Level of diabetes education and medical sophistication

Quality of the patient’s diabetes education

Variable engagement of the patient with his/her diabetes

Degree of insulin resistance often secondary to obesity

Genetics

Stress level

Gut microbiome

Variable physical activity and timing of activity—example shift worker challenges or jobs involving unanticipated physical activity superimposed on sedentary activity

Willingness or ability to engage in physical exercise (i.e. 150 minutes per week minimum as per ADA guidelines)

Underlying cognitive or psychiatric comorbid diagnosis (closed head injury, schizophrenia, depression)

Physical impairments (hand dexterity, visual impairment, tremor etc.)

Economics and insurance barriers

Access issues

Vegan and vegetarian diets

Minimal personal food preparation (eating prepared food outside the home)

Poor or no relationships providing support, marginal coping skills with a lifelong chronic illness, frustration and “burnout” especially when perceived personal effort is not leading to improved glycemic control, frank denial of diabetes as a coping mechanism

Language barriers including the deaf and blind

Literacy

Cultural, family, and faith-based practices that impact on caring for their own health with diabetes

Negative experiences with the health care system

Racial and ethnic bias—explicit and implicit; local and personal, national and systemic and gender bias

Age of the patient, age at the time if diagnosis, length of diabetes diagnosis

Family dysfunction