 inhibitors for the treatment of hyperglycemia in type 2 diabetes mellitus" and "Glucagon-like peptide 1-based therapies for the treatment of type 2 diabetes mellitus".

Of note, we avoid use of SGLT2 inhibitors in patients with frequent bacterial urinary tract infections or genitourinary yeast infections, low bone density and high risk for falls and fractures, foot ulceration, and factors predisposing to diabetic ketoacidosis eg, pancreatic insufficiency, drug or alcohol abuse disorder because of increased risk while using these agents.

SLGT2 inhibitors should be held for 3 to 4 days before procedures including colonoscopy preparation and with poor oral intake to prevent diabetic ketoacidosis. See "Sodium-glucose cotransporter 2 inhibitors for the treatment of hyperglycemia in type 2 diabetes mellitus", section on 'Contraindications and precautions'.

Repaglinide acts at the sulfonylurea receptor to increase insulin secretion but is much shorter acting than sulfonylureas and is principally metabolized by the liver, with less than 10 percent renally excreted.

Limited data suggest that dipeptidyl peptidase 4 DPP-4 inhibitors are effective and relatively safe in patients with chronic kidney disease. However, linagliptin is the only DPP-4 inhibitor that does not require a dose adjustment in the setting of kidney failure.

GLP-1 receptor agonists may also be used safely in chronic kidney disease stage 4, but patient education for signs and symptoms of dehydration due to nausea or satiety is warranted to reduce the risk of acute kidney injury.

Insulin may also be used, with a greater portion of the total daily dose administered during the day due to the risk of hypoglycemia, especially overnight, in chronic kidney disease and end-stage kidney disease ESKD.

See "Management of hyperglycemia in patients with type 2 diabetes and advanced chronic kidney disease or end-stage kidney disease", section on 'Patients not on dialysis'.

Without established cardiovascular or kidney disease — For patients without established CVD or kidney disease who cannot take metformin , many other options for initial therapy are available table 1.

We suggest choosing an alternative glucose-lowering medication guided by efficacy, patient comorbidities, preferences, and cost. Although historically insulin has been used for type 2 diabetes only when inadequate glycemic management persists despite oral agents and lifestyle intervention, there are increasing data to support using insulin earlier and more aggressively in type 2 diabetes.

By inducing near normoglycemia with intensive insulin therapy, both endogenous insulin secretion and insulin sensitivity improve; this results in better glycemic management, which can then be maintained with diet, exercise, and oral hypoglycemics for many months thereafter.

Insulin may cause weight gain and hypoglycemia. See "Insulin therapy in type 2 diabetes mellitus", section on 'Indications for insulin'. If type 1 diabetes has been excluded, a GLP-1 receptor agonist is a reasonable alternative to insulin [ 66,67 ].

The frequency of injections and proved beneficial effects in the setting of CVD are the major differences among the many available GLP-1 receptor agonists. In practice, given the high cost of this class of medications, formulary coverage often determines the choice of the first medication within the class.

Cost and insurance coverage may limit accessibility and adherence. See "Glucagon-like peptide 1-based therapies for the treatment of type 2 diabetes mellitus", section on 'Patient selection'.

Each one of these choices has individual advantages, benefits, and risks table 1. See "Sulfonylureas and meglitinides in the treatment of type 2 diabetes mellitus" and "Sodium-glucose cotransporter 2 inhibitors for the treatment of hyperglycemia in type 2 diabetes mellitus", section on 'Patient selection' and "Dipeptidyl peptidase 4 DPP-4 inhibitors for the treatment of type 2 diabetes mellitus", section on 'Patient selection' and "Thiazolidinediones in the treatment of type 2 diabetes mellitus", section on 'Potential indications'.

See "Sodium-glucose cotransporter 2 inhibitors for the treatment of hyperglycemia in type 2 diabetes mellitus", section on 'Weight loss' and "Dipeptidyl peptidase 4 DPP-4 inhibitors for the treatment of type 2 diabetes mellitus", section on 'Patient selection' and "Glucagon-like peptide 1-based therapies for the treatment of type 2 diabetes mellitus", section on 'Weight loss'.

The choice of sulfonylurea balances glucose-lowering efficacy, universal availability, and low cost with risk of hypoglycemia and weight gain. Pioglitazone , which is generic and another relatively low-cost oral agent, may also be considered in patients with specific contraindications to metformin and sulfonylureas.

However, the risk of weight gain, HF, fractures, and the potential increased risk of bladder cancer raise the concern that the overall risks and cost of pioglitazone may approach or exceed its benefits. See "Sulfonylureas and meglitinides in the treatment of type 2 diabetes mellitus" and "Thiazolidinediones in the treatment of type 2 diabetes mellitus", section on 'Potential indications'.

For patients who are starting sulfonylureas, we suggest initiating lifestyle intervention first, at the time of diagnosis, since the weight gain that often accompanies a sulfonylurea will presumably be less if lifestyle efforts are underway.

However, if lifestyle intervention has not produced a significant reduction in symptoms of hyperglycemia or in glucose values after one or two weeks, then the sulfonylurea should be added.

Side effects may be minimized with diabetes self-management education focusing on medication reduction or omission with changes in diet, food accessibility, or activity that may increase the risk of hypoglycemia. See "Glucagon-like peptide 1-based therapies for the treatment of type 2 diabetes mellitus", section on 'Suggested approach to the use of GLP-1 receptor agonist-based therapies' and "Sodium-glucose cotransporter 2 inhibitors for the treatment of hyperglycemia in type 2 diabetes mellitus", section on 'Mechanism of action' and "Dipeptidyl peptidase 4 DPP-4 inhibitors for the treatment of type 2 diabetes mellitus", section on 'Mechanism of action' and "Thiazolidinediones in the treatment of type 2 diabetes mellitus", section on 'Hypoglycemia'.

Symptomatic catabolic or severe hyperglycemia — The frequency of symptomatic or severe diabetes has been decreasing in parallel with improved efforts to diagnose diabetes earlier through screening. With rising A1C levels comes a greater risk for diabetes and its associated health conditions.

Even though sugar is arguably one of the most important energy sources in the body, it can also damage body tissues when there is too much of it. The flip side is that a decrease of just 0. Blood vessels in the retina—as another example—can deteriorate after prolonged exposure to high levels of sugar, leading to partial vision loss.

Similarly, nerve cells throughout the body can be damaged by high blood sugar which, among other things, results in pain 3. Given the negative effects of having high A1C levels, people with type 2 diabetes often want to lower their A1C levels.

Exactly what you should target for your A1C levels depends on your unique circumstances. Talk with your doctor to help you identify a personalized goal.

As A1C levels are a reflection of blood-sugar levels over time, having chronically high A1C levels increases your likelihood of developing cardiovascular disease, kidney disease, vision loss, and peripheral nerve damage—all of which are common in unmanaged type 2 diabetes 3.

A1C levels are influenced by a number of factors including:. Fortunately, this means A1C levels are not set in stone—if your A1C levels are high, there are multiple ways to lower them.

Lowering your A1C levels will take time, mostly because your A1C levels represent an average measurement of blood sugar over a month time period.

Because of this, momentary changes in blood sugar may not have a large effect on your A1C results. However, sustained efforts that help you lower your blood sugar levels for longer periods of time—such as dietary changes , medication, or restoration of beneficial bacteria to the gut microbiome —can lead to a drop in your A1C levels that may be noticeable after just a few months.

These questions have been the focus of research for decades. Through numerous clinical trials, various methods for managing A1C levels have been put to the test and some have shown very promising results. Weight loss has been shown in numerous studies to be correlated with a decrease in A1C levels.

This, in turn, leads to high A1C levels. Because excess body fat appears to suppress the effect of insulin, it makes sense that reducing body weight could potentially help re-sensitize the body to insulin signaling and result in a decrease of A1C levels 4. This theory has been put to the test in clinical trials.

An analysis of more than 50 clinical trials, involving more than 17, total participants, found that weight loss—via bariatric surgery or intensive lifestyle intervention—led to a decrease in A1C levels.

This study went on to suggest that, based on these previous findings, people with type 2 diabetes may expect to decrease their A1C levels by ~0.

Some may require more weight loss to see a decrease in their A1C levels. The study similarly notes that a reduction in A1C levels was more likely in people who initially had very high A1C levels, suggesting that as you get nearer to the diabetes threshold of 6.

Nonetheless, reducing body weight does appear to be an effective way to reduce A1C levels 6. According to the American Diabetes Association, exercise is defined as any planned physical activity that increases your energy output. This can take the form of walking, running, swimming, weight lifting, or resistance training among many other forms 8.

When we exercise, our muscles have to burn energy to contract. That energy enables us to propel ourselves forward or to lift heavy objects. And that energy largely comes from sugar. Muscle cells have their own stores of sugar that they turn to in times of need. However, those stores can be depleted relatively quickly.

Once that happens, they turn to the bloodstream for help. Muscle cells can remove sugar from the bloodstream when they need it, and this helps to lower blood sugar levels. Experts advise that people with type 2 diabetes get approximately minutes of moderate to intense exercise spread out across at least three days a week in order to reduce their blood sugar levels 8.

Both aerobic exercises such as running, swimming, biking , as well as anaerobic exercises powerlifting, isometric training, resistance training , have been shown to help reduce A1C levels. A major challenge to this method of blood sugar management is that its benefits are short-lived—once exercise has ceased, blood sugar levels are likely to rebound.

When it comes to managing type 2 diabetes, a healthy eating plan is also a major focus for intervention. This is because blood sugar levels are heavily influenced by the foods we eat: If we eat meals that are high in sugar content, our blood sugar is likely to be higher as well.

Many studies have looked at the effect of balanced calorie restriction on A1C levels. A calorie is a unit of measurement describing the amount of usable energy an item has.

Our bodies can use fats and sugars as fuel. When we need more energy than our food provides, our body will turn to its internal resources such as sugars that are in the bloodstream or stored in the liver.

Reducing calorie count in a healthy, balanced manner can be a reasonable way to encourage your body to use its sugar stores and ultimately lower your blood sugar levels. One clinical trial involving people with type 2 diabetes, known as the DIRECT study, had participants reduce their caloric intake to just calories per day for three to five months, followed by gradual reintroduction of higher calorie meals.

Many studies have found that low-calorie diets, as well as carbohydrate-restricted diets, can be effective at reducing A1C levels for short periods of time but often fail to have a sustained impact 7. Studies in which calorie restriction or low-carbohydrate diets were most effective also included professional guidance.

Strict diets are difficult to adhere to, but incorporating certain foods into your diet may be easier. Clinical trials have explored the effect of specific foods on A1C levels in people with type 2 diabetes. Primary among these are foods that are rich in soluble fibers.

Fibers are believed to help blood sugar levels in many ways. Additionally, certain dietary fibers may also encourage the growth of diverse and beneficial bacteria in the gut microbiome which can then have its own positive effects on blood sugar levels.

Large scale studies looking at the effect of dietary fibers on A1C levels have found that diets with large amounts of fiber specifically cereal fibers tend to cause a decrease in A1C levels of approximately 0. Some foods that are high in fiber include:.

Similar to foods high in fibers, foods that are high in resistant starches —complex sugars that are difficult for the human body to break down—are thought to have a positive impact on blood sugar levels. However, clinical trials have shown mixed results wherein some studies have found a positive impact on participant A1C levels while others have not.

Further research is needed to confirm whether resistant starches can help lower A1C levels.

A1C test results are unique. Push it to 6. Can exercise and diet reduce your A1C level? Fortunately, there is a lot you can do to lower your A1C level. Get in the gym consistently, and your A1C level will drop as well. What are the best foods to lower A1C?

Sadly, there is no magic A1C-lowering food. Good choices include: Carbohydrates — Go with limited servings of whole grains, fruits and starchy vegetables, such as squash and potatoes. Protein — Select eggs, soy, fish, chicken, lean cuts of beef and other healthy options.

Vegetables — Choose plenty of non-starchy options, such as broccoli, green beans and tomatoes. Can eating no carbs lower your A1C level? Carbohydrates raise your blood sugar levels. Assigned Categories: Tanner Medical Group, Get Healthy, Live Well, Family Health Care. bookmark the Permalink.

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The authors acknowledge the invited peer reviewers who provided comments on an earlier draft of this report: Kelli Begay Indian Health Service, Rockville, MD , Guoxun Chen University of Tennessee, Knoxville, TN , Frank Hu Harvard T.

Duality of Interest. The authors disclosed all potential financial conflicts of interest with industry. These disclosures were discussed at the onset of the consensus statement development process.

The ADA uses general revenues to fund development of its consensus reports and does not rely on industry support for these purposes. reports honorarium from the Academy of Nutrition and Dietetics and the ADA outside of the submitted work.

reports personal fees from Novo Nordisk, Merck, Amgen, Gilead, BOYDSense, the American Medical Group Association, and Janssen and grants from Sanofi, Pfizer, Merck, and Novo Nordisk outside of the submitted work.

reports personal fees from Sunstar Foundation outside of the submitted work. was previously employed by the ADA. reports grants from the National Institutes of Health and internal University of Michigan grants.

reports a consulting relationship with dietdoctor. com, which began after the Consensus Report was submitted to Diabetes Care. No other potential conflicts of interest relevant to this article were reported. Author Contributions. All authors were responsible for drafting the Consensus Report and revising it critically for important intellectual content.

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Volume 42, Issue 5. Previous Article Next Article. Data Sources, Searches, and Study Selection. EATING PATTERNS. MNT and Antihyperglycemic Medications Including Insulin. Article Information. Article Navigation. Continuing Evolution of Nutritional Therapy for Diabetes April 15 Nutrition Therapy for Adults With Diabetes or Prediabetes: A Consensus Report Alison B.

Evert ; Alison B. This Site. Google Scholar. Michelle Dennison ; Michelle Dennison. Christopher D. Gardner ; Christopher D. Timothy Garvey ; W. Timothy Garvey. Ka Hei Karen Lau ; Ka Hei Karen Lau.

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Corresponding author: William S. Yancy Jr. yancy duke. Diabetes Care ;42 5 — Get Permissions. toolbar search Search Dropdown Menu. toolbar search search input Search input auto suggest. Table 1 Goals of nutrition therapy.

View Large. Table 2 Academy of Nutrition and Dietetics evidence-based nutrition practice guidelines—recommended structure for the implementation of MNT for adults with diabetes 9.

Initial series of MNT encounters : The RDN should implement three to six MNT encounters during the first 6 months following diagnosis and determine if additional MNT encounters are needed based on an individualized assessment.

MNT follow-up encounters: The RDN should implement a minimum of one annual MNT follow-up encounter. Table 3 Eating patterns reviewed for this report. Type of eating pattern. USDA Dietary Guidelines For Americans DGA 8 Emphasizes a variety of vegetables from all of the subgroups; fruits, especially whole fruits; grains, at least half of which are whole intact grains; lower-fat dairy; a variety of protein foods; and oils.

This eating pattern limits saturated fats and trans fats, added sugars, and sodium. Some plans include fruit e. Avoids starchy and sugary foods such as pasta, rice, potatoes, bread, and sweets.

Often has a goal of 20—50 g of nonfiber carbohydrate per day to induce nutritional ketosis. May also be reduced in sodium. Avoids grains, dairy, salt, refined fats, and sugar.

Table 4 Quick reference conversion of percent calories from carbohydrate shown in grams per day as reported in the research reviewed for this report.

Replace sugar-sweetened beverages SSBs with water as often as possible. Selection of small-particle-size foods may improve symptoms of diabetes-related gastroparesis. Strategies to improve access, clinical outcomes, and cost effectiveness include the following.

reducing barriers to referrals and allowing self-referrals to MNT and DSMES; providing in-person or technology-enabled diabetes nutrition therapy and education integrated with medical management 9 , 12 , 13 , 15 , 16 , 19 , 22 , — , — ; engineering solutions that include two-way communication between the individual and his or her health care team to provide individualized feedback and tailored education based on the analyzed patient-generated health data 38 , , ; increasing the use of community health workers and peer coaches to provide culturally appropriate, ongoing support and clinically linked care coordination and improve the reach of MNT and DSMES 15 , 19 , 23 , 38 , , Diabetes self-management education and support in type 2 diabetes: a joint position statement of the American Diabetes Association, the American Association of Diabetes Educators, and the Academy of Nutrition and Dietetics.

Search ADS. Management of hyperglycemia in type 2 diabetes, a patient-centered approach: update to a position statement of the American Diabetes Association and the European Association for the Study of Diabetes.

American Diabetes Association. Nutrition therapy recommendations for the management of adults with diabetes. Management of diabetes in pregnancy: Standards of Medical Care in Diabetes— Institute of Medicine. Accessed 2 October Department of Health and Human Service; U. Accessed 18 January Academy of Nutrition and Dietetics Nutrition practice guideline for type 1 and type 2 diabetes in adults: systematic review of evidence for medical nutrition therapy effectiveness and recommendations for integration into the nutrition care process.

Nutrition Care Process and Model: ADA adopts road map to quality care and outcomes management. Legal Information Institute.

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Glycemic index, postprandial glycemia, and the shape of the curve in healthy subjects: analysis of a database of more than 1, foods. Effect of a chicken-based diet on renal function and lipid profile in patients with type 2 diabetes: a randomized crossover trial.

The effect of a high-egg diet on cardiovascular risk factors in people with type 2 diabetes: the Diabetes and Egg DIABEGG study—a 3-mo randomized controlled trial.

Dietary tartary buckwheat intake attenuates insulin resistance and improves lipid profiles in patients with type 2 diabetes: a randomized controlled trial. Salba-chia Salvia hispanica L. in the treatment of overweight and obese patients with type 2 diabetes: a double-blind randomized controlled trial.

Feasibility and efficacy of an isocaloric high-protein vs. standard diet on insulin requirement, body weight and metabolic parameters in patients with type 2 diabetes on insulin therapy.

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Food sources of fat may clarify the inconsistent role of dietary fat intake for incidence of type 2 diabetes. Total and subtypes of dietary fat intake and risk of type 2 diabetes mellitus in the Prevención con Dieta Mediterránea PREDIMED study.

Consumption of dairy foods and diabetes incidence: a dose-response meta-analysis of observational studies. A network meta-analysis on the comparative efficacy of different dietary approaches on glycaemic control in patients with type 2 diabetes mellitus.

Prevention of type 2 diabetes mellitus by changes in lifestyle among subjects with impaired glucose tolerance. Remission of pre-diabetes to normal glucose tolerance in obese adults with high protein versus high carbohydrate diet: randomized control trial. Which diet for prevention of type 2 diabetes?

A meta-analysis of prospective studies. Vegetarian diet, change in dietary patterns, and diabetes risk: a prospective study. Legume consumption is inversely associated with type 2 diabetes incidence in adults: a prospective assessment from the PREDIMED study.

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Long-term low-carbohydrate diets and type 2 diabetes risk: a systematic review and meta-analysis of observational studies. Effects of diet and exercise in preventing NIDDM in people with impaired glucose tolerance: The Da Qing IGT and Diabetes Study. Oslo Diet and Exercise Study ODES.

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One-year comparison of a high-monounsaturated fat diet with a high-carbohydrate diet in type 2 diabetes.

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A high-protein low-fat diet is more effective in improving blood pressure and triglycerides in calorie-restricted obese individuals with newly diagnosed type 2 diabetes. Influence of fat and carbohydrate proportions on the metabolic profile in patients with type 2 diabetes: a meta-analysis.

Long-term use of a high-complex-carbohydrate, high-fiber, low-fat diet and exercise in the treatment of NIDDM patients. Comparison of coronary risk factors and quality of life in coronary artery disease patients with versus without diabetes mellitus.

Effect of dietary carbohydrate restriction on glycemic control in adults with diabetes: a systematic review and meta-analysis. van Zuuren. Effects of low-carbohydrate- compared with low-fat-diet interventions on metabolic control in people with type 2 diabetes: a systematic review including GRADE assessments.

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Comparison of low- and high-carbohydrate diets for type 2 diabetes management: a randomized trial. Long-term effects of weight loss with a very-low carbohydrate, low saturated fat diet on flow mediated dilatation in patients with type 2 diabetes: a randomised controlled trial.

Effects of the Dietary Approaches to Stop Hypertension DASH eating plan on cardiovascular risks among type 2 diabetic patients: a randomized crossover clinical trial. Effects of the DASH diet and walking on blood pressure in patients with type 2 diabetes and uncontrolled hypertension: a randomized controlled trial.

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McCue, MD Ed. Comparative Physiology of Fasting, Starvation, and Food Limitation [Internet]. Berlin, Springer-Verlag, Accessed 19 November Intermittent fasting in type 2 diabetes mellitus and the risk of hypoglycaemia: a randomized controlled trial.

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Low carbohydrate diet in type 1 diabetes, long-term improvement and adherence: a clinical audit. Effect of low-fat vs low-carbohydrate diet on month weight loss in overweight adults and the association with genotype pattern or insulin secretion: the DIETFITS randomized clinical trial.

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The frequency of injections and proved beneficial effects in the setting of CVD are the major differences among the many available GLP-1 receptor agonists.

In practice, given the high cost of this class of medications, formulary coverage often determines the choice of the first medication within the class.

Cost and insurance coverage may limit accessibility and adherence. See "Glucagon-like peptide 1-based therapies for the treatment of type 2 diabetes mellitus", section on 'Patient selection'. Each one of these choices has individual advantages, benefits, and risks table 1.

See "Sulfonylureas and meglitinides in the treatment of type 2 diabetes mellitus" and "Sodium-glucose cotransporter 2 inhibitors for the treatment of hyperglycemia in type 2 diabetes mellitus", section on 'Patient selection' and "Dipeptidyl peptidase 4 DPP-4 inhibitors for the treatment of type 2 diabetes mellitus", section on 'Patient selection' and "Thiazolidinediones in the treatment of type 2 diabetes mellitus", section on 'Potential indications'.

See "Sodium-glucose cotransporter 2 inhibitors for the treatment of hyperglycemia in type 2 diabetes mellitus", section on 'Weight loss' and "Dipeptidyl peptidase 4 DPP-4 inhibitors for the treatment of type 2 diabetes mellitus", section on 'Patient selection' and "Glucagon-like peptide 1-based therapies for the treatment of type 2 diabetes mellitus", section on 'Weight loss'.

The choice of sulfonylurea balances glucose-lowering efficacy, universal availability, and low cost with risk of hypoglycemia and weight gain. Pioglitazone , which is generic and another relatively low-cost oral agent, may also be considered in patients with specific contraindications to metformin and sulfonylureas.

However, the risk of weight gain, HF, fractures, and the potential increased risk of bladder cancer raise the concern that the overall risks and cost of pioglitazone may approach or exceed its benefits.

See "Sulfonylureas and meglitinides in the treatment of type 2 diabetes mellitus" and "Thiazolidinediones in the treatment of type 2 diabetes mellitus", section on 'Potential indications'. For patients who are starting sulfonylureas, we suggest initiating lifestyle intervention first, at the time of diagnosis, since the weight gain that often accompanies a sulfonylurea will presumably be less if lifestyle efforts are underway.

However, if lifestyle intervention has not produced a significant reduction in symptoms of hyperglycemia or in glucose values after one or two weeks, then the sulfonylurea should be added.

Side effects may be minimized with diabetes self-management education focusing on medication reduction or omission with changes in diet, food accessibility, or activity that may increase the risk of hypoglycemia. See "Glucagon-like peptide 1-based therapies for the treatment of type 2 diabetes mellitus", section on 'Suggested approach to the use of GLP-1 receptor agonist-based therapies' and "Sodium-glucose cotransporter 2 inhibitors for the treatment of hyperglycemia in type 2 diabetes mellitus", section on 'Mechanism of action' and "Dipeptidyl peptidase 4 DPP-4 inhibitors for the treatment of type 2 diabetes mellitus", section on 'Mechanism of action' and "Thiazolidinediones in the treatment of type 2 diabetes mellitus", section on 'Hypoglycemia'.

Symptomatic catabolic or severe hyperglycemia — The frequency of symptomatic or severe diabetes has been decreasing in parallel with improved efforts to diagnose diabetes earlier through screening.

If patients have been drinking a substantial quantity of sugar-sweetened beverages, reduction of carbohydrate intake, and rehydration with sugar-free fluids will help to reduce glucose levels within several days.

See "Insulin therapy in type 2 diabetes mellitus", section on 'Initial treatment'. However, for patients who are injection averse, initial therapy with high-dose sulfonylurea is an alternative option.

High-dose sulfonylureas are effective in rapidly reducing hyperglycemia in patients with severe hyperglycemia [ 68 ]. Metformin monotherapy is not helpful in improving symptoms in this setting, because the initial dose is low and increased over several weeks.

However, metformin can be started at the same time as the sulfonylurea, slowly titrating the dose upward. Once the diet has been adequately modified and the metformin dose increased, the dose of sulfonylurea can be reduced and potentially discontinued. Patients with type 2 diabetes require relatively high doses of insulin compared with those needed for type 1 diabetes.

Insulin preparations, insulin regimens, and timing of dosing are discussed in detail elsewhere. See "Insulin therapy in type 2 diabetes mellitus". See "Glucagon-like peptide 1-based therapies for the treatment of type 2 diabetes mellitus", section on 'Administration'.

We typically use glimepiride 4 or 8 mg once daily. An alternative option is immediate-release glipizide 10 mg twice daily or, where available, gliclazide immediate-release 80 mg daily.

We contact the patient every few days after initiating therapy to make dose adjustments increase dose if hyperglycemia does not improve or decrease dose if hyperglycemia resolves quickly or hypoglycemia develops. See "Sulfonylureas and meglitinides in the treatment of type 2 diabetes mellitus", section on 'Sulfonylureas'.

Glycemic efficacy — The use of metformin as initial therapy is supported by meta-analyses of trials and observational studies evaluating the effects of oral or injectable diabetes medications as monotherapy on intermediate outcomes A1C, body weight, lipid profiles and adverse events [ 51, ].

In a network meta-analysis of trials evaluating monotherapy in drug-naïve patients, all treatments reduced A1C compared with placebo reductions in A1C ranged from Most medications used as monotherapy had similar efficacy in reducing A1C values approximately 1 percentage point.

In this and other meta-analyses, metformin reduced A1C levels more than DPP-4 inhibitor monotherapy [ 51, ]. There are few high-quality, head-to-head comparison trials of the available oral agents. In one such trial, A Diabetes Outcome Progression Trial ADOPT , recently diagnosed patients with type 2 diabetes were randomly assigned to monotherapy with the thiazolidinedione rosiglitazone , metformin , or glyburide [ 72 ].

At the four-year evaluation, 40 percent of the subjects in the rosiglitazone group had an A1C value less than 7 percent, as compared with 36 percent in the metformin group and 26 percent in the glyburide group.

Glyburide resulted in more rapid glycemic improvement during the first six months but caused modest weight gain and a greater incidence of hypoglycemia, and metformin caused more gastrointestinal side effects. Rosiglitazone caused greater increases in weight, peripheral edema, and concentrations of low-density lipoprotein LDL cholesterol.

There was also an unexpected increase in fractures in women taking rosiglitazone. The study was limited by a high rate of withdrawal of study participants. Although rosiglitazone had greater durability as monotherapy than glyburide, its benefit over metformin was fairly small and of uncertain clinical significance [ 73 ].

See "Thiazolidinediones in the treatment of type 2 diabetes mellitus", section on 'Safety'. Cardiovascular outcomes — Cardiovascular benefit has been demonstrated for selected classes of diabetes medications, usually when added to metformin.

See "Management of persistent hyperglycemia in type 2 diabetes mellitus", section on 'Monotherapy failure'. The cardiovascular effects of diabetes drugs are reviewed in the individual topics. See "Glucagon-like peptide 1-based therapies for the treatment of type 2 diabetes mellitus", section on 'Cardiovascular effects' and "Sodium-glucose cotransporter 2 inhibitors for the treatment of hyperglycemia in type 2 diabetes mellitus", section on 'Cardiovascular effects' and "Sulfonylureas and meglitinides in the treatment of type 2 diabetes mellitus", section on 'Cardiovascular effects' and "Thiazolidinediones in the treatment of type 2 diabetes mellitus", section on 'Cardiovascular effects' and "Dipeptidyl peptidase 4 DPP-4 inhibitors for the treatment of type 2 diabetes mellitus", section on 'Cardiovascular effects' and "Insulin therapy in type 2 diabetes mellitus".

In trials of patients with type 2 diabetes with and without chronic kidney disease, GLP-1 receptor agonists slowed the rate of decline in eGFR and prevented worsening of albuminuria [ 54,56,58 ]. These trials and other trials evaluating microvascular outcomes are reviewed in the individual topics.

Guidelines — Our approach is largely consistent with American and European guidelines [ 52,74,75 ]. A consensus statement regarding the management of hyperglycemia in type 2 diabetes by the American Diabetes Association ADA and the European Association for the Study of Diabetes EASD was developed in and has been updated regularly, with the most recent revision published in [ 75 ].

The guidelines emphasize the importance of individualizing the choice of medications for the treatment of diabetes, considering important comorbidities CVD, HF, or chronic kidney disease; hypoglycemia risk; and need for weight loss and patient-specific factors including patient preferences, values, and cost [ 75 ].

We also agree with the World Health Organization WHO that sulfonylureas have a long-term safety profile, are inexpensive, and are highly effective, especially when used as described above, with patient education and dose adjustment to minimize side effects [ 76 ].

Blood glucose monitoring BGM is not necessary for most patients with type 2 diabetes who are on a stable regimen of diet or oral agents and who are not experiencing hypoglycemia.

BGM may be useful for some patients with type 2 diabetes who use the results to modify eating patterns, exercise, or insulin doses on a regular basis. See "Glucose monitoring in the ambulatory management of nonpregnant adults with diabetes mellitus", section on 'Type 2 diabetes'.

The balance among efficacy in lowering A1C, side effects, and costs must be carefully weighed in considering which drugs or combinations to choose. Avoiding insulin, the most potent of all hypoglycemic medications, at the expense of poorer glucose management and greater side effects and cost, is not likely to benefit the patient in the long term.

See "Management of persistent hyperglycemia in type 2 diabetes mellitus", section on 'Our approach'. SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately.

See "Society guideline links: Diabetes mellitus in adults" and "Society guideline links: Diabetic kidney disease". These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed.

These articles are written at the 10 th to 12 th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon. Here are the patient education articles that are relevant to this topic.

We encourage you to print or e-mail these topics to your patients. You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword s of interest. Weight reduction through diet, exercise, and behavioral modification can all be used to improve glycemic management, although the majority of patients with type 2 diabetes will require medication.

See 'Diabetes education' above. Glycemic targets are generally set somewhat higher for older adults and for those with comorbidities or a limited life expectancy and little likelihood of benefit from intensive therapy.

See 'Glycemic management' above and "Glycemic control and vascular complications in type 2 diabetes mellitus", section on 'Choosing a glycemic target'. In the absence of specific contraindications, we suggest metformin as initial therapy for most patients Grade 2B. Although some guidelines and experts endorse the initial use of alternative agents as monotherapy or in combination with metformin, we prefer initiating a single agent typically metformin and then sequentially adding additional glucose-lowering agents as needed.

See 'Metformin' above and 'Glycemic efficacy' above. We suggest initiating metformin at the time of diabetes diagnosis Grade 2C , along with consultation for lifestyle intervention.

See 'When to start' above. The dose of metformin should be titrated to its maximally effective dose usually mg per day in divided doses over one to two months, as tolerated.

See 'Contraindications to or intolerance of metformin' above. See 'Established cardiovascular or kidney disease' above. The majority of patients in the cardiovascular and renal outcomes trials had established cardiovascular disease CVD or diabetic kidney disease DKD with severely increased albuminuria, and therefore, these are the primary indications for one of these drugs.

See 'Without established cardiovascular or kidney disease' above. Each one of these choices has individual advantages and risks table 1. Choice of medication is guided by efficacy, patient comorbidities, preferences, and cost.

Sulfonylureas remain a highly effective treatment for hyperglycemia, particularly when cost is a barrier. Side effects of hypoglycemia and weight gain can be mitigated with careful dosing and diabetes self-management education. For patients who are injection averse, initial therapy with high-dose sulfonylurea is an alternative, particularly for patients who have been consuming large amounts of sugar-sweetened beverages, in whom elimination of carbohydrates can be anticipated to cause a reduction in glucose within several days.

See 'Symptomatic catabolic or severe hyperglycemia' above and "Insulin therapy in type 2 diabetes mellitus". Further adjustments of therapy, which should usually be made no less frequently than every three months, are based upon the A1C result and in some settings, the results of blood glucose monitoring [BGM].

See 'Monitoring' above. See "Management of persistent hyperglycemia in type 2 diabetes mellitus" and "Insulin therapy in type 2 diabetes mellitus". Why UpToDate? Product Editorial Subscription Options Subscribe Sign in. Learn how UpToDate can help you. Select the option that best describes you.

View Topic. Font Size Small Normal Large. Initial management of hyperglycemia in adults with type 2 diabetes mellitus.

Formulary drug information for this topic. No drug references linked in this topic. Find in topic Formulary Print Share. View in. Language Chinese English. Author: Deborah J Wexler, MD, MSc Section Editor: David M Nathan, MD Deputy Editor: Katya Rubinow, MD Contributor Disclosures.

All topics are updated as new evidence becomes available and our peer review process is complete. Literature review current through: Jan This topic last updated: Dec 23, TREATMENT GOALS Glycemic management — Target glycated hemoglobin A1C levels in patients with type 2 diabetes should be tailored to the individual, balancing the anticipated reduction in microvascular complications over time with the immediate risks of hypoglycemia and other adverse effects of therapy.

Summary of glucose-lowering interventions. UK Prospective Diabetes Study UKPDS Group. Lancet ; Holman RR, Paul SK, Bethel MA, et al. N Engl J Med ; Hayward RA, Reaven PD, Wiitala WL, et al. Follow-up of glycemic control and cardiovascular outcomes in type 2 diabetes.

ADVANCE Collaborative Group, Patel A, MacMahon S, et al. Intensive blood glucose control and vascular outcomes in patients with type 2 diabetes. Action to Control Cardiovascular Risk in Diabetes Study Group, Gerstein HC, Miller ME, et al.

Effects of intensive glucose lowering in type 2 diabetes. Rawshani A, Rawshani A, Franzén S, et al. Risk Factors, Mortality, and Cardiovascular Outcomes in Patients with Type 2 Diabetes. Gaede P, Vedel P, Larsen N, et al. Multifactorial intervention and cardiovascular disease in patients with type 2 diabetes.

Kazemian P, Shebl FM, McCann N, et al. Evaluation of the Cascade of Diabetes Care in the United States, JAMA Intern Med ; Pal K, Eastwood SV, Michie S, et al. Computer-based diabetes self-management interventions for adults with type 2 diabetes mellitus. Cochrane Database Syst Rev ; :CD Saffari M, Ghanizadeh G, Koenig HG.

Health education via mobile text messaging for glycemic control in adults with type 2 diabetes: a systematic review and meta-analysis. Prim Care Diabetes ; Liang X, Wang Q, Yang X, et al.

Effect of mobile phone intervention for diabetes on glycaemic control: a meta-analysis. Diabet Med ; Henry RR, Scheaffer L, Olefsky JM. Glycemic effects of intensive caloric restriction and isocaloric refeeding in noninsulin-dependent diabetes mellitus.

J Clin Endocrinol Metab ; Utzschneider KM, Carr DB, Barsness SM, et al. Diet-induced weight loss is associated with an improvement in beta-cell function in older men. Wing RR, Blair EH, Bononi P, et al. Caloric restriction per se is a significant factor in improvements in glycemic control and insulin sensitivity during weight loss in obese NIDDM patients.

Diabetes Care ; Lean ME, Leslie WS, Barnes AC, et al. Primary care-led weight management for remission of type 2 diabetes DiRECT : an open-label, cluster-randomised trial.

Delahanty LM. The look AHEAD study: implications for clinical practice go beyond the headlines.