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ments that address both medical and psy-\nchosocial issues relevant to living withdiabetes are a promising model to consider(397,438).\nAlthough ef ficacy has been demon- | [
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Although ef ficacy has been demon-\nstrated with psychosocial interventions,there has been varying success regardingsustained increases in engagement in healthbehaviors and improved glycemic outcomesassociated with behavioral health issues.\nThus, health care professionals should | [
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Thus, health care professionals should\nsystematically monitor these outcomesfollowing implementation of current ev-idence-based psychosocial treatmentsto determine ongoing needs.\nDiabetes Distress\nRecommendation\n5.39 Screen people with diabetes, care-\ngivers, and family members for diabetes\ndistress at least annu... | [
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distress at least annually, and consider\nmore frequent monitoring when treat-\nment targets are not met, at transi-\ntional times, and/or in the presence of\ndiabetes complications. Health careprofessionals can address diabetes dis-\ntress and may consider referral to aqualified behavioral health professional, | [
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ideally one with experience in diabetes,for further assessment and treatment ifindicated. B\nDiabetes distress is very common (391,\n439–441). While it shares some features\nwith depression, diabetes distress is dis-\ntinct and has unique relationships with\nglycemic and other outcomes (440,442).\nDiabetes distress ref... | [
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Diabetes distress refers to signi ficant\nnegative psychological reactions relatedto emotional burdens and worries speci fic\nto an individual ’s experience in having to\nmanage a severe, complicated, and de-\nmanding chronic condition such as diabetes\n(439,440,443). The constant behavioral\ndemands of diabetes self-man... | [
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demands of diabetes self-management\n(medication dosing, frequency, and\ntitration as well as monitoring of glu-\ncose, food intake, eating patterns, and\nphysical activity) and the potential or\nactuality of disease progression are di-\nrectly associated with reports of diabe-\ntes distress (439). The prevalence of\nd... | [
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diabetes distress is reported to be\n18–45%, with an incidence of 38 –48%\nover 18 months in people with type 2diabetes (443). In the second Diabetes\nAttitudes, Wishes, and Needs (DAWN2)\nstudy, signi ficant diabetes distress was re-\nported by 45% of the participants, butonly 24% reported that their health care\nteams... | [
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teams asked them how diabetes affected\ntheir lives (391). Similar rates have been\nidenti fied among adolescents with type 1\ndiabetes (441) and in parents of youthwith type 1 diabetes. High levels of diabe-\nt e sd i s t r e s ss i g n i ficantly impact medication-\ntaking behaviors and are linked to higherA1C, lower s... | [
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Table 5.2 —Situations that warrant referral of a person with diabetes to a quali fied behavioral health professional for\nevaluation and treatment\n/C15A positive screen on a validated screening tool for depressive symptoms, diabetes distress, anxiety, fear of hypoglycemia, suicidality, or\ncognitive impairment | [
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cognitive impairment\n/C15The presence of symptoms or suspicions of disordered eating behavior, an eating disorder, or disrupted patterns of eating\n/C15Intentional omission of insulin or oral medication to cause weight loss is identi fied\n/C15A serious mental illness is suspected | [
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/C15A serious mental illness is suspected\n/C15In youth and families with behavioral self-care dif ficulties, repeated hospitalizations for diabetic ketoacidosis, failure to achieve expected\ndevelopmental milestones, or signi ficant distress | [
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developmental milestones, or signi ficant distress\n/C15Low engagement in diabetes self-management behaviors, including declining or impaired ability to perform diabetes self-management behaviors | [
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/C15Before undergoing bariatric or metabolic surgery and after surgery, if assessment reveals an ongoing need for adjustment supportdiabetesjournals.org/care Facilitating Positive Health Behaviors and Well-being S93\n©AmericanDiabetesAssociation | [
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eating and exercise behaviors (5,439,443).\nDiabetes distress is also associated withsymptoms of anxiety, depression, and re-duced health-related quality of life (444).\nDiabetes distress should be routinely\nmonitored (445) using diabetes-speci fic\nvalidated measures (1), such as thosea v a i l a b l et h r o u g ht h... | [
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(professional.diabetes.org/sites/default/files/media/ada_mental_health_toolkit_\nquestionnaires.pdf). As there are diabe-tes distress measures that are validatedfor people with type 1 and type 2 diabe-tes at different life stages, it is important\nto select a tool that is appropriate for | [
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to select a tool that is appropriate for\neach person or population. If diabetes dis-t r e s si si d e n t i fied, it should be acknowl-\nedged and addressed. If indicated, the\nperson should be referred for follow-up\ncare (403). This may include speci ficd i a b e - | [
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care (403). This may include speci ficd i a b e -\ntes education to address areas of diabetesself-care causing distress and impactingclinical management and/or behavioral\nintervention from a quali fied behavioral\nhealth professional, ideally one with exper-\ntise in diabetes, or from another trainedhealth care professi... | [
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and behavioral intervention strategies have\ndemonstrated bene fits for diabetes dis-\ntress and, to a lesser degree, glycemicoutcomes, including education, psychologi-\ncal therapies, such as cognitive behavioral | [
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cal therapies, such as cognitive behavioral\ntherapy (CBT) and mindfulness-basedtherapies, and health behavior changeapproaches, such as motivational interview-ing (429,430,446,447). Data support diabe-\ntes distress interventions delivered using | [
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tes distress interventions delivered using\ntechnology to reduce diabetes distress(437), including phone-delivered CBT com-bined with a smartphone application for\nCBT (448). DSMES has been shown to re-\nduce diabetes distress (5) and may alsobenefit A1C when combined with peer sup-\nport (449). It may be helpful to pro... | [
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port (449). It may be helpful to provide\ncounseling regarding expected diabetes-\nrelated versus generalized psychological dis-tress, both at diagnosis and when diseasestate or treatment changes occur (450). Amultisite RCT with adults with type 1 dia-\nbetes and elevated diabetes distress and | [
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betes and elevated diabetes distress and\nA1C demonstrated large improvements indiabetes distress and small reductions inA1C through two 3-month intervention ap-\nproaches: a diabetes education interven-\ntion with goal setting and a psychologicalintervention that included emotion regu-lation skills, motivational inter... | [
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and goal setting (451). Among adults with\ntype 2 diabetes in the Veterans Affairs sys-tem, an RCT demonstrated bene fits ofintegrating a single session of mindfulness | [
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intervention into DSMES, followed by abooster session and mobile app-basedhome practice over 24 weeks, with thestrongest effects on diabetes distress(452). An RCT of CBT demonstrated posi-tive bene fits for diabetes distress, A1C, | [
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and depressive symptoms for up to 1 yearamong adults with type 2 diabetes and el-evated symptoms of distress or depres-sion (453). An RCT among people withtype 1 and type 2 diabetes found mindfulself-compassion training increased self-compassion, reduced depression and dia-betes distress, and improved A1C (454).An RCT ... | [
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distress, and improved A1C (454).An RCT of a resilience-focused cognitivebehavioral and social problem-solving | [
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intervention compared with diabetes ed-\nucation (434) in teens with type 1 diabe-tes showed that diabetes distress anddepressive symptoms were signifi cantly | [
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reduced for up to 3 years post-interven-tion, although neither A1C nor self-management behaviors improved overtime. These recent studies support that acombination of educational, behavioral,and psychological intervention approachesis needed to address distress, depression,and A1C.\nAs with treatment of other diabetes- | [
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As with treatment of other diabetes-\nassociated behavioral and psychosocialfactors affecting disease outcomes, thereare few outcome data on long-term sys-\ntematic treatment of diabetes distress\nintegrated into routine care. As the dia-betes disease course and its manage-ment are fluid, it can be expected that\nrelate... | [
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related distress may fluctuate and may\nneed different methods of remediationat different points in the life course andas disease progression occurs.\nAnxiety\nRecommendation\n5.40 Consider screening people with\ndiabetes for anxiety symptoms, fear of\nhypoglycemia, or diabetes-related wor-\nries. Health care profession... | [
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ries. Health care professionals can dis-\ncuss diabetes-related worries andshould consider referral to a quali fied\nbehavioral health professional for fur-ther assessment and treatment if anxi-ety symptoms indicate interferencewith diabetes self-management behav-iors or quality of life. B\nAnxiety symptoms and diagnosa... | [
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Anxiety symptoms and diagnosable dis-\norders (e.g., generalized anxiety disorder,body dysmorphic disorder, obsessive\ncompulsive disorder, speci fic phobias,\nand posttraumatic stress disorder) are\ncommon in people with diabetes (455).\nThe Behavioral Risk Factor Surveillance\nSystem estimated the lifetime preva- | [
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System estimated the lifetime preva-\nlence of generalized anxiety disorder to\nbe 19.5% in people with either type 1 or\ntype 2 diabetes (456). A common diabe-\ntes-speci fic concern is fear related to hypo-\nglycemia (457 –459), which may explain\navoidance of behaviors associated withlowering glucose, such as increas... | [
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doses or frequency of monitoring. Factors\nrelated to greater fear of hypoglycemia in\npeople with diabetes and family members\ninclude history of nocturnal hypoglycemia,\npresence of other psychological concerns,\nand sleep concerns (460). See Section 6,\n“Glycemic Goals and Hypoglycemia, ”for | [
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“Glycemic Goals and Hypoglycemia, ”for\nmore information about impaired aware-ness of hypoglycemia and related fear ofhypoglycemia. Other common sources of\ndiabetes-related anxiety include not\nmeeting blood glucose targets (455), in-\nsulin injections or infusion (461), and on-\nset of complications (1). People with | [
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set of complications (1). People with\ndiabetes who exhibit excessive diabetes\nself-management behaviors well beyond\nwhat is prescribed or needed to achieve\nglycemic goals may be experiencingsymptoms of obsessive-compulsive disor-\nder (462). General anxiety is a predictor\nof injection-related anxiety and is associ... | [
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of injection-related anxiety and is associ-\nated with fear of hypoglycemia (458,463).\nPsychological and behavioral care can\nbe helpful to address symptoms of anxietyin people with diabetes. Among adults\nwith type 2 diabetes and elevated depres-\nsive symptoms, an RCT of collaborative\ncare demonstrated benefi ts on ... | [
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care demonstrated benefi ts on anxiety\nsymptoms for up to 1 year (464). An RCTof CBT for adults with type 2 diabetes\nshowed a reduction in health anxiety,\nwith CBT accounting for 77% of the re-duction in health anxiety at 16 weeks of\nfollow-up; this trial also found decreased\ndepressive symptoms and diabetes dis- | [
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depressive symptoms and diabetes dis-\ntress (465). Additionally, an RCT showed\nswitching from intermittently scanned\nCGM without alerts to real-time CGM\nwith alert functionality in adults with\ntype 1 diabetes decreased hypoglyce-\nmia-related anxiety at 24 months offollow-up while reducing A1C (466).\nThus, specia... | [
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Thus, specialized behavioral intervention\nfrom a quali fied professional is needed\nto treat hypoglycemia-related anxiety.S94 Facilitating Positive Health Behaviors and Well-being Diabetes Care Volume 47, Supplement 1, January 2024\n©AmericanDiabetesAssociation | [
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Depression\nRecommendations\n5.41 Conduct at least annual screening\nof depressive symptoms in all people\nwith diabetes and more frequently\namong those with a self-reported his-tory of depression. Use age-appropriate,\nv a l i d a t e dd e p r e s s i o ns c r e e n i n gm e a s - | [
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v a l i d a t e dd e p r e s s i o ns c r e e n i n gm e a s -\nures, recognizing that further evaluationwill be necessary for individuals whoh a v eap o s i t i v es c r e e n . B\n5.42 Beginning at diagnosis of compli-\ncations or when there are signi ficant\nchanges in medical status, consider as-sessment for depress... | [
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changes in medical status, consider as-sessment for depression. B\n5.43 Refer to quali fied behavioral\nhealth professionals or other trained\nhealth care professionals with experi-\nence using evidence-based treatmentapproaches for depression in conjunc-\ntion with collaborative care with the\ndiabetes treatment team. ... | [
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tion with collaborative care with the\ndiabetes treatment team. A\nHistory of depression, current depres-\nsion, and antidepressant medication use\nare risk factors for the development oftype 2 diabetes, especially if the individ-\nual has other risk factors, such as obesity\nand family history of type 2 diabetes(467– ... | [
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and depressive disorders are common\namong people with diabetes (385,459), af-\nfecting approximately one in four peoplewith type 1 or type 2 diabetes (390), andamong parents of youth with diabetes\n(470). Thus, routine screening for depres- | [
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(470). Thus, routine screening for depres-\nsive symptoms is indicated in this high-riskpopulation, including people with type 1or type 2 diabetes, gestational diabetes\nmellitus, and postpartum diabetes. Re-\ngardless of diabetes type, women havesignificantly higher rates of depression\nthan men (471).\nRoutine monitor... | [
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than men (471).\nRoutine monitoring with age-appropri-\nate validated measures (1) can help toidentify if referral is warranted (403,410).Multisite studies have demonstrated feasi-bility of implementing depressive symp-\ntom screening protocols in diabetes clinics\nand published practical guides for imple-mentation (40... | [
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history of depressive symptoms need on-going monitoring of depression recurrencewithin the context of routine care (467). In-tegrating behavioral and physical health\ncare can improve outcomes. When a per-\nson with diabetes is receiving psychologicaltherapy, the behavioral health professionalshould be incorporated int... | [
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with the diabetes treatment team (473).As with DSMES, person-centered collabora-\ntive care approaches have been shown to\nimprove both depression and medical out-\ncomes (473). Depressive symptoms may\nalso be a manifestation of reduced quality\nof life secondary to disease burden (also\nsee\nDIABETES DISTRESS , above... | [
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see\nDIABETES DISTRESS , above) and resultant\nchanges in resource allocation impactingthe person and their family. When de-pressive symptoms are identi fied, it is\nimportant to query origins, both diabetes-specifi c ones and those due to other life\ncircumstances (444,474).\nTrials have shown consistent evidence of\nim... | [
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improvements in depressive symptoms\nand variable bene fits for A1C when depres-\nsion is simultaneously treated (401,473,475), whether through pharmacological\ntreatment, group therapy, psychotherapy,\nor collaborative care (398,429,430,476,\n477). Psychological interventions targetingdepressive symptoms have shown effi... | [
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when delivered via digital technologies(478). A systematic review of internet-\ndelivered CBT studies indicated bene fits\nacross chronic health conditions, includingdiabetes (479). For people with diabetes,\nan RCT comparing internet plus tele-\nphonic CBT to usual care found moderate | [
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phonic CBT to usual care found moderate\nto large improvements in depressivesymptoms at 12 months (480). Physical\nactivity interventions also demonstrate\nbenefits for depressive symptoms and\nA1C (318). It is important to note that themedical treatment plan should also be\nmonitored in response to reduction in de-\npr... | [
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monitored in response to reduction in de-\npressive symptoms.\nDisordered Eating Behavior\nRecommendations\n5.44 Consider screening for disor-\ndered or disrupted eating using vali-\ndated screening measures whenhyperglycemia and weight loss areunexplained based on self-reported\nbehaviors related to medication dos- | [
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behaviors related to medication dos-\ning, meal plan, and physical activity.In addition, a review of the medicaltreatment plan is recommended toidentify potential treatment-related\neffects on hunger/caloric intake. B\n5.45 Consider reevaluating the treat-\nment plan of people with diabetes | [
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ment plan of people with diabetes\nwho present with symptoms of disor-dered eating behavior, an eating dis-order, or disrupted patterns of eating,in consultation with a quali fiedprofessional. Key quali fications include\nfamiliarity with diabetes disease physi- | [
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familiarity with diabetes disease physi-\nology, treatments for diabetes and dis-ordered eating behaviors, and weight-related and psychological risk factorsfor disordered eating behaviors. B\nEstimated prevalence of disordered eat-\ning behavior and diagnosable eating dis-\norders in people with diabetes varies\n(481–4... | [
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(481–483). For people with type 1 diabe-\ntes, insulin omission causing glycosuria\nin order to lose weight is the most com-\nmonly reported disordered eating be-\nhavior (484,485); in people with type 2diabetes, bingeing (excessive food intake\nwith an accompanying sense of loss of | [
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with an accompanying sense of loss of\ncontrol) is most commonly reported. Forpeople with type 2 diabetes treated with\ninsulin, intentional omission is also fre-\nquently reported (486). People with dia-betes and diagnosable eating disorders\nhave high rates of comorbid psychiatric\ndisorders (487). People with type 1... | [
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disorders (487). People with type 1 dia-\nbetes and eating disorders often have\nhigh rates of diabetes distress and fearof hypoglycemia (488).\nDiabetes care professionals should\nmonitor for disordered eating behaviorsusing validated measures (489). Whenevaluating symptoms of disordered or\ndisrupted eating (when the... | [
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disrupted eating (when the individual ex-\nhibits eating behaviors that appear mal-adaptive but are not volitional, such as\nbingeing caused by loss of satiety cues),\netiology and motivation for the behavior\nshould be evaluated (483,490). Mixed in-\ntervention results point to the need fortreatment of eating disorder... | [
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dered eating behavior in the context of\nthe disease and its treatment. Given thecomplexities of treating disordered eating\nbehaviors and disrupted eating patterns\nin people with diabetes, it is recom-mended that interprofessional care teams\ninclude or collaborate with a health pro- | [
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include or collaborate with a health pro-\nfessional trained to identify and treat eat-ing behaviors with expertise in disordered\neating and diabetes (491). Key quali fica-\ntions for such professionals include famil-\niarity with diabetes disease physiology,\nweight-related and psychological risk fac-\ntors for disord... | [
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tors for disordered eating behaviors, and\ntreatments for diabetes and disordered\neating behaviors. More rigorous methodsto identify underlying mechanisms of ac-\ntion that drive change in eating and treat-\nment behaviors, as well as associateddiabetesjournals.org/care Facilitating Positive Health Behaviors and Well-... | [
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©AmericanDiabetesAssociation | [
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mental distress, are needed (492). Health\ncare teams may consider the appropriate-ness of technology use among peoplewith diabetes and disordered eating be-haviors, although more research on therisks and bene fits is needed (493). Cau-\ntion should be taken in labeling individu-a l sw i t hd i a b e t e sa sh a v i n g... | [
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psychiatric disorder, i.e., an eating disor-\nder, when disordered or disrupted eatingpatterns are found to be associated withthe disease and its treatment. In otherwords, patterns of maladaptive food in-take that appear to have a psychologicalorigin may be driven by physiologic dis-ruption in hunger and satiety cues, ... | [
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bolic perturbations, and/or secondary\ndistress because of the individual ’s inabil-\nity to control their hunger and satiety(483,490).\nThe use of incretin therapies may have\npotential relevance to the treatment ofdisrupted or disordered eating (see Sec-tion 8, “Obesity and Weight Management | [
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for the Prevention and Treatment ofType 2 Diabetes ”). Incretin therapies work\nin the appetite and reward circuitries tomodulate food intake and energy bal-ance, reducing uncontrollable hunger,overeating, and bulimic symptoms (494),although mechanisms are not completelyunderstood (495). Weight loss from these\nmedicat... | [
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medications (496) may also improve\nquality of life. More research is neededabout whether use of incretins andother medications affects physiologi-cally based eating behavior in peoplewith diabetes.\nSerious Mental Illness\nRecommendations\n5.46 Provide an increased level of\nsupport for people with diabetes and | [
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support for people with diabetes and\nserious mental illness through en-hanced monitoring of and assistancewith diabetes self-management be-haviors. B\n5.47 Monitor changes in body weight,\nglycemia, and lipids in adolescents and\nadults with diabetes who are prescribed | [
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adults with diabetes who are prescribed\nsecond-generation antipsychotic medi-cations; adjust the treatment plan ac-cordingly, if needed. C\nStudies of individuals with serious mental\nillness, particularly schizophrenia and other\nthought disorders, show signi ficantly in-\ncreased rates of type 2 diabetes (497).People... | [
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thought disorders who are prescribed anti-psychotics should be monitored for predia-\nbetes and type 2 diabetes because of the\nknown comorbidity. Changes in body\nweight, glycemia, and lipids should be\nmonitored every 12 –16 weeks, unless clini-\ncally indicated sooner (498). Disorderedthinking and judgment can be ex... | [
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make it dif ficult to engage in behavior that\nreduces risk factors for type 2 diabetes,such as restrained eating for weight man-\nagement. Further, people with serious be-\nhavioral health disorders and diabetes\nfrequently experience moderate psycho-logical distress, suggesting pervasive intru-\nsion of behavioral hea... | [
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sion of behavioral health issues into daily\nfunctioning (499). Serious mental illness is\noften associated with the inability to eval-\nuate and apply information to make judg-\nments about treatment options. When a\nperson has an established diagnosis of a\nmental illness that impacts judgment, ac-\ntivities of daily... | [
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tivities of daily living, and ability to estab-\nlish a collaborative relationship with care\nprofessionals, it is helpful to include anonmedical caretaker in decision-making\nregarding the medical treatment plan.\nThis caretaker can help improve the per-\nson’s ability to follow the agreed-upon | [
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son’s ability to follow the agreed-upon\ntreatment plan through both monitoringand caretaking functions (500).\nCoordinated management of prediabe-\ntes or diabetes and serious mental illness isrecommended to achieve diabetes treat-\nment targets. The diabetes care team, in\ncollaboration with other care professionals, | [
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collaboration with other care professionals,\nshould work to provide an enhanced level\nof care and self-management support for\npeople with diabetes and serious mental\nillness based on individual capacity and\nneeds. Such care may include remotemonitoring, facilitating health care aides,\nand providing diabetes train... | [
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and providing diabetes training for family\nmembers, community support person-\nnel, and other caregivers. Qualitative re-\nsearch suggests that educational and\nbehavioral intervention may provide ben-\nefit via group support, accountability, and\nassistance with applying diabetes knowl-edge (501).\nCognitive Capacity/... | [
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Cognitive Capacity/Impairment\nRecommendations\n5.48 Cognitive capacity should be\nmonitored throughout the life span\nfor all individuals with diabetes, par-\nticularly in those who have docu-mented cognitive disabilities, thosewho experience severe hypoglyce-mia, very young children, and olderadults. B\n5.49 If cogni... | [
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5.49 If cognitive capacity changes or\nappears to be suboptimal for decision-making and/or behavioral self-man-agement, referral for a formal assess-ment should be considered. E\nCognitive capacity is generally de fined as\nattention, memory, logic and reasoning,\nand auditory and visual processing, all of\nwhich are in... | [
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which are involved in diabetes self-\nmanagement behavior (502). Having dia-betes (type 1 or type 2) over decades has\nbeen shown to be associated with cogni-\ntive decline (503 –505). A host of factors\nhave been linked with cognitive impair-ment in people with type 1 diabetes, in-cluding diabetes-speci fic (e.g., youn... | [
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age at diagnosis, longer disease duration,more time in glycemic extremes, recur-\nrent diabetic ketoacidosis, higher A1C,\nand presence of microvascular complica-\ntions), other medical (e.g., dyslipidemia,\nintestinal flora, and poorer sleep quality),\nand sociodemographic (e.g., female gen-\nder and lower educational ... | [
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der and lower educational level) factors\n(506). Declines have been shown to im-\npact executive function and information\nprocessing speed; they are not consistentbetween people, and evidence is lacking\nregarding a known course of decline (507).\nDiagnosis of dementia is more prevalent\namong people with diabetes, bo... | [
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among people with diabetes, both type 1\nand type 2 (508). Executive functioning is\nan aspect of cognitive capacity that has\nparticular relevance to diabetes manage-ment. Attention de ficit hyperactivity disor-\nder has been linked with twice the risk oftype 2 diabetes (509). Among youth and\nyoung adults with type 1 ... | [
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young adults with type 1 diabetes, lower\nexecutive functioning has been linked withmore dif ficulties with diabetes self-man-\nagement and higher A1C (510). In contrast,higher self-regulation has been linked with\nbetter emotional and diabetes-speci fic\nfunctioning (511). Thus, monitoring of cog-\nnitive capacity and s... | [
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nitive capacity and skills among individuals\nwith or at risk for diabetes is recom-\nmended, particularly regarding their ability\nto self-monitor and make judgments\nabout their symptoms, physical status, and\nneeded alterations to their self-manage-\nment behaviors, all of which are mediatedby executive function (50... | [
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ment behaviors, all of which are mediatedby executive function (508).\nAs with other disorders affecting men-\ntal capacity (e.g., major psychiatricS96 Facilitating Positive Health Behaviors and Well-being Diabetes Care Volume 47, Supplement 1, January 2024\n©AmericanDiabetesAssociation | [
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disorders), the key issue is whether the\nperson can collaborate with the careteam to achieve optimal metabolic out-comes and prevent complications, bothshort and long term (499). When this abil-\nity is shown to be altered, declining, or | [
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ity is shown to be altered, declining, or\nabsent, a lay care professional should beintroduced into the care team who servesin the capacities of a day-to-day monitor\nas well as a liaison with the rest of the\ncare team (1). Cognitive capacity also con-tributes to ability to bene fitf r o md i a b e t e s\neducation and... | [
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education and may indicate the need for\nalternative teaching approaches as well\nas remote monitoring. Youth will needsecond-party monitoring (e.g., parentsand adult caregivers) until they are de-velopmentally able to evaluate neces-\nsary information for self-management\ndecisions and to inform resultant behav-ior ch... | [
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decisions and to inform resultant behav-ior changes.\nEpisodes of severe hypoglycemia are in-\ndependently associated with decline as\nwell as the more immediate symptoms of\nmental confusion (512). Early-onset type 1diabetes has been shown to be associ-ated with potential long-term de ficits in | [
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intellectual abilities, especially in the con-text of repeated episodes of severe hypo-glycemia (513), and is correlated withhigher A1C and sensor glucose values\n(514). (See Section 14, “Children and\nAdolescents, ”for information on early-\nonset diabetes and cognitive abilities and | [
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onset diabetes and cognitive abilities and\nthe effects of severe hypoglycemia onchildren ’s cognitive and academic perfor-\nmance.) Thus, for myriad reasons, cogni-tive capacity should be assessed duringr o u t i n ec a r et oa s c e r t a i nt h ep e r s o n ’s\nability to maintain and adjust self-\nmanagement behavi... | [
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management behaviors, such as dosing\nof medications, remediation approachesto glycemic excursions, etc., and to de-termine whether to enlist a caregiver in\nmonitoring and decision-making regarding | [
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monitoring and decision-making regarding\nmanagement behaviors. If cognitive ca-pacity to carry out self-maintenance be-haviors is questioned, an age-appropriatetest of cognitive capacity is recommended\n(1). Cognitive capacity should be evalu-\nated in the context of the person ’sa g e , | [
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ated in the context of the person ’sa g e ,\nfor example, in very young children whoare not expected to manage their disease\nindependently and in older adults who\nmay need active monitoring of treatmentplan behaviors.\nCognitive decline is more severe in\nolder adults with type 2 diabetes (515).\nLongitudinal epidemi... | [
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Longitudinal epidemiological studies have\ndocumented that chronic hyperglycemia,older age, less education, retinopathy, | [
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and nephropathy are associated with dia-betes-related cognitive dysfunction (516).Importantly, the risk of cognitive declinec a nb er e d u c e dt h r o u g hi m p r o v e dA 1 C(517). Exercise may be a potential non-pharmacological treatment pathway forcognitive impairment in older adults withtype 2 diabetes (518,519)... | [
0.05604306980967522,
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0.020770613104104996,
0.0196530818939209,
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0.018761197105050087,
0.08119002729654312,
0.0005943487631157041,
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0.027782492339611053,
-0.10099735110998154,
0.10847492516040802,
-0.011453336104750633,
0.036... |
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