3. Foundations of Care andComprehensive MedicalEvaluationDiabetes Care 2016;39(Suppl. 1):S23–S35 | DOI: 10.2337/dc16-S006

The foundations of care include self-management education, nutrition, counseling,physical activity, smoking cessation, immunizations, psychosocial care, and med-ications (covered in other sections). The comprehensive medical evaluation in-cludes the initial and ongoing evaluations, assessment of complications,management of comorbid conditions, and engagement of the patient throughoutthe process.

FOUNDATIONS OF CARE

Optimal diabetes management starts with laying down the foundations of care. Thehealth care provider must take a holistic approach in providing care, accounting forall aspects of the patient’s life circumstances. A team approach to diabetes man-agement facilitates a comprehensive assessment and development of a plan thataddresses the patient’s values and circumstances. The investment of time andcollaboration can facilitate, and potentially expedite, care delivery and achieveand maintain outcomes.The initial clinical evaluation should be as comprehensive as possible as the pa-

tient will now have to address behavioral, dietary, lifestyle, and pharmaceuticalinterventions to effectively manage this newly identified chronic condition. Thecomponents for the comprehensive medical evaluation (Table 3.1) will providethe health care team with information necessary to optimally support a patientwith diabetes. In addition to the medical history and physical examination, labora-tory tests, nutrition, and psychosocial assessments should be obtained.

Patient EngagementAs discussed in Section 1 “Strategies for Improving Care,” the Chronic Care Model(CCM) has been shown to be an effective framework for improving the quality ofdiabetes care (1–3). This is a patient-centered approach to care that requires a closeworking relationship between the patient and clinicians involved in care planningand delivery. The foundation of successful diabetes management includes ongoingindividual lifestyle and behavioral changes, engagement of the patient, and assess-ment of the patient’s level of understanding about the disease and level of pre-paredness for self-management.

BASIS FOR INITIAL CARE

Diabetes self-management education (DSME), diabetes self-management sup-port (DSMS), medical nutrition therapy (MNT), counseling on smoking cessa-tion, education on physical activity, guidance on routine immunizations, andpsychosocial care are the cornerstone of diabetes management. Patientsshould be referred for such services if not readily available in the clinicalcare setting, i.e., referral for DSME, DSMS, MNT, and emotional health con-cerns. Additionally, specialty and lifestyle change services and programs maybe beneficial (Table 3.2). Patients should also receive recommended preven-tive care services (e.g., cancer screening and immunizations); referral for smok-ing cessation, if needed; and podiatric, ophthalmological, and dental referrals.Clinicians should ensure that individuals with diabetes are screened for com-plications and comorbidities. Identifying and implementing the initial approachto glycemic control with the patient is one part, not the sole aspect, of thecomprehensive care strategy.

Suggested citation: American Diabetes Associa-tion. Foundations of care and comprehensivemedical evaluation. Sec. 3. In Standards of Med-ical Care in Diabetesd2016. Diabetes Care2016;39(Suppl. 1):S23–S35

© 2016 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.

American Diabetes Association

Diabetes Care Volume 39, Supplement 1, January 2016 S23

3.FO

UNDATIO

NSOFCARE

ONGOING CARE MANAGEMENT

People with diabetes should receivemedical care from a collaborative, inte-grated team with diabetes expertise.This team may include physicians, nursepractitioners, physician assistants,nurses, dietitians, exercise specialists,pharmacists, dentists, podiatrists, andmental health professionals. Individuals

with diabetes must assume an active

role in their care.The patient, family, physician, and

other members of the health care teamshould formulate the management plan.Integral components of the managementplan include the foundations of care(DSME, DSMS, MNT, smoking cessation,physical activity, immunizations, and

psychosocial care). Various strategiesand techniques should be used to enablepatients to self-manage diabetes, includ-ing providing education on problem-solving skills for all aspects of diabetesmanagement. Treatment goals and plansshould be individualized and take patientpreferences into account. In developingthe plan, health care providers shouldconsider the patient’s age, school/workschedule and conditions, physical activ-ity, eating patterns, social situation, cul-tural factors, diabetes complications,health priorities, other medical condi-tions, preferences for care and self-management, and life expectancy.

DIABETES SELF-MANAGEMENTEDUCATION AND SUPPORT

Recommendations

c In accordance with the nationalstandards for diabetes self-man-agement education (DSME) andsupport (DSMS), all people with di-abetes should participate in DSMEto facilitate the knowledge, skills,and ability necessary for diabetesself-care and in DSMS to assist withimplementing and sustaining skillsand behaviors needed for ongoingself-management, both at diagnosisand as needed thereafter. B

c Effective self-management, im-proved clinical outcomes, healthstatus, and quality of life are keyoutcomes of DSME and DSMS andshould be measured and moni-tored as part of care. C

c DSME and DSMS should be patientcentered, respectful, and respon-sive to individual patient prefer-ences, needs, and values, whichshould guide clinical decisions. A

c DSME and DSMS programs shouldhave the necessary elements intheir curricula that are needed toprevent the onset of diabetes.DSME and DSMS programs shouldtherefore tailor their content spe-cifically when prevention of diabe-tes is the desired goal. B

c Because DSME and DSMS can re-sult in cost savings and improvedoutcomes B, DSME and DSMSshould be adequately reimbursedby third-party payers. E

DSME and DSMS are the ongoingprocesses of facilitating the knowledge,

Table 3.1—Components of the comprehensive diabetes medical evaluationMedical history

c Age and characteristics of onset of diabetes (e.g., diabetic ketoacidosis, asymptomaticlaboratory finding)

c Eating patterns, nutritional status, weight history, and physical activity habits; nutritioneducation and behavioral support history and needs

c Presence of common comorbidities, psychosocial problems, and dental diseasec Screen for depression using PHQ-2 (PHQ-9 if PHQ-2 is positive) or Edinburgh PostnatalDepression Scale (EPDS)

c Screen for diabetes distress using DDS or PAID-1c History of smoking, alcohol consumption, and substance usec Diabetes education, self-management, and support history and needsc Review of previous treatment regimens and response to therapy (A1C records)c Results of glucose monitoring and patient’s use of datac Diabetic ketoacidosis frequency, severity, and causec Hypoglycemia episodes, awareness, and frequency and causesc History of increased blood pressure, increased lipids, and tobacco usec Microvascular complications: retinopathy, nephropathy, and neuropathy (sensory,including history of foot lesions; autonomic, including sexual dysfunction andgastroparesis)

c Macrovascular complications: coronary heart disease, cerebrovascular disease, andperipheral arterial disease

Physical examinationc Height, weight, and BMI; growth and pubertal development in children and adolescentsc Blood pressure determination, including orthostatic measurements when indicatedc Fundoscopic examinationc Thyroid palpationc Skin examination (e.g., for acanthosis nigricans, insulin injection or infusion set insertionsites)

c Comprehensive foot examinationc Inspectionc Palpation of dorsalis pedis and posterior tibial pulsesc Presence/absence of patellar and Achilles reflexesc Determination of proprioception, vibration, and monofilament sensation

Laboratory evaluationc A1C, if the results are not available within the past 3 monthsc If not performed/available within the past year

c Fasting lipid profile, including total, LDL, and HDL cholesterol and triglycerides, as neededc Liver function testsc Spot urinary albumin–to–creatinine ratioc Serum creatinine and estimated glomerular filtration ratec Thyroid-stimulating hormone in patients with type 1 diabetes or dyslipidemia or womenaged .50 years

Table 3.2—Referrals for initial care managementc Eye care professional for annual dilated eye exam

c Family planning for women of reproductive age

c Registered dietitian for MNT

c DSME/DSMS

c Dentist for comprehensive dental and periodontal examination

c Mental health professional, if indicated

S24 Foundations of Care and Comprehensive Medical Evaluation Diabetes Care Volume 39, Supplement 1, January 2016

skills, and ability necessary for diabetesself-care. These processes incorporatethe needs, goals, and life experiencesof the person with diabetes. The overallobjectives of DSME and DSMS are tosupport informed decision making,self-care behaviors, problem solving,and active collaboration with the healthcare team to improve clinical outcomes,health status, and quality of life in acost-effective manner (4).DSME and DSMS are essential ele-

ments of diabetes care (5,6), and thecurrent national standards for DSMEand DSMS (4) are based on the evidenceof their benefits. Education helps peoplewith diabetes to initiate effective self-management and cope with diabeteswhen they are first diagnosed. OngoingDSMS helps people with diabetes tomaintain effective self-managementthroughout a lifetime of diabetes asthey face new challenges and as treat-ment advances become available.The DSME and DSMS algorithm de-

fines four critical time points for DSMEand DSMS delivery (7):

1. At diagnosis2. Annually for assessment of educa-

tion, nutrition, and emotional needs3. When new complicating factors arise

that influence self-management4. When transitions in care occur

Current best practice of DSME is a skill-based approach that focuses on helpingthose with diabetes to make informedself-management choices (4,5). DSME haschanged from a didactic approach thatfocused on providing information to em-powerment models that focus on helpingthosewith diabetes tomake informed self-management decisions (5). Diabetes carehas shifted to an approach that is morepatient centered and places the personwith diabetes and his or her family at thecenter of the care model, working in col-laboration with health care professionals.Patient-centered care is respectful of andresponsive to individual patient prefer-ences, needs, and values. It ensures thatpatient values guide all decisionmaking (8).

Evidence for the Benefits

Studies have found that DSME is associ-ated with improved diabetes knowl-edge, improved self-care behaviors (4),lower A1C (6,9,10), lower self-reportedweight (11,12), improved quality of life

(10,13), healthy coping (14,15), andlower costs (16,17). Better outcomeswere reported for DSME interventionsthat were longer (.10 h) and includedfollow-up support (DSMS) (18,19), wereculturally (20,21) and age appropriate(22,23), were tailored to individualneeds and preferences, and addressedpsychosocial issues and incorporatedbehavioral strategies (5,14,24,25). Bothindividual and group approaches havebeen found effective (12,26). There isgrowing evidence for the role of com-munity health workers (27), as well aspeer (27–29) and lay (30) leaders, in pro-viding ongoing support.

DSME is associated with increased pri-mary and preventive service use(16,31,32) and lower acute, inpatient hos-pital service use (11). Patientswho partic-ipate in DSME are more likely to followbest practice treatment recommenda-tions, particularly among the Medicarepopulation, and have lower Medicareand insurance claim costs (17,31).

ReimbursementDSME and DSMS, when provided by aprogram that meets the national stan-dards (4) and is recognized by the Amer-ican Diabetes Association (ADA) or otherapproval bodies, are reimbursed as partof the Medicare program as overseen bythe Centers forMedicare &Medicaid Ser-vices. DSME is also covered by mosthealth insurance plans. Although DSMShas been shown to be instrumental forimproving outcomes and can be providedvia phone calls and telehealth, it currentlyhas limited reimbursement as comparedwith in-person follow-up to DSME.

MEDICAL NUTRITION THERAPY

For many individuals with diabetes, themost challenging part of the treatmentplan is determining what to eat. It is theposition of the ADA that there is not aone-size-fits-all eating pattern for individ-uals with diabetes. The ADA recognizesthe integral role of MNT in overall diabe-tes management and recommends thateach person with diabetes be actively en-gaged in self-management, education,and treatment planning with his or herhealth care team, including the collabora-tive development of an individualizedeating plan (33,34). Therefore, it is impor-tant that eachmember of the health careteam be knowledgeable about nutritiontherapy principles for people with all

types of diabetes and be supportive oftheir implementation. See Table 3.3 forspecific nutrition recommendations.

Goals of Medical Nutrition Therapyfor Adults With Diabetes1. To promote and support healthful eat-

ing patterns, emphasizing a variety ofnutrient-dense foods in appropriateportion sizes, in order to improveoverall health and specifically to○ Achieve andmaintain bodyweight

goals○ Attain individualized glycemic,

blood pressure, and lipid goals○ Delay or prevent complications of

diabetes2. To address individual nutrition needs

based on personal and cultural prefer-ences, health literacy and numeracy,access to healthful foods, willingnessandability tomakebehavioral changes,and barriers to change

3. Tomaintain the pleasure of eating byproviding nonjudgmental messagesabout food choices

4. To provide an individual with diabe-tes with practical tools for develop-ing healthful eating patterns ratherthan focusing on individual macronu-trients, micronutrients, or singlefoods

MNT is an integral component of diabe-tes prevention, management, and self-management education. All individualswith diabetes should receive individual-ized MNT, preferably provided by a reg-istered dietitian who is knowledgeableand skilled in providing diabetes-specificMNT. MNT delivered by a registered di-etitian shows A1C decreases of 0.3–1%for people with type 1 diabetes (35–37)and 0.5–2% for people with type 2 di-abetes (38–41).

Weight ManagementIntensive lifestyle programs with fre-quent follow-up are required to achievesignificant reductions in excess bodyweight and improve clinical indicators.There is strong and consistent evidencethat obesity management can delay pro-gression from prediabetes to type 2 di-abetes (42,43) and benefits type 2diabetes treatment.

In overweight and obese patientswith type 2 diabetes, modest weightloss, defined as sustained reduction of5% of initial body weight, has beenshown to improve glycemic control

care.diabetesjournals.org Foundations of Care and Comprehensive Medical Evaluation S25

Table 3.3—Nutrition therapy recommendations

Topic Recommendations Evidence rating

Effectiveness of nutrition therapy c An individualized MNT program, preferably provided by a registered dietitian, isrecommended for all people with type 1 or type 2 diabetes.

A

c For people with type 1 diabetes or those with type 2 diabetes who are prescribeda flexible insulin therapy program, education on how to use carbohydratecounting or estimation to determine mealtime insulin dosing can improveglycemic control.

A

c For individuals whose daily insulin dosing is fixed, having a consistent pattern ofcarbohydrate intake with respect to time and amount can result in improvedglycemic control and a reduced risk of hypoglycemia.

B

c A simple and effective approach to glycemia and weight managementemphasizing healthy food choices and portion control may be more helpful forthose with type 2 diabetes who are not taking insulin, who have limited healthliteracy or numeracy, and who are elderly and prone to hypoglycemia.

C

c Because diabetes nutrition therapy can result in cost savings B and improvedoutcomes (e.g., A1C reduction) A, MNT should be adequately reimbursed byinsurance and other payers. E

B, A, E

Energy balance c Modest weight loss achievable by the combination of lifestyle modification andthe reduction of energy intake benefits overweight or obese adults with type 2diabetes and also those at risk for diabetes. Interventional programs to facilitatethis process are recommended.

A

Eating patterns and macronutrientdistribution

c As there is no single ideal dietary distribution of calories among carbohydrates,fats, and proteins for people with diabetes, macronutrient distribution should beindividualized while keeping total calorie and metabolic goals in mind.

E

c Carbohydrate intake from whole grains, vegetables, fruits, legumes, and dairyproducts, with an emphasis on foods higher in fiber and lower in glycemic load,should be advised over other sources, especially those containing sugars.

B

c People with diabetes and those at risk should avoid sugar-sweetened beveragesin order to control weight and reduce their risk for CVD and fatty liver B andshould minimize the consumption of sucrose-containing foods that have thecapacity to displace healthier, more nutrient-dense food choices. A

B, A

Protein c In individuals with type 2 diabetes, ingested protein appears to increase insulinresponse without increasing plasma glucose concentrations. Therefore,carbohydrate sources high in protein should not be used to treat or preventhypoglycemia.

B

Dietary fat c Whereas data on the ideal total dietary fat content for people with diabetes areinconclusive, an eating plan emphasizing elements of a Mediterranean-style dietrich in monounsaturated fats may improve glucose metabolism and lower CVDrisk and can be an effective alternative to a diet low in total fat but relatively highin carbohydrates.

B

c Eating foods rich in long-chain omega-3 fatty acids, such as fatty fish (EPA andDHA) and nuts and seeds (ALA), is recommended to prevent or treat CVD B;however, evidence does not support a beneficial role for omega-3 dietarysupplements. A

B, A

Micronutrients and herbal supplements c There is no clear evidence that dietary supplementation with vitamins, minerals,herbs, or spices can improve diabetes, and there may be safety concernsregarding the long-term use of antioxidant supplements such as vitamins E and Cand carotene.

C

Alcohol c Adults with diabetes who drink alcohol should do so in moderation (no morethan one drink per day for adult women and no more than two drinks per day foradult men).

C

c Alcohol consumption may place people with diabetes at increased risk fordelayed hypoglycemia, especially if taking insulin or insulin secretagogues.Education and awareness regarding the recognition andmanagement of delayedhypoglycemia are warranted.

B

Sodium c As for the general population, people with diabetes should limit sodiumconsumption to ,2,300 mg/day, although further restriction may be indicatedfor those with both diabetes and hypertension.

B

S26 Foundations of Care and Comprehensive Medical Evaluation Diabetes Care Volume 39, Supplement 1, January 2016

and to reduce the need for glucose-lowering medications (44–46). Weightloss canbeattainedwith lifestyle programsthat achieve a 500–750 kcal/day energydeficit or provide ;1,200–1,500 kcal/dayfor women and 1,500–1,800 kcal/day formen, adjusted for the individual’s baselinebody weight. Although benefits may beseen with as little as 5% weight loss, sus-tained weight loss of$7% is optimal.These diets may differ in the types of

foods they restrict (such as high-fat orhigh-carbohydrate foods) but are effec-tive if they create the necessary energydeficit (47–50). The diet choice shouldbe based on the patients’ health statusand preferences.

CarbohydratesStudies examining the ideal amount ofcarbohydrate intake for people with dia-betes are inconclusive, although monitor-ing carbohydrate intake and consideringthe blood glucose response to dietary car-bohydrate are key for improving post-prandial glucose control (51,52). Theliterature concerning glycemic index andglycemic load in individuals with diabetesis complex. Although in some studies low-ering the glycemic load of consumedcarbohydrates has demonstrated A1Creductions of20.2% to 20.5% (53,54), asystematic review (53) found that whole-grain consumption was not associatedwith improvements in glycemic controlin type 2 diabetes. One study did find apotential benefit of whole-grain intake inreducingmortality and cardiovascular dis-ease (CVD) among individuals with type 2diabetes (55). As for all Americans, indi-viduals with diabetes should be encour-aged to replace refined carbohydratesand added sugars with whole grains,legumes, vegetables, and fruits. The con-sumption of sugar-sweetened beveragesand “low-fat” or “nonfat” products withhigh amounts of refined grains and addedsugars should be discouraged (56).Individuals with type 1 or type 2 diabe-

tes taking insulin at mealtimes should beoffered intensive education on couplinginsulin administration with carbohydrateintake. For people whose meal schedulesor carbohydrate consumption is variable,regular counseling to help them to under-stand the complex relationship betweencarbohydrate intake and insulin needs, aswell as the carbohydrate-counting ap-proach to meal planning, can assist themwith effectively modifying insulin dosing

frommeal tomeal and improving glycemiccontrol (36,51,57,58). For individuals on afixed daily insulin schedule, meal planningshould emphasize a relatively fixed carbo-hydrate consumption patternwith respectto both time and amount (34). Bycontrast, a simpler diabetes meal planningapproach emphasizing portion control andhealthful food choices may be bettersuited for some elderly individuals, thosewith cognitive dysfunction, and those forwhom there are concerns over health lit-eracy and numeracy (34–36,38,51,57).

ProteinFor individuals without evidence of dia-betic kidney disease, the evidence is incon-clusive about recommending an idealamount of protein for optimizing glycemiccontrol or for improving one or more CVDrisk measures (53). Therefore, these goalsshould be individualized. For those with di-abetic kidney disease (with albuminuria,reduced estimated glomerular filtrationrate), dietary protein should bemaintainedat the recommended daily allowance of0.8 g/kg body weight per day. Reducingthe amount of dietary protein belowthe recommended daily allowance isnot recommended because it does notalter glycemic measures, cardiovascularrisk measures, or the rate at which glo-merular filtration rate declines (59,60).In individuals with type 2 diabetes, in-gested protein may enhance the insulinresponse to dietary carbohydrates (61).Therefore, carbohydrate sources high inprotein should not be used to treat or pre-vent hypoglycemia. The effects of proteinintake on blood glucose levels in type 1diabetes are less clear.

FatsLimited research exists concerning theideal amount of fat for individuals with di-abetes. The Institute of Medicine hasdefined an acceptable macronutrient dis-tribution range for all adults for total fat of20–35% of energy with no tolerable upperintake level defined (62). The type of fattyacids consumed is more important thantotal amount of fat when looking at meta-bolic goals and CVD risk (63–65). Multiplerandomized controlled trials including pa-tients with type 2 diabetes have reportedthat a Mediterranean-style eating pattern(63,66–68), rich in monounsaturated fats,can improve both glycemic control andblood lipids. However, a systematic reviewconcluded that dietary supplements with

omega-3 fatty acids did not improve glyce-mic control in individuals with type 2 di-abetes (53). Randomized controlled trialsalso do not support recommendingomega-3 supplements for primary or sec-ondary preventionofCVD (69–73). Peoplewith diabetes should be advised to followthe guidelines for the general populationfor the recommended intakes of saturatedfat, dietary cholesterol, and trans fat (64).In general, trans fats should be avoided.

SodiumAs for the general population, people withdiabetes should limit their sodium con-sumption to ,2,300 mg/day. Loweringsodium intake (i.e., 1,500 mg/day) maybenefit blood pressure in certain circum-stances (74). The American Heart Associa-tion recommends 1,500 mg/day forAfrican Americans; people diagnosedwith hypertension, diabetes, or chronickidney disease; and people over 51 yearsof age (75). However, other studies (76,77)have recommended caution for universalsodium restriction to 1,500mg in this pop-ulation. Sodium intake recommendationsshould take into account palatability, avail-ability, affordability, and the difficulty ofachieving low-sodium recommendationsin a nutritionally adequate diet (78).

For complete discussion and refer-ences of all recommendations, see theADA position statement “Nutrition Ther-apy Recommendations for the Manage-ment of Adults With Diabetes” (34).

PHYSICAL ACTIVITY

Recommendations

c Children with diabetes or predia-betes should be encouraged to en-gage in at least 60 min of physicalactivity each day. B

c Adults with diabetes should be ad-vised to perform at least 150 min/week of moderate-intensity aerobicphysical activity (50–70% of maxi-mumheart rate), spreadover at least3 days/week with no more than 2consecutive days without exercise.A

c All individuals, including those withdiabetes, should be encouraged toreduce sedentary time, particularlyby breaking up extended amountsof time (.90 min) spent sitting. B

c In the absence of contraindications,adultswith type2diabetes shouldbeencouraged to perform resistancetraining at least twice per week. A

care.diabetesjournals.org Foundations of Care and Comprehensive Medical Evaluation S27

Physical activity is a general term thatincludes all movement that increases en-ergy use and is an important part of thediabetes management plan. Exercise is amore specific form of physical activitythat is structured and designed to im-prove physical fitness. Although bothare important, exercise has been shownto improve blood glucose control, reducecardiovascular risk factors, contribute toweight loss, and improve well-being.Physical activity is as important for thosewith type 1 diabetes as it is for the generalpopulation, but its specific role in pre-venting diabetes complications and con-trolling blood glucose is not as clear as it isfor those with type 2 diabetes.Furthermore, regular exercise may

prevent type 2 diabetes in high-risk in-dividuals (43,79,80) (see Section 4 “Pre-vention or Delay of Type 2 Diabetes”).Structured exercise interventions of atleast 8 weeks’ duration have beenshown to lower A1C by an average of0.66% in people with type 2 diabetes,even with no significant change in BMI(80). There are also considerable datafor the health benefits (e.g., increasedcardiovascular fitness, muscle strength,improved insulin sensitivity, etc.) of reg-ular exercise for those with type 1 dia-betes (81). Higher levels of exerciseintensity are associated with greater im-provements in A1C and in fitness (82).Other benefits include slowing the de-cline in mobility among overweight pa-tients with diabetes (83). “Exercise andType 2 Diabetes: The American Collegeof Sports Medicine and the AmericanDiabetes Association: Joint PositionStatement” (84) reviews the evidencefor the benefits of exercise in peoplewith type 2 diabetes.

Exercise and ChildrenAs is recommended for all children, chil-dren with diabetes or prediabetes shouldbe encouraged to engage in at least 60min of physical activity each day. Includedin the 60 min each day, children shouldengage in vigorous-intensity aerobic ac-tivity, muscle-strengthening activities,and bone-strengthening activities at least3 of those days (85).

Frequency and Type of PhysicalActivityThe U.S. Department of Health and Hu-man Services’ physical activity guidelinesfor Americans (86) suggest that adults

over age 18 years do 150 min/week ofmoderate-intensity or 75 min/week ofvigorous-intensity aerobic physical activ-ity, or an equivalent combination of thetwo. In addition, the guidelines suggestthat adults domuscle-strengthening activ-ities that involve allmajormuscle groups 2or more days/week. The guidelines sug-gest that adults over age 65 years or thosewith disabilities follow the adult guide-lines if possible or, if this is not possible,be as physically active as they are able.

Recent evidence supports that all indi-viduals, including those with diabetes,should be encouraged to reduce theamount of time spent being sedentary(e.g., working at a computer, watchingTV), particularly, by breaking up extendedamounts of time (.90 min) spent sittingby briefly standing or walking (87).

Physical Activity and GlycemicControlOn the basis of physical activity studiesthat include people with diabetes, it isreasonable to recommend that peoplewith diabetes will specifically benefitfrom following the U.S. Department ofHealth and Human Services’ physical ac-tivity guidelines. For example, studies in-cluded in the meta-analysis of the effectsof exercise interventions on glycemic con-trol (80) reported a mean of 3.4 sessions/week, with a mean of 49 min/session.

Clinical trials have provided strong evi-dence for the A1C-lowering value of resis-tance training in older adults with type 2diabetes (84) and for an additive benefit ofcombined aerobic and resistance exercisein adults with type 2 diabetes (88,89). Ifnot contraindicated, patients with type 2diabetes should be encouraged to do atleast two weekly sessions of resistance ex-ercise (exercise with free weights orweight machines), with each session con-sisting of at least one set of five or moredifferent resistance exercises involving thelarge muscle groups (84).

Pre-exercise EvaluationAs discussed more fully in Section 8 “Car-diovascular Disease and Risk Manage-ment,” the best protocol for screeningasymptomatic patients with diabetesfor coronary artery disease remainsunclear. The ADA consensus report“Screening for Coronary Artery Diseasein Patients With Diabetes” (90) con-cluded that routine testing is not recom-mended. Providers should perform a

careful history being aware of the atyp-ical presentation of coronary artery dis-ease in patients with diabetes and assessother cardiovascular risk factors. Cer-tainly, high-risk patients should be en-couraged to start with short periods oflow-intensity exercise and slowly in-crease the intensity and duration. Pro-viders should assess patients forconditions that might contraindicatecertain types of exercise or predis-pose to injury, such as uncontrolledhypertension, autonomic neuropathy,peripheral neuropathy, a history offoot lesions, and untreated proliferativeretinopathy. The patient’s age and pre-vious physical activity level should beconsidered. The provider should cus-tomize the exercise regimen to theindividual’s needs. Those with compli-cations may require a more thoroughevaluation (81).

HypoglycemiaIn individuals taking insulin and/or insu-lin secretagogues, physical activity maycause hypoglycemia if the medicationdose or carbohydrate consumption isnot altered. Individuals on these thera-pies may need to ingest some addedcarbohydrate if pre-exercise glucose lev-els are ,100 mg/dL (5.6 mmol/L), de-pending on whether they can lowerinsulin levels during the workout (suchas with an insulin pump or reduced pre-exercise insulin dosage), the time of dayexercise is done, and the intensity andduration of the activity. Hypoglycemia isless common in patients with diabeteswho are not treated with insulin or in-sulin secretagogues, and no preventivemeasures for hypoglycemia are usuallyadvised in these cases. Intense activitiesmay actually raise blood glucose levelsinstead of lowering them (91).

Exercise in the Presence of SpecificLong-term Complications of Diabetes

Retinopathy

If proliferative diabetic retinopathy or se-vere nonproliferative diabetic retinopa-thy is present, then vigorous-intensityaerobic or resistance exercise may becontraindicated because of the risk oftriggering vitreous hemorrhage or retinaldetachment (92).

Peripheral Neuropathy

Decreased pain sensation and a higherpain threshold in the extremities resultin an increased risk of skin breakdown,

S28 Foundations of Care and Comprehensive Medical Evaluation Diabetes Care Volume 39, Supplement 1, January 2016

infection, and Charcot joint destructionwith some forms of exercise. There-fore, a thorough assessment shouldbe done to ensure that neuropathydoes not alter kinesthetic or propriocep-tive sensation during physical activity.Studies have shown that moderate-intensity walking may not lead to anincreased risk of foot ulcers or reulcera-tion in those with peripheral neuropa-thy who use proper footwear (93). Inaddition, 150 min/week of moderateexercise was reported to improve out-comes in patients with milder formsof neuropathy (94). All individuals withperipheral neuropathy should wearproper footwear and examine theirfeet daily to detect lesions early. Any-one with a foot injury or open soreshould be restricted to non–weight-bearing activities.

Autonomic Neuropathy

Autonomic neuropathy can increase therisk of exercise-induced injury or ad-verse events through decreased cardiacresponsiveness to exercise, postural hy-potension, impaired thermoregulation,impaired night vision due to impairedpapillary reaction, and greater suscepti-bility to hypoglycemia (95). Cardiovas-cular autonomic neuropathy is also anindependent risk factor for cardiovascu-lar death and silent myocardial ischemia(96). Therefore, individuals with dia-betic autonomic neuropathy should un-dergo cardiac investigation beforebeginning physical activity more intensethan that to which they are accustomed.

Albuminuria and Nephropathy

Physical activity can acutely increase uri-nary protein excretion. However, thereis no evidence that vigorous-intensityexercise increases the rate of progres-sion of diabetic kidney disease, andthere appears to be no need for specificexercise restrictions for people with di-abetic kidney disease (92).

SMOKING CESSATION: TOBACCOAND e-CIGARETTES

Recommendations

c Advise all patients not to use ciga-rettes, other tobacco products, ore-cigarettes. A

c Include smoking cessation coun-seling and other forms of treat-ment as a routine component ofdiabetes care. B

Results from epidemiological, case-control,and cohort studies provide convincing ev-idence to support the causal link betweencigarette smoking and health risks (97).Other studies of individuals with diabetesconsistently demonstrate that smokers(and people exposed to secondhandsmoke) have a heightened risk of CVD,premature death, and microvascularcomplications. Smoking may have a rolein the development of type 2 diabetes(98). One study in smokers with newlydiagnosed type 2 diabetes found thatsmoking cessation was associated withamelioration of metabolic parametersand reduced blood pressure and albumin-uria at 1 year (99).

The routine and thorough assessmentof tobacco use is essential to preventsmoking or encourage cessation. Nu-merous large randomized clinical trialshave demonstrated the efficacy and cost-effectivenessof brief counseling in smokingcessation, including the use of telephonequit lines, in reducing tobaccouse. For thepatient motivated to quit, the addition ofpharmacological therapy to counselingis more effective than either treatmentalone. Special considerations should in-clude assessment of level of nicotinedependence, which is associated withdifficulty in quitting and relapse (100).Although some patients may gain weightin the period shortly after smoking ces-sation, recent research has demon-strated that this weight gain does notdiminish the substantial CVD benefit re-alized from smoking cessation (101).Nonsmokers should be advised not touse e-cigarettes.

There are no rigorous studies that havedemonstrated that e-cigarettes are ahealthier alternative to smoking or thate-cigarettes can facilitate smoking cessa-tion. More extensive research of theirshort- and long-term effects is neededto determine their safety and their car-diopulmonary effects in comparisonwith smoking and standard approachesto smoking cessation (102–104).

IMMUNIZATION

Recommendations

c Provide routine vaccinations forchildren and adults with diabetesas for the general population ac-cording to age-related recommen-dations. C

c Administer hepatitis B vaccine tounvaccinated adults with diabeteswho are aged 19–59 years. C

c Consider administering hepatitis Bvaccine to unvaccinated adultswith diabetes who are aged $60years. C

As for the general population, all chil-dren and adults with diabetes should re-ceive routine vaccinations (105,106)according to age-specific recommenda-tions (see the adult vaccination sched-ule available from http://www.cdc.gov/vaccines/schedules/hcp/imz/adult.htmland the child and adolescent vaccina-tion schedule available from http://www.cdc.gov/vaccines/schedules/hcp/imz/child-adolescent.html).

The Centers for Disease Control andPrevention (CDC) Advisory Committeeon Immunization Practices recommendsinfluenza and pneumococcal vaccinesfor all individuals with diabetes (http://www.cdc.gov/vaccines/schedules).

InfluenzaInfluenza is a common, preventable in-fectious disease associated with highmortality and morbidity in vulnerablepopulations, such as the young andthe elderly and people with chronicdiseases. Regardless of sex, race, andsocioeconomic status, adults with dia-betes 25–64 years of age who died arefour times more likely to have pneu-monia and influenza recorded on theirdeath certificates than adults withoutdiabetes who died at comparable ages(107). In a case-control series, the in-fluenza vaccine was shown to reducediabetes-related hospital admissionby as much as 79% during flu epidemics(108).

Pneumococcal PneumoniaLike influenza, pneumococcal pneumo-nia is a common, preventable disease.People with diabetes may be at in-creased risk for the bacteremic form ofpneumococcal infection and have beenreported to have a high risk of nosoco-mial bacteremia, with a mortality rateas high as 50% (109). All patients withdiabetes 2 years of age and older shouldreceive the pneumococcal polysaccha-ride vaccine 23 (PPSV23). There is suffi-cient evidence to support that peoplewith diabetes have appropriate sero-logic and clinical responses to these

care.diabetesjournals.org Foundations of Care and Comprehensive Medical Evaluation S29

vaccinations. The ADA endorses theCDC advisory panel recommendationthat both pneumococcal conjugate vac-cine 13 (PCV13) and PPSV23 should beadministered routinely in series to alladults aged $65 years.

Hepatitis BCompared with the general population,people with type 1 or type 2 diabeteshave higher rates of hepatitis B. Thismay be due to contact with infectedblood or through improper equipmentuse (glucose monitoring devices or in-fected needles). Because of the higherlikelihood of transmission, hepatitis Bvaccine is recommended for adultswith diabetes.

PSYCHOSOCIAL ISSUES

Recommendations

c The patient’s psychological andsocial situation should be ad-dressed in the medical manage-ment of diabetes. B

c Psychosocial screening and follow-up may include, but are not lim-ited to, attitudes about the illness,expectations for medical man-agement and outcomes, affect/mood, general and diabetes-relatedquality of life, resources (financial,social, and emotional), and psy-chiatric history. E

c Routinely screen for psychoso-cial problems such as depression,diabetes-related distress, anxiety,eating disorders, and cognitive im-pairment. B

c Older adults (aged $65 years)with diabetes should be consid-ered for evaluation of cognitivefunction and depression screeningand treatment. B

c Patients with comorbid diabetesand depression should receive astepwise collaborative care ap-proach for the management of de-pression. A

Emotional well-being is an important partof diabetes care and self-management.Psychological and social problems canimpair the individual’s (110–112) orfamily’s (113) ability to carry outdiabetes care tasks and therefore com-promise health status. There are oppor-tunities for the clinician to routinelyassess psychosocial status in a timelyand efficient manner for referral for

appropriate services. A systematic re-view and meta-analysis showed thatpsychosocial interventions modestlybut significantly improved A1C (stan-dardized mean difference 20.29%)and mental health outcomes. However,there was a limited association be-tween the effects on A1C and mentalhealth, and no intervention characteris-tics predicted benefit on both outcomes(114).

ScreeningKey opportunities for psychosocialscreening occur at diabetes diagnosis,during regularly scheduled manage-ment visits, during hospitalizations,with new onset of complications, orwhen problems with glucose control,quality of life, or self-management areidentified. Patients are likely to exhibitpsychological vulnerability at diagnosis,when their medical status changes(e.g., end of the honeymoon period),when the need for intensified treat-ment is evident, and when complica-tions are discovered. Depressionaffects;20–25% of people with diabe-tes (115). Individuals with both diabe-tes and major depressive disorderhave a twofold increased risk for new-onset myocardial infarction comparedwith either disease state alone (116).There appears to be a bidirectional re-lationship between both diabetes (117)and metabolic syndrome (118) anddepression.

Diabetes DistressDiabetes-related distress (DD) is dis-tinct from depressive disorders and isvery common (119–121) in peoplewith diabetes and their family mem-bers (113). DD refers to significant neg-ative psychological reactions relatedto emotional burdens and worries spe-cific to an individual’s experience inhaving to manage a severe, compli-cated, and demanding chronic dis-ease such as diabetes (120–122). Itsprevalence is reported to be 18–45%,with an incidence of 38–48% over 18months. High levels of distress aresignificantly linked to medication non-adherence (122), higher A1C, lowerself-efficacy, and poorer dietary andexercise behaviors (15,120). The clini-cian needs to understand that individualsmay fall into one of three categories:those with depression and DD, those

with depression without significantDD, and those with DD without signifi-cant depression. Understanding thecategory in which a particular patientbelongs facilitates a customized careapproach that may include DSME,DSMS, cognitive therapy, or treatmentfor depression (psychotherapy and/or psychotropic medications). Thescreening of all patients with diabeteswith the Patient Health Questionnaire-2(PHQ-2) and either the Diabetes Dis-tress Scale (DDS) or Problem Areas inDiabetes (PAID)-1 scale can help tofacilitate this (24,123,124).

Other issues known to affect self-management and health outcomesinclude attitudes about the illness, ex-pectations for medical management andoutcomes, anxiety, general and diabetes-related quality of life, resources (financial,social, and emotional) (125), and psychi-atric history (126).

Referral to a Mental Health SpecialistIndications for referral to a mentalhealth specialist familiar with diabetesmanagement may include possibility ofself-harm, gross disregard for the med-ical regimen (by self or others) (127),depression, overall stress related towork-life balance, debilitating anxiety(alone or with depression), indicationsof an eating disorder (128), or cognitivefunctioning that significantly impairsjudgment. It is preferable to incorpo-rate psychological assessment andtreatment into routine care ratherthan waiting for a specific problem ordeterioration in metabolic or psycho-logical status (24,119). In the second Di-abetes Attitudes, Wishes and Needs(DAWN2) study, significant DD was re-ported by 45% of the participants, butonly 24% reported that their health careteam asked them how diabetes affectedtheir life (119).

Although the clinician may not feelqualified to treat psychological prob-lems (129), optimizing the patient–provider relationship as a foundationmay increase the likelihood of the pa-tient accepting referral for other ser-vices. Collaborative care interventionsand a team approach have demonstratedefficacy in diabetes and depression(130,131). Interventions to enhanceself-management and address severedistress have demonstrated efficacyin DD (15).

S30 Foundations of Care and Comprehensive Medical Evaluation Diabetes Care Volume 39, Supplement 1, January 2016

COMPREHENSIVE MEDICALEVALUATION

Recommendations

A complete medical evaluation shouldbe performed at the initial visit to

c Confirm the diagnosis and classifydiabetes. B

c Detect diabetes complications andpotential comorbid conditions. E

c Review previous treatment andrisk factor control in patientswith established diabetes. E

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

c Develop a plan for continuing care. B

Besides assessing diabetes-relatedcomplications and comorbidities, clini-cians and their patients need to beaware of other common conditionsthat affect people with diabetes. Im-proved disease prevention and treat-ment mean that people with diabetesare living longer and developing heartfailure, fatty liver disease, obstructivesleep apnea, and arthritisdconditionsthat affect people with diabetes moreoften than age-matched people withoutdiabetes and that may complicate dia-betes management (132–136).Adults who develop type 1 diabetes

may develop additional autoimmune dis-orders including thyroid or adrenal dys-function and celiac disease, although therisk of coexisting autoimmunity is lower inadults than for youth with type 1 diabe-tes. For additional details on autoimmuneconditions, see Section 11 “Children andAdolescents.”

COMORBIDITIES

Fatty Liver DiseaseElevations of hepatic transaminase con-centrations are significantly associatedwith higher BMI, waist circumference,and triglyceride levels and lower HDLcholesterol levels. In a prospective anal-ysis, diabetes was significantly associ-ated with incident nonalcoholic chronicliver disease and with hepatocellularcarcinoma (137). Interventions that im-prove metabolic abnormalities in pa-tients with diabetes (weight loss,glycemic control, and treatment withspecific drugs for hyperglycemia or dys-lipidemia) are also beneficial for fattyliver disease (138).

Obstructive Sleep ApneaAge-adjusted rates of obstructive sleepapnea, a risk factor for CVD, are signifi-cantly higher (4- to 10-fold) with obe-sity, especially with central obesity(139). The prevalence of obstructivesleep apnea in the population withtype 2 diabetes may be as high as 23%(140). In obese participants enrolled inthe Action for Health in Diabetes (LookAHEAD) trial, it exceeded 80% (141).Sleep apnea treatment significantly im-proves quality of life and blood pressurecontrol. The evidence for a treatmenteffect on glycemic control is mixed(142).

CancerDiabetes (possibly only type 2 diabetes)is associated with increased risk ofcancers of the liver, pancreas, endome-trium, colon/rectum, breast, and blad-der (143). The association may resultfrom shared risk factors betweentype 2 diabetes and cancer (older age,obesity, and physical inactivity) butmay also be due to hyperinsulinemiaor hyperglycemia (144). Patients withdiabetes should be encouraged to un-dergo recommended age- and sex-ap-propriate cancer screenings and toreduce their modifiable cancer risk fac-tors (smoking, obesity, and physical in-activity).

FracturesAge-specific hip fracture risk is signifi-cantly increased in both type 1 (relativerisk 6.3) and type 2 (relative risk 1.7) di-abetes in both sexes (145). Type 1 dia-betes is associated with osteoporosis,but in type 2 diabetes, an increasedrisk of hip fracture is seen despite higherbone mineral density (BMD) (146). Inthree large observational studies ofolder adults, femoral neck BMD T-scoreand theWorld Health Organization Frac-ture Risk Assessment Tool (FRAX) scorewere associated with hip and nonspinefractures. Fracture risk was higher inparticipants with diabetes comparedwith those without diabetes for a givenT-score and age for a given FRAX score(147). Providers should assess fracturehistory and risk factors in older patientswith diabetes and recommend measure-ment of BMD if appropriate for the pa-tient’s age and sex. Fracture preventionstrategies for people with diabetes arethe same as for the general populationand include vitamin D supplementation.

For patients with type 2 diabetes withfracture risk factors, thiazolidinediones(148) and sodium–glucose cotransporter2 inhibitors should be avoided as their usehas been associated with a higher risk offractures (149).

Low Testosterone in MenMean levels of testosterone are lower inmen with diabetes compared with age-matched men without diabetes, butobesity is a major confounder (150).Treatment in asymptomatic men is con-troversial. The evidence that testoster-one replacement affects outcomes ismixed, and recent guidelines do not rec-ommend testing and treating men with-out symptoms (151).

Periodontal DiseasePeriodontal disease is more severe, butnot necessarily more prevalent, in pa-tients with diabetes than in those with-out (152). Current evidence suggeststhat periodontal disease adversely af-fects diabetes outcomes, although evi-dence for treatment benefits remainscontroversial (136).

Hearing ImpairmentHearing impairment,both inhigh-frequencyand low/mid-frequency ranges, is morecommon in people with diabetes thanin those without, perhaps due to neu-ropathy and/or vascular disease. In aNational Health and Nutrition Examina-tion Survey (NHANES) analysis, hearingimpairment was about twice as preva-lent in people with diabetes comparedwith those without, after adjusting forage and other risk factors for hearingimpairment (153).

Cognitive ImpairmentDiabetes is associated with a signifi-cantly increased risk and rate of cogni-tive decline and an increased risk ofdementia (154,155). In a 15-year pro-spective study of community-dwellingpeople aged .60 years, the presenceof diabetes at baseline significantlyincreased the age- and sex-adjustedincidence of all-cause dementia, Alz-heimer disease, and vascular dementiacompared with rates in those withnormal glucose tolerance (156). In asubstudy of the Action to Control Car-diovascular Risk in Diabetes (ACCORD)clinical trial, there were no differencesin cognitive outcomes between the in-tensive and standard glycemic control

care.diabetesjournals.org Foundations of Care and Comprehensive Medical Evaluation S31

groups, although there was signifi-cantly less of a decrement in total brainvolume, as measured by MRI, in partic-ipants in the intensive arm (157). Theeffects of hyperglycemia and insulin onthe brain are areas of intense researchinterest.

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99. Voulgari C, Katsilambros N, Tentolouris N.Smoking cessation predicts amelioration of mi-croalbuminuria in newly diagnosed type 2 dia-betes mellitus: a 1-year prospective study.Metabolism 2011;60:1456–1464100. Ranney L, Melvin C, Lux L, McClain E, LohrKN. Systematic review: smoking cessation inter-vention strategies for adults and adults in spe-cial populations. Ann Intern Med 2006;145:845–856101. Clair C, Rigotti NA, Porneala B, et al. Asso-ciation of smoking cessation and weight changewith cardiovascular disease among adults withand without diabetes. JAMA 2013;309:1014–1021102. Schraufnagel DE, Blasi F, Drummond MB,et al.; Forum of International Respiratory Socie-ties. Electronic cigarettes. A position statementof the Forum of International Respiratory Socie-ties. Am J Respir Crit Care Med 2014;190:611–618103. Bam TS, Bellew W, Berezhnova I, et al.;Tobacco Control Department InternationalUnion Against Tuberculosis and Lung Disease.Position statement on electronic cigarettes orelectronic nicotine delivery systems. Int J Tu-berc Lung Dis 2014;18:5–7104. Bhatnagar A, Whitsel LP, Ribisl KM, et al.;American Heart Association Advocacy Coordi-nating Committee, Council on Cardiovascularand Stroke Nursing, Council on Clinical Cardiol-ogy, and Council on Quality of Care and Out-comes Research. Electronic cigarettes: a policystatement from the American Heart Associa-tion. Circulation 2014;130:1418–1436105. Strikas RA; Centers for Disease Controland Prevention (CDC); Advisory Committee onImmunization Practices (ACIP); ACIP Child/Ado-lescent Immunization Work Group. AdvisoryCommittee on Immunization Practices recom-mended immunization schedules for personsaged 0 through 18 yearsdUnited States, 2015.MMWR Morb Mortal Wkly Rep 2015;64:93–94106. Kim DK, Bridges CB, Harriman KH; Centersfor Disease Control and Prevention (CDC); Advi-sory Committee on Immunization Practices(ACIP); ACIP Adult Immunization Work Group.Advisory Committee on Immunization Practicesrecommended immunization schedule foradults aged 19 years or olderdUnited States,2015. MMWR Morb Mortal Wkly Rep 2015;64:91–92107. Valdez R, Narayan KM, Geiss LS, EngelgauMM. Impact of diabetes mellitus on mortalityassociated with pneumonia and influenzaamong non-Hispanic black and white US adults.Am J Public Health 1999;89:1715–1721108. Colquhoun AJ, Nicholson KG, Botha JL,Raymond NT. Effectiveness of influenza vaccinein reducing hospital admissions in people withdiabetes. Epidemiol Infect 1997;119:335–341109. Smith SA, Poland GA. Use of influenza andpneumococcal vaccines in people with diabetes.Diabetes Care 2000;23:95–108110. Anderson RJ, Grigsby AB, Freedland KE,et al. Anxiety and poor glycemic control: ameta-analytic review of the literature. Int J Psy-chiatry Med 2002;32:235–247111. Delahanty LM, Grant RW, Wittenberg E,et al. Association of diabetes-related emotionaldistress with diabetes treatment in primary care

patients with type 2 diabetes. DiabetMed 2007;24:48–54112. Anderson RJ, Freedland KE, Clouse RE,Lustman PJ. The prevalence of comorbid depres-sion in adults with diabetes: a meta-analysis.Diabetes Care 2001;24:1069–1078113. Kovacs Burns K, Nicolucci A, Holt RIG,et al.; DAWN2 Study Group. Diabetes Attitudes,Wishes and Needs second study (DAWN2):cross-national benchmarking indicators for fam-ily members living with people with diabetes.Diabet Med 2013;30:778–788114. Harkness E, Macdonald W, Valderas J,Coventry P, Gask L, Bower P. Identifying psycho-social interventions that improve both physicaland mental health in patients with diabetes: asystematic review and meta-analysis. DiabetesCare 2010;33:926–930115. Bot M, Pouwer F, Zuidersma M, van MelleJP, de Jonge P. Association of coexisting diabe-tes and depression with mortality after myocar-dial infarction. Diabetes Care 2012;35:503–509116. Scherrer JF, Garfield LD, Chrusciel T, et al.Increased risk of myocardial infarction in de-pressed patients with type 2 diabetes. DiabetesCare 2011;34:1729–1734117. Chen PC, Chan YT, Chen HF, Ko MC, Li CY.Population-based cohort analyses of the bidi-rectional relationship between type 2 diabetesand depression. Diabetes Care 2013;36:376–382118. Pan A, Keum N, Okereke OI, et al. Bidirec-tional association between depression andmetabolic syndrome: a systematic review andmeta-analysis of epidemiological studies. Dia-betes Care 2012;35:1171–1180119. Nicolucci A, Kovacs Burns K, Holt RIG,et al.; DAWN2 Study Group. Diabetes Attitudes,Wishes and Needs second study (DAWN2):cross-national benchmarking of diabetes-relatedpsychosocial outcomes for peoplewith diabetes.Diabet Med 2013;30:767–777120. Fisher L, Hessler DM, Polonsky WH,Mullan J. When is diabetes distress clinicallymeaningful? Establishing cut points for the Di-abetes Distress Scale. Diabetes Care 2012;35:259–264121. Fisher L, Glasgow RE, Strycker LA. The re-lationship between diabetes distress and clini-cal depression with glycemic control amongpatients with type 2 diabetes. Diabetes Care2010;33:1034–1036122. Aikens JE. Prospective associations betweenemotional distress and poor outcomes intype 2 diabetes. Diabetes Care 2012;35:2472–2478123. Fisher L, Glasgow RE, Mullan JT, Skaff MM,Polonsky WH. Development of a brief diabetesdistress screening instrument. Ann Fam Med2008;6:246–252124. McGuire BE, Morrison TG, Hermanns N,et al. Short-form measures of diabetes-relatedemotional distress: the Problem Areas in Diabe-tes Scale (PAID)-5 and PAID-1. Diabetologia2010;53:66–69125. Gary TL, Safford MM, Gerzoff RB, et al.Perception of neighborhood problems, healthbehaviors, and diabetes outcomes amongadults with diabetes in managed care: theTranslating Research Into Action for Diabetes(TRIAD) study. Diabetes Care 2008;31:273–278

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126. Zhang X, Norris SL, Gregg EW, Cheng YJ,Beckles G, Kahn HS. Depressive symptoms andmortality among persons with and without di-abetes. Am J Epidemiol 2005;161:652–660127. Rubin RR, Peyrot M. Psychological issuesand treatments for people with diabetes. J ClinPsychol 2001;57:457–478128. Young-Hyman DL, Davis CL. Disorderedeating behavior in individuals with diabetes: im-portance of context, evaluation, and classifica-tion. Diabetes Care 2010;33:683–689129. Beverly EA, Hultgren BA, Brooks KM,Ritholz MD, AbrahamsonMJ,Weinger K. Under-standing physicians’ challenges when treatingtype 2 diabetic patients’ social and emotionaldifficulties: a qualitative study. Diabetes Care2011;34:1086–1088130. Ciechanowski P. Diapression: an inte-grated model for understanding the experienceof individuals with co-occurring diabetes anddepression. Clin Diabetes 2011;29:43–49131. Katon WJ, Lin EH, Von Korff M, et al. Col-laborative care for patients with depression andchronic illnesses. N Engl J Med 2010;363:2611–2620132. Selvin E, Coresh J, Brancati FL. The burdenand treatment of diabetes in elderly individualsin the U.S. Diabetes Care 2006;29:2415–2419133. Grant RW, Ashburner JM, Hong CS, ChangY, Barry MJ, Atlas SJ. Defining patient complex-ity from the primary care physician’s perspec-tive: a cohort study. Ann Intern Med 2011;155:797–804134. Tinetti ME, Fried TR, Boyd CM. Design-ing health care for the most common chronicconditiondmultimorbidity. JAMA 2012;307:2493–2494135. Sudore RL, Karter AJ, Huang ES, et al.Symptom burden of adults with type 2 diabetesacross the disease course: Diabetes & AgingStudy. J Gen Intern Med 2012;27:1674–1681136. Borgnakke WS, Ylostalo PV, Taylor GW,Genco RJ. Effect of periodontal disease on di-abetes: systematic review of epidemiologic ob-servational evidence. J Periodontol 2013;84(Suppl.):S135–S152137. El-Serag HB, Tran T, Everhart JE. Diabetesincreases the risk of chronic liver disease and

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with risk of fracture in older adults with type 2diabetes. JAMA 2011;305:2184–2192148. Kahn SE, Zinman B, Lachin JM, et al.; Di-abetes Outcome Progression Trial (ADOPT)Study Group. Rosiglitazone-associated fracturesin type 2 diabetes: an Analysis from A DiabetesOutcome Progression Trial (ADOPT). DiabetesCare 2008;31:845–851149. Taylor SI, Blau JE, Rother KI. Possible ad-verse effects of SGLT2 inhibitors on bone. Lan-cet Diabetes Endocrinol 2015;3:8–10150. Dhindsa S, Miller MG, McWhirter CL, et al.Testosterone concentrations in diabetic andnondiabetic obese men. Diabetes Care 2010;33:1186–1192151. Bhasin S, Cunningham GR, Hayes FJ, et al.;Endocrine Society Task Force. Testosteronetherapy in men with androgen deficiency syn-dromes: an Endocrine Society clinical practiceguideline. J Clin Endocrinol Metab 2010;95:2536–2559152. Khader YS, Dauod AS, El-Qaderi SS, AlkafajeiA, Batayha WQ. Periodontal status of diabeticscompared with nondiabetics: a meta-analysis. JDiabetes Complications 2006;20:59–68153. Bainbridge KE, Hoffman HJ, Cowie CC. Di-abetes and hearing impairment in the UnitedStates: audiometric evidence from the NationalHealth and Nutrition Examination Survey, 1999to 2004. Ann Intern Med 2008;149:1–10154. Cukierman T, Gerstein HC, Williamson JD.Cognitive decline and dementia in diabetesdsystematic overview of prospective observationalstudies. Diabetologia 2005;48:2460–2469155. Biessels GJ, Staekenborg S, Brunner E,Brayne C, Scheltens P. Risk of dementia in di-abetes mellitus: a systematic review. LancetNeurol 2006;5:64–74156. Ohara T, Doi Y, Ninomiya T, et al. Glucosetolerance status and risk of dementia in thecommunity: the Hisayama study. Neurology2011;77:1126–1134157. Launer LJ, Miller ME, Williamson JD, et al.;ACCORD MIND Investigators. Effects of inten-sive glucose lowering on brain structure andfunction in people with type 2 diabetes(ACCORD MIND): a randomised open-label sub-study. Lancet Neurol 2011;10:969–977

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