Providing Diabetes Education and Support
Psychosocial problems and barriers to improved diabetes management: The American Association of Diabetes Educators position statement: Pediatricians should refer to existing services for nutrition support for pregnant and breastfeeding women, infants, and toddlers. It should be noted that programs that serve the nutritional needs of children after the first days form a crucial link from this early period to adulthood and are most effective when building on a scaffolding of optimal early nutrition. Elk Grove Village, IL: Why invest, and what it will take to improve breastfeeding practices?
The nutritional environment has an effect on whether brain growth and differentiation proceed normally or abnormally. Both adequate overall nutrition ie, absence of malnutrition and provision of adequate amounts of key macro- and micronutrients at critical periods in development are necessary for normal brain development.
It is important to recognize that many nutrients exhibit a U-shaped risk curve, whereby inadequate or excessive amounts both place the individual at risk. Each of these 2 forms of malnutrition affects neurodevelopment, and they may coexist in an individual. In this Policy Statement, we seek to inform pediatricians and other health care providers of the key role of nutrition in brain development in the first days of life conception to 2 years of age.
It is not meant as a comprehensive review of the data on brain-nutrient interaction for this, see Rao and Georgieff With this policy statement, we intend to support pediatricians and other health care providers in promoting healthy nutrition and advocating for the expansion of programs that affect early life nutrition as a means of providing scaffolding for later nutritional programs and preventing early developmental loss.
Macronutrient protein, fat, glucose sufficiency is essential for normal brain development. Early macronutrient undernutrition is associated with lower IQ scores, reduced school success, and more behavioral dysregulation.
Two villages received a high-calorie, high-protein supplement, and 2 villages received a low-calorie supplement without protein. Both supplements contained vitamins and minerals. The supplements were provided for pregnant and lactating women and children up to age 7 years.
The investigators measured locally relevant outcomes over a period longer than 10 years, assessing children between 13 and 19 years of age.
Children who had received high-calorie, high-protein supplementation before age 2 years scored higher on tests of knowledge, numeracy, reading, and vocabulary and had faster reaction times in information-processing tasks than age-matched children who received the low-calorie supplement. In villages receiving the high-calorie, high-protein supplement, there were no differences in test scores between children of high and low socioeconomic status, but in villages receiving the low-calorie supplements, children in the higher socioeconomic group had higher test scores.
In summary, early supplementation of nutrients to children at risk for macronutrient deficiency improved neurodevelopmental outcomes over an extended period of life, beyond the period of supplementation.
There are populations in the United States that, similar to the villages in Guatemala, have inadequate access to macronutrients or only access to low-quality macronutrients. Although parents shield children from the worst effects of food insecurity, in approximately half of these food-insecure households, children were food insecure. The failure to provide adequate macronutrients or key micronutrients at critical periods in brain development can have lifelong effects on a child.
In addition to generalized macronutrient undernutrition, deficiencies of individual nutrients may have a substantial effect on neurodevelopment Table 1. Prenatal and early infancy iron deficiency is associated with long-term neurobehavioral damage that may not be reversible, even with iron treatment.
Deficiency of iodine in pregnant women leads to cretinism in the child, with attendant severe, irreversible developmental delays. Mild to moderate postnatal chronic iodine deficiency is associated with reduced performance on IQ tests. Traditions in complementary feeding or restricted diets because of poverty or neglect may reduce infant intake of many key factors in normal neurodevelopment, including zinc, protein, and iron. As the normative infant feeding, human milk and breastfeeding play a crucial role in neurodevelopment.
Although randomized trials are not feasible, improved cognitive function in term and preterm infants who are fed human milk compared with those who are fed formula is supported by the weight of evidence on this topic. Although there is evidence that obesity in children and adolescents is associated with poorer educational success, studies are often complicated by small sample size, failure to control for confounding factors, and other aspects of study design.
Weight gain alone, particularly when excessive weight is gained, may not achieve the desired goal of preserving brain development in the very low birth weight preterm infant. In summary, nutrition is 1 of several factors affecting early neurodevelopment and is a factor that pediatricians and other health care providers have the capacity to improve by application of well-described, well-piloted, effective interventions.
Failure to provide adequate essential nutrients during the first days of life may result in increased expenditures later in the form of medical care, psychiatric and psychological care, remedial education, loss of wages, and management of behavior. Thus, early nutritional intervention provides enormous potential advantages across the life span and, if nutritional needs are unmet in this period, developmental losses occur that are difficult to recover.
Opportunities to improve early child nutrition, and thus neurodevelopment, are currently focused in 2 areas: It should be noted that programs that serve the nutritional needs of children after the first days form a crucial link from this early period to adulthood and are most effective when building on a scaffolding of optimal early nutrition.
As such, it is the most important program providing nutritional support in the first days. WIC supports breastfeeding prenatally through education and postpartum by helping mothers breastfeed, and they perform screening for anemia in women and children receiving services through the program.
Published evidence supports the impact of WIC on the health of children: Despite the impact of WIC, children in many families who do not qualify under current guidelines would benefit from the nutrients and educational support of this program. Children whose families are on the margin of qualification for WIC may, for economic reasons, subsist on cheaper, less nutritionally replete diets.
Many families fail to take advantage of the program after the first year of life, in part because of the challenge of access. Keeping families in the program longer for example, through the elimination of the requirement to recertify eligibility at 1 year of age and extending eligibility for WIC through 6 years of age will make supplemental food available to the growing toddler.
WIC is a crucial program in providing food and education to support neurodevelopment. Seventy-two percent of households served are families with children. The Child and Adult Care Food Program CACFP is administered by the USDA and, among other things, provides money to assist child care institutions and family or group day care homes in providing nutritious foods that contribute to the wellness, healthy growth, and development of children.
Completion of the revision of CACFP meal requirements to make them more consistent with the Dietary Guidelines for Americans DGA 39 should improve the nutritional quality of these meals for young children. Food pantries and soup kitchens are generally community-supported programs that serve as a safety net for children and families struggling with inadequate food.
However, many charitable food providers are not consistently able to provide healthful food in general, nutritional items appropriate for infants and toddlers, or amounts adequate to protect children from inadequate nutrition for more than a few days. Congress established the Maternal, Infant, and Early Childhood Home Visiting Program in to provide funds for states and tribes providing voluntary, evidence-based home visiting to at-risk families.
In , the Birth to 24 Months project was started to develop guidelines for children in that age group. It begins with the formulation of questions, systematic reviews through the Nutrition Evidence Library at the USDA, and the grading of evidence on the basis of study quality, consistency of findings, number of studies and subjects, impact of outcome, and generalizability of findings. The final report and incorporation of these guidelines into the overall DGA is expected in Because these guidelines are the reference point for state and federal policies and programs, pediatricians should be aware of the importance of these guidelines.
The DGA saw an organized and concerted effort by special interest groups to subvert or dilute the results of the guideline process and the process itself. It is important that pediatricians, who are familiar with using evidence-based clinical guidelines, advocate for the scientific foundations of this process and support implementation of the guidelines.
The American Academy of Pediatrics AAP provides substantial information on the nutritional needs and support of children from birth to age 2 years, including information and guidance on breastfeeding 45 and on feeding infants and toddlers. Pediatricians, family physicians, obstetricians, and other child health care providers need to be knowledgeable about breastfeeding to educate pregnant women about breastfeeding and be prepared to help breastfeeding mothers and their infants when problems occur.
The AAP recommends exclusive breastfeeding for approximately the first 6 months of life and continuation after complementary foods have been introduced for at least the first year of life and beyond, as long as mutually desired by mother and child. Several organizations have reviewed interventions to support breastfeeding. Pediatricians, family physicians, obstetricians, and other child health care providers can advocate at the local, state, and federal levels to preserve and strengthen nutrition programs with a focus on maternal, fetal, and neonatal nutrition.
Interventions to ensure normal neurodevelopment include programs to minimize adverse environmental influences and programs to mitigate the effects of adverse environmental influences. These interventions begin with nutritional health for the pregnant woman, including adequate protein-energy intake, appropriate gestational weight gain, and iron sufficiency. To some degree, the placenta protects the fetus in terms of prioritization of nutrients from the mother. After birth, human milk provides optimal neurodevelopmental nutrition for at least the first 6 months.
Pediatricians and other child health care providers can become conversant about food sources that supply the critical nutrients necessary for brain development during particularly important times. Although most pediatricians are aware that exclusive breastfeeding is the best source of nutrition for the first 6 months, dietary advice thereafter is less robust. Moreover, knowing which nutrients are at risk in the breastfed infant after 6 months eg, zinc, iron, vitamin D will guide dietary recommendations in the clinic or practice.
Guidance for pediatricians is provided in existing documents Tables 1 and 2 but over a spectrum of resources and chapters, and it is often without clear prescriptive recommendations;.
Leaders in childhood nutrition can advocate for incorporating into existing nutritional advice an actionable guide to healthy eating as a positive choice rather than an avoidance of unhealthy foods.
This would give pediatricians and families more prescriptive advice as to optimal dietary choices. Pediatricians and other child health care providers can focus the attention of existing programs on improving micro- and macronutrient offerings for infants and young children.
For example, providing information to existing food pantries and soup kitchens to create food packages and meals that target the specific needs of pregnant women, breastfeeding women, and children in the first 2 years of life;.
Pediatricians and other child health care providers can encourage families to take advantage of programs providing early childhood nutrition and advocate for eliminating barriers that families face to enrolling and remaining enrolled in such programs.
Many families do not take advantage of WIC services after the first year of life. Encouraging the use of services and benefits for which the family is eligible and eliminating the requirement to recertify eligibility for young children at 1 year of age can improve early life nutrition for children;. Pediatricians and other child health care providers can oppose changes in eligibility or financing structures that would adversely affect key programs providing early childhood nutrition.
Such changes include changing funding to block grants or delinking nutrition and health assistance programs, such as the adjunctive eligibility between WIC and Medicaid. Federal nutrition programs such as SNAP are successful because of eligibility rules and a funding structure that makes benefits available to children in almost all families with little income and few resources;.
Pediatricians and other child health care providers can anticipate neurodevelopmental concerns in children with early nutrient deficiency. Pediatricians can educate themselves as to which nutrients are at risk for deficiency and at what age as well as about appropriate screening for children at high risk. For example, the risk of iron deficiency is not equal throughout the pediatric life span. Pediatricians can be aware that the newborn, the toddler, and the adolescent are at highest risk and should be aware of factors that increase those risks;.
As pediatricians consider their personal contribution to social action, involvement in 1 of these organizations is an excellent option see Table 3. This document is copyrighted and is property of the American Academy of Pediatrics and its Board of Directors. All authors have filed conflict of interest statements with the American Academy of Pediatrics.
Any conflicts have been resolved through a process approved by the Board of Directors. The American Academy of Pediatrics has neither solicited nor accepted any commercial involvement in the development of the content of this publication.
Policy statements from the American Academy of Pediatrics benefit from expertise and resources of liaisons and internal AAP and external reviewers.
However, policy statements from the American Academy of Pediatrics may not reflect the views of the liaisons or the organizations or government agencies that they represent. The guidance in this statement does not indicate an exclusive course of treatment or serve as a standard of medical care.
Variations, taking into account individual circumstances, may be appropriate. All policy statements from the American Academy of Pediatrics automatically expire 5 years after publication unless reaffirmed, revised, or retired at or before that time. The 1, Days mark is used with permission from 1, Days. The authors have indicated they have no financial relationships relevant to this article to disclose. The authors have indicated they have no potential conflicts of interest to disclose.
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. Search for this keyword. From the American Academy of Pediatrics. Annual visits for diabetes education are recommended to assess all areas of self-management, to review behavior change and coping strategies and problem-solving skills, to identify strengths and challenges of living with diabetes, and to make adjustments in therapy 35 , Importantly, the educator is charged with communicating the revised plan to the referring provider.
Family members are an underutilized resource for ongoing support and often struggle with how to best provide this help 53 , Since the patient has now experienced living with diabetes, it is important to begin each maintenance visit by asking the patient about successes he or she has had and any concerns, struggles, and questions.
The focus of each session should be on patient decisions and issues—what choices has the patient made, why has the patient made those choices, and if those decisions are helping the patient to attain his or her goals— not on perceived adherence to recommendations. Through shared decision making, the plan is adjusted as needed in collaboration with the patient.
The identification of diabetes complications or other patient factors that may influence self-management should be considered a critical indicator for diabetes education that requires immediate attention and adequate resources.
During routine medical care, the provider may identify factors that influence treatment and the associated self-management plan. These factors may be identified at the initial diabetes encounter or may arise at any time. Such patient factors influence the clinical, psychosocial, and behavioral aspects of diabetes care.
The diagnosis of additional health conditions and the potential need for additional medications can complicate self-management for the patient. Diabetes education can address the integration of multiple medical conditions into overall care with a focus on maintaining or appropriately adjusting medication, eating plan, and physical activity levels to maximize outcomes and quality of life.
Diabetes-related health conditions can cause physical limitations, such as visual impairment, dexterity issues, and physical activity restrictions. Diabetes educators can help patients to manage limitations through education and various support resources.
Psychosocial and emotional factors have many contributors and include diabetes-related distress, life stresses, anxiety, and depression. In fact, these factors are often considered complications of diabetes and result in poorer diabetes outcomes 59 , It has a greater impact on behavioral and metabolic outcomes than does depression Social factors, including difficulty paying for food, medications, monitoring and other supplies, medical care, housing, or utilities, negatively affect metabolic control and increase resource use When basic living needs are not met, diabetes self-management becomes increasingly difficult.
Basic living needs include food security, adequate housing, safe environment, and access to medications and health care.
Education staff can address such issues, provide information about available resources, and collaborate with the patient to create a self-management plan that reflects these challenges. However, complicating factors may arise at any time; providers should be prepared to promptly refer patients who develop complications or other issues for diabetes education and ongoing support. Throughout the life span, changes in age, health status, living situation, or health insurance coverage may require a reevaluation of the diabetes care goals and self-management needs.
Critical transition periods include transitioning into adulthood, hospitalization, and moving into an assisted living facility, skilled nursing facility, correctional facility, or rehabilitation center. Providing input into the development of practical and realistic self-management and treatment plans can be an effective asset for successful navigation of changing situations.
A written plan prepared in collaboration with diabetes educators, the patient, family members, and caregivers to identify deficits, concerns, resources, and strengths can help to promote a successful transition. The plan should include personalized diabetes treatment targets; a medical, educational, and psychosocial history; hypo- and hyperglycemia risk factors; nutritional needs; resources for additional support; and emotional considerations 63 , The health care provider can make a referral to a diabetes educator to develop or provide input to the transition plan, provide education, and support successful transitions.
The goal is to minimize disruptions in therapy during the transition, while addressing clinical, psychosocial, and behavioral needs. The ADA publishes nutrition recommendations that detail nutrition therapy goals and nutrition and eating pattern recommendations For example, only 6. Barriers are associated with a number of factors including the health system, the individual health care professional, community resources, and the individual with diabetes.
Although people with diabetes report wanting to be actively engaged in their health care, most indicate that they are not actively engaged by their providers and that education and psychological services are not readily available Removing barriers to access and increasing quality care can be achieved by using data to coordinate care and build workforce capacity Studies have shown that implementing DSME programs that directly connect with primary care and rely on technology is effective in improving clinical, psychosocial, and behavioral outcomes 16 , 71 — Patients receiving care in these practice settings report more confidence in provider communication and satisfaction with direct access to an educator for information and ongoing support Despite the proven value and effectiveness of diabetes education and support services, one of the biggest looming threats to their success is low utilization, which has recently forced many such programs to close.
Attention to these challenges needs to be met to provide access particularly for areas such as rural and underserved communities. Diabetes is a complex and burdensome disease that requires the person with diabetes to make numerous daily decisions regarding food, physical activity, and medications. It also necessitates that the person be proficient in a number of self-management skills 35 , 75 , In order for people to learn the skills necessary to be effective self-managers, DSME is critical in laying the foundation with ongoing support to maintain gains made during education.
This position statement and algorithm provide the evidence and strategies for the provision of education and support services to all adults living with type 2 diabetes. The authors gratefully acknowledge the commitment and support of the collaborating organizations—the American Diabetes Association, the American Association of Diabetes Educators, and the Academy of Nutrition and Dietetics; their colleagues, including members of the Executive Committee of the National Diabetes Education Program, who participated in discussions and reviews about this inaugural position statement; and patients who teach and inspire them.
No potential conflicts of interest relevant to this article were reported. 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 Jul; 38 7: View inline View popup.
Table 1 Key definitions. Table 4 Sample questions to guide a patient-centered assessment New Diagnosis of Diabetes The diagnosis of diabetes is often overwhelming Annual Assessment of Education, Nutrition, and Emotional Needs The health care team and others can help to promote the adoption and maintenance of new diabetes management tasks 52 , yet sustaining these behaviors is frequently difficult.
Diabetes-Related Complications and Other Factors Influencing Self-management The identification of diabetes complications or other patient factors that may influence self-management should be considered a critical indicator for diabetes education that requires immediate attention and adequate resources.
Transitional Care and Changes in Health Status Throughout the life span, changes in age, health status, living situation, or health insurance coverage may require a reevaluation of the diabetes care goals and self-management needs. Table 5 Overview of MNT.
Conclusion Diabetes is a complex and burdensome disease that requires the person with diabetes to make numerous daily decisions regarding food, physical activity, and medications.
Acknowledgments The authors gratefully acknowledge the commitment and support of the collaborating organizations—the American Diabetes Association, the American Association of Diabetes Educators, and the Academy of Nutrition and Dietetics; their colleagues, including members of the Executive Committee of the National Diabetes Education Program, who participated in discussions and reviews about this inaugural position statement; and patients who teach and inspire them.
Diabetes self-management education improves quality of care and clinical outcomes determined by a diabetes bundle measure.
J Multidiscip Healthc ; 7: Association between participation in a brief diabetes education programme and glycaemic control in adults with newly diagnosed diabetes. Diabet Med ; Group based diabetes self-management education compared to routine treatment for people with type 2 diabetes mellitus.
A systematic review with meta-analysis. Assessing the value of diabetes education. Diabetes Educ ; Fan L , Sidani S. Effectiveness of diabetes self-management education intervention elements: Can J Diabetes ; Patient Educ Couns ; Self-management education for adults with type 2 diabetes: Diabetes Care ; Standards of medical care in diabetes— Diabetes Care ; 38 Suppl. Health Aff Millwood ; Inpatient diabetes education is associated with less frequent hospital readmission among patients with poor glycemic control.
Assessing the value of the diabetes educator. Diab Educ ; Nutritionist visits, diabetes classes, and hospitalization rates and charges: Cost-effectiveness analysis of a community health worker intervention for low-income Hispanic adults with diabetes. Prev Chronic Dis ; 9: Economic costs of diabetes in the U. Projection of the year burden of diabetes in the US adult population: Popul Health Metr ; 8: The effect of nurse-led diabetes self-management education on glycosylated hemoglobin and cardiovascular risk factors: Motivational interviewing delivered by diabetes educators: Diabetes Res Clin Pract ; Group based training for self-management strategies in people with diabetes mellitus.
Cochrane Database Syst Rev ; 2: Meta-analysis of randomized educational and behavioral interventions in type 2 diabetes. The effect of intensive treatment of diabetes on the development and progression of long-term complications in insulin-dependent diabetes mellitus.
N Engl J Med ; Association of glycaemia with macrovascular and microvascular complications of type 2 diabetes UKPDS BMJ ; Structured type 1 diabetes education delivered within routine care: Cochran J , Conn VS.
Meta-analysis of quality of life outcomes following diabetes self-management training. A 5-year randomized controlled study of learning, problem solving ability, and quality of life modifications in people with type 2 diabetes managed by group care. Biologic and quality-of-life outcomes from the Mediterranean Lifestyle Program: Long-term outcomes from a multiple-risk-factor diabetes trial for Latinas: Transl Behav Med ; 1: Lasting effects of a 2-year diabetes self-management support intervention: Facilitating healthy coping in patients with diabetes: The effect of a diabetes-specific cognitive behavioral treatment program DIAMOS for patients with diabetes and subclinical depression: Can lifestyle interventions do more than reduce diabetes risk?
Treating depression in adults with type 2 diabetes with exercise and cognitive behavioral therapy. Curr Diab Rep ; J Altern Complement Med ; 11 Suppl. Multidisciplinary management of type 2 diabetes in children and adolescents. J Multidiscip Healthc ; 3: National Standards for diabetes self-management education and support. American Association of Diabetes Educators. Reimbursement tips for primary care practice [Internet], Accessed 24 March Comparative effectiveness of peer leaders and community health workers in diabetes self-management support: Impact of peer health coaching on glycemic control in low-income patients with diabetes: Ann Fam Med ; A review of volunteer-based peer support interventions in diabetes.
Diabetes Spectrum ;