Glucose Tolerance Tests Accuracy In

Diagnosing Diabetes
According to the World Health Organization (WHO), more than 220 million people worldwide have
diabetes. An estimated 1.1 million people died from diabetes in 2005, and almost half of diabetic
deaths occurred in people under the age of 70 years of age. WHO projects that the number of
diabetic deaths will increase to 366 million by the year 2030 (8).
Diabetes Mellitus Type 2 is a prevalent disorder that causes one to have high blood sugar, or
hyperglycemia. This hyperglycemia can be the result from one or a combination of 1) decrease
production of insulin from beta cells of the pancreas; 2) increase sugar production from the liver; 3)
decrease sugar uptake by cells secondary to insulin receptors. Symptoms of DMII are excess
urination, excess thirst, dizziness, blurred vision, sweating, and fatigue. Patients presenting with
these symptoms should be screened by a finger stick, where a blood sample is taken from a quick
prick of the finger, to be tested for hyperglycemia. Normal blood sugar should range from 70-100mg.
If one has a fasting sugar of >126mg or an after eating sugar level > 200mg, then an oral glucose
tolerance test (OGTT) should be performed. During an OGTT, a patient consumes a 150-200g
carbohydrate diet for three days and fasts from midnight prior to test date. The morning of test, the
patient consumes 75g sugar mixed with 300ml of water within a 5 minute period. The patients blood
sugar level is be measured at baseline, and then again at 120 minutes. A diagnosis of DMII is made
if the baseline level is >126 mg and the 120 minute level is >200mg. These guidelines are set by the
American Diabetic Association (ADA) and the World Health Organization (WHO) (1,8).
Another option for obtaining a blood sugar level is measuring the percent of glycosylated red blood
cells, or the percent of sugar attached to a RBC. RBCs live for approximately 90 days in the human
body. By measuring this percentile one can observe the patients blood sugar level over the previous
3 months and not just at the moment an OGTT is performed. Today, HbA1c is a main tool for
following metabolic control in persons with diabetes(5). A HbA1c > 6.0 percent should permit a
diagnosis of DMII, but is not at this time a definite diagnostic tool.
Diabetes can cause complications of multiple organ systems. WHO defines consequences of
diabetes as follows:
Diabetes increases the risk of heart disease and stroke. 50% of people with diabetes die of
cardiovascular disease (primarily heart disease and stroke).
Combined with reduced blood flow, neuropathy in the feet increases the chance of foot ulcers and
eventual limb amputation.
Diabetic retinopathy is an important cause of blindness, and occurs as a result of long-term
accumulated damage to the small blood vessels in the retina. After 15 years of diabetes,
approximately 2% of people become blind, and about 10% develop severe visual impairment.
Diabetes is among the leading causes of kidney failure. 10-20% of people with diabetes die of
kidney failure.
Diabetic neuropathy is damage to the nerves as a result of diabetes, and affects up to 50% of people
with diabetes. Although many different problems can occur as a result of diabetic neuropathy,
common symptoms are tingling, pain, numbness, or weakness in the feet and hands.
The overall risk of dying among people with diabetes is at least double the risk of their peers without
diabetes (8).
Previous studies have showed that better control of plasma glucose levels reduced the risk of
developing long-term complications pertaining to diabetes (4). A higher HbA1c correlates well with
the likelihood of developing chronic complications such as the ones listed above.
This study is designed to explore if a HbA1c be used to diagnose diabetes. Observations suggest
that a reliable measure of chronic glycemic levels such as HbA1c, which captures the degree of
glucose exposure over time and which is related more intimately to the risk of complications than
single or episodic measures of glucose levels, may serve as a better biochemical marker of diabetes
and should be considered a diagnostic tool (2). As for the current gold standard for diagnosing
diabetes, the oral glucose tolerance test (OGTT) has its limitations (2). These include high
interindividual variability, low reproducibility compared to FPG, poor compliance with the conditions
needed to perform the test correctly, and is cumbersome and time-consuming for medical staff and
patients (4). Due to these factors one may ask, Is a HbA1c or an OGTT more accurate at
diagnosing new onset diabetes mellitus type 2 in a patient presenting with hyperglycemia? By
exploring this question and answering it from an evidence-based approach, the answer may help
clinicians advance to an easier and less time consuming way to diagnose diabetes mellitus type II.
CLINICAL CASE
A 57 year old African American male presented to the outpatient office with symptoms of dizziness,
blurred vision, polydipsia, and polyuria. He has a significant history of hypertension and
hyperlipidemia. The patient was unclear when his symptoms started. Upon evaluation in the office,
the patient was noted to have a marked glucose elevation of 420. An in-house HbA1c was also
noted at 13.0. Upon further questioning, the patient has not been taking any medications for
diabetes, and is currently taking Lisinopril and Zocor for his other medical conditions. Due to the
presenting symptoms and lab results, the patient was admitted to the hospital for hyperosmolar
nonketotic hyperglycemic state.
METHODS
A PubMed search was performed by using the Clinical queries and Diagnosis
filters. The terms A1c AND diagnosis AND diabetes and glycosylated hemoglobin
AND diagnosis AND diabetes were used to search the site for relating articles. With these
search terms, a total of 176 hits revealed articles pertaining to the requested information.
Articles that met all inclusion criteria for the research were evaluated and assigned a
type/level of evidence.
In order to be included in this evidence-based study, articles had to meet the following inclusion
criteria: