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They have been drinking it daily as a tea before work to increase their endurance and strength, and after work to relieve fatigue and promote good sleep. I am not diabetic, but do have many other health problems…what Could make my Glucose go from 56 to in one week…I had 2 blood tests during that period??? Volume refers to the number of muscles worked, exercises, sets, and reps during a single session. So, long story for short questions, could large amounts of insulin in my system be causing the seizures? Performance and Relieves Muscle Soreness. I have to keep a straw on me. If u do so, the rate of adrenaline in your body increases and so do your heart beat which ends up in your breathing.

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2018 FIFA World Cup

English pop singer Robbie Williams then performed two songs before he and Russian soprano Aida Garifullina performed a duet while other performers emerged, dressed in the flags of all 32 teams and carrying a sign bearing the name of each nation.

Dancers were also present. Competing countries were divided into eight groups of four teams groups A to H. Teams in each group played one another in a round-robin basis, with the top two teams of each group advancing to the knockout stage. Ten European teams and four South American teams progressed to the knockout stage, together with Japan and Mexico. For the first time since , Germany reigning champions did not advance past the first round.

For the first time since , no African team progressed to the second round. For the first time, the fair play criteria came into use, when Japan qualified over Senegal due to having received fewer yellow cards.

Only one match, France v Denmark, was goalless. Until then there were a record 36 straight games in which at least one goal was scored. All times listed below are local time. The ranking of teams in the group stage was determined as follows: In the knockout stages, if a match is level at the end of normal playing time, extra time is played two periods of 15 minutes each and followed, if necessary, by a penalty shoot-out to determine the winners.

If a match went into extra time, each team was allowed to make a fourth substitution, the first time this had been allowed in a FIFA World Cup tournament. Twelve own goals were scored during the tournament, doubling the record of six set in In total, only four players were sent off in the entire tournament, the fewest since A player is automatically suspended for the next match for the following offences: The following awards were given at the conclusion of the tournament. The award was sponsored by Hyundai.

FIFA also published an alternate team of the tournament based on player performances evaluated through statistical data. Prize money amounts were announced in October The tournament logo was unveiled on 28 October by cosmonauts at the International Space Station and then projected onto Moscow's Bolshoi Theatre during an evening television programme.

Russian Sports Minister Vitaly Mutko said that the logo was inspired by "Russia's rich artistic tradition and its history of bold achievement and innovation", and FIFA President Sepp Blatter stated that it reflected the "heart and soul" of the country.

The official mascot for the tournament was unveiled 21 October , and selected through a design competition among university students. A public vote was used to select from three finalists—a cat, a tiger, and a wolf. The first phase of ticket sales started on 14 September , The general visa policy of Russia did not apply to participants and spectators, who were able to visit Russia without a visa right before and during the competition regardless of their citizenship.

A Fan-ID was required to enter the country visa-free, while a ticket, Fan-ID and a valid passport were required to enter stadiums for matches. Fan-IDs also granted World Cup attendees free access to public transport services, including buses, and train service between host cities.

Fan-ID was administered by the Ministry of Digital Development, Communications and Mass Media , who could revoke these accreditations at any time to "ensure the defence capability or security of the state or public order". The official match ball of the World Cup group stage was " Telstar 18 ", based on the name and design of the first Adidas World Cup ball from It was introduced on 9 November After the group stage, "Telstar Mechta" was used for the knockout stage.

The word mechta Russian: The difference between Telstar 18 and Mechta is the red details on the design. Its music video was released on 8 June Thirty-three footballers who are alleged to be part of the steroid program are listed in the McLaren Report.

The choice of Russia as host has been challenged. Controversial issues have included the level of racism in Russian football, [] [] [] and discrimination against LGBT people in wider Russian society. Allegations of corruption in the bidding processes for the and World Cups caused threats from England's FA to boycott the tournament.

Garcia , a US attorney, to investigate and produce a report on the corruption allegations. Eckert's summary cleared Russia and Qatar of any wrongdoing, but was denounced by critics as a whitewash. On 3 June , the FBI confirmed that the federal authorities were investigating the bidding and awarding processes for the and World Cups.

In response to the March poisoning of Sergei and Yulia Skripal , British Prime Minister Theresa May announced that no British ministers or members of the royal family would attend the World Cup, and issued a warning to any travelling England fans.

The British Foreign Office and MPs had repeatedly warned English football fans and "people of Asian or Afro-Caribbean descent" travelling to Russia of "racist or homophobic intimidation, hooligan violence and anti-British hostility".

At the close of the World Cup Russia was widely praised for its success in hosting the tournament, with Steve Rosenberg of the BBC deeming it "a resounding public relations success" for Putin, adding, "The stunning new stadiums, free train travel to venues and the absence of crowd violence has impressed visiting supporters. Russia has come across as friendly and hospitable: All the foreign fans I have spoken to are pleasantly surprised. FIFA President Gianni Infantino stated, "Everyone discovered a beautiful country, a welcoming country, that is keen to show the world that everything that has been said before might not be true.

A lot of preconceived ideas have been changed because people have seen the true nature of Russia. The elimination of the US national team in qualifying led to concerns that US interest and viewership of this World Cup would be reduced especially among "casual" viewers interested in the US team , especially noting how much Fox paid for the rights, and that US games at the World Cup peaked at During a launch event prior to the elimination, Fox stated that it had planned to place a secondary focus on the Mexican team in its coverage to take advantage of their popularity among US viewers factoring Hispanic and Latino Americans.

Fox stated that it was still committed to broadcasting a significant amount of coverage for the tournament. In February , Ukrainian rightsholder UA: PBC stated that it would not broadcast the World Cup. This came in the wake of growing boycotts of the tournament among the Football Federation of Ukraine and sports minister Ihor Zhdanov.

Broadcast rights to the tournament in the Middle East were hampered by an ongoing diplomatic crisis in Qatar over alleged support of extremist groups.

Qatar is the home country of the region's rightsholder, beIN Sports. On 2 June , beIN pulled its channels from Du and Etisalat , but with service to the latter restored later that day. Etisalat subsequently announced that it would air the World Cup in the UAE, and continue to offer beIN normally and without interruptions.

On 12 July , FIFA stated that it "has engaged counsel to take legal action in Saudi Arabia and is working alongside other sports rights owners that have also been affected to protect its interests. From Wikipedia, the free encyclopedia. For other competitions of that name, see World Cup disambiguation. For the video game, see FIFA Not a FIFA member. Bronnitsy , Moscow Oblast Australia: Kazan , Republic of Tatarstan Belgium: Krasnogorsky , Moscow Oblast Brazil: Sochi , Krasnodar Krai Colombia: Verkhneuslonsky , Republic of Tatarstan Costa Rica: Roshchino , Leningrad Oblast [79] Denmark: Anapa , Krasnodar Krai Egypt: Grozny , Chechen Republic England: Repino , Saint Petersburg [80] France: Istra , Moscow Oblast Germany: Vatutinki , Moscow [81] Iceland: Gelendzhik , Krasnodar Krai Iran: Bakovka, Moscow Oblast Japan: Kazan, Republic of Tatarstan Mexico: Khimki , Moscow Oblast Morocco: Voronezh , Voronezh Oblast Nigeria: Yessentuki , Stavropol Krai Panama: Saransk , Republic of Mordovia Peru: Sochi, Krasnodar Krai Portugal: Ramenskoye , Moscow Oblast Russia: Khimki, Moscow Oblast Saudi Arabia: Kaluga , Kaluga Oblast Serbia: Svetlogorsk , Kaliningrad Oblast South Korea: Krasnodar , Krasnodar Krai Sweden: Gelendzhik, Krasnodar Krai Switzerland: Togliatti , Samara Oblast Tunisia: Pervomayskoye, Moscow Oblast Uruguay: Bor , Nizhny Novgorod Oblast.

FIFA Rules for classification: Group stage tiebreakers H Host. Luzhniki Stadium , Moscow. Central Stadium , Yekaterinburg. Krestovsky Stadium , Saint Petersburg.

Rostov Arena , Rostov-on-Don. Cosmos Arena , Samara. Ongoing DSMES helps people with diabetes to maintain effective self-management throughout a lifetime of diabetes as they face new challenges and as advances in treatment become available 4. When new complicating factors health conditions, physical limitations, emotional factors, or basic living needs arise that influence self-management.

DSMES focuses on supporting patient empowerment by providing people with diabetes the tools to make informed self-management decisions 5. Diabetes care has shifted to an approach that places the person with diabetes and his or her family at the center of the care model, working in collaboration with health care professionals. Patient-centered care is respectful of and responsive to individual patient preferences, needs, and values.

It ensures that patient values guide all decision making 6. Studies have found that DSMES is associated with improved diabetes knowledge and self-care behaviors 7 , lower A1C 6 , 8 — 10 , lower self-reported weight 11 , 12 , improved quality of life 9 , 13 , reduced all-cause mortality risk 14 , healthy coping 15 , 16 , and reduced health care costs 17 — Better outcomes were reported for DSMES interventions that were over 10 h in total duration 10 , included ongoing support 4 , 20 , were culturally 21 , 22 and age appropriate 23 , 24 , were tailored to individual needs and preferences, and addressed psychosocial issues and incorporated behavioral strategies 5 , 15 , 25 , Individual and group approaches are effective 12 , 27 , with a slight benefit realized by those who engage in both Emerging evidence demonstrates the benefit of Internet-based DSMES services for diabetes prevention and the management of type 2 diabetes 28 — 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 There is growing evidence for the role of community health workers 31 , as well as peer 31 — 33 and lay leaders 34 , in providing ongoing support.

DSMES is associated with an increased use of primary care and preventive services 17 , 35 , 36 and less frequent use of acute care and inpatient hospital services Patients who participate in DSMES are more likely to follow best practice treatment recommendations, particularly among the Medicare population, and have lower Medicare and insurance claim costs 18 , This low participation may be due to lack of referral or other identified barriers such as logistical issues timing, costs and the lack of a perceived benefit Thus, in addition to educating referring providers about the benefits of DSMES and the critical times to refer 1 , alternative and innovative models of DSMES delivery need to be explored and evaluated.

DSMES is also covered by most health insurance plans. Ongoing support has been shown to be instrumental for improving outcomes when it is implemented after the completion 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. For many individuals with diabetes, the most challenging part of the treatment plan is determining what to eat and following a meal plan.

There is not a one-size-fits-all eating pattern for individuals with diabetes, and meal planning should be individualized. Nutrition therapy has an integral role in overall diabetes management, and each person with diabetes should be actively engaged in education, self-management, and treatment planning with his or her health care team, including the collaborative development of an individualized eating plan 41 , All individuals with diabetes should be offered a referral for individualized MNT, preferably provided by a registered dietitian who is knowledgeable and skilled in providing diabetes-specific MNT.

MNT delivered by a registered dietitian is associated with A1C decreases of 1. To promote and support healthful eating patterns, emphasizing a variety of nutrient-dense foods in appropriate portion sizes, to improve overall health and:. To address individual nutrition needs based on personal and cultural preferences, health literacy and numeracy, access to healthful foods, willingness and ability to make behavioral changes, and barriers to change.

To maintain the pleasure of eating by providing nonjudgmental messages about food choices. To provide an individual with diabetes the practical tools for developing healthy eating patterns rather than focusing on individual macronutrients, micronutrients, or single foods. Evidence suggests that there is not an ideal percentage of calories from carbohydrate, protein, and fat for all people with diabetes.

Therefore, macronutrient distribution should be based on an individualized assessment of current eating patterns, preferences, and metabolic goals. Consider personal preferences e. It is important that each member of the health care team be knowledgeable about nutrition therapy principles for people with all types of diabetes and be supportive of their implementation. Emphasis should be on healthful eating patterns containing nutrient-dense foods with less focus on specific nutrients A variety of eating patterns are acceptable for the management of diabetes 51 , The Mediterranean 54 , 55 , Dietary Approaches to Stop Hypertension DASH 56 — 58 , and plant-based diets 59 , 60 are all examples of healthful eating patterns that have shown positive results in research, but individualized meal planning should focus on personal preferences, needs, and goals.

The diabetes plate method is commonly used for providing basic meal planning guidance 61 as it provides a visual guide showing how to control calories by featuring a smaller plate and carbohydrates by limiting them to what fits in one-quarter of the plate and puts an emphasis on low-carbohydrate or nonstarchy vegetables.

Management and reduction of weight is important for overweight and obese people with type 1 and type 2 diabetes. Lifestyle intervention programs should be intensive and have frequent follow-up to achieve significant reductions in excess body weight and improve clinical indicators.

Studies of reduced calorie interventions show reductions in A1C of 0. Sustaining weight loss can be challenging 64 but has long-term benefits; maintaining weight loss for 5 years is associated with sustained improvements in A1C and lipid levels The meal plans often used in intensive lifestyle management for weight loss may differ in the types of foods they restrict e.

Studies examining the ideal amount of carbohydrate intake for people with diabetes are inconclusive, although monitoring carbohydrate intake and considering the blood glucose response to dietary carbohydrate are key for improving postprandial glucose control 70 , The literature concerning glycemic index and glycemic load in individuals with diabetes is complex often yielding mixed results, though in some studies lowering the glycemic load of consumed carbohydrates has demonstrated A1C reductions of —0.

Studies longer than 12 weeks report no significant influence of glycemic index or glycemic load independent of weight loss on A1C; however, mixed results have been reported for fasting glucose levels and endogenous insulin levels.

The role of low-carbohydrate diets in patients with diabetes remains unclear Part of the confusion is due to the wide range of definitions for a low-carbohydrate diet 73 , While benefits to low-carbohydrate diets have been described, improvements tend to be in the short term and, over time, these effects are not maintained 74 — While some studies have shown modest benefits of very low—carbohydrate or ketogenic diets less than g carbohydrate per day 78 , 79 , this approach may only be appropriate for short-term implementation up to 3—4 months if desired by the patient, as there is little long-term research citing benefits or harm.

Efforts to modify habitual eating patterns are often unsuccessful in the long term; people generally go back to their usual macronutrient distribution As for all Americans, both children and adults with diabetes are encouraged to reduce intake of refined carbohydrates and added sugars and instead focus on carbohydrates from vegetables, legumes, fruits, dairy milk and yogurt , and whole grains. Individuals with type 1 or type 2 diabetes taking insulin at mealtime should be offered intensive and ongoing education on the need to couple insulin administration with carbohydrate intake.

For people whose meal schedules or carbohydrate consumption is variable, regular counseling to help them understand the complex relationship between carbohydrate intake and insulin needs is important. In addition, education on using the insulin-to-carbohydrate ratios for meal planning can assist them with effectively modifying insulin dosing from meal to meal and improving glycemic control 44 , 51 , 70 , 83 — Individuals who consume meals containing more protein and fat than usual may also need to make mealtime insulin dose adjustments to compensate for delayed postprandial glycemic excursions 86 — For individuals on a fixed daily insulin schedule, meal planning should emphasize a relatively fixed carbohydrate consumption pattern with respect to both time and amount By contrast, a simpler diabetes meal planning approach emphasizing portion control and healthful food choices may be better suited for some older individuals, those with cognitive dysfunction, and those for whom there are concerns over health literacy and numeracy 42 — 44 , 47 , 70 , The modified plate method which uses measuring cups to assist with portion measurement may be an effective alternative to carbohydrate counting for some patients to improve glycemia There is no evidence that adjusting the daily level of protein intake typically 1—1.

Therefore, protein intake goals should be individualized based on current eating patterns. Reducing the amount of dietary protein below the recommended daily allowance is not recommended because it does not alter glycemic measures, cardiovascular risk measures, or the rate at which glomerular filtration rate declines 89 , In individuals with type 2 diabetes, protein intake may enhance or increase the insulin response to dietary carbohydrates Therefore, carbohydrate sources high in protein should not be used to treat or prevent hypoglycemia due to the potential concurrent rise in endogenous insulin.

The ideal amount of dietary fat for individuals with diabetes is controversial. 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 93 — Multiple randomized controlled trials including patients with type 2 diabetes have reported that a Mediterranean-style eating pattern 93 , 98 — , rich in polyunsaturated and monounsaturated fats, can improve both glycemic control and blood lipids.

However, supplements do not seem to have the same effects as their whole food counterparts. A systematic review concluded that dietary supplements with n-3 fatty acids did not improve glycemic control in individuals with type 2 diabetes Randomized controlled trials also do not support recommending n-3 supplements for primary or secondary prevention of CVD — People with diabetes should be advised to follow the guidelines for the general population for the recommended intakes of saturated fat, dietary cholesterol, and trans fat In general, trans fats should be avoided.

In addition, as saturated fats are progressively decreased in the diet, they should be replaced with unsaturated fats and not with refined carbohydrates Lowering sodium intake i.

However, other studies , suggest caution for universal sodium restriction to 1, mg in people with diabetes. Sodium intake recommendations should take into account palatability, availability, affordability, and the difficulty of achieving low-sodium recommendations in a nutritionally adequate diet There continues to be no clear evidence of benefit from herbal or nonherbal i.

Metformin is associated with vitamin B12 deficiency, with a recent report from the Diabetes Prevention Program Outcomes Study DPPOS suggesting that periodic testing of vitamin B12 levels should be considered in patients taking metformin, particularly in those with anemia or peripheral neuropathy Routine supplementation with antioxidants, such as vitamins E and C and carotene, is not advised due to lack of evidence of efficacy and concern related to long-term safety.

In addition, there is insufficient evidence to support the routine use of herbals and micronutrients, such as cinnamon and vitamin D , to improve glycemic control in people with diabetes 42 , Moderate alcohol intake does not have major detrimental effects on long-term blood glucose control in people with diabetes.

Risks associated with alcohol consumption include hypoglycemia particularly for those using insulin or insulin secretagogue therapies , weight gain, and hyperglycemia for those consuming excessive amounts 42 , People with diabetes can follow the same guidelines as those without diabetes if they choose to drink.

For women, no more than one drink per day; for men, no more than two drinks per day is recommended one drink is equal to a oz beer, 5-oz glass of wine, or 1. For some people with diabetes who are accustomed to sugar-sweetened products, nonnutritive sweeteners containing few or no calories may be an acceptable substitute for nutritive sweeteners those containing calories such as sugar, honey, agave syrup when consumed in moderation.

While use of nonnutritive sweeteners does not appear to have a significant effect on glycemic control , they can reduce overall calorie and carbohydrate intake Most systematic reviews and meta-analyses show benefits for nonnutritive sweetener use in weight loss , ; however, some research suggests an association with weight gain All adults, and particularly those with type 2 diabetes, should decrease the amount of time spent in daily sedentary behavior.

B Prolonged sitting should be interrupted every 30 min for blood glucose benefits, particularly in adults with type 2 diabetes. Yoga and tai chi may be included based on individual preferences to increase flexibility, muscular strength, and balance. Physical activity is a general term that includes all movement that increases energy use and is an important part of the diabetes management plan. Exercise is a more specific form of physical activity that is structured and designed to improve physical fitness.

Both physical activity and exercise are important. Exercise has been shown to improve blood glucose control, reduce cardiovascular risk factors, contribute to weight loss, and improve well-being.

Physical activity is as important for those with type 1 diabetes as it is for the general population, but its specific role in the prevention of diabetes complications and the management of blood glucose is not as clear as it is for those with type 2 diabetes.

There are also considerable data for the health benefits e. Higher levels of exercise intensity are associated with greater improvements in A1C and in fitness Other benefits include slowing the decline in mobility among overweight patients with diabetes All children, including children with diabetes or prediabetes, should be encouraged to engage in regular physical activity.

Children should engage in at least 60 min of moderate-to-vigorous aerobic activity every day with muscle- and bone-strengthening activities for at least 3 days per week In general, youth with type 1 diabetes benefit from being physically active, and an active lifestyle should be recommended to all People with diabetes should perform aerobic and resistance exercise regularly Daily exercise, or at least not allowing more than 2 days to elapse between exercise sessions, is recommended to decrease insulin resistance, regardless of diabetes type , Many adults, including most with type 2 diabetes, would be unable or unwilling to participate in such intense exercise and should engage in moderate exercise for the recommended duration.

Although heavier resistance training with free weights and weight machines may improve glycemic control and strength , 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. Recent evidence supports that all individuals, including those with diabetes, should be encouraged to reduce the amount of time spent being sedentary e.

Avoiding extended sedentary periods may help prevent type 2 diabetes for those at risk and may also aid in glycemic control for those with diabetes. Clinical trials have provided strong evidence for the A1C-lowering value of resistance training in older adults with type 2 diabetes and for an additive benefit of combined aerobic and resistance exercise in adults with type 2 diabetes If not contraindicated, patients with type 2 diabetes should be encouraged to do at least two weekly sessions of resistance exercise exercise with free weights or weight machines , with each session consisting of at least one set group of consecutive repetitive exercise motions of five or more different resistance exercises involving the large muscle groups For type 1 diabetes, although exercise in general is associated with improvement in disease status, care needs to be taken in titrating exercise with respect to glycemic management.

Each individual with type 1 diabetes has a variable glycemic response to exercise. This variability should be taken into consideration when recommending the type and duration of exercise for a given individual Women with preexisting diabetes, particularly type 2 diabetes, and those at risk for or presenting with gestational diabetes mellitus should be advised to engage in regular moderate physical activity prior to and during their pregnancies as tolerated However, providers should perform a careful history, assess cardiovascular risk factors, and be aware of the atypical presentation of coronary artery disease in patients with diabetes.

Certainly, high-risk patients should be encouraged to start with short periods of low-intensity exercise and slowly increase the intensity and duration as tolerated. Providers should assess patients for conditions that might contraindicate certain types of exercise or predispose to injury, such as uncontrolled hypertension, untreated proliferative retinopathy, autonomic neuropathy, peripheral neuropathy, and a history of foot ulcers or Charcot foot.

Those with complications may require a more thorough evaluation prior to beginning an exercise program In some patients, hypoglycemia after exercise may occur and last for several hours due to increased insulin sensitivity. Hypoglycemia is less common in patients with diabetes 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 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 Consultation with an ophthalmologist prior to engaging in an intense exercise regimen may be appropriate.

Decreased pain sensation and a higher pain threshold in the extremities 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 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 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 Cardiovascular autonomic neuropathy is also an independent risk factor for cardiovascular death and silent myocardial ischemia Therefore, individuals with diabetic autonomic neuropathy should undergo cardiac investigation before beginning physical activity more intense than that to which they are accustomed.

Physical activity can acutely increase urinary albumin excretion. However, there is no evidence that vigorous-intensity exercise increases the rate of progression of diabetic kidney disease, and there appears to be no need for specific exercise restrictions for people with diabetic kidney disease in general Advise all patients not to use cigarettes and other tobacco products A or e-cigarettes.

Include smoking cessation counseling and other forms of treatment as a routine component of diabetes care. Results from epidemiological, case-control, and cohort studies provide convincing evidence to support the causal link between cigarette smoking and health risks Recent data show tobacco use is higher among adults with chronic conditions Smokers with diabetes and people with diabetes exposed to secondhand smoke have a heightened risk of CVD, premature death, and microvascular complications.

Smoking may have a role in the development of type 2 diabetes , The routine and thorough assessment of tobacco use is essential to prevent smoking or encourage cessation. Numerous large randomized clinical trials have demonstrated the efficacy and cost-effectiveness of brief counseling in smoking cessation, including the use of telephone quit lines, in reducing tobacco use. For the patient motivated to quit, the addition of pharmacologic therapy to counseling is more effective than either treatment alone Special considerations should include assessment of level of nicotine dependence, which is associated with difficulty in quitting and relapse Although some patients may gain weight in the period shortly after smoking cessation , recent research has demonstrated that this weight gain does not diminish the substantial CVD benefit realized from smoking cessation One study in smokers with newly diagnosed type 2 diabetes found that smoking cessation was associated with amelioration of metabolic parameters and reduced blood pressure and albuminuria at 1 year Nonsmokers should be advised not to use e-cigarettes.

There are no rigorous studies that have demonstrated that e-cigarettes are a healthier alternative to smoking or that e-cigarettes can facilitate smoking cessation. More extensive research of their short- and long-term effects is needed to determine their safety and their cardiopulmonary effects in comparison with smoking and standard approaches to smoking cessation — Psychosocial care should be integrated with a collaborative, patient-centered approach and provided to all people with diabetes, with the goals of optimizing health outcomes and health-related quality of life.

Psychosocial screening and follow-up may include, but are not limited to, attitudes about diabetes, expectations for medical management and outcomes, affect or mood, general and diabetes-related quality of life, available resources financial, social, and emotional , and psychiatric history.

Providers should consider assessment for symptoms of diabetes distress, depression, anxiety, disordered eating, and cognitive capacities using patient-appropriate standardized and validated tools at the initial visit, at periodic intervals, and when there is a change in disease, treatment, or life circumstance. Including caregivers and family members in this assessment is recommended. Complex environmental, social, behavioral, and emotional factors, known as psychosocial factors, influence living with diabetes, both type 1 and type 2, and achieving satisfactory medical 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.

Emotional well-being is an important part of diabetes care and self-management. There are opportunities for the clinician to routinely assess psychosocial status in a timely and efficient manner for referral to appropriate services.

A systematic review and meta-analysis showed that psychosocial interventions modestly but significantly improved A1C standardized mean difference —0. However, there was a limited association between the effects on A1C and mental health, and no intervention characteristics predicted benefit on both outcomes.

Key opportunities for psychosocial screening occur at diabetes diagnosis, during regularly scheduled management visits, during hospitalizations, with new onset of complications, or when problems with glucose control, quality of life, or self-management are identified 1.

Patients are likely to exhibit psychological vulnerability at diagnosis, when their medical status changes e. Providers can start with informal verbal inquires, for example, by asking if there have been changes in mood during the past 2 weeks or since their last visit.

Providers should consider asking if there are new or different barriers to treatment and self-management, such as feeling overwhelmed or stressed by diabetes or other life stressors. Standardized and validated tools for psychosocial monitoring and assessment can also be used by providers , with positive findings leading to referral to a mental health provider specializing in diabetes for comprehensive evaluation, diagnosis, and treatment.

Diabetes distress DD is very common and is distinct from other psychological disorders — The constant behavioral demands medication dosing, frequency, and titration; monitoring blood glucose, food intake, eating patterns, and physical activity of diabetes self-management and the potential or actuality of disease progression are directly associated with reports of DD High levels of DD significantly impact medication-taking behaviors and are linked to higher A1C, lower self-efficacy, and poorer dietary and exercise behaviors 16 , , It may be helpful to provide counseling regarding expected diabetes-related versus generalized psychological distress at diagnosis and when disease state or treatment changes DD should be routinely monitored using patient-appropriate validated measures If DD is identified, the person should be referred for specific diabetes education to address areas of diabetes self-care that are most relevant to the patient and impact clinical management.

People whose self-care remains impaired after tailored diabetes education should be referred by their care team to a behavioral health provider for evaluation and treatment. Other psychosocial issues known to affect self-management and health outcomes include attitudes about the illness, expectations for medical management and outcomes, available resources financial, social, and emotional , and psychiatric history. Indications for referral to a mental health specialist familiar with diabetes management may include positive screening for overall stress related to work-life balance, DD, diabetes management difficulties, depression, anxiety, disordered eating, and cognitive dysfunction see Table 4.

It is preferable to incorporate psychosocial assessment and treatment into routine care rather than waiting for a specific problem or deterioration in metabolic or psychological status to occur 25 , Providers should identify behavioral and mental health providers, ideally those who are knowledgeable about diabetes treatment and the psychosocial aspects of diabetes, to whom they can refer patients.

Ideally, psychosocial care providers should be embedded in diabetes care settings. Although the clinician may not feel qualified to treat psychological problems , optimizing the patient-provider relationship as a foundation may increase the likelihood of the patient accepting referral for other services.

Collaborative care interventions and a team approach have demonstrated efficacy in diabetes self-management and psychosocial functioning Situations that warrant referral of a person with diabetes to a mental health provider for evaluation and treatment.

Standards of Medical Care in Diabetes— Diabetes Care ;41 Suppl. 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 http: We only request your email address so that the person you are recommending the page to knows that you wanted them to see it, and that it is not junk mail.

We do not capture any email address. Skip to main content. Diabetes Care Jan; 41 Supplement 1: B There are four critical times to evaluate the need for diabetes self-management education and support: E Facilitating appropriate diabetes self-management and improving clinical outcomes, health status, and quality of life are key goals of diabetes self-management education and support to be measured and monitored as part of routine care.

C Effective diabetes self-management education and support should be patient centered, may be given in group or individual settings or using technology, and should help guide clinical decisions. A Because diabetes self-management education and support can improve outcomes and reduce costs B , adequate reimbursement by third-party payers is recommended.

E DSMES services facilitate the knowledge, skills, and abilities necessary for optimal diabetes self-care and incorporate the needs, goals, and life experiences of the person with diabetes. At diagnosis Annually for assessment of education, nutrition, and emotional needs When new complicating factors health conditions, physical limitations, emotional factors, or basic living needs arise that influence self-management When transitions in care occur DSMES focuses on supporting patient empowerment by providing people with diabetes the tools to make informed self-management decisions 5.

Evidence for the Benefits Studies have found that DSMES is associated with improved diabetes knowledge and self-care behaviors 7 , lower A1C 6 , 8 — 10 , lower self-reported weight 11 , 12 , improved quality of life 9 , 13 , reduced all-cause mortality risk 14 , healthy coping 15 , 16 , and reduced health care costs 17 — View inline View popup.

Goals of Nutrition Therapy for Adults With Diabetes To promote and support healthful eating patterns, emphasizing a variety of nutrient-dense foods in appropriate portion sizes, to improve overall health and: Eating Patterns, Macronutrient Distribution, and Meal Planning Evidence suggests that there is not an ideal percentage of calories from carbohydrate, protein, and fat for all people with diabetes.

Weight Management Management and reduction of weight is important for overweight and obese people with type 1 and type 2 diabetes. Carbohydrates Studies examining the ideal amount of carbohydrate intake for people with diabetes are inconclusive, although monitoring carbohydrate intake and considering the blood glucose response to dietary carbohydrate are key for improving postprandial glucose control 70 , Protein There is no evidence that adjusting the daily level of protein intake typically 1—1.

Fats The ideal amount of dietary fat for individuals with diabetes is controversial. Micronutrients and Supplements There continues to be no clear evidence of benefit from herbal or nonherbal i.

Alcohol Moderate alcohol intake does not have major detrimental effects on long-term blood glucose control in people with diabetes. Nonnutritive Sweeteners For some people with diabetes who are accustomed to sugar-sweetened products, nonnutritive sweeteners containing few or no calories may be an acceptable substitute for nutritive sweeteners those containing calories such as sugar, honey, agave syrup when consumed in moderation.

C Physical activity is a general term that includes all movement that increases energy use and is an important part of the diabetes management plan. Exercise and Children All children, including children with diabetes or prediabetes, should be encouraged to engage in regular physical activity.

Frequency and Type of Physical Activity People with diabetes should perform aerobic and resistance exercise regularly Physical Activity and Glycemic Control Clinical trials have provided strong evidence for the A1C-lowering value of resistance training in older adults with type 2 diabetes and for an additive benefit of combined aerobic and resistance exercise in adults with type 2 diabetes Exercise in the Presence of Specific Long-term Complications of Diabetes 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 Peripheral Neuropathy Decreased pain sensation and a higher pain threshold in the extremities result in an increased risk of skin breakdown, infection, and Charcot joint destruction with some forms of exercise.

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 Diabetic Kidney Disease Physical activity can acutely increase urinary albumin excretion.

E Include smoking cessation counseling and other forms of treatment as a routine component of diabetes care. B Results from epidemiological, case-control, and cohort studies provide convincing evidence to support the causal link between cigarette smoking and health risks A Psychosocial screening and follow-up may include, but are not limited to, attitudes about diabetes, expectations for medical management and outcomes, affect or mood, general and diabetes-related quality of life, available resources financial, social, and emotional , and psychiatric history.

E Providers should consider assessment for symptoms of diabetes distress, depression, anxiety, disordered eating, and cognitive capacities using patient-appropriate standardized and validated tools at the initial visit, at periodic intervals, and when there is a change in disease, treatment, or life circumstance.

Screening Key opportunities for psychosocial screening occur at diabetes diagnosis, during regularly scheduled management visits, during hospitalizations, with new onset of complications, or when problems with glucose control, quality of life, or self-management are identified 1. B Diabetes distress DD is very common and is distinct from other psychological disorders — Referral to a Mental Health Specialist Indications for referral to a mental health specialist familiar with diabetes management may include positive screening for overall stress related to work-life balance, DD, diabetes management difficulties, depression, anxiety, disordered eating, and cognitive dysfunction see Table 4.

Diabetes self-management education and support in type 2 diabetes: Diabetes Care ; Clin Diabetes ; Patient Educ Couns ; Twenty-first century behavioral medicine: Self-management education for adults with type 2 diabetes: National standards for diabetes self-management education and support. Diabetes Care ; 37 Suppl.

Evaluation of a behavior support intervention for patients with poorly controlled diabetes. Arch Intern Med ; Structured type 1 diabetes education delivered within routine care: Diabetes self-management education for adults with type 2 diabetes mellitus:

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