An estimated 37 million people — or 11% of the U.S. population — have diabetes (CDC data). Even more staggering, another 96 million adults (aged 18 years or older) have prediabetes. While pharmaceutical therapy (e.g., insulin) is the cornerstone of treating those with Type 1 diabetes, many individuals with Type 2 diabetes (T2D), as well as those with prediabetes, can improve or even reverse the course of their disorder with lifestyle modifications — either without pharmaceuticals or, in some cases, supplemented by them. Here are the most important non-pharmacological treatment for diabetes that all these individuals, working with their medical team for individualized guidance, should consider following.
Attend your regular physical exam and screenings
Disturbingly, the CDC estimates that 7.3 million adults (aged 18 years or older) who meet laboratory criteria for diabetes are not aware of or did not report having diabetes. So the starting point for taking advantage of non-pharmacological treatment for diabetes strategies is first to get the correct diagnosis; so don’t delay scheduling and attending your regular physician exams, as it’s a costly mistake to do so. The American Diabetes Association (ADA) recommends that the following people be screened for diabetes:
- Anyone with a body mass index higher than 25 (23 for Asian Americans), regardless of age, who has additional risk factors, such as high blood pressure, abnormal cholesterol levels, a sedentary lifestyle, a history of polycystic ovary syndrome or heart disease, and who has a close relative with diabetes.
- Anyone older than age 45 is advised to receive an initial blood sugar screening, and then, if the results are normal, to be screened every three years thereafter.
- Women who have had gestational diabetes are advised to be screened for diabetes every three years.
- Anyone who has been diagnosed with prediabetes is advised to be tested every year.
Understand where you are relative to the five markers of metabolic health
Even if at your physical exam it is determined that you don’t have diabetes or prediabetes, have a discussion with your medical team to discern whether you are at risk — as quite a few risk factors (such as elevated plasma glucose concentrations, being overweight, and leading too sedentary a lifestyle) are potentially reversible.
According to a 2019 study, only 12% of American adults are considered metabolically healthy, a rather astounding statistic. You’re considered metabolically healthy if the following five “markers” are in a healthy range. Commonly recommended benchmarks for each are as follows:
- Blood sugar: best below 100 mg/dL after an overnight fast
- Blood pressure: best below 120/80 mm Hg
- Triglycerides: best below 150 mg/dL
- Waist size: best less than 40 inches for men and 35 inches for women
- HDL cholesterol (the “good” kind): best greater than or equal to 40 mg/dL for men and 50 mg/dL for women.
Even if you’re only out of bounds on one marker, you’re at risk. If you’re out of bounds on three or more, you are at very serious risk of diabetes as well as other non-communicable disorders, such as heart disease.
If diagnosed, participate in DSME/S
After screening and follow-up, if you know you’ve been diagnosed with diabetes, your provider should inform you of Diabetes Self-management Education and Support (DSME/S), and your participation in this program is essential for facilitating the knowledge, decision-making, and skills mastery you need for diabetes self-care. As stated in the 2022 ADA Standards of Medical Care in Diabetes, “Studies have found that DSME/S is associated with improved diabetes knowledge and self-care behaviors, lower A1c, lower self-reported weight, improved quality of life, reduced all-cause mortality risk, positive coping behaviors, and reduced health care costs. Better outcomes were reported for DSME/S interventions that were >10 hours over the course of 6–12 months.”
Monitoring: Measuring the success of non-pharmacological treatment for diabetes
Lifestyle modifications alone can be hugely effective at reducing your risk of diabetes. The strongest evidence comes from the DPP trial, as reported in a 2002 New England Journal of Medicine paper: Lifestyle changes and treatment with metformin both reduced the incidence of diabetes in persons at high risk, but lifestyle intervention was more effective than metformin. From intensive lifestyle changes alone, over three years, the incidence of diabetes was reduced by 58% as compared with 31% from metformin.
Lifestyle modifications are also of paramount importance if you have T2D. But in order to measure the effectiveness of such non-pharmaceutical interventions, you need to monitor and analyze some vital metrics. The ADA recommends monitoring (1) blood glucose, (2) lipid levels, (3) blood pressure and (4) your weight — which, not coincidentally, would provide all the data required to assess metabolic health (the five markers we discussed previously).
1. Glycemic monitoring
If your healthcare provider thinks you may be at risk for or could have prediabetes or T2D, they will conduct an assessment of risk factors (which may be performed with an assessment tool, such as the ADA’s risk test, diabetes.org/socrisktest).
The provider may then go on to perform certain tests, and some of these same tests — especially the hemoglobin A1c (HbA1c, or A1c for short) test — are also used regularly if you’ve already received a diabetes diagnosis. In fact, regular blood sugar monitoring is the most important thing you can do to manage diabetes.
While it’s normal to experience a rise in your blood sugar after you eat, as more glucose enters the bloodstream, the key is to control the rise so it’s not too dramatic. (See our report, What Is Postprandial Blood Sugar?) Excessive spikes and less time spent in the normal range have the potential to increase the risk of or intensify the symptoms and potential complications (such as to the circulatory system) of diabetes. With regular monitoring, you’ll be able to see what makes your numbers go up or down, such as eating different foods, taking any medications, or being physically active. With this information, you can work with your health care team to make decisions about your best diabetes care plan.
Your doctor will tell you when and how often to check your blood sugar levels. (Current guidelines recommend that patients with diabetes self-monitor their glucose at least three times per day, or four if they take insulin.) For some individuals, a continuous glucose monitor (CGM) may be recommended, as it can measure interstitial fluid (where your glucose moves after it has been through your blood vessels and capillaries) and provide a detailed picture of what’s impacting (whether it be food or exercise or sleep) your blood glucose levels throughout the day and night. One study found that a cohort of individuals with T2D, who used a CGM for 10 days and adhered to the personalized lifestyle modifications that the device helped identify, experienced 66% improvement in the important “time in range” (TIR) measurement — the amount of time your body spends in its target healthy zone for glucose levels.
2. Lipid monitoring
Monitoring your level of triglycerides and how much of your cholesterol is the “good” (HDL) kind is important because of the complex interplay between these lipids, your glucose control, and your weight — not to mention the cardiovascular indications. There are a variety of lipid metabolism abnormalities that either cause or result from insulin resistance, and of course insulin resistance prevents your body from moving enough sugar (glucose) into your cells, so your blood glucose levels stay chronically high… which is the hallmark of diabetes.
3. Blood pressure monitoring
Because high blood pressure (hypertension) can be a problem on its own, and also can be a driving factor in potential complications from diabetes, your doctor may suggest that if you have diabetes, you regularly monitor your blood pressure at home, particularly if you are indeed hypertensive.
4. Waist and weight monitoring
Clearly, waist size and weight are significant risk factors for diabetes, and remaining overweight during diabetes complicates treatment considerably. Nearly 90% of adults with diabetes are overweight or obese with a body mass index (BMI) over 25, according the CDC. As we detailed in our report, The Top 7 Risk Factors for Prediabetes and Type 2 Diabetes, if you focus on bringing your weight down, even a little bit, the payoff can be huge for your blood sugar and total metabolic health. Even an extra 15 or 20 pounds can throw off your system as your fat cells send out compounds that ramp up inflammation. The closer you can get to your healthy weight (even if you don’t reach your summer-bathing-suit goal), the calmer your inflammatory response will be.
Non-pharmacological treatments: Embrace these lifestyle modifications
Now that you’ve got the measurements you need, it’s time to correlate them with the non-pharmacological interventions that can help you prevent the onset of diabetes or even (in the case of prediabetes or T2D) reverse the disorder if you’ve been diagnosed with it. Bear in mind that the impact of these interventions is often interrelated. For example, your weight can affect your lipid profile, but your lipid profile also affects your ability to shed pounds. Obesity can cause your blood glucose levels to rise, and yet the reverse can also happen: high blood glucose levels can cause your insulin levels to get out of whack and throw your body into fat-storage vs. fat-burning mode. High blood glucose (hyperglycemia) can worsen lipotoxicity, which can then worsen glucotoxicity (the set of negative outcomes associated with high blood glucose).
- Weight management: Because all five of the metabolic markers can be impacted by your weight, it’s critical to get it into a normal range. A 2016 study found that simply reducing weight by 5-10% could significantly lower all metabolic factors and reduce risk for diabetes and heart disease. Overall caloric restriction should certainly be a primary goal: portion control is key. But research has confirmed that weight management is highly individualized: a low-carbohydrate diet may work for some people, while others don’t lose weight on it and might respond better to a higher-carb/lower-fat diet.
What’s clear, however, is that beyond consideration of total weight, your body responds to some foods in ways that affect your metabolic health, and those same responses might not be as profound for other individuals. So the following “it’s what you eat, not just how much” generalizations are just that: population generalizations, but the best ones iterated by a consensus of scientists:
- Watch your total carb consumption: Many people with diabetes are guided to count carbohydrates in order to help manage blood sugar levels, since carbs turn into glucose through digestion, and those with diabetes — who either can’t make enough insulin or can no longer properly use the insulin they produce — cannot readily rid their bloodstream of glucose, increasing the chances for heart disease, stroke, kidney failure, and blindness. Better glycemic management, on the other hand, can help prevent those complications. For healthy individuals, research has demonstrated that a lifetime of high glucose-stimulated insulin secretion can cause obesity, more so than can genetics; and individuals with higher levels of post-meal (postprandial) glucose have a higher risk of developing diabetes.
- Choose “good” carbs: Most research indicates that choosing higher quality carbohydrate foods benefits glycemic control and is also associated with weight loss and decreased incidence of diabetes, cardiovascular disease, and cardiovascular mortality. The best of the best: non-starchy complex carbs that are high in fiber and lower on the Glycemic Index (GI), especially vegetables, whole fruits, nuts, lentils, beans and whole grains.
- We can’t overstate the importance of consuming high-fiber foods, which have been shown to significantly improve blood glucose levels in patients with T2D. Fiber also helps regulate digestion; keeps you feeling full (which helps keep weight in check); lowers blood pressure, cholesterol and inflammation; and enhances immunity. Learn more: What Is Fiber?; How Consuming More Fiber Can Benefit Diabetes Management
- Reduce your consumption of “bad carbs”: For most individuals, these are the most harmful: (1) sugar-sweetened beverages; (2) starchy carbs that are low in fiber (including many cereals, white bread, corn, refined pasta and white rice); and (3) the vast array of processed and ultra-processed foods containing gobs of added sugars and fats (everything from candy and cookies to ketchup, potato chips, hot dogs). Research has shown that even normal-weight young men between the ages of 19 and 25 who consumed 40 grams of added sugar from soda daily for three weeks had increased insulin resistance and blood sugar levels, higher LDL cholesterol (that’s the bad kind), and an uptick in inflammation. Learn more: Confused About Carbohydrates?
- Reduce your consumption of “bad fats” but don’t shy away from “healthy fats”: to improve your lipid profile, avoid saturated fat and trans fat, but increase your intake of “healthy fats” like monounsaturated fats (avocados, olive oil) and omega fatty acids (salmon, nuts, seeds, certain vegetables), particularly Omega-3 and Omega-6, which also help you optimize glycemic control and reduce the risk of atherosclerosis, obesity, and other diseases. Learn more: Dietary Fats: Which Are Healthy, Which Are Not?
- Balance your consumption of protein: While carbohydrates are the macronutrients that impact glucose levels the most, the way you “tolerate” carbohydrates can be influenced by the ingestion of protein and lipid nutrients. Protein ingestion has been shown to improve glucose tolerance to a threefold greater extent than fat in healthy participants, and a 2015 study showed that “pre-loading” with certain proteins and fats was able to improve glucose sensitivity in T2D individuals. Learn more about your healthiest protein choices.
- Moderate your sodium intake. The ADA recommends consuming less than 2,300 mg/day. Learn more: Salt and Diabetes.
- Stay hydrated. A 2011 study found that water intake was inversely associated with the risk of developing hyperglycemia (high blood sugar); the more water study subjects consumed, the lower their risk of extreme glucose spikes. On the other hand, those who reported drinking less than half a liter per day (that’s less than 2 eight-ounce glasses) were at increased risk. (Learn more: Dehydration and Diabetes.) And it’s best to replace sugar-sweetened beverages (including fruit juices) with water as much as possible in order to control glycemia and weight and reduce their risk for cardiovascular disease and fatty liver.
- Mind your meal timing: Much research is underway to determine what impact changes in meal timing can have on glycemic control and other metabolic markers. Intermittent fasting (IF) has been shown to positively influence glucose and lipid homeostasis in the short-to-medium term, but study authors cautioned that more long-term safety studies are required. Time restricted eating (TRE) is also gaining interest; a 2019 review concluded that “confining all caloric intake to within a defined time interval that is a few hours separated from the daily sleep interval has multiple health benefits.” Learn more in our report, Is Time Restricted Eating or Intermittent Fasting Good For You?
Regular physical activity is clearly an important part of any weight management program; but independent of weight gain/loss, exercise can also help with blood glucose control and other metabolic health markers.
- For adults with diabetes, the ADA recommends at least 150 minutes per week of moderate- to vigorous-intensity aerobic activity per week, spread over at least 3 days/week, with no more than 2 consecutive days without activity. Shorter durations (minimum 75 minutes/week) of vigorous-intensity or interval training may be sufficient for younger and more physically fit individuals.
- Studies indicate that, especially after a meal, moderate exercise consistently reduces glucose levels. Muscle contraction during exercise helps the body use glucose without the need for insulin, a phenomenon called insulin-independent glucose disposal. It is possible to blunt the post-meal glucose surge substantially by starting the physical activity about 30 minutes post-meal and continuing it for up to 60 minutes.
- Moderate resistance exercise, moderate endurance exercise or a combination of the two, practiced post-meal, has also been found to improve many cardio-metabolic markers such as high density lipoprotein, triglycerides, and markers of oxidative stress.
- Prolonged sitting should be interrupted every 30 minutes for blood glucose benefits.
- In individuals taking insulin and/or insulin secretagogues, physical activity may cause hypoglycemia if the medication dose or carbohydrate consumption is not adjusted for the exercise bout and post-bout impact on glucose. Patients need to be educated to check blood glucose levels before and after periods of exercise and about the potential prolonged effects of exercise, depending on its intensity and duration.
Mind your sleep hygiene.
The quality and duration of your sleep impacts your metabolic health, including your glycemic control. In a 2018 study, researchers found a compelling connection between lack of sleep and insulin resistance, which put subjects at greater risk for glucose intolerance and diabetes. Furthermore, poor sleep is associated with weight gain, and weight gain alone ups your risk of developing diabetes. Learn more about the best sleep duration (7 hours) and what high-quality sleeping looks like in our report, Why Sleep Matters For Your Metabolic Health.
Moderate your alcohol intake and don’t smoke.
Mind your stress and emotional stability.
Your psychological health is paramount to your metabolic health, so if you feel overwhelmed, distressed or unstable, seek help. Even everyday stress is associated with weight gain, and stress can negatively impact your ability to sleep, which in turn affects your weight and hurts your metabolic health in other ways as well. Learn more: Stress and Diabetes.
Keep up to date on your immunizations.
The importance of routine vaccinations for people living with diabetes has been elevated by the Covid-19 pandemic. Preventing avoidable infections not only directly prevents morbidity, but also reduces hospitalizations — which may additionally reduce the risk of acquiring infections such as Covid-19. Children and adults with diabetes should receive vaccinations according to age-appropriate recommendations.
Find additional help.
Beyond regular contact with your medical team, there are numerous diabetes self-help, support and information resource organizations that you might find worthwhile, including the CDC’s National DPP — a resource designed to bring evidence-based lifestyle change programs for preventing type 2 diabetes to communities, including eligible Medicare patients.
The onset of diabetes can be avoided if you keep your five metabolic markers in a healthy range by embracing and adhering to the lifestyle modifications outlined in this report. Non pharmacological treatment for diabetes are critical and highly effective for the optimal management of your condition. Your medical provider can work with you to tailor these interventions in ways that make sense given your unique health status, including the individualized intelligence gleaned from monitoring your glucose (and other markers) and correlating that information and data with your daily dietary, activity and other lifestyle practices.