April 2017 Page 1 of 6 

VA/DoD CLINICAL PRACTICE GUIDELINE FOR

THE MANAGEMENT OF TYPE 2 DIABETES

MELLITUS IN PRIMARY CARE

Department of Veterans Affairs

Department of Defense

Patient Guide

QUALIFYING STATEMENTS

The Department of Veterans Affairs and the Department of Defense guidelines use the best and most

recent information that is available at the time they are published. Guidelines provide information that

providers, healthcare team members and patients can use to provide better care for diabetes. They do not

define a standard of care and you should not use them in this way. They are also not the only way to

manage diabetes.

This Clinical Practice Guideline is based on a complete and organized review of both clinical studies and 

studies about how diseases affect the health and illness of groups of people. A panel of experts in a

number of clinical fields developed this guideline. The Guideline clearly explains how different care options

relate to health outcomes. To do this, the experts rated both the quality of the clinical studies and the

strength of the recommendations.

It is normal for providers to vary in how they treat patients with diabetes because they take into account

the needs of each patient, the available resources, and the limits that are unique to their healthcare

setting or type of practice. Healthcare professionals should assess how well these Guidelines apply to each

patient, and their clinical setting or situation. Patients can use the information in this Guideline to

understand the different ways that diabetes can be treated. This will help you discuss treatment options

with your provider and team. Working together, you can create a personalized diabetes care plan that

meets your needs and makes it easier for you to manage your diabetes.

These guidelines do not represent Department of Veterans Affairs or TRICARE policy. The Guideline

recommendations for specific tests and/or treatments do not guarantee coverage of the patient’s care by

civilian providers or healthcare facilities. You can find more information on current TRICARE benefits at

www.tricare.mil or by contacting your regional TRICARE Managed Care Support Contractor. 

Version 5.0 – 2017 
VA/DoD Clinical Practice Guideline for the Management of Type 2 Diabetes Mellitus in Primary Care

April 2017 Page 2 of 6

You have diabetes. What do you do now?

Diabetes is a chronic disease but you can manage diabetes by working with your healthcare provider and 

other members of your healthcare team. You and your healthcare team will make decisions together to 

come up with a treatment plan that is right for you.

What is diabetes mellitus?

We get glucose (also called sugar) from most of the carbohydrates (foods like breads, pasta, milk, and 

fruits) we eat. Our bodies use this sugar to give us the energy we need to live. People have a gland in the 

abdomen called the pancreas which makes insulin. Insulin is a hormone that flows through the blood and 

brings sugar into the cells of the body to provide energy. Therefore, when there is not enough insulin or 

when the body can’t use insulin as it should, the level of sugar in our blood goes up. Diabetes mellitus is a 

disease where the blood sugar (also called blood glucose) is higher than normal.[1] Some people who have 

diabetes do not make enough or do not make any insulin at all. This is called Type 1 diabetes. People with 

Type 2 diabetes cannot use insulin in the right way. When people first have Type 2 diabetes, they make 

more insulin to make up for the body not using it as it should. If Type 2 diabetes lasts for a long time, the 

pancreas may start to make less insulin. There are many reasons why some people get Type 2 diabetes. It 

can often be caused by too much fat tissue, especially around the waist. Less commonly, diabetes occurs

from taking cortisone-like medications for a long time or from being pregnant. 

What are the signs and symptoms of diabetes?

In the beginning, there are no outward signs of Type 2 diabetes. But when the disease becomes worse, 

patients start to notice some signs. For example, they may feel hungry, tired, the need to urinate often, 

thirsty, have dry mouth, vision problems, or weight loss.[2,3] If you have these symptoms, it is important 

to call your healthcare provider. If diabetes lasts for a long time, patients may notice symptoms of

complications or long-term problems. For example, they can have yeast infections, no feeling in the feet or 

legs, poor wound healing, heart problems, kidney problems, or eye problems.[4] You cannot know if you 

have diabetes on your own. Only a healthcare provider can know if you have diabetes.

How is diabetes treated?

It is important to talk with your healthcare provider and team about your goals for blood sugar and 

hemoglobin A1c (a test that lets patients and their healthcare team know about their diabetes 

control over 2 to 3 months) levels. Your healthcare provider will consider your present health, your 

preferences, and what is important for you now and in the future. Type 2 diabetes is treated with 

medications and changes in your physical activity, weight, and diet.[5] Some patients may also need

insulin or other injections.[5] Patients often need to monitor their blood sugar.[5] In addition to the 

hemoglobin A1c test, your healthcare provider will also do some other important tests. African 

American patients who have diabetes may have higher hemoglobin A1c test results even if their blood 

glucose measures are the same as other races. When African American patients work with their 

providers and teams to set hemoglobin A1c goals, they need to take this into account. Since the 

medications for the treatment of diabetes are rapidly changing, talk to your provider often about your 

medication(s). 
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Your provider or dietitian may suggest a Mediterranean diet. Table 1 shows some components of the 

Mediterranean diet.

Table 1: Summary of Dietary Recommendations in the Mediterranean Diet* 

Food Goal

Recommended

Olive Oil ≥ 4 tbsp. per day

Tree nuts and peanuts ≥ 3 servings per week

Fresh fruits including natural fruit juices ≥ 3 servings per day

Vegetables ≥ 2 servings per day

Seafood (primarily fatty fish) ≥ 3 servings per week

Legumes ≥ 3 servings per week

Sofrito† ≥ 2 servings per week

White meat In place of red meat

Wine with meals (optional) Discuss with provider

Discouraged

Soda drinks < 1 drink per day

Commercial baked goods, sweets, pastries‡ < 3 servings per week

Spread fats < 1 serving per day

Red and processed meats < 1 serving per day

*Adapted from Estruch, et al. (2013) [6]

† Sofrito is a sauce made with tomato and onion, and often includes garlic, herbs, and olive oil.

‡ Commercial bakery goods, sweets, and pastries include cakes, cookies, biscuits, and custard, and do not include those that are 

homemade.

If you do not see a dietitian, additional tools to plan food choices and menus are on the United States 

Department of Agriculture website, http://www.choosemyplate.gov/. 

Table 2 shows some advice on physical activity for adults and older adults.
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Table 2. Key Physical Activity Guidelines for Adults & Older Adults [7] 

All Adults Older Adults

Avoid inactivity. Some physical activity is better than 

none and adults who participate in any amount of 

physical activity gain some health benefits.

Be as physically active as abilities and conditions allow 

when unable to do 150 minutes of moderate-intensity 

aerobic* activity a week. 

For substantial health benefits, do at least 150 minutes 

(2 hours and 30 minutes) a week of moderate intensity 

or 75 minutes (1 hour and 15 minutes) of vigorous 

aerobic* physical activity, or an equivalent combination 

of moderate and vigorous intensity aerobic* activity.

Do exercises that maintain or improve balance if at 

risk of falling. 

Do muscle-strengthening activities that are moderate or 

high intensity and involve all major muscle groups on 2 

or more days a week, as these activities provide 

additional health benefits.

Consider level of fitness before determining level of 

activity. 

For additional and more extensive health benefits, 

increase aerobic physical activity to 300 minutes (5 

hours) a week of moderate intensity, or 150 minutes a 

week of vigorous intensity aerobic* physical activity, or 

an equivalent combination of moderate and vigorous 

intensity activity as additional health benefits are gained 

by engaging in physical activity beyond this amount.

Understand how chronic conditions affect ability to 

do regular physical activity safely. 

*Aerobic activity should be performed in episodes of at least 10 minutes, and preferably, it should be spread throughout the week.

Who is at risk for diabetes?

The risk for diabetes increases as people get older.[1] People of Asian, African, Native American, or Pacific 

Islands descent are more likely to get diabetes.[1] Being overweight and having little physical activity can 

lead to diabetes. People at risk for diabetes also often have high blood pressure and cholesterol problems. 

Women with diabetes when pregnant are also at risk for diabetes later in their life. Not all people with 

these risk factors will develop diabetes. It is important for everyone to work with their healthcare provider 

and team to prevent diabetes.

How can I best take care of myself if I have diabetes?

To live well with diabetes, work closely with your healthcare provider to choose the best treatment plan 

for you. Your healthcare provider and team want you to let them know about your goals and preferences 

so that they can work with you to create a treatment plan that’s right for you. Make sure to keep your 

appointments with your healthcare provider. It is also very important to take your medicines and to 

measure your blood sugar as discussed with your healthcare provider. You should also see your eye 

healthcare provider on a routine basis. Increasing physical activity will also help most people who have 

diabetes. Even light activity, such as walking, taking stairs, vacuuming the house, and dancing will help you 

control diabetes. You can also join diabetes education classes to get updates on new treatments.

When is low blood sugar an emergency?

Low blood sugar can make you feel light-headed, sweaty, shaky, or confused. If you feel any of these 

things, you should check your blood sugar immediately. These signs usually happen when blood sugar 
VA/DoD Clinical Practice Guideline for the Management of Type 2 Diabetes Mellitus in Primary Care

April 2017 Page 5 of 6 

drops under 70 mg/dL. If your blood sugar is low, drink 4 ounces of a drink containing sugar such as fruit

juice or regular soda/pop, or eat four glucose tablets. Then check your blood sugar again 15 minutes later. 

If your blood sugar is still under 70 mg/dL, you may have to drink more fruit juice or soda/pop or eat more 

glucose tablets. Let your provider and team know if this type of low blood sugar happens to you. Train 

family members, friends and co-workers to recognize signs and symptoms of hypoglycemia. If you pass out 

or if you have trouble swallowing, they should call 911.

Other than low blood sugar, when should I contact my healthcare provider? 

You should contact your healthcare provider if there are signs of high blood sugar: thirst, headache, blurry 

vision, or frequent urination. These are medical emergencies, so call your healthcare provider or visit the 

emergency room. Having chest pain, face drooping, arm weakness, or problems speaking could be signs of 

a heart attack or a stroke − call 911 immediately. When your blood sugar levels are constantly high, or you 

experience frequent or severe low blood sugar (any low sugar requiring help from another person), you 

may need to change your current plan. Contact your healthcare provider to discuss that.

Where Can I Find More Information?

Beware of websites and TV programs that make promises that have not been proven or try to sell

products that are not FDA-approved. For reliable information, see the following sites: 

National Institute of Diabetes and Digestive and Kidney Diseases: https://www.niddk.nih.gov/

health-information/diabetes#topics

American Diabetes Association: http://www.diabetes.org/

Centers for Disease Control and Prevention: https://www.cdc.gov/diabetes/home/
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April 2017 Page 6 of 6 

References

1. Centers for Disease Control and Prevention. Basics about diabetes. 2015; 

https://www.cdc.gov/diabetes/basics/diabetes.html. Accessed February 2, 2017.

2. WebMD. Early symptoms of diabetes. 2016; 

http://www.webmd.com/diabetes/guide/understanding-diabetes-symptoms#1-2. Accessed 

February 2, 2017.

3. Mayo Clinic. Type 2 diabetes. 2016; http://www.mayoclinic.org/diseases-conditions/type-2-

diabetes/symptoms-causes/dxc-20169861. Accessed February 1, 2017.

4. American Diabetes Association. Diagnosis and classification of diabetes mellitus. Diabetes Care. 

Revised 2010;33(Suppl 1):S62-S69.

5. Mayo Clinic. Type 2 diabetes. 2016; http://www.mayoclinic.org/diseases-conditions/type-2-

diabetes/diagnosis-treatment/treatment/txc-20169988. Accessed February 2, 2017.

6. Estruch R, Ros E, Salas-Salvadó J, et al. Primary prevention of cardiovascular disease with a 

Mediterranean diet. N Engl J Med. 2013;368(14):1279-1290.

7. U.S. Department of Health and Human Services. Physical activity guidelines for Americans. 2008; 

https://www.hhs.gov/fitness/be-active/physical-activity-guidelines-for-americans/. Accessed 

March 20, 2017.