This is the third article on the recently released Standards of Medical Care in Diabetes 2017. The focus of this article will be on the guidelines for lifestyle management.

Key Messages:

Lifestyle management includes

• Diabetes Self-Management Education (DSME),
• Diabetes Self-Management Support (DSMS),
• Medical Nutrition Therapy (MNT),
• Physical activity,
• Smoking cessation, and
• Psychosocial care.

DSME and DSMS

Recommendations

Effective self-management and improved clinical outcomes, health status, and quality of life are key goals of DSME and DSMS that should be measured and monitored as part of routine care.

DSME and DSMS should be patient-centered, respectful, and responsive to individual patient preferences, needs, and values, and should help guide clinical decisions.

The overall objectives of DSME and DSMS are to support

• informed decision-making,
• self-care behaviors,
• problem-solving, and
• active collaboration with the health care team

to improve clinical outcomes, health status, and quality of life in a cost-effective manner.

Four critical time points have been defined when the need for DSME and DSMS should be evaluated by the medical care provider and/or multidisciplinary team, with referrals made as needed:

1. At diagnosis
2. Annually for assessment of education, nutrition, and emotional needs
3. When new complicating factors (health conditions, physical limitations, emotional factors, or basic living needs) arise that influence self-management
4. When transitions in care occur

Nutrition Therapy

There is not a one-size-fits-all eating pattern for individuals with diabetes.

The Mediterranean diet, Dietary Approaches to Stop Hypertension (DASH) diet, and plant-based diets are all examples of healthful eating patterns. See Table 4.1 for specific nutrition recommendations.

In overweight and obese patients with type 2 diabetes, modest weight loss, defined as sustained reduction of 5% of initial body weight, has been shown to improve glycemic control and to reduce the need for glucose-lowering medications. However, sustaining weight loss can be challenging.

Weight loss can be attained with lifestyle programs that achieve a 500–750 kcal/day energy deficit or provide

• ~1,200–1,500 kcal/ day for women and
• 1,500–1,800 kcal/day for men,

adjusted for the individual’s baseline body weight.

Physical activity

Recommendations

Children and adolescents with type 1 or type 2 diabetes or prediabetes should engage in 60 min/ day or more of moderate or vigorous intensity aerobic activity, with vigorous, muscle-strengthening, and bone-strengthening activities included at least 3 days/week.

Most adults with with type 1 or type 2 diabetes should engage in 150 min or more of moderate-to-vigorous intensity activity per week, spread over at least 3 days/week, with no more than 2 consecutive days without activity. Shorter durations (minimum 75 min/week) of vigorous-intensity or interval training may be sufficient for younger and more physically fit individuals.

Adults with type 1 or type 2 diabetes should engage in 2−3 sessions/week of resistance exercise on nonconsecutive days.

All adults, and particularly those with type 2 diabetes, should decrease the amount of time spent in daily sedentary behavior.

Prolonged sitting should be interrupted every 30 min for blood glucose benefits, particularly in adults with type 2 diabetes.

Flexibility training and balance training are recommended 2−3 times/week for older adults with diabetes. Yoga and tai chi may be included based on individual preferences to increase flexibility, muscular strength, and balance.

Smoking Cessation

Tobacco and e-Cigarettes Recommendations

Advise all patients not to use cigarettes and other tobacco products or e-cigarettes.

Include smoking cessation counseling and other forms of treatment as a routine component of diabetes care.

Psychosocial Issues

Recommendations

Psychosocial care should be integrated with a collaborative, patient-centered approach and provided to all people with diabetes, with the goals of optimizing health outcomes and health-related quality of life.

Psychosocial screening and follow-up may include, but are not limited to,

• attitudes about the illness,
• expectations for medical management and outcomes,
• affect or mood,
• general and diabetes-related quality of life,
• available resources (financial, social, and emotional), and
• psychiatric history.

Providers should consider assessment for symptoms of

• diabetes distress,
• depression,
• anxiety, and
• disordered eating, as well as
• cognitive capacities,

using patient-appropriate standardized and validated tools at

• the initial visit,
• at periodic intervals, and
• when there is a change in disease, treatment, or life circumstances.

Including caregivers and family members in this assessment is recommended.

Consider screening older adults (aged ≥65 years) with diabetes for cognitive impairment and depression.

Useful Links:

Link to the ADA Standards of Medical Care in Diabetes document:

Click to access dc_40_s1_final.pdf

Link to the ADA news release:

http://www.diabetes.org/newsroom/press-releases/2016/american-diabetes-2017-standards-of-care.html?referrer=https://www.google.co.in/?referrer=http://www.diabetes.org/newsroom/press-releases/2016/american-diabetes-2017-standards-of-care.html