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History and Physical Examination
Focus the history on acute and chronic symptoms of the disease.
Examine for signs of dehydration, autonomic neuropathy, and vascular complications.
Laboratory Tests
Use laboratory studies to confirm the diagnosis and document metabolic and end-organ complications.
Differential Diagnosis
Differentiate type 1 diabetes from other forms of diabetes.
History and Physical Examination
Confirm the diagnosis in patients with symptoms of hyperglycemia and symptoms suggestive of known complications of the disease.
Confirm the diagnosis in patients with physical findings suggestive of known complications and epiphenomena of the disease.
Confirm the diagnosis of type 2 diabetes in any patient with a random plasma glucose level above the normal range.
Perform a careful history and physical examination in all patients with hyperglycemia to evaluate for the complications of diabetes.
Laboratory Tests
Order laboratory tests to establish baselines and to screen for complications of diabetes.
Differential Diagnosis
Consider the limited differential diagnosis for type 2 diabetes.
History and Physical Examination
Evaluate women with pregestational diabetes for diabetic complications before conception and review issues of diabetic control, and review symptoms of hyperglycemia in all pregnant women.
Laboratory Tests
Use laboratory testing to evaluate diabetic control and to screen for related medical conditions.
Differential Diagnosis
Not applicable to this module.
PIER Interactive is a new discussion forum in which PIER users (ACP members, only) can trade clinical insights and questions with colleagues, discuss important new data in the medical literature and suggest additions and changes to PIER modules. This new feature of PIER is a pilot project and includes the Diabetes Mellitus, Type 2 module.
Note: This feature is only available to ACP members. For more information, visit pier.acponline.org.
From the ACP Diabetes Care Guide
This chapter includes information on the following topics related to screening and diagnosis of diabetes:
Types of Diabetes
- How is diabetes classified? [Type 1 Diabetes Mellitus, Type 2 Diabetes Mellitus, Diabetes of Defined Etiology, Gestational Diabetes]
- How is diabetes diagnosed?
- What are the differences among the tests used for diagnosing diabetes? [Fasting Plasma Glucose, Oral Glucose Tolerance Test, Hemoglobin A1C]
- What is prediabetes?
- What educational issues should I discuss with patients with prediabetes?
- What educational issues should I discuss with patients with a new diagnosis of diabetes?
Screening for Diabetes (Who should be screened for diabetes?)
Gestational Diabetes
- Who should be screened for gestational diabetes?
- How is gestational diabetes managed?
- What educational issues should I discuss with women with gestational diabetes?
You may order free copies of the complete ACP Diabetes Care Guide (book and CD-ROM).
SPECIAL NOTE: Page 30 has been revised.
This session answers the following questions:
- What are the clinical manifestations of PCOS?
- What are the long-term effects on fertility, glucose metabolism, and the heart?
- What treatments can improve symptoms and what treatments can prevent long-term effects?
Diabetes mellitus and metabolic syndrome
Pituitary tumors
Thyroid disease and hyperthyroidism, hypothyroidism, thyroid cancer
Hyperparathyroidism and osteoporosis
Adrenal disease
This session answers the following questions:
- Is it better to start with multiple drug therapy?
- Are there cardiovascular benefits with any diabetic oral agent?
- Are there adverse cardiac outcomes with any diabetic oral agent?
This session includes an update in the field of Endocrinology and, specifically, regarding Diabetes.
Diabetes is a chronic metabolic condition characterized by elevated circulating glucose concentrations. In healthy persons, glucose concentrations are kept within a relatively narrow range by low concentrations of insulin during fasting and spikes of insulin during meals.
Patients with diabetes exhibit varying degrees of hyperglycemia both in fasting and especially in postprandial states. New treatment options and monitoring techniques are now available, making intensive glycemic control an achievable goal in many patients.
The American Diabetes Association and the World Health Organization now share identical diagnostic criteria for diabetes and prediabetic states (Table 1) (1). The two categories of milder abnormalities of glucose metabolism are thereby defined as:
- Impaired fasting glucose, in which the fasting plasma glucose level is between 100 and 125 mg/dL, and
- Impaired glucose tolerance (IGT), in which the glucose level reaches 140 to 199 mg/dL 2 hours after a 75-g oral glucose load.
Note: Subscription to MKSAP 14 is required to view this material. For more information, visit www.acponline.org.
A 55-year-old woman asks to be tested for diabetes mellitus because she had a fasting blood glucose value of 130 mg/dL (7.22 mmol/L) at a recent local health fair. She has no symptoms of polydipsia or polyuria. She has mild osteoarthritis but no other significant illnesses. Her mother and sister both developed type 2 diabetes mellitus in their 50s. She takes only occasional aspirin or acetaminophen for her joint pains.
On physical examination, the blood pressure is 120/75 mm Hg, pulse rate 72/min, and BMI 25.2.
Which of the following should be done next to establish a diagnosis of diabetes mellitus?
It is nearly impossible to be a practicing internist in the United States and have a day of clinical work pass without encountering at least 1 patient with type 2 diabetes. Currently, over 20 million Americans and over 150 million worldwide have type 2 diabetes. Models estimate that this number will nearly double by the year 2050 so that about one third of adult Americans will have the disease.
This In the Clinic feature includes answers to these and other practical, clinical questions:
- What are the diagnostic criteria for type 2 diabetes in nonpregnant adults?
- Should we screen for type 2 diabetes?
- Can we prevent type 2 diabetes?
- What should the initial evaluation of patients with newly diagnosed type 2 diabetes include?
- What measures do U.S. stakeholders use to evaluate the quality of care for patients with type 2 diabetes?
NOTE: Only ACP members and individual subscribers can access the electronic features of In the Clinic. Non-subscribers who wish to access this issue of In the Clinic can elect "Pay for View."
Taking a statin slightly increases patients' risk of developing diabetes, according to a new meta-analysis.
The analysis included 13 randomized, controlled trials of statins with more than 90,000 participants, of whom more than 4,000 developed diabetes during a mean follow-up of four years. Patients on statins had a 9% increased risk for incident diabetes (odds ratio, 1.09, 95% CI, 1.02 to 1.17) compared to those taking placebo. The diabetes risk was highest in trials with older patients, and controlling for body mass index and change in low-density lipoprotein cholesterol did not eliminate the association between statins and diabetes. The study was published online by The Lancet on Feb. 17.
Study authors were not able to determine the mechanism of the increased risk or exclude a potential confounding factor, such as patients who were not taking statins and suffered cardiovascular events converting to a healthy lifestyle and thereby lowering their diabetes risk. The finding of increased risk merits further study, but should not change practice for patients with moderate or high cardiovascular risk, the study authors concluded.
Treating 255 patients with statins for four years would result in one additional case of diabetes, but based on other trial data, it would also prevent 5.4 major coronary events, the researchers calculated. The potential diabetes risk should be taken into account when considering statin therapy in low-risk patients, the authors said. Clinicians may also want to respond to the results by monitoring the glucose levels of older patients on statins, an accompanying comment suggested.
The A1C test is now a recommended method of diagnosing diabetes, according to new clinical practice recommendations from the American Diabetes Association.
Under the new recommendations, an A1C of 5.7% to 6.4% should be considered prediabetes and an A1C of 6.5% or higher merits a diagnosis of diabetes. Previously, the ADA had recommended fasting plasma glucose and the oral glucose tolerance test as the preferred diagnostic methods. Those methods are still recommended, but ADA experts hope that the addition of the A1C, which does not require fasting, will increase the use of testing, according to a press release. The recommendations were published in a supplement to the January issue of Diabetes Care.
The ADA also recommended that aspirin therapy should be considered as a primary prevention strategy in patients with diabetes who have a 10-year cardiovascular risk greater than 10%. That group will include most men over 50 and women over 60 who have at least one additional major risk factor. Previously, the ADA had suggested low-dose aspirin for patients who were over 40 or had risk factors. However, the new recommendations found insufficient evidence for primary prevention in lower-risk patients. For younger patients with multiple risk factors, clinical judgment about the use of aspirin is required, the recommendations said.
The document includes many additional recommendations for optimizing diabetes care, both in the general population and specific groups such as children and the elderly, and in inpatient and outpatient settings.
An international committee of experts has called for the A1c assay to become the recommended method for diagnosing diabetes.
The committee included members of the American Diabetes Association, the European Association for the Study of Diabetes and the International Diabetes Federation. Their report, which was published online last week and appears in the July Diabetes Care, reviews the advantages of A1c testing over fasting glucose testing or two-hour glucose-tolerance testing. With current technology, A1c tests are as accurate and precise as the other measures, and provide a better index of overall glycemic exposure and risk for long-term complications, the experts said.
The report recommended that patients with an A1c of 6.5% or higher be diagnosed with diabetes, although the experts warned that the cutoff point is not absolute. Patients with A1c between 6.0% and 6.5% should be considered at highest risk of developing diabetes and receive demonstrably effective interventions, the committee said. They selected the cutoffs based on research showing the relationship between higher A1cs and retinopathy.
The use of retinopathy as the sole outcome is one potential problem with the recommendations, said the authors of an accompanying editorial. Additionally, the 6.5% threshold may be difficult to square with the 7% treatment target in current guidelines. Under the proposed system, there would also be controversy over the point at which to initiate metformin treatment, the editorial authors said.
The editorialists did conclude that the adoption of the A1c as a diagnostic criterion is reasonable. According to the international committee, the report is intended to serve as a stimulus to the international community and professional organizations to consider the use of A1c for diabetes diagnosis. It represents the views of its expert authors, but not necessarily the organizations that appointed them to the committee.
Although diabetes rates have climbed over the past three decades, vastly fewer cases are going undetected among American men, a new report says. The trend particularly affects black and Hispanic men, who are significantly more likely to know about their diabetes now than they were in the 1970s.
The study, published last week, tracked diabetes in U.S. men from 1976-1980, 1988-1994 and 1999-2002. In the first study period, 48% of men with diabetes were undiagnosed. By 1999-2002, the rate had fallen to 22%. The percentage of Hispanic men who did not know about their diabetes dropped even more dramatically, from 65% in the 1970s to 21% in 1999-2002. The rate of undiagnosed diabetes among black men has also dropped to the level of the general population, the study found. The research was conducted by the RAND Corporation and was published in the Aug. 14 Proceedings of the National Academy of Sciences.
One troubling finding of the study, the author noted, was the continuing presence of educational disparities in diabetes rates. In 1999-2002, 6% of men who graduated from high school had diabetes, compared with 10% of non-graduates. Less educated patients also had more difficulty managing the disease. Overall, the study found that diabetes prevalence among U.S. men rose from 6% to 9%, less of an increase than is often claimed, the study author said in a RAND press release.
The author concluded that health providers and officials have done well to eliminate disproportionate rates of undiagnosed diabetes among racial minorities, but that targeted efforts need to be made to reduce other equally important sources of health disparity.
Women with high blood pressure have a significantly higher risk of developing type 2 diabetes compared with those with optimal blood pressure, a new study found.
The Oct. 9 European Heart Journal prospective cohort study examined 38,172 U.S. female health professionals who were free of diabetes at baseline. Subjects were divided into four categories of self-reported blood pressure: less than 120/75 mm Hg, or optimal; 120-129/75-84 mm Hg, or normal; 130-139/85-89 mm Hg, or high-normal; and established hypertension. The latter meant the subject had a self-reported history of hypertension or of taking antihypertensive treatment, or a blood pressure of at least 140/90 mm Hg.
At 10.2 years of follow-up, 1,672 women had developed diabetes. Of all the women in the highest blood pressure group, 9.4% developed diabetes, compared with 5.7% in the high-normal group, 2.9% in the normal group and 1.4% in the optimal group. The study adjusted for age, body mass index, exercise level, family history, alcohol use and smoking.
Women whose blood pressure rose during the course of the study also had a greater risk of developing diabetes. If a woman's blood pressure rose but stayed in the "normal" range, her risk increased 26% compared with a woman whose blood pressure was stable or decreased. A woman whose blood pressure rose to become hypertensive had a 64% higher risk of developing diabetes.
While self-report of blood pressure is a possible limitation of the study, the validity of the approach was examined in the Nurses' Health Study, where 99% of self-reports were confirmed accurate, the authors said. The study thus provides strong evidence that baseline blood pressure and blood pressure progression are associated with a higher risk of type 2 diabetes, and clinicians should bear this in mind for patient management, they said.
New booklets released by the National Institutes of Health explain the special considerations needed in testing hemoglobin A1c in diabetics with sickle cell trait or other inherited forms of variant hemoglobin.
Six of the 20 different methods used in many U.S. labs to measure A1c in people with diabetes yield unreliable results for patients with sickle cell trait, the NIH said. The specific needs for testing blood glucose control in patients with variant hemoglobin are explained in two NIH booklets available online: "Sickle Cell Trait and Other Hemoglobinopathies and Diabetes: Important Information for Physicians" and "For People of African, Mediterranean, or Southeast Asian Heritage: Important Information about Diabetes Blood Tests."
Many people aren't aware they have a hemoglobin variant because the condition is often asymptomatic, the NIH said. A variant may be present if an A1c result:
- doesn't correlate with results of self blood glucose monitoring;
- is different than expected or radically differs from a previous test result after a change in lab A1c methods; or
- is more than 15%.
Diagnosed diabetes in the U.S. rose by about 90% in the past decade, according to a CDC analysis. The CDC analyzed data from Behavioral Risk Factor Surveillance System (BRFSS) surveys from 1995-97 and 2005-07 by a phone survey that covered adults by state or territory. They published their results in the Oct. 31 Morbidity and Mortality Weekly Report.
Age-adjusted incidence of diabetes increased nearly 90% from 4.8 per 1,000 in 1995-97 to 9.1 (range among states, 5.0 to 12.8) in 2005-07. Age-adjusted incidence rates were significantly higher for 2005-07 than for the earlier period in 27 of the 33 states (P <0.05).
By U.S. Census region, the average age-adjusted incidence was greatest in the South (10.5 per 1,000; CI = 9.9-11.1). This was followed by the Northeast (8.6, CI = 7.8-9.4), West (8.5, CI = 7.7-9.3), and Midwest (7.4, CI= 6.6-8.2).
States with the greatest number of annual new cases in California (208,000), Texas (156,000) and Florida (139,000).
This resource from the American Diabetes Association (ADA) includes new recommendations on the use of HbA1c for diagnosis, revised recommendations on aspirin use for primary prevention, and the role of tight glycemic control in the inpatient setting.
The 2007 ADA Clinical Practice Recommendations provide an in depth review of diabetes care and their current recommendations for practice.
The hemoglobin A1C (A1C) test can lead to false outcomes resulting in over-treatment or under-treatment of diabetes in people with inherited hemoglobin variants, also called hemoglobinopathies. Hemoglobin S and E are prevalent variants in people of African, Mediterranean, or Southeast Asian descent. These variants interfere with some A1C tests--both laboratory and point-of-care tests. If A1C tests are at odds with blood glucose monitoring results, interference should be considered. Reliable A1C tests, in which hemoglobin variants do not cause interference, are available. More information is available at www.ngsp.org, the National Glycohemoglobin Standardization Program. A1C should be measured at least twice annually to assess control of diabetes but should not be used to diagnose diabetes.
A new information campaign of the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK), part of the National Institutes of Health, highlights the importance of using accurate methods to test hemoglobin A1c in people with diabetes who have sickle cell trait or other inherited forms of variant hemoglobin. The specific needs for testing blood glucose control in these patients are explained in two booklets, "Sickle Cell Trait and Other Hemoglobinopathies and Diabetes: Important Information for Physicians" and "For People of African, Mediterranean, or Southeast Asian Heritage: Important Information about Diabetes Blood Tests" from NIDDK's National Diabetes Information Clearinghouse at: www.diabetes.niddk.nih.gov.
The ADA has issued their 2008 Comprehensive Guidelines for Diabetes Care
Developed by the National Collaborating Centre for Chronic Conditions at the Royal College of Physicians
Type 2 diabetes can cause severe complications, affecting the eye, the nervous system and the kidney. The overall risk of cardiovascular disease is more than doubled, and the life expectancy is reduced by an average seven years. In 2002, the National Institute for Health and Clinical Excellence (NICE) published a suite of five guidelines dealing with different aspects of the care of type 2 diabetes.
The rising prevalence of the disease, and the range of complications which can arise, reinforce the importance of up-to-date guidance and accordingly NICE have asked the NCC-CC to produce this guideline, amalgamating and updating the previously published work.
Topics of particular relevance to life expectancy, such as control of cholesterol and lipid levels, and management of hypertension, are covered in the guideline. It deals with major complications such as renal disease.
There are also key recommendations in areas of great importance to patients such as structured education and the monitoring of glucose levels. Naturally, there are also sections dealing with control of blood glucose levels and the use of the various drugs available for this purchase.
The guideline is an invaluable resource for general physicians, diabetologists, dieticians, general practitioners, nurses and healthcare professionals who are involved in the management and care of people with type 2 diabetes.
The challenge now is to implement its recommendations and to make a genuine difference to the well-being and health of those with type 2 diabetes.
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