Lifestyle changes (in nutrition and physical activity) are clearly important to delay the development of type 2 diabetes in individuals with insulin resistance and are the primary recommendation for prevention of diabetes in high-risk individuals. Metformin is the only drug recommended by guidelines, for those patients at highest risk. Education about these changes must be directed to all groups at risk for type 2 diabetes. Childhood obesity is epidemic and on the rise in the developed countries. Changes must be made in homes and school cafeterias to ensure healthier nutrition .
Replacement therapy includes basal-bolus insulin and correction or premixed insulin; an insulin pump may be used, but is beyond the scope of this article. Replacement should be considered for patients with type 2 diabetes that is uncontrolled with augmentation therapy and who are able to comply with such a regimen or who desire tighter control. Bolus insulin should be added to basal insulin if fasting glucose goals are met but postprandial goals are not. When blood glucose levels are above predefined targets, additional short-acting insulin may be added to the bolus dose before meals. For example, a patient takes 40 units of glargine daily and 12 units of lispro (Humalog) before each meal, and has a correction factor of 1 unit for every 20 mg per dL ( mmol per L) above 120 mg per dL ( mmol per L). If the blood glucose level at breakfast is 160 mg per dL ( mmol per L), the patient would take 12 units of lispro for the meal plus an additional 2 units for correction before eating.