*2.1.1 Self-monitoring of blood glucose (SMBG)*

The first primary technique to assess the effectiveness of glycemic control plan for diabetic patients is the self-monitoring of blood glucose since most people with diabetes get benefit from monitoring of blood glucose for a various reasons. SMBG is the optimal way to confirm and appropriately treat hypoglycemia. It can provide feedback on the results of healthy behavior interventions and antihyperglycemic pharmacological treatments. It can increase patient's empowerment and adherence to treatment. It can also provide information to both the diabetic patient and the diabetes health-care team to facilitate longer-term treatment modifications and titrations as well as shorter-term treatment decisions, such as insulin dosing for people with T1DM or T2DM. Finally, in situations where HbA1c does not accurately reflect glycaemia, monitoring of blood glucose is necessary to monitor glycaemia adequately [38].

For people with T2DM treated with healthy behavior interventions, with or without non-insulin antihyperglycemic agents, the effectiveness and frequency of monitoring of blood glucose in improving glycemic control is less clear. The evidence is less certain in people with T2DM treated with insulin, although the above principle likely applies. In a large, non-randomized study of individuals with stable T2DM using insulin, testing at least 3 times a day was associated with improved glycemic control [38].

## *2.1.2 Glycated hemoglobin (HbA1c)*

Glycated hemoglobin (HbA1c) can be used as a diagnostic test for diabetes providing that strict quality assurance tests. An HbA1c of 6.5% is recommended as the cut point for diagnosing diabetes. A value of less than 6.5% does not exclude diabetes diagnosed using glucose tests. HbA1c is a reliable estimate of mean plasma glucose levels over the previous 8 to 12 weeks. The mean blood glucose level in the 30 days immediately preceding the blood sampling (days 0 to 30) contributes 50% of the result and the prior 90 to 120 days contributes 10%. HbA1c is a valuable indicator of treatment effectiveness and should be measured at least every 3 months when glycemic targets are not being met and when diabetes therapy is being adjusted or changed. It is a measure of long-term blood glucose concentration and is not affected by acute changes in glucose levels due to stress or illness. Testing at 6-month intervals may be considered in situations where glycemic targets are consistently achieved. In some circumstances, such as when significant changes are made to therapy, or during pregnancy, it is appropriate to check HbA1c more frequently [38].

An appropriate level of HbA1c is difficult to define exactly; therefore Target HbA1c should be defined based on personal assessment of risks and benefits of treatment. The factors limiting the benefit of tight control are co-morbidities (e.g., end-stage cancer, severe heart failure), advanced diabetes complications (e.g., proliferative retinopathy, renal failure), inability to safely carry out treatment regimen, and limited life expectancy; or factors that heighten the risk of tight control: history of severe hypoglycemia (inability to treat without assistance), hypoglycemia unawareness and advanced cardiovascular or cerebrovascular disease, in addition to autonomic neuropathy (especially cardiac), comorbidities that impair the detection of hypoglycemia (e.g., alteration in mental status, alcoholism, etc…), and/or poor social support [39].

Patients who do not have any of these factors possibly would generally have a target HbA1c of ≤ 7%. Patients who do have one or more of these factors should have a goal of minimizing symptoms of hyperglycemia and to control glucose as well as possible without incurring side effects or excessive treatment burden; while an appropriate HbA1c is difficult to define exactly, treatment should be aimed to keep the HbA1c under 9% [39].

### **2.2 Type 2 diabetes mellitus lifestyle modification**

Lifestyle modification or modification of unhealthy lifestyle choices such as: physical inactivity, unhealthy diet, harmful use of tobacco and/or alcohols can reduce the risk of complications and premature death of T2DM, by contributing to a better glycemic control. At diagnosis, highly motivated patients with HbA1c levels (<7.5%) could be given opportunity to engage in lifestyle modification for 3-6 months before staring pharmacotherapy. Encouraging and supporting people to make the best choices about their health can lead to a real difference to people's quality of life. Some studies have conclusively shown that reducing hyperglycemia decreases the onset and progression of microvascular complications and individualized dietary plan, regular physical activity and weight loss, when required, have been recognized as key components of diabetes management [22, 40].

The required lifestyle changes in managing DM are influenced by patient's knowledge, attitudes, practices, culture and values. Lack of knowledge about diabetes has been identified as one of the barriers to self-management of diabetes. Lack of understanding of how to manage diabetes also has a significant impact on limited diabetes knowledge in this population. Lifestyle modification counseling or education is the key component to achieve good glycemic control, to reduce the risk of diabetes complications, improve self-management and enhance the quality of life of type 2 diabetic patients including medical nutrition therapy, regular physical activity, weight reduction, and diabetes self-management education and support. Lifestyle interventions with oral hypoglycemic agents are often effective [8, 41].

### **2.3 Components of the lifestyle modification program**
