The world’s first evidence-based clinical guideline is now published
A year ago, the European Association for the Study of Diabetes (EASD) launched a draft guideline. It was the world’s first guideline on assessing and managing diabetes distress to be built on a formal review of the evidence. It is now final and published.
You can read the full guideline here in Diabetologia. It is free to read.
How was the guideline finalised?
After the draft was launched, it was open for comment for six weeks. Anyone could read it and have their say. The Guideline Development Panel responded to the feedback and sent a revised guideline to the EASD Guidelines Oversight Committee and Board. Then, the journalpeer reviewed it. Further small changes were made.
What’s changed since the draft?
Most of the guideline remains the same. There are eight Good Practice Statements on assessing diabetes distress, and several recommendations on managing it, with separate advice for how to support adults with type 1 diabetes and type 2 diabetes.
There were some changes to the management recommendations. For example, automated insulin delivery systems are now recommended to reduce diabetes distress among adults with type 1 diabetes.
The evidence base behind each statement and recommendation is now published as well. Every recommendation state how certain we can be, based on the evidence, and how large the benefit is.
How should health professionals assess diabetes distress?
These eight Good Practice Statements apply both to adults with type 1 diabetes and adults with type 2 diabetes. Healthcare professionals should:
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- talk about the emotional side of diabetes at every consultation.
- ask about diabetes distress, using open-ended questions, such as what the person finds hard or most challenging about living with diabetes.
- assess diabetes distress using a questionnaire that has been shown to measure it well.
- assess and monitor diabetes distress at regular intervals, at least once a year, and also at times of major life events or big treatment changes.
- talk through the findings of the assessment with the person, whatever they are, as part of effective, person-centred care.
- record the findings and discussion in the clinical notes and share them with relevant members of the person’s healthcare team.
- agree the next steps with the person, when distress is high.
- be able to offer emotional support themselves, and know when and how to refer to a specialist when they are needed.
What should be offered to adults with type 1 diabetes who are experiencing distress?
Healthcare professionals should offer:
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- referral for psychological therapy, such as CBT, ACT, mindfulness, motivational interviewing. The benefit is small and the evidence is of low certainty.
- continuous glucose monitoring (CGM) rather than finger-prick monitoring. The benefit is small and the evidence is of moderate certainty.
- automated insulin delivery (AID) rather than other forms of insulin delivery. The benefit is small and the evidence is of moderate certainty.
There is no recommendation for or against psychoeducational interventions, which combines education with psychological support. There is not enough evidence to say whether one type of program works better than another. This does not mean that these approaches are harmful or that they do not work. It just means we don’t know yet. We need more research.
What should be offered to adults with type 2 diabetes who are experiencing distress?
Healthcare professionals should offer:
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- psychological, psychoeducational and educational interventions: each in addition to usual care. There is no reason to think that one might be better than another.
CGM is not recommended for reducing distress among adults with type 2 diabetes. The evidence does not show a benefit for this outcome. This does not mean people with type 2 diabetes should not be offered CGM. CGM may still be helpful and recommended for other reasons.
Where the evidence runs out
The Guideline Development Panel is explicit about the limits of the guideline:
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- Most recommendations rest on evidence of low or very low certainty.
- Peer support is not recommended, for reducing diabetes distress specifically, either on its own or in addition to usual care. Peer support may still help in other ways, such as with self-management or for social support. There is simply not enough evidence that it reduces diabetes distress for it to be recommended in this guideline.
- There were no eligible trials at all for education or peer support in type 1 diabetes, or for head-to-head comparisons of psychological versus psychoeducational interventions in either type of diabetes. So, rather than issue an unsupported recommendation, the panel named these as research priorities instead.
- The evidence base also skews heavily towards Europe, North America and the Western Pacific, with few trials from South Asia, the Middle East, Africa or South-East Asia.
- The guideline does not provide advice about diabetes distress among children or adolescents with type 1 diabetes or type 2 diabetes, or among adults with other types of diabetes.
What comes next?
A guideline that sits on a shelf helps no-one. It needs to be implemented into routine practice. Healthcare professionals now need to integrate these recommendations into their workflows to become part of routine clinic appointments and clinical records. Some healthcare professionals may feel they need or want training. The guideline will also need to be adapted to local settings and cultures. Key recommendations will need to be translated into languages other than English.
You can read the full guideline here:
You can read our previous blogs about the guideline here:
Disclosures
I was invited by the EASD to co-lead the EASD Guideline Development Panel (with Prof Richard Holt) in my capacity as Chair of the international PsychoSocial Aspects of Diabetes (PSAD) Study Group. I had also nominated this topic to the EASD. My time in co-leading the guideline was supported by my role as Foundation Director of the ACBRD (with core funding from Diabetes Victoria and Deakin University), as well as some of my personal time on evenings and weekends. The EASD funded my travel to attend two in-person two-day workshops in Germany in February and May 2025, as well as my travel to present the Guideline at the EASD in Vienna in September 2025. The ACBRD has previously led the development of the NDSS Diabetes and Emotional Health practical guide for health professionals, as well as Diabetes Distress eLearning and the LISTEN program.