5. Facilitating Behavior Changeand Well-being to Improve HealthOutcomes: Standards of MedicalCare in Diabetesd2020Diabetes Care 2020;43(Suppl. 1):S48–S65 | https://doi.org/10.2337/dc20-S005

The American Diabetes Association (ADA) “Standards of Medical Care in Diabe-tes” includes the ADA’s current clinical practice recommendations and is intendedto provide the components of diabetes care, general treatment goals and guide-lines, and tools to evaluate quality of care. Members of the ADA ProfessionalPractice Committee, a multidisciplinary expert committee (https://doi.org/10.2337/dc20-SPPC), are responsible for updating the Standards of Care annu-ally, or more frequently as warranted. For a detailed description of ADA stan-dards, statements, and reports, as well as the evidence-grading system for ADA’sclinical practice recommendations, please refer to the Standards of Care In-troduction (https://doi.org/10.2337/dc20-SINT). Readers who wish to com-ment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.

Effective behavior management and psychological well-being are foundationalto achieving treatment goals for people with diabetes (1,2). Essential to achievingthese goals are diabetes self-management education and support (DSMES), med-ical nutrition therapy (MNT), routine physical activity, smoking cessation counsel-ing when needed, and psychosocial care. Following an initial comprehensive medicalevaluation (see Section 4, “Comprehensive Medical Evaluation and Assessment ofComorbidities,” https://doi.org/10.2337/dc20-S004), patients and providers areencouraged to engage in person-centered collaborative care (3–6), which is guidedby shared decision-making in treatment regimen selection, facilitation of obtainingneeded medical and psychosocial resources, and shared monitoring of agreed-uponregimen and lifestyle (7). Re-evaluation during routine care should include not onlyassessment of medical health but also behavioral and mental health outcomes,especially during times of deterioration in health and well-being.

DIABETES SELF-MANAGEMENT EDUCATION AND SUPPORT

Recommendations

5.1 In accordance with the national standards for diabetes self-managementeducation and support, all peoplewith diabetes should participate in diabetesself-management education and receive the support needed to facilitate theknowledge, decision-making, and skills mastery necessary for diabetes self-care. A

5.2 There are four critical times to evaluate the need for diabetes self-management education to promote skills acquisition in support of regimen

Suggested citation: American Diabetes Associa-tion. 5. Facilitating behavior change and well-being to improve health outcomes: Standards ofMedical Care in Diabetesd2020. Diabetes Care2020;43(Suppl. 1):S48–S65

© 2019 by the American Diabetes Association.Readers may use this article as long as the workis properly cited, the use is educational and notfor profit, and the work is not altered. More infor-mation is available at http://www.diabetesjournals.org/content/license.

American Diabetes Association

S48 Diabetes Care Volume 43, Supplement 1, January 2020

5.FA

CILITATINGBEH

AVIORCHANGEANDWELL-BEING

implementation, medical nutri-tion therapy, and well-being: atdiagnosis, annually, when com-plicating factors arise, and whentransitions in care occur. E

5.3 Clinical outcomes, health status,and well-being are key goals ofdiabetes self-management edu-cation and support that shouldbe measured as part of routinecare. C

5.4 Diabetes self-management edu-cation and support should be pa-tient centered, may be given ingroup or individual settings and/or use technology, and should becommunicated with the entirediabetes care team. A

5.5 Becausediabetesself-managementeducationandsupportcanimproveoutcomes and reduce costs B,reimbursement by third-partypayers is recommended. C

Diabetes self-management educationand support (DSMES) services facilitatethe knowledge, decision-making, andskills mastery necessary for optimal dia-betes self-care and incorporate theneeds, goals, and life experiences ofthe person with diabetes. The overallobjectives of DSMES are to support in-formed decision-making, self-care be-havior, problem-solving, and activecollaboration with the health careteam to improve clinical outcomes,health status, and well-being in a cost-effective manner (2). Providers are en-couraged to consider the burden oftreatment and the patient’s level ofconfidence/self-efficacy for managementbehaviors aswell as the level of social andfamily support when providing DSMES.Patient performance of self-manage-ment behaviors, including its effect onclinical outcomes, health status, andquality of life, as well as the psychosocialfactors impacting the person’s abilityto self-manage should be monitored aspart of routine clinical care. A randomizedcontrolled trial testing a decision-makingeducation and skill-building program (8)showed that addressing these targetsimproved health outcomes in a popu-lation in need of health care resources.Furthermore, following a DSMES cur-riculum improves quality of care (9).In addition, in response to the grow-

ing literature that associates potentially

judgmental words with increased feelingsof shame and guilt, providers are encour-aged to consider the impact that languagehas on building therapeutic relationshipsand to choose positive, strength-basedwords and phrases that put people first(4,10). Patient performance of self-man-agementbehaviors, aswell as psychosocialfactors with the potential to impact theperson’s self-management, should bemonitored. Please see Section 4 “Compre-hensive Medical Evaluation and Assess-ment of Comorbidities”(https://doi.org/10.2337/dc20-S004) for more on use oflanguage.

DSMES and the current national stan-dards guiding it (2,11) are based on evi-dence of benefit. Specifically, DSMEShelps people with diabetes to identifyand implement effective self-managementstrategies and cope with diabetes at fourcritical time points (see below) (2). On-going DSMES helps people with diabetesto maintain effective self-managementthroughout a lifetime of diabetes as theyface new challenges and as advances intreatment become available (12).

Four critical time points have beendefined when the need for DSMES is tobe evaluated by the medical care pro-vider and/or multidisciplinary team,with referrals made as needed (2):

1. At diagnosis2. Annually for assessment of education,

nutrition, and emotional needs3. When new complicating factors (health

conditions, physical limitations, emo-tional factors, or basic living needs)arise that influence self-management

4. When transitions in care occur

DSMES focuses on supporting patientempowerment by providing peoplewith diabetes the tools tomake informedself-management decisions (13). Diabe-tes care has shifted to an approach thatplaces the person with diabetes and hisor her family/support system at the centerof the caremodel,working in collaborationwith health care professionals. Patient-centered care is respectful of and respon-sive to individual patient preferences,needs, and values. It ensures that patientvalues guide all decision-making (14).

Evidence for the BenefitsStudies have found that DSMES isassociated with improved diabetesknowledgeandself-carebehaviors (14,15),

lowerA1C(14,16–18), lower self-reportedweight (19,20), improved quality of life(17,21), reduced all-cause mortality risk(22), healthy coping (5,23), and reducedhealth care costs (24–26). Better out-comes were reported for DSMES inter-ventions that were over 10 h in totalduration (18), included ongoing support(12,27), were culturally (28,29) and ageappropriate (30,31), were tailored toindividual needs and preferences, andaddressed psychosocial issues and incor-poratedbehavioral strategies (13,23,32,33).Individual and group approaches areeffective (20,34,35), with a slight ben-efit realized by those who engage inboth (18).

Emerging evidence demonstrates thebenefit of internet-basedDSMESservicesfor diabetes prevention and the man-agement of type 2 diabetes (36–38).Technology-enabled diabetes self-man-agement solutions improve A1C mosteffectively when there is two-way com-munication between the patient and thehealth care team, individualized feed-back, use of patient-generated healthdata, and education (38). Current re-search supports nurses, dietitians, andpharmacists as providers of DSMES whomayalso tailor curriculum to theperson’sneeds (39–41). Members of the DSMESteam should have specialized clinicalknowledge in diabetes and behaviorchangeprinciples.Certificationasadiabeteseducator (see www.ncbde.org) and/orboard certification in advanced diabetesmanagement (see www.diabeteseducator.org/education/certification/bc_adm) dem-onstrates an individual’s specialized trainingin and understanding of diabetes manage-ment and support. (11). Additionally, thereis growing evidence for the role of com-munity health workers (42,43), as well aspeer (42–46) and lay leaders (47), in pro-viding ongoing support.

DSMES is associated with an increaseduse of primary care and preventive ser-vices (24,48,49) and less frequent use ofacute care and inpatient hospital services(19). Patients who participate in DSMESare more likely to follow best practicetreatment recommendations, particu-larly among the Medicare population,and have lower Medicare and insuranceclaim costs (25,48). Despite these bene-fits, reports indicate that only 5–7%of individuals eligible for DSMES throughMedicare or a private insurance planactually receive it (50,51). This low

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participation may be due to lack ofreferral or other identified barrierssuch as logistical issues (accessibility,timing, costs) and the lack of a perceivedbenefit (52). Thus, in addition to educat-ing referring providers about thebenefitsof DSMES and the critical times to refer(2), alternative and innovative modelsof DSMES delivery need to be exploredand evaluated.

ReimbursementMedicare reimburses DSMES when thatservice meets the national standards(2,11) and is recognized by the Ameri-can Diabetes Association (ADA) or otherapproval bodies. DSMES is also coveredby most health insurance plans. Ongoingsupport has been shown to be instru-mental for improving outcomes whenit is implemented after the completionof education services. DSMES is fre-quently reimbursed when performedin person. However, although DSMEScan also be provided via phone callsand telehealth, these remote versionsmay not always be reimbursed. Changesin reimbursement policies that increaseDSMES access and utilization will resultin a positive impact to beneficiaries’clinical outcomes, quality of life, healthcare utilization, and costs (53,54).

MEDICAL NUTRITION THERAPY

Please refer to the ADA consensus report“Nutrition Therapy for Adults With Di-abetes or Prediabetes: A Consensus Re-port” for more information on nutritiontherapy (41). For many individuals withdiabetes, the most challenging part ofthe treatment plan is determining whatto eat. There is not a “one-size-fits-all”eating pattern for individuals with diabe-tes, and meal planning should be individ-ualized. Nutrition therapy plays anintegral role in overall diabetes manage-ment, and each person with diabetesshould be actively engaged in education,self-management, and treatment plan-ning with his or her health care team,including the collaborative developmentof an individualized eating plan (41,55).All individuals with diabetes should bereferred for individualizedMNTprovidedby a registered dietitian nutritionist (RD/RDN) who is knowledgeable and skilledin providing diabetes-specific MNT (56)at diagnosis and as needed throughoutthe life span, similar to DSMES. MNTdelivered by an RD/RDN is associated

with A1C decreases of 1.0–1.9% for peo-ple with type 1 diabetes (57) and 0.3–2.0% forpeoplewith type2diabetes (57).See Table 5.1 for specific nutrition rec-ommendations. Because of the progres-sive nature of type 2 diabetes, behaviormodification alone may not be adequateto maintain euglycemia over time. How-ever, after medication is initiated, nu-trition therapy continues to be animportant component and should beintegrated with the overall treatmentplan (55).

Goals of Nutrition Therapy for AdultsWith Diabetes1. To promote and support healthful

eating patterns, emphasizing a varietyof nutrient-dense foods in appropri-ate portion sizes, to improve overallhealth and:c achieve and maintain body weight

goalsc attain individualized glycemic, blood

pressure, and lipid goalsc delay or prevent the complications

of diabetes2. To address individual nutrition needs

based on personal and cultural pref-erences, health literacy and numeracy,access to healthful foods, willingnessand ability tomake behavioral changes,and existing barriers to change

3. To maintain the pleasure of eating byproviding nonjudgmental messagesabout food choices while limitingfood choices only when indicatedby scientific evidence

4. To provide an individual with diabe-tes the practical tools for developinghealthy eating patterns rather thanfocusing on individual macronutrients,micronutrients, or single foods

Eating Patterns, MacronutrientDistribution, and Meal PlanningEvidence suggests that there is not anideal percentage of calories from carbo-hydrate, protein, and fat for people withdiabetes. Therefore, macronutrient dis-tribution should be based on an individ-ualized assessment of current eatingpatterns, preferences, and metabolicgoals. Consider personal preferences(e.g., tradition, culture, religion, healthbeliefs and goals, economics) as well asmetabolic goals when working with in-dividuals to determine the best eatingpattern for them (41,58,59). It is impor-tant that eachmember of the health care

team be knowledgeable about nutritiontherapy principles for people with alltypes of diabetes and be supportive oftheir implementation. Members of thehealth care team should complementMNT by providing evidence-based guid-ance that helps people with diabetesmake healthy food choices that meettheir individualized needs and improveoverall health. A variety of eating pat-ternsareacceptable for themanagementof diabetes (41,58,60). Until the evidencesurrounding comparative benefits of dif-ferent eating patterns in specific individ-uals strengthens, health care providersshould focus on the key factors that arecommon among the patterns: 1) empha-size nonstarchy vegetables, 2) minimizeadded sugars and refined grains, and 3)choose whole foods over highly pro-cessed foods to the extent possible(41). An individualized eating patternalso considers the individual’s healthstatus, skills, resources, food preferen-ces, and health goals. Referral to an RD/RDN is essential to assess the overallnutrition status of, and to work collab-oratively with, the patient to createa personalized meal plan that coordi-nates and aligns with the overall treat-ment plan, including physical activityand medication use. The Mediterranean-style (61,62), low-carbohydrate (63–65), and vegetarian or plant-based(66,67) eating patterns are all examplesof healthful eating patterns that haveshown positive results in research, butindividualized meal planning should fo-cus on personal preferences, needs, andgoals. Reducing overall carbohydrate in-take for individuals with diabetes hasdemonstrated the most evidence forimproving glycemia and may be appliedin a variety of eating patterns that meetindividual needs and preferences. Forindividuals with type 2 diabetes notmeeting glycemic targets or for whomreducing glucose-lowering drugs is apriority, reducing overall carbohydrateintake with a low- or very-low-carbohy-drate eating pattern is a viable option(63–65). As research studies on somelow-carbohydrate eating plans generallyindicate challenges with long-term sus-tainability, it is important to reassess andindividualize meal plan guidance regu-larly for those interested in this ap-proach. This eating pattern is notrecommended at this time for womenwho are pregnant or lactating, people

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Table 5.1—Medical nutrition therapy recommendations

Topic Recommendation Evidence rating

Effectiveness ofnutrition therapy

5.6 An individualized medical nutrition therapy program as needed to achieve treatment goals,provided by a registered dietitian nutritionist (RD/RDN), preferably one who hascomprehensive knowledge and experience in diabetes care, is recommended for all peoplewith type 1 or type 2 diabetes, prediabetes, and gestational diabetes mellitus.

A

5.7 Because diabetes medical nutrition therapy can result in cost savings B and improvedoutcomes (e.g., A1C reduction, reduced weight, decrease in cholesterol) A, medical nutritiontherapy should be adequately reimbursed by insurance and other payers. E

B, A, E

Energy balance 5.8 For all patients with overweight or obesity, lifestyle modification to achieve and maintaina minimumweight loss of 5% is recommended for all patients with diabetes and prediabetes.

A

Eating patterns andmacronutrientdistribution

5.9 There is no single ideal dietary distributionof calories among carbohydrates, fats, andproteinsfor people with diabetes; therefore, meal plans should be individualized while keeping totalcalorie and metabolic goals in mind.

E

5.10 A variety of eating patterns are acceptable for the management of type 2 diabetes andprediabetes.

B

Carbohydrates 5.11 Carbohydrate intake should emphasize nutrient-dense carbohydrate sources that arehigh in fiber and minimally processed. Eating plans should emphasize nonstarchy vegetables,minimal added sugars, fruits, whole grains, as well as dairy products.

B

5.12 Reducing overall carbohydrate intake for individuals with diabetes has demonstrated themost evidence for improving glycemia and may be applied in a variety of eating patternsthat meet individual needs and preferences.

B

5.13 For people with diabetes who are prescribed a flexible insulin therapy program, educationon how to use carbohydrate counting A and on dosing for fat and protein content B shouldbe used to determine mealtime insulin dosing.

A, B

5.14 For adults using fixed insulin doses, consistent pattern of carbohydrate intake with respect totime and amount, while considering the insulin action time, can result in improved glycemiaand reduce the risk for hypoglycemia.

B

5.15 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 weightand reduce their risk for cardiovascular disease and fatty liver B and should minimize theconsumption of foods with added sugar that have the capacity to displace healthier, morenutrient-dense food choices. A

B, A

Protein 5.16 In individuals with type 2 diabetes, ingested protein appears to increase insulin responsewithout increasing plasma glucose concentrations. Therefore, carbohydrate sources high inprotein should be avoided when trying to treat or prevent hypoglycemia.

B

Dietary fat 5.17 An eating plan emphasizing elements of a Mediterranean-style eating pattern rich inmonounsaturated and polyunsaturated fats may be considered to improve glucosemetabolism and lower cardiovascular disease risk.

B

5.18 Eating foods rich in long-chain n-3 fatty acids, such as fatty fish (EPA and DHA) and nuts andseeds (ALA), is recommended to prevent or treat cardiovascular diseaseB; however, evidencedoes not support a beneficial role for the routine use of n-3 dietary supplements. A

B, A

Micronutrients andherbal supplements

5.19 There is no clear evidence that dietary supplementation with vitamins, minerals (such aschromium and vitamin D), herbs, or spices (such as cinnamon or aloe vera) can improveoutcomes in people with diabetes who do not have underlying deficiencies, and they arenot generally recommended for glycemic control.

C

Alcohol 5.20 Adults with diabetes who drink alcohol should do so in moderation (no more than one drinkper day for adult women and no more than two drinks per day for adult men).

C

5.21 Educating people with diabetes about the signs, symptoms, and self-management of delayedhypoglycemia after drinking alcohol, especially when using insulin or insulin secretagogues,is recommended. The importance of glucose monitoring after drinking alcoholicbeverages to reduce hypoglycemia risk should be emphasized.

B

Sodium 5.22 As for the general population, people with diabetes and prediabetes should limit sodiumconsumption to ,2,300 mg/day.

B

Nonnutritivesweeteners

5.23 The use of nonnutritive sweeteners may have the potential to reduce overall calorie andcarbohydrate intake if substituted for caloric (sugar) sweetenersandwithoutcompensationbyintake of additional calories from other food sources. For those who consume sugar-sweetened beverages regularly, a low-calorie or nonnutritive-sweetened beveragemay serveas a short-term replacement strategy, but overall, people are encouraged to decrease bothsweetened and nonnutritive-sweetened beverages and use other alternatives, with anemphasis on water intake.

B

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with or at risk for disordered eating, orpeople who have renal disease, and itshould be used with caution in patientstaking sodium–glucose cotransporter2 inhibitors due to the potential riskof ketoacidosis (68,69). There is inade-quate research in type 1 diabetes tosupport one eating pattern over anotherat this time.The diabetes plate method is com-

monly used for providing basic mealplanning guidance (70) and provides avisual guide showing how to portioncalories (featuring a 9-inch plate) andcarbohydrates (by limiting them to whatfits in one-quarter of the plate) and placesan emphasis on low-carbohydrate (or non-starchy) vegetables. Providing a visual/small graphic of the diabetes plate methodis preferred, as descriptions of the conceptcan be confusing when unfamiliar.

Weight ManagementManagement and reduction of weightis important for people with type 1 di-abetes, type 2 diabetes, or prediabetesand overweight or obesity. To supportweight loss and improve A1C, cardio-vascular disease (CVD) risk factors, andwell-being in adults with overweight/obesity and prediabetes or diabetes,MNT and DSMES services should includean individualized eating plan in a formatthat results in an energy deficit in com-bination with enhanced physical activ-ity (41). Lifestyle intervention programsshould be intensive and have frequentfollow-up to achieve significant reduc-tions in excess body weight and improveclinical indicators. There is strong andconsistent evidence that modest persis-tent weight loss can delay the progres-sion from prediabetes to type 2 diabetes(58,71,72) (see Section 3 “Prevention orDelay of Type 2 Diabetes,” https://doi.org/10.2337/dc20-S003) and is benefi-cial to the management of type 2 diabe-tes (see Section8 “ObesityManagementfor the Treatment of Type 2 Diabetes,”https://doi.org/10.2337/dc20-S008).In prediabetes, the weight loss goal

is 7–10% for preventing progression totype 2 diabetes (73). In conjunctionwith lifestyle therapy, medication-assistedweight loss can be considered for peo-ple at risk for type 2 diabetes whenneeded to achieve and sustain 7–10%weight loss (74,75). People with predia-betes at a healthy weight should alsobe considered for lifestyle intervention

involving both aerobic and resistanceexercise (73,76,77) and a healthy eatingplan, such as aMediterranean-style eatingpattern (78).

For many individuals with overweightand obesity with type 2 diabetes, 5%weight loss is needed to achieve bene-ficial outcomes inglycemic control, lipids,and blood pressure (79). It should benoted, however, that the clinical benefitsof weight loss are progressive, and moreintensive weight loss goals (i.e., 15%)maybe appropriate to maximize benefit de-pending on need, feasibility, and safety(80,81). In select individuals with type 2diabetes, an overall healthy eating planthat results in energy deficit in conjunc-tion with weight lossmedications and/ormetabolic surgery should be consideredto help achieve weight loss and mainte-nance goals, lower A1C, and reduce CVDrisk (82–84). Overweight and obesityare also increasingly prevalent in peoplewith type 1 diabetes and present clinicalchallenges regarding diabetes treatmentand CVD risk factors (85,86). Sustainingweight loss canbechallenging (79,87)buthas long-term benefits; maintainingweight loss for 5 years is associatedwith sustained improvements in A1C andlipid levels (88). MNT guidance from anRD/RDN with expertise in diabetes andweight management, throughout thecourse of a structured weight loss plan,is strongly recommended.

People with diabetes and prediabetesshould be screened and evaluated duringDSMES and MNT encounters for disor-dered eating, and nutrition therapyshould be individualized to accommo-date disorders (41). Disordered eatingcan make following an eating plan chal-lenging, and individuals should be re-ferred to a mental health professional asneeded. Studies have demonstrated thata variety of eating plans, varying in mac-ronutrient composition, can be usedeffectively and safely in the short term(1–2 years) to achieve weight loss inpeople with diabetes. This includes struc-tured low-calorie meal plans with mealreplacements (80,88,89) and the Medit-erranean-style eating pattern (78), as wellas low-carbohydrate meal plans (90).However, no single approach has beenproven to be consistently superior(41,91,92), and more data are neededto identify and validate those meal plansthat are optimal with respect to long-termoutcomes and patient acceptability. The

importance of providing guidance onan individualized meal plan containingnutrient-dense foods, such as vegeta-bles, fruits, legumes, dairy, lean sourcesof protein (including plant-based sourcesas well as lean meats, fish, and poultry),nuts, seeds, and whole grains, cannot beoveremphasized (92), aswell as guidanceon achieving the desired energy deficit(93–96). Any approach to meal planningshould be individualized considering thehealth status, personal preferences, andability of the person with diabetes tosustain the recommendations in the plan.

CarbohydratesStudies examining the ideal amountof carbohydrate intake for people withdiabetes are inconclusive, although mon-itoring carbohydrate intake and con-sidering the blood glucose response todietary carbohydrate are key for improv-ing postprandial glucose management(97,98). The literature concerning gly-cemic index and glycemic load in in-dividuals with diabetes is complex, oftenyielding mixed results, though in somestudies lowering the glycemic load ofconsumed carbohydrates has demon-strated A1C reductions of 0.2% to 0.5%(99,100). Studies longer than 12 weeksreport no significant influence of glycemicindex or glycemic load independent ofweight loss on A1C; however, mixedresults have been reported for fastingglucose levels and endogenous insulinlevels.

Reducing overall carbohydrate intakefor individuals with diabetes has dem-onstrated evidence for improving gly-cemia and may be applied in a varietyof eating patterns that meet individ-ual needs and preferences (41). Forpeople with type 2 diabetes or predia-betes, low-carbohydrate eating plansshow potential to improve glycemiaand lipid outcomes for up to 1 year(63,65,90,101–104). Part of the chal-lenge in interpreting low-carbohydrateresearch has been due to the wide rangeof definitions for a low-carbohydrateeating plan (65,100). As research stud-ies on low-carbohydrate eating plansgenerally indicate challenges with long-term sustainability, it is important toreassess and individualize meal planguidance regularly for those interestedin this approach. Providers should main-tain consistent medical oversight andrecognize that certain groups are not

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appropriate for low-carbohydrate eatingplans, including women who are preg-nant or lactating, children, and peoplewho have renal disease or disorderedeating behavior, and these plans shouldbe used with caution in those takingsodium–glucose cotransporter 2 inhibitorsbecause of the potential risk of ketoacidosis(68,69). There is inadequate researchabout dietary patterns for type 1 diabe-tes to support one eating plan overanother at this time.Most individuals with diabetes re-

port a moderate intake of carbohydrate(44–46% of total calories) (58). Effortsto modify habitual eating patterns areoften unsuccessful in the long term;people generally go back to their usualmacronutrient distribution (58). Thus,the recommended approach is to indi-vidualizemeal plans tomeet caloric goalswith a macronutrient distribution that ismore consistent with the individual’susual intake to increase the likelihoodfor long-term maintenance.As for all individuals in developed

countries, both children and adultswith diabetes are encouraged to mini-mize intake of refined carbohydrates andadded sugars and instead focus on carbo-hydrates from vegetables, legumes, fruits,dairy (milk and yogurt), and whole grains.The consumption of sugar-sweetenedbeverages (including fruit juices) and pro-cessed food products with high amountsof refined grains and added sugars isstrongly discouraged (105–107).Individuals with type 1 or type 2 di-

abetes taking insulin at mealtime shouldbe offered intensive and ongoing edu-cation on the need to couple insulinadministration with carbohydrate intake.For people whose meal schedule or car-bohydrate consumption is variable, reg-ular counseling tohelp themunderstandthe complex relationship between car-bohydrate intake and insulin needsis important. In addition, education onusing the insulin-to-carbohydrate ratiosfor meal planning can assist them witheffectively modifying insulin dosing frommeal to meal and improving glycemicmanagement (58,97,108–111). Resultsfrom recent high-fat and/or high-proteinmixedmeals studies continue to supportprevious findings that glucose responsetomixedmeals high in protein and/or fatalong with carbohydrate differ amongindividuals; therefore, a cautious approachto increasing insulin doses for high-fat

and/or high-protein mixed meals isrecommended to address delayed hy-perglycemia that may occur 3 h or moreafter eating (41). Checking glucose 3 hafter eating may help to determine ifadditional insulin adjustments are required(112,113). Continuous glucose monitoringor self-monitoring of blood glucoseshould guide decision making for admin-istration of additional insulin. For indi-viduals on a fixed daily insulin schedule,meal planning should emphasize a rel-atively fixed carbohydrate consump-tion pattern with respect to both timeand amount, while considering insulinaction time (41).

ProteinThere is no evidence that adjusting thedaily level of protein intake (typically 1–1.5 g/kg body wt/day or 15–20% totalcalories) will improve health in individ-uals without diabetic kidney disease, andresearch is inconclusive regarding theideal amount of dietary protein to opti-mize either glycemic management orCVD risk (99,114). Therefore, proteinintake goals should be individualizedbased on current eating patterns.Some research has found successfulmanagement of type 2 diabetes withmeal plans including slightly higher levelsof protein (20–30%), which may contrib-ute to increased satiety (115).

Those with diabetic kidney disease(with albuminuria and/or reduced esti-mated glomerular filtration rate) shouldaim to maintain dietary protein at therecommendeddaily allowance of 0.8 g/kgbody wt/day. Reducing the amount ofdietary protein below the recommendeddaily allowance is not recommended be-cause it does not alter glycemic meas-ures, cardiovascular riskmeasures, or therate at which glomerular filtration ratedeclines (116,117).

In individuals with type 2 diabetes,protein intake may enhance or increasethe insulin response to dietary carbohy-drates (118). Therefore, use of carbohy-drate sources high in protein (such asmilk and nuts) to treat or prevent hypo-glycemia should be avoided due to thepotential concurrent rise in endogenousinsulin.

FatsThe ideal amount of dietary fat for in-dividuals with diabetes is controver-sial. New evidence suggests that there

is not an ideal percentage of caloriesfrom fat for people with or at risk fordiabetes and that macronutrient distri-bution should be individualized accord-ing to the patient’s eating patterns,preferences, and metabolic goals (41).The type of fats consumed is more im-portant than total amount of fat whenlooking at metabolic goals and CVDrisk, and it is recommended that thepercentage of total calories from satu-rated fats should be limited (78,105,119–121). Multiple randomized con-trolled trials including patients withtype 2 diabetes have reported that aMediterranean-style eating pattern (78,122–127), rich in polyunsaturated andmonounsaturated fats, can improve bothglycemic management and blood lipids.However, supplements do not seem tohave the same effects as their whole-food counterparts. A systematic reviewconcluded that dietary supplementswith n-3 fatty acids did not improveglycemic management in individualswith type 2 diabetes (99). Randomizedcontrolled trials also do not supportrecommending n-3 supplements for pri-mary or secondary prevention of CVD(128–132). People with diabetes shouldbe advised to follow the guidelines forthe general population for the recom-mended intakes of saturated fat, die-tary cholesterol, and trans fat (105). Ingeneral, trans fats should be avoided.In addition, as saturated fats are progres-sively decreased in the diet, they shouldbe replacedwith unsaturated fats and notwith refined carbohydrates (126).

SodiumAs for the general population, peoplewith diabetes are advised to limit theirsodium consumption to,2,300 mg/day(41). Restriction below 1,500 mg, evenfor those with hypertension, is generallynot recommended (133–135). Sodiumintake recommendations should takeinto account palatability, availability, af-fordability, and the difficulty of achiev-ing low-sodium recommendations in anutritionally adequate diet (136).

Micronutrients and SupplementsThere continues to be no clear evidenceof benefit from herbal or nonherbal(i.e., vitamin or mineral) supplemen-tation for people with diabetes withoutunderlying deficiencies (41). Metforminis associated with vitamin B12 deficiency

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per a report from the Diabetes Preven-tion Program Outcomes Study (DPPOS),suggesting that periodic testing of vita-min B12 levels should be consideredin patients taking metformin, particularlyin those with anemia or peripheralneuropathy (137). Routine supplemen-tation with antioxidants, such as vita-mins E and C and carotene, is not adviseddue to lack of evidence of efficacy andconcern related to long-term safety. Inaddition, there is insufficient evidence tosupport the routine use of herbal supple-ments and micronutrients, such as cin-namon (138), curcumin, vitamin D (139),aloe vera, or chromium, to improve gly-cemia in people with diabetes (41,140).However, for special populations, in-cluding pregnant or lactating women,older adults, vegetarians, and peoplefollowing very low-calorie or low-carbo-hydrate diets, a multivitamin may benecessary.

AlcoholModerate alcohol intake does not havemajor detrimental effects on long-termblood glucose management in peoplewith diabetes. Risks associated with al-cohol consumption include hypogly-cemia and/or delayed hypoglycemia(particularly for those using insulin orinsulin secretagogue therapies), weightgain, and hyperglycemia (for those con-suming excessive amounts) (41,140).Peoplewith diabetes should be educatedabout these risks and encouraged tomonitor blood glucose frequently afterdrinking alcohol to minimize such risks.Peoplewithdiabetes can follow the sameguidelines as those without diabetes ifthey choose to drink. For women, nomore than one drink per day, and formen, no more than two drinks per day isrecommended (one drink is equal to a12-oz beer, a 5-oz glass of wine, or 1.5 ozof distilled spirits).

Nonnutritive SweetenersFor some people with diabetes whoare accustomed to sugar-sweetenedproducts, nonnutritive sweeteners (con-taining few or no calories) may be anacceptable substitute for nutritive sweet-eners (those containing calories, suchas sugar, honey, and agave syrup) whenconsumed in moderation. While useof nonnutritive sweeteners does notappear to have a significant effect onglycemic management (141), they can

reduce overall calorie and carbohydrateintake (58). Most systematic reviews andmeta-analyses show benefits for nonnu-tritive sweetener use in weight loss(142,143); however, some research sug-gests an association with weight gain(144). When use of sugar substitutesis meant to reduce overall caloric andcarbohydrate intake, people should becounseled to avoid compensating withintake of additional calories from otherfood sources (41). Regulatory agenciesset acceptable daily intake levels for eachnonnutritive sweetener, defined as theamount that can be safely consumedover a person’s lifetime (41,145). Forthose who consume sugar-sweetenedbeverages regularly, a low-calorie ornonnutritive-sweetened beverage mayserve as a short-term replacement strat-egy, but overall, people are encour-aged to decrease both sweetened andnonnutritive-sweetened beverages anduse other alternatives, with an emphasison water intake (146).

PHYSICAL ACTIVITY

Recommendations

5.24 Children and adolescents withtype 1 or type 2 diabetes orprediabetes should engage in60 min/day or more of moder-ate- or vigorous-intensity aerobicactivity, with vigorous muscle-strengthening and bone-strength-ening activities at least 3 days/week. C

5.25 Most adults with type 1 C andtype 2 B diabetes should engagein 150 min or more of moderate-to vigorous-intensity aerobic ac-tivity per week, spread over atleast 3days/week,with nomorethan 2 consecutive dayswithoutactivity. Shorter durations (min-imum75min/week) of vigorous-intensity or interval training maybe sufficient for younger andmore physically fit individuals.

5.26 Adults with type 1 C and type 2 Bdiabetes should engage in 2–3sessions/week of resistance ex-ercise on nonconsecutive days.

5.27 All adults, and particularly thosewith type 2 diabetes, shoulddecrease the amount of timespent in daily sedentary behav-ior. B Prolonged sitting should

be interrupted every 30 min forblood glucose benefits. C

5.28 Flexibility training and balancetraining are recommended 2–3times/week for older adults withdiabetes. Yoga and tai chi maybe included based on individualpreferences to increase flexibil-ity, muscular strength, and bal-ance. C

Physical activity is a general term thatincludes all movement that increasesenergy use and is an important part ofthe diabetes management plan. Exerciseis a more specific form of physical activ-ity that is structured and designed toimprove physical fitness. Both physicalactivity and exercise are important. Ex-ercise has been shown to improve bloodglucose control, reduce cardiovascu-lar risk factors, contribute to weightloss, and improve well-being (147). Phys-ical activity is as important for those withtype 1 diabetes as it is for the generalpopulation, but its specific role in theprevention of diabetes complicationsand the management of blood glucoseis not as clear as it is for thosewith type 2diabetes. A recent study suggested thatthe percentage of people with diabeteswho achieved the recommended exer-cise level per week (150 min) varied byrace. Objective measurement by accel-erometer showed that 44.2%, 42.6%, and65.1% of whites, African Americans, andHispanics, respectively, met the thresh-old (148). It is important for diabetes caremanagement teams to understand thedifficulty that many patients have reach-ing recommended treatment targets andto identify individualized approaches toimprove goal achievement.

Moderate to high volumes of aerobicactivity are associated with substantiallylower cardiovascular and overall mortal-ity risks inboth type1and type2diabetes(149).A recentprospectiveobservationalstudy of adults with type 1 diabetessuggested that higher amounts of phys-ical activity led to reduced cardiovascularmortality after a mean follow-up time of11.4 years for patients with and withoutchronic kidney disease (150). Addition-ally, structured exercise interventions ofat least 8 weeks’ duration have beenshown to lower A1C by an average of0.66% in people with type 2 diabetes,even without a significant change in BMI

S54 Facilitating Behavior Change and Well-being to Improve Health Outcomes Diabetes Care Volume 43, Supplement 1, January 2020

(151). There are also considerable datafor the health benefits (e.g., increasedcardiovascular fitness, greater musclestrength, improved insulin sensitivity,etc.) of regular exercise for those withtype 1 diabetes (152). A recent studysuggested that exercise training in type 1diabetes may also improve several im-portant markers such as triglyceridelevel, LDL, waist circumference, andbodymass (153).Higher levels of exerciseintensity are associated with greaterimprovements in A1C and in fitness(154). Other benefits include slowingthe decline in mobility among over-weight patients with diabetes (155).The ADA position statement “PhysicalActivity/Exercise and Diabetes” reviewsthe evidence for the benefits of exercisein people with type 1 and type 2 diabetesand offers specific recommendation (156).Physical activity and exercise should berecommended and prescribed to all indi-viduals with diabetes as part of manage-ment of glycemia and overall health.Specific recommendations and precau-tions will vary by the type of diabetes,age, activity done, and presence of di-abetes-related health complications.Recommendations should be tailoredto meet the specific needs of each in-dividual (156).

Exercise and ChildrenAll children, including children with di-abetes or prediabetes, should be en-couraged to engage in regular physicalactivity. Children should engage in atleast 60 min of moderate to vigorousaerobic activity every day with muscle-and bone-strengthening activities atleast 3 days per week (157). In general,youth with type 1 diabetes benefit frombeing physically active, and an activelifestyle should be recommended toall (158). Youth with type 1 diabeteswho engage in more physical activitymay have better health outcomesand health-related quality of life (159,160).

Frequency and Type of PhysicalActivityPeople with diabetes should performaerobic and resistanceexercise regularly(156). Aerobic activity bouts should ide-ally last at least 10 min, with the goal of;30 min/day or more, most days of theweek for adults with type 2 diabetes.Daily exercise, or at least not allowing

more than 2 days to elapse betweenexercise sessions, is recommended todecrease insulin resistance, regardlessof diabetes type (161,162). Over time,activities should progress in intensity,frequency, and/or duration to at least150 min/week of moderate-intensity ex-ercise. Adults able to run at 6 miles/h(9.7 km/h) for at least 25 min can benefitsufficiently from shorter-intensity activ-ity (75 min/week) (156). Many adults,including most with type 2 diabetes,would be unable or unwilling to partic-ipate in such intense exercise and shouldengage in moderate exercise for therecommended duration. Adults with di-abetes should engage in 2–3 sessions/week of resistance exercise on noncon-secutive days (163). Although heavierresistance training with free weightsand weight machines may improveglycemic control and strength (164),resistance training of any intensity isrecommended to improve strength,balance, and the ability to engage inactivities of daily living throughout thelife span. Providers and staff should helppatients set stepwise goals towardmeet-ing the recommended exercise targets.As persons intensify their exercise pro-gram, medical monitoring may be indi-cated to ensure safety and evaluate theeffects on glucose management. (Seethe section PHYSICAL ACTIVITY AND GLYCEMIC

CONTROL below)Recent evidence supports that all in-

dividuals, including those with diabetes,should be encouraged to reduce theamount of time spent being sedentary(e.g., working at a computer, watchingtelevision) by breaking up bouts of sed-entary activity (.30 min) by brieflystanding, walking, or performing otherlight physical activities (165,166). Avoid-ing extended sedentary periodsmayhelpprevent type 2 diabetes for those at riskand may also aid in glycemic control forthose with diabetes.

A wide range of activities, includingyoga, tai chi, and other types, can havesignificant impacts on A1C, flexibility,muscle strength, and balance (147,167,168). Flexibility and balance exercisesmay be particularly important in olderadults with diabetes to maintain rangeof motion, strength, and balance (156).

Physical Activity andGlycemic ControlClinical trials have provided strong evi-dence for the A1C-lowering value of

resistance training in older adults withtype 2 diabetes (169) and for an additivebenefit of combined aerobic and resis-tance exercise in adults with type 2 di-abetes (170). If not contraindicated,patients with type 2 diabetes shouldbe encouraged to do at least two weeklysessions of resistance exercise (exercisewith free weights or weight machines),with each session consisting of at leastone set (group of consecutive repetitiveexercise motions) of five or more differ-ent resistance exercises involving thelarge muscle groups (169).

For type 1 diabetes, although exercisein general is associated with improve-ment in disease status, care needs to betaken in titrating exercise with respectto glycemic management. Each individ-ual with type 1 diabetes has a variableglycemic response to exercise. This var-iability should be taken into consider-ation when recommending the typeand duration of exercise for a given in-dividual (171).

Women with preexisting diabetes,particularly type 2 diabetes, and thoseat risk for or presenting with gestationaldiabetes mellitus should be advised toengage in regular moderate physicalactivity prior to and during their preg-nancies as tolerated (156).

Pre-exercise EvaluationAs discussed more fully in Section 10“Cardiovascular Disease and Risk Man-agement” (https://doi.org/10.2337/dc20-S010), the best protocol for as-sessing asymptomatic patients withdiabetes for coronary artery disease re-mainsunclear. TheADAconsensus report“Screening forCoronaryArteryDisease inPatients With Diabetes” (172) concludedthat routine testing is not recommended.However, providers should perform acareful history, assess cardiovascularrisk factors, and be aware of the atypicalpresentation of coronary artery diseasein patients with diabetes. Certainly, high-risk patients should be encouraged tostart with short periods of low-intensityexercise and slowly increase the inten-sity and duration as tolerated. Providersshould assess patients for conditionsthat might contraindicate certain typesof exercise or predispose to injury, such asuncontrolled hypertension, untreatedproliferative retinopathy, autonomicneuropathy, peripheral neuropathy, andahistoryof footulcersorCharcot foot. The

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patient’s age and previous physical activitylevel should be considered. The providershould customize the exercise regimento the individual’s needs. Those withcomplicationsmayrequireamorethoroughevaluation prior to beginning an exer-cise program (171).

HypoglycemiaIn individuals taking insulin and/or insulinsecretagogues, physical activity maycause hypoglycemia if the medicationdose or carbohydrate consumption isnot altered. Individuals on these thera-pies may need to ingest some addedcarbohydrate if pre-exercise glucose lev-els are,90mg/dL (5.0mmol/L), depend-ing on whether they are able to lowerinsulin doses during the workout (suchas with an insulin pump or reduced pre-exercise insulin dosage), the time of dayexercise is done, and the intensity andduration of the activity (156,171). Insome patients, hypoglycemia afterexercise may occur and last for severalhours due to increased insulin sensitivity.Hypoglycemia is less common in patientswith diabetes who are not treated withinsulin or insulin secretagogues, and noroutine preventive measures for hypo-glycemia are usually advised in thesecases. Intense activities may actuallyraise blood glucose levels instead oflowering them, especially if pre-exerciseglucose levels are elevated (152). Be-cause of the variation in glycemic re-sponse to exercise bouts, patients needto be educated to check blood glucoselevels before and after periods of ex-ercise and about the potential pro-longed effects (depending on intensityand duration) (see the section DIABETES

SELF-MANAGEMENT EDUCATION AND SUPPORT

above).

Exercise in the Presence ofMicrovascular ComplicationsSee Section 11 “Microvascular Compli-cations and Foot Care” (https://doi.org/10.2337/dc20-S011) for more informa-tion on these long-term complications.

Retinopathy

If proliferative diabetic retinopathy orsevere nonproliferative diabetic retinop-athy is present, then vigorous-intensityaerobic or resistance exercise may becontraindicated because of the risk oftriggering vitreous hemorrhage or ret-inal detachment (173). Consultation with

an ophthalmologist prior to engaging

in an intense exercise regimen may be

appropriate.

Peripheral Neuropathy

Decreased pain sensation and a higherpain threshold in the extremities can

result in an increased risk of skin break-

down, infection, and Charcot joint de-

struction with some forms of exercise.

Therefore, a thorough assessment

should be done to ensure that neurop-

athy does not alter kinesthetic or pro-

prioceptive 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 (174). Inaddition,150min/week

of moderate exercise was reported to

improve outcomes in patients with pre-

diabetic neuropathy (175). All individuals

with peripheral neuropathy should wear

proper footwear and examine their feet

daily to detect lesions early. Anyone

with a foot injury or open sore should

be restricted to non–weight-bearing

activities.

Autonomic Neuropathy

Autonomic neuropathy can increase therisk of exercise-induced injury or ad-

verse events through decreased cardiac

responsiveness to exercise, postural hy-

potension, impaired thermoregulation,

impaired night vision due to impaired

papillary reaction, and greater suscepti-

bility to hypoglycemia (176). Cardiovas-

cular autonomic neuropathy is also an

independent risk factor for cardiovascu-

lar death and silent myocardial ischemia

(177). Therefore, individuals with diabetic

autonomic neuropathy should undergo

cardiac investigation before beginning

physical activity more intense than

that to which they are accustomed.

Diabetic Kidney Disease

Physical activity can acutely increaseurinary albumin excretion. However,

there is no evidence that vigorous-

intensity exercise accelerates 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

(173).

SMOKING CESSATION: TOBACCOAND E-CIGARETTES

Recommendations

5.29 Advise all patients not to usecigarettes and other tobaccoproducts A or e-cigarettes. A

5.30 After identification of tobacco ore-cigarette use, include smokingcessation counseling and otherforms of treatment as a routinecomponent of diabetes care. A

Results from epidemiological, case-control, and cohort studies provide con-vincing evidence to support the causallink between cigarette smoking andhealth risks (178). Recent data showtobacco use is higher among adultswith chronic conditions (179) aswell asin adolescents and young adults withdiabetes (180). Smokers with diabetes(and people with diabetes exposed tosecond-hand smoke) have a height-ened risk of CVD, premature death,microvascular complications, and worseglycemic control when compared withnonsmokers (181–183). Smoking mayhave a role in the development of type 2diabetes (184–187).

The routine and thorough assessmentof tobacco use is essential to preventsmoking or encourage cessation. Numer-ous large randomized clinical trials havedemonstrated the efficacy and cost-effectiveness of brief counseling insmoking cessation, including the use oftelephone quit lines, in reducing tobaccouse. Pharmacologic therapy to assistwithsmoking cessation in people with diabe-tes has been shown to be effective (188),and for the patientmotivated to quit, theaddition of pharmacologic therapy tocounseling is more effective than eithertreatment alone (189). Special consider-ations should include assessment of levelof nicotine dependence, which is asso-ciated with difficulty in quitting and re-lapse (190). Although some patients maygain weight in the period shortly aftersmoking cessation (191), recent researchhas demonstrated that this weight gaindoes not diminish the substantial CVDbenefit realized from smoking cessation(192). One study in smokers with newlydiagnosed type 2 diabetes found thatsmoking cessation was associated withamelioration of metabolic parametersand reduced blood pressure and albu-minuria at 1 year (193).

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In recent years e-cigarettes havegained public awareness and popularitybecause of perceptions that e-cigaretteuse is less harmful than regular cigarettesmoking (194,195). However, in light ofrecent Centers for Disease Control andPrevention evidence (196) of deaths re-lated to e-cigarette use, no personsshould be advised to use e-cigarettes,either as a way to stop smoking tobaccoor as a recreational drug.

PSYCHOSOCIAL ISSUES

Recommendations

5.31 Psychosocial care should be in-tegrated with a collaborative,patient-centered approach andprovided to all people with di-abetes, with the goals of opti-mizing health outcomes andhealth-related quality of life. A

5.32 Psychosocial screening andfollow-up may include, but arenot limited to, attitudes aboutdiabetes, expectations for med-icalmanagement and outcomes,affect or mood, general anddiabetes-related quality of life,available resources (financial,social, and emotional), and psy-chiatric history. E

5.33 Providers should consider assess-ment for symptoms of diabetesdistress, depression, anxiety, dis-ordered eating, and cognitivecapacities using appropriatestandardized and validated toolsat the initial visit, at periodicintervals, and when there is achange in disease, treatment, orlife circumstance. Including care-givers and family members in thisassessment is recommended. B

5.34 Consider screening older adults(aged$65 years) with diabetesfor cognitive impairment anddepression. B

Please refer to the ADA position state-ment “Psychosocial Care for PeopleWithDiabetes” for a list of assessment toolsand additional details (1).Complex environmental, social, be-

havioral, and emotional factors, knownas psychosocial factors, influence livingwith diabetes, both type 1 and type 2,and achieving satisfactory medical out-comes and psychological well-being.Thus, individualswith diabetes and theirfamilies are challenged with complex,

multifaceted issues when integratingdiabetes care into daily life (11).

Emotional well-being is an importantpart of diabetes care and self-management.Psychological and social problems canimpair the individual’s (11,197–201) orfamily’s (200) ability to carry out di-abetes care tasks and therefore poten-tially compromise health status. Thereare opportunities for the clinician toroutinely assess psychosocial statusin a timely and efficient manner forreferral to appropriate services (202,203). A systematic review and meta-analysis showed that psychosocial in-terventions modestly but significantlyimproved A1C (standardized mean dif-ference –0.29%) and mental health out-comes (204). However, there was alimited association between the effectson A1C and mental health, and no in-tervention characteristics predicted ben-efit on both outcomes.

ScreeningKey opportunities for psychosocial screen-ing occur at diabetes diagnosis, duringregularly scheduled management visits,during hospitalizations, with new onsetof complications, during significant tran-sitions in care such as from pediatric toadult care teams (205), or when prob-lems with achieving A1C goals, quality oflife, or self-management are identified(2). Patients are likely to exhibit psycho-logical vulnerability at diagnosis, whentheir medical status changes (e.g., endof the honeymoon period), when theneed for intensified treatment is ev-ident, and when complications are dis-covered. Significant changes in lifecircumstances, often called social deter-minants of health, are known to con-siderably affect a person’s ability toself-manage their illness. Thus, screen-ing for social determinants of health(e.g., loss of employment, birth of a child,or other family-based stresses) shouldalso be incorporated into routine care(206).

Providers can start with informal ver-bal inquires, for example, by askingwhether there have been persistentchanges inmood during the past 2weeksor since the patient’s last visit andwhether the person can identify a trig-gering event or change in circumstan-ces. Providers should also ask whetherthere are new or different barriers totreatment and self-management, such

as feeling overwhelmed or stressed byhaving diabetes (see the section DIABETES

DISTRESS below), changes in finances, orcompeting medical demands (e.g., thediagnosis of a comorbid condition). Incircumstances where persons otherthan the patient are significantly in-volved in diabetes management, theseissues should be explored with non-medical care providers (205). Standard-ized and validated tools for psychosocialmonitoring and assessment can also beused by providers (1), with positivefindings leading to referral to a mentalhealth provider specializing in diabetesfor comprehensive evaluation, diagno-sis, and treatment.

Diabetes Distress

Recommendation

5.35 Routinely monitor people withdiabetes for diabetes distress,particularly when treatmenttargets are not met and/or atthe onset of diabetes complica-tions. B

Diabetes distress is very common and isdistinct from other psychological disor-ders (207–209). Diabetes distress refersto significant negative psychological re-actions related toemotional burdens andworries specific to an individual’s expe-rience in having to manage a severe,complicated, and demanding chronicdisease such as diabetes (208–210).The constant behavioral demands (med-ication dosing, frequency, and titration;monitoring blood glucose, food intake,eating patterns, and physical activity) ofdiabetes self-management and the po-tential or actuality of disease progressionare directly associated with reports ofdiabetes distress (208). The prevalenceof diabetes distress is reported to be 18–45% with an incidence of 38–48% over18 months in persons with type 2 di-abetes (210). In the second DiabetesAttitudes, Wishes and Needs (DAWN2)study, significant diabetes distress wasreported by 45% of the participants, butonly 24% reported that their health careteams asked themhowdiabetes affectedtheir lives (207). High levels of diabetesdistress significantly impact medication-taking behaviors and are linked to higherA1C, lower self-efficacy, and poorerdietary and exercise behaviors (5,208,210).DSMES has been shown to reduce diabe-tes distress (5). It may be helpful to

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provide counseling regarding expecteddiabetes-related versus generalized psy-chological distress, at diagnosis andwhendisease state or treatment changes (211).Diabetes distress should be routinely

monitored (212) using person-baseddiabetes-specific validated measures (1).If diabetesdistress is identified, thepersonshould be referred for specific diabeteseducation to address areas of diabetesself-care causing the patient distressand impacting clinical management.People whose self-care remains im-paired after tailored diabetes educationshould be referred by their care team to abehavioral health provider for evaluationand treatment.Other psychosocial issues known to

affect self-management and health out-comes includeattitudesabout the illness,expectations for medical managementand outcomes, available resources (fi-nancial, social, and emotional) (213), andpsychiatric history.

Referral to a Mental Health SpecialistIndications for referral to amental healthspecialist familiar with diabetes manage-ment may include positive screening foroverall stress related to work-life bal-ance, diabetes distress, diabetes man-agement difficulties, depression, anxiety,disorderedeating, andcognitivedysfunc-tion (see Table 5.2 for a complete list). Itis preferable to incorporate psychosocialassessment and treatment into routinecare rather than waiting for a specificproblem or deterioration in metabolic orpsychological status to occur (32,207).Providers should identify behavioral andmental health providers, ideally thosewho are knowledgeable about diabetestreatment and the psychosocial aspectsof diabetes, to whom they can refer pa-tients. The ADA provides a list of mentalhealth providers who have receivedadditional education in diabetes at the

ADA Mental Health Provider Directory(professional.diabetes.org/mhp_listing).Ideally, psychosocial care providersshould be embedded in diabetes caresettings. Although the clinician may notfeel qualified to treat psychological prob-lems (214), optimizing the patient-pro-vider relationship as a foundation mayincrease the likelihood of the patientaccepting referral for other services.Collaborative care interventions and ateam approach have demonstrated ef-ficacy in diabetes self-management, out-comes of depression, and psychosocialfunctioning (5,6).

Psychosocial/Emotional DistressClinically significant psychopathologic di-agnoses are considerably more preva-lent in people with diabetes than inthose without (215,216). Symptoms,both clinical and subclinical, that inter-fere with the person’s ability to carry outdaily diabetes self-management tasksmust be addressed. In addition to im-pacting a person’s ability to carry outself-management, and the association ofmental health diagnosis and poorershort-term glycemic stability, symptomsof emotional distress are associated withmortality risk (215). Providers shouldconsider an assessment of symptomsof depression, anxiety, disordered eat-ing, and cognitive capacities using ap-propriate standardized/validated tools atthe initial visit, at periodic intervals whenpatient distress is suspected, and whenthere is a change in health, treatment, orlife circumstance. Inclusion of caregiversand family members in this assessmentis recommended. Diabetes distress is ad-dressed as an independent condition (seethe section DIABETES DISTRESS above), as thisstate is very common and expected andis distinct from the psychological dis-orders discussed below (1). A list of age-appropriate screening and evaluation

measures is provided in the ADA positionstatement “Psychosocial Care for Peoplewith Diabetes” (1).

Anxiety Disorders

Recommendations

5.36 Consider screening for anxietyin people exhibiting anxietyor worries regarding diabetescomplications, insulin admin-istration, and takingmedications,as well as fear of hypoglyce-mia and/or hypoglycemia un-awareness that interferes withself-managementbehaviors,andin those who express fear,dread, or irrational thoughtsand/or show anxiety symp-toms such as avoidance be-haviors, excessive repetitivebehaviors, or social withdrawal.Refer for treatment if anxiety ispresent. B

5.37 People with hypoglycemia un-awareness, which can co-occurwith fear of hypoglycemia, shouldbe treated using blood glucoseawareness training (or other ev-idence-based intervention) tohelp re-establish awareness ofsymptoms of hypoglycemia andreduce fear of hypoglycemia. A

Anxiety symptoms and diagnosable dis-orders (e.g., generalized anxiety disorder,body dysmorphic disorder, obsessive-compulsive disorder, specific phobias,and posttraumatic stress disorder) arecommon in people with diabetes (217).The Behavioral Risk Factor SurveillanceSystem (BRFSS) estimated the lifetimeprevalence of generalized anxiety disorderto be 19.5% in peoplewith either type 1 ortype 2 diabetes (218). Common diabetes-specific concerns include fears related tohypoglycemia (219,220), not meetingblood glucose targets (217), and insulin

Table 5.2—Situations that warrant referral of a person with diabetes to a mental health provider for evaluation and treatmentc If self-care remains impaired in a person with diabetes distress after tailored diabetes education

c If a person has a positive screen on a validated screening tool for depressive symptoms

c In the presence of symptoms or suspicions of disordered eating behavior, an eating disorder, or disrupted patterns of eating

c If intentional omission of insulin or oral medication to cause weight loss is identified

c If a person has a positive screen for anxiety or fear of hypoglycemia

c If a serious mental illness is suspected

c In youth and families with behavioral self-care difficulties, repeated hospitalizations for diabetic ketoacidosis, or significant distress

c If a person screens positive for cognitive impairment

c Declining or impaired ability to perform diabetes self-care behaviors

c Before undergoing bariatric or metabolic surgery and after surgery if assessment reveals an ongoing need for adjustment support

S58 Facilitating Behavior Change and Well-being to Improve Health Outcomes Diabetes Care Volume 43, Supplement 1, January 2020

injections or infusion (221). Onset ofcomplications presents another criticalpoint in the disease course when anxietycan occur (1). People with diabetes whoexhibit excessive diabetes self-manage-ment behaviors well beyond what isprescribed or needed to achieve glyce-mic targets may be experiencing symp-toms of obsessive compulsive disorder(222).

General anxiety is a predictor of in-jection-related anxiety and associatedwith fear of hypoglycemia (220,223).Fear of hypoglycemia and hypoglyce-mia unawareness often co-occur. In-terventions aimed at treating one oftenbenefit both (224). Fear of hypoglycemiamay explain avoidance of behaviors as-sociated with lowering glucose such asincreasing insulin doses or frequency ofmonitoring. If fear of hypoglycemia isidentified and a person does not havesymptoms of hypoglycemia, a structuredprogram of blood glucose awarenesstraining delivered in routine clinical prac-tice can improve A1C, reduce the rateof severe hypoglycemia, and restorehypoglycemia awareness (225,226). Ifnot available within the practice setting,a structured program targeting bothfear of hypoglycemia and unawarenessshould be sought out and implementedby a qualified behavioral practitioner(224,227).

Depression

Recommendations

5.38 Providers should consider an-nual screening of all patientswith diabetes, especially thosewith a self-reported history ofdepression, fordepressive symp-toms with age-appropriate de-pression screening measures,recognizing that further evalu-ation will be necessary for in-dividuals who have a positivescreen. B

5.39 Beginning at diagnosis of com-plications or when there aresignificant changes in medicalstatus, consider assessment fordepression. B

5.40 Referrals for treatment of de-pression should be made tomental health providers withexperience using cognitive be-havioral therapy, interpersonaltherapy, or other evidence-based

treatment approaches in con-junction with collaborative carewith the patient’s diabetes treat-ment team. A

History of depression, current depres-sion, and antidepressant medication useare risk factors for the developmentof type 2 diabetes, especially if the in-dividual has other risk factors such asobesity and family history of type 2 di-abetes (228–230). Elevated depressivesymptoms and depressive disorders af-fect one in four patients with type 1 ortype 2 diabetes (199). Thus, routinescreening for depressive symptoms isindicated in this high-risk population in-cluding people with type 1 or type 2diabetes, gestational diabetes mellitus,and postpartum diabetes. Regardlessof diabetes type, women have signifi-cantly higher rates of depression thanmen (231).

Routine monitoring with appropriatevalidatedmeasures (1)canhelp to identifyif referral is warranted. Adult patientswith a history of depressive symptomsor disorder need ongoing monitoring ofdepression recurrence within the contextof routine care (228). Integrating mentaland physical health care can improveoutcomes. When a patient is in psycho-logical therapy (talk therapy), the mentalhealth provider should be incorporatedinto the diabetes treatment team (232).As with DSMES, person-centered collab-orative care approaches have beenshown to improve both depressionand medical outcomes (233).

Various randomized controlled trialshave shown improvements in diabetesand depression health outcomes whendepression is treated (233). It is impor-tant to note thatmedical regimen shouldalso be monitored in response to re-duction in depressive symptoms. Peoplemay agree to or adopt previously refusedtreatment strategies (improving abilityto follow recommended treatment be-haviors), which may include increasedphysical activity and intensification ofregimenbehaviorsandmonitoring, result-ing in changed glucose profiles.

Disordered Eating Behavior

Recommendations

5.41 Providers should consider reeval-uating the treatment regimen ofpeoplewith diabeteswhopresent

with symptoms of disordered eat-ingbehavior,aneatingdisorder,ordisrupted patterns of eating. B

5.42 Consider screening for disor-dered or disrupted eating usingvalidated screening measureswhen hyperglycemia andweightloss are unexplained based onself-reported behaviors relatedtomedication dosing, meal plan,and physical activity. In addi-tion, a review of the medicalregimen is recommended to iden-tify potential treatment-relatedeffects onhunger/caloric intake.B

Estimated prevalence of disorderedeating behavior and diagnosable eat-ing disorders in people with diabetesvaries (234–236). For people withtype 1 diabetes, insulin omission causingglycosuria in order to lose weight is themost commonly reported disordered eat-ing behavior (237,238); in people withtype 2 diabetes, bingeing (excessive foodintakewith anaccompanying senseof lossof control) is most commonly reported.For people with type 2 diabetes treatedwith insulin, intentional omission is alsofrequently reported (239). People withdiabetesanddiagnosableeatingdisordershave high rates of comorbid psychiatricdisorders (240). People with type 1 di-abetes and eating disorders have highrates of diabetes distress and fear ofhypoglycemia (241).

When evaluating symptoms of disor-dered or disrupted eating (when theindividual exhibits eating behavior thatis nonvolitional and maladaptive) inpeople with diabetes, etiology andmotivation for the behavior should beconsidered (236,242). Adjunctive med-ication such as glucagon-like peptide 1receptor agonists (243) may help indi-viduals not only to meet glycemic tar-gets but also to regulate hunger andfood intake, thus having the potential toreduce uncontrollable hunger and bu-limic symptoms.

Serious Mental Illness

Recommendations

5.43 Incorporate active monitoringof diabetes self-care activitiesinto treatment goals for peoplewith diabetes and serious men-tal illness. B

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5.44 Annually screen people who areprescribedatypical antipsychoticmedications for prediabetes ordiabetes. B

5.45 If a second-generation antipsy-chotic medication is prescribedfor adolescents or adults withdiabetes, changes in weight,glycemic control, and choles-terol levels should be carefullymonitored and the treatmentregimen shouldbe reassessed.C

Studies of individuals with serious men-tal illness, particularly schizophreniaand other thought disorders, show sig-nificantly increased rates of type 2 di-abetes (244). People with schizophreniashould bemonitored for type 2 diabetesbecause of the known comorbidity.Disordered thinking and judgment canbe expected to make it difficult toengage in behavior that reduces riskfactors for type 2 diabetes, such asrestrained eating for weight manage-ment. Coordinated management of di-abetes or prediabetes and seriousmental illness is recommended toachieve diabetes treatment targets.In addition, those taking second-gener-ation (atypical) antipsychotics, such asolanzapine, require greater monitoringbecause of an increase in risk of type 2diabetes associated with this medica-tion (245,246). Serious mental illness isoften associated with the inability toevaluate andutilize information tomakejudgments about treatment options.When a person has an established di-agnosis of a mental illness that impactsjudgment, activities of daily living, andability to establish a collaborative re-lationship with care providers, it iswise to include a nonmedical caretakerin decision-making regarding the med-ical regimen. This person can help im-prove the patient’s ability to follow theagreed-upon regimen through bothmonitoring and caretaking functions(247).

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114. Tuttle KR, Bakris GL, Bilous RW, et al. Di-abetic kidney disease: a report from an ADAConsensus Conference. Diabetes Care 2014;37:2864–2883115. Ley SH, Hamdy O, Mohan V, Hu FB. Pre-vention and management of type 2 diabetes:dietary components and nutritional strategies.Lancet 2014;383:1999–2007116. Pan Y, Guo LL, Jin HM. Low-protein diet fordiabetic nephropathy: a meta-analysis of ran-domizedcontrolled trials. AmJClinNutr2008;88:660–666117. Robertson L, Waugh N, Robertson A. Pro-tein restriction for diabetic renal disease. Co-chrane Database Syst Rev 2007;4:CD002181118. Layman DK, Clifton P, Gannon MC, KraussRM, Nuttall FQ. Protein in optimal health: heartdisease and type 2 diabetes. Am J Clin Nutr 2008;87:1571S–1575S119. Ros E. Dietary cis-monounsaturated fattyacids and metabolic control in type 2 diabe-tes. Am J Clin Nutr 2003;78(Suppl.):617S–625S120. Forouhi NG, Imamura F, Sharp SJ, et al.Association of plasma phospholipid n-3 and n-6polyunsaturated fatty acidswith type 2 diabetes:the EPIC-InterAct case-cohort study. PLoS Med2016;13:e1002094121. Wang DD, Li Y, Chiuve SE, et al. Associationof specific dietary fats with total and cause-specific mortality. JAMA Intern Med 2016;176:1134–1145122. Brehm BJ, Lattin BL, Summer SS, et al. One-year comparison of a high-monounsaturated fatdiet with a high-carbohydrate diet in type 2diabetes. Diabetes Care 2009;32:215–220123. Shai I, Schwarzfuchs D, Henkin Y, et al.;Dietary Intervention Randomized Controlled Tri-al (DIRECT) Group. Weight loss with a low-carbohydrate, Mediterranean, or low-fat diet.N Engl J Med 2008;359:229–241124. Brunerova L, Smejkalova V, Potockova J,AndelM.A comparisonof the influenceof a high-fat diet enriched in monounsaturated fatty acidsand conventional diet on weight loss and met-abolic parameters in obese non-diabetic andtype 2 diabetic patients. Diabet Med 2007;24:533–540125. Bloomfield HE, Koeller E, Greer N,MacDonald R, Kane R, Wilt TJ. Effects on healthoutcomes of a Mediterranean diet with no re-striction on fat intake: a systematic review andmeta-analysis. Ann Intern Med 2016;165:491–500126. Sacks FM, Lichtenstein AH, Wu JHY, et al.;American Heart Association. Dietary fats andcardiovascular disease: a presidential advisoryfrom theAmericanHeart Association. Circulation2017;136:e1–e23127. Jacobson TA, Maki KC, Orringer CE, et al.;NLA Expert Panel. National Lipid Associationrecommendations for patient-centeredmanage-ment of dyslipidemia: part 2. J Clin Lipidol 2015;9(Suppl.):S1–S122.e1128. Harris WS, Mozaffarian D, Rimm E, et al.Omega-6 fatty acids and risk for cardiovasculardisease: a science advisory from the AmericanHeart Association Nutrition Subcommittee ofthe Council on Nutrition, Physical Activity,and Metabolism; Council on CardiovascularNursing; and Council on Epidemiology andPrevention. Circulation 2009;119:902–907

129. Crochemore ICC, Souza AFP, de Souza ACF,Rosado EL. v-3 polyunsaturated fatty acid sup-plementation does not influence body compo-sition, insulin resistance, and lipemia in womenwith type 2 diabetes and obesity. Nutr Clin Pract2012;27:553–560130. Holman RR, Paul S, Farmer A, Tucker L,Stratton IM, Neil HA; Atorvastatin in Factorialwith Omega-3 EE90 Risk Reduction in DiabetesStudy Group. Atorvastatin in Factorial with Omega-3 EE90 Risk Reduction in Diabetes (AFORRD):a randomised controlled trial. Diabetologia 2009;52:50–59131. KromhoutD,Geleijnse JM,deGoede J, et al.n-3 fatty acids, ventricular arrhythmia-relatedevents, and fatal myocardial infarction in post-myocardial infarction patients with diabetes.Diabetes Care 2011;34:2515–2520132. Bosch J, Gerstein HC, Dagenais GR, et al.;ORIGIN Trial Investigators. n-3 fatty acids andcardiovascular outcomes in patients with dysgly-cemia. N Engl J Med 2012;367:309–318133. Thomas MC, Moran J, Forsblom C, et al.;FinnDianeStudyGroup. Theassociationbetweendietary sodium intake, ESRD, and all-cause mor-tality in patients with type 1 diabetes. DiabetesCare 2011;34:861–866134. Ekinci EI, ClarkeS, ThomasMC,et al.Dietarysalt intake and mortality in patients with type 2diabetes. Diabetes Care 2011;34:703–709135. Lennon SL, DellaValle DM, Rodder SG, et al.2015 Evidence Analysis Library evidence-basednutrition practice guideline for the managementof hypertension in adults. J Acad Nutr Diet 2017;117:1445–1458.e17136. Maillot M, Drewnowski A. A conflict be-tween nutritionally adequate diets and meetingthe 2010 dietary guidelines for sodium. Am JPrev Med 2012;42:174–179137. Aroda VR, Edelstein SL, Goldberg RB, et al.;Diabetes Prevention Program Research Group.Long-term metformin use and vitamin B12 de-ficiency in the Diabetes Prevention ProgramOutcomes Study. J Clin Endocrinol Metab2016;101:1754–1761138. Allen RW, Schwartzman E, Baker WL,Coleman CI, Phung OJ. Cinnamon use in type2 diabetes: an updated systematic review andmeta-analysis. Ann Fam Med 2013;11:452–459139. Mitri J, Pittas AG. Vitamin D and diabetes.Endocrinol Metab Clin North Am 2014;43:205–232140. Mozaffarian D. Dietary and policy prioritiesfor cardiovascular disease, diabetes, andobesity:a comprehensive review. Circulation 2016;133:187–225141. Grotz VL, Pi-Sunyer X, Porte D Jr, Roberts A,Richard Trout J. A 12-week randomized clinicaltrial investigating the potential for sucralose toaffect glucose homeostasis. Regul Toxicol Phar-macol 2017;88:22–33142. Miller PE, Perez V. Low-calorie sweetenersand body weight and composition: a meta-analysis of randomized controlled trials andprospective cohort studies. Am J Clin Nutr2014;100:765–777143. Rogers PJ, Hogenkamp PS, de Graaf C, et al.Does low-energy sweetener consumption affectenergy intake and body weight? A systematicreview, includingmeta-analyses, of the evidence

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for type 2 diabetes mellitus: a cohort study. AnnIntern Med 2010;152:10–17188. Tonstad S, Lawrence D. Varenicline insmokers with diabetes: a pooled analysis of15 randomized, placebo-controlled studiesof varenicline. J Diabetes Investig 2017;8:93–100189. West R. Tobacco smoking: health impact,prevalence, correlates and interventions. Psy-chol Health 2017;32:1018–1036190. Ranney L, Melvin C, Lux L, McClain E, LohrKN. Systematic review: smoking cessation in-tervention strategies for adults and adults inspecial populations. Ann Intern Med 2006;145:845–856191. Tian J, Venn A, Otahal P, Gall S. Theassociation between quitting smoking andweight gain: a systematic review and meta-analysis of prospective cohort studies. ObesRev 2015;16:883–901192. Clair C, Rigotti NA, Porneala B, et al. As-sociation of smoking cessation and weightchangewith cardiovasculardiseaseamongadultswith and without diabetes. JAMA 2013;309:1014–1021193. Voulgari C, Katsilambros N, Tentolouris N.Smoking cessation predicts amelioration of mi-croalbuminuria in newly diagnosed type 2 di-abetes mellitus: a 1-year prospective study.Metabolism 2011;60:1456–1464194. Huerta TR, Walker DM, Mullen D, JohnsonTJ, Ford EW. Trends in e-cigarette awareness andperceived harmfulness in the U.S. Am J PrevMed2017;52:339–346195. Pericot-Valverde I, Gaalema DE, Priest JS,Higgins ST. E-cigarette awareness, perceivedharmfulness, and ever use among U.S. adults.Prev Med 2017;104:92–99196. Centers for Disease Control and Preven-tion. Outbreak of lung injury associated withe-cigaretteuse,orvaping,2019.Accessed27Sep-tember 2019. Available from https://www.cdc.gov/tobacco/basic_information/e-cigarettes/severe-lung-disease.html197. Anderson RJ, Grigsby AB, Freedland KE,et al. Anxiety and poor glycemic control:a meta-analytic review of the literature. Int JPsychiatry Med 2002;32:235–247198. Delahanty LM, Grant RW, Wittenberg E,et al. Association of diabetes-related emo-tional distress with diabetes treatment in pri-mary care patients with type 2 diabetes. DiabetMed 2007;24:48–54199. Anderson RJ, Freedland KE, Clouse RE,Lustman PJ. The prevalence of comorbid de-pression in adults with diabetes: ameta-analysis.Diabetes Care 2001;24:1069–1078200. Kovacs Burns K, Nicolucci A, Holt RIG,et al.; DAWN2 Study Group. Diabetes Atti-tudes, Wishes and Needs second study(DAWN2�): cross-national benchmarkingindicators for family members living with peo-ple with diabetes. Diabet Med 2013;30:778–788201. Ducat L, Philipson LH, Anderson BJ. Themental health comorbidities of diabetes. JAMA2014;312:691–692202. Gonzalvo JD, Hamm J, Eaves S, et al. Apractical approach to mental health for thediabetes educator. AADE Pract 2019;7:29–44203. Robinson DJ, Coons M, Haensel H, Vallis M,Yale J-F; Diabetes Canada Clinical Practice

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