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Strategies for self-care in diabetes prevention

Strategies for self-care in diabetes prevention

American Diabetes Association. Whether patients considered diabetes to have a self-caee impact Strategies for self-care in diabetes prevention Stfategies daily life also seemed to influence their acceptance of diabetes and the new lifestyle. Previous Article Next Article. Carbohydrates for improving the cognitive performance of independent-living older adults with normal cognition or mild cognitive impairment.

Strategies for self-care in diabetes prevention -

People with Type 1 diabetes create little to no insulin and need to take medication every day. Type 2 , the most common form of diabetes, develops over many years.

It is usually diagnosed in adults. Individuals with Type 2 diabetes have developed an insulin resistance, meaning the body does not absorb insulin easily.

Taking charge of your diabetes self-care From diet and exercise to checkups and treatment, there are several simple things people with diabetes can do to stay on top of their health.

Stick with your schedule of checkups and doctor visits: The ADA advises patients schedule medical exams and blood tests at least once a year to evaluate new symptoms and complications.

If you have diabetes, your doctor will also recommend foot exams and eye exams. Take your medications: There are many different types of drugs that can work in different ways to lower your blood sugar. Sometimes one medication will be enough, but in other cases, your doctor may prescribe a combination of medications.

You might also need medications to manage other conditions that can come along with diabetes, such as heart issues or even depression and anxiety. Working with a nurse, dietician, or nutritionist can help you figure out a food plan that works best for you.

Stay active: Along with diet and medication, regular physical activity is an important part of managing diabetes. Light walking is a great way to start. The ADA recommends that those with diabetes aim for at least minutes of exercise weekly.

Plan ahead: Think ahead about activities that might require you to manage your diabetes away from home. Carry your medications close at hand and in their original containers with your prescription information. Ask your care team about any special steps you need to take for time away from home.

Speak up about your emotional health: Tracking your blood sugar, taking insulin, planning your meals, and staying active is a lot to think about. It can leave you feeling overwhelmed. Furthermore, the sample size was sufficient for the current qualitative study, as the aim was to get detailed insights into the experiences of individuals.

Nevertheless, to assess the generalizability of findings, it is important to replicate the current study with a larger sample of patients.

This may require different methodology as well. However, this methodology is less applicable to theory and model building [ 24 ]. To develop an overall representative theory of self-management from the patient perspective other qualitative methods such as grounded theory may be more appropriate.

Moreover, 7 out of 10 participants were female. Finally, the outcomes of this research do not yet provide insight in what patients currently miss regarding support in self-management. In order to further improve self-management support, additional research is needed on this aspect.

Two moments have been indicated by this study which are most optimal for providing support; when recently diagnosed and when problems occur. Future research can further explore the differences and similarities for providing support to people in these different moments.

It is possible that different strategies for support would be best for each moment. This research focused on the needs of a specific patient group; T2DM with stable, adequate glycaemic control. This population has not been researched before, and therefore new insights are generated for this target group specifically.

Outcomes of this study can now be further explored in a broader view, but these first insights already indicate the need for a more individualised approach to support patients with T2DM and a stable, adequate glycaemic control.

The current guidelines for treatment of T2DM are too standardised and lack personalised support in specific aspects as dietary behaviour, exercising, scheduled rhythm, medication, being in control, and knowledge. The interview records and sensitising booklets generated and analysed during the current study are not publicly available to protect participant confidentiality, but are available from the corresponding author on reasonable request.

International Diabetes Federation. IDF Diabetes Atlas, 7 ed. Brussels, Belgium: International Diabetes Federation; Cebolla Garrofé B, Björnberg A, Yung Phang A.

Euro Diabetes Index Täby: Health Consumer Powerhouse Ltd; Google Scholar. Transparent integrated care. Report care groups. Diabetes mellitus, VRM, COPD and asthma [Transparante ketenzorg. Rapportage zorggroepen. Diabetes mellitus, VRM, COPD en astma. Op weg naar genuanceerde rapportage van zorg].

Utrecht: InEen; Wermeling PR, Gorter KJ, Stellato RK, de Wit GA, Beulens JW, Rutten GE. Effectiveness and cost-effectiveness of 3-monthly versus 6-monthly monitoring of well-controlled type 2 diabetes patients: a pragmatic randomised controlled patient-preference equivalence trial in primary care EFFIMODI study.

Diabetes Obes Metab. Article CAS PubMed Google Scholar. Chatterjee S, Khunti K, Davies MJ. Type 2 diabetes. Tuomilehto J, Lindström J, Eriksson JG, Valle TT, Hämäläinen H, Ilanne-Parikka P, Uusitupa M. Prevention of type 2 diabetes mellitus by changes in lifestyle among subjects with impaired glucose tolerance.

N Engl J Med. Hu FB, Manson JE, Stampfer MJ, Colditz G, Liu S, Solomon CG, Willett WC. Diet, lifestyle, and the risk of type 2 diabetes mellitus in women. Koch T, Jenkin P, Kralik D.

J Adv Nurs. Article PubMed Google Scholar. Corbin J, Strauss A. Unending work and care: managing chronic illness at home. San Francisco, CA: Jossey-Bass; Bodenheimer T, Wagner E, Grumbach K. Improving primary care for patients with chronic illness: the chronic care model. Von Korff M, Gruman J, Schaefer J, Curry S, Wagner EH.

Collaborative management of chronic illness. Ann Intern Med. Article Google Scholar. Coleman K, Austin BT, Brach C, Wagner EH. Evidence on the chronic care model in the new millennium.

Health Aff. Furler J, Walker C, Blackberry I, Dunning T, Sulaiman N, Dunbar J, Young D. The emotional context of self-management in chronic illness: a qualitative study of the role of health professional support in the self-management of type 2 diabetes.

BMC Health Serv Res. Dale J, Caramlau I, Docherty A, Sturt J, Hearnshaw H. Telecare motivational interviewing for diabetes patient education and support: a randomised controlled trial based in primary care comparing nurse and peer supporter delivery.

Funnell MM. Peer-based behavioural strategies to improve chronic disease self-management and clinical outcomes: evidence, logistics, evaluation considerations and needs for future research. Family Practice, 27 Suppl. Elissen A, Nolte E, Knai C, Brunn M, Chevreul K, Conklin A, Vrijhoef H. Is Europe putting theory into practice?

A qualitative study of the level of self-management support in chronic care management approaches. Article PubMed PubMed Central Google Scholar. Norris SL, Engelgau MM, Venkat Narayan KM. Effectiveness of self-management training in type 2 diabetes: a systematic review of randomized controlled trials.

Diabetes Care. Barlow J, Wright C, Sheasby J, Turner A, Hainsworth J. Self-management approaches for people with chronic conditions: a review. Patient Educ Couns.

Street RL, Makoul G, Arora NK, Epstein RM. How does communication heal? Pathways linking clinician-patient communication to health outcomes. Elissen A, Hertroijs D, Shaper N, Vrijhoef H, Ruwaard D. Int J Integr Care. Gill P, Stewart K, Treasure E, Chadwick B.

Methods of data collection in qualitative research: interviews and focus groups. Br Dent J. Hertroijs DFL, Elissen AMJ, Brouwers MCGJ, et al.

A risk score including body massindex, glycated haemoglobin and triglycerides predicts future glycaemic control in people with type 2 diabetes. Sanders EBN, Stappers P. Convivial Toolbox. Amsterdam: BIS Publishers; Thomas DR. A general inductive approach for analyzing qualitative evaluation data.

Am J Eval. Inzucchi SE, Bergenstal RM, Buse JB, Diamant M, Ferrannini E, Nauck M. European Association for the Study of diabetes EASD. Management of hyperglycemia in type 2 diabetes: a patient-centered approach: position statement of the American Diabetes Association ADA and the European Association for the Study of diabetes EASD.

Article CAS PubMed PubMed Central Google Scholar. van HL, Rijken M, Heijmans M, Groenewegen P. Self-management support needs of patients with chronic illness: do needs for support differ according to the course of illness?

Lorig KR, Holman H. Self-management education: history, definition, outcomes, and mechanisms. Ann Behav Med. Frei A, Svarin A, Steurer-Stey C, Puhan MA. Self-efficacy instruments for patients with chronic diseases suffer from methodological limitations - a systematic review.

Health Qual Life Outcomes. Nolte E, Knai C, Saltman R. Assessing chronic disease management in European health systems : concepts and approaches. Copenhagen, Denmark: European Observatory on Health Systems and Policies, a partnership hosted by WHO; Powers MA, Bardsley J, Cypress M, Duker P, Funnell MM, Fischl AH, Vivian E.

Diabetes self-management education and support in type 2 diabetes: a joint position statement of the American Diabetes Association, the American Association of Diabetes Educators, and the academy of nutrition and dietetics. J Acad Nutr Diet. Kujala S. User involvement: a review of the benefits and challenges.

Behav Inform Technol. Download references. The authors thank the patients who participated in this study. We also thank the Dutch Association for Diabetes Diabetes Vereniging Nederland , Diabetes Café Rijswijk, and several diabetes-related Facebook groups for their support in recruitment of participants by sharing our call for participation amongst their members.

Faculty of Industrial Design Engineering, Delft University of Technology, Delft, the Netherlands. Astrid N. Department of Health Services Research, Care and Public Health Research Institute, Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, the Netherlands.

Dorijn F. Department of Public and Occupational Health, Amsterdam Public Health research institute, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands.

You can also search for this author in PubMed Google Scholar. AS, DH, TD, AE and MM designed the study. AS recruited participants and collected the data. AS conducted the analyses, which were reviewed by DH, TD, AE and MM.

AS prepared the first draft of the manuscript and AS, DH, TD, AE and MM critically reviewed and revised the manuscript. All authors read, contributed to, and approved the final version. Correspondence to Marijke Melles. All authors, A. van Smoorenburg, D. Hertroijs, T. Dekkers, A.

Elissen and M. Melles, declare that they have no conflict of interest. Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. Open Access This article is distributed under the terms of the Creative Commons Attribution 4.

Reprints and permissions. van Smoorenburg, A. et al. BMC Health Serv Res 19 , Download citation. Received : 23 December Accepted : 30 July Published : 28 August Anyone you share the following link with will be able to read this content:.

Sorry, a shareable link is not currently available for this article. Provided by the Springer Nature SharedIt content-sharing initiative. Skip to main content. Search all BMC articles Search. Download PDF. van Smoorenburg 1 , Dorijn F.

Hertroijs ORCID: orcid. Elissen ORCID: orcid. Abstract Background The number of type 2 diabetes mellitus T2DM patients and related treatment costs are rapidly increasing.

Methods Semi-structured interviews, preceded by preparatory assignments, were conducted with ten patients with T2DM treated in Dutch primary care. Conclusions With this knowledge, support solutions can be designed and implemented that better fit the needs, preferences and abilities of patients with T2DM.

Background Diabetes mellitus is a growing healthcare challenge. Study design Patients were invited to prepare themselves for the interviews by filling out so-called sensitising booklets [ 23 ]. Full size image.

Results Participant characteristics Sixteen people applied for participation in the study. Table 1 Overview of background characteristics of participants Full size table. Table 2 Aspects named by the participants having most impact 4 or 5 out of 5 on daily life of T2DM patients Full size table.

Discussion The daily care for type 2 diabetes mellitus T2DM mostly comes down to the person suffering from it. Conclusions This research focused on the needs of a specific patient group; T2DM with stable, adequate glycaemic control. Availability of data and materials The interview records and sensitising booklets generated and analysed during the current study are not publicly available to protect participant confidentiality, but are available from the corresponding author on reasonable request.

Abbreviations GP: General practitioner HbA1c: Glycated haemoglobin T2DM: Type 2 diabetes mellitus. References International Diabetes Federation.

Mayo Clinic diabtees appointments in Arizona, Florida Performance Nutrition Essentials Minnesota dabetes at Mayo Clinic Health System locations. Diabetes care is a lifelong responsibility. Consider 10 strategies to prevent diabetes complications. Diabetes is a serious disease. Following your diabetes treatment plan takes round-the-clock commitment. But your efforts are worthwhile. Strategies for self-care in diabetes prevention

BMC Health Services Research Strategkes 19Article number: Sepf-care this article. Metrics details. The number of type 2 diabetes mellitus Probiotics for gut health patients and related treatment costs are rapidly Startegies.

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This diabeetes, success of self-management will increase Strategies for self-care in diabetes prevention complications and self-cafe costs of T2DM can be reduced. Currently, self-management support is developed mainly from Strategjes perspective of health professionals ddiabetes caregivers, rather than patients.

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Previous research has Strxtegies that successful support of self-management of patients with T2DM can have a positive impact SStrategies their lifestyle self-csre, ultimately, result in Strategiies health outcomes self-fare 12131415 ].

However, international comparative research Stratgeies 16 ] also shows that Targeted fat percentage support remains relatively underdeveloped in most countries.

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The aim Strategies for self-care in diabetes prevention the PROFILe project is to determine optimal treatment strategies for subgroups of patients with T2DM with similar care needs, preferences and abilities, taking into account both clinical and non-clinical aspects [ 20 ].

As part of the PROFILe project, opportunities for improving self-management support for patients with T2DM were explored in this study.

No ethical approval was needed for the study; as the participants were not physically involved in the research and the questionnaires were not mentally exhausting, the study was not subject to the Dutch Medical Research Human Subject Act.

All patients participating in the study gave written informed consent. Therefore, patients from this specific group were targeted in this research. Accordingly, patients were included if they: 1 were diagnosed with T2DM no longer than five years ago; 2 made use of diabetes-related care provided by Dutch primary care; and 3 had a stable, adequate glycaemic control i.

Patients received a monetary reimbursement for participating in the research. Participation was voluntary, and all participants provided informed consent. Patients were invited to prepare themselves for the interviews by filling out so-called sensitising booklets [ 23 ]. The aim of the exercises in the booklets was to trigger participants to reflect on their experiences with self-management of diabetes.

An example of one of the pages from the sensitising booklet is shown in Fig. The use of sensitising booklets is a well-known tool within the domain of user-centred design research, i. a design research approach which emphasises user involvement throughout the design research process. Using sensitizing booklets enables the researcher to quickly engage with the interviewee, prepares the interviewee for the interview, and allows for elaboration on specific topics that were mapped prior to the interview.

This way, a deeper tacit or latent layer of information about the perspective of the patient can be addressed during the interviews [ 23 ]. Example page from the sensitising booklet in Dutch. The blue stickers were used to indicate moments in the day where the participant felt he or she had to take diabetes into account.

During the interview, the participant was asked to explain how diabetes was taken into account in these moments, and how the participant experienced this. Next, semi-structured face-to-face interviews were conducted by the first author from March to April The researcher prepared a set of interview questions aligned with the exercises in the sensitising booklet.

These aspects were written down and ranked by the participant according to impact on daily life scale 1 least — 5 most. The full list of interview questions is presented in Additional file 1. The interviews were voice recorded for analysis. The interviews were analysed in four steps.

First, voice recordings of the interviews were listened back, while making notes of the answers of all participants for each of the five topics of the booklet.

In the second step these notes were condensed to create statements within each of the topics according to a general inductive approach [ 24 ]. Third, the statements were discussed with the co-authors and categorized as concerning: 1 elements of self-management e.

exercising, knowledge, being in control ; 2 characteristics of the disease and treatment e. type of medication, diet, use of blood sugar level meter ; and 3 characteristics of the attitude towards the disease e.

acceptance, consequences, role of health professional vs. role of patient. Taking into account the objective of this paper, only the results of the first category will be presented.

Sixteen people applied for participation in the study. Ten people Mean HbA1c was All participants were treated for T2DM by a general practitioner GP and practice nurse specialized in diabetes care at the GP practice. Self-management is a term which is commonly used by health professionals.

Rather, they felt they dealt with their daily life as it is now, just as every other person with or without T2DM. But, apart from that, diabetes is not difficult; you just need to learn how to deal with it. Participants did not often experience problems caused by deteriorated glycaemic control, and therefore did not consider themselves as having to actively self-manage their disease.

Although self-management was generally described as diabetes in daily lifeparticipants also mentioned that if glycaemic control was no longer stable, a need for active self-management emerged.

They described that at such times, actions were required to prevent complications. However, over time, new lifestyles became part of their routine in daily life and were no longer experienced as active self-management. Over time, active self-management changes into routine in daily life.

When problems occur, patients shift back to active self-management grey peaks. All patients mentioned that T2DM influenced their daily life. Yet, the impact of T2DM on daily activities was greater for some patients than for others. Whether patients considered diabetes to have a large impact on their daily life also seemed to influence their acceptance of diabetes and the new lifestyle.

Some patients felt that diabetes had to be taken into account at all times. The health professional gives advice, but you have to do the work and decide what to eat and drink and what not. Since patients experienced diabetes in daily life rather than self-managementaspects which influence diabetes in daily life were investigated.

The aspects scored by the participants on a five-point scale that had the most impact 4 or 5 out of 5 on the daily life of T2DM patients were categorised and are shown in Table 2. To account for these different aspects patients felt required to be in control, and to have sufficient knowledge to keep control.

Participants mentioned very specific things that made them feel supported. For example, with regard to exercising, patients felt supported by their dog or children. However, patients were not able to mention specific causes for not feeling supported. For example, concerning exercise, they mentioned a lack of support in motivation.

Overall, patients felt supported in self-management in some ways, but mainly felt as if they had to find out everything about living with diabetes on their own.

In their view, health professionals provide medical advice, but could not explain how to deal with T2DM in daily life. The daily care for type 2 diabetes mellitus T2DM mostly comes down to the person suffering from it. To maintain adequate glycaemic control, patients with T2DM have to make many decisions and fulfil complex care activities every day [ 25 ].

Respondents in our study mentioned a need to gain knowledge, be in control, adapt their diet, exercise, maintain a regular schedule, and adhere to complex medication regimes. However, in fulfilling these responsibilities, they did not view themselves as actively participating in their treatment, at least not continuously.

This is in line with previous research indicating that patients who perceive their illness as stable have different needs for support than patients who experience their disease as episodic or progressively deteriorating [ 26 ].

An unpredictable course of illness can cause feelings of lower self-efficacy, i. patients might experience their self-management as unsuccessful and, as a result, feel a greater need for support [ 2728 ]. Although overall, respondents did not experience themselves as actively managing their diabetes, they did identify two time points of active self-management during their illness course, particularly in the period after diagnosis and when problems occurred.

With regard to support for their self-management, patients expressed that they did not feel optimally supported, which is in line with findings from previous studies [ 1629 ].

: Strategies for self-care in diabetes prevention

Benefits Associated With DSMES Healthy lifestyle choices physical activity, healthy eating, tobacco cessation, weight management, and effective coping Disease self-management taking and managing medications and, when clinically appropriate, self-monitoring of glucose and blood pressure Prevention of diabetes complications self-monitoring of foot health; active participation in screening for eye, foot, and renal complications; and immunizations. Having diabetes puts you are a higher risk for developing other health problems. The emotional context of self-management in chronic illness: a qualitative study of the role of health professional support in the self-management of type 2 diabetes. You can also search for this author in PubMed Google Scholar. Diabetes Care Concepts.
Examples of Rural Diabetes Self-Management Programs Take your medications: There Strattegies many different types Strateties drugs that can Dlabetes in different ways to lower your blood sugar. Performance Nutrition Essentials Nutrition strategies for sports success ; Amy Pgevention. Diabetes also affects children and adolescents. Diabetes can be isolating and overwhelming—and finding connection with people like you is the antidote. Providers should recognize that homelessness, poor literacy, and poor numeracy often occur with food insecurity, and appropriate resources should be made available for patients with diabetes. The common types of diabetes include: Type 1 occurs most often in children.
7 Self-Care Tips That Can Ease the Stress of Living With Type 2 Diabetes

A general inductive approach for analyzing qualitative evaluation data. Am J Eval. Inzucchi SE, Bergenstal RM, Buse JB, Diamant M, Ferrannini E, Nauck M. European Association for the Study of diabetes EASD.

Management of hyperglycemia in type 2 diabetes: a patient-centered approach: position statement of the American Diabetes Association ADA and the European Association for the Study of diabetes EASD. Article CAS PubMed PubMed Central Google Scholar. van HL, Rijken M, Heijmans M, Groenewegen P.

Self-management support needs of patients with chronic illness: do needs for support differ according to the course of illness?

Lorig KR, Holman H. Self-management education: history, definition, outcomes, and mechanisms. Ann Behav Med.

Frei A, Svarin A, Steurer-Stey C, Puhan MA. Self-efficacy instruments for patients with chronic diseases suffer from methodological limitations - a systematic review.

Health Qual Life Outcomes. Nolte E, Knai C, Saltman R. Assessing chronic disease management in European health systems : concepts and approaches. Copenhagen, Denmark: European Observatory on Health Systems and Policies, a partnership hosted by WHO; Powers MA, Bardsley J, Cypress M, Duker P, Funnell MM, Fischl AH, Vivian E.

Diabetes self-management education and support in type 2 diabetes: a joint position statement of the American Diabetes Association, the American Association of Diabetes Educators, and the academy of nutrition and dietetics. J Acad Nutr Diet. Kujala S. User involvement: a review of the benefits and challenges.

Behav Inform Technol. Download references. The authors thank the patients who participated in this study. We also thank the Dutch Association for Diabetes Diabetes Vereniging Nederland , Diabetes Café Rijswijk, and several diabetes-related Facebook groups for their support in recruitment of participants by sharing our call for participation amongst their members.

Faculty of Industrial Design Engineering, Delft University of Technology, Delft, the Netherlands. Astrid N. Department of Health Services Research, Care and Public Health Research Institute, Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, the Netherlands.

Dorijn F. Department of Public and Occupational Health, Amsterdam Public Health research institute, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands. You can also search for this author in PubMed Google Scholar.

AS, DH, TD, AE and MM designed the study. AS recruited participants and collected the data. AS conducted the analyses, which were reviewed by DH, TD, AE and MM.

AS prepared the first draft of the manuscript and AS, DH, TD, AE and MM critically reviewed and revised the manuscript. All authors read, contributed to, and approved the final version. Correspondence to Marijke Melles.

All authors, A. van Smoorenburg, D. Hertroijs, T. Dekkers, A. Elissen and M. Melles, declare that they have no conflict of interest. Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Open Access This article is distributed under the terms of the Creative Commons Attribution 4. Reprints and permissions. van Smoorenburg, A. et al. BMC Health Serv Res 19 , Download citation. Received : 23 December Accepted : 30 July Published : 28 August Anyone you share the following link with will be able to read this content:.

Sorry, a shareable link is not currently available for this article. Provided by the Springer Nature SharedIt content-sharing initiative. Skip to main content. Search all BMC articles Search.

Download PDF. van Smoorenburg 1 , Dorijn F. Hertroijs ORCID: orcid. Elissen ORCID: orcid. Abstract Background The number of type 2 diabetes mellitus T2DM patients and related treatment costs are rapidly increasing.

Methods Semi-structured interviews, preceded by preparatory assignments, were conducted with ten patients with T2DM treated in Dutch primary care. Conclusions With this knowledge, support solutions can be designed and implemented that better fit the needs, preferences and abilities of patients with T2DM.

Background Diabetes mellitus is a growing healthcare challenge. Study design Patients were invited to prepare themselves for the interviews by filling out so-called sensitising booklets [ 23 ]. Full size image. Results Participant characteristics Sixteen people applied for participation in the study.

Table 1 Overview of background characteristics of participants Full size table. Table 2 Aspects named by the participants having most impact 4 or 5 out of 5 on daily life of T2DM patients Full size table.

Discussion The daily care for type 2 diabetes mellitus T2DM mostly comes down to the person suffering from it. Conclusions This research focused on the needs of a specific patient group; T2DM with stable, adequate glycaemic control.

Availability of data and materials The interview records and sensitising booklets generated and analysed during the current study are not publicly available to protect participant confidentiality, but are available from the corresponding author on reasonable request.

Abbreviations GP: General practitioner HbA1c: Glycated haemoglobin T2DM: Type 2 diabetes mellitus. References International Diabetes Federation. Google Scholar InEen.

Google Scholar Wermeling PR, Gorter KJ, Stellato RK, de Wit GA, Beulens JW, Rutten GE. Article CAS PubMed Google Scholar Chatterjee S, Khunti K, Davies MJ.

Article CAS PubMed Google Scholar Tuomilehto J, Lindström J, Eriksson JG, Valle TT, Hämäläinen H, Ilanne-Parikka P, Uusitupa M. Article CAS PubMed Google Scholar Hu FB, Manson JE, Stampfer MJ, Colditz G, Liu S, Solomon CG, Willett WC.

Article CAS PubMed Google Scholar Koch T, Jenkin P, Kralik D. Article PubMed Google Scholar Corbin J, Strauss A. Google Scholar Bodenheimer T, Wagner E, Grumbach K.

Article PubMed Google Scholar Von Korff M, Gruman J, Schaefer J, Curry S, Wagner EH. Article Google Scholar Coleman K, Austin BT, Brach C, Wagner EH.

Article Google Scholar Furler J, Walker C, Blackberry I, Dunning T, Sulaiman N, Dunbar J, Young D. Article Google Scholar Elissen A, Nolte E, Knai C, Brunn M, Chevreul K, Conklin A, Vrijhoef H. Article PubMed PubMed Central Google Scholar Norris SL, Engelgau MM, Venkat Narayan KM.

Article CAS PubMed Google Scholar Barlow J, Wright C, Sheasby J, Turner A, Hainsworth J. Article PubMed Google Scholar Street RL, Makoul G, Arora NK, Epstein RM.

Article PubMed Google Scholar Elissen A, Hertroijs D, Shaper N, Vrijhoef H, Ruwaard D. Article CAS PubMed Google Scholar Hertroijs DFL, Elissen AMJ, Brouwers MCGJ, et al.

Article CAS PubMed Google Scholar Sanders EBN, Stappers P. Google Scholar Thomas DR. Article Google Scholar Inzucchi SE, Bergenstal RM, Buse JB, Diamant M, Ferrannini E, Nauck M. Article CAS PubMed PubMed Central Google Scholar van HL, Rijken M, Heijmans M, Groenewegen P.

Article Google Scholar Lorig KR, Holman H. Article PubMed Google Scholar Frei A, Svarin A, Steurer-Stey C, Puhan MA. Google Scholar Powers MA, Bardsley J, Cypress M, Duker P, Funnell MM, Fischl AH, Vivian E.

Article PubMed Google Scholar Kujala S. Article Google Scholar Download references. Acknowledgements The authors thank the patients who participated in this study.

Funding The authors received no specific funding for this work. Author information Authors and Affiliations Faculty of Industrial Design Engineering, Delft University of Technology, Delft, the Netherlands Astrid N.

Elissen Department of Public and Occupational Health, Amsterdam Public Health research institute, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands Marijke Melles Authors Astrid N.

van Smoorenburg View author publications. View author publications. Ethics declarations Ethics approval and consent to participate No ethical approval was needed for the study; as the participants were not physically involved in the research and the questionnaires were not mentally exhausting, the study was not subject to the Dutch Medical Research Human Subject Act.

Key stakeholders can use this Consensus Report and the current Standards of Medical Care in Diabetes from the American Diabetes Association ADA 8 to develop action plans for increased referral to and utilization of DSMES. The purpose of DSMES is to give people with diabetes the knowledge, skills, and confidence to accept responsibility for their self-management.

This includes collaborating with their health care team, making informed decisions, solving problems, developing personal goals and action plans, and coping with emotions and life stresses 9. This Consensus Report focuses on the particular needs of adults with type 2 diabetes.

DSMES needs are critical to those living with type 1 diabetes, prediabetes, and gestational diabetes mellitus; however, the evidence and examples referred to in this Consensus Report are for adults with type 2 diabetes.

A call to action for all health care systems and organizations is to engage needed resources and to effectively and efficiently manage and address this expensive epidemic affecting health outcomes.

We must address barriers that result in therapeutic inertia created by health policy, health systems, providers, people with diabetes, and the environment, including social determinants of health 10 , which encompass the conditions in which people live, work, learn, and play Rather than being overwhelmed and nonattentive to this crisis, all stakeholders must be creative and responsive to the needs of all involved and make it their priority.

This Consensus Report is an update of the joint position statement on DSMES The panel of experts authoring this report includes representatives from the three national organizations that jointly published the original article ADA, American Association of Diabetes Educators [AADE], and Academy of Nutrition and Dietetics , and, in an effort to widen the reach and stakeholder input, the American Academy of Family Physicians, American Academy of PAs, American Association of Nurse Practitioners, American Pharmacists Association, and a patient advocate were invited to participate.

At the beginning of the writing process all members of the expert panel participated in two surveys related to the joint position statement and its impact and the desired future use of this Consensus Report: one survey from their perspective and one completed while interviewing colleagues.

The expert panel agreed on the direction for this Consensus Report, established writing teams to author the various sections of the report, and reviewed the entire updated manuscript after each step.

An outside market research company was used to conduct the literature search and was paid using ADA funds. Monthly calls were held between March and December , with additional e-mail and web-based collaboration. Two in-person meetings were conducted to provide organization to the process, establish the review process, reach consensus on the content and key definitions see Table 2 , and discuss and deliberate the recommendations.

Once the draft was completed, the structured peer review process was implemented and the report was sent to two additional representatives from each of the seven participating organizations. A final draft was completed and submitted to all seven national organizations for final review and approval.

The recommendations are the informed, expert consensus of the seven contributing organizations. The benefits of DSMES are multifaceted and include clinical, psychosocial, and behavioral outcomes benefits.

Key clinical benefits are improved hemoglobin A 1c A1C with reductions that are additive to lifestyle and drug therapy 13 — Based on recent data 13 , 14 , 16 , DSMES results in an average A1C reduction of 0. DSMES improves quality of life 15 , 21 — 23 and promotes lifestyle behaviors including healthful meal planning and engagement in regular physical activity In addition, participation in DSMES services shows enhancement of self-efficacy and empowerment 25 , increased healthy coping 26 , and decreased diabetes-related distress These improvements clearly affirm the importance and benefits of utilizing DSMES and justify efforts to facilitate participation as a necessary part of quality diabetes care.

Table 3 highlights the multiple and varied benefits that make DSMES services a critical component of quality diabetes care and compares its effects to metformin therapy metformin therapy Evidence supports that better health outcomes are associated with an increased amount of time spent with a diabetes care and education specialist 13 , 28 , People with diabetes who completed more than 10 h of DSMES over the course of 6—12 months and those who participated on an ongoing basis were found to have significant reductions in mortality 20 and A1C average absolute reduction of 0.

Research shows that those who participate in diabetes education are more likely to use best practices and have lower health care costs 28 , Even though outpatient and pharmacy costs are higher for those who use diabetes education, t hese costs are offset by lower acute care costs DSMES is cost-effective by reducing emergency department visits, hospital admissions, and hospital readmissions 28 , 30 — The cost of diabetes in the U.

The cost of care for people with diabetes accounts for about one in four health care dollars spent in the U. The U. health care system cannot sustain the costs of care associated with the increasing incidence of diabetes and diabetes-related complications.

DSMES offers a pathway to decrease these costs and improve outcomes. DSMES improves quality of life and health outcomes and is cost-effective.

All members of the health care team and health systems should promote the benefits, emphasize the value, and support participation in initial and ongoing DSMES for all people with diabetes see Table 4.

Summary of DSMES benefits to discuss with people with diabetes 15 — 28 , 30 — 33 , 40 , A variety of DSMES approaches and settings need to be presented and discussed with people with diabetes, thus enabling self-selection of a method that best meets their specific needs Evolving health care delivery systems, primary care needs, and the needs of people with diabetes have resulted in the incorporation of DSMES services into additional and nontraditional settings such as those located within patient-centered medical homes, community health centers, pharmacies, and accountable care organizations ACOs , as well as faith-based organizations and home settings.

Technology-based services including web-based programs, telehealth, mobile applications, and remote monitoring enable and promote increased access and connectivity for ongoing management and support Recent health care concerns are rapidly expanding the use of these services, especially telehealth.

In conjunction with formal DSMES, online peer support communities are growing in popularity. Involvement in these groups can be a beneficial adjunct to learning, serving as an option for ongoing diabetes peer support 36 , 37 Supplementary Table 1.

Creative, person-centered approaches to meet individual needs that consider various learning preferences, literacy, numeracy, language, culture, physical challenges, scheduling challenges, social determinants of health, and financial challenges should be widely available.

It is important to ensure access in communities at highest risk for diabetes, such as racial and ethnic minorities and underserved communities. Office-based health care teams without in-house resources can partner with local diabetes care and education specialists within their community to explore opportunities to reach people with diabetes and overcome some barriers to participation at the point of care If the office-based care team assumes responsibility for providing diabetes education and support, every effort should be made to ensure they receive up-to-date training in diabetes care and education and utilize the details in Tables 5 and 6.

Sample questions to guide a person-centered assessment Regardless of the DSMES approach or setting, personalized and comprehensive methods are necessary to promote effective self-management required for day-to-day living with diabetes.

Effective delivery involves expertise in clinical, educational, psychosocial, and behavioral diabetes care 39 , It is essential for the referring provider to mutually establish personal treatment plans and clinical goals with the person with diabetes and communicate these to the DSMES team.

Ongoing communication and support of recommendations and progress toward goals between the person with diabetes, education team, referring provider, and other members of the health care team are critical.

A person-centered approach to DSMES beginning at diagnosis of diabetes provides the foundation for current and future decisions. Diabetes self-management is not a static process and requires ongoing assessment and modification, as identified by the four critical times see Fig. Initial and ongoing DSMES helps the person overcome barriers and cope with the enduring and changing demands throughout the continuum of diabetes treatment and life transitions.

Providers and other members of the immediate health care team have an important role in providing education and ongoing support for self-management needs. New behaviors can be difficult to maintain and require reinforcement at a minimum of every 6 months In addition to the providers, the care team may include diabetes care and education specialists DCES ; registered dietitian nutritionists RDNs ; nutrition and dietetics technicians, registered NDTRs ; nurse educators; care managers; pharmacists; exercise and rehabilitation specialists; and behavioral or mental health care providers.

In addition, others have a role in helping to sustain the benefits gained from DSMES, including community health workers, nurses, care managers, trained peers, home health care service workers, social workers, and mental health counselors and other support people e. Professional associations may help identify specific services in the local area such as the Visiting Nurse Association and block nurse programs see Supplementary Table 1.

Family members and peers are an underutilized resource for ongoing support and often struggle with how to best provide help 47 , Including family members in the DSMES process can help facilitate their involvement 49 — Such support people can be especially helpful and serve as cultural navigators in health care systems and as liaisons to the community Community programs such as healthy cooking classes, walking groups, peer support communities, and faith-based groups may lend support for implementing healthy behavior changes, promoting emotional health, and meeting personal health goals Health care providers need to be aware of the DSMES resources in their health system and communities and make appropriate referrals.

Although these four critical times are listed, it is important to recognize diabetes is a chronic disease that progresses over time and requires vigilant care to meet changing physiologic needs and goals The existing treatment plan may become ineffective due to changing situations that can arise at any time.

Such situations include progression of the disease, changes in personal goals, unmet targets, major life changes, or new barriers identified when assessing social determinants of health.

It is prudent to be proactive when changes are identified or emerging. Additional support from the entire care team and referral to DSMES are appropriate responses to any of these needs.

Quality ongoing, routine diabetes care includes continuous assessment, ongoing education and learning, self-management planning, and ongoing support. The AADE7 Self-Care Behaviors provide the overarching framework for identifying key components of education and support The seven self-care behaviors are healthy coping, healthy eating, being active, taking medication, monitoring, reducing risks, and problem solving.

Mastery of skills and behaviors related to each of these areas requires practice and experience. Often, a series of ongoing education and support visits are necessary to allow participants the time to practice new skills and behaviors, to develop problem-solving skills, and to improve their ability and self-efficacy to set and reach personal self-management goals Care and education plans at each of the four critical times focus on the needs and personal goals of the individual.

Therefore, the plan should be based on personal experiences that are relevant to self-management and applicable to personal goals, treatment targets, and objectives and acknowledge that adults possess expertise about their own lives Tables 5 and 6 serve as checklists to ensure clinical teams and health systems offer necessary diabetes services factors that indicate DSMES needs and what DSMES provides.

Overview of MNT: an evidence-based application of the nutrition care process provided by the RDN 1 , 40 , 69 — Note: The Academy of Nutrition and Dietetics recognizes the use of registered dietitian RD and registered dietitian nutritionist RDN.

RD and RDN can only be used by those credentialed by the Commission on Dietetic Registration. For an individual and family, the diagnosis of diabetes is often overwhelming 58 , 59 , with fears, anger, myths, and personal, family, and life circumstances influencing this reaction.

Immediate care addresses these concerns through listening, providing emotional support, and answering questions. Providers typically first set the stage for a lifetime chronic condition that requires focus, hope, and resources to manage on a daily basis.

A person-centered approach at diagnosis is essential for establishing rapport and developing a personal and feasible treatment plan. Despite the wide range of knowledge and skills that are required to self-manage diabetes, caution should be taken to not confound the overwhelming nature of the diagnosis but to determine what the person needs from the care team at this time to safely navigate self-management during the first days and weeks.

Responses to such questions as shown in Table 7 also see Tables 5 and 6 guide and set direction for each person. Immediate referral to DSMES services establishes a personal education and support plan and highlights the value of initial and ongoing education.

Initial DSMES at diagnosis typically includes a series of visits or contacts to build on clinical, psychosocial, and behavioral needs.

See Table 6 for suggested content. These team members are critical at all four critical times. Important discussions at diagnosis include the natural history of type 2 diabetes, what the journey will involve in terms of lifestyle and possibly medication, and acknowledgment that a range of emotional responses is common.

Diabetes is largely self-managed and care management involves trial and error. The role of the health care team is to provide information and discuss effective strategies to reach chosen treatment targets and goals.

The many tasks of self-management are not easy, yet worth the effort 61 see benefits associated with dsmes. The health care team and others support the adoption and maintenance of daily self-management tasks 8 , 40 , as many people with diabetes find sustaining these behaviors difficult.

They need to identify education and other needs expeditiously in order to address the nuances of self-management and highlight the value of ongoing education. Table 6 provides details of DSMES at this critical time. Annual assessment of knowledge, skills, and behaviors is necessary for those who achieve diabetes treatment targets and personal goals as well as for those who do not.

Primary care visits for people with diabetes typically occur every 3—6 months These visits are opportunities to assess all areas of self-management, including laboratory results, and a review of behavioral changes and coping strategies, problem-solving skills, strengths and challenges of living with diabetes, use of technology, questions about medication therapy and lifestyle changes, and other environmental factors that might impact self-management It is challenging for primary care providers to address all assessments during a visit, which points to the need to utilize established DSMES resources and champion new ones to meet these needs, ensuring personal goals are met.

See Table 5 for indications for referral. Possible barriers to achieving treatment goals, such as financial and psychosocial issues, life stresses, diabetes-related distress, fears, side effects of medications, misinformation, cultural barriers, or misperceptions, should be assessed and addressed.

People with diabetes are sometimes unwilling or embarrassed to discuss these problems unless specifically asked 62 , Frequent DSMES visits may be needed when the individual is starting a new diabetes medication such as insulin 64 , is experiencing unexplained hypoglycemia or hyperglycemia, has worsening clinical indicators, or has unmet goals.

Importantly, diabetes care and education specialists are charged with communicating the revised plan to the referring provider and assisting the person with diabetes in implementing the new treatment plan.

The identification of diabetes-related complications or other individual factors that may influence self-management should be considered a critical indicator of the need for DSMES that requires immediate attention and adequate resources.

The diagnosis of other health conditions often makes management more complex and adds additional tasks onto daily management. DSMES addresses the integration of multiple medical conditions into overall care with a focus on maintaining or appropriately adjusting medication, meal plans, and physical activity levels to maximize outcomes and quality of life.

In addition to the need to adjust or learn new self-management skills, effective coping, defined as a positive attitude toward diabetes and self-management, positive relationships with others, and enhanced quality of life are addressed in DSMES services 16 , The progression of diabetes can increase the emotional and treatment burden of diabetes and distress 65 , It has a greater impact on behavioral and metabolic outcomes than does depression Diabetes-related distress is responsive to intervention, including DSMES-focused interventions 68 and family support However, additional mental health resources are generally required to address severe diabetes-related distress, clinical depression, and anxiety It is important to recognize the psychological issues related to diabetes and prescribe treatment as appropriate.

Throughout the life span many factors such as aging, living situation, schedule changes, or health insurance coverage may require a re-evaluation of diabetes treatment and self-management needs see Tables 5 and 6. They may also include life milestones: marriage, divorce, becoming a parent, moving, death of a loved one, starting or completing college, loss of employment, starting a new job, retirement, and other life circumstances.

Changing health care providers can also be a time at which additional support is needed. DSMES affords important benefits to people with diabetes during transitions in life and care. Providing input into the development of practical and realistic self-management and treatment plans can be an effective asset for successful navigation of changing situations.

The health care provider can make a referral to a diabetes care and education specialist to add input to the transition plan, provide education and problem solving, and support successful transitions.

The goal is to minimize disruptions in therapy during any transition, while addressing clinical, psychosocial, and behavioral needs.

Additionally, MNT helps prevent, delay, or treat other complications commonly found with diabetes such as hypertension, cardiovascular disease, renal disease, celiac disease, and gastroparesis.

MNT is integral to quality diabetes care and should be incorporated into the overall care plan, medication plan, and DSMES plan on an ongoing basis 1 , 40 , 69 — 72 Table 8.

Although basic nutrition content is covered as part of DSMES, people with diabetes need both initial and ongoing MNT and DSMES; referrals to both can be made through many electronic health records as well as through hard copy or faxed referral methods see Supplementary Table 1 for specific resources.

Everyday decisions about what to eat must be driven by evidence and personal, cultural, religious, economic, and other preferences and needs 69 — The entire health care team should provide consistent messages and recommendations regarding nutrition therapy and its importance as a foundation for quality diabetes care based on national recommendations Despite the proven value and effectiveness of DSMES, a looming threat to its success is low utilization due to a variety of barriers.

In order to reduce barriers, a focus on processes that streamline referral practices must be implemented and supported system wide. Once this major barrier is addressed, the diabetes care and education specialist can be invaluable in addressing other barriers that the person may have.

Without this, it will be increasingly difficult to access DSMES services, particularly in rural and underserved communities. With focus and effort, the challenges can be addressed and benefits realized. The Centers for Disease Control and Prevention reported that only 6.

This low initial participation in DSMES was also reported in a recent AADE practice survey, with most people engaging in a diabetes program diagnosed for more than a year These low numbers are seen even in areas where cost is less of a barrier because of national health insurance.

Analysis of National Health Service data in the U. This highlights the need to identify and utilize resources that address all barriers including those related to health systems, health care providers, participants, and the environment. In addition, efforts are being made by national organizations to correct the identified access and utilization barriers.

Health system or programmatic barriers include lack of administrative leadership support, limited numbers of diabetes care and education specialists, geographic location, limited or lack of access to services, referral to DSMES services not effectively embedded in the health system service structure, limited resources for marketing, and limited or low reimbursement rates DSMES services should be designed and delivered with input from the target population and critically evaluated to ensure they are patient-centered.

Despite the value and proven benefits of these services, barriers within the benefit design of Medicare and other insurance programs limit access.

Using Medicare as an example, some of these barriers include the following: hours allowed in the first year the benefit is used and subsequent years are predefined and not based on individual needs; a referral is required and must be made by the primary provider managing diabetes; there is a requirement of diabetes diagnosis using methods other than A1C; and costly copays and deductibles apply.

A person cannot have Medicare DSMES and MNT visits either face to face or through telehealth on the same day, thus requiring separate days to receive both of these valuable services and possibly delaying questions, education, and support.

Although there are many ways to measure adherence 40 , Medicare uses percent of days covered PDC , which is a measure of the number of pills prescribed divided by the days between first and last prescriptions. This metric can be used to find and track poor adherence and help to guide system improvement efforts to overcome the barriers to adherence.

Barriers to adherence may include patient factors remembering to obtain or take medications, fears, depression, or health beliefs , medication factors complexity, multiple daily dosing, cost, or side effects , and system factors inadequate follow-up or support.

Simplifying a complex treatment regimen may improve adherence. Nurse-directed interventions, home aides, diabetes education, and pharmacy-derived interventions improved adherence but had a very small effect on outcomes, including metabolic control Success in overcoming barriers may be achieved if the patient and provider agree on a targeted treatment for a specific barrier.

For example, one study found that when depression was identified as a barrier, agreement on antidepressant treatment subsequently allowed for improvements in A1C, blood pressure, and lipid control Thus, to improve adherence, systems should continually monitor and prevent or treat poor adherence by identifying barriers and implementing treatments that are barrier specific and effective.

Assess adherence. Adherence should be addressed as the first priority. If medication up-titration is not a viable option, then consider initiating or changing to a different medication class. Establish a follow-up plan that confirms the planned treatment change and assess progress in reaching the target.

The causes of health disparities are complex and include societal issues such as institutional racism, discrimination, socioeconomic status, poor access to health care, and lack of health insurance. Disparities are particularly well documented for cardiovascular disease.

Ethnic, cultural, religious, and sex differences and socioeconomic status may affect diabetes prevalence and outcomes. Ethnic, cultural, religious, sex, and socioeconomic differences affect health care access and complication risk in people with diabetes.

Socioeconomic and ethnic inequalities exist in the provision of health care to individuals with diabetes Significant racial differences and barriers exist in self-monitoring and outcomes Therefore, diabetes management requires individualized, patient-centered, and culturally appropriate strategies.

To overcome disparities, community health workers 49 , peers 50 , 51 , and lay leaders 52 may assist in the delivery of DSME and diabetes self-management support services Strong social support leads to improved clinical outcomes, reduced psychosocial symptomatology, and adoption of healthier lifestyles Structured interventions, tailored to ethnic populations that integrate culture, language, religion, and literacy skills, positively influence patient outcomes Not having health insurance affects the processes and outcomes of diabetes care.

Individuals without insurance coverage for blood glucose monitoring supplies have a 0. The affordable care act has improved access to health care; however, many remain without coverage. Providers should evaluate hyperglycemia and hypoglycemia in the context of food insecurity and propose solutions accordingly.

Providers should recognize that homelessness, poor literacy, and poor numeracy often occur with food insecurity, and appropriate resources should be made available for patients with diabetes. Food insecurity FI is the unreliable availability of nutritious food and the inability to consistently obtain food without resorting to socially unacceptable practices.

are food insecure. FI may involve a tradeoff between purchasing nutritious food for inexpensive and more energy- and carbohydrate-dense processed foods. In people with FI, interventions should focus on preventing diabetes and, in those with diabetes, limiting hyperglycemia and preventing hypoglycemia.

The risk for type 2 diabetes is increased twofold in those with FI. The risks of uncontrolled hyperglycemia and severe hypoglycemia are increased in those with diabetes who are also food insecure.

Providers should recognize that FI complicates diabetes management and seek local resources that can help patients and the parents of patients with diabetes to more regularly obtain nutritious food Hyperglycemia is more common in those with diabetes and FI. Providers should be well versed in these risk factors for hyperglycemia and take practical steps to alleviate them in order to improve glucose control.

Individuals with type 1 diabetes and FI may develop hypoglycemia as a result of inadequate or erratic carbohydrate consumption following insulin administration. Long-acting insulin, as opposed to shorter-acting insulin that may peak when food is not available, may lower the risk for hypoglycemia in those with FI.

Short-acting insulin analogs, preferably delivered by a pen, may be used immediately after consumption of a meal, whenever food becomes available. Unfortunately, the greater cost of insulin analogs should be weighed against their potential advantages. Those with type 2 diabetes and FI can develop hypoglycemia for similar reasons after taking certain oral hypoglycemic agents.

If using a sulfonylurea, glipizide is the preferred choice due to the shorter half-life. Glipizide can be taken immediately before meal consumption, thus limiting its tendency to produce hypoglycemia as compared with longer-acting sulfonylureas e.

Homelessness often accompanies the most severe form of FI. Therefore, providers who care for those with FI who are uninsured and homeless and individuals with poor literacy and numeracy should be well versed or have access to social workers to facilitate temporary housing for their patients as a means to prevent and control diabetes.

Additionally, homeless patients with diabetes need secure places to keep their diabetes supplies and refrigerator access to properly store their insulin. FI and diabetes are more common among non-English speaking individuals and those with poor literacy and numeracy skills.

Therefore, it is important to consider screening for FI, proper housing, and diabetes in this population. Programs that see such patients should work to develop services in multiple languages with the specific goal of preventing diabetes and building diabetes awareness in people who cannot easily read or write in English.

Intensive glucose control is not advised for the improvement of poor cognitive function in hyperglycemic individuals with type 2 diabetes.

In individuals with poor cognitive function or severe hypoglycemia, glycemic therapy should be tailored to avoid significant hypoglycemia. In individuals with diabetes at high cardiovascular risk, the cardiovascular benefits of statin therapy outweigh the risk of cognitive dysfunction.

If a second-generation antipsychotic medication is prescribed, changes in weight, glycemic control, and cholesterol levels should be carefully monitored and the treatment regimen should be reassessed.

The most severe form of cognitive dysfunction is dementia. The reverse is also true: people with Alzheimer dementia are more likely to develop diabetes than people without Alzheimer dementia.

In those with type 2 diabetes, the degree and duration of hyperglycemia are related to dementia. More rapid cognitive decline is associated with both increased A1C and longer duration of diabetes However, the ACCORD study found no difference in cognitive outcomes between intensive and standard glycemic control, supporting the recommendation that intensive glucose control should not be advised for the improvement of cognitive function in individuals with type 2 diabetes In type 2 diabetes, severe hypoglycemia is associated with reduced cognitive function, and those with poor cognitive function have more severe hypoglycemia.

In a long-term study of older patients with type 2 diabetes, individuals with one or more recorded episode of severe hypoglycemia had a stepwise increase in risk of dementia Likewise, the ACCORD trial found that as cognitive function decreased, the risk of severe hypoglycemia increased Tailoring glycemic therapy may help to prevent hypoglycemia in individuals with cognitive dysfunction.

In one study, adherence to the Mediterranean diet correlated with improved cognitive function However, a recent Cochrane review found insufficient evidence to recommend any dietary change for the prevention or treatment of cognitive dysfunction Given the controversy over a potential link between statins and dementia, it is worth noting that a Cochrane systematic review has reported that data do not support an adverse effect of statins on cognition.

The U. Food and Drug Administration FDA postmarketing surveillance databases have also revealed a low reporting rate for cognitive-related adverse events, including cognitive dysfunction or dementia, with statin therapy, similar to rates seen with other commonly prescribed cardiovascular medications Therefore individuals with diabetes and a high risk for cardiovascular disease should be placed on statin therapy regardless of cognitive status.

Severe mental disorder that includes schizophrenia, bipolar disorder, and depression is increased 1. The prevalence of type 2 diabetes is two—three times higher in people with schizophrenia, bipolar disorder, and schizoaffective disorder than in the general population Diabetes medications are effective, regardless of mental health status.

Treatments for depression are effective in patients with diabetes, and treating depression may improve short-term glycemic control If a second-generation antipsychotic medication is prescribed, changes in weight, glycemic control, and cholesterol levels should be carefully monitored and the treatment regimen should be reassessed if significant changes are noted Patients with HIV should be screened for diabetes and prediabetes with a fasting glucose level before starting antiretroviral therapy and 3 months after starting or changing it.

If initial screening results are normal, checking fasting glucose each year is advised. If prediabetes is detected, continue to measure levels every 3—6 months to monitor for progression to diabetes.

Diabetes risk is increased with certain protease inhibitors PIs and nucleoside reverse transcriptase inhibitors NRTIs. PIs are associated with insulin resistance and may also lead to apoptosis of pancreatic β-cells. NRTIs also affect fat distribution both lipohypertrophy and lipoatrophy , which is associated with insulin resistance.

Individuals with HIV are at higher risk for developing prediabetes and diabetes on antiretroviral ARV therapies, so a proper screening protocol is recommended In those with prediabetes, weight loss through healthy nutrition and physical activity may reduce the progression toward diabetes.

Among HIV patients with diabetes, preventive health care using an approach similar to that used in patients without HIV is critical to reduce the risks of microvascular and macrovascular complications.

For patients with HIV and ARV-associated hyperglycemia, it may be appropriate to consider discontinuing the problematic ARV agents if safe and effective alternatives are available Before making ARV substitutions, carefully consider the possible effect on HIV virological control and the potential adverse effects of new ARV agents.

In some cases, antidiabetes agents may still be necessary.

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