What are the key components of comprehensive diabetes clinical management?

Comprehensive Diabetes Clinical Management

Diabetes management requires a systematic, team-based approach centered on glycemic control, cardiovascular risk reduction, complication prevention, and patient self-management education—all delivered through an interdisciplinary care model. 1, 2

Initial Evaluation and Diagnosis

Classification and Screening

• Screen high-risk adults using fasting plasma glucose (FPG), which is the preferred diagnostic test 1
• Screen asymptomatic adults with BMI ≥25 kg/m² who have additional risk factors: physical inactivity, first-degree relative with diabetes, high-risk ethnicity (African-American, Latino, Native American, Asian-American, Pacific Islander), history of gestational diabetes, hypertension (≥140/90 mmHg), HDL ≤35 mg/dL or triglycerides ≥250 mg/dL, polycystic ovary syndrome, or history of cardiovascular disease 1
• Screen children age ≥10 years (or at puberty onset) who are overweight (BMI >85th percentile) plus have two risk factors: family history of type 2 diabetes, high-risk race/ethnicity, signs of insulin resistance (acanthosis nigricans, hypertension, dyslipidemia, PCOS); repeat screening every 2 years 1

Comprehensive Initial Assessment

• Obtain complete medical history including symptoms, prior A1C records, eating patterns, weight history, growth/development (in children), previous treatment programs, current medications, and glucose monitoring results 1
• Perform laboratory evaluation: blood glucose tests, lipid profile, kidney function tests (serum creatinine, eGFR), urine albumin-to-creatinine ratio, and liver function tests 2
• Screen for autoimmune conditions in type 1 diabetes: thyroid function tests (TSH) and tissue transglutaminase antibodies for celiac disease 2
• Assess for comorbidities: obesity, hypertension, dyslipidemia, existing microvascular complications (retinopathy, nephropathy, neuropathy), and macrovascular disease 2

Glycemic Control Strategy

Target Setting

• Set A1C goal <7% for most nonpregnant adults to reduce microvascular complications 1
• Individualize targets based on: duration of diabetes, age/life expectancy, comorbid conditions, known cardiovascular disease, hypoglycemia risk, and patient preferences 1
• Consider less stringent A1C goals (7.5-8%) for patients with: history of severe hypoglycemia, limited life expectancy, advanced complications, extensive comorbidities, or longstanding diabetes difficult to control despite intensive efforts 1

Monitoring Frequency

• Check A1C at least twice yearly in patients meeting glycemic targets with stable control 3
• Check A1C quarterly in patients not meeting targets or when therapy changes 3
• Increase self-monitoring blood glucose frequency during medication changes, illness, or in patients at high hypoglycemia risk 4

Pharmacologic Management

Type 1 Diabetes

• Initiate multiple daily insulin injections (basal-bolus regimen) or continuous subcutaneous insulin infusion at diagnosis 2
• Use insulin analogues rather than regular human insulin to reduce hypoglycemia risk 2
• Calculate initial total daily insulin dose: 0.25-1.0 units/kg/day, with approximately 50% as basal insulin and 50% as prandial insulin divided among meals 5
• Educate patients to match prandial insulin doses to carbohydrate intake (typically 1 unit per 10-15g carbohydrate), preprandial glucose levels, and anticipated physical activity 2
• Administer rapid-acting insulin (e.g., insulin aspart) 5-10 minutes before meals; inject subcutaneously into abdomen, thigh, buttocks, or upper arm, rotating sites to prevent lipodystrophy 4

Type 2 Diabetes

• Initiate metformin at diagnosis alongside lifestyle interventions, unless contraindicated (renal impairment, metabolic acidosis risk) 1, 2
• Start metformin at low dose (500mg once or twice daily) and titrate gradually to minimize gastrointestinal side effects, up to maximum effective dose of 2000mg daily 2
• If A1C remains above target after 3 months on maximum tolerated metformin monotherapy, add a second agent: sulfonylurea, DPP-4 inhibitor, GLP-1 receptor agonist, SGLT2 inhibitor, or basal insulin 1, 2
• For newly diagnosed patients with marked symptoms (polyuria, polydipsia, weight loss) or severe hyperglycemia (A1C >10%, glucose >300 mg/dL), consider starting insulin immediately with or without additional agents 1
• Select second-line agents based on: cardiovascular disease presence (prefer GLP-1 agonists or SGLT2 inhibitors), heart failure (prefer SGLT2 inhibitors), hypoglycemia risk (avoid sulfonylureas), weight concerns (prefer GLP-1 agonists or SGLT2 inhibitors), and cost 2

Hypoglycemia Management

• Treat conscious patients with 15-20g rapid-acting carbohydrate (glucose tablets, juice, regular soda) 1, 3
• Recheck blood glucose 15 minutes after treatment; repeat treatment if hypoglycemia persists 1
• Educate patients on hypoglycemia risk factors: skipped meals, increased physical activity, alcohol consumption, medication errors, and renal/hepatic impairment 4
• Instruct patients taking insulin or sulfonylureas to carry a glucose source at all times 3
• Prescribe glucagon emergency kits for patients at risk of severe hypoglycemia; train family members on administration 3

Lifestyle Management

Medical Nutrition Therapy

• Refer all patients to a registered dietitian for individualized medical nutrition therapy at diagnosis and as needed 1, 2
• No single macronutrient distribution is ideal; individualize based on patient preferences, metabolic goals, and eating patterns 2
• Effective eating patterns include: Mediterranean-style, DASH, plant-based, lower-fat, and lower-carbohydrate diets 2
• Teach carbohydrate counting for patients on insulin: identify carbohydrate content of foods, understand portion sizes, and calculate insulin-to-carbohydrate ratios 3
• Limit alcohol to moderate amounts: ≤1 drink/day for women, ≤2 drinks/day for men; consume with food to prevent hypoglycemia 1
• Reduce saturated fat, trans fat, and cholesterol intake; increase omega-3 fatty acids, viscous fiber, and plant stanols/sterols 2

Weight Management

• Prescribe weight loss for all overweight/obese patients (BMI ≥25 kg/m²) with diabetes or prediabetes 1
• Target ≥5% weight loss through high-intensity behavioral interventions combining diet, physical activity, and behavioral therapy 2
• Create 500-750 kcal/day energy deficit through reduced caloric intake and increased physical activity 2
• Various dietary approaches are effective short-term (up to 2 years): low-carbohydrate, low-fat calorie-restricted, or Mediterranean diets 1
• Monitor lipid profiles, renal function, and protein intake (in nephropathy patients) when using low-carbohydrate diets; adjust diabetes medications as needed 1

Physical Activity

• Prescribe at least 150 minutes/week of moderate-intensity aerobic activity (50-70% maximum heart rate), spread over at least 3 days with no more than 2 consecutive days without exercise 1, 2
• Add resistance training at least twice weekly for type 2 diabetes patients unless contraindicated 1, 2
• Reduce sedentary time; interrupt prolonged sitting every 30 minutes with brief activity 2
• Screen for contraindications before prescribing vigorous exercise: uncontrolled hypertension, severe autonomic neuropathy, severe peripheral neuropathy, history of foot ulcers, unstable proliferative retinopathy 1
• Perform cardiac evaluation before starting intense exercise in patients with: cardiovascular disease, autonomic neuropathy, or multiple cardiovascular risk factors 1
• Avoid vigorous exercise when ketones are present in type 1 diabetes 1
• Instruct patients on insulin/sulfonylureas to consume 15-20g carbohydrate if pre-exercise glucose <100 mg/dL to prevent hypoglycemia 1

Cardiovascular Risk Management

Blood Pressure Control

• Target blood pressure <140/90 mmHg for most patients with diabetes 2
• Implement lifestyle modifications: weight loss, DASH diet (sodium <2300 mg/day), limited alcohol intake, increased physical activity 2
• Initiate pharmacologic therapy with ACE inhibitor or ARB (but never both simultaneously) as first-line agents 2
• Add additional antihypertensive agents (thiazide diuretics, calcium channel blockers) if needed to reach target 2

Lipid Management

• Prescribe statin therapy for all patients with diabetes aged ≥40 years regardless of baseline lipid levels 2
• Use high-intensity statins (atorvastatin 40-80mg or rosuvastatin 20-40mg) for patients with clinical cardiovascular disease 2
• Use moderate-intensity statins for patients aged 40-75 years without cardiovascular disease 2
• Implement lifestyle modifications: reduce saturated fat and trans fat intake, increase omega-3 fatty acids and fiber 2
• Monitor lipid panel, liver enzymes, and creatine kinase after starting statins 2

Antiplatelet Therapy

• Consider low-dose aspirin (75-162 mg/day) for primary prevention in patients with diabetes at increased cardiovascular risk (10-year risk >10%) 2
• Prescribe aspirin for secondary prevention in all patients with diabetes and known cardiovascular disease unless contraindicated 2

Diabetes Self-Management Education and Support (DSMES)

Core Educational Content

• Blood glucose monitoring: proper technique, target ranges, pattern recognition, and when to contact healthcare provider 3
• Medication administration: proper insulin injection technique (if applicable), oral medication timing, storage requirements, and side effects 3
• Hypoglycemia recognition and treatment: symptoms (shakiness, sweating, confusion, hunger), causes, treatment with 15-20g glucose, and prevention strategies 3
• Hyperglycemia recognition: symptoms (increased thirst, frequent urination, blurred vision, fatigue) and when to seek medical attention 3
• Sick day management: maintaining hydration, continuing medications, monitoring glucose more frequently, testing for ketones (type 1), and when to call provider 3
• Meal planning: carbohydrate counting, portion control, reading nutrition labels, and timing meals with medications 3
• Physical activity: safe exercise practices, adjusting food/insulin for activity, and recognizing exercise-induced hypoglycemia 3
• Foot care: daily inspection, proper footwear, nail care, and when to seek podiatric evaluation 3

Implementation Approach

• Provide DSMES at diagnosis and at critical times: new complications, transitions in care, or when not meeting targets 1, 2
• Use patient-centered communication that incorporates preferences, assesses health literacy and numeracy, and addresses cultural barriers 1, 3, 2
• Deliver education through individual or group sessions; utilize telemedicine when access barriers exist 3
• Provide ongoing support and follow-up after initial education; reassess knowledge and skills regularly 3, 2
• Address psychosocial issues during education: emotional well-being, diabetes distress, depression, anxiety, and coping strategies 1, 3

Psychosocial Care

Routine Assessment

• Include psychological and social assessment as ongoing part of diabetes management 1
• Screen for: attitudes about illness, expectations for treatment, mood/affect, quality of life, financial resources, social support, emotional resources, and psychiatric history 1
• Screen for depression at diagnosis and annually thereafter using validated tools (PHQ-9, PHQ-2) 1, 3
• Assess diabetes-related distress (distinct from clinical depression), which affects 18-45% of patients 1
• Screen for eating disorders, particularly in young adults with type 1 diabetes and recurrent diabetic ketoacidosis 1

Stress Management

• Address stress management, as stress hormones increase insulin resistance and worsen glycemic control 3
• Support positive coping strategies: problem-solving skills, cognitive reframing, social support utilization 3
• Refer to mental health professionals when screening identifies depression, anxiety, eating disorders, or cognitive impairment affecting self-management 1

Family and Social Support

• Teach family members, friends, and colleagues to recognize and treat hypoglycemia 3
• Encourage use of medical identification (bracelets, necklaces) to alert others in emergencies 3
• Involve family in education sessions, particularly for children, adolescents, and older adults 3

Complication Screening and Prevention

Microvascular Complications

• Perform comprehensive dilated eye examination by ophthalmologist or optometrist at diagnosis for type 2 diabetes, within 5 years of diagnosis for type 1 diabetes; repeat annually if abnormalities present, otherwise every 1-2 years 2
• Screen for diabetic kidney disease annually with urine albumin-to-creatinine ratio and estimated glomerular filtration rate (eGFR) 2
• Perform comprehensive foot examination annually: inspect for deformities, skin changes, ulcerations; assess protective sensation with 10-g monofilament; check pedal pulses 2
• Screen for distal symmetric polyneuropathy at diagnosis and annually using 10-g monofilament testing, vibration perception (128-Hz tuning fork), pinprick sensation, ankle reflexes, and symptom assessment 2
• Screen for autonomic neuropathy in type 1 diabetes after 5 years duration and at diagnosis in type 2 diabetes: assess for gastroparesis, erectile dysfunction, bladder dysfunction, and cardiovascular autonomic neuropathy 1

Macrovascular Complications

• Assess cardiovascular risk factors at every visit: blood pressure, lipid profile, smoking status, family history, obesity 2
• Obtain baseline electrocardiogram in adults with diabetes 2
• Consider stress testing in patients with: typical or atypical cardiac symptoms, abnormal resting ECG, peripheral arterial disease, carotid artery disease, or sedentary lifestyle planning vigorous exercise 2

Immunizations

Routine Vaccinations

• Provide all age-appropriate routine vaccinations for children and adults with diabetes per general population guidelines 1
• Administer annual influenza vaccine to all patients ≥6 months of age 1
• Give pneumococcal conjugate vaccine 13 (PCV13) to children before age 2 years 1
• Administer pneumococcal polysaccharide vaccine 23 (PPSV23) to all patients ≥2 years of age 1
• For adults ≥65 years not previously vaccinated: give PCV13 first, followed by PPSV23 6-12 months later 1
• For adults ≥65 years previously vaccinated with PPSV23: give PCV13 at least 1 year after PPSV23 1
• Vaccinate unvaccinated adults aged 19-59 years against hepatitis B 1
• Consider hepatitis B vaccination for unvaccinated adults ≥60 years 1

Team-Based Care Structure

Interdisciplinary Team Composition

• Assemble team including: primary care physician or endocrinologist, nurse practitioner or physician assistant, registered nurse, registered dietitian, exercise specialist, pharmacist, dentist, podiatrist, ophthalmologist, and mental health professional 1, 2
• Ensure productive interactions between prepared, proactive practice team and informed, activated patient using Chronic Care Model principles 2
• Make treatment decisions that are timely, evidence-based, and tailored to individual patient preferences, prognoses, and comorbidities 2

Follow-Up Care Structure

• Schedule follow-up visits every 3 months for patients not at glycemic target or when therapy changes 2
• Schedule visits every 6 months for patients meeting targets with stable control 2
• Include at each visit: interval medical history, medication adherence assessment, physical examination, laboratory evaluation (A1C, lipids as appropriate), complication risk assessment, diabetes self-management behaviors review, nutrition assessment, psychosocial health screening, and determination of referral needs 1

Special Population Considerations

Children and Adolescents

• Provide age-appropriate education involving family members in all aspects of care 3
• Monitor growth and development closely; adjust insulin doses for growth spurts and puberty 1
• Address school-related issues: glucose monitoring during school, hypoglycemia treatment access, physical education participation 3

Older Adults

• Assess cognitive function, physical limitations, social support, and life expectancy when setting targets 3
• Simplify medication regimens when possible; avoid medications with high hypoglycemia risk in frail elderly 3
• Screen for geriatric syndromes: polypharmacy, cognitive impairment, depression, urinary incontinence, falls, and persistent pain 3

Culturally Diverse Populations

• Ensure education is culturally sensitive and linguistically appropriate 3
• Address cultural beliefs about diabetes, food preferences, and traditional healing practices 3
• Use professional interpreters when language barriers exist; avoid using family members as interpreters 3

Patients with Low Health Literacy

• Use teach-back method: ask patients to explain information in their own words 3
• Provide written materials at appropriate reading level with visual aids 3
• Simplify instructions; focus on essential information first 3