4. Foundations of Care: Education,Nutrition, Physical Activity,Smoking Cessation, PsychosocialCare, and ImmunizationDiabetes Care 2015;38(Suppl. 1):S20–S30 | DOI: 10.2337/dc15-S007

DIABETES SELF-MANAGEMENT EDUCATION AND SUPPORT

Recommendations

c People with diabetes should receive diabetes self-management education(DSME) and diabetes self-management support (DSMS) according to the na-tional standards for DSME and DSMS when their diabetes is diagnosed and asneeded thereafter. B

c Effective self-management and quality of life are the key outcomes of DSMEand DSMS and should be measured and monitored as part of care. C

c DSME and DSMS should address psychosocial issues, as emotional well-beingis associated with positive diabetes outcomes. C

c DSME and DSMS programs are appropriate venues for people with prediabe-tes to receive education and support to develop and maintain behaviors thatcan prevent or delay the onset of diabetes. C

c Because DSME and DSMS can result in cost-savings and improved outcomes B,DSME and DSMS should be adequately reimbursed by third-party payers. E

DSME and DSMS are the ongoing processes of facilitating the knowledge, skill, andability necessary for diabetes self-care. This process incorporates the needs, goals,and life experiences of the person with diabetes. The overall objectives of DSME andDSMS are to support informed decision making, self-care behaviors, problem solv-ing, and active collaborationwith the health care team to improve clinical outcomes,health status, and quality of life in a cost-effective manner (1).DSME and DSMS are essential elements of diabetes care (2,3), and the current

national standards for DSME and DSMS (1) are based on evidence of their benefits.Education helps people with diabetes initiate effective self-management and copewith diabetes when they are first diagnosed. Ongoing DSME and DSMS also helppeople with diabetes maintain effective self-management throughout a lifetimeof diabetes as they face new challenges and as treatment advances become avail-able. DSME enables patients (including youth) to optimize metabolic control, pre-vent and manage complications, and maximize quality of life in a cost-effectivemanner (2,4).Current best practice of DSME is a skill-based approach that focuses on helping

those with diabetes make informed self-management choices (1,2). DSME haschanged from a didactic approach focusing on providing information to empow-erment models that focus on helping those with diabetes make informed self-management decisions (2). Diabetes care has shifted to an approach that is morepatient centered and places the person with diabetes and his or her family at thecenter of the care model, working in collaboration with health care professionals.Patient-centered care is respectful of and responsive to individual patient pref-erences, needs, and values and ensures that patient values guide all decisionmaking (5).

Evidence for the BenefitsMultiple studies have found that DSME is associated with improved diabetes knowl-edge, improved self-care behavior (1), improved clinical outcomes, such as lower

Suggested citation: American Diabetes Associa-tion. Foundations of care: education, nutrition,physical activity, smoking cessation, psychoso-cial care, and immunization. Sec. 4. In Standardsof Medical Care in Diabetesd2015. DiabetesCare 2015;38(Suppl. 1):S20–S30

© 2015 by the American Diabetes Association.Readers may use this article as long as the workis properly cited, the use is educational and notfor profit, and the work is not altered.

American Diabetes Association

S20 Diabetes Care Volume 38, Supplement 1, January 2015

POSITION

STATEMEN

T

A1C (3,6–8), lower self-reported weight(9,10), improved quality of life (8,11),healthy coping (12,13), and lower costs(14,15). Better outcomes were reportedfor DSME interventions that were longerand included follow-up support (DSMS)(16–18), that were culturally (19,20) andage appropriate (21,22), that were tai-lored to individual needs and prefer-ences, and that addressed psychosocialissues and incorporated behavioralstrategies (2,12,23,24). Both individualand group approaches have been foundeffective (10,25). There is growing evi-dence for the role of community healthworkers (26), as well as peer (27–30) andlay leaders (31), in delivering DSME andDSMS (32).Diabetes education is associated with

increased use of primary and preventiveservices (14,33,34) and lower use ofacute, inpatient hospital services (14).Patients who participate in diabetes ed-ucation are more likely to follow bestpractice treatment recommendations,particularly among the Medicare popu-lation, and have lower Medicare and in-surance claim costs (15,33).

National StandardsThe national standards for DSME andDSMS are designed to define qualityand to assist diabetes educators in a va-riety of settings to provide evidence-based education and self-managementsupport (1). The standards are reviewedand updated every 5 years by a taskforce representing key organizations in-volved in diabetes education and care.

ReimbursementDSME, when provided by a program thatmeets national standards for DSME andis recognized by the American DiabetesAssociation (ADA) or other approvalbodies, is reimbursed as part of theMedicare program as overseen by theCenters for Medicare & Medicaid Ser-vices. DSME is also covered by mosthealth insurance plans. Although DSMShas been shown to be instrumentalfor improving outcomes and can be pro-vided via phone calls and telehealth, itcurrently has limited reimbursement asin-person follow-up to DSME.

MEDICAL NUTRITION THERAPY

For many individuals with diabetes, themost challenging part of the treatment

plan is determining what to eat. It is theposition of the ADA that there is not aone-size-fits-all eating pattern for indi-viduals with diabetes. The ADA also rec-ognizes the integral role of nutritiontherapy in overall diabetes manage-ment and recommends that each per-son with diabetes be actively engagedin self-management, education, andtreatment planning with his or herhealth care provider, which includesthe collaborative development of anindividualized eating plan (35,36).Therefore, it is important that all mem-bers of the health care team be knowl-edgeable about diabetes nutritiontherapy and support its implementa-tion. See Table 4.1 for specific nutritionrecommendations.

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

eating patterns, emphasizing a varietyof nutrient-dense foods in appropriateportion sizes, in order to improveoverall health and specifically to○ Attain individualized glycemic,

blood pressure, and lipid goals○ Achieve andmaintain bodyweight

goals○ Delay or prevent complications of

diabetes2. To address individual nutrition needs

based on personal and cultural pref-erences, health literacy and numer-acy, access to healthful food choices,willingness and ability to make be-havioral changes, and barriers tochange.

3. Tomaintain the pleasure of eating byproviding positive messages aboutfood choices while limiting foodchoices only when indicated by sci-entific evidence.

4. To provide the individual with diabe-teswith practical tools for day-to-daymeal planning rather than focusingon individual macronutrients, micro-nutrients, or single foods.

Nutrition therapy is an integral compo-nent of diabetes prevention, manage-ment, and self-management education.All individuals with diabetes should re-ceive individualized medical nutritiontherapy (MNT), preferably provided by aregistered dietitian who is knowledgeableand skilled in providing diabetes MNT.Comprehensive group diabetes education

programs including nutrition therapy orindividualized education sessions have re-ported A1C decreases of 0.3–1% for type1 diabetes (37–41) and 0.5–2% for type 2diabetes (42–49).

Carbohydrate ManagementIndividuals with type 1 diabetes shouldbe offered intensive insulin therapyeducation using the carbohydrate-counting meal planning approach(37,39,40,43,50), which has been shownto improve glycemic control (50,51).Consistent carbohydrate intake with re-spect to time and amount can result inimproved glycemic control for individu-als using fixed daily insulin doses (36). Asimple diabetesmeal planning approach,such as portion control or healthful foodchoices, may be better suited for individ-uals with health literacy and numeracyconcerns (36–40,42).

Weight LossIntensive lifestyle programs with fre-quent follow-up are required to achievesignificant reductions in excess bodyweight and improve clinical indicators(52,53). Weight loss of 2–8 kg may pro-vide clinical benefits in those with type 2diabetes, especially early in the diseaseprocess (52,53). Although several studiesresulted in improvements in A1C at 1 year(52,54–56), not all weight-loss interven-tions led to 1-year A1C improvements(45,57–60). The most consistently identi-fied changes in cardiovascular risk factorswere an increase in HDL cholesterol(52,54,56,59,61), decrease in triglycerides(52,61–63), and decrease in blood pres-sure (52,54,57,59,61).

Weight-loss studies have used a vari-ety of energy-restricted eating patterns,with no clear evidence that one eatingpattern or optimal macronutrient dis-tribution was ideal, suggesting thatmacronutrient proportions should beindividualized (64). Studies show thatpeople with diabetes eat on averageabout 45% of their calories from carbo-hydrates,;36–40% of calories from fat,and ;16–18% from protein (57–59). Avariety of eating patterns have beenshown to be effective in managing di-abetes, including Mediterranean-style(53,65), Dietary Approaches to StopHypertension (DASH)-style (66), andplant-based (vegan or vegetarian) (67),lower-fat (68), and lower-carbohydratepatterns (68).

care.diabetesjournals.org Position Statement S21

Table 4.1—Nutrition therapy recommendations

Topic Recommendations Evidence rating

Effectiveness of nutrition therapy c Nutrition therapy is recommended for all people with type 1 and type 2diabetes as an effective component of the overall treatment plan.

A

c Individuals who have diabetes should receive individualized MNT toachieve treatment goals, preferably provided by a registered dietitianfamiliar with the components of diabetes MNT.

A

c For individuals with type 1 diabetes, participation in an intensive, flexibleinsulin therapy education program using the carbohydrate-countingmealplanning approach can result in improved glycemic control.

A

c For individuals using fixed daily insulin doses, consistent carbohydrateintake with respect to time and amount can result in improved glycemiccontrol and reduce hypoglycemia risk.

B

c A simple diabetes meal planning approach, such as portion control orhealthful food choices, may be better suited to individuals with type 2diabetes with health and numeracy literacy concerns. This strategy alsomay be effective for older adults.

C

c Because diabetes nutrition therapy can result in cost savings B andimproved outcomes (e.g., A1C reduction) A, MNT should be adequatelyreimbursed by insurance and other payers. E

B, A, E

Energy balance c For overweight or obese adults with type 2 diabetes or at risk fordiabetes, reducing energy intake while maintaining a healthful eatingpattern is recommended to promote weight loss.

A

cModest weight loss may provide clinical benefits in some individuals withdiabetes, especially those early in the disease process. To achievemodestweight loss, intensive lifestyle interventions with ongoing support arerecommended.

A

Eating patterns and macronutrientdistribution

c Evidence suggests that there is not an ideal percentage of calories fromcarbohydrate, protein, and fat for all people with diabetes B; therefore,macronutrient distribution should be based on individualized assessmentof current eating patterns, preferences, and metabolic goals. E

B, E

c Carbohydrate amount and available insulin may be the most importantfactors influencing glycemic response after eating and should beconsidered when developing the eating plan.

A

c Monitoring carbohydrate intake, whether by carbohydrate counting orexperience-based estimation, remains critical in achieving glycemiccontrol.

B

c Carbohydrate intake from vegetables, fruits, whole grains, legumes, anddairy products should be advised over intake from other carbohydratesources, especially those that contain added fats, sugars, or sodium.

B

c Substituting low glycemic2load foods for higher glycemic2load foodsmay modestly improve glycemic control.

C

c Individuals at high risk for type 2 diabetes should be encouraged toachieve the U.S. Department of Agriculture recommendation for dietaryfiber (14 g fiber/1,000 kcal) and to consume foods containing wholegrains (one-half of grain intake).

B

c While substituting sucrose-containing foods for isocaloric amounts ofother carbohydrates may have similar blood glucose effects,consumption should be minimized to avoid displacing nutrient-densefood choices.

A

c People with diabetes and those at risk should limit or avoid intake ofsugar-sweetened beverages to reduce risk for weight gain and worseningof cardiometabolic risk profile.

B

Protein c In individuals with type 2 diabetes, ingested protein appears to increaseinsulin response without increasing plasma glucose concentrations.Therefore, carbohydrate sources high in protein should not be used totreat or prevent hypoglycemia.

B

c Evidence is inconclusive regarding an ideal amount of total fat for peoplewith diabetes; therefore, goals should be individualized. C Fat qualityappears to be far more important than quantity. B

C, B

c A Mediterranean-style eating pattern, rich in monounsaturated fattyacids, may benefit glycemic control and CVD risk factors and cantherefore be recommended as an effective alternative to a lower-fat,higher-carbohydrate eating pattern.

B

Continued on p. S23

S22 Position Statement Diabetes Care Volume 38, Supplement 1, January 2015

Macronutrients

Carbohydrates

Studies examining the ideal amountof carbohydrate intake for people withdiabetes are inconclusive, althoughmonitoring carbohydrate intake andconsidering the available insulin arekey strategies for improving postpran-dial glucose control (37,69). The litera-ture concerning glycemic index andglycemic load in individuals with diabe-tes is complex, although reductions inA1C of20.2% to20.5% have been dem-onstrated in some studies (64,70). A sys-tematic review (64) found consumptionof whole grains was not associated withimprovements in glycemic control inpeople with type 2 diabetes, althoughit may reduce systemic inflammation.One study did find a potential benefit ofwhole-grain intake in reducing mortalityand cardiovascular disease (CVD) (71).

Proteins

For people with diabetes and no evi-dence of diabetic kidney disease, theevidence is inconclusive about recom-mending an ideal amount of proteinfor optimizing glycemic control or forimproving one or more CVD risk mea-sures (64). Therefore, these goals shouldbe individualized. For people with dia-betes and diabetic kidney disease (withalbuminuria), reducing the amount ofdietary protein below usual intake isnot recommended because it does notalter glycemic measures, cardiovascularrisk measures, or the course of glomer-ular filtration rate decline (72,73). In in-dividuals with type 2 diabetes, ingestedprotein appears to increase insulin re-sponsewithout increasing plasma glucoseconcentrations (74). Therefore, carbohy-drate sources high in protein should notbe used to treat or prevent hypoglycemia.

Protein’s effect on blood glucose levels intype 1 diabetes is less clear.

Fats

Limited research exists concerning theideal amount of fat for individuals withdiabetes. The Institute of Medicine hasdefined an acceptable macronutrientdistribution range for all adults for totalfat of 20–35% of energy with no tolera-ble upper intake level defined (75). Thetype of fatty acids consumed is moreimportant than total amount of fatwhen looking at metabolic goals andrisk of CVD (53,76,77). Multiple random-ized controlled trials including patientswith type 2 diabetes have reported im-proved glycemic control and/or blood lip-ids when a Mediterranean-style eatingpattern, rich in monounsaturated fattyacid, was consumed (53,57,78,79). A sys-tematic review (64) concluded that

Table 4.1—Continued

Topic Recommendations Evidence rating

Dietary fat c Increased consumption of foods containing long-chain omega-3 fatty acids(EPA and DHA), such as fatty fish, and omega-3 linolenic acid (ALA) isrecommended.

B

c The consumption of fish (particularly fatty fish) at least two times (twoservings) per week is recommended.

B

c The amount of dietary saturated fat, cholesterol, and trans fat recommendedfor people with diabetes is the same as that recommendedfor the general population.

C

c Evidencedoes not support recommending omega-3 supplements for peoplewith diabetes for the prevention or treatment of cardiovascular events.

A

Micronutrientsandherbal supplements c There is no clear evidence of benefit from vitamin or mineralsupplementation in people with diabetes who do not have underlyingdeficiencies.

C

c Routine supplementation with antioxidants, such as vitamins E and C andcarotene, is not advised due to insufficient evidence of efficacy andconcerns related to long-term safety.

C

c There is insufficient evidence to support the routine use ofmicronutrients such as chromium, magnesium, and vitamin D to improveglycemic control in people with diabetes.

C

c There is insufficient evidence to support the use of cinnamon or otherherbs/supplements for the treatment of diabetes.

E

c It is recommended that individualizedmeal planning include optimizationof food choices to meet recommended dietary allowance/dietaryreference intake for all micronutrients.

E

Alcohol c If adultswithdiabetes choose todrink alcohol, they should be advised to do soin moderation (no more than one drink per day for adult women and nomore than two drinks per day for adult men).

C

cAlcohol consumptionmayplace peoplewithdiabetes at an increased risk fordelayed hypoglycemia, especially if taking insulin or insulin secretagogues.Education and awareness regarding the recognition and managementof delayed hypoglycemia are warranted.

B

Sodium c The recommendation for the general population to reduce sodium to less than2,300 mg/day is also appropriate for people with diabetes.

B

c For individualswithbothdiabetes andhypertension, further reduction in sodiumintake should be individualized.

B

care.diabetesjournals.org Position Statement S23

supplementation with omega-3 fattyacids did not improve glycemic controlbut that higher dose supplementationdecreased triglycerides in individualswith type 2 diabetes. Randomized con-trolled trials also do not support recom-mending omega-3 supplements forprimary or secondary prevention of CVD(80–85). People with diabetes should beadvised to follow the guidelines for thegeneral population for the recommendedintakes of saturated fat, dietary choles-terol, and trans fat (86).

SodiumA review found that decreasing sodiumintake reduces blood pressure in thosewith diabetes (87). Incrementally lower-ing sodium intake (i.e., to 1,500mg/day)has shown beneficial effects on bloodpressure (87–89). The American HeartAssociation recommends 1,500 mg/dayfor African Americans, people diag-nosed with hypertension, diabetes, orchronic kidney disease, and those over51 years of age (90). However, otherstudies (88,89) have warranted cautionfor universal sodium restriction to1,500 mg in this population. For indi-viduals with diabetes and hyperten-sion, setting a sodium intake goal of,2,300 mg/day should be consideredon an individual basis. Sodium intakerecommendations should take into ac-count palatability, availability, additionalcost of specialty low-sodium products,and the difficulty of achieving both low-sodium recommendations and a nutri-tionally adequate diet (86).For complete discussion and refer-

ences of all recommendations, see theADA position statement “Nutrition Ther-apy Recommendations for the Manage-ment of Adults With Diabetes” (36).

PHYSICAL ACTIVITY

Recommendations

c Children with diabetes or predia-betes should be encouraged to en-gage in at least 60 min of physicalactivity each day. B

c Adults with diabetes should be ad-vised to perform at least 150 min/week of moderate-intensity aero-bic physical activity (50–70% ofmaximum heart rate), spreadover at least 3 days/week with nomore than 2 consecutive dayswithout exercise. A

c Evidence supports that all individ-uals, including those with diabe-tes, should be encouraged toreduce sedentary time, particu-larly by breaking up extendedamounts of time (.90 min) spentsitting. B

c In the absence of contraindica-tions, adults with type 2 diabetesshould be encouraged to performresistance training at least twiceper week. A

Exercise is an important part of the di-abetes management plan. Regular exer-cise has been shown to improve bloodglucose control, reduce cardiovascularrisk factors, contribute to weight loss,and improve well-being. Furthermore,regular exercise may prevent type 2 di-abetes in high-risk individuals (91–93).Structured exercise interventions of atleast 8 weeks’ duration have beenshown to lower A1C by an average of0.66% in people with type 2 diabetes,even with no significant change in BMI(94). There are considerable data for thehealth benefits (e.g., increased cardiovas-cular fitness, muscle strength, improvedinsulin sensitivity, etc.) of regular physicalactivity for those with type 1 diabetes(95). Higher levels of exercise intensityare associated with greater improve-ments in A1C and in fitness (96). Otherbenefits include slowing the decline inmobility among overweight patientswith diabetes (97). “Exercise and Type 2Diabetes: The American College of SportsMedicine and the American Diabetes As-sociation: Joint Position Statement Exec-utive Summary” reviews the evidence forthe benefits of exercise in people withtype 2 diabetes (98).

Exercise and ChildrenAs is recommended for all children, chil-dren with diabetes or prediabetes shouldbe encouraged to engage in at least 60min of physical activity each day. Includedin the 60 min each day, children shouldengage in vigorous-intensity aerobicactivity, muscle-strengthening activities,and bone-strengthening activities at least3 of those days (99).

Frequency and Type of ExerciseThe U.S. Department of Health andHuman Services’ physical activityguidelines for Americans (100) suggestthat adults over age 18 years do 150min/week of moderate-intensity or 75

min/week of vigorous-intensity aerobicphysical activity, or an equivalent com-bination of the two. In addition, theguidelines suggest that adults also domuscle-strengthening activities that in-volve all major muscle groups 2 or moredays/week. The guidelines suggest thatadults over age 65 years, or those withdisabilities, follow the adult guidelines ifpossible or, if this is not possible, be asphysically active as they are able.

Recent evidence supports that all in-dividuals, including those with diabetes,should be encouraged to reduce theamount of time spent being sedentary(e.g., working at a computer, watchingTV) particularly by breaking up ex-tended amounts of time (.90 min)spent sitting (101).

Exercise and Glycemic ControlBased on physical activity studies that in-clude people with diabetes, it seems rea-sonable to recommend that people withdiabetes follow the physical activity guide-lines as for the general population. Forexample, studies included in the meta-analysis of effects of exercise interventionson glycemic control (94) had amean of 3.4sessions/week, with a mean of 49 min/session. Also, theDiabetes PreventionPro-gram (DPP) lifestyle intervention included150min/weekofmoderate-intensity exer-cise and showed beneficial effect on gly-cemia in those with prediabetes (91).

Clinical trials have provided strong evi-dence for the A1C-lowering value of re-sistance training in older adults with type2 diabetes (98) and for an additive benefitof combined aerobic and resistance exer-cise in adults with type 2 diabetes(102,103). If not contraindicated, patientswith type 2 diabetes should be encour-aged to do at least two weekly sessionsof resistance exercise (exercise with freeweights or weight machines), with eachsession consisting of at least one set offive or more different resistance exercisesinvolving the large muscle groups (98).

Pre-exercise EvaluationAs discussed more fully in Section 8. Car-diovascular Disease and Risk Manage-ment, the best protocol for screeningasymptomatic diabetic patients for coro-nary artery disease (CAD) remains unclear.The ADA consensus report “Screening forCoronary Artery Disease in Patients WithDiabetes” (104) on this issue concludedthat routine screening is not recommended.Providers should use clinical judgment in

S24 Position Statement Diabetes Care Volume 38, Supplement 1, January 2015

this area. Certainly, high-risk patientsshould be encouraged to start with shortperiods of low-intensity exercise andslowly increase the intensity and dura-tion. Providers should assess patientsfor conditions that might contraindicatecertain types of exercise or predispose toinjury, such as uncontrolled hyperten-sion, severe autonomic neuropathy, se-vere peripheral neuropathy, a history offoot lesions, and unstable proliferativeretinopathy. The patient’s age and pre-vious physical activity level should beconsidered. For type 1 diabetic patients,the provider should customize the exer-cise regimen to the individual’s needs.Those with complications may require amore thorough evaluation (95).

Exercise in the Presence ofNonoptimal Glycemic Control

Hyperglycemia

When individuals with type 1 diabetesare deprived of insulin for 12–48 h andare ketotic, exercise can worsen hyper-glycemia and ketosis (105); therefore,vigorous activity should be avoidedwith ketosis. However, it is not neces-sary to postpone exercise based simplyon hyperglycemia, provided the patientfeels well and urine and/or blood ke-tones are negative.

Hypoglycemia

In individuals taking insulin and/or insu-lin secretagogues, physical activity cancause hypoglycemia if medication doseor carbohydrate consumption is not al-tered. For individuals on these thera-pies, added carbohydrate should beingested if pre-exercise glucose levelsare,100 mg/dL (5.6 mmol/L). Hypogly-cemia is less common in diabetic pa-tients who are not treated with insulinor insulin secretagogues, and no preven-tive measures for hypoglycemia are usu-ally advised in these cases.

Exercise in the Presence of SpecificLong-Term Complications of Diabetes

Retinopathy

If proliferative diabetic retinopathy orsevere nonproliferative diabetic reti-nopathy is present, then vigorous aero-bic or resistance exercise may becontraindicated because of the risk oftriggering vitreous hemorrhage or reti-nal detachment (106).

Peripheral Neuropathy

Decreased pain sensation and a higherpain threshold in the extremities result

in an increased risk of skin breakdownand infection and of Charcot joint de-struction with some forms of exercise.However, studies have shown thatmoderate-intensity walking may notlead to an increased risk of foot ulcersor reulceration in those with peripheralneuropathy (107). In addition, 150 min/week of moderate exercise was re-ported to improve outcomes in patientswith milder forms of neuropathy (106).All individuals with peripheral neuropa-thy should wear proper footwear andexamine their feet daily to detect le-sions early. Anyone with a foot injuryor open sore should be restricted tonon–weight-bearing activities.

Autonomic Neuropathy

Autonomic neuropathy can increase therisk of exercise-induced injury or ad-verse event through decreased cardiacresponsiveness to exercise, postural hy-potension, impaired thermoregulation,impaired night vision due to impairedpapillary reaction, and higher suscepti-bility to hypoglycemia (108). Cardiovas-cular autonomic neuropathy is also anindependent risk factor for cardiovascu-lar death and silent myocardial ischemia(109). Therefore, individuals with dia-betic autonomic neuropathy shouldundergo cardiac investigation beforebeginning physical activity more intensethan that to which they are accustomed.

Albuminuria and Nephropathy

Physical activity can acutely increase uri-nary protein excretion. However, thereis no evidence that vigorous exerciseincreases the rate of progression ofdiabetic kidney disease, and thereappears to be no need for specific exer-cise restrictions for people with diabetickidney disease (106).

SMOKING CESSATION

Recommendations

c Advise all patients not to smoke oruse tobacco products. A

c Include smoking cessation coun-seling andother forms of treatmentas a routine component of diabetescare. B

Results from epidemiological, case-control, and cohort studies provide con-vincing evidence to support the causallink between cigarette smoking andhealth risks.Much of thework document-ing the effect of smoking on health does

not separately discuss results on subsetsof individuals with diabetes, but it doessuggest that the identified risks are atleast equivalent to those found in thegeneral population. Other studies of in-dividuals with diabetes consistentlydemonstrate that smokers (and peopleexposed to secondhand smoke) have aheightened risk of CVD, prematuredeath, and the microvascular complica-tions of diabetes. Smoking may have arole in the development of type 2 diabe-tes (110). One study in smokers withnewly diagnosed type 2 diabetes foundthat smoking cessation was associatedwith amelioration of metabolic parame-ters and reduced blood pressure and al-buminuria at 1 year (111).

The routine and thorough assessmentof tobacco use is essential to preventsmoking or encourage cessation. Nu-merous large randomized clinical trialshave demonstrated the efficacy andcost-effectiveness of brief counseling insmoking cessation, including the use ofquit lines, in reducing tobacco use. Forthe patient motivated to quit, the addi-tion of pharmacological therapy to coun-seling is more effective than eithertreatment alone. Special considerationsshould include assessment of level ofnicotine dependence, which is associ-ated with difficulty in quitting and re-lapse (112). Although some patientsmay gainweight in the period shortly aftersmoking cessation, recent research hasdemonstrated that this weight gain doesnot diminish the substantial CVD risk ben-efit realized from smoking cessation (113).

There is no evidence that e-cigarettesare a healthier alternative to smoking orthat e-cigarettes can facilitate smokingcessation. Rigorous study of their short-and long-term effects is needed in de-termining their safety and efficacy andtheir cardiopulmonary effects in com-parison with smoking and standard ap-proaches to smoking cessation (114).

PSYCHOSOCIAL ASSESSMENT ANDCARE

Recommendations

c Include assessment of the pa-tient’s psychological and socialsituation as an ongoing partof the medical management ofdiabetes. B

c Psychosocial screening and follow-upmay include, but are not limited

care.diabetesjournals.org Position Statement S25

to, attitudes about the illness,expectations for medical man-agement and outcomes, affect/mood, general and diabetes-related quality of life, resources(financial, social, and emotional),and psychiatric history. E

c Routinely screen for psychosocialproblems such as depression,diabetes-related distress, anxi-ety, eating disorders, and cogni-tive impairment. B

c Older adults (aged $65 years)with diabetes should be consid-ered a high-priority populationfor depression screening andtreatment. B

c Patients with comorbid diabetesand depression should receive astepwise collaborative care ap-proach for the management ofdepression. A

Emotional well-being is an important partof diabetes care and self-management.Psychological and social problems canimpair the individual’s (115–117) orfamily’s (118) ability to carry outdiabetes care tasks and thereforecompromise health status. There areopportunities for the clinician to rou-tinely assess psychosocial status in atimely and efficient manner so that re-ferral for appropriate services can be ac-complished. A systematic review andmeta-analysis showed that psychosocialinterventions modestly but significantlyimproved A1C (standardized mean dif-ference20.29%) and mental health out-comes. However, there was a limitedassociation between the effects on A1Cand mental health, and no interventioncharacteristics predicted benefit on bothoutcomes (119).

ScreeningKey opportunities for routine screeningof psychosocial status occur at diagno-sis, during regularly scheduled manage-ment visits, during hospitalizations, withnew-onset complications, or when prob-lems with glucose control, quality of life,or self-management are identified. Pa-tients are likely to exhibit psychologicalvulnerability at diagnosis, when theirmedical status changes (e.g., end of thehoneymoon period), when the need forintensified treatment is evident, andwhen complications are discovered. De-pression affects about 20–25% of people

with diabetes (120) and increases the riskfor myocardial infarction and postmyo-cardial infarction (121) and all-causemortality (122). There appears to be abidirectional relationship between de-pression and both diabetes (123) andmetabolic syndrome (124).

Diabetes-related distress is distinctfrom clinical depression and is very com-mon (125–127) among people with di-abetes and their family members (118).Prevalence is reported as 18–45%, withan incidence of 38–48% over 18months.High levels of distress are significantlylinked to A1C, self-efficacy, dietary andexercise behaviors (13,126), and medi-cation adherence (128). Other issuesknown to impact self-management andhealth outcomes include, but are not lim-ited to, attitudes about the illness, ex-pectations for medical management andoutcomes, anxiety, general and diabetes-related quality of life, resources (finan-cial, social, and emotional) (129), andpsychiatric history (130). Screening toolsare available for a number of these areas(23,131,132).

Referral to Mental Health SpecialistIndications for referral to a mentalhealth specialist familiar with diabetesmanagement may include gross disre-gard for the medical regimen (by selfor others) (133), depression, overallstress related to work-life balance, pos-sibility of self-harm, debilitating anxiety(alone or with depression), indicationsof an eating disorder (134), or cognitivefunctioning that significantly impairsjudgment. It is preferable to incorporatepsychological assessment and treatmentinto routine care rather than waiting for aspecific problem or deterioration in met-abolic or psychological status (23,125). Inthe Second Diabetes Attitudes, Wishesand Needs (DAWN2) study, significantdiabetes-related distress was reportedby 44.6% of the participants, but only23.7% reported that their health careteam asked them how diabetes impactedtheir life (125).

Although the clinician may not feelqualified to treat psychological prob-lems (135), optimizing the patient-provider relationship as a foundationcan increase the likelihood that the pa-tient will accept referral for other ser-vices. Collaborative care interventionsand use of a team approach have dem-onstrated efficacy in diabetes and

depression (136,137). Interventions toenhance self-management and addresssevere distress have demonstrated effi-cacy in diabetes-related distress (13).

IMMUNIZATION

Recommendations

c Provide routine vaccinations forchildren and adults with diabetesas for the general population. C

c Annually provide an influenza vac-cine to all patients with diabetes$6 months of age. C

c Administer pneumococcal poly-saccharide vaccine 23 (PPSV23)to all patients with diabetes $2years of age. C

c Adults $65 years of age, if notpreviously vaccinated, should re-ceive pneumococcal conjugatevaccine 13 (PCV13), followed byPPSV23 6–12 months after initialvaccination. C

c Adults $65 years of age, if previ-ously vaccinated with PPSV23,should receive a follow-up $12months with PCV13. C

c Administer hepatitis B vaccinationto unvaccinated adults with diabe-tes who are aged 19–59 years. C

c Consider administering hepatitis Bvaccination to unvaccinated adultswith diabetes who are aged $60years. C

As for the general population, all chil-dren and adults with diabetes should re-ceive routine vaccinations (138,139).Influenza and pneumonia are common,preventable infectious diseases associ-ated with high mortality and morbidityin vulnerable populations, such as theyoung and the elderly, and in peoplewith chronic diseases. Although thereare limited studies reporting the mor-bidity and mortality of influenza andpneumococcal pneumonia specificallyin people with diabetes, observationalstudies of patients with a variety ofchronic illnesses, including diabetes,show that these conditions are associ-ated with an increase in hospitalizationsfor influenza and its complications. Peo-ple with diabetesmay be at an increasedrisk of the bacteremic form of pneumo-coccal infection and have been reportedto have a high risk of nosocomial bacter-emia, with a mortality rate as high as50% (140). In a case-control series,

S26 Position Statement Diabetes Care Volume 38, Supplement 1, January 2015

influenza vaccine was shown to reducediabetes-related hospital admission byas much as 79% during flu epidemics(141). There is sufficient evidence tosupport that people with diabeteshave appropriate serologic and clinicalresponses to these vaccinations. TheCenters for Disease Control and Preven-tion (CDC) Advisory Committee onImmunization Practices recommends in-fluenza and pneumococcal vaccines forall individuals with diabetes (http://www.cdc.gov/vaccines/recs).

Pneumococcal Vaccines in OlderAdultsThe ADA endorses a recent CDC advisorypanel that recommends that bothPCV13 and PPSV23 should be adminis-tered routinely in series to all adults 65years of age or older (142).

Pneumococcal Vaccine-Naïve People

Adults 65 years of age or older who havenot previously received pneumococcalvaccine or whose previous vaccinationhistory is unknown should receive adose of PCV13 first, followed by PPSV23.A dose of PPSV23 should be given 6–12months following a dose of PCV13. IfPPSV23 cannot be given within this timeperiod, a dose of PPSV23 should be givenduring the next visit. The two vaccinesshould not be coadministered, and theminimum interval between vaccine dos-ing should be 8 weeks.

Previous Vaccination With PPSV23

Adults 65 years of age or older who pre-viously have received one or more dosesof PPSV23 should also receive PCV13 ifthey have not yet received it. PCV13should be given no sooner than 12monthsafter receipt of the most recent PPSV23dose. For those for whom an additionaldose of PPSV23 is indicated, this subse-quent PPSV23 dose should be given 6–12months after PCV13 and at least 5 yearssince the most recent dose of PPSV23.

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S30 Position Statement Diabetes Care Volume 38, Supplement 1, January 2015