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The Ten Step Plan to escape the pain of Plantar Fasciitis
If cold air is your trigger, my son uses a scarf or bandanna over his mouth when going outside in the winter. Taking an allergy medicine like allegra daily, rubbing camphor oil on my back, chest and kidneys nightly; and writing down all my frustrations to help get them off my chest. With the added effect of the drink and some hectic weather at the time, well it wasn't a smart thing to do. Drink Red Wine with meals. The solution is moderation in all that you do. Not eating many foods that are processed, staying away from hydrogenated oils, juicing vegetables and making sure to exercise to strengthen the lungs is key.

DIABETES SELF-MANAGEMENT EDUCATION AND SUPPORT

Strength training

Jiaogulan also helps us reach peak mental and physical function by boosting the levels of the endogenous antioxidants superoxide dismutase SOD and glutathione, and lowering Malondialdehyde MDA. Finally, Gynostemma is able to regulate immune function during exercise, recovering immune indices to normal values from either originally lower or higher than the normal. This is important because it has been demonstrated that the immune system is suppressed after rigorous exercise.

Marathon runners and the high frequency of respiratory tract infections immediately after a run are one example. If you are involved in physical exercise, act like the pros and have some Jiaogulan before a workout for extra energy and stamina, and after workout to help your body repair more quickly from the damage physical exercise inevitably causes. Being an adaptogen, Jiaogulan reduces mental and physical stress. It has also been shown to have a significant anxiolytic anti-anxiety effect and to help recover dopamine and serotonin levels back to normal.

The subjects made no changes to their lifestyle. Body weight in the Jiaogulan group dropped by 1. None of these changes were observed in the placebo group. However, no studies have yet been done to test this claim. Jiaogulan has been widely reported to protect and cleanse the body from toxins. Jiaogulan was found to completely cure Hepatitis B in a 5. Jiaogulan prevents liver fatty degeneration in fatty liver disease by modulating fat metabolism, ameliorating liver dysfunction, reducing oxidative stress , and protecting liver cells from injury and death Three separate clinical studies with hundreds of patients suffering from chronic renal failure showed that Jiaogulan can decrease blood fats and improve kidney function, anemia, and the nutritional situation in these patients.

Jiaogulan is effective against respiratory issues, such as cough, asthma, chronic bronchitis, and chronic tracheitis inflammation of the trachea. Jiaogulan protects the GIT from damage due to toxins and improves digestion and metabolism. It protects against and heals gastric ulcers 46, , as well as chronic atrophic gastritis It improves bowel movement function and alleviates constipation.

Helps regulate the gut microbiome ecosystem by increasing the number of symbiotic bacteria. This may in part contribute to the anticancer effect of Gynostemma, since the gut ecosystem can play an important role in diseases such as cancer, autism, rheumatoid arthritis, and allergies.

Jiaogulan improves sexual function and helps with Erectile Dysfunction because it regulates Nitric Oxide production. Nitric Oxide plays a key role in developing and maintaining penile erection due to its ability to dilate the arteries and increase blood flow to the whole body, including the penis. Nitric Oxide is also important in sperm production and motility, ovarian function and ovulation, oviduct the tube that links the ovary to the uterus function, formation of the placenta, pregnancy, labor, sexual behavior, and generation of steroid hormones.

Gynostemma has been used as an effective treatment for insomnia in folk medicine, especially when it occurs because of excessive stress or anxiety. This is because it soothes the nerves and has anti-stress and anxiety effects on the body. Jiaogulan has been shown to protect from UV radiation when applied directly to the skin. This is important in the prevention of melanoma skin cancer and premature aging of the skin. Jiaogulan has shown promise in the treatment of Psoriasis, a chronic inflammatory skin disorder.

Jiaogulan has been used for hundreds of years in folk medicine for the prevention of colds and the flu. It has demonstrated strong anti-viral potential against Yellow Fever and Polio , diseases that have no known treatment drugs. It was also shown to have potent and selective anti-retroviral potential against the HIV-1 retrovirus, which is reported to cause AIDS. Jiaogulan has been shown to alleviate headaches and migraines. The fact that people have safely been using Jiaogulan daily for hundreds of years in China without reporting any negative side effects should be convincing enough that the herb has no toxicity.

In addition, however, there is also a great deal of scientific research that demonstrates its safety. Of the many hundreds of scientific studies on Jiaogulan, a significant number of which have checked for toxicity or adverse side-effects, there has never been a report of any toxic effects whatsoever to any organ in the body. In one study Wistar rats were given up to mg per kilogram of Jiaogulan extract orally every day for 6 months.

No toxic effects were observed. Considering that the daily recommended dose is usually somewhere between milligrams of gypenosides per day, it would be literally impossible for a human to consume enough Jiaogulan to get anywhere near these concentrations even if they tried extremely hard. Contrast this to prescription drugs people use every day, which cause , deaths per year in the United States alone!

Our Jiaogulan is grown by small farmers in a pristine high mountain region, designated a national park by the Royal Family and Government of Thailand. No pesticides or other chemicals are allowed or used in the farming process. If you are not happy with the results, simply let us know within 60 days of purchase and we will refund your money, minus shipping and handling. Moreover, you get to keep the tea! Order your Jiaogulan today and give yourself and your loved ones the greatest gift of all — good health!

Benefits of Jiaogulan and How It Works. When health is absent, wisdom cannot reveal itself, art cannot manifest, strength cannot fight, wealth becomes useless, and intelligence cannot be applied.

Your greatest wealth is good health. It is fundamental for a happy and fulfilling life. An ounce of prevention is worth a pound of cure. It can completely change life for you and your loved ones. Jiaogulan [is] an herb from my native southern China that I believe possesses the most wide-ranging benefits for human health and wellness of any plant yet discovered.

This may seem like a bold statement, but having studied this remarkable tonic herb for more than twenty years, I can assure you that there is strong scientific support to back up my passion for jiaogulan. Jialiu Liu, 'Father of Jiaogulan'. We began to use Jiaogulan in our medical university hospital with great success for a wide variety of conditions, and before long, it was also being used at numerous other hospitals throughout China.

Nontoxic An adaptogen is nontoxic to the recipient. Jiaogulan the Supreme Antioxidant. Jiaogulan as a Nitric Oxide Regulator. Jiaogulan Promotes Cardiovascular Health. This arterial damage has a two-fold negative effect. Jiaogulan Prevents Arterial Damage. Jiaogulan prevents damage to the arterial lining in two ways. Other Benefits of Jiaogulan to the Cardiovascular System. There are several problems with such a strategy: Chemotherapy and radiotherapy are so devastating to our body that the majority of people die as a result of the treatment and not the cancer itself.

The root cause of the problem is not being addressed, so even if conventional treatments do succeed in removing the cancer, it will usually reappear in due time. It is extremely expensive financially, costing up to hundreds of thousands of dollars. It works on several levels to prevent and heal cancer: A strong immune system is important for preventing the formation of tumors.

With its exceptional antioxidant effects, Jiaogulan scavenges free radicals within the body, minimizing DNA mutations that lead to tumors. See the Antioxidant section for more information Its chemical components like saponins gypenosides , flavonoids and polysaccharides have direct anticancer action. These effects have been demonstrated in several types of cancer, including: Jiaogulan Protects and Boosts the Immune System. Jiaogulan Protects and Strengthens the Nervous System.

Jiaogulan Improves Athletic Performance. This is also why Jiaogulan is given to race-horses. Jiaogulan is able to increase athletic performance in several ways: By regulating the production of Nitric Oxide. By improving heart function efficiency. By stimulating the production of the endogenous antioxidants glutathione and superoxide dismutase.

Other Health Benefits of Jiaogulan. Cleanses the Body From Toxins Jiaogulan has been widely reported to protect and cleanse the body from toxins. Protects the Liver Jiaogulan was found to completely cure Hepatitis B in a 5. Protects and Improves Kidney Function Three separate clinical studies with hundreds of patients suffering from chronic renal failure showed that Jiaogulan can decrease blood fats and improve kidney function, anemia, and the nutritional situation in these patients.

Fights Respiratory Issues and Supports the Lungs Jiaogulan is effective against respiratory issues, such as cough, asthma, chronic bronchitis, and chronic tracheitis inflammation of the trachea. Protects and Benefits the Reproductive System Jiaogulan improves sexual function and helps with Erectile Dysfunction because it regulates Nitric Oxide production. Treats Insomnia Gynostemma has been used as an effective treatment for insomnia in folk medicine, especially when it occurs because of excessive stress or anxiety.

Helps Against Psoriasis Jiaogulan has shown promise in the treatment of Psoriasis, a chronic inflammatory skin disorder. Anti-Viral, Anti-Fungal and Anti-Bacterial Jiaogulan has been used for hundreds of years in folk medicine for the prevention of colds and the flu. Headaches and Migraines Jiaogulan has been shown to alleviate headaches and migraines. Jiaogulan is Completely Safe and Non-Toxic. In addition, Jiaogulan is naturally resistant to pests, so pesticides are not necessary.

Because we work with small organic farms, we have limited quantities each month. Because we work with small organic farms, each month we have limited quantities. Guangxi Ribao Guangxi Daily Newspaper. Winston, David; Steven Maimes April Herbs for Strength, Stamina, and Stress Relief. Jialiu Liu, Michael Blumert April Materia Medica , 3rd Edition. Molecules , 17, New England Journal of Medicine Role of superoxide dismutases in oxidative damage and neurodegenerative disorders.

Extracellular superoxide dismutase in biology and medicine. Free Radic Biol Med. The role of reactive oxygen species ROS in persistent pain. Zingerone as an antioxidant against peroxynitrite. J Agric Food Chem. Activities of red blood cell anti-oxidative enzymes SOD, GPx and total anti-oxidative capacity of serum TAS in men with coronary atherosclerosis and in healthy pilots.

Inverse correlation with longevity of mammalian species. Low activity of superoxide dismutase and high activity of glutathione reductase in erythrocytes from centenarians. Effects of long-term supplementation with whey proteins on plasma glutathione levels of HIV-infected patients.

High blood glutathione levels accompany excellent physical and mental health in women ages 60 to years. J Lab Clin Med. The effect of antioxidant herbs on the erythrocytic SOD activity and serum MDA content in patients with endemic fluorosis.

Guizhou Medical Journal ; 22 3: Zhang, XL et al. Study of the antioxidant effect of Danshen extract in aged persons and patients with fluorosis. Chinese Journal of Endemic Diseases. Phytotherapy Research , 7: Gypenosides attenuate cholesterol induced DNA damage by inhibiting the production of reactive oxygen species in human umbilical vein endothelial cells.

The effect of Gynostemma pentaphyllum GP on plasma lipoprotein metabolism and lipoperoxidation lipoprotein in the experimental hyperglycemia rats.

Protective effect of gypenosides against oxidative stress in phagocytes, vascular endothelial cells and liver microsomes. The effect of antioxidant Chinese herbs on SOD activity, MDA content and ultrastructural damage of the kidney tissue in mice with chronic fluorosis. Guizhou Yiyao Guizhou Medical Journal ; 22 2: Zhang, Guang-Lin et al. Gypenosides improve cognitive impairment induced by chronic cerebral hypoperfusion in rats by suppressing oxidative stress and astrocytic activation.

October — Volume 22 — Issue 7 — p — doi: Preconditioning of brain slices against hypoxia induced injury by a Gynostemma pentaphyllum extract — Stimulation of anti-oxidative enzyme expression. Protective effects of gypenosides on PC12 cell injury induced by oxidative stress.

Gynostemma pentaphyllum protects mouse male germ cells against apoptosis caused by zearalenone via Bax and Bcl-2 regulation. Toxicology Mechanisms and Methods , Mar;20 3: The American Journal of Chinese Medicine. Effect of gypenosides on DMN-induced liver fibrosis in rats. The Chinese native medicine G. Pentaphyllum extraction resistance mouse skin senile experimental study. Makino polysaccharides supplementation on exercise tolerance and oxidative stress induced by exhaustive exercise in rats.

Zhuohong Xie et al. Epub Oct Tanner, Xin Bu, J. Alan Steimle, Paul R. Epub Feb Comparative study on anti-hypertensive effect of Gypenosides, Ginseng and Indapamide in patients with essential hypertension.

Guizhou Medical Journal ; Davies, and Basil D. Faculty of Pharmacy, University of Sydney , Practical Applications of Modern Herbal Medicine ;7 1: La Cour B, et al. Traditional Chinese medicine in treatment of hyperlipidemia. Journal of Ethnopharmacology May ;46 2: Hu X, et al. Antilipemic effect Gynostemma pentaphyllum in patients. Zhou H, et al. Treatment of hyperlipidemia with Gynostemma pentaphyllum Jiaogulan.

Epub Mar Liao Duan Fang et al. Epub Dec Zhou, Ying-Na et al. Effects of a gypenosides-containing tonic on the pulmonary function in exercise workload. Journal of Guiyang Medical College 18 4: Li Y, et al. Effects of total gypenosides on heart function and blood pressure of rabbits.

Acta Academiae Medicinae Shandong. Epub May Makino and their antiproliferation effect on hepatoma cell ; Journal of Medicinal Food ; Dec;13 6: Epub Sep 4. Epub Nov Journal of Cellular and Molecular Medicine , Epub Sep Epub Jul Lu KW et al. Epub Jun Chen JC et al. Epub Jan Yin Xiangmin Yu Xinmin et al. Epub Apr Hsu HY et al. Epub Aug Therapeutic and tonic effects of jiaogulan on leukopenic patients. Xin Zhong Yi Chinese ; ; 23 1: Therapeutic effect of jiaogulan on leukopenia due to irradiation and chemotherapy.

Wang J, et al. Immunological effects of jiaogulan granule in 19 cancer patients; Zhejiang Journal of Traditional Chinese Medicine; ; 24 Epub Mar 8.

Epub Nov 1. Studies of reduced calorie interventions show reductions in A1C of 0. Sustaining weight loss can be challenging 64 but has long-term benefits; maintaining weight loss for 5 years is associated with sustained improvements in A1C and lipid levels The meal plans often used in intensive lifestyle management for weight loss may differ in the types of foods they restrict e. Studies examining the ideal amount of carbohydrate intake for people with diabetes are inconclusive, although monitoring carbohydrate intake and considering the blood glucose response to dietary carbohydrate are key for improving postprandial glucose control 70 , The literature concerning glycemic index and glycemic load in individuals with diabetes is complex often yielding mixed results, though in some studies lowering the glycemic load of consumed carbohydrates has demonstrated A1C reductions of —0.

Studies longer than 12 weeks report no significant influence of glycemic index or glycemic load independent of weight loss on A1C; however, mixed results have been reported for fasting glucose levels and endogenous insulin levels. The role of low-carbohydrate diets in patients with diabetes remains unclear Part of the confusion is due to the wide range of definitions for a low-carbohydrate diet 73 , While benefits to low-carbohydrate diets have been described, improvements tend to be in the short term and, over time, these effects are not maintained 74 — While some studies have shown modest benefits of very low—carbohydrate or ketogenic diets less than g carbohydrate per day 78 , 79 , this approach may only be appropriate for short-term implementation up to 3—4 months if desired by the patient, as there is little long-term research citing benefits or harm.

Efforts to modify habitual eating patterns are often unsuccessful in the long term; people generally go back to their usual macronutrient distribution As for all Americans, both children and adults with diabetes are encouraged to reduce intake of refined carbohydrates and added sugars and instead focus on carbohydrates from vegetables, legumes, fruits, dairy milk and yogurt , and whole grains.

Individuals with type 1 or type 2 diabetes taking insulin at mealtime should be offered intensive and ongoing education on the need to couple insulin administration with carbohydrate intake.

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

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

The ideal amount of dietary fat for individuals with diabetes is controversial. The type of fats consumed is more important than total amount of fat when looking at metabolic goals and CVD risk, and it is recommended that the percentage of total calories from saturated fats should be limited 93 — Multiple randomized controlled trials including patients with type 2 diabetes have reported that a Mediterranean-style eating pattern 93 , 98 — , rich in polyunsaturated and monounsaturated fats, can improve both glycemic control and blood lipids.

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

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

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

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

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

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

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

While use of nonnutritive sweeteners does not appear to have a significant effect on glycemic control , they can reduce overall calorie and carbohydrate intake Most systematic reviews and meta-analyses show benefits for nonnutritive sweetener use in weight loss , ; however, some research suggests an association with weight gain All adults, and particularly those with type 2 diabetes, should decrease the amount of time spent in daily sedentary behavior. B Prolonged sitting should be interrupted every 30 min for blood glucose benefits, particularly in adults with type 2 diabetes.

Yoga and tai chi may be included based on individual preferences to increase flexibility, muscular strength, and balance. Physical activity is a general term that includes all movement that increases energy use and is an important part of the diabetes management plan.

Exercise is a more specific form of physical activity that is structured and designed to improve physical fitness. Both physical activity and exercise are important. Exercise has been shown to improve blood glucose control, reduce cardiovascular risk factors, contribute to weight loss, and improve well-being. Physical activity is as important for those with type 1 diabetes as it is for the general population, but its specific role in the prevention of diabetes complications and the management of blood glucose is not as clear as it is for those with type 2 diabetes.

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

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

Although heavier resistance training with free weights and weight machines may improve glycemic control and strength , resistance training of any intensity is recommended to improve strength, balance, and the ability to engage in activities of daily living throughout the life span. Recent evidence supports that all individuals, including those with diabetes, should be encouraged to reduce the amount of time spent being sedentary e. Avoiding extended sedentary periods may help prevent type 2 diabetes for those at risk and may also aid in glycemic control for those with diabetes.

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

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

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

Those with complications may require a more thorough evaluation prior to beginning an exercise program In some patients, hypoglycemia after exercise may occur and last for several hours due to increased insulin sensitivity.

Hypoglycemia is less common in patients with diabetes who are not treated with insulin or insulin secretagogues, and no routine preventive measures for hypoglycemia are usually advised in these cases. Intense activities may actually raise blood glucose levels instead of lowering them, especially if pre-exercise glucose levels are elevated If proliferative diabetic retinopathy or severe nonproliferative diabetic retinopathy is present, then vigorous-intensity aerobic or resistance exercise may be contraindicated because of the risk of triggering vitreous hemorrhage or retinal detachment Consultation with an ophthalmologist prior to engaging in an intense exercise regimen may be appropriate.

Decreased pain sensation and a higher pain threshold in the extremities result in an increased risk of skin breakdown, infection, and Charcot joint destruction with some forms of exercise. Therefore, a thorough assessment should be done to ensure that neuropathy does not alter kinesthetic or proprioceptive sensation during physical activity, particularly in those with more severe neuropathy.

Studies have shown that moderate-intensity walking may not lead to an increased risk of foot ulcers or reulceration in those with peripheral neuropathy who use proper footwear All individuals with peripheral neuropathy should wear proper footwear and examine their feet daily to detect lesions early.

Anyone with a foot injury or open sore should be restricted to non—weight-bearing activities. Autonomic neuropathy can increase the risk of exercise-induced injury or adverse events through decreased cardiac responsiveness to exercise, postural hypotension, impaired thermoregulation, impaired night vision due to impaired papillary reaction, and greater susceptibility to hypoglycemia Cardiovascular autonomic neuropathy is also an independent risk factor for cardiovascular death and silent myocardial ischemia Therefore, individuals with diabetic autonomic neuropathy should undergo cardiac investigation before beginning physical activity more intense than that to which they are accustomed.

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

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

Smoking may have a role in the development of type 2 diabetes , The routine and thorough assessment of tobacco use is essential to prevent smoking or encourage cessation. Numerous large randomized clinical trials have demonstrated the efficacy and cost-effectiveness of brief counseling in smoking cessation, including the use of telephone quit lines, in reducing tobacco use.

For the patient motivated to quit, the addition of pharmacologic therapy to counseling is more effective than either treatment alone Special considerations should include assessment of level of nicotine dependence, which is associated with difficulty in quitting and relapse Although some patients may gain weight in the period shortly after smoking cessation , recent research has demonstrated that this weight gain does not diminish the substantial CVD benefit realized from smoking cessation One study in smokers with newly diagnosed type 2 diabetes found that smoking cessation was associated with amelioration of metabolic parameters and reduced blood pressure and albuminuria at 1 year Nonsmokers should be advised not to use e-cigarettes.

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

Psychosocial screening and follow-up may include, but are not limited to, attitudes about diabetes, expectations for medical management and outcomes, affect or mood, general and diabetes-related quality of life, available resources financial, social, and emotional , and psychiatric history. Providers should consider assessment for symptoms of diabetes distress, depression, anxiety, disordered eating, and cognitive capacities using patient-appropriate standardized and validated tools at the initial visit, at periodic intervals, and when there is a change in disease, treatment, or life circumstance.

Including caregivers and family members in this assessment is recommended. Complex environmental, social, behavioral, and emotional factors, known as psychosocial factors, influence living with diabetes, both type 1 and type 2, and achieving satisfactory medical outcomes and psychological well-being.

Thus, individuals with diabetes and their families are challenged with complex, multifaceted issues when integrating diabetes care into daily life. Emotional well-being is an important part of diabetes care and self-management. There are opportunities for the clinician to routinely assess psychosocial status in a timely and efficient manner for referral to appropriate services. A systematic review and meta-analysis showed that psychosocial interventions modestly but significantly improved A1C standardized mean difference —0.

However, there was a limited association between the effects on A1C and mental health, and no intervention characteristics predicted benefit on both outcomes. Key opportunities for psychosocial screening occur at diabetes diagnosis, during regularly scheduled management visits, during hospitalizations, with new onset of complications, or when problems with glucose control, quality of life, or self-management are identified 1.

Patients are likely to exhibit psychological vulnerability at diagnosis, when their medical status changes e. Providers can start with informal verbal inquires, for example, by asking if there have been changes in mood during the past 2 weeks or since their last visit. Providers should consider asking if there are new or different barriers to treatment and self-management, such as feeling overwhelmed or stressed by diabetes or other life stressors.

Standardized and validated tools for psychosocial monitoring and assessment can also be used by providers , with positive findings leading to referral to a mental health provider specializing in diabetes for comprehensive evaluation, diagnosis, and treatment.

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

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

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

Ideally, psychosocial care providers should be embedded in diabetes care settings. Although the clinician may not feel qualified to treat psychological problems , optimizing the patient-provider relationship as a foundation may increase the likelihood of the patient accepting referral for other services. Collaborative care interventions and a team approach have demonstrated efficacy in diabetes self-management and psychosocial functioning Situations that warrant referral of a person with diabetes to a mental health provider for evaluation and treatment.

Standards of Medical Care in Diabetes— Diabetes Care ;41 Suppl. Readers may use this article as long as the work is properly cited, the use is educational and not for profit, and the work is not altered.

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We do not capture any email address. Skip to main content. Diabetes Care Jan; 41 Supplement 1: B There are four critical times to evaluate the need for diabetes self-management education and support: E Facilitating appropriate diabetes self-management and improving clinical outcomes, health status, and quality of life are key goals of diabetes self-management education and support to be measured and monitored as part of routine care. C Effective diabetes self-management education and support should be patient centered, may be given in group or individual settings or using technology, and should help guide clinical decisions.

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

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

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

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

Fats The ideal amount of dietary fat for individuals with diabetes is controversial. Micronutrients and Supplements There continues to be no clear evidence of benefit from herbal or nonherbal i. Alcohol Moderate alcohol intake does not have major detrimental effects on long-term blood glucose control in people with diabetes.

Nonnutritive Sweeteners For some people with diabetes who are accustomed to sugar-sweetened products, nonnutritive sweeteners containing few or no calories may be an acceptable substitute for nutritive sweeteners those containing calories such as sugar, honey, agave syrup when consumed in moderation. C Physical activity is a general term that includes all movement that increases energy use and is an important part of the diabetes management plan.

Exercise and Children All children, including children with diabetes or prediabetes, should be encouraged to engage in regular physical activity. Frequency and Type of Physical Activity People with diabetes should perform aerobic and resistance exercise regularly Physical Activity and Glycemic Control Clinical trials have provided strong evidence for the A1C-lowering value of resistance training in older adults with type 2 diabetes and for an additive benefit of combined aerobic and resistance exercise in adults with type 2 diabetes Exercise in the Presence of Specific Long-term Complications of Diabetes Retinopathy If proliferative diabetic retinopathy or severe nonproliferative diabetic retinopathy is present, then vigorous-intensity aerobic or resistance exercise may be contraindicated because of the risk of triggering vitreous hemorrhage or retinal detachment Peripheral Neuropathy Decreased pain sensation and a higher pain threshold in the extremities result in an increased risk of skin breakdown, infection, and Charcot joint destruction with some forms of exercise.

Autonomic Neuropathy Autonomic neuropathy can increase the risk of exercise-induced injury or adverse events through decreased cardiac responsiveness to exercise, postural hypotension, impaired thermoregulation, impaired night vision due to impaired papillary reaction, and greater susceptibility to hypoglycemia Diabetic Kidney Disease Physical activity can acutely increase urinary albumin excretion.

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

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

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

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