4. Lifestyle Management:Standards of Medical Care inDiabetesd2018Diabetes Care 2018;41(Suppl. 1):S38–S50 | https://doi.org/10.2337/dc18-S004

The American Diabetes Association (ADA) “Standards of Medical Care in Diabetes”includes ADA’s current clinical practice recommendations and is intended to providethe components of diabetes care, general treatment goals and guidelines, and toolsto evaluate quality of care. Members of the ADA Professional Practice Committee, amultidisciplinary expert committee, are responsible for updating the Standards ofCare annually, or more frequently as warranted. For a detailed description of ADAstandards, statements, and reports, aswell as the evidence-grading system forADA’sclinical practice recommendations, please refer to theStandardsofCare Introduction.Readers who wish to comment on the Standards of Care are invited to do so atprofessional.diabetes.org/SOC.

Lifestyle management is a fundamental aspect of diabetes care and includesdiabetes self-management education and support (DSMES), medical nutritiontherapy (MNT), physical activity, smoking cessation counseling, and psychosocialcare. Patients and care providers should focus together on how to optimizelifestyle from the time of the initial comprehensive medical evaluation, through-out all subsequent evaluations and follow-up, and during the assessment ofcomplications and management of comorbid conditions in order to enhance di-abetes care.

DIABETES SELF-MANAGEMENT EDUCATION AND SUPPORT

Recommendations

c In accordance with the national standards for diabetes self-management edu-cation and support, all people with diabetes should participate in diabetes self-management education to facilitate the knowledge, skills, and ability necessaryfor diabetes self-care and in diabetes self-management support to assist withimplementing and sustaining skills and behaviors needed for ongoing self-management. B

c There are four critical times to evaluate the need for diabetes self-managementeducation and support: at diagnosis, annually, when complicating factors arise,and when transitions in care occur. E

c Facilitating appropriate diabetes self-management and improving clinicaloutcomes, health status, and quality of life are key goals of diabetes self-management education and support to be measured and monitored as partof routine care. C

c Effective diabetes self-management education and support should be patientcentered, may be given in group or individual settings or using technology, andshould help guide clinical decisions. A

c Because diabetes self-management education and support can improve out-comes and reduce costs B, adequate reimbursement by third-party payers isrecommended. E

Suggested citation: American Diabetes Associa-tion. 4. Lifestyle management: Standards ofMedical Care in Diabetesd2018. Diabetes Care2018;41(Suppl. 1):S38–S50

© 2017 by the American Diabetes Association.Readers may use this article as long as the workis properly cited, the use is educational and notfor profit, and the work is not altered. More infor-mation is available at http://www.diabetesjournals.org/content/license.

American Diabetes Association

S38 Diabetes Care Volume 41, Supplement 1, January 2018

4.LIFESTYLE

MANAGEM

ENT

DSMES services facilitate the knowledge,skills, and abilities necessary for optimal di-abetes self-care and incorporate the needs,goals, and life experiences of the personwith diabetes. The overall objectives ofDSMES are to support informed decision-making, self-care behaviors, problem solv-ing, and active collaborationwith the healthcare team to improve clinical outcomes,health status, and quality of life in a cost-effectivemanner (1). Providers are encour-aged to consider the burden of treatmentand the patient’s level of confidence/self-efficacy formanagement behaviors aswellas the level of social and family supportwhen providing DSMES. In addition, in re-sponse to the growing literature that as-sociates potentially judgmental words toincreased feelings of shame and guilt,providers are encouraged to considerthe impact that language has on buildingtherapeutic relationships and to choosepositive, strength-basedwords and phrasesthat put people first (2). Patient perfor-mance of self-management behaviors aswell as psychosocial factors impacting theperson’s self-management should bemonitored.DSMES and the current national stan-

dards guiding it (1,3) are based on evi-dence of benefit. Specifically, DSMEShelps people with diabetes to identifyand implement effective self-managementstrategies and cope with diabetes at thefour critical time points (described below)(1). OngoingDSMEShelpspeoplewithdiabe-tes to maintain effective self-managementthroughout a lifetime of diabetes as theyfacenewchallengesandasadvances in treat-ment become available (4).Four critical time points have been de-

fined when the need for DSMES is to beevaluated by the medical care providerand/or multidisciplinary team, with refer-rals made as needed (1):

1. At diagnosis2. Annually for assessment of education,

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

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

4. When transitions in care occur

DSMES focuses on supporting patient em-powerment by providing people withdiabetes the tools to make informed self-management decisions (5). Diabetes carehas shifted to an approach that places the

person with diabetes and his or her familyat the center of the caremodel, working incollaborationwith health care professionals.Patient-centered care is respectful of andresponsive to individual patientpreferences,needs, and values. It ensures that patientvalues guide all decision making (6).

Evidence for the BenefitsStudies have found that DSMES is associ-ated with improved diabetes knowledgeand self-care behaviors (7), lower A1C (6,8–10), lower self-reportedweight (11,12),improved quality of life (9,13), reducedall-cause mortality risk (14), healthy cop-ing (15,16), and reduced health care costs(17–19). Better outcomes were reportedfor DSMES interventions that were over10 h in total duration (10), included ongo-ing support (4,20), were culturally (21,22)and ageappropriate (23,24),were tailoredto individual needs and preferences, andaddressed psychosocial issues and incor-porated behavioral strategies (5,15,25,26). Individual and group approachesare effective (12,27), with a slight benefitrealized by those who engage in both (10).Emerging evidence demonstrates the ben-efit of Internet-based DSMES services fordiabetes prevention and the managementof type 2 diabetes (28–30). Technology-enabled diabetes self-management so-lutions improve A1C most effectively whenthere is two-way communication betweenthe patient and the health care team, indivi-dualized feedback,useofpatient-generatedhealth data, and education (30). There isgrowing evidence for the role of commu-nity health workers (31), as well as peer(31–33) and lay leaders (34), in providingongoing support.

DSMES is associated with an increaseduse of primary care and preventive ser-vices (17,35,36) and less frequent use ofacute care and inpatient hospital services(11). Patients who participate in DSMESare more likely to follow best practicetreatment recommendations, particularlyamong the Medicare population, andhave lowerMedicare and insurance claimcosts (18,35). Despite these benefits, re-ports indicate that only 5–7% of individu-als eligible for DSMES through Medicareor a private insurance plan actually receiveit (37,38). This low participation may bedue to lack of referral or other identifiedbarriers such as logistical issues (timing,costs) and the lack of a perceived benefit(39). Thus, in addition to educating refer-ring providers about the benefits of

DSMES and the critical times to refer(1), alternative and innovative models ofDSMES delivery need to be explored andevaluated.

ReimbursementMedicare reimburses DSMES when thatservice meets the national standards (7)and is recognized by the American Diabe-tes Association (ADA) or other approvalbodies. DSMES is also covered by mosthealth insurance plans. Ongoing supporthas been shown to be instrumental forimproving outcomes when it is imple-mented after the completion of educationservices. DSMES is frequently reimbursedwhen performed in person. However, al-though DSMES can also be provided viaphone calls and telehealth, these remoteversions may not always be reimbursed.Changes in reimbursement policies thatincrease DSMES access and utilizationwill result in a positive impact to benefi-ciaries’ clinical outcomes, quality of life,health care utilization, and costs (40).

NUTRITION THERAPY

For many individuals with diabetes, themost challenging part of the treatmentplan is determining what to eat and follow-ing a meal plan. There is not a one-size-fits-alleatingpattern for individualswithdiabetes,and meal planning should be individualized.Nutrition therapy has an integral role inoverall diabetes management, and eachpersonwith diabetes should be actively en-gaged in education, self-management, andtreatment planning with his or her healthcare team, including the collaborative de-velopment of an individualized eatingplan (41,42). All individuals with diabetesshould be offered a referral for individu-alized MNT, preferably provided by a reg-istered dietitian who is knowledgeableand skilled in providing diabetes-specificMNT. MNT delivered by a registered di-etitian is associated with A1C decreasesof 1.0–1.9% for people with type 1 diabe-tes (43–46) and 0.3–2% for people withtype 2 diabetes (46–50). See Table 4.1 forspecific nutrition recommendations.

For complete discussion and references,see the ADAposition statement “NutritionTherapy Recommendations for the Man-agement of Adults With Diabetes” (42).

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

ing patterns, emphasizing a variety ofnutrient-dense foods in appropriate

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Table 4.1—MNT recommendations

Topic Recommendations Evidence rating

Effectiveness of nutrition therapy c An individualizedMNT program, preferably provided by a registered dietitian, isrecommended for all people with type 1 or type 2 diabetes or gestationaldiabetes mellitus.

A

c A simple and effective approach to glycemia and weight managementemphasizing portion control and healthy food choices may be considered forthose with type 2 diabetes who are not taking insulin, who have limited healthliteracy or numeracy, or who are older and prone to hypoglycemia.

B

c Because diabetes nutrition therapy can result in cost savings B and improvedoutcomes (e.g., A1C reduction) A, MNT should be adequately reimbursed byinsurance and other payers. E

B, A, E

Energy balance c Weight loss (.5%) achievable by the combination of reduction of calorie intakeand lifestyle modification benefits overweight or obese adults with type 2diabetes and also those with prediabetes. Intervention programs to facilitateweight loss are recommended.

A

Eating patterns and macronutrient distribution c There is no single ideal dietary distribution of calories among carbohydrates,fats, and proteins for peoplewith diabetes; therefore,macronutrient distributionshould be individualized while keeping total calorie andmetabolic goals in mind.

E

c A variety of eating patterns are acceptable for the management of type 2diabetes and prediabetes.

B

Carbohydrates c Carbohydrate intake from vegetables, fruits, legumes, whole grains, and dairyproducts, with an emphasis on foods higher in fiber and lower in glycemic load,is preferred over other sources, especially those containing added sugars.

B

c For people with type 1 diabetes and those with type 2 diabetes who areprescribed a flexible insulin therapy program, education on how to usecarbohydrate counting and in some cases fat and protein gram estimation todetermine mealtime insulin dosing is recommended to improve glycemiccontrol.

A

c For individuals whose daily insulin dosing is fixed, a consistent pattern ofcarbohydrate intakewith respect to time and amountmay be recommended toimprove glycemic control and reduce the risk of hypoglycemia.

B

c Peoplewith diabetes and those at risk should avoid sugar-sweetened beveragesin order to control weight and reduce their risk for CVD and fatty liver B andshould minimize the consumption of foods with added sugar that have thecapacity to displace healthier, more nutrient-dense food choices. A

B, A

Protein c In individuals with type 2 diabetes, ingested protein appears to increase insulinresponse without increasing plasma glucose concentrations. Therefore,carbohydrate sources high in protein should be avoided when trying to treat orprevent hypoglycemia.

B

Dietary fat c Data on the ideal total dietary fat content for people with diabetes areinconclusive, so an eating plan emphasizing elements of a Mediterranean-stylediet rich in monounsaturated and polyunsaturated fats may be considered toimprove glucose metabolism and lower CVD risk and can be an effectivealternative to a diet low in total fat but relatively high in carbohydrates.

B

c Eating foods rich in long-chain n-3 fatty acids, such as fatty fish (EPA and DHA)and nuts and seeds (ALA), is recommended to prevent or treat CVD B; however,evidence does not support a beneficial role for the routine use of n-3 dietarysupplements. A

B, A

Micronutrients and herbal supplements c There is no clear evidence that dietary supplementationwith vitamins,minerals,herbs, or spices can improve outcomes in peoplewith diabeteswho donot haveunderlying deficiencies, and are not generally recommended. There may besafety concerns regarding the long-termuse of antioxidant supplements such asvitamins E and C and carotene.

C

Alcohol c Adults with diabetes who drink alcohol should do so in moderation (no morethanone drink per day for adultwomenand nomore than twodrinks per day foradult men).

C

c Alcohol consumption may place people with diabetes at increased risk forhypoglycemia, especially if taking insulin or insulin secretagogues. Educationand awareness regarding the recognition and management of delayedhypoglycemia are warranted.

B

Sodium c As for the general population, people with diabetes should limit sodiumconsumption to,2,300 mg/day, although further restriction may be indicatedfor those with both diabetes and hypertension.

B

Continued on p. S41

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portion sizes, to improve overallhealth and:○ Achieve and maintain body weight

goals○ Attain individualized glycemic,

blood pressure, and lipid goals○ Delay or prevent the complications

of diabetes2. To address individual nutrition needs

based on personal and cultural prefer-ences, health literacy and numeracy,access to healthful foods, willingnessandability tomakebehavioral changes,and barriers to change

3. To maintain the pleasure of eating byproviding nonjudgmental messagesabout food choices

4. To provide an individual with diabetesthe practical tools for developinghealthy eating patterns rather than fo-cusing on individual macronutrients,micronutrients, or single foods

Eating Patterns, MacronutrientDistribution, and Meal PlanningEvidence suggests that there is not an idealpercentage of calories from carbohydrate,protein, and fat for all people with diabe-tes. Therefore, macronutrient distributionshould be based on an individualized as-sessment of current eating patterns, pref-erences, and metabolic goals. Considerpersonal preferences (e.g., tradition, cul-ture, religion, health beliefs and goals, eco-nomics) as well as metabolic goals whenworking with individuals to determine thebest eating pattern for them (42,51). It isimportant that each member of thehealth care team be knowledgeableabout nutrition therapy principles forpeople with all types of diabetes andbe supportive of their implementation.Emphasis should be on healthful eat-ing patterns containing nutrient-densefoods with less focus on specific nutrients(52). A variety of eating patterns areacceptable for the management ofdiabetes (51,53). The Mediterranean(54,55), Dietary Approaches to Stop Hyper-tension (DASH) (56–58), and plant-baseddiets (59,60) are all examples of healthful

eating patterns that have shown positiveresults in research, but individualizedmeal planning should focus on personalpreferences, needs, and goals.

The diabetes plate method is com-monly used for providing basicmeal plan-ning guidance (61) as it provides a visualguide showing how to control calories (byfeaturing a smaller plate) and carbohy-drates (by limiting them to what fits inone-quarter of the plate) and puts an em-phasis on low-carbohydrate (or non-starchy) vegetables.

Weight ManagementManagement and reduction of weight isimportant for overweight and obese peo-ple with type 1 and type 2 diabetes. Life-style intervention programs should beintensive and have frequent follow-up toachieve significant reductions in excessbody weight and improve clinical indica-tors. There is strong and consistent evi-dence that modest persistent weight losscandelay theprogression fromprediabetesto type 2 diabetes (51,62,63) (see Section5 “PreventionorDelay of Type 2Diabetes”)and is beneficial to the management oftype 2 diabetes (see Section 7 “ObesityManagement for the Treatment of Type 2Diabetes”).

Studies of reduced calorie interventionsshow reductions in A1C of 0.3% to 2.0% inadults with type 2 diabetes, as well as im-provements inmedicationdoses andqualityof life (51). Sustaining weight loss can bechallenging (64) but has long-term bene-fits; maintaining weight loss for 5 years isassociated with sustained improvementsin A1C and lipid levels (65). Weight losscan be attained with lifestyle programsthat achieve a 500–750 kcal/day energydeficit or provide;1,200–1,500 kcal/dayfor women and 1,500–1,800 kcal/day formen, adjusted for the individual’s base-line body weight. For many obese indi-viduals with type 2 diabetes, weightloss.5% is needed to produce beneficialoutcomes in glycemic control, lipids, andblood pressure, and sustainedweight lossof$7% is optimal (64).

The meal plans often used in intensivelifestyle management for weight loss maydiffer in the types of foods they restrict(e.g., high-fat vs. high-carbohydrate foods),but their emphasis should be on nutrient-dense foods, such as vegetables, fruits,legumes, low-fat dairy, lean meats, nuts,seeds, andwhole grains, as well as on achiev-ing the desired energy deficit (66–69). Theapproach to meal planning should be basedonthepatients’ healthstatusandpreferences.

CarbohydratesStudies examining the ideal amount ofcarbohydrate intake for people with dia-betes are inconclusive, althoughmonitor-ing carbohydrate intake and consideringthe blood glucose response to dietary car-bohydratearekey for improvingpostprandialglucose control (70,71). The literature con-cerning glycemic index and glycemic loadin individuals with diabetes is complexoften yielding mixed results, though insome studies lowering the glycemic loadof consumed carbohydrates has demon-strated A1C reductions of –0.2% to –0.5%(72,73). Studies longer than 12 weeks re-port no significant influence of glycemicindex or glycemic load independent ofweight loss on A1C; however, mixed re-sults have been reported for fasting glu-cose levels and endogenous insulin levels.

The role of low-carbohydrate diets in pa-tients with diabetes remains unclear (72).Partof theconfusion isdue to thewide rangeof definitions for a low-carbohydrate diet(73,74).Whilebenefits to low-carbohydratediets have been described, improvementstend to be in the short term and, overtime, these effects are not maintained(74–77). While some studies have shownmodest benefits of very low–carbohydrateor ketogenic diets (less than 50-g carbo-hydrate per day) (78,79), this approachmay only be appropriate for short-termimplementation (up to 3–4months) if de-sired by the patient, as there is little long-term research citing benefits or harm.

Most individuals with diabetes report amoderate intake of carbohydrate (44–46%of total calories) (51). Efforts to modify

Table 4.1—Continued

Topic Recommendations Evidence rating

Nonnutritive sweeteners c The use of nonnutritive sweeteners may have the potential to reduce overallcalorie and carbohydrate intake if substituted for caloric (sugar) sweeteners andwithout compensation by intake of additional calories from other food sources.Nonnutritive sweeteners are generally safe to usewithin the defined acceptabledaily intake levels.

B

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habitual eating patterns are often unsuc-cessful in the long term; people generallygo back to their usual macronutrient dis-tribution (51). Thus, the recommendedapproach is to individualize meal plansto meet caloric goals with a macronutri-ent distribution that is more consistentwith the individual’s usual intake toincrease the likelihood for long-termmaintenance.As for all Americans, both children and

adults with diabetes are encouraged toreduce intake of refined carbohydratesand added sugars and instead focuson carbohydrates from vegetables, le-gumes, fruits, dairy (milk and yogurt),and whole grains. The consumption ofsugar-sweetened beverages and pro-cessed “low-fat” or “nonfat” food prod-ucts with high amounts of refined grainsand added sugars is strongly discouraged(80–82).Individuals with type 1 or type 2 diabe-

tes taking insulin at mealtime should beoffered intensive and ongoing educationon the need to couple insulin administra-tion with carbohydrate intake. For peoplewhose meal schedules or carbohydrateconsumption is variable, regular counsel-ing to help them understand the com-plex relationship between carbohydrateintake and insulin needs is important. Inaddition, education on using the insulin-to-carbohydrate ratios for meal planning canassist them with effectively modifying insu-lin dosing from meal to meal and improv-ing glycemic control (44,51,70,83–85).Individuals who consume meals con-taining more protein and fat than usualmay also need to make mealtime insulindose adjustments to compensate for de-layed postprandial glycemic excursions(86–88). For individuals on a fixed dailyinsulin schedule, meal planning shouldemphasize a relatively fixed carbohy-drate consumption pattern with respectto both time and amount (42). By con-trast, a simpler diabetes meal planningapproach emphasizing portion controland healthful food choices may be bet-ter suited for some older individuals,those with cognitive dysfunction, andthose for whom there are concernsover health literacy and numeracy(42–44,47,70,83). The modified platemethod (which uses measuring cups toassist with portion measurement) maybe aneffective alternative to carbohydratecounting for some patients to improveglycemia (61).

ProteinThere is no evidence that adjusting thedaily level of protein intake (typically 1–1.5 g/kg bodyweight/day or 15–20% totalcalories) will improve health in individualswithout diabetic kidney disease, and re-search is inconclusive regarding the idealamount of dietary protein to optimize ei-ther glycemic control or cardiovasculardisease (CVD) risk (72). Therefore, proteinintake goals should be individualizedbased on current eating patterns. Someresearch has found successful manage-ment of type 2 diabetes with meal plansincluding slightly higher levels of protein(20–30%), which may contribute to in-creased satiety (57).

For those with diabetic kidney disease(with albuminuria and/or reduced esti-mated glomerular filtration rate), dietaryprotein should be maintained at the rec-ommended daily allowance of 0.8 g/kgbody weight/day. Reducing the amountofdietaryproteinbelow the recommendeddaily allowance is not recommended be-cause it does not alter glycemic measures,cardiovascular risk measures, or the rate atwhich glomerular filtration rate declines(89,90).

In individuals with type 2 diabetes, pro-tein intake may enhance or increase theinsulin response to dietary carbohydrates(91). Therefore, carbohydrate sourceshigh in protein should not beused to treator prevent hypoglycemia due to the po-tential concurrent rise in endogenousinsulin.

FatsThe ideal amount of dietary fat for indi-viduals with diabetes is controversial. TheNational Academy of Medicine has de-fined an acceptable macronutrient distri-bution for total fat for all adults to be20–35% of total calorie intake (92). Thetype of fats consumed is more importantthan total amount of fat when looking atmetabolic goals and CVD risk, and it isrecommended that the percentage of to-tal calories from saturated fats should belimited (93–97).Multiple randomized con-trolled trials including patients with type 2diabeteshavereportedthataMediterranean-style eating pattern (93,98–103), rich inpolyunsaturated and monounsaturatedfats, can improve both glycemic controland blood lipids. However, supplementsdo not seem to have the same effects astheir whole food counterparts. A systematicreview concluded that dietary supplements

withn-3 fatty acids didnot improveglycemiccontrol in individuals with type 2 diabetes(72). Randomized controlled trials also donot support recommending n-3 supple-ments forprimaryor secondarypreventionof CVD (104–108). People with diabetesshould be advised to follow the guidelinesfor the general population for the recom-mended intakes of saturated fat, dietarycholesterol, and trans fat (94). In general,trans fats should be avoided. In addition,as saturated fats are progressively de-creased in the diet, they should be re-placed with unsaturated fats and notwith refined carbohydrates (102).

SodiumAs for the general population, peoplewithdiabetes are advised to limit their sodiumconsumption to,2,300mg/day (42). Low-ering sodium intake (i.e., 1,500 mg/day)may improve blood pressure in certaincircumstances (109,110). However, otherstudies (111,112) suggest caution for uni-versal sodium restriction to 1,500 mg inpeople with diabetes. Sodium intake rec-ommendations should take into accountpalatability, availability, affordability, andthe difficulty of achieving low-sodium rec-ommendations in a nutritionally adequatediet (113).

Micronutrients and SupplementsThere continues to be no clear evidenceof benefit from herbal or nonherbal (i.e.,vitamin or mineral) supplementation forpeople with diabetes without underlyingdeficiencies (42). Metformin is associatedwith vitamin B12 deficiency, with a recentreport from the Diabetes Prevention Pro-gram Outcomes Study (DPPOS) suggest-ing that periodic testing of vitamin B12levels should be considered in patientstaking metformin, particularly in thosewith anemia or peripheral neuropathy(114). Routine supplementation with an-tioxidants, such as vitamins E and C andcarotene, is not advised due to lack ofevidence of efficacy and concern relatedto long-term safety. In addition, there isinsufficient evidence to support the rou-tine use of herbals and micronutrients,such as cinnamon (115) and vitamin D(116), to improve glycemic control in peo-ple with diabetes (42,117).

AlcoholModerate alcohol intake does not havemajor detrimental effects on long-termblood glucose control in people with

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diabetes. Risks associated with alcoholconsumption include hypoglycemia (par-ticularly for those using insulin or insulinsecretagogue therapies), weight gain, andhyperglycemia (for those consuming ex-cessive amounts) (42,117). People withdiabetes can follow the same guidelinesas those without diabetes if they chooseto drink. For women, no more than onedrink per day; for men, nomore than twodrinks per day is recommended (one drinkis equal to a 12-oz beer, 5-oz glass of wine,or 1.5-oz distilled spirits).

Nonnutritive SweetenersFor some people with diabetes who areaccustomed to sugar-sweetened prod-ucts, nonnutritive sweeteners (containingfew or no calories) may be an acceptablesubstitute for nutritive sweeteners (thosecontaining calories such as sugar, honey,agave syrup) when consumed in moder-ation.Whileuseofnonnutritive sweetenersdoes not appear to have a significant effecton glycemic control (118), they can reduceoverall calorie and carbohydrate intake(51). Most systematic reviews and meta-analyses show benefits for nonnutritivesweetener use in weight loss (119,120);however, some research suggests an as-sociation with weight gain (121). Reg-ulatory agencies set acceptable dailyintake levels for each nonnutritive sweet-ener, defined as the amount that can besafely consumed over a person’s lifetime(42,110).

PHYSICAL ACTIVITY

Recommendations

c Children and adolescents withtype 1 or type 2 diabetes or predi-abetes should engage in 60min/dayor more of moderate- or vigorous-intensity aerobic activity, with vig-orous muscle-strengthening andbone-strengthening activities atleast 3 days/week. C

c Most adults with type 1 C andtype 2 B diabetes should engage in150 min or more of moderate-to-vigorous intensity aerobic activityper week, spread over at least3 days/week, with no more than2 consecutive days without activity.Shorter durations (minimum75min/week) of vigorous-intensity or inter-val training may be sufficientfor younger and more physically fitindividuals.

c Adults with type 1 C and type 2 Bdiabetes should engage in 2–3sessions/week of resistance exer-cise on nonconsecutive days.

c All adults, and particularly thosewith type 2 diabetes, should de-crease the amount of time spentin daily sedentary behavior. B Pro-longed sitting should be interruptedevery 30min for blood glucose ben-efits, particularly in adults withtype 2 diabetes. C

c Flexibility training and balancetraining are recommended 2–3times/week for older adults withdiabetes. Yoga and tai chi may beincluded based on individual prefer-ences to increase flexibility, muscu-lar strength, and balance. C

Physical activity is a general term thatincludes all movement that increasesenergy use and is an important part ofthe diabetesmanagement plan. Exerciseis a more specific form of physical activ-ity that is structured and designed toimprove physical fitness. Both physicalactivity and exercise are important. Ex-ercise has been shown to improve bloodglucose control, reduce cardiovascularrisk factors, contribute to weight loss,and improve well-being. Physical activ-ity is as important for those with type 1diabetes as it is for the general popula-tion, but its specific role in the preven-tion of diabetes complications and themanagement of blood glucose is notas clear as it is for those with type 2diabetes.

Structured exercise interventions of atleast 8 weeks’ duration have been shownto lower A1C by an average of 0.66% inpeople with type 2 diabetes, even with-out a significant change in BMI (122).There are also considerable data for thehealth benefits (e.g., increased cardiovas-cular fitness, greater muscle strength, im-proved insulin sensitivity, etc.) of regularexercise for those with type 1 diabetes(123). Higher levels of exercise intensityare associated with greater improve-ments in A1C and in fitness (124). Otherbenefits include slowing the decline inmobility among overweight patientswith diabetes (125). The ADA positionstatement “Physical Activity/Exerciseand Diabetes” reviews the evidence forthe benefits of exercise in people withdiabetes (126).

Exercise and Children

All children, including childrenwith diabe-tes or prediabetes, should be encouragedto engage in regular physical activity. Chil-dren should engage in at least 60 min ofmoderate-to-vigorousaerobic activityeveryday with muscle- and bone-strengtheningactivities for at least 3 days per week (127).In general, youth with type 1 diabetesbenefit from being physically active, andan active lifestyle should be recom-mended to all (128).

Frequency and Type of PhysicalActivityPeople with diabetes should perform aer-obic and resistance exercise regularly(126). Aerobic activity bouts should ide-ally last at least 10 min, with the goal of;30 min/day or more, most days of theweek for adults with type 2 diabetes.Daily exercise, or at least not allowingmore than 2 days to elapse between ex-ercise sessions, is recommended to de-crease insulin resistance, regardless ofdiabetes type (129,130). Over time, activ-ities shouldprogress in intensity, frequency,and/or duration to at least 150 min/weekof moderate-intensity exercise. Adults ableto run at 6 miles/h (9.7 km/h) for at least25mincanbenefit sufficiently fromshorter-duration vigorous-intensity activity (75min/week). Many adults, including most withtype 2 diabetes, would be unable or unwill-ing to participate in such intense exerciseand should engage inmoderate exercise forthe recommended duration. Adults withdiabetes should engage in 223 sessions/week of resistance exercise on noncon-secutive days (131). Although heavier re-sistance training with free weights andweight machines may improve glycemiccontrol and strength (132), resistancetraining of any intensity is recommendedto improve strength, balance, and theability to engage in activities of daily livingthroughout the life span.

Recent evidence supports that all indi-viduals, including those with diabetes,should be encouraged to reduce theamount of time spent being sedentary(e.g., working at a computer, watchingTV) by breaking up bouts of sedentaryactivity (.30 min) by briefly standing,walking, or performing other light physi-cal activities (133,134). Avoiding ex-tended sedentary periods may helpprevent type 2 diabetes for those at riskand may also aid in glycemic control forthose with diabetes.

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Physical Activity and Glycemic ControlClinical trials have provided strong evi-dence for the A1C-lowering value of re-sistance training in older adults withtype 2 diabetes (135) and for an additivebenefit of combined aerobic and resis-tance exercise in adults with type 2 diabe-tes (136). If not contraindicated, patientswith type 2 diabetes should be encour-aged to do at least two weekly sessionsof resistance exercise (exercise with freeweights or weight machines), with eachsession consisting of at least one set(group of consecutive repetitive exercisemotions) of five or more different resis-tance exercises involving the largemusclegroups (135).For type 1 diabetes, although exercise

in general is associated with improve-ment in disease status, care needs to betaken in titrating exercise with respect toglycemic management. Each individualwith type 1 diabetes has a variable glyce-mic response to exercise. This variabilityshould be taken into consideration whenrecommending the type and duration ofexercise for a given individual (123).Womenwith preexisting diabetes, par-

ticularly type 2 diabetes, and those at riskfor or presenting with gestational diabetesmellitus should be advised to engage in reg-ular moderate physical activity prior to andduring their pregnancies as tolerated (126).

Pre-exercise EvaluationAs discussed more fully in Section 9“Cardiovascular Disease and Risk Man-agement,” the best protocol for assessingasymptomatic patients with diabetes forcoronary artery disease remains unclear.The ADA consensus report “Screening forCoronary Artery Disease in Patients WithDiabetes” (137) concluded that routinetesting is not recommended. However,providers should perform a careful his-tory, assess cardiovascular risk factors,and be aware of the atypical presentationof coronary artery disease in patientswithdiabetes. Certainly, high-risk patientsshould be encouraged to start with shortperiods of low-intensity exercise andslowly increase the intensity and durationas tolerated. Providers should assess pa-tients for conditions that might contrain-dicate certain types of exercise orpredispose to injury, such as uncontrolledhypertension, untreated proliferative reti-nopathy, autonomic neuropathy, periph-eral neuropathy, and a history of footulcers or Charcot foot. The patient’s age

and previous physical activity level shouldbe considered. The provider should cus-tomize the exercise regimen to the indi-vidual’s needs. Those with complicationsmay require a more thorough evaluationprior to beginning an exercise program(123).

HypoglycemiaIn individuals taking insulin and/or insulinsecretagogues, physical activity maycause hypoglycemia if the medicationdose or carbohydrate consumption isnot altered. Individuals on these thera-pies may need to ingest some added car-bohydrate if pre-exercise glucose levelsare,100mg/dL (5.6mmol/L), dependingon whether they are able to lower insulindoses during theworkout (such aswith aninsulin pump or reduced pre-exercise in-sulin dosage), the time of day exercise isdone, and the intensity and duration ofthe activity (123,126). In some patients,hypoglycemia after exercise may occurand last for several hours due to increasedinsulin sensitivity. Hypoglycemia is lesscommon in patients with diabetes whoare not treated with insulin or insulin se-cretagogues, and no routine preventivemeasures for hypoglycemia are usuallyadvised in these cases. Intense activitiesmay actually raise blood glucose levels in-stead of lowering them, especially if pre-exercise glucose levels are elevated (138).

Exercise in the Presence of SpecificLong-term Complications of Diabetes

Retinopathy

If proliferative diabetic retinopathy or se-vere nonproliferative diabetic retinopathyis present, then vigorous-intensity aerobicor resistance exercise may be contraindi-cated because of the risk of triggering vit-reous hemorrhage or retinal detachment(139). Consultation with an ophthalmolo-gist prior to engaging in an intense exer-cise regimen may be appropriate.

Peripheral Neuropathy

Decreased pain sensation and a higherpain threshold in the extremities resultin an increased risk of skin breakdown,infection, and Charcot joint destructionwith some forms of exercise. Therefore,a thorough assessment should be done toensure that neuropathy does not alterkinesthetic or proprioceptive sensationduring physical activity, particularly inthose with more severe neuropathy.Studies have shown thatmoderate-inten-sity walking may not lead to an increased

risk of foot ulcers or reulceration in thosewithperipheral neuropathywhouseproperfootwear (140). In addition, 150min/weekof moderate exercise was reported to im-proveoutcomes in patientswithprediabeticneuropathy (141). All individuals with pe-ripheral neuropathy should wear properfootwear and examine their feet daily todetect lesions early. Anyone with a footinjury or open sore should be restricted tonon–weight-bearing activities.

Autonomic Neuropathy

Autonomic neuropathy can increase therisk of exercise-induced injury or adverseevents through decreased cardiac respon-siveness to exercise, postural hypotension,impaired thermoregulation, impairednight vision due to impaired papillary re-action, and greater susceptibility to hypo-glycemia (142). Cardiovascular autonomicneuropathy is also an independent riskfactor for cardiovascular death and silentmyocardial ischemia (143). Therefore,individuals with diabetic autonomic neu-ropathy should undergo cardiac investi-gation before beginning physical activitymore intense than that to which they areaccustomed.

Diabetic Kidney Disease

Physical activity can acutely increase uri-nary albumin excretion. However, there isno evidence that vigorous-intensity exer-cise increases the rate of progression ofdiabetic kidney disease, and there ap-pears to be no need for specific exerciserestrictions for people with diabetic kid-ney disease in general (139).

SMOKING CESSATION: TOBACCOAND e-CIGARETTES

Recommendations

c Advise all patients not to use ciga-rettes and other tobacco productsA or e-cigarettes. E

c Include smoking cessation counsel-ing and other forms of treatmentas a routine component of diabetescare. B

Results from epidemiological, case-control,and cohort studies provide convincingevidence to support the causal link be-tween cigarette smoking and healthrisks (144). Recent data show tobaccouse is higher among adults with chronicconditions (145). Smokers with diabetes(andpeoplewithdiabetes exposed to sec-ondhand smoke) have a heightened risk

S44 Lifestyle Management Diabetes Care Volume 41, Supplement 1, January 2018

of CVD, premature death, and microvas-cular complications. Smoking may have arole in the development of type 2 diabe-tes (146,147).The routine and thorough assessment

of tobacco use is essential to preventsmoking or encourage cessation. Numer-ous large randomized clinical trials havedemonstrated the efficacy and cost-effectiveness of brief counseling in smok-ing cessation, including theuseof telephonequit lines, in reducing tobaccouse. For thepatient motivated to quit, the additionof pharmacologic therapy to counselingis more effective than either treatmentalone (148). Special considerations shouldinclude assessment of level of nicotinedependence, which is associatedwith dif-ficulty in quitting and relapse (149). Al-though some patients may gain weightin theperiodshortlyafter smokingcessation(150), recent research has demonstratedthat this weight gain does not diminishthe substantial CVD benefit realizedfrom smoking cessation (151). One studyin smokers with newly diagnosed type 2diabetes found that smoking cessationwas associated with amelioration of met-abolic parameters and reduced bloodpressure and albuminuria at 1 year (152).Nonsmokers should be advised not to

use e-cigarettes. There are no rigorousstudies that have demonstrated thate-cigarettes are a healthier alternativeto smoking or that e-cigarettes can facili-tate smoking cessation. More extensiveresearch of their short- and long-term ef-fects is needed to determine their safetyand their cardiopulmonary effects in com-parison with smoking and standard ap-proaches to smoking cessation (153–155).

PSYCHOSOCIAL ISSUES

Recommendations

c Psychosocial care should be inte-grated with a collaborative, patient-centeredapproachandprovidedto allpeople with diabetes, with the goalsof optimizing health outcomes andhealth-related quality of life. A

c Psychosocial screeningand follow-upmay include, but are not limited to,attitudes about diabetes, expecta-tions for medical management andoutcomes, affect or mood, generaland diabetes-related quality of life,available resources (financial, social,and emotional), and psychiatric his-tory. E

c Providers should consider assess-ment for symptoms of diabetesdistress, depression, anxiety, disor-dered eating, and cognitive ca-pacities using patient-appropriatestandardized and validated tools atthe initial visit, at periodic intervals,and when there is a change in dis-ease, treatment, or life circumstance.Including caregivers and familymem-bers in this assessment is recom-mended. B

c Consider screening older adults(aged $65 years) with diabetesfor cognitive impairment and de-pression. B

Please refer to the ADA position state-ment “Psychosocial Care for People WithDiabetes” for a list of assessment toolsand additional details (156).

Complex environmental, social, behav-ioral, and emotional factors, known as psy-chosocial factors, influence living withdiabetes, both type 1 and type 2, andachieving satisfactory medical outcomesand psychological well-being. Thus, indi-viduals with diabetes and their familiesare challengedwith complex,multifacetedissues when integrating diabetes care intodaily life.

Emotional well-being is an importantpart of diabetes care andself-management.Psychological and social problems can im-pair the individual’s (157–159) or family’s(160) ability to carry out diabetes caretasks and therefore potentially compro-mise health status. There are opportuni-ties for the clinician to routinely assesspsychosocial status in a timely and effi-cient manner for referral to appropriateservices. A systematic review and meta-analysis showed that psychosocial in-terventions modestly but significantlyimproved A1C (standardized mean differ-ence –0.29%) and mental health out-comes (161). However, there was alimited association between the effectson A1C and mental health, and no inter-vention characteristics predicted benefiton both outcomes.

ScreeningKey opportunities for psychosocialscreening occur at diabetes diagnosis,during regularly scheduled managementvisits, during hospitalizations, with newonset of complications, or when prob-lems with glucose control, quality of life,

or self-management are identified (1). Pa-tients are likely to exhibit psychologicalvulnerability at diagnosis, when theirmedical status changes (e.g., end of thehoneymoon period), when the need forintensified treatment is evident, andwhen complications are discovered.

Providers can start with informal verbalinquires, for example, by asking if therehave been changes in mood during thepast 2 weeks or since their last visit. Pro-viders should consider asking if there arenew or different barriers to treatment andself-management, such as feeling over-whelmed or stressed by diabetes or otherlife stressors. Standardized and validatedtools for psychosocial monitoring and as-sessment can also be used by providers(156), with positive findings leading to re-ferral to a mental health provider special-izing in diabetes for comprehensiveevaluation, diagnosis, and treatment.

Diabetes Distress

Recommendation

c Routinely monitor people with dia-betes for diabetes distress, particu-larly when treatment targets arenot met and/or at the onset of di-abetes complications. B

Diabetes distress (DD) is very commonand is distinct from other psychologicaldisorders (162–164). DD refers to signifi-cant negative psychological reactions re-lated to emotional burdens and worriesspecific to an individual’s experience inhaving to manage a severe, complicated,and demanding chronic disease such asdiabetes (163–165). The constant behav-ioral demands (medication dosing, fre-quency, and titration; monitoring bloodglucose, food intake, eating patterns,and physical activity) of diabetes self-management and the potential or actual-ity of disease progression are directlyassociated with reports of DD (163). Theprevalence of DD is reported to be 18–45% with an incidence of 38–48% over18 months (165). In the second DiabetesAttitudes, Wishes and Needs (DAWN2)study, significant DD was reported by45% of the participants, but only 24% re-ported that their health care teams askedthem how diabetes affected their lives(162). High levels of DD significantlyimpact medication-taking behaviorsand are linked to higher A1C, lower self-efficacy, and poorer dietary and exercise

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behaviors (16,163,165). DSMES has beenshown to reduce DD (16). It may be help-ful to provide counseling regarding ex-pected diabetes-related versus generalizedpsychological distress at diagnosis andwhen disease state or treatment changes(166).DD should be routinelymonitored (167)

using patient-appropriate validated mea-sures (156). If DD is identified, the personshould be referred for specific diabeteseducation to address areas of diabetes self-care that are most relevant to the patientand impact clinical management. Peoplewhose self-care remains impaired after tai-lored diabetes education should be referredby their care team to a behavioral healthprovider for evaluation and treatment.Other psychosocial issues known to af-

fect self-management and health out-comes include attitudes about the illness,expectations formedicalmanagement andoutcomes, available resources (financial,social, and emotional) (168), and psychiat-ric history. For additional information onpsychiatric comorbidities (depression,anxiety, disordered eating, and seriousmental illness), please refer to Section3 “Comprehensive Medical Evaluationand Assessment of Comorbidities.”

Referral to a Mental Health SpecialistIndications for referral to a mental healthspecialist familiar with diabetes manage-ment may include positive screening foroverall stress related towork-life balance,DD, diabetes management difficulties,depression, anxiety, disordered eating,and cognitive dysfunction (see Table 4.2for a complete list). It is preferable to in-corporate psychosocial assessment andtreatment into routine care rather thanwaiting for a specific problem or deterio-ration in metabolic or psychological sta-tus to occur (25,162). Providers shouldidentify behavioral and mental health

providers, ideally those who are knowl-edgeable about diabetes treatment andthe psychosocial aspects of diabetes, towhom they can refer patients. The ADAprovides a list of mental health providerswho have received additional educationin diabetes at the ADA Mental HealthProvider Directory (professional.diabetes.org/ada-mental-health-provider-directory).Ideally, psychosocial care providersshould be embedded in diabetes care set-tings. Although the clinician may not feelqualified to treat psychological problems(169), optimizing the patient-provider re-lationship as a foundation may increasethe likelihood of the patient accepting re-ferral for other services. Collaborativecare interventions and a team approachhave demonstrated efficacy in diabetesself-management and psychosocial func-tioning (16).

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Table 4.2—Situations that warrant referral of a person with diabetes to a mental health provider for evaluation and treatmentc If self-care remains impaired in a person with DD after tailored diabetes education

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

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

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

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

c If a serious mental illness is suspected

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

c If a person screens positive for cognitive impairment

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

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

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randomised controlled trial. Diabetologia 2009;52:50–59107. Kromhout D, Geleijnse JM, de Goede J, et al.n-3 fatty acids, ventricular arrhythmia-relatedevents, and fatal myocardial infarction in post-myocardial infarction patients with diabetes. Di-abetes Care 2011;34:2515–2520108. Bosch J, Gerstein HC, Dagenais GR, et al.;ORIGIN Trial Investigators. n-3 fatty acids and car-diovascular outcomes in patients with dysglyce-mia. N Engl J Med 2012;367:309–318109. Bray GA, VollmerWM, Sacks FM, ObarzanekE, Svetkey LP, Appel LJ; DASH Collaborative Re-search Group. A further subgroup analysis of theeffects of the DASH diet and three dietary sodiumlevels on blood pressure: results of the DASH-Sodium Trial. Am J Cardiol 2004;94:222–227110. Eckel RH, Jakicic JM, Ard JD, et al.; AmericanCollege of Cardiology/American Heart AssociationTask Force on Practice Guidelines. 2013 AHA/ACCguideline on lifestyle management to reduce car-diovascular risk: a report of the American Collegeof Cardiology/American Heart Association TaskForce on Practice Guidelines. Circulation 2014;129(25 Suppl. 2):S79–S99111. Thomas MC, Moran J, Forsblom C, et al.;FinnDiane Study Group. The association betweendietary sodium intake, ESRD, and all-cause mor-tality in patients with type 1 diabetes. DiabetesCare 2011;34:861–866112. Ekinci EI, Clarke S, ThomasMC, et al. Dietarysalt intake and mortality in patients with type 2diabetes. Diabetes Care 2011;34:703–709113. Maillot M, Drewnowski A. A conflict be-tween nutritionally adequate diets and meetingthe 2010 dietary guidelines for sodium. Am J PrevMed 2012;42:174–179114. Aroda VR, Edelstein SL, Goldberg RB, et al.;Diabetes Prevention Program Research Group.Long-term metformin use and vitamin B12 defi-ciency in the Diabetes Prevention Program Out-comes Study. J Clin Endocrinol Metab 2016;101:1754–1761115. Allen RW, Schwartzman E, Baker WL,Coleman CI, Phung OJ. Cinnamon use in type 2diabetes: an updated systematic review andmeta-analysis. Ann Fam Med 2013;11:452–459116. Mitri J, Pittas AG. Vitamin D and diabetes.Endocrinol Metab Clin North Am 2014;43:205–232117. MozaffarianD. Dietaryandpolicypriorities forcardiovascular disease, diabetes, and obesity: a com-prehensive review. Circulation 2016;133:187–225118. Grotz VL, Pi-Sunyer X, Porte D Jr, Roberts A,Richard Trout J. A 12-week randomized clinicaltrial investigating the potential for sucralose toaffect glucose homeostasis. Regul Toxicol Phar-macol 2017;88:22–33119. Miller PE, Perez V. Low-calorie sweetenersand body weight and composition: a meta-analysis of randomized controlled trials and pro-spective cohort studies. Am J Clin Nutr 2014;100:765–777120. Rogers PJ, Hogenkamp PS, de Graaf C, et al.Does low-energy sweetener consumption affectenergy intake and body weight? A systematic re-view, including meta-analyses, of the evidencefrom human and animal studies. Int J Obes(Lond) 2016;40:381–394121. AzadMB, Abou-SettaAM, ChauhanBF, et al.Nonnutritive sweeteners and cardiometabolichealth: a systematic review and meta-analysis of

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