2022+ADA／EASD共識報告：2型糖尿病高血糖的管理

Diabetologia

/10.1007/s00125-022-05787-2

CONSENSUSREPORT

Managementofhyperglycaemiaintype2diabetes,2022.AconsensusreportbytheAmericanDiabetesAssociation(ADA)andtheEuropeanAssociationfortheStudyofDiabetes(EASD)

MelanieJ.Davies1,2&VanitaR.Aroda3&BillyS.Collins4&RobertA.Gabbay5&JenniferGreen6&

NisaM.Maruthur7&SylviaE.Rosas8&StefanoDelPrato9&ChantalMathieu10&GeltrudeMingrone11,12,13&PeterRossing14,15&TsvetalinaTankova16&ApostolosTsapas17,18&JohnB.Buse19

Received:2August2022/Accepted:18August2022

#AmericanDiabetesAssociationandtheEuropeanAssociationfortheStudyofDiabetes2022

Abstract

TheAmericanDiabetesAssociationandtheEuropeanAssociationfortheStudyofDiabetesconvenedapaneltoupdatethepreviousconsensusstatementsonthemanagementofhyperglycaemiaintype2diabetesinadults,publishedsince2006andlastupdatedin2019.ThetargetaudienceisthefullspectrumoftheprofessionalhealthcareteamprovidingdiabetescareintheUSAandEurope.Asystematicexaminationofpublicationssince2018informednewrecommendations.Theseincludeadditionalfocusonsocialdeterminantsofhealth,thehealthcaresystemandphysicalactivitybehavioursincludingsleep.Thereisagreateremphasisonweightmanagementaspartoftheholisticapproachtodiabetesmanagement.Theresultsofcardiovascularandkidneyoutcomestrialsinvolvingsodium–glucosecotransporter-2inhibitorsandglucagon-likepeptide-1receptoragonists,includingassessmentofsubgroups,informbroaderrecommendationsforcardiorenalprotectioninpeoplewithdiabetesathighriskofcardiorenaldisease.Afterasummarylistingofconsensusrecommendations,practicaltipsforimplementationareprovided.

KeywordsCardiovasculardisease.Chronickidneydisease.Glucose-loweringtherapy.Guidelines.Heartfailure.Holisticcare.Person-centredcare.Socialdeterminantsofhealth.Type2diabetesmellitus.Weightmanagement

Abbreviations

ThisarticleisbeingsimultaneouslypublishedinDiabetologia(

https://

/10.1007/s00125-022-05787-2

)andDiabetesCare(

https://doi

.

org/10.2337/dci22-0034

)bytheEuropeanAssociationfortheStudyofDiabetesandAmericanDiabetesAssociation.

Aconsensusreportofaparticulartopiccontainsacomprehensiveexaminationandisauthoredbyanexpertpanelandrepresentsthepanel’scollectiveanalysis,evaluationandopinion.MJDandJBBwereco-chairsfortheConsensusReportWritingGroup.VRA,BSC,RAG,JG,NMMandSERwerethewritinggroupmembersforADA.SDP,CM,GM,PR,TTandATwerethewritinggroupmembersforEASD.ThearticlewasreviewedforEASDbyitsCommitteeonClinicalAffairsandapprovedbyitsExecutiveBoard.ThearticlewasreviewedforADAbyitsProfessionalPracticeCommittee.

*MelanieJ.Davies(forDiabetologia)melanie.davies@uhl-tr.nhs.uk

*JohnB.Buse(forDiabetesCare)jbuse@

Extendedauthorinformationavailableonthelastpageofthearticle

BGM

CGM

CSII

CVOT

DKA

DPP-4i

DSMES

ETD

GIPGLP-1RAHF

HHF

MACE

MNT

NAFLD

NASH

SGLT1i

Bloodglucosemonitoring

Continuousglucosemonitoring

ContinuoussubcutaneousinsulininfusionCardiovascularoutcomestrial

Diabeticketoacidosis

Dipeptidylpeptidase-4inhibitors

Diabetesself-managementeducationandsupport

Estimatedtreatmentdifference

Glucose-dependentinsulinotropicpolypeptideGlucagon-likepeptide-1receptoragonist(s)Heartfailure

Hospitalisationforheartfailure

Majoradversecardiovascularevents

Medicalnutritiontherapy

Non-alcoholicfattyliverdisease

Non-alcoholicsteatohepatitisSodium–glucosecotransporter-1inhibitor

Diabetologia

SGLT2i

TZD

UACR

Sodium–glucosecotransporter-2inhibitor(s)Thiazolidinedione

Urinaryalbumin/creatinineratio

Introduction

Type2diabetesisachroniccomplexdiseaseandmanagementrequiresmultifactorialbehaviouralandpharmacologicaltreat-mentstopreventordelaycomplicationsandmaintainqualityoflife(Fig.

1

).Thisincludesmanagementofbloodglucoselevels,weight,cardiovascularriskfactors,comorbiditiesandcomplications.Thisnecessitatesthatcarebedeliveredinanorganisedandstructuredway,suchasdescribedinthechroniccaremodel,andincludesaperson-centredapproachtoenhanceengagementinself-careactivities[

1

].Carefulconsid-erationofsocialdeterminantsofhealthandthepreferencesofpeoplelivingwithdiabetesmustinformindividualisationoftreatmentgoalsandstrategies[

2

].

Thisconsensusreportaddressestheapproachestomanage-mentofbloodglucoselevelsinnon-pregnantadultswithtype2diabetes.TheprinciplesandapproachforachievingthisaresummarisedinFig.

1

.Theserecommendationsarenotgener-allyapplicabletoindividualswithdiabetesduetoothercauses,forexamplemonogenicdiabetes,secondarydiabetesandtype1diabetes,ortochildren.

Datasources,searchesandstudyselection

ThewritinggroupmemberswereappointedbytheADAandEASD.Thegrouplargelyworkedvirtuallywithregulartelecon-ferencesfromSeptember2021,a3dayworkshopinJanuary2022andaface-to-face2daymeetinginApril2022.Thewritinggroupacceptedthe2012[

3

],2015[

4

],2018[

5

]and2019[

6

]editionsofthisconsensusreportasastartingpoint.Toidentifynewerevidence,asearchwasconductedonPubMedforRCTs,systematicreviewsandmeta-analysespublishedinEnglishbetween28January2018and13June2022;eligiblepublica-tionsexaminedtheeffectivenessorsafetyofpharmacologicalornon-pharmacologicalinterventionsinadultswithtype2diabe-tes.Referencelistsineligiblereportswerescannedtoidentifyadditionalrelevantarticles.Detailsofthekeywordsandthesearchstrategyareavailableat

/

datasets/h5rcnxpk8w/2

.Papersweregroupedaccordingtosubjectandtheauthorsreviewedthisnewevidence.Up-to-datemeta-analysesevaluatingtheeffectsoftherapeuticinterven-tionsacrossclinicallyimportantsubgrouppopulationswereassessedintermsoftheircredibilityusingrelevantguidance[

7

,

8

].EvidenceappraisalwasinformedbytheGradingofRecommendationsAssessment,DevelopmentandEvaluation(GRADE)guidelinesontheformulationofclinicalpracticerecommendations[

9

,

10

].Thedraftconsensus

recommendationswereevaluatedbyinvitedreviewersandpresentedforpubliccomment.Suggestionswereincorporatedasdeemedappropriatebytheauthors(seeAcknowledgements).Nevertheless,althoughevidencebasedwithstakeholderinput,therecommendationspresentedhereinreflectthevaluesandpreferencesoftheconsensusgroup.

Therationale,importanceandcontext

ofglucose-loweringtreatment

Fundamentalaspectsofdiabetescareincludepromotinghealthybehaviours,throughmedicalnutritiontherapy(MNT),physicalactivityandpsychologicalsupport,aswellasweightmanagementandtobacco/substanceabusecounsel-lingasneeded.Thisisoftendeliveredinthecontextofdiabe-tesself-managementeducationandsupport(DSMES).Theexpandingnumberofglucose-loweringinterventions—frombehaviouralinterventionstopharmacologicalinterventions,devicesandsurgery—andgrowinginformationabouttheirbenefitsandrisksprovidemoreoptionsforpeoplewithdiabe-tesandprovidersbutcomplicatedecisionmaking.Thedemonstratedbenefitsforhigh-riskindividualswithathero-scleroticCVD,heartfailure(HF)orchronickidneydisease(CKD)affordedbytheglucagon-likepeptide-1receptoragonists(GLP-1RA)andsodium–glucosecotransporter-2inhibitors(SGLT2i)provideimportantprogressintreatmentaimedatreducingtheprogressionandburdenofdiabetesanditscomplications.Thesebenefitsarelargelyindependentoftheirglucose-loweringeffects.Thesetreatmentswereinitiallyintroducedasglucose-loweringagentsbutarenowalsoprescribedfororganprotection.Inthisconsensusreport,wesummarisealargebodyofrecentevidenceforpractitionersintheUSAandEuropewiththeaimofsimplifyingclinicaldeci-sionmakingandfocusingoureffortsonprovidingholisticperson-centredcare.

Attainingrecommendedglycaemictargetsyieldssubstan-tialandenduringreductionsintheonsetandprogressionofmicrovascularcomplications[

11

,

12

]andearlyinterventionisessential[

13

].Thegreatestabsoluteriskreductioncomesfromimprovingveryelevatedglycaemiclevels,andamoremodestreductionresultsfromnearnormalisationofplasmaglucoselevels[

2

,

14

].Theimpactofglucosecontrolonmacrovascularcomplicationsislesscertainbutissupportedbymultiplemeta-analysesandepidemiologicalstudies.Becausethebene-fitsofintensiveglucosecontrolemergeslowlywhiletheharmscanbeimmediate,peoplewithlongerlifeexpectancyhavemoretogainfromearlyintensiveglycaemicmanage-ment.AreasonableHbA1ctargetformostnon-pregnantadultswithsufficientlifeexpectancytoseemicrovascularbenefits(generally~10years)isaround53mmol/mol(7%)orless[

2

].AimingforalowerHbA1clevelthanthismayhavevalueifitcanbeachievedsafelywithoutsignificanthypoglycaemiaor

Fig.1Decisioncycleforperson-centredglycaemicmanagementintype2diabetes.Adaptedfrom[5]withpermissionfromSpringerNature,?EuropeanAssociationfortheStudyofDiabetesand

AmericanDiabetesAssociation,2018

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Diabetologia

otheradversetreatmenteffects.Alowertargetmaybereason-able,particularlywhenusingpharmacologicalagentsthatarenotassociatedwithhypoglycaemicrisk.Highertargetscanbeappropriateincasesoflimitedlifeexpectancy,advancedcomplicationsorpoortolerabilityorifotherfactorssuchasfrailtyarepresent.Thus,glycaemictreatmenttargetsshouldbetailoredbasedonanindividual’spreferencesandcharac-teristics,includingyoungerage(i.e.age<40years),riskofcomplications,frailtyandcomorbidconditions[

2

,

15

–

17

],andtheimpactofthesefeaturesontheriskofadverseeffectsoftherapy(e.g.hypoglycaemiaandweightgain).

Principlesofcare

Languagematters

Communicationbetweenpeoplelivingwithtype2diabetesandhealthcareteammembersisatthecoreofintegratedcare,andcliniciansmustrecognisehowlanguagematters.Languageindiabetescareshouldbeneutral,freeofstigmaandbasedonfacts;bestrengths-based(focusonwhatiswork-ing),respectfulandinclusive;encouragecollaboration;andbeperson-centred[

18

].Peoplelivingwithdiabetesshouldnotbereferredtoas‘diabetics’ordescribedas‘non-compliant’orblamedfortheirhealthcondition.

Diabetesself-managementeducationandsupport

DSMESisakeyintervention,asimportanttothetreatmentplanastheselectionofpharmacotherapy[

19

–

21

].DSMESiscentraltoestablishingandimplementingtheprinciplesofcare(Fig.

1

).DSMESprogrammesusuallyinvolveface-to-facecontactingrouporindividualsessionswithtrainededucators,andkeycomponentsofDSMESareshowninSupplementaryTable1[

19

–

24

].Giventheever-changingnatureoftype2diabetes,DSMESshouldbeofferedonanongoingbasis.CriticaljunctureswhenDSMESshouldbeprovidedincludeatdiagnosis,annually,whencomplicationsarise,andduringtransitionsinlifeandcare(SupplementaryTable1)[

22

].

High-qualityevidencehasconsistentlyshownthatDSMESsignificantlyimprovesknowledge,glycaemiclevelsandclin- icalandpsychologicaloutcomes,reduceshospitaladmissionsandall-causemortalityandiscost-effective[

22

,

25

–

30

].DSMESisdeliveredthroughstructurededucationalprogrammesprovidedbytraineddiabetescareandeducationspecialists(termedDCESintheUSA;hereafterreferredtoas‘diabeteseducators’)thatfocusparticularlyonthefollowing: lifestylebehaviours(healthyeating,physicalactivityandweightmanagement),medication-takingbehaviour,self-monitoringwhenneeded,self-efficacy,copingandproblemsolving.

Importantly,DSMESistailoredtotheindividual’scontext,whichincludestheirbeliefsandpreferences.DSMEScanbeprovidedusingmultipleapproachesandinavarietyofsettings[

20

,

31

]anditisimportantforthecareteamtoknowhowtoaccesslocalDSMESresources.DSMESsupportsthepsycho-socialcareofpeoplewithdiabetesbutisnotareplacementforreferralformentalhealthserviceswhentheyarewarranted,forexamplewhendiabetesdistressremainsafterDSMES.Psychiatricdisorders,includingdisorderedeatingbehaviours,arecommon,oftenunrecognisedandcontributetopooroutcomesindiabetes[

32

].

ThebestoutcomesfromDSMESareachievedthroughprogrammeswithatheory-basedandstructuredcurriculumandwithcontacttimeofover10h[

26

].Whileonlineprogrammesmayreinforcelearning,acomprehensiveapproachtoeducationusingmultiplemethodsmaybemoreeffective[

26

].Emergingevidencedemonstratesthebenefitsoftelehealthorweb-basedDSMESprogrammes[

33

]andthesewereusedwithsuccessduringtheCOVID-19pandemic[

34

–

36

].Technologiessuchasmobileapps,simulationtools,digitalcoachinganddigitalself-managementinterventions

canbeusedtodeliverDSMESandextenditsreachtoa

broadersegmentofthepopulationwithdiabetesandprovidecomparableorevenbetteroutcomes[

37

].GreaterHbA1creductionsaredemonstratedwithincreasedengagementofpeoplewithdiabetes[

35

,

38

].However,datafromtrialsofdigitalstrategiestosupportbehaviourchangearestillprelim-inaryinnatureandquiteheterogeneous[

22

,

37

].

Individualisedandpersonalisedapproach

Type2diabetesisaveryheterogeneousdiseasewithvariableageatonset,relateddegreeofobesity,insulinresistanceandtendencytodevelopcomplications[

39

,

40

].Providingperson-centredcarethataddressesmultimorbidityandisrespectfulofandresponsivetoindividualpreferencesandbarriers,includingthedifferentialcostsoftherapies,isessen-tialforeffectivediabetesmanagement[

41

].Shareddecisionmaking,facilitatedbydecisionaidsthatshowtheabsolutebenefitandriskofalternativetreatmentoptions,isausefulstrategytodeterminethebesttreatmentcourseforanindivid-ual[

42

–

45

].WithcompellingindicationsfortherapiessuchasSGLT2iandGLP-1RAforhigh-riskindividualswithCVD,HForCKD,shareddecisionmakingisessentialtocontextualisetheevidenceonbenefits,safetyandrisks.Providersshouldevaluatetheimpactofanysuggestedinter-ventioninthecontextofcognitiveimpairment,limitedlitera-cy,distinctculturalbeliefsandindividualfearsorhealthconcerns.Thehealthcaresystemisanimportantfactorintheimplementation,evaluationanddevelopmentofthepersonalisedapproach.Furthermore,socialdeterminantsofhealth—oftenoutofdirectcontroloftheindividualandpoten-tiallyrepresentinglifelongrisk—contributetomedicaland

Diabetologia

psychosocialoutcomesandmustbeaddressedtoimprovehealthoutcomes.Fivesocialdeterminantsofhealthareashavebeenidentified:socioeconomicstatus(education,incomeandoccupation),livingandworkingconditions,multisectordomains(e.g.housing,educationandcriminaljusticesystem),socioculturalcontext(e.g.sharedculturalvalues,practicesandexperiences)andsociopoliticalcontext(e.g.societalandpolit-icalnormsthatarerootcauseideologiesandpoliciesunderly-inghealthdisparities)[

46

].Moregranularityonsocialdetermi-nantsofhealthastheypertaintodiabetesisprovidedinarecentADAreview[

47

],withaparticularfocusontheissuesfacedintheAfricanAmericanpopulationprovidedinasubsequentreport[

48

].Environmental,social,behaviouralandemotionalfactors,knownaspsychosocialfactors,alsoinfluencelivingwithdiabetesandachievingsatisfactorymedicaloutcomesandpsychologicalwell-being.Thus,thesemultifaceteddomains(heterogeneityacrossindividualcharacteristics,socialdeterminantsofhealthandpsychosocialfactors)challengeindi-vidualswithdiabetes,theirfamiliesandtheirproviderswhenattemptingtointegratediabetescareintodailylife[

49

].

Currentprinciplesof,andapproachesto,person-centredcareindiabetes(Fig.

1

)includeassessingkeycharacteristicsandpreferencestodetermineindividualisedtreatmentgoalsandstrategies.Suchcharacteristicsincludecomorbidities,clinicalcharacteristicsandcompellingindicationsforGLP-1RAorSGLT2ifororganprotection[

6

].

Weightreductionasatargetedintervention

WeightreductionhasmostlybeenseenasastrategytoimproveHbA1candreducetheriskforweight-relatedcompli-cations.However,itwasrecentlysuggestedthatweightlossof5–15%shouldbeaprimarytargetofmanagementformanypeoplelivingwithtype2diabetes[

50

].Ahighermagnitudeofweightlossconfersbetteroutcomes.Weightlossof5–10%confersmetabolicimprovement;weightlossof10–15%ormorecanhaveadisease-modifyingeffectandleadtoremis-sionofdiabetes[

50

],definedasnormalbloodglucoselevelsfor3monthsormoreintheabsenceofpharmacologicalther-apyina2021consensusreport[

51

].Weightlossmayexertbenefitsthatextendbeyondglycaemicmanagementtoimproveriskfactorsforcardiometabolicdiseaseandqualityoflife[

50

].

Glucosemanagement:monitoring

GlycaemicmanagementisprimarilyassessedwiththeHbA1ctest,whichwasthemeasureusedintrialsdemonstratingthebenefitsofglucoselowering[

2

,

52

].Aswithanylaboratorytest,HbA1cmeasurementhaslimitations[

2

,

52

].TheremaybediscrepanciesbetweenHbA1cresultsandanindividual’struemeanbloodglucoselevels,particularlyincertainracialandethnicgroupsandinconditionsthataltererythrocyte

turnover,suchasanaemia,end-stagekidneydisease(espe-ciallywitherythropoietintherapy)andpregnancy,orifanHbA1cassayinsensitivetohaemoglobinvariantsisusedinsomeonewithahaemoglobinopathy.DiscrepanciesbetweenmeasuredHbA1clevelsandmeasuredorreportedglucoselevelsshouldpromptconsiderationthatoneofthesemaynotbereliable[

52

,

53

].

Regularbloodglucosemonitoring(BGM)mayhelpwithself-managementandmedicationadjustment,particularlyinindividualstakinginsulin.BGMplansshouldbeindividualised.Peoplewithtype2diabetesandthehealthcareteamshouldusethemonitoringdatainaneffectiveandtimelymanner.Inpeoplewithtype2diabetesnotusinginsulin,routineglucosemonitoringisoflimitedadditionalclinicalbenefitwhileaddingburdenandcost[

54

,

55

].However,forsomeindividuals,glucosemonitoringcanprovideinsightintotheimpactoflifestyleandmedicationmanagementonbloodglucoseandsymptoms,particularlywhencombinedwitheducationandsupport[

53

].Technologiessuchasintermittent-lyscannedorreal-timecontinuousglucosemonitoring(CGM)providemoreinformationandmaybeusefulforpeoplewithtype2diabetes,particularlyinthosetreatedwithinsulin[

53

,

56

].

WhenusingCGM,standardised,singleglucosereports,suchastheambulatoryglucoseprofile,canbeuploadedfromCGMdevices.TheyshouldbeconsideredasstandardmetricsforallCGMdevicesandprovidevisualcuesformanagementopportunities.TimeinrangeisdefinedasthepercentageoftimethatCGMreadingsareintherange3.9–10.0mmol/l(70–180mg/dl).Timeinrangeisassociatedwiththeriskofmicrovascularcomplicationsandcanbeusedforassessmentofglycaemicmanagement[

57

].Additionally,timeaboveandbelowrangeareusefulvariablesfortheeval-uationoftreatmentregimens.Particularattentiontominimisingthetimebelowrangeinthosewithhypoglycaemiaunawarenessmayconveybenefit.Ifusingtheambulatoryglucoseprofiletoassessglycaemicmanagement,agoalparal-leltoanHbA1clevelof<53mmol/mol(<7%)formanyistimeinrangeof>70%,withadditionalrecommendationstoaimfortimebelowrangeof<4%andtimeat<3.0mmol/l(<54mg/dl)of<1%[

2

].

Treatmentbehaviours,persistenceandadherence

Suboptimalmedication-takingbehaviourandlowratesofcontinuedmedicationuse,orwhatistermed‘persistencetotherapyplans’affectsalmosthalfofpeoplewithtype2diabe-tes,leadingtosuboptimalglycaemicandCVDriskfactorcontrolaswellasincreasedrisksofdiabetescomplications,mortalityandhospitaladmissionsandincreasedhealthcarecosts[

58

–

62

].Althoughthisconsensusreportfocusesonmedication-takingbehaviour,theprinciplesarepertinenttoallaspectsofdiabetescare.Multiplefactorscontributeto

Diabetologia

inconsistentmedicationuseandtreatmentdiscontinuationamongpeoplewithdiabetes,includingperceivedlackofmedicationefficacy,fearofhypoglycaemia,lackofaccesstomedicationandadverseeffectsofmedication[

63

].Focusingonfacilitatorsofadherence,suchassocial/family/providersupport,motivation,educationandaccesstomedi-cations/foods,canprovidebenefits[

64

].Observedratesofmedicationadherenceandpersistencevaryacrossmedicationclassesandbetweenagents;carefulconsiderationofthesedifferencesmayhelpimproveoutcomes[

61

].Ultimately,individualpreferencesaremajorfactorsdrivingthechoiceofmedications.Evenwhenclinicalcharacteristicssuggesttheuseofaparticularmedicationbasedontheavailableevidencefromclinicaltrials,preferencesregardingrouteofadministra-tion,injectiondevices,sideeffectsorcostmaypreventusebysomeindividuals[

65

].

Therapeuticinertia

Therapeutic(orclinical)inertiadescribesalackoftreatmentintensificationwhentargetsorgoalsarenotmet.Italsoincludesfailuretode-intensifymanagementwhenpeopleareovertreated.Thecausesoftherapeuticinertiaaremultifactori-al,occurringatthelevelsofthepractitioner,personwithdiabetesand/orhealthcaresystem[

66

].Interventionstargetingtherapeuticinertiahavefacilitatedimprovementsinglycaemicmanagementandtimelyinsulinintensification[

67

,

68

].Forexample,theinvolvementofmultidisciplinaryteamsthatincludenon-physicianproviderswithauthorisationtoprescribe(e.g.pharmacists,specialistnursesandadvancedpracticeproviders)mayreducetherapeuticinertia[

69

,

70

].

Therapeuticoptions:lifestyleandhealthybehaviour,weightmanagement

andpharmacotherapyforthetreatment

oftype2diabetes

Thissectionsummarisesthelifestyleandbehaviouralther-apy,weightmanagementinterventionsandpharmacother-apythatsupportglycaemicmanagementinpeoplewithtype2diabetes.SpecificpharmacologicaltreatmentoptionsaresummarisedinTable

1

.AdditionaldetailsareavailableinthepreviousADA/EASDconsensusreportandupdate[

5

,

6

]andtheADA’s2022Standardsofmedicalcareindiabetes[

71

].

Nutritiontherapy

Nutritiontherapyisintegraltodiabetesmanagement,withgoalsofpromotingandsupportinghealthyeatingpatterns,addressingindividualnutritionneeds,maintainingtheplea-sureofeatingandprovidingthepersonwithdiabeteswith

thetoolsfordevelopinghealthyeating[

22

].MNTprovidedbyaregistereddietitian/registereddietitiannutritionistcomplementsDSMES,cansignificantlyreduceHbA1candcanhelpprevent,delayandtreatcomorbiditiesrelatedtodiabetes[

19

].TwocoredimensionsofMNTthatcanimproveglycaemicmanagementincludedietaryqualityandenergyrestriction.

Dietaryqualityandeatingpatterns

Thereisnosingleratioofcarbohydrate,proteinsandfatintakethatisoptimalforeverypersonwithtype2diabe-tes.Instead,individuallyselectedeatingpatternsthatemphasisefoodswithdemonstratedhealthbenefits,mini-misefoodsshowntobeharmfulandaccommodateindi-vidualpreferenceswiththegoalofidentifyinghealthydietaryhabitsthatarefeasibleandsustainablearerecom-mended.Anetenergydeficitthatcanbemaintainedisimportantforweightloss[

5

,

6

,

22

,

72

–

74

].

Anetworkanalysiscomparingtrialsofninedietaryapproachesof>12weeks’durationdemonstratedreduc-tionsinHbA1cfrom?9to?5.1mmol/mol(?0.82%to?0.47%),withallapproachescomparedwithacontroldiet.GreaterglycaemicbenefitswereseenwiththeMediterraneandietandlowcarbohydratediet[

75

].Thegreaterglycaemicbenefitsoflowcarbohydratediets(<26%ofenergy)at3and6monthsarenotevidentwithlongerfollow-up[

72

].Inasystematicreviewoftrialsof>6months’duration,comparedwithalow-fatdiet,theMediterraneandietdemonstratedgreaterreductionsinbodyweightandHbA1clevels,delayedtherequirementfordiabetesmedicationandprovidedbenefitsforcardio-vascularhealth[

76

,

77

].Similarbenefitshavebeenascribedtoveganandvegetariandiets[

78

].

Therehasbeenincreasedinterestintime-restrictedeatingandintermittentfastingtoimprovemetabolicvari-ables,althoughwithmixed,andmodest,results.Inameta-analysistherewerenodifferencesintheeffectofintermittentfastingandcontinuousenergyrestrictiononHbA1c,withintermittentfastinghavingamodesteffectonweight(?1.70kg)[

79

].Ina12monthRCTinadultswithtype2diabetescomparingintermittentenergyrestriction(2092–2510kJ[500–600kcal]dietfor2non-consecutivedays/weekfollowedbytheusualdietfor5days/week)withcontinuousenergyrestriction(5021–6276kJ[1200–1500kcal]dietfor7days/week),glycaemicimprovementswerecomparablebetweenthetwogroups.At24months’follow-up,HbA1cincreasedinbothgroupstoabovebaseline[

80

],whileweightloss(?3.9kg)wasmaintainedinbothgroups[

81

].Fastingmayincreasetheratesofhypoglycaemiainthosetreatedwithinsulinandsulfonylureas,highlightingtheneedforindividualised

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Table1Medicationsforloweringglucose,summaryofcharacteristics

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educationandproactivemedicationmanagementduringsignificantdietarychanges[

82

].

Non-surgicalenergyrestrictionforweightloss

Anoverallhealthyeatingplanthatresultsinanenergydeficit,inconjunctionwithmedicationsand/ormetabolicsurgeryasindividuallyappropriate,shouldbeconsideredtosupportglycaemicandweightmanagementgo