kelingwang/causation_strength_rating huggingface dataset:
In type 1 diabetes, HIIT is associated with reductions in A1C levels, reduction in insulin requirements, and improvement in cardiometabolic risk profiles (322).
Variability in glucose may occur with an increased risk in delayed hypoglycemia, so careful monitoring of glucose during and after HIIT is advised (322).
Pre-exercise Evaluation
As discussed more fully in Section 10, �Cardiovascular Disease and Risk Management,� the best protocol for assessing asymptomatic people with diabetes for coronary artery disease remains unclear.
The ADA consensus report �Screening for Coronary Artery Disease in Patients With Diabetes� (324) concluded that routine testing is not recommended.
However, health care professionals should perform a careful history, assess cardiovascular risk factors, and be aware of the atypical presentation of coronary artery disease, such as recent reported or tested decrease in exercise tolerance in people with diabetes.
Certainly, those with high risk should be encouraged to start with short periods of low-intensity exercise and slowly increase the duration and intensity as tolerated.
Health care professionals should assess for conditions that might contraindicate certain types of exercise or predispose to injury, such as uncontrolled hypertension, untreated proliferative retinopathy, autonomic neuropathy, peripheral neuropathy, balance impairment, and a history of foot ulcers or Charcot foot.
Age and previous physical activity level should be considered when customizing the exercise plan to the individual�s needs.
Those with complications may need a more thorough evaluation prior to starting an exercise program (293).
Hypoglycemia
In individuals taking insulin and/or insulin secretagogues, physical activity may cause hypoglycemia if the medication dose or carbohydrate consumption is not adjusted for the exercise bout and post-bout impact on glucose.
Individuals on these therapies may need to ingest some added carbohydrate if pre-exercise glucose levels are <90 mg/dL (<5.0 mmol/L), depending on whether they are able to lower insulin doses during the workout (such as with an insulin pump or reduced pre-exercise insulin dosage), the time of day exercise is done, and the intensity and duration of the activity (293).
In some people with diabetes, hypoglycemia after exercise may occur and last for several hours due to increased insulin sensitivity.
Hypoglycemia is less common in those who are not treated with insulin or insulin secretagogues, and no routine preventive measures for hypoglycemia are usually advised in these cases.
Intense activities may actually raise blood glucose levels instead of lowering them, especially if pre-exercise glucose levels are elevated (293).
Because of the variation in glycemic response to exercise bouts, people with diabetes need to be educated to check blood glucose levels or consult sensor glucose values before and after periods of exercise and about the potential prolonged effects (depending on intensity and duration) (325).
Exercise in the Presence of Microvascular Complications
See Section 11, �Chronic Kidney Disease and Risk Management,� and Section 12, �Retinopathy, Neuropathy, and Foot Care,� for more information on these long-term complications.
A meta-analysis on this topic demonstrated moderate certainty of evidence that high versus low levels of physical activity were associated with lower CVD incidence and mortality (summary risk ratio 0.84 [95% CI 0.77–0.92], n = 7, and 0.62 [0.55–0.69], n = 11) and fewer microvascular complications (0.76 [0.67–0.86], n = 8).
Dose-response meta-analyses showed that physical activity was associated with lower risk of diabetes-related complications even at lower levels (326).
Retinopathy
If proliferative diabetic retinopathy or severe nonproliferative diabetic retinopathy is present, then vigorous-intensity aerobic or resistance exercise may be contraindicated because of the risk of triggering vitreous hemorrhage or retinal detachment (327).
Consultation with an ophthalmologist prior to engaging in an intense exercise plan may be appropriate.
Peripheral Neuropathy
Decreased pain sensation and a higher pain threshold in the extremities can result in an increased risk of skin breakdown, infection, and Charcot joint destruction with some forms of exercise.
Therefore, a thorough assessment should be done to ensure that neuropathy does not alter kinesthetic or proprioceptive sensation during physical activity, particularly in those with more severe neuropathy.
Studies have shown that moderate-intensity walking may not lead to an increased risk of foot ulcers or reulceration in those with peripheral neuropathy who use proper footwear (328).
In addition, 150 min/week of moderate exercise was reported to improve outcomes in people with prediabetic neuropathy (329).
All individuals with peripheral neuropathy should wear proper footwear and examine their feet daily to detect lesions early.
Anyone with a foot injury or open sore should be restricted to non�weight-bearing activities.
Autonomic Neuropathy
Autonomic neuropathy can increase the risk of exercise-induced injury or adverse events through decreased cardiac responsiveness to exercise, postural hypotension, impaired thermoregulation, impaired night vision due to impaired papillary reaction, and greater susceptibility to hypoglycemia (330).
Cardiovascular autonomic neuropathy is also an independent risk factor for cardiovascular death and silent myocardial ischemia (331).
Therefore, individuals with diabetic autonomic neuropathy should undergo cardiac investigation before beginning physical activity more intense than that to which they are accustomed.
Diabetic Kidney Disease
Physical activity can acutely increase urinary albumin excretion.
However, there is no evidence that vigorous-intensity exercise accelerates the rate of progression of DKD, and there appears to be no need for specific exercise restrictions for people with DKD in general (327).
Adults with diabetes are encouraged to engage in 2–3 sessions/week of resistance exercise on nonconsecutive days (308).
Although heavier resistance training with free weights or weight machines may improve glycemia and strength (309), resistance training of any intensity is recommended to improve strength, balance, and the ability to engage in activities of daily living throughout the life span.
Health care professionals should support people with diabetes to set stepwise goals toward meeting the recommended exercise goals.
As individuals intensify their exercise program, medical monitoring may be indicated to ensure safety and evaluate the effects on glucose management.
(See physical activity and glycemic management, below.)
DSMES is associated with improved diabetes knowledge and self-care behaviors (17), lower A1C (17–22), lower self-reported weight (23), improved quality of life (19,24,25), reduced all-cause mortality risk (26), positive coping behaviors (5,27), and lower health care costs (28–30).
DSMES is associated with an increased use of primary care and preventive services (28,31,32) and less frequent use of acute care and inpatient hospital services (23).
People with diabetes who participate in DSMES are more likely to follow best practice treatment recommendations, particularly those with Medicare, and have lower Medicare and insurance claim costs (29,32).
Better outcomes were reported for DSMES interventions that were >10 h over the course of 6–12 months (20), included ongoing support (14,33), were culturally (34–36) and age appropriate (37,38), were tailored to individual needs and preferences, addressed psychosocial issues, and incorporated behavioral strategies (15,27,39,40).
Individual and group approaches are effective (41–43), with a slight benefit realized by those who engage in both (20).
A systematic review and meta-analysis found higher frequency of regular leisure-time physical activity was more effective in reducing A1C levels (314).
A wide range of activities, including yoga, tai chi, and other types, can have significant impacts on A1C, flexibility, muscle strength, and balance (286,315–317).
Flexibility and balance exercises may be particularly important in older adults with diabetes to maintain range of motion, strength, and balance (297) (Fig.5.1).
There is strong evidence that exercise interventions in individuals with type 2 diabetes improve depression, A1C, and overall psychosocial well-being (318).
Evidence supports that all individuals, including those with diabetes, should be encouraged to reduce the amount of time spent being sedentary�waking behaviors with low energy expenditure (e.g., seated work at a computer or watching television)�by breaking up bouts of sedentary activity (>30 min) by briefly standing, walking, or performing other light physical activities (310,311).
Participating in leisure-time activity and avoiding extended sedentary periods may help prevent type 2 diabetes for those at risk and may also aid in glycemic management for those with diabetes (312,313).
A causal link between cigarette smoking and diabetes has been established and reported on by the Surgeon General for over a decade (332).
Results from epidemiologic, case-control, and cohort studies provide convincing evidence to support the causal link between cigarette smoking and multiple health risks that can have a profound impact on morbidity and mortality for people with diabetes (332).
People with diabetes who smoke and are exposed to second-hand smoke have a heightened risk of macrovascular complications (e.g., cardiovascular and peripheral vascular disease), microvascular complications (e.g., kidney disease and visual impairment), worse glycemic outcomes, and premature death compared with those who do not smoke (333–336).
Emerging data suggest smoking has a role in the development of type 2 diabetes, and quitting has been shown to significantly decrease this risk over time (337–340).
The routine (every visit with every person), thorough assessment of all types of tobacco use is essential to prevent tobacco product initiation and promote cessation.
Evidence demonstrates significant benefits to quitting smoking for all people, resulting in a reduction and even reversal of adverse health effects in addition to an increase in life expectancy by as much as a decade (341).
However, data show tobacco use prevalence among adults with chronic conditions has remained persistently higher than that in the general population (342), with recent declines in smoking in middle-aged people with diabetes but not in adolescents and young adults (342).
Numerous large RCTs have demonstrated the efficacy and cost-effectiveness of both intensive and brief counseling in smoking cessation, including the use of telephone quit lines and web-based interventions, in reducing tobacco use and maintaining abstinence from smoking (341,343,344).
Current recommendations include both counseling and pharmacologic therapy to assist with smoking cessation in nonpregnant adults (345); however, more than two-thirds of people trying to quit do not receive treatment following evidence-based guidelines (341).
Weight gain after smoking cessation has been a concern related to diabetes management and risk for new onset of disease (346).
While post-cessation weight gain is an identified issue, studies have found that an average weight gain of 3–5 kg does not necessarily persist long term or diminish the substantial cardiovascular benefit realized from smoking cessation (337).
These findings highlight the need for tobacco cessation treatment that addresses eating and physical activity needs.
One study in people with newly diagnosed type 2 diabetes who smoke found that smoking cessation was associated with amelioration of microalbuminuria and reduction in blood pressure after 1 year (347).
In recent years, there has been an increase in the use and availability of multiple noncigarette nicotine products.
The evidence regarding the effect of these products on diabetes is not as clear as that for combustible cigarettes.
It is known that smokeless tobacco products, such as dip and chew, pose an increased risk for CVD (348).
E-cigarettes and vaping have gained public awareness and popularity because of perceptions that e-cigarette use is less harmful than regular cigarette smoking (349,350).
While combustible tobacco products are clearly the most harmful, electronic products should not be characterized as harmless, as health risks with use that affect the cardiovascular and respiratory systems have been identified (351,352).
Individuals with diabetes should be advised to avoid vaping and using e-cigarettes, either as a way to stop smoking combustible cigarettes or as a recreational drug.
If people are using e-cigarettes to quit, they should be advised to avoid using both combustible and electronic cigarettes, and if using only e-cigarettes, they should be advised to have a plan to quit these also (344).
Increased legalization and multiple formulations of cannabis products have resulted in increased prevalence in the use of these products in all age-groups (353,354).
Significant increases in tetrahydrocannabinol (THC) concentrations and use of additional psychoactive cannabinoid products, such as delta-8 THC, are of specific concern (355).
Most of these products are currently unregulated by the FDA, and public health warnings regarding use have been issued (356).
The FDA reports adverse effects related to delta-8 THC, some of which may have health implications for people with diabetes (e.g., vomiting) (356).
Evidence of specific increased risk of diabetic ketoacidosis and hyperglycemic ketosis associated with cannabis use and cannabis hyperemesis syndrome in adults with type 1 diabetes has been recently reported (357–359).
Diabetes education programs offer potential to systematically reach and engage individuals with diabetes in smoking cessation efforts.
A cluster randomized trial found statistically significant increases in quit rates and long-term abstinence rates (>6 months) when smoking cessation interventions were offered through diabetes education clinics, regardless of motivation to quit at baseline (360).
The increased prevalence in use of an expanding landscape of both tobacco and cannabis products and the impact on the health of people with diabetes highlights the need to ask about use of these products, educate individuals regarding the associated risks, and provide support for cessation.
Given associations with glycemic outcomes and risk for future complications (361,362), it is important for diabetes care professionals to support people with diabetes to engage in health-promoting behaviors (preventive, treatment, and maintenance), including blood glucose monitoring, taking insulin and medications, using diabetes technologies, engaging in physical activity, and making nutritional changes.
Evidence supports using a variety of behavioral strategies and multicomponent interventions to help people with diabetes and their caregivers or family members develop health behavior routines and overcome barriers to self-management behaviors (363–365).
Behavioral strategies with empirical support include motivational interviewing (366–368), patient activation (369), goal setting and action planning (368,370–372), problem-solving (371,373), tracking or self-monitoring health behaviors with or without feedback from a health care professional (368,370–372), and facilitating opportunities for social support (368,371,372).
There is mixed evidence about behavioral economics strategies (e.g., financial incentives and exposure to information about social norms) to promote engagement in health behaviors among people with diabetes; such strategies tend to enhance intentions and demonstrate short-term benefits for behavior change, although there is less evidence about sustained effects (374).
Multicomponent behavior change intervention packages have the highest efficacy for behavioral and glycemic outcomes (363,372,375).
For youth with diabetes, family-based behavioral intervention packages and multisystem interventions that facilitate health behavior change demonstrate benefit for increasing management behaviors and improving glycemic outcomes (364).
As with all diabetes health care, it is important to adapt and tailor behavior change strategies to the characteristics and needs of the individual and population (376–378).
Health behavior change strategies may be delivered by behavioral health professionals, DCES, other trained health care professionals (370,379–381), or qualified community health workers (370,371).
These approaches may be delivered via digital health tools (372,380,382).
There are effective strategies to train diabetes care professionals to use such methods (e.g., motivational interviewing) (383).
Please refer to the ADA position statement �Psychosocial Care for People With Diabetes� for a list of assessment tools and additional details (1) and the ADA Behavioral Health Toolkit for assessment questionnaires and surveys (professional.diabetes.org/meetings/behavioral-health-toolkit).
Throughout the Standards of Care, the broad term �behavioral health� is used to encompass both 1) health behavior engagement and relevant factors and 2) behavioral health concerns and care related to living with diabetes.
Complex environmental, social, family, behavioral, and emotional factors, known as psychosocial factors, influence living with type 1 and type 2 diabetes and achieving optimal health outcomes and psychological well-being.
Thus, individuals with diabetes and their families are challenged with complex, multifaceted issues when integrating diabetes care into daily life (384).
Clinically significant behavioral health diagnoses are considerably more prevalent in people with diabetes than in those without (385–387).
Emotional well-being is an important part of diabetes care and self-management.
Psychological and social problems can impair the individual�s (57,388–392) or family�s (391) ability to carry out diabetes care tasks and potentially compromise health status.
Therefore, psychological symptoms, both clinical and subclinical, must be addressed.
In addition to impacting a person�s ability to carry out self-management and the association of behavioral health diagnoses with poorer short-term glycemic stability, symptoms of emotional distress are associated with increased mortality risk (386,393).
There are opportunities for diabetes health care professionals to routinely monitor and screen psychosocial status in a timely and efficient manner for referral to appropriate services (394,395).
Various health care professionals working with people with diabetes may contribute to psychosocial care in different ways based on training, experience, need, and availability (380,396,397).
Ideally, qualified behavioral health professionals with specialized training and experience in diabetes should be integrated with or provide collaborative care as part of diabetes care teams (398–401).
Referrals for in-depth assessment and treatment for psychosocial concerns should be made to such behavioral health professionals when indicated (381,402,403).
A systematic review and meta-analysis showed that psychosocial interventions modestly but significantly improved A1C and behavioral health outcomes (404).
There was a limited association between the effects on A1C and behavioral health, and no intervention characteristics predicted benefit on both outcomes.
However, cost analyses have shown that behavioral health interventions are both effective and cost-efficient approaches to the prevention of diabetes (405).
Evidence supports interventions for people with diabetes and psychosocial concerns, including issues that affect behavioral health.
Successful therapeutic approaches include cognitive behavioral (400,402,429,430) and mindfulness-based therapies (427,431,432).
See the sections below for details about interventions for specific psychological concerns.
Behavioral interventions may also be indicated in a preventive manner even in the absence of positive psychosocial screeners, such as resilience-promoting interventions to prevent diabetes distress in adolescence (433,434) and behavioral family interventions to promote collaborative family diabetes management in early adolescence (435,436) or to support adjustment to a new treatment plan or technology (65).
Psychosocial interventions can be delivered via digital health platforms (437).
Group-based or shared diabetes appointments that address both medical and psychosocial issues relevant to living with diabetes are a promising model to consider (397,438).
Although efficacy has been demonstrated with psychosocial interventions, there has been varying success regarding sustained increases in engagement in health behaviors and improved glycemic outcomes associated with behavioral health issues.
Thus, health care professionals should systematically monitor these outcomes following implementation of current evidence-based psychosocial treatments to determine ongoing needs.
Health care teams should develop and implement psychosocial screening protocols to ensure routine monitoring of psychosocial well-being and to identify potential concerns among people with diabetes, following published guidance and recommendations (406–411).
Topics to screen for may include, but are not limited to, attitudes about diabetes, expectations for treatment and outcomes (especially related to starting a new treatment or technology), general and diabetes-related mood, stress, and/or quality of life (e.g., diabetes distress, depressive symptoms, anxiety symptoms, and/or fear of hypoglycemia), available resources (financial, social, family, and emotional), and/or psychiatric history.
Given elevated rates of suicidality among people with diabetes (412–415), screening for suicidality may also be appropriate (416–418), similar to U.S. Preventive Services Task Force statements regarding screening for some adolescents and adults in the general population (419,420).
A list of age-appropriate screening and evaluation measures is provided in the ADA position statement �Psychosocial Care for People with Diabetes� (1), and guidance has been published about selection of screening tools, clinical thresholds, and frequency of screening (408,421).
Key opportunities for psychosocial screening occur at diabetes diagnosis, during regularly scheduled management visits, during hospitalizations, with new onset of complications, during significant transitions in care such as from pediatric to adult care teams (422), at the time of medical treatment changes, or when problems with achieving A1C goals, quality of life, or self-management are identified.
People with diabetes are likely to exhibit psychological vulnerability at diagnosis, when their medical status changes (e.g., end of the honeymoon period), when the need for intensified treatment is evident, and when complications are discovered.
Significant changes in life circumstances and SDOH are known to considerably affect a person�s ability to self-manage their condition.
Thus, screening for SDOH (e.g., loss of employment, birth of a child, or other family-based stresses) should also be incorporated into routine care (423).
In circumstances where individuals other than the person with diabetes are significantly involved in diabetes management (e.g., caregivers or family members), these issues should be monitored and treated by appropriate professionals (422,424,425).
Standardized, validated, age-appropriate tools for psychosocial monitoring and screening can also be used (1).
The ADA provides access to tools for screening specific psychosocial topics, such as diabetes distress, fear of hypoglycemia, and other relevant psychological symptoms at professional.diabetes.org/sites/default/files/media/ada_mental_health_toolkit_questionnaires.pdf.
Additional information about developmentally specific psychosocial screening topics is available in Section 14, �Children and Adolescents,� and Section 13, �Older Adults.�
Health care professionals may also use informal verbal inquires, for example, by asking whether there have been persistent changes in mood during the past 2 weeks or since the individual�s last appointment and whether the person can identify a triggering event or change in circumstances.