LIFESTYLE MANAGEMENT: STANDARDSOFMEDICALCAREIN DIABETESD2019
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S46 Diabetes Care Volume 42, Supplement 1, January 2019
5. Lifestyle Management: American Diabetes Association
Standards of Medical Care in
Diabetesd2019
Diabetes Care 2019;42(Suppl. 1):S46–S60 | https://doi.org/10.2337/dc19-S005
The American Diabetes Association (ADA) “Standards of Medical Care in Diabetes”
includes ADA’s current clinical practice recommendations and is intended to pro-
vide the components of diabetes care, general treatment goals and guidelines,
5. LIFESTYLE MANAGEMENT
and tools to evaluate quality of care. Members of the ADA Professional Practice
Committee, a multidisciplinary expert committee, are responsible for updating
the Standards of Care annually, or more frequently as warranted. For a detailed
description of ADA standards, statements, and reports, as well as the evidence-
grading system for ADA’s clinical practice recommendations, please refer to the
Standards of Care Introduction. Readers who wish to comment on the Standards
of Care are invited to do so at professional.diabetes.org/SOC.
Lifestyle management is a fundamental aspect of diabetes care and includes diabetes
self-management education and support (DSMES), medical nutrition therapy (MNT),
physical activity, smoking cessation counseling, and psychosocial care. Patients and
care providers should focus together on how to optimize lifestyle from the time of
the initial comprehensive medical evaluation, throughout all subsequent evaluations
and follow-up, and during the assessment of complications and management of co-
morbid conditions in order to enhance diabetes care.
DIABETES SELF-MANAGEMENT EDUCATION AND SUPPORT
Recommendations
5.1 In accordance with the national standards for diabetes self-management
education and support, all people with diabetes should participate in diabetes
self-management education to facilitate the knowledge, skills, and ability
necessary for diabetes self-care. Diabetes self-management support is ad-
ditionally recommended to assist with implementing and sustaining skills
and behaviors needed for ongoing self-management. B
5.2 There are four critical times to evaluate the need for diabetes self-
management education and support: at diagnosis, annually, when compli-
cating factors arise, and when transitions in care occur. E
5.3 Clinical outcomes, health status, and quality of life are key goals of diabetes
self-management education and support that should be measured as part of Suggested citation: American Diabetes Associa-
tion. 5. Lifestyle management: Standards of
routine care. C
Medical Care in Diabetesd2019. Diabetes Care
5.4 Diabetes self-management education and support should be patient cen- 2019;42(Suppl. 1):S46–S60
tered, may be given in group or individual settings or using technology, and © 2018 by the American Diabetes Association.
should be communicated with the entire diabetes care team. A Readers may use this article as long as the work is
5.5 Because diabetes self-management education and support can improve properly cited, the use is educational and not
outcomes and reduce costs B, adequate reimbursement by third-party payers for profit, and the work is not altered. More infor-
is recommended. E mation is available at http://www.diabetesjournals
.org/content/license.care.diabetesjournals.org Lifestyle Management S47
DSMES services facilitate the knowledge, 3. When new complicating factors diabetes management (BC-ADM) certifi-
skills, and abilities necessary for optimal (health conditions, physical limita- cation demonstrates specialized training
diabetes self-care and incorporate the tions, emotional factors, or basic and mastery of a specific body of knowl-
needs, goals, and life experiences of the living needs) arise that influence edge (4). Additionally, there is growing
person with diabetes. The overall objec- self-management evidence for the role of community
tives of DSMES are to support informed 4. When transitions in care occur health workers (36,37), as well as peer
decision making, self-care behaviors, (36–40) and lay leaders (41), in providing
problem-solving, and active collabora- DSMES focuses on supporting patient ongoing support.
tion with the health care team to improve empowerment by providing people with DSMES is associated with an increased
clinical outcomes, health status, and diabetes the tools to make informed self- use of primary care and preventive ser-
quality of life in a cost-effective manner management decisions (6). Diabetes care vices (18,42,43) and less frequent use of
(1). Providers are encouraged to consider has shifted to an approach that places acute care and inpatient hospital services
the burden of treatment and the pa- the person with diabetes and his or her (12). Patients who participate in DSMES
tient’s level of confidence/self-efficacy family at the center of the care model, are more likely to follow best practice
for management behaviors as well as the working in collaboration with health care treatment recommendations, particu-
level of social and family support when professionals. Patient-centered care is re- larly among the Medicare population,
providing DSMES. Patient performance spectful of and responsive to individual and have lower Medicare and insurance
of self-management behaviors, including patient preferences, needs, and values. claim costs (19,42). Despite these bene-
its effect on clinical outcomes, health It ensures that patient values guide all fits, reports indicate that only 5–7% of
status, and quality of life, as well as the decision making (7). individuals eligible for DSMES through
psychosocial factors impacting the per- Medicare or a private insurance plan
son’s self-management should be mon- Evidence for the Benefits actually receive it (44,45). This low par-
itored as part of routine clinical care. Studies have found that DSMES is asso- ticipation may be due to lack of referral or
In addition, in response to the growing ciated with improved diabetes knowl- other identified barriers such as logistical
literature that associates potentially judg- edge and self-care behaviors (8), lower issues (timing, costs) and the lack of a
mental words with increased feelings of A1C (7,9–11), lower self-reported weight perceived benefit (46). Thus, in addition
shame and guilt, providers are encouraged (12,13), improved quality of life (10,14), to educating referring providers about
to consider the impact that language has reduced all-cause mortality risk (15), the benefits of DSMES and the critical
on building therapeutic relationships and healthy coping (16,17), and reduced times to refer (1), alternative and in-
to choose positive, strength-based words health care costs (18–20). Better out- novative models of DSMES delivery
and phrases that put people first (2,3). Pa- comes were reported for DSMES inter- need to be explored and evaluated.
tient performance of self-management ventions that were over 10 h in total
behaviors as well as psychosocial factors duration (11), included ongoing support Reimbursement
impacting the person’s self-management (5,21), were culturally (22,23) and age Medicare reimburses DSMES when that
should be monitored. Please see Section appropriate (24,25), were tailored to service meets the national standards
4, “Comprehensive Medical Evaluation individual needs and preferences, and ad- (1,4) and is recognized by the American
and Assessment of Comorbidities,” for dressed psychosocial issues and incorpo- Diabetes Association (ADA) or other ap-
more on use of language. rated behavioral strategies (6,16,26,27). proval bodies. DSMES is also covered by
DSMES and the current national stan- Individual and group approaches are most health insurance plans. Ongoing
dards guiding it (1,4) are based on evi- effective (13,28,29), with a slight benefit support has been shown to be instru-
dence of benefit. Specifically, DSMES realized by those who engage in both mental for improving outcomes when it
helps people with diabetes to identify (11). Emerging evidence demonstrates is implemented after the completion of
and implement effective self-manage- the benefit of Internet-based DSMES education services. DSMES is frequently
ment strategies and cope with diabetes services for diabetes prevention and reimbursed when performed in person.
at the four critical time points (described the management of type 2 diabetes However, although DSMES can also be
below) (1). Ongoing DSMES helps people (30–32). Technology-enabled diabe- provided via phone calls and telehealth,
with diabetes to maintain effective self- tes self-management solutions improve these remote versions may not always
management throughout a lifetime of A1C most effectively when there is be reimbursed. Changes in reimburse-
diabetes as they face new challenges two-way communication between the ment policies that increase DSMES ac-
and as advances in treatment become patient and the health care team, individ- cess and utilization will result in a positive
available (5). ualized feedback, use of patient-generated impact to beneficiaries’ clinical outcomes,
Four critical time points have been health data, and education (32). Current quality of life, health care utilization, and
defined when the need for DSMES is to research supports nurses, dietitians, and costs (47).
be evaluated by the medical care pro- pharmacists as providers of DSMES who
vider and/or multidisciplinary team, with may also develop curriculum (33–35). NUTRITION THERAPY
referrals made as needed (1): Members of the DSMES team should For many individuals with diabetes, the
have specialized clinical knowledge in most challenging part of the treat-
1. At diagnosis diabetes and behavior change principles. ment plan is determining what to eat and
2. Annually for assessment of education, Certification as a certified diabetes ed- following a meal plan. There is not a one-
nutrition, and emotional needs ucator (CDE) or board certified-advanced size-fits-all eating pattern for individualsS48 Lifestyle Management Diabetes Care Volume 42, Supplement 1, January 2019
with diabetes, and meal planning should carbohydrate, protein, and fat for all peo- support one eating plan over another
be individualized. Nutrition therapy has ple with diabetes. Therefore, macronu- at this time.
an integral role in overall diabetes man- trient distribution should be based on A simple and effective approach to
agement, and each person with diabetes an individualized assessment of current glycemia and weight management em-
should be actively engaged in education, eating patterns, preferences, and meta- phasizing portion control and healthy
self-management, and treatment plan- bolic goals. Consider personal preferen- food choices should be considered for
ning with his or her health care team, ces (e.g., tradition, culture, religion, those with type 2 diabetes who are not
including the collaborative development health beliefs and goals, economics) as taking insulin, who have limited health
of an individualized eating plan (35,48). well as metabolic goals when working literacy or numeracy, or who are older
All individuals with diabetes should be with individuals to determine the best and prone to hypoglycemia (50). The
offered a referral for individualized MNT eating pattern for them (35,51,52). It is diabetes plate method is commonly
provided by a registered dietitian (RD) important that each member of the used for providing basic meal planning
who is knowledgeable and skilled in health care team be knowledgeable guidance (67) as it provides a visual guide
providing diabetes-specific MNT (49). about nutrition therapy principles for showing how to control calories (by
MNT delivered by an RD is associated people with all types of diabetes and featuring a smaller plate) and carbohy-
with A1C decreases of 1.0–1.9% for peo- be supportive of their implementation. drates (by limiting them to what fits in
ple with type 1 diabetes (50) and 0.3–2% Emphasis should be on healthful eat- one-quarter of the plate) and puts an
for people with type 2 diabetes (50). See ing patterns containing nutrient-dense emphasis on low-carbohydrate (or non-
Table 5.1 for specific nutrition recom- foods, with less focus on specific nu- starchy) vegetables.
mendations. Because of the progres- trients (53). A variety of eating patterns
sive nature of type 2 diabetes, lifestyle are acceptable for the management of Weight Management
changes alone may not be adequate to diabetes (51,54), and a referral to an RD Management and reduction of weight is
maintain euglycemia over time. How- or registered dietitian nutritionist (RDN) important for people with type 1 dia-
ever, after medication is initiated, nutri- is essential to assess the overall nutrition betes, type 2 diabetes, or prediabetes
tion therapy continues to be an important status of, and to work collaboratively who have overweight or obesity. Life-
component and should be integrated with, the patient to create a personalized style intervention programs should be
with the overall treatment plan (48). meal plan that considers the individual’s intensive and have frequent follow-up
health status, skills, resources, food pref- to achieve significant reductions in ex-
Goals of Nutrition Therapy for Adults erences, and health goals to coordinate cess body weight and improve clinical
With Diabetes and align with the overall treatment indicators. There is strong and consis-
1. To promote and support healthful plan including physical activity and med- tent evidence that modest persistent
eating patterns, emphasizing a variety ication. The Mediterranean (55,56), Di- weight loss can delay the progression
of nutrient-dense foods in appropri- etary Approaches to Stop Hypertension from prediabetes to type 2 diabetes
ate portion sizes, to improve overall (DASH) (57–59), and plant-based (60,61) (51,68,69) (see Section 3 “Prevention
health and: diets are all examples of healthful eat- or Delay of Type 2 Diabetes”) and is
○ Achieve and maintain body weight ing patterns that have shown positive beneficial to the management of type
goals results in research, but individualized 2 diabetes (see Section 8 “Obesity
○ Attain individualized glycemic, meal planning should focus on per- Management for the Treatment of
blood pressure, and lipid goals sonal preferences, needs, and goals. In Type 2 Diabetes”).
○ Delay or prevent the complica- addition, research indicates that low- Studies of reduced calorie interven-
tions of diabetes carbohydrate eating plans may result in tions show reductions in A1C of 0.3%
2. To address individual nutrition needs improved glycemia and have the poten- to 2.0% in adults with type 2 diabetes,
based on personal and cultural pref- tial to reduce antihyperglycemic medi- as well as improvements in medication
erences, health literacy and numeracy, cations for individuals with type 2 doses and quality of life (50,51). Sustain-
access to healthful foods, willing- diabetes (62–64). As research studies ing weight loss can be challenging (70,71)
ness and ability to make behavioral on some low-carbohydrate eating plans but has long-term benefits; maintaining
changes, and barriers to change generally indicate challenges with long- weight loss for 5 years is associated with
3. To maintain the pleasure of eating by term sustainability, it is important to sustained improvements in A1C and lipid
providing nonjudgmental messages reassess and individualize meal plan levels (72). Weight loss can be attained
about food choices guidance regularly for those interested with lifestyle programs that achieve a
4. To provide an individual with diabe- in this approach. This meal plan is not 500–750 kcal/day energy deficit or pro-
tes the practical tools for developing recommended at this time for women vide ;1,200–1,500 kcal/day for women
healthy eating patterns rather than who are pregnant or lactating, people and 1,500–1,800 kcal/day for men,
focusing on individual macronutrients, with or at risk for disordered eating, or adjusted for the individual’s baseline
micronutrients, or single foods people who have renal disease, and it body weight. For many obese individ-
should be used with caution in patients uals with type 2 diabetes, weight loss
Eating Patterns, Macronutrient taking sodium–glucose cotransporter of at least 5% is needed to produce
Distribution, and Meal Planning 2 (SGLT2) inhibitors due to the potential beneficial outcomes in glycemic con-
Evidence suggests that there is not risk of ketoacidosis (65,66). There is in- trol, lipids, and blood pressure (70).
an ideal percentage of calories from adequate research in type 1 diabetes to It should be noted, however, that thecare.diabetesjournals.org Lifestyle Management S49
Table 5.1—Medical nutrition therapy recommendations
Topic Recommendations Evidence rating
Effectiveness of 5.6 An individualized medical nutrition therapy program as needed to achieve treatment goals, A
nutrition therapy preferably provided by a registered dietitian, is recommended for all people with type 1 or type 2
diabetes, prediabetes, and gestational diabetes mellitus.
5.7 A simple and effective approach to glycemia and weight management emphasizing portion control B
and healthy food choices may be considered for those with type 2 diabetes who are not taking insulin,
who have limited health literacy or numeracy, or who are older and prone to hypoglycemia.
5.8 Because diabetes nutrition therapy can result in cost savings B and improved outcomes (e.g., B, A, E
A1C reduction) A, medical nutrition therapy should be adequately reimbursed by insurance and
other payers. E
Energy balance 5.9 Weight loss (.5%) achievable by the combination of reduction of calorie intake and lifestyle A
modification benefits overweight or obese adults with type 2 diabetes and also those with
prediabetes. Intervention programs to facilitate weight loss are recommended.
Eating patterns and 5.10 There is no single ideal dietary distribution of calories among carbohydrates, fats, and proteins for E
macronutrient people with diabetes; therefore, meal plans should be individualized while keeping total calorie
distribution and metabolic goals in mind.
5.11 A variety of eating patterns are acceptable for the management of type 2 diabetes and prediabetes. B
Carbohydrates 5.12 Carbohydrate intake should emphasize nutrient-dense carbohydrate sources that are high in fiber, B
including vegetables, fruits, legumes, whole grains, as well as dairy products.
5.13 For people with type 1 diabetes and those with type 2 diabetes who are prescribed a flexible insulin A, B
therapy program, education on how to use carbohydrate counting A and in some cases how to
consider fat and protein content B to determine mealtime insulin dosing is recommended to improve
glycemic control.
5.14 For individuals whose daily insulin dosing is fixed, a consistent pattern of carbohydrate intake with B
respect to time and amount may be recommended to improve glycemic control and reduce the risk
of hypoglycemia.
5.15 People with diabetes and those at risk are advised to avoid sugar-sweetened beverages (including B, A
fruit juices) 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 5.16 In individuals with type 2 diabetes, ingested protein appears to increase insulin response without B
increasing plasma glucose concentrations. Therefore, carbohydrate sources high in protein should
be avoided when trying to treat or prevent hypoglycemia.
Dietary fat 5.17 Data on the ideal total dietary fat content for people with diabetes are inconclusive, so an eating B
plan emphasizing elements of a Mediterranean-style diet rich in monounsaturated and
polyunsaturated fats may be considered to improve glucose metabolism and lower cardiovascular
disease risk and can be an effective alternative to a diet low in total fat but relatively high in
carbohydrates.
5.18 Eating foods rich in long-chain n-3 fatty acids, such as fatty fish (EPA and DHA) and nuts and seeds B, A
(ALA), is recommended to prevent or treat cardiovascular disease B; however, evidence does not
support a beneficial role for the routine use of n-3 dietary supplements. A
Micronutrients and 5.19 There is no clear evidence that dietary supplementation with vitamins, minerals (such as C
herbal supplements 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.
Alcohol 5.20 Adults with diabetes who drink alcohol should do so in moderation (no more than one drink C
per day for adult women and no more than two drinks per day for adult men).
5.21 Alcohol consumption may place people with diabetes at increased risk for hypoglycemia, especially B
if taking insulin or insulin secretagogues. Education and awareness regarding the recognition and
management of delayed hypoglycemia are warranted.
Sodium 5.22 As for the general population, people with diabetes should limit sodium consumption B
to ,2,300 mg/day.
Nonnutritive 5.23 The use of nonnutritive sweeteners may have the potential to reduce overall calorie and B
sweeteners 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.
clinical benefits of weight loss are pro- on need, feasibility, and safety (73). structured weight loss plan, is strongly
gressive and more intensive weight MNT guidance from an RD/RDN with recommended.
loss goals (i.e., 15%) may be appropri- expertise in diabetes and weight man- Studies have demonstrated that a
ate to maximize benefit depending agement, throughout the course of a variety of eating plans, varying inS50 Lifestyle Management Diabetes Care Volume 42, Supplement 1, January 2019
macronutrient composition, can be used low-carbohydrate eating plans generally control (51,82,93–96). Individuals who
effectively and safely in the short term indicate challenges with long-term sus- consume meals containing more protein
(1–2 years) to achieve weight loss in tainability, it is important to reassess and fat than usual may also need to make
people with diabetes. This includes struc- and individualize meal plan guidance mealtime insulin dose adjustments to
tured low-calorie meal plans that include regularly for those interested in this compensate for delayed postprandial
meal replacements (72–74) and the approach. Providers should maintain glycemic excursions (97–99). For individ-
Mediterranean eating pattern (75) as consistent medical oversight and recog- uals on a fixed daily insulin schedule,
well as low-carbohydrate meal plans nize that certain groups are not ap- meal planning should emphasize a rela-
(62). However, no single approach has propriate for low-carbohydrate eating tively fixed carbohydrate consumption
been proven to be consistently superior plans, including women who are preg- pattern with respect to both time and
(76,77), and more data are needed to nant or lactating, children, and people amount (35).
identify and validate those meal plans who have renal disease or disordered
that are optimal with respect to long- eating behavior, and these plans should Protein
term outcomes as well as patient ac- be used with caution for those taking There is no evidence that adjusting
ceptability. The importance of providing SGLT2 inhibitors due to potential risk the daily level of protein intake (typically
guidance on an individualized meal plan of ketoacidosis (65,66). There is inade- 1–1.5 g/kg body weight/day or 15–20%
containing nutrient-dense foods, such as quate research about dietary patterns total calories) will improve health in
vegetables, fruits, legumes, dairy, lean for type 1 diabetes to support one eating individuals without diabetic kidney dis-
sources of protein (including plant-based plan over another at this time. ease, and research is inconclusive re-
sources as well as lean meats, fish, and Most individuals with diabetes report garding the ideal amount of dietary
poultry), nuts, seeds, and whole grains, a moderate intake of carbohydrate (44– protein to optimize either glycemic con-
cannot be overemphasized (77), as well 46% of total calories) (51). Efforts to trol or cardiovascular disease (CVD)
as guidance on achieving the desired en- modify habitual eating patterns are risk (84,100). Therefore, protein intake
ergy deficit (78–81). Any approach to often unsuccessful in the long term; goals should be individualized based
meal planning should be individualized people generally go back to their usual on current eating patterns. Some re-
considering the health status, personal macronutrient distribution (51). Thus, search has found successful manage-
preferences, and ability of the person the recommended approach is to in- ment of type 2 diabetes with meal
with diabetes to sustain the recommen- dividualize meal plans to meet caloric plans including slightly higher levels of
dations in the plan. goals with a macronutrient distribution protein (20–30%), which may contribute
that is more consistent with the individ- to increased satiety (58).
Carbohydrates ual’s usual intake to increase the likeli- Those with diabetic kidney disease
Studies examining the ideal amount of hood for long-term maintenance. (with albuminuria and/or reduced esti-
carbohydrate intake for people with As for all individuals in developed mated glomerular filtration rate) should
diabetes are inconclusive, although moni- countries, both children and adults aim to maintain dietary protein at the
toring carbohydrate intake and consid- with diabetes are encouraged to mini- recommended daily allowance of 0.8
ering the blood glucose response to mize intake of refined carbohydrates g/kg body weight/day. Reducing the
dietary carbohydrate are key for improv- and added sugars and instead focus amount of dietary protein below the
ing postprandial glucose control (82,83). on carbohydrates from vegetables, le- recommended daily allowance is not
The literature concerning glycemic index gumes, fruits, dairy (milk and yogurt), recommended because it does not alter
and glycemic load in individuals with di- and whole grains. The consumption of glycemic measures, cardiovascular risk
abetes is complex, often yielding mixed sugar-sweetened beverages (including measures, or the rate at which glomer-
results, though in some studies lowering fruit juices) and processed “low-fat” ular filtration rate declines (101,102).
the glycemic load of consumed carbohy- or “nonfat” food products with high In individuals with type 2 diabetes,
drates has demonstrated A1C reductions amounts of refined grains and added protein intake may enhance or increase
of 0.2% to 0.5% (84,85). Studies longer sugars is strongly discouraged (90–92). the insulin response to dietary carbohy-
than 12 weeks report no significant in- Individuals with type 1 or type 2 di- drates (103). Therefore, use of carbohy-
fluence of glycemic index or glycemic load abetes taking insulin at mealtime should drate sources high in protein (such as
independent of weight loss on A1C; how- be offered intensive and ongoing edu- milk and nuts) to treat or prevent hypo-
ever, mixed results have been reported cation on the need to couple insulin glycemia should be avoided due to the
for fasting glucose levels and endoge- administration with carbohydrate in- potential concurrent rise in endogenous
nous insulin levels. take. For people whose meal schedule or insulin.
For people with type 2 diabetes or carbohydrate consumption is variable,
prediabetes, low-carbohydrate eating regular counseling to help them under- Fats
plans show potential to improve glyce- stand the complex relationship between The ideal amount of dietary fat for in-
mia and lipid outcomes for up to 1 year carbohydrate intake and insulin needs dividuals with diabetes is controversial.
(62–64,86–89). Part of the challenge in is important. In addition, education on The National Academy of Medicine has
interpreting low-carbohydrate research using the insulin-to-carbohydrate ratios defined an acceptable macronutrient
has been due to the wide range of def- for meal planning can assist them with distribution for total fat for all adults
initions for a low-carbohydrate eating effectively modifying insulin dosing from to be 20–35% of total calorie intake (104).
plan (85,86). As research studies on meal to meal and improving glycemic The type of fats consumed is morecare.diabetesjournals.org Lifestyle Management S51
important than total amount of fat when or peripheral neuropathy (123). Routine beverage may serve as a short-term re-
looking at metabolic goals and CVD risk, supplementation with antioxidants, such placement strategy, but overall, people
and it is recommended that the per- as vitamins E and C and carotene, is not are encouraged to decrease both sweet-
centage of total calories from saturated advised due to lack of evidence of effi- ened and nonnutritive-sweetened bever-
fats should be limited (75,90,105–107). cacy and concern related to long-term ages and use other alternatives, with an
Multiple randomized controlled trials safety. In addition, there is insufficient emphasis on water intake (132).
including patients with type 2 diabetes evidence to support the routine use of
have reported that a Mediterranean- herbals and micronutrients, such as cin- PHYSICAL ACTIVITY
style eating pattern (75,108–113), rich namon (124), curcumin, vitamin D (125),
Recommendations
in polyunsaturated and monounsatu- or chromium, to improve glycemia in
5.24 Children and adolescents with
rated fats, can improve both glycemic people with diabetes (35,126). However,
type 1 or type 2 diabetes or
control and blood lipids. However, sup- for special populations, including preg-
prediabetes should engage
plements do not seem to have the nant or lactating women, older adults,
in 60 min/day or more of mod-
same effects as their whole-food coun- vegetarians, and people following very
erate- or vigorous-intensity
terparts. A systematic review concluded low-calorie or low-carbohydrate diets, a
aerobic activity, with vigor-
that dietary supplements with n-3 fatty multivitamin may be necessary.
ous muscle-strengthening and
acids did not improve glycemic con-
bone-strengthening activities at
trol in individuals with type 2 diabe- Alcohol
least 3 days/week. C
tes (84). Randomized controlled trials Moderate alcohol intake does not have
5.25 Most adults with type 1 C and
also do not support recommending n-3 major detrimental effects on long-term
type 2 B diabetes should engage
supplements for primary or secondary blood glucose control in people with
in 150 min or more of moderate-
prevention of CVD (114–118). People diabetes. Risks associated with alcohol
to-vigorous intensity aerobic ac-
with diabetes should be advised to follow consumption include hypoglycemia (par-
tivity per week, spread over at
the guidelines for the general population ticularly for those using insulin or insulin
least 3 days/week, with no more
for the recommended intakes of satu- secretagogue therapies), weight gain,
than 2 consecutive days without
rated fat, dietary cholesterol, and trans and hyperglycemia (for those consuming
activity. Shorter durations (min-
fat (90). In general, trans fats should excessive amounts) (35,126). People with
imum 75 min/week) of vigorous-
be avoided. In addition, as saturated diabetes can follow the same guidelines
intensity or interval training may
fats are progressively decreased in the as those without diabetes if they choose
be sufficient for younger and
diet, they should be replaced with un- to drink. For women, no more than one
more physically fit individuals.
saturated fats and not with refined car- drink per day, and for men, no more than
5.26 Adults with type 1 C and type 2 B
bohydrates (112). two drinks per day is recommended (one
diabetes should engage in 2–3
drink is equal to a 12-oz beer, a 5-oz glass
sessions/week of resistance ex-
Sodium of wine, or 1.5 oz of distilled spirits).
ercise on nonconsecutive days.
As for the general population, people
5.27 All adults, and particularly those
with diabetes are advised to limit their Nonnutritive Sweeteners
with type 2 diabetes, should
sodium consumption to ,2,300 mg/day For some people with diabetes who are
decrease the amount of time
(35). Restriction below 1,500 mg, even accustomed to sugar-sweetened prod-
spent in daily sedentary behav-
for those with hypertension, is gener- ucts, nonnutritive sweeteners (con-
ior. B Prolonged sitting should
ally not recommended (119–121). So- taining few or no calories) may be an
be interrupted every 30 min for
dium intake recommendations should acceptable substitute for nutritive sweet-
blood glucose benefits, partic-
take into account palatability, availabil- eners (those containing calories such as
ularly in adults with type 2 di-
ity, affordability, and the difficulty of sugar, honey, agave syrup) when con-
abetes. C
achieving low-sodium recommenda- sumed in moderation. While use of
5.28 Flexibility training and balance
tions in a nutritionally adequate diet nonnutritive sweeteners does not ap-
training are recommended 2–3
(122). pear to have a significant effect on
times/week for older adults with
glycemic control (127), they can reduce
diabetes. Yoga and tai chi may
Micronutrients and Supplements overall calorie and carbohydrate intake
be included based on individual
There continues to be no clear evidence (51). Most systematic reviews and meta-
preferences to increase flexibility,
of benefit from herbal or nonherbal analyses show benefits for nonnutritive
muscular strength, and balance. C
(i.e., vitamin or mineral) supplementation sweetener use in weight loss (128,129);
for people with diabetes without un- however, some research suggests an
derlying deficiencies (35). Metformin is association with weight gain (130). Reg- Physical activity is a general term that
associated with vitamin B12 deficiency, ulatory agencies set acceptable daily includes all movement that increases
with a recent report from the Diabetes intake levels for each nonnutritive energy use and is an important part of
Prevention Program Outcomes Study sweetener, defined as the amount that the diabetes management plan. Exercise
(DPPOS) suggesting that periodic test- can be safely consumed over a person’s is a more specific form of physical ac-
ing of vitamin B12 levels should be lifetime (35,131). For those who consume tivity that is structured and designed
considered in patients taking metfor- sugar-sweetened beverages regularly, to improve physical fitness. Both phys-
min, particularly in those with anemia a low-calorie or nonnutritive-sweetened ical activity and exercise are important.S52 Lifestyle Management Diabetes Care Volume 42, Supplement 1, January 2019
Exercise has been shown to improve 1 and type 2 diabetes and offers specific should be encouraged to reduce the
blood glucose control, reduce cardiovas- recommendation (142). amount of time spent being sedentary
cular risk factors, contribute to weight (e.g., working at a computer, watching
loss, and improve well-being (133). Phys- Exercise and Children TV) by breaking up bouts of sedentary
ical activity is as important for those with All children, including children with di- activity (.30 min) by briefly standing,
type 1 diabetes as it is for the general abetes or prediabetes, should be en- walking, or performing other light phys-
population, but its specific role in the couraged to engage in regular physical ical activities (150,151). Avoiding ex-
prevention of diabetes complications activity. Children should engage in at tended sedentary periods may help
and the management of blood glucose least 60 min of moderate-to-vigorous prevent type 2 diabetes for those at
is not as clear as it is for those with type aerobic activity every day with muscle- risk and may also aid in glycemic control
2 diabetes. A recent study suggested and bone-strengthening activities at for those with diabetes.
that the percentage of people with di- least 3 days per week (143). In general, A wide range of activities, includ-
abetes who achieved the recommended youth with type 1 diabetes benefit from ing yoga, tai chi, and other types, can
exercise level per week (150 min) var- being physically active, and an active have significant impacts on A1C, flexi-
ied by race. Objective measurement lifestyle should be recommended to all bility, muscle strength, and balance
by accelerometer showed that 44.2%, (144). Youth with type 1 diabetes who (133,152,153). Flexibility and balance
42.6%, and 65.1% of whites, African engage in more physical activity may exercises may be particularly important
Americans, and Hispanics, respectively, have better health-related quality of in older adults with diabetes to maintain
met the threshold (134). It is important life (145). range of motion, strength, and balance
for diabetes care management teams (142).
to understand the difficulty that many Frequency and Type of Physical
patients have reaching recommended Activity Physical Activity and Glycemic Control
treatment targets and to identify indi- People with diabetes should perform Clinical trials have provided strong evi-
vidualized approaches to improve goal aerobic and resistance exercise regularly dence for the A1C-lowering value of
achievement. (142). Aerobic activity bouts should ide- resistance training in older adults with
Moderate to high volumes of aerobic ally last at least 10 min, with the goal of type 2 diabetes (154) and for an additive
activity are associated with substantially ;30 min/day or more, most days of the benefit of combined aerobic and resis-
lower cardiovascular and overall mortal- week for adults with type 2 diabetes. tance exercise in adults with type 2
ity risks in both type 1 and type 2 diabetes Daily exercise, or at least not allowing diabetes (155). If not contraindicated,
(135). A recent prospective observa- more than 2 days to elapse between patients with type 2 diabetes should be
tional study of adults with type 1 diabetes exercise sessions, is recommended to encouraged to do at least two weekly
suggested that higher amounts of phys- decrease insulin resistance, regardless sessions of resistance exercise (exercise
ical activity led to reduced cardiovascular of diabetes type (146,147). Over time, with free weights or weight machines),
mortality after a mean follow-up time of activities should progress in intensity, with each session consisting of at least
11.4 years for patients with and without frequency, and/or duration to at least one set (group of consecutive repetitive
chronic kidney disease (136). Addition- 150 min/week of moderate-intensity ex- exercise motions) of five or more differ-
ally, structured exercise interventions ercise. Adults able to run at 6 miles/h ent resistance exercises involving the
of at least 8 weeks’ duration have been (9.7 km/h) for at least 25 min can benefit large muscle groups (154).
shown to lower A1C by an average of sufficiently from shorter-intensity activ- For type 1 diabetes, although exercise
0.66% in people with type 2 diabetes, even ity (75 min/week) (142). Many adults, in general is associated with improve-
without a significant change in BMI (137). including most with type 2 diabetes, ment in disease status, care needs to
There are also considerable data for the would be unable or unwilling to partic- be taken in titrating exercise with respect
health benefits (e.g., increased cardiovas- ipate in such intense exercise and should to glycemic management. Each individual
cular fitness, greater muscle strength, im- engage in moderate exercise for the with type 1 diabetes has a variable gly-
proved insulin sensitivity, etc.) of regular recommended duration. Adults with di- cemic response to exercise. This variabil-
exercise for those with type 1 diabetes abetes should engage in 2–3 sessions/ ity should be taken into consideration
(138). A recent study suggested that week of resistance exercise on noncon- when recommending the type and dura-
exercise training in type 1 diabetes secutive days (148). Although heavier tion of exercise for a given individual
may also improve several important resistance training with free weights (138).
markers such as triglyceride level, LDL, and weight machines may improve gly- Women with preexisting diabetes,
waist circumference, and body mass cemic control and strength (149), re- particularly type 2 diabetes, and those
(139). Higher levels of exercise intensity sistance training of any intensity is at risk for or presenting with gestational
are associated with greater improve- recommended to improve strength, bal- diabetes mellitus should be advised to
ments in A1C and in fitness (140). Other ance, and the ability to engage in activ- engage in regular moderate physical
benefits include slowing the decline in ities of daily living throughout the life activity prior to and during their preg-
mobility among overweight patients span. Providers and staff should help nancies as tolerated (142).
with diabetes (141). The ADA position patients set stepwise goals toward meet-
statement “Physical Activity/Exercise and ing the recommended exercise targets. Pre-exercise Evaluation
Diabetes” reviews the evidence for the Recent evidence supports that all in- As discussed more fully in Section
benefits of exercise in people with type dividuals, including those with diabetes, 10 “Cardiovascular Disease and Riskcare.diabetesjournals.org Lifestyle Management S53
Management,” the best protocol for Exercise in the Presence of Diabetic Kidney Disease
assessing asymptomatic patients with Microvascular Complications Physical activity can acutely increase uri-
diabetes for coronary artery disease re- See Section 11 “Microvascular Complica- nary albumin excretion. However, there is
mains unclear. The ADA consensus report tions and Foot Care” for more information no evidence that vigorous-intensity exer-
“Screening for Coronary Artery Disease on these long-term complications. cise increases the rate of progression of
in Patients With Diabetes” (156) con- Retinopathy diabetic kidney disease, and there appears
cluded that routine testing is not recom- If proliferative diabetic retinopathy or to be no need for specific exercise re-
mended. However, providers should severe nonproliferative diabetic retinop- strictions for people with diabetic kidney
perform a careful history, assess cardio- athy is present, then vigorous-intensity disease in general (158).
vascular risk factors, and be aware of aerobic or resistance exercise may be
the atypical presentation of coronary contraindicated because of the risk of
artery disease in patients with diabetes. SMOKING CESSATION: TOBACCO
triggering vitreous hemorrhage or ret- AND E-CIGARETTES
Certainly, high-risk patients should be inal detachment (158). Consultation
encouraged to start with short periods with an ophthalmologist prior to engag- Recommendations
of low-intensity exercise and slowly in- ing in an intense exercise regimen may 5.29 Advise all patients not to use
crease the intensity and duration as be appropriate. cigarettes and other tobacco
tolerated. Providers should assess pa- products A or e-cigarettes. B
Peripheral Neuropathy
tients for conditions that might contra- 5.30 Include smoking cessation coun-
indicate certain types of exercise or Decreased pain sensation and a higher
seling and other forms of treat-
predispose to injury, such as uncontrolled pain threshold in the extremities result
ment as a routine component
hypertension, untreated proliferative ret- in an increased risk of skin breakdown,
of diabetes care. A
inopathy, autonomic neuropathy, periph- infection, and Charcot joint destruction
eral neuropathy, and a history of foot with some forms of exercise. Therefore, a Results from epidemiological, case-control,
ulcers or Charcot foot. The patient’s age thorough assessment should be done to and cohort studies provide convincing
and previous physical activity level should ensure that neuropathy does not alter evidence to support the causal link be-
be considered. The provider should cus- kinesthetic or proprioceptive sensation tween cigarette smoking and health risks
tomize the exercise regimen to the indi- during physical activity, particularly in (163). Recent data show tobacco use is
vidual’s needs. Those with complications those with more severe neuropathy. Stud- higher among adults with chronic con-
may require a more thorough evaluation ies have shown that moderate-intensity ditions (164) as well as in adolescents
prior to beginning an exercise program walking may not lead to an increased risk and young adults with diabetes (165).
(138). of foot ulcers or reulceration in those with Smokers with diabetes (and people
peripheral neuropathy who use proper with diabetes exposed to second-hand
footwear (159). In addition, 150 min/week smoke) have a heightened risk of CVD,
Hypoglycemia
In individuals taking insulin and/or in- of moderate exercise was reported to premature death, microvascular com-
sulin secretagogues, physical activity may improve outcomes in patients with plications, and worse glycemic control
cause hypoglycemia if the medication prediabetic neuropathy (160). All indi- when compared with nonsmokers
dose or carbohydrate consumption is viduals with peripheral neuropathy (166,167). Smoking may have a role in
not altered. Individuals on these thera- should wear proper footwear and ex- the development of type 2 diabetes
pies may need to ingest some added amine their feet daily to detect lesions (168–171).
carbohydrate if pre-exercise glucose lev- early. Anyone with a foot injury or open The routine and thorough assessment
els are ,90 mg/dL (5.0 mmol/L), depend- sore should be restricted to non–weight- of tobacco use is essential to prevent
ing on whether they are able to lower bearing activities. smoking or encourage cessation. Nu-
insulin doses during the workout (such as Autonomic Neuropathy merous large randomized clinical trials
with an insulin pump or reduced pre- Autonomic neuropathy can increase the have demonstrated the efficacy and
exercise insulin dosage), the time of day risk of exercise-induced injury or adverse cost-effectiveness of brief counseling
exercise is done, and the intensity and events through decreased cardiac re- in smoking cessation, including the
duration of the activity (138,142). In sponsiveness to exercise, postural hy- use of telephone quit lines, in reducing
some patients, hypoglycemia after ex- potension, impaired thermoregulation, tobacco use. Pharmacologic therapy to
ercise may occur and last for several impaired night vision due to impaired assist with smoking cessation in people
hours due to increased insulin sensitiv- papillary reaction, and greater suscepti- with diabetes has been shown to be
ity. Hypoglycemia is less common in bility to hypoglycemia (161). Cardiovas- effective (172), and for the patient mo-
patients with diabetes who are not cular autonomic neuropathy is also an tivated to quit, the addition of pharma-
treated with insulin or insulin secreta- independent risk factor for cardiovascu- cologic therapy to counseling is more
gogues, and no routine preventive mea- lar death and silent myocardial ische- effective than either treatment alone
sures for hypoglycemia are usually mia (162). Therefore, individuals with (173). Special considerations should in-
advised in these cases. Intense activities diabetic autonomic neuropathy should clude assessment of level of nicotine
may actually raise blood glucose levels undergo cardiac investigation before dependence, which is associated with
instead of lowering them, especially if beginning physical activity more in- difficulty in quitting and relapse (174).
pre-exercise glucose levels are elevated tense than that to which they are Although some patients may gain weight
(157). accustomed. in the period shortly after smokingS54 Lifestyle Management Diabetes Care Volume 42, Supplement 1, January 2019
cessation (175), recent research has dem- psychological vulnerability at diagno-
disordered eating, and cogni-
onstrated that this weight gain does not sis, when their medical status changes
tive capacities using patient-
diminish the substantial CVD benefit re- (e.g., end of the honeymoon period),
appropriate standardized and
alized from smoking cessation (176). One when the need for intensified treat-
validated tools at the initial
study in smokers with newly diagnosed ment is evident, and when complica-
visit, at periodic intervals, and
type 2 diabetes found that smoking tions are discovered.
when there is a change in dis-
cessation was associated with amelio- Providers can start with informal
ease, treatment, or life circum-
ration of metabolic parameters and re- verbal inquires, for example, by asking
stance. Including caregivers and
duced blood pressure and albuminuria if there have been changes in mood
family members in this assess-
at 1 year (177). during the past 2 weeks or since the
ment is recommended. B
In recent years e-cigarettes have patient’s last visit. Providers should con-
5.34 Consider screening older adults
gained public awareness and popularity sider asking if there are new or different
(aged $65 years) with diabetes
because of perceptions that e-cigarette barriers to treatment and self-manage-
for cognitive impairment and
use is less harmful than regular cigarette ment, such as feeling overwhelmed or
depression. B
smoking (178,179). Nonsmokers should stressed by diabetes or other life stres-
be advised not to use e-cigarettes sors. Standardized and validated tools for
Please refer to the ADA position state-
(180,181). There are no rigorous studies psychosocial monitoring and assessment
ment “Psychosocial Care for People With
that have demonstrated that e-cigarettes can also be used by providers (187), with
Diabetes” for a list of assessment tools
are a healthier alternative to smoking
and additional details (187). positive findings leading to referral to a
or that e-cigarettes can facilitate smok- mental health provider specializing in
Complex environmental, social, be-
ing cessation (182). On the contrary, a diabetes for comprehensive evaluation,
havioral, and emotional factors, known
recently published pragmatic trial found diagnosis, and treatment.
as psychosocial factors, influence living
that use of e-cigarettes for smoking
with diabetes, both type 1 and type 2,
cessation was not more effective than
and achieving satisfactory medical out-
“usual care,” which included access to Diabetes Distress
comes and psychological well-being. Thus,
educational information on the health
individuals with diabetes and their fam- Recommendation
benefits of smoking cessation, strategies
ilies are challenged with complex, multi- 5.35 Routinely monitor people with
to promote cessation, and access to a
faceted issues when integrating diabetes diabetes for diabetes distress,
free text-messaging service that pro-
care into daily life. particularly when treatment tar-
vided encouragement, advice, and tips
Emotional well-being is an important gets are not met and/or at the
to facilitate smoking cessation (183). Sev-
part of diabetes care and self-management. onset of diabetes complications. B
eral organizations have called for more
Psychological and social problems can
research on the short- and long-term
impair the individual’s (188–190) or fam- Diabetes distress (DD) is very common
safety and health effects of e-cigarettes
ily’s (191) ability to carry out diabetes care and is distinct from other psychological
(184–186).
tasks and therefore potentially compro- disorders (193–195). DD refers to signif-
mise health status. There are opportu- icant negative psychological reactions
nities for the clinician to routinely assess related to emotional burdens and wor-
PSYCHOSOCIAL ISSUES
psychosocial status in a timely and effi- ries specific to an individual’s experience
Recommendations cient manner for referral to appropri- in having to manage a severe, compli-
5.31 Psychosocial care should be in- ate services. A systematic review and cated, and demanding chronic disease
tegrated with a collaborative, meta-analysis showed that psychosocial such as diabetes (194–196). The constant
patient-centered approach and interventions modestly but significantly behavioral demands (medication dos-
provided to all people with di- improved A1C (standardized mean dif- ing, frequency, and titration; monitoring
abetes, with the goals of op- ference –0.29%) and mental health blood glucose, food intake, eating pat-
timizing health outcomes and outcomes (192). However, there was a terns, and physical activity) of diabetes
health-related quality of life. A limited association between the effects
self-management and the potential or
5.32 Psychosocial screening and on A1C and mental health, and no in-
actuality of disease progression are di-
follow-up may include, but are tervention characteristics predicted
rectly associated with reports of DD
not limited to, attitudes about benefit on both outcomes.
(194). The prevalence of DD is reported
diabetes, expectations for
to be 18–45% with an incidence of
medical management and out-
Screening 38–48% over 18 months (196). In the
comes, affect or mood, general
Key opportunities for psychosocial screen- second Diabetes Attitudes, Wishes and
and diabetes-related quality of
ing occur at diabetes diagnosis, during Needs (DAWN2) study, significant DD
life, available resources (finan-
regularly scheduled management vis- was reported by 45% of the participants,
cial, social, and emotional), and
its, during hospitalizations, with new but only 24% reported that their health
psychiatric history. E
onset of complications, or when prob- care teams asked them how diabetes
5.33 Providers should consider assess-
lems with glucose control, quality of affected their lives (193). High levels
ment for symptoms of diabe-
life, or self-management are identi- of DD significantly impact medication-
tes distress, depression, anxiety,
fied (1). Patients are likely to exhibit taking behaviors and are linked to highercare.diabetesjournals.org Lifestyle Management S55
Table 5.2—Situations that warrant referral of a person with diabetes to a mental health provider for evaluation and treatment
c 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
A1C, lower self-efficacy, and poorer di- psychological status to occur (26,193). with diabetes: a consensus report. Diabetes
etary and exercise behaviors (17,194, Providers should identify behavioral and Care 2013;36:463–470
7. Norris SL, Lau J, Smith SJ, Schmid CH, Engelgau
196). DSMES has been shown to reduce mental health providers, ideally those
MM. Self-management education for adults
DD (17). It may be helpful to provide who are knowledgeable about diabetes with type 2 diabetes: a meta-analysis of the
counseling regarding expected diabetes- treatment and the psychosocial aspects of effect on glycemic control. Diabetes Care 2002;
related versus generalized psychological diabetes, to whom they can refer patients. 25:1159–1171
distress at diagnosis and when disease The ADA provides a list of mental health 8. Haas L, Maryniuk M, Beck J, et al.; 2012
Standards Revision Task Force. National stan-
state or treatment changes (197). providers who have received additional
dards for diabetes self-management education
DD should be routinely monitored education in diabetes at the ADA Mental and support. Diabetes Care 2014;37(Suppl. 1):
(198) using patient-appropriate vali- Health Provider Directory (professional. S144–S153
dated measures (187). If DD is identified, diabetes.org/ada-mental-health-provider- 9. Frosch DL, Uy V, Ochoa S, Mangione CM.
the person should be referred for specific directory). Ideally, psychosocial care Evaluation of a behavior support intervention
diabetes education to address areas of providers should be embedded in di- for patients with poorly controlled diabetes.
Arch Intern Med 2011;171:2011–2017
diabetes self-care that are most relevant abetes care settings. Although the cli- 10. Cooke D, Bond R, Lawton J, et al.; U.K. NIHR
to the patient and impact clinical man- nician may not feel qualified to treat DAFNE Study Group. Structured type 1 diabetes
agement. People whose self-care re- psychological problems (200), optimizing education delivered within routine care: im-
mains impaired after tailored diabetes the patient-provider relationship as a pact on glycemic control and diabetes-specific
education should be referred by their foundation may increase the likelihood quality of life. Diabetes Care 2013;36:270–
272
care team to a behavioral health pro- of the patient accepting referral for other 11. Chrvala CA, Sherr D, Lipman RD. Diabetes
vider for evaluation and treatment. services. Collaborative care interventions self-management education for adults with
Other psychosocial issues known to and a team approach have demonstrated type 2 diabetes mellitus: a systematic review
affect self-management and health out- efficacy in diabetes self-management, of the effect on glycemic control. Patient Educ
comes include attitudes about the illness, outcomes of depression, and psychoso- Couns 2016;99:926–943
12. Steinsbekk A, Rygg LØ, Lisulo M, Rise
expectations for medical management cial functioning (17,201).
MB, Fretheim A. Group based diabetes self-
and outcomes, available resources (fi- management education compared to routine
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