3. Initial Evaluation and Diabetes Management Planning

• Consider screening those with type 1 diabetes for autoimmune diseases (e.g., thyroid dysfunction, celiac disease) as appropriate. E

A complete medical evaluation should be performed at the initial visit to

1. Classify diabetes

2. Detect diabetes complications

3. Review previous treatment and risk factor control in patients with established diabetes

4. Assist in formulating a management plan

5. Provide a basis for continuing care

Laboratory tests appropriate to the evaluation of each patient’s medical condition should be completed. A focus on the components of comprehensive care (Table 3.1) will enable the health care team to optimally manage the patient with diabetes. Adults who develop type 1 diabetes can develop additional autoimmune disorders, although their risk is lower than that in children and adolescents with type 1 diabetes. For additional details on autoimmune conditions, see Section 11. Children and Adolescents.

People with diabetes should receive medical care from a collaborative, integrated team with expertise in diabetes. This team may include physicians, nurse practitioners, physician’s assistants, nurses, dietitians, pharmacists, and mental health professionals. Individuals with diabetes must also assume an active role in their care.

The management plan should be written with input from the patient and family, the physician, and other members of the health care team. Diabetes self-management education (DSME) and ongoing diabetes support should be integral components of the management plan. Various strategies and techniques should be used to enable patients to self-manage diabetes, including providing education on problem-solving skills for all aspects of diabetes management. Treatment goals and plans should be individualized and take patient preferences into account. In developing the plan, consideration should be given to the patient’s age, school/work schedule and conditions, physical activity, eating patterns, social situation, cultural factors, presence of diabetes complications, health priorities, and other medical conditions.

• Consider assessing for and addressing common comorbid conditions (e.g., depression, obstructive sleep apnea) that may complicate diabetes management. B

Improved disease prevention and treatment efficacy means that patients with diabetes are living longer, often with multiple comorbidities requiring complicated medical regimens (1). Obesity, hypertension, and dyslipidemia are the most commonly appreciated comorbidities. However, concurrent conditions, such as heart failure, depression, anxiety, and arthritis, are found at higher rates in people with diabetes than in age-matched people without diabetes and often complicate diabetes management. These concurrent conditions present clinical challenges related to polypharmacy, prevalent symptoms, and complexity of care (2–5).

As discussed in Section 4. Foundations of Care, depression, anxiety, and other mental health symptoms are highly prevalent in people with diabetes and are associated with worse outcomes.

Age-adjusted rates of obstructive sleep apnea, a risk factor for cardiovascular disease, are significantly higher (4- to 10-fold) with obesity, especially with central obesity, in men and women (6). The prevalence in general populations with type 2 diabetes may be up to 23% (7) and in obese participants enrolled in the Look AHEAD trial exceeded 80% (8). Treatment of sleep apnea significantly improves quality of life and blood pressure control. The evidence for a treatment effect on glycemic control is mixed (9).

Unexplained elevations of hepatic transaminase concentrations are significantly associated with higher BMI, waist circumference, triglycerides, and fasting insulin and with lower HDL cholesterol. In a prospective analysis, diabetes was significantly associated with incident nonalcoholic chronic liver disease and with hepatocellular carcinoma (10). Interventions that improve metabolic abnormalities in patients with diabetes (weight loss, glycemic control, and treatment with specific drugs for hyperglycemia or dyslipidemia) are also beneficial for fatty liver disease (11).

Diabetes (possibly only type 2 diabetes) is associated with increased risk of cancers of the liver, pancreas, endometrium, colon/rectum, breast, and bladder (12). The association may result from shared risk factors between type 2 diabetes and cancer (obesity, older age, and physical inactivity), but may also be due to hyperinsulinemia or hyperglycemia (13). Patients with diabetes should be encouraged to undergo recommended age- and sex-appropriate cancer screenings and to reduce their modifiable cancer risk factors (obesity, smoking, and physical inactivity).

Age-matched hip fracture risk is significantly increased in both type 1 (summary relative risk [RR] 6.3) and type 2 diabetes (summary RR 1.7) in both sexes (14). Type 1 diabetes is associated with osteoporosis, but in type 2 diabetes an increased risk of hip fracture is seen despite higher bone mineral density (BMD) (15). In three large observational studies of older adults, femoral neck BMD T score and the WHO Fracture Risk Algorithm (FRAX) score were associated with hip and nonspine fracture, although fracture risk was higher in participants with diabetes compared with those without diabetes for a given T score and age or for a given FRAX score (16). It is appropriate to assess fracture history and risk factors in older patients with diabetes and recommend BMD testing if appropriate for the patient’s age and sex. Prevention strategies are the same as for the general population. For type 2 diabetic patients with fracture risk factors, avoiding thiazolidinediones is warranted.

Diabetes is associated with a significantly increased risk, and rate, of cognitive decline and with increased risk of dementia (17,18). In a 15-year prospective study of community-dwelling people over the age of 60 years, the presence of diabetes at baseline significantly increased the age- and sex-adjusted incidence of all-cause dementia, Alzheimer disease, and vascular dementia compared with rates in those with normal glucose tolerance (19). In a substudy of the Action to Control Cardiovascular Risk in Diabetes (ACCORD) clinical trial, there were no differences in cognitive outcomes between intensive and standard glycemic control, although there was significantly less of a decrement in total brain volume, as measured by MRI, in participants in the intensive arm (20). The effects of hyperglycemia and insulin on the brain are areas of intense research interest.

Mean levels of testosterone are lower in men with diabetes compared with age-matched men without diabetes, but obesity is a major confounder (21). Treatment in asymptomatic men is controversial. The evidence that testosterone replacement affects outcomes is mixed, and recent guidelines suggest that testing and treating men without symptoms are not recommended (22).

Periodontal disease is more severe, but not necessarily more prevalent, in patients with diabetes than in those without (23). Current evidence suggests that periodontal disease adversely affects diabetes outcomes, although evidence for treatment benefits remains controversial (5).

Hearing impairment, both in high frequency and low/mid frequency ranges, is more common in people with diabetes than in those without, perhaps due to neuropathy and/or vascular disease. In a National Health and Nutrition Examination Survey (NHANES) analysis, hearing impairment was about twice as prevalent in people with diabetes compared with those without, after adjusting for age and other risk factors for hearing impairment (24).