Notes:

* The FPG is the preferred test for diagnosis, although any of the three is acceptable. In the absence of unequivocal hyperglycemia with acute metabolic decompensation, one of these three tests should be used on a different day to confirm the diagnosis.
** Fasting is defined as no caloric intake for at least eight hours.
*** Casual is defined as any time of day without regard to time since last meal; symptoms are the classic ones of polyuria, polydipsia, and unexplained weight loss.
**** OGTT should be performed using a 75 gram glucose load. The OGTT is not recommended for routine clinical use.

Diabetes screening guidelines strengthened
All adults should be tested by age 45

From CNN

From Medical Correspondent Rhonda Rowland

ATLANTA (CNN) -- Of the estimated 16 million people in the United States with diabetes, about half of them don't know they have it.

In an effort to improve that situation, new recommendations have been issued calling for changes in the way diabetes is detected and diagnosed. The guidelines were developed by an international panel of experts and have been endorsed by the National Institutes of Health.

For the first time, all adults are being urged to undergo a blood test for diabetes by age 45 and have additional tests every three years thereafter. Previously, only people who doctors suspected might have diabetes were screened.

"Potentially, there are 1 to 2 million people in the population who could be diagnosed using this criteria," said Dr. Richard Eastman of the NIH. "We think that many will be diagnosed, since it's a relatively easy test to perform on routine blood work done in a doctor's office."

There's another change being recommended in the arena of diabetes screening. Previously, a blood sugar reading of 140 or more would result in a diagnosis of diabetes. The new threshold is 126.

"The problem with the former cutoff of 140 is that by the time people were diagnosed with diabetes, about 20 percent already had complications," Eastman says. "We know that the risk goes up sharply for those complications when the blood sugar gets to be about 126."

Preventing complications is the impetus behind the new recommendations. Early diagnosis of diabetes is the key to preventing eye, heart, kidney and nerve damage that can be caused by an untreated diabetic condition.

"It's really a pity when the first time we see someone who's diagnosed as diabetic is when they're having their heart attack or when they're having a hemorrhage into their eye," says Dr. Carol Teutsch, a diabetes specialist.

Once a diagnosis is made, controlling blood sugar starts with diet and exercise. Some people also will have to take insulin or medications.

For those without diabetes, some studies suggest that exercise and good nutrition may prevent people from developing the condition. A large study now under way should provide a definitive answer in three to four years.

New diabetes guidelines urge testing for all at age 45

By The Associated Press

The guidelines, written by an international panel of experts, also lower the cutoff for declaring people diabetic and change the way the disease is classified.

The National Institutes of Health, which endorsed the recommendations, estimates that they could help identify 2 million of the 8 million Americans who have diabetes but don't know it.

The aim is to get these people started on diets, exercise programs and possibly drug treatment before the disease starts a cascade of complications that eventually damage the eyes, heart, kidneys and nerves.

The guidelines recommend using the readily available fasting plasma glucose test. The simple blood test costs $5 to $10 and requires that people not eat for eight hours beforehand.

The guidelines were released Monday at a meeting of the American Diabetes Association, which sponsored them. The World Health Organization plans to adopt them in slightly different form later this year.

Currently, there is no across-the-board recommendation for screening people for diabetes. Instead, doctors test patients when they have some reason to suspect they may be diabetic. Symptoms of diabetes can include excessive thirst, frequent urination and weight loss.

"The earlier we diagnose diabetes, the more likely we are to retard its progression and the development of complications," said Dr. James R. Gavin III of the Howard Hughes Medical Institute in Chevy Chase, Md., who headed the committee that drew up the guidelines.

A high level of sugar in the blood is the hallmark of diabetes. Gavin said that since the last diabetes guidelines were issued in 1979, doctors have learned that the disease begins its painless destruction at lower sugar levels than had been thought.

About 16 million Americans have diabetes, but only about half of them have been diagnosed with the disease. With the new guidelines, "I think we will begin to get into the missing 8 million," said Dr. Frank Vinicor of the Centers for Disease Control and Prevention in Atlanta.

The new cutoff on the blood test does not change the total number of Americans with the disease; the 16 million figure was based on a different type of glucose test.

Among the new guidelines:

• Every adult should have a diabetes test every three years starting at 45. Those who get a high reading should have the test repeated on another day.
• Those at higher than usual risk may need to be tested earlier or more often. These include American Indians, blacks, Asians, Hispanics and anyone who is overweight or has high blood pressure, high cholesterol or a strong family history of the disease.
• The cutoff for declaring someone diabetic should be lowered from the current 140 milligrams of glucose per deciliter of blood plasma to 126.
• Doctors should abandon the categories of insulin-dependent and non-insulin-dependent diabetes. Insulin-dependent, which once was called juvenile diabetes, should be termed type 1. Non-insulin-dependent, traditionally known as adult-onset diabetes, should be called type 2.
• Contrary to earlier recommendations, pregnant women do not need to be tested routinely if they are white, under 25, of normal size and have no close family members with the disease.

"This is very much a world consensus based on logic," he said.

About 700,000 Americans have type 1 diabetes. It usually results from a malfunction of the immune system that destroys insulin producing cells in the pancreas. Victims typically lose all ability to make insulin, often as children or young adults.

About 15.3 million people have type 2 diabetes. It is most common among older people and may involve a combination of too little insulin production and an inability of the body to use insulin properly.

If weight loss and exercise fail to bring the disease under control, it can be treated with a variety of pills or insulin injections.

New Guidelines Issued for Diagnosing Diabetes

NY Times

Levels of blood sugar that have long been accepted as normal are actually too high and should be considered a sign of diabetes, according to new guidelines issued Monday by the American Diabetes Association and endorsed by federal health authorities.

The guidelines call for testing all healthy people age 45 and older -- about 77 million Americans -- every three years, and are expected to lead to the detection of 2 million new cases.

Under the guidelines, testing would start earlier and be done more often in people with higher risk, including those who are obese, black, Hispanic, American Indian or closely related to someone with diabetes.

The new guidelines, announced at a medical conference in Boston, have been endorsed by the Centers for Disease Control and Prevention and the National Institute of Diabetes and Digestive and Kidney Diseases. A report on the recommendations will be published in the July issue of the journal Diabetes Care. Doctors usually follow the association's recommendations.

Dr. K.G.M.M. Alberti, director of the World Health Organization's Collaborating Center for Research and Development in Laboratory Techniques in Diabetes, said at a press conference that that organization fully supports the association's recommendations.

The redefinition of diabetes may have a powerful impact. Researchers say they hope that by leading to earlier detection, the guidelines will improve treatment and prevent complications like cardiovascular disease and blindness.

But it is not known whether those benefits will be realized, and in the meantime, the scientists say, there are potential risks in telling a large pool of symptom-free people they have a chronic disease with potentially devastating consequences. Those individuals would have to deal with employers and insurers, and in some cases make decisions about taking potent drugs whose long-term effects are not entirely known.

According to the new guidelines, a person has diabetes if two readings, on two different days, reach 126 milligrams per deciliter or higher on a simple blood test called a fasting plasma glucose -- better known as fasting blood sugar. The previous cutoff, set in 1979, was 140 or higher.

The association also decided that the fasting plasma glucose test was sufficient to make the diagnosis, and could replace a more expensive, time-consuming and unpleasant procedure, the oral glucose-tolerance test, which requires that patients drink a glucose solution and then have blood drawn two hours later. (The dipsticks used to test urine samples for glucose in many doctor's offices are not adequate for diagnosing diabetes.)

The association said it recommends lowering the blood-sugar cut-off to 126 because research has shown that people with readings in the low- to mid-120s develop complications of diabetes, including blood-vessel damage that can eventually lead to heart disease, stroke, kidney failure, blindness, nerve damage and amputation of the feet and legs.

The American Diabetes Association estimates that each year, the disease results in 54,000 amputations, 12,000 to 24,000 cases of blindness and 178,000 deaths from diabetes and its complications.

But in its early stages, high blood sugar produces no symptoms, and many adults have diabetes for 7 years or more before it is diagnosed. By that time, irreversible damage to the circulatory system and organs may already have occurred.

"Damage is occurring earlier than we previously thought," said Dr. James Gavin, senior scientific officer at the Howard Hughes Medical Institute in Chevy Chase, Md. He was the chairman of a group of international experts that developed the guidelines after analyzing 15 years of research.

"The earlier we pick up the disease and the more aggressive we are in treating it, the greater the likelihood we'll be able to avoid these kinds of complications," Gavin said. "This is an attempt to raise public awareness."

Although he thinks the new guidelines will ultimately benefit patients, Gavin said he did not expect the changes to be unanimously welcomed. He said many people fear a diagnosis of diabetes, not only because of what it means medically but also because it may expose them to insurance or employment discrimination. Cases of discrimination have occurred, he said.

"But diabetes has earned those negative connotations because we've been picking it up and trying to intervene late in its course when the complications have had a chance to get off to a running start," he said. "The sting is taken away if we can avoid complications."

Eight million Americans have been diagnosed with diabetes, and another 8 million are thought to have the disease without knowing it. The new guidelines won't change the combined total, but are expected to shift 2 million people who don't know they are diabetic into the group that does know.

Nearly all the new cases will be adult-onset or type 2 diabetes, which affects 90 percent to 95 percent of diabetics and which tends to develop after age 40. Type 1, which is more severe, usually develops in childhood or adolescence and is caused by a severe deficiency of the hormone insulin. Type 2 patients are more likely than type 1 to be overweight and to have high blood pressure and other risk factors for heart disease.

People with type 2 diabetes have high levels of blood sugar because their bodies cannot use insulin properly, and in some cases do not make enough of it to metabolize glucose and control its levels in the blood. The immediate goal of treatment is to keep blood sugar within the normal range. Although the benefit of that strategy has not been proved for type 2 diabetics, many researchers think it must exist.

Unlike people with type 1 diabetes, who require insulin shots to control the disease, those with type 2 don't always have to take drugs, Gavin said. Obesity and lack of exercise are major risk factors for type 2 diabetes, and it can sometimes be controlled with weight loss, exercise and attention to diet.

If those methods fail, or if blood sugar is very high, insulin shots or oral medications may be needed. The American Diabetes Association estimates that 10 percent to 20 percent of type 2 patients are treated with diet and exercise, 30 percent to 40 percent with oral drugs, and 30 percent to 40 percent with insulin or insulin and oral medications.

Dr. Richard C. Eastman, of the National Institute of Diabetes and Digestive and Kidney Diseases, who wrote an editorial accompanying the report on the new guidelines in Diabetes Care, said: "Many of the people who are newly diagnosed won't require any specific therapy because their level of blood sugar is not very high. But it goes up with time, and they need to be followed closely and therapy begun earlier."

A researcher who did not work on the new guidelines, Dr. David Nathan, director of the diabetes center at the Massachusetts General Hospital and Harvard Medical School, agreed that undiagnosed diabetes is a major health problem because millions of Americans don't realize they have it.

"The question that remains unresolved is, by screening, do we actually do them a favor?" Nathan said. "Will they have a better health status? It makes sense that they should, but there have never been studies to prove the case."

Just making the diagnosis does not guarantee patients better health care, Nathan said. "One problem in the U.S. is that physicians are not aggressive enough in treating type 2 diabetes," he said.

But if they were, he added, that might lead to another set of problems. Even though high blood sugar is dangerous, and patients would almost certainly be healthier if it could be lowered, he is concerned about the safety of the drugs used to lower it in type 2 diabetics.

Studies have suggested that some of the drugs may contribute to heart disease, and some are dispensed with warnings of the increased risk.

"We start with diet and exercise and rather rapidly move into a number of drugs, without data to suggest that's good for patients over a long time," Nathan said. "We must be careful we don't cause some mischief, don't make their heart disease worse."

Nonetheless, Nathan said, "On balance, I probably agree with the recommendations. But there is a cautionary side to this story."

In addition to establishing a fasting blood sugar of 126 as the cutoff for diabetes, the guidelines also designate normal as below 110, and identify a danger zone of 110 to 125 in which the body's ability to process glucose is considered to be impaired.

Gavin said people in that zone should be tested more frequently and counseled about ways to lower their blood sugar and reduce the risk of heart disease.

"That might include losing weight or not gaining any, increasing physical activity, stopping smoking, and aggressively treating high blood pressure or high blood fat," he said.

A nationwide study, still enrolling patients, is attempting to determine whether drugs or life style changes can prevent diabetes in people in this category, Nathan said. [Results of this study, the DPP, were announced on August 8, 2001, and are discussed at Diabetes Prevention Program]