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Lifestyle factors, self-management & patient empowerment in diabetes care

Comment by Maria Simonenko, Nucleus member, Secondary Rehabilitation Section on behalf of EAPC Almazov National Medical Research Centre, St. Petersburg

Preventive Cardiology

Diabetes mellitus type 2 (T2DM) is a major public health problem, affecting people of all ages worldwide [1] and is not always diagnosed at an early stage. T2DM leads to microvascular complications such as kidney disease and is associated with increased cardiovascular morbidity and mortality [2]. In past years, management of T2DM has improved but some inadequately managed cases still exist [1].

More emphasis should be on empowerment of patients with T2DM and their families, self-management education and lifestyle-related factors. T2DM self-management education and nutritional counselling are integral parts of any therapeutic programme throughout the disease course. This will ensure that the patient has access to information on methods to safely monitor and control blood glucose levels. Healthcare providers should focus on patients with T2DM and their families, and how they may have an active role in the prevention and management of this disease. They might be the key to dealing with the consequences of the rising epidemic of T2DM [1].

Interventional lifestyle change programmes in patients with T2DM recommend to simultaneously target diet and exercise to achieve a larger effect on body weight and glucose metabolism [3]. Several observational studies have shown that healthy dietary patterns characterized by high intake of fruit, vegetables, whole grains, nuts and legumes are associated with reduced risks of vascular complications in people with T2DM [4]. Whether a low carbohydrate diet provides additional benefit in this respect is currently debated [5]. Despite this, the LOOK AHEAD study, a large lifestyle intervention program in people with T2DM, only showed improvements of cardiovascular risk factors, but not significant reduction of CVD [6]. Recent intensive lifestyle intervention programs show promising results such as reductions of glycaemic medication use or even remission of diabetes [7]. Both sufficient baseline physical activity level and its temporal increase were associated with a lower risk of incident hypertension and diabetes mellitus in a large, relatively healthy, cohort [8]. Regular exercise training exerts pleiotropic effects, beneficial not only to metabolic, but also to cardiovascular endpoints in patients with T2DM (Figure 1). Exercise parameters, such as type, intensity and duration modulate effects on individual clinical target parameters. In addition, the patient’s individual genetic background, as well as sex, age, diet and medication interact with exercise and confer risks as well as effectiveness to meet treatment goals [3].

Figure 1. Effects of an exercise programme on target treatment parameters in T2DM

Effects of an exercise programme on target treatment parameters in T2DM are affected by modifiable and non- modifiable, patient-related parameters, in addition to exercise-related parameters. (T2DM – type 2 diabetes mellitus)

Moreover, patient empowerment is important. It is a patient-centred, collaborative approach tailored to match the fundamental realities of diabetes care, in which education is crucial component. It helps patients to discover and develop the inherent capacity to be responsible for their own life. Approaches to education within the empowerment philosophy incorporate interactive teaching strategies designed to involve T2DM patients in problem solving and address their cultural and psychosocial needs. Personal setting within the empowerment approach is a five-step process that provides patients with the information and clarity they need to develop and reach their diabetes and lifestyle-related goals (Figure 2) [9].

Figure 2. Personal setting within the empowerment approach.


In conclusion, once a patient is diagnosed with T2DM, their life will change. As healthcare practitioners, our approach is not only to prescribe glucose-lowering drugs but also explain to patients the importance of self-management, daily glucose control and teach them what modifiable lifestyle factors are. Similar to other chronic conditions, healthcare practitioners should work not only with a patient but his family too and their empowerment can be a key to a success leading to better disease control in the long-term perspective.

Note: The content of this article reflects the personal opinion of the author/s and is not necessarily the official position of the European Society of Cardiology


  1. E Lambrinou, TB Hansen, JWJ Beulens – Lifestyle factors, self-management and patient empowerment in diabetes care, European Journal of Preventive Cardiology, 2019; 26(2S): 55-63
  2. V Ritsinger, T Nystrom, N Saleh, B Lagerqvist, A Norhammar – Heart failure is a common complication after acute myocardial infarction in patients with diabetes: a nationwide study in the SWEDEHEART registry, European Journal of Preventive Cardiology, 2020; 1-12
  3. N Krankel, M Bahls, EM Van Craenenbroeck, V Adams, L Serratosa, EE Solberg, D Hansen, M Dorr, H Kemps – Exercise training to reduce cardiovascular risk in patients with metabolic syndrome and type 2 diabetes mellitus: How does it work? European Journal of Preventive Cardiology, 2019; 26(7): 701-708
  4. H Kahleova, J Salas-Salvado, D Rahelic, CWC Kendall, E Rembert, JL Sievenpiper – Dietary patterns and cardiometabolic outcomes in diabetes: a summary of systematic reviews and meta-analysis, Nutrients, 2019; 11(9), 2209: 1-28
  5. HJ van Wyk, RE Davis, JS Davies – A critical review of low-carbohydrate diets in people with type 2 diabetes, Diabetic Medicine, 2016; 33(2): 148-57
  6. Look AHEAD Research Group, RR Wing, P Bolin, FL Brancati, GA Bray, JM Clark, M Coday, RS Crow, JM Curtis, CM Egan, MA Espeland, M Evans, JP Foreyt, S Ghazarian, EW Gregg, B Harrison, HP Hazuda, JO Hill, ES Horton, VS Hubbard, JM Jakicic, RW Jeffery, KC Johnson, SE Kahn, AE Kitabchim WC Knowler, CE Lewis, BJ Maschak-Carey, MG Montez, A Murillo, DM Nathan, J Patricio, A Peters, X Pi-Sunyer, H Pownall, D Reboussin, JG Regensteiner, AD Rickman, DH Ryan, M Safford, TA Wadden, LE Wagenknecht, DS West, DF Williamson, SZ Yanovski – Cardiovascular effects of intensive lifestyle intervention in type 2 diabetes, New England Journal of Medicine, 2013; 369(2): 145-54
  7. MY Johansen, CS MacDonald, KB Hansen, K Karstoft, R Christensen, M Pedersen, LS Hansen, M Zacho, AS Wedell-Neergaard, ST Nielsen, UW Iepsen, H Langberg, AA Vaag, BK Pedersen, M Ried-Larsen – Effect of an intensive lifestyle intervention on glycemic control in patients with type 2 diabetes: a randomized clinical trial, JAMA, 2017; 318(7): 637-646
  8. JY Lee, S Ryu, KC Sung – Association of baseline level of physical activity and its temporal changes with incident hypertension and diabetes mellitus, European Journal of Preventive Cardiology, 2018; 25(10): 1065-1073
  9. D Hansen, N Kraenkel, H Kemps, M Wilhelm, A Abreu, AFH Pfeiffer, A Jordao, V Cornelissen, H Voller – Management of patients with type 2 diabetes in cardiovascular rehabilitation, European Journal of Preventive Cardiology, 2019; 26(25): 133-144