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ESSENTIALS OF DIAGNOSIS

ESSENTIALS OF DIAGNOSIS

  • Random plasma glucose ≥200 mg/dL with polydipsia, polyuria, polyphagia, and/or weight loss.

  • Fasting plasma glucose ≥126 mg/dL.

  • Two-hour oral glucose tolerance test (75-g glucose) ≥200 mg/dL.

  • Hemoglobin A1c ≥6.5%.

  • A confirmatory, repeat test or alternate test is required.

GENERAL CONSIDERATIONS

The age-adjusted prevalence of diabetes has doubled in the United States since the late 1990s. The adoption of a Western diet and the resulting worldwide explosion of obesity have led to an epidemic of diabetes with >422 million people worldwide afflicted. It is a major cause of blindness, renal failure, lower extremity amputations, cardiovascular disease (CVD), and congenital malformations. Rates are disproportionately high in African Americans, Native Americans, Pacific Islanders, Hispanics, and Asians. Only 14% of patients meet targets for glucose, blood pressure, and cholesterol while also not smoking. With one in eight persons developing diabetes and 90% of patients receiving their care from primary care physicians, diabetes management requires a chronic care model with an informed patient and an interactive team. The team should include lay health or community health workers if available.

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American Diabetes Association’s Standards of Medical Care in Diabetes—2018. Diabetes Care. 2018;41(Suppl 1):S1–S159. [No PMID]  [PubMed: 29222369]
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Centers for Disease Control and Prevention. Diabetes fact sheet. https://www.cdc.gov/diabetes/library/factsheets.html. Accessed November 18, 2019.
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National Institute of Diabetes and Digestive and Kidney Diseases. http://www2.niddk.nih.gov/. Accessed November 18, 2019.
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World Health Organization. Diabetes fact sheet. https://www.who.int/news-room/fact-sheets/detail/diabetes. Accessed November 18, 2019.

PATHOGENESIS

Type 1 diabetes is the result of an autoimmune destruction of the pancreatic β cells with an inability of the body to produce insulin. Type 2 diabetes develops from an increasing cellular resistance to insulin, a process that is accelerated by obesity and inactivity, and is becoming increasingly common in adolescents and children. This insulin resistance increases atherosclerotic CVD, polycystic ovarian syndrome, and nonalcoholic steatohepatitis. A small percentage of patients will develop a more insidious onset of autoimmune diabetes, latent autoimmune diabetes of adulthood (LADA), that may respond for a short period of time to oral medications but progresses to insulin dependence. Some older patients may develop diabetes with mild metabolic changes. Maturity-onset diabetes of the young refers to a group of hereditary diabetes disorders that often do not require insulin. A recently added type 3c results from pancreatitis and resulting destruction of the pancreatic β cells.

PREVENTION

Patients with metabolic syndrome or a hemoglobin A1c (HbA1c) of 5.7–6.4% (prediabetes) should be targeted for intensive lifestyle intervention. The following interventions have been shown to be more effective than medications and improve blood pressure and lipids, leading to greater reductions in cardiovascular risk:

  1. Conversion to a Mediterranean style diet

  2. Reduction in screen time to <2 hours per day

  3. At least 150 minutes of moderate-intensity exercise ...

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