MON-672 - Marked Glycemic Improvement with Lifestyle Modification Alone in A Patient with Newly Diagnosed Severe Type 2 Diabetes

Introduction
Current diabetes management guidelines recommend early pharmacologic therapy, including insulin, for patients with severe hyperglycemia and HbA1c levels greater than 9%, particularly when symptomatic¹. However, patient preference, adherence, and intensive lifestyle intervention may significantly influence outcomes.

Case
A 32-year-old Hispanic man presented to establish care with complaints of fatigue, nocturia, and excessive sweating. Physical examination was notable only for obesity. Initial laboratory evaluation demonstrated normal complete blood count and comprehensive metabolic panel except for hyperglycemia. Thyroid function tests were within normal limits. HbA1c was markedly elevated at 14%, fasting insulin was elevated at 31 μIU/mL, and vitamin D level was deficient at 9 ng/mL.
Guideline-directed pharmacologic therapy was recommended¹; however, the patient declined all medications. He reported a diet high in processed foods and sugar-sweetened beverages with minimal physical activity. He elected to pursue intensive lifestyle modification. A structured nutrition plan was implemented consisting of a low-carbohydrate diet ( < 150 g/day), 0.8gm/pound of protein intake, healthy fats, elimination of processed foods and sugary beverages, increased fiber intake (>35 g/day), and adequate hydration. A structured exercise regimen including resistance training and aerobic activity three times weekly was initiated. Supplementation included a multivitamin, vitamin D3 5,000 IU daily, omega-3 fatty acids, magnesium glycinate, and probiotics.

The patient demonstrated strict adherence and was followed every two months. Over six months, he achieved a 30-pound weight loss. Repeat laboratory testing showed vitamin D levels of 45 ng/mL and a HbA1c of 6%, without pharmacologic therapy. Similar outcomes have been reported in trials demonstrating diabetes remission and significant glycemic improvement with structured weight loss and low-carbohydrate dietary interventions2.
Conclusions
This case illustrates the profound impact of intensive lifestyle modification on glycemic control, even in patients presenting with severe hyperglycemia. While current guidelines recommend early insulin initiation for HbA1c levels above 9%¹ individualized care incorporating patient motivation and adherence may allow for alternative therapeutic approaches in select patients.
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References
1. Garber AJ, et al. Consensus Statement by the American Association of Clinical Endocrinologists and American College of Endocrinology on the Comprehensive Type 2 Diabetes Management Algorithm – 2022 Executive Summary. Endocr Pract. 2022;28(1):1–20.
2. Lean MEJ, et al. Primary care–led weight management for remission of type 2 diabetes (DiRECT): an open-label, cluster-randomised trial. Lancet. 2018;391(10120):541–551.

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