Whether the physician is leading the change effort or is part of a team approach, taking the time to ask about any behavior accomplishments and offering praise can be powerful motivators to continue the effort. Encouragement should be offered at each visit. Physicians should ask patients about behavior targets previously discussed, confirm how the targets are tracked, and review basic information about diabetes.

Asking about benefits noticed e. For patients quick to see failure, the focus should be on partial successes compared with their previous level. Because long-term change is more likely when patients systematically track their own behavior, physicians should provide or recommend a simple tracking system, strongly encourage its use, and follow up during office visits.

In the DPP and Look AHEAD studies, patients were taught to track all food consumption and physical activity, and were gradually coached to learn what works for them.

Popular consumer fitness trackers and phone apps are sufficiently reliable to track physical activity, such as walking and running, for the purposes of motivating behavior change. A variety of applications offer extensive lists of foods found in grocery stores and restaurants, track daily nutrition totals e.

Such tracking software may additionally include goal setting, support through social networking, reminders, reinforcement for achieving goals, and the ability to review achievements over time.

Although there is little evidence clarifying the optimal features for this emerging lifestyle technology, it seems clear that the best tracking system for patients is the one they are likely to use regularly. The maintenance phase is often a period of struggle Table 2.

Slips and relapses both begin with a mistake. If the patient quickly returns to the change effort, the mistake is considered a slip; however, if the patient reverts to a previous stage, it is considered the beginning of a relapse.

Persons who view a slip primarily as their personal failure tend to feel guilt and shame, and have increased risk of relapse. Persons who view a slip as the result of difficulty coping effectively with a specific high-risk situation are more likely to want to learn from the mistakes and develop effective ways to handle similar situations in the future.

A helpful approach involves focusing on specific examples and prompting the patient to brainstorm about possible triggers and how to overcome them next time. Commonly cited precipitants include negative emotions, interpersonal conflicts, social pressure, time pressure, and celebrations.

A person who can execute effective coping skills is less likely to relapse Table 4. Describe : I was planning to walk after dinner, but the friend I walk with canceled.

My daughter was watching a movie, so I watched with her instead. Brainstorm : I could listen to a podcast while I walk alone. Or, I could ask my daughter to walk with me now, and we'll watch a movie together afterward.

This article updates a previous article on this topic by Koenigsberg, et al. Data Sources : Literature searches were performed using the OVID Med-line Database with key terms prediabetes, prediabetic state, and diabetes mellitus, crossed with lifestyle, diet, exercise, physical activity, weight reduction programs, patient compliance, and adherence.

The search was limited to randomized controlled trials, review articles, or meta-analyses, with studies limited to those in English with human participants.

Later searches were done for specific areas such as follow-up publications on major studies Diabetes Prevention Program, Look AHEAD, Da Qing IGT and Diabetes Study, Malmo Study, Finnish Diabetes Prevention Study or meta-analyses for relevant areas e.

Also searched were AFP archives, Guideline. gov, Cochrane database, AHRQ. gov, CDC. gov, and Essential Evidence Plus. Search dates: November , January to March , October to December , and April Centers for Disease Control and Prevention.

National diabetes statistics report, Accessed March 21, National data. Updated April American Diabetes Association. Standards of medical care in diabetes— Diabetes Care.

Updated December Accessed November 8, Pippitt K, Li M, Gurgle HE. Diabetes mellitus: screening and diagnosis. Am Fam Physician. Diabetes Prevention Program Research Group. Long-term effects of lifestyle intervention or metformin on diabetes development and micro-vascular complications over year follow-up: the Diabetes Prevention Program Outcomes Study.

Lancet Diabetes Endocrinol. National Diabetes Prevention Program. Prevent T2 curricula and handouts. Accessed April 17, Knowler WC, Fowler SE, Hamman RF, et al. Li G, Zhang P, Wang J, et al.

The long-term effect of lifestyle interventions to prevent diabetes in the China Da Qing Diabetes Prevention Study: a year follow-up study. Lindström J, Ilanne-Parikka P, Peltonen M, et al.

Sustained reduction in the incidence of type 2 diabetes by lifestyle intervention: follow-up of the Finnish Diabetes Prevention Study. Look AHEAD Research Group.

Eight-year weight losses with an intensive lifestyle intervention: the look AHEAD study. Obesity Silver Spring. Gregg EW, Chen H, Wagenknecht LE, et al. Association of an intensive lifestyle intervention with remission of type 2 diabetes.

Colberg SR, Sigal RJ, Fernhall B, et al. Exercise and type 2 diabetes: the American College of Sports Medicine and the American Diabetes Association: joint position statement executive summary.

Lifestyle intervention materials. Diabetes Prevention Program DPP Research Group. The Diabetes Prevention Program DPP : description of lifestyle intervention. Garber AJ, Abrahamson MJ, Barzilay JI, et al. Consensus statement by the American Association of Clinical Endocrinologists and American College of Endocrinology on the comprehensive type 2 diabetes management algorithm— executive summary.

Endocr Pract. Preventive Services Task Force. Final recommendation statement: healthful diet and physical activity for cardiovascular disease prevention in adults with cardiovascular risk factors: behavioral counseling. August Accessed November 7, Mason P, Butler CC. Health Behavior Change: A Guide For Practitioners.

Edinburgh, United Kingdom: Churchill Livingstone Elsevier; Prochaska JO, Norcross JC. Systems Of Psychotherapy: A Transtheoretical Analysis. Stamford, Conn. Keller VF, White MK. Choices and changes: a new model for influencing patient health behavior.

J Clin Outcomes Manage. Wadden TA, West DS, Delahanty L, et al. The Look AHEAD study: a description of the lifestyle intervention and the evidence supporting it [published correction appears in Obesity Silver Spring.

Doran GT. There's a S. Dietary guidance should emphasize the importance of a healthy dietary pattern as a whole rather than focusing on individual nutrients, foods, or food groups, given that individuals rarely eat foods in isolation.

Personal preferences e. Members of the health care team should complement MNT by providing evidence-based guidance that helps people with diabetes make healthy food choices that meet their individualized needs and improve overall health.

A variety of eating patterns are acceptable for the management of diabetes 56 , — Until the evidence surrounding comparative benefits of different eating patterns in specific individuals strengthens, health care providers should focus on the key factors that are common among the patterns: 1 emphasize nonstarchy vegetables, 2 minimize added sugars and refined grains, and 3 choose whole foods over highly processed foods to the extent possible The Mediterranean-style , — , low-carbohydrate — , and vegetarian or plant-based , , , eating patterns are all examples of healthful eating patterns that have shown positive results in research for individuals with type 2 diabetes, but individualized meal planning should focus on personal preferences, needs, and goals.

There is currently inadequate research in type 1 diabetes to support one eating pattern over another. For individuals with type 2 diabetes not meeting glycemic targets or for whom reducing glucose-lowering drugs is a priority, reducing overall carbohydrate intake with a low- or very-low-carbohydrate eating pattern is a viable option — As research studies on low-carbohydrate eating plans generally indicate challenges with long-term sustainability , it is important to reassess and individualize meal plan guidance regularly for those interested in this approach.

Efforts to modify habitual eating patterns are often unsuccessful in the long term; people generally go back to their usual macronutrient distribution Thus, the recommended approach is to individualize meal plans with a macronutrient distribution that is more consistent with personal preference and usual intake to increase the likelihood for long-term maintenance.

The diabetes plate method is a commonly used visual approach for providing basic meal planning guidance. Carbohydrate counting is a more advanced skill that helps plan for and track how much carbohydrate is consumed at meals and snacks.

Meal planning approaches should be customized to the individual, including their numeracy and food literacy level. Food literacy generally describes proficiency in food-related knowledge and skills that ultimately impact health, although specific definitions vary across initiatives , Studies examining the ideal amount of carbohydrate intake for people with diabetes are inconclusive, although monitoring carbohydrate intake and considering the blood glucose response to dietary carbohydrate are key for improving postprandial glucose management , The literature concerning glycemic index and glycemic load in individuals with diabetes is complex, often with varying definitions of low and high glycemic index foods , The glycemic index ranks carbohydrate foods on their postprandial glycemic response, and glycemic load takes into account both the glycemic index of foods and the amount of carbohydrate eaten.

Studies have found mixed results regarding the effect of glycemic index and glycemic load on fasting glucose levels and A1C, with one systematic review finding no significant impact on A1C , while two others demonstrated A1C reductions of 0. Reducing overall carbohydrate intake for individuals with diabetes has demonstrated evidence for improving glycemia and may be applied in a variety of eating patterns that meet individual needs and preferences For people with type 2 diabetes, low-carbohydrate and very-low-carbohydrate eating patterns, in particular, have been found to reduce A1C and the need for antihyperglycemic medications 56 , , , — Part of the challenge in interpreting low-carbohydrate research has been due to the wide range of definitions for a low-carbohydrate eating plan , Weight reduction was also a goal in many low-carbohydrate studies, which further complicates evaluating the distinct contribution of the eating pattern 41 , 93 , 97 , Providers should maintain consistent medical oversight and recognize that insulin and other diabetes medications may need to be adjusted to prevent hypoglycemia; and blood pressure will need to be monitored.

In addition, very-low-carbohydrate eating plans are not currently recommended for women who are pregnant or lactating, children, people who have renal disease, or people with or at risk for disordered eating, and these plans should be used with caution in those taking sodium—glucose cotransporter 2 inhibitors because of the potential risk of ketoacidosis , Regardless of amount of carbohydrate in the meal plan, focus should be placed on high-quality, nutrient-dense carbohydrate sources that are high in fiber and minimally processed.

Both children and adults with diabetes are encouraged to minimize intake of refined carbohydrates with added sugars, fat, and sodium and instead focus on carbohydrates from vegetables, legumes, fruits, dairy milk and yogurt , and whole grains.

Regular intake of sufficient dietary fiber is associated with lower all-cause mortality in people with diabetes , , and prospective cohort studies have found dietary fiber intake is inversely associated with risk of type 2 diabetes — The consumption of sugar-sweetened beverages and processed food products with high amounts of refined grains and added sugars is strongly discouraged , — , as these have the capacity to displace healthier, more nutrient-dense food choices.

Individuals with type 1 or type 2 diabetes taking insulin at mealtime should be offered intensive and ongoing education on the need to couple insulin administration with carbohydrate intake.

For people whose meal schedule or carbohydrate consumption is variable, regular education to increase understanding of the relationship between carbohydrate intake and insulin needs is important. In addition, education on using insulin-to-carbohydrate ratios for meal planning can assist individuals with effectively modifying insulin dosing from meal to meal to improve glycemic management , , — Studies have shown that dietary fat and protein can impact early and delayed postprandial glycemia — , and it appears to have a dose-dependent response — Results from high-fat, high-protein meal studies highlight the need for additional insulin to cover these meals; however, more studies are needed to determine the optimal insulin dose and delivery strategy.

The effectiveness of insulin dosing decisions should be confirmed with a structured approach to blood glucose monitoring or continuous glucose monitoring to evaluate individual responses and guide insulin dose adjustments. Checking glucose 3 h after eating may help to determine if additional insulin adjustments are required i.

Food literacy, numeracy, interest, and capability should be evaluated For individuals on a fixed daily insulin schedule, meal planning should emphasize a relatively fixed carbohydrate consumption pattern with respect to both time and amount, while considering insulin action. Attention to resultant hunger and satiety cues will also help with nutrient modifications throughout the day 56 , There is no evidence that adjusting the daily level of protein intake typically 1—1.

Therefore, protein intake goals should be individualized based on current eating patterns. Reducing the amount of dietary protein below the recommended daily allowance of 0. In individuals with type 2 diabetes, protein intake may enhance or increase the insulin response to dietary carbohydrates Therefore, use of carbohydrate sources high in protein such as milk and nuts to treat or prevent hypoglycemia should be avoided due to the potential concurrent rise in endogenous insulin.

Providers should counsel patients to treat hypoglycemia with pure glucose i. The ideal amount of dietary fat for individuals with diabetes is controversial.

The type of fats consumed is more important than total amount of fat when looking at metabolic goals and CVD risk, and it is recommended that the percentage of total calories from saturated fats should be limited 92 , , — Multiple RCTs including patients with type 2 diabetes have reported that a Mediterranean-style eating pattern 92 , — , rich in polyunsaturated and monounsaturated fats, can improve both glycemic management and blood lipids.

Evidence does not conclusively support recommending n-3 eicosapentaenoic acid [EPA] and docosahexaenoic acid [DHA] supplements for all people with diabetes for the prevention or treatment of cardiovascular events 56 , , In individuals with type 2 diabetes, two systematic reviews with n-3 and n-6 fatty acids concluded that the dietary supplements did not improve glycemic management , People with diabetes should be advised to follow the guidelines for the general population for the recommended intakes of saturated fat, dietary cholesterol, and trans fat Trans fats should be avoided.

In addition, as saturated fats are progressively decreased in the diet, they should be replaced with unsaturated fats and not with refined carbohydrates Sodium recommendations should take into account palatability, availability, affordability, and the difficulty of achieving low-sodium recommendations in a nutritionally adequate diet There continues to be no clear evidence of benefit from herbal or nonherbal i.

Metformin is associated with vitamin B12 deficiency per a report from the Diabetes Prevention Program Outcomes Study DPPOS , suggesting that periodic testing of vitamin B12 levels should be considered in patients taking metformin, particularly in those with anemia or peripheral neuropathy Routine supplementation with antioxidants, such as vitamins E and C and carotene, is not advised due to lack of evidence of efficacy and concern related to long-term safety.

In addition, there is insufficient evidence to support the routine use of herbal supplements and micronutrients, such as cinnamon , curcumin, vitamin D , aloe vera, or chromium, to improve glycemia in people with diabetes 56 , Although the Vitamin D and Type 2 Diabetes D2d prospective RCT showed no significant benefit of vitamin D versus placebo on the progression to type 2 diabetes in individuals at high risk , post hoc analyses and meta-analyses suggest a potential benefit in specific populations — Further research is needed to define patient characteristics and clinical indicators where vitamin D supplementation may be of benefit.

For special populations, including pregnant or lactating women, older adults, vegetarians, and people following very-low-calorie or low-carbohydrate diets, a multivitamin may be necessary.

Moderate alcohol intake does not have major detrimental effects on long-term blood glucose management in people with diabetes. People with diabetes should be educated about these risks and encouraged to monitor blood glucose frequently after drinking alcohol to minimize such risks.

People with diabetes can follow the same guidelines as those without diabetes if they choose to drink. For women, no more than one drink per day, and for men, no more than two drinks per day is recommended one drink is equal to a oz beer, a 5-oz glass of wine, or 1.

The U. Food and Drug Administration has approved many nonnutritive sweeteners for consumption by the general public, including people with diabetes 56 , For some people with diabetes who are accustomed to regularly consuming sugar-sweetened products, nonnutritive sweeteners containing few or no calories may be an acceptable substitute for nutritive sweeteners those containing calories, such as sugar, honey, and agave syrup when consumed in moderation , Nonnutritive sweeteners do not appear to have a significant effect on glycemic management , , , but they can reduce overall calorie and carbohydrate intake , as long as individuals are not compensating with additional calories from other food sources 56 , There is mixed evidence from systematic reviews and meta-analyses for nonnutritive sweetener use with regard to weight management, with some finding benefit in weight loss — , while other research suggests an association with weight gain The addition of nonnutritive sweeteners to diets poses no benefit for weight loss or reduced weight gain without energy restriction Low-calorie or nonnutritive-sweetened beverages may serve as a short-term replacement strategy; however, people with diabetes should be encouraged to decrease both sweetened and nonnutritive-sweetened beverages, with an emphasis on water intake Additionally, some research has found that higher nonnutritive-sweetened beverage and sugar-sweetened beverage consumption may be associated with the development of type 2 diabetes, although substantial heterogeneity makes interpreting the results difficult — B Prolonged sitting should be interrupted every 30 min for blood glucose benefits.

Yoga and tai chi may be included based on individual preferences to increase flexibility, muscular strength, and balance. Promote increase in nonsedentary activities above baseline for sedentary individuals with type 1 E and type 2 B diabetes.

Examples include walking, yoga, housework, gardening, swimming, and dancing. Physical activity is a general term that includes all movement that increases energy use and is an important part of the diabetes management plan. Exercise is a more specific form of physical activity that is structured and designed to improve physical fitness.

Both physical activity and exercise are important. Exercise has been shown to improve blood glucose control, reduce cardiovascular risk factors, contribute to weight loss, and improve well-being Physical activity is as important for those with type 1 diabetes as it is for the general population, but its specific role in the prevention of diabetes complications and the management of blood glucose is not as clear as it is for those with type 2 diabetes.

A recent study suggested that the percentage of people with diabetes who achieved the recommended exercise level per week min varied by race. Objective measurement by accelerometer showed that It is important for diabetes care management teams to understand the difficulty that many patients have reaching recommended treatment targets and to identify individualized approaches to improve goal achievement.

Moderate to high volumes of aerobic activity are associated with substantially lower cardiovascular and overall mortality risks in both type 1 and type 2 diabetes A recent prospective observational study of adults with type 1 diabetes suggested that higher amounts of physical activity led to reduced cardiovascular mortality after a mean follow-up time of There are also considerable data for the health benefits e.

of regular exercise for those with type 1 diabetes A recent study suggested that exercise training in type 1 diabetes may also improve several important markers such as triglyceride level, LDL, waist circumference, and body mass In adults with type 2 diabetes, higher levels of exercise intensity are associated with greater improvements in A1C and in cardiorespiratory fitness ; sustained improvements in cardiorespiratory fitness and weight loss have also been associated with a lower risk of heart failure Other benefits include slowing the decline in mobility among overweight patients with diabetes Increased physical activity soccer training has also been shown to be beneficial for improving overall fitness in Latino men with obesity, demonstrating feasible methods to increase physical activity in an often hard-to-engage population Physical activity and exercise should be recommended and prescribed to all individuals who are at risk for or with diabetes as part of management of glycemia and overall health.

Specific recommendations and precautions will vary by the type of diabetes, age, activity done, and presence of diabetes-related health complications. Recommendations should be tailored to meet the specific needs of each individual All children, including children with diabetes or prediabetes, should be encouraged to engage in regular physical activity.

Children should engage in at least 60 min of moderate to vigorous aerobic activity every day, with muscle- and bone-strengthening activities at least 3 days per week In general, youth with type 1 diabetes benefit from being physically active, and an active lifestyle should be recommended to all Youth with type 1 diabetes who engage in more physical activity may have better health outcomes and health-related quality of life , People with diabetes should perform aerobic and resistance exercise regularly Daily exercise, or at least not allowing more than 2 days to elapse between exercise sessions, is recommended to decrease insulin resistance, regardless of diabetes type , A study in adults with type 1 diabetes found a dose-response inverse relationship between self-reported bouts of physical activity per week and A1C, BMI, hypertension, dyslipidemia, and diabetes-related complications such as hypoglycemia, diabetic ketoacidosis, retinopathy, and microalbuminuria Many adults, including most with type 2 diabetes, may be unable or unwilling to participate in such intense exercise and should engage in moderate exercise for the recommended duration.

Although heavier resistance training with free weights and weight machines may improve glycemic control and strength , resistance training of any intensity is recommended to improve strength, balance, and the ability to engage in activities of daily living throughout the life span.

Providers and staff should help patients set stepwise goals toward meeting the recommended exercise targets. As individuals intensify their exercise program, medical monitoring may be indicated to ensure safety and evaluate the effects on glucose management. See the section physical activity and glycemic control below.

Recent evidence supports that all individuals, including those with diabetes, should be encouraged to reduce the amount of time spent being sedentary—waking behaviors with low energy expenditure e. Participating in leisure-time activity and avoiding extended sedentary periods may help prevent type 2 diabetes for those at risk , and may also aid in glycemic control for those with diabetes.

A systematic review and meta-analysis found higher frequency of regular leisure-time physical activity was more effective in reducing A1C levels A wide range of activities, including yoga, tai chi, and other types, can have significant impacts on A1C, flexibility, muscle strength, and balance , — Flexibility and balance exercises may be particularly important in older adults with diabetes to maintain range of motion, strength, and balance Clinical trials have provided strong evidence for the A1C-lowering value of resistance training in older adults with type 2 diabetes and for an additive benefit of combined aerobic and resistance exercise in adults with type 2 diabetes If not contraindicated, patients with type 2 diabetes should be encouraged to do at least two weekly sessions of resistance exercise exercise with free weights or weight machines , with each session consisting of at least one set group of consecutive repetitive exercise motions of five or more different resistance exercises involving the large muscle groups For type 1 diabetes, although exercise in general is associated with improvement in disease status, care needs to be taken in titrating exercise with respect to glycemic management.

Each individual with type 1 diabetes has a variable glycemic response to exercise. This variability should be taken into consideration when recommending the type and duration of exercise for a given individual Women with preexisting diabetes, particularly type 2 diabetes, and those at risk for or presenting with gestational diabetes mellitus should be advised to engage in regular moderate physical activity prior to and during their pregnancies as tolerated However, providers should perform a careful history, assess cardiovascular risk factors, and be aware of the atypical presentation of coronary artery disease, such as recent patient-reported or tested decrease in exercise tolerance, in patients with diabetes.

Certainly, high-risk patients should be encouraged to start with short periods of low-intensity exercise and slowly increase the intensity and duration as tolerated. Providers should assess patients for conditions that might contraindicate certain types of exercise or predispose to injury, such as uncontrolled hypertension, untreated proliferative retinopathy, autonomic neuropathy, peripheral neuropathy, and a history of foot ulcers or Charcot foot.

Those with complications may need a more thorough evaluation prior to starting an exercise program , In some patients, hypoglycemia after exercise may occur and last for several hours due to increased insulin sensitivity. Hypoglycemia is less common in patients with diabetes who are not treated with insulin or insulin secretagogues, and no routine preventive measures for hypoglycemia are usually advised in these cases.

Intense activities may actually raise blood glucose levels instead of lowering them, especially if pre-exercise glucose levels are elevated Because of the variation in glycemic response to exercise bouts, patients need to be educated to check blood glucose levels before and after periods of exercise and about the potential prolonged effects depending on intensity and duration see the section diabetes self-management education and support above.

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

Decreased pain sensation and a higher pain threshold in the extremities can result in an increased risk of skin breakdown, infection, and Charcot joint destruction with some forms of exercise.

Therefore, a thorough assessment should be done to ensure that neuropathy does not alter kinesthetic or proprioceptive sensation during physical activity, particularly in those with more severe neuropathy. Studies have shown that moderate-intensity walking may not lead to an increased risk of foot ulcers or reulceration in those with peripheral neuropathy who use proper footwear 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 can increase the risk of exercise-induced injury or adverse events through decreased cardiac responsiveness to exercise, postural hypotension, impaired thermoregulation, impaired night vision due to impaired papillary reaction, and greater susceptibility to hypoglycemia Cardiovascular autonomic neuropathy is also an independent risk factor for cardiovascular death and silent myocardial ischemia Therefore, individuals with diabetic autonomic neuropathy should undergo cardiac investigation before beginning physical activity more intense than that to which they are accustomed.

Physical activity can acutely increase urinary albumin excretion. However, there is no evidence that vigorous-intensity exercise accelerates the rate of progression of DKD, and there appears to be no need for specific exercise restrictions for people with DKD in general Results from epidemiologic, case-control, and cohort studies provide convincing evidence to support the causal link between cigarette smoking and health risks Recent data show tobacco use is higher among adults with chronic conditions as well as in adolescents and young adults with diabetes People with diabetes who smoke and people with diabetes exposed to second-hand smoke have a heightened risk of CVD, premature death, microvascular complications, and worse glycemic control when compared with those who do not smoke — Smoking may have a role in the development of type 2 diabetes — The routine and thorough assessment of tobacco use is essential to prevent smoking or encourage cessation.

Numerous large randomized clinical trials have demonstrated the efficacy and cost-effectiveness of brief counseling in smoking cessation, including the use of telephone quit lines, in reducing tobacco use. Pharmacologic therapy to assist with smoking cessation in people with diabetes has been shown to be effective , and for the patient motivated to quit, the addition of pharmacologic therapy to counseling is more effective than either treatment alone Special considerations should include assessment of level of nicotine dependence, which is associated with difficulty in quitting and relapse Although some people may gain weight in the period shortly after smoking cessation , recent research has demonstrated that this weight gain does not diminish the substantial CVD benefit realized from smoking cessation One study in people who smoke who had newly diagnosed type 2 diabetes found that smoking cessation was associated with amelioration of metabolic parameters and reduced blood pressure and albuminuria at 1 year In recent years, e-cigarettes have gained public awareness and popularity because of perceptions that e-cigarette use is less harmful than regular cigarette smoking , However, in light of recent Centers for Disease Control and Prevention evidence of deaths related to e-cigarette use, no individuals should be advised to use e-cigarettes, either as a way to stop smoking tobacco or as a recreational drug.

Diabetes education programs offer potential to systematically reach and engage individuals with diabetes in smoking cessation efforts. Including caregivers and family members in this assessment is recommended.

B Monitoring of cognitive capacity, i. Complex environmental, social, behavioral, and emotional factors, known as psychosocial factors, influence living with diabetes, both type 1 and type 2, and achieving satisfactory medical outcomes and psychological well-being.

Thus, individuals with diabetes and their families are challenged with complex, multifaceted issues when integrating diabetes care into daily life Emotional well-being is an important part of diabetes care and self-management.

There are opportunities for the clinician to routinely assess psychosocial status in a timely and efficient manner for referral to appropriate services , A systematic review and meta-analysis showed that psychosocial interventions modestly but significantly improved A1C standardized mean difference —0.

There was a limited association between the effects on A1C and mental health, and no intervention characteristics predicted benefit on both outcomes. However, cost analyses have shown that behavioral health interventions are both effective and cost-efficient approaches to the prevention of diabetes Key opportunities for psychosocial screening occur at diabetes diagnosis, during regularly scheduled management visits, during hospitalizations, with new onset of complications, during significant transitions in care such as from pediatric to adult care teams , or when problems with achieving A1C goals, quality of life, or self-management are identified 2.

Patients are likely to exhibit psychological vulnerability at diagnosis, when their medical status changes e. Thus, screening for social determinants of health e.

Providers should also ask whether there are new or different barriers to treatment and self-management, such as feeling overwhelmed or stressed by having diabetes see the section diabetes distress below , changes in finances, or competing medical demands e.

In circumstances where individuals other than the patient are significantly involved in diabetes management, these issues should be explored with nonmedical care providers Standardized and validated tools for psychosocial monitoring and assessment can also be used by providers 1 , with positive findings leading to referral to a mental health provider specializing in diabetes for comprehensive evaluation, diagnosis, and treatment.

Diabetes distress is very common and is distinct from other psychological disorders , , The constant behavioral demands of diabetes self-management medication dosing, frequency, and titration; monitoring of blood glucose, food intake, eating patterns, and physical activity and the potential or actuality of disease progression are directly associated with reports of diabetes distress High levels of diabetes distress significantly impact medication-taking behaviors and are linked to higher A1C, lower self-efficacy, and poorer dietary and exercise behaviors 5 , , DSMES has been shown to reduce diabetes distress 5.

It may be helpful to provide counseling regarding expected diabetes-related versus generalized psychological distress, both at diagnosis and when disease state or treatment changes occur An RCT tested the effects of participation in a standardized 8-week mindful self-compassion program versus a control group among patients with type 1 and type 2 diabetes.

Mindful self-compassion training increased self-compassion, reduced depression and diabetes distress, and improved A1C in the intervention group An RCT of cognitive behavioral and social problem-solving approaches compared with diabetes education in teens aged 14—18 years showed that diabetes distress and depressive symptoms were significantly reduced for up to 3 years postintervention.

Neither glycemic control nor self-management behaviors were improved over time. These recent studies support that a combination of approaches is needed to address distress, depression, and metabolic status.

Diabetes distress should be routinely monitored using person-based diabetes-specific validated measures 1. If diabetes distress is identified, the person should be referred for specific diabetes education to address areas of diabetes self-care causing the patient distress and impacting clinical management.

Diabetes distress is associated with anxiety, depression, and reduced health-related quality of life People whose self-care remains impaired after tailored diabetes education should be referred by their care team to a behavioral health provider for evaluation and treatment.

Other psychosocial issues known to affect self-management and health outcomes include attitudes about the illness, expectations for medical management and outcomes, available resources financial, social, and emotional , and psychiatric history.

Indications for referral to a mental health specialist familiar with diabetes management may include positive screening for overall stress related to work-life balance, diabetes distress, diabetes management difficulties, depression, anxiety, disordered eating, and cognitive dysfunction see Table 5.

It is preferable to incorporate psychosocial assessment and treatment into routine care rather than waiting for a specific problem or deterioration in metabolic or psychological status to occur 34 , Providers should identify behavioral and mental health providers, ideally those who are knowledgeable about diabetes treatment and the psychosocial aspects of diabetes, to whom they can refer patients.

The ADA provides a list of mental health providers who have received additional education in diabetes at the ADA Mental Health Provider Directory professional. Ideally, psychosocial care providers should be embedded in diabetes care settings.

Although the provider may not feel qualified to treat psychological problems , optimizing the patient-provider relationship as a foundation may increase the likelihood of the patient accepting referral for other services.

Collaborative care interventions and a team approach have demonstrated efficacy in diabetes self-management, outcomes of depression, and psychosocial functioning 5 , 6. Situations that warrant referral of a person with diabetes to a mental health provider for evaluation and treatment.

Clinically significant psychopathologic diagnoses are considerably more prevalent in people with diabetes than in those without , Inclusion of caregivers and family members in this assessment is recommended.

Diabetes distress is addressed as an independent condition see the section diabetes distress above , as this state is very common and expected and is distinct from the psychological disorders discussed below 1.

Refer for treatment if anxiety is present. Anxiety symptoms and diagnosable disorders e. The Behavioral Risk Factor Surveillance System BRFSS estimated the lifetime prevalence of generalized anxiety disorder to be Common diabetes-specific concerns include fears related to hypoglycemia , , not meeting blood glucose targets , and insulin injections or infusion Onset of complications presents another critical point in the disease course when anxiety can occur 1.

People with diabetes who exhibit excessive diabetes self-management behaviors well beyond what is prescribed or needed to achieve glycemic targets may be experiencing symptoms of obsessive-compulsive disorder General anxiety is a predictor of injection-related anxiety and associated with fear of hypoglycemia , Fear of hypoglycemia and hypoglycemia unawareness often co-occur.

Interventions aimed at treating one often benefit both Fear of hypoglycemia may explain avoidance of behaviors associated with lowering glucose such as increasing insulin doses or frequency of monitoring.

If fear of hypoglycemia is identified and a person does not have symptoms of hypoglycemia, a structured program of blood glucose awareness training delivered in routine clinical practice can improve A1C, reduce the rate of severe hypoglycemia, and restore hypoglycemia awareness , If not available within the practice setting, a structured program targeting both fear of hypoglycemia and unawareness should be sought out and implemented by a qualified behavioral practitioner , — History of depression, current depression, and antidepressant medication use are risk factors for the development of type 2 diabetes, especially if the individual has other risk factors such as obesity and family history of type 2 diabetes — Elevated depressive symptoms and depressive disorders affect one in four patients with type 1 or type 2 diabetes Thus, routine screening for depressive symptoms is indicated in this high-risk population, including people with type 1 or type 2 diabetes, gestational diabetes mellitus, and postpartum diabetes.

Regardless of diabetes type, women have significantly higher rates of depression than men Routine monitoring with age-appropriate validated measures 1 can help to identify if referral is warranted Adult patients with a history of depressive symptoms need ongoing monitoring of depression recurrence within the context of routine care Integrating mental and physical health care can improve outcomes.

When a patient is in psychological therapy talk or cognitive behavioral therapy , the mental health provider should be incorporated into the diabetes treatment team What is Self-Care? Diabetes Self-Management Education DSME First, you need to be trained on how to manage your type of diabetes best.

Some key topics covered in DSME programs include: Understanding the different types of diabetes and their effects on the body The importance of regular blood glucose monitoring and interpreting the results Developing a personalised meal plan based on individual needs and preferences The benefits of regular physical activity and how to incorporate it into daily routines Recognizing and managing the signs and symptoms of high and low blood sugar levels Identifying and managing stress and other emotional issues related to diabetes Proper use of medications and insulin therapy, if applicable These programs often include individualised assessments, goal setting, problem-solving, and ongoing support from qualified professionals.

Gaining a Better Overview of Blood Sugar Levels Over Time Managing blood sugar levels is a crucial aspect of diabetes self-care.

Physical Self-Care Physical self-care is essential for maintaining good health and managing diabetes effectively. Regular physical activity has numerous benefits for people with diabetes, including: Improved insulin sensitivity, which helps the body use insulin more effectively Lower blood sugar levels and better overall blood sugar control Increased energy and reduced fatigue Weight management, which reduces the risk of diabetes-related complications Lower blood pressure and cholesterol levels, reducing the risk of heart disease Experts recommend 3 at least minutes of moderate-intensity physical activity or 75 minutes of vigorous-intensity exercise per week, along with muscle-strengthening activities on two or more days per week.

Mental Self-Care Mental self-care involves taking care of your mental and emotional health. Some effective mental self-care strategies for people with diabetes include: Practicing mindfulness e.

Yoga, Journaling, Breathing Methods, Meditation etc. to increase awareness and reduce stress Seeking professional help, such as counselling or therapy, to address emotional challenges related to diabetes Engaging in hobbies and activities that bring you joy and relaxation Building a solid support network of your family, friends, and fellow people with diabetes Prioritizing sleep and maintaining a consistent sleep schedule to promote mental and emotional well-being These practices will help you manage the emotional and mental toll of living with the condition and improve your quality of life.

Enriched Information for Your Healthcare Team Your healthcare team plays a critical role in your diabetes management, but they can only help you as much as the information you provide them. Conclusion Strive to build self-care practices and do them on a daily basis as they help you manage your condition more effectively and improve your quality of life.

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The association between Diabetes mellitus and Depression. J Med Life. Tags: blood sugar diabetes diabetes management exercise important stress. Share This Article. Share on Facebook Share on Facebook Tweet Share on Twitter Pin it Share on Pinterest Share on LinkedIn Share on LinkedIn.

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Table 1 shows that Most of the patients were married Moreover, most of them were homemakers The most common age of diagnosis was observed in the 40—49 age group The majority of patients managed their disease through both diet and oral medications The majority of the patients were 1st to 3rd degree overweight Mostly, they had no history of training According to Table 2 , the mean and standard deviation of SCB were 3.

In other words, patients with a training history had significantly higher mean scores of SCB than patients without a training history. Table number 3 shows the mean scores for 5 domains of SCB and self-efficacy. Among the five domains of self-care behavior, the highest score was related to medication compliance, with a mean score of 5.

Among the five dimensions of self-efficacy, self-efficacy in medication compliance had the highest mean score of 3.

Table number 4 displays the correlation coefficients between the scores of SCB and its domains with HDSCR and the self-efficacy constructs of type 2 diabetes patients. In all cases, these associations were statistically significant Table 4. Table 5 shows multiple linear regression results for the prediction of SCB among type 2 DM patients based on the HDSCR and the self-efficacy constructs.

The physical exercise construct of self-efficacy -based on the standardized coefficient 0. A unit increase in the physical exercise construct of self-efficacy score was associated with a 0. With a standard coefficient of 0.

A unit increase in the foot care construct of self-efficacy score was associated with a significant 0. The HDSCR construct 0.

The diet construct standard coefficient of 0. The coefficient for determining the final model was calculated at 0. The results of this study also demonstrated that type 2 diabetes patients had average self-care scores This too is consistent with many other studies in the literature [ 33 , 34 , 35 ].

Though, Kong et al. Furthermore, extensive training offered through the media can lead to different SCB among patients in different countries and even various regions of a single country. Our findings showed that most of our patients were female, and women had higher SCB scores than men.

However, gender did not significantly affect SCB, which agreed with many other studies [ 23 , 33 ]. In contrast, Nejat et al [ 34 ] and Kong et al. This discrepancy might be explained by the variation in gender inequality among individuals.

Moreover, other variables, such as education, physical, psychological and cultural factors, could also influence the impact of gender on SCB. Most of the participants were married, and their marital status did not significantly influence SCB, which was consistent with previous studies [ 23 , 33 ].

This suggested that SCB depended on various factors besides marital status. However, Abate et al. This inconsistency might be due to the differences in the sample characteristics and the proportion of single and married patients.

According to our results, most of the participants were homemakers, and their occupation did not significantly affect SCB. This was similar to the findings of many other studies [ 23 ]. However, Kong et al. This divergence might be attributed to the variations in the definitions of occupations across these studies and the relationships between these occupations and confounding and influential variables such as income, education, etc.

The majority of the participants were in the year-old age group, and the highest self-care score was in the year-old age group. The self-care scores decreased with increasing age, but the difference was not statistically significant among the age groups in terms of SCB.

In the present study, there was no significant association between SCB and duration of disease; longer disease duration did not result in better SCB in patients. However, Modaresi et al. Furthermore, the effects of confounding and influential variables such as knowledge, awareness, etc.

might also be involved. Our findings indicated that most of our participants had high school education Those with higher education levels showed more SCB than those with lower education levels, suggesting that education was a determinant factor of SCB in patients. Ebrahimi et al.

However, we did not find a significant association between education and self-care scores in this study, which might be due to the unequal distribution of participants across different education levels.

Our results were consistent with those of other studies [ 23 , 34 ]. In contrast, Abate et al. Most of our participants The self-care scores of these two groups did not differ significantly.

This was in line with our results, Ishak et al. On the other hand, Modaresi et al. The oldest age of diagnosis in our study was in the year-old age group. The self-care scores at ages of diagnosis below 30 years and over 60 years were lower than the other age groups, and this difference was statistically significant.

This might indicate that younger individuals have lower tendencies toward self-care due to their higher risk-taking and curiosity for new experiences. In the elderly over 60 years, lower levels of awareness, loss of abilities, reduced activity and mobility, loss of friends and loved ones, decreased financial and physical independence, and chronic diseases might account for their lower self-care scores compared to the other age groups.

Furthermore, this study showed that patients who had received training had higher self-care scores than those who had not, and this difference was statistically significant. Our finding agreed with those of Chali et al.

Our findings showed a strong correlation between SCB and self-efficacy, which agreed with many other studies. Rahaee et al [ 23 ], Kong et al. This means that individuals with higher self-efficacy set bigger goals and expect better outcomes; they view the challenges of self-care as solvable problems and adopt SCB.

However, some studies did not find any association between self-efficacy and SCB. Chlebowy et al. These differences might be due to the use of different assessment tools and the diversity of study populations and cultures.

SCB had strong correlations with diet adherence and foot care; moderate correlations with physical activity; and weak correlations with medication compliance and glycemic control.

SCB also had a moderate and negative correlation with HDSCR; that is, higher patient needs were associated with lower self-care. Among the self-care components, there was a strong correlation between dietary adherence and medication compliance. In addition, various components of SCB were statistically and significantly correlated with diet adherence, medication compliance, foot care, physical activity, and glycemic control.

The following pairs had statistically significant correlations: physical activity and foot care, glycemic control and foot care and medication compliance, and foot care and medication compliance. However, physical activity was not significantly correlated with medication compliance and glycemic control.

Physical inactivity is sometimes habitual, and in some cases, age and awareness of the role of physical activity can affect disease control; starting a regular exercise program requires ongoing training and a suitable environment [ 39 ].

Multiple linear regression was used to determine the predictability of self-efficacy and HDSCR in SCB. In our study, we ensured generalizability by carefully selecting a representative sample from the population of interest.

Specifically, we employed random sampling from 32 rural health houses in Rasht city, selecting 27 one with suitable geographical distribution.

We evaluated patients out of with active profiles registered in these centers based on our inclusion criteria. Furthermore, our statistical analysis was robust, enhancing the external validity of our findings.

While our methodology was designed to ensure the results are not confined to the specific sample, we caution against over-generalization and recommend further studies for broader applicability. Our study provides valuable insights into the complex relationship between self-care, self-efficacy, and Health Deviation Self-Care Requisites in patients with type 2 diabetes.

This contributes to the existing knowledge base and opens avenues for further research to explore these relationships in more depth.

Moreover, the strong and direct correlation between self-care behaviors and self-efficacy, as well as the role of the physical exercise construct of self-efficacy as a significant predictor of self-care behaviors, are key findings that could guide future research in this area.

The findings underscore the importance of addressing self-efficacy and specific self-care domains, such as physical activity and foot care, in diabetes management strategies. The results indicate that self-efficacy is a dynamic and changeable belief that can be influenced by behavioral interventions.

This suggests that teaching self-care behaviors is essential in promoting self-efficacy and empowering patients. The study may inform healthcare professionals and policymakers in developing targeted interventions to improve self-care practices in diabetic patients.

Specifically, purposeful and needs-based training grounded on promotion models that identify the determinant factors of self-care are necessary to overcome behavioral barriers.

The limitations of the study can be discussed in terms of potential sources of bias and imprecision. The study has several limitations that could introduce bias or imprecision. Firstly, the participant selection was limited to rural patients attending a comprehensive health center, which may not represent the broader population.

This could introduce selection bias, potentially skewing the results in an unknown direction. Secondly, there was a gender imbalance with a greater number of female participants compared to males.

This could lead to gender bias if the outcomes measured are differentially affected by gender. The direction of this bias is uncertain and could either overestimate or underestimate the true effect size.

Thirdly, the lower educational level of the participants was addressed by having the researcher complete the questionnaires. While this approach reduces the risk of information bias due to misunderstanding of questions, it could introduce observer bias if the researcher unconsciously influences the responses.

Lastly, the data were self-reported, which may introduce recall bias or social desirability bias. Participants may not accurately remember past events recall bias or may answer in a way that they believe is socially acceptable rather than truthful social desirability bias.

Both biases could lead to an overestimation or underestimation of the true effect size. However, while these limitations could potentially bias the results, the direction and magnitude of the bias are uncertain.

Future studies should aim to address these limitations to provide more accurate and generalizable results. As one of the most important determinants of SCB, self-efficacy is of paramount importance in diabetic patients. Self-efficacy is a dynamic and changeable belief, and can change with behavioral interventions.

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Khosravan S, Ahrari Z, Njafi M, Alami A. Med-Sur Nurs J. Asgharian R, Shariati A, Shahbazian H, Jahani S, Latifi M. My clinic employs a diabetes educator who is also a pharmacist.

The educator meets with patients one-on-one to provide information on nutrition, diet, and physical activity, and can also make medical treatment suggestions because of their pharmacy background. The educator is a great asset to our office because they can see patients for extended times, and the patient knows that the educator is communicating with me about their care.

There are four critical times to provide and modify diabetes self-management education and support: at diagnosis, annually or when not meeting treatment targets or goals, when complicating factors develop, and when transitions in life and care occur.

A physician must ensure that patients receive the education and support they need to navigate the intricacies of daily self-management.

A few of the many benefits of diabetes self-management education and support include lowering A1C levels; reducing hospital admissions, readmissions, and emergency department visits; reducing diabetes-related distress; and improving self-care behaviors.

Despite the benefits, diabetes self-management education and support programs are underutilized. Diabetes self-management education and support services are covered by most health insurance in office or out.

Family physicians need to prioritize diabetes self-management education and support during office visits and use a diabetes care and education specialist or another health care team member as a resource for patients. Evidence shows that the best outcomes are achieved when education is provided in both group and individual settings, includes collaboration among team members, involves more than 10 hours, focuses on behaviors, and engages the participant.

I call on you, family physicians who will provide care for this growing population of patients, to:. Expand awareness of, access to, and use of traditional, innovative, and nontraditional diabetes self-management education and support services. Identify and address practice and patient-level barriers to accessing and participating in diabetes self-management education and support services e.

Discuss with patients the benefits and value of initial and ongoing diabetes self-management education and support. Ensure coordination of a medical nutrition therapy plan as a part of the overall management strategy, including a diabetes self-management education and support plan, medications, and physical activity, on an ongoing basis.

Health systems and family physicians should mobilize to ensure that all people with type 2 diabetes have access to diabetes self-management education and support, including nutritional, physical, and emotional support.

Engage your clinical team, your organization, and your patients to design a process to make referrals to diabetes educators easy and impactful. Providing access to diabetes self-management education and support is an important part of the treatment plan for all patients with diabetes. The opinions and assertions contained herein are the private views of the author and are not to be construed as official or as reflecting the views of the U.

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