AN: Conceptualization, Methodology, Data curation, Formal analysis, Investigation, Visualization, Writing—original draft, Writing—review & editing, Project administration. BAM: Investigation, Resources, Validation, Supervision, Writing—review & editing. Both authors read and approved the final manuscript.
Conflicts of interest
The authors declare that they have no conflicts of interest.
Ethical approval
The intervention described in this report was delivered as part of routine clinical care rather than a predefined research program. All behavioral counseling and medication adjustments were components of standard management for uncontrolled diabetes in this primary care setting. The institutional framework determined that the case series met criteria for exemption from formal ethical review because the analysis was retrospective, all data were de-identified, and no procedures exceeded routine practice. No experimental treatments, investigational agents, or non-standard behavioral protocols were administered. The article complies with the Declaration of Helsinki (2013 version).
Consent to participate
Informed consent to participate in the study was obtained from all participants.
Consent to publication
Not applicable.
Availability of data and materials
De-identified data underlying this case series are available from the corresponding author upon reasonable request.
Open Exploration maintains a neutral stance on jurisdictional claims in published institutional affiliations and maps. All opinions expressed in this article are the personal views of the author(s) and do not represent the stance of the editorial team or the publisher.
References
Magliano DJ, Boyko EJ; IDF Diabetes Atlas 10th edition scientific committee. IDF DIABETES ATLAS [Internet].In: Chapter 1 What is diabetes? 10th ed. Brussels: International Diabetes Federation; 2021.
Świątoniowska-Lonc N, Tański W, Polański J, Jankowska-Polańska B, Mazur G. Psychosocial Determinants of Treatment Adherence in Patients with Type 2 Diabetes - A Review.Diabetes Metab Syndr Obes. 2021;14:2701–15. [DOI] [PubMed] [PMC]
Donnan PT, MacDonald TM, Morris AD. Adherence to prescribed oral hypoglycaemic medication in a population of patients with Type 2 diabetes: a retrospective cohort study.Diabet Med. 2002;19:279–84. [DOI] [PubMed]
Piragine E, Petri D, Martelli A, Calderone V, Lucenteforte E. Adherence to Oral Antidiabetic Drugs in Patients with Type 2 Diabetes: Systematic Review and Meta-Analysis.J Clin Med. 2023;12:1981. [DOI] [PubMed] [PMC]
Abbas Q, Latif S, Habib HA, Shahzad S, Sarwar U, Shahzadi M, et al. Cognitive behavior therapy for diabetes distress, depression, health anxiety, quality of life and treatment adherence among patients with type-II diabetes mellitus: a randomized control trial.BMC Psychiatry. 2023;23:86. [DOI] [PubMed] [PMC]
Vlachou E, Ntikoudi A, Owens DA, Nikolakopoulou M, Chalimourdas T, Cauli O. Effectiveness of cognitive behavioral therapy-based interventions on psychological symptoms in adults with type 2 diabetes mellitus: An update review of randomized controlled trials.J Diabetes Complications. 2022;36:108185. [DOI] [PubMed]
Das AK, Saboo B, Unnikrishnan AG. Current Practices and Gaps in Management of Dyslipidemia in Type 2 Diabetes Mellitus (T2DM) in Accordance with American Diabetes Association (ADA) Guidelines: A Subset Analysis from a Real-World, Cross-Sectional Observational Study (LEADD Study).Diabetes Metab Syndr Obes. 2021;14:2693–700. [DOI] [PubMed] [PMC]
Colling C, Atlas SJ, Wexler DJ. Application of 2021 American Diabetes Association Glycemic Treatment Clinical Practice Recommendations in Primary Care.Diabetes Care. 2021;44:1443–6. [DOI] [PubMed] [PMC]
Uchendu C, Blake H. Effectiveness of cognitive-behavioural therapy on glycaemic control and psychological outcomes in adults with diabetes mellitus: a systematic review and meta-analysis of randomized controlled trials.Diabet Med. 2017;34:328–39. [DOI] [PubMed]
Li C, Xu D, Hu M, Tan Y, Zhang P, Li G, et al. A systematic review and meta-analysis of randomized controlled trials of cognitive behavior therapy for patients with diabetes and depression.J Psychosom Res. 2017;95:44–54. [DOI] [PubMed]
American Diabetes Association Professional Practice Committee. 9. Pharmacologic Approaches to Glycemic Treatment: Standards of Care in Diabetes-2025.Diabetes Care. 2025;48:S181–206. [DOI] [PubMed] [PMC]
Heerspink HJL, Stefánsson BV, Correa-Rotter R, Chertow GM, Greene T, Hou F, et al.; DAPA-CKD Trial Committees and Investigators. Dapagliflozin in Patients with Chronic Kidney Disease.N Engl J Med. 2020;383:1436–46. [DOI] [PubMed]
Aroda VR, Edelstein SL, Goldberg RB, Knowler WC, Marcovina SM, Orchard TJ, et al.; Diabetes Prevention Program Research Group. Long-term Metformin Use and Vitamin B12 Deficiency in the Diabetes Prevention Program Outcomes Study.J Clin Endocrinol Metab. 2016;101:1754–61. [DOI] [PubMed] [PMC]
American Diabetes Association Professional Practice Committee. Summary of revisions: Standards of Care in Diabetes-2025.Diabetes Care. 2025;48:S6–13. [DOI] [PubMed] [PMC]
Gerstein HC, Yale J, Harris SB, Issa M, Stewart JA, Dempsey E. A randomized trial of adding insulin glargine vs. avoidance of insulin in people with Type 2 diabetes on either no oral glucose-lowering agents or submaximal doses of metformin and/or sulphonylureas. The Canadian INSIGHT (Implementing New Strategies with Insulin Glargine for Hyperglycaemia Treatment) Study.Diabet Med. 2006;23:736–42. [DOI] [PubMed]
Pavlou V, Cienfuegos S, Lin S, Ezpeleta M, Ready K, Corapi S, et al. Effect of Time-Restricted Eating on Weight Loss in Adults With Type 2 Diabetes: A Randomized Clinical Trial.JAMA Netw Open. 2023;6:e2339337. [DOI] [PubMed] [PMC]
Sarmento RA, Antonio JP, de Miranda IL, Nicoletto BB, de Almeida JC. Eating Patterns and Health Outcomes in Patients With Type 2 Diabetes.J Endocr Soc. 2017;2:42–52. [DOI] [PubMed] [PMC]
Campbell AP. DASH Eating Plan: An Eating Pattern for Diabetes Management.Diabetes Spectr. 2017;30:76–81. [DOI] [PubMed] [PMC]
Wheeler ML, Dunbar SA, Jaacks LM, Karmally W, Mayer-Davis EJ, Wylie-Rosett J, et al. Macronutrients, food groups, and eating patterns in the management of diabetes: a systematic review of the literature, 2010.Diabetes Care. 2012;35:434–45. [DOI] [PubMed] [PMC]
Papamichou D, Panagiotakos DB, Itsiopoulos C. Dietary patterns and management of type 2 diabetes: A systematic review of randomised clinical trials.Nutr Metab Cardiovasc Dis. 2019;29:531–43. [DOI] [PubMed]
Morales-Suarez-Varela M, Sánchez EC, Peraita-Costa I, Llopis-Morales A, Soriano JM. Intermittent Fasting and the Possible Benefits in Obesity, Diabetes, and Multiple Sclerosis: A Systematic Review of Randomized Clinical Trials.Nutrients. 2021;13:3179. [DOI] [PubMed] [PMC]
Albosta M, Bakke J. Intermittent fasting: is there a role in the treatment of diabetes? A review of the literature and guide for primary care physicians.Clin Diabetes Endocrinol. 2021;7:3. [DOI] [PubMed] [PMC]
Santos HO. Intermittent fasting in the management of diabetes: a review of glycemic control and safety.Nutr Rev. 2024;82:1437–43. [DOI] [PubMed]
Dyńka D, Rodzeń Ł, Rodzeń M, Łojko D, Deptuła A, Grzywacz Ż, et al. Intermittent fasting in the treatment of type 2 diabetes.Front Nutr. 2025;12:1629154. [DOI] [PubMed] [PMC]
Kahleova H, Belinova L, Malinska H, Oliyarnyk O, Trnovska J, Skop V, et al. Eating two larger meals a day (breakfast and lunch) is more effective than six smaller meals in a reduced-energy regimen for patients with type 2 diabetes: a randomised crossover study.Diabetologia. 2014;57:1552–60. [DOI] [PubMed] [PMC]
Goldenberg JZ, Day A, Brinkworth GD, Sato J, Yamada S, Jönsson T, et al. Efficacy and safety of low and very low carbohydrate diets for type 2 diabetes remission: systematic review and meta-analysis of published and unpublished randomized trial data.BMJ. 2021;372:m4743. [DOI] [PubMed] [PMC]
Rangaswami J, Bhalla V, de Boer IH, Staruschenko A, Sharp JA, Singh RR, et al.; American Heart Association Council on the Kidney in Cardiovascular Disease; Council on Arteriosclerosis, Thrombosis and Vascular Biology, Council on Cardiovascular and Stroke Nursing, Council on Clinical Cardiology, and Council on Lifestyle and Cardiometabolic Health. Cardiorenal Protection With the Newer Antidiabetic Agents in Patients With Diabetes and Chronic Kidney Disease: A Scientific Statement From the American Heart Association.Circulation. 2020;142:e265–86. [DOI] [PubMed]
Wang Y, Zeng Z, Ding J, Yuan R, Wang R, Zhang Y, et al. Fear of hypoglycaemia among patients with type 2 diabetes mellitus: a cross-sectional study.Sci Rep. 2021;11:7971. [DOI] [PubMed] [PMC]
Tomovic K, Lazarevic J, Kocic G, Deljanin-Ilic M, Anderluh M, Smelcerovic A. Mechanisms and pathways of anti-inflammatory activity of DPP-4 inhibitors in cardiovascular and renal protection.Med Res Rev. 2019;39:404–22. [DOI] [PubMed]
Wang H, Lin S, Hung S, Chiou Y, Hsu W, Chang C, et al. Renal Protective Effect of Metformin in Type 2 Diabetes Patients.J Clin Endocrinol Metab. 2025;110:1224–34. [DOI] [PubMed]
Esposito K, Giugliano F, Palo CD, Giugliano G, Marfella R, D’Andrea F, et al. Effect of lifestyle changes on erectile dysfunction in obese men: a randomized controlled trial.JAMA. 2004;291:2978–84. [DOI] [PubMed]
Wing RR, Rosen RC, Fava JL, Bahnson J, Brancati F, Gendrano INC, et al. Effects of weight loss intervention on erectile function in older men with type 2 diabetes in the Look AHEAD trial.J Sex Med. 2010;7:156–65. [DOI] [PubMed] [PMC]
Riddle MC, Cefalu WT, Evans PH, Gerstein HC, Nauck MA, Oh WK, et al. Consensus Report: Definition and Interpretation of Remission in Type 2 Diabetes.J Clin Endocrinol Metab. 2022;107:1–9. [DOI] [PubMed] [PMC]
Sherifali DT, Racey ME, Greenway MK, Alliston PE, Ali MU, Gerstein HC, et al. Type 2 Diabetes Remission: A Systematic Review and Meta-analysis of Nonsurgical Randomized Controlled Trials.Diabetes Care. 2025;48:2181–91. [DOI] [PubMed] [PMC]
Lean ME, Leslie WS, Barnes AC, Brosnahan N, Thom G, McCombie L, et al. Primary care-led weight management for remission of type 2 diabetes (DiRECT): an open-label, cluster-randomised trial.Lancet. 2018;391:541–51. [DOI] [PubMed]
Lean MEJ, Leslie WS, Barnes AC, Brosnahan N, Thom G, McCombie L, et al. Durability of a primary care-led weight-management intervention for remission of type 2 diabetes: 2-year results of the DiRECT open-label, cluster-randomised trial.Lancet Diabetes Endocrinol. 2019;7:344–55. [DOI] [PubMed]
Yang X, Li Z, Sun J. Effects of Cognitive Behavioral Therapy-Based Intervention on Improving Glycaemic, Psychological, and Physiological Outcomes in Adult Patients With Diabetes Mellitus: A Meta-Analysis of Randomized Controlled Trials.Front Psychiatry. 2020;11:711. [DOI] [PubMed] [PMC]
Dong N, Wang X, Yang L. The short- and long-term effects of cognitive behavioral therapy on the glycemic control of diabetic patients: a systematic review and meta-analysis.Biopsychosoc Med. 2023;17:18. [DOI] [PubMed] [PMC]
Marie M, Battat M. Access Limitation to Health Services in Palestine and its Consequences on Palestinian Mental Health and Wellbeing: Literature Review.Research Square rs.3.rs-167116 [Preprint]. 2021 [cited 2025 Aug 4]. Available from: https://www.researchsquare.com/article/rs-167116/v2
Radwan M, Akbari Sari A, Rashidian A, Takian A, Elsous A, Abou-Dagga S. Factors hindering the adherence to clinical practice guideline for diabetes mellitus in the Palestinian primary healthcare clinics: a qualitative study.BMJ Open. 2018;8:e021195. [DOI] [PubMed] [PMC]
Mikhael EM, Hassali MA, Hussain SA, Nouri AI, Shawky N. Pharmacist-led interventional programs for diabetic patients in Arab countries: A systematic review study.Int J Diabetes Dev Ctries. 2019;39:600–10. [DOI]
Islam MA, El-Dahiyat F, Nouri A, Alefan Q, Naqvi AA. Validation of the Arabic version of the general medication adherence scale in patients with type 2 diabetes mellitus in Jordan.Front Pharmacol. 2023;14:1194672. [DOI] [PubMed] [PMC]
American Diabetes Association. Standards of Care in Diabetes-2023 Abridged for Primary Care Providers.Clin Diabetes. 2022;41:4–31. [DOI] [PubMed] [PMC]
Simó R, Franch-Nadal J, Vlacho B, Real J, Amado E, Flores J, et al. Rapid Reduction of HbA1c and Early Worsening of Diabetic Retinopathy: A Real-world Population-Based Study in Subjects With Type 2 Diabetes.Diabetes Care. 2023;46:1633–9. [DOI] [PubMed]
Nouri AI, Abdi AM, Hassali MA. Synopsis of Research Methodologies: A Brief Guide for Pharmacists.JPRI. 2018;24:1–16. [DOI]
