Medical Evaluation
Recommendation
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
Classify diabetes
Detect diabetes complications
Review previous treatment and risk factor control in patients with established diabetes
Assist in formulating a management plan
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.
Medical history |
• Age and characteristics of onset of diabetes (e.g., DKA, asymptomatic laboratory finding) |
• Eating patterns, physical activity habits, nutritional status, and weight history; growth and development in children and adolescents |
• Presence of common comorbidities, psychosocial problems, and dental disease |
• Diabetes education history |
• Review of previous treatment regimens and response to therapy (A1C records) |
• Current treatment of diabetes, including medications, medication adherence and barriers thereto, meal plan, physical activity patterns, and readiness for behavior change |
• Results of glucose monitoring and patient’s use of data |
• DKA frequency, severity, and cause |
• Hypoglycemic episodes |
• Hypoglycemia awareness |
• Any severe hypoglycemia: frequency and cause |
• History of diabetes-related complications |
• Microvascular: retinopathy, nephropathy, neuropathy (sensory, including history of foot lesions; autonomic, including sexual dysfunction and gastroparesis) |
• Macrovascular: coronary heart disease, cerebrovascular disease, and peripheral arterial disease |
Physical examination |
• Height, weight, BMI |
• Blood pressure determination, including orthostatic measurements when indicated |
• Fundoscopic examination |
• Thyroid palpation |
• Skin examination (for acanthosis nigricans and insulin injection sites) |
• Comprehensive foot examination |
• Inspection |
• Palpation of dorsalis pedis and posterior tibial pulses |
• Presence/absence of patellar and Achilles reflexes |
• Determination of proprioception, vibration, and monofilament sensation |
Laboratory evaluation |
• A1C, if results not available within past 3 months |
• If not performed/available within past year |
• Fasting lipid profile, including total, LDL, and HDL cholesterol and triglycerides, as needed |
• Liver function tests |
• Test for urine albumin excretion with spot urine albumin-to-creatinine ratio |
• Serum creatinine and calculated glomerular filtration rate |
• TSH in type 1 diabetes, dyslipidemia, or women over age 50 years |
Referrals |
• Eye care professional for annual dilated eye exam |
• Family planning for women of reproductive age |
• Registered dietitian for medical nutrition therapy |
• DSME/DSMS |
• Dentist for comprehensive periodontal examination |
• Mental health professional, if needed |
Medical history |
• Age and characteristics of onset of diabetes (e.g., DKA, asymptomatic laboratory finding) |
• Eating patterns, physical activity habits, nutritional status, and weight history; growth and development in children and adolescents |
• Presence of common comorbidities, psychosocial problems, and dental disease |
• Diabetes education history |
• Review of previous treatment regimens and response to therapy (A1C records) |
• Current treatment of diabetes, including medications, medication adherence and barriers thereto, meal plan, physical activity patterns, and readiness for behavior change |
• Results of glucose monitoring and patient’s use of data |
• DKA frequency, severity, and cause |
• Hypoglycemic episodes |
• Hypoglycemia awareness |
• Any severe hypoglycemia: frequency and cause |
• History of diabetes-related complications |
• Microvascular: retinopathy, nephropathy, neuropathy (sensory, including history of foot lesions; autonomic, including sexual dysfunction and gastroparesis) |
• Macrovascular: coronary heart disease, cerebrovascular disease, and peripheral arterial disease |
Physical examination |
• Height, weight, BMI |
• Blood pressure determination, including orthostatic measurements when indicated |
• Fundoscopic examination |
• Thyroid palpation |
• Skin examination (for acanthosis nigricans and insulin injection sites) |
• Comprehensive foot examination |
• Inspection |
• Palpation of dorsalis pedis and posterior tibial pulses |
• Presence/absence of patellar and Achilles reflexes |
• Determination of proprioception, vibration, and monofilament sensation |
Laboratory evaluation |
• A1C, if results not available within past 3 months |
• If not performed/available within past year |
• Fasting lipid profile, including total, LDL, and HDL cholesterol and triglycerides, as needed |
• Liver function tests |
• Test for urine albumin excretion with spot urine albumin-to-creatinine ratio |
• Serum creatinine and calculated glomerular filtration rate |
• TSH in type 1 diabetes, dyslipidemia, or women over age 50 years |
Referrals |
• Eye care professional for annual dilated eye exam |
• Family planning for women of reproductive age |
• Registered dietitian for medical nutrition therapy |
• DSME/DSMS |
• Dentist for comprehensive periodontal examination |
• Mental health professional, if needed |
DKA, diabetic ketoacidosis; DSMS, diabetes self-management support; TSH, thyroid-stimulating hormone.
Management Plan
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.
Common Comorbid Conditions
Recommendation
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).
Depression
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.
Obstructive Sleep Apnea
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).
Fatty Liver Disease
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).
Cancer
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).
Fractures
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.
Cognitive Impairment
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.
Low Testosterone in Men
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
Hearing Impairment
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).
Suggested citation: American Diabetes Association. Initial evaluation and diabetes management planning. Sec. 3. In Standards of Medical Care in Diabetes—2015. Diabetes Care 2015;38(Suppl. 1):S17–S19