The number of US adults diagnosed with diabetes has more than doubled over the past 20 years, with this alarming change being driven by the aging population and the increase in overweight and obesity.¹ Chronic hyperglycemia, or high blood glucose, is known to cause organ damage, dysfunction, and failure.²Although pharmacologic agents are often prescribed to lower blood glucose levels among patients with hyperglycemia, nonpharmacologic treatments for diabetes, including dietary modifications and physical activity, play a key role in reducing microvascular complications associated with hyperglycemia.³ Therefore, such interventions should be included in diabetes treatment plans.

History and Epidemiology of Diabetes

Diabetes is a metabolic disease characterized by hyperglycemia caused by defects in insulin action, insulin secretion, or a combination of both.² Type 1 and type 2 diabetes are the most common forms of diabetes.⁴ Historically, type 1 diabetes was believed to be most frequently diagnosed in children and type 2 would be diagnosed in adults, but this is no longer accurate.⁴ The frequency of a diagnosis of type 2 diabetes in youth is increasing, and 5% to 15% of adults with a type 2 diabetes diagnosis actually have type 1 diabetes.⁵

In the United States, more than 37 million people have diabetes, with type 1 accounting for 5% to 10% of all diagnosed cases.¹ Type 2 diabetes accounts for the remaining 90% to 95%,with American Indian and Alaska Native individuals having the highest rate of diagnosis, followed by non-Hispanic Black individuals.^1,6

Etiology of and Risk Factors for Diabetes

Insulin deficiency due to autoimmune destruction of insulin-secreting β cells is the primary cause of type 1 diabetes.⁴ The presence of autoantibodies has a high correlation with being diagnosed with type 1 diabetes,⁴and numerous serum biomarkers are used for its diagnosis (Table).⁷

Table. Autoantibodies Commonly Evaluated for Diagnosis of Type 1 Diabetes⁷

Islet-cell cytoplasmic autoantibodies

Glutamic acid decarboxylase (GAD) autoantibodies

Insulinoma 2 (IA-2)-associated autoantibodies

Insulin autoantibodies

Zinc transporter 8 (ZNT8A) autoantibodies

A progressive loss or defect in insulin-secreting β cells and insulin resistance cause type 2 diabetes.⁴ Fat deposits in the liver and muscles, as well as accumulation in the pancreas, can lead to insulin resistance.^4,5Advancing age, lack of physical activity, being of a certain ethnic/racial group, and obesity increase the risk of developing type 2 diabetes.⁴ In addition, individuals with hypertension and/or dyslipidemia, and women with a history of gestational diabetes mellitus or polycystic ovary syndrome (PCOS) are at greater risk of developing type 2 diabetes.⁴ Although a genetic predisposition for type 2 diabetes has been postulated, this relationship is poorly understood and is the subject of current research.⁴

Prognosis

In the United States, diabetes is the seventh leading cause of death.¹ Individuals with type 1 diabetes have a decrease in life expectancy of 13 years compared with those without type 1 diabetes.⁵ Researchers have reported that the average life expectancy for patients with type 2 diabetes is 6 years less than for individuals without type 2 diabetes.⁸ The greatest health threat to those living with diabetes are microvascular and macrovascular complications.⁵

Presentation and Diagnosis of Diabetes

The immune-mediated destruction of β cells can often occur long before the diagnosis of type 1 diabetes, and the gradual decline in insulin secretion can begin more than 2 years prior to diagnosis in these individuals.^2,5 Individuals with type 1 diabetes often present with acute diabetic symptoms and significantly elevated blood glucose levels.⁴ As many as 40% of US children with type 1 diabetes will present with diabetic ketoacidosis at the time of diagnosis.⁹

Type 2 diabetes can go undiagnosed for years because hyperglycemia may develop slowly and is often not severe enough for the classic symptoms of diabetes to become noticeable to the individual.⁴ Classic symptoms of type 2 diabetes include polyuria (increased frequency of urination), weight loss, blurred vision, polydipsia (excessive thirst), and polyphagia (extreme hunger).⁴

The American Diabetes Association (ADA) has established the following criteria to diagnose diabetes⁴:

Fasting plasma glucose level ≥126 mg/dL, with fasting defined as no food consumption for at least 8 hours prior to obtaining the blood sample, OR
2-hour plasma glucose level ≥200 mg/dL during an oral glucose tolerance test, OR
Glycated hemoglobin (HbA_1c) value ≥6.5%, OR
Random plasma glucose level ≥200 mg/dL in the presence of classic symptoms of hyperglycemia or hyperglycemic crisis

The first 3 criteria require confirmation with repeat testing of either the same sample or of two separate samples in the absence of unequivocal hyperglycemia.⁴

Nonpharmacologic Treatments for Diabetes

Medical nutrition therapy (MNT), weight management, physical activity, smoking cessation, diabetes self-management education and support, and psychosocial care are essential for achieving treatment goals and improving quality of life among patients with diabetes.¹⁰

Dietary Modification in Diabetes Treatment

Encouraging adherence to an appropriate diet can be one of the most challenging aspects of diabetes care. At the time of diagnosis, referral to a registered dietitian nutritionist (RD/RDN) can facilitate implementation of diabetes-specific MNT.^10,11 According to the ADA, individuals with type 1 diabetes who received MNT delivered by an RD/RDN experienced HbA_1c reductions ranging from 1.0% to 1.9%; patients with type 2 diabetes experienced HbA_1c reductions ranging from 0.3% to 2%.¹⁰

Other benefits of MNT include¹¹:

Delaying or preventing the development of type 2 diabetes in high-risk individuals;
Tightening glycemic control, thus reducing diabetic complications; and
Helping to manage diabetes complications.

Macronutrient goals and food choices will differ among individuals. However, common recommendations include^11,12:

Adoption of a low glycemic index diet to improve postprandial blood glucose excursions
Use of non-nutritive sweeteners to replace sugar for calorie and carbohydrate control
Increased consumption of dietary fiber
Low-calorie and low-carbohydrate diet for weight management and metabolic control

Weight Management for Diabetes Control

Strategies for weight reduction and management are important for all patients with diabetes with overweight or obesity.¹⁰ An energy deficiency of 500 to 700 kcal/d can lead to significant weight loss.¹² Although weight reduction can improve insulin sensitivity in the liver and skeletal muscles and partially reverse insulin secretion defects in patients with prediabetes or recently diagnosed type 2 diabetes, it is not always successful in inducing diabetes remission.⁵

With a weight reduction of 5%, favorable outcomes associated with glycemic control, lipids, and blood pressure may be seen.¹⁰ However, a more intense weight loss goal of approximately 15% may be necessary for some individuals to achieve these benefits.¹⁰ If weight loss can be maintained for 5 years, long-term benefits can include sustained improvements in HbA_1c and lipid levels.¹⁰

Physical Activity as Treatment for Diabetes

Exercise improves blood glucose control, contributes to weight loss, decreases cardiovascular risk factors, and improves well-being.¹⁰ The benefits of physical activity for people with type 2 diabetes are well established; however, individuals with type 1 also stand to benefit from increasing their physical activity.¹⁰ Absent any contraindications, adults with diabetes should consider the following¹⁰:

Strive for moderate to vigorous intensity aerobic activity for 150 minutes or more per week. A short exercise duration of 75 minutes per week of vigorous intensity is appropriate for younger and more physically fit individuals.
Participate in resistance and flexibility/balance training for 2 to 3 sessions per week on nonconsecutive days.
Decrease sedentary behaviors, particularly among individuals with type 2 diabetes.

A personalized approach, taking into account the patient’s age, current activity level, and diabetic health complications, is the most appropriate way to encourage people with diabetes to achieve physical activity goals.¹⁰

According to the ADA, regardless of the type of diabetes, individuals who participated in aerobic activity at moderate to high volumes were found to be at lower risk of cardiovascular and overall mortality compared with those who did not.¹⁰People with type 2 diabetes who participated in higher levels of exercise intensity experienced improvement in HbA_1c, sustainment of cardiorespiratory fitness, and lower rates of heart failure with weight loss.¹⁰People with diabetes, particularly those on insulin therapy, should speak with their health care provider before starting an exercise regimen to minimize the potential for hypoglycemia, the risk of which may be increased during and after a workout.¹³

Smoking Cessation

Smoking or exposure to secondhand smoke puts individuals with diabetes at greater risk of microvascular complications, cardiovascular disease, poor glycemic control, and premature death.¹⁰ Although attendant weight gain is a concern among people who quit smoking, research has demonstrated that this weight gain does not detract from the cardiovascular benefits afforded by smoking cessation.¹⁰

Summary

Nonpharmacologic treatments for diabetes improve overall health and reduce complications associated with diabetes. An individualized approach created in partnership with patients and their health care providers is the most appropriate way to help those with diabetes meet their treatment goals.

Frequently Asked Questions

Can I take herbal supplements to improve my HbA1c?

According to the ADA, dietary supplements — including vitamins, minerals, herbs, or spices — have not been found to improve outcomes among people with diabetes and are not recommended for glycemic control.¹⁰

Can I continue to drink alcohol if I have diabetes?

The ADA advises that adults who drink alcohol should do so in moderation (no more than 1 alcoholic beverage per day for adult women and 2 or fewer alcoholic beverages per day for adult men). It is important for people with diabetes to understand that alcohol consumption can affect blood glucose, and they should be sure to monitor their glucose to avoid the risk of hypoglycemia, which can occur among those using insulin.¹⁰

Is diet soda bad for my diabetes?

Although replacing sugar-sweetened beverages (including sugar, honey, and agave syrup) with those containing non-nutritive sweeteners may reduce caloric intake, individuals with diabetes are encouraged to replace both types of beverages with water as there have been studies that may suggest a relationship between both sugar-sweetened and non-nutritive-sweetened beverages and type 2 diabetes development.¹⁰

I have physical limitations that restrict my ability to exercise. What should I do?

Physical activity has been associated with not only lower cardiovascular risk and overall mortality among people with diabetes, but exercise has also been associated with increased overall fitness, improved muscle strength, and improved insulin sensitivity.¹⁰ For those reasons, all people with diabetes are encouraged to exercise to the extent that they are able. Your health care team can identify specific activities based on the type of diabetes that you have, your age, your current activity level, and whether you have any health complications. Your physical activity recommendations will be created to meet your personal needs and ability.

I feel overwhelmed by everything I have to do now that I have diabetes. Help!

Your diabetes care team is available to provide the support you need to navigate the different aspects of your diabetes care. Diabetes self-management education programs can provide you with the knowledge you need for decision-making. These programs are centered on your personal needs, and you can participate in individual or group sessions, based on availability and your preference. Coaching and education provided remotely through telemedicine may also be available. Open and honest conversation with your health team about your concerns will ensure that you have the support that you need to manage your diabetes.

References

1. Centers for Disease Control and Prevention. Diabetes fast facts. Updated September 30, 2022. Accessed December 8, 2022. https://www.cdc.gov/diabetes/basics/quick-facts.html

2. American Diabetes Association. Diagnosis and classification of diabetes mellitus. Diabetes Care. 2014;37(Suppl_1):S81-S90. doi:10.2337/dc14-S081

3. Zhou R, Cui Y, Zhang Y, et al. The long-term effects of non-pharmacological interventions on diabetes and chronic complication outcomes in patients with hyperglycemia: a systematic review and meta-analysis. Front Endocrinol. 2022;13:838224. doi:10.3389/fendo.2022.838224

4. American Diabetes Association Professional Practice Committee. 2. Classification and diagnosis of diabetes: standards of medical care in diabetes—2022. Diabetes Care. 2022;45(Suppl_1):S17-S38. doi:10.2337/dc22-S002

5. Skyler JS, Bakris GL, Bonifacio E, et al. Differentiation of diabetes by pathophysiology, natural history, and prognosis. Diabetes. 2017;66(2):241-255. doi:10.2337/db16-0806

6. Centers for Disease Control and Prevention. By the numbers: diabetes in America. Updated October 25, 2022. Accessed December 8, 2022. https://www.cdc.gov/diabetes/health-equity/diabetes-by-the-numbers.html

7. Yi L, Swensen AC, Qian W-J. Serum biomarkers for diagnosis and prediction of type 1 diabetes. Transl Res. 2018;201:13-25.7

8. The Emerging Risk Factors Collaboration. Diabetes mellitus, fasting glucose, and risk of cause-specific death. N Engl J Med. 2011;364:829-841.

9. Nakhla M, Cuthbertson D, Becker DJ, et al. Diabetic ketoacidosis at the time of diagnosis of type 1 diabetes in children: insights from TRIGR. JAMA Pediatr. 2021;175(5):518-520.

10. American Diabetes Association Professional Practice Committee. 5. Facilitating behavior change and well-being to improve health outcomes: standards of medical care in diabetes—2022. Diabetes Care. 2022;45(Suppl_1):S60-S82. doi:10.2337/dc22-S005

11. Raveendran AV, Chacko EC, Pappachan JM. Non-pharmacological treatment options in the management of diabetes mellitus. Eur Endocrinol. 2018;14(2):31-39. doi:10.17925/ee.2018.14.2.31

12. American Diabetes Association Professional Practice Committee. 8. Obesity and weight management for the prevention and treatment of type 2 diabetes: standards of medical care in diabetes—2022. Diabetes Care. 2022;45(Suppl_1):S113-S124. doi:10.2337/dc22-S008

13. Cockcroft EJ, Narendran P, Andrews RC. Exercise-induced hypoglycaemia in type 1 diabetes. Exp Physiol. 2020;105(4):590-599. doi:10.1113/EP088219

Author Bio

Emilie White, PharmD, is a clinical pharmacist with more than a decade of providing direct patient care to those who are hospitalized. She received her doctor of pharmacy degree from the Massachusetts College of Pharmacy and Health Sciences. After graduation, she completed a postgraduate pharmacy residency. Her background includes caring for critical care, internal medicine, and surgical patients.

Treatments for Diabetes (Nonpharmacologic)