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Position Statements

4. Lifestyle Management

  1. American Diabetes Association
Diabetes Care 2017 Jan; 40(Supplement 1): S33-S43. https://doi.org/10.2337/dc17-S007
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Lifestyle management is a fundamental aspect of diabetes care and includes diabetes self-management education (DSME), diabetes self-management support (DSMS), nutrition therapy, physical activity, smoking cessation counseling, and psychosocial care. Patients and care providers should focus together on how to optimize lifestyle from the time of the initial comprehensive medical evaluation, throughout all subsequent evaluations and follow-up, and during the assessment of complications and management of comorbid conditions in order to enhance diabetes care.

DIABETES SELF-MANAGEMENT EDUCATION AND SUPPORT

Recommendations

  • In accordance with the national standards for diabetes self-management education and support, all people with diabetes should participate in diabetes self-management education to facilitate the knowledge, skills, and ability necessary for diabetes self-care and in diabetes self-management support to assist with implementing and sustaining skills and behaviors needed for ongoing self-management, both at diagnosis and as needed thereafter. B

  • Effective self-management and improved clinical outcomes, health status, and quality of life are key goals of diabetes self-management education and support that should be measured and monitored as part of routine care. C

  • Diabetes self-management education and support should be patient centered, respectful, and responsive to individual patient preferences, needs, and values and should help guide clinical decisions. A

  • Diabetes self-management education and support programs have the necessary elements in their curricula to delay or prevent the development of type 2 diabetes. Diabetes self-management education and support programs should therefore be able to tailor their content when prevention of diabetes is the desired goal. B

  • Because diabetes self-management education and support can improve outcomes and reduce costs B, diabetes self-management education and support should be adequately reimbursed by third-party payers. E

DSME and DSMS programs facilitate the knowledge, skills, and abilities necessary for optimal diabetes self-care and incorporate the needs, goals, and life experiences of the person with diabetes. The overall objectives of DSME and DSMS are to support informed decision making, self-care behaviors, problem solving, and active collaboration with the health care team to improve clinical outcomes, health status, and quality of life in a cost-effective manner (1). Providers should consider the burden of treatment and the patient’s level of confidence/self-efficacy for management behaviors as well as the level of social and family support when providing DSME or DSMS. Monitor patient performance of self-management behaviors as well as psychosocial factors impacting the person’s self-management.

DSME and DSMS, and the current national standards guiding them (1,2), are based on evidence of their benefits. Specifically, DSME helps people with diabetes to identify and implement effective self-management strategies and cope with diabetes at the four critical time points (described below) (1). Ongoing DSMS helps people with diabetes to maintain effective self-management throughout a lifetime of diabetes as they face new challenges and as advances in treatment become available (3).

Four critical time points have been defined when the need for DSME and DSMS should be evaluated by the medical care provider and/or multidisciplinary team, with referrals made as needed (1):

  • 1. At diagnosis

  • 2. Annually for assessment of education, nutrition, and emotional needs

  • 3. When new complicating factors (health conditions, physical limitations, emotional factors, or basic living needs) arise that influence self-management

  • 4. When transitions in care occur

DSME focuses on supporting patient empowerment by providing people with diabetes the tools to make informed self-management decisions (4). Diabetes care has shifted to an approach that is more patient centered and places the person with diabetes and his or her family at the center of the care model, working in collaboration with health care professionals. Patient-centered care is respectful of and responsive to individual patient preferences, needs, and values. It ensures that patient values guide all decision making (5).

Evidence for the Benefits

Studies have found that DSME is associated with improved diabetes knowledge and self-care behaviors (2), lower A1C (6–9), lower self-reported weight (10,11), improved quality of life (8,12), healthy coping (13,14), and reduced health care costs (15,16). Better outcomes were reported for DSME interventions that were over 10 h in total duration, included follow-up with DSMS (3,17), were culturally (18,19) and age appropriate (20,21), were tailored to individual needs and preferences, and addressed psychosocial issues and incorporated behavioral strategies (4,13,22,23). Individual and group approaches are effective (11,24). Emerging evidence is pointing to the benefit of Internet-based DSME programs for diabetes prevention and the management of type 2 diabetes (25,26). There is growing evidence for the role of community health workers (27), as well as peer (27–29) and lay (30) leaders, in providing ongoing support.

DSME is associated with an increased use of primary care and preventive services (15,31,32) and less frequent use of acute care and inpatient hospital services (10). Patients who participate in DSME are more likely to follow best practice treatment recommendations, particularly among the Medicare population, and have lower Medicare and insurance claim costs (16,31). Despite these benefits, reports indicate that only 5–7% of individuals eligible for DSME through Medicare or a private insurance plan actually receive it (33,34). This low participation may be due to lack of referral or other identified barriers such as logistical issues (timing, costs) and the lack of a perceived benefit (35). Thus, alternative and innovative models of DSME delivery need to be explored and evaluated.

Reimbursement

Medicare reimburses DSME and DSMS, when provided by a program that meets the national standards (2) and is recognized by the American Diabetes Association (ADA) or other approval bodies. DSME is also covered by most health insurance plans. DSMS has been shown to be instrumental for improving outcomes when it follows the completion of a DSME program. DSME and DSMS are frequently reimbursed when performed in person. However, although DSME and DSMS can also be provided via phone calls and telehealth, these remote versions may not always be reimbursed.

NUTRITION THERAPY

For many individuals with diabetes, the most challenging part of the treatment plan is determining what to eat and following a food plan. There is not a one-size-fits-all eating pattern for individuals with diabetes. Nutrition therapy has an integral role in overall diabetes management, and each person with diabetes should be actively engaged in education, self-management, and treatment planning with his or her health care team, including the collaborative development of an individualized eating plan (36,37). All individuals with diabetes should receive individualized medical nutrition therapy (MNT), preferably provided by a registered dietitian who is knowledgeable and skilled in providing diabetes-specific MNT. MNT delivered by a registered dietitian is associated with A1C decreases of 0.3–1% for people with type 1 diabetes (38–40) and 0.5–2% for people with type 2 diabetes (41–44).

It is important that each member of the health care team be knowledgeable about nutrition therapy principles for people with all types of diabetes and be supportive of their implementation. Emphasis should be on healthful eating patterns containing nutrient-dense, high-quality foods with less focus on specific nutrients. The Mediterranean (45), Dietary Approaches to Stop Hypertension (DASH) (46,47), and plant-based diets (48) are all examples of healthful eating patterns. See Table 4.1 for specific nutrition recommendations.

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Table 4.1

MNT recommendations

For complete discussion and references, see the ADA position statement “Nutrition Therapy Recommendations for the Management of Adults With Diabetes” (37).

Goals of Nutrition Therapy for Adults With Diabetes

  1. To promote and support healthful eating patterns, emphasizing a variety of nutrient-dense foods in appropriate portion sizes, in order to improve overall health and specifically to:

    • ○ Achieve and maintain body weight goals

    • ○ Attain individualized glycemic, blood pressure, and lipid goals

    • ○ Delay or prevent the complications of diabetes

  2. To address individual nutrition needs based on personal and cultural preferences, health literacy and numeracy, access to healthful foods, willingness and ability to make behavioral changes, and barriers to change

  3. To maintain the pleasure of eating by providing nonjudgmental messages about food choices

  4. To provide an individual with diabetes the practical tools for developing healthy eating patterns rather than focusing on individual macronutrients, micronutrients, or single foods

Weight Management

Body weight management is important for overweight and obese people with type 1 and type 2 diabetes. Lifestyle intervention programs should be intensive and have frequent follow-up to achieve significant reductions in excess body weight and improve clinical indicators. There is strong and consistent evidence that modest persistent weight loss can delay the progression from prediabetes to type 2 diabetes (49,50) and is beneficial to the management of type 2 diabetes (see Section 7 “Obesity Management for the Treatment of Type 2 Diabetes”).

In overweight and obese patients with type 2 diabetes, modest weight loss, defined as sustained reduction of 5% of initial body weight, has been shown to improve glycemic control and to reduce the need for glucose-lowering medications (51–53). Sustaining weight loss can be challenging (54). Weight loss can be attained with lifestyle programs that achieve a 500–750 kcal/day energy deficit or provide ∼1,200–1,500 kcal/day for women and 1,500–1,800 kcal/day for men, adjusted for the individual’s baseline body weight. For many obese individuals with type 2 diabetes, weight loss >5% is needed to produce beneficial outcomes in glycemic control, lipids, and blood pressure, and sustained weight loss of ≥7% is optimal (54).

The diets used in intensive lifestyle management for weight loss may differ in the types of foods they restrict (e.g., high-fat vs. high-carbohydrate foods), but their emphasis should be on nutrient-dense foods, such as whole grains, vegetables, fruits, legumes, low-fat dairy, lean meats, nuts, and seeds, as well as on achieving the desired energy deficit (55–58). The diet choice should be based on the patients’ health status and preferences.

Carbohydrates

Studies examining the ideal amount of carbohydrate intake for people with diabetes are inconclusive, although monitoring carbohydrate intake and considering the blood glucose response to dietary carbohydrate are key for improving postprandial glucose control (59,60). The literature concerning glycemic index and glycemic load in individuals with diabetes is complex, though in some studies lowering the glycemic load of consumed carbohydrates has demonstrated A1C reductions of –0.2% to –0.5% (61,62). A systematic review (61) found that whole-grain consumption was not associated with improvements in glycemic control in type 2 diabetes. One study did find a potential benefit of whole-grain intake in reducing mortality and cardiovascular disease (CVD) among individuals with type 2 diabetes (63).

As for all Americans, individuals with diabetes should be encouraged to replace refined carbohydrates and added sugars with whole grains, legumes, vegetables, and fruits. The consumption of sugar-sweetened beverages and processed “low-fat” or “nonfat” food products with high amounts of refined grains and added sugars should be strongly discouraged (64).

Individuals with type 1 or type 2 diabetes taking insulin at mealtimes should be offered intensive education on the need to couple insulin administration with carbohydrate intake. For people whose meal schedules or carbohydrate consumption is variable, regular counseling to help them understand the complex relationship between carbohydrate intake and insulin needs is important. In addition, education regarding the carbohydrate-counting approach to meal planning can assist them with effectively modifying insulin dosing from meal to meal and improving glycemic control (39,59,65–67). Individuals who consume meals containing more protein and fat than usual may also need to make mealtime insulin dose adjustments to compensate for delayed postprandial glycemic excursions (68,69). For individuals on a fixed daily insulin schedule, meal planning should emphasize a relatively fixed carbohydrate consumption pattern with respect to both time and amount (37). By contrast, a simpler diabetes meal planning approach emphasizing portion control and healthful food choices may be better suited for some elderly individuals, those with cognitive dysfunction, and those for whom there are concerns over health literacy and numeracy (37–39,41,59,65). The modified plate method (which uses measuring cups to assist with portion measurement) may be an effective alternative to carbohydrate counting for some patients in improving glycemia (70).

Protein

There is no evidence that adjusting the daily level of protein ingestion (typically 1–1.5 g/kg body weight/day or 15–20% total calories) will improve health in individuals without diabetic kidney disease, and research is inconclusive regarding the ideal amount of dietary protein to optimize either glycemic control or CVD risk (61). Therefore, protein intake goals should be individualized based on current eating patterns. Some research has found successful management of type 2 diabetes with meal plans including slightly higher levels of protein (20–30%), which may contribute to increased satiety (47).

For those with diabetic kidney disease (with albuminuria and/or reduced estimated glomerular filtration rate), dietary protein should be maintained at the recommended daily allowance of 0.8 g/kg body weight/day. Reducing the amount of dietary protein below the recommended daily allowance is not recommended because it does not alter glycemic measures, cardiovascular risk measures, or the rate at which glomerular filtration rate declines (71,72).

In individuals with type 2 diabetes, ingested protein may enhance the insulin response to dietary carbohydrates (73). Therefore, carbohydrate sources high in protein should not be used to treat or prevent hypoglycemia.

Fats

The ideal amount of dietary fat for individuals with diabetes is controversial. The Institute of Medicine has defined an acceptable macronutrient distribution for total fat for all adults to be 20–35% of energy (74). The type of fats consumed is more important than total amount of fat when looking at metabolic goals and CVD risk (64,75–78). Multiple randomized controlled trials including patients with type 2 diabetes have reported that a Mediterranean-style eating pattern (75,79–82), rich in monounsaturated fats, can improve both glycemic control and blood lipids. However, supplements do not seem to have the same effects. A systematic review concluded that dietary supplements with ω-3 fatty acids did not improve glycemic control in individuals with type 2 diabetes (61). Randomized controlled trials also do not support recommending ω-3 supplements for primary or secondary prevention of CVD (83–87). People with diabetes should be advised to follow the guidelines for the general population for the recommended intakes of saturated fat, dietary cholesterol, and trans fat (64). In general, trans fats should be avoided.

Sodium

As for the general population, people with diabetes should limit their sodium consumption to <2,300 mg/day. Lowering sodium intake (i.e., 1,500 mg/day) may benefit blood pressure in certain circumstances (88). However, other studies (89,90) have recommended caution for universal sodium restriction to 1,500 mg in people with diabetes. Sodium intake recommendations should take into account palatability, availability, affordability, and the difficulty of achieving low-sodium recommendations in a nutritionally adequate diet (91).

Micronutrients and Supplements

There continues to be no clear evidence of benefit from herbal or nonherbal (i.e., vitamin or mineral) supplementation for people with diabetes without underlying deficiencies (37). Metformin is associated with vitamin B12 deficiency, with a recent report from the Diabetes Prevention Program Outcomes Study (DPPOS) suggesting that periodic testing of vitamin B12 levels should be considered in metformin-treated patients, particularly in those with anemia or peripheral neuropathy (92). Routine supplementation with antioxidants, such as vitamins E and C and carotene, is not advised because of lack of evidence of efficacy and concern related to long-term safety. In addition, there is insufficient evidence to support the routine use of herbals and micronutrients, such as cinnamon (93) and vitamin D (94), to improve glycemic control in people with diabetes (37,95).

Alcohol

Moderate alcohol consumption does not have major detrimental effects on long-term blood glucose control in people with diabetes. Risks associated with alcohol consumption include hypoglycemia (particularly for those using insulin or insulin secretagogue therapies), weight gain, and hyperglycemia (for those consuming excessive amounts) (37,95).

Nonnutritive Sweeteners

For people who are accustomed to sugar-sweetened products, nonnutritive sweeteners have the potential to reduce overall calorie and carbohydrate intake and may be preferred to sugar when consumed in moderation. Regulatory agencies set acceptable daily intake levels for each nonnutritive sweetener, defined as the amount that can be safely consumed over a person’s lifetime (37,96).

PHYSICAL ACTIVITY

Recommendations

  • Children and adolescents with type 1 or type 2 diabetes or prediabetes should engage in 60 min/day or more of moderate- or vigorous-intensity aerobic activity, with vigorous muscle-strengthening and bone-strengthening activities at least 3 days/week. C

  • Most adults with with type 1 C and type 2 B diabetes should engage in 150 min or more of moderate-to-vigorous intensity physical activity per week, spread over at least 3 days/week, with no more than 2 consecutive days without activity. Shorter durations (minimum 75 min/week) of vigorous-intensity or interval training may be sufficient for younger and more physically fit individuals.

  • Adults with type 1 C and type 2 B diabetes should engage in 2–3 sessions/week of resistance exercise on nonconsecutive days.

  • All adults, and particularly those with type 2 diabetes, should decrease the amount of time spent in daily sedentary behavior. B Prolonged sitting should be interrupted every 30 min for blood glucose benefits, particularly in adults with type 2 diabetes. C

  • Flexibility training and balance training are recommended 2–3 times/week for older adults with diabetes. Yoga and tai chi may be included based on individual preferences to increase flexibility, muscular strength, and balance. C

Physical activity is a general term that includes all movement that increases energy use and is an important part of the diabetes management plan. Exercise is a more specific form of physical activity that is structured and designed to improve physical fitness. Both physical activity and exercise are important. Exercise has been shown to improve blood glucose control, reduce cardiovascular risk factors, contribute to weight loss, and improve well-being. Physical activity is as important for those with type 1 diabetes as it is for the general population, but its specific role in the prevention of diabetes complications and the management of blood glucose is not as clear as it is for those with type 2 diabetes.

Structured exercise interventions of at least 8 weeks’ duration have been shown to lower A1C by an average of 0.66% in people with type 2 diabetes, even without a significant change in BMI (97). There are also considerable data for the health benefits (e.g., increased cardiovascular fitness, greater muscle strength, improved insulin sensitivity, etc.) of regular exercise for those with type 1 diabetes (98). Higher levels of exercise intensity are associated with greater improvements in A1C and in fitness (99). Other benefits include slowing the decline in mobility among overweight patients with diabetes (100). The ADA position statement “Physical Activity/Exercise and Diabetes: A Position Statement of the American Diabetes Association” reviews the evidence for the benefits of exercise in people with diabetes (101).

Exercise and Children

All children, including children with diabetes or prediabetes, should be encouraged to engage in at least 60 min of physical activity each day. Children should engage in at least 60 min of moderate-to-vigorous aerobic activity every day with muscle- and bone-strengthening activities at least 3 days per week (102). In general, youth with type 1 diabetes benefit from being physically active, and an active lifestyle should be recommended to all.

Frequency and Type of Physical Activity

The U.S. Department of Health and Human Services’ physical activity guidelines for Americans (103) suggest that adults over age 18 years engage in 150 min/week of moderate-intensity or 75 min/week of vigorous-intensity aerobic physical activity, or an equivalent combination of the two. In addition, the guidelines suggest that adults do muscle-strengthening activities that involve all major muscle groups 2 or more days/week. The guidelines suggest that adults over age 65 years and those with disabilities follow the adult guidelines if possible or, if not possible, be as physically active as they are able.

Recent evidence supports that all individuals, including those with diabetes, should be encouraged to reduce the amount of time spent being sedentary (e.g., working at a computer, watching TV), by breaking up bouts of sedentary activity (>30 min) by briefly standing, walking, or performing at other light physical activities (104,105). Avoiding extended sedentary periods may help prevent type 2 diabetes for those at risk and may also aid in glycemic control for those with diabetes.

Physical Activity and Glycemic Control

Clinical trials have provided strong evidence for the A1C-lowering value of resistance training in older adults with type 2 diabetes (106) and for an additive benefit of combined aerobic and resistance exercise in adults with type 2 diabetes (107). If not contraindicated, patients with type 2 diabetes should be encouraged to do at least two weekly sessions of resistance exercise (exercise with free weights or weight machines), with each session consisting of at least one set (group of consecutive repetitive exercise motions) of five or more different resistance exercises involving the large muscle groups (106).

For type 1 diabetes, although exercise in general is associated with improvement in disease status, care needs to be taken in titrating exercise with respect to glycemic management. Each individual with type 1 diabetes has a variable glycemic response to exercise. This variability should be taken into consideration when recommending the type and duration of exercise for a given individual (98).

Women with preexisting diabetes, particularly type 2 diabetes, and those at risk for or presenting with gestational diabetes mellitus should be advised to engage in regular moderate physical activity prior to and during their pregnancies as tolerated (101).

Pre-exercise Evaluation

As discussed more fully in Section 9 “Cardiovascular Disease and Risk Management,” the best protocol for assessing asymptomatic patients with diabetes for coronary artery disease remains unclear. The ADA consensus report “Screening for Coronary Artery Disease in Patients With Diabetes” (108) concluded that routine testing is not recommended. However, providers should perform a careful history, assess cardiovascular risk factors, and be aware of the atypical presentation of coronary artery disease in patients with diabetes. Certainly, high-risk patients should be encouraged to start with short periods of low-intensity exercise and slowly increase the intensity and duration. Providers should assess patients for conditions that might contraindicate certain types of exercise or predispose to injury, such as uncontrolled hypertension, untreated proliferative retinopathy, autonomic neuropathy, peripheral neuropathy, and a history of foot ulcers or Charcot foot. The patient’s age and previous physical activity level should be considered. The provider should customize the exercise regimen to the individual’s needs. Those with complications may require a more thorough evaluation (98).

Hypoglycemia

In individuals taking insulin and/or insulin secretagogues, physical activity may cause hypoglycemia if the medication dose or carbohydrate consumption is not altered. Individuals on these therapies may need to ingest some added carbohydrate if pre-exercise glucose levels are <100 mg/dL (5.6 mmol/L), depending on whether they can lower insulin levels during the workout (such as with an insulin pump or reduced pre-exercise insulin dosage), the time of day exercise is done, and the intensity and duration of the activity (98,101). Hypoglycemia is less common in patients with diabetes who are not treated with insulin or insulin secretagogues, and no routine preventive measures for hypoglycemia are usually advised in these cases. In some patients, hypoglycemia after exercise may occur and last for several hours due to increased insulin sensitivity. Intense activities may actually raise blood glucose levels instead of lowering them, especially if pre-exercise glucose levels are elevated (109).

Exercise in the Presence of Specific Long-term Complications of Diabetes

Retinopathy

If proliferative diabetic retinopathy or severe nonproliferative diabetic retinopathy is present, then vigorous-intensity aerobic or resistance exercise may be contraindicated because of the risk of triggering vitreous hemorrhage or retinal detachment (110). Consultation with an ophthalmologist prior to engaging in an intense exercise regimen may be appropriate.

Peripheral Neuropathy

Decreased pain sensation and a higher pain threshold in the extremities result in an increased risk of skin breakdown, infection, and Charcot joint destruction with some forms of exercise. Therefore, a thorough assessment should be done to ensure that neuropathy does not alter kinesthetic or proprioceptive sensation during physical activity, particularly in those with more severe neuropathy. Studies have shown that moderate-intensity walking may not lead to an increased risk of foot ulcers or reulceration in those with peripheral neuropathy who use proper footwear (111). In addition, 150 min/week of moderate exercise was reported to improve outcomes in patients with prediabetic neuropathy (112). All individuals with peripheral neuropathy should wear proper footwear and examine their feet daily to detect lesions early. Anyone with a foot injury or open sore should be restricted to non–weight-bearing activities.

Autonomic Neuropathy

Autonomic neuropathy can increase the risk of exercise-induced injury or adverse events through decreased cardiac responsiveness to exercise, postural hypotension, impaired thermoregulation, impaired night vision due to impaired papillary reaction, and greater susceptibility to hypoglycemia (113). Cardiovascular autonomic neuropathy is also an independent risk factor for cardiovascular death and silent myocardial ischemia (114). Therefore, individuals with diabetic autonomic neuropathy should undergo cardiac investigation before beginning physical activity more intense than that to which they are accustomed.

Diabetic Kidney Disease

Physical activity can acutely increase urinary albumin excretion. However, there is no evidence that vigorous-intensity exercise increases the rate of progression of diabetic kidney disease, and there appears to be no need for specific exercise restrictions for people with diabetic kidney disease (110).

SMOKING CESSATION: TOBACCO AND e-CIGARETTES

Recommendations

  • Advise all patients not to use cigarettes and other tobacco products A or e-cigarettes. E

  • Include smoking cessation counseling and other forms of treatment as a routine component of diabetes care. B

Results from epidemiological, case-control, and cohort studies provide convincing evidence to support the causal link between cigarette smoking and health risks (115). Recent data show tobacco use is higher among adults with chronic conditions (116). Other studies of individuals with diabetes consistently demonstrate that smokers (and people exposed to secondhand smoke) have a heightened risk of CVD, premature death, and microvascular complications. Smoking may have a role in the development of type 2 diabetes (117). One study in smokers with newly diagnosed type 2 diabetes found that smoking cessation was associated with amelioration of metabolic parameters and reduced blood pressure and albuminuria at 1 year (118).

The routine and thorough assessment of tobacco use is essential to prevent smoking or encourage cessation. Numerous large randomized clinical trials have demonstrated the efficacy and cost-effectiveness of brief counseling in smoking cessation, including the use of telephone quit lines, in reducing tobacco use. For the patient motivated to quit, the addition of pharmacological therapy to counseling is more effective than either treatment alone. Special considerations should include assessment of level of nicotine dependence, which is associated with difficulty in quitting and relapse (119). Although some patients may gain weight in the period shortly after smoking cessation, recent research has demonstrated that this weight gain does not diminish the substantial CVD benefit realized from smoking cessation (120).

Nonsmokers should be advised not to use e-cigarettes. There are no rigorous studies that have demonstrated that e-cigarettes are a healthier alternative to smoking or that e-cigarettes can facilitate smoking cessation. More extensive research of their short- and long-term effects is needed to determine their safety and their cardiopulmonary effects in comparison with smoking and standard approaches to smoking cessation (121–123).

PSYCHOSOCIAL ISSUES

Recommendations

  • Psychosocial care should be integrated with a collaborative, patient-centered approach and provided to all people with diabetes, with the goals of optimizing health outcomes and health-related quality of life. A

  • Psychosocial screening and follow-up may include, but are not limited to, attitudes about the illness, expectations for medical management and outcomes, affect or mood, general and diabetes-related quality of life, available resources (financial, social, and emotional), and psychiatric history. E

  • Providers should consider assessment for symptoms of diabetes distress, depression, anxiety, disordered eating, and cognitive capacities using patient-appropriate standardized and validated tools at the initial visit, at periodic intervals, and when there is a change in disease, treatment, or life circumstance. Including caregivers and family members in this assessment is recommended. B

  • Consider screening older adults (aged ≥65 years) with diabetes for cognitive impairment and depression. B

Please refer to the ADA position statement “Psychosocial Care for People with Diabetes” for a list of assessment tools and additional details (124).

Emotional well-being is an important part of diabetes care and self-management. Psychological and social problems can impair the individual’s (125–127) or family’s (128) ability to carry out diabetes care tasks and therefore potentially compromise health status. There are opportunities for the clinician to routinely assess psychosocial status in a timely and efficient manner for referral to appropriate services. A systematic review and meta-analysis showed that psychosocial interventions modestly but significantly improved A1C (standardized mean difference –0.29%) and mental health outcomes (129). However, there was a limited association between the effects on A1C and mental health, and no intervention characteristics predicted benefit on both outcomes.

Screening

Key opportunities for psychosocial screening occur at diabetes diagnosis, during regularly scheduled management visits, during hospitalizations, with new onset of complications, or when problems with glucose control, quality of life, or self-management are identified (1). Patients are likely to exhibit psychological vulnerability at diagnosis, when their medical status changes (e.g., end of the honeymoon period), when the need for intensified treatment is evident, and when complications are discovered.

Providers can start with informal verbal inquires, for example, by asking if there have been changes in mood during the past 2 weeks or since their last visit. Providers should consider asking if there are new or different barriers to treatment and self-management, such as feeling overwhelmed or stressed by diabetes or other life stressors. Standardized and validated tools for psychosocial monitoring and assessment can also be used by providers, with positive findings leading to referral to a mental health provider specializing in diabetes for comprehensive evaluation, diagnosis, and treatment.

Diabetes Distress

Recommendation

  • Routinely monitor people with diabetes for diabetes distress, particularly when treatment targets are not met and/or at the onset of diabetes complications. B

Diabetes distress (DD) is very common and is distinct from other psychological disorders (130–132). DD refers to significant negative psychological reactions related to emotional burdens and worries specific to an individual’s experience in having to manage a severe, complicated, and demanding chronic disease such as diabetes (131–133). The constant behavioral demands (medication dosing, frequency, and titration; monitoring blood glucose, food intake, eating patterns, and physical activity) of diabetes self-management and the potential or actuality of disease progression are directly associated with reports of DD (131). The prevalence of DD is reported to be 18–45% with an incidence of 38–48% over 18 months (133). In the second Diabetes Attitudes, Wishes and Needs (DAWN2) study, significant DD was reported by 45% of the participants, but only 24% reported that their health care teams asked them how diabetes affected their lives (130). High levels of DD significantly impact medication-taking behaviors and are linked to higher A1C, lower self-efficacy, and poorer dietary and exercise behaviors (14,131,133). DSME has been shown to reduce DD (14). It may be helpful to provide counseling regarding expected diabetes-related versus generalized psychological distress at diagnosis and when disease state or treatment changes (134).

DD should be routinely monitored (135) using patient-appropriate validated measures. If DD is identified, the person should be referred for specific diabetes education to address areas of diabetes self-care that are most relevant to the patient and impact clinical management. People whose self-care remains impaired after tailored diabetes education should be referred by their care team to a behavioral health provider for evaluation and treatment.

Other psychosocial issues known to affect self-management and health outcomes include attitudes about the illness, expectations for medical management and outcomes, available resources (financial, social, and emotional) (136), and psychiatric history. For additional information on psychiatric comorbidities (depression, anxiety, disordered eating, and serious mental illness), please refer to Section 3 “Comprehensive Medical Evaluation and Assessment of Comorbidities.”

Referral to a Mental Health Specialist

Indications for referral to a mental health specialist familiar with diabetes management may include positive screening for overall stress related to work-life balance, DD, diabetes management difficulties, depression, anxiety, disordered eating, and cognitive functioning difficulties (see Table 4.2 for a complete list). It is preferable to incorporate psychosocial assessment and treatment into routine care rather than waiting for a specific problem or deterioration in metabolic or psychological status to occur (22,130). Providers should identify behavioral and mental health providers, ideally those who are knowledgeable about diabetes treatment and the psychosocial aspects of diabetes, to whom they can refer patients. Ideally, psychosocial care providers should be embedded in diabetes care settings. Although the clinician may not feel qualified to treat psychological problems (137), optimizing the patient–provider relationship as a foundation may increase the likelihood of the patient accepting referral for other services. Collaborative care interventions and a team approach have demonstrated efficacy in diabetes self-management and psychosocial functioning (14).

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Table 4.2

Situations that warrant referral of a person with diabetes to a mental health provider for evaluation and treatment

Footnotes

  • Suggested citation: American Diabetes Association. Lifestyle management. Sec. 4. In Standards of Medical Care in Diabetes—2017. Diabetes Care 2017;40(Suppl. 1):S33–S43

  • © 2017 by the American Diabetes Association.
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References

  1. ↵
    1. Powers MA,
    2. Bardsley J,
    3. Cypress M, et al
    . Diabetes self-management education and support in type 2 diabetes: a joint position statement of the American Diabetes Association, the American Association of Diabetes Educators, and the Academy of Nutrition and Dietetics. Diabetes Care 2015;38:1372–1382
    OpenUrlFREE Full Text
  2. ↵
    1. Haas L,
    2. Maryniuk M,
    3. Beck J, et al.; 2012 Standards Revision Task Force
    . National standards for diabetes self-management education and support. Diabetes Care 2014;37(Suppl. 1):S144–S153
    OpenUrlFREE Full Text
  3. ↵
    1. Tang TS,
    2. Funnell MM,
    3. Brown MB,
    4. Kurlander JE
    . Self-management support in “real-world” settings: an empowerment-based intervention. Patient Educ Couns 2010;79:178–184
    OpenUrlCrossRefPubMedWeb of Science
  4. ↵
    1. Marrero DG,
    2. Ard J,
    3. Delamater AM, et al
    . Twenty-first century behavioral medicine: a context for empowering clinicians and patients with diabetes: a consensus report. Diabetes Care 2013;36:463–470
    OpenUrlFREE Full Text
  5. ↵
    1. Crossing the Quality Chasm
    Committee on Quailty of Health Care in America; Institute of Medicine. Crossing the Quality Chasm. A New Health System for the 21st Century [Internet]. Washington, DC, National Academies Press, 2001. Available from http://www.nap.edu/catalog/10027. Accessed 8 September 2016
  6. ↵
    1. Norris SL,
    2. Lau J,
    3. Smith SJ,
    4. Schmid CH,
    5. Engelgau MM
    . Self-management education for adults with type 2 diabetes: a meta-analysis of the effect on glycemic control. Diabetes Care 2002;25:1159–1171
    OpenUrlAbstract/FREE Full Text
    1. Frosch DL,
    2. Uy V,
    3. Ochoa S,
    4. Mangione CM
    . Evaluation of a behavior support intervention for patients with poorly controlled diabetes. Arch Intern Med 2011;171:2011–2017
    OpenUrlCrossRefPubMedWeb of Science
  7. ↵
    1. Cooke D,
    2. Bond R,
    3. Lawton J, et al.; U.K. NIHR DAFNE Study Group
    . Structured type 1 diabetes education delivered within routine care: impact on glycemic control and diabetes-specific quality of life. Diabetes Care 2013;36:270–272
    OpenUrlAbstract/FREE Full Text
  8. ↵
    1. Chrvala CA,
    2. Sherr D,
    3. Lipman RD
    . Diabetes self-management education for adults with type 2 diabetes mellitus: a systematic review of the effect on glycemic control. Patient Educ Couns 2016;99:926–943
    OpenUrlCrossRefPubMed
  9. ↵
    1. Steinsbekk A,
    2. Rygg LØ,
    3. Lisulo M,
    4. Rise MB,
    5. Fretheim A
    . Group based diabetes self-management education compared to routine treatment for people with type 2 diabetes mellitus. A systematic review with meta-analysis. BMC Health Serv Res 2012;12:213
    OpenUrlCrossRefPubMed
  10. ↵
    1. Deakin T,
    2. McShane CE,
    3. Cade JE,
    4. Williams RDRR
    . Group based training for self-management strategies in people with type 2 diabetes mellitus. Cochrane Database Syst Rev 2005;2:CD003417
  11. ↵
    1. Cochran J,
    2. Conn VS
    . Meta-analysis of quality of life outcomes following diabetes self-management training. Diabetes Educ 2008;34:815–823
    OpenUrlAbstract/FREE Full Text
  12. ↵
    1. Thorpe CT,
    2. Fahey LE,
    3. Johnson H,
    4. Deshpande M,
    5. Thorpe JM,
    6. Fisher EB
    . Facilitating healthy coping in patients with diabetes: a systematic review. Diabetes Educ 2013;39:33–52
    OpenUrlAbstract/FREE Full Text
  13. ↵
    1. Fisher L,
    2. Hessler D,
    3. Glasgow RE, et al
    . REDEEM: a pragmatic trial to reduce diabetes distress. Diabetes Care 2013;36:2551–2558
    OpenUrlAbstract/FREE Full Text
  14. ↵
    1. Robbins JM,
    2. Thatcher GE,
    3. Webb DA,
    4. Valdmanis VG
    . Nutritionist visits, diabetes classes, and hospitalization rates and charges: the Urban Diabetes Study. Diabetes Care 2008;31:655–660
    OpenUrlAbstract/FREE Full Text
  15. ↵
    1. Duncan I,
    2. Ahmed T,
    3. Li QE, et al
    . Assessing the value of the diabetes educator. Diabetes Educ 2011;37:638–657
    OpenUrlAbstract/FREE Full Text
  16. ↵
    1. Piatt GA,
    2. Anderson RM,
    3. Brooks MM, et al
    . 3-year follow-up of clinical and behavioral improvements following a multifaceted diabetes care intervention: results of a randomized controlled trial. Diabetes Educ 2010;36:301–309
    OpenUrlAbstract/FREE Full Text
  17. ↵
    1. Glazier RH,
    2. Bajcar J,
    3. Kennie NR,
    4. Willson K
    . A systematic review of interventions to improve diabetes care in socially disadvantaged populations. Diabetes Care 2006;29:1675–1688
    OpenUrlAbstract/FREE Full Text
  18. ↵
    1. Hawthorne K,
    2. Robles Y,
    3. Cannings-John R,
    4. Edwards AG
    . Culturally appropriate health education for type 2 diabetes mellitus in ethnic minority groups. Cochrane Database Syst Rev 2008;3:CD006424
  19. ↵
    1. Chodosh J,
    2. Morton SC,
    3. Mojica W, et al
    . Meta-analysis: chronic disease self-management programs for older adults. Ann Intern Med 2005;143:427–438
    OpenUrlCrossRefPubMedWeb of Science
  20. ↵
    1. Sarkisian CA,
    2. Brown AF,
    3. Norris KC,
    4. Wintz RL,
    5. Mangione CM
    . A systematic review of diabetes self-care interventions for older, African American, or Latino adults. Diabetes Educ 2003;29:467–479
    OpenUrlAbstract/FREE Full Text
  21. ↵
    1. Peyrot M,
    2. Rubin RR
    . Behavioral and psychosocial interventions in diabetes: a conceptual review. Diabetes Care 2007;30:2433–2440
    OpenUrlFREE Full Text
  22. ↵
    1. Naik AD,
    2. Palmer N,
    3. Petersen NJ, et al
    . Comparative effectiveness of goal setting in diabetes mellitus group clinics: randomized clinical trial. Arch Intern Med 2011;171:453–459
    OpenUrlCrossRefPubMedWeb of Science
  23. ↵
    1. Duke S-AS,
    2. Colagiuri S,
    3. Colagiuri R
    . Individual patient education for people with type 2 diabetes mellitus. Cochrane Database Syst Rev 2009;1:CD005268
  24. ↵
    1. Pereira K,
    2. Phillips B,
    3. Johnson C,
    4. Vorderstrasse A
    . Internet delivered diabetes self-management education: a review. Diabetes Technol Ther 2015;17:55–63
    OpenUrlCrossRefPubMed
  25. ↵
    1. Sepah SC,
    2. Jiang L,
    3. Peters AL
    . Long-term outcomes of a Web-based diabetes prevention program: 2-year results of a single-arm longitudinal study. J Med Internet Res 2015;17:e92
    OpenUrlCrossRefPubMed
  26. ↵
    1. Shah M,
    2. Kaselitz E,
    3. Heisler M
    . The role of community health workers in diabetes: update on current literature. Curr Diab Rep 2013;13:163–171
    OpenUrlCrossRefPubMed
    1. Heisler M,
    2. Vijan S,
    3. Makki F,
    4. Piette JD
    . Diabetes control with reciprocal peer support versus nurse care management: a randomized trial. Ann Intern Med 2010;153:507–515
    OpenUrlCrossRefPubMedWeb of Science
  27. ↵
    1. Long JA,
    2. Jahnle EC,
    3. Richardson DM,
    4. Loewenstein G,
    5. Volpp KG
    . Peer mentoring and financial incentives to improve glucose control in African American veterans: a randomized trial. Ann Intern Med 2012;156:416–424
    OpenUrlCrossRefPubMedWeb of Science
  28. ↵
    1. Foster G,
    2. Taylor SJC,
    3. Eldridge SE,
    4. Ramsay J,
    5. Griffiths CJ
    . Self-management education programmes by lay leaders for people with chronic conditions. Cochrane Database Syst Rev 2007;4:CD005108
  29. ↵
    1. Duncan I,
    2. Birkmeyer C,
    3. Coughlin S,
    4. Li QE,
    5. Sherr D,
    6. Boren S
    . Assessing the value of diabetes education. Diabetes Educ 2009;35:752–760
    OpenUrlAbstract/FREE Full Text
  30. ↵
    1. Johnson TM,
    2. Murray MR,
    3. Huang Y
    . Associations between self-management education and comprehensive diabetes clinical care. Diabetes Spectrum 2010;23:41–46
    OpenUrlAbstract/FREE Full Text
  31. ↵
    1. Strawbridge LM,
    2. Lloyd JT,
    3. Meadow A,
    4. Riley GF,
    5. Howell BL
    . Use of Medicare’s diabetes self-management training benefit. Health Educ Behav 2015;42:530–538
    OpenUrlAbstract/FREE Full Text
  32. ↵
    1. Li R,
    2. Shrestha SS,
    3. Lipman R,
    4. Burrows NR,
    5. Kolb LE,
    6. Rutledge S; Centers for Disease Control and Prevention (CDC)
    . Diabetes self-management education and training among privately insured persons with newly diagnosed diabetes--United States, 2011-2012. MMWR Morb Mortal Wkly Rep 2014;63:1045–1049
    OpenUrlPubMed
  33. ↵
    1. Horigan G,
    2. Davies M,
    3. Findlay-White F,
    4. Chaney D,
    5. Coates V
    . Reasons why patients referred to diabetes education programmes choose not to attend: a systematic review. Diabet Med. Epub ahead of print 21 March 2016. DOI: 10.1111/dme.13120
  34. ↵
    1. Inzucchi SE,
    2. Bergenstal RM,
    3. Buse JB, et al
    . Management of hyperglycemia in type 2 diabetes, 2015: a patient-centered approach: update to a position statement of the American Diabetes Association and the European Association for the Study of Diabetes. Diabetes Care 2015;38:140–149
    OpenUrlFREE Full Text
  35. ↵
    1. Evert AB,
    2. Boucher JL,
    3. Cypress M, et al
    . Nutrition therapy recommendations for the management of adults with diabetes. Diabetes Care. 2014;37(Suppl. 1):S120–S143
  36. ↵
    1. Kulkarni K,
    2. Castle G,
    3. Gregory R, et al
    . Nutrition practice guidelines for type 1 diabetes mellitus positively affect dietitian practices and patient outcomes. The Diabetes Care and Education Dietetic Practice Group. J Am Diet Assoc 1998;98:62–70; quiz 71–72
  37. ↵
    1. Rossi MCE,
    2. Nicolucci A,
    3. Di Bartolo P, et al
    . Diabetes Interactive Diary: a new telemedicine system enabling flexible diet and insulin therapy while improving quality of life: an open-label, international, multicenter, randomized study. Diabetes Care 2010;33:109–115
    OpenUrlAbstract/FREE Full Text
  38. ↵
    1. Scavone G,
    2. Manto A,
    3. Pitocco D, et al
    . Effect of carbohydrate counting and medical nutritional therapy on glycaemic control in type 1 diabetic subjects: a pilot study. Diabet Med 2010;27:477–479
    OpenUrlCrossRefPubMed
  39. ↵
    1. UK Prospective Diabetes Study (UKPDS) Group
    . Effect of intensive blood-glucose control with metformin on complications in overweight patients with type 2 diabetes (UKPDS 34). Lancet 1998;352:854–865
    OpenUrlCrossRefPubMedWeb of Science
    1. Ziemer DC,
    2. Berkowitz KJ,
    3. Panayioto RM, et al
    . A simple meal plan emphasizing healthy food choices is as effective as an exchange-based meal plan for urban African Americans with type 2 diabetes. Diabetes Care 2003;26:1719–1724
    OpenUrlAbstract/FREE Full Text
    1. Wolf AM,
    2. Conaway MR,
    3. Crowther JQ, et al.; Improving Control with Activity and Nutrition (ICAN) Study
    . Translating lifestyle intervention to practice in obese patients with type 2 diabetes: Improving Control with Activity and Nutrition (ICAN) study. Diabetes Care 2004;27:1570–1576
    OpenUrlAbstract/FREE Full Text
  40. ↵
    1. Coppell KJ,
    2. Kataoka M,
    3. Williams SM,
    4. Chisholm AW,
    5. Vorgers SM,
    6. Mann JI
    . Nutritional intervention in patients with type 2 diabetes who are hyperglycaemic despite optimised drug treatment–Lifestyle Over and Above Drugs in Diabetes (LOADD) study: randomised controlled trial. BMJ 2010;341:c3337
  41. ↵
    1. Esposito K,
    2. Maiorino MI,
    3. Ciotola M, et al
    . Effects of a Mediterranean-style diet on the need for antihyperglycemic drug therapy in patients with newly diagnosed type 2 diabetes: a randomized trial. Ann Intern Med 2009;151:306–314
    OpenUrlCrossRefPubMedWeb of Science
  42. ↵
    1. Cespedes EM,
    2. Hu FB,
    3. Tinker L, et al
    . Multiple healthful dietary patterns and type 2 diabetes in the Women’s Health Initiative. Am J Epidemiol 2016;183:622–633
    OpenUrlAbstract/FREE Full Text
  43. ↵
    1. Ley SH,
    2. Hamdy O,
    3. Mohan V,
    4. Hu FB
    . Prevention and management of type 2 diabetes: dietary components and nutritional strategies. Lancet 2014;383:1999–2007
    OpenUrlCrossRefPubMedWeb of Science
  44. ↵
    1. Rinaldi S,
    2. Campbell EE,
    3. Fournier J,
    4. O’Connor C,
    5. Madill J
    . A comprehensive review of the literature supporting recommendations from the Canadian Diabetes Association for the use of a plant-based diet for management of type 2 diabetes. Can J Diabetes 2016;40:471–477
    OpenUrl
  45. ↵
    1. Mudaliar U,
    2. Zabetian A,
    3. Goodman M, et al
    . Cardiometabolic risk factor changes observed in diabetes prevention programs in US settings: a systematic review and meta-analysis. PLoS Med 2016;13:e1002095
    OpenUrl
  46. ↵
    1. Balk EM,
    2. Earley A,
    3. Raman G,
    4. Avendano EA,
    5. Pittas AG,
    6. Remington PL
    . Combined diet and physical activity promotion programs to prevent type 2 diabetes among persons at increased risk: a systematic review for the Community Preventive Services Task Force. Ann Intern Med 2015;164:164–175
  47. ↵
    1. UK Prospective Diabetes Study 7
    . UK Prospective Diabetes Study 7: response of fasting plasma glucose to diet therapy in newly presenting type II diabetic patients, UKPDS Group. Metabolism 1990;39:905–912
    OpenUrlCrossRefPubMedWeb of Science
    1. Goldstein DJ
    . Beneficial health effects of modest weight loss. Int J Obes Relat Metab Disord 1992;16:397–415
    OpenUrlPubMedWeb of Science
  48. ↵
    1. Pastors JG,
    2. Warshaw H,
    3. Daly A,
    4. Franz M,
    5. Kulkarni K
    . The evidence for the effectiveness of medical nutrition therapy in diabetes management. Diabetes Care 2002;25:608–613
    OpenUrlFREE Full Text
  49. ↵
    1. Franz MJ,
    2. Boucher JL,
    3. Rutten-Ramos S,
    4. VanWormer JJ
    . Lifestyle weight-loss intervention outcomes in overweight and obese adults with type 2 diabetes: a systematic review and meta-analysis of randomized clinical trials. J Acad Nutr Diet 2015;115:1447–1463
    OpenUrlCrossRefPubMed
  50. ↵
    1. Sacks FM,
    2. Bray GA,
    3. Carey VJ, et al
    . Comparison of weight-loss diets with different compositions of fat, protein, and carbohydrates. N Engl J Med 2009;360:859–873
    OpenUrlCrossRefPubMedWeb of Science
    1. de Souza RJ,
    2. Bray GA,
    3. Carey VJ, et al
    . Effects of 4 weight-loss diets differing in fat, protein, and carbohydrate on fat mass, lean mass, visceral adipose tissue, and hepatic fat: results from the POUNDS LOST trial. Am J Clin Nutr 2012;95:614–625
    OpenUrlAbstract/FREE Full Text
    1. Johnston BC,
    2. Kanters S,
    3. Bandayrel K, et al
    . Comparison of weight loss among named diet programs in overweight and obese adults: a meta-analysis. JAMA 2014;312:923–933
    OpenUrlCrossRefPubMedWeb of Science
  51. ↵
    1. Fox CS,
    2. Golden SH,
    3. Anderson C, et al.; American Heart Association Diabetes Committee of the Council on Lifestyle and Cardiometabolic Health; Council on Clinical Cardiology, Council on Cardiovascular and Stroke Nursing, Council on Cardiovascular Surgery and Anesthesia, Council on Quality of Care and Outcomes Research; American Diabetes Association
    . Update on prevention of cardiovascular disease in adults with type 2 diabetes mellitus in light of recent evidence: a scientific statement from the American Heart Association and the American Diabetes Association. Diabetes Care 2015;38:1777–1803
    OpenUrlAbstract/FREE Full Text
  52. ↵
    1. DAFNE Study Group
    . Training in flexible, intensive insulin management to enable dietary freedom in people with type 1 diabetes: Dose Adjustment for Normal Eating (DAFNE) randomised controlled trial. BMJ 2002;325:746
    OpenUrlAbstract/FREE Full Text
  53. ↵
    1. Delahanty LM,
    2. Nathan DM,
    3. Lachin JM, et al.; Diabetes Control and Complications Trial/Epidemiology of Diabetes
    . Association of diet with glycated hemoglobin during intensive treatment of type 1 diabetes in the Diabetes Control and Complications Trial. Am J Clin Nutr 2009;89:518–524
    OpenUrlAbstract/FREE Full Text
  54. ↵
    1. Wheeler ML,
    2. Dunbar SA,
    3. Jaacks LM, et al
    . Macronutrients, food groups, and eating patterns in the management of diabetes: a systematic review of the literature, 2010. Diabetes Care 2012;35:434–445
    OpenUrlFREE Full Text
  55. ↵
    1. Thomas D,
    2. Elliott EJ
    . Low glycaemic index, or low glycaemic load, diets for diabetes mellitus. Cochrane Database Syst Rev 2009;1:CD006296
  56. ↵
    1. He M,
    2. van Dam RM,
    3. Rimm E,
    4. Hu FB,
    5. Qi L
    . Whole-grain, cereal fiber, bran, and germ intake and the risks of all-cause and cardiovascular disease-specific mortality among women with type 2 diabetes mellitus. Circulation 2010;121:2162–2168
    OpenUrlAbstract/FREE Full Text
  57. ↵
    Office of Disease Prevention and Health Promotion, U.S. Department of Health and Human Services. Dietary Guidelines for Americans: 2015–2020. 8th ed. Available from https://health.gov/dietaryguidelines/2015/guidelines/. Accessed 17 October 2016
  58. ↵
    1. Laurenzi A,
    2. Bolla AM,
    3. Panigoni G, et al
    . Effects of carbohydrate counting on glucose control and quality of life over 24 weeks in adult patients with type 1 diabetes on continuous subcutaneous insulin infusion: a randomized, prospective clinical trial (GIOCAR). Diabetes Care 2011;34:823–827
    OpenUrlAbstract/FREE Full Text
    1. Sämann A,
    2. Mühlhauser I,
    3. Bender R,
    4. Kloos Ch,
    5. Müller UA
    . Glycaemic control and severe hypoglycaemia following training in flexible, intensive insulin therapy to enable dietary freedom in people with type 1 diabetes: a prospective implementation study. Diabetologia 2005;48:1965–1970
    OpenUrlCrossRefPubMedWeb of Science
  59. ↵
    1. Bell KJ,
    2. Barclay AW,
    3. Petocz P,
    4. Colagiuri S,
    5. Brand-Miller JC
    . Efficacy of carbohydrate counting in type 1 diabetes: a systematic review and meta-analysis. Lancet Diabetes Endocrinol 2014;2:133–140
    OpenUrlCrossRefPubMed
  60. ↵
    1. Bell KJ,
    2. Smart CE,
    3. Steil GM,
    4. Brand-Miller JC,
    5. King B,
    6. Wolpert HA
    . Impact of fat, protein, and glycemic index on postprandial glucose control in type 1 diabetes: implications for intensive diabetes management in the continuous glucose monitoring era. Diabetes Care 2015;38:1008–1015
    OpenUrlAbstract/FREE Full Text
  61. ↵
    1. Bell KJ,
    2. Toschi E,
    3. Steil GM,
    4. Wolpert HA
    . Optimized mealtime insulin dosing for fat and protein in type 1 diabetes: application of a model-based approach to derive insulin doses for open-loop diabetes management. Diabetes Care 2016;39:1631–1634
    OpenUrlAbstract/FREE Full Text
  62. ↵
    1. Bowen ME,
    2. Cavanaugh KL,
    3. Wolff K, et al
    . The diabetes nutrition education study randomized controlled trial: a comparative effectiveness study of approaches to nutrition in diabetes self-management education. Patient Educ Couns 2016;99:1368–1376
    OpenUrl
  63. ↵
    1. Pan Y,
    2. Guo LL,
    3. Jin HM
    . Low-protein diet for diabetic nephropathy: a meta-analysis of randomized controlled trials. Am J Clin Nutr 2008;88:660–666
    OpenUrlAbstract/FREE Full Text
  64. ↵
    1. Robertson L,
    2. Waugh N,
    3. Robertson A
    . Protein restriction for diabetic renal disease. Cochrane Database Syst Rev 2007;4:CD002181
  65. ↵
    1. Layman DK,
    2. Clifton P,
    3. Gannon MC,
    4. Krauss RM,
    5. Nuttall FQ
    . Protein in optimal health: heart disease and type 2 diabetes. Am J Clin Nutr 2008;87:1571S–1575S
    OpenUrlAbstract/FREE Full Text
  66. ↵
    1. Institute of Medicine
    . Dietary Reference Intakes for Energy, Carbohydrate, Fiber, Fat, Fatty Acids, Cholesterol, Protein, and Amino Acids [Internet]. Washington, DC, National Academies Press, 2005. Available from http://www.iom.edu/Reports/2002/Dietary-Reference-Intakes-for-Energy-Carbohydrate-Fiber-Fat-Fatty-Acids-Cholesterol-Protein-and-Amino-Acids.aspx. Accessed
  67. ↵
    1. Estruch R,
    2. Ros E,
    3. Salas-Salvadó J, et al.; PREDIMED Study Investigators
    . Primary prevention of cardiovascular disease with a Mediterranean diet. N Engl J Med 2013;368:1279–1290
    OpenUrlCrossRefPubMedWeb of Science
    1. Ros E
    . Dietary cis-monounsaturated fatty acids and metabolic control in type 2 diabetes. Am J Clin Nutr 2003;78(Suppl.):617S–625S
    OpenUrlAbstract/FREE Full Text
    1. Forouhi NG,
    2. Imamura F,
    3. Sharp SJ, et al
    . Association of plasma phospholipid n-3 and n-6 polyunsaturated fatty acids with type 2 diabetes: the EPIC-InterAct Case-Cohort Study. PLoS Med 2016;13:e1002094
    OpenUrl
  68. ↵
    1. Wang DD,
    2. Li Y,
    3. Chiuve SE, et al
    . Association of specific dietary fats with total and cause-specific mortality. JAMA Intern Med 2016;176:1134–1145
    OpenUrlCrossRefPubMed
  69. ↵
    1. Brehm BJ,
    2. Lattin BL,
    3. Summer SS, et al
    . One-year comparison of a high-monounsaturated fat diet with a high-carbohydrate diet in type 2 diabetes. Diabetes Care 2009;32:215–220
    OpenUrlAbstract/FREE Full Text
    1. Shai I,
    2. Schwarzfuchs D,
    3. Henkin Y, et al.; Dietary Intervention Randomized Controlled Trial (DIRECT) Group
    . Weight loss with a low-carbohydrate, Mediterranean, or low-fat diet. N Engl J Med 2008;359:229–241
    OpenUrlCrossRefPubMedWeb of Science
    1. Brunerova L,
    2. Smejkalova V,
    3. Potockova J,
    4. Andel M
    . A comparison of the influence of a high-fat diet enriched in monounsaturated fatty acids and conventional diet on weight loss and metabolic parameters in obese non-diabetic and type 2 diabetic patients. Diabet Med 2007;24:533–540
    OpenUrlCrossRefPubMed
  70. ↵
    1. Bloomfield HE,
    2. Koeller E,
    3. Greer N,
    4. MacDonald R,
    5. Kane R,
    6. Wilt TJ
    . Effects on health outcomes of a Mediterranean diet with no restriction on fat intake: a systematic review and meta-analysis. Ann Intern Med 2016;165:491–500
    OpenUrl
  71. ↵
    1. Harris WS,
    2. Mozaffarian D,
    3. Rimm E, et al
    . Omega-6 fatty acids and risk for cardiovascular disease: a science advisory from the American Heart Association Nutrition Subcommittee of the Council on Nutrition, Physical Activity, and Metabolism; Council on Cardiovascular Nursing; and Council on Epidemiology and Prevention. Circulation 2009;119:902–907
    OpenUrlFREE Full Text
    1. Crochemore ICC,
    2. Souza AFP,
    3. de Souza ACF,
    4. Rosado EL
    . ω-3 polyunsaturated fatty acid supplementation does not influence body composition, insulin resistance, and lipemia in women with type 2 diabetes and obesity. Nutr Clin Pract 2012;27:553–560
    OpenUrlAbstract/FREE Full Text
    1. Holman RR,
    2. Paul S,
    3. Farmer A,
    4. Tucker L,
    5. Stratton IM,
    6. Neil HA; Atorvastatin in Factorial with Omega-3 EE90 Risk Reduction in Diabetes Study Group
    . Atorvastatin in Factorial with Omega-3 EE90 Risk Reduction in Diabetes (AFORRD): a randomised controlled trial. Diabetologia 2009;52:50–59
    OpenUrlCrossRefPubMed
    1. Kromhout D,
    2. Geleijnse JM,
    3. de Goede J, et al
    . n-3 fatty acids, ventricular arrhythmia-related events, and fatal myocardial infarction in postmyocardial infarction patients with diabetes. Diabetes Care 2011;34:2515–2520
    OpenUrlAbstract/FREE Full Text
  72. ↵
    1. Bosch J,
    2. Gerstein HC,
    3. Dagenais GR, et al.; ORIGIN Trial Investigators
    . n-3 fatty acids and cardiovascular outcomes in patients with dysglycemia. N Engl J Med 2012;367:309–318
    OpenUrlCrossRefPubMedWeb of Science
  73. ↵
    1. Bray GA,
    2. Vollmer WM,
    3. Sacks FM,
    4. Obarzanek E,
    5. Svetkey LP,
    6. Appel LJ; DASH Collaborative Research Group
    . A further subgroup analysis of the effects of the DASH diet and three dietary sodium levels on blood pressure: results of the DASH-Sodium Trial. Am J Cardiol 2004;94:222–227
    OpenUrlCrossRefPubMedWeb of Science
  74. ↵
    1. Thomas MC,
    2. Moran J,
    3. Forsblom C, et al.; FinnDiane Study Group
    . The association between dietary sodium intake, ESRD, and all-cause mortality in patients with type 1 diabetes. Diabetes Care 2011;34:861–866
    OpenUrlAbstract/FREE Full Text
  75. ↵
    1. Ekinci EI,
    2. Clarke S,
    3. Thomas MC, et al
    . Dietary salt intake and mortality in patients with type 2 diabetes. Diabetes Care 2011;34:703–709
    OpenUrlAbstract/FREE Full Text
  76. ↵
    1. Maillot M,
    2. Drewnowski A
    . A conflict between nutritionally adequate diets and meeting the 2010 dietary guidelines for sodium. Am J Prev Med 2012;42:174–179
    OpenUrlCrossRefPubMed
  77. ↵
    1. Aroda VR,
    2. Edelstein SL,
    3. Goldberg RB, et al.; Diabetes Prevention Program Research Group
    . Long-term metformin use and vitamin B12 deficiency in the Diabetes Prevention Program Outcomes Study. J Clin Endocrinol Metab 2016;101:1754–1761
    OpenUrlCrossRefPubMed
  78. ↵
    1. Allen RW,
    2. Schwartzman E,
    3. Baker WL,
    4. Coleman CI,
    5. Phung OJ
    . Cinnamon use in type 2 diabetes: an updated systematic review and meta-analysis. Ann Fam Med 2013;11:452–459
    OpenUrlAbstract/FREE Full Text
  79. ↵
    1. Mitri J,
    2. Pittas AG
    . Vitamin D and diabetes. Endocrinol Metab Clin North Am 2014;43:205–232
    OpenUrlCrossRefPubMed
  80. ↵
    1. Mozaffarian D
    . Dietary and policy priorities for cardiovascular disease, diabetes, and obesity: a comprehensive review. Circulation 2016;133:187–225
    OpenUrlAbstract/FREE Full Text
  81. ↵
    1. Gardner C,
    2. Wylie-Rosett J,
    3. Gidding SS, et al.; American Heart Association Nutrition Committee of the Council on Nutrition, Physical Activity and Metabolism, Council on Arteriosclerosis, Thrombosis and Vascular Biology, Council on Cardiovascular Disease in the Young; American Diabetes Association
    . Nonnutritive sweeteners: current use and health perspectives: a scientific statement from the American Heart Association and the American Diabetes Association. Diabetes Care 2012;35:1798–1808
    OpenUrlFREE Full Text
  82. ↵
    1. Boulé NG,
    2. Haddad E,
    3. Kenny GP,
    4. Wells GA,
    5. Sigal RJ
    . Effects of exercise on glycemic control and body mass in type 2 diabetes mellitus: a meta-analysis of controlled clinical trials. JAMA 2001;286:1218–1227
    OpenUrlCrossRefPubMedWeb of Science
  83. ↵
    1. Peters A,
    2. Laffel L
    1. Colberg SR,
    2. Riddell MC
    . Physical activity: regulation of glucose metabolism, clinicial management strategies, and weight control. In American Diabetes Association/JDRF Type 1 Diabetes Sourcebook. Peters A, Laffel L, Eds. Alexandria, VA, American Diabetes Association, 2013
  84. ↵
    1. Boulé NG,
    2. Kenny GP,
    3. Haddad E,
    4. Wells GA,
    5. Sigal RJ
    . Meta-analysis of the effect of structured exercise training on cardiorespiratory fitness in type 2 diabetes mellitus. Diabetologia 2003;46:1071–1081
    OpenUrlCrossRefPubMedWeb of Science
  85. ↵
    1. Rejeski WJ,
    2. Ip EH,
    3. Bertoni AG, et al.; Look AHEAD Research Group
    . Lifestyle change and mobility in obese adults with type 2 diabetes. N Engl J Med 2012;366:1209–1217
    OpenUrlCrossRefPubMedWeb of Science
  86. ↵
    1. Colberg SR,
    2. Sigal RJ,
    3. Yardley JE, et al
    . Physical activity/exercise and diabetes: a position statement of the American Diabetes Association. Diabetes Care 2016;39:2065–2079
  87. ↵
    1. Janssen I,
    2. Leblanc AG
    . Systematic review of the health benefits of physical activity and fitness in school-aged children and youth. Int J Behav Nutr Phys Act 2010;7:40
    OpenUrlCrossRefPubMed
  88. ↵
    1. Office of Disease Prevention and Health Promotion, U.S. Department of Health and Human Services
    . 2008 Physical Activity Guidelines for Americans [Internet]. Available from http://www.health.gov/paguidelines/guidelines/default.aspx. Accessed 1 October 2014
  89. ↵
    1. Katzmarzyk PT,
    2. Church TS,
    3. Craig CL,
    4. Bouchard C
    . Sitting time and mortality from all causes, cardiovascular disease, and cancer. Med Sci Sports Exerc 2009;41:998–1005
    OpenUrlCrossRefPubMedWeb of Science
  90. ↵
    1. Dempsey PC,
    2. Larsen RN,
    3. Sethi P, et al
    . Benefits for type 2 diabetes of interrupting prolonged sitting with brief bouts of light walking or simple resistance activities. Diabetes Care 2016;39:964–972
    OpenUrlAbstract/FREE Full Text
  91. ↵
    1. Colberg SR,
    2. Sigal RJ,
    3. Fernhall B, et al.; American College of Sports Medicine; American Diabetes Association
    . Exercise and type 2 diabetes: the American College of Sports Medicine and the American Diabetes Association: joint position statement executive summary. Diabetes Care 2010;33:2692–2696
    OpenUrlFREE Full Text
  92. ↵
    1. Church TS,
    2. Blair SN,
    3. Cocreham S, et al
    . Effects of aerobic and resistance training on hemoglobin A1c levels in patients with type 2 diabetes: a randomized controlled trial. JAMA 2010;304:2253–2262
    OpenUrlCrossRefPubMedWeb of Science
  93. ↵
    1. Bax JJ,
    2. Young LH,
    3. Frye RL,
    4. Bonow RO,
    5. Steinberg HO,
    6. Barrett EJ; American Diabetes Association
    . Screening for coronary artery disease in patients with diabetes. Diabetes Care 2007;30:2729–2736
    OpenUrlAbstract/FREE Full Text
  94. ↵
    1. Peters A,
    2. Laffel L
    1. Peters AL,
    2. Laffel L; American Diabetes Association; JDRF
    . American Diabetes Association/JDRF Type 1 Diabetes Sourcebook. Peters A, Laffel L, Eds. Alexandria, VA, American Diabetes Association, 2013
  95. ↵
    1. Colberg SR
    . Exercise and Diabetes: A Clinician’s Guide to Prescribing Physical Activity. 1st ed. Alexandria, VA, American Diabetes Association, 2013
  96. ↵
    1. Lemaster JW,
    2. Reiber GE,
    3. Smith DG,
    4. Heagerty PJ,
    5. Wallace C
    . Daily weight-bearing activity does not increase the risk of diabetic foot ulcers. Med Sci Sports Exerc 2003;35:1093–1099
    OpenUrlCrossRefPubMedWeb of Science
  97. ↵
    1. Smith AG,
    2. Russell J,
    3. Feldman EL, et al
    . Lifestyle intervention for pre-diabetic neuropathy. Diabetes Care 2006;29:1294–1299
    OpenUrlAbstract/FREE Full Text
  98. ↵
    1. Spallone V,
    2. Ziegler D,
    3. Freeman R, et al.; Toronto Consensus Panel on Diabetic Neuropathy
    . Cardiovascular autonomic neuropathy in diabetes: clinical impact, assessment, diagnosis, and management. Diabetes Metab Res Rev 2011;27:639–653
    OpenUrlCrossRefPubMed
  99. ↵
    1. Pop-Busui R,
    2. Evans GW,
    3. Gerstein HC, et al.; Action to Control Cardiovascular Risk in Diabetes Study Group
    . Effects of cardiac autonomic dysfunction on mortality risk in the Action to Control Cardiovascular Risk in Diabetes (ACCORD) trial. Diabetes Care 2010;33:1578–1584
    OpenUrlAbstract/FREE Full Text
  100. ↵
    1. Suarez L,
    2. Barrett-Connor E
    . Interaction between cigarette smoking and diabetes mellitus in the prediction of death attributed to cardiovascular disease. Am J Epidemiol 1984;120:670–675
    OpenUrlAbstract/FREE Full Text
  101. ↵
    1. Stanton CA,
    2. Keith DR,
    3. Gaalema DE, et al
    . Trends in tobacco use among US adults with chronic health conditions: National Survey on Drug Use and Health 2005-2013. Prev Med 2016;92:160–168
    OpenUrl
  102. ↵
    1. Jankowich M,
    2. Choudhary G,
    3. Taveira TH,
    4. Wu W-C
    . Age-, race-, and gender-specific prevalence of diabetes among smokers. Diabetes Res Clin Pract 2011;93:e101–e105
    OpenUrlCrossRefPubMed
  103. ↵
    1. Voulgari C,
    2. Katsilambros N,
    3. Tentolouris N
    . Smoking cessation predicts amelioration of microalbuminuria in newly diagnosed type 2 diabetes mellitus: a 1-year prospective study. Metabolism 2011;60:1456–1464
    OpenUrlCrossRefPubMed
  104. ↵
    1. Ranney L,
    2. Melvin C,
    3. Lux L,
    4. McClain E,
    5. Lohr KN
    . Systematic review: smoking cessation intervention strategies for adults and adults in special populations. Ann Intern Med 2006;145:845–856
    OpenUrlCrossRefPubMedWeb of Science
  105. ↵
    1. Clair C,
    2. Rigotti NA,
    3. Porneala B, et al
    . Association of smoking cessation and weight change with cardiovascular disease among adults with and without diabetes. JAMA 2013;309:1014–1021
    OpenUrlCrossRefPubMedWeb of Science
  106. ↵
    1. Schraufnagel DE,
    2. Blasi F,
    3. Drummond MB, et al.; Forum of International Respiratory Societies
    . Electronic cigarettes. A position statement of the Forum of International Respiratory Societies. Am J Respir Crit Care Med 2014;190:611–618
    OpenUrlCrossRefPubMedWeb of Science
    1. Bam TS,
    2. Bellew W,
    3. Berezhnova I, et al.; Tobacco Control Department International Union Against Tuberculosis and Lung Disease
    . Position statement on electronic cigarettes or electronic nicotine delivery systems. Int J Tuberc Lung Dis 2014;18:5–7
    OpenUrlCrossRefPubMed
  107. ↵
    1. Bhatnagar A,
    2. Whitsel LP,
    3. Ribisl KM, et al.; American Heart Association Advocacy Coordinating Committee, Council on Cardiovascular and Stroke Nursing, Council on Clinical Cardiology, and Council on Quality of Care and Outcomes Research
    . Electronic cigarettes: a policy statement from the American Heart Association. Circulation 2014;130:1418–1436
    OpenUrlFREE Full Text
  108. ↵
    1. Young-Hyman D,
    2. de Groot M,
    3. Hill-Briggs F,
    4. Gonzalez JS,
    5. Hood K,
    6. Peyrot M
    . Psychosocial care for people with diabetes: a position statement of the American Diabetes Association. Diabetes Care 2016;39:2126–2140
    OpenUrlFREE Full Text
  109. ↵
    1. Anderson RJ,
    2. Grigsby AB,
    3. Freedland KE, et al
    . Anxiety and poor glycemic control: a meta-analytic review of the literature. Int J Psychiatry Med 2002;32:235–247
    OpenUrlAbstract/FREE Full Text
    1. Delahanty LM,
    2. Grant RW,
    3. Wittenberg E, et al
    . Association of diabetes-related emotional distress with diabetes treatment in primary care patients with type 2 diabetes. Diabet Med 2007;24:48–54
    OpenUrlCrossRefPubMedWeb of Science
  110. ↵
    1. Anderson RJ,
    2. Freedland KE,
    3. Clouse RE,
    4. Lustman PJ
    . The prevalence of comorbid depression in adults with diabetes: a meta-analysis. Diabetes Care 2001;24:1069–1078
    OpenUrlAbstract/FREE Full Text
  111. ↵
    1. Kovacs Burns K,
    2. Nicolucci A,
    3. Holt RIG, et al.; DAWN2 Study Group
    . Diabetes Attitudes, Wishes and Needs second study (DAWN2™): cross-national benchmarking indicators for family members living with people with diabetes. Diabet Med 2013;30:778–788
    OpenUrlCrossRefPubMed
  112. ↵
    1. Harkness E,
    2. Macdonald W,
    3. Valderas J,
    4. Coventry P,
    5. Gask L,
    6. Bower P
    . Identifying psychosocial interventions that improve both physical and mental health in patients with diabetes: a systematic review and meta-analysis. Diabetes Care 2010;33:926–930
    OpenUrlAbstract/FREE Full Text
  113. ↵
    1. Nicolucci A,
    2. Kovacs Burns K,
    3. Holt RIG, et al.; DAWN2 Study Group
    . Diabetes Attitudes, Wishes and Needs second study (DAWN2™): cross-national benchmarking of diabetes-related psychosocial outcomes for people with diabetes. Diabet Med 2013;30:767–777
    OpenUrlCrossRefPubMed
  114. ↵
    1. Fisher L,
    2. Hessler DM,
    3. Polonsky WH,
    4. Mullan J
    . When is diabetes distress clinically meaningful?: Establishing cut points for the Diabetes Distress Scale. Diabetes Care 2012;35:259–264
    OpenUrlAbstract/FREE Full Text
  115. ↵
    1. Fisher L,
    2. Glasgow RE,
    3. Strycker LA
    . The relationship between diabetes distress and clinical depression with glycemic control among patients with type 2 diabetes. Diabetes Care 2010;33:1034–1036
    OpenUrlAbstract/FREE Full Text
  116. ↵
    1. Aikens JE
    . Prospective associations between emotional distress and poor outcomes in type 2 diabetes. Diabetes Care 2012;35:2472–2478
    OpenUrlAbstract/FREE Full Text
  117. ↵
    1. Fisher L,
    2. Skaff MM,
    3. Mullan JT, et al
    . Clinical depression versus distress among patients with type 2 diabetes: not just a question of semantics. Diabetes Care 2007;30:542–548
    OpenUrlAbstract/FREE Full Text
  118. ↵
    1. Snoek FJ,
    2. Bremmer MA,
    3. Hermanns N
    . Constructs of depression and distress in diabetes: time for an appraisal. Lancet Diabetes Endocrinol 2015;3:450–460
    OpenUrl
  119. ↵
    1. Gary TL,
    2. Safford MM,
    3. Gerzoff RB, et al
    . Perception of neighborhood problems, health behaviors, and diabetes outcomes among adults with diabetes in managed care: the Translating Research Into Action for Diabetes (TRIAD) study. Diabetes Care 2008;31:273–278
    OpenUrlAbstract/FREE Full Text
  120. ↵
    1. Beverly EA,
    2. Hultgren BA,
    3. Brooks KM,
    4. Ritholz MD,
    5. Abrahamson MJ,
    6. Weinger K
    . Understanding physicians’ challenges when treating type 2 diabetic patients’ social and emotional difficulties: a qualitative study. Diabetes Care 2011;34:1086–1088
    OpenUrlAbstract/FREE Full Text
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4. Lifestyle Management
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Diabetes Care Jan 2017, 40 (Supplement 1) S33-S43; DOI: 10.2337/dc17-S007

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4. Lifestyle Management
American Diabetes Association
Diabetes Care Jan 2017, 40 (Supplement 1) S33-S43; DOI: 10.2337/dc17-S007
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