Sitting (or not), stepping, sweating, strengthening and sleeping – the five S’s approach to managing Type 2 Diabetes

Earlier in 2022 we had a update to the NICE Type 2 diabetes guidelines with significant changes around prescribing, especially first line medications with an emphasis on using metformin and SGLT2 inhibitors as dual therapy for a broad range of our patients with type 2 diabetes, with a focus on using the SGLT2 inhibitors for organ protection beyond glycaemic control. The NICE update focused almost entirely on changes to prescribing algorithms, while maintaining previous advice around lifestyle interventions and structured education.

In September 2022 we had an update to the international ADA/EASD Consensus statement (from the American and European Diabetes Associations) for the management of type 2 diabetes.  This was presented at a conference in Stockholm where I was fortunate enough to attend and the whole document is very refreshing and well worth a look.

This update, just like NICE, also contains prescribing changes with a focus on SGLT2i’s and GLP1’s as organ-protectors in high risk patients, indeed going as far as recommending their use in the highest risk patient independently of metformin.

Perhaps the most refreshing part of this update however, is a strong focus on weight management – putting this alongside glucose management in terms of importance in the support and treatment of people living with type 2 diabetes, and a real deep dive into the impact of 24 hour physical behaviours for people with type 2 diabetes. 

In terms of nutrition therapy, the guidelines brings us fully up to date with the current evidence for different approaches in type 2 diabetes, often a contentious issue – including a low carb, low calorie, Mediterranean diet and time-restricted eating. The evidence is very mixed with benefits seen for all, and the overall conclusion is that people should be offered individualised nutrition advice that is feasible and sustainable for that person.

My favourite part of this guideline is a focus on 24 hour physical activity behaviours and their impact on cardiometabolic health in type 2 diabetes, the five S’s, with some lovely simple but high impact facts attached to a nice illustration which would sit well on a consulting room wall.

1. Sitting / breaking up prolonged sitting – breaking up prolonged sitting every 30 minutes can improve glucose metabolism .
2. Stepping – a 5-6 minute brisk intensity walk per day equates to approx. 4 years greater life expectancy. 
3. Sweating – as little as 30 minutes per week of moderate-intensity physical activity improves metabolic profile.
4. Strengthening – resistance exercise improves insulin sensitivity and glucose levels.
5. Sleep – long (> 8 hrs) and short (< 6 hours) sleep durations negatively impact HBA1c.

I especially like this mention of sleep duration and quality with healthy sleep considered a key lifestyle component in the management of type 2 diabetes. The evidence shows that the quantity of sleep is known to be associated, in a ‘U’ shaped manner, with health including obesity and HbA1c, with both long and short duration having a negative impact. By extending the sleep duration of short sleepers, it is possible to improve insulin sensitivity and reduce energy intake. However, ’catch-up’ weekend sleep alone is not enough to reverse the impact of regular insufficient sleep – not good news for those of us that look forward to that Sunday morning lie in to make up for the week gone by!

Look at the full guideline including the five S’s illustration here: ADA/EASD 2022 Consensus Report