5. Lifestyle Management:Standards of Medical Care inDiabetesd2019Diabetes Care 2019;42(Suppl. 1):S46–S60 | https://doi.org/10.2337/dc19-S005

The American Diabetes Association (ADA) “Standards of Medical Care in Diabetes”includes ADA’s current clinical practice recommendations and is intended to pro-vide the components of diabetes care, general treatment goals and guidelines,and tools to evaluate quality of care. Members of the ADA Professional PracticeCommittee, a multidisciplinary expert committee, are responsible for updatingthe Standards of Care annually, or more frequently as warranted. For a detaileddescription of ADA standards, statements, and reports, as well as the evidence-grading system for ADA’s clinical practice recommendations, please refer to theStandards of Care Introduction. Readers who wish to comment on the Standardsof Care are invited to do so at professional.diabetes.org/SOC.

Lifestylemanagement is a fundamental aspect of diabetes care and includes diabetesself-management education and support (DSMES), medical nutrition therapy (MNT),physical activity, smoking cessation counseling, and psychosocial care. Patients andcare providers should focus together on how to optimize lifestyle from the time ofthe initial comprehensive medical evaluation, throughout all subsequent evaluationsand follow-up, and during the assessment of complications and management of co-morbid conditions in order to enhance diabetes care.

DIABETES SELF-MANAGEMENT EDUCATION AND SUPPORT

Recommendations

5.1 In accordance with the national standards for diabetes self-managementeducation and support, all peoplewith diabetes should participate in diabetesself-management education to facilitate the knowledge, skills, and abilitynecessary for diabetes self-care. Diabetes self-management support is ad-ditionally recommended to assist with implementing and sustaining skillsand behaviors needed for ongoing self-management. B

5.2 There are four critical times to evaluate the need for diabetes self-management education and support: at diagnosis, annually, when compli-cating factors arise, and when transitions in care occur. E

5.3 Clinical outcomes, health status, and quality of life are key goals of diabetesself-management education and support that should be measured as part ofroutine care. C

5.4 Diabetes self-management education and support should be patient cen-tered, may be given in group or individual settings or using technology, andshould be communicated with the entire diabetes care team. A

5.5 Because diabetes self-management education and support can improveoutcomes and reduce costsB, adequate reimbursement by third-party payersis recommended. E

Suggested citation: American Diabetes Associa-tion. 5. Lifestyle management: Standards ofMedical Care in Diabetesd2019. Diabetes Care2019;42(Suppl. 1):S46–S60

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American Diabetes Association

S46 Diabetes Care Volume 42, Supplement 1, January 2019

5.LIFESTYLEMANAGEM

ENT

DSMES services facilitate the knowledge,skills, and abilities necessary for optimaldiabetes self-care and incorporate theneeds, goals, and life experiences of theperson with diabetes. The overall objec-tives of DSMES are to support informeddecision making, self-care behaviors,problem-solving, and active collabora-tion with the health care team to improveclinical outcomes, health status, andquality of life in a cost-effective manner(1). Providers are encouraged to considerthe burden of treatment and the pa-tient’s level of confidence/self-efficacyformanagement behaviors as well as thelevel of social and family support whenproviding DSMES. Patient performanceof self-management behaviors, includingits effect on clinical outcomes, healthstatus, and quality of life, as well as thepsychosocial factors impacting the per-son’s self-management should be mon-itored as part of routine clinical care.In addition, in response to the growing

literature that associates potentially judg-mental words with increased feelings ofshame and guilt, providers are encouragedto consider the impact that language hason building therapeutic relationships andto choose positive, strength-based wordsand phrases that put people first (2,3). Pa-tient performance of self-managementbehaviors as well as psychosocial factorsimpacting the person’s self-managementshould be monitored. Please see Section4, “Comprehensive Medical Evaluationand Assessment of Comorbidities,” formore on use of language.DSMES and the current national stan-

dards guiding it (1,4) are based on evi-dence of benefit. Specifically, DSMEShelps people with diabetes to identifyand implement effective self-manage-ment strategies and cope with diabetesat the four critical time points (describedbelow) (1). Ongoing DSMES helps peoplewith diabetes to maintain effective self-management throughout a lifetime ofdiabetes as they face new challengesand as advances in treatment becomeavailable (5).Four critical time points have been

defined when the need for DSMES is tobe evaluated by the medical care pro-vider and/or multidisciplinary team, withreferrals made as needed (1):

1. At diagnosis2. Annually for assessmentof education,

nutrition, and emotional needs

3. When new complicating factors(health conditions, physical limita-tions, emotional factors, or basicliving needs) arise that influenceself-management

4. When transitions in care occur

DSMES focuses on supporting patientempowerment by providing people withdiabetes the tools to make informed self-management decisions (6). Diabetes carehas shifted to an approach that placesthe person with diabetes and his or herfamily at the center of the care model,working in collaboration with health careprofessionals. Patient-centered care is re-spectful of and responsive to individualpatient preferences, needs, and values.It ensures that patient values guide alldecision making (7).

Evidence for the BenefitsStudies have found that DSMES is asso-ciated with improved diabetes knowl-edge and self-care behaviors (8), lowerA1C (7,9–11), lower self-reported weight(12,13), improved quality of life (10,14),reduced all-cause mortality risk (15),healthy coping (16,17), and reducedhealth care costs (18–20). Better out-comes were reported for DSMES inter-ventions that were over 10 h in totalduration (11), included ongoing support(5,21), were culturally (22,23) and ageappropriate (24,25), were tailored toindividual needs and preferences, and ad-dressed psychosocial issues and incorpo-rated behavioral strategies (6,16,26,27).Individual and group approaches areeffective (13,28,29), with a slight benefitrealized by those who engage in both(11). Emerging evidence demonstratesthe benefit of Internet-based DSMESservices for diabetes prevention andthe management of type 2 diabetes(30–32). Technology-enabled diabe-tes self-management solutions improveA1C most effectively when there istwo-way communication between thepatient and the health care team, individ-ualized feedback, use of patient-generatedhealth data, and education (32). Currentresearch supports nurses, dietitians, andpharmacists as providers of DSMES whomay also develop curriculum (33–35).Members of the DSMES team shouldhave specialized clinical knowledge indiabetes and behavior change principles.Certification as a certified diabetes ed-ucator (CDE) or board certified-advanced

diabetes management (BC-ADM) certifi-cation demonstrates specialized trainingand mastery of a specific body of knowl-edge (4). Additionally, there is growingevidence for the role of communityhealth workers (36,37), as well as peer(36–40) and lay leaders (41), in providingongoing support.

DSMES is associated with an increaseduse of primary care and preventive ser-vices (18,42,43) and less frequent use ofacute care and inpatient hospital services(12). Patients who participate in DSMESare more likely to follow best practicetreatment recommendations, particu-larly among the Medicare population,and have lower Medicare and insuranceclaim costs (19,42). Despite these bene-fits, reports indicate that only 5–7% ofindividuals eligible for DSMES throughMedicare or a private insurance planactually receive it (44,45). This low par-ticipation may be due to lack of referral orother identified barriers such as logisticalissues (timing, costs) and the lack of aperceived benefit (46). Thus, in additionto educating referring providers aboutthe benefits of DSMES and the criticaltimes to refer (1), alternative and in-novative models of DSMES deliveryneed to be explored and evaluated.

ReimbursementMedicare reimburses DSMES when thatservice meets the national standards(1,4) and is recognized by the AmericanDiabetes Association (ADA) or other ap-proval bodies. DSMES is also covered bymost health insurance plans. Ongoingsupport has been shown to be instru-mental for improving outcomes when itis implemented after the completion ofeducation services. DSMES is frequentlyreimbursed when performed in person.However, although DSMES can also beprovided via phone calls and telehealth,these remote versions may not alwaysbe reimbursed. Changes in reimburse-ment policies that increase DSMES ac-cess andutilizationwill result in apositiveimpact to beneficiaries’ clinical outcomes,quality of life, health care utilization, andcosts (47).

NUTRITION THERAPY

For many individuals with diabetes, themost challenging part of the treat-ment plan is determining what to eat andfollowing a meal plan. There is not a one-size-fits-all eating pattern for individuals

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with diabetes, and meal planning shouldbe individualized. Nutrition therapy hasan integral role in overall diabetes man-agement, and each person with diabetesshould be actively engaged in education,self-management, and treatment plan-ning with his or her health care team,including the collaborative developmentof an individualized eating plan (35,48).All individuals with diabetes should beoffered a referral for individualized MNTprovided by a registered dietitian (RD)who is knowledgeable and skilled inproviding diabetes-specific MNT (49).MNT delivered by an RD is associatedwith A1C decreases of 1.0–1.9% for peo-ple with type 1 diabetes (50) and 0.3–2%for people with type 2 diabetes (50). SeeTable 5.1 for specific nutrition recom-mendations. Because of the progres-sive nature of type 2 diabetes, lifestylechanges alone may not be adequate tomaintain euglycemia over time. How-ever, after medication is initiated, nutri-tion therapy continues to be an importantcomponent and should be integratedwith the overall treatment plan (48).

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

eatingpatterns, emphasizing a varietyof nutrient-dense foods in appropri-ate portion sizes, to improve overallhealth and:○ Achieve and maintain body weight

goals○ Attain individualized glycemic,

blood pressure, and lipid goals○ Delay or prevent the complica-

tions of diabetes2. To address individual nutrition needs

based on personal and cultural pref-erences, health literacy andnumeracy,access to healthful foods, willing-ness and ability to make behavioralchanges, and barriers to change

3. To maintain the pleasure of eating byproviding nonjudgmental messagesabout food choices

4. To provide an individual with diabe-tes the practical tools for developinghealthy eating patterns rather thanfocusing on individual macronutrients,micronutrients, or single foods

Eating Patterns, MacronutrientDistribution, and Meal PlanningEvidence suggests that there is notan ideal percentage of calories from

carbohydrate, protein, and fat for all peo-ple with diabetes. Therefore, macronu-trient distribution should be based onan individualized assessment of currenteating patterns, preferences, and meta-bolic goals. Consider personal preferen-ces (e.g., tradition, culture, religion,health beliefs and goals, economics) aswell as metabolic goals when workingwith individuals to determine the besteating pattern for them (35,51,52). It isimportant that each member of thehealth care team be knowledgeableabout nutrition therapy principles forpeople with all types of diabetes andbe supportive of their implementation.Emphasis should be on healthful eat-ing patterns containing nutrient-densefoods, with less focus on specific nu-trients (53). A variety of eating patternsare acceptable for the management ofdiabetes (51,54), and a referral to an RDor registered dietitian nutritionist (RDN)is essential to assess the overall nutritionstatus of, and to work collaborativelywith, the patient to create a personalizedmeal plan that considers the individual’shealth status, skills, resources, food pref-erences, and health goals to coordinateand align with the overall treatmentplan including physical activity and med-ication. The Mediterranean (55,56), Di-etary Approaches to Stop Hypertension(DASH) (57–59), and plant-based (60,61)diets are all examples of healthful eat-ing patterns that have shown positiveresults in research, but individualizedmeal planning should focus on per-sonal preferences, needs, and goals. Inaddition, research indicates that low-carbohydrate eating plans may result inimproved glycemia and have the poten-tial to reduce antihyperglycemic medi-cations for individuals with type 2diabetes (62–64). As research studieson some low-carbohydrate eating plansgenerally indicate challenges with long-term sustainability, it is important toreassess and individualize meal planguidance regularly for those interestedin this approach. This meal plan is notrecommended at this time for womenwho are pregnant or lactating, peoplewith or at risk for disordered eating, orpeople who have renal disease, and itshould be used with caution in patientstaking sodium–glucose cotransporter2 (SGLT2) inhibitors due to the potentialrisk of ketoacidosis (65,66). There is in-adequate research in type 1 diabetes to

support one eating plan over anotherat this time.

A simple and effective approach toglycemia and weight management em-phasizing portion control and healthyfood choices should be considered forthose with type 2 diabetes who are nottaking insulin, who have limited healthliteracy or numeracy, or who are olderand prone to hypoglycemia (50). Thediabetes plate method is commonlyused for providing basic meal planningguidance (67) as it provides a visual guideshowing how to control calories (byfeaturing a smaller plate) and carbohy-drates (by limiting them to what fits inone-quarter of the plate) and puts anemphasis on low-carbohydrate (or non-starchy) vegetables.

Weight ManagementManagement and reduction of weight isimportant for people with type 1 dia-betes, type 2 diabetes, or prediabeteswho have overweight or obesity. Life-style intervention programs should beintensive and have frequent follow-upto achieve significant reductions in ex-cess body weight and improve clinicalindicators. There is strong and consis-tent evidence that modest persistentweight loss can delay the progressionfrom prediabetes to type 2 diabetes(51,68,69) (see Section 3 “Preventionor Delay of Type 2 Diabetes”) and isbeneficial to the management of type2 diabetes (see Section 8 “ObesityManagement for the Treatment ofType 2 Diabetes”).

Studies of reduced calorie interven-tions show reductions in A1C of 0.3%to 2.0% in adults with type 2 diabetes,as well as improvements in medicationdoses and quality of life (50,51). Sustain-ing weight loss can be challenging (70,71)but has long-term benefits; maintainingweight loss for 5 years is associated withsustained improvements in A1C and lipidlevels (72). Weight loss can be attainedwith lifestyle programs that achieve a500–750 kcal/day energy deficit or pro-vide ;1,200–1,500 kcal/day for womenand 1,500–1,800 kcal/day for men,adjusted for the individual’s baselinebody weight. For many obese individ-uals with type 2 diabetes, weight lossof at least 5% is needed to producebeneficial outcomes in glycemic con-trol, lipids, and blood pressure (70).It should be noted, however, that the

S48 Lifestyle Management Diabetes Care Volume 42, Supplement 1, January 2019

clinical benefits of weight loss are pro-gressive and more intensive weightloss goals (i.e., 15%) may be appropri-ate to maximize benefit depending

on need, feasibility, and safety (73).MNT guidance from an RD/RDN withexpertise in diabetes and weight man-agement, throughout the course of a

structured weight loss plan, is stronglyrecommended.

Studies have demonstrated that avariety of eating plans, varying in

Table 5.1—Medical nutrition therapy recommendations

Topic Recommendations Evidence rating

Effectiveness ofnutrition therapy

5.6 An individualized medical nutrition therapy program as needed to achieve treatment goals,preferably provided by a registered dietitian, is recommended for all people with type 1 or type 2diabetes, prediabetes, and gestational diabetes mellitus.

A

5.7 A simple and effective approach to glycemia and weight management emphasizing portion controlandhealthy foodchoicesmaybeconsidered for thosewith type2diabeteswhoarenot taking insulin,who have limited health literacy or numeracy, or who are older and prone to hypoglycemia.

B

5.8 Because diabetes nutrition therapy can result in cost savings B and improved outcomes (e.g.,A1C reduction) A, medical nutrition therapy should be adequately reimbursed by insurance andother payers. E

B, A, E

Energy balance 5.9 Weight loss (.5%) achievable by the combination of reduction of calorie intake and lifestylemodification benefits overweight or obese adults with type 2 diabetes and also those withprediabetes. Intervention programs to facilitate weight loss are recommended.

A

Eating patterns andmacronutrientdistribution

5.10 There is no single ideal dietary distribution of calories among carbohydrates, fats, and proteins forpeople with diabetes; therefore, meal plans should be individualized while keeping total calorieand metabolic goals in mind.

E

5.11Avarietyof eatingpatternsareacceptable for themanagementof type2diabetesandprediabetes. B

Carbohydrates 5.12Carbohydrate intake should emphasize nutrient-dense carbohydrate sources that are high infiber,including vegetables, fruits, legumes, whole grains, as well as dairy products.

B

5.13 For peoplewith type1diabetes and thosewith type2diabeteswhoareprescribedaflexible insulintherapy program, education on how to use carbohydrate counting A and in some cases how toconsider fat andprotein contentB to determinemealtime insulin dosing is recommended to improveglycemic control.

A, B

5.14 For individualswhose daily insulin dosing is fixed, a consistent pattern of carbohydrate intakewithrespect to time and amount may be recommended to improve glycemic control and reduce the riskof hypoglycemia.

B

5.15 People with diabetes and those at risk are advised to avoid sugar-sweetened beverages (includingfruit juices) in order to control glycemia and weight and reduce their risk for cardiovascular diseaseand fatty liver B and should minimize the consumption of foods with added sugar that have thecapacity to displace healthier, more nutrient-dense food choices. A

B, A

Protein 5.16 In individuals with type 2 diabetes, ingested protein appears to increase insulin response withoutincreasing plasma glucose concentrations. Therefore, carbohydrate sources high in protein shouldbe avoided when trying to treat or prevent hypoglycemia.

B

Dietary fat 5.17 Data on the ideal total dietary fat content for people with diabetes are inconclusive, so an eatingplan emphasizing elements of a Mediterranean-style diet rich in monounsaturated andpolyunsaturated fats may be considered to improve glucose metabolism and lower cardiovasculardisease risk and can be an effective alternative to a diet low in total fat but relatively high incarbohydrates.

B

5.18 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; however, evidence does notsupport a beneficial role for the routine use of n-3 dietary supplements. A

B, A

Micronutrients andherbal supplements

5.19 There is no clear evidence that dietary supplementation with vitamins, minerals (such aschromium and vitamin D), herbs, or spices (such as cinnamon or aloe vera) can improve outcomes inpeople with diabetes who do not have underlying deficiencies and they are not generallyrecommended for glycemic control.

C

Alcohol 5.20 Adults with diabetes who drink alcohol should do so in moderation (no more than one drinkper day for adult women and no more than two drinks per day for adult men).

C

5.21Alcohol consumptionmayplacepeoplewithdiabetesat increased risk for hypoglycemia, especiallyif taking insulin or insulin secretagogues. Education and awareness regarding the recognition andmanagement of delayed hypoglycemia are warranted.

B

Sodium 5.22 As for the general population, people with diabetes should limit sodium consumptionto ,2,300 mg/day.

B

Nonnutritivesweeteners

5.23 The use of nonnutritive sweeteners may have the potential to reduce overall calorie andcarbohydrate intake if substituted for caloric (sugar) sweetenersandwithoutcompensationby intakeof additional calories from other food sources. For those who consume sugar-sweetened beveragesregularly, a low-calorie or nonnutritive-sweetened beveragemay serve as a short-term replacementstrategy, but overall, people are encouraged to decrease both sweetened and nonnutritive-sweetened beverages and use other alternatives, with an emphasis on water intake.

B

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macronutrient composition, can be usedeffectively and safely in the short term(1–2 years) to achieve weight loss inpeople with diabetes. This includes struc-tured low-calorie meal plans that includemeal replacements (72–74) and theMediterranean eating pattern (75) aswell as low-carbohydrate meal plans(62). However, no single approach hasbeen proven to be consistently superior(76,77), and more data are needed toidentify and validate those meal plansthat are optimal with respect to long-term outcomes as well as patient ac-ceptability. The importance of providingguidance on an individualized meal plancontaining nutrient-dense foods, such asvegetables, fruits, legumes, dairy, leansources of protein (including plant-basedsources as well as lean meats, fish, andpoultry), nuts, seeds, and whole grains,cannot be overemphasized (77), as wellas guidance on achieving the desired en-ergy deficit (78–81). Any approach tomeal planning should be individualizedconsidering the health status, personalpreferences, and ability of the personwith diabetes to sustain the recommen-dations in the plan.

CarbohydratesStudies examining the ideal amount ofcarbohydrate intake for people withdiabetes are inconclusive, although moni-toring carbohydrate intake and consid-ering the blood glucose response todietary carbohydrate are key for improv-ing postprandial glucose control (82,83).The literature concerning glycemic indexand glycemic load in individuals with di-abetes is complex, often yielding mixedresults, though in some studies loweringthe glycemic load of consumed carbohy-drates has demonstrated A1C reductionsof 0.2% to 0.5% (84,85). Studies longerthan 12 weeks report no significant in-fluence of glycemic index or glycemic loadindependent of weight loss on A1C; how-ever, mixed results have been reportedfor fasting glucose levels and endoge-nous insulin levels.For people with type 2 diabetes or

prediabetes, low-carbohydrate eatingplans show potential to improve glyce-mia and lipid outcomes for up to 1 year(62–64,86–89). Part of the challenge ininterpreting low-carbohydrate researchhas been due to the wide range of def-initions for a low-carbohydrate eatingplan (85,86). As research studies on

low-carbohydrate eating plans generallyindicate challenges with long-term sus-tainability, it is important to reassessand individualize meal plan guidanceregularly for those interested in thisapproach. Providers should maintainconsistent medical oversight and recog-nize that certain groups are not ap-propriate for low-carbohydrate eatingplans, including women who are preg-nant or lactating, children, and peoplewho have renal disease or disorderedeating behavior, and these plans shouldbe used with caution for those takingSGLT2 inhibitors due to potential riskof ketoacidosis (65,66). There is inade-quate research about dietary patternsfor type 1 diabetes to support one eatingplan over another at this time.

Most individuals with diabetes reporta moderate intake of carbohydrate (44–46% of total calories) (51). Efforts tomodify habitual eating patterns areoften unsuccessful in the long term;people generally go back to their usualmacronutrient distribution (51). Thus,the recommended approach is to in-dividualize meal plans to meet caloricgoals with a macronutrient distributionthat is more consistent with the individ-ual’s usual intake to increase the likeli-hood for long-term maintenance.

As for all individuals in developedcountries, both children and adultswith diabetes are encouraged to mini-mize intake of refined carbohydratesand added sugars and instead focuson carbohydrates from vegetables, le-gumes, fruits, dairy (milk and yogurt),and whole grains. The consumption ofsugar-sweetened beverages (includingfruit juices) and processed “low-fat”or “nonfat” food products with highamounts of refined grains and addedsugars is strongly discouraged (90–92).

Individuals with type 1 or type 2 di-abetes taking insulin at mealtime shouldbe offered intensive and ongoing edu-cation on the need to couple insulinadministration with carbohydrate in-take. For people whose meal schedule orcarbohydrate consumption is variable,regular counseling to help them under-stand the complex relationship betweencarbohydrate intake and insulin needsis important. In addition, education onusing the insulin-to-carbohydrate ratiosfor meal planning can assist them witheffectively modifying insulin dosing frommeal to meal and improving glycemic

control (51,82,93–96). Individuals whoconsume meals containing more proteinand fat than usual may also need to makemealtime insulin dose adjustments tocompensate for delayed postprandialglycemic excursions (97–99). For individ-uals on a fixed daily insulin schedule,meal planning should emphasize a rela-tively fixed carbohydrate consumptionpattern with respect to both time andamount (35).

ProteinThere is no evidence that adjustingthe daily level of protein intake (typically1–1.5 g/kg body weight/day or 15–20%total calories) will improve health inindividuals without diabetic kidney dis-ease, and research is inconclusive re-garding the ideal amount of dietaryprotein to optimize either glycemic con-trol or cardiovascular disease (CVD)risk (84,100). Therefore, protein intakegoals should be individualized basedon current eating patterns. Some re-search has found successful manage-ment of type 2 diabetes with mealplans including slightly higher levels ofprotein (20–30%), which may contributeto increased satiety (58).

Those with diabetic kidney disease(with albuminuria and/or reduced esti-mated glomerular filtration rate) shouldaim to maintain dietary protein at therecommended daily allowance of 0.8g/kg body weight/day. Reducing theamount of dietary protein below therecommended daily allowance is notrecommended because it does not alterglycemic measures, cardiovascular riskmeasures, or the rate at which glomer-ular filtration rate declines (101,102).

In individuals with type 2 diabetes,protein intake may enhance or increasethe insulin response to dietary carbohy-drates (103). Therefore, use of carbohy-drate sources high in protein (such asmilk and nuts) to treat or prevent hypo-glycemia should be avoided due to thepotential concurrent rise in endogenousinsulin.

FatsThe ideal amount of dietary fat for in-dividuals with diabetes is controversial.The National Academy of Medicine hasdefined an acceptable macronutrientdistribution for total fat for all adultstobe20–35%of total calorie intake (104).The type of fats consumed is more

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important than total amount of fat whenlooking at metabolic goals and CVD risk,and it is recommended that the per-centage of total calories from saturatedfats should be limited (75,90,105–107).Multiple randomized controlled trialsincluding patients with type 2 diabeteshave reported that a Mediterranean-style eating pattern (75,108–113), richin polyunsaturated and monounsatu-rated fats, can improve both glycemiccontrol and blood lipids. However, sup-plements do not seem to have thesame effects as their whole-food coun-terparts. A systematic review concludedthat dietary supplements with n-3 fattyacids did not improve glycemic con-trol in individuals with type 2 diabe-tes (84). Randomized controlled trialsalso do not support recommending n-3supplements for primary or secondaryprevention of CVD (114–118). Peoplewithdiabetes shouldbe advised to followthe guidelines for the general populationfor the recommended intakes of satu-rated fat, dietary cholesterol, and transfat (90). In general, trans fats shouldbe avoided. In addition, as saturatedfats are progressively decreased in thediet, they should be replaced with un-saturated fats and not with refined car-bohydrates (112).

SodiumAs for the general population, peoplewith diabetes are advised to limit theirsodium consumption to,2,300 mg/day(35). Restriction below 1,500 mg, evenfor those with hypertension, is gener-ally not recommended (119–121). So-dium intake recommendations shouldtake into account palatability, availabil-ity, affordability, and the difficulty ofachieving low-sodium recommenda-tions in a nutritionally adequate diet(122).

Micronutrients and SupplementsThere continues to be no clear evidenceof benefit from herbal or nonherbal(i.e., vitamin ormineral) supplementationfor people with diabetes without un-derlying deficiencies (35). Metformin isassociated with vitamin B12 deficiency,with a recent report from the DiabetesPrevention Program Outcomes Study(DPPOS) suggesting that periodic test-ing of vitamin B12 levels should beconsidered in patients taking metfor-min, particularly in those with anemia

or peripheral neuropathy (123). Routinesupplementationwith antioxidants, suchas vitamins E and C and carotene, is notadvised due to lack of evidence of effi-cacy and concern related to long-termsafety. In addition, there is insufficientevidence to support the routine use ofherbals and micronutrients, such as cin-namon (124), curcumin, vitamin D (125),or chromium, to improve glycemia inpeople with diabetes (35,126). However,for special populations, including preg-nant or lactating women, older adults,vegetarians, and people following verylow-calorie or low-carbohydrate diets, amultivitamin may be necessary.

AlcoholModerate alcohol intake does not havemajor detrimental effects on long-termblood glucose control in people withdiabetes. Risks associated with alcoholconsumption include hypoglycemia (par-ticularly for those using insulin or insulinsecretagogue therapies), weight gain,and hyperglycemia (for those consumingexcessive amounts) (35,126). People withdiabetes can follow the same guidelinesas those without diabetes if they chooseto drink. For women, no more than onedrink per day, and for men, no more thantwo drinks per day is recommended (onedrink is equal to a 12-oz beer, a 5-oz glassof wine, or 1.5 oz of distilled spirits).

Nonnutritive SweetenersFor some people with diabetes who areaccustomed to sugar-sweetened prod-ucts, nonnutritive sweeteners (con-taining few or no calories) may be anacceptable substitute for nutritive sweet-eners (those containing calories such assugar, honey, agave syrup) when con-sumed in moderation. While use ofnonnutritive sweeteners does not ap-pear to have a significant effect onglycemic control (127), they can reduceoverall calorie and carbohydrate intake(51). Most systematic reviews and meta-analyses show benefits for nonnutritivesweetener use in weight loss (128,129);however, some research suggests anassociation with weight gain (130). Reg-ulatory agencies set acceptable dailyintake levels for each nonnutritivesweetener, defined as the amount thatcan be safely consumed over a person’slifetime (35,131). For those who consumesugar-sweetened beverages regularly,a low-calorie or nonnutritive-sweetened

beverage may serve as a short-term re-placement strategy, but overall, peopleare encouraged to decrease both sweet-ened and nonnutritive-sweetened bever-ages and use other alternatives, with anemphasis on water intake (132).

PHYSICAL ACTIVITY

Recommendations

5.24 Children and adolescents withtype 1 or type 2 diabetes orprediabetes should engagein 60 min/day or more of mod-erate- or vigorous-intensityaerobic activity, with vigor-ous muscle-strengthening andbone-strengthening activities atleast 3 days/week. C

5.25 Most adults with type 1 C andtype 2 B diabetes should engagein 150 min or more of moderate-to-vigorous intensity aerobic ac-tivity per week, spread over atleast 3days/week,withnomorethan 2 consecutive days withoutactivity. Shorter durations (min-imum 75 min/week) of vigorous-intensity or interval training maybe sufficient for younger andmore physically fit individuals.

5.26 Adults with type 1 C and type 2 Bdiabetes should engage in 2–3sessions/week of resistance ex-ercise on nonconsecutive days.

5.27 All adults, and particularly thosewith type 2 diabetes, shoulddecrease the amount of timespent in daily sedentary behav-ior. B Prolonged sitting shouldbe interrupted every 30 min forblood glucose benefits, partic-ularly in adults with type 2 di-abetes. C

5.28 Flexibility training and balancetraining are recommended 2–3times/week for older adults withdiabetes. Yoga and tai chi maybe included based on individualpreferences to increase flexibility,muscular strength, and balance. C

Physical activity is a general term thatincludes all movement that increasesenergy use and is an important part ofthe diabetes management plan. Exerciseis a more specific form of physical ac-tivity that is structured and designedto improve physical fitness. Both phys-ical activity and exercise are important.

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Exercise has been shown to improveblood glucose control, reduce cardiovas-cular risk factors, contribute to weightloss, and improve well-being (133). Phys-ical activity is as important for those withtype 1 diabetes as it is for the generalpopulation, but its specific role in theprevention of diabetes complicationsand the management of blood glucoseis not as clear as it is for those with type2 diabetes. A recent study suggestedthat the percentage of people with di-abetes who achieved the recommendedexercise level per week (150 min) var-ied by race. Objective measurementby accelerometer showed that 44.2%,42.6%, and 65.1% of whites, AfricanAmericans, and Hispanics, respectively,met the threshold (134). It is importantfor diabetes care management teamsto understand the difficulty that manypatients have reaching recommendedtreatment targets and to identify indi-vidualized approaches to improve goalachievement.Moderate to high volumes of aerobic

activity are associated with substantiallylower cardiovascular and overall mortal-ity risks in both type 1 and type 2 diabetes(135). A recent prospective observa-tional studyof adultswith type1diabetessuggested that higher amounts of phys-ical activity led to reduced cardiovascularmortality after a mean follow-up time of11.4 years for patients with and withoutchronic kidney disease (136). Addition-ally, structured exercise interventionsof at least 8 weeks’ duration have beenshown to lower A1C by an average of0.66%inpeoplewithtype2diabetes,evenwithout a significant change in BMI (137).There are also considerable data for thehealth benefits (e.g., increased cardiovas-cular fitness, greater muscle strength, im-proved insulin sensitivity, etc.) of regularexercise for those with type 1 diabetes(138). A recent study suggested thatexercise training in type 1 diabetesmay also improve several importantmarkers such as triglyceride level, LDL,waist circumference, and body mass(139). Higher levels of exercise intensityare associated with greater improve-ments in A1C and in fitness (140). Otherbenefits include slowing the decline inmobility among overweight patientswith diabetes (141). The ADA positionstatement “Physical Activity/Exercise andDiabetes” reviews the evidence for thebenefits of exercise in people with type

1 and type 2 diabetes and offers specificrecommendation (142).

Exercise and ChildrenAll children, including children with di-abetes or prediabetes, should be en-couraged to engage in regular physicalactivity. Children should engage in atleast 60 min of moderate-to-vigorousaerobic activity every day with muscle-and bone-strengthening activities atleast 3 days per week (143). In general,youth with type 1 diabetes benefit frombeing physically active, and an activelifestyle should be recommended to all(144). Youth with type 1 diabetes whoengage in more physical activity mayhave better health-related quality oflife (145).

Frequency and Type of PhysicalActivityPeople with diabetes should performaerobic and resistance exercise regularly(142). Aerobic activity bouts should ide-ally last at least 10 min, with the goal of;30 min/day or more, most days of theweek for adults with type 2 diabetes.Daily exercise, or at least not allowingmore than 2 days to elapse betweenexercise sessions, is recommended todecrease insulin resistance, regardlessof diabetes type (146,147). Over time,activities should progress in intensity,frequency, and/or duration to at least150 min/week of moderate-intensity ex-ercise. Adults able to run at 6 miles/h(9.7 km/h) for at least 25 min can benefitsufficiently from shorter-intensity activ-ity (75 min/week) (142). Many adults,including most with type 2 diabetes,would be unable or unwilling to partic-ipate in such intense exercise and shouldengage in moderate exercise for therecommended duration. Adults with di-abetes should engage in 2–3 sessions/week of resistance exercise on noncon-secutive days (148). Although heavierresistance training with free weightsand weight machines may improve gly-cemic control and strength (149), re-sistance training of any intensity isrecommended to improve strength, bal-ance, and the ability to engage in activ-ities of daily living throughout the lifespan. Providers and staff should helppatients set stepwise goals towardmeet-ing the recommended exercise targets.

Recent evidence supports that all in-dividuals, including those with diabetes,

should be encouraged to reduce theamount of time spent being sedentary(e.g., working at a computer, watchingTV) by breaking up bouts of sedentaryactivity (.30 min) by briefly standing,walking, or performing other light phys-ical activities (150,151). Avoiding ex-tended sedentary periods may helpprevent type 2 diabetes for those atrisk and may also aid in glycemic controlfor those with diabetes.

A wide range of activities, includ-ing yoga, tai chi, and other types, canhave significant impacts on A1C, flexi-bility, muscle strength, and balance(133,152,153). Flexibility and balanceexercises may be particularly importantin older adults with diabetes to maintainrange of motion, strength, and balance(142).

Physical Activity and Glycemic ControlClinical trials have provided strong evi-dence for the A1C-lowering value ofresistance training in older adults withtype 2 diabetes (154) and for an additivebenefit of combined aerobic and resis-tance exercise in adults with type 2diabetes (155). If not contraindicated,patients with type 2 diabetes should beencouraged to do at least two weeklysessions of resistance exercise (exercisewith free weights or weight machines),with each session consisting of at leastone set (group of consecutive repetitiveexercise motions) of five or more differ-ent resistance exercises involving thelarge muscle groups (154).

For type 1 diabetes, although exercisein general is associated with improve-ment in disease status, care needs tobe taken in titrating exercisewith respectto glycemic management. Each individualwith type 1 diabetes has a variable gly-cemic response to exercise. This variabil-ity should be taken into considerationwhen recommending the type and dura-tion of exercise for a given individual(138).

Women with preexisting diabetes,particularly type 2 diabetes, and thoseat risk for or presenting with gestationaldiabetes mellitus should be advised toengage in regular moderate physicalactivity prior to and during their preg-nancies as tolerated (142).

Pre-exercise EvaluationAs discussed more fully in Section10 “Cardiovascular Disease and Risk

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Management,” the best protocol forassessing asymptomatic patients withdiabetes for coronary artery disease re-mains unclear. The ADA consensus report“Screening for Coronary Artery Diseasein Patients With Diabetes” (156) con-cluded that routine testing is not recom-mended. However, providers shouldperform a careful history, assess cardio-vascular risk factors, and be aware ofthe atypical presentation of coronaryartery disease in patients with diabetes.Certainly, high-risk patients should beencouraged to start with short periodsof low-intensity exercise and slowly in-crease the intensity and duration astolerated. Providers should assess pa-tients for conditions that might contra-indicate certain types of exercise orpredispose to injury, such as uncontrolledhypertension, untreated proliferative ret-inopathy, autonomic neuropathy, periph-eral neuropathy, and a history of footulcers or Charcot foot. The patient’s ageand previous physical activity level shouldbe considered. The provider should cus-tomize the exercise regimen to the indi-vidual’s needs. Those with complicationsmay require a more thorough evaluationprior to beginning an exercise program(138).

HypoglycemiaIn individuals taking insulin and/or in-sulin secretagogues, physical activity maycause hypoglycemia if the medicationdose or carbohydrate consumption isnot altered. Individuals on these thera-pies may need to ingest some addedcarbohydrate if pre-exercise glucose lev-els are,90 mg/dL (5.0 mmol/L), depend-ing on whether they are able to lowerinsulin doses during theworkout (such aswith an insulin pump or reduced pre-exercise insulin dosage), the time of dayexercise is done, and the intensity andduration of the activity (138,142). Insome patients, hypoglycemia after ex-ercise may occur and last for severalhours due to increased insulin sensitiv-ity. Hypoglycemia is less common inpatients with diabetes who are nottreated with insulin or insulin secreta-gogues, and no routine preventive mea-sures for hypoglycemia are usuallyadvised in these cases. Intense activitiesmay actually raise blood glucose levelsinstead of lowering them, especially ifpre-exercise glucose levels are elevated(157).

Exercise in the Presence ofMicrovascular ComplicationsSee Section 11 “Microvascular Complica-tions and Foot Care” for more informationon these long-term complications.

Retinopathy

If proliferative diabetic retinopathy orsevere nonproliferative diabetic retinop-athy is present, then vigorous-intensityaerobic or resistance exercise may becontraindicated because of the risk oftriggering vitreous hemorrhage or ret-inal detachment (158). Consultationwith an ophthalmologist prior to engag-ing in an intense exercise regimen maybe appropriate.

Peripheral Neuropathy

Decreased pain sensation and a higherpain threshold in the extremities resultin an increased risk of skin breakdown,infection, and Charcot joint destructionwith some formsof exercise. Therefore, athorough assessment should be done toensure that neuropathy does not alterkinesthetic or proprioceptive sensationduring physical activity, particularly inthose with more severe neuropathy. Stud-ies have shown that moderate-intensitywalking may not lead to an increased riskof foot ulcers or reulceration in those withperipheral neuropathy who use properfootwear (159). In addition, 150 min/weekof moderate exercise was reported toimprove outcomes in patients withprediabetic neuropathy (160). All indi-viduals with peripheral neuropathyshould wear proper footwear and ex-amine their feet daily to detect lesionsearly. Anyone with a foot injury or opensore should be restricted to non–weight-bearing activities.

Autonomic Neuropathy

Autonomic neuropathy can increase therisk of exercise-induced injury or adverseevents through decreased cardiac re-sponsiveness to exercise, postural hy-potension, impaired thermoregulation,impaired night vision due to impairedpapillary reaction, and greater suscepti-bility to hypoglycemia (161). Cardiovas-cular autonomic neuropathy is also anindependent risk factor for cardiovascu-lar death and silent myocardial ische-mia (162). Therefore, individuals withdiabetic autonomic neuropathy shouldundergo cardiac investigation beforebeginning physical activity more in-tense than that to which they areaccustomed.

Diabetic Kidney Disease

Physical activity can acutely increase uri-nary albumin excretion. However, there isno evidence that vigorous-intensity exer-cise increases the rate of progression ofdiabetic kidney disease, and there appearsto be no need for specific exercise re-strictions for people with diabetic kidneydisease in general (158).

SMOKING CESSATION: TOBACCOAND E-CIGARETTES

Recommendations

5.29 Advise all patients not to usecigarettes and other tobaccoproducts A or e-cigarettes. B

5.30 Include smoking cessation coun-seling and other forms of treat-ment as a routine componentof diabetes care. A

Results from epidemiological, case-control,and cohort studies provide convincingevidence to support the causal link be-tween cigarette smoking and health risks(163). Recent data show tobacco use ishigher among adults with chronic con-ditions (164) as well as in adolescentsand young adults with diabetes (165).Smokers with diabetes (and peoplewith diabetes exposed to second-handsmoke) have a heightened risk of CVD,premature death, microvascular com-plications, and worse glycemic controlwhen compared with nonsmokers(166,167). Smoking may have a role inthe development of type 2 diabetes(168–171).

The routine and thorough assessmentof tobacco use is essential to preventsmoking or encourage cessation. Nu-merous large randomized clinical trialshave demonstrated the efficacy andcost-effectiveness of brief counselingin smoking cessation, including theuse of telephone quit lines, in reducingtobacco use. Pharmacologic therapy toassist with smoking cessation in peoplewith diabetes has been shown to beeffective (172), and for the patient mo-tivated to quit, the addition of pharma-cologic therapy to counseling is moreeffective than either treatment alone(173). Special considerations should in-clude assessment of level of nicotinedependence, which is associated withdifficulty in quitting and relapse (174).Although some patients may gain weightin the period shortly after smoking

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cessation (175), recent research has dem-onstrated that this weight gain does notdiminish the substantial CVD benefit re-alized from smoking cessation (176). Onestudy in smokers with newly diagnosedtype 2 diabetes found that smokingcessation was associated with amelio-ration of metabolic parameters and re-duced blood pressure and albuminuriaat 1 year (177).In recent years e-cigarettes have

gained public awareness and popularitybecause of perceptions that e-cigaretteuse is less harmful than regular cigarettesmoking (178,179). Nonsmokers shouldbe advised not to use e-cigarettes(180,181). There are no rigorous studiesthat have demonstrated that e-cigarettesare a healthier alternative to smokingor that e-cigarettes can facilitate smok-ing cessation (182). On the contrary, arecently published pragmatic trial foundthat use of e-cigarettes for smokingcessation was not more effective than“usual care,” which included access toeducational information on the healthbenefits of smoking cessation, strategiesto promote cessation, and access to afree text-messaging service that pro-vided encouragement, advice, and tipsto facilitate smoking cessation (183). Sev-eral organizations have called for moreresearch on the short- and long-termsafety and health effects of e-cigarettes(184–186).

PSYCHOSOCIAL ISSUES

Recommendations

5.31 Psychosocial care should be in-tegrated with a collaborative,patient-centered approach andprovided to all people with di-abetes, with the goals of op-timizing health outcomes andhealth-related quality of life. A

5.32 Psychosocial screening andfollow-up may include, but arenot limited to, attitudes aboutdiabetes, expectations formedical management and out-comes, affect or mood, generaland diabetes-related quality oflife, available resources (finan-cial, social, and emotional), andpsychiatric history. E

5.33 Providers should consider assess-ment for symptoms of diabe-tes distress, depression, anxiety,

disordered eating, and cogni-tive capacities using patient-appropriate standardized andvalidated tools at the initialvisit, at periodic intervals, andwhen there is a change in dis-ease, treatment, or life circum-stance. Including caregivers andfamily members in this assess-ment is recommended. B

5.34 Consider screening older adults(aged$65 years) with diabetesfor cognitive impairment anddepression. B

Please refer to the ADA position state-ment “Psychosocial Care for People WithDiabetes” for a list of assessment toolsand additional details (187).

Complex environmental, social, be-havioral, and emotional factors, knownas psychosocial factors, influence livingwith diabetes, both type 1 and type 2,and achieving satisfactory medical out-comes and psychological well-being. Thus,individuals with diabetes and their fam-ilies are challenged with complex, multi-faceted issues when integrating diabetescare into daily life.

Emotional well-being is an importantpart of diabetes care and self-management.Psychological and social problems canimpair the individual’s (188–190) or fam-ily’s (191) ability to carry out diabetes caretasks and therefore potentially compro-mise health status. There are opportu-nities for the clinician to routinely assesspsychosocial status in a timely and effi-cient manner for referral to appropri-ate services. A systematic review andmeta-analysis showed that psychosocialinterventions modestly but significantlyimproved A1C (standardized mean dif-ference –0.29%) and mental healthoutcomes (192). However, there was alimited association between the effectson A1C and mental health, and no in-tervention characteristics predictedbenefit on both outcomes.

ScreeningKey opportunities for psychosocial screen-ing occur at diabetes diagnosis, duringregularly scheduled management vis-its, during hospitalizations, with newonset of complications, or when prob-lems with glucose control, quality oflife, or self-management are identi-fied (1). Patients are likely to exhibit

psychological vulnerability at diagno-sis, when their medical status changes(e.g., end of the honeymoon period),when the need for intensified treat-ment is evident, and when complica-tions are discovered.

Providers can start with informalverbal inquires, for example, by askingif there have been changes in moodduring the past 2 weeks or since thepatient’s last visit. Providers should con-sider asking if there are new or differentbarriers to treatment and self-manage-ment, such as feeling overwhelmed orstressed by diabetes or other life stres-sors. Standardized andvalidated tools forpsychosocial monitoring and assessmentcan also be used by providers (187), withpositive findings leading to referral to amental health provider specializing indiabetes for comprehensive evaluation,diagnosis, and treatment.

Diabetes Distress

Recommendation

5.35 Routinely monitor people withdiabetes for diabetes distress,particularly when treatment tar-gets are not met and/or at theonset of diabetes complications. B

Diabetes distress (DD) is very commonand is distinct from other psychologicaldisorders (193–195). DD refers to signif-icant negative psychological reactionsrelated to emotional burdens and wor-ries specific to an individual’s experiencein having to manage a severe, compli-cated, and demanding chronic diseasesuch as diabetes (194–196). The constantbehavioral demands (medication dos-ing, frequency, and titration; monitoringblood glucose, food intake, eating pat-terns, and physical activity) of diabetesself-management and the potential oractuality of disease progression are di-rectly associated with reports of DD(194). The prevalence of DD is reportedto be 18–45% with an incidence of38–48% over 18 months (196). In thesecond Diabetes Attitudes, Wishes andNeeds (DAWN2) study, significant DDwas reported by 45% of the participants,but only 24% reported that their healthcare teams asked them how diabetesaffected their lives (193). High levelsof DD significantly impact medication-taking behaviors and are linked to higher

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A1C, lower self-efficacy, and poorer di-etary and exercise behaviors (17,194,196). DSMES has been shown to reduceDD (17). It may be helpful to providecounseling regarding expected diabetes-related versus generalized psychologicaldistress at diagnosis and when diseasestate or treatment changes (197).DD should be routinely monitored

(198) using patient-appropriate vali-dated measures (187). If DD is identified,the person should be referred for specificdiabetes education to address areas ofdiabetes self-care that are most relevantto the patient and impact clinical man-agement. People whose self-care re-mains impaired after tailored diabeteseducation should be referred by theircare team to a behavioral health pro-vider for evaluation and treatment.Other psychosocial issues known to

affect self-management and health out-comes include attitudes about the illness,expectations for medical managementand outcomes, available resources (fi-nancial, social, and emotional) (199), andpsychiatric history. For additional infor-mation on psychiatric comorbidities(depression, anxiety, disordered eat-ing, and serious mental illness), pleaserefer to Section 4 “ComprehensiveMedical Evaluation and Assessment ofComorbidities.”

Referral to a Mental Health SpecialistIndications for referral to a mental healthspecialist familiar with diabetes man-agement may include positive screeningfor overall stress related to work-lifebalance, DD, diabetes management dif-ficulties, depression, anxiety, disorderedeating, and cognitive dysfunction (seeTable 5.2 for a complete list). It is pref-erable to incorporate psychosocial assess-ment and treatment into routine carerather than waiting for a specific prob-lem or deterioration in metabolic or

psychological status to occur (26,193).Providers should identify behavioral andmental health providers, ideally thosewho are knowledgeable about diabetestreatment and the psychosocial aspects ofdiabetes, to whom they can refer patients.The ADA provides a list of mental healthproviders who have received additionaleducation in diabetes at the ADAMentalHealth Provider Directory (professional.diabetes.org/ada-mental-health-provider-directory). Ideally, psychosocial careproviders should be embedded in di-abetes care settings. Although the cli-nician may not feel qualified to treatpsychological problems (200), optimizingthe patient-provider relationship as afoundation may increase the likelihoodof the patient accepting referral for otherservices. Collaborative care interventionsand a team approach have demonstratedefficacy in diabetes self-management,outcomes of depression, and psychoso-cial functioning (17,201).

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Table 5.2—Situations that warrant referral of a person with diabetes to a mental health provider for evaluation and treatmentc If self-care remains impaired in a person with diabetes distress after tailored diabetes education

c If a person has a positive screen on a validated screening tool for depressive symptoms

c In the presence of symptoms or suspicions of disordered eating behavior, an eating disorder, or disrupted patterns of eating

c If intentional omission of insulin or oral medication to cause weight loss is identified

c If a person has a positive screen for anxiety or fear of hypoglycemia

c If a serious mental illness is suspected

c In youth and families with behavioral self-care difficulties, repeated hospitalizations for diabetic ketoacidosis, or significant distress

c If a person screens positive for cognitive impairment

c Declining or impaired ability to perform diabetes self-care behaviors

c Before undergoing bariatric or metabolic surgery and after surgery if assessment reveals an ongoing need for adjustment support

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