Diabetes Mellitus, Recommendations for Diagnosis

The Expert Committee on the Diagnosis and Classification of Diabetes Mellitus published new classification and diagnostic criteria for diabetes in July (Diabetes Care 1997; 20:1183-97). The Committee recommended replacing the old categories of insulin dependent diabetes mellitus (IDDM) and non-insulin dependent diabetes mellitus (NIDDM) with type 1 and type 2 diabetes, respectively. Approximately 700,000 Americans have type1 diabetes, which is caused by autoimmune destruction of the pancreatic islet beta cells leading to an absolute deficiency of insulin secretion. It usually occurs in slender children or young adults who are prone to ketoacidosis. Approximately 15.3 million Americans have type 2 diabetes, which usually arises from a combination of resistance to insulin action and an inadequate compensatory insulin secretory response. Type 2 diabetes usually occurs in adults over 45 years who are overweight, sedentary and have a positive family history.

The diagnostic criteria for diabetes mellitus have been modified from those previously recommended by the National Diabetes Data Group (NDDG) and the World Health Organization (WHO). The Expert Committee stated that diabetes can be diagnosed in any one of the following three ways:

A fasting plasma glucose of 126 mg/dL or greater (no caloric intake for 8 h);
A casual plasma glucose of 200 mg/dL plus symptoms of diabetes such as polyuria, polydipsia, and unexplained weight loss;
An oral glucose tolerance test (OGTT) value of >/=200 mg/dL in the two hour sample (75 g glucose load).

Fasting plasma glucose is the preferred diagnostic test because it is easier to obtain and less subject to day to day variation than is the OGTT.

The Expert Committee also recommended that testing for diabetes be considered in all adults age 45 and older. If results are normal, testing should be repeated at three year intervals. An abnormal result should be confirmed on a different day by any one of the three tests. Physicians should consider testing people at a younger age who are at risk of diabetes, including those who:

are obese
have a first degree relative with diabetes
are a member of a high risk ethnic group
have a history of gestational diabetes or delivered a baby weighing >9 lb
have hypertension (>=140/90)
have HDL cholesterol < /=35 mg/dL and/or triglyceride level >/=250 mg/dL
have a history of impaired fasting glucose or impaired glucose tolerance

The American Diabetes Association published new recommendations for diabetes screening in January 2004 (Diabetes Care 2004;27, Suppl 1:S11-14). Normoglycemia is now defined as a fasting plasma glucose level of less than 100 mg/dL. Fasting is defined as no consumption of food or beverage other than water for at least 8 hours before testing. Nondiabetic individuals with a fasting plasma glucose level of >100 but < 126 mg/dL are considered to have impaired fasting glucose.

Gestational diabetes mellitus (GDM) complicates about 4% of all pregnancies in the United States. Previous recommendations have been that all pregnant women should be screened for GDM with a 50 g OGTT. The Expert Committee now recommends that women at low risk not be screened. This includes women who satisfy all of the following criteria: less than 25 years of age, normal body weight, no family history of diabetes, and not a member of an ethnic/racial group with a high prevalence of diabetes (e.g. Hispanic, Native American, Asian, African-American).

The revised criteria are for diagnosis of diabetes mellitus and are not treatment criteria or goals of therapy. No change was made in the American Diabetes Association's recommended treatment goals of a fasting plasma glucose < 120 mg/dL and HbA1c < 7%.




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