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Facilitating Behavior Change and Well-being to Improve

在文檔中 IN DIABETES—2022 (頁 65-88)

GOALS OF CARE

5. Facilitating Behavior Change and Well-being to Improve

Health Outcomes: Standards of Medical Care in Diabetes—2022

Diabetes Care 2022;45(Suppl. 1):S60–S82 | https://doi.org/10.2337/dc22-S005

American Diabetes Association Professional Practice Committee*

The American Diabetes Association (ADA) “Standards of Medical Care in Dia-betes” includes the ADA’s current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Profes-sional Practice Committee, a multidisciplinary expert committee (https://doi .org/10.2337/dc22-SPPC), are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA’s clinical practice recommendations, please refer to the Standards of Care Intro-duction (https://doi.org/10.2337/dc22-SINT). Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.

Building positive health behaviors and maintaining psychological well-being are foundational for achieving diabetes treatment goals and maximizing qual-ity of life (1,2). Essential to achieving these goals are diabetes self-manage-ment education and support (DSMES), medical nutrition therapy (MNT), routine physical activity, smoking cessation counseling when needed, and psy-chosocial care. Following an initial comprehensive medical evaluation (see Section 4, “Comprehensive Medical Evaluation and Assessment of Com-orbidities,” https://doi.org/10.2337/dc22-S004), patients and providers are encouraged to engage in person-centered collaborative care (3–6), which is guided by shared decision-making in treatment regimen selection; facilitation of obtaining medical, psychosocial, and technology resources as needed; and shared monitoring of agreed-upon regimens and behavioral goals (7,8).

Reevaluation during routine care should include assessment of medical, behavioral, and mental health outcomes, especially during times of deteriora-tion in health and well-being.

DIABETES SELF-MANAGEMENT EDUCATION AND SUPPORT Recommendations

5.1 In accordance with the national standards for diabetes self-management education and support, all people with diabetes should participate in dia-betes self-management education and receive the support needed to facilitate the knowledge, decision-making, and skills mastery for diabetes self-care.A

*A complete list of members of the American Diabetes Association Professional Practice Com-mittee can be found at https://doi.org/10.2337/

dc22-SPPC.

Suggested citation: American Diabetes Asso-ciation Professional Practice Committee. 5.

Facilitating behavior change and well-being to improve health outcomes: Standards of Medical Care in Diabetes—2022. Diabetes Care 2022;45 (Suppl. 1):S60–S82

© 2021 by the American Diabetes Association.

Readers may use this article as long as the work is properly cited, the use is educational and not for profit, and the work is not altered.

More information is available at https://

diabetesjournals.org/journals/pages/license.

5.FACILITATINGBEHAVIORCHANGEANDWELL-BEING

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5.2 There are four critical times to evaluate the need for diabetes self-management education to promote skills acquisition in sup-port of regimen implementation, medical nutrition therapy, and well-being: at diagnosis, annually and/or when not meeting treat-ment targets, when complicating factors develop (medical, physi-cal, psychosocial), and when tran-sitions in life and care occur.E 5.3 Clinical outcomes, health status,

and well-being are key goals of diabetes self-management edu-cation and support that should be measured as part of routine care.C

5.4 Diabetes self-management edu-cation and support should be patient-centered, may be offered in group or individual settings, and should be communicated with the entire diabetes care team.A

5.5 Digital coaching and digital self-management interventions can be effective methods to deliver diabetes self-management edu-cation and support.B

5.6 Because diabetes self-manage-ment education and support can improve outcomes and reduce costsB, reimbursement by third-party payers is recom-mended.C

5.7 Barriers to diabetes self-man-agement education and sup-port exist at the health system, payer, provider, and patient levels. A Efforts to identify and address barriers to diabetes self-management education and sup-port should be prioritized.E 5.8 Some barriers to diabetes

self-management education and sup-port access may be mitigated through telemedicine approa-ches.B

DSMES services facilitate the knowledge, decision-making, and skills mastery nec-essary for optimal diabetes self-care and incorporate the needs, goals, and life experiences of the person with diabetes.

The overall objectives of DSMES 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 well-being in a cost-effective manner (2). Providers are encouraged to consider the burden of treatment (9) and the patient’s level of confidence and self-efficacy for manage-ment behaviors as well as the level of social and family support when providing DSMES. Patient engagement in self-man-agement behaviors and their effects on clinical outcomes, health status, and quality of life, as well as the psychosocial factors impacting the person’s ability to self-manage, should be monitored as part of routine clinical care. A random-ized controlled trial (RCT) testing a deci-sion-making education and skill-building program (10) showed that addressing these targets improved health outcomes in a population in need of health care resources. Furthermore, following a DSMES curriculum improves quality of care (11).

Additionally, in response to the grow-ing literature that associates potentially judgmental words with increased feel-ings of shame and guilt, health care pro-fessionals are encouraged to consider the impact that language has on build-ing therapeutic relationships and to choose positive, strength-based words and phrases that put peoplefirst (4,12).

Please see Section 4, “Comprehensive Medical Evaluation and Assessment of Comorbidities” (https://doi.org/10.2337/

dc22-S004), for more on use of lang-uage.

Guidelines for DSMES are based on evidence of benefit (2,13). Specifically, DSMES helps people with diabetes to identify and implement effective self-management strategies and cope with diabetes at four critical time points (see below) (2). Ongoing DSMES helps peo-ple with diabetes to maintain effective self-management throughout the life course as they encounter new chal-lenges and as advances in treatment become available (14).

There are four critical time points when the need for DSMES should be evaluated by the medical care provider and/or multidisciplinary team, with referrals made as needed (2):

1. At diagnosis

2. Annually and/or when not meeting treatment targets

3. When complicating factors (health conditions, physical limitations, emo-tional factors, or basic living needs) develop that influence self-manage-ment

4. When transitions in life and care occur

DSMES focuses on supporting patient empowerment by providing people with diabetes the tools to make informed self-management decisions (15). Diabe-tes care requires an approach that places the person with diabetes and their family and/or support system at the center of the care model, working in collaboration with health care profes-sionals. Patient-centered care is respect-ful of and responsive to individual pre-ferences, needs, and values. It ensures that patient values guide all decision-making (16).

Evidence for the Benefits

Studies have found that DSMES is associ-ated with improved diabetes knowledge and self-care behaviors (16,17), lower A1C (16,18–21), lower self-reported wei-ght (22), improved quality of life (19,23), reduced all-cause mortality risk (24), posi-tive coping behaviors (5,25), and reduced health care costs (26–28). Better out-comes were reported for DSMES inter-ventions that were more than 10 h over the course of 6–12 months (20), included ongoing support (14,29), were culturally (30,31) and age appropriate (32,33), were tailored to individual needs and preferen-ces, and addressed psychosocial issues and incorporated behavioral strategies (15,25,34,35). Individual and group app-roaches are effective (36,37), with a slight benefit realized by those who engage in both (20).

Emerging evidence demonstrates the benefit of telemedicine or internet-based DSMES services for diabetes pre-vention and the management of type 2 diabetes (38–45).

Technologies such as mobile apps, simulation tools, digital coaching, and digital self-management interventions can be used to deliver DSMES (46,47).

These methods provide comparable or even improved outcomes compared with traditional in-person care (48). Greater A1C reductions are demonstrated with increased patient engagement (49), although data from trials is preliminary in nature and quite heterogeneous.

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Technology-enabled diabetes self-management solutions improve A1C most effectively when there is two-way communication between the patient and the health care team, individualized feedback, use of patient-generated health data, and education (40). Incor-porating a systematic approach for tech-nology assessment, adoption, and integration into the care plan may help ensure equity in access and standard-ized application of technology-enabled solutions (8,50–53).

Current research supports diabetes care and education specialists including nurses, dietitians, and pharmacists as pro-viders of DSMES who may also tailor cur-riculum to the person’s needs (54–56).

Members of the DSMES team should have specialized clinical knowledge in dia-betes and behavior change principles. In addition, a diabetes care and education specialist needs to be knowledgeable about technology-enabled services and may serve as a technology champion within their practice (50). Certification as a diabetes care and education specialist (see www.cbdce.org/) and/or board certi-fication in advanced diabetes manage-ment (see www.diabeteseducator.org/

education/certification/bc_adm) demon-strates an individual’s specialized training in and understanding of diabetes man-agement and support (13), and engage-ment with qualified providers has been shown to improve disease-related out-comes. Additionally, there is growing evi-dence for the role of community health workers (57,58), as well as peer (57–62) and lay leaders (63), in providing ongoing support.

Evidence suggests people with diabe-tes who completed more than 10 h of DSMES over the course of 6–12 months and those who participated on an ongo-ing basis had significant reductions in mortality (24) and A1C (decrease of 0.57%) (20) compared with those who spent less time with a diabetes care and education specialist. Given individual needs and access to resources, a variety of culturally adapted DSMES programs need to be offered in a variety of set-tings. Use of technology to facilitate access to DSMES services, support self-management decisions, and decrease therapeutic inertia suggests that these approaches need broader adoption.

DSMES is associated with an inc-reased use of primary care and

preventive services (26,52,64) and less frequent use of acute care and inpatient hospital services (22). Patients who par-ticipate in DSMES are more likely to follow best practice treatment recom-mendations, particularly among the Medicare population, and have lower Medicare and insurance claim costs (27,64). Despite these benefits, reports indicate that only 5–7% of individuals eligible for DSMES through Medicare or a private insurance plan actually receive it (65,66). Barriers to DSMES exist at the health system, payer, provider, and patient levels. This low participation may be due to lack of referral or other identified barriers such as logistical issues (accessibility, timing, costs) and the lack of a perceived benefit (66).

Health system, programmatic, and payer barriers include lack of adminis-trative leadership support, limited num-bers of DSMES providers, not having referral to DSMES services effectively embedded in the health system service structure, and limited reimbursement rates (67). Thus, in addition to educating referring providers about the benefits of DSMES and the critical times to refer, efforts need to be made to identify and address all of the various potential bar-riers (2). Alternative and innovative models of DSMES delivery (47) need to be explored and evaluated, including the integration of technology-enabled diabetes and cardiometabolic health services (8,50).

Reimbursement

Medicare reimburses DSMES when that service meets the national standards (2,13) and is recognized by the American Diabetes Association (ADA) through the Education Recognition Program (https://

professional.diabetes.org/diabetes-education) or Association of Diabetes Care & Edu-cation Specialists. DSMES is also cov-ered by most health insurance plans.

Ongoing support has been shown to be instrumental for improving outcomes when it is implemented after the com-pletion of education services. DSMES is frequently reimbursed when performed in person. However, although DSMES can also be provided via phone calls and telehealth, these remote versions may not always be reimbursed. Some barriers to DSMES access may be miti-gated through telemedicine approaches.

Changes in reimbursement policies that increase DSMES access and utilization will result in a positive impact to bene fi-ciaries’ clinical outcomes, quality of life, health care utilization, and costs (68– 70). During the time of the coronavirus disease 2019 (COVID-19) pandemic, reimbursement policies have changed (professional.diabetes.org/content-page/

dsmes-and-mnt-during-covid-19-national-pandemic), and these changes may pro-vide a new reimbursement paradigm for future provision of DSMES through telehealth channels.

MEDICAL NUTRITION THERAPY Please refer to the ADA consensus report

“Nutrition Therapy for Adults With Dia-betes or Prediabetes: A Consensus Report” for more information on nutri-tion therapy (56). For many individuals with diabetes, the most challenging part of the treatment plan is determining what to eat. There is not a “one-size-fits-all” eating pattern for individuals with diabetes, and meal planning should be individualized. Nutrition therapy plays an integral role in overall diabetes manage-ment, and each person with diabetes should be actively engaged in education, self-management, and treatment plan-ning with his or her health care team, including the collaborative develop-ment of an individualized eating plan (56,71). All providers should refer people with diabetes for individual-ized MNT provided by a registered dietitian nutritionist (RD/RDN) who is knowledgeable and skilled in providing diabetes-specific MNT (72) at diagnosis and as needed throughout the life span, similar to DSMES. MNT delivered by an RD/RDN is associated with A1C absolute decreases of 1.0–1.9% for people with type 1 diabetes (73) and 0.3–2.0% for people with type 2 diabetes (73). See Table 5.1 for specific nutrition recommen-dations. Because of the progressive nature of type 2 diabetes, behavior modification alone may not be adequate to maintain euglycemia over time. However, after medication is initiated, nutrition therapy continues to be an important component, and RD/RDNs providing MNT in diabetes care should assess and monitor medica-tion changes in relamedica-tion to the nutrimedica-tion care plan (56,71).

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Table 5.1—Medical nutrition therapy recommendations

Topic Recommendation

Effectiveness of nutrition therapy 5.9 An individualized medical nutrition therapy program as needed to achieve treatment goals, provided by a registered dietitian nutritionist (RD/RDN), preferably one who has comprehensive knowledge and experience in diabetes care, is recommended for all people with type 1 or type 2 diabetes, prediabetes, and gestational diabetes mellitus.A 5.10 Because diabetes medical nutrition therapy can result in cost savingsBand improved

outcomes (e.g., A1C reduction, reduced weight, decrease in cholesterol)A, medical nutrition therapy should be adequately reimbursed by insurance and other payers.E

Energy balance 5.11 For all patients with overweight or obesity, behavioral modification to achieve and maintain a minimum weight loss of 5% is recommended.A

Eating patterns and macronutrient distribution

5.12 There is no ideal macronutrient pattern for people with diabetes; meal plans should be individualized while keeping total calorie and metabolic goals in mind.E

5.13 A variety of eating patterns can be considered for the management of type 2 diabetes and to prevent diabetes in individuals with prediabetes.B

5.14 Reducing overall carbohydrate intake for individuals with diabetes has demonstrated the most evidence for improving glycemia and may be applied in a variety of eating patterns that meet individual needs and preferences.B

Carbohydrates 5.15 Carbohydrate intake should emphasize nutrient-dense carbohydrate sources that are high infiber (at least 14 g fiber per 1,000 kcal) and minimally processed. Eating plans should emphasize nonstarchy vegetables, fruits, and whole grains, as well as dairy products, with minimal added sugars.B

5.16 People with diabetes and those at risk are advised to replace sugar-sweetened beverages (including fruit juices) with water as much as possible in order to control glycemia and weight and reduce their risk for cardiovascular disease and fatty liverB and should minimize the consumption of foods with added sugar that have the capacity to displace healthier, more nutrient-dense food choices.A

5.17 When using a flexible insulin therapy program, education on the glycemic impact of carbohydrateA, fat, and proteinBshould be tailored to an individual’s needs and preferences and used to optimize mealtime insulin dosing.

5.18 When using fixed insulin doses, individuals should be provided education about consistent pattern of carbohydrate intake with respect to time and amount, while considering the insulin action time, as it can result in improved glycemia and reduce the risk for hypoglycemia.B

Protein 5.19 In individuals with type 2 diabetes, ingested protein appears to increase insulin response without increasing plasma glucose concentrations. Therefore, carbohydrate sources high in protein should be avoided when trying to treat or prevent hypoglycemia.B

Dietary fat 5.20 An eating plan emphasizing elements of a Mediterranean-style eating pattern rich in monounsaturated and polyunsaturated fats may be considered to improve glucose metabolism and lower cardiovascular disease risk.B

5.21 Eating foods rich in long-chain n-3 fatty acids, such as fatty fish (EPA and DHA) and nuts and seeds (ALA), is recommended to prevent or treat cardiovascular disease.B Micronutrients and herbal

supplements

5.22 There is no clear evidence that dietary supplementation with vitamins, minerals (such as chromium and vitamin D), herbs, or spices (such as cinnamon or aloe vera) can improve outcomes in people with diabetes who do not have underlying deficiencies, and they are not generally recommended for glycemic control.C

Alcohol 5.23 Adults with diabetes who drink alcohol should do so in moderation (no more than one drink per day for adult women and no more than two drinks per day for adult men).C 5.24 Educating people with diabetes about the signs, symptoms, and self-management of

delayed hypoglycemia after drinking alcohol, especially when using insulin or insulin secretagogues, is recommended. The importance of glucose monitoring after drinking alcoholic beverages to reduce hypoglycemia risk should be emphasized.B

Sodium 5.25 Sodium consumption should be limited to <2,300 mg/day.B

Nonnutritive sweeteners 5.26 The use of nonnutritive sweeteners as a replacement for sugar-sweetened products may reduce overall calorie and carbohydrate intake as long as there is not a compensatory increase of energy intake from other sources. Overall, people are encouraged to decrease both sweetened and nonnutritive-sweetened beverages, with an emphasis on water intake.B

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Goals of Nutrition Therapy for Adults With Diabetes

1. To promote and support healthful eat-ing patterns, emphasizeat-ing a variety of nutrient-dense foods in appropriate portion sizes, to improve overall health and:

• achieve and maintain body weight goals

• attain individualized glycemic, blood pressure, and lipid goals

• delay or prevent the complica-tions of diabetes

2. To address individual nutrition needs based on personal and cultural pref-erences, health literacy and numer-acy, access to healthful foods, willingness and ability to make behav-ioral changes, and existing barriers to change

3. To maintain the pleasure of eating by providing nonjudgmental messages about food choices while limiting food choices only when indicated by scientific evidence

4. To provide an individual with diabetes the practical tools for developing healthy eating patterns rather than focusing on individual macronutrients, micronutrients, or single foods Weight Management

Management and reduction of weight is important for people with type 1 diabe-tes, type 2 diabediabe-tes, or prediabetes with overweight or obesity. To support weight loss and improve A1C, cardiovascular dis-ease (CVD) risk factors, and well-being in adults with overweight/obesity and pre-diabetes or pre-diabetes, MNT and DSMES services should include an individualized eating plan in a format that results in an energy deficit in combination with enhanced physical activity (56). Lifestyle intervention programs should be inten-sive and have frequent follow-up to achieve significant reductions in excess body weight and improve clinical indica-tors. There is strong and consistent evi-dence that modest, sustained weight loss can delay the progression from predia-betes to type 2 diapredia-betes (73–75) (see Section 3,“Prevention or Delay of Type 2 Diabetes and Associated Comorbidities,” https://doi.org/10.2337/dc22-S003) and is beneficial for the management of type 2 diabetes (see Section 8, “Obesity and Weight Management for the Prevention and Treatment of Type 2 Diabetes,” https:

//doi.org/10.2337/dc22-S008).

In prediabetes, the weight loss goal is 7–10% for preventing progression to type 2 diabetes (76). In conjunction with sup-port for healthy lifestyle behaviors, medi-cation-assisted weight loss can be considered for people at risk for type 2 diabetes when needed to achieve and sustain 7–10% weight loss (77,78) (see Section 8,“Obesity and Weight Manage-ment for the Prevention and TreatManage-ment of Type 2 Diabetes,” https://doi.org/

10.2337/dc22-S008). People with predia-betes at a healthy weight should also be considered for behavioral interventions to help establish routine aerobic and resis-tance exercise (76,79,80), as well as to establish healthy eating patterns. Services delivered by practitioners familiar with diabetes and its management, such as an RD/RDN, have been found to be effective (72).

For many individuals with overweight and obesity with type 2 diabetes, 5%

weight loss is needed to achieve bene fi-cial outcomes in glycemic control, lipids, and blood pressure (81). It should be noted, however, that the clinical benefits of weight loss are progressive, and more intensive weight loss goals (i.e., 15%) may be appropriate to maximize benefit depending on need, feasibility, and safety (82,83). In select individuals with type 2 diabetes, an overall healthy eating plan that results in energy deficit in conjunc-tion with weight loss medicaconjunc-tions and/or metabolic surgery should be considered to help achieve weight loss and mainte-nance goals, lower A1C, and reduce CVD risk (77,84,85). Overweight and obesity are also increasingly prevalent in people with type 1 diabetes and present clinical challenges regarding diabetes treatment and CVD risk factors (86,87). Sustaining weight loss can be challenging (81,88) but has long-term benefits; maintaining weight loss for 5 years is associated with sustained improvements in A1C and lipid levels (89). MNT guidance from an RD/

RDN with expertise in diabetes and weight management, throughout the course of a structured weight loss plan, is strongly recommended.

Along with routine medical manage-ment visits, people with diabetes and prediabetes should be screened during DSMES and MNT encounters for a his-tory of dieting and past or current disordered eating behaviors. Nutrition therapy should be individualized to help address maladaptive eating behavior

(e.g., purging) or compensatory changes in medical regimen (e.g., overtreatment of hypoglycemic episodes, reduction in medication dosing to reduce hunger) (56) (seeDISORDERED EATING BEHAVIORbelow).

Disordered eating and/or eating disor-ders can increase challenges for weight and diabetes management. For example, caloric restriction may be essential for glycemic control and weight mainte-nance, but rigid meal plans may be con-traindicated for individuals who are at increased risk of clinically significant mal-adaptive eating behaviors (90). If clini-cally significant eating disorders are identified during screening with diabe-tes-specific questionnaires, individuals should be referred to a mental health professional as needed (1).

Studies have demonstrated that a variety of eating plans, varying in macro-nutrient composition, can be used effec-tively and safely in the short term (1–2 years) to achieve weight loss in people with diabetes. These plans include struc-tured low-calorie meal plans with meal replacements (82,89,91), a Mediterra-nean-style eating pattern (92), and low-carbohydrate meal plans with additional support (93,94). However, no single approach has been proven to be consis-tently superior (56,95–97), and more data are needed to identify and validate those meal plans that are optimal with respect to long-term outcomes and patient acceptability. The importance of providing guidance on an individualized meal plan containing nutrient-dense foods, such as vegetables, fruits, legumes, dairy, lean sources of protein (including plant-based sources as well as lean meats, fish, and poultry), nuts, seeds, and whole grains, cannot be overempha-sized (96), as well as guidance on achiev-ing the desired energy deficit (98–101).

Any approach to meal planning should be individualized considering the health status, personal preferences, and ability of the person with diabetes to sustain the recommendations in the plan.

Eating Patterns and Meal Planning Evidence suggests that there is not an ideal percentage of calories from carbohy-drate, protein, and fat for people with dia-betes. Therefore, macronutrient distribu-tion should be based on an individualized assessment of current eating patterns, preferences, and metabolic goals. Dietary

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guidance should emphasize the impor-tance of a healthy dietary pattern as a whole rather than focusing on individual nutrients, foods, or food groups, given that individuals rarely eat foods in isola-tion. Personal preferences (e.g., tradi-tion, culture, religion, health beliefs and goals, economics) as well as metabolic goals need to be considered when work-ing with individuals to determine the best eating pattern for them (56, 73,102). Members of the health care team should complement MNT by pro-viding evidence-based guidance that helps people with diabetes make healthy food choices that meet their individualized needs and improve overall health. A variety of eating patterns are acceptable for the management of dia-betes (56,103–105). Until the evidence surrounding comparative benefits of dif-ferent eating patterns in specific individ-uals strengthens, health care providers should focus on the key factors that are common among the patterns: 1) empha-size nonstarchy vegetables, 2) minimize added sugars and refined grains, and 3) choose whole foods over highly proc-essed foods to the extent possible (56).

An individualized eating pattern also considers the individual’s health status, food and numeracy skills, resources, food preferences, and health goals.

Referral to an RD/RDN is essential to assess the overall nutrition status of, and to work collaboratively with, the patient to create a personalized meal plan that coordinates and aligns with the overall treatment plan, including physical activity and medication use. The Mediterranean-style (102,106–108), low-carbohydrate (109–111), and vegetarian or plant-based (107,108,112,113) eating patterns are all examples of healthful eating patterns that have shown positive results in research for individuals with type 2 dia-betes, but individualized meal planning should focus on personal preferences, needs, and goals. There is currently inad-equate research in type 1 diabetes to support one eating pattern over another.

For individuals with type 2 diabetes not meeting glycemic targets or for whom reducing glucose-lowering drugs is a priority, reducing overall carbohydrate intake with a low- or very-low-carbohy-drate eating pattern is a viable option (109–111). As research studies on low-carbohydrate eating plans generally indicate challenges with long-term

sustainability (114), it is important to reassess and individualize meal plan guid-ance regularly for those interested in this approach. Most individuals with diabetes report a moderate intake of carbohydrate (44–46% of total calories) (103). Efforts to modify habitual eating patterns are often unsuccessful in the long term; peo-ple generally go back to their usual mac-ronutrient distribution (103). Thus, the recommended approach is to individual-ize meal plans with a macronutrient dis-tribution that is more consistent with personal preference and usual intake to increase the likelihood for long-term maintenance.

An RCT found that two meal planning approaches were effective in helping achieve improved A1C, particularly for individuals with an A1C between 7% and 10% (115). The diabetes plate method is a commonly used visual approach for providing basic meal planning guidance.

This simple graphic (featuring a 9-inch plate) shows how to portion foods (1/2 of the plate for nonstarchy vegetables, 1/

4 of the plate for protein, and 1/4 of the plate for carbohydrates). Carbohydrate counting is a more advanced skill that helps plan for and track how much car-bohydrate is consumed at meals and snacks. Meal planning approaches should be customized to the individual, including their numeracy (115) and food literacy level. Food literacy generally describes proficiency in food-related knowledge and skills that ultimately impact health, although specific definitions vary across initiatives (116,117).

Carbohydrates

Studies examining the ideal amount of carbohydrate intake for people with dia-betes are inconclusive, although monitor-ing carbohydrate intake and considermonitor-ing the blood glucose response to dietary carbohydrate are key for improving postprandial glucose management (118, 119). The literature concerning glycemic index and glycemic load in individuals with diabetes is complex, often with varying definitions of low and high glyce-mic index foods (120,121). The glyceglyce-mic index ranks carbohydrate foods on their postprandial glycemic response, and gly-cemic load takes into account both the glycemic index of foods and the amount of carbohydrate eaten. Studies have found mixed results regarding the effect

of glycemic index and glycemic load on fasting glucose levels and A1C, with one systematic review finding no significant impact on A1C (122), while two others demonstrated A1C reductions of 0.15%

(120) to 0.5% (123).

Reducing overall carbohydrate intake for individuals with diabetes has demon-strated evidence for improving glycemia and may be applied in a variety of eating patterns that meet individual needs and preferences (56). For people with type 2 diabetes, low-carbohydrate and very-low-carbohydrate eating patterns, in particu-lar, have been found to reduce A1C and the need for antihyperglycemic medica-tions (56,102,114,124–126). Systematic reviews and meta-analyses of RCTs found carbohydrate-restricted eating patterns, particularly those considered low-carbo-hydrate (<26% total energy), were effec-tive in reducing A1C in the short term (<6 months), with less difference in eat-ing patterns beyond 1 year (97,98,109, 110,125). Part of the challenge in inter-preting low-carbohydrate research has been due to the wide range of definitions for a low-carbohydrate eating plan (111,123). Weight reduction was also a goal in many low-carbohydrate studies, which further complicates evaluating the distinct contribution of the eating pattern (41,93,97,127). As research studies on low-carbohydrate eating plans generally indicate challenges with long-term sus-tainability (114), it is important to reas-sess and individualize meal plan guidance regularly for those interested in this approach. Providers should maintain con-sistent medical oversight and recognize that insulin and other diabetes medica-tions may need to be adjusted to prevent hypoglycemia; and blood pressure will need to be monitored. In addition, very-low-carbohydrate eating plans are not currently recommended for women who are pregnant or lactating, children, people who have renal disease, or people with or at risk for disordered eating, and these plans should be used with caution in those taking sodium–glucose cotrans-porter 2 inhibitors because of the poten-tial risk of ketoacidosis (128,129).

Regardless of amount of carbohydrate in the meal plan, focus should be placed on high-quality, nutrient-dense carbohy-drate sources that are high in fiber and minimally processed. Both children and adults with diabetes are encouraged to minimize intake of refined carbohydrates

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with added sugars, fat, and sodium and instead focus on carbohydrates from vegetables, legumes, fruits, dairy (milk and yogurt), and whole grains. People with diabetes and those at risk for diabe-tes are encouraged to consume a mini-mum of 14 g offiber/1,000 kcal, with at least half of grain consumption being whole, intact grains, according to the Dietary Guidelines for Americans (130).

Regular intake of sufficient dietary fiber is associated with lower all-cause mortal-ity in people with diabetes (131,132), and prospective cohort studies have found dietary fiber intake is inversely associated with risk of type 2 diabetes (133–135). The consumption of sugar-sweetened beverages and processed food products with high amounts of refined grains and added sugars is strongly discouraged (130,136–138), as these have the capacity to displace healthier, more nutrient-dense food choices.

Individuals with type 1 or type 2 dia-betes taking insulin at mealtime should be offered intensive and ongoing educa-tion on the need to couple insulin admin-istration with carbohydrate intake. For people whose meal schedule or carbohy-drate consumption is variable, regular education to increase understanding of the relationship between carbohydrate intake and insulin needs is important. In addition, education on using insulin-to-carbohydrate ratios for meal planning can assist individuals with effectively modifying insulin dosing from meal to meal to improve glycemic management (103,118,139–142). When consuming a mixed meal that contains carbohydrate and is high in fat and/or protein, insulin dosing should not be based solely on car-bohydrate counting (56). Studies have shown that dietary fat and protein can impact early and delayed postprandial glycemia (143–146), and it appears to have a dose-dependent response (147– 149). Results from high-fat, high-protein meal studies highlight the need for addi-tional insulin to cover these meals; how-ever, more studies are needed to determine the optimal insulin dose and delivery strategy. The results from these studies also point to individual differences in postprandial glycemic response; there-fore, a cautious approach to increasing insulin doses for high-fat and/or high-pro-tein mixed meals is recommended to address delayed hyperglycemia that may

occur 3 h or more after eating (56). If using an insulin pump, a split bolus fea-ture (part of the bolus delivered immedi-ately, the remainder over a programmed duration of time) may provide better insulin coverage for fat and/or high-protein mixed meals (144,150).

The effectiveness of insulin dosing decisions should be confirmed with a structured approach to blood glucose monitoring or continuous glucose moni-toring to evaluate individual responses and guide insulin dose adjustments.

Checking glucose 3 h after eating may help to determine if additional insulin adjustments are required (i.e., increas-ing or stoppincreas-ing bolus) (144,150,151).

Refining insulin doses to account for high-fat and/or -protein meals requires determination of anticipated nutrient intake to calculate the mealtime dose.

Food literacy, numeracy, interest, and capability should be evaluated (56). For individuals on a fixed daily insulin schedule, meal planning should empha-size a relativelyfixed carbohydrate con-sumption pattern with respect to both time and amount, while considering insulin action. Attention to resultant hunger and satiety cues will also help with nutrient modifications throughout the day (56,152).

Protein

There is no evidence that adjusting the daily level of protein intake (typically 1–1.5 g/kg body wt/day or 15–20% total calories) will improve health, and research is inconclusive regarding the ideal amount of dietary protein to optimize either glyce-mic management or CVD risk (121,153).

Therefore, protein intake goals should be individualized based on current eating patterns. Some research has found suc-cessful management of type 2 diabetes with meal plans including slightly higher levels of protein (20–30%), which may contribute to increased satiety (154).

Historically, low-protein eating plans were advised for individuals with diabetic kidney disease (DKD) (with albuminuria and/or reduced estimated glomerular fil-tration rate); however, new evidence does not suggest that people with DKD need to restrict protein to less than the generally recommended protein intake (56). Reducing the amount of dietary pro-tein below the recommended daily allow-ance of 0.8 g/kg is not recommended

because it does not alter glycemic meas-ures, cardiovascular risk measmeas-ures, or the rate at which glomerular filtration rate declines and may increase risk for malnu-trition (155,156).

In individuals with type 2 diabetes, pro-tein intake may enhance or increase the insulin response to dietary carbohydrates (157). Therefore, use of carbohydrate sources high in protein (such as milk and nuts) to treat or prevent hypoglycemia should be avoided due to the potential concurrent rise in endogenous insulin.

Providers should counsel patients to treat hypoglycemia with pure glucose (i.e., glu-cose tablets) or carbohydrate-containing foods at the hypoglycemia alert value of

<70 mg/dL. See Section 6, “Glycemic Targets” (https://doi.org/10.2337/dc22-S006), for more information.

Fats

The ideal amount of dietary fat for indi-viduals with diabetes is controversial.

New evidence suggests that there is not an ideal percentage of calories from fat for people with or at risk for diabetes and that macronutrient distribution should be individualized according to the patient’s eating patterns, preferen-ces, and metabolic goals (56). The type of fats consumed is more important than total amount of fat when looking at metabolic goals and CVD risk, and it is recommended that the percentage of total calories from saturated fats should be limited (92,130,158–160). Multiple RCTs including patients with type 2 dia-betes have reported that a Mediterra-nean-style eating pattern (92,161–166), rich in polyunsaturated and monounsat-urated fats, can improve both glycemic management and blood lipids.

Evidence does not conclusively support recommending n-3 (eicosapentaenoic acid [EPA] and docosahexaenoic acid [DHA]) supplements for all people with diabetes for the prevention or treatment of cardiovascular events (56,167,168). In individuals with type 2 diabetes, two sys-tematic reviews with n-3 and n-6 fatty acids concluded that the dietary supple-ments did not improve glycemic manage-ment (121,169). In the ASCEND trial (A Study of Cardiovascular Events iN Diabe-tes), when compared with placebo, sup-plementation with n-3 fatty acids at the dose of 1 g/day did not lead to cardiovas-cular benefit in people with diabetes

S66 Facilitating Behavior Change and Well-being to Improve Health Outcomes Diabetes Care Volume 45, Supplement 1, January 2022

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