Dr Selim_Comprehensive medical evaluation and assessment of Comorbidities of Diabetes

Comprehensive Medical
Evaluation and Assessment
of Comorbidities
Dr Shahjada Selim
Assistant Professor
Department of Endocrinology
Bangabandhu Sheikh Mujib Medical University, Dhaka
Email: selimshahjada@gmail.com, info@shahjadaselim.com

Patient-Centered Collaborative Care
• A patient-centered communication style that
uses active listening, elicits patient preferences,
and assesses literacy, numeracy, and potential
barriers to care should be used to optimize
patient health outcomes and health-related
quality of life. B
American Diabetes Association Standards of Medical Care in Diabetes. Comprehensive Medical
Evaluation and Assessment of Comorbidities. Diabetes Care 2018; 40 (Suppl. 1): S25-S32

Comprehensive Medical Evaluation
A complete medical evaluation should be
performed at the initial visit to:
•Confirm & classify diagnosis B
•Detect complications & potential comorbid
conditions E
•Review prior treatment & risk factor control E
•Begin formulation of care management plan B
•Develop a continuing care plan B

Components of the Comprehensive Diabetes Evaluation
Medical history:
•Age and characteristics of onset of diabetes
•Eating patterns, nutritional status, weight history, sleep
behaviors, physical activity habits, nutrition education
•Presence of common comorbidities and dental disease
•Screen for psychosocial problems and other barriers to
self-management
•History of tobacco use, alcohol consumption, and
substance use

Components of the Comprehensive Diabetes Evaluation (2)
Medical History (2):
•Diabetes education, self-management, and support
history & needs
•Previous treatment regimens and response to therapy
(A1C records)
•Results of glucose monitoring and patient’s use of data
•DKA frequency, severity, and cause
•Hypoglycemia episodes, awareness, frequency & causes
•Assess medication-taking behaviors/barriers to adherence

Medical History (3):
•History of increased blood pressure, abnormal lipids
•Microvascular: retinopathy, nephropathy, and neuropathy
(sensory, including history of foot lesions; autonomic,
including sexual dysfunction and gastroparesis)
•Macrovascular: coronary heart disease, cerebrovascular
disease, and peripheral arterial disease
•For women with childbearing capacity, review
contraception and preconception planning

Physical Examination:
•Height, weight, and BMI; growth and pubertal development
in children and adolescents
•Blood pressure determination, including orthostatic
measurements when indicated
•Fundoscopic examination
•Thyroid palpation
•Skin examination
•Comprehensive foot examination

Laboratory Evaluation
•A1C, if results not available within past 3 months
•If not performed/available within past year:
– Fasting lipid profile
– Liver function tests
– Spot urinary albumin-to-creatinine ratio
– Serum creatinine and eGFR
– Thyroid-stimulating hormone in patients with type 1 diabetes

Common Comorbidities

Assessment of Glycemic Control
• Two primary techniques available for health
providers and patients to assess effectiveness of
management plan on glycemic control
1. Patient self-monitoring of blood glucose (SMBG)
2. A1C
• CGM or interstitial glucose may have an
important role assessing the effectiveness and
safety of treatment in selected patients.
American Diabetes Association Standards of Medical Care in Diabetes.
Glycemic targets. Diabetes Care 2017; 40 (Suppl. 1): S48-S56

Recommendations: Glucose Monitoring
• When prescribed as part of a broader educational
context, SMBG results may be helpful to guide treatment
decisions and/or patient self-management for patients
using less frequent insulin injections B or noninsulin
therapies. E
• When prescribing SMBG, ensure that patients receive
ongoing instruction and regular evaluation of SMBG
technique and SMBG results, and their ability to use
SMBG data to adjust therapy. E

Recommendations: Glucose Monitoring (2)
• Most patients on multiple-dose insulin (MDI) or
insulin pump therapy should do SMBG B
– Prior to meals and snacks
– At bedtime
– Prior to exercise
– When they suspect low blood glucose
– After treating low blood glucose until they are
normoglycemic
– Prior to critical tasks such as driving
– Occasionally postprandially

• When used properly, CGM in conjunction with intensive
insulin regimens is a useful tool to lower A1C in selected
adults (aged 25 years) with type 1 diabetes.≥ A
• Although the evidence for A1C lowering is less strong in
children, teens, and younger adults, CGM may be helpful
in these groups. Success correlates with adherence to
ongoing use of the device. B
• CGM may be a supplemental tool to SMBG in those with
hypoglycemia unawareness and/or frequent
hypoglycemic episodes. C

• Given variable adherence to CGM, assess individual
readiness for continuing use of CGM prior to
prescribing. E
• When prescribing CGM, robust diabetes education,
training, and support are required for optimal CGM
implementation and ongoing use. E
• People who have been successfully using CGM
should have continued access after they turn 65
years of age. E

Recommendations: A1C Testing
• Perform the A1C test at least 2x annually in
patients that meet treatment goals (and have
stable glycemic control). E
• Perform the A1C test quarterly in patients whose
therapy has changed or who are not meeting
glycemic goals. E
• Use of point-of-care (POC) testing for A1C
provides the opportunity for more timely treatment
changes. E

Mean Glucose Levels for Specified A1C Levels

Mean Glucose
Mean Plasma Glucose* Fasting Premeal Postmeal Bedtime
A1C% mg/dL mmol/L mg/dL mg/dL mg/dL mg/dL
6 126 7.0
<6.5 122 118 144 136
6.5-6.99 142 139 164 153
7 154 8.6
7.0-7.49 152 152 176 177
7.5-7.99 167 155 189 175
8 183 10.2
8-8.5 178 179 206 222
9 212 11.8
10 240 13.4
11 269 14.9
12 298 16.5
professional.diabetes.org/eAG

Recommendations: Glycemic Goals in
Adults
• A reasonable A1C goal for many nonpregnant adults is
<7% (53 mmol/mol). A
• Consider more stringent goals (e.g. <6.5%) for select
patients if achievable without significant hypos or other
adverse effects. C
• Consider less stringent goals (e.g. <8%) for patients with
a history of severe hypoglycemia, limited life expectancy,
or other conditions that make <7% difficult to attain. B

Glycemic Recommendations for Nonpregnant Adults with
Diabetes
A1C <7.0%*
(<53 mmol/mol)
Preprandial capillary
plasma glucose
80–130 mg/dL*
(4.4–7.2 mmol/L)
Peak postprandial capillary
plasma glucose†
<180 mg/dL*
(<10.0 mmol/L)
* Goals should be individualized.
† Postprandial glucose measurements should be made 1–2 hours after the
beginning of the meal.

Glycemic Recommendations for Nonpregnant Adults with Diabetes
• More or less stringent glycemic goals may be
appropriate for individual patients.
• Postprandial glucose may be targeted if A1C
goals are not met despite reaching preprandial
glucose goals.

Obesity Management for the
Treatment of Type 2 Diabetes

Recommendations: Assessment
• At each patient encounter, BMI should be
calculated and documented in the medical
record. B
– Discuss with the patient
– Asian American cutpoints:
Normal <23 BMI kg/m2
Overweight 23.0 - 27.4 kg/m2
Obese 27.5 - 37.4 kg/m2
Extremely obese ≥37.5 kg/m2
American Diabetes Association Standards of Medical Care in Diabetes. Obesity management
for the treatment of type 2 diabetes. Diabetes Care 2017; 40 (Suppl. 1): S57-S63

Pharmacologic Approaches
to Glycemic Treatment

Cardiovascular Disease
and Risk Management

Cardiovascular Disease
• CVD is the leading cause of morbidity & mortality for those
with diabetes.
• Largest contributor to direct/indirect costs
• Common conditions coexisting with type 2 diabetes (e.g.,
hypertension, dyslipidemia) are clear risk factors for ASCVD.
• Diabetes itself confers independent risk
• Control individual cardiovascular risk factors to prevent/slow
CVD in people with diabetes.
• Systematically assess all patients with diabetes for
cardiovascular risk factors.
Cardiovascular disease and risk management. Diabetes Care 2017; 40 (Suppl. 1): S75-S87

Hypertension
• Common DM comorbidity
• Prevalence depends on diabetes type, age, BMI,
ethnicity
• Major risk factor for ASCVD & microvascular
complications
• In T1DM, HTN often results from underlying kidney
disease.
• In T2DM, HTN coexists with other cardiometabolic
risk factors.

Blood Pressure Control & T2DM
Action to Control Cardiovascular Risk in Diabetes
(ACCORD):
•Does SBP <120 provide better cardiovascular
protection than SBP 130-140? No.
ADVANCE-BP:
•Significant risk reduction

Recommendations: Hypertension/ Blood Pressure Control
Screening and Diagnosis:
•Blood pressure should be measured at every
routine visit. B
•Patients found to have elevated blood pressure
should have blood pressure confirmed on a
separate day. B

Recommendations: Hypertension/ Blood Pressure Control (2)
Systolic Targets:
•People with diabetes and hypertension should be
treated to a systolic blood pressure goal of <140
mmHg. A
•Lower systolic targets, such as <130 mmHg, may
be appropriate for certain individuals at high risk of
CVD, if they can be achieved without undue
treatment burden. C

Diastolic Targets:
•Patients with diabetes should be treated to a
diastolic blood pressure <90 mmHg. A
•Lower diastolic targets, such as <80 mmHg, may
be appropriate for certain individuals at high risk for
CVD if they can be achieved without undue
treatment burden. C

Pregnant patients:
•In pregnant patients with diabetes and chronic
hypertension, blood pressure targets of 120–
160/80–105 mmHg are suggested in the interest of
optimizing long-term maternal health and
minimizing impaired fetal growth. E

Recommendations: Hypertension/ Blood Pressure Treatment
• Patients with BP >120/80 should be advised on
lifestyle changes to reduce BP. B
• Patients with confirmed BP >140/90 should, in
addition to lifestyle therapy, have prompt initiation
and timely subsequent titration of
pharmacological
therapy to achieve blood pressure goals. A

Recommendations: Coronary Heart Disease
Screening
•In asymptomatic patients, routine screening for CAD
isn’t recommended & doesn’t improve outcomes
provided ASCVD risk factors are treated. A
•Consider investigations for CAD with:
– Atypical cardiac symptoms (e.g. unexplained dyspnea, chest discomfort)
– Signs or symptoms of associated vascular disease incl. carotid bruits,
transient ischemic attack, stroke, claudication or PAD
– EKG abnormalities (e.g. Q waves) E

Microvascular Complications
and Foot Care

Recommendations: Diabetic Kidney Disease
Screening
•At least once a year, assess urinary albumin
and estimated glomerular filtration rate
(eGFR):
– In patients with type 1 diabetes duration of 5 years≥ B
– In all patients with type 2 diabetes B
– In all patients with comorbid hypertension B
Microvascular complications and foot care. Diabetes Care 2018; 40 (Suppl. 1): S88-S98

Stages of Chronic Kidney Disease
Stage Description
eGFR
(mL/min/1.73 m2
)
1 Kidney damage*
with normal or
increased eGFR
≥ 90
2 Kidney damage*
with mildly decreased
eGFR
60–89
3 Moderately decreased eGFR 30–59
4 Severely decreased eGFR 15–29
5 Kidney failure <15 or dialysis
eGFR = estimated glomerular filtration rate
* Kidney damage defined as abnormalities on pathologic, urine, blood,
or imaging tests.

Management of CKD in Diabetes
eGFR Recommended
All
patients
Yearly measurement of creatinine, urinary albumin
excretion, potassium
45-60 Referral to a nephrologist if possibility for nondiabetic
kidney disease exists
Consider dose adjustment of medications
Monitor eGFR every 6 months
Monitor electrolytes, bicarbonate, hemoglobin, calcium,
phosphorus, parathyroid hormone at least yearly
Assure vitamin D sufficiency
Consider bone density testing
Referral for dietary counselling

Management of CKD in Diabetes (2)
eGF
R
Recommended
30-44 Monitor eGFR every 3 months
Monitor electrolytes, bicarbonate, calcium,
phosphorus, parathyroid hormone,
hemoglobin, albumin
weight every 3–6 months
Consider need for dose adjustment of
medications
<30 Referral to a nephrologist

Recommendations: Diabetic Retinopathy
• To reduce the risk or slow the progression of
retinopathy
– Optimize glycemic control A
– Optimize blood pressure control A

Screening:
•Initial dilated and comprehensive eye
examination by an ophthalmologist or optometrist:
– Adults with type 1 diabetes, within 5 years of diabetes
onset. B
– Patients with type 2 diabetes at the time of diabetes
diagnosis. B

Screening (2):
•If no evidence of retinopathy for one or more eye exam,
exams every 2 years may be considered. B
•If diabetic retinopathy is present, subsequent examinations
should be repeated at least annually by an
ophthalmologist or optometrist. B
•If retinopathy is progressing or sight-threatening, more
frequent exams required. B

Screening (3):
•Retinal photography may serve as a screening tool for
retinopathy, but is not a substitute for a comprehensive
eye exam. E

Screening (4):
•Women with preexisting diabetes who are
planning pregnancy or who have become
pregnant: B
– Counseled on risk of development and/or progression
of diabetic retinopathy
– Eye examination should occur before pregnancy or in
1st
trimester and then monitored every trimester and
for 1 year postpartum as indicated by degree of
retinopathy

Early recognition & management is important because:
1. DN is a diagnosis of exclusion.
2. Numerous treatment options exist.
3. Up to 50% of DPN may be asymptomatic.
4. Recognition & treatment may improve symptoms,
reduce sequelae, and improve quality-of-life.
Neuropathy

Screening:
•Assess all patients for DPN at dx for T2DM, 5 years after
dx for T1DM, and at least annually thereafter. B
•Assessment should include history & 10g monofilament
testing, vibration sensation (large-fiber function), and
temperature or pinprick (small-fiber function) B
•Symptoms of autonomic neuropathy should be assessed
in patients with microvascular & neuropathic complications.
E
Recommendations: Neuropathy (1)

• Perform a comprehensive foot evaluation annually to
identify risk factors for ulcers & amputations. B
• All patients with diabetes should have their feet
inspected at every visit. C
• History should contain prior hx of ulceration,
amputation, Charcot foot, angioplasty or vascular
surgery, cigarette smoking, retinopathy & renal
disease; and should assess current symptoms of
neuropathy and vascular disease. B
Recommendations: Foot Care

• Exam should include inspection of the skin,
assessment of foot deformities, neurologic
assessment & vascular assessment including
pulses in the legs and feet. B
Recommendations: Foot Care (2)

• Patients with symptoms of claudication,
decreased, or absent pedal pulses should be
referred for ABI & further vascular assessment. C
• A multidisciplinary approach is recommended for
individuals with foot ulcers and high-risk feet. B
• The use of specialized therapeutic footwear is
recommended for patients with high-risk feet. B

• Refer patients who smoke or who have hx of
lower-extremity complications, loss of protective
sensation, structural abnormalities or PAD to
foot care specialists for ongoing preventive care
and lifelong surveillance. C
• Provide general foot self-care education to all
patients with diabetes. B

• To perform the 10-g
monofilament test, place the
device perpendicular to the
skin; Apply pressure until
monofilament buckles.
• Hold in place for 1 second &
release.
• The monofilament test should
be performed at the highlighted
sites while the patient’s eyes
are closed.
Boulton A, Armstrong D, Albert, S et. al. Comprehensive
Foot Examination and Risk Assessment. Diabetes Care. 2018; 31: 1679-1685

Management of Diabetes
in Pregnancy

Preexisting Diabetes
• Starting at puberty, preconception counseling
should be incorporated into routine diabetes care
for all girls of childbearing potential. A
• Family planning should be discussed and
effective contraception should be prescribed and
used until a woman is prepared and ready to
become pregnant. A
American Diabetes Association. Standards of Medical Care in Diabetes
Management of Diabetes in Pregnancy Diabetes Care 2018;40(Suppl. 1):S114–S119

Preexisting Diabetes (2)
• Provide preconception counseling that
addresses the importance of glycemic control as
close to normal as safely possible, ideally <6.5%,
to reduce the risk of congenital anomalies. B

Preexisting Diabetes (3)
• Women w/ preexisting type 1 or type 2 diabetes
who are pregnant or planning to become
pregnant should be counseled on the risk of
development and/or progression of diabetic
retinopathy. Eye exams should occur before
pregnancy or in the first trimester & then be
monitored every trimester and for 1 year
postpartum as indicated by degree of
retinopathy. B

Gestational Diabetes Mellitus (GDM)
• Lifestyle change is an essential part GDM mgmt.
and may suffice for many women. Add medications
if needed to achieve glycemic targets. A
• Insulin is the preferred medication for treating
hyperglycemia in GDM, as it does not cross the
placenta. Metformin and glyburide may be used but
both, particularly metformin, cross the placenta. All
oral agents lack long-term safety data. A

Gestational Diabetes Mellitus (GDM)
• Metformin, when used to treat polycystic ovary
syndrome and induce ovulation, need not be
continued once pregnancy has been confirmed.
A

Glycemic Targets in Pregnancy
For women with gestational diabetes or preexisting
type 1 or type 2 diabetes in pregnancy, the
following targets are recommended:
– Fasting 95 mg/dL (5.3 mmol/L)≤
and either
– One-hour postprandial 140 mg/dL (7.8 mmol/L)≤ or
– Two-hour postprandial 120 mg/dL (6.7 mmol/L)≤

Recommendations: Diabetes Care in the Hospital (6)
• The treatment regimen should be reviewed and
changed if necessary to prevent further
hypoglycemia when a blood glucose value is <70
mg/dL (3.9 mmol/L). C
• There should be a structured discharge plan
tailored to the individual patient. B
American Diabetes Association. Standards of Medical Care in Diabetes.
Diabetes care in the hospital. Diabetes Care 2018;40(Suppl. 1):S120–S127

• ADA publishes evidence-based advocacy statements on
issues including:
– Diabetes and employment
– Diabetes and driving
– Diabetes management in schools, child care programs, and correctional
institutions.
• These are important tools in educating:
– Schools
– Employers
– Licensing agencies
– Policy makers
– Professional.diabetes.org/SOC
Advocacy Position Statements
American Diabetes Association. Standards of Medical Care in Diabetes.
Diabetes advocacy. Diabetes Care 2018;40(Suppl. 1):S128–S129

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