**Background:** Diabetes mellitus is a long-term illness profoundly affected by lifestyle, requiring a holistic approach that goes beyond glycemic control. Holistic care in clinical medicine focuses on overall health and well-being, encompassing clinical, human, and societal contexts. This perspective is grounded in the contextual mindfulness of clinicians. The paper argues that factors such as health literacy, access to care, family support, living conditions, availability of whole foods, home-cooked meals, household support, access to parks, safe walking paths, and clean neighborhoods all influence diabetes outcomes. Children, women who are pregnant, ethnic minorities, those who are older, individuals with extreme obesity, rural residents, and those with comorbid mental health conditions require special consideration regarding these contextual factors.
**Methods:** This is a narrative review article that synthesizes existing literature and clinical expertise to provide practical guidelines for a holistic approach to diabetes care. The authors present structured frameworks including a table of contextual factors to elicit during clinical interviews, covering domains such as social factors (diabetes distress, cost of care, access to care, stress, family support), lifestyle (physical activity, nutrition), patient perspective (ideas, concerns, expectations), and motivational interviewing techniques (goal setting, affirmation, rephrasing/summarizing, change talk). The paper also provides a curated table of selected resources for diabetes care including websites, apps, printable materials, videos, meal plans, online communities, decision aids, and calculators.
**Key Results:** The paper identifies several critical findings from the literature: Diabetes distress is more common in patients with type 1 diabetes and insulin-treated type 2 diabetes. Higher diabetes distress correlates with worse glycemic control and lower overall well-being. However, a normal HbA1c level does not rule out diabetes distress. Diabetes distress is more common than and can be confused with depression. Increasing pill burden and frequent glucose monitoring worsen distress. The authors note that excessive fingerstick glucose testing may be less useful in patients with stable type 2 diabetes receiving oral medication. Simply informing patients about their HbA1c results, without discussing behavioral issues, does not seem to improve lifestyle choices. The paper emphasizes that monitoring clinical parameters such as blood pressure, waist circumference, vision (fundoscopy, visual acuity, and peripheral vision), and foot sensation may be more useful in resource-constrained settings. Although less effective than an in-person interaction, follow-up via telephone can reduce the burden of clinic visits.
**Clinical Implications:** The authors provide several actionable recommendations for clinical practice. First, clinicians should ask about, document, and consider nonmedical factors (social determinants of health) in treatment planning. Second, patient-centered communication should be the foundation of a trust-based relationship, with core skills including eliciting the patient's agenda and priorities, asking open-ended questions, active listening, responding with empathy and non-verbal gestures, and exploring the patient's perspective. Third, physicians should be more mindful of the costs borne by patients and their healthcare systems, as overburdened care can lead to discontinuation of essential interventions. Fourth, the target HbA1c level must be tailored according to context, considering factors such as frailty (but not necessarily age), risk of hypoglycemia, support from household family members, and food security. An aggressive target may not be justifiable in an individual who is frail with a limited life expectancy. Fifth, clinicians should use motivational interviewing techniques that create a nonthreatening space for patients to express their issues, avoiding assigning blame for poor disease outcomes on patients. The clinician's role mimics that of a coach, using non-directive techniques such as patient engagement, nonjudgmental listening, exploring ambivalence about behavioral change, encouraging patient-led goal setting, and evoking patient motivation to change. Not all clinic visits should include lifestyle counseling, and physicians should be mindful of the patient's emotional state when handling conversations about change. Emotionally distressed patients may not be able to assimilate detailed instructions, and in these situations, the physician takes a 'backseat' and lets the patient express his/her ideas, fears, desires, and hopes.