Misdiagnosis By Design - The Story Behind The Ada Diagnostic Criteria
This is the little known story of how--and why--the American Diabetes Association keeps doctors from diagnosing Type 2 diabetes early. If you wait for your doctor to give you a diabetes diagnosis, the chances are good that by the time you are diagnosed you'll already have one or more serious diabetic complications. These include retinal damage, nerve damage, and early kidney damage. It is now known that these diabetic complications only develop after years of chronic exposure to high blood sugars. But, tragically, the way that today's doctors are forced to diagnose diabetes ensures that you will get no warning that you are experiencing those chronically high blood sugars until they have reached a level so high they have already done irreversible damage. This is not an accident. Years ago a committee of medical experts whose task was to decide how diabetes should be diagnosed decided it was better to avoid diagnosing patients with diabetes than to give them early warning that they were suffering from elevated blood sugars. As a result, these medical experts intentionally set the standards for diagnosing diabetes artificially high, so that most patients do not get diagnosed until their blood sugar has reached a level where they may soon develop the diabetic eye disease that leads to blindness. Their reasons for doing this this made sense in the late 1970s when these diagnostic criteria were originally crafted. At that time there was no treatment that could help people with early diabetes, while delivering a diabetes diagnosis could make it impossible for their patients to get health or life insurance. These circumstances led the experts to conclude that an early diagnosis of diabetes was more likely to harm than help their patients. So they defined diagnostic criteria tha Continue reading >>
Clinical Presentation And Diagnosis Of Diabetes Mellitus In Adults
INTRODUCTION The term diabetes mellitus describes several diseases of abnormal carbohydrate metabolism that are characterized by hyperglycemia. It is associated with a relative or absolute impairment in insulin secretion, along with varying degrees of peripheral resistance to the action of insulin. Every few years, the diabetes community reevaluates the current recommendations for the classification, diagnosis, and screening of diabetes, reflecting new information from research and clinical practice. The American Diabetes Association (ADA) issued diagnostic criteria for diabetes mellitus in 1997, with follow-up in 2003 and 2010 [1-3]. The diagnosis is based on one of four abnormalities: glycated hemoglobin (A1C), fasting plasma glucose (FPG), random elevated glucose with symptoms, or abnormal oral glucose tolerance test (OGTT) (table 1). Patients with impaired fasting glucose (IFG) and/or impaired glucose tolerance (IGT) are referred to as having increased risk for diabetes or prediabetes. (See 'Diagnostic criteria' below.) Screening for and prevention of diabetes is reviewed elsewhere. The etiologic classification of diabetes mellitus is also discussed separately. (See "Screening for type 2 diabetes mellitus" and "Prevention of type 2 diabetes mellitus" and "Prevention of type 1 diabetes mellitus" and "Classification of diabetes mellitus and genetic diabetic syndromes".) CLINICAL PRESENTATION Type 2 diabetes is by far the most common type of diabetes in adults (>90 percent) and is characterized by hyperglycemia and variable degrees of insulin deficiency and resistance. The majority of patients are asymptomatic, and hyperglycemia is noted on routine laboratory evaluation, prompting further testing. The frequency of symptomatic diabetes has been decreasing in parallel wi Continue reading >>
Diagnosis And Classification Of Diabetes Mellitus: New Criteria
New recommendations for the classification and diagnosis of diabetes mellitus include the preferred use of the terms “type 1” and “type 2” instead of “IDDM” and “NIDDM” to designate the two major types of diabetes mellitus; simplification of the diagnostic criteria for diabetes mellitus to two abnormal fasting plasma determinations; and a lower cutoff for fasting plasma glucose (126 mg per dL [7 mmol per L] or higher) to confirm the diagnosis of diabetes mellitus. These changes provide an easier and more reliable means of diagnosing persons at risk of complications from hyperglycemia. Currently, only one half of the people who have diabetes mellitus have been diagnosed. Screening for diabetes mellitus should begin at 45 years of age and should be repeated every three years in persons without risk factors, and should begin earlier and be repeated more often in those with risk factors. Risk factors include obesity, first-degree relatives with diabetes mellitus, hypertension, hypertriglyceridemia or previous evidence of impaired glucose homeostasis. Earlier detection of diabetes mellitus may lead to tighter control of blood glucose levels and a reduction in the severity of complications associated with this disease. Diabetes mellitus is a group of metabolic disorders with one common manifestation: hyperglycemia. Chronic hyperglycemia causes damage to the eyes, kidneys, nerves, heart and blood vessels. The etiology and pathophysiology leading to the hyperglycemia, however, are markedly different among patients with diabetes mellitus, dictating different prevention strategies, diagnostic screening methods and treatments. The adverse impact of hyperglycemia and the rationale for aggressive treatment have recently been reviewed.1 In June 1997, an international Continue reading >>
Diagnosis Of Type 2 Diabetes Mellitus
There is a continuum of risk for poor patient outcomes as glucose tolerance progresses from normal to overt type 2 diabetes. AACE-defined glucose tolerance categories are listed in Table 1.1 Table 1. Glucose Testing and Interpretation1 Normal High Risk for Diabetes Diabetes FPG < 100 mg/dL IFG FPG ≥100-125 mg/dL FPG ≥126 mg/dL 2-hour PG <140 mg/dL (measured with an OGTT performed 2 hours after 75 g oral glucose load taken after 8-hour fast) IGT 2-hour PG ≥140-199 mg/dL 2-hour PG ≥200 mg/dL Random PG ≥200 mg/dL plus symptoms of diabetes (polyurea, polydipsia, or polyphagia) A1C < 5.5% 5.5% to 6.4% For screening of prediabetesa ≥6.5% Secondaryb Abbreviations: A1C = hemoglobin A1C; FPG = fasting plasma glucose; IFG = impaired fasting glucose; IGT = impaired glucose tolerance; PG = plasma glucose. a A1C should be used only for screening prediabetes. The diagnosis of prediabetes, which may manifest as either IFG or IGT, should be confirmed with glucose testing. b Glucose criteria are preferred for the diagnosis of DM. In all cases, the diagnosis should be confirmed on a separate day by repeating glucose or A1C testing. When A1C is used for diagnosis, follow-up glucose testing should be done when possible to help manage diabetes. The diagnostic cut points recommended by the American Diabetes Association (ADA) differ slightly from the AACE recommendations; please see the ADA Standards of Medical Care in Diabetes for details.2 In addition to glucose criteria, type 1 diabetes (T1D) is diagnosed according to the presence of autoantibodies to glutamic acid decarboxylase, pancreatic islet (beta) cells, or insulin.1,2 Type 2 diabetes (T2D) accounts for 90% of diabetes cases and is usually identified in individuals 30 years or older who are overweight or obese and/or have Continue reading >>
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Diagnostic Criteria For Diabetes Mellitus
To the Editor: In his editorial article (1), Dr. Sacks welcomes the new guidelines for diagnosis of diabetes published recently by the American Diabetes Association (ADA) (2). Replacement of the oral glucose tolerance test (OGTT) by measurement of fasting plasma glucose (FPG) on more than one occasion certainly simplifies the diagnostic procedure, and the chosen FPG cutoff of ≥7.0 mmol/L (≥126 mg/dL) appears to be almost as sensitive for diabetes detection as the OGTT 2-h plasma glucose (2hPG). Unfortunately, the situation is not quite as simple as that. We recently conducted a survey of 401 nonpregnant subjects having OGTT because of suspected diabetes mellitus (3). The OGTT was performed according to WHO protocol and interpreted on the basis of the 2hPG value. The prevalence of diabetes in this population according to the results of the OGTT was 44.4%, compared with 41.4% by the ADA FPG criterion. This is in line with the ADA’s data on the different sensitivities of the two tests and suggests that they are giving approximately the same answers. However, when we compared results by the two methods for individual patients, the agreement was not always so good. Of 178 patients positive for diabetes by 2hPG, only 139 were positive by the ADA FPG criterion, which means the latter gave 39 (22%) false negatives if the OGTT 2hPG is regarded as the reference method. This discrepancy was not immediately apparent in the prevalence figures because 27 other subjects were falsely positive by the ADA criterion, and these partially balanced the false negatives. In its overall view of the situation, the ADA seems to have omitted considering in any detail the possibility of a substantial number of individual discrepancies within the population. Furthermore, subjects whose FPG is Continue reading >>
- Mastery in Diabetes Management: New Diabetes Diagnosis Criteria Req'd for Asian Patients?
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Diabetes: Diagnosis, Laboratory Testing, And The Current American Diabetes Association Guidelines (online Ce Course)
Objectives Define diabetes and differentiate between type 1 and type 2 diabetes. Discuss gestational diabetes and other causes of diabetes. Explain the role of the clinical laboratory in the diagnosis and monitoring diabetes. Discuss the signs and symptoms of diabetes. List the common ways to prevent, manage, and treat diabetes. Identify clinical and laboratory criteria that indicates increased risk for diabetes. List the current assays used to monitor diabetic patients. Explain the recommendations made by the American Diabetes Association in regards to diagnosis and monitoring of diabetes. Course Outline Click on the links below to preview selected pages from this course. Overview of Diabetes: Definition and Facts Diabetes: Definition Which of the following statements about insulin are TRUE? (Select all that apply.) Diabetes: Facts Diabetes: A Metabolic Disorder True or false? There is an emerging global epidemic of diabetes that has been traced to rapid increases in overweight people, including obesity, and p... Blood Glucose and Hormonal Control Blood Glucose and Hormonal Control (continued) Blood Glucose and Hormonal Control (continued) _________________ is the metabolic process whereby glycogen is broken down or hydrolyzed in the liver into glucose which is released into the bloodstr... Which statement s are TRUE about the roles of insulin and glucagon in the regulation of normal blood glucose? (Select all that apply.) Which of the following hormones is mainly responsible for the entry of glucose into the cell for energy production? Classification of Diabetes The Four Clinical Classes of Diabetes Which of the following statements are TRUE with regard to the clinical classes of diabetes? (Select all that apply.) Type 2 Diabetes True or false? Class 2 diabetes was fo Continue reading >>
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Type 2 Diabetes Ada Diagnosis Criteria
Type 2 Diabetes ADA Diagnosis Criteria The American Diabetes Association (ADA) criteria for the diagnosis of diabetes are any of the following: [1] A hemoglobin A1c (HbA1c) level of 6.5% or higher; the test should be performed in a laboratory using a method that is certified by the National Glycohemoglobin Standardization Program (NGSP) and standardized or traceable to the Diabetes Control and Complications Trial (DCCT) reference assay, or A fasting plasma glucose (FPG) level of 126 mg/dL (7 mmol/L) or higher; fasting is defined as no caloric intake for at least 8 hours, or A 2-hour plasma glucose level of 200 mg/dL (11.1 mmol/L) or higher during a 75-g oral glucose tolerance test (OGTT), or A random plasma glucose of 200 mg/dL (11.1 mmol/L) or higher in a patient with classic symptoms of hyperglycemia (ie, polyuria, polydipsia, polyphagia, weight loss) or hyperglycemic crisis Continue reading >>
Diagnosis And Classification Of Diabetes Mellitus
Go to: DEFINITION AND DESCRIPTION OF DIABETES MELLITUS Diabetes is a group of metabolic diseases characterized by hyperglycemia resulting from defects in insulin secretion, insulin action, or both. The chronic hyperglycemia of diabetes is associated with long-term damage, dysfunction, and failure of differentorgans, especially the eyes, kidneys, nerves, heart, and blood vessels. Several pathogenic processes are involved in the development of diabetes. These range from autoimmune destruction of the β-cells of the pancreas with consequent insulin deficiency to abnormalities that result in resistance to insulin action. The basis of the abnormalities in carbohydrate, fat, and protein metabolism in diabetes is deficient action of insulin on target tissues. Deficient insulin action results from inadequate insulin secretion and/or diminished tissue responses to insulin at one or more points in the complex pathways of hormone action. Impairment of insulin secretion and defects in insulin action frequently coexist in the same patient, and it is often unclear which abnormality, if either alone, is the primary cause of the hyperglycemia. Symptoms of marked hyperglycemia include polyuria, polydipsia, weight loss, sometimes with polyphagia, and blurred vision. Impairment of growth and susceptibility to certain infections may also accompany chronic hyperglycemia. Acute, life-threatening consequences of uncontrolled diabetes are hyperglycemia with ketoacidosis or the nonketotic hyperosmolar syndrome. Long-term complications of diabetes include retinopathy with potential loss of vision; nephropathy leading to renal failure; peripheral neuropathy with risk of foot ulcers, amputations, and Charcot joints; and autonomic neuropathy causing gastrointestinal, genitourinary, and cardiovascul Continue reading >>
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- Women in India with Gestational Diabetes Mellitus Strategy (WINGS): Methodology and development of model of care for gestational diabetes mellitus (WINGS 4)
Who And Ada Criteria For The Diagnosis Of Diabetes Mellitus In Relation To Body Mass Index. Insulin Sensitivity And Secretion In Resulting Subcategories Of Glucose Tolerance
OBJECTIVE: To determine the influence of body mass index (BMI) on agreement between the American Diabetes Association (ADA) and the new World Health Organization diagnostic criteria for the diagnosis of diabetes mellitus and to investigate the metabolic profile of the resulting subcategories. DESIGN: Cross-sectional study SUBJECTS: A total of 3018 subjects with no previous history of diabetes and fasting glucose <7.8 mmol/l, with a wide range of BMIs. MEASUREMENTS: (1) Prevalence of impaired glucose regulation (IGR) and diabetes (DM) according to ADA and WHO diagnostic criteria; (2) basal and post-load insulin sensitivity and secretion, calculated on the basis of data derived from an oral glucose tolerance test (OGTT). RESULTS: The diagnosis according to the two classifications was concordant in 2490 subjects, discordant in 528 (452 were identified as impaired glucose tolerance (IGT) and 76 as DM only by means of OGTT). The disagreement increased with increasing BMI, being as high as 25.3% in subjects with BMI ≥35 kg/m2. Subjects with isolated fasting hyperglycaemia were mainly characterised by reduced insulin sensitivity and secretion in the basal state, but normal first-phase insulin secretion and moderately reduced insulin sensitivity after glucose challenge. Subjects with isolated 2 h hyperglycaemia were mainly characterised by normal basal insulin secretion and by a marked insulin resistance associated with a blunted first-phase insulin secretion after the glucose load. CONCLUSIONS: The disagreement between ADA and WHO classifications is particularly relevant in obesity, making OGTT mandatory in these subjects. Different pathogenic mechanisms are involved in isolated fasting or post-load hyperglycaemia, possibly related to a different site of insulin resistance ( Continue reading >>
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Will New Diagnostic Criteria For Diabetes Mellitus Change Phenotype Of Patients With Diabetes? Reanalysis Of European Epidemiological Data
Go to: Abstract Objective: To evaluate the impact of the revised diagnostic criteria for diabetes mellitus adopted by the American Diabetes Association on prevalence of diabetes and on classification of patients. For epidemiological purposes the American criteria use a fasting plasma glucose concentration 7.0mmol/l in contrast with the current World Health Organisation criteria of 2 hour glucose concentration 11.1mmol/l. Design: Data were collected from 13 populations and three occupational based studies from eight European countries. All studies used a 75g oral glucose tolerance test to measure fasting and 2 hour glucose concentrations. Subjects: 17881 men; 8309 women; age range 17-92 years. Main outcome measures: Classification of diabetes according to both sets of criteria. Results: The application of the American criteria on European populations induced changes in prevalence of diabetes ranging from a reduction of 4.0% to an increase of 13.2%. A total of 1517 previously undiagnosed individuals had diabetes according to either the WHO or the American criteria. Among 1044 with diabetes according to American criteria, only 45% had 2 hour values fulfilling the WHO criteria. The risk of disagreement of classification decreased with increasing body mass index (P<0.00001) and increasing age (P<0.0001); the impact of sex was not significant (P=0.08). Conclusions: This shift in strategy from using 2 hour to fasting plasma glucose will cause an increase in the prevalence of diabetes in some European populations. A high degree of disagreement in the classification was observed between the two recommendations. Prospective data are needed to evaluate whether the WHO or the American criteria best identify individuals at risk of developing microvascular complications and cardiovas Continue reading >>
- Mastery in Diabetes Management: New Diabetes Diagnosis Criteria Req'd for Asian Patients?
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Tailoring Treatment To Reduce Disparities:
The American Diabetes Association (ADA) publishes the Standards of Medical Care in Diabetes annually, based on the latest medical research. The following narrative provides a summary of the 2017 updated recommendations that have been developed for clinical practice. The ADA guidelines are not intended to aid or preclude clinical judgment. The full guidelines can be accessed at ADA’s Diabetes Pro website. Tailoring Treatment to Reduce Disparities: Updated guidelines focus on improving outcomes and reducing disparities in populations with diabetes such as: Ethnic/Cultural/Sex/Socioeconomic Differences and Disparities: Provide structured interventions that are tailored to ethnic populations and integrate culture, language, religion, and literacy skills. Food Insecurity: Evaluate hyperglycemia and hypoglycemia in the context of food insecurity (FI), which is defined as the unreliable availability of nutritious food. Recognize that homelessness and poor literacy and numeracy often occur with FI. Propose solutions and resources accordingly. Comprehensive Medical Evaluation and Assessment of Comorbidities: The clinical evaluation should include conversation about lifestyle modifications and healthy living. PAs should address barriers including patient factors (e.g., remembering to obtain or take medications, fears, depression, and health beliefs), medication factors (e.g., complex directions, cost) and system factors (e.g., inadequate follow up). Simplifying treatment regimens may improve adherence. This section highlights the elements of a patient-centered comprehensive medical exam, including the importance of assessing comorbidities such as: Cognitive Dysfunction: Tailor glycemic therapy to avoid significant hypoglycemia. Cardiovascular benefits of statin therapy outweigh Continue reading >>
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