The American Diabetes Association (ADA) recently released the "Standards of Care in Diabetes-2025 (SoC-25)". Recommendation 5.1 was amended to emphasize that participation in Diabetes Self-Management Education and Support (DSMES) should be advised rather than just encouraged [1]. This is a step in the right direction and a huge deviation from prior attitudes held among participants in the medical industry (MI). Despite multiple decades of advocacy from the inventor of self-monitoring of blood glucose (SMBG) to the ADA, it was not until the results from the Diabetes Control and Complications Trial (DCCT) that the ADA would recommend SMBG to diabetic patients [2,3]. The MI has traditionally shunned teaching patients how to manage their health care in favor of providing certain services for a fee. Weekly follow-up visits to monitor blood glucose are bread and butter to business-related cover overhead costs. Now that there is a severe physician shortage and patients subjected to conventional medical services may only see their doctor for 10-15 minutes, the time has come to help patients learn some basics to manage their health.

In 1997 congress authorized Medicare coverage for up to 10 hours of annual outpatient diabetes self-management training in the Balanced Budget Act of 1997. As a result, much of the research is based on 10-hour annual allocations. Despite the limited exposure, there appear to be significant reductions in mortality [4], and glycemic control [5] in participants with more than 10 hours of DSMES when compared to controls with less exposure to diabetes care and education specialists. Other compelling evidence suggesting both monetary and clinical benefits of DSMES are provided in the SoC [1]. For DSMES to qualify for Medicare reimbursement it must comply with the National Standards for DSMES [6,7]. Fortunately, the National Standards are vague enough to allow guidance to be tailored to the individual. Healthy eating is recommended, but there is no definition of what that is in the National Standards. Medicare Part B participants are only allowed 10 hours (1 hour individual, 9 hours group) of DSMES the first year, then 2 hours per year thereafter. Hospital inpatient facilities, nursing homes, and kidney dialysis facilities are excluded from being reimbursed by Medicare for DSMES [8]. This is in dire contrast to Japan where insurance covers 70% of inpatient DSMES. Takao Hospital in Kyoto provides up to 4 weeks of inpatient DSMES, which costs the participant a little over 1,000 USD. Participants are put on a continuous glucose monitor and given 2 days of the low-fat high-carbohydrate semi-starvation diet recommended by the Japan Diabetes Society (JDS) [9]. Participants experience first-hand how erratic glucose excursions can be on the JDS-recommended diet. Thereafter for the remainder of the 2 or 4 weeks, the participants are placed on a low-carbohydrate diet (LCD) to observe real-time glucose stabilization. Participants are also allowed to participate in tai chi and other wellness events. Participants learn how to cook and the essentials for self-management. In an already financially struggling government-run healthcare scheme, funding to pay for something like this is hard to obtain in the US. Thus, Medicare will by necessity be unable to provide sufficient DSMES. Recommendation 5.7 (grade B) recommends reimbursement of DSMES by third parties due to improved outcomes and reduced healthcare costs. As a result, DSMES is also covered by most private health insurance plans, similar to what Medicare provides.

The ADA recommends 3-7% weight loss as a goal for those who are overweight or obese [1]. Specific MNT is not mentioned in the DSMES-related recommendations. Rather, the ADA states in the SoC-25 that diets should be “individualized” for each patient. This is fortunate because Recommendation 5.6 advocates for using digital interventions as needed to meet individual preferences. Many conventional providers may feel uncomfortable guiding their patients with LCD utilization, especially when deprescribing medications that become unnecessary, as an LCD can markedly lower the requirements for blood glucose and blood pressure lowering medications [10], it is imperative to receive instruction on how to decrease or discontinue these medications. Many online clinics focus on LCD MNT services to deprescribe medications to augment traditional primary care. Other services aim to provide primary care with MNT-mediated deprescription of medications and DSMES [11]. Some organizations have seen a reduction in body weight, A1c, and medication use from utilizing remote DSMES in combination with variations of an LCD as an MNT via paid subscription plans [11,12]. In an open-label non-randomized clinical trial participants with diabetes who lowered A1c below 6.5% and reduced weight using GLP-1 receptor agonists were offered to continue medical therapy or use continuous clinical intervention with an LCD in place of medication [12]. Both groups maintained A1c below 6.5% and maintained weight after 1 year.

Diversa Health is an Australia-based online clinic that offers medical monitoring, real-time one-on-one coaching, an online member portal, an online community, and supporting resources for a monthly fee [11]. Collected data showed a reduction in body weight by 4.5 ± 4.3 kg (5.7%) and 7.9 ± 7.2 kg (7.5%) in overweight and obese participants, respectively. A1c was reduced by −1.4 ± 1.3% in obese participants. We believe community-building is an important component of DSMES. The Japan Low-Carbohydrate Diet Promotion Association (JLCDPA) is a non-profit founded in 2013 that unites more than 75 affiliated organizations that provide LCD-related food, support, or services (13). Biannual LCD journals, frequent mail magazines, seminars, and cooking workshops are continuously being organized. The JLCDPA and its affiliated organizations provide information free of charge in the form of social media and online videos.

The use of DSMES improves clinical outcomes and reduces healthcare costs. Online DSMES in the form of smartphone apps, online communities, 24-hour coaching, and frequent provider access are effective. DSMES should utilize an individualized MNT to encourage adherence. LCD gaining recognition and more and more providers can provide care to those that utilize it. However, there continues to be a shortage of providers available to provide adequate care to those on an LCD. Access to providers of DSMES, especially in conjunction with an LCD, contributes to superior comfort and efficacy for the participant. Congress authorized Medicare coverage for up to 10 hours of annual outpatient diabetes self-management training in the Balanced Budget Act of 1997. Data supports the benefit of this. Given the worsening diabetes epidemic, the benefit appears to be insufficient (or perhaps DSMES is underutilized), although more data are needed. Given the growing public interest in health and the political wind behind the “Make America Healthy Again” movement, it would be prudent to explore increasing DSMES through legislation and organizational recommendations. Personal health choices are best made on a personal level and based on educated decisions. Finally, practitioners should be aware of free online resources to provide to patients to help DSMES be successful without adding financial burden to the participant [Figure 1].

Figure 1: Delivering Components of DSMES.

Conflict of interest

The authors declare no conflict of interest.

Funding

There was no funding received for this paper.

1. American Diabetes Association Professional Practice Committee; 2. Diagnosis and Classification of Diabetes: Standards of Care in Diabetes—2025. Diabetes Care. 2025; 48: S27-S49.
2. Diabetes Control and Complications Trial Research Group, Nathan DM, Genuth S, Lachin J, Cleary P, Crofford O, et al. The effect of intensive treatment of diabetes on the development and progression of long-term complications in insulin-dependent diabetes mellitus. N Engl J Med. 1993; 329: 977-986.
3. Singer P. Vindication' for a Diabetes Expert. 1993.
4. He X, Li J, Wang B, Yao Q, Li L, Song R, et al. Diabetes self-management education reduces risk of all-cause mortality in type 2 diabetes patients: a systematic review and meta-analysis. Endocrine. 2017; 55: 712-731.
5. Chrvala CA, Sherr D, Lipman RD. Diabetes self-management education for adults with type 2 diabetes mellitus: A systematic review of the effect on glycemic control. Patient Educ Couns. 2016; 99: 926-943.
6. Powers MA, Bardsley JK, Cypress M, Funnell MM, Harms D, Hess-Fischl A, et al. Diabetes Self-management Education and Support in Adults With Type 2 Diabetes: A Consensus Report of the American Diabetes Association, the Association of Diabetes Care & Education Specialists, the Academy of Nutrition and Dietetics, the American Academy of Family Physicians, the American Academy of PAs, the American Association of Nurse Practitioners, and the American Pharmacists Association. Diabetes Care. 2020; 43: 1636-1649.
7. Davis J, Fischl AH, Beck J, Browning L, Carter A, Condon JE, et al. 2022 National Standards for Diabetes Self-Management Education and Support. Diabetes Care. 2022; 45: 484-494.
8. Medicare Reimbursement Guidelines. 2024.
9. Wood M, Ebe K, Bando H (2023). Honeymoon Phase by the effect of Low Carbohydrate Diet (LCD) after onset of Type I Diabetes (T1D). Int J Endocrinol Diabetes. 2023; 6: 158.
10. Westman EC, Yancy WS Jr, Mavropoulos JC, Marquart M, McDuffie JR. The effect of a low-carbohydrate, ketogenic diet versus a low-glycemic index diet on glycemic control in type 2 diabetes mellitus. Nutr Metab (Lond). 2008; 5: 36.
11. Brinkworth GD, Wycherley TP, Taylor PJ, Thompson CH. A Health Care Professional Delivered Low Carbohydrate Diet Program Reduces Body Weight, Haemoglobin A1c, Diabetes Medication Use and Cardiovascular Risk Markers-A Single-Arm Intervention Analysis. Nutrients. 2022; 14: 4406.
12. McKenzie AL, Athinarayanan SJ. Impact of Glucagon-Like Peptide 1 Agonist Deprescription in Type 2 Diabetes in a Real-World Setting: A Propensity Score Matched Cohort Study. Diabetes Ther. 2024; 15: 843-853.
13. Wood M, Ebe K, Bando H. Adherence to Medical and Dietary Therapy in Type 2 Diabetes Patients. SunText Rev Endocrine Care. 2024; 4: 119.