The treatment of type 2 diabetes (T2D) and prediabetes has historically focused on pharmacological interventions. However, a new paradigm has been proposed by the American College of Lifestyle Medicine (ACLM), with the publication of the first clinical guideline that places lifestyle interventions as first-line treatment for T2D and prediabetes in adults. This guideline represents a significant shift in clinical practice by emphasizing therapeutic interventions based on six pillars: a predominantly plant-based and whole-food diet, regular physical activity, restorative sleep, stress management, positive social connections, and avoidance of risky substances (Rosenfeld et al., 2025).
The relevance of this approach is evident in the face of an alarming epidemiological scenario: more than half of the adult population in the United States has prediabetes or T2D, diseases that together account for approximately US$456 billion in annual health care expenditures in the country. Globally, it is estimated that 1.3 billion people will be living with diabetes by 2050. The ACLM guideline is therefore not only timely but necessary given the magnitude and complexity of this public health crisis (Rosenfeld et al., 2025).
Unlike the traditional approach, which often underestimates or downplays behavioral factors, the guideline emphasizes that these changes are not complementary but rather the core of therapy. Remission of T2D—defined as HbA1c <6.5% for at least 3 months without the use of glycemic control medication—is a concrete possibility in many cases when there is intensive adherence to these interventions (Rosenfeld et al., 2025).
One of the most innovative aspects of the guideline is the systematic use of recommendations called Key Action Statements (KAS), each supported by rigorous assessments of evidence, magnitude of benefits, risks, and practical implications. KAS 1, for example, states that health care professionals should actively advocate for lifestyle interventions as initial management of T2D and prediabetes. This recommendation is supported by randomized controlled trials, systematic reviews, and previous guidelines, constituting grade A evidence. Despite this, many clinicians still treat these strategies as adjuncts to pharmacotherapy rather than as the primary treatment (Rosenfeld et al., 2025).
Another crucial point is the recognition of the need to assess lifestyle habits as an integral part of the clinical consultation, according to KAS 2. This initial assessment allows us to understand the patient’s readiness for change and to personalize therapeutic plans. Based on this assessment, professionals are guided to establish SMART goals (specific, measurable, achievable, relevant, and time-bound) and to prescribe structured physical activity — highlighting the use of the FITT approach (frequency, intensity, time, and type) — in addition to an individualized nutritional plan, preferably based on whole foods of plant origin (Rosenfeld et al., 2025).
The guideline also recognizes the importance of aspects that are often neglected in medical practice, such as sleep quality (KAS 6), social support (KAS 9), and identification of psychological intervention needs (KAS 10). These components are essential not only for adherence, but for the sustainability of changes. A practical example: sleep disorders such as obstructive sleep apnea and shift work are associated with worsening glycemic control, making early detection essential (Rosenfeld et al., 2025).
In terms of clinical impact, the evidence is robust: in addition to promoting glycemic control and weight loss, lifestyle interventions improve quality of life, reduce cardiovascular risk, favor drug deprescription and can lead to total remission of type 2 diabetes. These effects are not merely associative, but causal, and apply to different sociodemographic contexts, including in low- and middle-income countries (Rosenfeld et al., 2025).
Yet only about 20 percent of adults in the United States follow a lifestyle that is considered healthy. The gap between scientific evidence and clinical practice remains wide, and part of the problem lies in the lack of training of health care professionals in lifestyle medicine, the lack of time spent in consultations, and the lack of institutional support for sustained behavior change.
The merit of the ACLM guideline lies in offering a practical, evidence-based roadmap to fill this gap. It does not replace existing pharmacological guidelines, but complements them by offering a more holistic, patient-centered approach. Adopting this new paradigm requires not only technical updates, but also a change in mindset: it is necessary to see the patient as the protagonist and not as a mere passive recipient of prescriptions.
In daily clinical practice, I find that by integrating behavioral change approaches—such as health coaching, motivational interviewing, and self-care education—patients tend to become more engaged, not only in adhering to the behaviors, but in actively constructing their own healing process. The guideline validates and structures this practice, providing technical support for an approach that has already been empirically perceived as more effective.
Reference:
ROSENFELD, Richard M.; GREGA, Meagan L.; GULATI, Mahima. Lifestyle Interventions for Treatment and Remission of Type 2 Diabetes and Prediabetes in Adults: Implications for Clinicians. American Journal of Lifestyle Medicine, vol. 0, n. 0, p. 1–33, 2025. DOI: 10.1177/15598276251325802.
