Diet and exercise are a fundamental part of comprehensive care for type 2 diabetes

IF 3.2 3区 医学
Yun Kai Yeh, Fu-Shun Yen, Chii-Min Hwu
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Among various lifestyle modifications, dietary adjustments and exercise hold significant importance in the management of type 2 diabetes mellitus, offering numerous benefits such as improved glycated hemoglobin (HbA1c) levels and a reduced risk of cardiovascular events.</p><p>Appropriate medical nutrition therapy has been shown to reduce HbA1c levels by 0.3–2.0% in patients with type 2 diabetes mellitus<span><sup>1</sup></span>. Even after initiating medication, nutrition therapy continues to play a crucial role in the overall management of diabetes. In an animal study involving mice, it was observed that the use of sodium–glucose cotransporter 2 inhibitors (SGLT-2i) in conjunction with controlled feeding led to weight loss and a decrease in hepatic gluconeogenic response. However, these effects were diminished in a group of mice with unrestricted access to food<span><sup>2</sup></span>. This suggests that dietary control remains essential when combined with glucose-lowering medications such as SGLT-2i for optimal glycemic control.</p><p>Currently, there is no specific recommendation for the ideal percentage of calories from carbohydrates, proteins, and fats for individuals with diabetes based on existing evidence. Instead, the emphasis is on developing individualized nutrition plans. While there is no specific ideal percentage for the nutritional components in the diet of individuals with type 2 diabetes mellitus, there are general recommendations that can be followed. These recommendations emphasize the importance of consuming non-starchy vegetables, minimizing the intake of added sugars and refined grain, and opting for whole foods instead of highly processed foods<span><sup>3, 4</sup></span>. Some studies have revealed that exogenous ketone ingestion would decrease the blood sugar level which may be related to an increase of early phase insulin<span><sup>5, 6</sup></span>. Still, evidence for prolonged ketone ingestion for blood glucose is limited<span><sup>6</sup></span>. There are also several eating patterns that have been proposed for individuals with type 2 diabetes mellitus. These include the Mediterranean diet, low-carbohydrate diet, fiber-rich diet, intermittent very-low-calorie diet, and vegetarian or plant-based diet (Table 1)<span><sup>7-16</sup></span>. Some of these eating patterns have also been associated with a lower risk of developing type 2 diabetes mellitus in healthy individuals<span><sup>8, 10</sup></span>.</p><p>Excessive alcohol intake should be avoided in individuals with type 2 diabetes mellitus due to several reasons. First, it increases the risk of hypoglycemia in patients with type 2 diabetes mellitus. Furthermore, alcohol consumption has been associated with impaired fasting glucose in non-diabetic individuals. This suggests that alcohol may disrupt glucose homeostasis and lead to fluctuations in blood glucose levels<span><sup>7, 17</sup></span>.</p><p>To determine individual nutrition needs in individuals with type 2 diabetes mellitus requires the consideration of various factors. These factors include the patient's age, body weight, appetite, presence of diabetic complications, co-morbidities, overall health status, cultural food preferences, existing barriers to dietary changes, and access to healthy food options. Nutritional education and intervention play a vital role in the management of type 2 diabetes mellitus. Evidence has shown that frequent nutrition education or interventions can reduce the risk for diabetic kidney disease in patients with type 2 diabetes mellitus<span><sup>18</sup></span>. Additionally, providing nutritional counseling can help to decrease the discontinuation rate of physician visits in newly diagnosed diabetes patients<span><sup>19</sup></span>. In a study, dietary interventions with the support of dieticians have been shown to improve dietary habits and to reduce calorie intake in patients with type 2 diabetes mellitus<span><sup>20</sup></span>. Therefore, diet control is an integral part of the comprehensive care of individuals with type 2 diabetes mellitus, and the involvement of dieticians in the management of patients with diabetes is crucial. Dieticians can provide personalized nutritional guidance, monitor dietary changes, and help patients to make sustainable modifications to their eating habits.</p><p>In addition to diet control, exercise plays an important role in the management of type 2 diabetes mellitus. Previous study has shown that an exercise intervention of at least 8 weeks can lead to an average reduction of 0.66% in HbA1c levels in individuals with type 2 diabetes mellitus<span><sup>21</sup></span>. Regular exercise not only improves blood glucose levels but also reduces cardiovascular risk factors and contributes to weight loss. Moreover, physical activity also demonstrated the benefits for diabetic neuropathy in a previous study<span><sup>22</sup></span>. In that study, type 2 diabetes mellitus was associated with neuropathy and a progressive loss of corneal nerve fibers. However, engaging in physical activity has been found to prevent significant corneal nerve fiber loss in individuals with type 2 diabetes mellitus. Therefore, it is important to avoid prolonged sedentary time and to maintain regular physical activity in patients with diabetes.</p><p>Current guidelines suggest that most adults with type 2 diabetes mellitus should engage in at least 150 min of moderate to intensive exercise spread over at least 3 days per week<span><sup>7</sup></span>. It is advised to avoid more than 2 consecutive days without exercise. Additionally, individualized exercise intensity is encouraged, taking into account factors such as age, co-morbidities, diabetic complications, health status, and exercise preferences. For example, individuals with proliferative diabetic retinopathy should avoid vigorous exercise due to the risk of vitreous hemorrhage.</p><p>A study conducted on elderly pre-diabetic patients found that the type of exercise did not significantly affect the glucose response to exercise<span><sup>23</sup></span>. However, it was observed that initial poor HbA1c levels and a high body mass index were associated with a poor response to exercise in terms of blood glucose tolerance and HbA1c reduction. Therefore, in addition to exercise, weight management and glycemic control remain essential aspects of the management of type 2 diabetes mellitus.</p><p>While exercise is essential for glycemic control, it can also lead to hypoglycemia. Patients with autonomous neuropathy or those using insulin or insulin secretagogues are at a higher risk of experiencing hypoglycemia after exercise. If the pre-exercise blood glucose level is below 90 mg/dL, carbohydrate supplementation, and lowering the dosage of insulin or of insulin secretagogues should be considered<span><sup>24</sup></span>.</p><p>In conclusion, there are numerous concepts and new approaches in the treatment of type 2 diabetes mellitus. Lifestyle modifications, particularly dietary adjustments and exercise, remain foundational components alongside the wide array of novel glucose-lowering medications. However, there is no universally ideal diet that suits every patient. Current evidence emphasizes the importance of individualized plans for diet and exercise tailored to each individual's specific needs.</p><p>The authors declare no conflict of interest.</p><p>Approval of the research protocol: N/A.</p><p>Informed consent: N/A.</p><p>Registry and the registration no. of the study/trial: N/A.</p><p>Animal studies: N/A.</p>","PeriodicalId":190,"journal":{"name":"Journal of Diabetes Investigation","volume":"14 8","pages":"936-939"},"PeriodicalIF":3.2000,"publicationDate":"2023-06-20","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://onlinelibrary.wiley.com/doi/epdf/10.1111/jdi.14043","citationCount":"1","resultStr":null,"platform":"Semanticscholar","paperid":null,"PeriodicalName":"Journal of Diabetes Investigation","FirstCategoryId":"3","ListUrlMain":"https://onlinelibrary.wiley.com/doi/10.1111/jdi.14043","RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":null,"EPubDate":"","PubModel":"","JCR":"","JCRName":"","Score":null,"Total":0}
引用次数: 1

Abstract

In this modern era, numerous innovative glucose-lowering medications have emerged, leading to a wide range of treatment options for type 2 diabetes mellitus. While pharmacologic interventions are crucial for achieving glycemic control in type 2 diabetes mellitus, it is essential to recognize the fundamental role of lifestyle modifications in attaining glycemic targets. Among various lifestyle modifications, dietary adjustments and exercise hold significant importance in the management of type 2 diabetes mellitus, offering numerous benefits such as improved glycated hemoglobin (HbA1c) levels and a reduced risk of cardiovascular events.

Appropriate medical nutrition therapy has been shown to reduce HbA1c levels by 0.3–2.0% in patients with type 2 diabetes mellitus1. Even after initiating medication, nutrition therapy continues to play a crucial role in the overall management of diabetes. In an animal study involving mice, it was observed that the use of sodium–glucose cotransporter 2 inhibitors (SGLT-2i) in conjunction with controlled feeding led to weight loss and a decrease in hepatic gluconeogenic response. However, these effects were diminished in a group of mice with unrestricted access to food2. This suggests that dietary control remains essential when combined with glucose-lowering medications such as SGLT-2i for optimal glycemic control.

Currently, there is no specific recommendation for the ideal percentage of calories from carbohydrates, proteins, and fats for individuals with diabetes based on existing evidence. Instead, the emphasis is on developing individualized nutrition plans. While there is no specific ideal percentage for the nutritional components in the diet of individuals with type 2 diabetes mellitus, there are general recommendations that can be followed. These recommendations emphasize the importance of consuming non-starchy vegetables, minimizing the intake of added sugars and refined grain, and opting for whole foods instead of highly processed foods3, 4. Some studies have revealed that exogenous ketone ingestion would decrease the blood sugar level which may be related to an increase of early phase insulin5, 6. Still, evidence for prolonged ketone ingestion for blood glucose is limited6. There are also several eating patterns that have been proposed for individuals with type 2 diabetes mellitus. These include the Mediterranean diet, low-carbohydrate diet, fiber-rich diet, intermittent very-low-calorie diet, and vegetarian or plant-based diet (Table 1)7-16. Some of these eating patterns have also been associated with a lower risk of developing type 2 diabetes mellitus in healthy individuals8, 10.

Excessive alcohol intake should be avoided in individuals with type 2 diabetes mellitus due to several reasons. First, it increases the risk of hypoglycemia in patients with type 2 diabetes mellitus. Furthermore, alcohol consumption has been associated with impaired fasting glucose in non-diabetic individuals. This suggests that alcohol may disrupt glucose homeostasis and lead to fluctuations in blood glucose levels7, 17.

To determine individual nutrition needs in individuals with type 2 diabetes mellitus requires the consideration of various factors. These factors include the patient's age, body weight, appetite, presence of diabetic complications, co-morbidities, overall health status, cultural food preferences, existing barriers to dietary changes, and access to healthy food options. Nutritional education and intervention play a vital role in the management of type 2 diabetes mellitus. Evidence has shown that frequent nutrition education or interventions can reduce the risk for diabetic kidney disease in patients with type 2 diabetes mellitus18. Additionally, providing nutritional counseling can help to decrease the discontinuation rate of physician visits in newly diagnosed diabetes patients19. In a study, dietary interventions with the support of dieticians have been shown to improve dietary habits and to reduce calorie intake in patients with type 2 diabetes mellitus20. Therefore, diet control is an integral part of the comprehensive care of individuals with type 2 diabetes mellitus, and the involvement of dieticians in the management of patients with diabetes is crucial. Dieticians can provide personalized nutritional guidance, monitor dietary changes, and help patients to make sustainable modifications to their eating habits.

In addition to diet control, exercise plays an important role in the management of type 2 diabetes mellitus. Previous study has shown that an exercise intervention of at least 8 weeks can lead to an average reduction of 0.66% in HbA1c levels in individuals with type 2 diabetes mellitus21. Regular exercise not only improves blood glucose levels but also reduces cardiovascular risk factors and contributes to weight loss. Moreover, physical activity also demonstrated the benefits for diabetic neuropathy in a previous study22. In that study, type 2 diabetes mellitus was associated with neuropathy and a progressive loss of corneal nerve fibers. However, engaging in physical activity has been found to prevent significant corneal nerve fiber loss in individuals with type 2 diabetes mellitus. Therefore, it is important to avoid prolonged sedentary time and to maintain regular physical activity in patients with diabetes.

Current guidelines suggest that most adults with type 2 diabetes mellitus should engage in at least 150 min of moderate to intensive exercise spread over at least 3 days per week7. It is advised to avoid more than 2 consecutive days without exercise. Additionally, individualized exercise intensity is encouraged, taking into account factors such as age, co-morbidities, diabetic complications, health status, and exercise preferences. For example, individuals with proliferative diabetic retinopathy should avoid vigorous exercise due to the risk of vitreous hemorrhage.

A study conducted on elderly pre-diabetic patients found that the type of exercise did not significantly affect the glucose response to exercise23. However, it was observed that initial poor HbA1c levels and a high body mass index were associated with a poor response to exercise in terms of blood glucose tolerance and HbA1c reduction. Therefore, in addition to exercise, weight management and glycemic control remain essential aspects of the management of type 2 diabetes mellitus.

While exercise is essential for glycemic control, it can also lead to hypoglycemia. Patients with autonomous neuropathy or those using insulin or insulin secretagogues are at a higher risk of experiencing hypoglycemia after exercise. If the pre-exercise blood glucose level is below 90 mg/dL, carbohydrate supplementation, and lowering the dosage of insulin or of insulin secretagogues should be considered24.

In conclusion, there are numerous concepts and new approaches in the treatment of type 2 diabetes mellitus. Lifestyle modifications, particularly dietary adjustments and exercise, remain foundational components alongside the wide array of novel glucose-lowering medications. However, there is no universally ideal diet that suits every patient. Current evidence emphasizes the importance of individualized plans for diet and exercise tailored to each individual's specific needs.

The authors declare no conflict of interest.

Approval of the research protocol: N/A.

Informed consent: N/A.

Registry and the registration no. of the study/trial: N/A.

Animal studies: N/A.

饮食和运动是2型糖尿病综合护理的基本组成部分
在这个现代时代,许多创新的降糖药物已经出现,导致广泛的治疗2型糖尿病的选择。虽然药物干预对于实现2型糖尿病的血糖控制至关重要,但必须认识到生活方式改变在达到血糖目标方面的基本作用。在各种生活方式的改变中,饮食调整和运动对2型糖尿病的管理具有重要意义,提供了许多好处,如改善糖化血红蛋白(HbA1c)水平和降低心血管事件的风险。适当的药物营养治疗已被证明可使2型糖尿病患者的HbA1c水平降低0.3-2.0% 1。即使在开始药物治疗后,营养治疗在糖尿病的整体管理中仍然发挥着至关重要的作用。在一项涉及小鼠的动物研究中,观察到使用钠-葡萄糖共转运蛋白2抑制剂(SGLT-2i)结合控制喂养导致体重减轻和肝脏糖异生反应减少。然而,在一组不受限制地获得食物的小鼠中,这些影响减弱了。这表明,当与SGLT-2i等降糖药物联合使用时,饮食控制仍然是必要的,以达到最佳的血糖控制。目前,根据现有的证据,对于糖尿病患者从碳水化合物、蛋白质和脂肪中摄取的卡路里的理想百分比没有具体的建议。相反,重点是制定个性化的营养计划。虽然对于2型糖尿病患者的饮食中营养成分的理想比例没有具体的规定,但有一些一般的建议可以遵循。这些建议强调食用非淀粉类蔬菜的重要性,尽量减少添加糖和精制谷物的摄入量,选择天然食物而不是高度加工的食物3,4。有研究表明外源性酮类摄入会降低血糖水平,这可能与早期胰岛素升高有关5,6。尽管如此,长期摄入酮类以提高血糖的证据还是有限的。还有几种针对2型糖尿病患者的饮食模式。这些饮食包括地中海饮食、低碳水化合物饮食、富含纤维的饮食、间歇性极低热量饮食和素食或植物性饮食(表1)7-16。其中一些饮食模式还与健康个体患2型糖尿病的风险较低有关8,10。由于几个原因,2型糖尿病患者应避免过量饮酒。首先,它增加了2型糖尿病患者低血糖的风险。此外,在非糖尿病患者中,饮酒与空腹血糖受损有关。这表明酒精可能会破坏葡萄糖稳态,导致血糖水平波动7,17。确定2型糖尿病患者的个人营养需求需要考虑多种因素。这些因素包括患者的年龄、体重、食欲、是否存在糖尿病并发症、合并症、总体健康状况、文化饮食偏好、饮食改变的现有障碍以及获得健康食品选择的机会。营养教育和干预在2型糖尿病的治疗中起着至关重要的作用。有证据表明,频繁的营养教育或干预可以降低2型糖尿病患者患糖尿病肾病的风险18。此外,提供营养咨询有助于降低新诊断的糖尿病患者的停诊率。在一项研究中,在营养师的支持下,饮食干预已被证明可以改善2型糖尿病患者的饮食习惯,减少热量摄入。因此,饮食控制是2型糖尿病患者综合护理的一个组成部分,营养师参与糖尿病患者的管理是至关重要的。营养师可以提供个性化的营养指导,监测饮食变化,并帮助患者对饮食习惯进行可持续的调整。除了控制饮食外,运动在2型糖尿病的治疗中也起着重要作用。先前的研究表明,至少8周的运动干预可以使2型糖尿病患者的HbA1c水平平均降低0.66%。有规律的运动不仅能改善血糖水平,还能减少心血管疾病的危险因素,有助于减肥。此外,在之前的一项研究中,体育锻炼也证明了对糖尿病神经病变的益处22。 在该研究中,2型糖尿病与神经病变和角膜神经纤维的进行性丧失有关。然而,从事体育活动已被发现可以防止2型糖尿病患者角膜神经纤维的显著丧失。因此,糖尿病患者应避免长时间久坐,保持规律的身体活动。目前的指南建议,大多数2型糖尿病成人患者应每周至少3天进行至少150分钟的中等至高强度运动7。建议避免连续2天以上不运动。此外,鼓励个性化的运动强度,考虑到年龄、合并症、糖尿病并发症、健康状况和运动偏好等因素。例如,患有增殖性糖尿病视网膜病变的个体应避免剧烈运动,因为有玻璃体出血的风险。一项针对老年糖尿病前期患者的研究发现,运动类型对血糖对运动的反应没有显著影响23。然而,研究发现,在血糖耐量和HbA1c降低方面,初始低HbA1c水平和高体重指数与运动反应差有关。因此,除了运动外,体重管理和血糖控制仍然是2型糖尿病管理的重要方面。虽然运动对控制血糖至关重要,但它也会导致低血糖。患有自主神经病变或使用胰岛素或胰岛素分泌剂的患者在运动后出现低血糖的风险更高。如果运动前血糖水平低于90 mg/dL,应考虑补充碳水化合物,并降低胰岛素或胰岛素促分泌剂的剂量24。总之,在2型糖尿病的治疗中有许多概念和新方法。生活方式的改变,特别是饮食的调整和锻炼,仍然是各种新型降糖药物的基本组成部分。然而,没有一种普遍适用于所有病人的理想饮食。目前的证据强调了根据每个人的具体需要量身定制饮食和锻炼计划的重要性。作者声明无利益冲突。研究方案的批准:无。知情同意:无。注册表及注册编号研究/试验:无。动物研究:无。
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来源期刊
Journal of Diabetes Investigation
Journal of Diabetes Investigation Medicine-Internal Medicine
自引率
9.40%
发文量
218
期刊介绍: Journal of Diabetes Investigation is your core diabetes journal from Asia; the official journal of the Asian Association for the Study of Diabetes (AASD). The journal publishes original research, country reports, commentaries, reviews, mini-reviews, case reports, letters, as well as editorials and news. Embracing clinical and experimental research in diabetes and related areas, the Journal of Diabetes Investigation includes aspects of prevention, treatment, as well as molecular aspects and pathophysiology. Translational research focused on the exchange of ideas between clinicians and researchers is also welcome. Journal of Diabetes Investigation is indexed by Science Citation Index Expanded (SCIE).
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