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Overview of medical care in adults with diabetes mellitus

David K McCulloch, MD
Section Editor
David M Nathan, MD
Deputy Editor
Jean E Mulder, MD


The estimated overall prevalence of diabetes among adults in the United States ranges from 5.8 to 12.9 percent (median 8.4 percent) [1,2]. However, because of the associated microvascular and macrovascular disease, diabetes accounts for almost 14 percent of United States health care expenditures, at least one-half of which are related to complications such as myocardial infarction (MI), stroke, end-stage renal disease, retinopathy, and foot ulcers [3].

Numerous factors, in addition to directly related medical complications, contribute to the impact of diabetes on quality of life and economics. Diabetes is associated with a high prevalence of depression [4] and adversely impacts employment, absenteeism, and work productivity [5].

This review will provide an overview of the medical care for patients with diabetes (table 1). The management approach is consistent with guidelines from the American Diabetes Association (ADA) for health maintenance in patients with diabetes, which are published yearly [6]. Consensus recommendations for the management of glycemia in type 2 diabetes were published in 2006 and are updated regularly. Detailed discussions relating to screening, diagnosis, and management of hyperglycemia are discussed separately. (See "Screening for type 2 diabetes mellitus" and "Clinical presentation and diagnosis of diabetes mellitus in adults" and "Initial management of blood glucose in adults with type 2 diabetes mellitus" and "Management of persistent hyperglycemia in type 2 diabetes mellitus".)


Initial — Patients with newly diagnosed diabetes require a history and physical examination to assess the characteristics of onset of diabetes (asymptomatic laboratory finding or symptomatic polyuria and polydipsia), nutrition and weight history, physical activity, cardiovascular risk factors, history of diabetes-related complications, hypoglycemic episodes, diabetic ketoacidosis (DKA) frequency (type 1 diabetes only), and current management.

If not measured in the past two to three months, we measure glycated hemoglobin (A1C) (See "Estimation of blood glucose control in diabetes mellitus", section on 'Glycated hemoglobin'.)


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Literature review current through: Mar 2017. | This topic last updated: Jan 04, 2017.
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  1. Li C, Balluz LS, Okoro CA, et al. Surveillance of certain health behaviors and conditions among states and selected local areas --- Behavioral Risk Factor Surveillance System, United States, 2009. MMWR Surveill Summ 2011; 60:1.
  2. Centers for Disease Control and Prevention. 2011 National Diabetes Fact Sheet http://www.cdc.gov/diabetes/pubs/pdf/ndfs_2011.pdf (Accessed on June 20, 2013).
  3. Mokdad AH, Ford ES, Bowman BA, et al. Prevalence of obesity, diabetes, and obesity-related health risk factors, 2001. JAMA 2003; 289:76.
  4. Kan C, Silva N, Golden SH, et al. A systematic review and meta-analysis of the association between depression and insulin resistance. Diabetes Care 2013; 36:480.
  5. Tunceli K, Bradley CJ, Nerenz D, et al. The impact of diabetes on employment and work productivity. Diabetes Care 2005; 28:2662.
  6. Standards of Medical Care in Diabetes-2017: Summary of Revisions. Diabetes Care 2017; 40:S4.
  7. Harris MI, Klein R, Welborn TA, Knuiman MW. Onset of NIDDM occurs at least 4-7 yr before clinical diagnosis. Diabetes Care 1992; 15:815.
  8. Gregg EW, Li Y, Wang J, et al. Changes in diabetes-related complications in the United States, 1990-2010. N Engl J Med 2014; 370:1514.
  9. Kennon B, Leese GP, Cochrane L, et al. Reduced incidence of lower-extremity amputations in people with diabetes in Scotland: a nationwide study. Diabetes Care 2012; 35:2588.
  10. Booth GL, Kapral MK, Fung K, Tu JV. Recent trends in cardiovascular complications among men and women with and without diabetes. Diabetes Care 2006; 29:32.
  11. Vamos EP, Bottle A, Edmonds ME, et al. Changes in the incidence of lower extremity amputations in individuals with and without diabetes in England between 2004 and 2008. Diabetes Care 2010; 33:2592.
  12. Pasquale LR, Kang JH, Manson JE, et al. Prospective study of type 2 diabetes mellitus and risk of primary open-angle glaucoma in women. Ophthalmology 2006; 113:1081.
  13. Obrosova IG, Chung SS, Kador PF. Diabetic cataracts: mechanisms and management. Diabetes Metab Res Rev 2010; 26:172.
  14. Centers for Disease Control and Prevention (CDC). Correctable visual impairment among persons with diabetes--United States, 1999-2004. MMWR Morb Mortal Wkly Rep 2006; 55:1169.
  15. Mogensen CE, Vestbo E, Poulsen PL, et al. Microalbuminuria and potential confounders. A review and some observations on variability of urinary albumin excretion. Diabetes Care 1995; 18:572.
  16. Mogensen CE. Prediction of clinical diabetic nephropathy in IDDM patients. Alternatives to microalbuminuria? Diabetes 1990; 39:761.
  17. Qaseem A, Hopkins RH Jr, Sweet DE, et al. Screening, monitoring, and treatment of stage 1 to 3 chronic kidney disease: A clinical practice guideline from the American College of Physicians. Ann Intern Med 2013; 159:835.
  18. Colberg SR, Sigal RJ, Fernhall B, et al. Exercise and type 2 diabetes: the American College of Sports Medicine and the American Diabetes Association: joint position statement. Diabetes Care 2010; 33:e147.
  19. American Diabetes Association. Standards of medical care in diabetes--2014. Diabetes Care 2014; 37 Suppl 1:S14.
  20. Wackers FJ, Young LH, Inzucchi SE, et al. Detection of silent myocardial ischemia in asymptomatic diabetic subjects: the DIAD study. Diabetes Care 2004; 27:1954.
  21. Scognamiglio R, Negut C, Ramondo A, et al. Detection of coronary artery disease in asymptomatic patients with type 2 diabetes mellitus. J Am Coll Cardiol 2006; 47:65.
  22. American Diabetes Association. 3. Comprehensive Medical Evaluation and Assessment of Comorbidities. Diabetes Care 2017; 40:S25.
  23. Centers for Disease Control and Prevention (CDC). Dental visits among dentate adults with diabetes--United States, 1999 and 2004. MMWR Morb Mortal Wkly Rep 2005; 54:1181.
  24. Inoue M, Iwasaki M, Otani T, et al. Diabetes mellitus and the risk of cancer: results from a large-scale population-based cohort study in Japan. Arch Intern Med 2006; 166:1871.
  25. Stattin P, Björ O, Ferrari P, et al. Prospective study of hyperglycemia and cancer risk. Diabetes Care 2007; 30:561.
  26. Hemminki K, Li X, Sundquist J, Sundquist K. Risk of cancer following hospitalization for type 2 diabetes. Oncologist 2010; 15:548.
  27. Giovannucci E, Harlan DM, Archer MC, et al. Diabetes and cancer: a consensus report. Diabetes Care 2010; 33:1674.
  28. Larsson SC, Mantzoros CS, Wolk A. Diabetes mellitus and risk of breast cancer: a meta-analysis. Int J Cancer 2007; 121:856.
  29. Tsilidis KK, Kasimis JC, Lopez DS, et al. Type 2 diabetes and cancer: umbrella review of meta-analyses of observational studies. BMJ 2015; 350:g7607.
  30. Liao WC, Tu YK, Wu MS, et al. Blood glucose concentration and risk of pancreatic cancer: systematic review and dose-response meta-analysis. BMJ 2015; 349:g7371.
  31. Emerging Risk Factors Collaboration, Seshasai SR, Kaptoge S, et al. Diabetes mellitus, fasting glucose, and risk of cause-specific death. N Engl J Med 2011; 364:829.
  32. Intensive blood-glucose control with sulphonylureas or insulin compared with conventional treatment and risk of complications in patients with type 2 diabetes (UKPDS 33). UK Prospective Diabetes Study (UKPDS) Group. Lancet 1998; 352:837.
  33. Diabetes Control and Complications Trial Research Group, Nathan DM, Genuth S, et al. The effect of intensive treatment of diabetes on the development and progression of long-term complications in insulin-dependent diabetes mellitus. N Engl J Med 1993; 329:977.
  34. United Kingdom Prospective Diabetes Study (UKPDS). 13: Relative efficacy of randomly allocated diet, sulphonylurea, insulin, or metformin in patients with newly diagnosed non-insulin dependent diabetes followed for three years. BMJ 1995; 310:83.
  35. Ohkubo Y, Kishikawa H, Araki E, et al. Intensive insulin therapy prevents the progression of diabetic microvascular complications in Japanese patients with non-insulin-dependent diabetes mellitus: a randomized prospective 6-year study. Diabetes Res Clin Pract 1995; 28:103.
  36. Nathan DM, Cleary PA, Backlund JY, et al. Intensive diabetes treatment and cardiovascular disease in patients with type 1 diabetes. N Engl J Med 2005; 353:2643.
  37. ADVANCE Collaborative Group, Patel A, MacMahon S, et al. Intensive blood glucose control and vascular outcomes in patients with type 2 diabetes. N Engl J Med 2008; 358:2560.
  38. Action to Control Cardiovascular Risk in Diabetes Study Group, Gerstein HC, Miller ME, et al. Effects of intensive glucose lowering in type 2 diabetes. N Engl J Med 2008; 358:2545.
  39. Knowler WC, Barrett-Connor E, Fowler SE, et al. Reduction in the incidence of type 2 diabetes with lifestyle intervention or metformin. N Engl J Med 2002; 346:393.
  40. Nathan DM, Buse JB, Davidson MB, et al. Management of hyperglycemia in type 2 diabetes: A consensus algorithm for the initiation and adjustment of therapy: a consensus statement from the American Diabetes Association and the European Association for the Study of Diabetes. Diabetes Care 2006; 29:1963.
  41. Nathan DM, Buse JB, Davidson MB, et al. Medical management of hyperglycemia in type 2 diabetes: a consensus algorithm for the initiation and adjustment of therapy: a consensus statement of the American Diabetes Association and the European Association for the Study of Diabetes. Diabetes Care 2009; 32:193.
  42. Inzucchi SE, Bergenstal RM, Buse JB, et al. Management of hyperglycemia in type 2 diabetes, 2015: a patient-centered approach: update to a position statement of the American Diabetes Association and the European Association for the Study of Diabetes. Diabetes Care 2015; 38:140.
  43. U.K. prospective diabetes study 16. Overview of 6 years' therapy of type II diabetes: a progressive disease. U.K. Prospective Diabetes Study Group. Diabetes 1995; 44:1249.
  44. Franco OH, Steyerberg EW, Hu FB, et al. Associations of diabetes mellitus with total life expectancy and life expectancy with and without cardiovascular disease. Arch Intern Med 2007; 167:1145.
  45. Livingstone SJ, Levin D, Looker HC, et al. Estimated life expectancy in a Scottish cohort with type 1 diabetes, 2008-2010. JAMA 2015; 313:37.
  46. Tancredi M, Rosengren A, Svensson AM, et al. Excess Mortality among Persons with Type 2 Diabetes. N Engl J Med 2015; 373:1720.
  47. Uusitupa MI, Niskanen LK, Siitonen O, et al. Ten-year cardiovascular mortality in relation to risk factors and abnormalities in lipoprotein composition in type 2 (non-insulin-dependent) diabetic and non-diabetic subjects. Diabetologia 1993; 36:1175.
  48. Stamler J, Vaccaro O, Neaton JD, Wentworth D. Diabetes, other risk factors, and 12-yr cardiovascular mortality for men screened in the Multiple Risk Factor Intervention Trial. Diabetes Care 1993; 16:434.
  49. Turner RC, Millns H, Neil HA, et al. Risk factors for coronary artery disease in non-insulin dependent diabetes mellitus: United Kingdom Prospective Diabetes Study (UKPDS: 23). BMJ 1998; 316:823.
  50. Yudkin JS. How can we best prolong life? Benefits of coronary risk factor reduction in non-diabetic and diabetic subjects. BMJ 1993; 306:1313.
  51. Mogensen CE. Combined high blood pressure and glucose in type 2 diabetes: double jeopardy. British trial shows clear effects of treatment, especially blood pressure reduction. BMJ 1998; 317:693.
  52. Fan AZ, Rock V, Zhang X, et al. Trends in cigarette smoking rates and quit attempts among adults with and without diagnosed diabetes, United States, 2001-2010. Prev Chronic Dis 2013; 10:E160.
  53. Antithrombotic Trialists' Collaboration. Collaborative meta-analysis of randomised trials of antiplatelet therapy for prevention of death, myocardial infarction, and stroke in high risk patients. BMJ 2002; 324:71.
  54. Capodanno D, Angiolillo DJ. Aspirin for Primary Cardiovascular Risk Prevention and Beyond in Diabetes Mellitus. Circulation 2016; 134:1579.
  55. Kunutsor SK, Seidu S, Khunti K. Aspirin for primary prevention of cardiovascular and all-cause mortality events in diabetes: updated meta-analysis of randomized controlled trials. Diabet Med 2017; 34:316.
  56. De Berardis G, Sacco M, Evangelista V, et al. Aspirin and Simvastatin Combination for Cardiovascular Events Prevention Trial in Diabetes (ACCEPT-D): design of a randomized study of the efficacy of low-dose aspirin in the prevention of cardiovascular events in subjects with diabetes mellitus treated with statins. Trials 2007; 8:21.
  57. Nicolucci A. Aspirin for primary prevention of cardiovascular events in diabetes: still an open question. JAMA 2008; 300:2180.
  58. Gaziano JM, Greenland P. When should aspirin be used for prevention of cardiovascular events? JAMA 2014; 312:2503.
  59. Steering Committee of the Physicians' Health Study Research Group. Final report on the aspirin component of the ongoing Physicians' Health Study. N Engl J Med 1989; 321:129.
  60. Ikeda Y, Shimada K, Teramoto T, et al. Low-dose aspirin for primary prevention of cardiovascular events in Japanese patients 60 years or older with atherosclerotic risk factors: a randomized clinical trial. JAMA 2014; 312:2510.
  61. De Berardis G, Lucisano G, D'Ettorre A, et al. Association of aspirin use with major bleeding in patients with and without diabetes. JAMA 2012; 307:2286.
  62. Chew EY, Klein ML, Murphy RP, et al. Effects of aspirin on vitreous/preretinal hemorrhage in patients with diabetes mellitus. Early Treatment Diabetic Retinopathy Study report no. 20. Arch Ophthalmol 1995; 113:52.
  63. Bergerhoff K, Clar C, Richter B. Aspirin in diabetic retinopathy. A systematic review. Endocrinol Metab Clin North Am 2002; 31:779.
  64. Buse JB, Ginsberg HN, Bakris GL, et al. Primary prevention of cardiovascular diseases in people with diabetes mellitus: a scientific statement from the American Heart Association and the American Diabetes Association. Circulation 2007; 115:114.
  65. Gaede P, Vedel P, Larsen N, et al. Multifactorial intervention and cardiovascular disease in patients with type 2 diabetes. N Engl J Med 2003; 348:383.
  66. Gaede P, Lund-Andersen H, Parving HH, Pedersen O. Effect of a multifactorial intervention on mortality in type 2 diabetes. N Engl J Med 2008; 358:580.
  67. Ji L, Hu D, Pan C, et al. Primacy of the 3B approach to control risk factors for cardiovascular disease in type 2 diabetes patients. Am J Med 2013; 126:925.e11.
  68. Fenton JJ, Von Korff M, Lin EH, et al. Quality of preventive care for diabetes: effects of visit frequency and competing demands. Ann Fam Med 2006; 4:32.
  69. Lau D, Eurich DT, Majumdar SR, et al. Effectiveness of influenza vaccination in working-age adults with diabetes: a population-based cohort study. Thorax 2013; 68:658.
  70. Looijmans-Van den Akker I, Verheij TJ, Buskens E, et al. Clinical effectiveness of first and repeat influenza vaccination in adult and elderly diabetic patients. Diabetes Care 2006; 29:1771.
  71. Centers for Disease Control and Prevention (CDC). Use of hepatitis B vaccination for adults with diabetes mellitus: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Morb Mortal Wkly Rep 2011; 60:1709.
  72. Lutfiyya MN, McCullough JE, Mitchell L, et al. Adequacy of diabetes care for older U.S. rural adults: a cross-sectional population based study using 2009 BRFSS data. BMC Public Health 2011; 11:940.
  73. McBean AM, Yu X. The underuse of screening services among elderly women with diabetes. Diabetes Care 2007; 30:1466.
  74. Fernandez A, Schillinger D, Warton EM, et al. Language barriers, physician-patient language concordance, and glycemic control among insured Latinos with diabetes: the Diabetes Study of Northern California (DISTANCE). J Gen Intern Med 2011; 26:170.
  75. Kerr EA, Heisler M, Krein SL, et al. Beyond comorbidity counts: how do comorbidity type and severity influence diabetes patients' treatment priorities and self-management? J Gen Intern Med 2007; 22:1635.
  76. Alegre-Díaz J, Herrington W, López-Cervantes M, et al. Diabetes and Cause-Specific Mortality in Mexico City. N Engl J Med 2016; 375:1961.
  77. Grant RW, Buse JB, Meigs JB, University HealthSystem Consortium (UHC) Diabetes Benchmarking Project Team. Quality of diabetes care in U.S. academic medical centers: low rates of medical regimen change. Diabetes Care 2005; 28:337.
  78. Khunti K, Wolden ML, Thorsted BL, et al. Clinical inertia in people with type 2 diabetes: a retrospective cohort study of more than 80,000 people. Diabetes Care 2013; 36:3411.
  79. Wagner EH, Austin BT, Von Korff M. Organizing care for patients with chronic illness. Milbank Q 1996; 74:511.
  80. Phillips LS, Branch WT, Cook CB, et al. Clinical inertia. Ann Intern Med 2001; 135:825.
  81. Rodondi N, Peng T, Karter AJ, et al. Therapy modifications in response to poorly controlled hypertension, dyslipidemia, and diabetes mellitus. Ann Intern Med 2006; 144:475.
  82. Pimouguet C, Le Goff M, Thiébaut R, et al. Effectiveness of disease-management programs for improving diabetes care: a meta-analysis. CMAJ 2011; 183:E115.
  83. Egginton JS, Ridgeway JL, Shah ND, et al. Care management for Type 2 diabetes in the United States: a systematic review and meta-analysis. BMC Health Serv Res 2012; 12:72.
  84. Hurwitz B, Goodman C, Yudkin J. Prompting the clinical care of non-insulin dependent (type II) diabetic patients in an inner city area: one model of community care. BMJ 1993; 306:624.
  85. MacKinnon M. General practice diabetes care: the past, the present and the future. Diabet Med 1990; 7:171.
  86. Gruesser M, Bott U, Ellermann P, et al. Evaluation of a structured treatment and teaching program for non-insulin-treated type II diabetic outpatients in Germany after the nationwide introduction of reimbursement policy for physicians. Diabetes Care 1993; 16:1268.
  87. Sperl-Hillen J, Beaton S, Fernandes O, et al. Comparative effectiveness of patient education methods for type 2 diabetes: a randomized controlled trial. Arch Intern Med 2011; 171:2001.
  88. Pillay J, Armstrong MJ, Butalia S, et al. Behavioral Programs for Type 2 Diabetes Mellitus: A Systematic Review and Network Meta-analysis. Ann Intern Med 2015; 163:848.
  89. Pillay J, Armstrong MJ, Butalia S, et al. Behavioral Programs for Type 1 Diabetes Mellitus: A Systematic Review and Meta-analysis. Ann Intern Med 2015; 163:836.
  90. Thompson DM, Kozak SE, Sheps S. Insulin adjustment by a diabetes nurse educator improves glucose control in insulin-requiring diabetic patients: a randomized trial. CMAJ 1999; 161:959.
  91. Legorreta AP, Peters AL, Ossorio RC, et al. Effect of a comprehensive nurse-managed program: an HMO prospective study. Am J Manag Care 1996; 2:1024.
  92. Espinet LM, Osmick MJ, Ahmed T, Villagra VG. A cohort study of the impact of a national disease management program on HEDIS diabetes outcomes. Dis Manag 2005; 8:86.
  93. Rothman RL, Malone R, Bryant B, et al. A randomized trial of a primary care-based disease management program to improve cardiovascular risk factors and glycated hemoglobin levels in patients with diabetes. Am J Med 2005; 118:276.
  94. Mangione CM, Gerzoff RB, Williamson DF, et al. The association between quality of care and the intensity of diabetes disease management programs. Ann Intern Med 2006; 145:107.
  95. Housden L, Wong ST, Dawes M. Effectiveness of group medical visits for improving diabetes care: a systematic review and meta-analysis. CMAJ 2013; 185:E635.
  96. Huang Z, Tao H, Meng Q, Jing L. Management of endocrine disease. Effects of telecare intervention on glycemic control in type 2 diabetes: a systematic review and meta-analysis of randomized controlled trials. Eur J Endocrinol 2015; 172:R93.
  97. Montori VM, Helgemoe PK, Guyatt GH, et al. Telecare for patients with type 1 diabetes and inadequate glycemic control: a randomized controlled trial and meta-analysis. Diabetes Care 2004; 27:1088.
  98. Liang X, Wang Q, Yang X, et al. Effect of mobile phone intervention for diabetes on glycaemic control: a meta-analysis. Diabet Med 2011; 28:455.
  99. Verlato G, Muggeo M, Bonora E, et al. Attending the diabetes center is associated with increased 5-year survival probability of diabetic patients: the Verona Diabetes Study. Diabetes Care 1996; 19:211.
  100. Greenfield S, Rogers W, Mangotich M, et al. Outcomes of patients with hypertension and non-insulin dependent diabetes mellitus treated by different systems and specialties. Results from the medical outcomes study. JAMA 1995; 274:1436.
  101. Greenfield S. Comparison by systems and specialties of medical outcomes in patients with hypertension and non-insulin dependent diabetes mellitus. Am J Manag Care 1996; 2:535.
  102. Ho M, Marger M, Beart J, et al. Is the quality of diabetes care better in a diabetes clinic or in a general medicine clinic? Diabetes Care 1997; 20:472.
  103. Zgibor JC, Songer TJ, Kelsey SF, et al. Influence of health care providers on the development of diabetes complications: long-term follow-up from the Pittsburgh Epidemiology of Diabetes Complications Study. Diabetes Care 2002; 25:1584.