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Diagnosing Diabetes With Glucose Criteria: Worshipping A False God

Diagnosing Diabetes With Glucose Criteria: Worshipping A False God

In this issue of Diabetes Care, Dr. David Sacks has nicely delineated the pros and cons of the measurements of glucose concentrations and A1C levels and the resulting effects on using each to diagnose diabetes (1). With the continued improvement in A1C assays, the balance seems to increasingly favor using A1C levels. This commentary will examine an issue that has received scant attention in the past, i.e., what is the actual evidence upon which the current glucose criteria for diagnosing diabetes mellitus is based? Glucose concentrations in almost all populations (except those with very high prevalences of diabetes, e,g., Pima Indians), are distributed unimodally with a rightward skew (2,3), making the choice of a diagnostic value for diabetes arbitrary. If glucose concentrations are log-transformed to minimize the rightward skewness, a bimodal distribution has been noted (4–8). However, cutoff values defining the two distributions have ranged from 200–307 mg/dL, mostly depending on the ages of the population surveyed (3–8). Prior to 1979, at least six different sets of criteria diagnosed diabetes (9). In 1979, the National Diabetes Data Group (NDDG) resolved this issue by establishing one set of criteria (10). They selected these criteria based on glucose concentrations that allegedly predicted the development of diabetic retinopathy, a specific microvascular complication of diabetes. Three prospective studies (11–13) were available to the NDDG on which to base their decision. A total of 1,213 patients were followed for 3 to 8 years after oral glucose tolerance tests (OGTTs), 77 of whom developed retinopathy. There was no further evaluation of their glycemic status after the original OGTT, although it was very likely that the 77 people who developed retinopathy Continue reading >>

Gestational Diabetes Mellitus

Gestational Diabetes Mellitus

Alison Nankervis Background Recommendations to change the diagnostic criteria for gestational diabetes mellitus (GDM) are controversial. Two sets of criteria are currently in use in Australia, which has led to considerable confusion. Objective/s This article discusses the rationale behind the proposed changes to the diagnostic criteria, and aims to clarify the current approach to the testing for and diagnosis of GDM in Australia. Discussion Gestational diabetes mellitus has adverse effects on pregnancy outcomes and implications for the long term wellbeing of mother and infant. New information about the relationship between hyperglycaemia in pregnancy and fetal outcomes has led to the formulation of revised recommendations for testing and diagnosis of GDM. The changes to the diagnostic threshold will increase the numbers of women diagnosed with GDM by up to 50%. Evidence that management of GDM improves neonatal outcomes mandates a proactive approach to diagnosis and management. General practitioners will have an increasing role in managing GDM. Gestational diabetes mellitus (GDM) is associated with short and long term risks to mother and infant. Yet, there is considerable controversy as to how to diagnose GDM and provide optimal management during and after pregnancy. This article will try to make some sense of the current debate regarding ‘old’ versus ‘new’ diagnostic criteria, and provide practical guidance for the management and follow up of GDM in general practice. What is GDM? GDM is defined as ‘any degree of glucose intolerance with onset or first recognition during pregnancy’. GDM affects approximately 8–10% of pregnancies in Australia.1 It includes previously unrecognised type 2 diabetes mellitus (DM) and, rarely, type 1 DM arising in pregnancy. In m Continue reading >>

How Do You Know If You Have Diabetes Or Pre-diabetes?

How Do You Know If You Have Diabetes Or Pre-diabetes?

"How Do You Know If You Have Diabetes or Pre-Diabetes?" is an important question given the current epidemic of adult-onset diabetes. The short answer is - ask your doctor who will order a test. However, as we shall see, it is far from that simple. Another short answer is that it simply a matter of a definition, and that there are more than one. Diabetes is a metabolic disease characterized by abnormally elevated levels of blood glucose (hyperglycemia) resulting from defects in insulin secretion, insulin action or both. Chronic hyperglycaemia of diabetes in associated with the dysfunction, long-term damage and failure of various organs and systems, especially the kidneys, eyes, nerves, heart and blood vessels. These long-term complications include retinopathy with potential loss of vision, nephropathy leading to kidney failure, peripheral neuropathy with risk of foot ulcers, amputations, and neuropathy of the autonomic nervous system resulting in gastrointestinal, genitourinary and cardiovascular symptoms and sexual dysfunction. Thus diagnosing diabetes or pre-diabetes and then attempting to reverse the associated hyperglycemia or at least minimize the micro- and macrovascular damage is an important and significant challenge with profound public health implications. The vast majority of cases of diabetics are so-called Type 2, which historically was termed adult-onset diabetes and is caused by a combination of resistance to the action of insulin and an inadequate compensatory insulin secretory response. Type 1 diabetes, on the other hand, is caused by an absolute deficiency of insulin secretion, frequently occurs at a young age and requires generally requires life-long insulin injections. In Type 2 diabetes the degree of hyperglycemia sufficient to cause pathologic and f Continue reading >>

Optimal Hemoglobin A1c Levels For Screening Of Diabetes And Prediabetes In The Japanese Population

Optimal Hemoglobin A1c Levels For Screening Of Diabetes And Prediabetes In The Japanese Population

Copyright © 2015 Masanori Shimodaira et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Abstract The aim of this study was to evaluate the utility of hemoglobin A1c (HbA1c) to identify individuals with diabetes and prediabetes in the Japanese population. A total of 1372 individuals without known diabetes were selected for this study. A 75 g oral glucose tolerance test (OGTT) was used to diagnose diabetes and prediabetes. The ability of HbA1c to detect diabetes and prediabetes was investigated using receiver operating characteristic (ROC) analysis. The kappa (κ) coefficient was used to test the agreement between HbA1c categorization and OGTT-based diagnosis. ROC analysis demonstrated that HbA1c was a good test to identify diabetes and prediabetes, with areas under the curve of 0.918 and 0.714, respectively. Optimal HbA1c cutoffs for diagnosing diabetes and prediabetes were 6.0% (sensitivity 83.7%, specificity 87.6%) and 5.7% (sensitivity 60.6%, specificity 72.1%), respectively, although the cutoff for prediabetes showed low accuracy (67.6%) and a high false-negative rate (39.4%). Agreement between HbA1c categorization and OGTT-based diagnosis was low in diabetes () and prediabetes (). In Japanese subjects, the HbA1c cutoff of 6.0% had appropriate sensitivity and specificity for diabetes screening, whereas the cutoff of 5.7% had modest sensitivity and specificity in identifying prediabetes. Thus, HbA1c may be inadequate as a screening tool for prediabetes. 1. Introduction Diabetes is reaching pandemic proportions across the world. The number of diabetes patients is estimated to increase from 8.3% (366 Continue reading >>

Misdiagnosis By Design - The Story Behind The Ada Diagnostic Criteria

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 >>

Diagnosis Of Diabetes Mellitus

Diagnosis Of Diabetes Mellitus

Diabetes is diagnosed on the basis of history (ie polyuria, polydipsia and unexplained weight loss) PLUS a random venous plasma glucose concentration >= 11.1 mmol/l OR a fasting plasma glucose concentration >= 7.0 mmol/l (whole blood >= 6.1 mmol/l) OR 2 hour plasma glucose concentration >= 11.1 mmol/l 2 hours after 75g anhydrous glucose in an oral glucose tolerance test (OGTT) With no symptoms diagnosis should not be based on a single glucose determination but requires confirmatory plasma venous determination. At least one additional glucose test result on another day with a value in the diabetic range is essential, either fasting, from a random sample or from the two hour post glucose load (1,2). If the fasting or random values are not diagnostic the 2-hour value should be used. These diagnostic criteria for diagnosing and classifying diabetes were applied to the management of diabetes in the UK from June 1st 2000 (1). The new criteria included lowering the threshold for diagnosing diabetes from a fasting glucose level of 7.8 mmol/l to 7.0 mmol/l. It should be noted that children usually present with severe symptoms and diagnosis should then be based on a single raised blood glucose result, as above. Immediate referral to a Paediatric Diabetes Team should not be delayed. A diagnosis should never be made on the basis of glycosuria or a stick reading of a finger prick blood glucose alone, although such tests may be useful for screening purposes. HbA1c in the diagnosis of diabetes mellitus (3) HbA1c can be used as a diagnostic test for diabetes providing that stringent quality assurance tests are in place and assays are standardised to criteria aligned to the international reference values, and there are no conditions present which preclude its accurate measurement an HbA Continue reading >>

[study Of Glycated Albumin Cut-off Point In Diabetes Mellitus And Impaired Glucose Regulation].

[study Of Glycated Albumin Cut-off Point In Diabetes Mellitus And Impaired Glucose Regulation].

Abstract To investigate the cut-off point of glycated albumin (GA) in the detection of diabetes mellitus (DM) and impaired glucose regulation (IGR).This study was conducted in 20-84 years-old adults who had risk factors of diabetes but no previously diagnosed diabetes. There were finally 392 individuals included and received the measurement of GA and HbA1c. Receiver operating characteristic curve (ROC) was plotted to determine the performance of GA.(1) Based on the diabetes diagnosis criteria of WHO (1999), the subjects were divided into DM group (n = 131), IGR group (n = 126), and normal glucose tolerance (NGT) group (n = 135). The GA level in the three groups tended to increase (P < 0.05). (2) Spearman correlation analysis demonstrated that GA was positively correlated with glycated haemoglobin A1c (HbA1c) (r = 0.942 1, P < 0.05), fasting plasma glucose (FPG) (r = 0.856 6, P < 0.05) and 2 h post-load plasma glucose (2-hPG) (r = 0.813 7, P < 0.05). (3) The mean levels of serum GA/HbA1c were 2.58 +/- 0.37, 2.44 +/- 0.37 and 2.17 +/- 0.25 for DM, IGR and NGT respectively. (4) The optimal cut-off points for detecting diabetes were 16.6% in GA [area under the carve (AUC) = 0.888], producing the sensitivity of 71.8% and the specificity of 87.4%.GA as a single screening test shows adequate to detect newly diagnosed DM, and the optimal GA cut-off point was 16.6% in this study. Continue reading >>

Optimal Hemoglobin A1c Cutoff Value For Diagnosing Type 2 Diabetes Mellitus In Korean Adults☆

Optimal Hemoglobin A1c Cutoff Value For Diagnosing Type 2 Diabetes Mellitus In Korean Adults☆

Abstract Commonly used tests for the diagnosis of diabetes include measurements of fasting plasma glucose levels and the oral glucose tolerance test (OGTT). Recently, a hemoglobin A1C (A1C) level of 6.5% has been included as a criterion for diabetes diagnosis by the American Diabetes Association. We aimed to determine appropriate A1C cutoff values for identifying patients with diabetes or prediabetes, including impaired glucose tolerance and impaired fasting glucose among Korean adults and to determine whether these cutoffs vary according to age. We recruited 4616 adults without a history of diabetes from 10 university hospitals. A 75-g OGTT and A1C sampling were performed in all examinees. Pointwise area under the receiver operating characteristic curve was used to evaluate the diagnostic accuracy of the A1C cutoff. An A1C threshold of 6.1% proved to be the optimal limit for diagnosing diabetes, with 63.8% sensitivity and 88.1% specificity. The cutoff value increased with age (5.9% in 18–39 years, 6.2% in 40–64 years, and 6.4% in older than 65 years) and were similar for men and women. An A1C cutoff of 5.7% had reasonable sensitivity (48.6%) and specificity (65.7%) for the identification of prediabetes. Further prospective studies should be carried out to determine whether the application of age-specific diagnostic criteria is appropriate. Continue reading >>

Glycated Hemoglobin In Diagnosis Of Diabetes Mellitus And Pre-diabetes; Validation By Oral Glucose Tolerance Test. The Tromsø Ogtt Study

Glycated Hemoglobin In Diagnosis Of Diabetes Mellitus And Pre-diabetes; Validation By Oral Glucose Tolerance Test. The Tromsø Ogtt Study

Abstract Background: Glycated hemoglobin (HbA1c) 6.5% has recently been recommended by the World Health Organization (WHO) and the American Diabetes Association (ADA) as an alternative diagnostic criterion for diabetes mellitus (DM). Aim: To evaluate HbA1c as an alternative to oral glucose tolerance test (OGTT) for diagnosis of DM and pre-diabetes and to find the optimal HbA1c cut-off points for DM and pre-diabetes in our population. Subjects and methods: The subjects were recruited from the Tromsø Study, performed for the 6th time in 2007–2008 with 12,984 participants. All subjects with HbA1c in the range 5.8–6.9% and a random sample of subjects with levels 5.3–5.7% were invited to an OGTT. Results: Among 3476 subjects who completed the OGTT, 199 were diagnosed with DM. The best sensitivity (69.8%) and specificity (81.8%) were found at HbA1c 6.2%. For HbA1c 6.5% we found a sensitivity of 34.7% and specificity 97.1%. The best cut-off points for impaired fasting glucose (no.=314) and impaired glucose tolerance (no.=404) were found at HbA1c 5.9% and 6.0%, respectively. Pre-diabetes detected only by OGTT was associated with worse metabolic characteristics than pre-diabetes detected only by HbA1c. Conclusions: The optimum HbA1c cutoff point for DM in our population was lower than that proposed by WHO and ADA. To establish more precisely the HbA1c levels predictive of micro- and macro-vascular complications, long-term prospective studies are needed. Population-specific optimum cut-off points may be necessary. Preview Unable to display preview. Download preview PDF. Continue reading >>

Implications Of The Revised Criteria For Diagnosis And Classification Of Diabetes Mellitus

Implications Of The Revised Criteria For Diagnosis And Classification Of Diabetes Mellitus

Diabetes mellitus is a heterogeneous disease. It comprises several distinct pathophysiologic disorders of carbohydrate metabolism, each of which ultimately manifests with hyperglycemia. Although the prevalence of the disease is unknown, >13 million people are estimated to have diabetes in the US (1). The severe complications (renal, retinal, and cardiovascular) associated with the disease contribute to the $92 000 000 000 in annual healthcare costs in the US (1992 estimate) (2). Therefore, the recent Report of the Expert Committee on the Diagnosis and Classification of Diabetes Mellitus that recommends new classification and diagnostic criteria for diabetes (3) merits contemplation. Since the advent of blood glucose assays, the exclusive criterion for the diagnosis of diabetes has been hyperglycemia, either fasting or postprandial. For many years diabetes was diagnosed by the oral glucose tolerance test (OGTT), the cutoff having been established as 2SD above the mean of the glucose concentrations in healthy volunteers. In 1975 Siperstein estimated that more than half the population older than 60 years was abnormal by these criteria (4). However, those values had more statistical than clinical significance, as follow-up for 10 years revealed that a substantial proportion of these individuals did not develop diabetes and many returned to normal glucose tolerance. Moreover, there was considerable variability among diabetologists in the diagnostic criteria used in practice (5). To resolve these issues, in 1979 the National Diabetes Data Group (6) proposed criteria that were based on the bimodal distribution of blood glucose concentrations in populations with a high prevalence of diabetes, such as Pima Indians and Nauruans. Optimal separation between nondiabetic and diabetic Continue reading >>

Impaired Fasting Glucose

Impaired Fasting Glucose

Impaired fasting glucose, or Impaired Fasting Glycemia (IFG) is a type of prediabetes, in which a person's blood sugar levels during fasting are consistently above the normal range, but below the diagnostic cut-off for a formal diagnosis of diabetes mellitus.[1] Together with impaired glucose tolerance, it is a sign of insulin resistance. In this manner, it is also one of the conditions associated with Metabolic Syndrome. Those with impaired fasting glucose are at an increased risk of vascular complications of diabetes, though to a lesser extent. The risks are cumulative, with both higher blood glucose levels, and the total amount of time it spends elevated, increasing the overall complication rate. IFG can eventually progress to type 2 diabetes mellitus without intervention, which typically involves lifestyle modification. Those with impaired fasting glucose have a 1.5 fold increased risk of developing clinical diabetes within 10 years, when compared to the general population. Some studies suggest that without lifestyle changes, IFG will progress to clinically diagnosable diabetes in just under 3 years, on average.[2] Impaired fasting glucose is often, though not always, associated with impaired glucose tolerance, though it may occur in isolation, with such persons having a normal response to a glucose tolerance test. Signs and Symptoms[edit] Impaired fasting glucose is often without any signs or symptoms, other than higher than normal glucose levels being detected in an individual's fasting blood sample. There may be signs and symptoms associated with elevated blood glucose, though these are likely to be minor, with significant symptoms suggestive of complete progression to type 2 diabetes. Such symptoms include:[3] Increased thirst Increased urination, especially wak Continue reading >>

Diagnosis Of Diabetes

Diagnosis Of Diabetes

A diabetes diagnosis often follows a person seeking medical advice after experiencing symptoms of diabetes, such as feeling thirsty, frequent urination, fatigue and unexpected weight loss. A doctor may arrange blood and urine tests to check for high glucose levels which indicate diabetes. How are diabetes and pre-diabetes diagnosed? The following tests are used for the diagnosis of diabetes: HbA1c blood test. An HbA1c reading of 48 mmol/mol (6.5%) is the recommended cut off point for diagnosing diabetes. A value below this does not exclude diabetes diagnosed using glucose tests. A fasting plasma glucose test measures your blood glucose after you have gone at least eight hours without eating or drinking anything but plain water. This test is used to detect diabetes or pre-diabetes. An oral glucose tolerance test measures your blood sugar after you have gone at least eight hours without eating and drinking and two hours after you drink a glucose-containing beverage. This test can be used to diagnose diabetes or pre-diabetes. In a random plasma glucose test, your doctor checks your blood glucose without regard to when you ate your last meal. This test, along with an assessment of symptoms, is used to diagnose diabetes but not pre-diabetes. Positive test results should be confirmed by repeating the fasting plasma glucose test or the oral glucose tolerance test on a different day. Fasting plasma glucose (FPG) test The FPG is the preferred test for diagnosing diabetes and is most reliable when done in the morning. Results and their meaning are shown in table 1. If your fasting glucose level is more than 6 but less than 7mmol/l you have impaired fasting glucose (IFG), meaning that you are more likely to develop type 2 diabetes but do not have it yet. A level of 7mmol/l or abov Continue reading >>

About Diabetes

About Diabetes

Intermediate states of hyperglycemia IFG, IGT, and diabetes mellitus are seen as progressive stages of the same disease process, and treatment at earlier stages has been shown to prevent progression to later stages (by diet, exercise and lifestyle management). Not all patients with IGT have IFG, so it is considered a separate category. As well, the implications of the two states are slightly different. Impaired Fasting Hyperglycemia (IFG) is a state of higher than normal fasting blood (or plasma) glucose concentration, but lower than the diagnostic cut-off for diabetes. Impaired Glucose Tolerance (IGT) is a state of higher than normal blood (or plasma) glucose concentration 2 hours after 75 gram oral glucose load but less than the diagnostic cut-off for diabetes. Symptoms Patients usually have no symptoms and are diagnosed because a test is done upon patient request or because he/she falls into a high risk category. Diagnosis IFG: fasting plasma glucose >=6.1 mmol/L (110 mg/dL) and <7 mmol/L (126 mg/dL) per WHO 1999 criteria. (ADA has chosen a lower cutoff of 5.6mmol/L or 100mg/dL). IGT: fasting plasma glucose (if available) <7.0 mmol/L (126 mg/dL) AND 2 hour post 75g glucose drink of >= 7.8 mmol/L (140 mg/dL) and <11.1 mmol/L (200 mg/dL). Treatment lifestyle modifications (diet, physical activity, weight loss) are the mainstay of treatment, although sometimes medications are used. large, population-based studies in China , Finland and USA have recently demonstrated the feasibility of preventing, or delaying, the onset of diabetes in overweight subjects with mild glucose intolerance (IGT). studies suggest that even moderate reduction in weight and only half an hour of walking each day reduces the incidence of diabetes by more than one half. Complications of diabetes Dia Continue reading >>

The Cutoff Value Of Fasting Plasma Glucose To Differentiate Frequencies Of Cardiovascular Risk Factors In A Korean Population

The Cutoff Value Of Fasting Plasma Glucose To Differentiate Frequencies Of Cardiovascular Risk Factors In A Korean Population

Diabetes and impaired glucose tolerance (IGT) are associated with increased cardiovascular mortality. Almost all studies, however, failed to detect evidence of the presence of a fasting plasma glucose (FPG) threshold for risk of cardiovascular disease that would clearly identify groups with a low or high risk (1,2). Some studies suggested that an FPG of 5.4–5.7 mmol/l has been found to be closer to a 2-h cutoff of 7.8 mmol/l both in terms of the sensitivity for future diabetes and in defining a category of similar prevalence to IGT (3,4). The interrelationships between cardiovascular risk factors and glucose levels may vary between different populations. Therefore, these findings need to be tested in other populations with different environmental and genetic backgrounds. The medical records of 54,623 subjects (30,435 men and 24,188 women) who attended the Health Promotion Center in the Samsung Medical Center between 1998 and 2001 were examined for this analysis. Obesity was defined as a BMI ≥27 kg/m2. Hypertension was defined as systolic blood pressure ≥140 mmHg, diastolic blood pressure ≥90 mmHg, and/or the current use of antihypertensive drugs. Dyslipidemia was defined as LDL cholesterol ≥4.1 mmol/l, triglycerides ≥2.46 mmol/l, HDL cholesterol <1.04 mmol/l, and/or current use of antilipid drugs. Cases of previous history of diabetes were excluded. All study subjects were classified into 12 groups according to FPG (10 deciles of normal fasting glucose [NFG]: NFG 1, −4.56, n = 5,370; NFG 2, 4.57–4.72, n = 4,495; NFG 3, 4.73–4.89, n = 6,321; NFG 4, 4.90–5.00, n = 4,655; NFG 5, 5.01–5.11, n = 4,841; NFG 6, 5.12–5.22, n = 4,503; NFG 7. 5.23–5.33, n = 4,233; NFG 8, 5.34–5.50, n = 5,236; NFG 9, 5.51–5.72, n = 4,926; NFG 10, 5.73–6.09, n = 4,23 Continue reading >>

Diagnosing Gestational Diabetes: The Nih Consensus Conference Day 1

Diagnosing Gestational Diabetes: The Nih Consensus Conference Day 1

March 4, 2013 by Rebecca Dekker, PhD, RN, APRN © Copyright Evidence Based Birth®. Please see disclaimer and terms of use. For two days (March 4 and March 5, 2013), I live-blogged the NIH Consensus Development Conference on Diagnosing Gestational Diabetes. The purpose of this conference is to come to a consensus on two things: the best way to diagnose gestational diabetes (GDM), and whether we should change the criteria we use to diagnose GDM in the U.S. This blog post covers day 1 of the conference. To read about the information presented on day 2, click here. Note: The information presented in this blog comes directly from the presentations at the conference, and does not necessarily represent my opinion or the opinion of Evidence Based Birth. The topics that will be covered include: What are the current screening and diagnostic approaches for gestational diabetes mellitus, what are the glycemic thresholds for each approach, and how were these thresholds chosen? What are the effects of various gestational diabetes mellitus screening/diagnostic approaches for patients, providers, and U.S. healthcare systems? In the absence of treatment, how do health outcomes of mothers who meet various criteria for gestational diabetes mellitus and their offspring compare with those who do not? Does treatment modify the health outcomes of mothers who meet various criteria for gestational diabetes mellitus and their offspring? What are the harms of treating gestational diabetes mellitus, and do they vary by diagnostic approach? Given all of the above, what diagnostic approach(es) for gestational diabetes mellitus should be recommended, if any? What are the key research gaps in the diagnostic approach of gestational diabetes mellitus? Evidence Based Birth® is now offering you access t Continue reading >>

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