It’s been 20 years since the standards for the diagnosis of diabetes were set. Things have changed.
In June, an international panel of doctors and diabetes healthcare professionals announced new recommendations at the AMSS.
Lowering the Level
In the past, diabetes was diagnosed when the FBG was 140 mg/dl. However, new data from research has shown that diabetes complications can occur in people with FBGs in the mid 120s. As a result, the panel has recommended that the new diagnosis level for diabetes be 126 mg/dl.
16 Million and Growing?
16 million – you’ve heard this number cited before as the estimated number of people with diabetes in the United States. Will the new lower diagnosis level raise it even higher? Some experts say no.
The figure 16 million will stay the same, but of the eight million undiagnosed, the ADA estimates that up to two million of these individuals may now be diagnosed as a result of the new guidelines.
What’s in a Name?
The committee has also recommended doing away with the old categories of insulin-dependent diabetes mellitus (IDDM) and non-insulin dependent diabetes mellitus (NIDDM). This is because both types are managed with a wide variety of treatments and do not necessarily conform to one category or the other. For example, many people with type 2 take insulin.
Additionally, the use of Arabic instead of Roman numerals has been suggested. In journals and other printed materials, type I and type 2 will now be referred to as type 1 and type 2 in order to prevent confusion.
In the past, the medical community primarily diagnosed type 2 diabetes using the oral glucose tolerance test (OGTT). The test measured BGs two hours after drinking glucose dissolved in water. However, the expert panel now recommends using the simpler and less expensive fasting blood glucose test. This test is typically given in the morning before breakfast.
The committee has also released new guidelines for who should and shouldn’t be tested. Rather than screening all pregnant women in their third trimester, they advocate not screening women at low risk for diabetes. Women at low risk who need not be tested for gestational diabetes include: those under 25 years of age, those with normal body weight, those who have no family history of diabetes and those who are not part of a high-risk ethnic group. High-risk ethnicities include Hispanics, Native Americans, African-Americans and Asians.
The committee also recommends that everyone over the age of 45 should be tested for diabetes at three-year intervals, and that testing be done at an earlier age if any of the following risk factors are evident (see page 18).
Impaired Glucose Homeostasis
Impaired glucose homeostasis (IGH) is the state between “normal” and “diabetes” in which the body is no longer using and/or secreting insulin properly.
People with IGH have a higher risk of developing diabetes and developing serious complications. As a result, the committee has defined two categories of IGH as risk factors for future diabetes and cardiovascular disease: 1) Impaired Fasting Glucose (IFG), when the fasting glucose level is above 110 but less than 126 mg/dl. and 2) Impaired Glucose Tolerance (IGT), when results of the OGTT are above 140 but less than 200 mg/dl.
A major clinical trial, the Diabetes Prevention Program, is currently underway to determine if early treatment can prevent the development of diabetes in people with IGH.
And the Results Are…
Many type 2s often go undiagnosed until serious complications such as vision or heart problems surface. Experts say that many type 2s live as many as seven years or more with diabetes before it is diagnosed. Doctors hope that the new, lower level of 126 mg/dl will help diagnose a greater number of the type 2s who may not realize they have diabetes.
Alan Marcus, MD, an endocrinologist in Laguna Hills, California was pleased to hear that the committee had changed diagnosis guidelines. “This change in diagnostic criteria is the first step in recognizing that there is no such thing as ‘a touch of diabetes.’ And most importantly, earlier diagnosis and effective intervention may prevent the progression to diabetes.”
Health or Wealth?
Some in the diabetes community wonder if the new guidelines will boost drug sales for pharmaceutical companies. The ADA says no.
It claims that earlier diagnosis and treatment does not necessarily mean that drug therapy will start sooner, as type 2 diabetes can often be effectively treated with diet and exercise, especially in its earlier forms. Christine Beeve, president of Health Care and Education at the ADA, believes that the two million newly diagnosed will make little difference to the pharmaceutical companies.
“The new lower diagnosis level will allow dietitians like myself to help patients make major lifestyle changes early on so that they won’t have to resort to medication,” says Beeve.
Still, others argue that for many type 2s diet and exercise will fail. Most will require medication and monitoring supplies which can be quite costly. For instance, monitoring BGs twice a day and taking diabetes medications can cost at least 2,000 dollars a year or more. If diet and exercise fail, then the ADA’s projected two million new diabetics could generate up to four billion dollars a year for the diabetes care industry.
Only time will tell.