Diagnosis of diabetes mellitus

1. Prof Dr .Dilek Gogas Yavuz, MD
Marmara University
Department of Internal Medicine
Section of Endocrinology and Metabolism
CLASSIFICATION
AND DIAGNOSIS OF
DIABETES MELLITUS

3. Diabetes Mellitus Diabetes Mellitus
Increasing Prevalence of Diagnosed CasesIncreasing Prevalence of Diagnosed Cases
Persons With Diagnosed Persons With Diagnosed
Diabetes (millions) Diabetes (millions)
Diabetes OverviewDiabetes Overview. October 1995 (updated 1996). NIDDK publication NIH 96. October 1995 (updated 1996). NIDDK publication NIH 96--1468.1468.
Kenny SJ et al. In: Kenny SJ et al. In: Diabetes in AmericaDiabetes in America. 2nd ed. 1995:47. 2nd ed. 1995:47--67.67.
YearYear
88
77
66
55
44
33
22
00
11
19581958 19631963 19681968 19791979 19841984 19891989 19941994
8,000,0008,000,000
5X increase5X increase

4. 1.0
7.9
22.4
13.1
13.4
1997 = 124 million
World
66.1
1.3
14.1
32.9
22.5
17.5
2010 = 221 million
132.3
Global Estimates and Projections of Diabetes (in
millions) 1997-2010
Increase (78%)
(31%)
(72%)
(47%)
(78%)
(100%)
(30%)

5. TürkiyedeDiyabet
1.991 1.991 milyonmilyonkikişşii(1998)(1998)
NNüüfusfus: 64.4 : 64.4 milyonmilyonkikişşii
2.217 milyonkişi(2000)
4.551 4.551 milyonmilyonkikişşii(2025)(2025)
WHO Diabetes Report 2000 Prevelance 6% in Turkey
DIABETES IN TÜRKİYE
Estimated diabetes prevalance according to WHO

6. Type 2 diabetes prevalance in
TURKEY 1997-20107,4
13,7
3
5
7
9
11
13
15
1998 2010
Prevalanc eof diaberes (%)
TURDEP I and II

7. 1-diabetes type 2%7.2
2-impaired glucose tolerance %6.7
TURDEP-1-1997
1 TURDEP-2-2010
1-diabetes type 2%13,7
2-impaired glucose tolerance %13,9
1. Turdep I Population-Based Study of Diabetes andRisk Characteristics in Turkey.Satman et al. DiabCare,2002.25:1551–1556.
2. TURDEP II. Satman et al.2010.
prevalence

8. Definition of Diabetes
“A group of metabolic diseases characterized
by hyperglycemia resulting from defects in
insulin secretion, insulin action, or both.”
“Hyperglycemia of diabetes is associated
with long-term damage, dysfunction, and
failure of various organs, especially the eyes,
kidneys, nerves, heart, and blood vessels.”
ADA Diabetes Care (Suppl1) 2007

9. Etiologic classification of diabetes mellitus
1.Type 1 diabetes
(B-cell destruction usually leading to absolute insulin deficiency)
a.Immune mediated
b.Idiopathic
2.Type 2 diabetes
(combination of resistance to insulin action and an inadequate compensatory
insulin secretory response)
3.Other spesific types
(diabetes secondary to recognized genetic defects, diseases of the exocrine
pancreas, other endocrinopathies, or to drugs)
4. Gestational diabetes Mellitus

10. 3.Other spesific types
A. Genetic defects of B-cell function
MODY3,MODY2,MODY1
Mitekondrial DNA defects
B.Genetic defects in insulin action
type A insulin resistance
leprechaunism
Rabson-Mendenhall syndrome
lipoatrophic diabetes
C.Diseases of the exocrine pancreas
pancreatitis
trauma/ pancreatectomy
Neoplasia,
Cystic fibrosis
hemochromatosis
fibrocalculous pancreatopathy
D. Endocrinopathies
Acromegaly
Cushings Syndrome
Glucagonoma,pheochromocytoma
Hyperthyroidism,somatostatinoma
aldosteronoma
E. Drug or chemical induced
Vacor, pentamidine
nicotinic acid,glucocorticoids
thyroid hormons,diazoxide
B-adrenergic agonists
thiazides,dilantin,a-interferon
F. Infections
congenital rubella
cytomegalovirus
G.Uncommon forms of immune-mediated DM
stiff man syndrome
anti-insulin receptor antibodies
H. Genetic syndromes sametimes associated
with diabetes
Down’s syndrome
Klenifelter Syndrome
Turner’s syndrome
Wolframs Syndrome
friedrich’s ataxia
myotonic dystrophy
porphyria

11. Incidence of Diabetes Mellitus
7%Type 1 (formerly Insulin dependent diabetes mellitus)
90%Type 2 (formerly Non-insulin dependent diabetes mellitus)
Gestational Diabetes
5% of all pregnancies

12. Fasting plasma glucose > 126 mg/dl (7mmol/L)
Symptoms of diabetes + plasma glucose >200 mg/dl
Symptoms:polyuria,polydipsia,unexplained weight loss
2 hour plasma glucose >200 mg/dl during OGTT
A1C ≥6.5%
American diabetes association 20112
Diabetes care 2012 suppl 1
Criteria for the diagnosis of
diabetes mellitus
OGTT: oral glukoz tolerance test

13. Categories of Fasting plasma glucose (FPG)
< 110 mg/dl = normal fasting glucose
>110 mg/dl-<126 mg/dl =impaired fasting
glucose
>126 mg/dl =provisional diagnosis of diabetes
the diagnosis must be confirmed
Fasting is defined as no caloric intake for at least eight hours

14. Oral glucose tolerance test (OGTT)
2-h postload glucose <140 mg/dl= normal
glucose tolerance
2-h PG > 140 mg/dl and < 200 mg/dl= impaired
glucose tolerance
2-h PG > 200 mg/dl = DIABETES

15. HOW TO PERFORM
ORAL GLUCOSE TOLERANCE TEST ?
dissolve 75 gr glucose in a glass of drinking water
(200-300 ml water)
Ask patient to drink in 5 min (zero point)
Check plasma glucose level at the
second hour of glucose load

16. Blood glucose response after an oral glucose load
in Non diabetic and Diabetic subject
Hour
Serum glucose (mg/dl)

17. Blood glucose and insulin response
after an oral glucose load(75 g glucose)in type 2 diabetes
Hour

18. As with most diagnostic tests, a test result
diagnostic of diabetes should be repeated to rule out
laboratory error
•unless the diagnosis is clear on clinical grounds, such
as a patient with a hyperglycemic crisis or classic
symptoms of hyperglycemia and a random plasma glucose
≥200 mg/dL
•It is preferable that the same test be repeated for
confirmation, since there will be a greater likelihood of
concurrence in this case.
•However, if two different tests (such as A1C and FPG)
are both above the diagnostic thresholds, the
diagnosis of diabetes is also confirmed

19. Prediabetes associated with the metabolic syndrome, which includes
obesity (especially abdominal or visceral obesity), dyslipidemia of the
high-triglyceride and/or low-HDL type, and hypertension
pre-diabetes
FPG 100 -125 mg/dl =impairedfasting glucose
2-h PG in the OGTT 140 -199 mg/dl =
impaired glucose tolerance
A1C 5.7–6.4%
Categories of increased risk for diabetes

20. NATURAL HISTORY OF IGT
After 10 years
Normal
Diabetes
IGT
IGT

21. Glucose Tolerance Categories
Adapted from The Expert Committee on the Diagnosis and Classification of Diabetes Mellitus. Diabetes Care.2013 suppl1.
FPG
126 mg/dL
110 mg/dL
7.0 mmol/L
6.1 mmol/L
Impaired Fasting
Glucose
Normal
2-Hour PG on OGTT
200 mg/dL
140 mg/dL
11.1 mmol/L
7.8 mmol/L
Diabetes Mellitus
Impaired Glucose
Tolerance
Normal
Diabetes Mellitus

22. Testing to detect type 2 diabetes and assess risk for future
diabetes in asymptomatic people should be considered in
adults of any age who are overweight or obese (BMI ≥25 kg/m
2
)
and who have one or more additional risk factors for diabetes
TESTING FOR DIABETES IN
ASYMPTOMATIC PATIENTS

23. Criteria for testing for diabetes
in asymptomatic adult individuals
Testing should be considered in all adults who are overweight (BMI ≥25
kg/m
2*
) and who have one or more additional risk factors:
•physical inactivity
•first-degree relative with diabetes
•high-risk race/ethnicity (e.g., African American, Latino, Native American, Asian
•women who delivered a baby weighing >4 kgor who were diagnosed with GDM
•hypertension (blood pressure ≥140/90 mmHg or on therapy for hypertension)
•HDL cholesterol level <35 mg/dL(0.90 mmol/L) and/or a triglyceride level >250 mg/dL(2.82 mmol/L)
•women with PCOS
•A1C ≥5.7%, IGT, or IFG on previous testing
•other clinical conditions associated with insulin resistance (e.g., severe obesity, acanthosisnigricans)
•history of CVD

24. Risk Factors for Type 2 Diabetes
Age > 40
Family history of diabetes
Ethnicity
Obesity; abdominal fat distribution
GDM, orgive birthinfant > 4 kg
Hypertension, hyperlipidemia
Previous Impaired Glucose Tolerance

25. In those without these risk factors, testing should begin at age 45
years.
If tests are normal, repeat testing at least at 3-year intervals is
reasonable.
To test for diabetes or to assess risk of future diabetes, the A1C,
FPG, or 2-h 75-g OGTT are appropriate.
TESTING FOR DIABETES IN
ASYMPTOMATIC PATIENTS

26. GESTATIONAL DIABETES MELLITUS

27. GESTATIONAL DIABETES MELLITUS (GDM)
•GDM is defined as any degree of glucose intolerance
with onset or first recognition during pregnancy
•GDM complicate 4-5 % of all pregnancies
•Six months or more after pregnancy ends, the women
should be reclassified

28. Low risk MediumriskVery highrisk
BMI< 25 kg/m
2
BMI25-29.9 kg/m
2
BMI> 30kg/m
2
BMI: body mass index
Screen for undiagnosed type 2 diabetes at the first prenatal visit in those
with risk factors, using standard diagnostic criteria

29. DETECTION AND DIAGNOSIS OF GESTATIONAL
DIABETES MELLITUS (GDM)
Screen for undiagnosed type 2 diabetes at the first prenatal visit in
those with risk factors, using standard diagnostic criteria.
In pregnant women not previously known to have diabetes, screen
for GDM at 24–28 weeks’ gestation, using a 75-g 2-h OGTT and the
diagnostic cut points
Screen women with GDM for persistent diabetes at 6–12 weeks’
postpartum, using a test other than A1C.
Women with a history of GDM should have lifelong screening for
the development of diabetes or prediabetes at least every 3 years.

30. Perform a 75-g OGTT, with plasma glucose measurement
fasting and at 1 and 2 h, at 24–28 weeks’ gestation in
women not previously diagnosed with overt diabetes.
The diagnosis of GDM is made when any of the following
plasma glucose values are exceeded:
plasma glucose
• Fasting ≥92 mg/dL
• 1 h ≥180 mg/dL
• 2h ≥153 mg/dL
Screening for and diagnosis of GDM
The OGTT should be performed in the morning after an overnight fast of at least 8 h.

31. BecausesomecasesofGDMmayrepresentpreexisting
undiagnosedtype2diabetes,womenwithahistoryofGDMshould
bescreenedfordiabetes6–12weeks’postpartum,using
nonpregnantOGTTcriteria.
Becauseoftheirprepartumtreatmentforhyperglycemia,useof
theA1Cfordiagnosisofpersistentdiabetesatthepostpartumvisit
isnotrecommended
WomenwithahistoryofGDMhaveagreatlyincreased
subsequentriskfordiabetesandshouldbefollowedupwith
subsequentscreeningforthedevelopmentofdiabetesor
prediabetes
Postpartum period

32. Thank you