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Great and very informative article. Thus, the study may have been underpowered or done in too short a time frame the test was done after only 5 days of loading to observe any possible effects. Studies conducted in vegetarians tend to show cognitive enhancement in youth, possibly due to a creatine deficiency, as compared to omnivores. Benefits were observed in body cell mass and phase angle indicative of cellular viability , but only in the subsample with less aggressive chemotherapy. Supplementation of creatine monohydrate increases stores of both of these compounds in myocytes, neurons, eyes, kidneys and testes. Similarly to complex training, contrast loading relies on the intense nervous system activation and enhanced muscle fibre recruitment from the heavy lift to help improve the power with which the subsequent exercise can be performed. I realize the above has more changes than you would run in a single study, since the correlation could become unclear.

Why protein?

Weight training

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.

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Diabetes Educ ; Diabetes self-management education reduces risk of all-cause mortality in type 2 diabetes patients: Endocrine ; Facilitating healthy coping in patients with diabetes: Nutritionist visits, diabetes classes, and hospitalization rates and charges: Assessing the value of the diabetes educator.

One-year outcomes of diabetes self-management training among Medicare beneficiaries newly diagnosed with diabetes. Med Care ; A systematic review of interventions to improve diabetes care in socially disadvantaged populations. Culturally appropriate health education for type 2 diabetes mellitus in ethnic minority groups. Cochrane Database Syst Rev ;3: Ann Intern Med ; A systematic review of diabetes self-care interventions for older, African American, or Latino adults.

Peyrot M , Rubin RR. Behavioral and psychosocial interventions in diabetes: Comparative effectiveness of goal setting in diabetes mellitus group clinics: Individual patient education for people with type 2 diabetes mellitus.

Cochrane Database Syst Rev ; 1: Internet delivered diabetes self-management education: Diabetes Technol Ther ; Long-term outcomes of a Web-based diabetes prevention program: J Med Internet Res ; A systematic review of reviews evaluating technology-enabled diabetes self-management education and support.

J Diabetes Sci Technol ; The role of community health workers in diabetes: Curr Diab Rep ; Diabetes control with reciprocal peer support versus nurse care management: Peer mentoring and financial incentives to improve glucose control in African American veterans: Self-management education programmes by lay leaders for people with chronic conditions. Cochrane Database Syst Rev ; 4: Assessing the value of diabetes education.

Associations between self-management education and comprehensive diabetes clinical care. Diabetes Spectr ; Health Educ Behav ; Diabetes self-management education and training among privately insured persons with newly diagnosed diabetes--United States, Reasons why patients referred to diabetes education programmes choose not to attend: Diabet Med ; Reconsidering cost-sharing for diabetes self-management education: Accessed 25 September Management of hyperglycemia in type 2 diabetes, Nutrition therapy recommendations for the management of adults with diabetes.

Nutrition practice guidelines for type 1 diabetes mellitus positively affect dietitian practices and patient outcomes. J Am Diet Assoc ; Effect of carbohydrate counting and medical nutritional therapy on glycaemic control in type 1 diabetic subjects: Academy of Nutrition and Dietetics nutrition practice guideline for type 1 and type 2 diabetes in adults: J Acad Nutr Diet ; Effect of intensive blood-glucose control with metformin on complications in overweight patients with type 2 diabetes UKPDS Lancet ; A simple meal plan emphasizing healthy food choices is as effective as an exchange-based meal plan for urban African Americans with type 2 diabetes.

Translating lifestyle intervention to practice in obese patients with type 2 diabetes: BMJ ; Academy of Nutrition and Dietetics Nutrition practice guideline for type 1 and type 2 diabetes in adults: From pyramids to plates to patterns: Food groups and risk of all-cause mortality: Am J Clin Nutr ; Effects of a Mediterranean-style diet on the need for antihyperglycemic drug therapy in patients with newly diagnosed type 2 diabetes: Am J Epidemiol ; Prevention and management of type 2 diabetes: A comprehensive review of the literature supporting recommendations from the Canadian Diabetes Association for the use of a plant-based diet for management of type 2 diabetes.

Can J Diabetes ; Vegetarian diets in the prevention and management of diabetes and its complications. The Diabetes Nutrition Education Study randomized controlled trial: Cardiometabolic risk factor changes observed in diabetes prevention programs in US settings: PLoS Med ; Combined diet and physical activity promotion programs to prevent type 2 diabetes among persons at increased risk: Lifestyle weight-loss intervention outcomes in overweight and obese adults with type 2 diabetes: Long-term effect of intensive lifestyle intervention on cardiovascular risk factors in patients with diabetes in real-world clinical practice: Comparison of weight-loss diets with different compositions of fat, protein, and carbohydrates.

N Engl J Med ; Effects of 4 weight-loss diets differing in fat, protein, and carbohydrate on fat mass, lean mass, visceral adipose tissue, and hepatic fat: Comparison of weight loss among named diet programs in overweight and obese adults: JAMA ; Update on prevention of cardiovascular disease in adults with type 2 diabetes mellitus in light of recent evidence: Training in flexible, intensive insulin management to enable dietary freedom in people with type 1 diabetes: Association of diet with glycated hemoglobin during intensive treatment of type 1 diabetes in the Diabetes Control and Complications Trial.

Macronutrients, food groups, and eating patterns in the management of diabetes: Thomas D , Elliott EJ. Low glycaemic index, or low glycaemic load, diets for diabetes mellitus.

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Efficacy of low carbohydrate diet for type 2 diabetes mellitus management: Diabetes Res Clin Pract ; Comparison of low- and high-carbohydrate diets for type 2 diabetes management: Short-term safety, tolerability and efficacy of a very low-calorie-ketogenic diet interventional weight loss program versus hypocaloric diet in patients with type 2 diabetes mellitus.

Nutr Diabetes ; 6: An online intervention comparing a very low-carbohydrate ketogenic diet and lifestyle recommendations versus a plate method diet in overweight individuals with type 2 diabetes: Department of Health and Human Services.

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