What Should You Do to Prevent Diabetes Complications?
Take a comprehensive approach: maintain A1C below 7 percent, blood pressure below 130/80 mmHg, and LDL cholesterol below 100 mg/dL with statin therapy when indicated. Do not smoke. Follow all recommended screening schedules for eyes, kidneys, feet, and cardiovascular health. Take all prescribed medications consistently. These strategies together can reduce complication risk by 50 to 75 percent.
Complication prevention requires managing multiple risk factors simultaneously, not just blood sugar. The Steno-2 study demonstrated that intensive multifactorial intervention targeting glucose, blood pressure, lipids, and lifestyle reduced the risk of cardiovascular events by 53 percent, nephropathy by 61 percent, retinopathy by 58 percent, and autonomic neuropathy by 63 percent compared to standard care. This comprehensive approach to risk factor management is more effective than targeting any single risk factor alone. The ADA Standards of Care 2025 recommend individualized cardiovascular risk assessment and treatment for all people with diabetes.
Medication adherence is critical for complication prevention. The ADA recommends moderate-intensity statin therapy for all adults with diabetes aged 40 to 75, and high-intensity statin therapy for those with atherosclerotic cardiovascular disease or 10-year cardiovascular risk above 20 percent. ACE inhibitors or angiotensin receptor blockers are recommended for patients with albuminuria and/or hypertension. For patients with established cardiovascular disease, heart failure, or chronic kidney disease, SGLT2 inhibitors and GLP-1 receptor agonists with proven organ-protective benefits should be part of the treatment regimen regardless of A1C level. Aspirin therapy (75 to 162 mg daily) is recommended for secondary prevention in those with established cardiovascular disease.
Smoking cessation deserves special emphasis. Smoking doubles the risk of cardiovascular disease in people with diabetes, accelerates kidney disease progression, worsens neuropathy, and impairs wound healing. The ADA recommends addressing tobacco use at every visit and offering counseling and pharmacotherapy (nicotine replacement, varenicline, or bupropion) to all smokers with diabetes. Quitting smoking produces immediate cardiovascular benefit, with risk reduction beginning within weeks and continuing for years.
The Steno-2 study showed that intensive multifactorial intervention reduced cardiovascular events by 53 percent and microvascular complications by 58 to 63 percent
How Does Diabetes Affect the Heart and Blood Vessels?
Cardiovascular disease is the leading cause of death and disability in people with diabetes. Adults with diabetes are 2 to 4 times more likely to develop heart disease or stroke compared to those without diabetes. Chronic hyperglycemia accelerates atherosclerosis, damages endothelial function, promotes inflammation, and creates a prothrombotic state that increases heart attack and stroke risk.
The pathophysiology of cardiovascular disease in diabetes involves multiple interacting mechanisms. Chronic hyperglycemia produces advanced glycation end products (AGEs) that damage blood vessel walls, promote oxidative stress, and trigger inflammatory cascades. Insulin resistance drives atherogenic dyslipidemia characterized by elevated triglycerides, low HDL cholesterol, and small dense LDL particles that are particularly prone to oxidation and vascular penetration. Hyperinsulinemia promotes vascular smooth muscle cell proliferation and enhances platelet aggregation, accelerating plaque formation and rupture risk.
Modern diabetes medications have transformed cardiovascular risk management. The EMPA-REG OUTCOME trial (2015) was a watershed moment, demonstrating that empagliflozin (an SGLT2 inhibitor) reduced cardiovascular death by 38 percent in patients with type 2 diabetes and established cardiovascular disease. The LEADER trial showed liraglutide (a GLP-1 receptor agonist) reduced major adverse cardiovascular events by 13 percent and cardiovascular death by 22 percent. These findings, confirmed by subsequent trials of other SGLT2 inhibitors and GLP-1 agonists, led to a fundamental shift in diabetes management: the ADA now recommends these agents for cardiovascular protection regardless of A1C level in patients with established cardiovascular disease or high cardiovascular risk.
The EMPA-REG OUTCOME trial showed empagliflozin reduced cardiovascular death by 38 percent in patients with type 2 diabetes and established cardiovascular disease
What Is Diabetic Retinopathy and How Is It Prevented?
Diabetic retinopathy is damage to the blood vessels in the retina caused by chronic high blood sugar. It is the most common cause of new blindness in working-age adults, affecting approximately one-third of people with diabetes. It develops silently and can be detected and treated before vision loss occurs through annual dilated eye exams.
Diabetic retinopathy progresses through stages. Non-proliferative diabetic retinopathy (NPDR) begins with microaneurysms (tiny bulges in retinal blood vessel walls), progresses to cotton-wool spots, hard exudates, and venous beading as retinal blood vessels become increasingly damaged. Proliferative diabetic retinopathy (PDR), the advanced stage, occurs when the retina develops new fragile blood vessels (neovascularization) in response to ischemia. These abnormal vessels are prone to bleeding into the vitreous humor, causing sudden vision loss. Diabetic macular edema (DME) — swelling in the central part of the retina responsible for sharp vision — can occur at any stage and is the most common cause of visual impairment in diabetes.
Prevention centers on glycemic control, blood pressure management, and regular screening. The DCCT showed that intensive glycemic control reduced retinopathy onset by 76 percent in type 1 diabetes. The UKPDS demonstrated similar benefits in type 2 diabetes, and the ACCORD Eye study showed that intensive glycemic control (A1C below 6 percent) significantly reduced retinopathy progression. Tight blood pressure control also reduces retinopathy risk. When retinopathy is detected, anti-VEGF injections (aflibercept, ranibizumab) are the first-line treatment for DME and are also used for severe NPDR and PDR. The ADA recommends annual dilated eye exams beginning at type 2 diabetes diagnosis and 5 years after type 1 diagnosis.
The DCCT demonstrated that intensive glycemic control reduced retinopathy onset by 76 percent in type 1 diabetes
What Is Diabetic Kidney Disease and How Is It Managed?
Diabetic kidney disease (diabetic nephropathy) is the leading cause of end-stage kidney disease in the United States, affecting approximately 40 percent of people with diabetes. It is detected through annual urine albumin testing and eGFR monitoring. Treatment includes blood sugar control, blood pressure management with ACE inhibitors or ARBs, and SGLT2 inhibitors, which have shown remarkable kidney-protective benefits.
Diabetic nephropathy develops when chronic hyperglycemia damages the glomeruli, the tiny filtering units of the kidneys. Early kidney damage is detected by measuring the urine albumin-to-creatinine ratio, which identifies microalbuminuria (30 to 300 mg/g) before clinical symptoms appear. As damage progresses, protein leakage increases (macroalbuminuria above 300 mg/g), and the glomerular filtration rate (measured by eGFR) declines. Without intervention, diabetic nephropathy can progress to end-stage kidney disease requiring dialysis or kidney transplantation. The ADA recommends annual screening beginning at type 2 diabetes diagnosis and 5 years after type 1 diagnosis.
Management of diabetic kidney disease has been transformed by SGLT2 inhibitors. The CREDENCE trial demonstrated that canagliflozin reduced the composite kidney outcome (dialysis, transplant, doubling of creatinine, renal or cardiovascular death) by 30 percent compared to placebo. The DAPA-CKD trial showed dapagliflozin reduced kidney disease progression by 39 percent in patients with chronic kidney disease, regardless of diabetes status. These kidney-protective benefits are partly independent of glucose lowering, involving reductions in intraglomerular pressure, inflammation, and fibrosis. The ADA now recommends SGLT2 inhibitors for all patients with type 2 diabetes and chronic kidney disease with eGFR of 20 mL/min or higher. ACE inhibitors or ARBs remain first-line for blood pressure control and albuminuria reduction.
The DAPA-CKD trial showed dapagliflozin reduced kidney disease progression by 39 percent in patients with CKD
How Does Diabetes Lead to Foot Problems and Amputations?
Diabetes-related foot complications arise from the combination of peripheral neuropathy (loss of sensation), peripheral arterial disease (reduced blood flow), and impaired immune function. This triad allows minor injuries to go undetected, heal poorly, and become infected. Diabetes is the leading cause of non-traumatic lower limb amputations, but up to 85 percent of amputations are preventable with proper foot care.
The pathway from diabetes to amputation is well-understood and largely preventable. Peripheral neuropathy causes loss of protective sensation in the feet, so injuries from ill-fitting shoes, stepping on sharp objects, or thermal burns go unnoticed. Peripheral arterial disease reduces blood flow to the extremities, impairing wound healing and oxygen delivery to tissues. Hyperglycemia impairs white blood cell function, increasing susceptibility to infection. When an undetected wound becomes infected and inadequate blood flow prevents healing, tissue death (gangrene) may necessitate amputation. The International Working Group on the Diabetic Foot reports that a lower limb or part of a lower limb is amputated every 30 seconds worldwide due to diabetes.
Prevention requires a multifaceted approach. The ADA recommends annual comprehensive foot exams for all people with diabetes, with more frequent examinations for those with neuropathy, deformities, or history of foot ulcers. Patient education on daily self-inspection, proper footwear, skin care, and nail care is essential. Therapeutic footwear and custom orthotics are covered by Medicare for patients with diabetes and qualifying conditions. Prompt evaluation and treatment of any foot wound is critical — even a small blister or callus can rapidly progress to an ulcer requiring hospitalization. Multidisciplinary diabetic foot teams combining podiatry, vascular surgery, infectious disease, wound care, and orthopedics have been shown to reduce amputation rates by 45 to 85 percent.
What Are the Screening Schedules for Diabetes Complications?
Regular screening detects complications early when treatment is most effective. The ADA recommends annual dilated eye exams, annual kidney function testing, annual comprehensive foot exams, lipid panel at diagnosis and at least annually, blood pressure at every visit, and dental exams every 6 months. Additional screening is guided by individual risk factors.
For retinopathy screening, adults with type 2 diabetes should have an initial dilated eye exam at diagnosis and annually thereafter. Adults with type 1 diabetes should begin screening 5 years after diagnosis and annually thereafter. If no retinopathy is present after one or more normal exams, screening may be reduced to every 2 years. For kidney disease, annual urine albumin-to-creatinine ratio and eGFR should begin at type 2 diabetes diagnosis and 5 years after type 1 diagnosis. For neuropathy, annual clinical assessment with the 10-gram monofilament should begin at type 2 diagnosis and 5 years after type 1 diagnosis.
Cardiovascular risk assessment should be ongoing. Lipid panel should be obtained at initial evaluation, at diagnosis, at the initiation of statin therapy, and annually thereafter. Blood pressure should be measured at every clinical encounter. The ADA recommends cardiovascular risk calculators to guide statin intensity and aspirin use. Hepatic steatosis screening (for nonalcoholic fatty liver disease) should be considered in all patients with type 2 diabetes. Mental health screening for diabetes distress and depression is recommended at diagnosis, at regular intervals, and whenever there is a change in disease management or life circumstances. Periodontal evaluation is recommended at least annually because diabetes increases the risk and severity of gum disease.
The ADA Standards of Care 2025 provide comprehensive screening schedules for all diabetes complications
- Eyes: dilated exam annually (at diagnosis for type 2, after 5 years for type 1)
- Kidneys: urine albumin and eGFR annually (same timing as eyes)
- Feet: comprehensive exam annually, daily self-inspection
- Cardiovascular: lipid panel annually, blood pressure every visit
- Dental: exam every 6 months
- Mental health: screen for depression and diabetes distress regularly
- Neuropathy: clinical assessment annually (same timing as eyes)
- Liver: consider screening for fatty liver disease in type 2 diabetes
How Do Newer Medications Protect Against Complications?
GLP-1 receptor agonists and SGLT2 inhibitors provide organ-protective benefits beyond glucose lowering. SGLT2 inhibitors reduce heart failure hospitalization by 30 to 35 percent, slow kidney disease progression by 30 to 39 percent, and reduce cardiovascular death. GLP-1 agonists reduce major cardiovascular events by 12 to 26 percent. The ADA recommends these medications for organ protection regardless of A1C.
The cardiovascular outcome trials that established these benefits represent some of the most impactful research in diabetes. The EMPA-REG OUTCOME trial showed empagliflozin reduced cardiovascular death by 38 percent and heart failure hospitalization by 35 percent. The DECLARE-TIMI 58 trial demonstrated dapagliflozin reduced heart failure hospitalization by 27 percent. For GLP-1 receptor agonists, the LEADER trial showed liraglutide reduced major adverse cardiovascular events by 13 percent, the SUSTAIN-6 trial showed semaglutide reduced MACE by 26 percent, and the REWIND trial showed dulaglutide reduced MACE by 12 percent in a broader population with both established and risk-factor-only cardiovascular disease.
The kidney-protective benefits of SGLT2 inhibitors have been equally transformative. These medications reduce intraglomerular pressure by causing afferent arteriolar constriction, reduce tubular workload and oxygen consumption, and have anti-inflammatory and anti-fibrotic effects on kidney tissue. The CREDENCE trial showed canagliflozin reduced the primary renal composite endpoint by 30 percent, and the DAPA-CKD trial showed dapagliflozin reduced kidney disease progression by 39 percent. Remarkably, the kidney benefits of SGLT2 inhibitors extend to patients without diabetes who have chronic kidney disease, suggesting mechanisms independent of glucose lowering. The ADA now recommends that for patients with established cardiovascular disease, heart failure, or CKD, the choice of glucose-lowering therapy should prioritize agents with proven organ-protective benefits.
The SUSTAIN-6 trial showed semaglutide reduced major adverse cardiovascular events by 26 percent in patients with type 2 diabetes
How Does Diabetes Affect Mental Health and Quality of Life?
Diabetes significantly impacts mental health and quality of life. People with diabetes have 2 to 3 times higher rates of depression, and diabetes distress affects up to 45 percent of patients. Depression worsens glycemic control and increases complication risk, creating a harmful bidirectional cycle. The ADA recommends routine mental health screening and integrated psychosocial care.
Diabetes distress is distinct from clinical depression and refers to the emotional burden specific to living with and managing diabetes. It includes feeling overwhelmed by the demands of diabetes management, worrying about complications, frustration with blood sugar fluctuations, guilt about dietary choices, and fatigue from the constant vigilance required. The Diabetes Distress Scale is a validated tool for screening. Up to 45 percent of people with diabetes experience significant diabetes distress, which is associated with higher A1C, worse self-care behaviors, and lower quality of life. Addressing diabetes distress through counseling, peer support, and simplifying treatment regimens can improve both emotional well-being and glycemic control.
Clinical depression in diabetes requires integrated treatment addressing both conditions simultaneously. Untreated depression impairs diabetes self-management — patients with depression are less likely to take medications, check blood sugar, exercise, and follow dietary recommendations. Effective treatments include cognitive behavioral therapy (which has strong evidence in diabetes populations), antidepressant medication (SSRIs are generally preferred as they may also modestly improve glycemic control), and collaborative care models that integrate mental health support into diabetes care. The ADA recommends screening for depression and diabetes distress at diagnosis, at periodic intervals, and at times of complication onset, disease transition, or significant life changes.
