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1.0.0.0 In­tro­duc­tion

The Amer­i­can Di­a­betes As­so­ci­a­tion (ADA) “Stan­dards of Med­i­cal Care in Di­a­betes” in­cludes ADA’s cur­rent clin­i­cal prac­tice rec­om­men­da­tions and is in­tend­ed to pro­vide the com­po­nents of di­a­betes care, gen­er­al treat­ment goals and guide­lines, and tools to eval­u­ate qual­i­ty of care. Mem­bers of the ADA Pro­fes­sion­al Prac­tice Com­mit­tee, a mul­ti­dis­ci­plinary ex­pert com­mit­tee, are re­spon­si­ble for up­dat­ing the Stan­dards of Care an­nu­al­ly, or more fre­quent­ly as war­rant­ed. For a de­tailed de­scrip­tion of ADA stan­dards, state­ments, and re­ports, as well as the ev­i­dence-‍grad­ing sys­tem for ADA’s clin­i­cal prac­tice rec­om­men­da­tions, please refer to the Stan­dards of Care In­tro­duc­tion. Read­ers who wish to com­ment on the Stan­dards of Care are in­vit­ed to do so at pro­fes­sion­al.di­a­betes.org/‍SOC.

Lifestyle man­age­ment is a fun­da­men­tal as­pect of di­a­betes care and in­cludes di­a­betes self-‍man­age­ment ed­u­ca­tion and sup­port (DSMES), med­i­cal nu­tri­tion ther­a­py (MNT), 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.

Sug­gest­ed ci­ta­tion: Amer­i­can Di­a­betes As­so­ci­a­tion. 5. Lifestyle man­age­ment: Stan­dards of Med­i­cal Care in Di­a­betesd2019. Di­a­betes Care 2019;42(Suppl. 1):S46–S60 © 2018 by the Amer­i­can Di­a­betes As­so­ci­a­tion. Read­ers may use this ar­ti­cle as long as the work is prop­er­ly cited, the use is ed­u­ca­tional and not for prof­it, and the work is not al­tered. More in­for­ma­tion is avail­able at http://www.di­a­betesjournals .org/‍content/‍license.

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2.0.0.0 DM Self-‍Man­age­ment Ed­u­ca­tion & Sup­port

2.1.0.0 Rec­om­men­da­tions

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2.2.0.0 Overview

DSMES ser­vices 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 DSMES 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 are en­cour­aged to 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 DSMES. Pa­tient per­for­mance of self-‍man­age­ment be­hav­iors, in­clud­ing its ef­fect on clin­i­cal out­comes, health sta­tus, and qual­i­ty of life, as well as the psy­choso­cial fac­tors im­pact­ing the per­son’s self-‍man­age­ment should be mon­i­tored as part of rou­tine clin­i­cal care.

In ad­di­tion, in re­sponse to the grow­ing lit­er­a­ture that as­so­ci­ates po­ten­tial­ly judg­men­tal words with in­creased feel­ings of shame and guilt, pro­viders are en­cour­aged to con­sid­er the im­pact that lan­guage has on build­ing ther­a­peu­tic re­la­tion­ships and to choose pos­i­tive, strength-‍based words and phras­es that put peo­ple first (2,3). Pa­tient per­for­mance of self-‍man­age­ment be­hav­iors as well as psy­choso­cial fac­tors im­pact­ing the per­son’s self-‍man­age­ment should be mon­i­tored. Please see Sec­tion 4, “Com­pre­hen­sive Med­i­cal Eval­u­a­tion and As­sess­ment of Co­mor­bidi­ties,” for more on use of lan­guage.

DSMES and the cur­rent na­tion­al stan­dards guid­ing it (1,4) are based on ev­i­dence of benefit. Specifically, DSMES 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 DSMES 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 (5).

Four crit­i­cal time points have been defined when the need for DSMES is to 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

DSMES fo­cus­es on sup­porting pa­tient em­pow­er­ment by pro­vid­ing peo­ple with di­a­betes the tools to make in­formed self-‍man­age­ment de­ci­sions (6). Di­a­betes care has shift­ed to an ap­proach that 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 (7).

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2.3.0.0 Ev­i­dence for the Ben­e­fits

Stud­ies have found that DSMES is as­so­ci­at­ed with im­proved di­a­betes knowl­edge and self-‍care be­hav­iors (8), lower A1C (7,9–11), lower self-‍re­port­ed weight (12,13), im­proved qual­i­ty of life (10,14), re­duced all-‍cause mor­tal­i­ty risk (15), healthy cop­ing (16,17), and re­duced health care costs (18-20). Bet­ter out­comes were re­port­ed for DSMES in­ter­ven­tions that were over 10 h in total du­ra­tion (11), in­clud­ed on­go­ing sup­port (5,21), were cul­tur­al­ly (22,23) and age ap­pro­pri­ate (24,25), were tai­lored to in­di­vid­u­al needs and pref­er­ences, and ad­dressed psy­choso­cial is­sues and in­cor­po­rated be­hav­ioral strate­gies (6,16,26,27). In­di­vid­u­al and group ap­proaches are ef­fective (13,28,29), with a slight benefit re­al­ized by those who en­gage in both (11). Emerg­ing ev­i­dence demon­strates the benefit of In­ter­net-‍based DSMES ser­vices for di­a­betes pre­ven­tion and the man­age­ment of type 2 di­a­betes (30-32). Tech­nol­o­gy-‍en­abled di­a­betes self-‍man­age­ment so­lu­tions im­prove A1C most ef­fectively when there is two-‍way com­mu­ni­ca­tion be­tween the pa­tient and the health care team, in­di­vid­u­alized feed­back, use of pa­tient-generated health data, and ed­u­ca­tion (32). Cur­rent re­search sup­ports nurs­es, di­eti­tians, and phar­ma­cists as pro­viders of DSMES who may also de­vel­op cur­ricu­lum (33-35). Mem­bers of the DSMES team should have spe­cial­ized clin­i­cal knowl­edge in di­a­betes and be­hav­ior change prin­ci­ples. Certification as a certified di­a­betes ed­u­ca­tor (CDE) or board certified-‍ad­vanced di­a­betes man­age­ment (BC-‍ADM) certification demon­strates spe­cial­ized train­ing and mas­tery of a specific body of knowl­edge (4). Ad­di­tion­al­ly, there is grow­ing ev­i­dence for the role of com­mu­ni­ty health work­ers (36,37), as well as peer (36-40) and lay lead­ers (41), in pro­vid­ing on­go­ing sup­port.

DSMES is as­so­ci­at­ed with an in­creased use of pri­ma­ry care and pre­ven­tive ser­vices (18,42,43) and less fre­quent use of acute care and inpa­tient hos­pi­tal ser­vices (12). Pa­tients who par­tic­i­pate in DSMES are more like­ly to fol­low best prac­tice treat­ment rec­om­men­da­tions, par­tic­u­lar­ly among the Medi­care pop­u­la­tion, and have lower Medi­care and in­sur­ance claim costs (19,42). De­spite these benefits, re­ports in­di­cate that only 5–7% of in­di­vid­u­als el­i­gi­ble for DSMES through Medi­care or a pri­vate in­sur­ance plan ac­tu­al­ly re­ceive it (44,45). 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 (46). Thus, in ad­di­tion to ed­u­cat­ing re­fer­ring pro­viders about the benefits of DSMES and the crit­i­cal times to refer (1), al­ter­na­tive and in­no­va­tive mod­els of DSMES de­liv­ery need to be ex­plored and eval­u­ated.

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2.4.0.0 Re­im­burse­ment

Medi­care re­im­burs­es DSMES when that ser­vice meets the na­tion­al stan­dards (1,4) and is rec­og­nized by the Amer­i­can Di­a­betes As­so­ci­a­tion (ADA) or other ap­proval bod­ies. DSMES is also cov­ered by most health in­sur­ance plans. On­go­ing sup­port has been shown to be in­stru­men­tal for im­prov­ing out­comes when it is im­ple­mented after the com­ple­tion of ed­u­ca­tion ser­vices. DSMES is fre­quent­ly re­im­bursed when per­formed in per­son. How­ev­er, al­though DSMES can also be pro­vided via phone calls and tele­health, these re­mote ver­sions may not al­ways be re­im­bursed. Changes in re­im­burse­ment poli­cies that in­crease DSMES ac­cess and uti­liza­tion will re­sult in a pos­i­tive im­pact to beneficia­ries’ clin­i­cal out­comes, qual­i­ty of life, health care uti­liza­tion, and costs (47).

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3.0.0.0 NU­TRI­TION THER­A­PY

3.1.0.0 Overview

For many in­di­vid­u­als with di­a­betes, the most chal­leng­ing part of the treat­ment plan is de­ter­min­ing what to eat and fol­lowing a meal plan. There is not a one-‍size-‍fits-‍all eat­ing pat­tern for in­di­vid­u­als with di­a­betes, and meal plan­ning should be in­di­vid­u­alized. 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 (35,48). All in­di­vid­u­als with di­a­betes should be of­fered a re­fer­ral for in­di­vid­u­alized MNT pro­vided by a reg­is­tered di­eti­tian (RD) who is knowl­edgeable and skilled in pro­vid­ing di­a­betes-‍specific MNT (49). MNT de­liv­ered by an RD is as­so­ci­at­ed with A1C de­creas­es of 1.0–1.9% for peo­ple with type 1 di­a­betes (50) and 0.3–2% for peo­ple with type 2 di­a­betes (50). See Table 5.1 for specific nu­tri­tion rec­om­men­da­tions. Be­cause of the pro­gres­sive na­ture of type 2 di­a­betes, lifestyle changes alone may not be ad­e­quate to main­tain eu­g­lycemia over time. How­ev­er, after med­i­ca­tion is ini­ti­at­ed, nu­tri­tion ther­a­py con­tin­ues to be an im­por­tant com­po­nent and should be in­te­grat­ed with the over­all treat­ment plan (48).

Table 5.1—Med­i­cal nu­tri­tion ther­a­py rec­om­men­da­tions

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3.2.0.0 Adults With DM, Goals of Nu­tri­tion Ther­a­py

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

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

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3.3.0.0 Eat­ing Pat­terns and Meal Plan­ning

Ev­i­dence sug­gests that there is not an ideal per­cent­age of calo­ries from car­bo­hy­drate, pro­tein, and fat for all peo­ple with di­a­betes. There­fore, macronu­tri­ent dis­tri­bu­tion should be based on an in­di­vid­u­alized as­sess­ment of cur­rent eat­ing pat­terns, pref­er­ences, and metabol­ic goals. Con­sid­er per­sonal pref­er­ences (e.g., tra­di­tion, cul­ture, re­li­gion, health be­liefs and goals, eco­nomics) as well as metabol­ic goals when work­ing with in­di­vid­u­als to de­ter­mine the best eat­ing pat­tern for them (35,51,52). 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 foods, with less focus on specific nu­tri­ents (53). A va­ri­ety of eat­ing pat­terns are ac­cept­able for the man­age­ment of di­a­betes (51,54), and a re­fer­ral to an RD or reg­is­tered di­eti­tian nu­tri­tionist (RDN) is es­sen­tial to as­sess the over­all nu­tri­tion sta­tus of, and to work col­lab­o­ra­tively with, the pa­tient to cre­ate a per­sonalized meal plan that con­sid­ers the in­di­vid­u­al’s health sta­tus, skills, re­sources, food pref­er­ences, and health goals to co­or­di­nate and align with the over­all treat­ment plan in­clud­ing phys­i­cal ac­tiv­i­ty and med­i­ca­tion. The Mediter­ranean (55,56), Di­etary Ap­proach­es to Stop Hy­per­ten­sion (DASH) (57-59), and plant-‍based (60,61) diets are all ex­am­ples of health­ful eat­ing pat­terns that have shown pos­i­tive re­sults in re­search, but in­di­vid­u­alized meal plan­ning should focus on per­sonal pref­er­ences, needs, and goals. In ad­di­tion, re­search in­di­cates that lowcar­bo­hy­drate eat­ing plans may re­sult in im­proved glycemia and have the po­ten­tial to re­duce an­ti­hy­per­glycemic med­i­ca­tions for in­di­vid­u­als with type 2 di­a­betes (62-64). As re­search stud­ies on some low-‍car­bo­hy­drate eat­ing plans gen­er­ally in­di­cate chal­lenges with longterm sus­tainabil­i­ty, it is im­por­tant to reas­sess and in­di­vid­u­alize meal plan guid­ance reg­u­lar­ly for those in­ter­est­ed in this ap­proach. This meal plan is not rec­om­mend­ed at this time for women who are preg­nant or lac­tat­ing, peo­ple with or at risk for dis­or­dered eat­ing, or peo­ple who have renal dis­ease, and it should be used with cau­tion in pa­tients tak­ing sodi­um–glu­cose co­trans­porter 2 (SGLT2) in­hibitors due to the po­ten­tial risk of ke­toaci­do­sis (65,66). There is inad­e­quate re­search in type 1 di­a­betes to sup­port one eat­ing plan over an­oth­er at this time.

A sim­ple and ef­fective ap­proach to glycemia and weight man­age­ment em­pha­siz­ing por­tion con­trol and healthy food choic­es should be con­sid­ered for those with type 2 di­a­betes who are not tak­ing in­sulin, who have lim­it­ed health lit­er­a­cy or nu­mer­a­cy, or who are older and prone to hy­po­glycemia (50). The di­a­betes plate method is com­mon­ly used for pro­vid­ing basic meal plan­ning guid­ance (67) as it pro­vides a vi­su­al guide show­ing how to con­trol calo­ries (by fea­tur­ing a small­er plate) and car­bo­hy­drates (by lim­it­ing them to what fits in one-‍quar­ter of the plate) and puts an em­pha­sis on low-‍car­bo­hy­drate (or non­starchy) veg­etables.

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3.4.0.0 Weight Man­age­ment

Man­age­ment and re­duc­tion of weight is im­por­tant for peo­ple with type 1 di­a­betes, type 2 di­a­betes, or predi­a­betes who have over­weight or obe­si­ty. 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 (51,68,69) (see Sec­tion 3 “Pre­ven­tion or Delay of Type 2 Di­a­betes”) and is beneficial to the man­age­ment of type 2 di­a­betes (see Sec­tion 8 “Obe­si­ty Man­age­ment for the Treat­ment of Type 2 Di­a­betes”).

Stud­ies of re­duced calo­rie in­ter­ven­tions show re­duc­tions in A1C of 0.3% to 2.0% in adults with type 2 di­a­betes, as well as im­provements in med­i­ca­tion doses and qual­i­ty of life (50,51). Sus­tain­ing weight loss can be chal­leng­ing (70,71) but has long-‍term benefits; main­taining weight loss for 5 years is as­so­ci­at­ed with sus­tained im­provements in A1C and lipid lev­els (72). 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 of at least 5% is need­ed to pro­duce beneficial out­comes in glycemic con­trol, lipids, and blood pres­sure (70). It should be noted, how­ev­er, that the clin­i­cal benefits of weight loss are pro­gres­sive and more in­ten­sive weight loss goals (i.e., 15%) may be ap­pro­pri­ate to max­i­mize benefit de­pend­ing on need, fea­si­bil­i­ty, and safe­ty (73). MNT guid­ance from an RD/‍RDN with ex­pertise in di­a­betes and weight man­age­ment, through­out the course of a struc­tured weight loss plan, is strong­ly rec­om­mend­ed.

Stud­ies have demon­strat­ed that a va­ri­ety of eat­ing plans, vary­ing in macronu­tri­ent com­po­si­tion, can be used ef­fectively and safe­ly in the short term (1–2 years) to achieve weight loss in peo­ple with di­a­betes. This in­cludes struc­tured low-‍calo­rie meal plans that in­clude meal re­place­ments (72-74) and the Mediter­ranean eat­ing pat­tern (75) as well as low-‍car­bo­hy­drate meal plans (62). How­ev­er, no sin­gle ap­proach has been proven to be con­sis­tently su­pe­ri­or (76,77), and more data are need­ed to iden­ti­fy and val­i­date those meal plans that are op­ti­mal with re­spect to longterm out­comes as well as pa­tient acceptabil­i­ty. The im­por­tance of pro­vid­ing guid­ance on an in­di­vid­u­alized meal plan con­tain­ing nu­tri­ent-‍dense foods, such as veg­etables, fruits, legumes, dairy, lean sources of pro­tein (in­clud­ing plant-‍based sources as well as lean meats, fish, and poul­try), nuts, seeds, and whole grains, can­not be overem­pha­sized (77), as well as guid­ance on achiev­ing the de­sired en­er­gy deficit (78-81). Any ap­proach to meal plan­ning should be in­di­vid­u­alized con­sid­ering the health sta­tus, per­sonal pref­er­ences, and abil­i­ty of the per­son with di­a­betes to sus­tain the rec­om­men­da­tions in the plan.

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3.5.0.0 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 (82,83). The lit­er­a­ture con­cern­ing glycemic index and glycemic load in in­di­vid­u­als with di­a­betes is com­plex, often yield­ing mixed re­sults, though in some stud­ies low­er­ing the glycemic load of con­sumed car­bo­hy­drates has demon­strat­ed A1C re­duc­tions of 0.2% to 0.5% (84,85). Stud­ies longer than 12 weeks re­port no significant influence of glycemic index or glycemic load in­de­pen­dent of weight loss on A1C; how­ev­er, mixed re­sults have been re­port­ed for fast­ing glu­cose lev­els and en­doge­nous in­sulin lev­els.

For peo­ple with type 2 di­a­betes or predi­a­betes, low-‍car­bo­hy­drate eat­ing plans show po­ten­tial to im­prove glycemia and lipid out­comes for up to 1 year (62–64,86–89). Part of the chal­lenge in in­ter­pret­ing low-‍car­bo­hy­drate re­search has been due to the wide range of def­i­ni­tions for a low-‍car­bo­hy­drate eat­ing plan (85,86). As re­search stud­ies on low-‍car­bo­hy­drate eat­ing plans gen­er­ally in­di­cate chal­lenges with long-‍term sus­tainabil­i­ty, it is im­por­tant to reas­sess and in­di­vid­u­alize meal plan guid­ance reg­u­lar­ly for those in­ter­est­ed in this ap­proach. Providers should main­tain con­sis­tent med­i­cal over­sight and rec­og­nize that cer­tain groups are not ap­pro­pri­ate for low-‍car­bo­hy­drate eat­ing plans, in­clud­ing women who are preg­nant or lac­tat­ing, chil­dren, and peo­ple who have renal dis­ease or dis­or­dered eat­ing be­hav­ior, and these plans should be used with cau­tion for those tak­ing SGLT2 in­hibitors due to po­ten­tial risk of ke­toaci­do­sis (65,66). There is inad­e­quate re­search about di­etary pat­terns for type 1 di­a­betes to sup­port one eat­ing plan over an­oth­er at this time.

Most in­di­vid­u­als with di­a­betes re­port a mod­er­ate in­take of car­bo­hy­drate (44– 46% of total calo­ries) (51). Ef­forts to mod­i­fy ha­bit­u­al eat­ing pat­terns are often un­suc­cess­ful in the long term; peo­ple gen­er­ally go back to their usual macronu­tri­ent dis­tri­bu­tion (51). Thus, the rec­om­mend­ed ap­proach is to in­di­vid­u­alize meal plans to meet caloric goals with a macronu­tri­ent dis­tri­bu­tion that is more con­sis­tent with the in­di­vid­u­al’s usual in­take to in­crease the like­li­hood for long-‍term main­te­nance.

As for all in­di­vid­u­als in de­vel­oped coun­tries, both chil­dren and adults with di­a­betes are en­cour­aged to min­i­mize in­take of refined car­bo­hy­drates and added sug­ars and in­stead focus on car­bo­hy­drates from veg­etables, legumes, fruits, dairy (milk and yo­gurt), and whole grains. The con­sump­tion of sugar-‍sweet­ened bev­er­ages (in­clud­ing fruit juices) and pro­cessed “low-‍fat” or “non­fat” food prod­ucts with high amounts of refined grains and added sug­ars is strong­ly dis­cour­aged (90-92). In­di­vid­u­als with type 1 or type 2 di­a­betes tak­ing in­sulin at meal­time should be of­fered in­ten­sive and on­go­ing ed­u­ca­tion on the need to cou­ple in­sulin ad­min­is­tra­tion with car­bo­hy­drate in­take. For peo­ple whose meal sched­ule 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 on using the in­sulin-to-car­bo­hy­drate ra­tios for meal plan­ning can as­sist them with ef­fectively mod­i­fying in­sulin dos­ing from meal to meal and im­prov­ing glycemic con­trol (51,82,93–96). 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 (97-99). 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 (35).

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3.6.0.0 Pro­tein

There is no ev­i­dence that ad­just­ing the daily level of pro­tein in­take (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 car­dio­vas­cu­lar dis­ease (CVD) risk (84,100). 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 (58).

Those with di­a­bet­ic kid­ney dis­ease (with al­bu­min­uria and/‍or re­duced es­ti­mat­ed glomeru­lar filtra­tion rate) should aim to main­tain di­etary pro­tein 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 (101,102).

In in­di­vid­u­als with type 2 di­a­betes, pro­tein in­take may en­hance or in­crease the in­sulin re­sponse to di­etary car­bo­hy­drates (103). There­fore, use of car­bo­hy­drate sources high in pro­tein (such as milk and nuts) to treat or pre­vent hy­po­glycemia should be avoid­ed due to the po­ten­tial concur­rent rise in en­doge­nous in­sulin.

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3.7.0.0 Fats

The ideal amount of di­etary fat for in­di­vid­u­als with di­a­betes is con­tro­ver­sial. The Na­tion­al Acade­my of Medicine has defined an ac­cept­able macronu­tri­ent dis­tri­bu­tion for total fat for all adults to be 20–35% of total calo­rie in­take (104). The type of fats con­sumed is more im­por­tant than total amount of fat when look­ing at metabol­ic goals and CVD risk, and it is rec­om­mend­ed that the per­cent­age of total calo­ries from sat­u­rat­ed fats should be lim­it­ed (75,90,105–107). Mul­ti­ple ran­dom­ized con­trolled tri­als in­clud­ing pa­tients with type 2 di­a­betes have re­port­ed that a Mediter­ranean-‍style eat­ing pat­tern (75,108–113), rich in polyunsat­u­rat­ed and monounsat­u­rat­ed fats, can im­prove both glycemic con­trol and blood lipids. How­ev­er, sup­ple­ments do not seem to have the same ef­fects as their whole-‍food coun­ter­parts. A sys­tematic re­view con­clud­ed that di­etary sup­ple­ments with n-3 fatty acids did not im­prove glycemic con­trol in in­di­vid­u­als with type 2 di­a­betes (84). Ran­dom­ized con­trolled tri­als also do not sup­port rec­om­mend­ing n-3 sup­ple­ments for pri­ma­ry or sec­ondary pre­ven­tion of CVD (114-118). 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 (90). In gen­er­al, trans fats should be avoid­ed. In ad­di­tion, as sat­u­rat­ed fats are pro­gres­sively de­creased in the diet, they should be re­placed with unsat­u­rat­ed fats and not with refined car­bo­hy­drates (112).

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3.8.0.0 Sodi­um

As for the gen­er­al pop­u­la­tion, peo­ple with di­a­betes are ad­vised to limit their sodi­um con­sump­tion to <2,300 mg/‍day (35). Re­stric­tion below 1,500 mg, even for those with hy­per­ten­sion, is gen­er­ally not rec­om­mend­ed (119-121). Sodi­um in­take rec­om­men­da­tions should take into ac­count palatabil­i­ty, availabil­i­ty, affordabil­i­ty, and the difficulty of achiev­ing low-‍sodi­um rec­om­men­da­tions in a nu­tri­tionally ad­e­quate diet (122).

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3.9.0.0 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 (35). 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 pa­tients tak­ing met­formin, par­tic­u­lar­ly in those with ane­mia or pe­riph­er­al neu­ropa­thy (123). Rou­tine sup­ple­men­ta­tion with an­tiox­i­dants, such as vi­ta­mins E and C and carotene, is not ad­vised due to 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 (124), cur­cum­in, vi­ta­min D (125), or chromi­um, to im­prove glycemia in peo­ple with di­a­betes (35,126). How­ev­er, for spe­cial pop­u­la­tions, in­clud­ing preg­nant or lac­tat­ing women, older adults, veg­e­tar­i­ans, and peo­ple fol­lowing very low-‍calo­rie or low-‍car­bo­hy­drate diets, a multivi­ta­min may be nec­es­sary.

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3.10.0.0 Al­co­hol

Mod­er­ate al­co­hol in­take 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) (35,126). Peo­ple with di­a­betes can fol­low the same guide­lines as those with­out di­a­betes if they choose to drink. For women, no more than one drink per day, and for men, no more than two drinks per day is rec­om­mend­ed (one drink is equal to a 12-oz beer, a 5-oz glass of wine, or 1.5 oz of di­stil­led spir­its).

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3.11.0.0 Non­nu­tri­tive Sweet­en­ers

For some peo­ple with di­a­betes who are ac­cus­tomed to sugar-‍sweet­ened prod­ucts, non­nu­tri­tive sweet­en­ers (con­tain­ing few or no calo­ries) may be an ac­cept­able sub­sti­tute for nu­tri­tive sweet­en­ers (those con­tain­ing calo­ries such as sugar, honey, agave syrup) when con­sumed in mod­er­a­tion. While use of non­nu­tri­tive sweet­en­ers does not ap­pear to have a significant ef­fect on glycemic con­trol (127), they can re­duce over­all calo­rie and car­bo­hy­drate in­take (51). Most sys­tematic re­views and me­ta­ana­ly­ses show benefits for non­nu­tri­tive sweet­en­er use in weight loss (128,129); how­ev­er, some re­search sug­gests an as­so­ci­a­tion with weight gain (130). 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 (35,131). For those who con­sume sugar-‍sweet­ened bev­er­ages reg­u­lar­ly, a low-‍calo­rie or non­nu­tri­tive-‍sweet­ened bev­er­age may serve as a short-‍term re­place­ment strat­e­gy, but over­all, peo­ple are en­cour­aged to de­crease both sweet­ened and non­nu­tri­tive-‍sweet­ened bev­er­ages and use other al­ter­na­tives, with an em­pha­sis on water in­take (132).

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4.0.0.0 Phys­i­cal Ac­tiv­i­ty

4.1.0.0 Overview

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 (133). 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. A re­cent study sug­gest­ed that the per­cent­age of peo­ple with di­a­betes who achieved the rec­om­mend­ed ex­er­cise level per week (150 min) var­ied by race. Ob­jec­tive mea­sure­ment by ac­celerom­e­ter showed that 44.2%, 42.6%, and 65.1% of whites, African Amer­i­cans, and His­pan­ics, re­spectively, met the thresh­old (134). It is im­por­tant for di­a­betes care man­age­ment teams to un­der­stand the difficulty that many pa­tients have reach­ing rec­om­mend­ed treat­ment tar­gets and to iden­ti­fy in­di­vid­u­alized ap­proaches to im­prove goal achieve­ment.

Mod­er­ate to high vol­umes of aer­o­bic ac­tiv­i­ty are as­so­ci­at­ed with sub­stan­tial­ly lower car­dio­vas­cu­lar and over­all mor­tal­i­ty risks in both type 1 and type 2 di­a­betes (135). A re­cent prospec­tive ob­ser­va­tion­al study of adults with type 1 di­a­betes sug­gest­ed that high­er amounts of phys­i­cal ac­tiv­i­ty led to re­duced car­dio­vas­cu­lar mor­tal­i­ty after a mean fol­low-‍up time of 11.4 years for pa­tients with and with­out chron­ic kid­ney dis­ease (136). Ad­di­tion­al­ly, struc­tured ex­er­cise in­ter­ven­tions of at least 8 weeks’ du­ra­tion have been shown to lower A1C by an av­er­age of 0.66% inpeo­plewithtype 2 di­a­betes, even with­out a sig­nif­i­cant change in BMI (137). 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 (138). A re­cent study sug­gest­ed that ex­er­cise train­ing in type 1 di­a­betes may also im­prove sev­er­al im­por­tant mark­ers such as triglyc­eride level, LDL, waist cir­cum­fer­ence, and body mass (139). High­er lev­els of ex­er­cise in­ten­si­ty are as­so­ci­at­ed with greater im­provements in A1C and in fitness (140). Other benefits in­clude slow­ing the de­cline in mo­bil­i­ty among over­weight pa­tients with di­a­betes (141). The ADA po­si­tion state­ment “Phys­i­cal Ac­tiv­i­ty/Ex­er­cise and Di­a­betes” re­views the ev­i­dence for the benefits of ex­er­cise in peo­ple with type 1 and type 2 di­a­betes and of­fers specific rec­om­men­da­tion (142).

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4.2.0.0 Rec­om­men­da­tions

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4.3.0.0 Ex­er­cise and Chil­dren

All chil­dren, in­clud­ing chil­dren with di­a­betes or predi­a­betes, should be en­cour­aged to en­gage in reg­u­lar phys­i­cal ac­tiv­i­ty. 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 (143). In gen­er­al, youth with type 1 di­a­betes benefit from being phys­i­cally ac­tive, and an ac­tive lifestyle should be rec­om­mend­ed to all (144). Youth with type 1 di­a­betes who en­gage in more phys­i­cal ac­tiv­i­ty may have bet­ter health-‍re­lat­ed qual­i­ty of life (145).

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4.4.0.0 Fre­quen­cy and Type of Phys­i­cal Ac­tiv­i­ty

Peo­ple with di­a­betes should per­form aer­o­bic and re­sis­tance ex­er­cise reg­u­lar­ly (142). Aer­o­bic ac­tiv­i­ty bouts should ide­al­ly last at least 10 min, with the goal of ˜30 min/‍day or more, most days of the week for adults with type 2 di­a­betes. Daily ex­er­cise, or at least not al­low­ing more than 2 days to elapse be­tween ex­er­cise ses­sions, is rec­om­mend­ed to de­crease in­sulin re­sis­tance, re­gard­less of di­a­betes type (146,147). Over time, ac­tiv­i­ties should progress in in­ten­si­ty, fre­quen­cy, and/‍or du­ra­tion to at least 150 min/‍week of mod­er­ate-‍in­ten­si­ty ex­er­cise. Adults able to run at 6 miles/‍h (9.7 km/h) for at least 25 min can benefit sufficient­ly from shorter-in­ten­si­ty ac­tiv­i­ty (75 min/‍week) (142). Many adults, in­clud­ing most with type 2 di­a­betes, would be un­able or un­will­ing to par­tic­i­pate in such in­tense ex­er­cise and should en­gage in mod­er­ate ex­er­cise for the rec­om­mend­ed du­ra­tion. Adults with di­a­betes should en­gage in 2–3 ses­sions/ week of re­sis­tance ex­er­cise on noncon­sec­u­tive days (148). Al­though heav­ier re­sis­tance train­ing with free weights and weight ma­chines may im­prove glycemic con­trol and strength (149), re­sis­tance train­ing of any in­ten­si­ty is rec­om­mend­ed to im­prove strength, bal­ance, and the abil­i­ty to en­gage in ac­tiv­i­ties of daily liv­ing through­out the life span. Providers and staff should help pa­tients set step­wise goals to­ward meet­ing the rec­om­mend­ed ex­er­cise tar­gets. 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 other light phys­i­cal ac­tiv­i­ties (150,151). 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.

A wide range of ac­tiv­i­ties, in­clud­ing yoga, tai chi, and other types, can have significant im­pacts on A1C, flex­i­bil­i­ty, mus­cle strength, and bal­ance (133,152,153). Flex­i­bil­i­ty and bal­ance ex­er­cises may be par­tic­u­lar­ly im­por­tant in older adults with di­a­betes to main­tain range of mo­tion, strength, and bal­ance (142).

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4.5.0.0 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 (154) and for an ad­di­tive benefit of com­bined aer­o­bic and re­sis­tance ex­er­cise in adults with type 2 di­a­betes (155). 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 (154).

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 (138).

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 (142).

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4.6.0.0 Pre-‍ex­er­cise Eval­u­a­tion

As dis­cussed more fully in Sec­tion 10 “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” (156) 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 as tol­er­at­ed. 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 prior to be­gin­ning an ex­er­cise pro­gram (138).

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4.7.0.0 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 <90 mg/dL (5.0 mmol/‍L), de­pend­ing on whether they are able to lower in­sulin doses 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 (138,142). In some pa­tients, hy­po­glycemia after ex­er­cise may occur and last for sev­er­al hours due to in­creased in­sulin sen­si­tiv­i­ty. 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. In­tense ac­tiv­i­ties may ac­tu­al­ly raise blood glu­cose lev­els in­stead of low­er­ing them, espe­cially if pre-‍ex­er­cise glu­cose lev­els are el­e­vat­ed (157).

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4.8.0.0 Ex­er­cise in the Pres­ence of Spe­cif­ic Long-‍term Com­pli. of DM

4.8.1.0 Retinopa­thy

See Sec­tion 11 “Mi­crovas­cu­lar Com­plications and Foot Care” for more in­for­ma­tion on these long-‍term com­pli­ca­tions.

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 (158). Con­sul­ta­tion with an oph­thal­mol­o­gist prior to en­gag­ing in an in­tense ex­er­cise reg­i­men may be ap­pro­pri­ate.

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4.8.2 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 (159). In ad­di­tion, 150 min/‍week of mod­er­ate ex­er­cise was re­port­ed to im­prove out­comes in pa­tients with predi­a­bet­ic neu­ropa­thy (160). 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.

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4.8.3.0 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 (161). Car­dio­vas­cu­lar au­to­nom­ic neu­ropa­thy is also an in­de­pen­dent risk fac­tor for car­dio­vas­cu­lar death and silent my­ocar­dial is­chemia (162). There­fore, in­di­vid­u­als with di­a­bet­ic au­to­nom­ic neu­ropa­thy should un­der­go car­diac in­ves­ti­ga­tion be­fore be­gin­ning phys­i­cal ac­tiv­i­ty more in­tense than that to which they are ac­cus­tomed.

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4.8.4.0 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 in gen­er­al (158).

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5.0.0.0 Smok­ing Ces­sa­tion: To­bac­co and e-‍Cigarettes

5.1.0.0 Overview

Re­sults from epi­demi­o­log­i­cal, case-‍con­trol, and co­hort stud­ies pro­vide con­vinc­ing ev­i­dence to sup­port the causal link be­tween cigarette smok­ing and health risks (163). Re­cent data show to­bac­co use is high­er among adults with chron­ic con­di­tions (164) as well as in ado­les­cents and young adults with di­a­betes (165). Smok­ers with di­a­betes (and peo­ple with di­a­betes ex­posed to sec­ond-‍hand smoke) have a height­ened risk of CVD, pre­ma­ture death, mi­crovas­cu­lar com­pli­ca­tions, and worse glycemic con­trol when com­pared with non­smok­ers (166,167). Smok­ing may have a role in the de­vel­opment of type 2 di­a­betes (168-171).

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. Phar­ma­co­log­ic ther­a­py to as­sist with smok­ing ces­sa­tion in peo­ple with di­a­betes has been shown to be ef­fective (172), and for the pa­tient mo­ti­vat­ed to quit, the ad­di­tion of phar­ma­co­log­ic ther­a­py to coun­sel­ing is more ef­fective than ei­ther treat­ment alone (173). Spe­cial con­sid­erations should in­clude as­sess­ment of level of nico­tine de­pen­dence, which is as­so­ci­at­ed with difficulty in quit­ting and re­lapse (174). Al­though some pa­tients may gain weight in the pe­ri­od short­ly after smok­ing ces­sa­tion (175), re­cent re­search has demon­strat­ed that this weight gain does not di­min­ish the sub­stan­tial CVD benefit re­al­ized from smok­ing ces­sa­tion (176). 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 (177).

In re­cent years e-‍cigarettes have gained pub­lic aware­ness and pop­u­lar­i­ty be­cause of per­cep­tions that e-‍cigarette use is less harm­ful than reg­u­lar cigarette smok­ing (178,179). Nonsmok­ers should be ad­vised not to use e-‍cigarettes (180,181). 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 (182). On the con­trary, a re­cently pub­lished prag­mat­ic trial found that use of e-‍cigarettes for smok­ing ces­sa­tion was not more ef­fective than “usual care,” which in­clud­ed ac­cess to ed­u­ca­tional in­for­ma­tion on the health benefits of smok­ing ces­sa­tion, strate­gies to pro­mote ces­sa­tion, and ac­cess to a free text-‍mes­sag­ing ser­vice that pro­vided en­cour­agement, ad­vice, and tips to fa­cil­i­tate smok­ing ces­sa­tion (183). Sev­er­al or­ga­ni­za­tions have called for more re­search on the short-‍ and long-‍term safe­ty and health ef­fects of e-‍cigarettes (184-186).

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5.2.0.0 Rec­om­men­da­tions

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6.0.0.0 Psychoso­cial Is­sues

6.1.0.0 Overview

Please refer to the ADA po­si­tion state­ment “Psychoso­cial Care for Peo­ple With Di­a­betes” for a list of as­sess­ment tools and ad­di­tional de­tails (187).

Com­plex en­vi­ron­men­tal, so­cial, be­hav­ioral, and emo­tion­al fac­tors, known as psy­choso­cial fac­tors, influence liv­ing with di­a­betes, both type 1 and type 2, and achiev­ing satisfac­tory med­i­cal out­comes and psy­cho­log­i­cal well-‍being. Thus, in­di­vid­u­als with di­a­betes and their fam­i­lies are chal­lenged with com­plex, mul­ti­faceted is­sues when in­te­grat­ing di­a­betes care into daily life.

Emo­tional well-‍being is an im­por­tant part of di­a­betes care and self-‍man­age­ment. Psy­cho­log­i­cal and so­cial prob­lems can im­pair the in­di­vid­u­al’s (188-190) or fam­i­ly’s (191) abil­i­ty to carry outdi­a­betes 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 (192). How­ev­er, there was a lim­it­ed as­so­ci­a­tion be­tween the ef­fects on A1C and men­tal health, and no in­ter­ven­tion char­ac­ter­is­tics pre­dict­ed benefit on both out­comes.

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6.2.0.0 Rec­om­men­da­tions

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6.3.0.0 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 the pa­tient’s 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 (187), with pos­i­tive find­ings lead­ing to re­fer­ral to a men­tal health pro­vider spe­cializing in di­a­betes for com­pre­hen­sive eval­u­a­tion, di­ag­no­sis, and treat­ment.

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6.4.0.0 Di­a­betes Dis­tress

6.4.1.0 Overview

Di­a­betes dis­tress (DD) is very com­mon and is dis­tinct from other psy­cho­log­i­cal dis­or­ders (193-195). 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 (194-196). 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 (194). The preva­lence of DD is re­port­ed to be 18–45% with an in­ci­dence of 38–48% over 18 months (196). 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 (193). High lev­els of DD significant­ly im­pact med­i­ca­tiontak­ing be­hav­iors and are linked to high­er A1C, lower self-‍efficacy, and poor­er di­etary and ex­er­cise be­hav­iors (17,194, 196). DSMES has been shown to re­duce DD (17). It may be help­ful to pro­vide coun­sel­ing re­gard­ing ex­pect­ed di­a­betes-‍re­lat­ed ver­sus gen­er­alized psy­cho­log­i­cal dis­tress at di­ag­no­sis and when dis­ease state or treat­ment changes (197).

DD should be rou­tinely mon­i­tored (198) using pa­tient-‍ap­pro­pri­ate val­i­dated mea­sures (187). 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) (199), and psy­chi­atric his­to­ry. For ad­di­tional in­for­ma­tion on psy­chi­atric co­mor­bidities (de­pres­sion, anx­i­ety, dis­or­dered eat­ing, and se­ri­ous men­tal ill­ness), please refer to Sec­tion 4 “Com­pre­hen­sive Med­i­cal Eval­u­a­tion and As­sess­ment of Co­mor­bidi­ties.”

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6.4.2.0 Rec­om­men­da­tions

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

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6.5.0.0 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 dys­func­tion (see Table 5.2 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 (26,193). 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. The ADA pro­vides a list of men­tal health pro­viders who have re­ceived ad­di­tional ed­u­ca­tion in di­a­betes at the ADA Men­tal Health Provider Di­rec­to­ry (pro­fes­sion­al. di­a­betes.org/ada-men­tal-health-pro­vider-directory). Ide­al­ly, psy­choso­cial care pro­viders should be em­bed­ded in di­a­betes care set­tings. Al­though the clin­i­cian may not feel qualified to treat psy­cho­log­i­cal prob­lems (200), 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, out­comes of de­pres­sion, and psy­choso­cial func­tion­ing (17,201).

Table 5.2—Sit­u­a­tions that war­rant re­fer­ral of a per­son with di­a­betes to a men­tal health pro­vider for eval­u­a­tion and treat­ment

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7.0.0.0 Ref­er­ences

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