A-Z Diabetes Boot Camp 2026

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Diabetes and Oral Health: A Bidirectional Relationship with Major Clinical Implications

Diabetes significantly increases the risk and severity of oral health problems, especially periodontal (gum) disease, while poor oral health can worsen glycemic control and diabetes complications. This relationship is driven by complex biological, behavioral, and healthcare factors.

Key Findings on Diabetes and Oral Health

Increased Risk and Severity of Periodontal Disease

• Diabetes (both type 1 and type 2) is a major risk factor for periodontal disease, with susceptibility and severity closely linked to glycemic control. Poorly controlled diabetes leads to more severe periodontal inflammation, bone loss, and tooth loss (Graves et al., 2020; Genco & Borgnakke, 2020; Genco et al., 2020; Vlachou et al., 2024; Nibali et al., 2022; Costa et al., 2023; Preshaw et al., 2011; Costa et al., 2025).
• Bidirectional relationship: Not only does diabetes worsen periodontal disease, but periodontitis can also negatively affect glycemic control and increase the risk of diabetes complications, including cardiovascular and kidney disease (Genco et al., 2020; Preshaw et al., 2011; Shinjo & Nishimura, 2023).

Biological Mechanisms

• Hyperglycemia in diabetes increases inflammatory responses in periodontal tissues, impairs bone formation, and alters the oral microbiome, making it more pathogenic (Graves et al., 2020; Vlachou et al., 2024; Polak et al., 2020; Matsha et al., 2020; Shinjo & Nishimura, 2023; Graves et al., 2018).
• Advanced glycation end-products, oxidative stress, and pro-inflammatory cytokines (e.g., TNF-α, IL-6) play central roles in tissue destruction and impaired healing (Graves et al., 2020; Vlachou et al., 2024; Polak et al., 2020; Shinjo & Nishimura, 2023).
• Altered oral microbiota: Diabetes shifts the oral microbiome toward more pathogenic species, further increasing periodontal risk (Vlachou et al., 2024; Matsha et al., 2020; Shinjo & Nishimura, 2023; Graves et al., 2018).

Other Oral Health Complications

• Diabetes increases the risk of oral fungal infections, reduced salivary flow, caries, burning mouth, and delayed wound healing (Genco & Borgnakke, 2020; Nibali et al., 2022; Costa et al., 2023).
• Tooth loss is more common in people with diabetes, which can negatively impact nutrition and glycemic control (Genco & Borgnakke, 2020; Genco et al., 2020; Nibali et al., 2022; Chang et al., 2020).

Impact of Oral Health on Diabetes Outcomes

• Treating periodontal disease can improve glycemic control, with studies showing reductions in HbA1c after periodontal therapy (Genco et al., 2020; Preshaw et al., 2011; Shinjo & Nishimura, 2023).
• Good oral hygiene and regular dental care are associated with lower risk of new-onset diabetes and better diabetes outcomes (Hasan et al., 2021; Chang et al., 2020; Poudel et al., 2018).

Knowledge, Attitudes, and Care Practices

• Many people with diabetes lack awareness of their increased oral health risks and do not receive adequate oral health education or dental referrals from healthcare providers (Poudel et al., 2018; Oguntimein et al., 2020).
• Education and interdisciplinary care (between medical and dental professionals) are essential for prevention and management (Genco & Borgnakke, 2020; Nibali et al., 2022; Oates & Khandelwal, 2019; Poudel et al., 2018; Oguntimein et al., 2020).

Clinical Recommendations

• Routine periodontal screening and preventive care should be part of diabetes management (Genco & Borgnakke, 2020; Nibali et al., 2022; Oates & Khandelwal, 2019; Preshaw et al., 2011; Shinjo & Nishimura, 2023; Oguntimein et al., 2020).
• Glycemic control, smoking cessation, and oral hygiene are critical for reducing oral health complications (Genco & Borgnakke, 2020; Nibali et al., 2022; Oates & Khandelwal, 2019; Hasan et al., 2021; Poudel et al., 2018).

Diabetes and Oral Health: Key Relationships

Figure 1: Summary of key diabetes–oral health relationships and clinical impacts.

Summary

Diabetes and oral health are closely linked in a two-way relationship. Effective management requires integrated medical and dental care, patient education, and proactive prevention to reduce complications and improve quality of life (Graves et al., 2020; Genco & Borgnakke, 2020; Genco et al., 2020; Vlachou et al., 2024; Nibali et al., 2022; Costa et al., 2023; Oates & Khandelwal, 2019; Preshaw et al., 2011; Costa et al., 2025; Shinjo & Nishimura, 2023; Hasan et al., 2021; Chang et al., 2020; Graves et al., 2018; Poudel et al., 2018; Oguntimein et al., 2020).

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References

Graves, D., Ding, Z., & Yang, Y. (2020). The impact of diabetes on periodontal diseases.. Periodontology 2000, 82 1, 214-224. https://doi.org/10.1111/prd.12318

Genco, R., & Borgnakke, W. (2020). Diabetes as a potential risk for periodontitis: association studies.. Periodontology 2000, 83 1, 40-45. https://doi.org/10.1111/prd.12270

Genco, R., Graziani, F., & Hasturk, H. (2020). Effects of periodontal disease on glycemic control, complications, and incidence of diabetes mellitus.. Periodontology 2000, 83 1, 59-65. https://doi.org/10.1111/prd.12271

Vlachou, S., Loumé, A., Giannopoulou, C., Papathanasiou, E., & Zekeridou, A. (2024). Investigating the Interplay: Periodontal Disease and Type 1 Diabetes Mellitus—A Comprehensive Review of Clinical Studies. International Journal of Molecular Sciences, 25. https://doi.org/10.3390/ijms25137299

Nibali, L., Gkranias, N., Mainas, G., & Di Pino, A. (2022). Periodontitis and implant complications in diabetes. Periodontology 2000, 90, 88 - 105. https://doi.org/10.1111/prd.12451

Costa, R., Ríos-Carrasco, B., Monteiro, L., López-Jarana, P., Carneiro, F., & Relvas, M. (2023). Association between Type 1 Diabetes Mellitus and Periodontal Diseases. Journal of Clinical Medicine, 12. https://doi.org/10.3390/jcm12031147

Polak, D., Sanui, T., Nishimura, F., & Shapira, L. (2020). Diabetes as a risk factor for periodontal disease-plausible mechanisms.. Periodontology 2000, 83 1, 46-58. https://doi.org/10.1111/prd.12298

Oates, T., & Khandelwal, N. (2019). Diabetes and Periodontal Disease. Endocrinology. https://doi.org/10.1007/978-3-319-27316-7_15-1

Matsha, T., Prince, Y., Davids, S., Chikte, U., Erasmus, R., Kengne, A., & Davison, G. (2020). Oral Microbiome Signatures in Diabetes Mellitus and Periodontal Disease. Journal of Dental Research, 99, 658 - 665. https://doi.org/10.1177/0022034520913818

Preshaw, P., Alba, A., Herrera, D., Jepsen, S., Konstantinidis, A., Makrilakis, K., & Taylor, R. (2011). Periodontitis and diabetes: a two-way relationship. Diabetologia, 55, 21 - 31. https://doi.org/10.1007/s00125-011-2342-y

Costa, R., Ríos-Carrasco, B., López-Jarana, P., Cabral, C., Cunha, F., Gonçalves, M., & Relvas, M. (2025). Periodontal status and risk factors in patients with type 1 diabetes mellitus. Clinical Oral Investigations, 29. https://doi.org/10.1007/s00784-024-06113-3

Shinjo, T., & Nishimura, F. (2023). The bidirectional association between diabetes and periodontitis, from basic to clinical. The Japanese Dental Science Review, 60, 15 - 21. https://doi.org/10.1016/j.jdsr.2023.12.002

Hasan, S., Rahman, M., Nakamura, K., Tashiro, Y., Miyashita, A., & Seino, K. (2021). Relationship between diabetes self-care practices and control of periodontal disease among type2 diabetes patients in Bangladesh. PLoS ONE, 16. https://doi.org/10.1371/journal.pone.0249011

Chang, Y., Lee, J., Lee, K., Woo, H., & Song, T. (2020). Improved oral hygiene is associated with decreased risk of new-onset diabetes: a nationwide population-based cohort study. Diabetologia, 63, 924-933. https://doi.org/10.1007/s00125-020-05112-9

Graves, D., Corrêa, J., & Silva, T. (2018). The Oral Microbiota Is Modified by Systemic Diseases. Journal of Dental Research, 98, 148 - 156. https://doi.org/10.1177/0022034518805739

Poudel, P., Griffiths, R., Wong, V., Arora, A., Flack, J., Khoo, C., & George, A. (2018). Oral health knowledge, attitudes and care practices of people with diabetes: a systematic review. BMC Public Health, 18. https://doi.org/10.1186/s12889-018-5485-7

Oguntimein, O., Butler, J., Desmond, S., Green, K., He, X., & Horowitz, A. (2020). Patients’ Understanding of the Relationship Between Their Diabetes and Periodontal Disease. The Journal of the American Board of Family Medicine, 33, 1004 - 1010. https://doi.org/10.3122/jabfm.2020.06.190454

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Diabetic Foot Pathologies – Clinical Approach: Evidence-Based Strategies

Diabetic foot pathologies, including ulcers, infections, Charcot neuroarthropathy, and peripheral artery disease (PAD), are major causes of morbidity and amputation in diabetes. A comprehensive, multidisciplinary clinical approach is essential for prevention, early detection, and effective management.

Key Clinical Principles

• Risk Assessment & Prevention: Regular foot examinations, identification of at-risk feet (neuropathy, deformity, PAD, previous ulcer/amputation), patient education, and use of appropriate footwear are foundational for prevention (Hingorani et al., 2016; Schaper et al., 2016; Pérez-Panero et al., 2019; Bakker et al., 2012; Crawford et al., 2020).
• Multidisciplinary Care: Optimal outcomes require coordinated care involving endocrinologists, podiatrists, vascular surgeons, infectious disease specialists, and diabetes educators (Hingorani et al., 2016; Schaper et al., 2016; Pérez-Panero et al., 2019; Wukich et al., 2013).
• Patient & Provider Education: Education on foot care, early signs of complications, and prompt reporting of issues is critical to reduce ulceration and amputation rates (Hingorani et al., 2016; Schaper et al., 2016; Pérez-Panero et al., 2019; Bakker et al., 2012).

Clinical Approach to Common Pathologies

Figure 1: Summary of clinical steps for major diabetic foot pathologies.

Diagnostic and Therapeutic Strategies

• Ulcer Evaluation: Assess type, depth, infection, and perfusion. Use probe-to-bone test and imaging (X-ray, MRI) for suspected osteomyelitis (Hingorani et al., 2016; Schaper et al., 2016; Lipsky et al., 2016).
• Infection Management: Obtain tissue cultures before antibiotics, classify severity, and tailor therapy. Surgical intervention for abscess, necrosis, or osteomyelitis may be required (Senneville et al., 2023; Lipsky et al., 2006; Alavi et al., 2014; Lipsky et al., 2016; Grigoropoulou et al., 2017).
• PAD Management: Assess with bedside tests (e.g., ABI), imaging, and consider revascularization for non-healing ulcers or gangrene (Fitridge et al., 2023).
• Wound Care: Regular debridement, moist wound environment, and advanced therapies (e.g., negative pressure, skin substitutes) for refractory cases (Boulton et al., 2018; Hingorani et al., 2016; Aldana & Khachemoune, 2019; Bowling et al., 2015).
• Remission & Recurrence Prevention: Ongoing surveillance, patient education, and multidisciplinary follow-up are vital to prevent recurrence (Boulton et al., 2018; Schaper et al., 2016; Pérez-Panero et al., 2019; Wukich et al., 2013; Crawford et al., 2020).

Special Considerations

• Hospitalized Patients: All diabetic inpatients should have foot exams on admission; urgent specialist input for infection, ischemia, or unexplained swelling (Wukich et al., 2013).
• Adjunctive Therapies: Novel treatments (e.g., growth factors, hyperbaric oxygen) show promise but require further evidence for routine use (Boulton et al., 2018; Aldana & Khachemoune, 2019; Chang & Nguyen, 2021).

Summary

A structured, evidence-based clinical approach—emphasizing prevention, early detection, multidisciplinary management, and individualized therapy—significantly reduces complications and amputations in diabetic foot pathologies (Boulton et al., 2018; Senneville et al., 2023; Hingorani et al., 2016; Schaper et al., 2016; Fitridge et al., 2023; Aldana & Khachemoune, 2019; Pérez-Panero et al., 2019; Lipsky et al., 2006; Alavi et al., 2014; Lipsky et al., 2016; Fitridge et al., 2023; Bakker et al., 2012; Wukich et al., 2013; Crawford et al., 2020; Grigoropoulou et al., 2017; Bowling et al., 2015; Chang & Nguyen, 2021).

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References

Boulton, A., Armstrong, D., Kirsner, R., Attinger, C., Lavery, L., Lipsky, B., Mills, J., & Steinberg, J. (2018). Diagnosis and Management of Diabetic Foot Complications. Diabetes. https://doi.org/10.2337/db20182-1

Senneville, É., Albalawi, Z., Van Asten, S., Abbas, Z., Allison, G., Aragón-Sánchez, J., Embil, J., Lavery, L., Alhasan, M., Oz, O., Uçkay, I., Urbančič-Rovan, V., Xu, Z., & Peters, E. (2023). IWGDF/IDSA Guidelines on the Diagnosis and Treatment of Diabetes-related Foot Infections (IWGDF/IDSA 2023).. Clinical infectious diseases: an official publication of the Infectious Diseases Society of America. https://doi.org/10.1093/cid/ciad527

Hingorani, A., LaMuraglia, G., Henke, P., Meissner, M., Loretz, L., Zinszer, K., Driver, V., Frykberg, R., Carman, T., Marston, W., Mills, J., & Murad, M. (2016). The management of diabetic foot: A clinical practice guideline by the Society for Vascular Surgery in collaboration with the American Podiatric Medical Association and the Society for Vascular Medicine.. Journal of vascular surgery, 63 2 Suppl, 3S-21S. https://doi.org/10.1016/j.jvs.2015.10.003

Schaper, N., Van Netten, J., Apelqvist, J., Lipsky, B., & Bakker, K. (2016). Prevention and management of foot problems in diabetes: a Summary Guidance for Daily Practice 2015, based on the IWGDF Guidance Documents. Diabetes/Metabolism Research and Reviews, 32, 15 - 7. https://doi.org/10.1002/dmrr.2695

Fitridge, R., Chuter, V., Mills, J., Hinchliffe, R., Azuma, N., Behrendt, C., Boyko, E., Conte, M., Humphries, M., Kirksey, L., McGinigle, K., Nikol, S., Nordanstig, J., Rowe, V., Russell, D., Van Den Berg, J., Venermo, M., & Schaper, N. (2023). The intersocietal IWGDF, ESVS, SVS guidelines on peripheral artery disease in people with diabetes mellitus and a foot ulcer. Journal of vascular surgery. https://doi.org/10.1016/j.jvs.2023.07.020

Aldana, P., & Khachemoune, A. (2019). Diabetic Foot Ulcers: Appraising Standard of Care and Reviewing New Trends in Management. American Journal of Clinical Dermatology, 21, 255-264. https://doi.org/10.1007/s40257-019-00495-x

Pérez-Panero, A., Ruiz-Muñoz, M., Cuesta-Vargas, A., & Gónzalez-Sánchez, M. (2019). Prevention, assessment, diagnosis and management of diabetic foot based on clinical practice guidelines. Medicine, 98. https://doi.org/10.1097/md.0000000000016877

Lipsky, B., Berendt, A., Deery, H., Embil, J., Joseph, W., Karchmer, A., Lefrock, J., Lew, D., Mader, J., Norden, C., & Tan, J. (2006). Diagnosis and Treatment of Diabetic Foot Infections. Plastic and Reconstructive Surgery, 117, 212S-238S. https://doi.org/10.1097/01.prs.0000222737.09322.77

Alavi, A., Sibbald, R., Mayer, D., Goodman, L., Botros, M., Armstrong, D., Woo, K., Boeni, T., Ayello, E., & Kirsner, R. (2014). Diabetic foot ulcers: Part II. Management. Journal of the American Academy of Dermatology, 70 1, 21.e1-24; quiz 45-6. https://doi.org/10.1016/j.jaad.2013.07.048

Lipsky, B., Aragón-Sánchez, J., Diggle, M., Embil, J., Kono, S., Lavery, L., Senneville, É., Urbančič-Rovan, V., Van Asten, S., & Peters, E. (2016). IWGDF guidance on the diagnosis and management of foot infections in persons with diabetes. Diabetes/Metabolism Research and Reviews, 32, 45 - 74. https://doi.org/10.1002/dmrr.2699

Fitridge, R., Chuter, V., Mills, J., Hinchliffe, R., Azuma, N., Behrendt, C., Boyko, E., Conte, M., Humphries, M., Kirksey, L., McGinigle, K., Nikol, S., Nordanstig, J., Rowe, V., Russell, D., Van Den Berg, J., Venermo, M., & Schaper, N. (2023). The Intersocietal IWGDF, ESVS, SVS Guidelines on Peripheral Artery Disease in People With Diabetes Mellitus and a Foot Ulcer. European journal of vascular and endovascular surgery: the official journal of the European Society for Vascular Surgery. https://doi.org/10.1016/j.ejvs.2023.07.020

Bakker, K., Apelqvist, J., & Schaper, N. (2012). Practical guidelines on the management and prevention of the diabetic foot 2011. Diabetes/Metabolism Research and Reviews, 28. https://doi.org/10.1002/dmrr.2253

Wukich, D., Armstrong, D., Attinger, C., Boulton, A., Burns, P., Frykberg, R., Hellman, R., Kim, P., Lipsky, B., Pile, J., Pinzur, M., & Siminerio, L. (2013). Inpatient Management of Diabetic Foot Disorders: A Clinical Guide. Diabetes Care, 36, 2862 - 2871. https://doi.org/10.2337/dc12-2712

Crawford, F., Chappell, F., Lewsey, J., Riley, R., Hawkins, N., Nicolson, D., Heggie, R., Smith, M., Horne, M., Amanna, A., Martín, Á., Gupta, S., Gray, K., Weller, D., Brittenden, J., & Leese, G. (2020). Risk assessments and structured care interventions for prevention of foot ulceration in diabetes: development and validation of a prognostic model. Health technology assessment, 24 62, 1-198. https://doi.org/10.3310/hta24620

Grigoropoulou, P., Eleftheriadou, I., Jude, E., & Tentolouris, N. (2017). Diabetic Foot Infections: an Update in Diagnosis and Management. Current Diabetes Reports, 17, 1-12. https://doi.org/10.1007/s11892-017-0831-1

Bowling, F., Rashid, S., & Boulton, A. (2015). Preventing and treating foot complications associated with diabetes mellitus. Nature Reviews Endocrinology, 11, 606-616. https://doi.org/10.1038/nrendo.2015.130

Chang, M., & Nguyen, T. (2021). Strategy for Treatment of Infected Diabetic Foot Ulcers. Accounts of chemical research. https://doi.org/10.1021/acs.accounts.0c00864

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Motivational Interviewing for Patients with Diabetes: Evidence, Outcomes, and Limitations

Motivational interviewing (MI) is a patient-centered counseling approach designed to enhance motivation for behavior change. In diabetes care, MI has been widely studied for its impact on self-management, glycemic control, psychological well-being, and treatment adherence, with mixed but generally positive short-term results.

Key Findings from the Research

Glycemic Control (HbA1c)

• Short-term MI interventions (≤6 months) consistently improve glycemic control in patients with type 2 diabetes, with meta-analyses showing modest but significant reductions in HbA1c (ranging from -0.29% to -0.4%) compared to usual care (Berhe et al., 2020; Steffen et al., 2021; Song et al., 2014).
• Long-term effects are less clear: Some studies found no sustained HbA1c improvement beyond 6–12 months, especially after group education or in real-world settings (Minet et al., 2011; Browning et al., 2016; Mayer‐Davis et al., 2018; Winkley et al., 2020; Ismail et al., 2018).
• Adolescents and type 1 diabetes: Small studies suggest MI may help improve glycemic control in adolescents, but large trials show no significant long-term effect (Channon et al., 2003; Mayer‐Davis et al., 2018).

Self-Management and Adherence

• MI improves diabetes self-management behaviors (diet, exercise, medication adherence) and self-efficacy in both type 1 and type 2 diabetes (Chen et al., 2012; Steffen et al., 2021; Berhe et al., 2020; Song et al., 2014; Li et al., 2014).
• Medication adherence: MI-based interventions, even when delivered by pharmacy students, can significantly improve medication adherence and reduce discontinuation rates (Abughosh et al., 2017).

Psychological and Quality of Life Outcomes

• Mixed results: MI may improve quality of life and reduce diabetes-related distress in some studies, but effects on depression and anxiety are generally not significant (Chen et al., 2012; Berhe et al., 2020; Browning et al., 2016; Woodard et al., 2022; Mayer‐Davis et al., 2018; Winkley et al., 2020).
• Collaborative goal-setting approaches using MI can modestly reduce diabetes-associated distress, though sustained improvements in glycemic control are less certain (Woodard et al., 2022).

Implementation and Training

• MI skills can be acquired by diabetes healthcare practitioners with training, but ongoing supervision is needed to maintain proficiency and ensure effective delivery (Kaczmarek et al., 2021).
• Intervention fidelity and provider competency are critical for achieving positive outcomes (Minet et al., 2011; Kaczmarek et al., 2021; Ismail et al., 2018).

Limitations and Research Gaps

• Heterogeneity in study design, intervention duration, and provider training leads to variable results and limits generalizability (Browning et al., 2016; Carpenter et al., 2018; Winkley et al., 2020).
• Cost-effectiveness and long-term sustainability of MI interventions remain uncertain (Ismail et al., 2010; Winkley et al., 2020; Ismail et al., 2018).

Motivational Interviewing in Diabetes: Summary of Outcomes

Figure 1: Summary of motivational interviewing outcomes in diabetes care.

Summary

Motivational interviewing offers modest, short-term improvements in glycemic control and self-management for patients with diabetes, especially type 2. Its effects on psychological outcomes are limited, and long-term benefits depend on intervention fidelity and provider training (Chen et al., 2012; Steffen et al., 2021; Berhe et al., 2020; Minet et al., 2011; Browning et al., 2016; Channon et al., 2003; Song et al., 2014; Woodard et al., 2022; Li et al., 2014; Mayer‐Davis et al., 2018; Kaczmarek et al., 2021; Winkley et al., 2020; Ismail et al., 2018; Abughosh et al., 2017).

These papers were sourced and synthesized using Consensus, an AI-powered search engine for research. Try it at https://consensus.app

References

Chen, S., Creedy, D., Lin, H., & Wollin, J. (2012). Effects of motivational interviewing intervention on self-management, psychological and glycemic outcomes in type 2 diabetes: a randomized controlled trial.. International journal of nursing studies, 49 6, 637-44. https://doi.org/10.1016/j.ijnurstu.2011.11.011

Steffen, P., Mendonça, C., Meyer, E., & Faustino-Silva, D. (2021). Motivational Interviewing in the Management of Type 2 Diabetes Mellitus and Arterial Hypertension in Primary Health Care: An RCT.. American journal of preventive medicine. https://doi.org/10.1016/j.amepre.2020.12.015

Berhe, K., Gebru, H., & Kahsay, H. (2020). Effect of motivational interviewing intervention on HgbA1C and depression in people with type 2 diabetes mellitus (systematic review and meta-analysis). PLoS ONE, 15. https://doi.org/10.1371/journal.pone.0240839

Minet, L., Wagner, L., Lønvig, E., Hjelmborg, J., & Henriksen, J. (2011). The effect of motivational interviewing on glycaemic control and perceived competence of diabetes self-management in patients with type 1 and type 2 diabetes mellitus after attending a group education programme: a randomised controlled trial. Diabetologia, 54, 1620-1629. https://doi.org/10.1007/s00125-011-2120-x

Browning, C., Chapman, A., Yang, H., Liu, S., Zhang, T., Enticott, J., & Thomas, S. (2016). Management of type 2 diabetes in China: the Happy Life Club, a pragmatic cluster randomised controlled trial using health coaches. BMJ Open, 6. https://doi.org/10.1136/bmjopen-2015-009319

Channon, S., Smith, V., & Gregory, J. (2003). A pilot study of motivational interviewing in adolescents with diabetes. Archives of Disease in Childhood, 88, 680 - 683. https://doi.org/10.1136/adc.88.8.680

Song, D., Xu, T., & Sun, Q. (2014). Effect of motivational interviewing on self-management in patients with type 2 diabetes mellitus: A meta-analysis. International Journal of Nursing Sciences, 1, 291-297. https://doi.org/10.1016/j.ijnss.2014.06.002

Woodard, L., Amspoker, A., Hundt, N., Gordon, H., Hertz, B., Odom, E., Utech, A., Razjouyan, J., Rajan, S., Kamdar, N., Lindo, J., Kiefer, L., Mehta, P., & Naik, A. (2022). Comparison of Collaborative Goal Setting With Enhanced Education for Managing Diabetes-Associated Distress and Hemoglobin A1c Levels. JAMA Network Open, 5. https://doi.org/10.1001/jamanetworkopen.2022.9975

Li, M., Li, T., Shi, B., & Gao, C. (2014). Impact of motivational interviewing on the quality of life and its related factors in type 2 diabetes mellitus patients with poor long-term glycemic control. International Journal of Nursing Sciences, 1, 250-254. https://doi.org/10.1016/j.ijnss.2014.05.022

Ismail, K., Maissi, E., Thomas, S., Chalder, T., Schmidt, U., Bartlett, J., Patel, A., Dickens, C., Creed, F., & Treasure, J. (2010). A randomised controlled trial of cognitive behaviour therapy and motivational interviewing for people with Type 1 diabetes mellitus with persistent sub-optimal glycaemic control: a Diabetes and Psychological Therapies (ADaPT) study. Health technology assessment, 14 22, 1-101, iii-iv. https://doi.org/10.3310/hta14220

Carpenter, R., Dichiacchio, T., & Barker, K. (2018). Interventions for self-management of type 2 diabetes: An integrative review. International Journal of Nursing Sciences, 6, 70 - 91. https://doi.org/10.1016/j.ijnss.2018.12.002

Mayer‐Davis, E., Maahs, D., Seid, M., Crandell, J., Bishop, F., Driscoll, K., Hunter, C., Kichler, J., Standiford, D., & Thomas, J. (2018). Efficacy of the Flexible Lifestyles Empowering Change intervention on metabolic and psychosocial outcomes in adolescents with type 1 diabetes (FLEX): a randomised controlled trial. The Lancet. Child & adolescent health, 2 9, 635-646. https://doi.org/10.1016/s2352-4642(18)30208-6

Kaczmarek, T., Kavanagh, D., Lazzarini, P., Warnock, J., & Van Netten, J. (2021). Training diabetes healthcare practitioners in motivational interviewing: a systematic review. Health Psychology Review, 16, 430 - 449. https://doi.org/10.1080/17437199.2021.1926308

Winkley, K., Upsher, R., Ståhl, D., Pollard, D., Kasera, A., Brennan, A., Heller, S., & Ismail, K. (2020). Psychological interventions to improve self-management of type 1 and type 2 diabetes: a systematic review. Health technology assessment, 24 28, 1-232. https://doi.org/10.3310/hta24280

Ismail, K., Winkley, K., De Zoysa, N., Patel, A., Heslin, M., Graves, H., Thomas, S., Stringer, D., Ståhl, D., & Amiel, S. (2018). Nurse-led psychological intervention for type 2 diabetes: a cluster randomised controlled trial (Diabetes-6 study) in primary care. The British journal of general practice : the journal of the Royal College of General Practitioners, 68 673, e531-e540. https://doi.org/10.3399/bjgp18x696185

Abughosh, S., Wang, X., Serna, O., Esse, T., Mann, A., Masilamani, S., Holstad, M., Essien, E., & Fleming, M. (2017). A Motivational Interviewing Intervention by Pharmacy Students to Improve Medication Adherence. Journal of managed care & specialty pharmacy, 23 5, 549-560. https://doi.org/10.18553/jmcp.2017.23.5.549

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Diabetes and Pregnancy: Risks, Outcomes, and Management

Diabetes during pregnancy—including pregestational diabetes (type 1 or type 2) and gestational diabetes mellitus (GDM)—poses significant risks for both mother and child. Research highlights increased rates of complications, the importance of glycemic control, and the need for tailored management strategies.

Maternal and Fetal Risks

• Pregestational Diabetes (PGDM): Increases risk of congenital malformations (especially cardiac, neural, and musculoskeletal), spontaneous abortion, stillbirth, perinatal death, macrosomia, and neonatal complications such as hypoglycemia and respiratory distress. Poor glycemic control before and during early pregnancy is a major risk factor (Ornoy et al., 2021; Murphy et al., 2021; Asuni et al., 2025; Capobianco et al., 2020).
• Gestational Diabetes (GDM): Associated with higher rates of preeclampsia, hypertensive disorders, preterm delivery, cesarean section, large-for-gestational-age infants, and neonatal intensive care admission. Early-onset GDM (before 20 weeks) is linked to worse outcomes than later-onset GDM (Simmons et al., 2023; Sweeting et al., 2024; Buchanan et al., 2012; Mcintyre et al., 2019; Greco et al., 2023; Modzelewski et al., 2022; Capobianco et al., 2020).
• Long-term Offspring Effects: Both PGDM and GDM increase the risk of childhood obesity, impaired glucose tolerance, type 2 diabetes, and neurodevelopmental disorders in offspring (Ornoy et al., 2021; Sweeting et al., 2022; Buchanan et al., 2012; Mcintyre et al., 2019; Moon & Jang, 2022; Alejandro et al., 2020).

Modifiable Risk Factors and Management

• Glycemic Control: Higher maternal HbA1c in pregnancy is strongly associated with adverse outcomes. Tight glycemic control before and during pregnancy reduces risks of congenital anomalies, preterm birth, and perinatal mortality (Ornoy et al., 2021; Murphy et al., 2021; Ringholm et al., 2019; Wahabi et al., 2020).
• Pre-pregnancy Care: Structured preconception care for women with diabetes reduces congenital malformations by 71%, lowers perinatal mortality by 54%, and improves glycemic control (Wahabi et al., 2020).
• Lifestyle and Pharmacologic Management: Nutritional counseling, physical activity, and, when needed, insulin or oral agents are key for GDM management. Early treatment of GDM modestly reduces adverse neonatal outcomes (Simmons et al., 2023; Rasmussen et al., 2020; Ringholm et al., 2019).
• Technology and Education: Use of insulin analogues, insulin pumps, continuous glucose monitoring, and patient education (including digital tools) can improve outcomes in women with pre-existing diabetes (Ringholm et al., 2019).

Special Populations and Considerations

• Type 1 vs. Type 2 Diabetes: Type 1 diabetes is associated with higher rates of preterm delivery, large-for-gestational-age infants, and neonatal complications compared to type 2 diabetes, though both types increase risk compared to non-diabetic pregnancies (Murphy et al., 2021; Asuni et al., 2025).
• Twin Pregnancies: GDM increases risks in both singleton and twin pregnancies, but some adverse outcomes may be less pronounced in twins (Greco et al., 2023).
• Long-term Follow-up: Both mothers and offspring require ongoing monitoring for development of type 2 diabetes and cardiovascular disease (Buchanan et al., 2012; Mcintyre et al., 2019; Moon & Jang, 2022).

Diabetes and Pregnancy: Key Outcomes and Interventions

Figure 1: Summary of major risks and interventions in diabetes and pregnancy.

Summary

Diabetes in pregnancy significantly increases risks for both mother and child, but many complications can be reduced with preconception care, tight glycemic control, and individualized management strategies (Ornoy et al., 2021; Murphy et al., 2021; Simmons et al., 2023; Asuni et al., 2025; Buchanan et al., 2012; Mcintyre et al., 2019; Rasmussen et al., 2020; Moon & Jang, 2022; Ringholm et al., 2019; Wahabi et al., 2020; Greco et al., 2023; Alejandro et al., 2020; Modzelewski et al., 2022; Capobianco et al., 2020).

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References

Ornoy, A., Becker, M., Weinstein-Fudim, L., & Ergaz, Z. (2021). Diabetes during Pregnancy: A Maternal Disease Complicating the Course of Pregnancy with Long-Term Deleterious Effects on the Offspring. A Clinical Review. International Journal of Molecular Sciences, 22. https://doi.org/10.3390/ijms22062965

Murphy, H., Howgate, C., O'Keefe, J., Myers, J., Morgan, M., Coleman, M., Jolly, M., Valabhji, J., Scott, E., Knighton, P., Young, B., & Lewis‐Barned, N. (2021). Characteristics and outcomes of pregnant women with type 1 or type 2 diabetes: a 5-year national population-based cohort study. The lancet. Diabetes & endocrinology. https://doi.org/10.1016/s2213-8587(20)30406-x

Simmons, D., Immanuel, J., Hague, W., Teede, H., Nolan, C., Peek, M., Flack, J., Mclean, M., Wong, V., Hibbert, E., Kautzky-Willer, A., Harreiter, J., Backman, H., Gianatti, E., Sweeting, A., Mohan, V., Enticott, J., & Cheung, N. (2023). Treatment of Gestational Diabetes Mellitus Diagnosed Early in Pregnancy.. The New England journal of medicine. https://doi.org/10.1056/nejmoa2214956

Sweeting, A., Wong, J., Murphy, H., & Ross, G. (2022). A Clinical Update on Gestational Diabetes Mellitus. Endocrine Reviews, 43, 763 - 793. https://doi.org/10.1210/endrev/bnac003

Asuni, T., Guo, Y., Lane, R., Kerr, D., & Farrokhi, F. (2025). 1241-P: Maternal, Fetal, and Neonatal Outcomes in Pregnant Women with Type 1 and Type 2 Diabetes in a Large Health Care System. Diabetes. https://doi.org/10.2337/db25-1241-p

Sweeting, A., Hannah, W., Backman, H., Catalano, P., Feghali, M., Herman, W., Hivert, M., Immanuel, J., Meek, C., Oppermann, M., Nolan, C., Ram, U., Schmidt, M., Simmons, D., Chivese, T., & Benhalima, K. (2024). Epidemiology and management of gestational diabetes. The Lancet, 404, 175-192. https://doi.org/10.1016/s0140-6736(24)00825-0

Buchanan, T., Xiang, A., & Page, K. (2012). Gestational diabetes mellitus: risks and management during and after pregnancy. Nature Reviews Endocrinology, 8, 639-649. https://doi.org/10.1038/nrendo.2012.96

Mcintyre, H., Catalano, P., Zhang, C., Desoye, G., Mathiesen, E., & Damm, P. (2019). Gestational diabetes mellitus. Nature Reviews Disease Primers, 5, 1-19. https://doi.org/10.1038/s41572-019-0098-8

Rasmussen, L., Poulsen, C., Kampmann, U., Smedegaard, S., Ovesen, P., & Fuglsang, J. (2020). Diet and Healthy Lifestyle in the Management of Gestational Diabetes Mellitus. Nutrients, 12. https://doi.org/10.3390/nu12103050

Moon, J., & Jang, H. (2022). Gestational Diabetes Mellitus: Diagnostic Approaches and Maternal-Offspring Complications. Diabetes & Metabolism Journal, 46, 3 - 14. https://doi.org/10.4093/dmj.2021.0335

Ringholm, L., Damm, P., & Mathiesen, E. (2019). Improving pregnancy outcomes in women with diabetes mellitus: modern management. Nature Reviews Endocrinology, 15, 406-416. https://doi.org/10.1038/s41574-019-0197-3

Wahabi, H., Fayed, A., Esmaeil, S., Elmorshedy, H., Titi, M., Amer, Y., Alzeidan, R., Alodhayani, A., Saeed, E., Bahkali, K., Kahili-Heede, M., Jamal, A., & Sabr, Y. (2020). Systematic review and meta-analysis of the effectiveness of pre-pregnancy care for women with diabetes for improving maternal and perinatal outcomes. PLoS ONE, 15. https://doi.org/10.1371/journal.pone.0237571

Greco, E., Calanducci, M., Nicolaides, K., Barry, E., Huda, M., & Iliodromiti, S. (2023). Gestational diabetes mellitus and adverse maternal and perinatal outcomes in twin and singleton pregnancies: a systematic review and meta-analysis. American journal of obstetrics and gynecology. https://doi.org/10.1016/j.ajog.2023.08.011

Alejandro, E., Mamerto, T., Chung, G., Villavieja, A., Gaus, N., Morgan, E., & Pineda-Cortel, M. (2020). Gestational Diabetes Mellitus: A Harbinger of the Vicious Cycle of Diabetes. International Journal of Molecular Sciences, 21. https://doi.org/10.3390/ijms21145003

Modzelewski, R., Stefanowicz-Rutkowska, M., Matuszewski, W., & Bandurska-Stankiewicz, E. (2022). Gestational Diabetes Mellitus—Recent Literature Review. Journal of Clinical Medicine, 11. https://doi.org/10.3390/jcm11195736

Capobianco, G., Gulotta, A., Tupponi, G., Dessole, F., Pola, M., Virdis, G., Petrillo, M., Mais, V., Olzai, G., Antonucci, R., Saderi, L., Cherchi, P., Dessole, S., & Sotgiu, G. (2020). Materno-Fetal and Neonatal Complications of Diabetes in Pregnancy: A Retrospective Study †. Journal of Clinical Medicine, 9. https://doi.org/10.3390/jcm9092707

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Diabetic Kidney Pathologies: Mechanisms, Progression, and Therapeutic Insights

Diabetic kidney disease (DKD) is a leading cause of chronic kidney disease (CKD) and end-stage renal disease (ESRD) worldwide, driven by complex metabolic, hemodynamic, inflammatory, and fibrotic processes.

Pathophysiological Mechanisms

DKD arises from chronic hyperglycemia, which induces metabolic stress, mitochondrial dysfunction, and oxidative stress in renal cells. This leads to glomerular hyperfiltration, podocyte injury, endothelial dysfunction, and progressive fibrosis. Key histological features include glomerular basement membrane (GBM) thickening, mesangial expansion, and nodular sclerosis. Tubulointerstitial lesions and tubular basement membrane thickening are also prominent, reflecting the interplay between glomerular and tubular injury (Mohandes et al., 2023; Joumaa et al., 2025; Młynarska et al., 2024; Tuttle et al., 2022; DeFronzo et al., 2021; Lassén & Daehn, 2020; Reidy et al., 2014).

Inflammation is central to DKD progression, with innate immune pathways (e.g., Toll-like receptors, NLRP3 inflammasome) and proinflammatory cytokines driving renal injury and fibrosis. Epigenetic modifications contribute to "metabolic memory," perpetuating inflammation and fibrogenesis even after glycemic control is improved (Donate-Correa et al., 2020; Zheng et al., 2021; Tang & Yiu, 2020; Gupta et al., 2022).

Clinical Presentation and Epidemiology

DKD affects 30–40% of patients with type 1 diabetes and up to 50% with type 2 diabetes, making it the most common cause of ESRD. Diagnosis is based on persistent albuminuria and reduced estimated glomerular filtration rate (eGFR), though non-albuminuric phenotypes also exist. DKD is associated with increased cardiovascular risk and mortality (Mohandes et al., 2023; Joumaa et al., 2025; Młynarska et al., 2024; Gembillo et al., 2021; Thomas et al., 2016; Ratan et al., 2025; Reidy et al., 2014).

Molecular and Genetic Insights

Podocyte and endothelial cell dysfunction are early drivers of albuminuria, while proximal tubule changes correlate with GFR decline. Mitochondrial defects and altered energy metabolism exacerbate oxidative stress and inflammation. Genetic susceptibility and epigenetic changes modulate individual risk and disease progression (Mohandes et al., 2023; Forbes & Thorburn, 2018; Zheng et al., 2021; Tuttle et al., 2022; Reidy et al., 2014).

Therapeutic Approaches

Current management emphasizes glycemic and blood pressure control, often using renin-angiotensin system (RAS) blockers and sodium-glucose cotransporter-2 (SGLT2) inhibitors, which provide renoprotective effects beyond glucose lowering. Newer agents, such as GLP-1 receptor agonists and anti-inflammatory therapies, are under investigation. Despite advances, many patients progress to ESRD, highlighting the need for novel, targeted therapies and early biomarkers (Mohandes et al., 2023; Joumaa et al., 2025; Młynarska et al., 2024; Tuttle et al., 2022; DeFronzo et al., 2021; Barrera-Chimal & Jaisser, 2020; Ricciardi & Gnudi, 2021).

Key Pathological Features and Mechanisms in DKD

Figure 1: Summary of key pathological features and mechanisms in diabetic kidney disease.

Conclusion

DKD is a multifactorial disease involving metabolic, hemodynamic, inflammatory, and genetic factors. Early detection, comprehensive management, and ongoing research into molecular mechanisms and novel therapies are essential to improve outcomes for diabetic patients with kidney involvement.

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References

Mohandes, S., Doke, T., Hu, H., Mukhi, D., Dhillon, P., & Suszták, K. (2023). Molecular pathways that drive diabetic kidney disease. The Journal of Clinical Investigation, 133. https://doi.org/10.1172/jci165654

Forbes, J., & Thorburn, D. (2018). Mitochondrial dysfunction in diabetic kidney disease. Nature Reviews Nephrology, 14, 291-312. https://doi.org/10.1038/nrneph.2018.9

Donate-Correa, J., Luis-Rodríguez, D., Martín-Núñez, E., Tagua, V., Hernández-Carballo, C., Ferri, C., Rodríguez-Rodríguez, A., Mora-Fernández, C., & Navarro-González, J. (2020). Inflammatory Targets in Diabetic Nephropathy. Journal of Clinical Medicine, 9. https://doi.org/10.3390/jcm9020458

Zheng, W., Guo, J., & Liu, Z. (2021). Effects of metabolic memory on inflammation and fibrosis associated with diabetic kidney disease: an epigenetic perspective. Clinical Epigenetics, 13. https://doi.org/10.1186/s13148-021-01079-5

Joumaa, J., Raffoul, A., Sarkis, C., Chatrieh, E., Zaidan, S., Attieh, P., Harb, F., Azar, S., & Ghadieh, H. (2025). Mechanisms, Biomarkers, and Treatment Approaches for Diabetic Kidney Disease: Current Insights and Future Perspectives. Journal of Clinical Medicine, 14. https://doi.org/10.3390/jcm14030727

Młynarska, E., Buławska, D., Czarnik, W., Hajdys, J., Majchrowicz, G., Prusinowski, F., Stabrawa, M., Rysz, J., & Franczyk, B. (2024). Novel Insights into Diabetic Kidney Disease. International Journal of Molecular Sciences, 25. https://doi.org/10.3390/ijms251810222

Tuttle, K., Agarwal, R., Alpers, C., Bakris, G., Brosius, F., Kolkhof, P., & Uribarri, J. (2022). Molecular Mechanisms and Therapeutic Targets for Diabetic Kidney Disease.. Kidney international. https://doi.org/10.1016/j.kint.2022.05.012

Tang, S., & Yiu, W. (2020). Innate immunity in diabetic kidney disease. Nature Reviews Nephrology, 16, 206-222. https://doi.org/10.1038/s41581-019-0234-4

Gembillo, G., Ingrasciotta, Y., Crisafulli, S., Luxi, N., Siligato, R., Santoro, D., & Trifirò, G. (2021). Kidney Disease in Diabetic Patients: From Pathophysiology to Pharmacological Aspects with a Focus on Therapeutic Inertia. International Journal of Molecular Sciences, 22. https://doi.org/10.3390/ijms22094824

Thomas, M., Cooper, M., & Zimmet, P. (2016). Changing epidemiology of type 2 diabetes mellitus and associated chronic kidney disease. Nature Reviews Nephrology, 12, 73-81. https://doi.org/10.1038/nrneph.2015.173

DeFronzo, R., Reeves, W., & Awad, A. (2021). Pathophysiology of diabetic kidney disease: impact of SGLT2 inhibitors. Nature Reviews Nephrology, 17, 319 - 334. https://doi.org/10.1038/s41581-021-00393-8

Ratan, Y., Rajput, A., Pareek, A., Pareek, A., & Singh, G. (2025). Comprehending the Role of Metabolic and Hemodynamic Factors Alongside Different Signaling Pathways in the Pathogenesis of Diabetic Nephropathy. International Journal of Molecular Sciences, 26. https://doi.org/10.3390/ijms26073330

Gupta, A., Singh, K., Fatima, S., Ambreen, S., Zimmermann, S., Younis, R., Krishnan, S., Rana, R., Gadi, I., Schwab, C., Biemann, R., Shahzad, K., Rani, V., Ali, S., Mertens, P., Kohli, S., & Isermann, B. (2022). Neutrophil Extracellular Traps Promote NLRP3 Inflammasome Activation and Glomerular Endothelial Dysfunction in Diabetic Kidney Disease. Nutrients, 14. https://doi.org/10.3390/nu14142965

Lassén, E., & Daehn, I. (2020). Molecular Mechanisms in Early Diabetic Kidney Disease: Glomerular Endothelial Cell Dysfunction. International Journal of Molecular Sciences, 21. https://doi.org/10.3390/ijms21249456

Barrera-Chimal, J., & Jaisser, F. (2020). Pathophysiologic mechanisms in diabetic kidney disease: A focus on current and future therapeutic targets. Diabetes, 22, 16 - 31. https://doi.org/10.1111/dom.13969

Ricciardi, C., & Gnudi, L. (2021). Kidney disease in diabetes: from mechanisms to clinical presentation and treatment strategies. Metabolism: clinical and experimental, 154890. https://doi.org/10.1016/j.metabol.2021.154890

Reidy, K., Kang, H., Hostetter, T., & Suszták, K. (2014). Molecular mechanisms of diabetic kidney disease. The Journal of clinical investigation, 124 6, 2333-40. https://doi.org/10.1172/jci72271

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Chronic Complications of Diabetes: Macrovascular Disease, Dyslipidemia, and Cardiovascular Risk Reduction

Chronic complications of diabetes include both macrovascular (large vessel) and microvascular (small vessel) diseases, with dyslipidemia playing a central role in increased cardiovascular risk. Recent research highlights the importance of comprehensive risk factor management and the evolving landscape of therapeutic strategies.

Macrovascular Complications

Macrovascular complications in diabetes primarily involve atherosclerotic cardiovascular disease (ASCVD), including coronary heart disease, stroke, and peripheral artery disease. These complications are the leading cause of morbidity and mortality in diabetes, with rapid onset and high prevalence, especially in those with established ASCVD (Dunn et al., 2025; Kosiborod et al., 2018; Wong & Sattar, 2023; Zhao et al., 2024). Early vascular changes can be detected even in children with type 1 diabetes, emphasizing the need for early intervention and glycemic control (Bergdahl et al., 2025).

Dyslipidemia in Diabetes

Diabetic dyslipidemia is characterized by elevated triglycerides, low HDL cholesterol, and increased small dense LDL particles, all of which contribute to atherogenesis (Wu & Parhofer, 2014; Vergès, 2020; Kane et al., 2021; Goldberg, 2001). Even with good glycemic control, qualitative lipoprotein abnormalities persist in type 1 diabetes, increasing cardiovascular risk (Vergès, 2020). Dyslipidemia is a modifiable risk factor, and aggressive lipid management is crucial for cardiovascular risk reduction (Wu & Parhofer, 2014; Banach et al., 2022).

Cardiovascular Risk Reduction Strategies

• Pharmacological Interventions: Newer glucose-lowering agents, such as SGLT2 inhibitors and GLP-1 receptor agonists, have demonstrated significant reductions in major adverse cardiovascular events, independent of glycemic control (Marx et al., 2022; Joseph et al., 2022; Marx & Mcguire, 2016; Yun & Ko, 2021; Arnold et al., 2023). Statins remain the cornerstone of lipid management, with additional benefit from PCSK9 inhibitors and other novel agents (Wu & Parhofer, 2014; Banach et al., 2022).
• Comprehensive Risk Factor Control: Simultaneous management of glycemia, blood pressure, and lipids can reduce cardiovascular events by over 50%, but less than 20% of patients achieve all targets (Wong & Sattar, 2023; Joseph et al., 2022; Banach et al., 2022).
• Lifestyle and Patient-Centered Approaches: Lifestyle modification, including weight loss and smoking cessation, remains foundational. Social determinants of health and individualized care are increasingly recognized as critical to effective risk reduction (Joseph et al., 2022; Wong & Sattar, 2023; Banach et al., 2022).

Key Findings on Diabetes Complications and Risk Reduction

Figure 1: Summary of macrovascular, lipid, and risk reduction strategies in diabetes.

Conclusion

Macrovascular complications and dyslipidemia are major drivers of cardiovascular risk in diabetes. Early, aggressive, and multifactorial intervention—including novel pharmacotherapies and lifestyle changes—are essential for reducing morbidity and mortality in this population.

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References

Marx, N., Husain, M., Lehrke, M., Verma, S., & Sattar, N. (2022). GLP-1 Receptor Agonists for the Reduction of Atherosclerotic Cardiovascular Risk in Patients With Type 2 Diabetes. Circulation, 146 24, 1882-1894. https://doi.org/10.1161/circulationaha.122.059595

Vergès, B. (2020). Dyslipidemia in Type 1 Diabetes: A Masked Danger. Trends in Endocrinology & Metabolism, 31, 422-434. https://doi.org/10.1016/j.tem.2020.01.015

Joseph, J., Deedwania, P., Acharya, T., Aguilar, D., Bhatt, D., Chyun, D., Di Palo, K., Golden, S., & Sperling, L. (2022). Comprehensive Management of Cardiovascular Risk Factors for Adults With Type 2 Diabetes: A Scientific Statement From the American Heart Association. Circulation, 145, e722 - e759. https://doi.org/10.1161/cir.0000000000001040

Dunn, T., Tan, X., Harton, J., Kim, S., Xie, L., Gamble, C., & Rotroff, D. (2025). Macrovascular and microvascular complications in US Medicare enrollees with type 2 diabetes with and without atherosclerotic cardiovascular disease. Diabetes, Obesity & Metabolism, 27, 4137 - 4147. https://doi.org/10.1111/dom.16441

Kane, J., Pullinger, C., Goldfine, I., & Malloy, M. (2021). Dyslipidemia and diabetes mellitus: Role of lipoprotein species and interrelated pathways of lipid metabolism in diabetes mellitus.. Current opinion in pharmacology, 61, 21-27. https://doi.org/10.1016/j.coph.2021.08.013

Wong, N., & Sattar, N. (2023). Cardiovascular risk in diabetes mellitus: epidemiology, assessment and prevention. Nature Reviews Cardiology, 20, 685 - 695. https://doi.org/10.1038/s41569-023-00877-z

Kosiborod, M., Gomes, M., Nicolucci, A., Pocock, S., Rathmann, W., Shestakova, M., Watada, H., Shimomura, I., Chen, H., Cid-Ruzafa, J., Fenici, P., Hammar, N., Surmont, F., Tang, F., & Khunti, K. (2018). Vascular complications in patients with type 2 diabetes: prevalence and associated factors in 38 countries (the DISCOVER study program). Cardiovascular Diabetology, 17. https://doi.org/10.1186/s12933-018-0787-8

Wu, L., & Parhofer, K. (2014). Diabetic dyslipidemia. Metabolism: clinical and experimental, 63 12, 1469-79. https://doi.org/10.1016/j.metabol.2014.08.010

Zhao, M., Dong, Y., Chen, L., & Shen, H. (2024). Influencing factors of stroke in patients with type 2 diabetes: A systematic review and meta-analysis. PLOS ONE, 19. https://doi.org/10.1371/journal.pone.0305954

Marx, N., & Mcguire, D. (2016). Sodium-glucose cotransporter-2 inhibition for the reduction of cardiovascular events in high-risk patients with diabetes mellitus. European heart journal, 37 42, 3192-3200. https://doi.org/10.1093/eurheartj/ehw110

Goldberg, I. (2001). Diabetic Dyslipidemia: Causes and Consequences. The Journal of Clinical Endocrinology and Metabolism, 86, 965-971. https://doi.org/10.1210/jcem.86.3.7304

Yun, J., & Ko, S. (2021). Current trends in epidemiology of cardiovascular disease and cardiovascular risk management in type 2 diabetes. Metabolism: clinical and experimental, 154838. https://doi.org/10.1016/j.metabol.2021.154838

Banach, M., Surma, S., Reiner, Ž., Katsiki, N., Penson, P., Fras, Z., Sahebkar, A., Paneni, F., Rizzo, M., & Kastelein, J. (2022). Personalized management of dyslipidemias in patients with diabetes—it is time for a new approach (2022). Cardiovascular Diabetology, 21. https://doi.org/10.1186/s12933-022-01684-5

Arnold, S., Gosch, K., Kosiborod, M., Wong, N., Sperling, L., Newman, J., Gamble, C., Hamersky, C., Rajpura, J., & Vaduganathan, M. (2023). Contemporary Use of Cardiovascular Risk Reduction Strategies in Type 2 Diabetes. Insights from The Diabetes Collaborative Registry. American heart journal. https://doi.org/10.1016/j.ahj.2023.05.002

Bergdahl, E., Forsander, G., Sundberg, F., Milkovic, L., & Dangardt, F. (2025). Investigating the presence and detectability of structural peripheral arterial changes in children with well-regulated type 1 diabetes versus healthy controls using ultra-high frequency ultrasound: a single-centre cross-sectional and case-control study. eClinicalMedicine, 81. https://doi.org/10.1016/j.eclinm.2025.103097

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Diabetes Distress: Prevalence, Risk Factors, and Interventions

Diabetes distress (DD) is the emotional burden and negative feelings associated with managing diabetes, distinct from clinical depression. Research consistently shows that DD is common, impacts self-management and glycemic control, and can be addressed through targeted interventions.

Prevalence and Risk Factors

• Prevalence: DD affects approximately 20–30% of adults and adolescents with diabetes, with some studies reporting even higher rates in certain populations (e.g., 24% in young adults with youth-onset type 2 diabetes, 25–33% in emerging adults with type 1 diabetes) (Trief et al., 2022; Kortegaard et al., 2024; Iturralde et al., 2019; Hagger et al., 2016; Tripathi et al., 2024; Cox et al., 2023).
• Risk Factors: Higher DD is associated with female sex, higher HbA1c, insulin treatment, longer diabetes duration, comorbid depression or anxiety, lack of health care coverage, and younger age (Trief et al., 2022; Kortegaard et al., 2024; Iturralde et al., 2019; Hagger et al., 2016; Sturt et al., 2015; Tripathi et al., 2024; Cox et al., 2023). In type 2 diabetes, hypertension and family history also increased risk (Trief et al., 2022; Tripathi et al., 2024).
• Distinct from Depression: While DD and depression overlap, DD is more closely linked to diabetes outcomes and is a unique contributor to poor self-care and glycemic control (Rodríguez-Muñoz et al., 2024; Hagger et al., 2016; Gonzalez et al., 2016).

Impact on Diabetes Management

• Glycemic Control: Elevated DD is consistently associated with suboptimal glycemic control and poor self-management behaviors (Trief et al., 2022; Kortegaard et al., 2024; Iturralde et al., 2019; Hagger et al., 2016; Gonzalez et al., 2016; Hilliard et al., 2018).
• Quality of Life: DD negatively affects quality of life and increases the risk of complications (Trief et al., 2022; Iturralde et al., 2019; Hagger et al., 2016; Gonzalez et al., 2016).
• Family and Social Context: DD can also affect partners and family members, especially regarding worries about hypoglycemia and management burden (Polonsky et al., 2016).

Assessment and Measurement

• Validated Tools: The Problem Areas in Diabetes (PAID) and Diabetes Distress Scale (DDS) are widely used to assess DD in both adults and adolescents (Trief et al., 2022; Hagger et al., 2016; Polonsky et al., 1995).
• Routine Screening: Regular assessment is recommended, especially for high-risk groups, to guide timely interventions (Iturralde et al., 2019; Hilliard et al., 2018; Kostiuk et al., 2025).

Interventions and Management

• Psychosocial and Behavioral Interventions: Group-based, empowerment-based, and emotion-focused interventions have shown effectiveness in reducing DD and improving glycemic outcomes (Kortegaard et al., 2024; Cheng et al., 2019; Fisher et al., 2018; Kostiuk et al., 2025).
• Digital and Peer Support: Digitally enabled peer support and mobile health interventions are emerging as accessible ways to reduce DD and depressive symptoms (Yakubu et al., 2024).
• Integrated Care: Interdisciplinary approaches involving mental health professionals, diabetes educators, and medical providers are recommended for comprehensive management (Tenreiro & Hatipoglu, 2025; Hilliard et al., 2018; Kostiuk et al., 2025).
• Primary Care Integration: Structured educational, behavioral, and emotion-focused techniques can be feasibly integrated into primary care settings (Kostiuk et al., 2025).

Diabetes Distress: Key Findings and Interventions

Figure 1: Summary of prevalence, impact, and interventions for diabetes distress.

Conclusion

Diabetes distress is common and significantly affects diabetes outcomes. Early identification and targeted, multidisciplinary interventions are essential to improve both psychological well-being and diabetes management.

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References

Trief, P., Uschner, D., Tung, M., Marcus, M., Rayas, M., Macleish, S., Farrell, R., Keady, J., Chao, L., & Weinstock, R. (2022). Diabetes Distress in Young Adults With Youth-Onset Type 2 Diabetes: TODAY2 Study Results.. Diabetes care. https://doi.org/10.2337/dc21-1689

Rodríguez-Muñoz, A., Picón-César, M., Tinahones, F., & Martínez-Montoro, J. (2024). Type 1 diabetes-related distress: Current implications in care. European journal of internal medicine. https://doi.org/10.1016/j.ejim.2024.03.030

Kortegaard, A., Rokkjær, R., Harboe, H., Lund, S., Andersen, A., & Bohl, M. (2024). A group-based intervention for diabetes-related emotional distress among emerging adults with type 1 diabetes: A pilot study. European journal of internal medicine. https://doi.org/10.1016/j.ejim.2024.06.002

Iturralde, E., Rausch, J., Weissberg-Benchell, J., & Hood, K. (2019). Diabetes-Related Emotional Distress Over Time. Pediatrics, 143. https://doi.org/10.1542/peds.2018-3011

Hagger, V., Hendrieckx, C., Sturt, J., Skinner, T., & Speight, J. (2016). Diabetes Distress Among Adolescents with Type 1 Diabetes: a Systematic Review. Current Diabetes Reports, 16, 1-14. https://doi.org/10.1007/s11892-015-0694-2

Sturt, J., Dennick, K., Due-Christensen, M., & McCarthy, K. (2015). The Detection and Management of Diabetes Distress in People With Type 1 Diabetes. Current Diabetes Reports, 15, 1-14. https://doi.org/10.1007/s11892-015-0660-z

Polonsky, W., Anderson, B., Lohrer, P., Welch, G., Jacobson, A., Aponte, J., & Schwartz, C. (1995). Assessment of Diabetes-Related Distress. Diabetes Care, 18, 754 - 760. https://doi.org/10.2337/diacare.18.6.754

Cheng, L., Sit, J., Choi, K., Chair, S., Li, X., Wu, Y., Long, J., & Yang, H. (2019). The effects of an empowerment-based self-management intervention on empowerment level, psychological distress, and quality of life in patients with poorly controlled type 2 diabetes: A randomized controlled trial. International journal of nursing studies, 103407. https://doi.org/10.1016/j.ijnurstu.2019.103407

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Fisher, L., Hessler, D., Polonsky, W., Masharani, U., Guzman, S., Bowyer, V., Strycker, L., Ahmann, A., Basina, M., Blumer, I., Chloe, C., Kim, S., Peters, A., Shumway, M., Weihs, K., & Wu, P. (2018). T1-REDEEM: A Randomized Controlled Trial to Reduce Diabetes Distress Among Adults With Type 1 Diabetes. Diabetes Care, 41, 1862 - 1869. https://doi.org/10.2337/dc18-0391

Gonzalez, J., Tanenbaum, M., & Commissariat, P. (2016). Psychosocial factors in medication adherence and diabetes self-management: Implications for research and practice. The American psychologist, 71 7, 539-551. https://doi.org/10.1037/a0040388

Hilliard, M., De Wit, M., Wasserman, R., Butler, A., Evans, M., Weissberg-Benchell, J., & Anderson, B. (2018). Screening and support for emotional burdens of youth with type 1 diabetes: Strategies for diabetes care providers. Pediatric Diabetes, 19, 534 - 543. https://doi.org/10.1111/pedi.12575

Kostiuk, M., Kramer, E., Nederveld, A., Hessler, D., Fisher, L., Parascando, J., & Oser, T. (2025). Addressing Diabetes Distress in Primary Care: Where Are We Now, and Where Do We Need to Go?. Current diabetes reports, 25 1, 17. https://doi.org/10.1007/s11892-025-01576-4

Tripathi, P., Kadam, N., Sharma, B., Kulkarni, P., Biswas, M., Ganla, M., Hiremath, M., & Saboo, B. (2024). 686-P: Prevalence and Determinants of Diabetes Distress in Type 2 Diabetes Patients in India—A Cross-Sectional Study. Diabetes. https://doi.org/10.2337/db24-686-p

Polonsky, W., Fisher, L., Hessler, D., & Johnson, N. (2016). Emotional Distress in the Partners of Type 1 Diabetes Adults: Worries About Hypoglycemia and Other Key Concerns. Diabetes technology & therapeutics, 18 5, 292-7. https://doi.org/10.1089/dia.2015.0451

Yakubu, T., Pawer, S., West, N., Tang, T., & Görges, M. (2024). Impact of Digitally Enabled Peer Support Interventions on Diabetes Distress and Depressive Symptoms in People Living with Type 1 Diabetes: A Systematic Review. Current diabetes reports, 25 1, 1. https://doi.org/10.1007/s11892-024-01560-4

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These papers were sourced and synthesized using Consensus, an AI-powered search engine for research. Try it at https://consensus.app

Foot Care in Diabetes: Prevention, Self-Care, and Clinical Management

Foot complications are among the most serious and costly issues for people with diabetes, often leading to ulcers, infections, and amputations. Research emphasizes prevention, patient education, regular screening, and multidisciplinary care as the cornerstones of effective foot care.

Key Principles of Diabetic Foot Care

• Risk Identification and Regular Screening: Annual foot examinations are essential to identify patients at risk for ulceration, focusing on signs of neuropathy, peripheral artery disease, foot deformities, and previous ulcers or amputations (Schaper et al., 2016; Bus et al., 2016; Bowling et al., 2015; Bus et al., 2023).
• Patient and Family Education: Education on daily foot inspection, hygiene, proper footwear, and early reporting of foot problems is crucial. While education improves knowledge and self-care behavior in the short term, evidence for its impact on reducing ulcers and amputations is mixed, highlighting the need for more comprehensive interventions (Hingorani et al., 2016; Bakker et al., 2012; Pérez-Panero et al., 2019; Bossman et al., 2021; Goodall et al., 2020; Dorresteijn et al., 2014).
• Appropriate Footwear: Custom therapeutic footwear and insoles are recommended for high-risk patients to prevent first and recurrent ulcers (Hingorani et al., 2016; Bus et al., 2016; Crawford et al., 2019; Pérez-Panero et al., 2019).
• Self-Care Practices: Good self-care includes daily inspection, washing and drying feet, avoiding walking barefoot, and seeking prompt care for injuries. Knowledge, female sex, and urban residence are associated with better self-care practices, but gaps remain, especially in rural and low-resource settings (Feleke et al., 2025; Suglo et al., 2024; Bossman et al., 2021).
• Integrated, Multidisciplinary Care: Multidisciplinary teams—including podiatrists, diabetologists, surgeons, and nurses—are vital for prevention, wound care, and management of complications. Integrated care can reduce ulcer recurrence and improve outcomes (Schaper et al., 2016; Bus et al., 2016; Bus et al., 2023).
• Wound and Infection Management: Off-loading, debridement, infection control, and revascularization are key for treating ulcers and infections. New guidelines stress evidence-based approaches and highlight research gaps in optimal interventions (Hingorani et al., 2016; Senneville et al., 2023; Fitridge et al., 2023; Turzańska et al., 2023).

Summary of Effective Foot Care Strategies

Figure 1: Summary of research-backed strategies for diabetic foot care and prevention.

Research Gaps and Future Directions

• More high-quality trials are needed to determine the most effective combinations of education, self-care, and integrated care for preventing ulcers and amputations (Bus et al., 2016; Crawford et al., 2019; Dorresteijn et al., 2014; Bus et al., 2023).
• There is a need for culturally tailored interventions, especially in low-resource and rural settings, and for research on cost-effectiveness and implementation (Feleke et al., 2025; Suglo et al., 2024; Bus et al., 2023).

Conclusion

Effective diabetic foot care relies on early risk identification, patient education, self-care, appropriate footwear, and multidisciplinary management. While some strategies are well-supported, ongoing research is needed to optimize prevention and treatment, especially in diverse healthcare settings.

These papers were sourced and synthesized using Consensus, an AI-powered search engine for research. Try it at https://consensus.app

References

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