Sec­tion 4. Com­pre­hen­sive Med­i­cal Eval­u­a­tion and As­sess­ment of Co­mor­bidi­ties

(https:/​/​doi.org/​10.2337/​dc23-​S004)

In Rec­om­men­da­tion 4.3, lan­guage was modified to in­clude eval­u­a­tion for over­all health sta­tus and set­ting of ini­tial goals.

Con­sid­er­able changes were made in the im­mu­niza­tions sub­sec­tion to reflect new in­di­ca­tions and guid­ance, par­tic­u­lar­ly for COVID-​19 and pneu­mo­coc­cal pneu­mo­nia vac­ci­na­tions, in­clud­ing age­specific rec­om­men­da­tions and the bi­va­lent COVID-​19 boost­er.

Table 4.1 was modified to in­clude changes through­out Sec­tion 4.

The sub­sec­tion “Non­al­co­holic Fat­ty Liv­er Dis­ease” (NAFLD) in­cor­po­rates more de­tail re­gard­ing its di­ag­no­sis and risk stratification in pri­ma­ry care and di­a­betes clin­ics, such as us­ing the fibro­sis-​4 in­dex to as­sess the risk of liv­er fibro­sis, and in­cludes a fibro­sis-​4 in­dex risk cal­cu­la­tor. It ex­pands on the ra­tio­nale for fibro­sis risk stratification in peo­ple with di­a­betes and when to re­fer to a gas­troen­terol­o­gist or hep­a­tol­o­gist for fur­ther workup.

Dis­cus­sion was added about the man­age­ment of peo­ple with type 2 di­a­betes who have NAFLD, high­light­ing lifestyle changes that pro­mote weight loss, the use of obe­si­ty phar­ma­cother­a­py with em­pha­sis on treat­ment with glucagon­like pep­tide 1 (GLP-​1) re­cep­tor ag­o­nists, bariatric surgery, and the role of di­a­betes med­i­ca­tions (e.g., pi­ogli­ta­zone and GLP-​1 re­cep­tor ag­o­nists) to treat peo­ple with type 2 di­a­betes and non­al­co­holic fat­ty liv­er dis­ease (NASH).

Re­vi­sions to Sec­tion 4, in­clud­ing the ad­di­tion of Fig. 4.2, are based on the Amer­i­can Gas­troen­tero­log­i­cal As­so­ci­a­tion 2021 “Prepar­ing for the NASH Epi­dem­ic: A Call to Ac­tion” (ref­er­ence 64 in this sec­tion) and its as­so­ci­at­ed “Clin­i­cal Care Path­way for the Risk Stratification and Man­age­ment of Pa­tients with Non­al­co­holic Fat­ty Liv­er Dis­ease” (ref­er­ence 66 in this sec­tion), agreed upon by a mul­ti­dis­ci­plinary task force of ex­perts, in­clud­ing rep­re­sen­ta­tives of the ADA. De­tailed rec­om­men­da­tions from an ADA con­sen­sus state­ment will be pub­lished sep­a­rate­ly in 2023.