4. Comprehensive MedicalEvaluation and Assessment ofComorbidities: Standards ofMedical Care in Diabetesd2019Diabetes Care 2019;42(Suppl. 1):S34–S45 | https://doi.org/10.2337/dc19-S004

The American Diabetes Association (ADA) “Standards of Medical Care in Diabetes”includes ADA’s current clinical practice recommendations and is intended toprovide the components of diabetes care, general treatment goals and guidelines,and tools to evaluate quality of care. Members of the ADA Professional PracticeCommittee, a multidisciplinary expert committee, are responsible for updating theStandards of Care annually, or more frequently as warranted. For a detaileddescription of ADA standards, statements, and reports, as well as the evidence-grading system for ADA’s clinical practice recommendations, please refer to theStandards of Care Introduction. Readers who wish to comment on the Standardsof Care are invited to do so at professional.diabetes.org/SOC.

PATIENT-CENTERED COLLABORATIVE CARE

Recommendations

4.1 A patient-centered communication style that uses person-centered andstrength-based language and active listening, elicits patient preferencesand beliefs, and assesses literacy, numeracy, and potential barriers to careshould be used to optimize patient health outcomes and health-relatedquality of life. B

4.2 Diabetes care should be managed by a multidisciplinary team that may drawfrom primary care physicians, subspecialty physicians, nurse practitioners,physician assistants, nurses, dietitians, exercise specialists, pharmacists,dentists, podiatrists, and mental health professionals. E

A successful medical evaluation depends on beneficial interactions between thepatient and the care team. The Chronic Care Model (1–3) (see Section 1 “ImprovingCare and Promoting Health in Populations”) is a patient-centered approach tocare that requires a close working relationship between the patient and cliniciansinvolved in treatment planning. People with diabetes should receive health carefrom an interdisciplinary team that may include physicians, nurse practitioners,physician assistants, nurses, dietitians, exercise specialists, pharmacists, dentists,podiatrists, and mental health professionals. Individuals with diabetes must assumean active role in their care. The patient, family or support people, physicians, andhealth care team should together formulate the management plan, which includeslifestyle management (see Section 5 “Lifestyle Management”).The goals of treatment for diabetes are to prevent or delay complications

and maintain quality of life (Fig. 4.1). Treatment goals and plans should be created

Suggested citation: American Diabetes Associa-tion. 4. Comprehensive medical evaluation andassessment of comorbidities: Standards ofMedical Care in Diabetesd2019. Diabetes Care2019;42(Suppl. 1):S34–S45

© 2018 by the American Diabetes Association.Readers may use this article as long as the workis properly cited, the use is educational and notfor profit, and the work is not altered. More infor-mation is available at http://www.diabetesjournals.org/content/license.

American Diabetes Association

S34 Diabetes Care Volume 42, Supplement 1, January 2019

4.MED

ICALEV

ALU

ATIONANDCOMORBIDITIES

with the patients based on their individ-ual preferences, values, and goals. Themanagement plan should take intoaccount the patient’s age, cognitive abil-ities, school/work schedule and condi-tions, health beliefs, support systems,eating patterns, physical activity, socialsituation, financial concerns, cultural fac-tors, literacy and numeracy (mathemat-ical literacy), diabetes complicationsand duration of disease, comorbidities,health priorities, other medical condi-tions, preferences for care, and lifeexpectancy. Various strategies and tech-niques should be used to supportpatients’ self-management efforts, in-cluding providing education on problem-solving skills for all aspects of diabetesmanagement.Provider communicationswithpatients

and families should acknowledge thatmultiple factors impact glycemic manage-ment but also emphasize that collab-oratively developed treatment plansand a healthy lifestyle can significantlyimprove disease outcomes and well-being (4–7). Thus, the goal of provider-patient communication is to establisha collaborative relationship and to

assess and address self-managementbarriers without blaming patients for“noncompliance” or “nonadherence”when the outcomes of self-managementare not optimal (8). The familiar terms“noncompliance” and “nonadherence”denote a passive, obedient role for aperson with diabetes in “following doc-tor’s orders” that is at odds with theactive role people with diabetes take indirecting the day-to-day decision mak-ing, planning, monitoring, evaluation,and problem-solving involved in diabetesself-management. Using a nonjudg-mental approach that normalizes peri-odic lapses in self-management may helpminimize patients’ resistance to report-ing problems with self-management.Empathizing and using active listeningtechniques, such as open-ended ques-tions, reflective statements, and summa-rizing what the patient said, can helpfacilitate communication. Patients’ per-ceptions about their own ability, or self-efficacy, to self-manage diabetes are oneimportant psychosocial factor related toimproved diabetes self-managementand treatment outcomes in diabetes (9–13) and should be a target of ongoing

assessment, patient education, andtreatment planning.

Language has a strong impact on per-ceptions and behavior. The use of em-powering language in diabetes care andeducation can help to inform andmotivatepeople, yet language that shames andjudges may undermine this effort. TheAmerican Diabetes Association (ADA) andAmerican Association of Diabetes Educa-tors consensus report, “The Use of Lan-guage in Diabetes Care and Education,”provides the authors’ expert opinion re-garding the use of language byhealth careprofessionals when speaking or writingaboutdiabetes forpeoplewithdiabetesorfor professional audiences (14). Althoughfurther research is needed to address theimpact of language on diabetes outcomes,the report includes five key consensusrecommendations for language use:

○ Use language that is neutral, nonjudg-mental, and based on facts, actions, orphysiology/biology.

○ Use language that is free from stigma.○ Use language that is strength based,

respectful, and inclusive and that im-parts hope.

Figure 4.1—Decision cycle for patient-centered glycemic management in type 2 diabetes. Adapted from Davies et al. (119).

care.diabetesjournals.org Comprehensive Medical Evaluation and Assessment of Comorbidities S35

○ Use language that fosters collabora-tion between patients and providers.

○ Use language that is person centered(e.g., “person with diabetes” is pre-ferred over “diabetic”).

COMPREHENSIVE MEDICALEVALUATION

Recommendations

4.3 A complete medical evaluationshould be performed at the ini-tial visit to:

○ Confirm thediagnosis and classifydiabetes. B

○ Evaluate for diabetes complica-tions and potential comorbidconditions. B

○ Review previous treatment andrisk factor control in patientswith established diabetes. B

○ Begin patient engagement in theformulation of a care manage-ment plan. B

○ Develop a plan for continuingcare. B

4.4 A follow-up visit should includemost components of the initialcomprehensive medical evalua-tion including: interval medicalhistory, assessment of medication-taking behavior and intolerance/side effects, physical examina-tion, laboratory evaluation as ap-propriate to assess attainmentof A1C and metabolic targets,and assessment of risk for compli-cations, diabetes self-managementbehaviors, nutrition, psychosocialhealth, and the need for referrals,immunizations, or other routinehealth maintenance screening. B

4.5 Ongoing management should beguided by the assessment of di-abetes complications and shareddecision making to set therapeu-tic goals. B

4.6 The 10-year risk of a first athero-sclerotic cardiovascular diseaseevent should be assessed usingthe race- and sex-specific PooledCohort Equations to better strat-ify atherosclerotic cardiovasculardisease risk. B

The comprehensive medical evaluationincludes the initial and follow-up evalua-tions, assessment of complications, psy-chosocial assessment, management ofcomorbid conditions, and engagement

of the patient throughout the process.While a comprehensive list is providedin Table 4.1, in clinical practice, theprovider may need to prioritize the com-ponents of the medical evaluation giventhe available resources and time. Thegoal is to provide the health care teaminformation to optimally support a pa-tient. In addition to the medical history,physical examination, and laboratorytests, providers should assess diabetesself-management behaviors, nutrition,and psychosocial health (see Section 5“Lifestyle Management”) and give guid-ance on routine immunizations. Theassessment of sleep pattern and dura-tion should be considered; a recent meta-analysis found that poor sleep quality,short sleep, and long sleep were associ-ated with higher A1C in people withtype 2 diabetes (15). Interval follow-upvisits should occur at least every 3–6months, individualized to the patient,and then annually.

Lifestyle management and psychoso-cial care are the cornerstones of diabe-tes management. Patients should bereferred for diabetes self-managementeducation and support, medical nutri-tion therapy, and assessment of psy-chosocial/emotional health concerns ifindicated. Patients should receive rec-ommended preventive care services(e.g., immunizations, cancer screening,etc.), smoking cessation counseling, andophthalmological, dental, and podiatricreferrals.

The assessment of risk of acute andchronic diabetes complications and treat-ment planning are key components ofinitial and follow-up visits (Table 4.2).The risk of atherosclerotic cardiovascu-lar disease and heart failure (Section10 “Cardiovascular Disease and RiskManagement”), chronic kidney diseasestaging (Section 11 “MicrovascularComplications and Foot Care”), andrisk of treatment-associated hypogly-cemia (Table 4.3) should be used toindividualize targets for glycemia (Sec-tion 6 “Glycemic Targets”), blood pres-sure, and lipids and to select specificglucose-lowering medication (Section 9“Pharmacologic Approaches to GlycemicTreatment”), antihypertension medica-tion, or statin treatment intensity.

Additional referrals should be ar-ranged as necessary (Table 4.4). Clini-cians should ensure that individualswith diabetes are appropriately screened

for complications and comorbidities. Dis-cussing and implementing an approachto glycemic control with the patient is apart, not the sole goal, of the patientencounter.

Immunizations

Recommendations

4.7 Provide routinely recommendedvaccinations for children andadults with diabetes by age. C

4.8 Annual vaccination against in-fluenza is recommended for allpeople $6 months of age, es-pecially those with diabetes. C

4.9 Vaccination against pneumo-coccal disease, including pneu-mococcal pneumonia, with13-valent pneumococcal conju-gate vaccine (PCV13) is recom-mended for children before age2 years. People with diabetesages 2 through 64 years shouldalso receive 23-valent pneu-mococcal polysaccharide vaccine(PPSV23). At age $65 years,regardless of vaccination his-tory, additional PPSV23 vacci-nation is necessary. C

4.10 Administer a 2- or 3-dose seriesof hepatitis B vaccine, depend-ing on the vaccine, to unvacci-nated adults with diabetes ages18 through 59 years. C

4.11 Consider administering 3-doseseries of hepatitis B vaccine tounvaccinated adults with dia-betes ages $60 years. C

Children and adults with diabetesshould receive vaccinations accordingto age-appropriate recommendations(16,17). The child and adolescent (#18years of age) vaccination schedule isavailable at www.cdc.gov/vaccines/schedules/hcp/imz/child-adolescent.html,and the adult ($19 years of age) vacci-nation schedule is available at www.cdc.gov/vaccines/schedules/hcp/imz/adult.html. These immunization schedules in-clude vaccination schedules specificallyfor children, adolescents, and adultswithdiabetes.

People with diabetes are at higherrisk for hepatitis B infection and aremore likely to develop complicationsfrom influenza and pneumococcal dis-ease. The Centers for Disease Control andPrevention (CDC) Advisory Committee

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Continued on p. S38

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on Immunization Practices (ACIP) recom-mends influenza, pneumococcal, andhepatitis B vaccinations specifically forpeople with diabetes. Vaccinationsagainst tetanus-diphtheria-pertussis,measles-mumps-rubella, human papillo-mavirus, and shingles are also importantfor adults with diabetes, as they are forthe general population.

Influenza

Influenza is a common, preventable in-fectious disease associated with highmortality and morbidity in vulnerablepopulations including the young and

the elderly and people with chronic dis-eases. Influenza vaccination in peoplewith diabetes has been found to signif-icantly reduce influenza and diabetes-related hospital admissions (18).

Pneumococcal Pneumonia

Like influenza, pneumococcal pneumo-nia is a common, preventable disease.People with diabetes are at increasedrisk for the bacteremic form of pneu-mococcal infection and have been re-ported to have a high risk of nosocomialbacteremia, with a mortality rate ashigh as 50% (19). The ADA endorses

recommendations from the CDC ACIPthat adults age $65 years, who are athigher risk for pneumococcal disease,receive an additional 23-valent pneumo-coccal polysaccharide vaccine (PPSV23),regardless of prior pneumococcal vacci-nation history. See detailed recommen-dations at www.cdc.gov/vaccines/hcp/acip-recs/vacc-specific/pneumo.html.

Hepatitis B

Compared with the general population,people with type 1 or type 2 diabeteshave higher rates of hepatitis B. This maybe due to contact with infected blood

S38 Comprehensive Medical Evaluation and Assessment of Comorbidities Diabetes Care Volume 42, Supplement 1, January 2019

or through improper equipment use(glucose monitoring devices or infectedneedles). Because of the higher likeli-hood of transmission, hepatitis B vac-cine is recommended for adults withdiabetes age,60 years. For adults age$60 years, hepatitis B vaccine may beadministered at the discretion of thetreating clinician based on the patient’slikelihood of acquiring hepatitis Binfection.

ASSESSMENT OF COMORBIDITIES

Besides assessing diabetes-related com-plications, clinicians and their patientsneed to be aware of common comorbid-ities that affect people with diabetesand may complicate management(20–24). Diabetes comorbidities are con-ditions that affect people with diabetesmore often than age-matched peoplewithout diabetes. This section includesmany of the common comorbidities ob-served in patientswith diabetes but is notnecessarily inclusive of all the conditionsthat have been reported.

Autoimmune Diseases

Recommendation

4.12 Consider screening patientswith type 1 diabetes for auto-immune thyroid disease andceliac disease soon after diag-nosis. B

People with type 1 diabetes are at in-creased risk for other autoimmunediseases including thyroid disease, pri-mary adrenal insufficiency, celiac disease,autoimmune gastritis, autoimmune hep-atitis, dermatomyositis, and myastheniagravis (25–27). Type 1 diabetes may alsooccur with other autoimmune diseasesin the context of specific genetic dis-orders or polyglandular autoimmune syn-dromes (28). In autoimmune diseases,the immune system fails to maintainself-tolerance to specific peptides withintarget organs. It is likely that many factorstrigger autoimmune disease; however,common triggering factors are knownfor only some autoimmune condi-tions (i.e., gliadin peptides in celiac

disease) (see Section 13 “Children andAdolescents”).

CancerDiabetes is associated with increasedrisk of cancers of the liver, pancreas,endometrium, colon/rectum, breast,and bladder (29). The association mayresult from shared risk factors betweentype 2 diabetes and cancer (older age,obesity, and physical inactivity) but mayalso be due to diabetes-related factors(30), such as underlying disease physiol-ogy or diabetes treatments, althoughevidence for these links is scarce.Patientswith diabetes should be encouraged toundergo recommended age- and sex-appropriate cancer screenings and toreduce their modifiable cancer risk fac-tors (obesity, physical inactivity, andsmoking). New onset of atypical diabetes(lean body habitus, negative family his-tory) in a middle-aged or older patientmay precede the diagnosis of pancre-atic adenocarcinoma (31). However, inthe absence of other symptoms (e.g.,weight loss, abdominal pain), routinescreening of all such patients is notcurrently recommended.

Cognitive Impairment/Dementia

Recommendation

4.13 In people with a history of cog-nitive impairment/dementia, in-tensive glucose control cannotbe expected to remediate def-icits. Treatment should betailored to avoid significanthypoglycemia. B

Diabetes is associated with a significantlyincreased risk and rate of cognitive de-cline and an increased risk of demen-tia (32,33). A recent meta-analysis ofprospective observational studies in peo-ple with diabetes showed 73% in-creased risk of all types of dementia,56% increased risk of Alzheimer de-mentia, and 127% increased risk ofvascular dementia compared with in-dividuals without diabetes (34). Thereverse is also true: people with Alz-heimer dementia are more likely todevelop diabetes than people withoutAlzheimer dementia. In a 15-year pro-spective study of community-dwellingpeople .60 years of age, the presenceof diabetes at baseline significantlyincreased the age- and sex-adjusted

Table 4.3—Assessment of hypoglycemia riskFactors that increase risk of treatment-associated hypoglycemia

c Use of insulin or insulin secretagogues (i.e., sulfonylureas, meglitinides)

c Impaired kidney or hepatic function

c Longer duration of diabetes

c Frailty and older age

c Cognitive impairment

c Impaired counterregulatory response, hypoglycemia unawareness

c Physical or intellectual disability that may impair behavioral response to hypoglycemia

c Alcohol use

c Polypharmacy (especially ACE inhibitors, angiotensin receptor blockers, nonselectiveb-blockers)

See references 114–118.

Table 4.2—Assessment and treatment plan*Assess risk of diabetes complications

c ASCVD and heart failure history

c ASCVDrisk factors (seeTable10.2) and10-yearASCVDrisk assessment

c Staging of chronic kidney disease (see Table 11.1)

c Hypoglycemia risk (Table 4.3)

Goal setting

c Set A1C/blood glucose target

c If hypertension present, establish blood pressure target

c Diabetes self-management goals (e.g., monitoring frequency)

Therapeutic treatment plan

c Lifestyle management

c Pharmacologic therapy (glucose lowering)

c Pharmacologic therapy (cardiovascular disease risk factors and renal)

c Use of glucose monitoring and insulin delivery devices

c Referral to diabetes education and medical specialists (as needed)

ASCVD, atherosclerotic cardiovascular disease. *Assessment and treatment planning is anessential component of initial and all follow-up visits.

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incidence of all-cause dementia, Alz-heimer dementia, and vascular demen-tia compared with rates in those withnormal glucose tolerance (35).

Hyperglycemia

In those with type 2 diabetes, the degreeand duration of hyperglycemia are relatedtodementia.Morerapidcognitivedeclineisassociated with both increased A1C andlongerdurationofdiabetes(34).TheActionto Control Cardiovascular Risk in Diabetes(ACCORD)study foundthateach1%higherA1C level was associated with lower cog-nitive function in individuals with type 2diabetes (36). However, the ACCORDstudy found no difference in cognitiveoutcomes in participants randomlyassigned to intensive and standardglycemic control, supporting the recom-mendation that intensive glucose con-trol should not be advised for theimprovement of cognitive function inindividuals with type 2 diabetes (37).

Hypoglycemia

In type 2 diabetes, severe hypoglycemiais associated with reduced cognitivefunction, and those with poor cognitivefunction have more severe hypoglyce-mia. In a long-term study of older pa-tients with type 2 diabetes, individualswith one or more recorded episode ofsevere hypoglycemia had a stepwise in-crease in risk of dementia (38). Likewise,the ACCORD trial found that as cog-nitive function decreased, the risk ofsevere hypoglycemia increased (39).Tailoring glycemic therapy may help toprevent hypoglycemia in individuals withcognitive dysfunction.

Nutrition

In one study, adherence to the Mediter-ranean diet correlated with improvedcognitive function (40). However, a re-cent Cochrane review found insufficient

evidence to recommend any dietarychange for the prevention or treatmentof cognitive dysfunction (41).

Statins

A systematic review has reported thatdata do not support an adverse effectof statins on cognition (42). The U.S. Foodand Drug Administration postmarket-ing surveillance databases have alsorevealed a low reporting rate for cog-nitive-related adverse events, includingcognitive dysfunction or dementia, withstatin therapy, similar to rates seenwithother commonly prescribed cardiovas-cular medications (42). Therefore, fearof cognitive decline should not be a bar-rier to statin use in individuals with di-abetes and a high risk for cardiovasculardisease.

Nonalcoholic Fatty Liver Disease

Recommendation

4.14 Patients with type 2 diabetes orprediabetes and elevated liverenzymes (alanine aminotrans-ferase) or fatty liver on ultra-sound should be evaluated forpresence of nonalcoholic steato-hepatitis and liver fibrosis. C

Diabetes is associated with the develop-ment of nonalcoholic fatty liver disease,including its more severe manifesta-tions of nonalcoholic steatohepatitis,liver fibrosis, cirrhosis, and hepatocel-lular carcinoma (43). Elevations of he-patic transaminase concentrations areassociated with higher BMI, waist cir-cumference, and triglyceride levels andlower HDL cholesterol levels. Noninva-sive tests, such as elastography or fi-brosis biomarkers, may be used toassess risk of fibrosis, but referral toa liver specialist and liver biopsy maybe required for definitive diagnosis(43a). Interventions that improve met-abolic abnormalities in patients withdiabetes (weight loss, glycemic control,and treatment with specific drugs forhyperglycemia or dyslipidemia) are alsobeneficial for fatty liver disease (44,45).Pioglitazone and vitamin E treatment ofbiopsy-proven nonalcoholic steatohe-patitis have been shown to improveliver histology, but effects on longer-term clinical outcomes are not known(46,47). Treatment with liraglutide andwith sodium–glucose cotransporter 2 in-hibitors (dapagliflozin and empagliflozin)

has also shown some promise in pre-liminary studies, although benefits maybe mediated, at least in part, by weightloss (48–50).

Pancreatitis

Recommendation

4.15 Islet autotransplantation shouldbe considered for patients re-quiring total pancreatectomyfor medically refractory chronicpancreatitis to prevent postsur-gical diabetes. C

Diabetes is linked to diseases of theexocrine pancreas such as pancreatitis,which may disrupt the global architectureor physiology of the pancreas, often re-sulting in both exocrine and endocrinedysfunction. Up to half of patients withdiabetesmay have impaired exocrine pan-creas function (51). People with diabetesare at an approximately twofold higher riskof developing acute pancreatitis (52).

Conversely, prediabetes and/or dia-betes has been found to develop in ap-proximately one-third of patients afteran episode of acute pancreatitis (53),thus the relationship is likely bidirec-tional. Postpancreatitis diabetes mayincludeeither new-onset diseaseor previ-ously unrecognized diabetes (54). Studiesof patients treated with incretin-basedtherapies for diabetes have also reportedthat pancreatitis may occur more fre-quently with these medications, but re-sults have been mixed (55,56).

Islet autotransplantation should beconsidered for patients requiring totalpancreatectomy for medically refractorychronic pancreatitis to prevent postsur-gical diabetes. Approximately one-thirdof patients undergoing total pancreatec-tomy with islet autotransplantation areinsulin free 1 year postoperatively, andobservational studies from differentcenters have demonstrated islet graftfunctionup to a decade after the surgeryin some patients (57–61). Both patientand disease factors should be carefullyconsidered when deciding the indica-tions and timing of this surgery. Surger-ies should be performed in skilledfacilities that have demonstrated exper-tise in islet autotransplantation.

FracturesAge-specific hip fracture risk is signifi-cantly increased in people with both

Table 4.4—Referrals for initial caremanagementc Eye care professional for annual dilatedeye exam

c Family planning for women ofreproductive age

c Registered dietitian for medical nutritiontherapy

c Diabetes self-management educationand support

c Dentist for comprehensive dental andperiodontal examination

c Mental health professional, if indicated

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type 1 (relative risk 6.3) and type 2(relative risk 1.7) diabetes in both sexes(62). Type 1 diabetes is associated withosteoporosis, but in type 2 diabetes, anincreased risk of hip fracture is seendespite higher bone mineral density(BMD) (63). In three large observationalstudies of older adults, femoral neckBMD T score and the World HealthOrganization Fracture Risk AssessmentTool (FRAX) score were associated withhip and nonspine fractures. Fracturerisk was higher in participants with di-abetes compared with those withoutdiabetes for a given T score and ageor for a given FRAX score (64). Providersshould assess fracture history and riskfactors in older patients with diabetesand recommend measurement of BMD ifappropriate for the patient’s age and sex.Fracture prevention strategies for peoplewith diabetes are the same as for thegeneral population and include vitaminD supplementation. For patients withtype 2 diabetes with fracture risk fac-tors, thiazolidinediones (65) and sodium–

glucose cotransporter 2 inhibitors (66)should be used with caution.

Hearing ImpairmentHearing impairment, both in high fre-quency and low/midfrequency ranges, ismore common in people with diabetesthan in those without, perhaps due toneuropathy and/or vascular disease. In aNational Health and Nutrition Examina-tion Survey (NHANES) analysis, hearingimpairmentwas about twice asprevalentin people with diabetes compared withthose without, after adjusting for ageand other risk factors for hearing impair-ment (67).

HIV

Recommendation

4.16 Patients with HIV should bescreened for diabetes and pre-diabetes with a fasting glucosetest before starting antiretrovi-ral therapy, at the timeof switch-ing antiretroviral therapy, and3–6 months after starting orswitching antiretroviral therapy.If initial screening results arenormal, checking fasting glucoseevery year is advised. E

Diabetes risk is increased with certainprotease inhibitors (PIs) and nucleoside

reverse transcriptase inhibitors (NRTIs).New-onset diabetes is estimated to oc-cur in more than 5% of patients infectedwith HIV on PIs, whereas more than 15%may have prediabetes (68). PIs are asso-ciatedwith insulin resistance andmay alsolead to apoptosis of pancreatic b-cells.NRTIs also affect fat distribution (bothlipohypertrophy and lipoatrophy), whichis associated with insulin resistance.

Individuals with HIV are at higher riskfor developing prediabetes and diabe-tes on antiretroviral (ARV) therapies, soa screening protocol is recommended(69). The A1C test may underestimateglycemia in people with HIV and is notrecommended for diagnosis and maypresent challenges for monitoring (70).In those with prediabetes, weight lossthrough healthy nutrition and physicalactivity may reduce the progressiontoward diabetes. Among patients withHIV and diabetes, preventive health careusing an approach similar to that used inpatients without HIV is critical to reducethe risks of microvascular and macro-vascular complications.

For patients with HIV and ARV-associated hyperglycemia, it may be ap-propriate to consider discontinuing theproblematic ARV agents if safe and ef-fective alternatives are available (71).Before making ARV substitutions, care-fully consider the possible effect on HIVvirological control and the potential ad-verse effects of new ARV agents. In somecases, antihyperglycemia agents maystill be necessary.

Low Testosterone in Men

Recommendation

4.17 In men with diabetes who havesymptoms or signs of hypogo-nadism, such as decreased sex-ual desire (libido) or activity, orerectile dysfunction, considerscreeningwith amorning serumtestosterone level. B

Mean levels of testosterone are lower inmen with diabetes compared with age-matched men without diabetes, butobesity is a major confounder (72,73).Treatment in asymptomatic men is con-troversial. Testosterone replacement inmen with symptomatic hypogonadismmay have benefits including improvedsexual function, well-being, muscle massand strength, and bone density (74). In

men with diabetes who have symptomsor signs of low testosterone (hypogonad-ism), a morning total testosterone shouldbe measured using an accurate and reli-able assay. Free or bioavailable testos-terone levels should also be measured inmen with diabetes who have total tes-tosterone levels close to the lower limit,given expected decreases in sex hormone–binding globulin with diabetes. Furthertesting (such as luteinizing hormone andfollicle-stimulating hormone levels) may beneeded to distinguish between primaryand secondary hypogonadism.

Obstructive Sleep ApneaAge-adjusted rates of obstructive sleepapnea, a risk factor for cardiovasculardisease, are significantly higher (4- to10-fold) with obesity, especially withcentral obesity (75). The prevalence ofobstructive sleep apnea in the popula-tion with type 2 diabetes may be as highas 23%, and the prevalence of any sleep-disordered breathing may be as high as58% (76,77). In obese participants en-rolled in the Action for Health in Diabetes(Look AHEAD) trial, it exceeded 80% (78).Patients with symptoms suggestive ofobstructive sleep apnea (e.g., excessivedaytime sleepiness, snoring, witnessedapnea) should be considered for screen-ing (79). Sleep apnea treatment (lifestylemodification, continuous positive airwaypressure, oral appliances, and surgery)significantly improves quality of life andblood pressure control. The evidencefor a treatment effect on glycemic con-trol is mixed (80).

Periodontal DiseasePeriodontal disease is more severe, andmay be more prevalent, in patients withdiabetes than in those without (81,82).Current evidence suggests that perio-dontal disease adversely affects diabetesoutcomes, although evidence for treat-ment benefits remains controversial (24).

Psychosocial/Emotional DisordersPrevalence of clinically significant psy-chopathology diagnoses are considerablymore common in people with diabetesthan in those without the disease (83).Symptoms, both clinical and subclinical,that interfere with the person’s ability tocarry out daily diabetes self-managementtasks must be addressed. Providers shouldconsider an assessment of symptoms of

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depression, anxiety, and disordered eat-ing and of cognitive capacities usingpatient-appropriate standardized/validatedtools at the initial visit, at periodic in-tervals, and when there is a change indisease, treatment, or life circumstance.Including caregivers and familymembersin this assessment is recommended.Diabetes distress is addressed in Section5 “LifestyleManagement,” as this state isvery common and distinct from the psy-chological disorders discussed below(84).

Anxiety Disorders

Recommendations

4.18 Consider screening for anxietyin people exhibiting anxietyor worries regarding diabetescomplications, insulin injectionsor infusion, taking medications,and/or hypoglycemia that in-terfere with self-managementbehaviors and those who ex-press fear, dread, or irrationalthoughts and/or show anxietysymptoms such as avoidancebehaviors, excessive repetitivebehaviors, or social withdrawal.Refer for treatment if anxietyis present. B

4.19 People with hypoglycemia un-awareness, which can co-occurwith fearofhypoglycemia, shouldbe treated using blood glucoseawareness training (or otherevidence-based intervention)to help reestablish awarenessof hypoglycemia and reducefear of hypoglycemia. A

Anxiety symptoms and diagnosabledisorders (e.g., generalized anxietydisorder, body dysmorphic disorder,obsessive-compulsive disorder, spe-cific phobias, and posttraumatic stressdisorder) are common in people withdiabetes (85).The Behavioral Risk Factor Surveil-

lance System (BRFSS) estimated the life-time prevalence of generalized anxietydisorder to be 19.5% in people witheither type 1 or type 2 diabetes (86).Common diabetes-specific concerns in-clude fears related to hypoglycemia (87,88), not meeting blood glucose targets(85), and insulin injections or infusion(89). Onset of complications presentsanother critical point when anxiety can

occur (90). People with diabetes who ex-hibit excessive diabetes self-managementbehaviors well beyond what is prescribedorneededtoachieveglycemic targetsmaybe experiencing symptoms of obsessive-compulsive disorder (91).

General anxiety is a predictor ofinjection-related anxiety and associatedwith fear of hypoglycemia (88,92). Fearof hypoglycemia and hypoglycemia un-awareness often co-occur, and interven-tions aimed at treating one often benefitboth (93). Fear of hypoglycemia mayexplain avoidance of behaviors associ-ated with lowering glucose such as in-creasing insulin doses or frequency ofmonitoring. If fear of hypoglycemia isidentified and a person does not havesymptoms of hypoglycemia, a structuredprogram of blood glucose awarenesstraining delivered in routine clinicalpractice can improve A1C, reduce therate of severe hypoglycemia, and restorehypoglycemia awareness (94,95).

Depression

Recommendations

4.20 Providers should consider an-nual screening of all patientswith diabetes, especially thosewith a self-reported history ofdepression, fordepressive symp-toms with age-appropriate de-pression screening measures,recognizing that further evalu-ation will be necessary for in-dividuals who have a positivescreen. B

4.21 Beginning at diagnosis of com-plications or when there aresignificant changes in medicalstatus, consider assessment fordepression. B

4.22 Referrals for treatment of de-pression should be made tomental health providers withexperience using cognitive be-havioral therapy, interpersonaltherapy, or other evidence-based treatment approachesin conjunction with collaborativecare with the patient’s diabetestreatment team. A

History of depression, current depres-sion, and antidepressant medication useare risk factors for the development oftype 2 diabetes, especially if the individ-ual has other risk factors such as obesity

and family history of type 2 diabetes(96–98). Elevated depressive symptomsand depressive disorders affect one infour patients with type 1 or type 2 di-abetes (99). Thus, routine screening fordepressive symptoms is indicated in thishigh-risk population including peoplewith type 1 or type 2 diabetes, gesta-tional diabetes mellitus, and postpartumdiabetes. Regardless of diabetes type,women have significantly higher ratesof depression than men (100).

Routine monitoring with patient-appropriate validated measures can helpto identify if referral is warranted. Adultpatients with a history of depressivesymptoms or disorder need ongoingmonitoring of depression recurrencewithin the context of routine care (96).Integrating mental and physical healthcare can improve outcomes. When apatient is in psychological therapy (talktherapy), the mental health providershould be incorporated into the diabe-tes treatment team (101).

Disordered Eating Behavior

Recommendations

4.23 Providers should considerreevaluating the treatment reg-imen of people with diabeteswho present with symptoms ofdisordered eating behavior, aneating disorder, or disruptedpatterns of eating. B

4.24 Consider screening for disor-dered or disrupted eating usingvalidated screening measureswhen hyperglycemia and weightloss are unexplained based onself-reported behaviors relatedto medication dosing, mealplan, and physical activity. Inaddition, a review of the med-ical regimen is recommendedto identify potential treatment-related effects on hunger/caloric intake. B

Estimated prevalence of disordered eat-ing behaviors and diagnosable eatingdisorders in people with diabetes varies(102–104). For people with type 1 di-abetes, insulin omission causing glycos-uria in order to lose weight is the mostcommonly reported disordered eatingbehavior (105,106); in people withtype 2 diabetes, bingeing (excessive foodintake with an accompanying sense of

S42 Comprehensive Medical Evaluation and Assessment of Comorbidities Diabetes Care Volume 42, Supplement 1, January 2019

loss of control) is most commonly re-ported. For people with type 2 diabe-tes treated with insulin, intentionalomission is also frequently reported(107). People with diabetes and diagnos-able eating disorders have high rates ofcomorbid psychiatric disorders (108).People with type 1 diabetes and eatingdisorders have high rates of diabetesdistress and fear of hypoglycemia (109).When evaluating symptoms of disor-

dered or disrupted eating in peoplewith diabetes, etiology and motivationfor the behavior should be considered(104,110). Adjunctive medication such asglucagon-like peptide 1 receptor agonists(111) may help individuals not only tomeet glycemic targets but also to regu-late hunger and food intake, thus havingthe potential to reduce uncontrollablehunger and bulimic symptoms.

Serious Mental Illness

Recommendations

4.25 Annually screen people whoare prescribed atypical antipsy-chotic medications for predia-betes or diabetes. B

4.26 If a second-generation antipsy-chotic medication is prescribedfor adolescents or adults withdiabetes, changes in weight,glycemic control, and choles-terol levels should be carefullymonitored and the treatmentregimen should be reassessed. C

4.27 Incorporate monitoring of dia-betes self-care activities intotreatment goals in people withdiabetes and serious mentalillness. B

Studiesof individualswith seriousmentalillness, particularly schizophrenia andother thought disorders, show signifi-cantly increased rates of type 2 diabetes(112). People with schizophrenia shouldbemonitored for type2diabetesbecauseof the known comorbidity. Disorderedthinking and judgment can be expectedtomake it difficult to engage in behaviorsthat reduce risk factors for type 2 di-abetes, such as restrained eating forweight management. Coordinated man-agement of diabetes or prediabetes andseriousmental illness is recommended toachieve diabetes treatment targets. Inaddition, those taking second-genera-tion (atypical) antipsychotics, such as

olanzapine, require greater monitoringbecause of an increase in risk of type 2diabetes associated with this medica-tion (113).

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