Lifestyle Interventions for Treatment and Remission of Type 2 Diabetes and Prediabetes in Adults: Implications for Clinicians

Abstract

This review is based on a presentation at the 2024 Annual Meeting of the American College of Lifestyle Medicine (ACLM), which showcased ACLM’s first clinical practice guideline on Lifestyle Interventions for Treatment and Remission of Type 2 Diabetes and Prediabetes in Adults. Our goal is to offer pragmatic implications of the guideline for everyday patient care, including case presentations showing how the guideline recommendations (key action statements) can be implemented. The target audience is any clinician or healthcare professional in a community or outpatient healthcare setting involved in managing non-pregnant adults with T2D, prediabetes or a history of gestational diabetes mellitus (GDM). Unique features of the ACLM guideline include placing lifestyle interventions as the foundation of T2D management and prevention, offering strategies for sustained behavior change, and emphasizing all six pillars of lifestyle medicine: plant-predominant nutrition, regular physical activity, restorative sleep, stress reduction, social connectedness, and avoiding risky substances. This review is not intended to substitute for the full guideline, which should be read before doing the recommended actions.

“Lifestyle interventions can reduce the risk of gestational diabetes progressing to T2D.”

Introduction

This review summarizes pragmatic implications of Lifestyle Interventions for Treatment and Remission of Type 2 Diabetes and Prediabetes in Adults, A Clinical Practice Guideline (CPG) from the American College of Lifestyle Medicine (ACLM). ¹ Content from the guideline was first showcased at the ACLM’s annual meeting in 2024 by the authors as the chair (RMR) and assistant chairs (MLG, MG) responsible for leading the multidisciplinary guideline development group (GDG). The purpose of this review is to provide insight into how the CPG was developed, why it is novel and important, and to highlight the recommendations from the key action statements (KASs). We also provide expanded case presentations showing how the KASs can be implemented to optimize patient care and outcomes.

Diabetes has been termed an epidemic and a defining disease of the 21st century because of its rising prevalence, association with obesity, and enormous health impact.^2,3 In the United States (US) over 38 million people have diabetes (T2D) ⁴ (Table 1), making it the eighth leading cause of death. ⁵ Of the total number of individuals with diabetes, approximately 90-95% of these have type 2 diabetes. ⁶ The prevalence of diabetes and prediabetes in US adults are 14.7% and 38.0%, respectively, meaning that about one-half the US adult population has either condition. ⁴ Diabetes and prediabetes account for $413 billion and $43 billion of US annual healthcare spending, respectively, and people with diabetes account for 25% of total health care dollars.^4,7 Globally, about 1.3 billion people are expected to be living with diabetes by the year 2050, ⁸ with projected annual expenditures for T2D exceeding $1  trillion. ⁹

Table 1.

Abbreviations and Definitions of Common Terms.

Term	Definition
Intervention	An action, strategy, or program that is intended to benefit an individual with a specific plan for implementation, monitoring adherence, and assessing outcomes
Lifestyle interventions	One or more interventions as defined above, based on the 6 pillars of comprehensive lifestyle change (Table 2)
Lifestyle medicine	A medical specialty that uses therapeutic lifestyle interventions as a primary modality to treat chronic conditions including, but not limited to, cardiovascular diseases, T2D, and obesity. Lifestyle medicine certified clinicians are trained to apply evidence-based, whole-person, prescriptive lifestyle changes to treat and, when followed intensively, often reverse such conditions. Applying the six pillars of lifestyle medicine (Table 2) also provides effective prevention for these conditions
Standard American diet (SAD)	Also called the Western diet, this eating pattern includes high sodium intake and excess calories from meats, added fats, processed foods, and refined carbohydrates, while lacking many nutrients found in fruits, vegetables, and whole grains
Ultra-processed foods	Foods that are energy-dense and high in salt, additives, unhealthy fats, refined starches, and free sugars that are formulated to be attractive and to trigger the brain’s reward system and encourage excess eating. These foods can be poor sources of protein, dietary fiber, and micronutrients
Whole-food, plant-predominant diet	An eating plan composed primarily of nutrient-dense whole grains, vegetables, legumes, fruits, nuts, and seeds while avoiding or minimizing animal foods, refined foods, and ultra-processed foods
Prediabetes	A condition characterized by blood glucose levels that are higher than normal but not high enough for a diabetes diagnosis. Prediabetes increases an individual’s risk of developing T2D and cardiovascular disease. There are no clear symptoms of prediabetes, so a person may have it and not know it unless they get blood tests for their sugar levels. A diagnosis of prediabetes is defined by the American Diabetes Association as average HbA1c of 5.7% to 6.4%
Type 2 diabetes	Previously referred to as “non-insulin-dependent diabetes” or “adult-onset diabetes,” accounts for about 95% of all diabetes, and encompasses individuals who have relative (rather than absolute) insulin deficiency and have insulin resistance that is hepatic, peripheral, or both. At least initially, and often throughout their lifetime, these individuals may not need insulin treatment to survive. A diagnosis of T2D is defined by the American Diabetes Association as average HbA1c of ≥ 6.5% and is confirmed by a second test with a similar result
Gestational diabetes mellitus	Occurs in the second half of pregnancy because placental hormones lead to insulin resistance; symptoms usually resolve after delivery, but although this condition (not symptoms) usually resolves after delivery it may sometimes persist. Even when it does resolve postpartum, these individuals have a much higher risk of developing T2D in the future
Remission	The disappearance of diabetes signs and symptoms for a specified minimum time without excluding the possibility of recurrence. Remission of T2D is defined by the American College of Lifestyle Medicine as HbA1c <6.5% for at least 3 months with no surgery, devices, or active pharmacologic therapy for the specific purpose of lowering blood glucose
Medication deprescribing	Also called deintensification or de-escalation, refers to a planned and supervised process of withdrawal, discontinuation, dose reduction, or substitution of a medication that may be causing harm or is no longer providing benefit to the patient

Encouragingly, there is expanding evidence in this global epidemic as to how lifestyle changes can delay or prevent T2D, and in some cases achieve complete remission (Table 1), such that glucose-lowering pharmacotherapy is reduced or eliminated. ¹⁰ Yet despite this empowering message, supported by robust and rapidly growing research, there are no CPGs focusing primarily on the 6 pillars of lifestyle interventions (Table 2) as the foundation for management of T2D in adults. Lifestyle interventions have long been demonstrated as being more effective than drug therapy (metformin) in preventing prediabetes from becoming T2D, ¹¹ a finding reaffirmed in subsequent research.^12-15 Lifestyle interventions can also reduce the risk of gestational diabetes progressing to T2D. ¹⁶

Table 2.

Six Pillars of Lifestyle Medicine Interventions

Intervention	Description	Importance
Nutrition	Focuses on foods and food substances that provide energy and nutrients for health, including the behaviors and social factors that influence food choices	Extensive scientific evidence supports a whole-food, predominantly plant-based eating plan as an important strategy in preventing chronic disease, treating chronic conditions, and, in intensive therapeutic doses, reversing chronic illness. Such an eating plan is rich in fiber, antioxidants, and nutrient-dense, with a variety of minimally processed vegetables, fruits, whole grains, legumes, nuts, and seeds
Physical activity	Any movement of the body done through skeletal muscle contraction that causes the energy expenditure to be beyond its baseline	Regular and consistent physical activity combats the negative effects of sedentary behavior. Engaging in general physical activity and purposeful exercise weekly builds mental health, overall health, and resiliency
Stress Management	The mechanisms involved in the body’s physiological arousal to survive a real or perceived threat	Stress, when appropriate, may improve health and productivity, but in excess can lead to anxiety, depression, obesity, immune dysfunction and more. Helping people recognize negative stress responses, identify coping mechanisms and stress reduction techniques leads to improved well-being
Sleep	Defined by how much sleep a person gets (sleep duration), when a person slept (sleep timing), and how well a person slept (sleep quality)	Inadequate or disordered sleep causes sluggishness, low attention span, decreased sociability, depressed mood, decreased daytime caloric burn, increased hunger, decreased satiety, insulin resistance, and decreased performance. Seven to nine hours nightly is associated with optimal health; under six hours or more than nine hours is associated with increased mortality
Social connectedness	Exemplified by relationships wherein individuals feel seen, heard, and valued, and from which they derive sustenance and strength	Positive social connections and relationships affect our physical, mental, and emotional health. Leveraging the power of relationships and social networks can help reinforce healthy behaviors
Avoidance of risky substances	Avoiding tobacco, recreational drugs, and excessive alcohol consumption	Tobacco and excessive alcohol consumption increase the risk of chronic diseases and death, with similar impact from opioids and recreational drug use. Treatments take time, requiring varying approaches and many attempts, with patience and support essential to cease risky substance habits

Lifestyle interventions for adults with T2D can improve quality of life, promote weight loss, optimize glucose management, reduce cardiovascular risk factors, facilitate medication deprescribing (Table 1), increase employment, and achieve full remission.^17-20 These effects are causal, not associational, ²¹ apply to low- and middle-income countries, ²² and have been achieved in persons who leave their usual place of residence for reasons other than conflict or persecution. ²³ Unfortunately, these benefits are not being fully realized because only about 20% of US adults surveyed in 2020 reported a healthy lifestyle that included at least 4 of the following: healthy diet (25% prevalence), healthy weight (25%), never smoking (58%), sufficient physical activity (69%), and moderate or lighter alcohol consumption (91%). ²⁴

The intent of this review, and the parent CPG, is to offer clear, pragmatic, and actionable recommendations for clinicians and healthcare professionals (HCPs) in caring for individuals with prediabetes, T2D, or a history of gestational diabetes mellitus (GDM). We do not seek to replace existing CPGs or standards, but rather to enhance awareness of lifestyle interventions (Table 2) in preventing and managing T2D, while also adding nuance and practical strategies for using these interventions in clinical care. Additional information can be found in the full-length CPG, ¹ an Executive Summary that emphasizes the key action statements (KASs) and their evidence profiles, ²⁵ and in a Plain Language summary of the CPG intended for patients and families. ²⁶

Guideline Key Action Statements

Each evidence-based statement in the CPG is organized in a similar fashion: an evidence-based KAS in bold, followed by the strength of the recommendation, and an action statement profile that explicitly states the quality improvement opportunity, aggregate evidence quality (Table 3), level of confidence in evidence (high, medium, low), benefits, harms, risks, costs, and a benefit-harm assessment that determines the strength of recommendation (Figure 1). Additionally, there are statements of any value judgments, the role of patient preferences, clarification of any intentional vagueness by the panel, exceptions to the statement, any differences of opinion among panel members, and implementation considerations. The full KAS profiles appear in the CPG and Executive Summary but appear here in abbreviated form with implications for practice. In the full CPG, several paragraphs of text subsequently discuss the evidence base supporting the statement. Please see Table 4 for an overview of each evidence-based statement in this guideline and Figure 2 for their interrelationships.

Table 3.

Aggregate Grades of Evidence by Question Type. ^a

Grade	Level	Treatment	Harm	Diagnosis	Prognosis
A	1	Systematic review b of randomized trials	Systematic review b of randomized trials, nested case-control studies, or observational studies with dramatic effect b	Systematic review b of cross-sectional studies with consistently applied reference standard and blinding	Systematic review b of inception cohort studies c
B	2	Randomized trials, or observational studies with dramatic effects or highly consistent evidence	Randomized trials, or observational studies with dramatic effects or highly consistent evidence	Cross-sectional studies with consistently applied reference standard and blinding	Inception cohort studies c
C	3-4	Non-randomized or historically controlled studies, including case-control and observational studies	Non-randomized controlled cohort or follow-up study (post-marketing surveillance) with sufficient numbers to rule out a common harm, case-series, case-control, or historically controlled studies	Non-consecutive studies, case-control studies, or studies with poor, non-independent, or inconsistently applied reference standards	Cohort study, control arm of a randomized trial, case series, or case-control studies, or poor-quality prognostic cohort study
D	5	Case reports, mechanism-based reasoning, or reasoning from first principles
X	n/a	Exceptional situations where validating studies cannot be performed and there is a clear preponderance of benefit over harm

Abbreviations: n/a, not applicable; OCEBM, Oxford Centre for Evidence-Based Medicine.

^aAdapted from Howick and colleagues. ³²

^bA systematic review may be downgraded to level B because of study limitations, heterogeneity, or imprecision.

^cA group of individuals identified for subsequent study at an early, uniform point in the course of the specified health condition, or before the condition develops.

Figure 1.

Criteria for determining recommendation strength. The recommendation strength for a key action statement is determined by the aggregate evidence grade (Table 3) and the benefit vs. harm relationship (e.g., preponderance vs. balance). For some combinations with a preponderance of benefit or harm the guideline development group can choose between two possibilities (e.g., for evidence grades B, C, and X). Adapted from American Academy of Pediatrics.33

Table 4.

Summary of Guideline Key Action Statements.

Statement	Action	Strength
KAS 1: Advocacy for Lifestyle Interventions	The clinician or HCP should be an advocate for lifestyle interventions as first-line management for prediabetes and T2D, including restorative sleep, stress management, adequate physical activity, positive social connections, a whole-food, plant-predominant eating plan, and avoiding risky substances	Strong Recommendation
KAS 2: Assessment of Baseline Lifestyle Habits	The clinician or health care professional should assess the baseline lifestyle habits, in adults with prediabetes, T2D or a history of GDM with regards to the 6 pillars of lifestyle medicine (See Table 2), educate the individual regarding opportunities to improve their lifestyle behaviors, and evaluate the individual’s readiness to change	Strong Recommendation
KAS 3: Establishing Priorities for Lifestyle Change	For an adult with prediabetes, T2D, or a history of GDM, the clinician or HCP should establish priorities for lifestyle change with regards to the 6 pillars of lifestyle intervention (See Table 2) through shared decision-making and should discuss the role of using SMART (Specific, Measurable, Achievable, Relevant, And Time-Bound) goals in supporting positive lifestyle change	Strong Recommendation
KAS 4: Prescribing Aerobic and Muscle Strength Physical Activity	The clinician or HCP should prescribe physical activity, with an emphasis on aerobic and muscle strength training, by establishing SMART goals and using the FITT (frequency, intensity, time, type) framework for implementation for adults with prediabetes, T2D, or a history of GDM.	Strong Recommendation
KAS 5: Reducing Sedentary Time	The clinician or HCP should prescribe physical activity to reduce sedentary time, using SMART goals, for adults with prediabetes, T2D, or a history of GDM.	Strong Recommendation
KAS 6: Identifying Sleep Disorders	In adults with prediabetes, T2D, or a history of GDM, the clinician or HCP should ask about sleep quality, quantity, and patterns, determine if a sleep disorder is present, and refer, as indicated, for further evaluation and management. Sleep disorders associated with prediabetes, (T2D), and a history of GDM include, but are not limited to, obstructive sleep apnea, shift work sleep disorder, chronic insomnia, and short or long sleep duration	Strong Recommendation
KAS 7: Prescribing a Nutrition Plan for Prevention	In adults with prediabetes, or a history of GDM, the clinician, HCP, or their designee, should prescribe a nutrition plan using SMART goals that is consistent with the individual’s cultural background and is framed in food-based advice regarding caloric intake, nutrient needs, and the importance of a whole-food, plant-predominant eating plan	Strong Recommendation
KAS 8: Prescribing a Nutrition Plan for Treatment	The clinician, HCP, or their designee, should clarify with the person with T2D if their goal is to achieve T2D remission or T2D improvement and should prescribe a nutrition plan using SMART goals that is consistent with the person’s desired outcome(s), cultural background, and is framed in food-based guidance promoting appropriate energy intake, nutrient needs, and the benefits of a whole-food, plant-predominant eating plan	Strong Recommendation
KAS 9: Peer/Familial Support and Social Connections	The clinician or HCP should counsel adults with prediabetes, T2D, or a history of GDM regarding the importance of cultivating positive social connections provided by peers, family members, and/or other professionals trained in lifestyle change methods to achieve SMART goals and optimize glucose management	Strong Recommendation
KAS 10: Identifying Need for Psychological Interventions	In adults with prediabetes, T2D, or a history of GDM the clinician or HCP should identify or refer to someone who can identify serious mental illness such as severe mood/affective disorders, anxiety disorders, or psychotic disorders. For individuals experiencing stress or symptoms of depression or anxiety, prescribe mindfulness-based, cognitive behavioral therapy (CBT), or CBT-based interventions to improve diabetes clinical outcomes	Recommendation
KAS 11: Tobacco, Alcohol, and Recreational Drugs	The clinician or HCP should assess adults with T2D for use of tobacco, alcohol, and other recreational drugs and should counsel them on how using these substances can adversely impact management of T2D	Strong Recommendation
KAS 12: Achieving Person-Driven, Sustained Positive Behavior Change	For adults with prediabetes, T2D, or a history of GDM, the clinician, HCP, or their designee, should help individuals achieve sustained, person-centered, positive behavior change using evidence-based approaches including, but not limited to, coaching, motivational interviewing, and cognitive behavioral therapy	Strong Recommendation
KAS 13: Establishing a Plan for Continuity of Care	For adults with prediabetes, T2D, or a history of GDM, the clinician or HCP should establish a plan for continuity of care that prescribes lifestyle interventions and specifies the frequency of visits, anticipated duration of care, potential need for adjustments of pharmacologic therapy, and expectations regarding the individual’s engagement	Strong Recommendation
KAS 14: Adjusting Pharmacologic Therapy	For adults with prediabetes, T2D, or a history of GDM, the clinician or HCP should adjust the type and dosing of an individual’s pharmacologic therapy based on the impact of lifestyle intervention on their medication needs	Recommendation

Abbreviations: GDM, gestational diabetes mellitus; HCP, healthcare professional; KAS, key action statement; T2D, type 2 diabetes.

Figure 2.

Flowchart showing the interrelationships of the guideline key action statements (KAS), with the numbering for each KAS corresponding to its order in the text.

KAS 1: Advocacy for Lifestyle Interventions

Action Statement

The clinician or HCP should be an advocate for lifestyle interventions as first-line management for prediabetes and T2D, including restorative sleep, stress management, adequate physical activity, positive social connections, a whole-food, plant-predominant eating plan, and avoiding risky substances. Strong recommendation based on randomized controlled trials (RCTs), systematic review, and observational studies with a preponderance of benefit over harm.

Abbreviated Action Statement Profile

• • Aggregate evidence quality: Grade A, for the benefits of lifestyle interventions, based on 5 meta-analyses and systematic reviews and 3 CPGs; Grade B, for the importance of advocacy based on observational studies

• • Level of confidence in evidence: High

• • Benefits: Raising awareness of lifestyle interventions, self-management skills for patients, and their efficacy; increasing access to evidence-based care; promoting shared decision-making; empowering individuals to take control of their health; drawing explicit attention to an aspect of diabetes management that may be overlooked or underappreciated by clinicians or health professionals, specifically lifestyle behaviors and associated factors; articulating the 6 pillars of lifestyle medicine with supporting evidence for benefiting adults with diabetes; facilitating the translation and implementation of public health knowledge into public health messaging; shifting the paradigm of diabetes management from pharmacological therapy to lifestyle interventions

• • Risk, harm, cost: Improper advocacy could stigmatize the individual or create animosity; miscommunication could lead to unrealistic expectations about the benefits of lifestyle interventions; inadequate resources to support advocacy could lead to dissatisfaction; overemphasis of lifestyle interventions could undermine or trivialize the role of pharmacological management in cases where needed

Implications for Practice

The purpose of this KAS is to provide a context for clinicians or HCPs to recognize the need for advocacy regarding lifestyle interventions as the first line of management for prediabetes and T2D, including restorative sleep, stress management, adequate physical activity, positive social connections, avoiding risky substances, and a whole-food, plant-predominant eating plan. Whereas this need may be apparent, or obvious, to clinicians or HCPs who already engage actively with lifestyle medicine, the guideline development group (GDG) members agreed that in many healthcare settings, these lifestyle interventions are not discussed in the context of primary management, but often described in very general terms, or as an adjunct to pharmacological intervention. Social connectivity, for example, is an important pillar of lifestyle medicine that warrants emphasis in diabetes care, because of the critical role of family, community, and other groups (workplace, faith-based) in sustained adherence to positive behavior change. The CPG has a useful handout (Figure 3) for patients that can facilitate informed discussions and document adherence to this KAS in the electronic health record.

Figure 3.

(a) Handout on advocacy for lifestyle changes in preventing and managing type 2 diabetes in adults, part 1 (b) handout on advocacy for lifestyle changes in preventing and managing type 2 diabetes in adults, part 2.

KAS 2: Assessment of Baseline Lifestyle Habits

Action Statement

The clinician or HCP should assess the baseline lifestyle habits, in adults with prediabetes, T2D or a history of GDM with regards to the 6 pillars of lifestyle medicine (See Table 2), educate the individual regarding opportunities to improve their lifestyle behaviors, and evaluate the individual’s readiness to change. Strong recommendation based on RCTs, systematic review, and observational studies with a preponderance of benefit over harm.

Abbreviated Action Statement Profile

• • Aggregate evidence quality: Grade A, based on 2 systematic reviews and 14 RCTs on the effectiveness of using education, coaching, and motivational interviewing in managing adults with prediabetes and T2D

• • Level of confidence in evidence: High

• • Benefits: Establishing a baseline; raising awareness; gaining insights into the individual’s understanding and self-awareness of their lifestyle habits; identifying areas for improvement; promoting individual awareness of opportunities for improvement; individual empowerment; setting the stage for goal-setting; enhancing individual understanding regarding the validity and credibility of lifestyle interventions; prioritizing lifestyle change; supporting the willingness of the individual to consider moving forward with lifestyle change; guiding the action plan for implementing lifestyle change; alerting the clinician or HCP to prior efforts of unsuccessful change and barriers to change; personalizing the approach to the individual; and setting the stage for true shared decision-making

• • Risk, harm, cost: Individual anxiety or sense of stigma, shame, and judgment by the clinician or HCP; blame, embarrassment, or both; time burden involved in assessment

Implications for Practice

The purpose of this KAS is to provide a framework for clinicians and HCPs to pragmatically assess baseline lifestyle habits, educate individuals about opportunities to improve their behaviors, and personalize the delivery of this content in a way that facilitates action steps towards improved health behaviors and sustainable change. There was consensus among the GDG members that these fundamental issues of implementing lifestyle interventions are not routinely assessed in clinical care, and that many clinicians or HCPs are unaware of how to efficiently assess lifestyle interventions and readiness for change.

A baseline assessment of lifestyle habits is necessary to highlight domains individuals are doing well in and to identify areas that could be improved. This can be accomplished by using a general lifestyle medicine screening tool, a detailed domain specific questionnaire, or inquiring about the pillars as they relate to the visit focus. Validated questionnaires are ideally used, though clinically relevant and practical approaches can be utilized as appropriate. The CPG has a table with recommended tools by domain and purpose (screening, brief assessment, or in-depth assessment) and several figures to facilitate motivational interviewing, behavior change, and assessing readiness to change .

KAS 3: Establishing Priorities for Lifestyle Change

Action Statement

For an adult with prediabetes, T2D, or a history of GDM, the clinician or HCP should establish priorities for lifestyle change with regards to the 6 pillars of lifestyle intervention (See Table 2) through shared decision-making and should discuss the role of using SMART (Specific, Measurable, Achievable, Relevant, And Time-Bound) goals in supporting positive lifestyle change. Strong recommendation based on RCTs, systematic review, and observational studies with a preponderance of benefit over harm.

Abbreviated Action Statement Profile

• • Aggregate evidence quality: Grade B, based on 6 observational studies, 6 RCTs, 2 cluster randomized trials, and 8 systematic reviews of RCTs

• • Level of confidence in evidence: High

• • Benefits: Facilitates individual engagement, empowerment for change, and buy-in; ensures that interventions align with the individual’s priorities; establishes structure and accountability for a more comprehensive plan; reassures the individual that there will be specific tailored advice to help them implement change; sets the stage for tailored SMART goals for specific behaviors related to individual lifestyle medicine pillars; establishes consistency in care; avoids non-specific prescriptive statements of “eat a healthy diet” and “exercise more” that rarely lead to sustained lifestyle change; informs the individual about how tailored goal-setting will be created for lifestyle change; emphasizes the role of SMART goals in making lifestyle change more manageable, by emphasizing process not outcome (e.g., acknowledge progress); increases feasibility, accountability, and sustainability of change

• • Risk, harm, cost: Time in gathering information, time counseling individuals

• • Benefit-harm assessment: Preponderance of benefit over harm

Implications for Practice

The purpose of this statement is to ensure that clinicians and HCPs utilize SMART goal-setting (Figures 4 and 5) and shared decision-making when counseling and coaching people with prediabetes and T2D about behavior change. The GDG agreed that the preferred way to implement lifestyle change is by using and tracking SMART goals, assuming that individuals are more likely to engage in and adhere to care plans when based on their priorities.

Figure 4.

Examples of SMART goals and goals that are not in the SMART framework.

Figure 5.

Worksheet for shared decision-making in implementing SMART goals for behavior change. The framework applies to all six pillars of lifestyle intervention, namely physical activity, nutrition, sleep, stress management, social connections, and avoidance of risk substances.

Telling people what to do and demanding that they change is not motivating, nor is it effective behavior change counseling. Coaching is a type of behavior change counseling that focuses on the person as the expert in their own life and the HCP as a partner and collaborator who can help empower the person to adopt and sustain healthy lifestyle change. HCPs should partner with individuals through shared decision-making, give individuals autonomy, and work to co-create SMART goals that promote ownership over the change process.

KAS 4: Prescribing Aerobic and Muscle Strength Physical Activity

Action Statement

The clinician or HCP should prescribe physical activity, with an emphasis on aerobic and muscle strength training, by establishing SMART goals and using the FITT (frequency, intensity, time, type) framework for implementation for adults with prediabetes, T2D, or a history of GDM. Strong recommendation based on RCTs and systematic reviews with a preponderance of benefit over harm.

Abbreviated Action Statement Profile

• • Aggregate evidence quality: Grade A, based on 3 systematic reviews and meta-analyses, 2 RCTs, and 2 longitudinal cohort studies demonstrating the benefits of regular physical activity for individuals with dysglycemia

• • Level of confidence in evidence: High

• • Benefits: Improved glucose management, cardiorespiratory fitness, sleep quality, cognitive function, mental health, health-related quality of life (HRQOL), and cardiometabolic markers; assistance with stress and weight management; fewer major adverse cardiovascular events (MACE); decreased all-cause and diabetes-related mortality; less progression of sarcopenia, preserve lean muscle mass; reduced disability; improved resilience; reduced healthcare costs; enhanced bone health; increased adherence to physical activity recommendations

• • Risk, harm, cost: Injury from improper activity; hypoglycemia; compensatory overeating; individual frustration if unable to adhere to prescription (e.g., limited access to needed facilities); overexercise; ischemic and arrhythmogenic heart disease; cost of access to equipment, facilities

Implications for Practice

The purpose of this statement is to highlight the importance of prescribing regular physical activity as part of a comprehensive approach to improving lifestyle behaviors and managing disease. Within this context, some individuals with physical limitations or disabilities may be unable to adhere to all recommendations in this section and may therefore require additional evaluation or counseling when prescribing aerobic or muscle-strengthening activity. The GDG chose to emphasize aerobic activity and muscle strength training because they align with physical activity guidelines for Americans, and are most evidence-based, but also recognize that physical activity can include other modalities. There are several figures in the supporting KAS text to assist in implementing this recommendation, including a summary of the Move Your Way Physical Activity Guidelines for Americans ²⁷ and a person-centered exercise form to prescribe physical activity goals using the FITT framework (Figures 6–8). ²⁸

Figure 6.

Move Your Way Physical Activity Guidelines for Americans (PAGA). Note that the guidelines include recommendations for both aerobic and muscle-strengthening activity. Department of Health and Human Services. Office of Disease Prevention and Health Promotion.34

Figure 7.

Person-centered exercise form that can be used by clinicians and healthcare professionals to engage individuals in physical activity by prescribing goals using the FITT framework: frequency, intensity, time and type. Reproduced with permission from the American College of Sports Medicine.35

Figure 8.

Examples of bite-sized activities that individuals can utilize to break up or reduce sedentary time.

KAS 5: Reducing Sedentary Time

Action Statement

The clinician or HCP should prescribe physical activity to reduce sedentary time, using SMART goals, for adults with prediabetes, T2D, or a history of GDM. Strong recommendation based on RCTs, systematic review, and observational studies with a preponderance of benefit over harm.

Abbreviated Action Statement Profile

• • Aggregate evidence quality: Grade B, based on systematic reviews, meta-analyses, and RCTs on the effectiveness of using physical activity to reduce sedentary time in the management of prediabetes and T2D

• • Level of confidence in evidence: High

• • Benefits: Promote awareness of the adverse impact of sedentary activity; educate individuals about how even small levels of physical activity to interrupt sedentary time are beneficial; improve glucose management

• • Risk, harm, cost: None

Implications for Practice

The purpose of this statement is to highlight the status of sedentary lifestyle habits that contribute to the high prevalence of T2D, prediabetes and GDM, and how that can be remedied by incorporating physical activity throughout the day. Although physical activity has been fully discussed in the prior KAS, our GDG considered it equally important to raise awareness of the detrimental effects of sedentary time, and the need to reduce or interrupt it, in addition to achieving adequate physical activity. There was a perception among GDG members of a potential lack of awareness by clinicians and individuals of how harmful excessive sedentary time can be for T2D an overall health.

KAS 6: Identifying Sleep Disorders

Action Statement

In adults with prediabetes, T2D, or a history of GDM, the clinician or HCP should ask about sleep quality, quantity, and patterns, determine if a sleep disorder is present, and refer, as indicated, for further evaluation and management. Sleep disorders associated with prediabetes, T2D, and a history of GDM include, but are not limited to, obstructive sleep apnea, shift work sleep disorder, chronic insomnia, and short or long sleep duration. Strong recommendation based on RCTs, systematic reviews, and observational studies with a preponderance of benefit over harm.

Abbreviated Action Statement Profile

• • Aggregate evidence quality: Grade B, based on RCTs and systematic reviews with meta-analyses of both RCTs and observational studies indicating an association and examining management of prediabetes and T2D for delineated sleep disorders

• • Level of confidence in evidence: High

• • Benefits: Prioritize additional assessment and intervention of individuals who require further evaluation to improve sleep quality, avoid complications, or sequelae, of an underlying sleep disorder that may not have been previously recognized or diagnosed; better inform the management plan for diabetes mellitus by taking into account comorbid sleep disorders; raise awareness of optimal sleep duration and patterns for better disease-specific and overall health, providing information and strategies on how to improve sleep behaviors, avoiding lifestyle behaviors that could impair sleep patterns; offer specific, individualized advice acceptable to the individual and consistent with their values

• • Risk, harm, cost: Time counseling individuals; cost of additional assessment, testing, or referral; limited access to individuals who can perform the needed additional evaluations; frustration if unable to achieve goals

Implications for Practice

The purpose of this statement is to highlight the importance of obtaining information about sleep quality, quantity, and patterns in people with prediabetes, T2D, or a history of GDM. Poor sleep habits and sleep disorders are associated with a higher prevalence and incident risk of T2D and GDM, and worse glucose management in the setting of T2D. Several sleep disorders are considered here including obstructive sleep apnea (OSA), chronic insomnia disorder/insomnia symptoms/poor sleep quality, shift work disorder (SWD), and short and long sleep duration. Although the KAS supporting text also discusses more generic recommendations for improving sleep quality and quantity (Figure 9), the GDG considered it important to emphasize not missing a sleep disorder that requires special assessment or management.

Figure 9.

Tips and guidelines for maintaining good sleep habits for better management of diabetes and prediabetes.

KAS 7: Prescribing a Nutrition Plan for Prevention

Action Statement

In adults with prediabetes, or a history of GDM, the clinician, HCP, or their designee, should prescribe a nutrition plan using SMART goals that is consistent with the individual’s cultural background and is framed in food-based advice regarding caloric intake, nutrient needs, and a whole-food, plant-predominant eating plan. Strong recommendation based on RCTs and systematic reviews with a preponderance of benefit over harm.

Abbreviated Action Statement Profile

• • Aggregate evidence quality: Grade A, based on systematic reviews, meta-analyses, and RCTs on the effectiveness of using evidence-based strategies for implementing nutrition and food-based strategies for preventing T2D

• • Level of confidence in evidence: High

• • Benefits: Prevent progression of prediabetes to T2D, achieve normoglycemia in people with prediabetes, prevent recurrence of GDM, prevent progression of GDM to T2D, dispel nutrition myths and misinformation

• • Risk, harm, cost: Cost of food, a focus on weight loss could be problematic for someone with a disordered eating behavior, time counseling individuals

• • Benefit-harm assessment: Preponderance of benefit over harm

Implications for Practice

The purpose of this statement is to provide practical and evidence-based strategies for implementing a whole-food, plant-predominant eating plan in treating prediabetes, and preventing prediabetes or GDM from progressing to T2D. There is a perception among the GDG members that a history of GDM is an underappreciated opportunity for nutritional intervention to prevent recurrence or progression. Although the GDG recognizes that preventing T2D is the optimal goal for people at risk for T2D, not everyone may be willing to commit to the degree of intervention, and should this occur, a goal of improvement is reasonable. The GDG agreed that for T2D prevention, nutrition, and physical activity should be a frontline approach to treatment for prediabetes and are not always communicated and offered as a management option.

The supporting text in the CPG for this KAS has extensive information to facilitate understanding and implementing this strong recommendation. This includes eating patterns and food-based strategies for preventing diabetes, emphasizing whole-foods and avoiding ultra-processed foods, knowing the risks of very low carbohydrate eating patterns, and implementing a nutrition plan while anticipating barriers. There are several figures and tables in the text to aid implementation, including an educational handout for understanding ultra-processed foods and healthy whole-food alternatives (Figure 10).

Figure 10.

Handout for individuals explaining the health risks of ultra-processed foods, why whole-foods are better, and how to increase fiber in the eating plan.

KAS 8: Prescribing a Nutrition Plan for Treatment

Action Statement

The clinician, HCP, or their designee, should clarify with the person with T2D if their goal is to achieve T2D remission or T2D improvement and should prescribe a nutrition plan using SMART goals that is consistent with the person’s desired outcome(s), cultural background, and is framed in food-based guidance promoting appropriate energy intake, nutrient needs, and the benefits of a whole-food, plant-predominant eating plan. Strong recommendation based on RCTs and systematic reviews with a preponderance of benefit over harm.

Abbreviated Action Statement Profile

• • Aggregate evidence quality: Grade A, based on 31 systematic reviews or meta-analyses and on 11 RCTs

• • Level of confidence in evidence: High

• • Benefits: Determine the type and intensity of nutritional intervention; avoid implementing a plan that is unlikely to be accepted by, or adhered to, by the individual; educate the individual about the potential to achieve remission in many adults with T2D; promote individual autonomy and agency; enhance collaborative relationship with the individual; promote adherence to recommendations; educate, advise, and inform the individual; offer specific and actionable advice that is tailored to the person’s needs and preferences; raise awareness regarding the three key areas of focus: energy/calories, nutrients, and a low-fat plant-predominant eating pattern; focus on process. Not outcomes, to improve adherence

• • Risk, harm, cost: No risk for asking individuals to clarify their T2D remission or improvement goals; however, the individual may be unreceptive to advice, or overwhelmed, if not managed in a sensitive, easy to understand, professional manner. Costs include food cost, risk of disordered eating, stigma, lack of access to appropriate and culturally acceptable food (e.g., problems in food deserts, food swamps, and with food apartheid), time counseling individuals

Implications for Practice

The purpose of this statement is to identify the need to elicit an individual’s goals and preferences regarding their targeted health outcomes with respect to diabetes progression, improvement, or remission of T2D. Although the GDG recognized that remission is the optimal goal for adults with T2D if physiologically feasible, not all individuals may be willing to commit to this degree of intervention, and should this occur, a goal of improvement is reasonable. Further, the GDG perceived that remission and utilizing a whole-food, plant-predominant eating plan as a frontline approach to treatment are not always communicated as options to people with T2D; and the nuance of tailoring the eating plan to the goal may not be fully appreciated by clinicians and HCPs (Table 5).

Table 5.

Comparison of Dietary Approaches for Improved Glucose Management vs Diabetes Remission. ^a

	Goal of improved glucose management with possible reduction of medications	Goal of diabetes remission
Food groups	Emphasize high-fiber, plant foods including whole grains, fruit, and legumes	Eat a low-fat, high-fiber, whole-food, plant-predominant eating plan emphasizing leafy greens, other vegetables including starchy vegetables, fruit, whole grain, and legumes. Aim for limited consumption of more energy-dense plant foods or foods higher in fat, such as nuts, seeds, avocado
Processed/refined foods and foods with added fats/oils	Reduce highly processed/refined foods such as sugar-sweetened beverages, refined flour products, fried foods, and salty snacks	Avoid all highly processed/refined foods such as sugar-sweetened beverages, refined flour products, fried foods, and salty snacks. Avoid eating or using added fats/oils
Calorie restriction, meal replacements, or intermittent fasting	Improvements in glucose management are possible without necessarily engaging in energy restriction or intermittent fasting	For individuals open to a more intensive phase-in period, begin the dietary change with an initial program of intermittent fasting or calorie restriction, aiming for sufficient reduction (>500 kcal deficit or <1000 kcal/day) to produce >10% weight loss, with duration to be determined based on the individual’s ability to tolerate or not experience any negative effects. Meal replacements may be used temporarily to achieve substantive energy reduction. Individuals should be informed of any potential negative signs and symptoms, including those associated with hypoglycemia from diabetes medications (e.g., insulin and sulfonylureas)
Implementation strategies	Individuals must demonstrate some degree of motivation and readiness to change; having support family members or friends in the household is very helpful, while having non-supportive social networks can derail efforts	Individuals must demonstrate motivation and readiness to make substantive eating plan changes; having support family members or friends in the household is very helpful, while having non-supportive social networks can derail efforts Additionally, for the great level of commitment required for an intensive eating plan change or calorie restriction, individuals must exhibit strong motivation and self-efficacy with making different nutrition choices. Clinicians and HCPs should discuss anticipated challenges from the food environment, social networks, or habits and construct tailored strategies with the individual to counter them

^aReference citations are omitted from this table for brevity and clarity, but can be found in the corresponding table (Table 11) in the full CPG. ¹

The supporting text in the CPG for this KAS discusses remission as an optimal T2D outcome, energy restricted eating plans, low-carbohydrate eating patterns, cautions regarding various eating patterns, achieving behavior change, and referrals to interdisciplinary team members. In addition to the table noted above, there are tables describing conversation prompts for shared decision-making, and eating patterns observed to be effective for improving glucose management and weight loss. There is also a 4-page handout from ACLM entitled “Healthy Foods are Everywhere” that provides culturally diverse, plant-based examples of food ingredients and international cuisines.

KAS 9: Peer/Familial Support and Social Connections

Action Statement

The clinician or HCP should counsel adults with prediabetes, T2D, or a history of GDM regarding the importance of cultivating positive social connections provided by peers, family members, and/or other professionals trained in lifestyle change methods to achieve SMART goals and optimize glucose management. Strong recommendation based on RCTs, systematic reviews and metanalyses with a preponderance of benefit over harm.

Abbreviated Action Statement Profile

• • Aggregate evidence quality: Grade A, based on 41 RCTs, 6 meta-analyses, 4 systematic reviews, and 1 umbrella review demonstrating consistently that support interventions lead to improved outcomes in prediabetes and T2D management

• • Level of confidence in evidence: High

• • Benefits: Improve adherence to SMART goals, promote sustainable lifestyle behaviors, enhance positive social connections

• • Risk, harm, cost: Potential for a negative social connection

Implications for Practice

The purpose of this statement is to advise clinicians or HCPs to promote social support interventions for people with prediabetes, T2D, or a history of GDM. Clinicians or HCPs should inform individuals that optimal management of prediabetes, T2D, or history of GDM includes building a strong network of social support outside the clinic. The GDG agreed that peer support, family support, and positive social connections may be underappreciated as important factors that influence diabetes outcomes. For example, a lack of social integration, support systems, and community engagement can lead to social isolation and loneliness that can negatively influence health by increasing health risks, decreasing function, and reducing quality-of-life.

The supporting text in the CPG for this KAS includes several tables to support implementation, including a 3-item loneliness assessment scale and strategies (characteristics, best practices and methods, other considerations) for peer support, family support, and professional or multimodal support. Appendix A (citation #1) shows the UCLA 20-item Loneliness Assessment and Appendix B (citation #1) presents the Problem Areas in Diabetes Scale. There is also a useful, customizable handout for patients (Figure 11) showing how strong relationships reinforce healthy lifestyle habits.

Figure 11.

Handout for individuals showing how strong relationships can reinforce healthy lifestyle habits.

KAS 10: Identify Need for Psychological Interventions

Action Statement

In adults with prediabetes, T2D, or a history of GDM the clinician or HCP should identify or refer to someone who can identify serious mental illness such as severe mood/affective disorders, anxiety disorders, or psychotic disorders. For individuals experiencing stress or symptoms of depression or anxiety, prescribe mindfulness-based, cognitive behavioral therapy (CBT), or CBT-based interventions to improve diabetes clinical outcomes. Recommendation based on RCTs, systematic reviews, and meta-analyses with a preponderance of benefit over harm.

Abbreviated Action Statement Profile

• • Aggregate evidence quality: Grade B, based on 10 combined systematic reviews and meta-analyses, 2 systematic reviews, and 9 RTCs, with some limitations regarding methodology, study design, and sample size-indicating the relationship between diabetes and mental health and the effectiveness of mindfulness-based, CBT, and CBT-based interventions for managing T2D

• • Level of confidence in evidence: High

• • Benefits: Prioritize additional assessment and intervention for individuals who require further evaluation to improve mental health; avoid complications or sequelae of an underlying mental illness that may not have been previously recognized or diagnosed, better inform the management plan for diabetes mellitus by taking into account comorbid mental illness; raise awareness of stress management strategies for better disease-specific and overall health; identify diabetes distress burden and develop strategies to reduce them; provide information and strategies on how to improve mental health; reduce symptoms of anxiety and depression; and improve coping skills

• • Risk, harm, cost: Time counseling individuals, cost of additional assessment testing or referral, limited access to individuals who can perform the needed additional evaluations; frustration if unable to achieve goals

Implications for Practice

The purpose of this statement is to ensure that clinicians and HCPs recognize and inform individuals about the relationship between mental health and T2D, given a higher risk of depression that is 2-3 times that of the general population, and risk of anxiety about 20% more than the general population. ²⁹ Additionally, they should identify potentially serious mental illness and incorporate psychological interventions in the treatment plan. Although stress management (Figure 12), in general, is a key pillar for lifestyle intervention and is certainly relevant to individuals with diabetes or prediabetes, the emphasis of this KAS is to ensure that more serious illness is not overlooked. The supporting text in the CPG for this KAS includes a table describing the symptoms of depression, anxiety, stress, and diabetes distress, along with citations for validated tools and measures to assess for their presence.

Figure 12.

Handout for individuals with suggestions on how to think about and manage stress for better health.

KAS 11: Tobacco, Alcohol, and Recreational Drugs

Action Statement

The clinician or HCP should assess adults with T2D for use of tobacco, alcohol, and other recreational drugs and should counsel them on how using these substances can adversely impact management of T2D. Strong recommendation based on RCTs, systematic reviews, and observational studies with a preponderance of benefit over harm.

Abbreviated Action Statement Profile

• • Aggregate evidence quality: Grade B, based on 3 RCTs, 3 systematic reviews, and 1 meta-analysis emphasizing the value of counseling on tobacco, nicotine and recreational drugs in adults with T2D

• • Level of confidence in evidence: High

• • Benefits: Raising awareness of an issue that might not have been fully appreciated by the individual; identifying opportunities to reduce harmful habits; triaging individuals for smoking cessation programs, identify alcohol use disorder

• • Risk, harm, cost: Perception of being judgmental, potential harm to clinician-person relationship

Implications for Practice

The purpose of this statement is to encourage the clinician or HCP to assess tobacco, alcohol and other recreational drug use at regular intervals using standardized screening tools. This assessment should be part of routine care for people with diabetes and prediabetes to identify substance use early and to tailor interventions accordingly. Individuals should be educated about the specific risks of tobacco, alcohol, and recreational drugs (e.g., cannabis), which include poorer glucose management, increased risk of diabetes-related complications, and interference with diabetes medications. Included in this section of the CPG are validated screening tools for nicotine dependence, alcohol use disorder, and using illegal drugs or prescription drugs for non-medical reasons. The NIDA quick screen (Figure 13) ³⁰ is a brief and efficient tool for a global assessment of potential substance abuse.

Figure 13.

NIDA quick screen questionnaire for substance use with directions for coding the responses.36

KAS 12: Achieving Person-Driven, Sustained Positive Behavior Change

Action Statement

For adults with prediabetes, T2D, or a history of GDM, the clinician, HCP, or their designee, should help individuals achieve sustained, person-centered, positive behavior change using evidence-based approaches including, but not limited to, coaching, motivational interviewing, and cognitive behavioral therapy. Strong recommendation based on RCTs, systematic reviews, and observational studies with a preponderance of benefit over harm.

Abbreviated Action Statement Profile

• • Aggregate evidence quality: Grade B, based on 6 systematic reviews, 8 RCTs, and 2 quasi-experimental studies for health coaching-centered interventions; an umbrella systematic review of 41 systematic reviews for self-management interventions; 1 systematic review about digital technology integration; and 32 systematic reviews with combined 27 RCTs for CBT and 10 additional RCTs from cross referencing

• • Level of confidence in evidence: Low to medium

• • Benefits: Improve chances of successful behavior change; person engagement and empowerment; long-term sustainability of changes; person’s ability to brainstorm and solve problems; and enhance the therapeutic relationship

• • Risk, harm, cost: Time counseling individuals, cost of coaching, reimbursement hurdles, potential for ineffective approaches from insufficiently trained clinicians

Implications for Practice

The purpose of this statement is to promote sustained, person-driven behavior change. As we partner with our patients, we need to approach care through the lens of “work with the being; not just the doing” and that we are caring for the whole person, not just the person’s health condition. The GDG chose to emphasize sustained, long-term change because of the perception that without specific attention to this goal, any lifestyle changes made by individuals are more likely to be of short-term duration. The KAS supporting text in the CPG focuses on motivational interviewing, health and wellness coaching, cognitive behavioral therapy, and continuous engagement and education. These approaches are summarized in several tables, including a list for frequently asked questions by clinicians and HCPs (Table 6).

Table 6.

Frequently Asked Questions for Clinicians and Healthcare Professional on Practical Methods to Achieve Person-Driven, Sustained Positive Behavior Change.

Q1: Why are behavior change-centered interventions important in diabetes care?

A1: These interventions are crucial as they empower individuals to take an active role in managing their diabetes. They can lead to improved glucose management, better self-management skills, and enhanced overall well-being—thus, supporting the mission of DM clinicians.

Q2: What are the broad categories of approaches in behavior change-centered interventions?

A2: The main categories include Health and Wellness Coaching (HWC), Cognitive Behavioral Therapy (CBT), Self-Management Education and Support (DSMES), and Digital Diabetes Prevention Interventions (DDPI). The Five As are also used in counseling individuals about behavior change. They include Ask, Assess, Advise, Agree, Assist.

Q3: What is OARS and how can it be used in practice?

A3: OARS is a person-centered communication technique used in motivational interviewing that includes:

• Open-ended Questions: Encourages detailed responses for better understanding.

• Affirmations: Strengthens motivation with positive reinforcement.

• Reflections: Shows active listening and understanding of the person’s perspective.

• Summaries: Validates the conversation and clarifies the next steps.

• In practice, use OARS to guide conversations with individuals about their health behaviors and goals.

Q4: Can you provide an example of how to use an open-ended question with a person?

A4: Instead of asking, “Did you check your blood sugar levels regularly?”, you might ask, “Can you tell me about your experience with monitoring your blood sugar levels this week?”

Q5: How do affirmations enhance person communication?

A5: Affirmations like “You’ve made a significant effort in adjusting your eating plan” acknowledge progress and effort, boosting confidence and motivation.

Q6: When should I employ reflective listening?

A6: Reflective listening should be a constant practice. For instance, after a person describes their challenges with exercise, you could reflect by saying, “It sounds like finding time for exercise has been a real challenge for you.”

Q7: Why are summaries a powerful tool in person conversations?

A7: Summaries restate what the person has shared, demonstrating that you have listened and understood, which helps build trust and sets the stage to call out change talk and for creating action plans.

Q8: What can I use now in my practice to facilitate behavior change?

A8: Begin incorporating the OARS technique into your person conversations immediately. It is a simple yet effective way to engage people and encourage them to talk more about their behaviors, concerns, and goals.

Q9: When should I refer a person to a specialist, and to whom should I refer?

A9: Refer to a specialist when:

• The person’s needs exceed the scope of your practice, experience, and/or time feasibility.

• There is a lack of progress with current interventions.

• Complex psychological issues are affecting their diabetes management. Specialists can include certified health coaches for HWC, psychologists or therapists for CBT, diabetes educators for DSMES, or tech consultants for DDPI.

Q10: How do digital tools fit into these behavior change approaches?

A10: Digital tools can enhance traditional interventions, offering remote monitoring, facilitating telehealth coaching, and support for goal-setting and feedback. They can be particularly effective for engaging people in their self-management between visits.

KAS 13: Establishing a Plan for Continuity of Care

Action Statement

For adults with prediabetes, T2D, or a history of GDM, the clinician or HCP should establish a plan for continuity of care that prescribes lifestyle interventions and specifies the frequency of visits, anticipated duration of care, potential need for adjustments of pharmacologic therapy, and expectations regarding the individual’s engagement. Strong recommendation based on RCTs, systematic reviews, and observational studies with a preponderance of benefit over harm.

Abbreviated Action Statement Profile

• • Aggregate evidence quality: Grade B, based on over 20 systematic reviews, several meta-analyses, and RCTs that demonstrate consistent benefits related to continuity of care for people with T2D

• • Level of confidence in evidence: High

• • Benefits: Maintain person engagement in care; promote success and sustainability; establish clear goals and expectations regarding the need for future care; and assess the need to alter the management plan based on the person’s needs

• • Risk, harm, cost: Time counseling individuals and expense of follow-up visits (e.g., treatment, medical supplies, transportation etc.)

Implications for Practice

The purpose of this statement is to describe considerations for establishing a comprehensive plan of care for lifestyle interventions, specifying frequency of visits, duration of care, oversight for pharmacologic therapy, and potential follow-up for people with prediabetes, T2D, or a history of GDM. Continuity of care is defined as the ongoing process followed by the interdisciplinary care team to collaborate for the purpose of providing high quality care over time that supports positive experience for individuals and a sustained, stable relationship with the person’s clinicians. Although continuity of care is naturally suited to lifestyle treatment, the GDG agreed that continuity may be inadequately discussed or specified as a part of the person’s care plan. The key components of continuity of care for people with T2D who are being treated with lifestyle interventions are shown in Table 7 and the CPG also includes handout for persons with T2D with key questions to ask at follow-up visits.

Table 7.

Key Components of Continuity of Care for People With Type 2 Diabetes Who Are Being Treated With Lifestyle Interventions. ^a

Component	Evidence	Recommendations
Frequency of visits and duration of care	Extended care, including more frequent, and longer person contact improves adherence to behavior goals and aids in maintaining health behaviors	Clinicians should schedule additional visits closely following the first initial visit when lifestyle is discussed, and then as often as possible given restrictions based on billing/reimbursement, availability of the clinicians, and person need for further education and support
Glucose monitoring	Lifestyle changes, particularly calorie restriction and whole-food, plant-predominant eating plan interventions, have been shown to reduce blood glucose, sometimes rapidly. Glucose self-monitoring should be encouraged as a way to increase person motivation as well as to enhance safety	Clinicians should, when possible, use continuous glucose monitoring (CGM) devices to track glucose levels during the first month and beyond lifestyle changes. When the use of CGM is not possible, frequent person self-monitoring is indicated, as often as twice daily during the first week of eating plan interventions targeting remission, as described in KAS 8
Medication management	Regularly scheduled visits with the clinician or HCP demonstrated improved ability to monitor pharmacologic agents to detect or prevent untoward effects such as hypoglycemia, drug-to-drug interactions, falls, or weight gain. Prompt modification of the pharmacologic regimen is advised when unsafe or side effects are detected	See KAS 14 for specific recommendations on medication management
Use of technology	The use of multiple platforms between the HCP and the person (face-to-face, telemedicine, virtual follow-up, AI driven) consistently yields improved glucose management, weight loss, and safety for people with diabetes	Telemedicine, automated follow-up emails, and referrals to supportive social media accounts should be considered to help create an environment conducive to sustaining healthy lifestyle changes
Referrals to other team members and shared medical appointments	Referrals to dietitians, Certified Diabetes Care and Education Specialist or diabetes educator, and health coaches have been shown to improve blood glucose management when used in conjunction with encounters with the PCP or endocrinologist for behavior change Shared medical appointments also yield favorable outcomes related to weight loss and improved glycemic outcomes	When possible, clinicians should refer to other available team members for additional contact and extended follow-up
Follow-up	Evidence shows that fostering continuity of care with regular follow-up visits promotes successful adoption of lifestyle interventions and person self-care engagement.163, 263, 522, 528-530 Maintaining that relationship for regularly scheduled follow-up visits for the duration of the condition favors continuity of care and person metrics	When beginning intensive, therapeutic lifestyle changes with people diagnosed with T2D, increased attention should be placed on person monitoring in the first few weeks, especially if the person indicates they are ready and willing to make substantive eating plan changes Ongoing follow-up visits should be scheduled regularly to assess maintenance of lifestyle changes, based on a person’s characteristics and needs

Abbreviations: HCP, healthcare professional; KAS, key action statement; T2D, type 2 diabetes.

^aReference citations are omitted from this table for brevity and clarity, but can be found in the corresponding table (Table 23) in the full CPG. ¹

KAS 14: Adjusting Pharmacologic Therapy

Action Statement

For adults with prediabetes, T2D, or a history of GDM, the clinician or HCP should adjust the type and dosing of an individual’s pharmacologic therapy based on the impact of lifestyle intervention on their medication needs. Recommendation based on observational studies, with a preponderance of benefit over harm.

Abbreviated Action Statement Profile

• • Aggregate evidence quality: Grade B, regarding the need for deprescribing, dangers of hypoglycemia, and lack of previous guidance on deprescribing based on 8 systematic reviews. Grade C, regarding the likelihood of lifestyle interventions to necessitate deprescribing and potential hypoglycemia based on several non-randomized, observational, or alternative method designed studies

• • Level of confidence in evidence: Medium

• • Benefits: Avoid adverse effects from hypoglycemia or overmedication; avoid hypotension; minimize weight gain; enable prescribed lifestyle changes; and promote sustainability of changes

• • Risk, harm, cost: Person anxiety regarding changes in therapy; some medications may be costly, or not covered by insurance; short-term, permissive hyperglycemia

Implications for Practice

The purpose of this statement is to provide guidance to clinicians for adjusting the type and dosing of pharmacological therapy for people with T2D who are engaging in intensive or moderate therapeutic lifestyle change interventions, particularly when the goal is to achieve remission. The GDG agreed that people may experience anxiety about lifestyle interventions because of the potential impact on their medications. Further, there may be a lack of awareness (for both medical teams and people) about anticipating the need to adjust pharmacologic therapy once lifestyle interventions are implemented. Any adjustment should also consider how the medication change may impact comorbid conditions, if present, such as chronic kidney disease, heart failure (with reduced or preserved ejection fraction), or a history of myocardial infarction.

There are four steps for deprescribing glucose-lowering medications in a lifestyle treatment context (Table 8). The supporting text in the CPG for this KAS includes several other tools to facilitate deprescribing, including figures on deprescribing considerations, deprescribing approach, and a handout for persons with T2D letting them know when to call their provider. In addition, there are tables showing how to anticipate and handle adverse events (e.g., hypoglycemia, hypotension) when deprescribing and managing insulin dose reduction during intensive or moderate lifestyle intervention.

Table 8.

Four Steps for Deprescribing Glucose-Lowering Medications in a Lifestyle Treatment Context.

Steps for deprescribing glucose-lowering medications	Implementation considerations
(1) Ongoing review and assessment of medication use	Review needs to be ongoing as glucose management and medication needs will change based on adherence to treatment, duration of adherence, and intensity of treatment. Adjustments made at the outset of lifestyle treatment will need to be revisited
(2) Person-centered and individualized plan of deprescribing	SDM about deprescribing decisions is ideal. People should be educated about the effects of medications, risks of both medications and deprescribing, lifestyle alternatives to pharmacologic therapy, and other considerations such as cost, and should be involved in creating a medications plan with the clinician
(3) Timely and efficient communication among members of the care team	Effective communication among all members of the interdisciplinary care team is essential, as behavior changes, especially intensive ones, may have strong effects on medication needs and risk for hypoglycemia. All members of the care team should share information in such a way that makes rapid responses or adjustments in communicating with the person possible
(4) Continuous and tailored medication education to meet the person’s needs	People should be educated on an ongoing basis regarding the risks of medications, benefits, other side effects, and the importance of communication with their clinician about behavior changes because of the immediate and potent effect on blood glucose

Case Studies Putting Guideline Recommendations (KASs) Into Practice

The following abbreviated case studies are based on patients cared for by two of the authors (MLG, MG) in their clinical practices and serve to illustrate the power of lifestyle intervention in managing prediabetes and T2D. For more detailed and complete case histories, please see online Appendix.

Prediabetes Case #1

Case Presentation

A 53-year-old man (BMI 37) was diagnosed with prediabetes (HbA1c 5.8%) upon joining a community-based therapeutic lifestyle change group intervention program to lose weight and improve his overall health. His past medical history included obesity (BMI 37), gout, hypertension, and hyperlipidemia. Prior to lifestyle intervention he occasionally drank alcohol, often slept less than 7 h a night, had a high stress level related to employment, had no regular physical activity (primarily sedentary), and ate a standard American omnivorous diet with frequent convenience foods, sugar-sweetened beverages, and snacks.

Outcomes Achieved

Within 6 weeks he lost significant weight, improved his blood pressure, and noted more energy, less fatigue, and improved mood. After the 3-month intervention he lost 12% of his body weight and had a normal HbA1c (5.2%). In his words, “I feel this program is very effective and does work very well if the person has the right frame of mind to do it. It also has sustainability, so it can become a lifetime set of habits…I feel much better...I am not tired all the time, and the previous nearly constant pain in my feet and hands is gone.”

KAS Recommendations Implemented to Achieve Outcomes

• • KAS 2: Baseline screening questionnaire evaluating diet, physical activity, sleep stress, social connection, motivation for desired changes, confidence in making changes, and resources for social support.

• • KAS 4: Walking most weekdays, after work, along with partner, gradually increasing the time to over 30 min per session.

• • KAS 6: Going to bed earlier to get over 7 h of sleep nightly

• • KAS 7: Culinary medicine activities, weekly recipes, cookbooks, and culinary websites to focus on home food preparation and batch-cooking using unprocessed fruits, vegetables, whole grains and legumes, which increased his fiber intake significantly while lowering caloric density of meals and promoting satiety. He removed meat, processed snacks, grain-based desserts and sugar-sweetened beverages from his diet and eliminated late-night snacking.

• • KAS 9: He joined the lifestyle intervention program with a significant other, who provided support and made lifestyle changes to address her own health issues. Other support in the program included educational presentations, strategies for behavior change, individualized goal-setting, group support and discussion, and contact between visits through email and a private cohort discussion forum.

• • KAS 12: Shared decision-making and motivational interviewing techniques were used to encourage person-driven, sustained positive behavior change.

• • KAS 13: Continuity of care was promoted with a staged, behavior change plan during the 3-month intervention period.

Prediabetes Case #2

Case Presentation

A 68-year-old woman prediabetes (HbA1c 5.8%) and impaired glucose tolerance was referred for metabolic management, with a history of phrenic nerve palsy, iatrogenic adrenal insufficiency from long-term high dose corticosteroids for recurrent episodes of bronchitis, and glucocorticoid-induced osteoporosis. After 3 years, her body weight peaked at 317 pounds (waist circumference over 35 inches) requiring a cane for ambulation and limiting physical activity. Shortly after, she began attending lifestyle endocrinology shared medical appointments that addressed all six lifestyle medicine pillars.

Outcomes Achieved

After about 2 years, she reduced her body weight by 9% and her prediabetes resolved (HgA1c 5.5%). She cultivated a positive mental attitude despite significant turmoil and distress in her life and benefited tremendously from the community of learning in the endocrinology shared medical appointments.

KAS Recommendations Implemented to Achieve Outcomes

• • KAS 4 and 5: She “promised to self to move each day,” even though limited by the diaphragmatic paralysis, and fulfilled this promise doing chair yoga, viewing yoga channels on YouTube, and using an under desk pedaling (elliptical) machine while sitting, working, or watching TV.

• • KAS 6: Her sleep improved remarkably, despite long-term use of a BiPAP for bilateral diaphragmatic paralysis, after adding an early afternoon cup of tea with relaxation, meditation, or an occasional nap.

• • KAS 7: She joined a local farm-share for weekly fresh fruits and vegetables and began incorporating new whole grains and legumes into her diet. She also focused on unprocessed, organic or locally grown meat in limited portions, with more emphasis on plant proteins. The shared medical appointments introduced her to new recipes, spices, and ethnic foods that could be replicated at home.

• • KAS 9: In her words, “We have to love ourselves before we can love others.” She likens this to an airplane preflight instruction of putting the oxygen mask on oneself before helping others with their oxygen masks. She now understands that being positive and developing a self-care routine “is a process, as we have been taught to take care of others often forgetting about our needs.”

• • KAS 10: She developed a rigorous strategy to journal and “take time daily to be grateful in the morning and take time in the evening to review the day.” By recording “thoughts for the day” and her food intake and “food attitude,” she is accountable to her plan, can track her progress, is empowered to say “no,” and can “permit herself to feel” and “to respond rather than react.”

T2D Case #1

Case Presentation

A 67-year-old woman diagnosed with T2D five years earlier, presents on multiple daily insulin injections with obesity (BMI 54.4), breast cancer, schizoaffective disorder, and limited mobility (wheelchair because of knee replacements). Metformin was begun and increased to 2000 mg per day concurrent with lifestyle medicine shared medical appointments. A registered dietician implemented a 1500-calorie whole-food, plant-based eating plan and chair exercises were added to reduce sedentary time.

Outcomes Achieved

After 3 years, she lost 10% of body weight and reduced her daily insulin needs by about 37%. With continued management, her HbA1c was 5.8% and mean glucose was 95 mg/dl with continuous monitoring (variability of 32%), never exceeding 250 mg/dl, allowing a 71% reduction from baseline for daily insulin needs.

KAS Recommendations Implemented to Achieve Outcomes

• • KASs 1, 2, and 3: The provider team and patient worked together and embarked on a prioritized, patient-driven, goal-oriented, systematic lifestyle therapy plan.

• • KAS 4 and 5: She worked with the lifestyle shared medical appointments and her orthopedic team to improve her activity levels and decrease sedentary time.

• • KAS 8: She worked very closely with the registered dietician to create a tailored plan with calorie deficit, adequate fiber and protein intake.

• • KAS 9: At the shared medical appointments, she flourished by fostering collaborative social connections with her fellow participants who also had T2D, obesity, and other chronic medical conditions, and by unwavering support from her loving, devoted spouse who attended every appointment.

• • KAS 12 and 13: Multiple lifestyle appointments, with high frequency of touchpoints and significantly enhanced continuity of care.

• • KAS 14: Systematically deprescribing T2D pharmacotherapy with emphasis on lowering doses of insulins (bolus first and then basal) and titrating closely in real time with continuous glucose monitoring to avoid hypoglycemia and promote adherence to lifestyle changes.

T2D Case #2

Case Presentation

A 70-year-old woman was diagnosed with T2D at a routine primary care visit (HbA1c 6.5%), with recommendations for metformin 1000 mg daily, diabetes education, daily blood glucose checks, and advice to limit carbohydrates. She chose to delay medication and instead connected with a lifestyle medicine physician to explore healthy behavior change. Her medical history included obesity (BMI 30), hypertension, hyperlipidemia, obstructive sleep apnea (requiring CPAP), essential tremor, anxiety, and depression. Prior to lifestyle intervention she was sedentary except for some yoga and ate a standard American omnivorous diet with frequent convenience foods and sugary snacks.

Outcomes Achieved

After lifestyle intervention, she lost over 13% of her body weight, normalized her blood pressure, improved her blood glucose variability (majority about 100 mg/dl), normalized her HbA1c (5.6%) without pharmaceutical therapy, and reported improved mood and energy.

KAS Recommendations Implemented to Achieve Outcomes

• • KAS 2: Baseline screening questionnaire evaluating diet, physical activity, sleep stress, social connection, motivation for desired changes, confidence in making changes, and resources for social support.

• • KAS 4: Walk at least 30 min daily, in addition to the yoga, and add resistance training twice weekly. An additional SMART goal was created to walk for 10 min in her yard with her dogs after dinner daily.

• • KAS 6: Continue to use CPAP but implement improved sleep hygiene habits to reduce sleep fragmentation.

• • KAS 8: Switch breakfast routine to whole-food, plant-predominant options and begin batch-cooking (recipes provided; websites and cookbooks recommended) for nutrient-dense lunch or dinner options, with more high-fiber (fruits, vegetables, whole grains, and legumes) to increase satiety and lower caloric density. A SMART goal was created to eat at least one cup of green, leafy vegetables daily as a “first course” for lunch or dinner while avoiding processed foods and sugar-free diabetic snacks.

• • KAS 9: Joined a gym along with several friends, creating a support system and positive reinforcement for the new physical activity regimen.

• • KAS 10: Stress management strategies, such as connecting with friends more frequently, visiting grandchildren, increasing physical activity, and resuming enjoyable hobbies.

• • KAS 11: Not applicable; no use of tobacco, alcohol, or other substances.

• • KAS 12 and 13: Staged behavior change plan was developed using motivational interviewing techniques and monitored with frequent follow-up visits over 6 months, including a log of daily blood glucose levels weekly morning body weight (“weigh-in Wednesdays”) that was reviewed weekly by her physician.

Conclusions

The new, ACLM CPG on which this summary is based is the first CPG putting lifestyle interventions front and center as the foundation in managing prediabetes, GDM, and T2D. It is also the first diabetes CPG to emphasize all 6 pillars of lifestyle medicine (including behavior change) and the first diabetes CPG with detailed and explicit lifestyle change strategies that are relevant not only to the ACLM CPG but to other CPGs that recommend lifestyle changes. We also provide a plain language summary to foster informed discussions among patients, families, clinicians, and HCPs. ³¹ These discussions will hopefully facilitate positive lifestyle change, less progression of prediabetes or GDM to T2D, better T2D outcomes, more deprescribing of T2D medications, and greater opportunities to achieve T2D remission.

ORCID iDs

Richard M. Rosenfeld https://orcid.org/0000-0002-3557-3795

Mahima Gulati https://orcid.org/0009-0004-6726-4163