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An elevated blood pressure is defined as a systolic blood pressure 120–129 mmHg and a diastolic blood pressure <80 mmHg (17).
Hypertension is defined as a systolic blood pressure =130 mmHg or a diastolic blood pressure =80 mmHg (17).
This is in agreement with the definition of hypertension by the American College of Cardiology and American Heart Association (17).
Hypertension is common among people with either type 1 or type 2 diabetes.
"Hypertension is a major risk factor for ASCVD, heart failure, and microvascular complications."
"Moreover, numerous studies have shown that antihypertensive therapy reduces ASCVD events, heart failure, and microvascular complications."
"Please refer to the ADA position statement “Diabetes and Hypertension” for a detailed review of the epidemiology, diagnosis, and treatment of hypertension (18) and recent updated hypertension guideline recommendations (17,19,20)."
"Blood pressure should be measured at every routine clinical visit by a trained individual and should follow the guidelines established for the general population: measurement in the seated position, with feet on the floor and arm supported at heart level, after 5 min of rest."
Cuff size should be appropriate for the upper-arm circumference (21).
"Elevated values should preferably be confirmed on a separate day; however, in individuals with cardiovascular disease and blood pressure =180/110 mmHg, it is reasonable to diagnose hypertension at a single visit (19)."
Postural changes in blood pressure and pulse may be evidence of autonomic neuropathy and therefore require adjustment of blood pressure targets.
Orthostatic blood pressure measurements should be checked on initial visit and as indicated.
"Lifestyle intervention, including weight loss in people with overweight or obesity (when appropriate) (85), increased physical activity, and medical nutrition therapy, allows some individuals to reduce ASCVD risk factors."
"Nutrition intervention should be tailored according to each person’s age, pharmacologic treatment, lipid levels, and medical conditions."
"Recommendations should focus on application of a Mediterranean (83) or Dietary Approaches to Stop Hypertension (DASH) eating pattern, reducing saturated and trans fat intake, and increasing plant stanol/sterol, n-3 fatty acid, and viscous fiber (such as in oats, legumes, and citrus) intake (86,87)."
"Glycemic control may also beneficially modify plasma lipid levels, particularly in people with very high triglycerides and poor glycemic control."
"See Section 5, “Facilitating Positive Health Behaviors and Well-being to Improve Health Outcomes,” for additional nutrition information."
"In adults with diabetes, it is reasonable to obtain a lipid profile (total cholesterol, LDL cholesterol, HDL cholesterol, and triglycerides) at the time of diagnosis, at the initial medical evaluation, and at least every 5 years thereafter in individuals <40 years of age."
"In younger people with longer duration of disease (such as those with youth-onset type 1 diabetes), more frequent lipid profiles may be reasonable."
A lipid panel should also be obtained immediately before initiating statin therapy.
" Once an individual is taking a statin, LDL cholesterol levels should be assessed 4–12 weeks after initiation of statin therapy, after any change in dose, and annually (e.g., to monitor for medication taking and efficacy)."
Monitoring lipid profiles after initiation of statin therapy and during therapy increases dose titration and statin adherence (88–90).
"If LDL cholesterol levels are not responding in spite of medication taking, clinical judgment is recommended to determine the need for and timing of lipid panels."
"In individual patients, the highly variable LDL cholesterol–lowering response seen with statins is poorly understood (91)."
Clinicians should attempt to find a dose or alternative statin that is tolerable if side effects occur.
"There is evidence for benefit from even extremely low, less than daily statin doses (92)."
"Home blood pressure self-monitoring and 24-h ambulatory blood pressure monitoring may provide evidence of white coat hypertension, masked hypertension, or other discrepancies between office and “true” blood pressure (22,23)."
"In addition to confirming or refuting a diagnosis of hypertension, home blood pressure assessment may be useful to monitor antihypertensive treatment."
"Studies of individuals without diabetes found that home measurements may better correlate with ASCVD risk than office measurements (22,23)."
"Moreover, home blood pressure monitoring may improve medication-taking behavior and thus help reduce cardiovascular risk (24)."
People with diabetes and clinicians should engage in a shared decision-making process to determine individual blood pressure targets (17).
This approach acknowledges that the benefits and risks of intensive blood pressure targets are uncertain and may vary across individuals and is consistent with a person-focused approach to care that values individual priorities and health care professional judgment (38).
"Secondary analyses of ACCORD BP and SPRINT suggest that clinical factors can help determine individuals more likely to benefit and less likely to be harmed by intensive blood pressure control (39,40)."
"Absolute benefit from blood pressure reduction correlated with absolute baseline cardiovascular risk in SPRINT and in earlier clinical trials conducted at higher baseline blood pressure levels (40,41)."
Extrapolation of these studies suggests that people with diabetes may also be more likely to benefit from intensive blood pressure control when they have high absolute cardiovascular risk.
"This approach is consistent with guidelines from the American College of Cardiology and American Heart Association, which also advocate a blood pressure target of <130/80 mmHg for all people, with or without diabetes (18)."
"Potential adverse effects of antihypertensive therapy (e.g., hypotension, syncope, falls, AKI, and electrolyte abnormalities) should also be taken into account (32,34,42,43)."
"Individuals with older age, CKD, and frailty have been shown to be at higher risk of adverse effects of intensive blood pressure control (42)."
"In addition, individuals with orthostatic hypotension, substantial comorbidity, functional limitations, or polypharmacy may be at high risk of adverse effects, and some individuals may prefer higher blood pressure targets to enhance quality of life."
"However, ACCORD BP demonstrated that intensive blood pressure lowering decreased the risk of cardiovascular events irrespective of baseline diastolic blood pressure in individuals who also received standard glycemic control (44)."
"Therefore, the presence of low diastolic blood pressure is not necessarily a contraindication to more intensive blood pressure management in the context of otherwise standard care."
Randomized clinical trials have demonstrated unequivocally that treatment of hypertension reduces cardiovascular events as well as microvascular complications (25–31).
There has been controversy on the recommendation of a specific blood pressure goal in people with diabetes.
The committee recognizes that there has been no randomized controlled trial to specifically demonstrate a decreased incidence of cardiovascular events in people with diabetes by targeting a blood pressure <130/80 mmHg.
"The recommendation to support a blood pressure goal of <130/80 mmHg in people with diabetes is consistent with guidelines from the American College of Cardiology and American Heart Association (18), the International Society of Hypertension (19), and the European Society of Cardiology (20)."
The committee’s recommendation for the blood pressure target of <130/80 mmHg derives primarily from the collective evidence of the following randomized controlled trials.
"The Systolic Blood Pressure Intervention Trial (SPRINT) demonstrated that treatment to a target systolic blood pressure of <120 mmHg decreases cardiovascular event rates by 25% in high-risk individuals, although people with diabetes were excluded from this trial (32)."
The recently completed Strategy of Blood Pressure Intervention in the Elderly Hypertensive Patients (STEP) trial included nearly 20% of people with diabetes and noted decreased cardiovascular events with treatment of hypertension to a blood pressure target of <130 mmHg (33).
"While the ACCORD (Action to Control Cardiovascular Risk in Diabetes) blood pressure trial (ACCORD BP) did not confirm that targeting a systolic blood pressure of <120 mmHg in people with diabetes results in decreased cardiovascular event rates, the prespecified secondary outcome of stroke was reduced by 41% with intensive treatment (34)."
The Action in Diabetes and Vascular Disease: Preterax and Diamicron MR Controlled Evaluation (ADVANCE) trial revealed that treatment with perindopril/indapamide to an achieved systolic blood pressure of ~135 mmHg significantly decreased cardiovascular event rates compared with a placebo treatment with an achieved blood pressure of 140 mmHg (35).
"Therefore, it is recommended that people with diabetes who have hypertension should be treated to blood pressure targets of <130/80 mmHg."
"Notably, there is an absence of high-quality data available to guide blood pressure targets in people with type 1 diabetes, but a similar blood pressure target of <130/80 mmHg is recommended in people with type 1 diabetes."
"As discussed below, treatment should be individualized, and treatment should not be targeted to <120/80 mmHg, as a mean achieved blood pressure of <120/80 mmHg is associated with adverse events."
"SPRINT provides the strongest evidence to support lower blood pressure goals in individuals at increased cardiovascular risk, although this trial excluded people with diabetes (32)."
"The trial enrolled 9,361 individuals with a systolic blood pressure of =130 mmHg and increased cardiovascular risk and treated to a systolic blood pressure target of <120 mmHg (intensive treatment) versus a target of <140 mmHg (standard treatment)."
"The primary composite outcome of MI, coronary syndromes, stroke, heart failure, or death from cardiovascular causes was reduced by 25% in the intensive treatment group."
"The achieved systolic blood pressures in the trial were 121 mmHg and 136 mmHg in the intensive versus standard treatment group, respectively."
"Adverse outcomes, including hypotension, syncope, electrolyte abnormality, and acute kidney injury (AKI), were more common in the intensive treatment arm; risk of adverse outcomes needs to be weighed against the cardiovascular benefit of more intensive blood pressure lowering."
ACCORD BP provides the strongest direct assessment of the benefits and risks of intensive blood pressure control in people with type 2 diabetes (34).
"In the study, a total of 4,733 individuals with type 2 diabetes were assigned to intensive therapy (targeting a systolic blood pressure <120 mmHg) or standard therapy (targeting a systolic blood pressure <140 mmHg)."
"The mean achieved systolic blood pressures were 119 mmHg and 133 mmHg in the intensive versus standard group, respectively."
"The primary composite outcome of nonfatal MI, nonfatal stroke, or death from cardiovascular causes was not significantly reduced in the intensive treatment group."
The prespecified secondary outcome of stroke was significantly reduced by 41% in the intensive treatment group.
"Adverse events attributed to blood pressure treatment, including hypotension, syncope, bradycardia, hyperkalemia, and elevations in serum creatinine, occurred more frequently in the intensive treatment arm than in the standard therapy arm (Table 10.1 )."
"Of note, the ACCORD BP and SPRINT trials targeted a similar systolic blood pressure <120 mmHg, but in contrast to SPRINT, the primary composite cardiovascular end point was nonsignificantly reduced in ACCORD BP."
"The results have been interpreted to be generally consistent between both trials, but ACCORD BP was viewed as underpowered due to the composite primary end point being less sensitive to blood pressure regulation (32)."
"The more recent STEP trial assigned 8,511 individuals aged 60–80 years with hypertension to a systolic blood pressure target of 110 to <130 mmHg (intensive treatment) or a target of 130 to <150 mmHg (33)."
"In this trial, the primary composite outcome of stroke, acute coronary syndrome, acute decompensated heart failure, coronary revascularization, atrial fibrillation, or death from cardiovascular causes occurred in 3.5% of individuals in the intensive treatment group versus 4.6% in the standard treatment group (hazard ratio [HR] 0.74 [95% CI 0.60–0.92]; P = 0.007)."
"In this trial, 18.9% of individuals in the intensive treatment arm and 19.4% in the standard treatment arm had a diagnosis of type 2 diabetes."
"Hypotension occurred more frequently in the intensive treatment group (3.4%) compared with the standard treatment group (2.6%), without significant differences in other adverse events, including dizziness, syncope, or fractures."
"In ADVANCE, 11,140 people with type 2 diabetes were randomized to receive either treatment with a fixed combination of perindopril/indapamide or matching placebo (35)."
"The primary end point, a composite of cardiovascular death, nonfatal stroke infarction, or worsening renal or diabetic eye disease, was reduced by 9% in the combination treatment."
The achieved systolic blood pressure was ~135 mmHg in the treatment group and 140 mmHg in the placebo group.
"The Hypertension Optimal Treatment (HOT) trial enrolled 18,790 individuals and targeted diastolic blood pressure <90 mmHg, <85 mmHg, or <80 mmHg (36)."
"The cardiovascular event rates, defined as fatal or nonfatal MI, fatal and nonfatal strokes, and all other cardiovascular events, were not significantly different between diastolic blood pressure targets (=90 mmHg, =85 mmHg, and =80 mmHg), although the lowest incidence of cardiovascular events occurred with an achieved diastolic blood pressure of 82 mmHg."
"However, in people with diabetes, there was a significant 51% reduction in the treatment group with a target diastolic blood pressure of <80 mmHg compared with a target diastolic blood pressure of <90 mmHg."
"To clarify optimal blood pressure targets in people with diabetes, multiple meta-analyses have been performed."
"One of the largest meta-analyses included 73,913 people with diabetes."
"Compared with a less tight blood pressure control, allocation to a tighter blood pressure control significantly reduced the risk of stroke by 31% but did not reduce the risk of MI (37)."
"Another meta-analysis of 19 trials that included 44,989 individuals showed that a mean blood pressure of 133/76 mmHg is associated with a 14% risk reduction for major cardiovascular events compared with a mean blood pressure of 140/81 mmHg (31)."
This benefit was greatest in people with diabetes.
An analysis of trials including people with type 2 diabetes and impaired glucose tolerance with achieved systolic blood pressures of <135 mmHg in the intensive blood pressure treatment group and <140 mmHg in the standard treatment group revealed a 10% reduction in all-cause mortality and a 17% reduction in stroke (29).
More intensive reduction to <130 mmHg was associated with a further reduction in stroke but not other cardiovascular events.
Several meta-analyses stratified clinical trials by mean baseline blood pressure or mean blood pressure attained in the intervention (or intensive treatment) arm.
"Based on these analyses, antihypertensive treatment appears to be most beneficial when mean baseline blood pressure is =140/90 mmHg (17,25,26,28–30)."
"Among trials with lower baseline or attained blood pressure, antihypertensive treatment reduced the risk of stroke, retinopathy, and albuminuria, but effects on other ASCVD outcomes and heart failure were not evident."
There are few randomized controlled trials of antihypertensive therapy in pregnant individuals with diabetes.
"A 2018 Cochrane systematic review of antihypertensive therapy for mild to moderate chronic hypertension included 63 trials and over 5,909 women and suggested that antihypertensive therapy probably reduces the risk of developing severe hypertension but may not affect the risk of fetal or neonatal death, small-for-gestational-age babies, or preterm birth (45)."
The Control of Hypertension in Pregnancy Study (CHIPS) (46) enrolled mostly women with chronic hypertension.
"In CHIPS, targeting a diastolic blood pressure of 85 mmHg during pregnancy was associated with reduced likelihood of developing accelerated maternal hypertension and no demonstrable adverse outcome for infants compared with targeting a higher diastolic blood pressure."
"The mean systolic blood pressure achieved in the more intensively treated group was 133.1 ± 0.5 mmHg, and the mean diastolic blood pressure achieved in that group was 85.3 ± 0.3 mmHg."
"A similar approach is supported by the International Society for the Study of Hypertension in Pregnancy, which specifically recommends use of antihypertensive therapy to maintain systolic blood pressure between 110 and 140 mmHg and diastolic blood pressure between 80 and 85 mmHg (47)."
"The more recent Chronic Hypertension and Pregnancy (CHAP) trial assigned pregnant individuals with mild chronic hypertension to antihypertensive medications to target a blood pressure goal of <140/90 mmHg (active treatment group) or to control treatment, in which antihypertensive therapy was withheld unless severe hypertension (systolic pressure =160 mmHg or diastolic pressure =105 mmHg) developed (control group) (48)."
"The primary outcome, a composite of preeclampsia with severe features, medically indicated preterm birth at <35 weeks of gestation, placental abruption, or fetal/neonatal death, occurred in 30.2% of female participants in the active treatment group versus 37.0% in the control group (P < 0.001)."
The mean systolic blood pressure between randomization and delivery was 129.5 mmHg in the active treatment group and 132.6 mmHg in the control group.
Current evidence supports controlling blood pressure to 110–135/85 mmHg to reduce the risk of accelerated maternal hypertension but also to minimize impairment of fetal growth.
"During pregnancy, treatment with ACE inhibitors, angiotensin receptor blockers (ARBs), direct renin inhibitors, and spironolactone are contraindicated, as they may cause fetal damage."
"Special consideration should be taken for individuals of childbearing potential, and people intending to become pregnant should switch from an ACE inhibitor/ARB or spironolactone to an alternative antihypertensive medication approved during pregnancy."
"Antihypertensive drugs known to be effective and safe in pregnancy include methyldopa, labetalol, and long-acting nifedipine, while hydralazine may be considered in the acute management of hypertension in pregnancy or severe preeclampsia (49)."
"Diuretics are not recommended for blood pressure control in pregnancy but may be used during late-stage pregnancy if needed for volume control (49,50)."
"The American College of Obstetricians and Gynecologists also recommends that postpartum individuals with gestational hypertension, preeclampsia, and superimposed preeclampsia have their blood pressures observed for 72 h in the hospital and 7–10 days postpartum."
"Long-term follow-up is recommended for these individuals, as they have increased lifetime cardiovascular risk (51)."
"See Section 15, “Management of Diabetes in Pregnancy,” for additional information."
"Lifestyle management is an important component of hypertension treatment because it lowers blood pressure, enhances the effectiveness of some antihypertensive medications, promotes other aspects of metabolic and vascular health, and generally leads to few adverse effects."
"Lifestyle therapy consists of reducing excess body weight through caloric restriction (see Section 8, “Obesity and Weight Management for the Prevention and Treatment of Type 2 Diabetes”), at least 150 min of moderate-intensity aerobic activity per week (see Section 3, “Prevention or Delay of Diabetes and Associated Comorbidities”), restricting sodium intake (<2,300 mg/day), increasing consumption of fruits and vegetables (8–10 servings per day) and low-fat dairy products (2–3 servings per day), avoiding excessive alcohol consumption (no more than 2 servings per day in men and no more than 1 serving per day in women) (52), and increasing activity levels (53) (see Section 5, “Facilitating Positive Health Behaviors and Well-being to Improve Health Outcomes”)."
These lifestyle interventions are reasonable for individuals with diabetes and mildly elevated blood pressure (systolic >120 mmHg or diastolic >80 mmHg) and should be initiated along with pharmacologic therapy when hypertension is diagnosed (Fig. 10.2 ) (53).
A lifestyle therapy plan should be developed in collaboration with the person with diabetes and discussed as part of diabetes management.
"Use of internet or mobile-based digital platforms to reinforce healthy behaviors may be considered as a component of care, as these interventions have been found to enhance the efficacy of medical therapy for hypertension (54,55)."
"Although minimizing hyperglycemia may be important in older individuals with diabetes, greater reductions in morbidity and mortality are likely to result from a clinical focus on comprehensive cardiovascular risk factor modification."
"There is strong evidence from clinical trials of the value of treating hypertension in older adults (70,71), with treatment of hypertension to individualized target levels indicated in most."
"There is less evidence for lipid-lowering therapy and aspirin therapy, although the benefits of these interventions for primary and secondary prevention are likely to apply to older adults whose life expectancies equal or exceed the time frames of the clinical trials (72)."
"In the case of statins, the follow-up time of clinical trials ranged from 2 to 6 years."
"While the time frame of trials can be used to inform treatment decisions, a more specific concept is the time to benefit for a therapy."
"For statins, a meta-analysis of the previously mentioned trials showed that the time to benefit is 2.5 years (73)."
Lifestyle management in older adults should be tailored to frailty status.
"Diabetes in the aging population is associated with reduced muscle strength, poor muscle quality, and accelerated loss of muscle mass, which may result in sarcopenia and/or osteopenia (74,75)."
Diabetes is also recognized as an independent risk factor for frailty.
Frailty is characterized by decline in physical performance and an increased risk of poor health outcomes due to physiologic vulnerability and functional or psychosocial stressors.
"Inadequate nutritional intake, particularly inadequate protein intake, can increase the risk of sarcopenia and frailty in older adults."
"Management of frailty in diabetes includes optimal nutrition with adequate protein intake combined with an exercise program that includes aerobic, weightbearing, and resistance training."
"The benefits of a structured exercise program (as in the Lifestyle Interventions and Independence for Elders [LIFE] study) in frail older adults include reducing sedentary time, preventing mobility disability, and reducing frailty (76,77)."
The goal of these programs is not weight loss but enhanced functional status.
"For nonfrail older adults with type 2 diabetes and overweight or obesity, an intensive lifestyle intervention designed to reduce weight is beneficial across multiple outcomes."
"The Look AHEAD (Action for Health in Diabetes) trial is described in Section 8, “Obesity and Weight Management for the Prevention and Treatment of Type 2 Diabetes.”"
Look AHEAD specifically excluded individuals with a low functional status.
"It enrolled people between 45 and 74 years of age and required that they be able to perform a maximal exercise test (78,79)."
"While the Look AHEAD trial did not achieve its primary outcome of reducing cardiovascular events, the intensive lifestyle intervention had multiple clinical benefits that are important to the quality of life of older adults."
"Benefits included weight loss, improved physical fitness, increased HDL cholesterol, lowered systolic blood pressure, reduced A1C levels, reduced waist circumference, and reduced need for medications (80)."
"Additionally, several subgroups, including participants who lost at least 10% of baseline body weight at year 1, had improved cardiovascular outcomes (81)."
"Risk factor management was improved with reduced utilization of antihypertensive medications, statins, and insulin (82)."
"In age-stratified analyses, older adults in the trial (60 to early 70s) had similar benefits compared with younger people (83,84)."
"In addition, lifestyle intervention produced benefits on aging relevant outcomes such as reductions in multimorbidity and improvements in physical function and quality of life (85–88)."
"Older adults are at higher risk of hypoglycemia for many reasons, including erratic meal intake, insulin deficiency necessitating insulin therapy, and progressive renal insufficiency (29)."
"As described above, older adults have higher rates of unidentified cognitive impairment and dementia, leading to difficulties in adhering to complex self-care activities (e.g., glucose monitoring and insulin dose adjustment)."
"Cognitive decline has been associated with increased risk of hypoglycemia, and conversely, severe hypoglycemia has been linked to increased risk of dementia (30–32)."
"Therefore, as discussed in Recommendation 13.3, it is important to routinely screen older adults for cognitive impairment and dementia and discuss findings with the individuals and their caregivers."
"People with diabetes and their caregivers should be routinely queried about hypoglycemia (e.g., selected questions from the Diabetes Care Profile) (33) and impaired hypoglycemia awareness as discussed in Section 6, “Glycemic Goals and Hypoglycemia.”"
"Older adults can also be stratified for future risk for hypoglycemia with validated risk calculators (e.g., Kaiser Hypoglycemia Model) (34) and with consideration of hypoglycemia risk factors (Table 6.5)."
An important step to mitigate hypoglycemia risk is to determine whether the person with diabetes is skipping meals or inadvertently repeating doses of their medications.
Glycemic goals and pharmacologic treatments may need to be adjusted to minimize the occurrence of hypoglycemic events (2).
"This recommendation is supported by results from multiple randomized controlled trials, such as the Action to Control Cardiovascular Risk in Diabetes (ACCORD) study and the Veterans Affairs Diabetes Trial (VADT), which showed that intensive treatment protocols aimed to achieve an A1C <6.0% with complex drug plans significantly increased the risk for hypoglycemia requiring assistance compared with standard treatment (35,36)."
"However, these intensive treatment plans included extensive use of insulin and minimal use of GLP-1 receptor agonists, and they preceded the availability of sodium–glucose cotransporter 2 (SGLT2) inhibitors."
"While the current evidence base for older adults is primarily in type 1 diabetes, the evidence demonstrating the clinical benefits of CGM for people with type 2 diabetes using insulin is growing (42) (see Section 7, “Diabetes Technology”)."
"The DIAMOND (Multiple Daily Injections and Continuous Glucose Monitoring in Diabetes) study demonstrated that in adults =60 years of age with either type 1 or type 2 diabetes using multiple daily injections, CGM use was associated with improved A1C and reduced glycemic variability (43)."
Older adults with physical or cognitive limitations who require monitoring of blood glucose by a surrogate or reside in group homes or assisted living centers are other populations for which CGM may play a useful role.
"The care of older adults with diabetes is complicated by their clinical, cognitive, and functional heterogeneity and their varied prior experience with disease management."
"Some older individuals may have developed diabetes years earlier and have significant complications, others are newly diagnosed and may have had years of undiagnosed diabetes with resultant complications, and still, other older adults may have truly recent-onset disease with few or no complications (47)."
"Some older adults with diabetes have other underlying chronic conditions, substantial diabetes-related comorbidity, limited cognitive or physical functioning, or frailty (48,49)."
Other older individuals with diabetes have little comorbidity and are active.
Life expectancies are highly variable but are often longer than clinicians realize.
"Multiple prognostic tools for life expectancy for older adults are available (50,51)."
"Notably, the Life Expectancy Estimator for Older Adults with Diabetes (LEAD) tool was developed and validated among older adults with diabetes, and a high risk score was strongly associated with having a life expectancy of <5 years (52)."
"These data may be a useful starting point to inform decisions about selecting less stringent glycemic goals (52,53)."
Older adults also vary in their preferences for the intensity and mode of glucose management (54).
"Health care professionals caring for older adults with diabetes must take this heterogeneity into consideration when setting and prioritizing treatment goals (9,10) (Table 13.1 )."
"In addition, older adults with diabetes should be assessed for disease treatment and self-management knowledge, health literacy, and mathematical literacy (numeracy) at the onset of treatment."
See Fig. 6.2 for individual/disease-related factors to consider when determining individualized glycemic goals.
"(Table13.1) Healthy (few coexisting chronic illnesses, intact cognitive and functional status), Longer remaining life expectancy, <7.0–7.5% (<53–58 mmol/mol), 80–130 mg/dL (4.4–7.2 mmol/L), 80–180 mg/dL (4.4–10.0 mmol/L), <130/80 mmHg, Statin, unless contraindicated or not tolerated."
"A1C may have limitations in those who have medical conditions that impact red blood cell turnover (see Section 2, “Diagnosis and Classification of Diabetes,” for additional details on the limitations of A1C) (55)."
"Many conditions associated with increased red blood cell turnover, such as hemodialysis, recent blood loss or transfusion, or erythropoietin therapy, are commonly seen in older adults and can falsely increase or decrease A1C."
"In these instances, blood glucose monitoring and/or CGM should be used for goal setting (Table 13.1 )."
"Serum glycated protein assays (fructosamine and glycated albumin) may also be useful for glycemic monitoring in conjunction with other measures (see Section 6, “Glycemic Goals and Hypoglycemia”) (56–60)."
"There are few long-term studies in older adults demonstrating the benefits of intensive glycemic, blood pressure, and lipid management."
"Older adults who can be expected to live long enough to realize the benefits of long-term intensive diabetes management, who have good cognitive and physical function, and who choose to do so via shared decision-making may be treated using therapeutic interventions and goals similar to those for younger adults with diabetes (Table 13.1 )."
"As for all people with diabetes, diabetes self-management education and ongoing diabetes self-management support are vital components of diabetes care for older adults and their caregivers."
Self-management knowledge and skills should be reassessed when treatment plan changes are made or an individual’s functional abilities diminish.
"In addition, declining or impaired ability to perform diabetes self-care behaviors may be an indication that an older person with diabetes needs a referral for cognitive and physical functional assessment, using age-normalized evaluation tools, as well as help establishing a support structure for diabetes care (3,28)."
Older adults with diabetes categorized as having complex or intermediate health (Table 13.1 ) are heterogeneous with respect to their function and life expectancy (61–63).
"Based on concepts of competing mortality and time to benefit, some people in this category with shorter life expectancy will have less benefit from glucose lowering and should have less stringent glycemic goals (64)."
"This is especially true for individuals with advanced diabetes complications, life-limiting comorbid illnesses, frailty, or substantial cognitive or functional impairments."
"These individuals are also more likely to suffer serious adverse effects of therapeutics, such as hypoglycemia (65)."
"However, those with poorly managed diabetes may be subject to acute complications of diabetes, including dehydration, poor wound healing, and hyperglycemic hyperosmolar coma."
"Glycemic goals should, at a minimum, avoid these consequences."
Factors to consider for individualizing glycemic goals are outlined in Fig. 6.2.
"While Table 13.1  provides overall guidance for identifying complex and very complex patients, there is not yet global consensus on geriatric patient classification."
"Ongoing empiric research on the classification of older adults with diabetes based on comorbid illness has repeatedly found three major classes of patients: a healthy, a geriatric, and a cardiovascular class (9,61,66)."
"The geriatric class has the highest prevalence of obesity, hypertension, arthritis, and incontinence, and the cardiovascular class has the highest prevalence of myocardial infarctions, heart failure, and stroke."
"Compared with the healthy class, the cardiovascular class has the highest risk of frailty and subsequent mortality."
Additional research is needed to develop a reproducible classification scheme to distinguish the natural history of disease as well as differential response to glucose management and specific glucose-lowering agents (67).
"(Note from Table) Coexisting chronic illnesses are conditions serious enough to require medications or lifestyle management and may include arthritis, cancer, heart failure, depression, emphysema, falls, hypertension, incontinence, stage 3 or worse chronic kidney disease, myocardial infarction, and stroke. “Multiple” means at least three, but many individuals may have five or more (74)."
"For people with diabetes receiving palliative care and end-of-life care, the focus should be to avoid hypoglycemia and symptomatic hyperglycemia while reducing the burdens of glycemic management."
"Thus, as organ failure develops, several agents will have to be deintensified or discontinued."
"For a dying person, most agents for type 2 diabetes may be removed (68)."
"There is, however, no consensus for the management of type 1 diabetes in this scenario (69)."
See the section end-of-life care below for additional information.
"(Notes from Table) The presence of a single end-stage chronic illness, such as stage 3–4 heart failure or oxygen-dependent lung disease, chronic kidney disease requiring dialysis, or uncontrolled metastatic cancer, may cause significant symptoms or impairment of functional status and significantly reduce life expectancy; adapted from Kirkman et al. (3)."
" Clinicians should also consider the balance of risks and benefits of an individual’s diabetes medications, including disease-specific benefits (such as reducing symptomatic heart failure) and burdens such as hypoglycemia risk, tolerability, difficulties of administration, and financial cost."
"In addition, attention to oral health, foot care, fall prevention, and early detection of depression will improve quality of life."
"Screening for prediabetes and type 2 diabetes risk through an assessment of risk factors (Table 2.5) or with an assessment tool, such as the American Diabetes Association risk test (Fig. 2.2), is recommended to guide whether to perform a diagnostic test for prediabetes (Table 2.2) and type 2 diabetes (Table 2.1) (see Section 2, “Diagnosis and Classification of Diabetes”)."
"Testing high-risk adults for prediabetes is warranted because the laboratory assessment is safe and reasonable in cost, substantial time exists before the development of type 2 diabetes and its complications during which one can intervene, and there are effective approaches delaying type 2 diabetes in those with prediabetes with an A1C 5.7–6.4% (39–47 mmol/mol), impaired glucose tolerance (IGT), or impaired fasting glucose (IFG)."
The utility of screening with A1C for prediabetes and diabetes may be limited in the presence of hemoglobinopathies and conditions that affect red blood cell turnover.
"See Section 2, “Diagnosis and Classification of Diabetes,” and Section 6, “Glycemic Goals and Hypoglycemia,” for additional details on the appropriate use and limitations of A1C testing."
"Individualized risk-to-benefit ratio should be considered in screening, intervention, and monitoring to lower the risk of type 2 diabetes and associated comorbidities."
"Multiple factors, including age, BMI, and other comorbidities, may influence the risk of progression to diabetes and lifetime risk of complications (121,122)."
"Prediabetes is associated with increased cardiovascular disease and mortality (102), which emphasizes the importance of attending to cardiovascular risk in this population."
"In the DPP, which enrolled high-risk individuals with IGT, elevated fasting glucose, and elevated BMI, the crude incidence of diabetes within the placebo group was 11 cases per 100 person-years, with a cumulative 3-year incidence of diabetes of 29% (4)."
"Characteristics of individuals in the DPP/DPPOS who were at particularly high risk of progression to diabetes (crude incidence of diabetes 14–22 cases per 100 person-years) included BMI =35 kg/m2, higher glucose levels (e.g., fasting plasma glucose 110–125 mg/dL [6–6.9 mmol/L], 2–h postchallenge glucose 173–199 mg/dL [9.6–11.0 mmol/L], and A1C =6.0% [=42 mmol/mol]), and a history of GDM (4,91,92)."
"In contrast, in the community-based Atherosclerosis Risk in Communities (ARIC) study, observational follow-up of adults with mean age 75 years with laboratory evidence of prediabetes (based on A1C 5.7–6.4% [39–47 mmol/mol] and/or fasting glucose 100–125 mg/dL [5.6–6.9 mmol/L]), but not meeting specific BMI criteria, found lower progression to diabetes over 6 years: 9% of those with A1C-defined prediabetes, 8% with IFG (122)."
"Thus, it is important to individualize the risk-to-benefit ratio of intervention and consider person-centered goals."
Risk models have generally found higher benefit of the intervention in those at highest risk (12).
Diabetes prevention trials and observational studies highlight key principles that may guide person-centered goals.
"In the DPP, which enrolled a high-risk population meeting criteria for overweight or obesity, weight loss was an important mediator of diabetes prevention or delay, with greater metabolic benefit seen with greater weight loss (12,123)."
"In the DPP/DPPOS, progression to diabetes, duration of diabetes, and mean level of glycemia were important determinants of the development of microvascular complications (10)."
"Achieving normal glucose regulation, even once, during the DPP was associated with a lower risk of diabetes and lower risk of microvascular complications (124)."
Observational follow-up of the Da Qing study also showed that regression from IGT to normal glucose tolerance or remaining with IGT rather than progressing to type 2 diabetes at the end of the 6-year intervention trial resulted in significantly lower risk of cardiovascular disease and microvascular disease over 30 years (125).
"Three distinct stages of type 1 diabetes have been defined, with symptomatic type 1 diabetes being stage 3 (Table 2.3)."
"In individuals at risk for development of clinical type 1 diabetes, younger age of seroconversion (particularly under age 3 years), the total number of diabetes related autoantibodies (1), and the development of autoantibodies against islet antigen 2 (IA-2) have all been associated with more rapid progression to clinical type 1 diabetes."
"While continuous glucose monitoring can predict progression to overt diabetes in children with autoantibodies (2), oral glucose tolerance testing–based metrics are superior in predicting progression compared with continuous glucose monitoring (3)."
"The decision to perform an oral glucose tolerance test may depend on such factors as eligibility and interest for stage-specific treatments, participation in clinical research, and availability and burden of testing."
"Several major randomized controlled trials, including the Diabetes Prevention Program (DPP) trial (4), the Finnish Diabetes Prevention Study (DPS) (5), and the Da Qing Diabetes Prevention Study (Da Qing study) (6), demonstrate that lifestyle/behavioral intervention with an individualized reduced-calorie meal plan is highly effective in preventing or delaying type 2 diabetes and improving other cardiometabolic risk factors (such as blood pressure, lipids, and inflammation) (7)."
The strongest evidence for diabetes prevention in the U.S. comes from the DPP trial (4).
The DPP demonstrated that intensive lifestyle intervention could reduce the risk of incident type 2 diabetes by 58% over 3 years.
"Follow-up of three large trials of lifestyle intervention for diabetes prevention showed sustained reduction in the risk of progression to type 2 diabetes: 39% reduction at 30 years in the Da Qing study (8), 43% reduction at 7 years in the Finnish DPS (5), and 34% reduction at 10 years (9) and 27% reduction at 15 years (10) in the U.S. Diabetes Prevention Program Outcomes Study (DPPOS)."
The DPP lifestyle intervention was a goal-based intervention.
"All participants were given the same weight loss and physical activity goals, but individualization was permitted in the specific methods used to achieve the goals (11)."
"The two major goals of the DPP intensive lifestyle intervention were to achieve and maintain a minimum of 7% weight loss and 150 min of moderate-intensity physical activity per week, such as brisk walking."
"Although weight loss was the most important factor in reducing the risk of incident diabetes, achieving the behavioral goal of at least 150 min of physical activity per week, even without achieving the weight loss goal, reduced the incidence of type 2 diabetes by 44% (12)."
The 7% weight loss goal was selected because it was feasible to achieve and maintain and likely to lessen the risk of developing diabetes (as well as improve other cardiometabolic risk factors).
Participants were encouraged to achieve the =7% weight loss during the first 6 months of the intervention.
Further analysis suggests higher benefit for prevention of diabetes with at least 7–10% weight loss with lifestyle interventions (12).
The recommended pace of weight loss was 1–2 lb/week.
"Calorie goals were calculated by estimating the daily calories needed to maintain the participant’s initial weight and subtracting 500–1,000 calories/day (depending on initial body weight)."
The initial focus of the dietary intervention was on reducing total fat rather than calories.
"After several weeks, the concept of calorie balance and the need to restrict calories and fat was introduced (11)."
The goal for physical activity was selected to approximate at least 700 kcal/week expenditure from physical activity.
"For ease of translation, this goal was described as at least 150 min of moderate-intensity physical activity per week, similar in intensity to brisk walking."
Participants were encouraged to distribute their activity throughout the week with a minimum frequency of three times per week and at least 10 min per session.
A maximum of 75 min of strength training could be applied toward the total 150 min/week physical activity goal (11).
"To implement the weight loss and physical activity goals, the DPP used an individual model of treatment rather than a group-based approach."
This choice was based on a desire to intervene before participants had the possibility of developing diabetes or losing interest in the program.
The individual approach also allowed for the tailoring of interventions to reflect the diversity of the population (11).
"The DPP intervention was administered as a structured core curriculum followed by a flexible maintenance program of individual counseling, group sessions, motivational campaigns, and restart opportunities."
The 16-session core curriculum was completed within the first 24 weeks of the program.
"It included sessions on lowering calories, increasing physical activity, self-monitoring, maintaining healthy lifestyle behaviors (such as how to choose healthy food options when eating out), and guidance on managing psychological, social, and motivational challenges."
Further details are available regarding the core curriculum sessions (11).
"Moderate-intensity physical activity, such as brisk walking for 150 min/week, has shown beneficial effects in those with prediabetes (4)."
"Similarly, moderate-intensity physical activity has been shown to improve insulin sensitivity and reduce abdominal fat in children and young adults (27,28)."
Health care professionals are encouraged to promote a DPP-style program to all individuals who have been identified to be at an increased risk of type 2 diabetes.
"In addition to aerobic activity, a physical activity plan designed to prevent diabetes may include resistance training (11,29,30)."
"Breaking up prolonged sedentary time may also be encouraged, as it is associated with moderately lower postprandial glucose levels (31,32)."
The effects of physical activity appear to extend to the prevention of gestational diabetes mellitus (GDM) (33).
"Nutrition counseling for weight loss in the DPP lifestyle intervention arm included a reduction of total dietary fat and calories (4,11,12)."
"However, evidence suggests that there is not an ideal percentage of calories from carbohydrate, protein, and fat for all people to prevent diabetes; therefore, macronutrient distribution should be based on an individualized assessment of current eating patterns, preferences, and metabolic goals (13)."
"Based on other trials, a variety of eating patterns (13,14) may also be appropriate for individuals with prediabetes (13), including Mediterranean-style and low-carbohydrate eating plans (15–18)."
"Observational studies have also shown that vegetarian, plant-based (may include some animal products), and Dietary Approaches to Stop Hypertension (DASH) eating patterns are associated with a lower risk of developing type 2 diabetes (19–22)."
"Evidence suggests that the overall quality of food consumed (as measured by the Healthy Eating Index, Alternative Healthy Eating Index, and DASH score), with an emphasis on whole grains, legumes, nuts, fruits, and vegetables and minimal refined and processed foods, is also associated with a lower risk of type 2 diabetes (21,23–25)."
"As is the case for those with diabetes, individualized medical nutrition therapy (see Section 5, “Facilitating Positive Health Behaviors and Well-being to Improve Health Outcomes,” for more detailed information) is effective in lowering A1C in individuals diagnosed with prediabetes (26)."
"Because the intensive lifestyle intervention in the DPP was effective in preventing type 2 diabetes among those at high risk for the disease and lifestyle behavior change programs for diabetes prevention were shown to be cost-effective, broader efforts to disseminate scalable lifestyle behavior change programs for diabetes prevention with coverage by third-party payers ensued (34–38)."
Group delivery of DPP content in community or primary care settings has demonstrated the potential to reduce overall program costs while still producing weight loss and diabetes risk reduction (39–43).
"The Centers for Disease Control and Prevention (CDC) developed the National Diabetes Prevention Program (National DPP), a resource designed to bring such evidence-based lifestyle change programs for preventing type 2 diabetes to communities (cdc.gov/diabetes/prevention/index.htm)."
This online resource includes locations of CDC-recognized diabetes prevention lifestyle change programs (cdc.gov/diabetes/prevention/find-a-program.html).
"To be eligible for this program, individuals must have a BMI in the overweight range and be at risk for diabetes based on laboratory testing, a previous diagnosis of GDM, or a positive risk test (cdc.gov/prediabetes/takethetest/)."
"During the first 4 years of implementation of the CDC’s National DPP, 36% achieved the 5% weight loss goal (44)."
The CDC has also developed the Diabetes Prevention Impact Tool Kit (nccd.cdc.gov/toolkit/diabetesimpact) to help organizations assess the economics of providing or covering the National DPP (45).
"To expand preventive services using a cost-effective model, the Centers for Medicare & Medicaid Services expanded Medicare reimbursement coverage for the National DPP to organizations recognized by the CDC that become Medicare suppliers for this service (innovation.cms.gov/innovation-models/medicare-diabetes-prevention-program)."
The locations of Medicare DPPs are available online at innovation.cms.gov/innovation-models/medicare-diabetes-prevention-program/mdpp-map.
"To qualify for Medicare coverage, individuals must have BMI >25 kg/m2 (or BMI >23 kg/m2 if self-identified as Asian) and glycemic testing consistent with prediabetes in the last year."
Medicaid coverage of the National DPP is also expanding on a state-by-state basis.
"While CDC-recognized behavioral counseling programs, including Medicare DPP services, have met minimum quality standards and are reimbursed by many payers, lower retention rates have been reported for younger adults and racial and ethnic minority populations (46)."
"Therefore, other programs and modalities of behavioral counseling for diabetes prevention may also be appropriate and efficacious based on individual preferences and availability."
"The use of community health workers to support DPP-like interventions has been shown to be effective and cost-effective (47,48) (see Section 1, “Improving Care and Promoting Health in Populations,” for more information)."
The use of community health workers may facilitate the adoption of behavior changes for diabetes prevention while bridging barriers related to social determinants of health.
"However, coverage by third-party payers remains limited."
"Counseling by a registered dietitian nutritionist (RDN) has been shown to help individuals with prediabetes improve eating habits, increase physical activity, and achieve 7–10% weight loss (13,49–51)."
"Individualized medical nutrition therapy (see Section 5, “Facilitating Positive Health Behaviors and Well-being to Improve Health Outcomes,” for more detailed information) is also effective in improving glycemia in individuals diagnosed with prediabetes (26,49)."
"Furthermore, trials involving medical nutrition therapy for adults with prediabetes found significant reductions in weight, waist circumference, and glycemia."
"Individuals with prediabetes can benefit from referral to an RDN for individualized medical nutrition therapy upon diagnosis and at regular intervals throughout their treatment plan (50,52)."
"Other health care professionals, such as pharmacists and diabetes care and education specialists, may be considered for diabetes prevention efforts (53,54)."
Technology-assisted programs may effectively deliver a DPP-like intervention (55–60).
A digital diabetes prevention program improved cardiovascular risk at 4 months but not at 12 months (61).
"Such technology-assisted programs may deliver content through smartphones, web-based applications, and telehealth and may be an acceptable and efficacious option to bridge barriers, particularly for individuals with low income and people in rural locations; however, not all technology-assisted programs are effective (55,62–64)."
"The CDC Diabetes Prevention Recognition Program (DPRP) (cdc.gov/diabetes/prevention/requirements-recognition.htm) certifies technology-assisted modalities as effective vehicles for DPP-based interventions; such programs must use an approved curriculum, include interaction with a coach, and attain the DPP outcomes of participation, physical activity reporting, and weight loss."
Health care professionals should consider referring adults with prediabetes to certified technology-assisted programs.
"People with prediabetes often have other cardiovascular risk factors, including hypertension and dyslipidemia (100), and are at increased risk for cardiovascular disease (101,102)."
Evaluation for tobacco use and referral for tobacco cessation should be part of routine care for those at risk for diabetes.
"Of note, the years immediately following smoking cessation may represent a time of increased risk for diabetes (103–105), and individuals should be monitored for diabetes development and receive evidence-based lifestyle behavior change for diabetes prevention described in this section."
"See Section 5, “Facilitating Positive Health Behaviors and Well-being to Improve Health Outcomes,” for more detailed information."
"The lifestyle interventions for weight loss in study populations at risk for type 2 diabetes have shown a reduction in cardiovascular risk factors and the need for medications used to treat these cardiovascular risk factors (106,107)."
"The lifestyle intervention in the Da Qing study was associated with lowering cardiovascular disease and mortality at 23 and 30 years of observational follow-up (6,8)."
Treatment goals and therapies for hypertension and dyslipidemia in the primary and secondary prevention of cardiovascular disease for people with prediabetes should be based on their level of cardiovascular risk.
Increased vigilance is warranted to identify and treat these and other cardiovascular diseases risk factors (108).
"The overall objectives of DSMES are to support informed decision-making, self-care behaviors, problem-solving, and active collaboration with the health care team to improve clinical outcomes, health status, and well-being in a cost-effective manner (2)."
"DSMES services facilitate the knowledge, decision-making, and skills mastery necessary for optimal diabetes self-care and incorporate the needs, goals, and life experiences of the person with diabetes."
Health care professionals are encouraged to consider the burden of treatment (9) and the person’s level of confidence and self-efficacy for management behaviors as well as the level of social and family support when providing DSMES.
"An individual’s engagement in self-management behaviors and the effects on clinical outcomes, health status, and quality of life, as well as the psychosocial factors impacting the person’s ability to self-manage, should be monitored as part of routine clinical care."
A randomized controlled trial (RCT) testing a decision-making education and skill-building program (10) showed that addressing these targets improved health outcomes in a population in need of health care resources.
"Furthermore, following a DSMES curriculum improves quality of care (11)."
"As the use of judgmental words is associated with increased feelings of shame and guilt, health care professionals are encouraged to consider the impact that language has on building therapeutic relationships and should choose positive, strength-based words and phrases that put people first (4,12)."
"Please see Section 4, “Comprehensive Medical Evaluation and Assessment of Comorbidities,” for more on use of language."
"In accordance with the national standards for DSMES (13), all people with diabetes should participate in DSMES, as it helps people with diabetes to identify and implement effective self-management strategies and cope with diabetes (2)."
Ongoing DSMES helps people with diabetes to maintain effective self-management throughout the life course as they encounter new challenges and as advances in treatment become available (14).
"Management and reduction of weight is important for people with type 1 diabetes, type 2 diabetes, or prediabetes with overweight or obesity."
"To support weight loss and improve A1C, cardiovascular disease (CVD) risk factors, and well-being in adults with overweight/obesity and prediabetes or diabetes, MNT and DSMES services should include an individualized eating plan in a format that results in an energy deficit in combination with enhanced physical activity (73)."
Lifestyle intervention programs should be intensive and have frequent follow-up to achieve significant reductions in excess body weight and improve clinical indicators.
"Behavior modification targets include physical activity, calorie restriction, weight management strategies, and motivation."
"There is strong and consistent evidence that modest, sustained weight loss can delay the progression from prediabetes to type 2 diabetes (103,105,106) (see Section 3, “Prevention or Delay of Diabetes and Associated Comorbidities”) and is beneficial for the management of type 2 diabetes (see Section 8, “Obesity and Weight Management for the Prevention and Treatment of Type 2 Diabetes”)."
"In prediabetes, the weight loss goal is 5–7% or higher for reducing risk of progression to type 2 diabetes (107)."
"In conjunction with support for healthy lifestyle behaviors, medication-assisted weight loss can be considered for people at risk for type 2 diabetes when needed to achieve and sustain 7–10% weight loss (108,109) (see Section 8, “Obesity and Weight Management for the Prevention and Treatment of Type 2 Diabetes”)."
"People with prediabetes at a healthy weight should also be considered for behavioral interventions to help establish routine aerobic and resistance exercise (107,110,111) as well as to establish healthy eating patterns."
"Services delivered by health care professionals familiar with diabetes and its management, such as an RDN, have been found to be effective (102)."
"For many individuals with overweight and obesity with type 2 diabetes, 5% weight loss is needed to achieve beneficial outcomes in glycemic control, lipids, and blood pressure (112,113)."
"It should be noted, however, that the clinical benefits of weight loss are progressive, and more intensive weight loss goals (i.e., 15%) may be appropriate to maximize benefit depending on need, feasibility, and safety (114,115)."
"Long-term durability of weight loss remains a challenge; however, newer medications (beyond metabolic surgery) may have potential for sustainability, impact on cardiovascular outcomes, and weight reduction beyond 10–15% (116–120)."
"In select individuals with type 2 diabetes, an overall healthy eating plan that results in energy deficit in conjunction with weight loss medications and/or metabolic surgery should be considered to help achieve weight loss and maintenance goals, lower A1C, and reduce CVD risk (108,121,122)."
"Overweight and obesity are also increasingly prevalent in people with type 1 diabetes and present clinical challenges regarding diabetes treatment and CVD risk factors (123,124)."
"Sustaining weight loss can be challenging (112,125) but has long-term benefits; maintaining weight loss for 5 years is associated with sustained improvements in A1C and lipid levels (126)."
MNT guidance from an RDN with expertise in diabetes and weight management throughout the course of a structured weight loss plan is strongly recommended.
"Studies have demonstrated that a variety of eating plans, varying in macronutrient composition, can be used effectively and safely in the short term (1–2 years) to achieve weight loss in people with diabetes."
"These plans include structured low-calorie meal plans with meal replacements (114,126,128), a Mediterranean eating pattern (129), and low-carbohydrate meal plans with additional support (130,131)."
"However, no single approach has been proven to be consistently superior (73,132–134), and more data are needed to identify and validate those meal plans that are optimal with respect to long-term outcomes and acceptability."
"Any approach to meal planning should be individualized, considering the health status, personal and cultural preferences, health goals, ability to sustain the recommendations, and ultimately food access and nutrition security (73)."
"Evidence suggests that there is not an ideal percentage of calories from carbohydrate, protein, and fat for people with diabetes."
"Therefore, macronutrient distribution should be based on an individualized assessment of current eating patterns, preferences, and metabolic goals."
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.
"Research confirms that a variety of eating patterns are acceptable for the management of diabetes (73,104,141,142)."
"Until the evidence around benefits of different eating patterns is strengthened, health care professionals should focus on the core dimensions common among patterns: inclusion of nonstarchy vegetables, whole fruits, legumes, whole grains, nuts, seeds, and low-fat dairy products and minimizing consumption of meat, sugar-sweetened beverages, sweets, refined grains, and ultraprocessed foods (143,144)."
"Evidence for eating patterns has been informed by RCTs, prospective cohort studies, systematic reviews, and network meta-analysis."
"Those most frequently referenced include Mediterranean, DASH, low-fat, carbohydrate-restricted, vegetarian, and vegan eating patterns."
"As stated previously, there is insufficient evidence to select one over the other (137,141,142,145–154)."
"Ultimately, ongoing diabetes and nutrition education paired with appropriate support to implement and sustain health behaviors is recommended (103)."
"Referral to and ongoing support from an RDN is essential to assess the overall nutrition status of, and to work collaboratively with, the person with diabetes to create a personalized meal plan that coordinates and aligns with the overall lifestyle treatment plan, including physical activity and medication use."
Using shared decision-making to collaboratively select a method for how to execute the plan may be part of the nutrition care process.
Few head-to-head studies have compared different dietary approaches.
"In a systematic review and meta-analysis of carbohydrate counting versus other forms of dietary advice (standard education, low glycemic index, and fixed carbohydrate quantities), no significant differences were seen in A1C levels compared with standard education (145)."
"In another RCT, a simplified carbohydrate counting tool based on individual glycemic response was noninferior to conventional carbohydrate counting in 85 adults with type 1 diabetes (146)."
"In a randomized crossover trial, carbohydrate counting and qualitative meal size (low, medium, and high carbohydrate) were compared."
Time in range was 74% for carbohydrate counting and 70.5% for the quantitative meal size estimates.
Noninferiority was not confirmed for the qualitative method (147).
"Newer technologies (smart phone apps and CGM), including automated insulin delivery, may decrease the need for precise carbohydrate counting and allow for personalized nutrition approaches (148,149)."
An RCT found that two meal-planning approaches (diabetes plate method and carbohydrate counting) were effective in helping achieve improved A1C (150).
The diabetes plate method is a commonly used visual approach for providing basic meal planning guidance in type 1 and type 2 diabetes.
"This simple graphic (featuring a 9-inch plate) shows how to portion foods (one-half of the plate for nonstarchy vegetables, one-quarter of the plate for protein, and one-quarter of the plate for carbohydrates)."
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 (150) and food literacy level."
Health numeracy refers to understanding and using numbers and numerical concepts in relation to health and self-management (155).
"Food literacy generally describes proficiency in food-related knowledge and skills that ultimately impact health, although specific definitions vary across initiatives (151,152)."
Intermittent fasting or time-restricted eating as strategies for weight and glucose management have been studied and have gained popularity.
"Intermittent fasting is an umbrella term that includes three main forms of restricted eating: alternate-day fasting (energy restriction of 500–600 calories on alternate days), the 5:2 diet (energy restriction of 500–600 calories on consecutive or nonconsecutive days with usual intake the other five), and time-restricted eating (daily calorie restriction based on window of time of 8–15 h)."
"Each produces mild to moderate weight loss (3–8% loss from baseline) over short durations (8–12 weeks) with no significant differences in weight loss when compared with continuous calorie restriction (153,154,156,157)."
A few studies have extended up to 52 weeks and show similar findings (158–162) with diverse populations.
"Generally, time-restricted eating or shortening the eating window can be adapted to any eating pattern and has been shown to be safe for adults with type 1 or type 2 diabetes (161)."
People with diabetes who are on insulin and/or secretagogues should be medically monitored during the fasting period (163).
"Because of the simplicity of intermittent fasting and time-restricted eating, these may be useful strategies for people with diabetes who are looking for practical eating management tools."
Use of partial meal replacements or total meal replacements is an additional tool or strategy for energy restriction.
"Meal replacements are prepackaged foods (bars, shakes, and soups) that contain a fixed amount of macroutrients and micronutrients."
They have been shown to improve nutrient quality and glycemic management and to reduce portion size and consequent energy intake.
"In a meta-analysis involving 17 studies incorporating both partial and total meal replacements, greater weight loss and improvement in A1C and fasting blood glucose were demonstrated compared with conventional diets (164)."
"Meal replacements have been used in several landmark clinical trials, including Look AHEAD (Action for Health in Diabetes) (165), DiRECT (Diabetes Remission Clinical Trial) (166), and PREVIEW (Prevention of Diabetes Through Lifestyle Intervention and Population Studies in Europe and Around the World) (167), showing partial or total meal replacements can be a potential short-term strategy for weight loss."
"Regardless of the eating pattern, meal plan, and/or dietary approach selected, long-term follow-up and support from members of the diabetes care team are needed to optimize self-efficacy and maintain behavioral changes (140)."
Chrononutrition is a growing and emerging specialty in the field of nutrition and biology that tries to understand how the timing of food ingestion affects metabolic health (168).
"Glucose metabolism follows a circadian rhythm through diurnal variation of glucose tolerance, peaking during daylight hours when food is consumed."
Some preliminary studies show cardiometabolic benefits when food is consumed earlier (169).
"Similarly, circadian disruptions found in shift workers increase risk of type 2 diabetes (170)."
"Although more research needs to be done, this evolving area of research may show promise to improve glucose regulation."
"Although intermittent fasting and time-restricted eating are specific dietary strategies for energy restriction, religious fasting has been practiced for thousands of years and is part of many faith-based traditions."
"Duration, frequency, and type of fast vary among different religions (171)."
"For example, Jewish people abstain from any intake for ~24 h during Yom Kippur (172,173)."
"For Muslims, Ramadan fasting lasts for a full month, when abstinence from any food or drink is required from dawn to dusk (174)."
"Individuals with diabetes who fast have an increased risk for hypoglycemia, dehydration, hyperglycemia, and ketoacidosis."
"Risk can vary depending on the type of diabetes, type of therapy, and presence and severity of diabetes-related complications (175)."
"Health care professionals, including RDNs, certified DCES, and others, should inquire about any religious fasting for people with diabetes and provide education and support to accommodate their choice."
"Education regarding glucose checking, medication/fluid adjustment, timing and intensity of physical activity, and meal choices pre- and post-fast should be provided (176)."
Treatment pre- and post-fast should be culturally sensitive and individualized (177).
Specific recommendations for diabetes management during Ramadan (175) and Yom Kippur (172) are available.
"Carbohydrates
Studies examining the optimal amount of carbohydrate intake for people with diabetes are inconclusive, although monitoring carbohydrate intake is a key strategy in reaching glucose goals in people with type 1 and type 2 diabetes (178,179)."
"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 (139,180–184)."
"Systematic reviews and meta-analyses of RCTs found carbohydrate-restricted eating patterns, particularly those considered low carbohydrate (<26% total energy), were effective in reducing A1C in the short term (<6 months), with less difference in eating patterns beyond 1 year (134,182,185–187)."
Questions still remain about the optimal degree of carbohydrate restriction and the long-term effects of those meal patterns on CVD.
"A systematic review and meta-analysis of RCTs investigating the dose-dependent effects of carbohydrate restriction found each 10% decrease in carbohydrate intake had reductions in levels of A1C, fasting plasma glucose, body weight, lipids, and systolic blood pressure at 6 months, but favorable effects diminished and were not maintained at follow-up or at greater than 12 months."
This systematic review highlights the metabolic complexity of response to dietary intervention in type 2 diabetes as well as the need to better understand longer-term sustainability and results (188).
"Part of the challenge in interpreting low-carbohydrate research has been due to the wide range of definitions for a low-carbohydrate eating plan (189,190)."
"Weight reduction was also a goal in many low-carbohydrate studies, which further complicates evaluating the distinct contribution of the eating pattern (48,130,134,188)."
"As studies on low-carbohydrate eating plans generally indicate challenges with long-term sustainability (180), it is important to reassess and individualize meal plan guidance regularly for those interested in this approach."
"Health care professionals 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 individuals 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 (191–193)."
"Regardless of the 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."
The addition of dietary fiber modulates composition of gut microbiota and increases gut microbial diversity.
"Although there is still much to be elucidated with the gut microbiome and chronic disease, higher-fiber diets are advantageous (194)."
"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."
"People with diabetes and those at risk for diabetes are encouraged to consume a minimum of 14 g of fiber/1,000 kcal, with at least half of grain consumption being whole, intact grains, according to the Dietary Guidelines for Americans (98)."
"Regular intake of sufficient dietary fiber is associated with lower all-cause mortality in people with diabetes (195,196), and prospective cohort studies have found dietary fiber intake is inversely associated with risk of type 2 diabetes (197–199)."
"The consumption of sugar-sweetened beverages and processed food products with large amounts of refined grains and added sugars is strongly discouraged (98,200,201), as these have the capacity to displace healthier, more nutrient-dense food choices."
"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 (202,203)."
"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 (204) while others demonstrated A1C reductions of 0.15% (202) to 0.5% (190,205)."
Individuals with type 1 or type 2 diabetes taking insulin at mealtime should be offered comprehensive and ongoing education about nutrition content and 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 (104,178,206–208)."
"Studies have shown that dietary fat and protein can impact early and delayed postprandial glycemia (209–212), and it appears to have a dose-dependent response (213–216)."
"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 results from these studies also point to individual differences in postprandial glycemic response; therefore, a cautious approach to increasing insulin doses for high-fat and/or high-protein mixed meals is recommended to address delayed hyperglycemia that may occur after eating (73,217,218)."
"If using an insulin pump, a split bolus feature (part of the bolus delivered immediately, the remainder over a programmed duration of time) may provide better insulin coverage for high-fat and/or high-protein mixed meals (210,219)."
The effectiveness of insulin dosing decisions should be confirmed with a structured approach to blood glucose monitoring or CGM 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.e., increasing or stopping bolus) (210,219,220)."
Adjusting insulin doses to account for high-fat and/or high-protein meals requires determination of anticipated nutrient intake to calculate the mealtime dose.
"Food literacy, numeracy, interest, and capability should be evaluated (73)."
"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 (73,221)."
"Commercially available automated insulin delivery systems still require basic diabetes management skills, including carbohydrate counting and understanding of the impact of protein and fat on postprandial glucose response (222)."
"There is no evidence that adjusting the daily level of protein intake (typically 1–1.5 g/kg body weight/day or 15–20% of total calories) will improve health, and research is inconclusive regarding the ideal amount of dietary protein to optimize either glycemic management or CVD risk (203,223)."
"Therefore, protein intake goals should be individualized based on current eating patterns."
"Some research has found successful management of type 2 diabetes with meal plans including slightly higher levels of protein (20–30%), which may contribute to increased satiety (224)."
"Historically, low-protein eating plans were advised for individuals with diabetic kidney disease (DKD) (with albuminuria and/or reduced estimated glomerular filtration rate); however, current evidence does not suggest that people with DKD need to restrict protein to less than the generally recommended protein intake (73)."
"Reducing the amount of dietary protein below the recommended daily allowance of 0.8 g/kg is not recommended because it does not alter glycemic measures, cardiovascular risk measures, or the rate at which glomerular filtration rate declines and may increase risk for malnutrition (225–227)."
Strong evidence suggests higher plant protein intake and replacement of animal protein with plant protein is associated with lower risk of all-cause and cardiovascular mortality in the Women’s Health Initiative cohort study (228).
A meta-analysis of 13 RCTs showed replacing animal with plant proteins leads to small improvements in A1C and fasting glucose in individuals with type 2 diabetes (229).
Plant proteins are lower in saturated fat and support planetary health (230).
"In addition to annually, there are critical time points when the need for DSMES should be evaluated by the health care professional and/or interprofessional team, with referrals made as needed (2): At diagnosis; When not meeting treatment goals; When complicating factors (e.g., health conditions, physical limitations, emotional factors, or basic living needs) that influence self-management develop; When transitions in life and care occur."
"Evidence suggests that there is not an optimal percentage of calories from fat for people with or at risk for diabetes and that macronutrient distribution should be individualized according to the individual’s eating patterns, preferences, and metabolic goals (73)."
"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 (98,129,231–233)."
"Multiple RCTs including people with type 2 diabetes have reported that a Mediterranean eating pattern (95,129,234–239) can improve both glycemic management and blood lipids."
The Mediterranean eating pattern is based on the traditional eating habits in the countries bordering the Mediterranean Sea.
"Although eating styles vary by country or culture, they share a number of common features, including consumption of fresh fruits and vegetables, whole grains, beans, and nuts/seeds; olive oil as the primary fat source; low to moderate amounts of fish, eggs, and poultry; and limited added sugars, sugary beverages, sodium, highly processed foods, refined carbohydrates, saturated fats, and fatty or processed meats."
"Evidence does not conclusively support recommending n-3 (eicosapentaenoic acid and docosahexaenoic acid) supplements for all people with diabetes for the prevention or treatment of cardiovascular events (73,240,241)."
"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 (203,242)."
"In the ASCEND (A Study of Cardiovascular Events iN Diabetes) trial, when compared with placebo, supplementation with n-3 fatty acids at a dose of 1 g/day did not lead to cardiovascular benefit in people with diabetes without evidence of CVD (243)."
"However, results from the Reduction of Cardiovascular Events With Icosapent Ethyl-Intervention Trial (REDUCE-IT) found that supplementation with 4 g/day of pure eicosapentaenoic acid significantly lowered the risk of adverse cardiovascular events."
"This trial of 8,179 participants, in which over 50% had diabetes, found a 5% absolute reduction in cardiovascular events for individuals with established atherosclerotic CVD taking a preexisting statin with residual hypertriglyceridemia (135–499 mg/dL [1.52–5.63 mmol/L]) (244)."
"See Section 10, “Cardiovascular Disease and Risk Management,” for more information."
"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 (98)."
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 (238)."
"Despite lack of evidence of benefit from dietary supplements, consumers continue to take them."
Estimates show that up to 59% of people with diabetes in the U.S. use supplements (250).
"Without underlying deficiency, there is no benefit from herbal or nonherbal (i.e., vitamin or mineral) supplementation for people with diabetes (73,251)."
"Federal law in the U.S. broadly defines dietary supplements as having one or more dietary ingredients, including vitamins, minerals, herbs or other botanicals, amino acids, enzymes, tissues from organs or glands, or extracts of these (252)."
Routine antioxidant supplementation (such as vitamins E and C) is not recommended 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 (254), curcumin, vitamin D (255), aloe vera, or chromium, to improve glycemia in people with diabetes (73,256)."
"Although the Vitamin D and Type 2 Diabetes Study (D2d) prospective RCT and Diabetes Prevention and Active Vitamin D (DPVD) showed no significant benefit of vitamin D versus placebo on the progression to type 2 diabetes in individuals at high risk (257,258), post hoc analyses and meta-analyses suggest a potential benefit in specific populations (257,259–261)."
Further research is needed to define individual characteristics and clinical indicators where vitamin D supplementation may be of benefit.
"Metformin is associated with vitamin B12 deficiency per a report from the Diabetes Prevention Program Outcomes Study (DPPOS), which suggests that periodic testing of vitamin B12 levels should be considered in people taking metformin, particularly in those with anemia or peripheral neuropathy (262,263) (see Section 9, “Pharmacologic Approaches to Glycemic Treatment”)."
Consumers can consult the U.S. Food and Drug Administration (FDA) Dietary Supplement Ingredient Directory to locate information about ingredients used in dietary supplements and any action taken by the agency with regard to that ingredient (264).
"For special populations, including pregnant or lactating individuals, older adults, vegetarians, and people following very-low-calorie or low-carbohydrate diets, a multivitamin may be necessary (265)."
"Based on the 2022 U.S. Preventative Services Task Force statement, the harms of ß-carotene outweigh the benefits for the prevention of CVD or cancer."
ß-Carotene was associated with increased lung cancer and cardiovascular mortality risk (253).
Moderate alcohol intake ingested with food does not have major detrimental effects on long-term blood glucose management in people with diabetes.
"Risks associated with alcohol consumption include hypoglycemia and/or delayed hypoglycemia (particularly for those using insulin or insulin secretagogue therapies), weight gain, and hyperglycemia (for those consuming excessive amounts) (73,256)."
The available evidence does not support recommending alcohol consumption in people who do not currently drink (266).
"To reduce risk of alcohol-related harms, adults can choose not to drink or to drink in moderation by limiting intake to =2 drinks a day for men or =1 drink a day for women (one drink is equal to a 12-oz beer, a 5-oz glass of wine, or 1.5 oz of distilled spirits) (266)."
People with diabetes should be educated about these risks and encouraged to monitor glucose frequently after drinking alcohol to minimize such risks.
"People with diabetes can follow the same guidelines as those without diabetes consistent with Dietary Guidelines for Americans, 2020–2025 (98)."
"There is growing evidence for psychoeducational interventions that may increase knowledge about alcohol use and diabetes, may enhance perceived risks, and may reduce alcohol use among young people with type 1 diabetes (267)."
"As for the general population, people with diabetes are advised to limit their sodium consumption to <2,300 mg/day (73)."
"Restriction to <1,500 mg, even for those with hypertension, is generally not recommended (245–247)."
"Sodium recommendations should take into account palatability, availability, affordability, and the difficulty of achieving low-sodium recommendations in a nutritionally adequate eating plan (248,249)."
"The FDA has approved many nonnutritive sweeteners (NNS) for consumption by the general public, including people with diabetes (73,268)."
"However, the safety and role of NNS continue to be sources of concern and confusion for the public (269)."
"This confusion has been heightened with the World Health Organization’s conditional recommendation (270) against NNS for weight management, the Cleveland Clinic study on erythritol and its relationship to CVD (271), and the International Agency for Research on Cancer classifying aspartame as a possible carcinogen to humans (272)."
It should be noted the systematic analysis that informed the World Health Organization recommendation excluded individuals with diabetes.
"In an editorial from the Journal of Clinical Investigation, Nobs and Elinav (273) from the Weizmann Institute described the impact these recent studies have had on the public perception of safety of NNS: The burden of proof has shifted from a need to prove that NNS are unsafe to a necessity of understanding their potential scope of effects on humans in order to optimize their recommended use by populations at risk."
"
Despite FDA approval and generally recognized as safe (GRAS) status for NNS, as well as established acceptable daily intake (ADI), questions remain."
Implementation and interpretation of human NNS studies are inherently challenging.
"Each of the sweeteners are their own distinct compounds with different molecular structures, although they are often considered together in studies."
"Issues of duration of exposure (short or long), different physical forms (packets/powder or in beverages), cardiometabolic health of the host, personalized individual response, presence of other nutrient components, the emerging evidence about the microbiome, and limited RCTs complicate the science (273)."
"For some people with diabetes who are accustomed to regularly consuming sugar-sweetened products, NNS (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 (274,275)."
"NNS do not appear to have a significant effect on glycemic management (104,276,277), and they can reduce overall calorie and carbohydrate intake (104,274) as long as individuals are not compensating with additional calories from other food sources (73,278)."
"There is mixed evidence from systematic reviews and meta-analyses for NNS use with regard to weight management, with some finding benefit in weight loss (279–281) while other research suggests an association with weight gain (282,283)."
This may be explained by reverse causality and residual confounding variables (283).
The addition of NNS to eating plans poses no benefit for weight loss or reduced weight gain without energy restriction (284).
"In a recent systematic review and meta-analysis using low-calorie and no-calorie sweetened beverages as an intended substitute for sugar-sweetened beverages, a small improvement in body weight and cardiometabolic risk factors was seen without evidence of harm and had a direction of benefit similar to that seen with water."
"Health care professionals should continue to recommend water, but people with overweight or obesity and diabetes may also have a variety of no-calorie or low-calorie sweetened products so that they do not feel deprived (285)."
Health care professionals should continue to recommend reductions in sugar intake and calories with or without the use of NNS.
Assuring people with diabetes that NNS have undergone extensive safety evaluation by regulatory agencies and are continually monitored can allay unnecessary concern for harm.
Health care professionals can regularly assess individual use of NNS based on the acceptable daily intake (amount of a substance considered safe to consume each day over a person’s life) and recommend moderation.
See the chart from the FDA on safe levels of sweeteners found at fda.gov/food/food-additives-petitions/aspartame-and-other-sweeteners-food.
"Exercise and Youth
Youth with diabetes or prediabetes should be encouraged to engage in regular physical activity, including at least 60 min of moderate to vigorous aerobic activity every day and muscle- and bone-strengthening activities at least 3 days per week (299)."
"In general, youth with type 1 diabetes benefit from being physically active, and meta-analyses have demonstrated a significant association between physical activity and lower A1C (300)."
"Thus, an active lifestyle should be recommended to all (301)."
"Youth with type 1 diabetes who engage in more physical activity may have better health outcomes and health-related quality of life (302,303)."
"See Section 14, “Children and Adolescents,” for details."
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 levels, reduce cardiovascular risk factors, contribute to weight loss, and improve well-being (286)."
"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."
Many individuals with type 2 diabetes do not meet the recommended exercise level per week (150 min).
"Objective measurement by accelerometer in 871 individuals with type 2 diabetes showed that 44.2%, 42.6%, and 65.1% of White, African American, and Hispanic individuals, respectively, met the recommended threshold of exercise (287)."
"An RCT in 1,366 individuals with prediabetes combined a physical activity intervention with text messaging and telephone support, which showed improvement in daily step count at 12 months compared with the control group."
"Unfortunately, this was not sustained at 48 months (288)."
"Another RCT, including 324 individuals with prediabetes, showed increased physical activity at 8 weeks with supportive text messages, but by 12 weeks there was no difference between groups (289)."
"It is important for diabetes care management teams to understand the difficulty that many people have reaching recommended treatment goals and to identify individualized approaches to improve goal achievement, which may need to change over time."
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 (290).
A prospective observational study of adults with type 1 diabetes suggested that higher amounts of physical activity led to reduced cardiovascular mortality after a mean follow-up time of 11.4 years for people with and without chronic kidney disease (291).
"Additionally, structured exercise interventions of at least 8 weeks’ duration have been shown to lower A1C by an average of 0.66% in people with type 2 diabetes, even without a significant change in BMI (292)."
"There are also considerable data for the health benefits (e.g., increased cardiovascular fitness, greater muscle strength, improved insulin sensitivity) of regular exercise for those with type 1 diabetes (293)."
"Exercise training in type 1 diabetes may also improve several important markers such as triglyceride level, LDL cholesterol, waist circumference, and body mass (294)."
"In adults with type 2 diabetes, higher levels of exercise intensity are associated with greater improvements in A1C and in cardiorespiratory fitness (295); sustained improvements in cardiorespiratory fitness and weight loss have also been associated with a lower risk of heart failure (258)."
Other benefits include slowing the decline in mobility among overweight people with diabetes (296).
The ADA position statement “Physical Activity/Exercise and Diabetes” reviews the evidence for the benefits of exercise in people with type 1 and type 2 diabetes and offers specific recommendations (297).
"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 this population (298)."
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, and presence of diabetes-related health complications."
Recommendations should be tailored to meet the specific needs of each individual (297).
"For all people with diabetes, evaluate baseline physical activity and time spent in sedentary behavior (quiet sitting, lying, and leaning)."
"For people who do not meet activity guidelines, encourage an increase in physical activity (walking, yoga, housework, gardening, swimming, and dancing) above baseline (304)."
Health care professionals should counsel people with diabetes to engage in aerobic and resistance exercise regularly (240).
"Aerobic activity bouts should last at least 10 min, with the goal of ~30 min/day or more most days of the week for adults with type 2 diabetes."
"Daily exercise, or at least not allowing more than 2 days to elapse between exercise sessions, is recommended to decrease insulin resistance, regardless of diabetes type (305,306)."
"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 (307)."
"Over time, activities should progress in intensity, frequency, and/or duration to at least 150 min/week of moderate-intensity exercise."
Adults able to run at 6 miles/h (9.7 km/h) for at least 25 min can benefit sufficiently from shorter durations of vigorous-intensity activity or interval training (75 min/week) (297).
"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."
"Physical Activity and Glycemic Management
Clinical trials have provided strong evidence for the A1C-lowering value of resistance training in older adults with type 2 diabetes (297) and for an additive benefit of combined aerobic and resistance exercise in adults with type 2 diabetes (319)."
"If not contraindicated, people with type 2 diabetes should be encouraged to do at least two weekly sessions of resistance exercise (free weights, machines, elastic bands, or body weight as resistance), 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 (320)."
"For people with 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 (293).
"Individuals of childbearing potential 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 (297)."
"High-Intensity Interval Training
High-intensity interval training (HIIT) is a plan that involves aerobic training done between 65% and 90% VO2peak or 75% and 95% heart rate peak for 10 s to 4 min with 12 s to 5 min of active or passive recovery."
"HIIT has gained attention as a potentially time-efficient modality that can elicit significant physiological and metabolic adaptations for individuals with type 1 and type 2 diabetes (321,322)."
Higher intensities of aerobic training are generally considered superior to low-intensity training (323).
HIIT showed reductions in A1C and BMI and improvement in fitness levels in individuals with type 2 diabetes.
"Because HIIT can lead to transient increases in post-exercise hyperglycemia, individuals with type 2 diabetes are encouraged to monitor blood glucose when starting (320)."
"In type 1 diabetes, HIIT is associated with reductions in A1C levels, reduction in insulin requirements, and improvement in cardiometabolic risk profiles (322)."
"Variability in glucose may occur with an increased risk in delayed hypoglycemia, so careful monitoring of glucose during and after HIIT is advised (322)."
"Pre-exercise Evaluation
As discussed more fully in Section 10, “Cardiovascular Disease and Risk Management,” the best protocol for assessing asymptomatic people with diabetes for coronary artery disease remains unclear."
The ADA consensus report “Screening for Coronary Artery Disease in Patients With Diabetes” (324) concluded that routine testing is not recommended.
"However, health care professionals should perform a careful history, assess cardiovascular risk factors, and be aware of the atypical presentation of coronary artery disease, such as recent reported or tested decrease in exercise tolerance in people with diabetes."
"Certainly, those with high risk should be encouraged to start with short periods of low-intensity exercise and slowly increase the duration and intensity as tolerated."
"Health care professionals should assess for conditions that might contraindicate certain types of exercise or predispose to injury, such as uncontrolled hypertension, untreated proliferative retinopathy, autonomic neuropathy, peripheral neuropathy, balance impairment, and a history of foot ulcers or Charcot foot."
Age and previous physical activity level should be considered when customizing the exercise plan to the individual’s needs.
Those with complications may need a more thorough evaluation prior to starting an exercise program (293).
"Hypoglycemia
In individuals taking insulin and/or insulin secretagogues, physical activity may cause hypoglycemia if the medication dose or carbohydrate consumption is not adjusted for the exercise bout and post-bout impact on glucose."
"Individuals on these therapies may need to ingest some added carbohydrate if pre-exercise glucose levels are <90 mg/dL (<5.0 mmol/L), depending on whether they are able to lower insulin doses during the workout (such as with an insulin pump or reduced pre-exercise insulin dosage), the time of day exercise is done, and the intensity and duration of the activity (293)."
"In some people with diabetes, hypoglycemia after exercise may occur and last for several hours due to increased insulin sensitivity."
"Hypoglycemia is less common in those 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 (293)."
"Because of the variation in glycemic response to exercise bouts, people with diabetes need to be educated to check blood glucose levels or consult sensor glucose values before and after periods of exercise and about the potential prolonged effects (depending on intensity and duration) (325)."
"Exercise in the Presence of Microvascular Complications
See Section 11, “Chronic Kidney Disease and Risk Management,” and Section 12, “Retinopathy, Neuropathy, and Foot Care,” for more information on these long-term complications."
"A meta-analysis on this topic demonstrated moderate certainty of evidence that high versus low levels of physical activity were associated with lower CVD incidence and mortality (summary risk ratio 0.84 [95% CI 0.77–0.92], n = 7, and 0.62 [0.55–0.69], n = 11) and fewer microvascular complications (0.76 [0.67–0.86], n = 8)."
Dose-response meta-analyses showed that physical activity was associated with lower risk of diabetes-related complications even at lower levels (326).
"Retinopathy
If proliferative diabetic retinopathy or severe nonproliferative diabetic retinopathy is present, then vigorous-intensity aerobic or resistance exercise may be contraindicated because of the risk of triggering vitreous hemorrhage or retinal detachment (327)."
Consultation with an ophthalmologist prior to engaging in an intense exercise plan may be appropriate.
"Peripheral Neuropathy
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 (328).
"In addition, 150 min/week of moderate exercise was reported to improve outcomes in people with prediabetic neuropathy (329)."
All individuals with peripheral neuropathy should wear proper footwear and examine their feet daily to detect lesions early.
Anyone with a foot injury or open sore should be restricted to non–weight-bearing activities.
"Autonomic Neuropathy
Autonomic neuropathy can increase 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 (330)."
Cardiovascular autonomic neuropathy is also an independent risk factor for cardiovascular death and silent myocardial ischemia (331).
"Therefore, individuals with diabetic autonomic neuropathy should undergo cardiac investigation before beginning physical activity more intense than that to which they are accustomed."
"Diabetic Kidney Disease
Physical activity can acutely 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 (327)."
Adults with diabetes are encouraged to engage in 2–3 sessions/week of resistance exercise on nonconsecutive days (308).
"Although heavier resistance training with free weights or weight machines may improve glycemia and strength (309), 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."
Health care professionals should support people with diabetes to set stepwise goals toward meeting the recommended exercise goals.
"As individuals intensify their exercise program, medical monitoring may be indicated to ensure safety and evaluate the effects on glucose management."
"(See physical activity and glycemic management, below.)"
"DSMES is associated with improved diabetes knowledge and self-care behaviors (17), lower A1C (17–22), lower self-reported weight (23), improved quality of life (19,24,25), reduced all-cause mortality risk (26), positive coping behaviors (5,27), and lower health care costs (28–30)."
"DSMES is associated with an increased use of primary care and preventive services (28,31,32) and less frequent use of acute care and inpatient hospital services (23)."
"People with diabetes who participate in DSMES are more likely to follow best practice treatment recommendations, particularly those with Medicare, and have lower Medicare and insurance claim costs (29,32)."
"Better outcomes were reported for DSMES interventions that were >10 h over the course of 6–12 months (20), included ongoing support (14,33), were culturally (34–36) and age appropriate (37,38), were tailored to individual needs and preferences, addressed psychosocial issues, and incorporated behavioral strategies (15,27,39,40)."
"Individual and group approaches are effective (41–43), with a slight benefit realized by those who engage in both (20)."
A systematic review and meta-analysis found higher frequency of regular leisure-time physical activity was more effective in reducing A1C levels (314).
"A wide range of activities, including yoga, tai chi, and other types, can have significant impacts on A1C, flexibility, muscle strength, and balance (286,315–317)."
"Flexibility and balance exercises may be particularly important in older adults with diabetes to maintain range of motion, strength, and balance (297) (Fig.5.1)."
"There is strong evidence that exercise interventions in individuals with type 2 diabetes improve depression, A1C, and overall psychosocial well-being (318)."
"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.g., seated work at a computer or watching television)—by breaking up bouts of sedentary activity (>30 min) by briefly standing, walking, or performing other light physical activities (310,311)."
"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 management for those with diabetes (312,313)."
A causal link between cigarette smoking and diabetes has been established and reported on by the Surgeon General for over a decade (332).
"Results from epidemiologic, case-control, and cohort studies provide convincing evidence to support the causal link between cigarette smoking and multiple health risks that can have a profound impact on morbidity and mortality for people with diabetes (332)."
"People with diabetes who smoke and are exposed to second-hand smoke have a heightened risk of macrovascular complications (e.g., cardiovascular and peripheral vascular disease), microvascular complications (e.g., kidney disease and visual impairment), worse glycemic outcomes, and premature death compared with those who do not smoke (333–336)."
"Emerging data suggest smoking has a role in the development of type 2 diabetes, and quitting has been shown to significantly decrease this risk over time (337–340)."
"The routine (every visit with every person), thorough assessment of all types of tobacco use is essential to prevent tobacco product initiation and promote cessation."
"Evidence demonstrates significant benefits to quitting smoking for all people, resulting in a reduction and even reversal of adverse health effects in addition to an increase in life expectancy by as much as a decade (341)."
"However, data show tobacco use prevalence among adults with chronic conditions has remained persistently higher than that in the general population (342), with recent declines in smoking in middle-aged people with diabetes but not in adolescents and young adults (342)."
"Numerous large RCTs have demonstrated the efficacy and cost-effectiveness of both intensive and brief counseling in smoking cessation, including the use of telephone quit lines and web-based interventions, in reducing tobacco use and maintaining abstinence from smoking (341,343,344)."
"Current recommendations include both counseling and pharmacologic therapy to assist with smoking cessation in nonpregnant adults (345); however, more than two-thirds of people trying to quit do not receive treatment following evidence-based guidelines (341)."
Weight gain after smoking cessation has been a concern related to diabetes management and risk for new onset of disease (346).
"While post-cessation weight gain is an identified issue, studies have found that an average weight gain of 3–5 kg does not necessarily persist long term or diminish the substantial cardiovascular benefit realized from smoking cessation (337)."
These findings highlight the need for tobacco cessation treatment that addresses eating and physical activity needs.
One study in people with newly diagnosed type 2 diabetes who smoke found that smoking cessation was associated with amelioration of microalbuminuria and reduction in blood pressure after 1 year (347).
"In recent years, there has been an increase in the use and availability of multiple noncigarette nicotine products."
The evidence regarding the effect of these products on diabetes is not as clear as that for combustible cigarettes.
"It is known that smokeless tobacco products, such as dip and chew, pose an increased risk for CVD (348)."
"E-cigarettes and vaping have gained public awareness and popularity because of perceptions that e-cigarette use is less harmful than regular cigarette smoking (349,350)."
"While combustible tobacco products are clearly the most harmful, electronic products should not be characterized as harmless, as health risks with use that affect the cardiovascular and respiratory systems have been identified (351,352)."
"Individuals with diabetes should be advised to avoid vaping and using e-cigarettes, either as a way to stop smoking combustible cigarettes or as a recreational drug."
"If people are using e-cigarettes to quit, they should be advised to avoid using both combustible and electronic cigarettes, and if using only e-cigarettes, they should be advised to have a plan to quit these also (344)."
"Increased legalization and multiple formulations of cannabis products have resulted in increased prevalence in the use of these products in all age-groups (353,354)."
"Significant increases in tetrahydrocannabinol (THC) concentrations and use of additional psychoactive cannabinoid products, such as delta-8 THC, are of specific concern (355)."
"Most of these products are currently unregulated by the FDA, and public health warnings regarding use have been issued (356)."
"The FDA reports adverse effects related to delta-8 THC, some of which may have health implications for people with diabetes (e.g., vomiting) (356)."
Evidence of specific increased risk of diabetic ketoacidosis and hyperglycemic ketosis associated with cannabis use and cannabis hyperemesis syndrome in adults with type 1 diabetes has been recently reported (357–359).
Diabetes education programs offer potential to systematically reach and engage individuals with diabetes in smoking cessation efforts.
"A cluster randomized trial found statistically significant increases in quit rates and long-term abstinence rates (>6 months) when smoking cessation interventions were offered through diabetes education clinics, regardless of motivation to quit at baseline (360)."
"The increased prevalence in use of an expanding landscape of both tobacco and cannabis products and the impact on the health of people with diabetes highlights the need to ask about use of these products, educate individuals regarding the associated risks, and provide support for cessation."
"Given associations with glycemic outcomes and risk for future complications (361,362), it is important for diabetes care professionals to support people with diabetes to engage in health-promoting behaviors (preventive, treatment, and maintenance), including blood glucose monitoring, taking insulin and medications, using diabetes technologies, engaging in physical activity, and making nutritional changes."
Evidence supports using a variety of behavioral strategies and multicomponent interventions to help people with diabetes and their caregivers or family members develop health behavior routines and overcome barriers to self-management behaviors (363–365).
"Behavioral strategies with empirical support include motivational interviewing (366–368), patient activation (369), goal setting and action planning (368,370–372), problem-solving (371,373), tracking or self-monitoring health behaviors with or without feedback from a health care professional (368,370–372), and facilitating opportunities for social support (368,371,372)."
"There is mixed evidence about behavioral economics strategies (e.g., financial incentives and exposure to information about social norms) to promote engagement in health behaviors among people with diabetes; such strategies tend to enhance intentions and demonstrate short-term benefits for behavior change, although there is less evidence about sustained effects (374)."
"Multicomponent behavior change intervention packages have the highest efficacy for behavioral and glycemic outcomes (363,372,375)."
"For youth with diabetes, family-based behavioral intervention packages and multisystem interventions that facilitate health behavior change demonstrate benefit for increasing management behaviors and improving glycemic outcomes (364)."
"As with all diabetes health care, it is important to adapt and tailor behavior change strategies to the characteristics and needs of the individual and population (376–378)."
"Health behavior change strategies may be delivered by behavioral health professionals, DCES, other trained health care professionals (370,379–381), or qualified community health workers (370,371)."
"These approaches may be delivered via digital health tools (372,380,382)."
"There are effective strategies to train diabetes care professionals to use such methods (e.g., motivational interviewing) (383)."
Please refer to the ADA position statement “Psychosocial Care for People With Diabetes” for a list of assessment tools and additional details (1) and the ADA Behavioral Health Toolkit for assessment questionnaires and surveys (professional.diabetes.org/meetings/behavioral-health-toolkit).
"Throughout the Standards of Care, the broad term “behavioral health” is used to encompass both 1) health behavior engagement and relevant factors and 2) behavioral health concerns and care related to living with diabetes."
"Complex environmental, social, family, behavioral, and emotional factors, known as psychosocial factors, influence living with type 1 and type 2 diabetes and achieving optimal health 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 (384)."
Clinically significant behavioral health diagnoses are considerably more prevalent in people with diabetes than in those without (385–387).
Emotional well-being is an important part of diabetes care and self-management.
"Psychological and social problems can impair the individual’s (57,388–392) or family’s (391) ability to carry out diabetes care tasks and potentially compromise health status."
"Therefore, psychological symptoms, both clinical and subclinical, must be addressed."
"In addition to impacting a person’s ability to carry out self-management and the association of behavioral health diagnoses with poorer short-term glycemic stability, symptoms of emotional distress are associated with increased mortality risk (386,393)."
"There are opportunities for diabetes health care professionals to routinely monitor and screen psychosocial status in a timely and efficient manner for referral to appropriate services (394,395)."
"Various health care professionals working with people with diabetes may contribute to psychosocial care in different ways based on training, experience, need, and availability (380,396,397)."
"Ideally, qualified behavioral health professionals with specialized training and experience in diabetes should be integrated with or provide collaborative care as part of diabetes care teams (398–401)."
"Referrals for in-depth assessment and treatment for psychosocial concerns should be made to such behavioral health professionals when indicated (381,402,403)."
A systematic review and meta-analysis showed that psychosocial interventions modestly but significantly improved A1C and behavioral health outcomes (404).
"There was a limited association between the effects on A1C and behavioral 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 (405)."
"Evidence supports interventions for people with diabetes and psychosocial concerns, including issues that affect behavioral health."
"Successful therapeutic approaches include cognitive behavioral (400,402,429,430) and mindfulness-based therapies (427,431,432)."
See the sections below for details about interventions for specific psychological concerns.
"Behavioral interventions may also be indicated in a preventive manner even in the absence of positive psychosocial screeners, such as resilience-promoting interventions to prevent diabetes distress in adolescence (433,434) and behavioral family interventions to promote collaborative family diabetes management in early adolescence (435,436) or to support adjustment to a new treatment plan or technology (65)."
Psychosocial interventions can be delivered via digital health platforms (437).
"Group-based or shared diabetes appointments that address both medical and psychosocial issues relevant to living with diabetes are a promising model to consider (397,438)."
"Although efficacy has been demonstrated with psychosocial interventions, there has been varying success regarding sustained increases in engagement in health behaviors and improved glycemic outcomes associated with behavioral health issues."
"Thus, health care professionals should systematically monitor these outcomes following implementation of current evidence-based psychosocial treatments to determine ongoing needs."
"Health care teams should develop and implement psychosocial screening protocols to ensure routine monitoring of psychosocial well-being and to identify potential concerns among people with diabetes, following published guidance and recommendations (406–411)."
"Topics to screen for may include, but are not limited to, attitudes about diabetes, expectations for treatment and outcomes (especially related to starting a new treatment or technology), general and diabetes-related mood, stress, and/or quality of life (e.g., diabetes distress, depressive symptoms, anxiety symptoms, and/or fear of hypoglycemia), available resources (financial, social, family, and emotional), and/or psychiatric history."
"Given elevated rates of suicidality among people with diabetes (412–415), screening for suicidality may also be appropriate (416–418), similar to U.S. Preventive Services Task Force statements regarding screening for some adolescents and adults in the general population (419,420)."
"A list of age-appropriate screening and evaluation measures is provided in the ADA position statement “Psychosocial Care for People with Diabetes” (1), and guidance has been published about selection of screening tools, clinical thresholds, and frequency of screening (408,421)."
"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 (422), at the time of medical treatment changes, or when problems with achieving A1C goals, quality of life, or self-management are identified."
"People with diabetes are likely to exhibit psychological vulnerability at diagnosis, when their medical status changes (e.g., end of the honeymoon period), when the need for intensified treatment is evident, and when complications are discovered."
Significant changes in life circumstances and SDOH are known to considerably affect a person’s ability to self-manage their condition.
"Thus, screening for SDOH (e.g., loss of employment, birth of a child, or other family-based stresses) should also be incorporated into routine care (423)."
"In circumstances where individuals other than the person with diabetes are significantly involved in diabetes management (e.g., caregivers or family members), these issues should be monitored and treated by appropriate professionals (422,424,425)."
"Standardized, validated, age-appropriate tools for psychosocial monitoring and screening can also be used (1)."
"The ADA provides access to tools for screening specific psychosocial topics, such as diabetes distress, fear of hypoglycemia, and other relevant psychological symptoms at professional.diabetes.org/sites/default/files/media/ada_mental_health_toolkit_questionnaires.pdf."
"Additional information about developmentally specific psychosocial screening topics is available in Section 14, “Children and Adolescents,” and Section 13, “Older Adults.”"
"Health care professionals may also use informal verbal inquires, for example, by asking whether there have been persistent changes in mood during the past 2 weeks or since the individual’s last appointment and whether the person can identify a triggering event or change in circumstances."
"Diabetes care professionals 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 diabetes distress, below), changes in finances, or competing medical demands (e.g., the diagnosis of a comorbid condition)."
"When psychosocial concerns are identified, referral to a qualified behavioral health professional, ideally one specializing in diabetes, should be made for comprehensive evaluation, diagnosis, and treatment (380,381,402,403)."
"Indications for referral 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 5.2  for a complete list)."
"It is preferable to incorporate psychosocial assessment and treatment into routine care rather than waiting for a specific problem or deterioration in metabolic or psychological status to occur (39,391)."
"Health care professionals should identify behavioral health professionals, knowledgeable about diabetes treatment and the psychosocial aspects of diabetes, to whom they can refer individuals."
The ADA provides a list of behavioral health professionals who have specialized expertise or who have received education about psychosocial and behavioral issues related to diabetes in the ADA Mental Health Professional Directory (professional.diabetes.org/ada-mental-health-provider-directory).
"Ideally, behavioral health professionals should be embedded in diabetes care settings."
"In recognition of limited behavioral health resources and to optimize availability, other health care professionals who have been trained in behavioral health interventions may also provide this specialized psychosocial care (396,399,426,427)."
"Although some health care professionals may not feel qualified to treat psychological problems (428), strengthening the relationship between a person with diabetes and the health care professional may increase the likelihood of the individual 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)."
The ADA provides resources for a range of health professionals to support behavioral health in people with diabetes at professional.diabetes.org/meetings/behavioral-health-toolkit.
"Diabetes distress is very common (391,439–441)."
"While it shares some features with depression, diabetes distress is distinct and has unique relationships with glycemic and other outcomes (440,442)."
"Diabetes distress refers to significant negative psychological reactions related to emotional burdens and worries specific to an individual’s experience in having to manage a severe, complicated, and demanding chronic condition such as diabetes (439,440,443)."
"The constant behavioral demands of diabetes self-management (medication dosing, frequency, and titration as well as monitoring of glucose, food intake, eating patterns, and physical activity) and the potential or actuality of disease progression are directly associated with reports of diabetes distress (439)."
"The prevalence of diabetes distress is reported to be 18–45%, with an incidence of 38–48% over 18 months in people with type 2 diabetes (443)."
"In the second Diabetes Attitudes, Wishes, and Needs (DAWN2) study, significant diabetes distress was reported by 45% of the participants, but only 24% reported that their health care teams asked them how diabetes affected their lives (391)."
Similar rates have been identified among adolescents with type 1 diabetes (441) and in parents of youth with type 1 diabetes.
"High levels of diabetes distress significantly impact medication-taking behaviors and are linked to higher A1C, lower self-efficacy, and less optimal eating and exercise behaviors (5,439,443)."
"Diabetes distress is also associated with symptoms of anxiety, depression, and reduced health-related quality of life (444)."
"Diabetes distress should be routinely monitored (445) using diabetes-specific validated measures (1), such as those available through the ADA’s website (professional.diabetes.org/sites/default/files/media/ada_mental_health_toolkit_questionnaires.pdf)."
"As there are diabetes distress measures that are validated for people with type 1 and type 2 diabetes at different life stages, it is important to select a tool that is appropriate for each person or population."
"If diabetes distress is identified, it should be acknowledged and addressed."
"If indicated, the person should be referred for follow-up care (403)."
"This may include specific diabetes education to address areas of diabetes self-care causing distress and impacting clinical management and/or behavioral intervention from a qualified behavioral health professional, ideally one with expertise in diabetes, or from another trained health care professional."
"Several educational and behavioral intervention strategies have demonstrated benefits for diabetes distress and, to a lesser degree, glycemic outcomes, including education, psychological therapies, such as cognitive behavioral therapy (CBT) and mindfulness-based therapies, and health behavior change approaches, such as motivational interviewing (429,430,446,447)."
"Data support diabetes distress interventions delivered using technology to reduce diabetes distress (437), including phone-delivered CBT combined with a smartphone application for CBT (448)."
DSMES has been shown to reduce diabetes distress (5) and may also benefit A1C when combined with peer support (449).
"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 (450)."
"A multisite RCT with adults with type 1 diabetes and elevated diabetes distress and A1C demonstrated large improvements in diabetes distress and small reductions in A1C through two 3-month intervention approaches: a diabetes education intervention with goal setting and a psychological intervention that included emotion regulation skills, motivational interviewing, and goal setting (451)."
"Among adults with type 2 diabetes in the Veterans Affairs system, an RCT demonstrated benefits of integrating a single session of mindfulness intervention into DSMES, followed by a booster session and mobile app-based home practice over 24 weeks, with the strongest effects on diabetes distress (452)."
"An RCT of CBT demonstrated positive benefits for diabetes distress, A1C, and depressive symptoms for up to 1 year among adults with type 2 diabetes and elevated symptoms of distress or depression (453)."
"An RCT among people with type 1 and type 2 diabetes found mindful self-compassion training increased self-compassion, reduced depression and diabetes distress, and improved A1C (454)."
"An RCT of a resilience-focused cognitive behavioral and social problem-solving intervention compared with diabetes education (434) in teens with type 1 diabetes showed that diabetes distress and depressive symptoms were significantly reduced for up to 3 years post-intervention, although neither A1C nor self-management behaviors improved over time."
"These recent studies support that a combination of educational, behavioral, and psychological intervention approaches is needed to address distress, depression, and A1C."
"As with treatment of other diabetes-associated behavioral and psychosocial factors affecting disease outcomes, there are few outcome data on long-term systematic treatment of diabetes distress integrated into routine care."
"As the diabetes disease course and its management are fluid, it can be expected that related distress may fluctuate and may need different methods of remediation at different points in the life course and as disease progression occurs."
DSMES focuses on empowering individuals with diabetes by providing them with the tools to make informed self-management decisions (15).
"DSMES should be person-centered; this is an approach that places the person with diabetes and their family and/or support system at the center of the care model, working in collaboration with health care professionals."
"Person-centered care is respectful of and responsive to individual and cultural preferences, needs, and values."
It ensures that the values of the person with diabetes guide all decision-making (16).
"Research supports diabetes care and education specialists (DCES), including nurses (registered nurses and nurse practitioners), registered dietitian nutritionists (RDNs), pharmacists, and other health professionals as providers of DSMES who can also tailor curricula to individual needs (71–73)."
Members of the DSMES team should have specialized clinical knowledge of diabetes and behavior change principles.
"In addition, a DCES needs to be knowledgeable about technology-enabled services and may serve as a technology champion within their practice (68)."
"Certification as a DCES (cbdce.org/) and/or board certification in advanced diabetes management (diabeteseducator.org/education/certification/bc_adm) demonstrates an individual’s specialized training in and understanding of diabetes management and support (56), and engagement with qualified professionals has been shown to improve diabetes-related outcomes (74)."
"Additionally, there is growing evidence for the role of community health workers (75,76), as well as peer (75–80) and lay leaders (81), in providing ongoing support."
"Given individual needs and access to resources, a variety of culturally adapted DSMES programs need to be offered in a variety of settings."
"The use of technology to facilitate access to DSMES, support self-management decisions, and decrease therapeutic inertia calls for broader adoption of these approaches (82)."
"Additionally, it is important to include social determinants of health (SDOH) of the target population in guiding design and delivery of DSMES."
"The DSMES team should consider demographic characteristics such as race, ethnic/cultural background, sex/gender, age, geographic location, technology access, education, literacy, and numeracy (56,83)."
"For example, a systematic review and meta-analysis of telehealth DSMES interventions with Black and Hispanic people with diabetes showed a 0.465% decrease in A1C, demonstrating the importance of considering demographic factors in relation to DSMES interventions (53)."
"Anxiety symptoms and diagnosable disorders (e.g., generalized anxiety disorder, body dysmorphic disorder, obsessive compulsive disorder, specific phobias, and posttraumatic stress disorder) are common in people with diabetes (455)."
The Behavioral Risk Factor Surveillance System estimated the lifetime prevalence of generalized anxiety disorder to be 19.5% in people with either type 1 or type 2 diabetes (456).
"A common diabetes-specific concern is fear related to hypoglycemia (457–459), which may explain avoidance of behaviors associated with lowering glucose, such as increasing insulin doses or frequency of monitoring."
"Factors related to greater fear of hypoglycemia in people with diabetes and family members include history of nocturnal hypoglycemia, presence of other psychological concerns, and sleep concerns (460)."
"See Section 6, “Glycemic Goals and Hypoglycemia,” for more information about impaired awareness of hypoglycemia and related fear of hypoglycemia."
"Other common sources of diabetes-related anxiety include not meeting blood glucose targets (455), insulin injections or infusion (461), and onset of complications (1)."
People with diabetes who exhibit excessive diabetes self-management behaviors well beyond what is prescribed or needed to achieve glycemic goals may be experiencing symptoms of obsessive-compulsive disorder (462).
"General anxiety is a predictor of injection-related anxiety and is associated with fear of hypoglycemia (458,463)."
Psychological and behavioral care can be helpful to address symptoms of anxiety in people with diabetes.
"Among adults with type 2 diabetes and elevated depressive symptoms, an RCT of collaborative care demonstrated benefits on anxiety symptoms for up to 1 year (464)."
"An RCT of CBT for adults with type 2 diabetes showed a reduction in health anxiety, with CBT accounting for 77% of the reduction in health anxiety at 16 weeks of follow-up; this trial also found decreased depressive symptoms and diabetes distress (465)."
"Additionally, an RCT showed switching from intermittently scanned CGM without alerts to real-time CGM with alert functionality in adults with type 1 diabetes decreased hypoglycemia-related anxiety at 24 months of follow-up while reducing A1C (466)."
"Thus, specialized behavioral intervention from a qualified professional is needed to treat hypoglycemia-related anxiety."
"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 (467–469)."
"Elevated depressive symptoms and depressive disorders are common among people with diabetes (385,459), affecting approximately one in four people with type 1 or type 2 diabetes (390), and among parents of youth with diabetes (470)."
"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 (471)."
"Routine monitoring with age-appropriate validated measures (1) can help to identify if referral is warranted (403,410)."
"Multisite studies have demonstrated feasibility of implementing depressive symptom screening protocols in diabetes clinics and published practical guides for implementation (407–410,472)."
Adults with a history of depressive symptoms need ongoing monitoring of depression recurrence within the context of routine care (467)
Integrating behavioral and physical health care can improve outcomes.
"When a person with diabetes is receiving psychological therapy, the behavioral health professional should be incorporated into or collaborate with the diabetes treatment team (473)."
"As with DSMES, person-centered collaborative care approaches have been shown to improve both depression and medical outcomes (473)."
"Depressive symptoms may also be a manifestation of reduced quality of life secondary to disease burden (also see diabetes distress, above) and resultant changes in resource allocation impacting the person and their family."
"When depressive symptoms are identified, it is important to query origins, both diabetes-specific ones and those due to other life circumstances (444,474)."
"Trials have shown consistent evidence of improvements in depressive symptoms and variable benefits for A1C when depression is simultaneously treated (401,473,475), whether through pharmacological treatment, group therapy, psychotherapy, or collaborative care (398,429,430,476,477)."
Psychological interventions targeting depressive symptoms have shown efficacy when delivered via digital technologies (478).
"A systematic review of internet-delivered CBT studies indicated benefits across chronic health conditions, including diabetes (479)."
"For people with diabetes, an RCT comparing internet plus telephonic CBT to usual care found moderate to large improvements in depressive symptoms at 12 months (480)."
Physical activity interventions also demonstrate benefits for depressive symptoms and A1C (318).
It is important to note that the medical treatment plan should also be monitored in response to reduction in depressive symptoms.
Estimated prevalence of disordered eating behavior and diagnosable eating disorders in people with diabetes varies (481–483).
"For people with type 1 diabetes, insulin omission causing glycosuria in order to lose weight is the most commonly reported disordered eating behavior (484,485); in people with type 2 diabetes, bingeing (excessive food intake with an accompanying sense of loss of control) is most commonly reported."
"For people with type 2 diabetes treated with insulin, intentional omission is also frequently reported (486)."
People with diabetes and diagnosable eating disorders have high rates of comorbid psychiatric disorders (487).
People with type 1 diabetes and eating disorders often have high rates of diabetes distress and fear of hypoglycemia (488).
Diabetes care professionals should monitor for disordered eating behaviors using validated measures (489).
"When evaluating symptoms of disordered or disrupted eating (when the individual exhibits eating behaviors that appear maladaptive but are not volitional, such as bingeing caused by loss of satiety cues), etiology and motivation for the behavior should be evaluated (483,490)."
Mixed intervention results point to the need for treatment of eating disorders and disordered eating behavior in the context of the disease and its treatment.
"Given the complexities of treating disordered eating behaviors and disrupted eating patterns in people with diabetes, it is recommended that interprofessional care teams include or collaborate with a health professional trained to identify and treat eating behaviors with expertise in disordered eating and diabetes (491)."
"Key qualifications for such professionals include familiarity with diabetes disease physiology, weight-related and psychological risk factors for disordered eating behaviors, and treatments for diabetes and disordered eating behaviors."
"More rigorous methods to identify underlying mechanisms of action that drive change in eating and treatment behaviors, as well as associated mental distress, are needed (492)."
"Health care teams may consider the appropriateness of technology use among people with diabetes and disordered eating behaviors, although more research on the risks and benefits is needed (493)."
"Caution should be taken in labeling individuals with diabetes as having a diagnosable psychiatric disorder, i.e., an eating disorder, when disordered or disrupted eating patterns are found to be associated with the disease and its treatment."
"In other words, patterns of maladaptive food intake that appear to have a psychological origin may be driven by physiologic disruption in hunger and satiety cues, metabolic perturbations, and/or secondary distress because of the individual’s inability to control their hunger and satiety (483,490)."
"The use of incretin therapies may have potential relevance to the treatment of disrupted or disordered eating (see Section 8, “Obesity and Weight Management for the Prevention and Treatment of Type 2 Diabetes”)."
"Incretin therapies work in the appetite and reward circuitries to modulate food intake and energy balance, reducing uncontrollable hunger, overeating, and bulimic symptoms (494), although mechanisms are not completely understood (495)."
Weight loss from these medications (496) may also improve quality of life.
More research is needed about whether use of incretins and other medications affects physiologically based eating behavior in people with diabetes.
"Studies of individuals with serious mental illness, particularly schizophrenia and other thought disorders, show significantly increased rates of type 2 diabetes (497)."
People with schizophrenia and other thought disorders who are prescribed antipsychotics should be monitored for prediabetes and type 2 diabetes because of the known comorbidity.
"Changes in body weight, glycemia, and lipids should be monitored every 12–16 weeks, unless clinically indicated sooner (498)."
"Disordered thinking and judgment can be expected to make it difficult to engage in behavior that reduces risk factors for type 2 diabetes, such as restrained eating for weight management."
"Further, people with serious behavioral health disorders and diabetes frequently experience moderate psychological distress, suggesting pervasive intrusion of behavioral health issues into daily functioning (499)."
Serious mental illness is often associated with the inability to evaluate and apply information to make judgments about treatment options.
"When a person has an established diagnosis of a mental illness that impacts judgment, activities of daily living, and ability to establish a collaborative relationship with care professionals, it is helpful to include a nonmedical caretaker in decision-making regarding the medical treatment plan."
This caretaker can help improve the person’s ability to follow the agreed-upon treatment plan through both monitoring and caretaking functions (500).
Coordinated management of prediabetes or diabetes and serious mental illness is recommended to achieve diabetes treatment targets.
"The diabetes care team, in collaboration with other care professionals, should work to provide an enhanced level of care and self-management support for people with diabetes and serious mental illness based on individual capacity and needs."
"Such care may include remote monitoring, facilitating health care aides, and providing diabetes training for family members, community support personnel, and other caregivers."
"Qualitative research suggests that educational and behavioral intervention may provide benefit via group support, accountability, and assistance with applying diabetes knowledge (501)."
"Cognitive capacity is generally defined as attention, memory, logic and reasoning, and auditory and visual processing, all of which are involved in diabetes self-management behavior (502)."
Having diabetes (type 1 or type 2) over decades has been shown to be associated with cognitive decline (503–505).
"A host of factors have been linked with cognitive impairment in people with type 1 diabetes, including diabetes-specific (e.g., younger age at diagnosis, longer disease duration, more time in glycemic extremes, recurrent diabetic ketoacidosis, higher A1C, and presence of microvascular complications), other medical (e.g., dyslipidemia, intestinal flora, and poorer sleep quality), and sociodemographic (e.g., female gender and lower educational level) factors (506)."
"Declines have been shown to impact executive function and information processing speed; they are not consistent between people, and evidence is lacking regarding a known course of decline (507)."
"Diagnosis of dementia is more prevalent among people with diabetes, both type 1 and type 2 (508)."
Executive functioning is an aspect of cognitive capacity that has particular relevance to diabetes management.
Attention deficit hyperactivity disorder has been linked with twice the risk of type 2 diabetes (509).
"Among youth and young adults with type 1 diabetes, lower executive functioning has been linked with more difficulties with diabetes self-management and higher A1C (510)."
"In contrast, higher self-regulation has been linked with better emotional and diabetes-specific functioning (511)."
"Thus, monitoring of cognitive capacity and skills among individuals with or at risk for diabetes is recommended, particularly regarding their ability to self-monitor and make judgments about their symptoms, physical status, and needed alterations to their self-management behaviors, all of which are mediated by executive function (508)."
"As with other disorders affecting mental capacity (e.g., major psychiatric disorders), the key issue is whether the person can collaborate with the care team to achieve optimal metabolic outcomes and prevent complications, both short and long term (499)."
"When this ability is shown to be altered, declining, or absent, a lay care professional should be introduced into the care team who serves in the capacities of a day-to-day monitor as well as a liaison with the rest of the care team (1)."
Cognitive capacity also contributes to ability to benefit from diabetes education and may indicate the need for alternative teaching approaches as well as remote monitoring.
"Youth will need second-party monitoring (e.g., parents and adult caregivers) until they are developmentally able to evaluate necessary information for self-management decisions and to inform resultant behavior changes."
Episodes of severe hypoglycemia are independently associated with decline as well as the more immediate symptoms of mental confusion (512).
"Early-onset type 1 diabetes has been shown to be associated with potential long-term deficits in intellectual abilities, especially in the context of repeated episodes of severe hypoglycemia (513), and is correlated with higher A1C and sensor glucose values (514)."
"(See Section 14, “Children and Adolescents,” for information on early-onset diabetes and cognitive abilities and the effects of severe hypoglycemia on children’s cognitive and academic performance.)"
"Thus, for myriad reasons, cognitive capacity should be assessed during routine care to ascertain the person’s ability to maintain and adjust self-management behaviors, such as dosing of medications, remediation approaches to glycemic excursions, etc., and to determine whether to enlist a caregiver in monitoring and decision-making regarding management behaviors."
"If cognitive capacity to carry out self-maintenance behaviors is questioned, an age-appropriate test of cognitive capacity is recommended (1)."
"Cognitive capacity should be evaluated in the context of the person’s age, for example, in very young children who are not expected to manage their disease independently and in older adults who may need active monitoring of treatment plan behaviors."
Cognitive decline is more severe in older adults with type 2 diabetes (515).
"Longitudinal epidemiological studies have documented that chronic hyperglycemia, older age, less education, retinopathy, and nephropathy are associated with diabetes-related cognitive dysfunction (516)."
"Importantly, the risk of cognitive decline can be reduced through improved A1C (517)."
"Exercise may be a potential nonpharmacological treatment pathway for cognitive impairment in older adults with type 2 diabetes (518,519)."
"Strong evidence now exists on the benefits of virtual, telehealth, telephone-based, or internet-based DSMES for diabetes prevention and management in a wide variety of populations and age-groups of people with diabetes (44–56)."
"Technologies such as mobile apps, simulation tools, digital coaching, and digital self-management interventions can also be used to deliver DSMES (57–62)."
These methods provide comparable or even improved outcomes compared with traditional in-person care (63).
"Greater A1C reductions are demonstrated with increased engagement (64), although data from trials are considerably heterogeneous."
"Technology-enabled diabetes self-management solutions improve A1C most effectively when there is two-way communication between the person with diabetes and the health care team, individualized feedback, use of person-generated health data, and education (47)."
"Continuous glucose monitoring (CGM), when combined with individualized diabetes education or behavioral interventions, has demonstrated greater improvement on glycemic and psychosocial outcomes compared with CGM alone (64,65)."
"Similarly, DSMES plus intermittently scanned CGM has demonstrated increased time in range (70–180 mg/dL [3.9–10.0 mmol/L]), less time above range, and a greater reduction in A1C compared with DSMES alone (66)."
"Incorporating a systematic approach for technology assessment, adoption, and integration into the care plan may help ensure equity in access and standardized application of technology-enabled solutions (www.diabeteseducator.org/danatech/home) (8,31,67–70)."
"The associations between sleep problems and diabetes are complex: sleep disorders are a risk factor for developing type 2 diabetes (520,521) and possibly gestational diabetes mellitus (522,523)."
"People with diabetes across the life span often experience sleep disruptions and reduced sleep quality (524,525), and sleep problems are also common in parents of youth with diabetes, especially soon after diagnosis (526,527)."
"Disrupted sleep and sleep disorders, including obstructive sleep apnea (528), insomnia, and sleep disturbances (529), are common among people with diabetes."
"In type 1 diabetes, estimates of poor sleep range from 30% to 50% (530), and estimates of moderate to severe obstructive sleep apnea are >50% (531)."
"In type 2 diabetes, 24–86% of people are estimated to have obstructive sleep apnea (532), 39% to have insomnia, and 8–45% to have restless leg syndrome (i.e., an uncontrollable urge to move legs) (533)."
"Further, people with type 2 diabetes and restless leg syndrome are more likely to experience microvascular and macrovascular complications (534) as well as depression (535)."
"Additionally, people with diabetes who perform shift work increase their risk for circadian rhythm disorders, which are associated with higher A1C (536), neuropathy (537), and decreased psychological well-being (537)."
"Health care professionals should consider a comprehensive evaluation of the daily lifestyles of people with diabetes to decrease risk factors, including low sleep duration, shift work, and days off, given their associations with hyperglycemia, hypertension, dyslipidemia, and weight gain (538)."
"Sleep disturbances are associated with less engagement in diabetes self-management and may interfere with glucose levels within the target range among people with type 1 and type 2 diabetes (525,529,531,533,539,540)."
Risk of hypoglycemia poses specific challenges for sleep in people with type 1 diabetes and may require targeted assessment and treatment approaches (541).
People with type 1 diabetes and their family members also describe diabetes management needs interfering with sleep and experiencing worries about poor sleep (542).
"Both helpful and challenging aspects of diabetes technology use have been described in relation to sleep (542), with the greatest perceived benefits being related to automated insulin delivery systems (543–545)."
"For these reasons, detection and treatment of sleep disorders should be considered a part of standardized care for people with type 1 and type 2 diabetes."
"As for the general population, there are evidence-based strategies to improve sleep for people with diabetes."
"CBT shows benefits for sleep in people with diabetes (429), including CBT for insomnia, which demonstrates improvements in sleep outcomes and possible small improvements in A1C and fasting glucose (546)."
"There is also evidence that sleep extension and pharmacological treatments for sleep can improve sleep outcomes and possibly insulin resistance (541,546)."
"Lastly, sleep education, or sleep hygiene, improves sleep quality, reduces A1C, and decreases insulin resistance in adults with type 2 diabetes (547)."
"Thus, diabetes care professionals are encouraged to counsel people with diabetes to use sleep-promoting routines and practices, such as establishing a regular bedtime and rise time, creating a dark, quiet area for sleep with temperature and humidity control, establishing a pre-sleep routine, putting electronic devices (except diabetes management devices) in silent/off mode, exercising during the day, avoiding daytime naps, limiting caffeine and nicotine in the evening, avoiding spicy foods at night, and avoiding alcohol before bedtime (548)."
"For people with diabetes who have significant sleep difficulties, referral to sleep specialists to address the medical and behavioral aspects of sleep is recommended, ideally in collaboration with the diabetes care professional (Fig. 5.1). "
"Despite the benefits of DSMES, data from the 2017 and 2018 Behavioral Risk Factor Surveillance System of 61,424 adults with self-reported diabetes indicate that only 53% of individuals eligible for DSMES through their health insurance receive it (84)."
"Medicare reimburses DSMES when that service meets the national standards (2,56) and is recognized by the American Diabetes Association (ADA) through the Education Recognition Program (professional.diabetes.org/diabetes-education) or by the Association of Diabetes Care & Education Specialists (diabeteseducator.org/practice/diabetes-education-accreditation-program)."
DSMES is also covered by most health insurance plans.
Ongoing support has been shown to be instrumental for improving outcomes when it is implemented after the completion of education services.
Medicare reimburses remote physiologic monitoring for glucose and other cardiometabolic data if certain conditions are met (89).
"For Medicare Part B, the basics of the DSMES benefit include individual encounters reimbursable for the first 10 h (1 h of individual training and 9 h of group training); if special needs that would interfere with effective group participation are identified on the referral order, individual DSMES encounters are reimbursable for the initial 10 h."
"For Medicaid, DSMES coverage varies by state."
"Although DSMES is frequently reimbursed when performed in person, DSMES can also be provided via telehealth and phone calls (13)."
"These versions may not always be reimbursed; however, changes in reimbursement policies that increase DSMES access and utilization will result in a positive impact on beneficiaries’ clinical outcomes, quality of life, health care utilization, and costs (13,90–92)."
"During the time of the coronavirus disease 2019 (COVID-19) pandemic, reimbursement policies were revised (professional.diabetes.org/content-page/dsmes-and-mnt-during-covid-19-national-pandemic), and these changes may provide a new reimbursement paradigm for future provision of DSMES through telehealth channels."
"Per updated guidance from the Centers for Medicare & Medicaid Services, DSMES telehealth reimbursements remain the same as they were during the public health emergency for most practice settings."
"Both ADA-recognized and Association of Diabetes Care & Education Specialists–accredited programs were added to the list of approved telehealth professionals via the Consolidated Appropriations Act, 2023."
The reimbursement of DSMES telehealth services was extended through the end of 2024.
"Importantly, DSMES is paid on the physician fee schedule and not the outpatient prospective payment system."
"Per the Consolidated Appropriations Act, 2023, distant-site health care professionals may be able to bill DSMES as a Medicare telehealth service through 31 December 2024."
"Barriers to DSMES exist at the health system, payer, clinic, health care professional, and individual levels."
"Low participation may be due to lack of referral or other identified barriers, such as logistical issues (accessibility, timing, and costs) and the lack of a perceived benefit (85)."
"Health system, clinic, programmatic, and payer barriers include lack of administrative leadership support, limited numbers of DSMES professionals, not having a referral to DSMES effectively embedded in the health system service structure, and limited reimbursement rates (86)."
"Thus, in addition to educating referring health care professionals about the benefits of DSMES and the critical times to refer, efforts need to be made to identify and address potential barriers at each level (2)."
"For example, a multilevel diabetes care intervention that combined clinical outreach, standardized protocols, and DSMES with SDOH screening and referrals to social needs support documented a 15% increase in receipt of DSMES, including among people on Medicaid (87)."
Support from institutional leadership is foundational for the success of DSMES.
Expert stakeholders should also support DSMES by providing input and advocacy (56).
"Alternative and innovative models of DSMES delivery (58) need to be explored and evaluated, including the integration of technology-enabled diabetes and cardiometabolic health services (8,68)."
"One potential model is virtual environments, which allow people with diabetes to self-represent as avatars and interact in a world with embedded informational resources accessed using principles of gamification."
"An RCT testing DSMES in a virtual environment demonstrated greater weight loss but similar decreases in A1C, blood pressure, cholesterol, and triglycerides compared with DSMES via a standard website (88)."
"Barriers to equitable access to DSMES may be addressed through telehealth delivery of care, virtual environments, and other digital health solutions (56)."
"When the first ADA Standards of Care guidelines were published in 1989, nutrition was mentioned in two sentences in the entire 4-page document (93)."
"Even now, in 2024, the science of nutrition for diabetes continues to evolve."
"At the same time, there has been change of emphasis from nutrients (macronutrients and micronutrients) to a focus on foods and, more broadly, dietary patterns."
"This integrative approach aligns with the 2021 American Heart Association dietary guidance to improve cardiovascular health (94), the Kidney Disease: Improving Global Outcomes (KDIGO) guidelines (95), the European Association for the Study of Diabetes/ADA type 1 consensus report (96) and type 2 consensus report (97), and the Dietary Guidelines for Americans, 2020–2025 (98)."
"Simply put, people eat food, not nutrients, and nutrient recommendations need to be applied to what people eat."
"Additionally, macronutrients are not interchangeable entities and vary by nutrient type and quality."
"As an example, carbohydrates include legumes, whole grains, and fruits and are in the same category as refined grains, but their health effects are very different (99)."
"For more detailed information on nutrition therapy, please refer to the ADA consensus report on nutrition therapy (73)."
"Contained in the report is an important and often repeated tenet, i.e., there is not a one-size-fits-all eating pattern for individuals with diabetes, and meal planning should be individualized."
"Nutrition therapy plays an integral role in overall diabetes management, and each person with diabetes should be actively engaged in education, self-management, and treatment planning with the health care team, including the collaborative development of an individualized eating plan (73,100)."
"All health care professionals should refer people with diabetes for individualized MNT provided by an RDN who is knowledgeable and skilled in providing diabetes-specific MNT (101–103) at diagnosis and as needed throughout the life span, similar to DSMES."
MNT delivered by an RDN is associated with A1C absolute decreases of 1.0–1.9% for people with type 1 diabetes (104) and 0.3–2.0% for people with type 2 diabetes (104).
See Table 5.1  for specific nutrition recommendations.
"Because of the progressive nature of type 2 diabetes, behavior modification alone may not be adequate to maintain euglycemia over time."
"However, after medication is initiated, nutrition therapy continues to be an important component, and RDNs providing MNT in diabetes care should assess and monitor medication changes in relation to the nutrition care plan (73,100)."
Obesity is defined by the World Health Organization as an abnormal or excessive fat accumulation that presents a risk to health (25).
"BMI (calculated as weight in kilograms divided by the square of height in meters [kg/m2]) has been used widely to diagnose and stage obesity (overweight: BMI 25–29.9 kg/m2; obesity class I: BMI 30–34.9 kg/m2; obesity class II: BMI 35–39.9 kg/m2; obesity class III: BMI =40 kg/m2); however, BMI should not be relied on as a sole diagnostic and staging tool (19)."
"Despite its ease of measurement, BMI is at most an imperfect measure of adipose tissue mass and does not measure adipose tissue distribution or function, nor does it factor in the presence of weight-related health or well-being consequences (26,27)."
"BMI is especially prone to misclassification in individuals who are very muscular or frail, as well as in populations with different body composition and cardiometabolic risk (28)."
"A diagnosis of obesity should be made based on an overall assessment of the individual’s adipose tissue mass (BMI can be used as a general guidance), distribution (using other anthropometric measurements like waist circumference, waist-to-hip circumference ratio, or waist-to-height ratio), or function and, importantly, the presence of associated health or well-being consequences: metabolic, physical, or psychological/well-being (29)."
"Obesity is a key pathophysiologic driver of diabetes, other cardiovascular risk factors (e.g., hypertension, hyperlipidemia, nonalcoholic fatty liver disease, and inflammatory state), and ultimately cardiovascular and kidney disease (30)."
"Diabetes can further exacerbate obesity, setting up a vicious cycle that contributes to disease progression and occurrence of microvascular and macrovascular complications."
"As such, treatment goals for both glycemia and weight are recommended in people with diabetes to address both hyperglycemia and its underlying pathophysiologic driver (obesity) and therefore benefit the person holistically."
A person-centered communication style that uses inclusive and nonjudgmental language and active listening to elicit individual preferences and beliefs and assesses potential barriers to care should be used to optimize health outcomes and health-related quality of life.
"Use person-first language (e.g., “person with obesity” rather than “obese person”) to avoid defining people by their condition (26,31,32)."
"The nutrition choice should be based on the individual’s health status and preferences, including a determination of food availability and other cultural circumstances that could affect nutrition patterns (59)."
"Health disparities adversely affect people who have systematically experienced greater obstacles to health based on their race or ethnicity, socioeconomic status, gender, disability, or other factors."
"Overwhelming research shows that these disparities may significantly affect health outcomes, including increasing the risk for obesity, diabetes, and diabetes-related complications."
"Health care professionals should evaluate systemic, structural, and socioeconomic factors that may impact food choices, access to healthful foods, and nutrition patterns; behavioral patterns, such as neighborhood safety and availability of safe outdoor spaces for physical activity; environmental exposures; access to health care; social contexts; and, ultimately, diabetes risk and outcomes."
"For a detailed discussion of social determinants of health, refer to “Social Determinants of Health: A Scientific Review” (79)."
"People with type 2 diabetes and overweight or obesity who have lost weight should be offered long-term (=1 year) comprehensive weight loss maintenance programs that provide at least monthly contact with trained individuals and focus on ongoing monitoring of body weight (weekly or more frequently) and/or other self-monitoring strategies such as tracking intake, steps, etc.; continued focus on nutrition and behavioral changes; and participation in high levels of physical activity (200–300 min/week) (63,64)."
"Some commercial and proprietary weight loss programs have shown promising weight loss results; however, results vary across these programs, most lack evidence of effectiveness, many do not satisfy guideline recommendations, and some promote unscientific and possibly dangerous practices (65,66)."
"Structured, very-low-calorie meals, typically 800–1,000 kcal/day, utilizing high-protein foods and meal replacement products, may increase the pace and/or magnitude of initial weight loss and glycemic improvements compared with standard behavioral interventions (20,21)."
"However, such an intensive nutritional intervention should be provided only by trained practitioners in medical settings with close ongoing monitoring and integration with behavioral support and counseling, and only for short term (generally up to 3 months)."
"Furthermore, due to the high risk of complications (electrolyte abnormalities, severe fatigue, cardiac arrhythmias, etc.), such intensive intervention should be prescribed only to carefully selected individuals, such as those requiring weight loss and/or glycemic management before a needed surgery, if the benefits exceed the potential risks (67–69)."
"As weight recurrence is common, such interventions should include long-term, comprehensive weight maintenance strategies and counseling to maintain weight loss and behavioral changes (70,71)."
"Despite widespread marketing and exorbitant claims, there is no clear evidence that nutrition supplements (such as herbs and botanicals, high-dose vitamins and minerals, amino acids, enzymes, antioxidants, etc.) are effective for obesity management or weight loss (72–75)."
Several large systematic reviews show that most trials evaluating nutrition supplements for weight loss are of low quality and at high risk for bias.
High-quality published studies show little or no weight loss benefits.
"In contrast, vitamin/mineral (e.g., iron, vitamin B12, vitamin D) supplementation may be indicated in cases of documented deficiency (76), and protein supplements may be indicated as adjuncts to medically supervised weight loss therapies (77,78)."
Measurement of weight and height (to calculate BMI) and other anthropometric measurements... (33).
...should be performed at least annually to aid the diagnosis of obesity and to monitor its progression and response to treatment (33).
"Clinical considerations, such as the presence of comorbid heart failure or unexplained weight change, may warrant more frequent evaluation (34,35)."
"If such measurements are questioned or declined by the individual, the practitioner should be mindful of possible prior stigmatizing experiences and query for concerns, and the value of monitoring should be explained as a part of the medical evaluation process that helps to inform treatment decisions (36,37)."
"Accommodations should be made to ensure privacy during weighing and other anthropometric measurements, particularly for those individuals who report or exhibit a high level of disease-related distress or dissatisfaction."
Anthropometric measurements should be performed and reported nonjudgmentally; such information should be regarded as sensitive health information.
"Health care professionals should advise individuals with overweight or obesity and those with increasing weight trajectories that, in general, greater fat accumulation increases the risk of diabetes, cardiovascular disease, and all-cause mortality and has multiple adverse health and quality of life consequences."
Health care professionals should assess readiness to engage in behavioral changes for weight loss and jointly determine behavioral and weight loss goals and individualized intervention strategies using shared decision-making (38).
"Strategies may include nutrition and dietary changes, physical activity and exercise, behavioral counseling, pharmacotherapy, medical devices, and metabolic surgery."
"The initial and subsequent therapeutic choice should be individualized based on the person’s medical history, life circumstances, preferences, and motivation (39)."
Combination treatment approaches may be appropriate in higher-risk individuals.
"Among people with type 2 diabetes and overweight or obesity who have inadequate glycemic, blood pressure, and lipid management and/or other obesity-related metabolic complications, modest and sustained weight loss (3–7% of body weight) improves glycemia, blood pressure, and lipids and may reduce the need for disease-specific medications (7–9,40)."
"In people at risk, 3–7% weight loss reduces progression to diabetes (2,7,8,41,42)."
"Greater weight loss may produce additional benefits (20,21)."
"Mounting data have shown that >10% body weight loss usually confers greater benefits on glycemia and possibly diabetes remission and improves other metabolic comorbidities, including cardiovascular outcomes, nonalcoholic steatohepatitis, nonalcoholic fatty liver disease, adipose tissue inflammation, and sleep apnea, as well as physical comorbidities and quality of life (6,20,21,30,41,43–52)."
"With the increasing availability of more effective treatments, individuals with diabetes and overweight or obesity should be informed of the potential benefits of both modest and more substantial weight loss and guided in the range of available treatment options, as discussed in the sections below."
"Shared decision-making should be used when counseling on behavioral changes, intervention choices, and weight management goals."
"For a more detailed discussion of lifestyle management approaches and recommendations, see Section 5, “Facilitating Positive Health Behaviors and Well-being to Improve Health Outcomes.” For a detailed discussion of nutrition interventions, please also refer to “Nutrition Therapy for Adults With Diabetes or Pre-diabetes: A Consensus Report” (53)."
"Although the Action for Health in Diabetes (Look AHEAD) trial did not show that the intensive lifestyle intervention reduced cardiovascular events in adults with type 2 diabetes and overweight or obesity (41), it did confirm the feasibility of achieving and maintaining long-term weight loss in people with type 2 diabetes."
"In the intensive lifestyle intervention group, mean weight loss was 4.7% at 8 years (42)."
"Approximately 50% of intensive lifestyle intervention participants lost and maintained =5% of their initial body weight, and 27% lost and maintained =10% of their initial body weight at 8 years (42)."
"Participants assigned to the intensive lifestyle group required fewer glucose-, blood pressure-, and lipid-lowering medications than those randomly assigned to standard care."
"Secondary analyses of the Look AHEAD trial and other large cardiovascular outcome studies document additional weight loss benefits in people with type 2 diabetes, including improved mobility, physical and sexual function, and health-related quality of life (34)."
"Moreover, several subgroups had improved cardiovascular outcomes, including those who achieved >10% weight loss (43)."
"Clinical benefits typically begin upon achieving 5% weight loss (19,54), and the benefits of weight loss are progressive; more intensive weight loss goals (>7%, >10%, >15%, etc.) may be pursued to achieve further health improvements if the individual is motivated and more intensive goals can be feasibly and safely attained."
"Significant weight loss can be attained with lifestyle programs that achieve a 500–750 kcal/day energy deficit, which in most cases is approximately 1,200–1,500 kcal/day for women and 1,500–1,800 kcal/day for men, adjusted for the individual’s baseline body weight (19,54)."
"Proven intensive behavioral interventions included =16 sessions during an initial 6 months and focus on nutritional changes, physical activity, and behavioral strategies to achieve an ~500–750 kcal/day energy deficit."
Such interventions should be provided by trained individuals and can be conducted in either individual or group sessions (54).
"Assessing a person’s motivation level, life circumstances, and willingness to implement behavioral changes to achieve weight loss should be considered along with medical status when such interventions are recommended and initiated (38,60)."
"If such intensive behavioral interventions are not available or accessible, structured programs delivering behavioral counseling (face-to-face or remote) can be considered; however, their effectiveness varies (61,62)."
"Nutrition interventions may differ by macronutrient goals and food choices as long as they create the necessary energy deficit to promote weight loss (19,55–57)."
"Using meal replacement plans prescribed by trained practitioners, with close monitoring, can be beneficial."
"Within the intensive lifestyle intervention group of the Look AHEAD trial, for example, the use of a partial meal replacement plan was associated with improvements in nutrition quality and weight loss (54), and improvement in cardiovascular risk factors (41)."
"In a systematic review and meta-analysis, efficacy and safety of meal replacements (partial or total meal replacement) as compared with conventional diets showed improvements in A1C, FBG, body weight, and BMI (58)."
"In the most recent ESC/EURObservational Research Programme (EORP) EUROASPIRE surveys, history of hypertension was present in 80% of men and 87% of women with known diabetes and in 74% of men and 81% of women with newly diagnosed diabetes with a history of coronary heart disease (CHD) (191)."
Regular BP measurements under standardized conditions are mandatory in all patients with diabetes (Figure 9; Table 8).
"Hypertension should be confirmed in both arms using multiple readings, including measurements on separate days (48,157)."
"In patients with CVD and values >180/110 mmHg, it could be reasonable to diagnose hypertension at a single visit (192)."
"Details on BP measurements are comprehensively summarized in the 2018 ESC/European Society of Hypertension (ESH) Guidelines for the management of arterial hypertension and in the Supplementary data online, Section 2.6.1 (193)."
"In general, the diagnosis and treatment of hypertension is comparable between sexes, except for women of child-bearing potential or during pregnancy, when some drugs, such as RAS blockers, can have adverse effects on the foetus, especially in early gestation (227)."
The possible effect of oral contraceptives on BP should also be considered (48).
There is some evidence from RCTs that BP targets during pregnancy should range from 110 to 135 mmHg for SBP and 80 to 85 mmHg for DBP (228).
"This is also supported by the recent CHAP (Chronic Hypertension and Pregnancy) study of mild chronic hypertension in pregnancy, where 16% of the pregnant women had diabetes (229)."
The strategy targeting a BP of <140/90 mmHg was related with better pregancy outcomes without an increase in the number of Small for Gestational Age babies.
"Women usually show greater differences in BP and higher proportions of hypertension than men already at diagnosis of T2DM compared with women and men without T2DM, and worse BP control thereafter (191,230)."
"Moreover sex-specific, hypertension-mediated organ damage was evidenced with a very high risk of HFpEF in women, especially in the presence of diabetes (231)."
"Randomized controlled trials have shown the benefit (reduction of stroke, coronary events, and kidney disease) of lowering SBP to <140 mmHg and diastolic blood pressure (DBP) to <90 mmHg in patients with diabetes (Evidence in Table S10)."
"However, the optimal BP target in patients with diabetes is still a matter of debate."
"The UKPDS post-trial, 10-year follow-up study reported no benefits persisting from the earlier period of tight BP control with respect to macrovascular events, death, and microvascular complications, while initial between-group BP differences were no longer maintained (132)."
"RCTs evaluating the benefits and risks of more intense compared with standard hypertension treatment strategies in patients with diabetes are summarized in Supplementary data online, Table S10."
"In a meta-analysis of RCTs involving patients with diabetes or pre-diabetes, an SBP reduction to =135 mmHg compared with a less intensive control reduced the RR of all-cause mortality by 10% (odds ratio [OR] 0.90; 95% CI, 0.83–0.98), whereas more intensive BP control (=130 mmHg) was associated with a greater reduction in stroke but did not reduce other events (194,195)."
"Similarly, anti-hypertensive treatment significantly reduced mortality in people with T2DM, CAD, HF, and stroke, with an achieved mean SBP of 138 mmHg, whereas only stroke was reduced significantly, with a mean SBP of 122 mmHg compared with higher BP values (196)."
"Thus, reducing SBP to <130 mmHg may benefit patients with a particularly high risk of a cerebrovascular event, such as those with a history of stroke (193,194,196–200)."
"However, SBP >140 mmHg or <120 mmHg were related to higher risk of adverse renal outcomes in patients with diabetes when compared with those without diabetes and with high CV risk (199–202)."
"The 2018 ESC/ESH Guidelines for the management of arterial hypertension recommend that in all patients with diabetes, office BP should be targeted to an SBP of 130 mmHg, and lower if tolerated but not <120 mmHg; DBP should be lowered to <80 mmHg but not <70 mmHg (193)."
"In older patients (age =65 years), the SBP target range should be 130–140 mmHg if tolerated (193)."
"However, more recent data challenge these recommendations for all patients with diabetes, and highlight a potential need for more individualized target levels (157,203,204)."
"The 2021 ESC Prevention Guideline recommends office SBP treatment target ranges of 120–130 mmHg in patients with diabetes, with lower SBP acceptable if tolerated until the age of 69 years (48)."
"In patients aged =70 years, SBP values <140 mmHg, down to 130 mmHg if tolerated are recommended."
DBP treatment target <80 mmHg is recommended for all treated patients.
"Diets rich in vegetables, fruits, and low-fat dairy products, such as the Mediterranean diets and Dietary Approaches to Stop Hypertension-style eating patterns (including reducing sodium to <100 mmol/day and increasing potassium intake), improve BP control (205–207)."
Long-term exercise training intervention modestly but significantly reduces SBP (by -7 mmHg) and DBP (by -5 mmHg).
"Ideally, an exercise prescription aimed at lowering BP in individuals with normal BP or hypertension would include a mix of predominantly aerobic exercise training supplemented with dynamic resistance exercise training (208)."
"A marked improvement in CV risk factors (hypertension, dyslipidaemia, diabetes), associated with marked weight loss, was observed after bariatric surgery (209)."
"In the Look AHEAD trial, those who lost 5 to <10% of body weight had increased odds of achieving a 5 mmHg decrease in SBP and DBP compared with those who lost >10% or <5% (210)."
"The frequency of CV complications appears to be modulated by ethnicity or racial identity (193,211,212)."
Home BP self-monitoring should be considered in patients with diabetes on anti-hypertensive treatments to check that BP is appropriately controlled (242).
"24 h ambulatory blood pressure monitoring should be considered to assess abnormal 24 h BP patterns, including nocturnal hypertension and reduced or reversed nocturnal BP dipping, and to adjust anti-hypertensive treatment (243)."
"Optimal risk factor and lifestyle management, as well as early identification and treatment of comorbidities, is a cornerstone of treatment for T2DM (357–359)."
"The Swedish National Diabetes Registry revealed a clear improvement of clinical outcomes by each risk factor within the target range (HbA1c, LDL-C, albuminuria, smoking, and SBP) (360)."
"In patients with advanced disease, e.g. T2DM and established microalbuminuria, an intensive, target-driven, multifactorial therapy (Steno-2 study; targets: HbA1c <6.5%, total cholesterol <4.5 mmol/L [175 mg/dL], and BP <130/80 mmHg) resulted in 50% fewer microvascular and macrovascular events after 7.8 years of follow-up (361)."
"Long-term follow-up (21 years from baseline) showed significantly reduced end-stage renal disease combined with death (HR 0.53; 95% CI, 0.35–0.80), and risk of HF hospitalization reduced by 70% (362)."
"Overall, this resulted in a 7.9 year gain of life expectancy (363)."
"These positive effects were not observed in the clinical intervention trials of intensified, multifactorial treatment for T2DM in primary care and early in the disease trajectory."
"The ADDITION (Anglo-Danish-Dutch Study of Intensive Treatment in People with Screen Detected Diabetes in Primary Care) trial showed that microvascular or macrovascular events were not significantly reduced after 5 or 10 years (17% and 13% reduction, respectively), while intervention only slightly improved HbA1c (364,365)."
"In accordance, the J-DOIT3 (Japan Diabetes Optimal Integrated Treatment Study for 3 Major Risk Factors of Cardiovascular Diseases) trial in patients with T2DM aged 45–69 years revealed a non-significant trend towards a reduced primary composite outcome (non-fatal MI, stroke, revascularization, or all-cause death; HR 0.81; 95% CI, 0.63–1.04; P = 0.094) with intensive vs. conventional therapy (366)."
"Post-hoc analyses showed that only cerebrovascular events were reduced (HR 0.42; 95% CI, 0.24–0.74; P = 0.002), while no differences were seen for all-cause death and coronary events."
"In addition, the Look AHEAD trial, introducing lifestyle intervention in patients with obesity and T2DM with 10 years’ follow-up, did not demonstrate a reduction in the composite CV outcome (56)."
"Key problems in optimally treating patients with T2DM and CVD are the low rate of detection of T2DM in patients with CVD, the low referral rate to diabetes specialists, and the difficulty of prolonged adherence to medication or lifestyle interventions in this patient group."
"The EUROASPIRE V survey reported that many patients with CVD (29.7%) had known diabetes, while 41.1% of those with unknown T2DM were dysglycaemic (367)."
"Of patients with known diabetes, 31% had been advised to attend a diabetes clinic, though only 24% attended."
"Only 58% of dysglycaemic patients were prescribed all cardio-protective drugs, and use of SGLT2 inhibitors or GLP-1 RAs was limited (3% and 1%, respectively) (367)."
"A BP target <140/90 mmHg was achieved in only 61% of patients with newly detected T2DM, and in 54% of patients with previously known T2DM (34)."
"An LDL-C target <1.8 mmol/L was only achieved in 18% and 28% of patients, respectively."
"This was explained by low prescription rates of the combination of all cardio-protective drugs (antiplatelet therapy, beta-blockers, RAS inhibitors, and statins) in only 55% of patients with newly detected T2DM, and in 60% of patients with previously known T2DM (34)."
"The concept of a polypill, e.g. containing aspirin, ramipril, and atorvastatin, may even improve clinical events in secondary cardiovascular prevention (368)."
"Furthermore, adherence to lifestyle intervention fades over time, with continuously increasing body weight after 1 year (56)."
"To overcome adherence failures, the 2021 ESC Guidelines on cardiovascular disease prevention in clinical practice outlines a stepwise approach to treating risk factors and intensifying treatment to help physicians and patients pursue risk-factor targets, taking into account patient profiles and preferences, ensuring targets are a part of a shared decision-making process involving healthcare professionals and patients (48)."
"This stepwise approach starts with assessing CVD risk in all patients with diabetes, including glycaemic state and lifestyle risk-factor profile (Figure 13)."
"CVD risk stratification should be individually adapted according to comorbidities, e.g. CAD, HF, AF, or PAD, as well as age, frailty, and sex."
"This includes discussing individual preferences with the patient, particularly regarding lifestyle strategies and potential treatment benefits."
"Particularly in the field of T2DM, studies have shown benefits of a stepwise approach to intensify treatment, and it appears that attaining treatment goals is similar, side effects are fewer, and patient satisfaction is significantly higher with such an approach (369,370)."
"Supporting evidence comes from the Italian Diabetes and Exercise Study 2, which showed that a behavioural intervention strategy compared with standard care resulted in a sustained increase in physical activity and decrease in sedentary time among patients with T2DM (371)."
Multidisciplinary behavioural approaches that combine the knowledge and skills of different caregivers are recommended (104).
Adding exercise intervention combined with psychological support to diet recommendations is more effective than diet education alone (375).
"Assessing depression and depressive symptoms is important in patients with CVD and T2DM, as adequate treatment improves adherence (376,377)."
"To achieve a high adherence and optimization of target goals, clinician–patient communication is crucial and should include a personalized approach explaining background and targets to improve understanding and encourage lifestyle changes and drug-therapy adherence."
"Aside from the disease entity, including symptoms, the patient’s ability to adopt a healthy lifestyle depends on individual cognitive and emotional factors, educational level, socioeconomic factors, and mental health."
Perceived susceptibility to illness and the anticipated severity of the consequences are also prominent components of patients’ motivation (372).
"Patients can be motivated by motivational interviewing including the Open-ended questions, Affirmation, Reflective listening, and Summarizing (OARS) and Specific, Measurable, Achievable, Realistic, Timely (SMART) principles (372–374)."
"Mobile phone applications may improve adherence to both medication and behavioural changes, but more evidence, particularly in patients with CVD and T2DM, is needed (378)."
"Regarding the education method, individual education is more effective than face-to-face or web and mobile phone education (375)."
Whether a tailored and automated text message (SMS) support programme may improve glycaemic control in adults with poorly controlled diabetes is equivocal (379).
Lifestyle changes are recommended as the basic measure for preventing and managing T2DM (48).
Advice should be addressed by a multifactorial approach with patient-centred communication adapted to the health status and health literacy of the patient (Section 5.7).
"In T2DM, as investigated in the Action for Health in Diabetes trial (Look AHEAD; 5145 T2DM patients, 59% female, mean age 58 years, mean body mass index [BMI] 36 kg/m2), lifestyle intervention by nutritional counselling, meal replacement, and exercise induced an average of 8.6% weight loss, which was associated with a significant reduction in HbA1c and BP (56)."
Effects on weight and risk-factor control diminished after 5 years in those with low adherence to the lifestyle programme (56).
"After 10 years, CV events (i.e. a composite endpoint of CV death, non-fatal MI, non-fatal stroke, and hospitalization for angina) were not different to usual care (56)."
"However, microvascular disease complications (i.e. development of CKD) were significantly reduced (hazard ratio [HR] 0.69; 95% confidence interval [CI], 0.55–0.87; P = 0.002) by lifestyle intervention, an effect associated with improvements in CV risk factors (57)."
"Additional analyses 16.7 years after the start of the study (9.6 years of intervention and then observation) revealed that participants who lost =10% of weight at 1 year of intervention had a 21% reduced risk of mortality (HR 0.79; 95% CI, 0.67–0.94; P = 0.007) (58)."
"The decline in body fat mass was significantly associated with a lower risk of HF with reduced ejection fraction (HFrEF) and HF with preserved ejection fraction (HFpEF), while a decline in waist circumference was only significantly associated with a lower risk of HFpEF (59)."
"In addition, baseline cardio-pulmonary fitness was associated with reduced risks of mortality and CV events during follow-up of 9.2 years (60)."
"The DiRECT (Diabetes Remission Clinical Trial)—an open-label, cluster-randomized trial in patients with T2DM—assigned practices to provide either a weight-management programme including exercise (intervention group) or best-practice care by guidelines (control group)."
"At 12 months, almost half of the participants in the intervention group achieved remission to a non-diabetic state and were off glucose-lowering drugs (61)."
"Home-based exercise intervention in patients with CAD and T2DM (ARTEMIS study; Finnish randomized controlled trial [RCT]; n = 127; 2-year controlled, home-based exercise training vs. usual care), however, did not significantly improve CV risk factors despite significant improvements in exercise capacity (P = 0.030) (62)."
"In patients with obesity and T2DM, reducing weight is one of the cornerstones of treatment (63)."
"Weight loss of >5% improves glycaemic control, lipid levels, and BP in overweight and obese adults with T2DM (64,65)."
These effects can be achieved by improving energy balance and/or introducing obesity medications.
"Orlistat, naltrexone/bupropion, and phentermine/topiramate are each associated with achieving >5% weight loss at 52 weeks compared with placebo (66)."
"However, glucose-lowering agents such as GLP-1 RAs, the dual agonist tirzepatide, and SGLT2 inhibitors also significantly reduce body weight (67,68)."
Adding exercise to a GLP-1 RA (liraglutide) had a greater effect on weight reduction and maintenance (69).
"Comparing the effects on weight reduction between GLP-1 RAs and SGLT2 inhibitors, the former seems to be superior."
"Given the additional beneficial effects of GLP-1 RAs and SGLT2 inhibitors on CV outcomes in T2DM (Section 5.3), these agents should be the preferred glucose-lowering medication in overweight and obese patients with CVD and T2DM, as obesity medications have, to date, not shown to reduce CV events (70–72)."
"If weight is not managed effectively by lifestyle interventions and medication, bariatric surgery should be considered in patients with T2DM and a BMI =35 kg/m2 (=Class II; WHO classification) to achieve long-term weight loss, reduce blood glucose, and improve CV risk factors."
"Data from the Swedish Obesity Subjects (SOS) study revealed that after 24-year follow-up, bariatric surgery was associated with a prolonged life expectancy compared with lifestyle and intensive medical management alone (73,74)."
"The corresponding HR was 0.70 (95% CI, 0.57–0.85) for CV death and 0.77 (95% CI, 0.61–0.96) for death from cancer (75,76)."
"This evidence has been extended to patients with CVD and obesity, as a large case-control study (n = 2638) revealed that bariatric surgery was also associated with a lower incidence of major adverse cardiovascular events (MACE) in those patients (77)."
"Still, potential adverse events after bariatric surgery should also be considered (78)."
"In general, patients with T2DM should follow nutritional recommendations that reduce body weight and improve metabolic control and outcomes (48)."
"A Mediterranean-style eating pattern improves glycaemic control, lipids, and BP (80,81)."
"If this diet is supplemented with olive oil or nuts, as in the non-randomized PREvencion con Dieta MEDiterranea (PREDIMED) study in individuals at high CV risk (49% T2DM), the risk of ASCVD was reduced by 28–31% (82)."
Recent data from the Coronary Diet Intervention With Olive Oil and Cardiovascular Prevention (CORDIOPREV) study confirmed the benefit of a Mediterranean diet by showing that male patients with established CAD benefitted more from a Mediterranean diet than from a low-fat diet intervention after 7 years of follow-up.
A shift from a more animal-based to a plant-based food pattern may also reduce ASCVD risk (83–85).
"Data from studies on supplementation with n–3 fatty acids do not support recommending n–3 fatty acid supplements for secondary prevention of CVD in T2DM (86,87)."
"The consumption of sugars, sugar-sweetened soft drinks, and fruit juices should be avoided (88,89)."
"Moreover, alcohol intake should generally be moderate, as any amount of alcohol uniformly increases BP and BMI (90–92)."
"A high-protein diet (30% protein, 40% carbohydrates, and 30% fat) seems to be superior to a standard-protein diet (15% protein, 55% carbohydrates, and 30% fat) in overweight and obese (mean weight 107.8 ± 20.8 kg) patients with HF; both diets were equal in reducing body weight (3.6 vs. 2.9 kg, respectively) and waist circumference (1.9 vs. 1.3 cm, respectively), but the high-protein diet resulted in greater reductions in CV risk factors, e.g. HbA1c, cholesterol, triglycerides, and BP (93)."
"People with CVD and T2DM are encouraged to reduce sodium intake, as this may reduce systolic BP by, on average, 5.8 mmHg in hypertensive patients and 1.9 mmHg in normotensive patients (94,95)."
"In a meta-analysis, in hypertensive and normotensive people, reducing salt intake by 2.5 g/day resulted in a 20% relative reduction of ASCVD events (95)."
"In addition, salt substitution with reduced sodium levels and increased potassium levels has been shown to reduce stroke, CVD, and overall mortality in patients with high CV risk (96)."
Regular moderate to vigorous PA has favourable effects on metabolic control and CV risk factors in T2DM (97–100).
"Intervention programmes reduce HbA1c by 0.6% in patients with T2DM, with the combination of endurance and resistance exercise having the most beneficial effects (101)."
"Moreover, compared with low total PA, high total PA is associated with a lower CV mortality risk, as well as a reduction in all-cause mortality (all-cause mortality: HR 0.60 [95% CI, 0.49–0.73], comparing high vs. low total PA) (97)."
"Interventions are based on encouraging an increase in any PA, as even small amounts were shown to have beneficial effects; even an extra 1000 steps of walking per day is advantageous and may be a good starting point for many patients (98,100)."
"Moreover, a gradual increase in activity level is recommended."
Structured exercise should be additionally introduced at the start or after first achievements to increase activity.
Patients should perform =2 sessions per week of endurance exercise and/or resistance exercise training.
"PA accumulated in bouts of even <10 min is associated with favourable outcomes, including reduced mortality (110,111)."
" Exercise prescription is recommended to be adapted to T2DM-associated comorbidities, e.g. CAD, HF, AF, diabetic peripheral neuropathy, or retinopathy, as well as age and frailty (104,107,108)."
"Structured exercise intervention is also recommended in patients with T2DM with established CVD (e.g. CAD, AF, HFpEF; heart failure with mildly reduced ejection fraction [HFmrEF]; HFrEF) (102–104)."
"Interval endurance exercise training of more vigorous intensity (e.g. interval walking, alternating between moderate to vigorous intensities) has superior effects compared with moderate-intensity continuous walking regarding body weight, waist circumference, and glucose control (105)."
Resistance exercise is recommended to be performed at least twice weekly (intensity of 60–80% of the individual’s one-repetition maximum).
"For older or deconditioned adults, less volume and lower intensities are recommended, particularly during the initiation phase of 3–6 weeks (106)."
"Interventions shown to increase PA level or reduce sedentary behaviour include behaviour theory-based interventions, such as goal-setting, re-evaluation of goals, self-monitoring, and feedback (112,113)."
"Before starting a structured exercise programme in patients with T2DM and established CVD, performing a maximal exercise stress test to assess CV pathologies should be considered."
"Moreover, assessment of aerobic and anaerobic thresholds by spiroergometry is particularly useful to provide an individualized endurance exercise prescription including exercise intensity (106–108)."
"Optimal intensity is determined based on an individual’s maximum (peak) effort during spiroergometry, e.g. percentage of cardiorespiratory fitness (% peak oxygen consumption), percentage of maximum (peak) heart rate (% HRmax), or perceived exertion rate according to the Borg scale (107–109)."
Using a wearable activity tracker (e.g. smartphones) may help increase PA (114).
"Most important is to encourage PA that people enjoy and/or can include in their daily routines, as such activities are more likely to be feasible and sustainable."
Smoking cessation is a key lifestyle intervention in patients with T2DM with or without CVD with evidence suggesting a 36% reduction in mortality in CVD patients (118–120).
"If advice, encouragement, and motivation are insufficient, then drug therapies should be considered early, including nicotine replacement therapy (chewing gum, transdermal nicotine patches, nasal spray, inhaler, sublingual tablets) followed by bupropion (121)."
"In patients with ASCVD, varenicline, bupropion, telephone therapy, and individual counselling all increase success rates (122)."
"Electronic cigarettes (e-cigarettes) have been addressed as a potential smoking cessation aid to bridge transition from smoking to abstention, but—if used at all—should be limited for a short period of time."
"A consensus regarding the efficacy and safety for this approach has yet to be reached (123,124)."
"Overall, smoking cessation programmes have low efficacy at 12 months; nonetheless, cessation measures should be repetitively addressed for smoking abstention to succeed (125)."
People with type 2 diabetes often have lifestyles (eating and physical activity habits) which contribute to their problem.
"It is essential they receive help soon after diagnosis to consider how they may modify lifestyle in ways which enable them to take control of their blood glucose, blood lipid and blood pressure, even if they also require pharmacotherapy (see Chapter 9: Glucose control therapy)."
Evidence supports the effectiveness of nutrition therapy and physical activity in the prevention and management of type 2 diabetes [1–4].
"This is reflected in the Canadian [5], UK NICE [6] and Australian guidelines [7] as well as the ADA standards of medical care [2,8,9]."
Lifestyle modification can be difficult to achieve and maintain [6].
"Most lifestyle intervention studies have been short-term, however this is being addressed by the Look AHEAD study [10]."
"Other considerations include a lack of knowledge about the ongoing contribution of lifestyle measures once medication has been introduced, or what kind of support is required on a continuing basis."
"The UKPDS initial nutrition intervention was very effective in lowering blood glucose after diagnosis and some people were then able to maintain target glucose control for many years by nutrition modifications alone [11,12]."
"RCTs and outcomes studies of medical nutrition therapy (MNT) in the management of type 2 diabetes have reported improved glycaemic outcomes (HbA1c decreases of ~1.0–2.0%/11–22 mmol/mol; range: -0.5 to 2.6%/-6.5 to 29 mmol/mol, depending on the duration of diabetes) and level of glycaemic control [1]."
MNT in these studies was provided by dietitians (nutritionists) as MNT only or as MNT in combination with diabetes self-management training.
"Interventions included reduced energy intake and/or reduced carbohydrate/fat intake, carbohydrate counting, and basic nutrition and healthy food choices for improved glycaemic control."
"Central to these interventions are multiple encounters to provide education initially and on a continued basis [5,9,13–19]."
"Cardioprotective nutrition therapy (saturated and trans fats less than 7% of daily energy, dietary cholesterol less than 200 mg daily, and a daily fat intake of 25–35%) can reduce total cholesterol by 7–21%, low density lipoprotein (LDL)-cholesterol by 7–22%, and triglycerides by 11–31% [20]."
Energy from saturated or trans fatty acids may be replaced by energy from unsaturated fatty acids.
"If a reduced energy intake is a goal, reduction rather than replacement of saturated fat energy is recommended."
Pharmacological therapy should be considered if goals are not achieved between 3 and 6 months after initiating MNT.
A meta-analysis of studies of non-diabetic people reported that reductions in sodium intake to =2.4 g/day decreased blood pressure by 5/2 mmHg in hypertensive subjects.
"Meta-analyses, clinical trials and expert committees support the role of reduced sodium intake, modest weight loss (4–5 kg), increased physical activity, a low-fat diet that includes fruits, vegetables and low-fat dairy products, and moderate alcohol intake, in reducing blood pressure [21]."
"A systematic review and meta-analysis of exercise (aerobic, resistance training or both) reported an HbA1c reduction of 0.7%/8 mmol/mol, independent of changes in body weight, in people with type 2 diabetes [22]."
"In long-term prospective cohort studies of people with type 2 diabetes, higher physical activity levels predicted lower long-term morbidity and mortality and increases in insulin sensitivity."
"Interventions included both aerobic exercise (such as walking) and resistance exercise (such as weight-lifting) [2,23,24]."
"The Canadian Diabetes Association and ADA guidelines have a section on the management of obesity in type 2 diabetes, which addresses lifestyle measures and also pharmacotherapy and surgical options [5,9]."
"In addition to behavioural and medical approaches, various types of surgery on the gastrointestinal tract, originally developed to treat morbid obesity (“bariatric surgery”), constitute powerful options to ameliorate diabetes in severely obese patients, often normalising blood glucose levels, reducing or avoiding the need for medications and providing a potentially cost-effective approach to treating the disease [25]."
A recent IDF position paper recommended bariatric surgery should be considered earlier in the treatment of eligible patients to help stem the serious complications that can result from diabetes [26].
"Eligible patients include those who have type 2 diabetes and a BMI =35 kg/m2; or with a BMI between 30 and 35 kg/m2 when diabetes cannot be adequately controlled by optimal medical regimen, especially in the presence of other major CVD risk factors."
"It is noted than in general costs of educational initiatives to change lifestyle are low, because unlike pharmacotherapy they are provided on an intermittent rather than continuing basis."
"From a health-provider perspective many of the costs fall outside their budget, healthier foods and exercise programmes and equipment generally being a cost met directly by the person with diabetes."
"For these reasons, and because, for glucose control, the gain from lifestyle modification is greater than that from any individual therapy, lifestyle measures are heavily promoted."
"Lifestyle modification is, however, sometimes difficult for the individual to maintain in the long-term, or to develop further after early changes have been made."
"Where professional nutritionists are unavailable, it was noted that other health-care professionals should be trained in basic nutritional and other lifestyle education."
Diabetes is common in older people and is often undiagnosed.
"While undiagnosed, diabetes may produce symptoms, result in complications and aggravate existing comorbidities."
Type 2 diabetes has a long asymptomatic preclinical phase which frequently goes undetected and complications are commonly present at the time of diagnosis.
"Although there is debate about screening and early detection of diabetes in the general population, it is usually favoured in older people because of its high prevalence and the potential negative impact on health."
"Populations throughout the world consistently show an increase in prevalence of diagnosed and undiagnosed type 2 diabetes with increasing age, reaching a plateau or even declining slightly in the very old."
"For example, in Australia in the age group 25-34, 0.2% have diagnosed and 0.1% have undiagnosed diabetes, increasing respectively to 9.4% and 8.5% in 65-74 year olds and 10.9% and 12.1% for people aged 75 years and older [24]."
"In the US in the age groups 70-74, 75-79, 80-84, and = 85 years the prevalence of diabetes was 20%, 21.1%, 20.2%, and 17.3%, respectively [25]."
The DECODE Study analysed data from nine European countries and reported a prevalence of type 2 diabetes of < 10% in people age < 60 years and 10-20% in those aged 60-79 years [26].
The findings of the DECODA study in 11 Asian cohorts were similar [27].
"The usual risk factors for undiagnosed diabetes also apply in older people, including increasing weight and ethnicity."
"Undiagnosed diabetes is particularly common in older people with acute myocardial infarction (34% in the Glucose Tolerance in Acute Myocardial Infarction study in people over 80 years of age) [28], and with cerebrovascular disease (46% with newly diagnosed diabetes of people with a mean age of 71 years with acute ischaemic stroke) [29]."
"Mental illness seems to be associated with an increase in type 2 diabetes [30] but data regarding antipsychotic medication varies with the strongest association reported for treatment with olanzapine in people with major psychiatric illness [31,32]."
However it is difficult to differentiate the effect of the mental illness from its treatment [33].Postprandial hyperglycaemia is common in older people [34].
Therefore older people are more likely to have a non-diabetic fasting plasma glucose and a diabetic 2 hour post-challenge glucose level [35].
This has implications for diagnosis and results in differences in prevalence depending on which diagnostic test is used [36].
"In addition, a number of studies in older populations have demonstrated that isolated post-challenge hyperglycaemia is associated with adverse outcomes compared with normal glucose-tolerant individuals [37-39]."
The implications for the individual require balancing the risks and benefits of performing an OGTT and the likelihood of missing significant hyperglycaemia.
"For example, an individual with a non-diabetic fasting plasma glucose and HbA1c is unlikely to have clinically relevant hyperglycaemia."
"However, an OGTT may be clinically indicated in an older individual with equivocal results."
"Screening for diabetes will also identify individuals with intermediate hyperglycaemia (IGT and impaired fasting glucose IFG) who may benefit from interventions to prevent or delay progression to diabetes, and to prevent cardiovascular disease (CVD) and other diabetes-specific complications."
The prevalence of IGT and IFG also increase with increasing age.
For example in the NHANES III study [40] the prevalence of IGT increased from 11.1% in people aged 40-49 to 20.9% in those aged 60-74 years.
IGT and IFG are important risk factors for the development of future diabetes and increase risk 10-20 fold compared with those with normal glucose tolerance.
This increased risk does not seem to vary with age.
"Several studies have shown that progression to diabetes can be prevented or delayed in people with IGT [41,42]."
"In the US Diabetes Prevention Program (DPP), lifestyle modification achieved a 58% reduction compared with a 31% reduction with metformin in progression to diabetes."
"The effect of lifestyle modification was greatest in people aged = 60 years, whereas the effect of metformin was not significant in this age group [42]."
"Follow-up of the DPP cohort for 10 years showed that the group 60 years and over age group appeared to benefit more from the lifestyle intervention than younger participants, but did not appear to benefit from metformin (49% risk reduction in those aged > 60 years at randomization compared with 34% for the total cohort) [43] and additional benefits of the lifestyle intervention that might impact older adults, such as reduction in urinary incontinence [44] and improvement in quality of life [45]."
The benefits of identifying IGT or IFG in older adults depend on the time taken to achieve benefit and the person’s life expectancy.
"Although prevention studies suggest a benefit in relatively healthy older adults, these studies did not enrol significant numbers over the age of 70 years or those with functional or cognitive impairments."
Nutrition is an important part of diabetes care for all age groups.
"However, there are important additional concerns for older adults with diabetes [46]."
"Malnutrition is common in older people, especially in aged care homes [47]."
"Malnutrition is associated with longer length of stay in hospital and increased mortality [48], is a strong predictor of readmission and is associated with pressure ulcers, delirium, and depression [49]."
"Concomitant diseases that increase the risk of malnutrition in older people with diabetes include: Gastroparesis, which is present in up to 25-55% of people with type 1 and 30% with type 2 diabetes [50] and may affect glucose stability and orally administered medicines absorption and may cause significant discomfort;  Parkinson's disease; Psychiatric disorders and depression; Chronic obstructive pulmonary disease; Renal failure; Neurological dysfunction;  Dental disease."
"Energy needs decline with age, but micronutrient needs remain similar throughout adulthood."
"Meeting micronutrient needs where there is lower energy intake can be challenging and older people often have micronutrient deficiencies and are at risk of under nutrition due to anorexia, altered taste and smell, swallowing difficulties, oral and dental issues, and functional impairments, which compromise their capacity to shop for, prepare, and eat a healthy, balanced diet [5] , especially when they live alone and have financial difficulties."
Food in aged care homes is rarely the same as the person is accustomed to.
"Over restrictive eating patterns, either self-imposed or provider-directed can contribute additional nutritional risks for older people."
Several specific nutrition assessment tools designed for older adults are available and can identify older people at risk.
"For example, the Mini Nutritional Assessment (MNA) and helps determine whether referral to a dietitian is needed [5]."
"Other tools include the Malnutrition Universal Screening Tool (MUST), the Simplified Nutritional Assessment Questionnaire (SNAQ), Subjective Global Assessment (SGA), and the Patient-Generated SGA (PG-SGA) [47]."
"Sometimes it is easier to assess malnutrition by measuring the mid-arm circumference, especially in frail older people."
"Biochemical assessment may include electrolytes, serum transferrin, albumin, prealbumin, thyroid function tests, cholesterol, iron, vitamin B12, folate, and vitamin D."
Hydration status can be assessed using the Hydration Assessment Checklist.
Even mild dehydration can contribute to cognitive changes.
"In addition, a medicine review may be required because some medicines affect vitamin B12 absorption (e.g. digitalis, metformin, and sedatives)."
Alcohol also affects the absorption of vitamin B12.
Supplementary vitamins and minerals may be needed.
"Likewise, antihypertensive medications such as angiotensin converting enzyme (ACE)-inhibitors, angiotensin 2 receptor antagonists (ARB), and thiazide diuretics may cause a diverse range of disturbances in electrolyte homeostasis [51]."
Food-medicine interactions should be considered as part of the structured medicine review.
"When nutritional needs are not met by the person's usual food intake, the following strategies might help: encourage smaller more frequent meals, fortify usual foods, change food texture, or include liquid nutrition supplements between meals [5,52]."
Some older people are overweight or obese.
However the body mass index (BMI) is not an accurate predictor of the degree of adiposity in older people due to age related changes in body composition [53].
Obesity exacerbates the age related decline in physical function and increases the risk of frailty [54].
Intentional weight loss in overweight and obese older people can worsen bone mineral density and nutritional deficits [55].
Strategies that combine physical activity with nutritional therapy to promote weight loss may result in improved physical performance and function and reduced cardio-metabolic risk in older adults [54].
"Age-related changes in the immune system increase the susceptibility of older people to bacterial and viral infections, and this is exacerbated by medical comorbidities such as diabetes, renal impairment, and multiple drug therapies."
"Although immune responses to antigens can be impaired with advancing age, all people in high-risk groups such as those with diabetes are recommended to receive a seasonal influenza vaccination as this has been associated with a reduction in complications, hospitalizations, and death [56]."
"In older people with diabetes, this may also be associated with reduced admissions to intensive care units and reduced hospitalization costs [57]."
"Exercise should be an integral component of the management of diabetes in older people and can be associated with benefits relating to mobility, balance, reduced falls risk, psycho-social benefits, and enhancing quality of life."
"Muscle mass and muscle strength decline with age and may be exacerbated by diabetes complications, other comorbidities, and periods of hospitalization."
People with diabetes of longer duration and those with higher HbA1c levels have lower muscle strength per unit of muscle mass than BMI and age matched people without diabetes and people with shorter duration of diabetes or who have better glycaemic control [58].
"Although age and diabetes both reduce fitness and strength, physical activity improves functional status in older adults with and without diabetes [59]."
Even light intensity physical activity is associated with higher self-rated physical health and psychosocial well-being [60].
"Ways of facilitating increased physical activity and fitness include healthcare professional recommendation and encouragement, and referral to community supervised walking schemes, and community-based group exercise and fitness programmes where these are available."
Falls are a leading cause of morbidity and mortality in older people and associated disability and declined quality of life are one of the greatest challenges facing the frail older population.
"Older people with diabetes are at high risk of falls, recurrent falls, and fractures [278-280]."
"Risks factors for falls in older persons with diabetes include polypharmacy, muscle weakness, previous stroke, motor and sensory neuropathy, poor glycaemic control, hypoglycaemia, insulin use, cognitive dysfunction, orthostatic hypotension, and visual impairment [281-283]."
"Lower HbA1c (< 7.0% / 53 mmol/mol) has been associated with higher risk of falls frail elderly people [284] and hip fracture [285], especially in those treated with insulin [282]."
Measurement of gait velocity and ankle muscle strength have been used to identify people at risk of falling [286].
"Many studies using gait, balance, and strength training have shown reduced risk of falls for people with diabetes [287-300]."
Pain is common and often undetected in older people and older people are at increased risk of pain and the pain is often chronic.
People in pain are at increased risk of falling and other adverse events.
People with diabetes are at increased risk of all types of pain including ‘silent pain’ from myocardial infarction and urinary tract infections.
Pain is often under-reported and under-treated in many older people with diabetes and is particularly prevalent in people with long duration of diabetes.
"Changes in body language, grimacing, restlessness, increased wandering, crying out, groaning, hypertension, tachycardia, and rapid shallow breathing may be indications of pain."
"Pain can be acute, chronic, or intermittent."
"Managing pain in older people is a key aspect of the national strategies for all healthcare settings [22,291]."
"Pain is defined as ‘a subjective, unpleasant sensory, and emotional experience of actual or potential tissue damage’ [292,293]."
Pain is always subjective.
It is important to distinguish between acute and chronic pain.
"Chronic and recurrent pain is often associated with depression and affects quality of life and social, psychological, and physical functioning, with implications for self-care and independence."
"Significantly, older people often under-report or do not report the sensory and affective components of pain and attribute pain to other things including age [294]."
Some people deny pain out fear (e.g. having to go into hospital) and some do not disclose their pain because healthcare professionals do not ask about it.
Consequently even serious problems (e.g. silent myocardial infarction and peritonitis) may not be recognized or reported [294].
Assessment of pain is not straightforward but a number of key instruments have been designed to bring objectivity to this area (Table 3).
More than 20% of people over 65 years experience persistent pain which affects their quality of life [295].
Pain becomes more prevalent with increasing age: 30% of women aged 80-84 years have pain and 80% of these are under-treated.
"Peripheral neuropathy occurs in up to 50% of people with long duration of diabetes and is associated with increased morbidity and mortality [296,297] and is often not reported."
"Significantly, 80% of older people who do report pain have moderate to severe pain and lower quality of life [298]."
A recent study in aged care home residents found 23% with documented pain did not have scheduled analgesia prescribed and those with cognitive impairment were less likely to receive analgesia [299].
"Recently, changes in brain grey matter density and cortical thickness have been linked to chronic pain [300] but the clinical significance of the finding is unclear."
Pain is costly and the costs are expected to increase throughout most of the world.
Pain management is a fundamental human right [301].
In addition it represents a significant caregiver burden that is difficult to quantify.
"Pain may present atypically [302,303]."
"Physical consequences of pain include: Respiratory changes e.g. unable to take a deep breath or cough which increase the risk of chest infection and delays recovery; Increased cardiovascular sympathetic activity which can lead to hypertension, tachycardia, and myocardial ischaemia especially if the person has pre-existing CVD and can increase the risk of venous stasis and pressure ulcers; Gastrointestinal pain can affect gastric emptying and intestinal motility, lead to erratic blood glucose levels, nausea, vomiting, and constipation; Depression, sleep deprivation, and worry [303,304]."
"It is important to appropriately classify pain (e.g. acute, chronic, postoperative) to adequately manage it and reduce the associated risks such as falls and behavioural changes."
Managing pain reduces behavioural problems and agitation and enables antipsychotic medicine doses to be reduced or de-prescribed [305].
Management must be tailored to the individual and consists of non-medicines as well as medicines or a combination of both.
A nutritious diet to avoid nutritional deficiencies that contribute to pain and keeping active to avoid muscle wasting are important management strategies.
"Non-medicine options often enable lower medication doses to be used and options include cognitive behavioural therapy, relaxation therapies, mediation, transcutaneous electrical nerve stimulation (TENS), heat/cold, exercise, hydrotherapy, massage, acupuncture, and complementary and alternative medicines (e.g. glucosamine) [22,293]."
Pain management is different in older people.
It consists of paying meticulous attention to detail and undertaking thorough and regular pain assessments [294].
The 1990 WHO analgesic ladder is a useful decision aid as are the Beer’s criteria [114].
"Generally, commence with mild analgesics such as paracetamol and non-medicine options."
Non-steroidal anti-inflammatory medications can be useful for inflammatory pain but older people are sensitive to this class of medicines.
Mild opioids such as codeine and tramadol can be used depending on the type of pain or a combination of medicines.
Strong opioids may be needed at the end of life to promote comfort [306].
"Tricyclic antidepressants are often used for neuropathic pain but can cause dry mouth, confusion, postural hypotension, urine retention, and exacerbate or cause glaucoma, especially in frail older people."
"Likewise, antiepileptic medicines are effective for neurological pain, but older people may have unpredictable responses."
"Common side-effects are gastrointestinal tract bleeding, fluid retention, hypertension, and interact with diuretic blood pressure effects of frusemide and thiazide diuretics [306]."
Some older people benefit from lipoic acid 600mg four times per day but the evidence is not strong [307].
Local analgesics such a lidocaine patches and corticosteroids may be useful.
"The latter cause muscle wasting and hyperglycaemia, which might outweigh benefits."