Diabetes Self-managementEducation and Support in AdultsWith Type 2 Diabetes: AConsensus Report of the AmericanDiabetes Association, theAssociation of Diabetes Care andEducation Specialists, theAcademy of Nutrition andDietetics, the American Academyof Family Physicians, theAmerican Academy of PAs, theAmerican Association of NursePractitioners, and the AmericanPharmacists Associationhttps://doi.org/10.2337/dci20-0023

Diabetes is a complex and challenging disease that requires daily self-managementdecisions made by the person with diabetes. Diabetes self-management education andsupport (DSMES) addresses the comprehensive blend of clinical, educational, psycho-social, andbehavioralaspectsofcareneededfordaily self-managementandprovides thefoundation to help all peoplewith diabetes navigate their daily self-carewith confidenceand improved outcomes (1,2).The prevalence of diagnosed diabetes is projected to increase in the U.S. from 22.3

million (9.1%of the total population) in 2014, to 39.7million (13%) in2030, and to60.6million (17%) in 2060 (3). Approximately 90–95% of those with diabetes have type 2diabetes (4). Diabetes is an expensive disease, and the medical costs of health carealone for a person with diabetes are 2.3 times more than for a person without diabetes(5). Confounding the diabetes epidemic and high costs, therapeutic targets are not beingmet (6). There is a lack of improvement in reaching clinical target goals since 2005 despiteadvancements in medication and technology treatment modalities. Indeed, between2010 and 2016 improved outcomes stalled or reversed (6).The goals of this Consensus Report are to improve clinical care and education

services, to improve thehealthof individuals andpopulations, and to reducediabetes-associated per capita health care costs (1,7). This article is specifically directed towardhealth care providers (physicians, nurse practitioners, physician assistants [PAs]),referred to herein as providers, as it outlines the benefits of DSMES, defines fourcritical times to provide andmodify DSMES (see Fig. 1), proposeshowto locateDSMES-related resources, anddiscusses potential solutions to access andutilization barriers. Thisreport provides guidance to others as well: health systems and organizations can usethis report to anticipate and address the needs of persons with diabetes and create

1HealthPartners, Bloomington, MN2Medstar Health Research Institute, MedStarDiabetes Institute, and MedStar Health SystemNursing, Hyattsville, MD3Independent consultant, Albuquerque, NM4University of Michigan Medical School, AnnArbor, MI5MercyOne Clive Internal Medicine, Clive, IA6Section of Adult and Pediatric Endocrinology,Diabetes, andMetabolism,Universityof Chicago,Chicago, IL7MartinArmyCommunityHospital, FortBenning,GA8Cleveland Clinic Diabetes Center, Cleveland, OH9Johnson & Wales University, Providence, RI10Maryniuk & Associates, Boston, MA11DiabetesSisters, Chicago, IL12Association of Diabetes Care & EducationSpecialists, Chicago, IL13University of Pittsburgh, Pittsburgh, PA

Corresponding author: Margaret A. Powers,margaret.powers@parknicollet.com

This article contains supplementary material onlineat https://doi.org/10.2337/figshare.12098571.

This article is being published simultaneously in Di-abetesCare (DOI: 10.2337/dci20-0023),TheDiabetesEducator (DOI: 10.1177/0145721720930959), theJournal of the Academy of Nutrition and Dietetics(DOI: 10.1016/j.jand.2020.04.020), the Journal of theAmerican Academy of Physician Assistants (DOI: 10.1097/01.JAA.0000668828.47294.2a), the Journal oftheAmericanAssociationofNursePractitioners (DOI:10.1097/JXX.0000000000000473), and the Journal oftheAmericanPharmacistsAssociation (DOI:10.1016/j.japh.2020.04.018).

© 2020 by the American Diabetes Association,the Association of Diabetes Care and EducationSpecialists, the Academy of Nutrition and Di-etetics, the American Academy of PAs, the Amer-ican Association of Nurse Practitioners, and theAmerican Pharmacists Association. Readers mayuse this article as long as the work is properlycited, theuse is educational andnot forprofit,andthe work is not altered. More information is avail-able at https://www.diabetesjournals.org/content/license.

Margaret A. Powers,1

Joan K. Bardsley,2

Marjorie Cypress,3

Martha M. Funnell,4 Dixie Harms,5

Amy Hess-Fischl,6 Beulette Hooks,7

Diana Isaacs,8 Ellen D. Mandel,9

Melinda D. Maryniuk,10

Anna Norton,11 Joanne Rinker,12

Linda M. Siminerio,13 andSacha Uelmen12

Diabetes Care 1

CONSEN

SUSREP

ORT

Diabetes Care Publish Ahead of Print, published online June 8, 2020

access to DSMES services; persons withdiabetes can increase their awareness ofDSMESservicesaspartofquality careandcan advocate for self-management edu-cation and support; and payers and policymakers canwork to design reimbursementprocesses that support participation inDSMES. The Consensus Report’s recom-mendations are listed in Table 1.This Consensus Report focuses on a

component of diabetes care that is oftennotaccessedorutilizedeffectivelydDSMES.DSMES is identified as one of the essen-tial elements of comprehensive diabetesmedical care, along with medical nutri-tion therapy (MNT) (see MEDICAL NUTRITION

THERAPYASA CORECOMPONENTOFQUALITY DIABETES

CARE). DSMES improves health outcomesand quality of life and is cost effective(see BENEFITS ASSOCIATEDWITH DSMES). Currentutilization is quite low because of a va-riety of barriers, yet solutions are avail-able (see PROVIDINGDSMES and IDENTIFYINGAND

ADDRESSING BARRIERS). Solutions begin withan organizational commitment to the

value of access to, and participationin, DSMES. Financial support for DSMESservices is available yet requires specialattention (see REIMBURSEMENT). Key stake-holders can use this Consensus Reportand the current Standards of MedicalCare in Diabetes from the American Di-abetes Association (ADA) (8) to developaction plans for increased referral to andutilization of DSMES. These efforts areneeded to increase the focus on achievingtreatment targets early and maintainingthem throughout a person’s lifetime.

ThepurposeofDSMES is togivepeoplewith diabetes the knowledge, skills, andconfidence to accept responsibility fortheir self-management. This includes col-laborating with their health care team,making informed decisions, solving prob-lems, developing personal goals and ac-tion plans, and copingwith emotions andlife stresses (9). This Consensus Reportfocuses on the particular needs of adultswith type 2 diabetes. DSMES needs arecritical to those living with type 1 diabetes,

prediabetes, and gestational diabetes melli-tus; however, the evidence and examplesreferred to in this Consensus Report are foradults with type 2 diabetes.

A call to action for all health caresystems and organizations is to engageneeded resources and to effectively andefficiently manage and address this ex-pensive epidemic affecting health out-comes. We must address barriers thatresult in therapeutic inertia created byhealth policy, health systems, providers,people with diabetes, and the environ-ment, including social determinants ofhealth (10), which encompass the con-ditions in which people live, work, learn,and play (11). Rather than being over-whelmed and nonattentive to this crisis,all stakeholders must be creative andresponsive to the needs of all involvedand make it their priority.

Methods

This ConsensusReport is anupdateof the2015 joint position statement on DSMES(12). The panel of experts authoring thisreport includes representatives from thethree national organizations that jointlypublished the original article (ADA, Amer-ican Association of Diabetes Educators[AADE], and Academy of Nutrition andDietetics), and, in an effort to widen thereach and stakeholder input, the AmericanAcademy of Family Physicians, AmericanAcademy of PAs, American Association ofNurse Practitioners, American Pharma-cists Association, and a patient advocatewere invited to participate. At the begin-ning of thewriting process all members ofthe expert panel participated in two sur-veys related to the 2015 joint positionstatement and its impact and the desiredfuture use of this Consensus Report: onesurvey from their perspective and onecompleted while interviewing colleagues.The expert panel agreed on the directionfor this Consensus Report, establishedwriting teams to author the various sec-tions of the report, and reviewed theentire updated manuscript after eachstep. An outside market research com-pany was used to conduct the literaturesearch and was paid using ADA funds.Monthly calls were held between March2019 andDecember 2019,with additionale-mail and web-based collaboration. Twoin-person meetings were conducted toprovide organization to the process, es-tablish the review process, reach consensuson the content and key definitions (see

Figure 1—The four critical times to provide andmodify diabetes self-management education andsupport.

2 Consensus Report Diabetes Care

Table 2), and discuss and deliberate therecommendations. Once the draft wascompleted, the structured peer reviewprocesswas implemented and the reportwas sent to two additional representa-tives fromeachof the seven participatingorganizations. A final draft was com-pleted and submitted to all seven na-tional organizations for final review andapproval. The recommendations are theinformed, expert consensus of the sevencontributing organizations.

Benefits Associated With DSMES

Consensus recommendation

c Providers should discuss with allpersons with diabetes the benefitsand value of initial and ongoingDSMES.

The benefits of DSMES are multifacetedand include clinical, psychosocial, andbehavioral outcomes benefits. Key clin-ical benefits are improved hemoglobinA1c (A1C) with reductions that are addi-tive to lifestyle anddrug therapy (13–16).Based on recent data (13,14,16), DSMESresults in an average A1C reduction of0.45–0.57% when compared with usualcare for people with type 2 diabetestreated with a variety of modalities (life-style alone, oral and injectedmedication)(13–17), as well as reduction in the onsetand/or worsening of diabetes-relatedcomplications (18,19) and reduction ofall-causemortality (20). DSMES improvesquality of life (15,21–23) and promoteslifestyle behaviors including healthfulmeal planning and engagement in reg-ular physical activity (24). In addition,participation in DSMES services showsenhancement of self-efficacy and em-powerment (25), increased healthy

coping (26), and decreased diabetes-relateddistress (27). These improvementsclearly affirm the importance and bene-fits of utilizing DSMES and justify efforts tofacilitate participation as a necessary partof quality diabetes care. Table 3 high-lights the multiple and varied benefitsthat make DSMES services a criticalcomponent of quality diabetes care andcompares its effects to metformin therapy(17).

Evidence supports that better healthoutcomes are associated with an in-creased amount of time spent with adiabetes care and education specialist(13,28,29). People with diabetes whocompleted more than 10 h of DSMESover the course of 6–12months and thosewho participated on an ongoing basiswere found to have significant reductionsin mortality (20) and A1C (average abso-lute reduction of 0.57%) (16) comparedwith those who spent less time with adiabetes care and education specialist.

Research shows that those who par-ticipate in diabetes education are morelikely to use best practices and havelower health care costs (28,30). Eventhough outpatient and pharmacy costsare higher for those who use diabeteseducation, these costs are offset by loweracute care costs (28). DSMES is cost-effective by reducing emergency depart-ment visits, hospital admissions, and hos-pital readmissions (28,30–33). The cost ofdiabetes in the U.S. in 2017 was reportedto be $327 billion including directmedicalcosts ($176 billion) and lost productivity($69billion) (5).Thecostofcare forpeoplewith diabetes accounts for about one infour health care dollars spent in the U.S.;61%of costs are attributed to people overage 65 and are incurred by Medicare (5).

The U.S. health care system cannot sus-tain the costs of care associated with theincreasing incidence of diabetes anddiabetes-related complications. DSMES of-fers a pathway to decrease these costsand improve outcomes.

DSMES improves quality of life andhealth outcomes and is cost-effective. Allmembers of the health care team andhealth systems should promote the ben-efits, emphasize the value, and supportparticipation in initial and ongoingDSMESfor all people with diabetes (see Table 4).

Providing DSMES

Consensus recommendation

c Health policy, payers, health sys-tems, providers, and health careteams need to expand awareness,access, and utilization of innovativeandnontraditionalDSMESservices.

A variety of DSMES approaches and set-tings need to be presented and discussedwith people with diabetes, thus en-abling self-selection of a method thatbest meets their specific needs (34).Historically, DSMES services were pro-vided in a formal series of didactic classeswhere people with diabetes and theirfamily members participated at a hospital-based/health care facility location. Evolv-ing health care delivery systems, primarycare needs, and the needs of people withdiabetes have resulted in the incorpora-tion of DSMES services into additionaland nontraditional settings such as thoselocated within patient-centered medicalhomes, community health centers, phar-macies, andaccountable careorganizations(ACOs), as well as faith-based organiza-tions and home settings.

Table 1—DSMES Consensus Report recommendations

DSMES improves health outcomes, quality of life, and is cost effective, and people with diabetes deserve the right to DSMES services. Therefore, it isrecommended that:

Providers1. Discuss with all persons with diabetes the benefits and value of initial and ongoing DSMES.2. Initiate referral to and facilitate participation in DSMES at the 4 critical times: 1) at diagnosis, 2) annually and/or when not meeting treatment

targets, 3) when complicating factors develop, and 4) when transitions in life and care occur.3. Ensure coordination of the medical nutrition therapy plan with the overall management strategy, including the DSMES plan, medications, and

physical activity on an ongoing basis.4. Identify and address barriers affecting participation with DSMES services following referral.

Health policy, payers, health systems, providers, and health care teams5. Expand awareness, access, and utilization of innovative and nontraditional DSMES services.6. Identify and address barriers influencing providers’ referrals to DSMES services.7. Facilitate reimbursement processes and other means of financial support in consideration of cost savings related to the benefits of

DSMES services.

care.diabetesjournals.org Powers and Associates 3

Technology-based services includingweb-based programs, telehealth, mobileapplications, and remote monitoringenable and promote increased accessand connectivity for ongoing manage-ment and support (35). Recent healthcare concerns are rapidly expanding theuse of these services, especially tele-health. Inconjunctionwith formalDSMES,online peer support communities aregrowing in popularity. Involvement inthese groups can be a beneficial adjunctto learning, serving as an option forongoing diabetes peer support (36,37)(Supplementary Table 1).Creative, person-centered approaches

to meet individual needs that considervarious learning preferences, literacy,numeracy, language, culture, physicalchallenges, scheduling challenges, socialdeterminants of health, and financialchallenges should be widely available.

It is important to ensure access in com-munities at highest risk for diabetes, suchas racial and ethnic minorities and un-derserved communities.

Office-based health care teams with-out in-house resources can partner withlocaldiabetes careandeducationspecial-ists within their community to exploreopportunities to reach people with di-abetes and overcome some barriers toparticipation at the point of care (38). Ifthe office-based care team assumes re-sponsibility for providing diabetes edu-cation and support, every effort shouldbe made to ensure they receive up-to-date training in diabetes care and edu-cation and utilize the details in Tables 5and 6.

Regardless of the DSMES approach orsetting, personalized and comprehen-sive methods are necessary to promoteeffective self-management required for

day-to-day living with diabetes. Ef-fective delivery involves expertise inclinical, educational, psychosocial, andbehavioral diabetes care (39,40). It isessential for the referring provider tomutually establish personal treatmentplans and clinical goals with the personwith diabetes and communicate theseto the DSMES team. Ongoing commu-nication and support of recommenda-tions and progress toward goals betweenthe person with diabetes, educationteam, referring provider, and othermembers of the health care team arecritical.

A person-centered approach to DSMESbeginning at diagnosis of diabetes pro-vides the foundation for current andfuture decisions. Without the focus ona person’s beliefs and desires, ongoingtreatment goals can rarely be met.Diabetes self-management is not a static

Table 2—Key definitionsDiabetes self-management education and support (DSMES)

c DSMES (40): The ongoing process of facilitating the knowledge, skills, and ability necessary for diabetes self-management as well as activities thatassist a person in implementing and sustaining the behaviors needed to manage his or her condition on an ongoing basis, beyond or outside offormal self-management training. This process incorporates the needs, goals, and life experiences of the person with diabetes.

c Support (40): Helps implement informed decision making, self-management behaviors, problem solving, and active collaboration with the healthcare team to improve clinical outcomes, health status, and quality of life.

Note: Diabetes services and specialized providers and educators often provide both education and support. Yet on-going support from the primaryhealth care team, family and friends, specialized home services, and the community are necessary to maximize implementation of needed self-management.Note: CMS uses the term “training” (DSMT) instead of “education” (DSMES) when defining the reimbursableMedicare benefit. Education is used inthe National Standards for Diabetes Self-Management Education and Support andmore commonly used in practice. In the context of this article, theterms have the same meaning.

Person-centered care (96)c Providing care and education that is respectful of and responsive to an individual person’s preferences, needs, and values and ensuring that thosevalues guide all clinical decisions.

Diabetes-related distress (23,26,97)c Diabetes-related distress is defined as the emotional burden of diabetes, the constant demands from diabetes self-management (taking andadjustingmedications,monitoringblood glucose,meal planning, andphysical activity) and the possibility of developing complications, and the lackof support and access to care.

c The emotional burden of diabetes has the greatest impact on diabetes distress and outcomes.

Diabetes care and education specialist (DCES) (98)cA trusted expert of the integrated care teamwho provides collaborative, comprehensive, and person-centered care and education to personswithdiabetes and related cardiometabolic conditions.

Note: In 2019 a new title to identify health professionals who specialize in diabetes care and education was created by the Association of DiabetesCare and Education Specialists. Clinical staff who qualify for this title may or may not be a CDCES or BC-ADM, yet all who hold the CDCESand BC-ADM certifications are diabetes care and education specialists.

Certified Diabetes Care and Education Specialist (CDCES) (99)c A health care professional who has completed a minimum number of hours in clinical diabetes practice, passed the Certification Examination forDiabetes Care and Education (administered by the Certification Board for Diabetes Care and Education [CBDCE]), and has responsibilities thatinclude the direct provision of diabetes education.

Note: The Certified Diabetes Educator (CDE) certification title is now CDCES.

Board Certified-Advanced Diabetes Management (BC-ADM) (100)cAhealth careprofessionalwhohas completedaminimumnumberof hours in advanceddiabetesmanagement, holds a graduatedegree, passed theBC-ADM certification exam (administered by the Association of Diabetes Care & Education Specialists), and has responsibilities of an increasedcomplexity of decision making related to diabetes management and education.

Social determinants of health (11,83)c The conditions in which people live, work, learn, play, and the wider set of forces and systems shaping the conditions of daily life. These forces andsystems include economic policies and systems, development agendas, social norms, social policies, and political systems.

4 Consensus Report Diabetes Care

process and requires ongoing assess-ment and modification, as identified bythe four critical times (see Fig. 1). Initialand ongoing DSMES helps the personovercome barriers and cope with the en-during and changing demands through-out the continuum of diabetes treatmentand life transitions.Providers and other members of the

immediate health care team have animportant role in providing educationand ongoing support for self-managementneeds. New behaviors can be difficult tomaintain and require reinforcement at aminimum of every 6 months (41). Inaddition to the providers, the careteam may include diabetes care andeducation specialists (DCES); registereddietitian nutritionists (RDNs); nutritionand dietetics technicians, registered(NDTRs); nurse educators; care manag-ers; pharmacists; exercise and rehabili-tation specialists; and behavioral ormental health care providers. In addition,others have a role in helping to sustainthe benefits gained from DSMES, includ-ing community health workers, nurses,care managers, trained peers, home

health care service workers, social work-ers, and mental health counselors andother support people (e.g., family mem-bers) (42–46). Professional associationsmay help identify specific services in thelocal area such as the Visiting NurseAssociation and block nurse programs(see Supplementary Table 1).

Family members and peers are anunderutilized resource for ongoing sup-port and often struggle with how to bestprovide help (47,48). Including familymembers in the DSMES process can helpfacilitate their involvement (49–51).Such support people can be especiallyhelpful and serve as cultural navigatorsin health care systems and as liaisonsto the community (52). Communityprograms such as healthy cooking clas-ses, walking groups, peer support com-munities, and faith-based groups maylend support for implementing healthybehavior changes, promoting emotionalhealth, and meeting personal healthgoals (12).

All health care providers and/or sys-temsneed to identifyadequate resourcesavailable in their respective communities,

demonstrate commitment to supportthese services, and offer them as partof quality diabetes care. Health care pro-viders need to be aware of the DSMESresources in their health system andcommunities and make appropriatereferrals.

FourCritical Times toRefer toDSMES

Consensus recommendation

c Providers should initiate referralto and facilitate participation inDSMES at the four critical times 1)at diagnosis, 2) annually and/orwhen not meeting treatment targets,3) when complicating factors de-velop, and 4) when transitions inlife and care occur.

There are four critical times to provideand modify DSMES: 1) at diagnosis, 2)annually and/or when notmeeting treat-ment targets, 3) when complicating fac-tors develop, and 4) when transitions inlife and care occur. These critical timesaremoments when peoplewith diabetesmay need themost assistance to achieveand/or adjust their goals and care plansfor successful daily self-management.Although these four critical times arelisted, it is important torecognizediabetesis a chronic disease that progresses overtime and requires vigilant care to meetchanging physiologic needs and goals(53).

The existing treatment plan may be-come ineffective due to changing situationsthat can arise at any time. Such situationsinclude progression of the disease,changes in personal goals, unmet targets,major life changes, or new barriers iden-tified when assessing social determi-nants of health.

It is prudent to be proactive whenchanges are identified or emerging. Ad-ditional support from the entire careteam and referral to DSMES are appro-priate responses to any of these needs.Quality ongoing, routine diabetes careincludes continuous assessment, ongoingeducationand learning, self-managementplanning, and ongoing support.

The AADE7 Self-Care Behaviors pro-vide the overarching framework for iden-tifying key components of education andsupport (54). The seven self-care behaviorsare healthy coping, healthy eating, beingactive, taking medication, monitoring,reducing risks, and problem solving.

Table 3—Comparing the benefits of DSMES/MNT vs. metformin therapy (17)

Criteria

Benefits rating

DSMES/MNT Metformin

Efficacy High High

Hypoglycemia risk Low Low

Weight Neutral/loss Neutral/loss

Side effects None Gastrointestinal

Cost Low/savings Low

Psychosocial benefits* High N/A

N/A, not applicable. *Psychosocial benefits include improvements to quality of life, self-efficacy,empowerment, healthy coping, knowledge, self-care behaviors, meal planning, healthier foodchoices, more activity, use of glucose monitoring, lower blood pressure and lipids and reductionsin problems in managing diabetes, diabetes distress, and the risk of long-term complications (andprevention of acute complications).

Table 4—Summary of DSMES benefits to discuss with people with diabetes(15–28,30–33,40,89)

c Provides critical education and support forimplementing treatment plan

c Reduces emergency department visits,hospital admissions, and hospitalreadmissions

c Reduces hypoglycemiac Reduces all-cause mortalityc Lowers A1C

c Promotes lifestyle behaviors includinghealthful meal planning andengagement in regular physical activity

c Addresses weight maintenance or lossc Enhances self-efficacy andempowerment

c Increases healthy copingc Decreases diabetes-related distressc Improves quality of life

No negative side effects

Medicare and most insurers cover the costs

care.diabetesjournals.org Powers and Associates 5

Mastery of skills and behaviors related toeach of these areas requires practice andexperience. Often, a series of ongoingeducation and support visits are neces-sary to allow participants the time topractice new skills and behaviors, todevelop problem-solving skills, and toimprove their ability and self-efficacyto set and reach personal self-manage-ment goals (55). Targeted questions,such as those now used in social deter-minants of health surveys utilized bymany organizations, systems, and creden-tialed DSMES programs, can identify andfacilitate addressing the immediate needsof the person with diabetes (56) and/orfacilitate referral to the most appropriateteam member (see Table 7).Careandeducationplansateachof the

four critical times focus on the needsand personal goals of the individual.Therefore, the plan should be based on

personal experiences that are relevant toself-management and applicable to per-sonal goals, treatment targets, and ob-jectives and acknowledge that adultspossess expertise about their own lives(57). Tables 5 and 6 serve as checklists toensure clinical teams and health systemsoffer necessary diabetes services (factorsthat indicate DSMES needs and whatDSMES provides).

1. At DiagnosisFor an individual and family, the diag-nosis of diabetes is often overwhelming(58,59), with fears, anger, myths, and per-sonal, family, and life circumstances influ-encing this reaction. Immediate careaddresses these concerns through listen-ing, providing emotional support, andanswering questions. Providers typicallyfirst set the stage for a lifetime chroniccondition that requires focus, hope, and

resources to manage on a daily basis. Aperson-centered approach at diagnosis isessential for establishing rapport anddeveloping a personal and feasible treat-ment plan.

Despite the wide range of knowledgeand skills that are required to self-managediabetes, caution should be taken to notconfound theoverwhelmingnatureof thediagnosis but to determine what the per-son needs from the care team at this timetosafelynavigateself-managementduringthe first days and weeks. Responses tosuch questions as shown in Table 7 (alsosee Tables 5 and 6) guide and set di-rection for each person. Immediate re-ferral to DSMES services establishes apersonal education and support plan andhighlights the value of initial and ongoingeducation. Initial DSMES at diagnosistypically includes a series of visits orcontacts tobuildonclinical, psychosocial,

Table 5—Factors that indicate referral to DSMES services is neededAt diagnosis c Newly diagnoseddall newly diagnosed people with type 2

diabetes should receive DSMESc Ensure that both nutrition and emotional health areappropriately addressed in educationormake separate referrals

Annually and/or when not meeting treatment targets c Review of knowledge, skills, psychosocial, and behavioraloutcomes or factors that inhibit or facilitate achievementof treatment target and goals

c Long-standing diabetes with limited prior educationc Treatment ineffective for attaining therapeutic targetc Change in medication, activity, or nutritional intake orpreferences

c Maintenance of clinical and quality of life outcomesc Unexplained hypoglycemia or hyperglycemiac Support toattainor sustain improvedbehavioral orpsychosocialoutcomes

When complicating factors develop Change in:c Health conditions, such as renal disease and stroke, need forsteroids, or complicated medication plan

c Health status requiring changes in nutrition, physical activity,etc.

c Planning pregnancy or pregnantc Physical limitations such as cognitive impairment, visualimpairment, dexterity issues, movement restrictions

c Emotional factors such as diabetes distress, anxiety, and clinicaldepression

c Basic living needs such as access to shelter, food, health care,medicines, and financial limitations

When transitions in life and care occur Change in:c Living situation such as inpatient or outpatient or other changein living situation (i.e., living alone, with family, assisted living,etc.)

c Clinical care teamc Initiationor intensificationof insulin, newdevicesor technology,and other treatment changes

c Insurance coverage that results in treatment change (i.e.,provider changes, changes in medication coverage)

c Age-related changes affecting cognition, vision, hearing, self-management, etc.

6 Consensus Report Diabetes Care

and behavioral needs. See Table 6 forsuggested content.Education at diagnosis focuses on safety

concerns, often referred to as survival-levelskills education, and addresses “what do IneedtodoonceI leaveyouroffice?”Tobeginthe process of managing the diagnosis andincorporating self-management into dailylife, a diabetes care and education specialistand/or other members of the health careteam work closely with the person withdiabetes and his or her family membersand/or significant others to answer ques-tions, address initial concerns, and providesupport and referrals to needed resources.It is recommended that all persons

with diabetes be offered a referral forindividualized MNT with a registereddietitian nutritionist (RD/RDN) knowl-edgeable and skilled in diabetes-specificMNT and a mental health assessment, asindicated, from qualified providers withexpertise in diabetes management (60)(see Supplementary Table 1). These teammembers are critical at all four criticaltimes.Important discussions at diagnosis in-

clude the natural history of type 2 di-abetes, what the journey will involve interms of lifestyle and possibly medica-tion, and acknowledgment that a rangeof emotional responses is common.Emphasizing the importance of involv-ing family members and/or significantothers in ongoing education and supportis also a key part of the process (47–51).Diabetes is largely self-managed and caremanagement involves trial and error.The role of the health care team is toprovide information and discuss effec-tive strategies to reach chosen treat-ment targets and goals. The many tasksof self-management are not easy, yetworth the effort (61) (see BENEFITS ASSO-

CIATED WITH DSMES).

2. Annually and/or When Not MeetingTreatment TargetsThe health care team and others supportthe adoption and maintenance of dailyself-management tasks (8,40), as manypeople with diabetes find sustainingthese behaviors difficult. They need toidentify education and other needs ex-peditiously in order to address the nu-ances of self-management and highlightthe value of ongoing education. Table 6provides details of DSMES at this criticaltime. Annual assessment of knowledge,

skills, and behaviors is necessary forthose who achieve diabetes treatmenttargets and personal goals as well as forthose who do not.

Primary care visits for people with di-abetes typically occur every 3–6 months(60). These visits are opportunities toassess all areas of self-management, in-cluding laboratory results, and a reviewofbehavioral changes and coping strategies,problem-solving skills, strengths and chal-lenges of living with diabetes, use oftechnology, questions about medicationtherapy and lifestyle changes, and otherenvironmental factors that might impactself-management (40). It is challengingfor primary care providers to address allassessmentsduring a visit, which points tothe need to utilize established DSMESresources and champion new ones tomeet these needs, ensuring personalgoals are met. See Table 5 for indicationsfor referral.

Possible barriers to achieving treatmentgoals, such as financial and psychosocialissues, life stresses, diabetes-related dis-tress, fears, side effects of medications,misinformation, cultural barriers, or mis-perceptions, should be assessed andaddressed. People with diabetes aresometimes unwilling or embarrassedto discuss these problems unless spe-cifically asked (62,63).

Frequent DSMES visits may be neededwhen the individual is starting a newdiabetes medication such as insulin (64),is experiencing unexplained hypogly-cemia or hyperglycemia, has worsen-ing clinical indicators, or has unmetgoals. Importantly, diabetes care andeducation specialists are charged withcommunicating the revised plan to thereferring provider and assisting theperson with diabetes in implementingthe new treatment plan.

3. When Complicating Factors DevelopThe identification of diabetes-relatedcomplications or other individual factorsthat may influence self-managementshould be considered a critical indicatorof the need for DSMES that requiresimmediate attention and adequate re-sources. During clinical care, the providermay identify factors other than diabetesthat may influence the individual’s dia-betes treatment and associated self-management plan (see Tables 5 and 6).These factors may require a change in

self-management or affect an individual’sability to manage their diabetes and mayinvolve additional medications, new phys-ical limitations, and/or new emotionalneeds. Examples could include a new di-agnosis of renal disease or visual impair-ment, starting steroids,planningpregnancy,and/or psychosocial factors such as depres-sion and anxiety.

The diagnosis of other health condi-tions often makes management morecomplex and adds additional tasks ontodaily management. DSMES addresses theintegrationofmultiplemedical conditionsinto overall care with a focus on main-taining or appropriately adjusting medi-cation, meal plans, and physical activitylevels to maximize outcomes and qualityof life. In addition to the need to adjust orlearn new self-management skills, effectivecoping, defined as a positive attitudetoward diabetes and self-management,positive relationships with others, andenhanced quality of life are addressed inDSMES services (16,26). Focused emo-tional support may be needed for anx-iety, stress, and diabetes-related distressand/or depression.

The progression of diabetes can in-crease the emotional and treatmentburden of diabetes and distress (65,66).Diabetes-relateddistress,which is distinctfrom major depressive disorder, is partic-ularly common, with overall prevalencerates reported to be 36% (67). It has agreater impact on behavioral and meta-bolic outcomes than does depression (66).Diabetes-related distress is responsive tointervention, including DSMES-focusedinterventions (68) and family support(49). However, additional mental healthresources are generally required to ad-dress severe diabetes-related distress,clinical depression, and anxiety (65). Itis important to recognize the psycholog-ical issues related to diabetes and pre-scribe treatment as appropriate.

4. When Transitions in Life and CareOccurThroughout the life spanmany factors suchas aging, living situation, schedule changes,or health insurance coverage may requirea re-evaluation of diabetes treatment andself-management needs (see Tables 5 and6). Critical transition periods may includetransitioning into adulthood, living onone’s own, hospitalization, and movinginto an assisted living or skilled nursing

care.diabetesjournals.org Powers and Associates 7

Table 6—Checklist for providing and modifying DSMES at four critical times

Four critical timesPrimary care provider/endocrinologist/clinical care

team’s role in diabetes educationDiabetes care and education specialist’s role

in diabetes education

At diagnosis (series ofvisits)

c Answer questions and provide emotional supportregarding diagnosis

c Assess cultural influences, social determinants ofhealth, health beliefs, current knowledge, physicallimitations, family support, financial and work status,medical history, learning preferences and barriers,literacy, and numeracy to determine which content toprovide and how

c Shared decision-making of treatment and treatmenttargets

c Medication – choices, access, action, titration, sideeffects

c Teachsurvival skills toaddress immediate requirements(safe use of medication, hypoglycemia treatment ifneeded, introduction of eating guidelines)

c Monitoringbloodglucose –when to check, interpretingand using glucose pattern management for feedback

c Identify and discuss resources for education andongoing support

c Physical activity – safety, short-term vs. long-termgoals/recommendations

c Make referrals for DSMES and MNT c Preventing, detecting, and treating acute and chroniccomplications

c Nutrition – food plan, planningmeals, purchasing food,preparing meals, portioning food

c Risk reduction – smoking cessation, foot care, cardiacrisk

c Developing personal strategies to address psychosocialissues and concerns; adjusting to a life with diabetes

c Developing personal strategies to promote health andbehavior change

c Problem identification and solutionsc Identifying and accessing resources

Annually and/or whennot meetingtreatment targets

c Refer for new techniques, technology, andupdated information

c Review and reinforce treatment goals and self-management needs

c Assess and refer if self-management targets not met toaddress barriers to self-care

c Review barriers to treatment effectiveness

c Emphasize reducing risk for complications andpromoting quality of life

c Discuss how to adjust diabetes treatment and self-management to life situations and competing demands

c Support efforts to sustain initial behavior changes andcope with the ongoing burden of diabetes

When complicatingfactors develop

c Identify presence of factors that inhibit or facilitateachievement of treatment targets and personal goals

c Provide support for the provision of self-managementskills in an effort to delay progression of the disease andprevent new complications

c Discuss impact of complications and successes withtreatment and self-management

c Provide/refer for emotional support for diabetes-related distress and depression

c Develop and support personal strategies for behaviorchange and healthy coping

c Develop personal strategies to accommodate sensoryorphysical limitation(s), adapt tonewself-managementdemands, and promote health and behavior change

When transitions inlife andcare occur

c Develop diabetes transition plan c Adjust diabetes self-management plan as neededc Communicate transition plan to new health care teammembers

c Provide support for independent self- managementskills and self-efficacy

c Establish DSMES regular follow-up care c Identify level of significant other involvement andfacilitate education and support

c Assist with facing challenges affecting usual level ofactivity, ability to function, health benefits and feelingsof well-being

c Maximize quality of life and emotional support for theperson with diabetes (and family members)

c Provide education for others now involved in carec Establish communication and follow-up plans with theprovider, family, and others

c Develop goals and personal strategies to promote healthand behavioral change and improve quality of life

8 Consensus Report Diabetes Care

facility, correctional facility, or rehabilitationcenter. They may also include life mile-stones: marriage, divorce, becoming aparent, moving, death of a loved one,starting or completing college, loss ofemployment, starting a new job, re-tirement, and other life circumstances.Changing health care providers can alsobe a time at which additional support isneeded.DSMES affords important benefits to

people with diabetes during transitionsin life and care. Providing input into thedevelopment of practical and realisticself-management and treatment planscan be an effective asset for successfulnavigation of changing situations.The health care provider can make a

referral to a diabetes care and educationspecialist to add input to the transitionplan, provide education and problemsolving, and support successful transi-tions. The goal is to minimize disruptionsin therapy during any transition, whileaddressing clinical, psychosocial, and be-havioral needs.

Medical Nutrition Therapy as a CoreComponent ofQuality DiabetesCare

Consensus recommendation

c Providers should ensure coordina-tion of the medical nutrition therapyplan with the overall managementstrategy, including the DSMES plan,medications, and physical activity onan ongoing basis.

MNT can reduce A1Cby up to 2%,makingit an essential component of initial andongoing diabetes care (1,69,70). Addi-tionally, MNT helps prevent, delay, ortreat other complications commonlyfound with diabetes such as hyperten-sion, cardiovascular disease, renal dis-ease, celiac disease, and gastroparesis.MNT provided by an RD/RDN is cost-effective, and people who have receivedMNT show improved clinical outcomesand quality of life (69). MNT is integral toquality diabetes care and should be

incorporated into the overall care plan,medication plan, and DSMES plan on anongoing basis (1,40,69–72) (Table 8).

Referral to the RD/RDN forMNT alongwith DSMES is recommended as a sep-arate and distinct service provided by anRD/RDN. Although basic nutrition con-tent is covered as part of DSMES, peoplewith diabetes need both initial and on-going MNT and DSMES; referrals to bothcanbemadethroughmanyelectronichealthrecords as well as through hard copy orfaxed referral methods (see Supplemen-tary Table 1 for specific resources).

Everyday decisions about what to eatmustbedrivenbyevidenceandpersonal,cultural, religious, economic, and otherpreferences and needs (69–71). With anin-depth understanding of a person’sfood intake, factors influencing eatingbehaviors, coping strategies related tostress, and nutrition goals, the RD/RDNcan work closely with the health careteam to attain treatment goals, optimizemedication management, or minimizethe need for medications to meet glyce-mic targets and support progress towardother goals influenced by food intake.

The entire health care team shouldprovide consistent messages and recom-mendations regarding nutrition therapyand its importance as a foundation forquality diabetes care based on nationalrecommendations (70). Ongoing collabo-ration and communication with RD/RDNscan facilitate this aspect of care and sup-port self-management and everyday fooddecisions.

Identifying and Addressing Barriers

Consensus recommendations

c Providers should identify and addressbarriers affecting participation withDSMES services following referral.

c Health policy, payers, health systems,providers, and health care teamsshould identify and address barriersinfluencing providers’ referrals toDSMES services.

Despite the proven value and effective-ness of DSMES, a looming threat to itssuccess is low utilization due to a varietyof barriers. In order to reduce barriers, afocus on processes that streamline re-ferral practices must be implementedand supported system wide. Once thismajor barrier is addressed, the diabetescare and education specialist can beinvaluable in addressing other barriersthat thepersonmayhave.Without this, itwill be increasingly difficult to accessDSMES services, particularly in ruraland underserved communities. With fo-cus and effort, the challenges can beaddressed and benefits realized.

The Centers for Disease Control andPrevention reported that only 6.8% ofprivately insured individuals with newlydiagnosed type2diabetes participated inDSMES within 12 months of diagnosis(73). Furthermore, the Centers for Me-dicare and Medicaid Services (CMS)state that only 5% of Medicare partic-ipants receive DSMES during the firstyear of diagnosis (74). This low initialparticipation inDSMESwas also reportedin a recent AADE practice survey, withmost people engaging in a diabetesprogram diagnosed for more than ayear (75). These low numbers are seeneven in areas where cost is less of abarrier because of national health in-surance. Analysis of National Health Ser-vice data in the U.K. reveals that only 8%of those referred to formal diabeteseducation, an annually reviewed stan-dardof care, attended. Thishighlights theneed to identify andutilize resources thataddress all barriers including those re-lated to health systems, health careproviders, participants, and the environ-ment. In addition, efforts are beingmade by national organizations to cor-rect the identified access and utilizationbarriers.

Health system or programmatic bar-riers include lackof administrative leader-ship support, limited numbers of diabetescareandeducation specialists, geographiclocation, limited or lack of access toservices, referral to DSMES services noteffectively embedded in the health sys-tem service structure, limited resourcesfor marketing, and limited or low reim-bursement rates (76). DSMES servicesshould be designed and delivered withinput from the target population andcritically evaluated to ensure they arepatient-centered.

Table 7—Sample questions to guide a person-centered assessment (56)c How is diabetes affecting your daily life and that of your family?

c What questions do you have?

c What are one to two positive things you are doing right now to manage your diabetes?

c What is the hardest part about your diabetes right now, causing you the most concern, or ismost worrisome to you about your diabetes?

c How can we best help you?

care.diabetesjournals.org Powers and Associates 9

Despite the value and proven benefitsof these services, barriers within thebenefit design of Medicare and otherinsurance programs limit access. UsingMedicare as an example, some of thesebarriers include the following: hoursallowed in the first year the benefit isused and subsequent years are prede-fined andnot basedon individual needs; areferral is required and must be made bythe primary provider managing diabetes;there is a requirement of diabetes di-agnosis using methods other than A1C;andcostly copaysanddeductiblesapply.Aperson cannot haveMedicare DSMES andMNT visits either face to face or throughtelehealthonthe sameday, thus requiringseparate days to receive both of thesevaluable services and possibly delayingquestions, education, and support.Referring health care providers’ bar-

riers include lack of awareness of DSMESservices, limitations of referring pro-viders to those providing ongoing treat-ment of diabetes, misunderstanding ofthenecessity andeffectiveness ofDSMES,confusion regarding when and how tomake referrals, and inconvenient or lim-ited access (77–80). Referrals may also belimited by unconscious or implicit bias,which perpetuates health care disparitiesand leads to therapeutic inertia. Theprovider may too quickly judge an indi-vidual’s potential to benefit from DSMES(81) and may incorrectly assume theperson’s willingness/ability to partici-pate. Toaddress thesebarriers, providerscan meet with those currently providingDSMES services in their area to better

understand the benefits, access, andreferral processes and to develop collab-orative partnerships.

Participant-related barriers includelogistical factors such as cost, timing,transportation, and medical status(34,77,78,82). For those who avail them-selves of DSMES services, few com-plete their planned education due tosuch factors. The 2017 AADE practicesurvey of over 4,696 diabetes educatorsreported that only 23% of participants indiabetes education services completed75% or more of the program (75). Un-derutilization of servicesmay be becauseof a lack of understanding or knowledgeof the benefits, cultural factors, a desireto keepdiabetes privatedue toperceivedstigmaand shame, lack of family support,and perceptions that the standard pro-gram did not meet their needs and is notrelevant for their life, and the referringproviders may not emphasize the valueandbenefitsof initial andongoingDSMES(34,79,80,82).

Health systems, clinical practices, peo-ple with diabetes, and those providingDSMES services can collaborate to iden-tify solutions to the barriers to utilizationof DSMES for the population they serve.Creative and innovative solutions includeoffering a variety of DSMES options thatmeet individual needs within a popula-tion such as telehealth formats, coachingprograms, just-in-time services, online re-sources, discussion groups, and intenseprograms for select groups, whilemax-imizing community resources related tosupporting healthy behaviors.

Credentialed DSMES programs as wellas individual diabetes care and educationspecialists perform a comprehensive as-sessment of needs for each participant,including factors contributing to socialdeterminants of health such as foodaccess, financial means, health literacyand numeracy, social support systems,and health beliefs and attitudes. Thisallows the diabetes care and educationspecialist to individualize a plan thatmeets the needs of the person withdiabetes and provide referrals to resour-ces that address those factors that maynot be directly addressed in DSMES. It isbest that all potential participants arenotfunneled into a set program; classesbased on a person-centered curriculumdesigned to address social determinantsof health and self-determined goal set-ting can meet the varied needs of eachperson.

Environment-related barriers includelimited transportation services and in-adequate offerings to meet the variouscultural, language, and ethnic needs ofthe population. Additionally, these typesof barriers include those related to socialdeterminants of healthdthe economic,environmental, political, and socialconditions in which one lives (83). Thehealth system may be limited in chang-ing some of these conditions but needsto help each person navigate their sit-uation to maximize their choices thataffect their health. It is important torecognize that some individuals are lesslikely to attend DSMES services, includingthose who are older, male, nonwhite, less

Table 8—Overview of MNT: an evidence-based application of the nutrition care process provided by the RDN (1,40,69–72)1. Characteristics of MNT reducing A1C by 0.5–2% for type 2 diabetes:

c Initial series of MNT encountersc 3–6 during first 6 months of diagnosisc Determine if more encounters are needed based on a personal assessment and person’s goals

MNT follow-up encounters are based on needsc Health care team assesses needs at critical times and makes referrals – change in medication, health status, schedule, activity, stress, access tofood, need for on-going support, etc.

cMinimum of one annual follow-up encounterc Keyareasof focus andaction steps for positiveoutcomes: personswithdiabetes shouldhave knowledgeof foodplan, planningmeals, purchasingfood, preparing meals, and portioning food. If they are not confident in these areas it is difficult to take advantage of the full impact of nutritiontherapy. Implementation and assessment will drive confidence

2.MNT provides nutrition assessment, nutrition diagnosis, and an intervention andmanagement plan including the creation of personal food plan andsupport

c Development of food plan/physical activity/medication dosing for improved postprandial glucose level, hypoglycemia prevention, and overallglycemic improvement

c Ongoing weight management planning and coachingc Development of food plan for managing related complications and comorbidities such as hypertension, celiac disease, gastroparesis, eatingdisorders/disordered eating, kidney disease, disorders of lipid metabolism, etc.

Note: TheAcademyofNutrition andDietetics recognizes the use of registered dietitian (RD) and registered dietitian nutritionist (RDN). RD andRDN canonly be used by those credentialed by the Commission on Dietetic Registration.

10 Consensus Report Diabetes Care

educated, of lower socioeconomic status,andwith clinically greater disease severity(84,85). Further, studies support the im-portance of cultural considerations inachieving successful outcomes (84–87).Solutions include exploring communityresources to address factors that affecthealth behaviors, providing seamless re-ferral and access to such programs, andoffering flexible programing that is af-fordable and engages persons frommany backgrounds and living situations.The key is creating community-clinicpartnerships that provide the right in-terventions, at the right time, in the rightplace, and using the right workforces(88).

Reimbursement

Consensus recommendation

c Health policy, payers, health systems,providers, and health care teams needto facilitate reimbursement processesand other means of financial supportin consideration of cost savings relatedto the benefits of DSMES services.

Several common payment models andnewer emerging models that reimbursefor DSMES services are described below.For a list of diabetes education codes thatcanbe submitted for reimbursement, seeSupplementary Table 2 (Billing codes tomaximize return on investment (ROI) indiabetes care and education).CMS has reimbursed diabetes edu-

cation services billed as diabetes self-management training since 2001 (40,89).DSMES servicesmust receive accreditationby one of the current national accreditingorganizations (AssociationofDiabetesCare& Education Specialists and ADA) to beeligible for reimbursement. In order tomeet the requirements, DSMES servicesmust adhere to National Standards forDiabetes Self-Management Education andSupport and meet the billing providerrequirements (40,89).Ten hours are available for the first

year of receiving this benefit and 2 h insubsequent years. Any provider (physi-cian, nurse practitioner, PA) who is theprimary provider of diabetes treatmentcan make a referral; there is a copay touse these services.CMS also reimburses for diabetes

MNT, which expands access to needededucation and support. Three hoursare available the first year of receivingthis benefit and 2 h are available in

subsequent years. A physician can re-quest additional MNT hours through anMNT referral that describes why morehours are needed, such as a change indiagnosis, medical condition, or treat-ment plan. There are no specific limits setfor additional hours. There is no copay orneed tomeet a Part B deductible in orderto use these services. Many other payersalso provide reimbursement for diabetesMNT (90). Additional discipline-specificcounseling that further enhances DSMESincludes medication therapy managementdelivered by pharmacists and psychosocialcounseling offered by mental health pro-fessionals, also reimbursed through CMSand/or third-party payers (40,77).

Reimbursement by private payers ishighly variable. Many will match CMSguidelines, and those who recognize theimmediate and longer-term cost savingsassociated with DSMES will expand cov-erage, sometimes with no copay.

With the transition to value-basedhealth care, organizations may receive

financial returns if they meet specified

quality performance measures. Diabetes

is typically part of a set of contracted

quality measures impacting the payment

model. Health systems should maximize

the benefits of DSMES and factor them

into the potential financial structure.There are reimbursable billing codes

available for remotemonitoring of blood

glucose and other health parameters

that are related to diabetes. The use

of devices that can monitor glucose,

blood pressure, weight, and sleep allow

the health care team to review the data,

provide intervention, and recommend

treatment changes remotely.Sample referral forms that provide the

information required by CMS and otherpayers for referral toDSMESandMNTareavailable along with reimbursement re-sources (see Supplementary Tables 1 and2). These or similar forms can be em-bedded into an electronic health recordfor easy referral.

Health systems and clinical organiza-tions can maximize billing potential byfacilitating the reimbursement process,ensuring all applicable codes are beingutilized and submitted appropriately.This usually requires support from thosewho frequently work with health carecodes such as staff in billing and com-pliance departments. Shared medicalappointments can be performed with

DSMES and they are reimbursable med-ical visits.

Conclusions

This Consensus Report is a resource fortheentirehealth care teamanddescribesthe four critical times to refer to DSMESservices with very specific recommenda-tions for ensuring that all adults withdiabetes receive these benefits. Diabe-tes is a complex condition that requiresthe person with diabetes to make nu-merous daily decisions regarding theirself-management. DSMES delivered byqualified personnel using best practicemethods has a profound effect on theability to effectively undertake these re-sponsibilities and is supported by strongevidence presented in this report. DSMEShas a positive effect on clinical, psycho-social, and behavioral aspects of diabetes.DSMES provides the foundation with on-going support to promote achievement ofpersonal goals and influence optimal out-comes. Despite proven benefits and dem-onstrated value of DSMES, the number ofpeople with diabetes who are referred toand receive DSMES is significantly low(73–75). Barriers will not disappear with-out intentional, holistic interventions rec-ognizing the roles of the entire health careteam, individuals with diabetes, and sys-tems in overcoming issues of therapeuticinertia (10). The increasing prevalence oftype 2 diabetes requires accountability byall stakeholders to ensure these importantservices are available and utilized.

TheU.S.health care systemhas changedwith increased attention on primary care,technology, and quality measures (91).DSMES services that directly connectwith primary care are effective in improv-ing clinical, psychosocial, and behavioraloutcomes (92–95).

This changing health care environ-ment provides a platform to use DSMESservices as an effective, cost saving,high-impact resource integral to a per-son’s ability to self-manage diabetes.A variety of culturally appropriate serv-ices need to be offered in a variety ofsettings, utilizing technology to facili-tate access to DSMES services, supportself-management decisions, and de-crease therapeutic inertia.

Acknowledgments. The authors would like toacknowledge Mindy Saraco (Managing Director,Scientific and Medical Affairs) from the ADA

care.diabetesjournals.org Powers and Associates 11

for her help with the development of theConsensus Report and related meetings andpresentations, as well as the ADA ProfessionalPractice Committee for providing valuablereview and feedback. The authors also ac-knowledge Leslie Kolb, Chief Science and Prac-tice Officer, Association of Diabetes Care &Education Specialists, for her review and sup-port of the Consensus Report. The authorsacknowledge the invited peer reviewers whoprovided comments on an earlier draft of thisreport: ChristineBeebe (Quantumed Consulting,San Diego, CA), Anne L. Burns (American Phar-macists Association, Alexandria, VA), Amy Butts(Wheeling Hospital at the Wellsburg Clinic,Wellsburg, PA), Susan Chiarito (Mission PrimaryCare Clinic, Vicksburg, MS), Maria Duarte-Gardea (The University of Texas at El Paso,El Paso, TX), Joy A. Dugan (Touro UniversityCalifornia, Vallejo, CA), PaulinaN. Duker (HealthSolutions Consultant, King of Prussia, PA), LisaHodgson (SaratogaHospital, Saratoga Springs, NY),Wahida Karmally (Columbia University, New York,NY), Darlene Lawrence (MedStar Health, Wash-ington, DC), Anne Norman (American Associationof Nurse Practitioners, Austin, TX), Jim Owen(American Pharmacists Association, Alexandria,VA), Diane Padden (American Association of NursePractitioners, Austin, TX), Teresa Pearson (Inno-vativeHealthCareDesigns, LLC,Minneapolis,MN),Barb Schreiner (Capella University, Pearland, TX),EvaM.Vivian (UniversityofWisconsin,Madison,WI),andGretchenYoussef (MedStarHealth,Washington,DC).Funding. This activity was funded by the ADAand theAssociationofDiabetesCare&EducationSpecialists.Duality of Interest. M.A.P. reports researchfunding fromAbbottNutrition, is a senior advisorfor ADA’s Nutrition Interest Group, and is amember of ADA/American Heart AssociationScience Advisory Group for Know Diabetes byHeart. J.K.B reports being a past chair of theCertification Board for Diabetes Care and Edu-cation, is the programchair for the Association ofDiabetes Care & Education Specialists annualmeeting, and has been a consultant to JoslinDiabetes Center. M.M.F. is on an advisory boardof Eli Lilly. D.H. is the treasurer for the AmericanAcademy of Nurse Practitioners CertificationBoard of Commissioners and Vice President ofthe American Nurse Practitioner Foundation.A.H.-F. reports receiving an honorarium fromADA as an Education Recognition Program au-ditor and is a participant in a speakers bureausponsoredbyAbbottDiabetesCareandXeris.D.I.reports being a participant in a speakers bureau/consultant for Xeris Pharmaceuticals, Novo Nor-disk, Dexcom, and Lifescan. M.D.M. reportsbeing a paid consultant of Diabetes – What toKnow, Arkray, and DayTwo. A.N. reports being aparticipant in speakers bureaus sponsored byBoehringer Ingelheim, Novo Nordisk, and Xeris.L.M.S. reports research grant funding from Bec-ton Dickinson. S.U. has received honoraria fromADA. No other potential conflicts of interestrelevant to this article were reported.Author Contributions. All authors were respon-sible for drafting the article and revising it criticallyfor important intellectual content. All authorsapproved the version to be published.

References1. American Diabetes Association. 5. Facilitatingbehavior change and well-being to improvehealth outcomes: Standards of Medical Care inDiabetesd2020.DiabetesCare2020;43(Suppl.1):S48–S652. Davies MJ, D’Alessio DA, Fradkin J, et al.Management of hyperglycemia in type 2 diabe-tes, 2018. A consensus report by the AmericanDiabetes Association (ADA) and the EuropeanAssociation for the Study of Diabetes (EASD).Diabetes Care 2018;41:2669–27013. Lin J, Thompson TJ, Cheng YJ, et al. Projectionof the future diabetes burden in the UnitedStates through 2060. Popul Health Metr 2018;16:94. American Diabetes Association. 2. Classifica-tion and diagnosis of diabetes: Standards ofMedical Care in Diabetesd2020. Diabetes Care2020;43(Suppl. 1):S14–S315. American Diabetes Association. Economiccosts of diabetes in the U.S. in 2017. DiabetesCare 2018;41:917–9286. Kazemian P, Shebl FM, McCann N, WalenskyRP, Wexler DJ. Evaluation of the cascade ofdiabetes care in the United States, 2005-2016.JAMA Intern Med 2019;179:1376–13857. Berwick DM, Nolan TW, Whittington J. Thetriple aim: care, health, and cost. Health Aff(Millwood) 2008;27:759–7698. American Diabetes Association. Standards ofMedical Care in Diabetesd2020. Diabetes Care2020;43(Suppl. 1):S1–S2129. Funnell MM. Patient empowerment: whatdoes it really mean? Patient Educ Couns 2016;99:1921–192210. AmericanDiabetes Association. Overcomingtherapeutic inertia [Internet]. Accessed3September2019. Available from https://professional.diabetes.org/meeting/other/overcoming-therapeutic-inertia11. Centers for Disease Control and Prevention.Social determinants of health [Internet], 2019.Accessed 30March 2020. Available from https://www.cdc.gov/socialdeterminants/index.htm12. Powers MA, Bardsley J, Cypress M, et al.Diabetes self-management education and sup-port in type2diabetes: a joint position statementof the American Diabetes Association, the Amer-ican Association of Diabetes Educators, and theAcademy of Nutrition and Dietetics. DiabetesCare 2015;38:1372–138213. Steinsbekk A, Rygg LØ, Lisulo M, Rise MB,FretheimA.Groupbaseddiabetesself-managementeducation compared to routine treatment forpeople with type 2 diabetes mellitus. A system-atic review with meta-analysis. BMC Health ServRes 2012;12:21314. Tshiananga JKT, Kocher S, Weber C, Erny-Albrecht K, Berndt K, Neeser K. The effect ofnurse-led diabetes self-management educationon glycosylated hemoglobin and cardiovascularrisk factors: ameta-analysis. Diabetes Educ 2012;38:108–12315. Deakin T, McShane CE, Cade JE, WilliamsRDRR. Group based training for self-managementstrategies in people with type 2 diabetes mellitus.Cochrane Database Syst Rev 2005;(2):CD00341716. Chrvala CA, Sherr D, Lipman RD. Diabetesself-management education for adults withtype 2 diabetes mellitus: a systematic reviewof the effect on glycemic control. Patient EducCouns 2016;99:926–943

17. Powers MA. 2016 Health Care & EducationPresidentialAddress: IfDSMEwereapill,wouldyouprescribe it? Diabetes Care 2016;39:2101–210718. Diabetes Control and Complications Trial Re-searchGroup;NathanDM,GenuthS,Lachin J,etal.The effect of intensive treatment of diabetes onthe development and progression of long-termcomplications in insulin-dependent diabetes mel-litus. N Engl J Med 1993;329:977–98619. Stratton IM, Adler AI, Neil HAW, et al.Association of glycaemia with macrovascularand microvascular complications of type 2 di-abetes (UKPDS 35): prospective observationalstudy. BMJ 2000;321:405–41220. He X, Li J, Wang B, et al. Diabetes self-management education reduces risk of all-causemortality in type2diabetespatients:a systematicreview and meta-analysis. Endocrine 2017;55:712–73121. Cooke D, Bond R, Lawton J, et al.; U.K. NIHRDAFNE Study Group. Structured type 1 diabeteseducation delivered within routine care: impacton glycemic control and diabetes-specific qualityof life. Diabetes Care 2013;36:270–27222. Cochran J, Conn VS. Meta-analysis of qualityof life outcomes following diabetes self-manage-ment training. Diabetes Educ 2008;34:815–82323. Toobert DJ, Glasgow RE, Strycker LA, et al.Biologic and quality-of-life outcomes from theMediterranean Lifestyle Program: a randomizedclinical trial. Diabetes Care 2003;26:2288–229324. Toobert DJ, Strycker LA, King DK, Barrera MJr, Osuna D, Glasgow RE. Long-term outcomesfrom a multiple-risk-factor diabetes trial forLatinas: ¡Viva Bien! Transl Behav Med 2011;1:416–42625. Tang TS, Funnell MM, Oh M. Lasting effectsof a 2-year diabetes self-management supportintervention: outcomes at 1-year follow-up. PrevChronic Dis 2012;9:E10926. Thorpe CT, Fahey LE, Johnson H, DeshpandeM, Thorpe JM, Fisher EB. Facilitating healthycoping in patients with diabetes: a systematicreview. Diabetes Educ 2013;39:33–5227. Fisher L, Hessler D, Glasgow RE, et al. RE-DEEM: a pragmatic trial to reduce diabetesdistress. Diabetes Care 2013;36:2551–255828. Duncan I, AhmedT, Li QE, et al. Assessing thevalue of the diabetes educator. Diabetes Educ2011;37:638–65729. Pillay J, Armstrong MJ, Butalia S, et al.Behavioral programs for type2diabetesmellitus:a systematic review and network meta-analysis.Ann Intern Med 2015;163:848–86030. Robbins JM, Thatcher GE, Webb DA,Valdmanis VG. Nutritionist visits, diabetes classes,and hospitalization rates and charges: the UrbanDiabetes Study. Diabetes Care 2008;31:655–66031. Strawbridge LM, Lloyd JT, Meadow A, RileyGF, Howell BL. One-year outcomes of diabetesself-management training amongMedicare ben-eficiaries newly diagnosed with diabetes. MedCare 2017;55:391–39732. Healy SJ, Black D, Harris C, Lorenz A, DunganKM. Inpatient diabetes education is associatedwith less frequent hospital readmission amongpatients with poor glycemic control. DiabetesCare 2013;36:2960–296733. Nassar CM,MonteroA,MageeMF. inpatientdiabeteseducation in the realworld: anoverviewof guidelines and delivery models. Curr Diab Rep2019;19:103

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34. Horigan G, Davies M, Findlay-White F,Chaney D, Coates V. Reasons why patients re-ferred to diabetes education programmes choosenot to attend: a systematic review. Diabet Med2017;34:14–2635. Greenwood DA, Gee PM, Fatkin KJ, PeeplesM. A systematic review of reviews evaluatingtechnology-enabled diabetes self-managementeducation and support. J Diabetes Sci Technol2017;11:1015–102736. Litchman ML, Rothwell E, Edelman LS. Thediabetes online community: older adults sup-porting self-care through peer health. PatientEduc Couns 2018;101:518–52337. LitchmanML, Walker HR, Ng AH, et al. Stateof the science: a scoping review and gap analysisof diabetes online communities. J Diabetes SciTechnol 2019;13:466–49238. Siminerio L, HammM, Kanter J, Cameron FA,Krall J. A diabetes education model in primarycare: provider and staff perspectives. DiabetesEduc 2019;45:498–50639. Bowen ME, Rothman RL. Multidisciplinarymanagement of type 2 diabetes in children andadolescents. J Multidiscip Healthc 2010;3:113–12440. Beck J,GreenwoodDA,BlantonL, et al.; 2017Standards Revision Task Force. 2017 NationalStandards for Diabetes Self-Management Edu-cation and Support. Diabetes Care 2017;40:1409–141941. Norris SL, Lau J, Smith SJ, Schmid CH,Engelgau MM. Self-management education foradults with type 2 diabetes: a meta-analysis ofthe effect on glycemic control. Diabetes Care2002;25:1159–117142. Tang TS, Funnell M, Sinco B, et al. Compar-ative effectiveness of peer leaders and commu-nity healthworkers in diabetes self-managementsupport: results of a randomized controlled trial.Diabetes Care 2014;37:1525–153443. Thom DH, Ghorob A, Hessler D, De Vore D,Chen E, Bodenheimer TA. Impact of peer healthcoaching on glycemic control in low-incomepatients with diabetes: a randomized controlledtrial. Ann Fam Med 2013;11:137–14444. Tang TS, Ayala GX, Cherrington A, Rana G. Areview of volunteer-based peer support inter-ventions in diabetes. Diabetes Spectr 2011;24:85–9845. Funnell MM. Peer-based behavioural strate-gies to improve chronic disease self-managementand clinical outcomes: evidence, logistics, evalua-tion considerations and needs for future research.Fam Pract 2010;27(Suppl. 1):i17–i2246. HeislerM. Overview of peer support modelsto improve diabetes self-management and clin-ical outcomes. Diabetes Spectr 2007;20:214–22147. Kovacs Burns K, Nicolucci A, Holt RIG, et al.;DAWN2StudyGroup.DiabetesAttitudes,WishesandNeedssecondstudy(DAWN2�):cross-nationalbenchmarking indicators for family members livingwith people with diabetes. Diabet Med 2013;30:778–78848. PeyrotM, Burns KK, DaviesM, et al. DiabetesAttitudes Wishes and Needs 2 (DAWN2): a mul-tinational, multi-stakeholder study of psychoso-cial issues in diabetes and person-centred diabetescare. Diabetes Res Clin Pract 2013;99:174–18449. Lee AA, Piette JD, Heisler M, Rosland A-M.Diabetes distress and glycemic control: the buff-eringeffectof autonomysupport from important

familymembers and friends.DiabetesCare2018;41:1157–116350. Whitehead L, Jacob E, Towell A, Abu-QamarM, Cole-Heath A. The role of the family insupporting the self-management of chronic con-ditions: A qualitative systematic review. J ClinNurs 2018;27:22–3051. Lee AA, Piette JD, Heisler M, Janevic MR,Langa KM, Rosland A-M. Family members’ ex-periences supporting adults with chronic illness:a national survey. Fam Syst Health 2017;35:463–47352. Pearson TL, Bardsley J, Weiner S, Kolb L.Populationhealth: thediabeteseducator’sevolv-ing role. Diabetes Educ 2019;45:333–34853. ChildsBP, CypressM, SpollettG, Eds. CompleteNurse’s Guide to Diabetes Care. 3rd ed. Arlington,VA, American Diabetes Association, 201754. AmericanAssociationofDiabetes Educators.An effective model of diabetes care and educa-tion: revising the AADE7 Self-Care Behaviors�.Diabetes Educ 2020;46:139–16055. Coulter A, Entwistle VA, Eccles A, Ryan S,Shepperd S, Perera R. Personalised care planningfor adults with chronic or long-term healthconditions. Cochrane Database Syst Rev 2015;(3):CD01052356. Funnell MM, Bootle S, Stuckey HL. TheDiabetes Attitudes, Wishes and Needs secondstudy. Clin Diabetes 2015;33:32–3657. Peters AL, Laffel L, American Diabetes As-sociation, JDRF. American Diabetes Association/JDRF Type 1 Diabetes Sourcebook. Alexandria,VA, American Diabetes Association, 201358. Skovlund SE, Peyrot M. The Diabetes Atti-tudes, Wishes, and Needs (DAWN) program:a new approach to improving outcomes of di-abetes care. Diabetes Spectr 2005;18:136–14259. Nicolucci A, Kovacs Burns K, Holt RIG, et al.;DAWN2 Study Group. Diabetes Attitudes,Wishes and Needs second study (DAWN2�):cross-national benchmarking of diabetes-relatedpsychosocial outcomes for people with diabetes.Diabet Med 2013;30:767–77760. American Diabetes Association. 4. Compre-hensive medical evaluation and assessment ofcomorbidities: Standards of Medical Care inDiabetesd2020. Diabetes Care 2020;43(Suppl.1):S37–S4761. Weiss MA, Funnell MM. In the beginning:setting the stage for effective diabetes care. ClinDiabetes 2009;27:149–15162. Beverly EA,GandaOP,RitholzMD,et al. Lookwho’s (not) talking: diabetic patients’willingnessto discuss self-care with physicians. DiabetesCare 2012;35:1466–147263. RitholzMD, Beverly EA, Brooks KM,AbrahamsonMJ, Weinger K. Barriers and facilitators to self-carecommunication during medical appointments inthe United States for adults with type 2 diabetes.Chronic Illn 2014;10:303–31364. Yehl K. AADE Practice Paper in Brief: Diabeteseducators play a critical role in successful insulinmanagement. AADE Pract 2018;6:36–3765. Young-Hyman D, de Groot M, Hill-Briggs F,Gonzalez JS, Hood K, PeyrotM. Psychosocial carefor peoplewith diabetes: a position statement ofthe American Diabetes Association. DiabetesCare 2016;39:2126–214066. Peyrot M, Rubin RR, Lauritzen T, SnoekFJ, Matthews DR, Skovlund SE. Psychosocialproblems and barriers to improved diabetes

management: results of the Cross-National Di-abetes Attitudes, Wishes and Needs (DAWN)Study. Diabet Med 2005;22:1379–138567. Perrin NE, DaviesMJ, RobertsonN, Snoek FJ,Khunti K. The prevalence of diabetes-specificemotional distress in people with type 2 di-abetes: a systematic review and meta-analysis.Diabet Med 2017;34:1508–152068. Gonzalvo JD, Hamm J, Eaves S, et al. Apractical approach to mental health for thediabetes educator. AADE Pract 2019;7:29–4469. Franz MJ, MacLeod J, Evert A, et al. Acad-emyofNutritionandDietetics nutritionpracticeguideline for type 1 and type 2 diabetes inadults: systematic review of evidence for med-ical nutrition therapy effectiveness and recom-mendations for integration into the nutritioncare process. J Acad Nutr Diet 2017;117:1659–167970. Evert AB, Dennison M, Gardner CD, et al.Nutrition therapy for adults with diabetes orprediabetes: a consensus report. Diabetes Care2019;42:731–75471. Marincic PZ, Hardin A, Salazar MV, Scott S,Fan SX, Gaillard PR. Diabetes self-managementeducation and medical nutrition therapy im-prove patient outcomes: a pilot study docu-menting the efficacy of registered dietitiannutritionist interventions through retrospec-tive chart review. J Acad Nutr Diet 2017;117:1254–126472. Briggs Early K, Stanley K. Position of theAcademy of Nutrition and Dietetics: The role ofmedical nutrition therapy and registered dieti-tiannutritionists in thepreventionandtreatmentof prediabetes and type 2 diabetes. J Acad NutrDiet 2018;118:343–35373. Li R, Shrestha SS, LipmanR,BurrowsNR, KolbLE, Rutledge S; Centers for Disease Control andPrevention (CDC). Diabetes self-managementeducation and training among privately insuredpersonswith newly diagnosed diabetesdUnitedStates, 2011-2012. MMWR Morb Mortal WklyRep 2014;63:1045–104974. Strawbridge LM, Lloyd JT, Meadow A, RileyGF, Howell BL. Use of Medicare’s diabetes self-management trainingbenefit.HealthEducBehav2015;42:530–53875. Rinker J,Dickinson JK, LitchmanML,et al. The2017 diabetes educator and the Diabetes Self-Management Education National Practice Sur-vey. Diabetes Educ 2018;44:260–26876. Carey ME, Agarwal S, Horne R, Davies M,Slevin M, Coates V. Exploring organizationalsupport for the provision of structured self-management education for people with type 2diabetes: findings from a qualitative study. DiabetMed 2019;36:761–77077. Centers for Disease Control and Prevention.Diabetes Self-Management Education and Sup-port (DSMES) Toolkit [Internet], 2018. Accessed3 September 2019. Available from https://www.cdc.gov/diabetes/dsmes-toolkit/index.html78. Peyrot M, Rubin RR, Funnell MM, SiminerioLM. Access to diabetes self-management edu-cation: results of national surveys of patients,educators, and physicians. Diabetes Educ 2009;35:246–248, 252–256, 258–26379. Lawal M, Woodman A, Fanghanel J, Ohl M.Barriers to attendance at diabetes educationcentres: perceptions of education providers. JDiabetes Nurs 2017;21:61–66

care.diabetesjournals.org Powers and Associates 13

80. Azam LS, Jackson TA, Knudson PE, Meurer JR,Tarima SS. Use of secondary clinical data for re-search related to diabetes self-management edu-cation. Res Social Adm Pharm 2017;13:494–50281. Chapman EN, Kaatz A, Carnes M. Physiciansand implicit bias: how doctors may unwittinglyperpetuate health care disparities. J Gen InternMed 2013;28:1504–151082. Winkley K, Evwierhoma C, Amiel SA, LemppHK, Ismail K, Forbes A. Patient explanations fornon-attendance at structured diabetes educa-tion sessions for newly diagnosed type 2 di-abetes: a qualitative study. DiabetMed 2015;32:120–12883. World Health Organization. About social de-terminants of health [Internet]. Accessed 28 Jan-uary 2020. Available from http://www.who.int/social_determinants/sdh_definition/en/84. Harris S, Mulnier H, Amiel S. The Barriers toUptake of Diabetes Education study (Abstract).Lancet 2017;389:S4485. Ross S, Benavides-Vaello S, Schumann L,HabermanM. Issues that impact type-2 diabetesself-management in rural communities. J AmAssoc Nurse Pract 2015;27:653–66086. Gonzales KL, Lambert WE, Fu R, Jacob M,Harding AK. Perceived racial discrimination inhealth care, completion of standard diabetesservices, and diabetes control among a sample ofAmerican Indianwomen.DiabetesEduc2014;40:747–75587. Jones V, Crowe M. How people from ethnicminorities describe their experiences of manag-ing type-2 diabetes mellitus: a qualitative meta-synthesis. Int J Nurs Stud 2017;76:78–9188. Hill-Briggs F. 2018 Health Care & EducationPresidential Address: The American Diabetes

Association in the era of health care transfor-mation. Diabetes Care 2019;42:352–35889. Centers for Medicare & Medicaid Services.Diabetic Self-Management Training (DSMT) Ac-creditationProgram[Internet].Accessed4Decem-ber 2019. Available from https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertificationGenInfo/DSMT-Accreditation-Program90. Medicare.com. Does Medicare Cover Med-icalNutritionTherapy? [Internet]. Accessed4De-cember 2019. Available from https://medicare.com/coverage/does-medicare-cover-medical-nutrition-therapy/91. CusackCM,KnudsonAD,Kronstadt JL, SingerRF, Brown AL. Practice-Based Population Health:Information Technology to Support Transforma-tion to Proactive Primary Care. Rockville, MD,Agency for Healthcare Research and Quality,2010.AHRQPublicationNo.10-0092-EF[Internet].Accessed 3 September 2019. Available fromhttps://pcmh.ahrq.gov/sites/default/files/attachments/Information%20Technology%20to%20Support%20Transformation%20to%20Proactive%20Primary%20Care.pdf92. Siminerio L, Ruppert K, Huber K, Toledo FGS.Telemedicine for Reach, Education, Access, andTreatment (TREAT): linking telemedicine withdiabetes self-management education to improvecare in rural communities. Diabetes Educ 2014;40:797–80593. PhillipsLS,BarbD,YongC,etal.Translatingwhatworks: a new approach to improve diabetes man-agement. J Diabetes Sci Technol 2015;9:857–86494. Shea S, Weinstock RS, Teresi JA, et al.;IDEATel Consortium. A randomized trial com-paring telemedicine case management with

usual care in older, ethnically diverse, medicallyunderserved patients with diabetes mellitus:5 year results of the IDEATel study. J Am MedInform Assoc 2009;16:446–45695. Hunt JS, Siemienczuk J, Gillanders W, et al.The impact of a physician-directed health in-formation technology system on diabetes outcomesin primary care: a pre- and post-implementationstudy. Inform Prim Care 2009;17:165–17496. Institute of Medicine Committee on Qualityof Health Care in America. Crossing the QualityChasm: A New Health System for the 21stCentury [Internet]. Washington, DC, NationalAcademies Press, 2001. Accessed 1 October2019. Available from https://www.ncbi.nlm.nih.gov/books/NBK222274/97. Fisher L, Hessler DM, PolonskyWH,Mullan J.When is diabetes distress clinically meaningful?:establishing cut points for the Diabetes DistressScale. Diabetes Care 2012;35:259–26498. Association of Diabetes Care and Educa-tion Specialists. Repositioning the Specialtyand Association [Internet]. Accessed 15 No-vember 2019. Available from https://www.diabeteseducator.org/practice/new-name-title99. NDBDE. What is a CDE? Certification Info,Diabetes Education, Certification, Examination[Internet]. Accessed 15 November 2019. Avail-able from https://www.ncbde.org/certification_info/what-is-a-cde/100. Associationof Diabetes Care and EducationSpecialists. Board Certified-Advanced DiabetesManagement (BC-ADM) [Internet]. Accessed15 November 2019. Available from https://www.diabeteseducator.org/education/certification/bc_adm

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