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1.0.0.0 Pa­tient-‍Cen­tered Col­lab­o­ra­tive Care

The Amer­i­can Di­a­betes As­so­ci­a­tion (ADA) “Stan­dards of Med­i­cal Care in Di­a­betes” in­cludes ADA’s cur­rent clin­i­cal prac­tice rec­om­men­da­tions and is in­tend­ed to pro­vide the com­po­nents of di­a­betes care, gen­er­al treat­ment goals and guide­lines, and tools to eval­u­ate qual­i­ty of care. Mem­bers of the ADA Pro­fes­sion­al Prac­tice Com­mit­tee, a mul­ti­dis­ci­plinary ex­pert com­mit­tee, are re­spon­si­ble for up­dat­ing the Stan­dards of Care an­nu­al­ly, or more fre­quent­ly as war­rant­ed. For a de­tailed de­scrip­tion of ADA stan­dards, state­ments, and re­ports, as well as the ev­i­dence-‍grad­ing sys­tem for ADA’s clin­i­cal prac­tice rec­om­men­da­tions, please refer to the Stan­dards of Care In­tro­duc­tion. Read­ers who wish to com­ment on the Stan­dards of 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 and strength-‍based lan­guage and ac­tive lis­ten­ing, elic­its pa­tient pref­er­ences and be­liefs, and as­sess­es lit­er­a­cy, nu­mer­a­cy, and po­ten­tial bar­ri­ers to care should be used to op­ti­mize pa­tient health out­comes and health-‍re­lat­ed qual­i­ty of life. B

4.2 Di­a­betes care should be man­aged by a mul­ti­dis­ci­plinary team that may draw from 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 the pa­tient and the care team. The Chron­ic Care Model (1–3) (see Sec­tion 1 “Im­prov­ing Care and Pro­mot­ing Health in Pop­u­la­tions”) is a pa­tient-‍cen­tered ap­proach to care that re­quires a close work­ing re­la­tion­ship be­tween the pa­tient and clin­i­cians in­volved in treat­ment plan­ning. Peo­ple with di­a­betes should re­ceive health care from 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 as­sume an ac­tive role in their care. The pa­tient, fam­i­ly or sup­port peo­ple, physi­cians, and health care team should to­geth­er for­mu­late the man­age­ment plan, which in­cludes lifestyle 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 with the pa­tients based on their in­di­vid­u­al pref­er­ences, val­ues, and goals. The man­age­ment plan should take into ac­count the pa­tient’s age, cog­ni­tive abil­i­ties, school/‍work sched­ule and con­di­tions, health be­liefs, sup­port sys­tems, eat­ing pat­terns, phys­i­cal ac­tiv­i­ty, so­cial sit­u­a­tion, finan­cial con­cerns, cul­tur­al fac­tors, lit­er­a­cy and nu­mer­a­cy (math­e­mat­i­cal lit­er­a­cy), di­a­betes com­pli­ca­tions and du­ra­tion of dis­ease, co­mor­bidi­ties, health pri­or­i­ties, other med­i­cal con­di­tions, pref­er­ences for care, and life ex­pectan­cy. Var­i­ous strate­gies and tech­niques should be used to sup­port pa­tients’ self-‍man­age­ment ef­forts, in­clud­ing pro­vid­ing ed­u­ca­tion on prob­lem-‍solv­ing skills for all as­pects of di­a­betes man­age­ment.

Pro­vider com­mu­ni­ca­tions withpa­tients and fam­i­lies should ac­knowl­edge that mul­ti­ple fac­tors im­pact glycemic man­age­ment but also em­pha­size that col­la­bo­ra­tively de­vel­oped treat­ment plans and a healthy lifestyle can significant­ly im­prove dis­ease out­comes and well­be­ing (4–7). Thus, the goal of pro­vider-pa­tient com­mu­ni­ca­tion is to es­tab­lish a col­lab­o­ra­tive re­la­tion­ship and to as­sess and ad­dress self-‍man­age­ment bar­ri­ers with­out blam­ing pa­tients for “non­com­pli­ance” or “non­ad­her­ence” when the out­comes of self-‍man­age­ment are not op­ti­mal (8). The fa­mil­iar terms “non­com­pli­ance” and “non­ad­her­ence” de­note a pas­sive, obe­di­ent role for a per­son with di­a­betes in “fol­low­ing doc­tor’s or­ders” that is at odds with the ac­tive role peo­ple with di­a­betes take in di­rect­ing the day-‍to-‍day de­ci­sion mak­ing, plan­ning, mon­i­tor­ing, eval­u­a­tion, and prob­lem-‍solv­ing in­volved in di­a­betes self-‍man­age­ment. Using a nonjudgmen­tal ap­proach that nor­mal­izes pe­ri­od­ic laps­es in self-‍man­age­ment may help min­i­mize pa­tients’ re­sis­tance to re­port­ing prob­lems with self-‍man­age­ment. Em­pathiz­ing and using ac­tive lis­ten­ing tech­niques, such as open-‍ended ques­tions, reflec­tive state­ments, and sum­ma­riz­ing what the pa­tient said, can help fa­cil­i­tate com­mu­ni­ca­tion. Pa­tients’ per­cep­tions about their own abil­i­ty, or self­efficacy, to self-‍man­age di­a­betes are one im­por­tant psychoso­cial fac­tor re­lat­ed to im­proved di­a­betes self-‍man­age­ment and treat­ment out­comes in di­a­betes (9–13) and should be a tar­get of on­go­ing as­sessment, pa­tient ed­u­ca­tion, and treat­ment plan­ning.

Lan­guage has a strong im­pact on per­cep­tions and be­hav­ior. The use of em­pow­er­ing lan­guage in di­a­betes care and ed­u­ca­tion can help to in­form and mo­ti­vate peo­ple, yet lan­guage that shames and judges may un­der­mine this ef­fort. The Amer­i­can Di­a­betes As­so­ci­a­tion (ADA) and Amer­i­can As­so­ci­a­tion of Di­a­betes Ed­u­ca­tors con­sen­sus re­port, “The Use of Lan­guage in Di­a­betes Care and Ed­u­ca­tion,” pro­vides the au­thors’ ex­pert opin­ion re­gard­ing the use of lan­guage by health care pro­fes­sion­als when speak­ing or writ­ing aboutdi­a­betesforpeo­ple with di­a­betesor for pro­fes­sion­al au­di­ences (14). Al­though fur­ther re­search is need­ed to ad­dress the im­pact of lan­guage on di­a­betes out­comes, the re­port in­cludes five key con­sen­sus rec­om­men­da­tions for lan­guage use:

Use lan­guage that is neu­tral, nonjudgmen­tal, and based on facts, ac­tions, or phys­i­ol­o­gy/‍biology.

Use lan­guage that is free from stigma.

Use lan­guage that is strength based, re­spect­ful, and in­clu­sive and that im­parts hope.

Use lan­guage that fos­ters col­lab­o­ra­tion be­tween pa­tients and pro­viders.

Use lan­guage that is per­son cen­tered (e.g., “per­son with di­a­betes” is pre­ferred over “di­a­bet­ic”).

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

Sug­gest­ed ci­ta­tion: Amer­i­can Di­a­betes As­so­ci­a­tion. 4. Com­pre­hen­sive med­i­cal eval­u­a­tion and as­sessment of co­mor­bidi­ties: Stan­dards of Med­i­cal Care in Di­a­betesd2019. Di­a­betes Care 2019;42(Suppl. 1):S34–S45
© 2018 by the Amer­i­can Di­a­betes As­so­ci­a­tion. Read­ers may use this ar­ti­cle as long as the work is prop­er­ly cited, the use is ed­u­ca­tional and not for prof­it, and the work is not al­tered. More in­formation is avail­able at http://www.di­a­betesjournals .org/‍content/‍license.

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2.0.0.0 COM­PRE­HEN­SIVE MED­I­CAL EVAL­U­A­TION

Rec­om­men­da­tions

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

Confirm the di­ag­no­sis and clas­si­fy di­a­betes. B

Eval­u­ate for di­a­betes com­pli­ca­tions and po­ten­tial co­mor­bid con­di­tions. B

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

Begin pa­tient en­gage­ment in the for­mu­la­tion of a care man­age­ment plan.B

De­vel­op a plan for con­tin­u­ing care. B

4.4 A fol­low-‍up visit should in­clude most com­po­nents of the ini­tial com­pre­hen­sive med­i­cal eval­u­a­tion in­clud­ing: in­ter­val med­i­cal his­to­ry, as­sessment of med­i­ca­tion-‍tak­ing be­hav­ior and intol­er­ance/‍ side ef­fects, phys­i­cal ex­am­i­na­tion, lab­o­ra­to­ry eval­u­a­tion as ap­pro­pri­ate to as­sess at­tain­ment of A1C and metabol­ic tar­gets, and as­sessment of risk for com­pli­ca­tions, di­a­betes self-‍man­age­ment be­hav­iors, nu­tri­tion, psychoso­cial health, and the need for re­fer­rals, im­mu­niza­tions, or other rou­tine health main­te­nance screen­ing. B

4.5 On­go­ing man­age­ment should be guid­ed by the as­sessment of di­a­betes com­pli­ca­tions and shared de­ci­sion mak­ing to set ther­a­peu­tic goals. B

4.6 The 10-year risk of a first atheroscle­rot­ic car­dio­vas­cu­lar dis­ease event should be as­sessed using the race- and sex-‍specific Pooled Co­hort Equa­tions to bet­ter strat­i­fy atheroscle­rot­ic car­dio­vas­cu­lar dis­ease risk. B

The com­pre­hen­sive med­i­cal eval­u­a­tion in­cludes the ini­tial and fol­low-‍up eval­u­a­tions, as­sessment of com­pli­ca­tions, psychoso­cial as­sessment, man­age­ment of co­mor­bid con­di­tions, and en­gage­ment of the pa­tient through­out the pro­cess. While a com­pre­hen­sive list is pro­vided in Table 4.1, in clin­i­cal prac­tice, the pro­vider may need to pri­or­i­tize the com­po­nents of the med­i­cal eval­u­a­tion given the avail­able re­sources and time. The goal is to pro­vide the health care team in­formation to op­ti­mally sup­port a pa­tient. In ad­di­tion to the med­i­cal his­to­ry, phys­i­cal ex­am­i­na­tion, and lab­o­ra­to­ry tests, pro­viders should as­sess di­a­betes self-‍man­age­ment be­hav­iors, nu­tri­tion, and psychoso­cial health (see Sec­tion 5 “Lifestyle Man­age­ment”) and give guid­ance on rou­tine im­mu­niza­tions. The as­sessment of sleep pat­tern and du­ra­tion should be con­sid­ered; a re­cent meta­anal­y­sis found that poor sleep qual­i­ty, short sleep, and long sleep were as­so­ci­at­ed with high­er A1C in peo­ple with type 2 di­a­betes (15). In­ter­val fol­low-‍up vis­its should occur at least every 3–6 months, in­di­vid­u­alized to the pa­tient, and then an­nu­al­ly.

Lifestyle man­age­ment and psychoso­cial care are the cor­ner­stones of di­a­betes man­age­ment. Pa­tients should be re­ferred for di­a­betes self-‍man­age­ment ed­u­ca­tion and sup­port, med­i­cal nu­tri­tion ther­a­py, and as­sessment of psychoso­cial/emotional health con­cerns if in­di­cat­ed. Pa­tients should re­ceive rec­om­mend­ed pre­ventive care ser­vices (e.g., im­mu­niza­tions, can­cer screen­ing, etc.), smok­ing ces­sa­tion coun­sel­ing, and oph­thal­mo­log­i­cal, den­tal, and po­di­atric re­fer­rals.

The as­sessment of risk of acute and chron­ic di­a­betes com­pli­ca­tions and treat­ment plan­ning are key com­po­nents of ini­tial and fol­low-‍up vis­its (Table 4.2). The risk of atheroscle­rot­ic car­dio­vas­cu­lar dis­ease and heart fail­ure (Sec­tion 10 “Car­dio­vas­cu­lar Dis­ease and Risk Man­age­ment”), chron­ic kid­ney dis­ease stag­ing (Sec­tion 11 “Mi­crovas­cu­lar Com­pli­ca­tions and Foot Care”), and risk of treat­ment-‍as­so­ci­at­ed hy­po­glycemia (Table 4.3) should be used to in­di­vid­u­alize tar­gets for glycemia (Sec­tion 6 “Glycemic Tar­gets”), blood pres­sure, and lipids and to se­lect specific glu­cose-‍low­er­ing med­i­ca­tion (Sec­tion 9 “Phar­ma­co­log­ic Ap­proach­es to Glycemic Treat­ment”), an­ti­hy­per­ten­sion med­i­ca­tion, or statin treat­ment in­ten­sity.

Ad­di­tion­al re­fer­rals should be ar­ranged as nec­es­sary (Table 4.4). Clin­i­cians should en­sure that in­di­vid­u­als with di­a­betes are ap­pro­pri­ately screened for com­pli­ca­tions and co­mor­bidi­ties. Dis­cussing and im­ple­ment­ing an ap­proach to glycemic con­trol with the pa­tient is a part, not the sole goal, of the pa­tient en­counter.

Table 4.1 Com­po­nents of the com­pre­hen­sive di­a­betes med­i­cal eval­u­a­tion at ini­tial, fol­low-‍up , and an­nu­al vis­its

Table 4.2—As­sess­ment and treat­ment plan*

Table 4.3—As­sess­ment of hy­po­glycemia risk

Table 4.4—Re­fer­rals for ini­tial care man­age­ment

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3.0.0.0 Im­mu­niza­tions

Rec­om­men­da­tions

4.7 Pro­vide rou­tinely rec­om­mend­ed vac­ci­na­tions for chil­dren and adults with di­a­betes by age. C

4.8 An­nu­al vac­ci­na­tion against influenza is rec­om­mend­ed for all peo­ple ≥6 months of age, es­pe­cially those with di­a­betes. C

4.9 Vac­ci­na­tion against pneu­mo­coc­cal dis­ease, in­clud­ing pneu­mo­coc­cal pneu­mo­nia, with 13-‍va­lent pneu­mo­coc­cal con­ju­gate vac­cine (PCV13) is rec­om­mend­ed for chil­dren be­fore age 2 years. Peo­ple with di­a­betes ages 2 through 64 years should also re­ceive 23-‍va­lent pneu­mo­coc­cal polysac­cha­ride vac­cine (PPSV23). At age ≥65 years, re­gard­less of vac­ci­na­tion his­to­ry, ad­di­tional PPSV23 vac­ci­na­tion is nec­es­sary. C

4.10 Ad­min­is­ter a 2- or 3-dose se­ries of hep­ati­tis B vac­cine, de­pend­ing on the vac­cine, to un­vac­ci­nat­ed adults with di­a­betes ages 18 through 59 years. C

4.11 Con­sid­er ad­min­is­ter­ing 3-dose se­ries of hep­ati­tis B vac­cine to un­vac­ci­nat­ed adults with di­a­betes ages ≥60 years. C

Chil­dren and adults with di­a­betes should re­ceive vac­ci­na­tions ac­cord­ing to age-‍ap­pro­pri­ate rec­om­men­da­tions (16,17). The child and ado­les­cent (≤18 years of age) vac­ci­na­tion sched­ule is avail­able at www.cdc.gov/vac­cines/ sched­ules/hcp/imz/child-ado­les­cent.html, and the adult (≥19 years of age) vac­ci­na­tion sched­ule is avail­able at www.cdc.gov/vac­cines/sched­ules/hcp/imz/adult.html. These im­mu­niza­tion sched­ules in­clude vac­ci­na­tion sched­ules specifically for chil­dren, ado­les­cents, and adults with di­a­betes.

Peo­ple with di­a­betes are at high­er risk for hep­ati­tis B in­fec­tion and are more like­ly to de­vel­op com­pli­ca­tions from influenza and pneu­mo­coc­cal dis­ease. The Cen­ters for Dis­ease Con­trol and Pre­ven­tion (CDC) Ad­vi­so­ry Com­mit­tee on Im­mu­niza­tion Prac­tices (ACIP) rec­om­mends influenza, pneu­mo­coc­cal, and hep­ati­tis B vac­ci­na­tions specifically for peo­ple with di­a­betes. Vac­ci­na­tions against tetanus-‍diph­the­ria-‍pertussis, measles-‍mumps-‍rubella, human pa­pil­lo­mavirus, and shin­gles are also im­por­tant for adults with di­a­betes, as they are for the gen­er­al pop­u­la­tion.

Influenza

Influenza is a com­mon, pre­ventable in­fec­tious dis­ease as­so­ci­at­ed with high mor­tal­i­ty and mor­bid­i­ty in vul­ner­a­ble pop­u­la­tions in­clud­ing the young and the el­der­ly and peo­ple with chron­ic dis­eases. Influenza vac­ci­na­tion in peo­ple with di­a­betes has been found to significant­ly re­duce influenza and di­a­betes-‍re­lat­ed hos­pi­tal ad­mis­sions (18).

Pneu­mo­coc­cal Pneu­mo­nia

Like influenza, pneu­mo­coc­cal pneu­mo­nia is a com­mon, pre­ventable dis­ease. Peo­ple with di­a­betes are at in­creased risk for the bac­teremic form of pneu­mo­coc­cal in­fec­tion and have been re­ported to have a high risk of noso­co­mi­al bac­teremia, with a mor­tal­i­ty rate as high as 50% (19). The ADA en­dors­es rec­om­men­da­tions from the CDC ACIP that adults age ≥65 years, who are at high­er risk for pneu­mo­coc­cal dis­ease, re­ceive an ad­di­tional 23-‍va­lent pneu­mo­coc­cal polysac­cha­ride vac­cine (PPSV23), re­gard­less of prior pneu­mo­coc­cal vac­ci­na­tion his­to­ry. See de­tailed rec­om­men­da­tions 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 di­a­betes have high­er rates of hep­ati­tis B. This may be due to con­tact with in­fect­ed blood or through im­prop­er equip­ment use (glu­cose mon­i­tor­ing de­vices or in­fect­ed nee­dles). Be­cause of the high­er like­li­hood of trans­mis­sion, hep­ati­tis B vac­cine is rec­om­mend­ed for adults with di­a­betes age <60 years. For adults age ≥60 years, hep­ati­tis B vac­cine may be ad­min­is­tered at the dis­cre­tion of the treat­ing clin­i­cian based on the pa­tient’s like­li­hood of ac­quir­ing hep­ati­tis B in­fec­tion.

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4.0.0.0 AS­SESS­MENT OF CO­MOR­BIDI­TIES

4.1.0.0 In­tro­duc­tion

Be­sides as­sessing di­a­betes-‍re­lat­ed com­pli­ca­tions, clin­i­cians and their pa­tients need to be aware of com­mon co­mor­bidi­ties that af­fect peo­ple with di­a­betes and may com­pli­cate man­age­ment (20–24). Di­a­betes co­mor­bidi­ties are con­di­tions that af­fect peo­ple with di­a­betes more often than age-‍matched peo­ple with­out di­a­betes. This sec­tion in­cludes many of the com­mon co­mor­bidi­ties ob­served in pa­tients with di­a­betes but is not nec­es­sar­i­ly in­clu­sive of all the con­di­tions that have been re­ported.

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4.2.0.0 Au­toim­mune Dis­eases

Rec­om­men­da­tion

4.12 Con­sid­er screen­ing pa­tients with type 1 di­a­betes for au­toim­mune thy­roid dis­ease and celi­ac dis­ease soon after di­ag­no­sis. B

Peo­ple with type 1 di­a­betes are at in­creased risk for other au­toim­mune dis­eases in­clud­ing thy­roid dis­ease, pri­ma­ry adrenal insufficien­cy, celi­ac dis­ease, au­toim­mune gas­tri­tis, au­toim­mune hep­ati­tis, der­mato­myosi­tis, and myas­the­nia gravis (25–27). Type 1 di­a­betes may also occur with other au­toim­mune dis­eases in the con­text of specific ge­net­ic disor­ders or polyg­lan­du­lar au­toim­mune syn­dromes (28). In au­toim­mune dis­eases, the im­mune sys­tem fails to main­tain self-‍tol­er­ance to specific pep­tides with­in tar­get or­gans. It is like­ly that many fac­tors trig­ger au­toim­mune dis­ease; how­ev­er, com­mon trig­gering fac­tors are known for only some au­toim­mune con­di­tions (i.e., gliadin pep­tides in celi­ac dis­ease) (see Sec­tion 13 “Chil­dren and Ado­les­cents”).

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4.3.0.0 Can­cer

Di­a­betes is as­so­ci­at­ed with in­creased risk of can­cers of the liver, pan­creas, en­dometri­um, colon/‍rectum, breast, and blad­der (29). The as­so­ci­a­tion may re­sult from shared risk fac­tors be­tween type 2 di­a­betes and can­cer (older age, obe­si­ty, and phys­i­cal inac­tiv­i­ty) but may also be due to di­a­betes-‍re­lat­ed fac­tors (30), such as un­der­ly­ing dis­ease phys­i­ol­o­gy or di­a­betes treat­ments, al­though ev­i­dence for these links is scarce. Pa­tients with di­a­betes should be en­cour­aged to un­der­go rec­om­mend­ed age- and sex- ap­pro­pri­ate can­cer screen­ings and to re­duce their modifiable can­cer risk fac­tors (obe­si­ty, phys­i­cal inac­tiv­i­ty, and smok­ing). New onset of atyp­i­cal di­a­betes (lean body habi­tus, neg­a­tive fam­i­ly his­to­ry) in a mid­dle-‍aged or older pa­tient may pre­cede the di­ag­no­sis of pan­cre­at­ic ade­no­car­ci­no­ma (31). How­ev­er, in the ab­sence of other symp­toms (e.g., weight loss, ab­dom­i­nal pain), rou­tine screen­ing of all such pa­tients is not cur­rently rec­om­mend­ed.

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4.4.0.0 Cog­ni­tive Im­pair­ment/‍Dementia

Rec­om­men­da­tion

4.13 In peo­ple with a his­to­ry of cog­ni­tive im­pair­ment/‍de­men­tia, in­ten­sive glu­cose con­trol can­not be ex­pect­ed to re­me­di­ate deficits. Treat­ment should be tai­lored to avoid significant hy­po­glycemia. B

Di­a­betes is as­so­ci­at­ed with a significant­ly in­creased risk and rate of cog­ni­tive de­cline and an in­creased risk of de­men­tia (32,33). A re­cent meta-‍anal­y­sis of prospec­tive ob­ser­va­tion­al stud­ies in peo­ple with di­a­betes showed 73% in­creased risk of all types of de­men­tia, 56% in­creased risk of Alzheimer de­men­tia, and 127% in­creased risk of vas­cu­lar de­men­tia com­pared with in­di­vid­u­als with­out di­a­betes (34). The re­verse is also true: peo­ple with Alzheimer de­men­tia are more like­ly to de­vel­op di­a­betes than peo­ple with­out Alzheimer de­men­tia. In a 15-year prospec­tive study of com­mu­ni­ty-‍dwelling peo­ple >60 years of age, the pres­ence of di­a­betes at base­line significant­ly in­creased the age- and sex-‍ad­just­ed in­ci­dence of all-‍cause de­men­tia, Alzheimer de­men­tia, and vas­cu­lar de­men­tia com­pared with rates in those with nor­mal glu­cose tol­er­ance (35).

Hy­per­glycemia

In those with type 2 di­a­betes, the de­gree and du­ra­tion of hy­per­glycemia are re­lat­ed tode­men­tia. More rapid cog­ni­tive de­cline is as­so­ci­at­ed with both in­creased A1C and longer du­ra­tion ofdi­a­betes (34). The Ac­tion to Con­trol Car­dio­vas­cu­lar Risk in Di­a­betes (AC­CORD) study found that each 1% high­er A1C level was as­so­ci­at­ed with lower cog­ni­tive func­tion in in­di­vid­u­als with type 2 di­a­betes (36). How­ev­er, the AC­CORD study found no dif­fer­ence in cog­ni­tive out­comes in par­tic­i­pants ran­dom­ly as­signed to in­ten­sive and stan­dard glycemic con­trol, sup­porting the rec­om­men­da­tion that in­ten­sive glu­cose con­trol should not be ad­vised for the im­provement of cog­ni­tive func­tion in in­di­vid­u­als with type 2 di­a­betes (37).

Hy­po­glycemia

In type 2 di­a­betes, se­vere hy­po­glycemia is as­so­ci­at­ed with re­duced cog­ni­tive func­tion, and those with poor cog­ni­tive func­tion have more se­vere hy­po­glycemia. In a long-‍term study of older pa­tients with type 2 di­a­betes, in­di­vid­u­als with one or more record­ed episode of se­vere hy­po­glycemia had a step­wise in­crease in risk of de­men­tia (38). Like­wise, the AC­CORD trial found that as cog­ni­tive func­tion de­creased, the risk of se­vere hy­po­glycemia in­creased (39). Tai­lor­ing glycemic ther­a­py may help to pre­vent hy­po­glycemia in in­di­vid­u­als with cog­ni­tive dysfunc­tion.

Nu­tri­tion

In one study, ad­her­ence to the Mediter­ranean diet corre­lat­ed with im­proved cog­ni­tive func­tion (40). How­ev­er, a re­cent Cochrane re­view found insufficient ev­i­dence to rec­om­mend any di­etary change for the pre­vention or treat­ment of cog­ni­tive dysfunc­tion (41).

Statins

A sys­tematic re­view has re­ported that data do not sup­port an ad­verse ef­fect of statins on cog­ni­tion (42). The U.S. Food and Drug Ad­min­is­tra­tion post­mar­ket­ing surveil­lance databas­es have also re­vealed a low re­port­ing rate for cog­ni­tive-‍re­lat­ed ad­verse events, in­clud­ing cog­ni­tive dysfunc­tion or de­men­tia, with statin ther­a­py, sim­i­lar to rates seen with other com­monly pre­scribed car­dio­vas­cu­lar med­i­ca­tions (42). There­fore, fear of cog­ni­tive de­cline should not be a bar­ri­er to statin use in in­di­vid­u­als with di­a­betes and a high risk for car­dio­vas­cu­lar dis­ease.

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4.5.0.0 Non­al­co­holic Fatty Liver Dis­ease

Rec­om­men­da­tion

4.14 Pa­tients with type 2 di­a­betes or predi­a­betes and el­e­vat­ed liver en­zymes (ala­nine amino­trans­ferase) or fatty liver on ul­tra­sound should be eval­u­ated for pres­ence of non­al­co­holic steatohep­ati­tis and liver fibro­sis. C

Di­a­betes is as­so­ci­at­ed with the de­vel­opment of non­al­co­holic fatty liver dis­ease, in­clud­ing its more se­vere man­i­fes­ta­tions of non­al­co­holic steatohep­ati­tis, liver fibro­sis, cir­rho­sis, and hep­a­to­cel­lu­lar car­ci­no­ma (43). El­e­va­tions of hep­at­ic transam­i­nase con­cen­tra­tions are as­so­ci­at­ed with high­er BMI, waist cir­cum­fer­ence, and triglyc­eride lev­els and lower HDL choles­terol lev­els. Non­in­va­sive tests, such as elas­tog­ra­phy or fibro­sis biomark­ers, may be used to as­sess risk of fibro­sis, but re­fer­ral to a liver spe­cial­ist and liver biop­sy may be re­quired for defini­tive di­ag­no­sis (43a). 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 (44,45). Pi­ogli­ta­zone and vi­ta­min E treat­ment of biop­sy-‍proven non­al­co­holic steatohep­ati­tis have been shown to im­prove liver his­tol­o­gy, but ef­fects on longert­erm clin­i­cal out­comes are not known (46,47). Treat­ment with li­raglu­tide and with sodi­um–glu­cose co­trans­porter 2 in­hibitors (da­pagliflozin and em­pagliflozin) has also shown some promise in pre­lim­i­nary stud­ies, al­though benefits may be me­di­at­ed, at least in part, by weight loss (48–50).

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4.6.0.0 Pan­cre­ati­tis

Rec­om­men­da­tion

4.15 Islet au­to­trans­plan­ta­tion should be con­sid­ered for pa­tients re­quir­ing total pan­cre­a­te­c­to­my for med­i­cally re­frac­to­ry chron­ic pan­cre­ati­tis to pre­vent post­sur­gi­cal di­a­betes. C

Di­a­betes is linked to dis­eases of the ex­ocrine pan­creas such as pan­cre­ati­tis, which may dis­rupt the glob­al ar­chi­tec­ture or phys­i­ol­o­gy of the pan­creas, often re­sulting in both ex­ocrine and en­docrine dysfunc­tion. Up to half of pa­tients with di­a­betes may have im­paired ex­ocrine pan­creas func­tion (51). Peo­ple with di­a­betes are at an ap­prox­i­mate­ly twofold high­er risk of de­vel­oping acute pan­cre­ati­tis (52).

Con­verse­ly, predi­a­betes and/‍or di­a­betes has been found to de­vel­op in ap­prox­i­mate­ly one-‍third of pa­tients after an episode of acute pan­cre­ati­tis (53), thus the re­la­tion­ship is like­ly bidi­rec­tion­al. Postpan­cre­ati­tis di­a­betes may in­clude ei­ther new-‍onset dis­ease or pre­vi­ously un­rec­og­nized di­a­betes (54). Stud­ies of pa­tients treat­ed with in­cretin-‍based ther­a­pies for di­a­betes have also re­ported that pan­cre­ati­tis may occur more fre­quent­ly with these med­i­ca­tions, but re­sults have been mixed (55,56).

Islet au­to­trans­plan­ta­tion should be con­sid­ered for pa­tients re­quir­ing total pan­cre­a­te­c­to­my for med­i­cally re­frac­to­ry chron­ic pan­cre­ati­tis to pre­vent post­sur­gi­cal di­a­betes. Ap­prox­i­mate­ly one-‍third of pa­tients un­der­going total pan­cre­a­te­c­to­my with islet au­to­trans­plan­ta­tion are in­sulin free 1 year post­op­er­a­tive­ly, and ob­ser­va­tion­al stud­ies from dif­fer­ent cen­ters have demon­strat­ed islet graft func­tion up to a decade after the surgery in some pa­tients (57–61). Both pa­tient and dis­ease fac­tors should be care­ful­ly con­sid­ered when de­cid­ing the in­di­ca­tions and tim­ing of this surgery. Surg­eries should be per­formed in skilled fa­cil­i­ties that have demon­strat­ed ex­pertise in islet au­to­trans­plan­ta­tion.

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4.7.0.0 Frac­tures

Age-‍specific hip frac­ture risk is significant­ly in­creased in peo­ple with both type 1 (rel­a­tive risk 6.3) and type 2 (rel­a­tive risk 1.7) di­a­betes in both sexes (62). 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) (63). In three large ob­ser­va­tion­al stud­ies of older adults, femoral neck BMD T score and the World Health Or­ga­ni­za­tion Frac­ture Risk As­sess­ment Tool (FRAX) score were as­so­ci­at­ed with hip and non­spine frac­tures. 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 (64). Pro­viders should as­sess frac­ture his­to­ry and risk fac­tors in older pa­tients with di­a­betes and rec­om­mend mea­sure­ment of BMD if ap­pro­pri­ate for the pa­tient’s age and sex. Frac­ture pre­vention strate­gies for peo­ple with di­a­betes are the same as for the gen­er­al pop­u­la­tion and in­clude vi­ta­min D sup­ple­men­ta­tion. For pa­tients with type 2 di­a­betes with frac­ture risk fac­tors, thi­a­zo­lidine­diones (65) and sodi­um– glu­cose co­trans­porter 2 in­hibitors (66) should be used with cau­tion.

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4.8.0.0 Hear­ing Im­pair­ment

Hear­ing im­pair­ment, both in high fre­quen­cy and low/midfre­quen­cy 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 (67).

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4.9.0.0 HIV

Rec­om­men­da­tion

4.16 Pa­tients with HIV should be screened for di­a­betes and pre-‍di­a­betes with a fast­ing glu­cose test be­fore start­ing an­tiretro­vi­ral ther­a­py, at the time of­switch­ing an­tiretro­vi­ral ther­a­py, and 3–6 months after start­ing or switch­ing an­tiretro­vi­ral ther­a­py. If ini­tial screen­ing re­sults are nor­mal, check­ing fast­ing glu­cose every year is ad­vised. E

Di­a­betes risk is in­creased with cer­tain pro­tease in­hibitors (PIs) and nu­cle­o­side re­verse tran­scrip­tase in­hibitors (NRTIs). New-‍onset di­a­betes is es­ti­mat­ed to occur in more than 5% of pa­tients in­fect­ed with HIV on PIs, where­as more than 15% may have predi­a­betes (68). PIs are as­so­ci­at­ed with in­sulin re­sis­tance and may also lead to apop­to­sis of pan­cre­at­ic β-‍cells. NRTIs also af­fect fat dis­tri­bu­tion (both lipo­hy­per­tro­phy and lipoa­t­ro­phy), which is as­so­ci­at­ed with in­sulin re­sis­tance.

In­di­vid­u­als with HIV are at high­er risk for de­vel­oping predi­a­betes and di­a­betes on an­tiretro­vi­ral (ARV) ther­a­pies, so a screen­ing pro­to­col is rec­om­mend­ed (69). The A1C test may un­der­es­ti­mate glycemia in peo­ple with HIV and is not rec­om­mend­ed for di­ag­no­sis and may pre­sent chal­lenges for mon­i­tor­ing (70). In those with predi­a­betes, weight loss through healthy nu­tri­tion and phys­i­cal ac­tiv­i­ty may re­duce the pro­gres­sion to­ward di­a­betes. Among pa­tients with HIV and di­a­betes, pre­ventive health care using an ap­proach sim­i­lar to that used in pa­tients with­out HIV is crit­i­cal to re­duce the risks of microvas­cu­lar and macrovas­cu­lar com­pli­ca­tions.

For pa­tients with HIV and ARV-‍as­so­ci­at­ed hy­per­glycemia, it may be ap­pro­pri­ate to con­sid­er discon­tin­u­ing the prob­lem­at­ic ARV agents if safe and effec­tive al­ter­na­tives are avail­able (71). Be­fore mak­ing ARV sub­sti­tu­tions, care­ful­ly con­sid­er the pos­si­ble ef­fect on HIV vi­ro­log­i­cal con­trol and the po­ten­tial ad­verse ef­fects of new ARV agents. In some cases, antihy­per­glycemia agents may still be nec­es­sary.

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4.10.0.0 Low Testos­terone_ in Men

Rec­om­men­da­tion

4.17 In men with di­a­betes who have symp­toms or signs of hy­pog­o­nadism, such as de­creased sex­u­al de­sire (li­bido) or ac­tiv­i­ty, or erec­tile dysfunc­tion, con­sid­er screen­ing with a morn­ing serum testos­terone level. B

Mean lev­els of testos­terone are lower in men with di­a­betes com­pared with age-‍matched men with­out di­a­betes, but obe­si­ty is a major con­founder (72,73). Treat­ment in asymp­tomat­ic men is con­tro­ver­sial. Testos­terone_ re­place­ment in men with symp­tomat­ic hy­pog­o­nadism may have benefits in­clud­ing im­proved sex­u­al func­tion, well-‍being, mus­cle mass and strength, and bone den­si­ty (74). In men with di­a­betes who have symp­toms or signs of low testos­terone (hy­pog­o­nadism), a morn­ing total testos­terone should be mea­sured using an ac­cu­rate and re­li­able assay. Free or bioavail­able testos­terone lev­els should also be mea­sured in men with di­a­betes who have total testos­terone lev­els close to the lower limit, given ex­pect­ed de­creas­es in sex hor­mone– bind­ing glob­u­lin with di­a­betes. Fur­ther test­ing (such as luteiniz­ing hor­mone and fol­li­cle-‍stim­u­lat­ing hor­mone lev­els) may be need­ed to dis­tin­guish be­tween pri­ma­ry and sec­ondary hy­pog­o­nadism.

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4.11.0.0 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 (75). The preva­lence of ob­struc­tive sleep apnea in the pop­u­la­tion with type 2 di­a­betes may be as high as 23%, and the preva­lence of any sleep­dis­or­dered breath­ing may be as high as 58% (76,77). In obese par­tic­i­pants en­rolled in the Ac­tion for Health in Di­a­betes (Look AHEAD) trial, it ex­ceed­ed 80% (78). Pa­tients with symp­toms sug­ges­tive of ob­struc­tive sleep apnea (e.g., ex­ces­sive day­time sleepi­ness, snor­ing, wit­nessed apnea) should be con­sid­ered for screen­ing (79). Sleep apnea treat­ment (lifestyle modification, con­tin­u­ous pos­i­tive air­way pres­sure, oral ap­pli­ances, and surgery) significant­ly im­proves qual­i­ty of life and blood pres­sure con­trol. The ev­i­dence for a treat­ment ef­fect on glycemic con­trol is mixed (80).

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4.12.0.0 Pe­ri­odon­tal Dis­ease

Pe­ri­odon­tal dis­ease is more se­vere, and may be more preva­lent, in pa­tients with di­a­betes than in those with­out (81,82). Cur­rent ev­i­dence sug­gests that pe­ri­odon­tal dis­ease ad­versely af­fects di­a­betes out­comes, al­though ev­i­dence for treat­ment benefits re­mains con­tro­ver­sial (24).

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4.13.0.0 Psychoso­cial/Emotional Disor­ders

4.13.1.0 In­tro­duc­tion

Preva­lence of clin­i­cally significant psy­chopathol­o­gy di­ag­noses are con­sid­erably more com­mon in peo­ple with di­a­betes than in those with­out the dis­ease (83). Symp­toms, both clin­i­cal and subclin­i­cal, that in­ter­fere with the per­son’s abil­i­ty to carry out daily di­a­betes self-‍man­age­ment tasks must be ad­dressed. Pro­viders should con­sid­er an as­sessment of symp­toms of de­pres­sion, anx­i­ety, and dis­or­dered eat­ing and of cog­ni­tive ca­pac­i­ties using pa­tient-‍ap­pro­pri­ate stan­dardized/val­i­dat­ed tools at the ini­tial visit, at pe­ri­od­ic in­ter­vals, and when there is a change in dis­ease, treat­ment, or life cir­cum­stance. In­clud­ing care­givers and fam­i­ly mem­bers in this as­sessment is rec­om­mend­ed. Di­a­betes dis­tress is ad­dressed in Sec­tion 5 “Lifestyle Man­age­ment,” as this state is very com­mon and dis­tinct from the psy­cho­log­i­cal disor­ders dis­cussed below (84).

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4.13.2.0 Anx­i­ety Disor­ders

Rec­om­men­da­tions

4.18 Con­sid­er screen­ing for anx­i­ety in peo­ple ex­hibit­ing anx­i­ety or wor­ries re­gard­ing di­a­betes com­pli­ca­tions, in­sulin in­jec­tions or in­fu­sion, tak­ing med­i­ca­tions, and/‍or hy­po­glycemia that in­ter­fere with self-‍man­age­ment be­hav­iors and those who ex­press fear, dread, or ir­ra­tional thoughts and/‍or show anx­i­ety symp­toms such as avoid­ance be­hav­iors, ex­ces­sive repet­i­tive be­hav­iors, or so­cial with­draw­al. Refer for treat­ment if anx­i­ety is pre­sent. B

4.19 Peo­ple with hy­po­glycemia un­aware­ness, which can co-‍occur with fear of hy­po­glycemia, should be treat­ed using blood glu­cose aware­ness train­ing (or other ev­i­dence-‍based in­ter­ven­tion) to help rees­tab­lish aware­ness of hy­po­glycemia and re­duce fear of hy­po­glycemia. A

Anx­i­ety symp­toms and di­ag­nos­able disor­ders (e.g., gen­er­alized anx­i­ety dis­or­der, body dys­mor­phic dis­or­der, ob­ses­sive-‍com­pul­sive dis­or­der, spe-‍cific pho­bias, and post­trau­mat­ic stress dis­or­der) are com­mon in peo­ple with di­a­betes (85).

The Be­hav­ioral Risk Fac­tor Surveil-‍lance Sys­tem (BRFSS) es­ti­mat­ed the life-‍time preva­lence of gen­er­alized anx­i­ety dis­or­der to be 19.5% in peo­ple with ei­ther 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 pre­sents an­oth­er crit­i­cal point when anx­i­ety can occur (90). Peo­ple with di­a­betes who ex­hib­it ex­ces­sive di­a­betes self-‍man­age­ment be­hav­iors well be­yond what is pre­scribed or need­ed to achieve glycemic tar­gets may be ex­pe­ri­enc­ing symp­toms of ob­ses­sive-‍com­pul­sive dis­or­der (91).

Gen­er­al anx­i­ety is a pre­dic­tor of injection-re­lat­ed anx­i­ety and as­so­ci­at­ed with fear of hy­po­glycemia (88,92). Fear of hy­po­glycemia and hy­po­glycemia un­aware­ness often co-‍occur, and in­ter­ven­tions aimed at treat­ing one often benefit both (93). Fear of hy­po­glycemia may ex­plain avoid­ance of be­hav­iors as­so­ci­at­ed with low­er­ing glu­cose such as in­creas­ing in­sulin doses or fre­quen­cy of mon­i­tor­ing. If fear of hy­po­glycemia is iden­tified and a per­son does not have symp­toms of hy­po­glycemia, a struc­tured pro­gram of blood glu­cose aware­ness train­ing de­liv­ered in rou­tine clin­i­cal prac­tice can im­prove A1C, re­duce the rate of se­vere hy­po­glycemia, and re­store hy­po­glycemia aware­ness (94,95).

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4.13.3.0 De­pres­sion

Rec­om­men­da­tions

4.20 Pro­viders should con­sid­er an­nu­al screen­ing of all pa­tients with di­a­betes, es­pe­cially those with a self-re­ported his­to­ry of de­pres­sion, for de­pres­sivesymp­toms with age-‍ap­pro­pri­ate de­pres­sion screen­ing mea­sures, rec­og­niz­ing that fur­ther eval­u­a­tion will be nec­es­sary for in­di­vid­u­als who have a pos­i­tive screen. B

4.21 Be­gin­ning at di­ag­no­sis of com­pli­ca­tions or when there are significant changes in med­i­cal sta­tus, con­sid­er as­sessment for de­pres­sion. B

4.22 Re­fer­rals for treat­ment of de­pres­sion should be made to men­tal health pro­viders with ex­pe­ri­ence using cog­ni­tive be­hav­ioral ther­a­py, interper­sonal ther­a­py, or other ev­i­dence-‍based treat­ment ap­proaches in con­junc­tion with col­lab­o­ra­tive care with the pa­tient’s di­a­betes treat­ment team. A

His­to­ry of de­pres­sion, cur­rent de­pres­sion, and an­tide­pres­sant med­i­ca­tion use are risk fac­tors for the de­vel­opment of type 2 di­a­betes, es­pe­cially if the in­di­vid­u­al has other risk fac­tors such as obe­si­ty and fam­i­ly his­to­ry of type 2 di­a­betes (96–98). El­e­vat­ed de­pres­sive symp­toms and de­pres­sive disor­ders af­fect one in four pa­tients with type 1 or type 2 di­a­betes (99). Thus, rou­tine screen­ing for de­pres­sive symp­toms is in­di­cat­ed in this high-‍risk pop­u­la­tion in­clud­ing peo­ple with type 1 or type 2 di­a­betes, ges­ta­tion­al di­a­betes mel­li­tus, and post­par­tum di­a­betes. Re­gard­less of di­a­betes type, women have significant­ly high­er rates of de­pres­sion than men (100).

Rou­tine mon­i­tor­ing with pa­tient-‍ap­pro­pri­ate val­i­dat­ed mea­sures can help to iden­tify if re­fer­ral is war­rant­ed. Adult pa­tients with a his­to­ry of de­pres­sive symp­toms or dis­or­der need on­go­ing mon­i­tor­ing of de­pres­sion re­cur­rence with­in the con­text of rou­tine care (96). In­te­grat­ing men­tal and phys­i­cal health care can im­prove out­comes. When a pa­tient is in psy­cho­log­i­cal ther­a­py (talk ther­a­py), the men­tal health pro­vider should be in­cor­po­rat­ed into the di­a­betes treat­ment team (101).

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4.13.4.0 Dis­or­dered Eat­ing Be­hav­ior

Rec­om­men­da­tions

4.23 Pro­viders should con­sid­er reeval­u­at­ing the treat­ment reg­i­men of peo­ple with di­a­betes who pre­sent with symp­toms of dis­or­dered eat­ing be­hav­ior, an eat­ing dis­or­der, or dis­rupted pat­terns of eat­ing. B

4.24 Con­sid­er screen­ing for dis­or­dered or dis­rupted eat­ing using val­i­dat­ed screen­ing mea­sures when hy­per­glycemia and weight loss are unex­plained based on self-re­ported be­hav­iors re­lat­ed to med­i­ca­tion dos­ing, meal plan, and phys­i­cal ac­tiv­i­ty. In ad­di­tion, a re­view of the med­i­cal reg­i­men is rec­om­mend­ed to iden­tify po­ten­tial treat­ment-‍re­lat­ed ef­fects on hunger/‍ caloric in­take. B

Es­ti­mat­ed preva­lence of dis­or­dered eat­ing be­hav­iors and di­ag­nos­able eat­ing disor­ders in peo­ple with di­a­betes varies (102–104). For peo­ple with type 1 di­a­betes, in­sulin omis­sion caus­ing gly­co­suria in order to lose weight is the most com­monly re­ported dis­or­dered eat­ing be­hav­ior (105,106); in peo­ple with type 2 di­a­betes, binge­ing (ex­ces­sive food in­take with an ac­com­pa­ny­ing sense of loss of con­trol) is most com­monly re­ported. For peo­ple with type 2 di­a­betes treat­ed with in­sulin, in­ten­tion­al omis­sion is also fre­quent­ly re­ported (107). Peo­ple with di­a­betes and di­ag­nos­able eat­ing disor­ders have high rates of co­mor­bid psy­chi­atric disor­ders (108). Peo­ple with type 1 di­a­betes and eat­ing disor­ders have high rates of di­a­betes dis­tress and fear of hy­po­glycemia (109). When eval­u­at­ing symp­toms of dis­or­dered or dis­rupted eat­ing in peo­ple with di­a­betes, eti­ol­o­gy and mo­ti­va­tion for the be­hav­ior should be con­sid­ered (104,110). Ad­junc­tive med­i­ca­tion such as glucagon-‍like pep­tide 1 re­cep­tor ag­o­nists (111) may help in­di­vid­u­als not only to meet glycemic tar­gets but also to reg­u­late hunger and food in­take, thus hav­ing the po­ten­tial to re­duce uncon­trollable hunger and bu­lim­ic symp­toms.

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4.13.5.0 Se­ri­ous Men­tal Ill­ness

Rec­om­men­da­tions

An­nu­ally screen peo­ple who are pre­scribed atyp­i­cal an­tipsy­chot­ic med­i­ca­tions for predi­a­betes or di­a­betes. B

If a sec­ond-‍gen­er­a­tion an­tipsy­chot­ic med­i­ca­tion is pre­scribed for ado­les­cents or adults with di­a­betes, changes in weight, glycemic con­trol, and choles­terol lev­els should be care­ful­ly mon­i­tored and the treat­ment reg­i­men should be reas­sessed. C

In­cor­po­rate mon­i­tor­ing of di­a­betes self-‍care ac­tiv­i­ties into treat­ment goals in peo­ple with di­a­betes and se­ri­ous men­tal ill­ness. B

Stud­ies of in­di­vid­u­als with se­ri­ous men­tal ill­ness, par­tic­u­lar­ly schizophre­nia and other thought disor­ders, show significant­ly in­creased rates of type 2 di­a­betes (112). Peo­ple with schizophre­nia should bemon­i­tored for type 2 di­a­betes be­cause of the known co­mor­bidity. Dis­or­dered think­ing and judg­ment can be ex­pect­ed to make it difficult to en­gage in be­hav­iors that re­duce risk fac­tors for type 2 di­a­betes, such as re­strained eat­ing for weight man­age­ment. Co­or­di­nat­ed man­age­ment of di­a­betes or predi­a­betes and se­ri­ous men­tal ill­ness is rec­om­mend­ed to achieve di­a­betes treat­ment tar­gets. In ad­di­tion, those tak­ing sec­ond-‍gen­er­a­tion (atyp­i­cal) an­tipsy­chot­ics, such as olan­za­p­ine, re­quire greater mon­i­tor­ing be­cause of an in­crease in risk of type 2 di­a­betes as­so­ci­at­ed with this med­i­ca­tion (113).

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