FACILITATING BEHAVIOR CHANGE AND WELL-BEING TO IMPROVE HEALTH OUTCOMES: STANDARDSOFMEDICAL CAREINDIABETESD2021 - DIABETES CARE
←
→
Page content transcription
If your browser does not render page correctly, please read the page content below
Diabetes Care Volume 44, Supplement 1, January 2021 S53
5. Facilitating Behavior Change American Diabetes Association
and Well-being to Improve Health
Outcomes: Standards of Medical
Care in Diabetesd2021
Diabetes Care 2021;44(Suppl. 1):S53–S72 | https://doi.org/10.2337/dc21-S005
5. FACILITATING BEHAVIOR CHANGE AND WELL-BEING
The American Diabetes Association (ADA) “Standards of Medical Care in Diabetes”
includes the 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 (https://doi.org/10.2337/dc21-
SPPC), 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 (https://doi
.org/10.2337/dc21-SINT). Readers who wish to comment on the Standards of Care
are invited to do so at professional.diabetes.org/SOC.
Effective behavior management and psychological well-being are foundational to
achieving treatment goals for people with diabetes (1,2). Essential to achieving these
goals are diabetes self-management education and support (DSMES), medical nutrition
therapy (MNT), routine physical activity, smoking cessation counseling when needed,
and psychosocial care. Following an initial comprehensive medical evaluation (see
Section 4 “Comprehensive Medical Evaluation and Assessment of Comorbidities,”
https://doi.org/10.2337/dc21-S004), patients and providers are encouraged to engage
in person-centered collaborative care (3–6), which is guided by shared decision-making
in treatment regimen selection, facilitation of obtaining needed medical and psycho-
social resources, and shared monitoring of agreed-upon regimen and lifestyle (7).
Reevaluation during routine care should include not only assessment of medical health,
but also behavioral and mental health outcomes, especially during times of de-
terioration in health and well-being.
DIABETES SELF-MANAGEMENT EDUCATION AND SUPPORT
Recommendations Suggested citation: American Diabetes Associa-
5.1 In accordance with the national standards for diabetes self-management tion. 5. Facilitating behavior change and well-
being to improve health outcomes: Standards of
education and support, all people with diabetes should participate in diabetes
Medical Care in Diabetesd2021. Diabetes Care
self-management education and receive the support needed to facilitate 2021;44(Suppl. 1):S53–S72
the knowledge, decision-making, and skills mastery necessary for diabetes © 2020 by the American Diabetes Association.
self-care. A Readers may use this article as long as the work is
5.2 There are four critical times to evaluate the need for diabetes self-manage- properly cited, the use is educational and not for
ment education to promote skills acquisition in support of regimen imple- profit, and the work is not altered. More infor-
mentation, medical nutrition therapy, and well-being: at diagnosis, annually mation is available at https://www.diabetesjournals
.org/content/license.S54 Facilitating Behavior Change and Well-being to Improve Health Outcomes Diabetes Care Volume 44, Supplement 1, January 2021
program (8) showed that addressing these preferences, needs, and values. It ensures
and/or when not meeting treat-
targets improved health outcomes in a that patient values guide all decision-
ment targets, when complicating
population in need of health care resour- making (14).
factors develop (medical, physi-
ces. Furthermore, following a DSMES cur-
cal, psychosocial), and when tran-
riculum improves quality of care (9). Evidence for the Benefits
sitions in life and care occur. E
In addition, in response to the growing Studies have found that DSMES is asso-
5.3 Clinical outcomes, health status,
literature that associates potentially ciated with improved diabetes knowl-
and well-being are key goals of
judgmental words with increased feel- edge and self-care behaviors (14,15),
diabetes self-management edu-
ings of shame and guilt, providers are lower A1C (14,16–19), lower self-reported
cation and support that should
encouraged to consider the impact that weight (20,21), improved quality of life
be measured as part of routine
language has on building therapeutic (17,22), reduced all-cause mortality risk
care. C
relationships and to choose positive, (23), healthy coping (5,24), and reduced
5.4 Diabetes self-management edu-
strength-based words and phrases that health care costs (25–27). Better out-
cation and support should be pa-
put people first (4,10). Patient perfor- comes were reported for DSMES inter-
tient centered, may be given in
mance of self-management behaviors, ventions that were more than 10 h over
group or individual settings and/
as well as psychosocial factors with the the course of 6–12 months (18), included
or use technology, and should be
potential to impact the person’s self- ongoing support (12,28), were culturally
communicated with the entire
management, should be monitored. Please (29,30) and age appropriate (31,32),
diabetes care team. A
see Section 4 “Comprehensive Medical were tailored to individual needs and
5.5 Because diabetes self-management
Evaluation and Assessment of Comorbid- preferences, and addressed psychoso-
education and support can improve
ities” (https://doi.org/10.2337/dc21-S004) cial issues and incorporated behavioral
outcomes and reduce costs B, re-
for more on use of language. strategies (13,24,33,34). Individual and
imbursement by third-party payers
DSMES and the current national stand- group approaches are effective (21,35,
is recommended. C
ards guiding it (2,11) are based on evi- 36), with a slight benefit realized by those
5.6 Barrierstodiabetesself-management
dence of benefit. Specifically, DSMES who engage in both (18).
education and support exist at
helps people with diabetes to identify Emerging evidence demonstrates the
the health system, payor, provider,
and implement effective self-management benefit of telemedicine or internet-
and patient levels A and efforts
strategies and cope with diabetes at based DSMES services for diabetes pre-
need to be made to identify and
four critical time points (see below) (2). vention and the management of type 2
address them. E
Ongoing DSMES helps people with diabe- diabetes (37–43). Technology-enabled di-
5.7 Some barriers to diabetes self-
tes to maintain effective self-management abetes self-management solutions im-
management education and support
throughout a lifetime of diabetes as they prove A1C most effectively when there
access may be mitigated through
face new challenges and as advances in is two-way communication between the
telemedicine approaches. B
treatment become available (12). patient and the health care team, in-
Four critical time points have been dividualized feedback, use of patient-
DSMES services facilitate the knowledge,
defined when the need for DSMES is to be generated health data, and education
decision-making, and skills mastery nec-
evaluated by the medical care provider (39).
essary for optimal diabetes self-care and
and/or multidisciplinary team, with re- Current research supports diabetes care
incorporate the needs, goals, and life
ferrals made as needed (2): and education specialists including nurses,
experiences of the person with diabetes.
dietitians, and pharmacists as providers
The overall objectives of DSMES are to 1. At diagnosis
of DSMES who may also tailor curriculum
support informed decision-making, self- 2. Annually and/or when not meeting
to the person’s needs (44–46). Members
care behavior, problem-solving, and ac- treatment targets
of the DSMES team should have special-
tive collaboration with the health care 3. When complicating factors (health
ized clinical knowledge in diabetes and
team to improve clinical outcomes, health conditions, physical limitations, emo-
behavior change principles. Certification
status, and well-being in a cost-effective tional factors, or basic living needs)
as a diabetes care and education specialist
manner (2). Providers are encouraged to develop that influence self-management
(see https://www.cbdce.org/) and/or
consider the burden of treatment and the 4. When transitions in life and care
board certification in advanced diabetes
patient’s level of confidence/self-efficacy occur
management (see www.diabeteseducator
for management behaviors as well as the DSMES focuses on supporting patient .org/education/certification/bc_adm)
level of social and family support when empowerment by providing people with demonstrates an individual’s specialized
providing DSMES. Patient performance of diabetes the tools to make informed self- training in and understanding of diabetes
self-management behaviors, including its management decisions (13). Diabetes management and support (11), and en-
effect on clinical outcomes, health status, care requires an approach that places gagement with qualified providers has
and quality of life, as well as the psycho- the person with diabetes and his or her been shown to improve disease-related
social factors impacting the person’s abil- family/support system at the center of outcomes. Additionally, there is growing
ity to self-manage, should be monitored the care model, working in collabora- evidence for the role of community
as part of routine clinical care. A random- tion with health care professionals. health workers (47,48), as well as peer
ized controlled trial testing a decision- Patient-centered care is respectful of (47–51) and lay leaders (52), in providing
making education and skill-building and responsive to individual patient ongoing support.care.diabetesjournals.org Facilitating Behavior Change and Well-being to Improve Health Outcomes S55
Evidence suggests people with diabe- of Diabetes Care & Education Specialists Table 5.1 for specific nutrition recommen-
tes who completed more than 10 hours (ADCES). DSMES is also covered by most dations. Because of the progressive nature
of DSMES over the course of 6–12 months health insurance plans. Ongoing support of type 2 diabetes, behavior modification
and those who participated on an ongo- has been shown to be instrumental for alone may not be adequate to maintain
ing basis had significant reductions in improving outcomes when it is imple- euglycemia over time. However, after med-
mortality (23) and A1C (decrease of mented after the completion of educa- ication is initiated, nutrition therapy con-
0.57%) (18) compared with those who tion services. DSMES is frequently reimbursed tinues to be an important component and
spent less time with a diabetes care and when performed in person. However, RD/RDNs providing MNT in diabetes care
education specialist. Given individual although DSMES can also be provided should assess and monitor medication
needs and access to resources, a variety via phone calls and telehealth, these changes in relation to the nutrition care
of culturally adapted DSMES programs remote versions may not always be re- plan (46,63).
need to be offered in a variety of settings. imbursed. Some barriers to DSMES access
Use of technology to facilitate access to may be mitigated through telemedicine Goals of Nutrition Therapy for Adults
DSMES services, support self-management approaches. Changes in reimbursement With Diabetes
decisions, and decrease therapeutic in- policies that increase DSMES access and 1. To promote and support healthful
ertia suggests that these approaches need utilization will result in a positive im- eating patterns, emphasizing a variety
broader adoption. pact to beneficiaries’ clinical outcomes, of nutrient-dense foods in appropriate
DSMES is associated with an increased quality of life, health care utilization, portion sizes, to improve overall health
use of primary care and preventive serv- and costs (60–62). During the time of and:
ices (25,53,54) and less frequent use of the coronavirus disease 2019 (COVID- c achieve and maintain body weight
acute care and inpatient hospital services 19) pandemic, reimbursement policies goals
(20). Patients who participate in DSMES have changed (https://professional c attain individualized glycemic, blood
are more likely to follow best practice .diabetes.org/content-page/dsmes-and- pressure, and lipid goals
treatment recommendations, particularly mnt-during-covid-19-national-pandemic), c delay or prevent the complications
among the Medicare population, and and these changes may provide a new of diabetes
have lower Medicare and insurance claim reimbursement paradigm for future 2. To address individual nutrition needs
costs (26,53). Despite these benefits, re- provision of DSMES through telehealth based on personal and cultural prefer-
ports indicate that only 5–7% of individ- channels. ences, health literacy and numeracy,
uals eligible for DSMES through Medicare access to healthful foods, willingness
or a private insurance plan actually receive and ability to make behavioral changes,
it (55,56). Barriers to DSMES exist at the MEDICAL NUTRITION THERAPY and existing barriers to change
health system, payor, provider, and pa- Please refer to the ADA consensus report 3. To maintain the pleasure of eating by
tient levels. This low participation may be “Nutrition Therapy for Adults With Di- providing nonjudgmental messages
due to lack of referral or other identified abetes or Prediabetes: A Consensus Re- about food choices while limiting
barriers such as logistical issues (accessi- port” for more information on nutrition food choices only when indicated
bility, timing, costs) and the lack of a therapy (46). For many individuals with by scientific evidence
perceived benefit (56). Health system, diabetes, the most challenging part of the 4. To provide an individual with diabetes
programmatic, and payor barriers include treatment plan is determining what to eat. the practical tools for developing healthy
lack of administrative leadership support, There is not a “one-size-fits-all” eating eating patterns rather than focusing
limited numbers of DSMES providers, not pattern for individuals with diabetes, and on individual macronutrients, micro-
having referral to DSMES services effec- meal planning should be individualized. nutrients, or single foods
tively embedded in the health system Nutrition therapy plays an integral role in
service structure, and limited reimburse- overall diabetes management, and each Eating Patterns and Meal Planning
ment rates (57). Thus, in addition to person with diabetes should be actively Evidence suggests that there is not an
educating referring providers about the engaged in education, self-management, ideal percentage of calories from carbo-
benefits of DSMES and the critical times to and treatment planning with his or her hydrate, protein, and fat for people with
refer, efforts need to be made to identify health care team, including the collabo- diabetes. Therefore, macronutrient dis-
and address all of the various potential rative development of an individualized tribution should be based on an individ-
barriers (2). Alternative and innovative eating plan (46,63). All providers should ualized assessment of current eating
models of DSMES delivery need to be refer people with diabetes for individu- patterns, preferences, and metabolic goals.
explored and evaluated, including the alized MNT provided by a registered di- Consider personal preferences (e.g., tra-
integration of technology-enabled diabe- etitian nutritionist (RD/RDN) who is dition, culture, religion, health beliefs and
tes and cardiometabolic health services knowledgeable and skilled in providing goals, economics) as well as metabolic
(58,59). diabetes-specific MNT (64) at diagnosis goals when working with individuals to
and as needed throughout the life span, determine the best eating pattern for
Reimbursement similar to DSMES. MNT delivered by an them (46,66,67). Members of the health
Medicare reimburses DSMES when that RD/RDN is associated with A1C absolute care team should complement MNT
service meets the national standards decreases of 1.0–1.9% for people with by providing evidence-based guidance
(2,11) and is recognized by the American type 1 diabetes (65) and 0.3–2.0% for that helps people with diabetes make
Diabetes Association (ADA) or Association people with type 2 diabetes (65). See healthy food choices that meet theirS56 Facilitating Behavior Change and Well-being to Improve Health Outcomes Diabetes Care Volume 44, Supplement 1, January 2021
Table 5.1—Medical nutrition therapy recommendations
Topic Recommendation
Effectiveness of nutrition therapy 5.8 An individualized medical nutrition therapy program as needed to achieve treatment goals,
provided by a registered dietitian nutritionist (RD/RDN), preferably one who has
comprehensive knowledge and experience in diabetes care, is recommended for all people
with type 1 or type 2 diabetes, prediabetes, and gestational diabetes mellitus. A
5.9 Because diabetes medical nutrition therapy can result in cost savings B and improved
outcomes (e.g., A1C reduction, reduced weight, decrease in cholesterol) A, medical
nutrition therapy should be adequately reimbursed by insurance and other payers. E
Energy balance 5.10 For all patients with overweight or obesity, lifestyle modification to achieve and maintain
a minimum weight loss of 5% is recommended for all patients with diabetes and
prediabetes. A
Eating patterns and macronutrient distribution 5.11 There is no single ideal dietary distribution of calories among carbohydrates, fats, and
proteins for people with diabetes; therefore, meal plans should be individualized while
keeping total calorie and metabolic goals in mind. E
5.12 A variety of eating patterns can be considered for the management of type 2 diabetes and
to prevent diabetes in individuals with prediabetes. B
Carbohydrates 5.13 Carbohydrate intake should emphasize nutrient-dense carbohydrate sources that are high
in fiber and minimally processed. Eating plans should emphasize nonstarchy vegetables,
minimal added sugars, fruits, whole grains, as well as dairy products. B
5.14 Reducing overall carbohydrate intake for individuals with diabetes has demonstrated the
most evidence for improving glycemia and may be applied in a variety of eating patterns
that meet individual needs and preferences. B
5.15 For people with diabetes who are prescribed a flexible insulin therapy program, education
on how to use carbohydrate counting A and on dosing for fat and protein content B should
be used to determine mealtime insulin dosing.
5.16 For adults using fixed insulin doses, consistent pattern of carbohydrate intake with respect
to time and amount, while considering the insulin action time, can result in improved
glycemia and reduce the risk for hypoglycemia. B
5.17 People with diabetes and those at risk are advised to replace sugar-sweetened beverages
(including fruit juices) with water as much as possible in order to control glycemia and
weight and reduce their risk for cardiovascular disease and fatty liver B and should minimize
the consumption of foods with added sugar that have the capacity to displace healthier,
more nutrient-dense food choices. A
Protein 5.18 In individuals with type 2 diabetes, ingested protein appears to increase insulin response
without increasing plasma glucose concentrations. Therefore, carbohydrate sources high in
protein should be avoided when trying to treat or prevent hypoglycemia. B
Dietary fat 5.19 An eating plan emphasizing elements of a Mediterranean-style eating pattern rich in
monounsaturated and polyunsaturated fats may be considered to improve glucose
metabolism and lower cardiovascular disease risk. B
5.20 Eating foods rich in long-chain n-3 fatty acids, such as fatty fish (EPA and DHA) and nuts and
seeds (ALA), is recommended to prevent or treat cardiovascular disease. B
Micronutrients and herbal supplements 5.21 There is no clear evidence that dietary supplementation with vitamins, minerals (such as
chromium and vitamin D), herbs, or spices (such as cinnamon or aloe vera) can improve
outcomes in people with diabetes who do not have underlying deficiencies, and they are
not generally recommended for glycemic control. C
Alcohol 5.22 Adults with diabetes who drink alcohol should do so in moderation (no more than one drink
per day for adult women and no more than two drinks per day for adult men). C
5.23 Educating people with diabetes about the signs, symptoms, and self-management of
delayed hypoglycemia after drinking alcohol, especially when using insulin or insulin
secretagogues, is recommended. The importance of glucose monitoring after drinking
alcoholic beverages to reduce hypoglycemia risk should be emphasized. B
Sodium 5.24 As for the general population, people with diabetes and prediabetes should limit sodium
consumption to ,2,300 mg/day. B
Nonnutritive sweeteners 5.25 The use of nonnutritive sweeteners may have the potential to reduce overall calorie and
carbohydrate intake if substituted for caloric (sugar) sweeteners and without compensation
by intake of additional calories from other food sources. 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. Bcare.diabetesjournals.org Facilitating Behavior Change and Well-being to Improve Health Outcomes S57
individualized needs and improve over- the potential risk of ketoacidosis (78,79). People with prediabetes at a healthy
all health. A variety of eating patterns There is inadequate research in type 1 weight should also be considered for
are acceptable for the management of diabetes to support one eating pattern behavioral interventions to help estab-
diabetes (46,66,68,69). Until the evi- over another at this time. lish routine aerobic and resistance exer-
dence surrounding comparative bene- A randomized controlled trial found cise (83,86,87) as well as to establish
fits of different eating patterns in specific that two meal planning approaches were healthy eating patterns. Services deliv-
individuals strengthens, health care pro- effective in helping achieve improved ered by practitioners familiar with diabe-
viders should focus on the key factors A1C, particularly for individuals with tes and its management, such as an RD/
that are common among the patterns: 1) an A1C between 7% and 10% (80). The RDN, have been found to be effective
emphasize nonstarchy vegetables, 2) min- diabetes plate method is a commonly (64).
imize added sugars and refined grains, used visual approach for providing basic For many individuals with overweight
and 3) choose whole foods over highly meal planning guidance. This simple and obesity with type 2 diabetes, 5%
processed foods to the extent possible graphic (featuring a 9-inch plate) shows weight loss is needed to achieve bene-
(46). An individualized eating pattern also how to portion foods (1/2 of the plate for ficial outcomes in glycemic control, lipids,
considers the individual’s health status, nonstarchy vegetables, 1/4 of the plate and blood pressure (88). It should be
skills, resources, food preferences, and for protein, and 1/4 of the plate for noted, however, that the clinical benefits
health goals. Referral to an RD/RDN is carbohydrates). Carbohydrate counting of weight loss are progressive, and more
essential to assess the overall nutrition is a more advanced skill that helps plan intensive weight loss goals (i.e., 15%) may
status of, and to work collaboratively for and track how much carbohydrate is be appropriate to maximize benefit de-
with, the patient to create a personal- consumed at meals and snacks. Meal pending on need, feasibility, and safety
ized meal plan that coordinates and planning approaches should be custom- (89,90). In select individuals with type 2
aligns with the overall treatment plan, ized to the individual, including their diabetes, an overall healthy eating plan
including physical activity and medication numeracy level (80). that results in energy deficit in conjunc-
use. The Mediterranean-style (67,70–72), tion with weight loss medications and/or
low-carbohydrate (73–75), and vegetarian Weight Management metabolic surgery should be considered
or plant-based (71,72,76,77) eating pat- Management and reduction of weight is to help achieve weight loss and mainte-
terns are all examples of healthful eating important for people with type 1 diabe- nance goals, lower A1C, and reduce CVD
patterns that have shown positive results tes, type 2 diabetes, or prediabetes and risk (84,91,92). Overweight and obesity
in research, but individualized meal plan- overweight or obesity. To support weight are also increasingly prevalent in people
ning should focus on personal preferen- loss and improve A1C, cardiovascular with type 1 diabetes and present clinical
ces, needs, and goals. disease (CVD) risk factors, and well-being challenges regarding diabetes treatment
Reducing overall carbohydrate intake in adults with overweight/obesity and and CVD risk factors (93,94). Sustaining
for individuals with diabetes has dem- prediabetes or diabetes, MNT and DSMES weight loss can be challenging (88,95) but
onstrated the most evidence for improv- services should include an individualized has long-term benefits; maintaining weight
ing glycemia and may be applied in eating plan in a format that results in an loss for 5 years is associated with sus-
a variety of eating patterns that meet energy deficit in combination with en- tained improvements in A1C and lipid
individual needs and preferences (46). hanced physical activity (46). Lifestyle levels (96). MNT guidance from an RD/
For individuals with type 2 diabetes not intervention programs should be inten- RDN with expertise in diabetes and weight
meeting glycemic targets or for whom sive and have frequent follow-up to management, throughout the course of
reducing glucose-lowering drugs is a achieve significant reductions in excess a structured weight loss plan, is strongly
priority, reducing overall carbohydrate body weight and improve clinical indica- recommended.
intake with a low- or very-low-carbohydrate tors. There is strong and consistent ev- People with diabetes and prediabetes
eating pattern is a viable option (73–75). idence that modest persistent weight should be screened and evaluated dur-
As research studies on low-carbohydrate loss can delay the progression from pre- ing DSMES and MNT encounters for
eating plans generally indicate chal- diabetes to type 2 diabetes (66,81,82) disordered eating, and nutrition therapy
lenges with long-term sustainability, it (see Section 3 “Prevention or Delay of should be individualized to accommo-
is important to reassess and individualize Type 2 Diabetes,” https://doi.org/10 date disorders (46). Disordered eating
meal plan guidance regularly for those .2337/dc20-S003) and is beneficial to can make following an eating plan chal-
interested in this approach, recognizing the management of type 2 diabetes lenging, and individuals should be re-
that insulin and other diabetes medica- (see Section 8 “Obesity Management ferred to a mental health professional
tions may need to be adjusted to prevent for the Treatment of Type 2 Diabetes,” as needed. Studies have demonstrated
hypoglycemia and blood pressure will need https://doi.org/10.2337/dc20-S008). that a variety of eating plans, varying
to be monitored. Very-low-carbohydrate In prediabetes, the weight loss goal is in macronutrient composition, can be
eating patterns are not recommended 7–10% for preventing progression to type used effectively and safely in the short
at this time for women who are pregnant 2 diabetes (83). In conjunction with term (1–2 years) to achieve weight loss in
or lactating, people with or at risk for support for healthy lifestyle behaviors, people with diabetes. This includes struc-
disordered eating, or people who have medication-assisted weight loss can tured low-calorie meal plans with meal
renal disease, and they should be used be considered for people at risk for replacements (89,96,97), the Mediterranean-
with caution in patients taking sodium– type 2 diabetes when needed to achieve style eating pattern (98), and low-
glucose cotransporter 2 inhibitors due to and sustain 7–10% weight loss (84,85). carbohydrate meal plans with additionalS58 Facilitating Behavior Change and Well-being to Improve Health Outcomes Diabetes Care Volume 44, Supplement 1, January 2021
support (99,100). However, no single carbohydrate-restricted eating patterns, recommended for the general public.
approach has been proven to be consis- particularly those considered very low The Dietary Guidelines for Americans
tently superior (46,101–103), and more carbohydrate (,26% total energy), were recommend a minimum of 14 g of fi-
data are needed to identify and validate effective in reducing A1C in the short term ber/1,000 kcal, with at least half of grain
those meal plans that are optimal with (,6 months), with less difference in eating consumption being whole, intact grains
respect to long-term outcomes and pa- patterns beyond 1 year (73,74,103,115). (118). Regular intake of sufficient dietary
tient acceptability. The importance of Part of the challenge in interpreting low- fiber is associated with lower all-cause mor-
providing guidance on an individualized carbohydrate research has been due to tality in people with diabetes (119,120), and
meal plan containing nutrient-dense foods, the wide range of definitions for a low- prospective cohort studies have found
such as vegetables, fruits, legumes, dairy, carbohydrate eating plan (75,113). Weight dietary fiber intake is inversely associated
lean sources of protein (including plant- reduction was also a goal in many low- with risk of type 2 diabetes (121,122).
based sources as well as lean meats, fish, carbohydrate studies, which further com- The consumption of sugar-sweetened
and poultry), nuts, seeds, and whole grains, plicates evaluating the distinct contribution beverages and processed food products
cannot be overemphasized (102), as well of the eating pattern (40,99,103,116). As with high amounts of refined grains and
as guidance on achieving the desired research studies on low-carbohydrate added sugars is strongly discouraged
energy deficit (104–107). Any approach eating plans generally indicate challenges (118,123,124).
to meal planning should be individualized with long-term sustainability (115), it is Individuals with type 1 or type 2 di-
considering the health status, personal important to reassess and individualize abetes taking insulin at mealtime should
preferences, and ability of the person meal plan guidance regularly for those be offered intensive and ongoing edu-
with diabetes to sustain the recommen- interested in this approach. Providers cation on the need to couple insulin
dations in the plan. should maintain consistent medical over- administration with carbohydrate intake.
sight and recognize that insulin and other For people whose meal schedule or
Carbohydrates diabetes medications may need to be carbohydrate consumption is variable,
Studies examining the ideal amount of adjusted to prevent hypoglycemia and regular counseling to help them under-
carbohydrate intake for people with di- blood pressure will need to be monitored. stand the complex relationship between
abetes are inconclusive, although monitor- In addition, very-low-carbohydrate eating carbohydrate intake and insulin needs is
ing carbohydrate intake and considering the plans are not currently recommended for important. In addition, education on
blood glucose response to dietary car- women who are pregnant or lactating, using the insulin-to-carbohydrate ratios
bohydrate are key for improving post- children, people who have renal disease, for meal planning can assist them with
prandial glucose management (108,109). or people with or at risk for disordered effectively modifying insulin dosing from
The literature concerning glycemic index eating, and these plans should be used with meal to meal and improving glycemic
and glycemic load in individuals with caution in those taking sodium–glucose management (66,108,125–128). Results
diabetes is complex, often with varying cotransporter 2 inhibitors because of the from recent high-fat and/or high-protein
definitions of low and high glycemic in- potential risk of ketoacidosis (78,79). There mixed meals studies continue to sup-
dex foods (110,111). The glycemic index is inadequate research about dietary pat- port previous findings that glucose re-
ranks carbohydrate foods on their post- terns for type 1 diabetes to support one sponse to mixed meals high in protein
prandial glycemic response, and glyce- eating plan over another at this time (117). and/or fat along with carbohydrate
mic load takes into account both the Most individuals with diabetes report a differs among individuals; therefore,
glycemic index of foods and the amount moderate intake of carbohydrate (44– a cautious approach to increasing insulin
of carbohydrate eaten. Studies have 46% of total calories) (66). Efforts to doses for high-fat and/or high-protein
found mixed results regarding the effect modify habitual eating patterns are of- mixed meals is recommended to ad-
of glycemic index and glycemic load on ten unsuccessful in the long term; peo- dress delayed hyperglycemia that may
fasting glucose levels and A1C, with one ple generally go back to their usual occur 3 h or more after eating (46).
systematic review finding no significant macronutrient distribution (66). Thus, Checking glucose 3 h after eating may
impact on A1C (112), while two others the recommended approach is to individ- help to determine if additional insulin
demonstrated A1C reductions of 0.15% ualize meal plans with a macronutrient adjustments are required (129,130).
(110) to 0.5% (113). distribution that is more consistent with Continuous glucose monitoring or self-
Reducing overall carbohydrate intake personal preference and usual intake to monitoring of blood glucose should
for individuals with diabetes has dem- increase the likelihood for long-term guide decision-making for administration
onstrated evidence for improving glyce- maintenance. of additional insulin. For individuals on
mia and may be applied in a variety of As for all individuals in developed coun- a fixed daily insulin schedule, meal
eating patterns that meet individual tries, both children and adults with di- planning should emphasize a relatively
needs and preferences (46). For people abetes are encouraged to minimize intake fixed carbohydrate consumption pattern
with type 2 diabetes, low-carbohydrate of refined carbohydrates and added sug- with respect to both time and amount,
and very-low-carbohydrate eating pat- ars and instead focus on carbohydrates while considering insulin action time
terns, in particular, have been found to from vegetables, legumes, fruits, dairy (46).
reduce A1C and the need for antihyper- (milk and yogurt), and whole grains.
glycemic medications (46,67,114,115). People with diabetes and those at risk Protein
Systematic reviews and meta-analyses for diabetes are encouraged to consume There is no evidence that adjusting the
of randomized controlled trials found at least the amount of dietary fiber daily level of protein intake (typicallycare.diabetesjournals.org Facilitating Behavior Change and Well-being to Improve Health Outcomes S59
1–1.5 g/kg body wt/day or 15–20% total Evidence does not conclusively support with vitamin B12 deficiency per a report
calories) will improve health, and re- recommending n-3 (eicosapentaenoic acid from the Diabetes Prevention Program
search is inconclusive regarding the ideal [EPA] and docosahexaenoic acid [DHA]) Outcomes Study (DPPOS), suggesting
amount of dietary protein to optimize supplements for all people with diabetes that periodic testing of vitamin B12 levels
either glycemic management or CVD for the prevention or treatment of cardio- should be considered in patients taking
risk (111,131). Therefore, protein intake vascular events (46,145,146). In individuals metformin, particularly in those with ane-
goals should be individualized based on with type 2 diabetes, two systematic re- miaorperipheralneuropathy(154).Routine
current eating patterns. Some research views with n-3 and n-6fatty acids concluded supplementation with antioxidants, such as
has found successful management of that the dietary supplements did not im- vitaminsEandCandcarotene,isnotadvised
type 2 diabetes with meal plans including prove glycemic management (111,147). In due to lack of evidence of efficacy and
slightly higher levels of protein (20–30%), the ASCEND trial (A Study of Cardiovas- concern related to long-term safety. In
which may contribute to increased cular Events iN Diabetes), when compared addition, there is insufficient evidence to
satiety (132). with placebo, supplementation with n-3 support the routine use of herbal supple-
Historically, low-protein eating plans fatty acids at the dose of 1 g/day did not ments and micronutrients, such as cinna-
were advised for individuals with diabetic lead to cardiovascular benefit in people mon (155), curcumin, vitamin D (156), aloe
kidney disease (DKD) (with albuminuria with diabetes without evidence of CVD vera, or chromium, to improve glycemia in
and/or reduced estimated glomerular (148). However, results from the Reduc- people with diabetes (46,157). However,
filtration rate); however, new evidence tion of Cardiovascular Events With Icosa- for special populations, including preg-
does not suggest that people with DKD pent Ethyl–Intervention Trial (REDUCE-IT) nant or lactating women, older adults,
need to restrict protein to less than the did find that supplementation with 4 g/ vegetarians, and people following very-
generally recommended protein intake day of pure EPA significantly lowered the low-calorie or low-carbohydrate diets, a
(46). Reducing the amount of dietary risk of adverse cardiovascular events. This multivitamin may be necessary.
protein below the recommended daily trial of 8,179 participants, in which over
allowance of 0.8 g/kg is not recommen- 50% had diabetes, found a 5% absolute Alcohol
ded because it does not alter glycemic reduction in cardiovascular events for in- Moderate alcohol intake does not have
measures, cardiovascular risk measures, dividuals with established atherosclerotic major detrimental effects on long-term
or the rate at which glomerular filtration CVD taking a preexisting statin with re- blood glucose management in people
rate declines and may increase risk for sidual hypertriglyceridemia (135–499 mg/ with diabetes. Risks associated with alco-
malnutrition (133,134). dL) (149). See Section 10 “Cardiovascular hol consumption include hypoglycemia
In individuals with type 2 diabetes, Disease and Risk Management” (https:// and/or delayed hypoglycemia (particu-
protein intake may enhance or increase doi.org/10.2337/dc21-S010) for more in- larly for those using insulin or insulin
the insulin response to dietary carbohy- formation. People with diabetes should be secretagogue therapies), weight gain,
drates (135). Therefore, use of carbohy- advised to follow the guidelines for the and hyperglycemia (for those consuming
drate sources high in protein (such as milk general population for the recommended excessive amounts) (46,157). People
and nuts) to treat or prevent hypoglyce- intakes ofsaturated fat, dietarycholesterol, with diabetes should be educated about
mia should be avoided due to the poten- and trans fat (118). Trans fats should be these risks and encouraged to monitor
tial concurrent rise in endogenous insulin. avoided. In addition, as saturated fats are blood glucose frequently after drinking
progressively decreased in the diet, they alcohol to minimize such risks. People
Fats shouldbe replacedwith unsaturated fats and with diabetes can follow the same guide-
The ideal amount of dietary fat for in- not with refined carbohydrates (143). lines as those without diabetes if they
dividuals with diabetes is controversial. choose to drink. For women, no more than
New evidence suggests that there is not Sodium one drink per day, and for men, no more
an ideal percentage of calories from fat As for the general population, people than two drinks per day is recommended
for people with or at risk for diabetes and with diabetes are advised to limit their (one drink is equal to a 12-oz beer, a 5-oz
that macronutrient distribution should sodium consumption to ,2,300 mg/day glass of wine, or 1.5 oz of distilled spirits).
be individualized according to the pa- (46). Restriction below 1,500 mg, even
tient’s eating patterns, preferences, and for those with hypertension, is generally Nonnutritive Sweeteners
metabolic goals (46). The type of fats not recommended (150–152). Sodium The U.S. Food and Drug Administration
consumed is more important than total recommendations should take into account has approved many nonnutritive sweet-
amount of fat when looking at metabolic palatability, availability, affordability, and eners for consumption by the general
goals and CVD risk, and it is recommen- the difficulty of achieving low-sodium rec- public, including people with diabetes
ded that the percentage of total calories ommendations in a nutritionally adequate (46,158). For some people with diabetes
from saturated fats should be limited diet (153). who are accustomed to regularly con-
(98,118,136–138). Multiple randomized suming sugar-sweetened products, non-
controlled trials including patients with Micronutrients and Supplements nutritive sweeteners (containing few or
type 2 diabetes have reported that a There continues to be no clear evidence no calories) may be an acceptable sub-
Mediterranean-style eating pattern (98, of benefit from herbal or nonherbal (i.e., stitute for nutritive sweeteners (those
139–144), rich in polyunsaturated and vitamin or mineral) supplementation for containing calories, such as sugar, honey,
monounsaturated fats, can improve both people with diabetes without underlying and agave syrup) when consumed in
glycemic management and blood lipids. deficiencies (46). Metformin is associated moderation (159,160). Use of nonnutritiveS60 Facilitating Behavior Change and Well-being to Improve Health Outcomes Diabetes Care Volume 44, Supplement 1, January 2021
sweeteners does not appear to have a observational study of adults with
decrease the amount of time
significant effect on glycemic management type 1 diabetes suggested that higher
spent in daily sedentary behav-
(66,66a), but they can reduce overall amounts of physical activity led to re-
ior. B Prolonged sitting should
calorie and carbohydrate intake (66), as duced cardiovascular mortality after a
be interrupted every 30 min for
long as individuals are not compensating mean follow-up time of 11.4 years for
blood glucose benefits. C
with additional calories from other food patients with and without chronic kid-
5.30 Flexibility training and balance
sources (46). There is mixed evidence from ney disease (170). Additionally, struc-
training are recommended 2–3
systematic reviews and meta-analyses tured exercise interventions of at least
times/week for older adults with
for nonnutritive sweetener use with re- 8 weeks’ duration have been shown to
diabetes. Yoga and tai chi may
gard to weight management, with some lower A1C by an average of 0.66% in
be included based on individual
finding benefit in weight loss (161,162), people with type 2 diabetes, even
preferences to increase flexibil-
while other research suggests an associ- without a significant change in BMI
ity, muscular strength, and bal-
ation with weight gain (163). The addition (171). There are also considerable data
ance. C
of nonnutritive sweeteners to diets poses for the health benefits (e.g., increased
5.31 Evaluate baseline physical activ-
no benefit for weight loss or reduced cardiovascular fitness, greater muscle
ity and sedentary time. Promote
weight gain without energy restriction strength, improved insulin sensitivity,
increase innonsedentaryactivities
(163a). Low-calorie or nonnutritive-sweet- etc.) of regular exercise for those with
above baseline for sedentary in-
ened beverages may serve as a short-term type 1 diabetes (172). A recent study
dividuals with type 1 E and type
replacement strategy; however, people suggested that exercise training in
2 B diabetes. Examples include
with diabetes should be encouraged to type 1 diabetes may also improve several
walking, yoga, housework, gar-
decrease both sweetened and nonnutri- important markers such as triglyceride
dening, swimming, and dancing.
tive-sweetened beverages, with an em- level, LDL, waist circumference, and
phasis on water intake (160). Additionally, body mass (173). In adults with type 2
Physical activity is a general term that
some research has found that higher non- diabetes, higher levels of exercise inten-
includes all movement that increases
nutritive-sweetened beverage and sugar- sity are associated with greater improve-
energy use and is an important part of
sweetened beverage consumption may ments in A1C and in cardiorespiratory
the diabetes management plan. Exercise
be positively associated with the devel- fitness (174); sustained improvements
is a more specific form of physical activity
opment of type 2 diabetes, although in cardiorespiratory fitness and weight
that is structured and designed to im-
substantial heterogeneity makes inter- loss have also been associated with a
prove physical fitness. Both physical ac-
preting the results difficult (164–166). lower risk of heart failure (175). Other
tivity and exercise are important. Exercise benefits include slowing the decline in
PHYSICAL ACTIVITY has been shown to improve blood glucose mobility among overweight patients with
control, reduce cardiovascular risk factors, diabetes (176). The ADA position state-
Recommendations contribute to weight loss, and improve ment “Physical Activity/Exercise and Di-
5.26 Children and adolescents with well-being (167). Physical activity is as abetes” reviews the evidence for the
type 1 or type 2 diabetes or pre- important for those with type 1 diabetes benefits of exercise in people with
diabetes should engage in 60 min/ as it is for the general population, but its type 1 and type 2 diabetes and offers
day or more of moderate- or specific role in the prevention of diabetes specific recommendations (177). Physical
vigorous-intensity aerobic activity, complications and the management of activity and exercise should be recom-
with vigorous muscle-strengthening blood glucose is not as clear as it is for mended and prescribed to all individuals
and bone-strengthening activi- those with type 2 diabetes. A recent study with diabetes as part of management of
ties at least 3 days/week. C suggested that the percentage of people glycemia and overall health. Specific rec-
5.27 Most adults with type 1 C and with diabetes who achieved the recom- ommendations and precautions will vary
type 2 B diabetes should engage
mended exercise level per week (150 min) by the type of diabetes, age, activity done,
in 150 min or more of moderate-
varied by race. Objective measurement and presence of diabetes-related health
to vigorous-intensity aerobic ac-
by accelerometer showed that 44.2%, complications. Recommendations should
tivityperweek,spreadoveratleast
42.6%, and 65.1% of Whites, African Amer- be tailored to meet the specific needs of
3 days/week, with no more than
icans, and Hispanics, respectively, met each individual (177).
2 consecutive days without ac-
the threshold (168). It is important for
tivity.Shorterdurations(minimum
diabetes care management teams to Exercise and Children
75min/week)ofvigorous-intensity
understand the difficulty that many All children, including children with di-
or interval training may be suffi-
patients have reaching recommended abetes or prediabetes, should be encour-
cient for younger and more phys-
treatment targets and to identify in- aged to engage in regular physical activity.
ically fit individuals.
dividualized approaches to improve Children should engage in at least 60 min
5.28 Adults with type 1 C and type 2 B
goal achievement. of moderate to vigorous aerobic activ-
diabetes should engage in 2–3
Moderate to high volumes of aerobic ity every day, with muscle- and bone-
sessions/week of resistance ex-
activity are associated with substan- strengthening activities at least 3 days
ercise on nonconsecutive days.
tially lower cardiovascular and overall per week (178). In general, youth with
5.29 All adults, and particularly those
mortality risks in both type 1 and type type 1 diabetes benefit from being
with type 2 diabetes, should
2 diabetes (169). A recent prospective physically active, and an active lifestylecare.diabetesjournals.org Facilitating Behavior Change and Well-being to Improve Health Outcomes S61
should be recommended to all (179). expenditure (e.g., working at a computer, Pre-exercise Evaluation
Youth with type 1 diabetes who engage watching television)dby breaking up As discussed more fully in Section 10
in more physical activity may have bouts of sedentary activity (.30 min) “Cardiovascular Disease and Risk Manage-
better health outcomes and health- by briefly standing, walking, or per- ment” (https://doi.org/10.2337/dc21-S010),
related quality of life (180,181). forming other light physical activities the best protocol for assessing asymp-
(187,188). Participating in leisure-time tomatic patients with diabetes for cor-
Frequency and Type of Physical activity and avoiding extended seden- onary artery disease remains unclear.
Activity tary periods may help prevent type 2 The ADA consensus report “Screening
People with diabetes should perform diabetes for those at risk (189,190) and for Coronary Artery Disease in Patients
aerobic and resistance exercise regularly may also aid in glycemic control for With Diabetes” (197) concluded that
(177). Aerobic activity bouts should ide- those with diabetes. routine testing is not recommended.
ally last at least 10 min, with the goal of A systematic review and meta-analysis However, providers should perform a
;30 min/day or more, most days of the found higher frequency of regular leisure- careful history, assess cardiovascular risk
week for adults with type 2 diabetes. Daily time physical activity was more effec- factors, and be aware of the atypical pre-
exercise, or at least not allowing more tive in reducing A1C levels (191). A sentation of coronary artery disease, such as
than 2 days to elapse between exercise wide range of activities, including recent patient-reported or tested decrease
sessions, is recommended to decrease yoga, tai chi, and other types, can in exercise tolerance, in patients with
insulin resistance, regardless of diabetes have significant impacts on A1C, flex- diabetes. Certainly, high-risk patients
type (182,183). A study in adults with ibility, muscle strength, and balance should be encouraged to start with short
type 1 diabetes found a dose-response (167,192–194). Flexibility and balance periods of low-intensity exercise and slowly
inverse relationship between self-reported exercises may be particularly impor- increase the intensity and duration as
bouts of physical activity per week with tant in older adults with diabetes to tolerated. Providers should assess patients
A1C, BMI, hypertension, dyslipidemia, and maintain range of motion, strength, for conditions that might contraindicate
diabetes-related complications, such as and balance (177). certain types of exercise or predispose to
hypoglycemia, diabetic ketoacidosis, reti- injury, such as uncontrolled hypertension,
nopathy and microalbuminuria (184). Over Physical Activity and Glycemic Control untreated proliferative retinopathy, auto-
time, activities should progress in intensity, Clinical trials have provided strong evi- nomic neuropathy, peripheral neuropathy,
frequency, and/or duration to at least dence for the A1C-lowering value of and a history of foot ulcers or Charcot foot.
150 min/week of moderate-intensity ex- resistance training in older adults with The patient’s age and previous physical
ercise. Adults able to run at 6 miles/h type 2 diabetes (195) and for an additive activity level should be considered when
(9.7 km/h) for at least 25 min can benefit benefit of combined aerobic and resis- customizing the exercise regimen to the
sufficiently from shorter-intensity activity tance exercise in adults with type 2 diabetes individual’s needs. Those with complica-
(75 min/week) (177). Many adults, includ- (196). If not contraindicated, patients tions may need a more thorough evaluation
ing most with type 2 diabetes, may be with type 2 diabetes should be encour- prior to starting an exercise program (198).
unable or unwilling to participate in such aged to do at least two weekly sessions
intense exercise and should engage in of resistance exercise (exercise with free Hypoglycemia
moderate exercise for the recommen- weights or weight machines), with each In individuals taking insulin and/or insulin
ded duration. Adults with diabetes should session consisting of at least one set secretagogues, physical activity may
engage in 2–3 sessions/week of resistance (group of consecutive repetitive exer- cause hypoglycemia if the medication
exercise on nonconsecutive days (185). cise motions) of five or more different dose or carbohydrate consumption is
Although heavier resistance training with resistance exercises involving the large not adjusted for the exercise bout and
free weights and weight machines may muscle groups (195). post-bout impact on glucose. Individuals
improve glycemic control and strength For type 1 diabetes, although exercise on these therapies may need to ingest
(186), resistance training of any intensity is in general is associated with improve- some added carbohydrate if pre-exercise
recommended to improve strength, bal- ment in disease status, care needs to be glucose levels are ,90 mg/dL (5.0 mmol/
ance, and the ability to engage in activities taken in titrating exercise with respect to L), depending on whether they are able to
of daily living throughout the life span. glycemic management. Each individual lower insulin doses during the workout
Providers and staff should help patients with type 1 diabetes has a variable gly- (such as with an insulin pump or reduced
set stepwise goals toward meeting the cemic response to exercise. This variability pre-exercise insulin dosage), the time of
recommended exercise targets. As indi- should be taken into consideration when day exercise is done, and the intensity
viduals intensify their exercise program, recommending the type and duration and duration of the activity (172,198).
medical monitoring may be indicated to of exercise for a given individual In some patients, hypoglycemia after
ensure safety and evaluate the effects on (172). exercise may occur and last for several
glucose management. (See the section Women with preexisting diabetes, hours due to increased insulin sensi-
PHYSICAL ACTIVITY AND GLYCEMIC CONTROL below) particularly type 2 diabetes, and those tivity. Hypoglycemia is less common in
Recent evidence supports that all in- at risk for or presenting with gestational patients with diabetes who are not
dividuals, including those with diabetes, diabetes mellitus should be advised to treated with insulin or insulin secreta-
should be encouraged to reduce the engage in regular moderate physical ac- gogues, and no routine preventive
amount of time spent being sedentaryd tivity prior to and during their pregnancies measures for hypoglycemia are usually
waking behaviors with low energy as tolerated (177). advised in these cases. Intense activitiesS62 Facilitating Behavior Change and Well-being to Improve Health Outcomes Diabetes Care Volume 44, Supplement 1, January 2021
may actually raise blood glucose levels hypotension, impaired thermoregula- cost-effectiveness of brief counseling
instead of lowering them, especially if tion, impaired night vision due to im- in smoking cessation, including the use
pre-exercise glucose levels are elevated paired papillary reaction, and greater of telephone quit lines, in reducing to-
(172). Because of the variation in glycemic susceptibility to hypoglycemia (202). Car- bacco use. Pharmacologic therapy to
response to exercise bouts, patients need diovascular autonomic neuropathy is assist with smoking cessation in people
to be educated to check blood glucose also an independent risk factor for with diabetes has been shown to be
levels before and after periods of exercise cardiovascular death and silent myo- effective (214), and for the patient mo-
and about the potential prolonged effects cardial ischemia (203). Therefore, in- tivated to quit, the addition of pharma-
(depending on intensity and duration) (see dividuals with diabetic autonomic cologic therapy to counseling is more
the section DIABETES SELF-MANAGEMENT EDUCATION neuropathy should undergo cardiac effective than either treatment alone
AND SUPPORT above). investigation before beginning physical (215). Special considerations should
activity more intense than that to which include assessment of level of nicotine
Exercise in the Presence of they are accustomed. dependence, which is associated with
Microvascular Complications Diabetic Kidney Disease difficulty in quitting and relapse (216).
See Section 11 “Microvascular Compli- Physical activity can acutely increase uri- Although some patients may gain weight
cations and Foot Care” (https://doi.org/ nary albumin excretion. However, there in the period shortly after smoking ces-
10.2337/dc21-S011) for more informa- is no evidence that vigorous-intensity sation (217), recent research has demon-
tion on these long-term complications. exercise accelerates the rate of progres- strated that this weight gain does not
Retinopathy sion of DKD, and there appears to be no diminish the substantial CVD benefit re-
If proliferative diabetic retinopathy or need for specific exercise restrictions for alized from smoking cessation (218). One
severe nonproliferative diabetic retinop- people with DKD in general (199). study in people who smoke who had
athy is present, then vigorous-intensity newly diagnosed type 2 diabetes found
aerobic or resistance exercise may be that smoking cessation was associated
SMOKING CESSATION: TOBACCO
contraindicated because of the risk of with amelioration of metabolic param-
AND E-CIGARETTES
triggering vitreous hemorrhage or ret- eters and reduced blood pressure and
inal detachment (199). Consultation with Recommendations albuminuria at 1 year (219).
an ophthalmologist prior to engaging 5.32 Advise all patients not to use In recent years, e-cigarettes have
in an intense exercise regimen may be cigarettes and other tobacco gained public awareness and popularity
appropriate. products or e-cigarettes. A because of perceptions that e-cigarette
5.33 After identification of tobacco or use is less harmful than regular cigarette
Peripheral Neuropathy smoking (220,221). However, in light of
e-cigarette use, include smoking
Decreased pain sensation and a higher cessation counseling and other recent Centers for Disease Control and
pain threshold in the extremities can re- forms of treatment as a routine Prevention evidence (222) of deaths re-
sult in an increased risk of skin breakdown, component of diabetes care. A lated to e-cigarette use, no persons
infection, and Charcot joint destruction 5.34 Address smoking cessation as should be advised to use e-cigarettes,
with some forms of exercise. Therefore, a part of diabetes education pro- either as a way to stop smoking tobacco
thorough assessment should be done to grams for those in need. B or as a recreational drug.
ensure that neuropathy does not alter Diabetes education programs offer
kinesthetic or proprioceptive sensation Results from epidemiologic, case- potential to systematically reach and
during physical activity, particularly in control, and cohort studies provide con- engage individuals with diabetes in
those with more severe neuropathy. Stud- vincing evidence to support the causal smoking cessation efforts. A cluster
ies have shown that moderate-intensity link between cigarette smoking and randomized trial found statistically sig-
walking may not lead to an increased risk health risks (204). Recent data show nificant increases in quit rates and long-
of foot ulcers or reulceration in those with tobacco use is higher among adults term abstinence rates (.6 months)
peripheral neuropathy who use proper with chronic conditions (205) as well when smoking cessation interventions
footwear (200). In addition, 150 min/week as in adolescents and young adults with were offered through diabetes educa-
of moderate exercise was reported to diabetes (206). People with diabetes tion clinics, regardless of motivation to
improve outcomes in patients with pre- who smoke (and people with diabetes quit at baseline (223).
diabetic neuropathy (201). All individ- exposed to second-hand smoke) have a
uals with peripheral neuropathy should heightened risk of CVD, premature death,
wear proper footwear and examine microvascular complications, and worse PSYCHOSOCIAL ISSUES
their feet daily to detect lesions early. glycemic control when compared with Recommendations
Anyone with a foot injury or open sore those who do not smoke (207–209). Smok-
should be restricted to non–weight- 5.35 Psychosocial care should be in-
ing may have a role in the development tegrated with a collaborative,
bearing activities. of type 2 diabetes (210–213). patient-centered approach and
Autonomic Neuropathy The routine and thorough assessment provided to all people with di-
Autonomic neuropathy can increase the of tobacco use is essential to prevent abetes, with the goals of opti-
risk of exercise-induced injury or ad- smoking or encourage cessation. Nu- mizing health outcomes and
verse events through decreased cardiac merous large randomized clinical trials health-related quality of life. A
responsiveness to exercise, postural have demonstrated the efficacy andYou can also read
