Social Determinants of Health & Psychosocial Wellbeing

CDCES Certified Diabetes Care and Education Specialist

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1 Introduction & the CDCES Exam

About the CDCES Credential & Current Exam Facts The July 2024 Exam Content Outline & Domain Weights The ADCES7 Self-Care Behaviors Framework

2 Pathophysiology, Classification & Diagnosis

Normal Glucose Regulation and the Pathophysiology of T1DM and T2DM Classification and Diagnostic Criteria Risk Factors and Primary Prevention Treatment Goals and Glycemic Targets

3 Assessment: History, Physical & Data

Health History & Diabetes-Specific Physical Assessment Interpreting Diabetes Measures & Laboratory Data Social Determinants of Health & Psychosocial Wellbeing

4 Assessing Self-Management & Learning

Assessing Self-Management Behaviors & Knowledge Assessing Technology Use, Problem-Solving & Risk-Reduction Behaviors Assessing Learning: Goals, Readiness to Change & Literacy Learning Considerations & Barriers

5 Developing the Education & Care Plan

Developing the Individualized Education/Care Plan Instructional Methods & Person-Centered Teaching Strategies SMART Goals, Behavior-Change Theory & Motivational Interviewing

6 Nutrition Therapy

Nutrition Recommendations & Eating Patterns Carbohydrate Counting & Insulin-Food Timing Fats, Protein, Alcohol & Dietary Supplements Food Labels, Weight Management & Special Nutrition Considerations

7 Physical Activity

Physical Activity Recommendations, Benefits, Challenges & Safety Activity Planning with FITT and Adjusting for Planned & Unplanned Activity

8 Pharmacologic Therapy

Insulin — Types, Pharmacokinetics & Delivery Systems Non-Insulin Glucose-Lowering Agents Guideline-Based Medication Selection Medication Titration & Immunizations for People with Diabetes

9 Monitoring

Glucose Monitoring: SMBG, CGM & Time in Range A1C and Ketone Monitoring Cardiometabolic and Organ System Monitoring

10 Acute Complications

Hypoglycemia Hyperglycemia, DKA, and HHS

11 Chronic Complications

Screening Schedules and Microvascular Disease Macrovascular Disease and Lower-Extremity Foot Care Infections, Dental Disease, Sexual Dysfunction, and Other Comorbidities

12 Special Situations & Populations

Sick-Day Management, Surgery, Travel & Emergency Preparedness Special Populations Across the Lifespan Preconception, Pregnancy, Postpartum & Gestational Diabetes Daily Living, Psychosocial Wellbeing & Safety

13 Evaluation & Documentation

Evaluating Intervention Effectiveness & Outcomes Documentation, Plan Revision & Referral

14 Standards, Guidelines & Professional Practice

National Standards for DSMES and the National DPP Applying Evidence-Based Practice Guidelines Population Health, Health Equity & Advocacy

Social Determinants of Health & Psychosocial Wellbeing

Key Takeaways Explain This Topic AI

ADA-cited studies estimate diabetes distress affects roughly 18-45% of people with diabetes, a construct distinct from but overlapping with clinical depression.

Social determinants of health screened routinely include food insecurity, housing instability, health-insurance/cost barriers, and health, numeracy, and digital literacy, since each independently predicts glycemic outcomes.

Psychological insulin resistance describes fear-driven reluctance to start or intensify insulin and is addressed with targeted, non-judgmental education rather than pressure or repetition of facts.

Diabetes distress and major depressive disorder are separate clinical constructs that can coexist and require different, dedicated screening.

Self-care planning must account for cognitive ability, physical/sensory ability, language, cultural and spiritual beliefs, caregiver dynamics, and major life transitions.

Last updated: July 2026

Social Determinants of Health

Glycemic outcomes are shaped as much by circumstances outside the exam room as by pathophysiology. Assessment must routinely screen social determinants of health (SDOH) rather than assume they will surface on their own:

Economic stability — income, employment, and ability to afford medications, supplies, and healthy food

Food and housing security — food insecurity directly conflicts with consistent carbohydrate intake and medication timing; unstable housing disrupts refrigeration for insulin and storage of supplies

Healthcare access — insurance status, cost-sharing burden, transportation to appointments and pharmacies, and continuity with a care team

Neighborhood and environment — access to safe spaces for activity, grocery access ("food deserts"), and community resources

Health, numeracy, and digital literacy — ability to read labels, count carbohydrates, interpret device screens, and use patient portals or telehealth

A positive screen on any domain should generate a referral (social work, community health worker, patient assistance programs, SNAP/WIC, or a diabetes-specific cost-assistance program) rather than simply being documented and left unaddressed — identifying a barrier without acting on it does not change outcomes. Cost, in particular, deserves a direct question every visit, not an assumption: someone who is rationing insulin or test strips because of price will rarely volunteer that information unprompted, and the resulting "nonadherence" is actually an unaffordable regimen. Asking a simple, non-judgmental question — "In the past year, have you ever had to cut back on medication or supplies because of cost?" — surfaces a barrier that changes the entire treatment plan, from medication selection to referral to a patient-assistance program.

Mental Health and Diabetes Distress

Adjustment to a diabetes diagnosis is a process, not an event, and assessment should ask how the person is coping, not only what they know. Two distinct but overlapping constructs are screened for:

Diabetes distress — the emotional burden of living with diabetes itself: frustration, guilt, burnout, and worry specifically about the disease and its daily demands. ADA-cited estimates place diabetes distress prevalence at roughly 18–45% of people with diabetes, making it common enough to screen for at every diabetes-focused visit, not just at diagnosis.

Clinical depression and anxiety — generalized mood and anxiety disorders that may or may not be diabetes-specific in content, screened with validated general tools (for example, the PHQ-9).

The two are related — each raises the risk of the other, and both are associated with worse self-management and higher A1C — but they are not interchangeable, and an elevated score on one does not substitute for screening the other. A person can be clinically well-adjusted mentally yet still carry significant diabetes distress, and the reverse also occurs. Refer to behavioral health or a diabetes-specific mental-health resource when either screen is positive.

Fears, Myths, and Psychological Insulin Resistance

Assessment should explicitly surface fears and misconceptions, because unaddressed beliefs quietly undermine even a technically correct treatment plan. Common examples include fear of hypoglycemia limiting activity or appropriate medication titration, fear of needles or injection pain, and beliefs that starting insulin means "the diabetes has gotten worse," that it signals personal failure, or that it inevitably causes complications or blindness. This cluster of insulin-specific fear and avoidance is often called psychological insulin resistance , and it is addressed the same way any other fear-driven barrier is addressed: with specific, non-judgmental education that responds to the actual belief rather than simply repeating clinical facts louder.

Self-Care Considerations

Beyond the clinical picture, the individualized plan has to fit the whole person. Assessment should account for:

• Consideration Why it matters
• Cognitive ability Determines complexity of regimen and teaching method the person can safely execute

Physical/sensory ability Vision, dexterity, and hearing affect device use, injection technique, and label reading

Language Education must be delivered in the person's preferred language, not translated on the fly

Cultural and spiritual beliefs Shape food choices, fasting practices (e.g., religious fasting), and beliefs about illness and treatment

Family/caregiver dynamics Determines who else needs education and who supports (or unintentionally undermines) the plan

Life transitions Adolescence, college, new employment, retirement, and aging each change resources, routine, and risk

None of these considerations is a footnote — each directly determines which self-care behaviors are realistic for this person to sustain, which is the bridge from Domain I assessment into the individualized education plan built in Domain II.

Putting It Together at the Visit

A practical way to hold all of this in one visit is to ask open-ended questions before closed ones: "How has managing diabetes been going for you?" surfaces distress, fear, and unspoken cost barriers far more reliably than a checklist read verbatim. Reassess routinely rather than once — diabetes distress can emerge years after a stable diagnosis in response to a new complication, a medication change, or an unrelated life stressor, and a caregiver who was fully engaged at diagnosis can become unavailable after a life transition. Document findings in a way that travels with the person across visits and providers, since a fear or barrier identified once but never revisited is, functionally, a fear or barrier that was never addressed at all.