Secondary prevention

  • Routine vaccinations for people with diabetes are more important than ever following the COVID-19 pandemic.[1]​ Patients should be up to date with their vaccination schedule, with vaccines provided in accordance with age-specific guidelines for the general population.​​[198]​​​[199]​​​ Patients with diabetes are at increased risk for influenza and pneumococcal pneumonia and should be vaccinated against these infections.[1] Diabetes is also associated with an increased risk for severe respiratory syncytial virus disease and in 2023 the US Advisory Committee on Immunization Practices recommended that adults ages ≥60 years may receive a single dose of RSV vaccine, using shared clinical decision-making.[200] People with chronic conditions, such as diabetes, should receive inactive or recombinant (not live attenuated) influenza vaccines.[1] Further, people with type 1 and type 2 diabetes have higher rates of hepatitis than the general population.[1]​​​ Hepatitis B vaccine should be provided for adults with diabetes ages <60 years.[1]​ Hepatitis B vaccination for adults ages ≥60 years is at the treating clinician’s discretion based on risk of acquiring infection.[1] In the US, COVID-19 vaccination and boosters are recommended for all people ages 6 months and over, including those with diabetes.[1]​​​ Patients with type 1 diabetes are at higher risk for severe COVID-19 infection.[201]​​​ They are more likely to need hospitalization, intensive care, and mechanical ventilation if they develop COVID-19, compared with patients who do not have diabetes, and have a higher case fatality rate and increased odds of in-hospital death with COVID-19.[202][203][204][205]​​ Poor glycemic control, hypertension, recent diabetic ketoacidosis, previous stroke, previous heart failure, renal impairment, body mass index <20 kg/m² or ≥40 kg/m², male sex, older age, non-white ethnicity, and socioeconomic deprivation are associated with increased mortality from COVID-19.[205][206]​​​[207] See Coronavirus disease 2019 (COVID-19) (Management).

  • Patients should be encouraged to discuss any mental health concerns or feelings of depression with their physicians so that appropriate treatment can be offered.[1]​ Physicians can help prompt these conversations with informal verbal inquiries: for example, by asking whether the patient has experienced any persistent changes in mood, or if there are any new or different barriers to their diabetes treatment.​[1]

  • The ADA advises that older adults should be assessed for fracture risk as part of their routine diabetes care, according to risk factors and comorbidities.[1]​​ In addition to general risk factors, diabetes-specific risk factors for fracture include frequent hypoglycemic events, diabetes duration >10 years, use of insulin, A1C >8%, and presence of microvascular complications.[1]​​ A dual-energy X-ray absorptiometry (DEXA) scan every 2 to 3 years is recommended by the ADA for high-risk older adults (ages >65 years); they recommend the same for younger people with multiple risk factors.[1]​​ Those with low bone mineral density (T-score ≤-2.0) or with previous fragility fractures should be considered for bone protection agents (e.g., antiresorptive or osteoanabolic medications).[1]​​ Steps should be taken to reduce the risk of falls, including individualizing glycemic goals for those at elevated fracture risk and avoiding hypoglycemia.[1]​​ Regular bone densitometry in children and adolescents is not recommended by the International Society for Pediatric and Adolescent Diabetes, but individualized evaluation of bone health may be considered in specific populations (e.g., those with coexisting celiac disease, or family history of early osteoporosis).[56]​ It is important that people with diabetes (including children) have adequate calcium and vitamin D intake, either through diet alone or with supplementation, and that other bone health promoting behaviors are encouraged (e.g., avoiding smoking, regular weight-bearing exercise).[1][56]​​ Screening for vitamin D deficiency should be considered, especially in high-risk groups and those with darker skin tone.[56]

  • The ADA advises that, given the association between diabetes and an increased risk of various cancers, people should be encouraged to attend recommended age- and sex-appropriate cancer screenings, and to reduce modifiable risk factors such as obesity, physical inactivity and smoking.[1]

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