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Saturday, December 20, 2014

Division of Diabetes Treatment and Prevention - Leading the effort to treat and prevent diabetes in American Indians and Alaska Natives


Standards of Care and Clinical Practice
Recommendations: Type 2 Diabetes

 

Diagnosis of Type 2 Diabetes and Prediabetes

Clinical Practice Recommendations

Diagnostic Criteria for Type 2 Diabetes

Last updated: July 2012

recommendations icon Recommendations for Diagnosing Type 2 Diabetes

  • Use the criteria below to diagnose type 2 diabetes in non-pregnant patients:
    • Hemoglobin A1C (A1C) ≥ 6.5%; or
    • Fasting plasma glucose (FPG) ≥ 126 mg/dL, where FPG is defined as no caloric intake for at least 8 hours; or
    • 2-hour oral glucose tolerance test (OGTT) ≥ 200 mg/dL; or
    • Casual plasma glucose ≥ 200 mg/dL with symptoms of hyperglycemia, where “casual” is defined as any time of day without regard to time of last meal.
  • In the absence of unequivocal hyperglycemia, confirm a positive result by repeat testing on a different day.

Note: While it is acceptable to screen for diabetes using a point-of-care (POC) capillary A1C and/or glucose, diabetes should only be diagnosed using laboratory-run tests. In addition, the A1C test alone may be less accurate when used to diagnose diabetes in youth.

Categories of Increased Risk for Diabetes (Prediabetes)

Last updated: August 2012

recommendations icon Recommendations for Identifying Patients at Increased Risk for Diabetes

  • Use the following criteria to identify patients at increased risk for diabetes:
    • Impaired fasting glucose (IFG) defined as FPG 100-125 mg/dL (if positive, consider obtaining a second test to confirm prediabetes), or
    • Impaired glucose tolerance (IGT) defined as 2-hour OGTT 140-199 mg/dL (if positive, consider obtaining a second test to confirm prediabetes)
  • A1C may be used as a screening test. If the result is 5.7-6.4%, perform either a FPG or an OGTT to confirm a diagnosis of prediabetes.

Patients with blood glucose levels higher than normal but not high enough to be considered diabetes are at increased risk for developing diabetes. Patients with either impaired fasting glucose or impaired glucose tolerance have been referred to as having “prediabetes.” Providers are encouraged to identify patients at increased risk for diabetes so they can start or intensify efforts to prevent progression to diabetes. Diabetes prevention programs for these patients are available in many AI/AN communities.

Note: The American Diabetes Association (ADA) criteria include use of the A1C alone to identify prediabetes. However, all other major standard-setting diabetes organizations do not recommend using the A1C test alone to identify patients with prediabetes.

Testing for Diabetes/Prediabetes in Non-pregnant Asymptomatic AI/AN People

Last updated: July 2012

recommendations icon Recommendations for Testing for Diabetes/Prediabetes in AI/AN Adults

  • Test AI/AN adults at least every 3 years.
  • Consider testing more frequently in patients with additional risk factors, including:
    • Overweight/obese (Body Mass Index [BMI] ≥ 25 kg/m2)
    • Family history of type 2 diabetes in first degree relative
    • History of gestational diabetes (GDM) or delivery of a baby weighing > 9 pounds
    • Polycystic ovarian syndrome (PCOS)
    • Cardiovascular disease (CVD)
    • Hypertension
    • HDL cholesterol < 35 mg/dL and/or triglycerides > 250 mg/dL
    • Acanthosis nigricans

recommendations icon Recommendations for Testing for Diabetes/Prediabetes in AI/AN Youth

  • Test overweight AI/AN youth (BMI > 85th percentile) with any of the following risk factors:
    • Family history of diabetes
    • Signs of insulin resistance or conditions associated with it [e.g., acanthosis nigricans, polycycstic ovarian syndrome (PCOS), hypertension, dyslipidemia, small-for-gestational-age (SGA), or large-for-gestational-age (LGA) birth weight]
    • Maternal history of diabetes or gestational diabetes during child’s gestation.
  • Start testing at-risk children at age 10 years (or younger if puberty occurs earlier).
  • Test at-risk children ≤ every 3 years.

Note: In patients who present with hyperglycemic symptoms, testing for diabetes is warranted regardless of risk factors listed above.

 

Resources

Tools for Clinicians and Educators

tools and resources icon Key Tools and Resources

American Association of Clinical Endocrinologists (AACE)/American College of Endocrinology (ACE) A1C position statement on the use of hemoglobin A1C for the diagnosis of diabetes. Exit Disclaimer: You Are Leaving www.ihs.gov [PDF]  Endocr Pract. 2010 Mar/Apr;16(2):155-6.

American Diabetes Association. Diagnosis and Classification of Diabetes Mellitus. Diabetes Care. 2012 Jan;35(Suppl 1):S64-71.

Pogach L, Conlin PR, Hobbs C, Vigersky RA, Aron D. VA-DoD update of diabetes guidelines: what clinicians need to know about absolute risk of benefits and harms and A1C laboratory accuracy. Fed Pract. 2011;28(4):39-44. (Note, it is already in the bibliography section)

World Health Organization. Use of glycated haemoglobin (HbA1c) in the diagnosis of diabetes mellitus: abbreviated report of a WHO consultation. Exit Disclaimer: You Are Leaving www.ihs.gov [PDF]  WHO/NMH/CHP/CPM/11.1. Geneva, 2011.

additional resources icon Additional Resources

Healthy Native Communities Partnership Inc. (HNCP).

  • Native Lifestyle Balance. Exit Disclaimer: You Are Leaving www.ihs.gov Modified, Native American versions of the lifestyle intervention manuals and curriculum used in the NIH Diabetes Prevention Program (DPP) study. Native Lifestyle Balance Core Manual. Manual includes the tools needed to provide the 16 Core sessions of the NLB curriculum.
  • Native Lifestyle Balance After Core Manual. Exit Disclaimer: You Are Leaving www.ihs.gov Manual provides tools and lessons for participants after they have completed the 16 Core sessions.

National Diabetes Education Program.

Small Steps. Big Rewards: Your Game Plan to Prevent Type 2 Diabetes. Healthcare Provider’s Toolkit. Exit Disclaimer: You Are Leaving www.ihs.gov [PDF]  NIH Publication No. 06-5334. 2006.

  • Toolkit contains a decision pathway to diagnose and treat pre-diabetes, evidence-based strategies to motivate patients, and copier-ready education materials.

Patient Education Materials

Indian Health Service Division of Diabetes Treatment and Prevention. Health for Native Life Magazine [DPP Special Edition].

  • This special issue focuses on preventing type 2 diabetes and strategies for reducing risk with stories about lifestyle changes made by the participants of the Diabetes Prevention Program study. 39 pages.

American Association of Indian Physicians (AAIP). Diabetes Prevention Success Stories. Exit Disclaimer: You Are Leaving www.ihs.gov

  • Features stories of youth, adults, and elders.

National Diabetes Education Program. We Have the Power to Prevent Diabetes. Exit Disclaimer: You Are Leaving www.ihs.gov [PDF]  NIH Publication No. 08-5525. 2008.

  • Tips to help American Indians and Alaska Natives at risk for type 2 diabetes move more and eat less to lower their risk for diabetes.

National Diabetes Information Clearinghouse. Exit Disclaimer: You Are Leaving www.ihs.gov [PDF]  I Can Lower My Risk for Type 2 Diabetes: A Guide for American Indians. NIH Publication No. 11–5337. 2011. 16 p.

  • Booklet focuses on strategies for reducing risk with photos of and quotes by American Indian participants in the Diabetes Prevention Program study.

Bibliography

American Association of Clinical Endocrinologists (AACE)/American College of Endocrinology (ACE) A1C position statement on the use of hemoglobin A1C for the diagnosis of diabetes. Exit Disclaimer: You Are Leaving www.ihs.gov [PDF]  Endocr Pract. 2010 Mar/Apr;16(2):155-6.

American Diabetes Association. Diagnosis and classification of diabetes mellitus: position statement. Exit Disclaimer: You Are Leaving www.ihs.gov [PDF]  Diabetes Care. 2012 Jan;35 Suppl 1:S64-71.

American Diabetes Association. Standards of medical care in diabetes—2013. Exit Disclaimer: You Are Leaving www.ihs.gov [PDF]  Diabetes Care. 2013 Jan;36 Suppl 1:s1166.

Nathan DM, Kuenen J, Borg R, Zheng H, Schoenfeld D, Heine RJ; A1C-Derived Average Glucose (ADAG) Study Group. Translating the A1C assay into estimated average glucose values. Exit Disclaimer: You Are Leaving www.ihs.gov [PDF]  Diabetes Care. 2008;31(8):1473-8.

Pogach L, Conlin PR, Hobbs C, Vigersky RA, Aron D. VA-DoD update of diabetes guidelines: what clinicians need to know about absolute risk of benefits and harms and A1C laboratory accuracy. Fed Pract. 2011;28(4):39-44.

Tabák AG, Herder C, Rathmann W, Brunner EJ, Kivimäki M. Lancet. Published online June 9, 2012 DOI:10.1016/S0140-6736(12)60283-9.

US Department of Veterans Affairs Office of Quality and Performance; US Army Medical Command Quality Management Division. VA/DoD clinical practice guideline for the management of diabetes mellitus. Exit Disclaimer: You Are Leaving www.ihs.gov   Version 4.0. Washington (DC): Veterans Health Administration and Department of Defense; 2010. 146 p.

World Health Organization. Use of glycated haemoglobin (HbA1c) in the diagnosis of diabetes mellitus: abbreviated report of a WHO consultation. Exit Disclaimer: You Are Leaving www.ihs.gov [PDF]  WHO/NMH/CHP/CPM/11.1. Geneva, 2011.

Division of Diabetes Treatment and Prevention | Phone: (505) 248-4182 | Fax: (505) 248-4188 | diabetesprogram@ihs.gov