Diagnosis and screening for

diabetes mellitus--- part 1

Dr Bahlul Amer Ben Masaud

Consultant at diabetic center
Tripoli-Libya
9-11-2020 post graduate diploma
Definition
Diabetes mellitus is recognized as being a
syndrome characterized by hyperglycemia as the
hallmark .
 Hyperglycemia is due to one of the following

1-absolute insulin deficiency by beta cell

destruction as in T1 DM, or
2-relative insulin deficiency and or impaired
effectiveness of insulin action due to insulin
resistance as in T2 DM .
 Hyperglycemia
consequences
 is associated with premature mortality.

 seriously damages many of the body’s

systems, especially the blood vessels and
nerves.
Why we care about diabetes?

 1-acute complications.

 2-Chronic complications(micro and macro vascular).

 3-Major cause of disability and work absenteeism.

 4-A huge economic impact (complications, meds, labs,.)

 5-it confers an equivalent risk to ageing 15 years.

1-The short term complications of diabetes

 Sever hyperglycemia with ketoacidosis in T1 DM.

 Sever hyperglycemia with non ketotic hyperglycemic
hyperosmolar state or coma in T2 DM.
 hypoglycemia (abnormally low blood glucose resulting
from treatment) may cause coma and, if untreated,
may be fatal.
 Theterm
Long major chronic diabetic
complications complications
of diabetes -2
Stroke Visual impairment:
(cerebrovascular disease) diabetic retinopathy, cataract and
glaucoma

Heart disease
(cardiovascular disease)
Kidney disease
Bacterial and fungal infections (diabetic nephropathy)
of the skin Severe hardening of
the arteries (atherosclerosis) Autonomic neuropathy
Sexual dysfunction (including slow emptying
of the stomach and diarrhea)
Poor blood supply to lower limbs
(peripheral vascular disease)

Necrobiosis lipidoica Sensory impairment

(peripheral neuropathy)
Gangrene Ulceration

,Type 2 diabetes
the metabolic syndrome and cardiovascular disease
in Europe
 A growing threat
Burden of diabetes of diabetes
The complications

• Diabetes is the leading cause of blindness and

visual impairment in adults in developed
countries.
• Diabetes is the most common cause of
amputation which is not the result of an
accident.(every 30 sec there is amputation of a
limp because of diabetes in the world)
• People with diabetes are 15 to 40 times more
likely to require a lower-limb amputation
compared to the general population.
• Diabetes is the most common cause of ESRD ,
which may be fatal if left untreated.

TIM
T ET
IME OA
TO CT
AC T ,Type 2 diabetes
the metabolic syndrome and cardiovascular disease in Europe
Number of people with diabetes worldwide and per
region in 2017 and 2045 (20-79 years)
Diabetes in the MENA Region: An
Overview 2015

16%
Main Risk Factors for Type 2 Diabetes
Roots of the problem

Physical Jobs Before … and Now ???

Roots of the Problem

1940’s 1990’s
 Diabetes : Roots of the Problem
Physical exercise …having fun Relaxing in front of large
under the sun. screen TV …
 Diagnosis of DIABETES

1-Clinical
 history (symptoms , other comorbidities).
 physical examination ( acute or chronic
complications ,secondary cause).
2-laboratory investigations (FPG,RPG,HBA1C,
UREA,CREATININE,LIPIDS,URINE EXA
1-Clinical Presentation
Type 1 DM
 Symptoms such as
polyuria, polydipsia, polyphagia,
weight loss, and lethargy accompanied by
hyperglycemia are the most common.
Type 2 DM
 Asymptomatic with a slow onset over 5-
10 years.
 High frequency of complications.
Triplitt
13 CL, Repas T, Alvarez C. Diabetes Mellitus. In: DiPiro JT, Talbert RL,Yee GC, Matzke GR, Wells BG, Posey
L. eds. Pharmacotherapy: A Pathophysiologic Approach, 10e. New York, NY: McGraw-Hill; 2017.
 Clinical Presentation(comparison T1&T2)
Characteristic Type1DM Type2 DM
Age The traditional paradigms of T2DM occurring only in
adults
andT1DM only in children are no longer accurate ,
as both
Diseases occur in both cohorts
Onset Abrupt Gradual
Most patients are over
weight or
Obese. Or May have an
Body habitus Lean increased % of Body fat
distributed
Predominantly in The
abdominal region
Insulin Absent Present
resistance
Autoantibodies Present Autoimmune destruction
OfMatzke
Triplitt CL,14Repas T, Alvarez C. Diabetes Mellitus. In: DiPiro JT, Talbert RL,Yee GC, b-cells does
GR, Wells BG,not
Poseyoccur
.L. eds. Pharmacotherapy: A Pathophysiologic Approach, 10e. New York, NY: McGraw-Hill; 2017
 Cont,
Characteristic Type1DM Type2DM
Ketoacidosis seldom
occurs spontaneously.
Present Seen with
Ketones at diagnosis Stress of another
(Mainlychildren)
illness such as
infection.
Need for insulin Immediate Years after diagnosis
therapy
Microvascular No Common
Complications at
diagnosis

Macrovascular
Complications at or Rare Common
before diagnosis
Triplitt CL, Repas T, Alvarez C. Diabetes Mellitus. In: DiPiro JT, Talbert RL,Yee GC, Matzke GR, Wells BG, Posey
15
L. eds. Pharmacotherapy: A Pathophysiologic Approach, 10e. New York, NY: McGraw-Hill; 2017.
General considerations
 Type 1 diabetes and type 2 diabetes are heterogeneous diseases in

which clinical presentation and disease progression may vary

considerably.

 Classification is important for determining therapy, but some

individuals cannot be clearly classified as having type 1 or type 2

diabetes at the time of diagnosis.

 The traditional paradigms of type 2 diabetes occurring only in adults

and type 1 diabetes only in children are no longer accurate, as both

diseases occur in both age-groups.

 Etiological classification of diabetes
A-Type 1 diabetes mellitus
(beta cell destruction usually leading to absolute insulin deficiency)

1-aoutiimmune mediated 2-idiopathic

B- Type 2 diabetes mellitus

(may range from predominantly insulin resistance with relative insulin deficiency

to a predominantly secretory defect with or without insulin resistance )

C- Gestational diabetes mellitus (GDM)

(diabetes diagnosed in the second or third trimester of pregnancy that was not

clearly overt diabetes prior to gestation).

 D-other specific types (secondary to recognized causes)

1-genetic defect of B-cell function (monogenic diabetes syndromes )such as

1-neonatal diabetes (infants < 6 months ) have special gene
2- maturity-onset diabetes of the young (MODY 1 to 7).
2-genetic defect in insulin action
-type A insulin resistance -leprechaunism
-Rabson-Mendenhall syndrome -Lipoatrophic diabetes
3-disease of the exocrine pancreas
pancreatitis , pancreatectomy, neoplastic disease ,
cystic fibrosis hemochromatosis , fibrocalculous pancreatopathy
4-Endocrinopathies
Acromegaly Cushing syndrome Glucagonoma
Pheochromocytoma Hyperthyroidism Somatostatinoma
Aldosteronoma
5-Drug or Chemical induced
Vacor Pentamidine Nicotinic acid diazoxide Glucocorticoids

Thyroid hormones Dilantin thiazides

B adrenergic agonists ᾀ interferon.
6-infectious
congenital rubella Cytomegalovirus
7-uncommon forms of immune-mediated DM
Stiff man syndrome Anti-insulin receptor Ab
8-genetic syndromes can be associated with DM
Down syndrome Klenifelters syndrome Turners syndrome
Wolframs syndrome Friedrichs ataxia myotonic dystrophy
porphyria
2- LABORATORY DIAGNOSIS
Stages of glycaemia(blood glucose level)
 -Normoglycemia ( euglycemia )/normal glucose
tolerance/normal HbA1C

 -Impaired fasting plasma glucose/impaired

glucose Tolerance /impaired A1c= prediabetes state

 -Diabetes mellitus:
A-not insulin requiring
B-insulin: required for control
C-insulin: required for survival
What are the diagnostic tests usually used
for screening &diagnosis of DM?

 -Fasting plasma glucose=FPG.

 -Random plasma glucose=RPG.
 -2 hours plasma glucose after a 75 gram oral
glucose =OGTT.
(3 hours after 100 gram in gestational diabetes)

 -Glycated hemoglobin A1c=HbA1c.

Why we need plasma glucose and HbA1c
estimation?

 For diagnostic purposes.

 For detection of the duration.

 For treatment decision.

Screening for prediabetes &
diabetes
 A-Screening for Type 1 DM
 Screening for : Type 1 Diabetes

• Blood glucose rather than A1C should be used to

dx type 1 diabetes in symptomatic individuals.

• Screening for type 1 diabetes with an antibody

panel is recommended only in the setting of a
clinical research study or in a first-degree family
members of a proband with type 1 diabetes.

www.DiabetesTrialNet.org
American Diabetes Association Standards of Medical Care in Diabetes.
Classification and diagnosis of diabetes. Diabetes Care 2017; 40 (Suppl. 1): S11-S24
Screening for prediabetes &
diabetes
 B-Screening
for Type 2 DM in
Adults & non pregnant women
 Who is to be screened & how to be screened

 1-Testing should begin at age 45 for all asymptomatic people.

 2-Consider testing for prediabetes in asymptomatic adults of

any age w/ BMI ≥25 kg/m2 or ≥23 kg/m2 (in Asian Americans)
who have 1 or more add’l risk factors for diabetes.

 If tests are normal, repeat at a minimum of 3-year intervals.

 Patients with pre-diabetes (A1C ≥ 5.7% IGT, or IFG) should be
tested yearly
 >>> more frequent testing depending on initial results and
risk status.
American Diabetes Association Standards of Medical Care in Diabetes.
Classification and diagnosis of diabetes. Diabetes Care 2017; 40 (Suppl. 1): S11-S24
 Risk factors for Prediabetes and T2D

www.diabetes.org/are-you-at-risk
American Diabetes Association Standards of Medical Care in Diabetes.
Classification and diagnosis of diabetes. Diabetes Care 2017; 40 (Suppl. 1): S11-S24
 How we screen?
• Screening for prediabetes with an informal
assessment of risk factors or validated tools
should be considered in asymptomatic adults

American Diabetes Association Standards of Medical Care in Diabetes.

Classification and diagnosis of diabetes. Diabetes Care 2017; 40 (Suppl. 1): S11-S24
Diabetes Risk
Test
 Screening for diabetes
?which test

fasting plasma glucose

h OGTT-2 HbA1C

 Any test cane be used.

 But …the 2-h PG during OGTT diagnoses more
people with prediabetes and diabetes than FPG
and A1C
 Prediabetes ranges *

FPG 100–125 mg/dL

(5.6–6.9 mmol/L): IFG
OR

2-h plasma glucose 140–199 mg/dL

(7.8–11.0 mmol/L): IGT
OR

A1C 5.7–6.4%
* For all three tests, risk is continuous, extending below the lower limit of a
range and becoming disproportionately greater at higher ends of the range.

American Diabetes Association Standards of Medical Care in Diabetes.

Classification and diagnosis of diabetes. Diabetes Care 2017; 40 (Suppl. 1): S11-S24
Screening for prediabetes &
diabetes
 B-Screening for Type 2 DM
in children & Adolescents
 Criteria for Testing for T2DM in Children &
Adolescents

• Overweight plus any 2 :

– Family history of type 2 diabetes in 1st or 2nd degree
relative
– Race/ethnicity
– Signs of insulin resistance or conditions associated with
insulin resistance
– Maternal history of diabetes or GDM
• Age of initiation 10 years or at onset of puberty
• Frequency: every 3 years
• Test with FPG, OGTT, or A1C
American Diabetes Association Standards of Medical Care in Diabetes.
Classification and diagnosis of diabetes. Diabetes Care 2017; 40 (Suppl. 1): S11-S24
Diagnosis of diabetes
mellitus
 Criteria for the Diagnosis of Diabetes
Fasting plasma glucose (FPG)
≥126 mg/dL (7.0 mmol/L)
OR

2-h plasma glucose ≥200 mg/dL

(11.1 mmol/L) during an OGTT
OR
A1C ≥6.5%
OR

Classic diabetes symptoms + random plasma

glucose ≥200 mg/dL (11.1 mmol/L)
American Diabetes Association Standards of Medical Care in Diabetes.
Classification and diagnosis of diabetes. Diabetes Care 2017; 40 (Suppl. 1): S11-S24
The American Diabetes Association (ADA) issued diagnostic criteria
for diabetes mellitus in 1997, with follow-up in 2003 and 2010.

The diagnosis is based on one of four abnormalities:

1. Glycated hemoglobin (A1c).

2. Fasting plasma glucose (FPG). With/without
3. Abnormal oral glucose tolerance test (OGTT) symptoms
4. Random elevated glucose with symptoms.

Diagnosis cannot be made from:

- Blood glucose strips read visually or by a meter (capillary blood).

- Urine testing.
 Confirming the diagnosis
• No need for confirmation: If there is a clear clinical

diagnosis (patient in a hyperglycemic crisis or with classic

symptoms of hyperglycemia) and RBS ≥ 200 mg/dl.

• You need FBS level and A1c to decide about the

management and to know the duration of hyperglycemia.

• Other wise Do not diagnose diabetes from one abnormal

test result a second test is required for confirmation:
 • It is recommended that the same test be repeated or a
different test be performed without delay using a same
or new blood sample for confirmation.
HbA1c 7.0% & 6.8% >>>> Diabetes
HbA1c 7.0% & FPG 130 mg/dl >>> Diabetes

Abnormally high results in 2 occasions >>>>>> Dx. of

Diabetes is confirmed

??? 2 different results

Discordant results from 2 tests >>> then the test result that is above the
diagnostic cut point should be repeated.
HbA1c 6.8% & FPG 95 mg/dl >>> repeat HbA1c
One Abnormally high results and one normal >>>>>>
repeat high test/result before Dx of DM is confirmed

#Test results near margins of diagnostic threshold >> should follow the patient closely
and repeat the test in 3–6 mths
Thank you for listening