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With the recent pivot to telehealth as a direct result of the COVID-19 pandemic, there is an imperative to ensure that access to affordable devices and technologies with remote monitoring capabilities for people with diabetes becomes equitable. In addition, expanding the use of remote Diabetes Self-Management Education and Support (DSMES) and Medical Nutrition Therapy (MNT) services will require new strategies for achieving long-term, effective, continuous, data-driven care. The current COVID-19 pandemic has especially impacted underserved US communities that were already disproportionately impacted by diabetes. Historically, these same communities have faced barriers in accessing timely and effective diabetes care including access to DSMES and MNT services, and diabetes technologies. Our call to action encourages all involved to urge US Federal representatives to widen access to the array of technologies necessary for successful telehealth-delivered care beyond COVID-19.

PurposeMore than 7 million Americans who have diabetes use insulin therapy. The majority continue to use syringes and vials or traditional insulin pens to deliver their insulin doses. Using these tools to deliver insulin presents numerous challenges for both the person with diabetes and their clinicians. This article provides an in-depth introduction to a new category of insulin delivery devices and integrated management systems, referred to as smart insulin pens. The article includes information about how these integrated insulin delivery systems can reduce many of the challenges of rapid-acting insulin dosing via injection by enabling easier and more accurate dose recording, dose calculations, and sharing of diabetes management data with clinicians. This article also discusses new roles for diabetes care and education specialists in diabetes data-driven care and practice and addresses how smart insulin pens represent one of many newer digital diabetes management tools that can assist people with diabetes and their clinicians to optimally achieve and deliver quality, data-driven diabetes care.ConclusionsNewer and simplified insulin delivery devices with their integrated management systems, such as smart insulin pens, have the potential to minimize the challenges and complexities associated with insulin injection therapy while also providing people with diabetes and their clinicians more complete and integrated data in easily transmitted reports that support more efficient data analysis.

Diabetes self-management education and support (DSMES) is an effective approach for improving diabetes self-care behaviors to achieve improved glycemic management and other health outcomes. Engaging family members may improve outcomes, both for the person with diabetes (PWD) and for the family members. However, family models of DSMES have been inconsistently defined and delivered. We operationalize Family-DSMES to be generalizable and replicable, detail our protocol for a comparative effectiveness trial comparing Standard-DSMES with Family-DSMES on outcomes for PWDs and family members, and detail our mixed-methods implementation evaluation plan.We will examine Family-DSMES relative to Standard-DSMES using a Hybrid Type 1 effectiveness-implementation design. Participants are ≥18 years old with type 2 diabetes mellitus and hemoglobin A1c ≥7.0%, recruited from rural and urban primary care clinics that are part of an academic medical center. Each participant invites a family member. Dyads are randomly assigned to Family- or Standard-DSMES, delivered in a small-group format via telehealth. Data are collected at baseline, immediately post-intervention, and 6-, 12-, and 18-months post-intervention. Outcomes include PWDs' hemoglobin A1c (primary), other biometric, behavioral, and psychosocial outcomes (secondary), and family members' diabetes-related distress, involvement in the PWD's diabetes management, self-efficacy for providing support, and biometric outcomes (exploratory). Our mixed-methods implementation evaluation will include process data collected during the trial and stakeholder interviews guided by the Consolidated Framework for Implementation Research.Results will fill knowledge gaps about which type of DSMES may be most effective and guide Family-DSMES implementation efforts.The trial is pre-registered at clinicaltrials.gov (#NCT04334109).

Overconsumption of added sugars is a key contributor to the growing obesity, prediabetes, and type 2 diabetes pandemics. The nutrition therapy guidance of the American Diabetes Association recognizes that using low- and no-calorie sweeteners (LNCS) to reduce consumption of added sugars can reduce low–nutrient-density sources of calories and carbohydrate to beneficially affect glycemia, weight, and cardiometabolic health. This article provides information for primary care providers, diabetes care and education specialists, and other diabetes clinicians on the safety of LNCS and summarizes research evidence on the role of LNCS in glycemic and weight management. It also provides practical strategies for counseling individuals about how to integrate LNCS into their healthy eating pattern.

Purpose The purpose of this study is to report a systematic review of reviews of evidence and gaps focused on in-person and technology-mediated diabetes peer support and its impact on clinical, behavioral, and psychosocial outcomes. Methods We conducted a systematic review of reviews in accordance with the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) guidelines. Reviews published in English from December 1978 through December 2018 examining clinical, behavioral, and psychosocial outcomes were included. The search yielded 167 reviews that were examined for inclusion/exclusion criteria. Results Nine systematic reviews and meta-analyses meeting criteria were included. Findings suggest peer support interventions can have a positive impact on clinical (A1C, blood pressure, cholesterol, weight), behavioral (diabetes knowledge, being active, healthy eating, medication management, self-management, self-efficacy, empowerment), and psychosocial (social support, health and diabetes distress, depression, quality of life) outcomes. Research gaps exist related to understanding the effects of emerging technology-mediated peer support modalities and the effects of peer support on gestational diabetes. Conclusion Many clinical, behavioral, and psychosocial benefits related to in-person and technology-mediated peer support exist. Diabetes care and education specialists should incorporate and recommend peer support resources for people with diabetes.

Diabetes, regardless of type, is a complex disease. Successful management to achieve both short- and long-term health goals and outcomes is highly dependent on learning, mastery, and regular implementation and execution of self-care behaviors. The importance of a positive mental outlook and minimization of psychosocial barriers to care is increasingly identified as important in managing the whole person with diabetes and, as appropriate, the caregivers. Ongoing support from HCP and increasingly ongoing support from peers are critical elements of quality diabetes care. With the availability of virtually accessible technologies for social media and networking, the volume of peer support among people with diabetes and their caregivers has increased exponentially and will likely continue to do so. With the value of ongoing peer support recognized as an important element in diabetes health, a growing number of peer support communities and increasing engagement in these communities among some diabetes educators, the American Association of Diabetes Educators (AADE) embarked on an initiative to more formally work with diabetes peer support communities and their leaders. To initiate this effort AADE held and supported a consensus meeting in 2017. This article reviews the history and goals of this effort and details the meeting outcomes. It also discusses the collaborations completed since the initial meeting along with plans for the near future. This collaboration is unique and presents a model for similar endeavors in diabetes or other chronic diseases.

To support safe and effective insulin therapy, a number of devices have been developed with features of potential value for people with diabetes (PWDs) who take insulin. These include a bolus calculator, digital logbook, and dose reminders and alerts. In the not-too-distant future, clinicians and PWDs will work within a “digital diabetes ecosystem.” This will combine the Internet of Medical Things (connected physiological and behavioral sensors embedded within multiple medical devices worn or used by an individual) and smart insulin delivery systems comprising insulin pumps and more recently smart insulin pens. These latter devices will allow devices used to inject insulin to automatically upload and analyze insulin dosing and related information with the potential to (1) reduce the personal burden of insulin self-management, (2) improve the safety of insulin therapy, and (3) allow clinicians greater opportunities to work with PWDs who take insulin to achieve clinical and personal goals through optimization of insulin therapy.

Purpose Increasing attention is being given to the challenges and emotional toll of managing diabetes. This Perspectives in Practice details the specialty’s guiding documents for initial and ongoing support. It also defines various types of social support, including peer support, for optimal diabetes care. Focusing on peer support, this paper provides a review of the body of evidence demonstrating the value of peer support to improve clinical and behavioral outcomes. To achieve positive outcomes, it is optimal for people with diabetes to have access to ongoing support from their health care provider, including diabetes care and education specialists. They should also be made aware of, and given referral to options and opportunities for peer support. This Perspectives in Practice concludes with a call to action for diabetes care and education specialists to deliver to integrate and promote the value of peer support in the care they provide. Conclusion Managing diabetes during the stages and ages of life is chronically challenging and complex. Various types of support offered by health care providers, including diabetes care and education specialists and others in the person’s social support milieu, can positively affect emotional well-being. Health care providers should routinely assess their client’s social supports and refer the person with diabetes and/or their caregivers to evidence-based types of peer support mutually determined to be of most value. Diabetes care and education specialists should increase their awareness of opportunities to integrate the value of and referral to peer support in their counseling and to gain greater insight into the diabetes-lived experience.

BACKGROUND: Relationships among dietary sugars and a variety of chronic diseases have spawned interest in investigating the metabolic effects of dietary sugars. An approach developed by the Agency for Healthcare Research and Quality (AHRQ) for assessing Future Research Needs (FRN) was implemented with modifications that integrated an evidence mapping process. METHODS: A panel of 14 stakeholders across 7 pre-defined areas of expertise (lay audience, policy makers, health providers, research funders, evidence-based methodologists, product makers, and researchers) was assembled to prioritize research needs. The panel was facilitated by an independent research team. A total of 213 studies were analyzed descriptively for evidence mapping, and the results were used to inform the stakeholder panel discussions on research needs. RESULTS: The stakeholder panel identified and prioritized 14 sets of research questions. The top three high-priority FRN questions selected by the stakeholder panel focused on the effects of dietary sugars on body weight or body composition, fat deposition, and satiety and appetite. Research considerations for the top three research questions and crosscutting research design issues are discussed. CONCLUSION: Involving a multidisciplinary stakeholder panel to prioritize the direction of future research in this or other content areas has potential to add diverse perspectives to the determination of research needs, and to the development of public health policy.

Natural resistant starch has been consumed from a variety of carbohydrate-containing foods for centuries. Due to the discovery of potential health benefits of resistant starch, it is now being incorporated into a growing array of commonly consumed foods. Added resistant starch in the diet can help consumers increase their fiber intake. Nutritional professionals should explore the potential health benefits of resistant starch and gather ways to help consumers increase their intake to more closely achieve the fiber goals of the Dietary Guidelines.

Purpose To describe the evolving and expanding role of nurse practitioners (NPs) in providing diabetes medical nutrition therapy (MNT) as the United States faces epidemics of diabetes and obesity. Data Sources Scientific literature and reports from the public health, diabetes, and nutrition fields. Conclusions Although clinically effective for both prevention and treatment of diabetes, MNT is often underutilized. The majority of people with diabetes are cared for by primary care providers; the role of NPs as primary care providers is evolving and expanding. NPs are recognized as leaders who creatively adapt to the rapidly changing health care delivery system. Implications for Practice NPs can serve as role models by presenting accurate, basic nutrition messages, referring patients to registered dietitians for MNT, reinforcing nutrition and the importance of lifestyle change as primary treatments for their disease, and following up on their patients' progress with nutrition interventions.

Numerous advances in diabetes management and medical nutrition therapy (MNT) for individuals with diabetes make this an exciting time. Historically, a challenge to proving the benefit of MNT has been the lack of clinical and behavioral research. In recent years, however, evidence-based outcomes research that documents the clinical effectiveness of MNT in diabetes has been reported. The term “medical nutrition therapy” was introduced in 1994 by the American Dietetic Association to better articulate the nutrition therapy process. It is defined as the use of specific nutrition services to treat an illness, injury, or condition and involves two phases: 1 ) assessment of the nutritional status of the client and 2 ) treatment, which includes nutrition therapy, counseling, and the use of specialized nutrition supplements (1). MNT for diabetes incorporates a process that, when implemented correctly, includes: 1 ) an assessment of the patient’s nutrition and diabetes self-management knowledge and skills; 2 ) identification and negotiation of individually designed nutrition goals ; 3 ) nutrition intervention involving a careful match of both a meal-planning approach and educational materials to the patient’s needs, with flexibility in mind to have the plan be implemented by the patient; and 4) evaluation of outcomes and ongoing monitoring. These four steps are necessary to assist patients in acquiring and maintaining the knowledge, skills, attitudes, behaviors, and commitment to successfully meet the challenges of daily diabetes self-management (2). The primary purpose of this article is to review the evidence for the effectiveness of MNT in diabetes, both as an independent variable and in combination with other components of diabetes self-management training (DSMT). In addition, the recent studies that have demonstrated the effectiveness of lifestyle intervention, which included MNT, in preventing type 2 diabetes will be highlighted. Evidence from several studies that supports the cost-effectiveness of MNT in diabetes will also be …

The scientific literature demonstrates that fat replacers have a reasonable certainty of no harm. Whether they help produce desired health outcomes, i.e., decreased risk of coronary heart disease and certain types of cancer related to excess fat intake, weight reduction, changes in lipid profile, improved glycemic control, etc., depends on how individuals use these foods to change food choices and eating behaviors. As Miller and Rolls conclude, ...the use of fat-replaced foods alone should not be expected to produce spontaneous improvements in weight management. Such improvements will still be dependent on long-term behavioral changes that include not only modifications in fat, but also modifications in overall energy intake and increase in energy expenditure. (53) Though it has not been studied, one may conjecture that encouraging people with diabetes to use foods with fat replacers to achieve nutrition management goals requires sufficient education, continuous counseling, and an individual's conscientious commitment and readiness to change food habits.

Current fiber intakes are alarmingly low, with long-term implications for public health related to risk of coronary heart disease, stroke, hypertension, certain gastrointestinal disorders, obesity, and the continuum of metabolic dysfunctions including prediabetes and type 2 diabetes. Eating patterns high in certain fibers are known to lower LDL cholesterol and blood pressure, lower blood glucose, and decrease insulin resistance in people with prediabetes and type 2 diabetes; help with both weight loss and maintenance; and improve bowel regularity and gastrointestinal health. With >90% of adults and children who fall short of meeting their daily fiber recommendations, the 2010 Dietary Guidelines for Americans once again classified fiber as a nutrient of concern. Despite efforts over the past decade to promote adequate fiber through fruit, vegetable, and whole-grain intakes, fiber consumption has remained flat at approximately half the daily recommended amount. The public health implications of inadequate fiber intake prompted the roundtable session "Filling America's Fiber Gap: Probing Realistic Solutions," which assembled nutrition researchers, educators, and communicators to identify challenges, opportunities, and realistic solutions to help fill the current fiber gap. The roundtable discussions highlighted the need for both consumer and professional education to improve acceptance for and inclusion of grain-based foods with added fiber as one strategy for increasing fiber intakes within daily energy goals.

Research supports the importance of medical nutrition therapy in achieving diabetes treatment goals. For persons requiring insulin therapy, the first priority is to integrate an insulin regimen into the patient’s lifestyle. For type 2 diabetes, the priority is to focus on lifestyle strategies (that is, nutrition and exercise) that will improve metabolic outcomes at diagnosis and as the disease progresses. Patients with diabetes need nutrition recommendations that are supported by scientific evidence and that can be easily understood and translated into everyday life. To achieve positive outcomes, a coordinated team effort that provides continued education and support is essential.

Advocacy efforts conducted within the diabetes community during the past few years have contributed to improvements in diabetes care, increased funding for diabetes research, and reduced discrimination towards people with diabetes. Two significant victories in diabetes care have been the passage of legislation that increases Medicare coverage for diabetes self-management training (DSMT) and supplies and medical nutrition therapy (MNT) for diabetes and renal disease. In brief, the Balanced Budget Act of 1997 (effective since February 27, 2001) provides coverage for all people with diabetes, if eligible, to receive coverage for both diabetes supplies and DSMT. When Medicare beneficiaries with Part B coverage meet the specified eligibility criteria, the plan will cover the costs of up to 10 hours of initial training within a continuous 12-month period. The plan also covers 2 hours of follow-up training per year thereafter for those eligible.1 In 2000, as part of the Medicare, Medicaid, and SCHIP Benefits Improvement and Protection Act of 2000 (BIPA), Congress created The Medical Nutrition Therapy Benefit (effective since January 1, 2002) for Medicare Part B beneficiaries with diabetes and renal disease. The diabetes MNT benefit consists of a maximum of 3 hours of MNT services in the 12-month period beginning with the initial assessment (episode of care) and 2 hours per year in subsequent years. Additional hours of MNT services may be covered within …