Module 2 Pathophysiology Type Diabetes

DIABETES LEARNING SYSTEM
MODULE 2: DIAGNOSIS OF TYPE 2 DIABETES
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Module 2: Diagnosis of Type 2 Diabetes _________________________________________________________________
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___________________________________________________________________________________Table of Contents
TABLE OF CONTENTS
INTRODUCTION.................................................................................................................................................................... 1
CHAPTER 1: DIAGNOSIS OF DIABETES ............................................................................................................................ 3

Introduction ....................................................................................................................................................................... 3
Learning Objectives .......................................................................................................................................................... 3
Diagnosis in Symptomatic Patients ................................................................................................................................... 5
Diagnostic Tests for Diabetes ........................................................................................................................................... 6
Measurement of A1C .................................................................................................................................................... 6
Casual (or random) Plasma Glucose ............................................................................................................................ 9
Measurement of Fasting Plasma Glucose .................................................................................................................. 10
Measurement of OGTT ............................................................................................................................................... 10
Confirmation of Test Results ....................................................................................................................................... 11
Edwards Case: Follow-up Visit................................................................................................................................... 11
Screening in Asymptomatic Adults.................................................................................................................................. 11
Diagnostic Criteria for Diabetes....................................................................................................................................... 14
Summary......................................................................................................................................................................... 15
SELF-ASSESSMENT QUESTIONS .................................................................................................................................... 17

Self-Assessment QuestionsAnswers........................................................................................................................... 20
CHAPTER 2: COMPREHENSIVE MANAGEMENT OF DIABETES .................................................................................... 21

Introduction ..................................................................................................................................................................... 21
Learning Objectives ........................................................................................................................................................ 21
Comprehensive Diabetes Evaluation .............................................................................................................................. 23
Healthcare Professionals ................................................................................................................................................ 24
Ongoing Evaluation......................................................................................................................................................... 27
The ABCs of Diabetes................................................................................................................................................. 27
A1C Testing ................................................................................................................................................................ 28
Self-Monitored Blood Glucose..................................................................................................................................... 28
Blood Pressure and Cholesterol Monitoring................................................................................................................ 29
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Smoking Cessation......................................................................................................................................................29
Monitoring for Microvascular Complications ................................................................................................................30
Summary of Ongoing Monitoring .................................................................................................................................30
Summary .........................................................................................................................................................................31
SELF-ASSESSMENT QUESTIONS.....................................................................................................................................33
Self-Assessment QuestionsAnswers ...........................................................................................................................34
MODULE SUMMARY...........................................................................................................................................................35
GLOSSARY..........................................................................................................................................................................39
REFERENCES .....................................................................................................................................................................41
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_______________________________________________________________________________________ Introduction
INTRODUCTION
Diabetes is a chronic illness that requires continual medical care and educated patient
participation and support to prevent acute complications and to reduce the risk of long-
term complications. Diabetes care is complex and requires that many issues, beyond
glycemic control, be addressed. Achieving and maintaining recommended blood glucose,
blood pressure, and cholesterol levels has been shown to reduce the complications
associated with diabetes. These three treatment areas are collectively referred to as the
ABCs of diabetes (A = A1C; B = blood pressure; C = cholesterol).
Module 2: The Diagnosis of Type 2 Diabetes provides you with a background on how
type 2 diabetes is diagnosed and introduces the healthcare professionals who work with
the patient to treat the disease. Throughout the module, case studies are used to describe
the perspectives of healthcare professionals and patients, and the challenges they face.
The initial event leading to the diagnosis of type 2 diabetes varies from patient to patient.
Some patients visit their physicians because they have symptoms. Others who are
asymptomatic may be diagnosed with type 2 diabetes when they visit their physicians for
other reasons, such as routine checkups or incidental illness While the presence of
certain symptoms may cause a physician to suspect a patient has diabetes, diagnostic
tests are required to confirm the diagnosis in all patients.
Type 2 diabetes is a serious and potentially devastating disease; care of the patient with
type 2 diabetes involves many clinical issues and often many comorbidities. Guidelines
have been developed by a number of organizations, including the following, based on
expert consensus and clinical practice to assist healthcare professionals and standardize
the care delivered:
American Diabetes Association (ADA), which publishes a variety of clinical materials,

including yearly updates to its diagnostic criteria and standards of care
American Association of Clinical Endocrinologists (AACE), which publishes a variety

of clinical materials, including diagnostic criteria and standards of care
This module discusses the diagnosis and treatment of type 2 diabetes. Specific topics
in this module include the following:
Chapter 1 describes how type 2 diabetes is diagnosed, using 2 patient case studies
Chapter 2 discusses who treats diabetes and how healthcare professionals work
with patients to manage type 2 diabetes to meet treatment goals
Throughout the text, medical terms are defined in the margin. The module concludes
with a summary, a glossary, and a bibliography.
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2 CONFIDENTIAL: For Training Purposes OnlyNot for Promotional Use

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______________________________________________________________________ Chapter 1: Diagnosis of Diabetes
CHAPTER 1: DIAGNOSIS OF DIABETES

INTRODUCTION
Type 2 diabetes is a chronic illness that requires ongoing medical care. The longer the
disease is present, the greater the risk of morbidity and mortality, so effort is being morbidity (mawr-BID-i-tee):
focused on earlier diagnosis of the disease. This chapter presents the diagnostic sickness or disease
approach for type 2 diabetes. Throughout this chapter, case studies are used to highlight mortality (mawr-TAL-i-tee):
how you may encounter this information as you meet with healthcare professionals. The death rate
basis for our discussion is the guidelines published by the ADA and AACE. However,
keep in mind that guidelines are developed to assist physicians, not to dictate all decision
making, and that physicians rely on their experience and clinical judgment in the
evaluation of a patient.
The first caseEdwardillustrates how type 2 diabetes is diagnosed in a symptomatic

patient. The second caseMariaillustrates how type 2 diabetes is detected incidentally
in an asymptomatic patient. Follow along throughout this chapter as Edward and Maria
make their initial visits to physicians and receive a diagnosis of type 2 diabetes.
LEARNING OBJECTIVES
Upon completion of this chapter, you should be able to:
1. Define the tests used to diagnose diabetes: A1C, fasting plasma glucose test,
oral glucose tolerance test, and casual plasma glucose test.
2. List the recommendations for screening in asymptomatic patients.
3. List the criteria for the diagnosis of diabetes.
4. Discuss risk factors for development of diabetes.

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DIAGNOSIS IN SYMPTOMATIC PATIENTS
Edward: Initial Assessment by Dr. Chu (Part 1)

Edward is a 55-year-old Caucasian man, who is 6 feet tall and weighs 230 pounds.
For the past month, he has experienced blurred vision and tingling and numbness
in his feet. He decides to visit his general practitioner (GP), Dr. Chu, because hes
concerned about these symptoms. Dr. Chu performs a medical history and physical
examination, which includes a blood pressure check. Dr. Chu notes that Edward rarely
exercises, normally eats a diet high in fat, and his mother was diagnosed with type 2
diabetes when she was 50 years old. In addition, Edwards blood pressure is up to
160/100 mm Hg. At the end of the physical examination, Dr. Chu sends Edward
across the hall where the medical assistant draws blood to determine his glycosylated glycosylated hemoglobin (A1C):
(glahy-KOS-uhl-ahyt-ed HEE-muh-
hemoglobin (A1C) level. Dr. Chu explains that this test will provide information on gloh-bin) the amount of hemoglobin
what his blood glucose levels have been over the past 2 to 3 months. She also within red blood cells with glucose
schedules Edward for a return visit for the following week. attached; provides an estimate of
blood sugar control for the previous
2 to 3 months
Like Edward, some patients who are diagnosed with type 2 diabetes visit their physicians
because they have symptoms. Symptoms that can lead a physician to suspect diabetes
include polyuria (poly = many, uria = urine), polydipsia (poly = many, dipsia = drink), polyuria (pol-ee-YOOR-ee-uh):
excessive urination
polyphagia (poly = many, phagia = eat), and weight loss. In addition to these symptoms,
patients with type 2 diabetes may present with long-term complications of diabetes. For polydipsia (pol-ee-DIP-see-uh):
example, Edward is experiencing both blurred vision (either from hyperglycemia or a excessive thirst
symptom of vision complications) and tingling and numbness in his feet (a symptom of polyphagia (pol-ee-FEY-jee-uh):
nerve complications). excessive eating
hyperglycemia
When symptomatic patients like Edward enter a physicians office, the physician will (hahy-per-glahy-SEE-mee-uh):
perform a complete medical examination, including a medical history and physical abnormally high blood glucose levels
examination. The patient will also undergo laboratory tests that can diagnose diabetes.

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DIAGNOSTIC TESTS FOR DIABETES

Although the presence of certain symptoms may suggest that a patient has diabetes,
it is necessary to confirm the diagnosis based on laboratory test results. Tests that can
be used to confirm a diagnosis of diabetes include:
A1C: provides an estimate of the blood glucose levels over the previous 2 to 3 months;
A1C has become the standard test for the diagnosis of diabetes
Casual plasma glucose (also known as random plasma glucose): measured

regardless of mealtime and when a patient is not fasting
fasting plasma glucose (FPG): Fasting plasma glucose (FPG): measured when the patient has not eaten for at least
test of blood glucose levels; 8 hours
measured when the patient has
not eaten for at least 8 hours
Oral glucose tolerance test (OGTT): measures the patients glucose level 2 hours
oral glucose tolerance test (OGTT):
measures the 2-hour postload
after the patient drinks a solution that contains a high glucose concentration
glucose (PG) value; patient is
tested 2 hours after ingesting 75 g
of glucose
Measurement of A1C
A1C has been used for many years for monitoring blood glucose control in patients with
diabetes. Because the A1C test has several advantages over tests used to diagnose
diabetes, including convenience and worldwide standardization, it is now the preferred
test for diagnosis of diabetes. Data have shown that glycemic threshold levels (the values
at which diabetes is diagnosed) correlate well between the A1C, FPG, and 2-hour OGTT.
Hemoglobin (hemo = blood, globin = protein) is a protein found within red blood cells that
carries oxygen from the lungs to all body cells. The major type of hemoglobin is called
hemoglobin A, and some molecules of hemoglobin A can link with sugars, including
glycosylation glucose. This linking is called glycosylation (glyco = glucose, sylation = linking), and the
(glayh-KOS-uhl-ay-shun):
the chemical linkage of sugar combination of hemoglobin A and glucose produces glycosylated hemoglobin A, termed
molecules to proteins A1C. While all red blood cells contain some glucose, patients with diabetes have too
much glucose in their blood. This extra glucose attaches (glycosylates) to molecules of
hemoglobin. Figure 1 illustrates how A1C is formed.

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Figure 1. Formation of A1C
The more glucose in a patients blood, the more glycosylated hemoglobin, or A1C, is
created in the red blood cells over the life span of the cells (approximately 120 days)
(see Figure 2). Since the reaction that causes the formation of A1C is irreversible, a single
A1C measurement provides an average of A1C content in red blood cells of all ages in a
given individual and can be used as a surrogate marker of the average blood glucose
levels over the previous 8 to12 weeks.
Figure 2. Normal Versus Elevated Levels of A1C
While A1C values are reported as the percentage of hemoglobin that is glycated, daily
monitoring of blood glucose is reported as either mg/dL or mmol/L. A1C values can be
correlated to glucose values (estimated average glucose), as shown in the following table.

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Table 1. Correlation Between A1C and Mean Plasma Glucose Levels

(over 2 to 3 months)*
A1C Mean Plasma Glucose

6% 126 mg/dL (7.0 mmol/L)
7% 154 mg/dL (8.6 mmol/L)
8% 183 mg/dL (10.2 mmol/L)
9% 212 mg/dL (11.8 mmol/L)
10% 240 mg/dL (13.4 mmol/L)
11% 269 mg/dL (14.9 mmol/L)
12% 298 mg/dL (16.5 mmol/L)
* Estimates based on average daily adjusted glucose (ADAG) data of ~2700 glucose
measurements over 3 months per A1C measurement in 507 adults with type 1 diabetes,
type 2diabetes, and no diabetes. Correlation between A1C and average glucose: 0.92. for
A calculator converting A1C results into estimated average glucose, in either mg/dL or mmol/L,
is available at http://professional.diabetes.org/eAG.
A1C testing has several advantages over FPG and OGTT testing, including that A1C:
Is more convenient, since neither fasting nor the requirements of an OGTT are
necessary
Data show good correlation between A1C, FPG, and 2-hour OGTT
Worldwide standardized testing (less chance for error)
Is less affected by day-to-day changes caused by stress or illness
Disadvantages to the use of A1C include that it is more costly than an FPG and it may
not be widely available in some regions of the world. Additionally, the A1C assay is less
sensitive for the diagnosis of diabetes compared with FPG. Assuming universal screening
of individuals who have not been diagnosed with diabetes, A1C would identify one-third
fewer individuals with diabetes compared with FPG. However, because A1C is more
convenient and practical to use, the loss in sensitivity may be offset by more widespread
screening, potentially leading to an increase in diagnoses. Some of the advantages to the
use of A1C to diagnose diabetes are summarized in Table 2.

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Table 2. Selected Advantages to the Use of A1C for the Diagnosis of Diabetes
Advantages to Using A1C to Diagnose Diabetes

Identifies chronic hyperglycemia
Does not require fasting
Not affected by day-to-day perturbations (e.g., stress, diet, exercise, smoking)
Greater pre-analytical stability than blood glucose
Good correlation between A1C, FPG, and 2-hour OGTT
Wider use of more convenient test may increase number of diabetes diagnoses
Lets take a closer look at the other tests that can be used to diagnose diabetes.
These tests provide direct measurements of the glucose in the blood.
Casual (or random) Plasma Glucose

Unless patients are alerted beforehand, they usually are not fasting when they come for
an office visit. A glucose value measured regardless of mealtime and when a patient is
not fasting is called a casual (or random) plasma glucose. Because eating will affect the
glucose level, a glucose value may be called:
Preprandial (pre = before, prandial = eating) preprandial (pree-PRAN-dee-uhl):

before a meal
Postprandial (post = after, prandial = eating) postprandial

(pohst-PRAN-dee-uhl): after a meal
Results of a casual plasma glucose are classified as abnormal when they are 200 mg/dL
(11.1 mmol/L). A casual plasma glucose test is diagnostic of diabetes if glucose levels
are 200 mg/dL (11.1 mmol/L) and the patient has classic symptoms of hyperglycemia
or hyperglycemic crisis.

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Measurement of Fasting Plasma Glucose

An FPG requires that a patient cannot have eaten for 8 hours. Because many physicians
do not ask patients to fast before an appointment, an FPG is usually not performed as
part of the initial evaluation of a patient. When an FPG is performed, the results can be
classified as:
Normal (indicating no diabetes)
impaired fasting glucose (IFG): Impaired fasting glucose (IFG): blood glucose levels that are higher than normal
fasting glucose levels higher than but not high enough for a diagnosis of diabetes; patients with impaired fasting glucose
normal but not high enough for a
diagnosis of diabetes; defined as are sometimes referred to as having prediabetes because they have a high risk of
glucose 100 mg/dL to 125 mg/dL developing type 2 diabetes in the future. Prediabetes is considered to be a risk factor
(5.6 mmol/L to 6.9 mmol/L)
for diabetes (and cardiovascular disease) and should not be considered a diagnosis
in its own right.
Diagnostic of diabetes
Measurement of OGTT
An OGTT measures the patients glucose level after he/she has fasted for at least 8 hours
and 2 hours after the patient drinks a solution that contains a high glucose concentration.
An OGTT is commonly used to screen for gestational diabetes mellitus in pregnant
women. Similar to the FPG, the results of the OGTT tests can be classified as:
Normal (indicating no diabetes)
impaired glucose tolerance (IGT): Impaired glucose tolerance (IGT): blood glucose levels that are higher than normal
glucose levels measured during an
oral glucose tolerance test that are
but not high enough for a diagnosis of diabetes; patients with impaired glucose
higher than normal but not high tolerance are sometimes referred to as having prediabetes because they have a high
enough for a diagnosis of diabetes; risk of developing type 2 diabetes in the future. is considered to be a risk factor for
defined as glucose 140 mg/dL to
199 mg/dL (7.8 mmol/L to 11 mmol/L)
diabetes (and cardiovascular disease) and should not be considered a diagnosis in
its own right.
Diagnostic of diabetes

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Confirmation of Test Results

A test result that is diagnostic of diabetes usually is repeated to rule out laboratory
error, unless the patient has clear symptoms (such as a patient in a hyperglycemic
crisis or classic symptoms of diabetes accompanying a random glucose 200 mg/dL).
It is preferred that the test used for confirmation be the same test as the initial test.
Edwards Case: Follow-up Visit

The following continues Edwards case.
Edward: Follow-up Visit

Dr. Chu checks the results of Edwards A1C test from his initial visit. The A1C result
is 7.5%, which is in the diagnostic range for diabetes. After Dr. Chu meets with
Edward and explains the results, she sends Edward to the lab so that his A1C can
be rechecked. The second A1C result is 7.4%.
Because Edwards initial A1C was above normal, she repeated the test at his
second visit. When the result of the second test was 7.4%, she diagnosed Edward
with type 2 diabetes.
SCREENING IN ASYMPTOMATIC ADULTS

While some patients display symptoms of diabetes, other patients are asymptomatic.
Diabetes is diagnosed when they visit their physicians for other reasons, such as routine
checkups or incidental illness. In fact, type 2 diabetes may not be diagnosed until
complications appear. As discussed in Module 1: Exploring Diabetes, patients with type 2
diabetes may have diabetes for several years before they are actually diagnosed with the
disease. For this reason, some organizations recommend screening for diabetes in high-
risk patient populations. Maria, a woman who visits her physician for a routine checkup, is
an example of such a patient.

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Maria: Initial Assessment by Dr. Wilkins (Part 1)

Maria is a 45-year-old Hispanic woman. She sees her GP, Dr. Wilkins, sporadically.
In previous years, Dr. Wilkins has advised Maria that she should exercise more
frequently and try to eat healthier foods. During Marias checkup this year, Dr. Wilkins
sees that Maria has gained weight and now weighs 68.6 kg (154 lb) at 5 feet 4 inches
body mass index (BMI): tall. He calculates Marias body mass index (BMI)* as 26 kg/m2, which indicates that
calculated value used to describe
an individuals weight relative
she is overweight. Marias blood pressure, which was measured at 141/89 mm Hg,
to height; calculated using the is elevated. Dr. Wilkins begins to tally Marias risk factorsher father died of a heart
following formula: BMI = kg/m2 attack when he was 58, she is physically inactive, overweight, a member of a high-risk
ethnic group, and she has had elevated blood pressure on several occasions.
Dr. Wilkins informs Maria that he is concerned about these factors, and he tells
her that he wants to test for diabetes. He sends her to the lab to have blood drawn
for an A1C and asks her to return for a follow-up visit the next week.
* While some guidelines discuss calculating BMI, keep in mind that many physicians are
comfortable simply using the patients weight as an indication of obesity.
Both the AACE and the ADA guidelines recommend screening for diabetes in certain
high-risk adult patient populations (see Table 3 for the ADA guidelines). The ADA also
recommends screening for type 2 diabetes in asymptomatic children aged 10 or older who
are overweight and have 2 additional risk factors. Additional risk factors for children
insulin (IN-suh-lin): hormone include: family history of diabetes, race/ethnicity, signs of insulin resistance or presence
secreted by the beta-cells of the
pancreas that is the key regulator of
of a condition associated with insulin resistance, and maternal history of diabetes or
the metabolism of glucose and gestational diabetes during the childs gestation.
processes necessary for metabolism
of fats, carbohydrates, and proteins;
opposes the action of glucagon

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Table 3. ADA Recommendations for Testing in Asymptomatic Adults
ADA Recommendations for Testing in Asymptomatic Adults

Testing should be considered in all adults who are overweight (BMI 25 kg/m2*)
and who have one or more additional risk factors:
Physical inactivity
First-degree relative with diabetes
High-risk race/ethnicity (e.g., African American, Latino, Native American,
Asian American, Pacific Islander)
Women who delivered a baby weighing >9 lb or who were diagnosed
with gestational diabetes
Hypertension (blood pressure 140/90 mm Hg or on therapy for hypertension
(hahy-per-TEN-shuhn):
hypertension) elevated blood pressure
High-density lipoprotein cholesterol (HDL-C) level <35 mg/dL
high-density lipoprotein
(0.90 mmol/L) and/or a triglyceride level >250 mg/dL (2.82 mmol/L) cholesterol (HDL-C) (lip-oh-PROH-
teen kuh-LES-tuh-rohl): good
Women with polycystic ovary syndrome (PCOS) with BMI 30 kg/m2 cholesterol; transports excess
A1C between 5.7% and 6.4%, IGT, or IFG on previous testing cholesterol to the liver for elimination
Other clinical conditions associated with insulin resistance (e.g., severe triglycerides
obesity, acanthosis nigricans) (trahy-GLIS-uh-rahydz):
lipid molecules containing 3 fatty
History of cardiovascular disease (CVD) acids bound to glycerol; the
primary fat in the diet and the primary
In the absence of the above criteria, testing for diabetes should begin at age molecule used for fuel storage
45 years
polycystic ovary syndrome
If results are normal, testing should be repeated at least at 3-year intervals, (POL-ee-sis-tik): a health problem
with consideration of more-frequent testing depending on initial results that can affect a womans menstrual
cycle, fertility, hormones, insulin
(e.g., those with prediabetes should be tested yearly) and risk status production, heart, blood vessels, and
appearance; may be characterized
* At-risk BMI may be lower in some ethnic groups. by high levels of male hormones
(androgens), abnormal menstrual
cycle, and small cysts in ovaries

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DIAGNOSTIC CRITERIA FOR DIABETES

Any of the tests for diabetesFPG, OGTT, and A1Cmay provide a diagnosis of the
disease. In an asymptomatic person, a definitive diagnosis requires at least one additional
test result. In addition, if repeat testing is inconclusive, the ADA suggests that physicians
may choose to monitor patients closely and repeat the testing in 3 to 6 months.
The following table lists glucose test values that are consistent with a diagnosis
of diabetes.
Table 4. Diagnostic Glucose Values and A1C Levels
ADA Diagnostic Glucose Values and A1C Levels

Fasting plasma glucose (at least 8 hours without caloric intake)*
Prediabetes (IFG) 100 mg/dL to 125 mg/dL (5.6 mmol/L to 6.9 mmol/L)
Diabetes 126 mg/dL (7 mmol/L)
OGTT (2-hour plasma glucose after ingesting 75-g load)*
Prediabetes (IGT) 140 mg/dL to 199 mg/dL (7.8 mmol/L to 11.0 mmol/L)
Diabetes 200 mg/dL (11.1 mmol/L)
Casual plasma glucose (plasma glucose taken without regard to fasting)
Diabetes Levels 200 mg/dL (11.1 mmol/L) are considered diagnostic
of diabetes in a patient with classic symptoms of
hyperglycemia or hyperglycemic crisis
A1C (measurement of blood glucose over a 2- to 3-month period)*
Prediabetes 5.7% to 6.4%
Diabetes 6.5%
* The risk of developing diabetes in patients is continuous, extending below the lower limit
of the range for identified prediabetes and becoming disproportionately greater at the higher
end of the range.
Prediabetes is considered to be a risk factor for diabetes (and cardiovascular disease)
and should not be considered a diagnosis in its own right.

Unless there is unequivocal hyperglycemia, a second test should be performed to confirm
a diagnosis of diabetes.
Maria: Initial Diagnosis of Diabetes (Part 2)

Maria returns to Dr. Wilkins office a week later to go over the results of the A1C test.
The results show that Maria has an A1C of 7.2%, which meets one of the criteria for
the diagnosis of diabetes. Dr. Wilkins conducts another A1C test, and the result of this
one is 7.3%.

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SUMMARY
The following table summarizes the information presented in this chapter on the diagnosis of diabetes.
Diagnosis of Diabetes
Diagnosis in Symptomatic Patients
Some patients with diabetes are diagnosed by their physicians only after they develop symptoms of the disease
(e.g., polyuria, polydipsia, polyphagia)
At diagnosis, patients with diabetes may already be experiencing some of the long-term complications of diabetes
long-term complications of diabetes include macrovascular disease (e.g., coronary artery disease) and
microvascular disease (e.g., retinopathy)
When symptomatic patients enter a physicians office, the physician will perform a complete medical examination,
including a medical history and physical examination; the patient will also undergo laboratory tests that can
diagnose diabetes
Diagnostic Tests for Diabetes
Laboratory tests are required to confirm a diagnosis of diabetes. Tests that are used to confirm the diagnosis
of diabetes include:
A1C: measured regardless of fasting status
; provides an estimate of the patients glucose levels over the preceding 2 to 3 months
Casual plasma glucose: glucose is measured regardless of whether the patient has eaten or is fasting
Fasting plasma glucose: glucose is measured when the patient has not eaten for at last 8 hours
OGGT: glucose is measured in a patient who has fasted for at least 8 hours and 2 hours after the patient
drinks a solution containing a high glucose concentration
Unless the patient has clear symptoms (e.g., hyperglycemic crisis) a second laboratory test should be conducted
to confirm a diagnosis of diabetes
Screening in Asymptomatic Adults
Some patients may be diagnosed when they are asymptomatic (e.g., during screening of a high-risk patient, or
incidentally when the patient visits the doctor for treatment of another ailment)
The ADA recommends screening for diabetes in certain high-risk populations, including individuals who are
overweight and have one or more additional risk factors. Additional risks factors include: lead a sedentary lifestyle;
have a family history of diabetes; individuals of certain race/ethnicity; individuals with hypertension, dyslipidemia,
prediabetes (i.e., A1C between 5.7% and 6.4%, IGT, or IFG on previous testing), PCOS with BMI 30 mg/kg2, or
another condition associated with insulin resistance; and women who have a history of gestational diabetes or have
delivered a baby weighing >9 lb
(cont.)

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Diagnosis of Diabetes (cont.)

ADA: Diagnostic Criteria for Diabetes
A1C: levels 6.5% are considered diagnostic of diabetes; patients with levels between 5.7% and 6.4% are at high
risk for development of diabetes
Casual plasma glucose: levels 200 mg/dL (11.1 mmol/L) are considered diagnostic of diabetes in a patient with
classic symptoms of hyperglycemia or hyperglycemic crisis
Fasting plasma glucose: levels 126 mg/dL (7 mmol/L) are considered diagnostic of diabetes; patients with levels
100 mg/dL to 125 mg/dL (5.6 mmol/L to 6.9 mmol/L) are considered to have IFG
OGGT: levels 200 mg/dL (11.1 mmol/L) are considered diagnostic of diabetes; patients with levels 140 mg/dL
to 199 mg/dL (7.8 mmol/L to 11.0 mmol/L) are considered to have IGT
Individuals with A1C between 5.7% and 6.4%, IFG, or IGT may be referred to as having prediabetes because they
have a very high risk for development of diabetes in the future; however, prediabetes is considered to be a risk
factor for diabetes (and cardiovascular disease) and should not be considered a diagnosis in its own right

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___________________________________________________________________________Self-Assessment Questions
SELF-ASSESSMENT QUESTIONS
There may be more than one correct answer to each question.
1. Symptoms that may lead a physician to suspect diabetes include:
_____ A. polyphagia.
_____ B. polymeria.
_____ C. polyuria.
_____ D. polydipsia.
2. A(n) _____________ test is taken without regard to the timing and content of the last meal.
_____ A. postprandial glucose
_____ B. oral glucose tolerance
_____ C. casual plasma glucose
_____ D. fasting plasma glucose
3. Match each test with its description.
A. A1C _____ 1 Measured when the patient has not eaten

for 8 hours
B. Casual plasma glucose _____
2 Provides an estimate of blood glucose
C. OGTT _____ control over the previous 2 to 3 months
D. FPG _____ 3 Measured after the patient drinks a solution

high in glucose
4 Provides the blood glucose level regardless

of the last meal

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4. When evaluating an FPG test, the range consistent with impaired fasting glucose is:
_____ A. 80 to 90 mg/dL (4.4 to 5.0 mmol/L).
_____ B. 100 to 125 mg/dL (5.6 to 6.9 mmol/L).
_____ C. 140 to 199 mg/dL (7.8 to 11.0 mmol/L).
_____ D. 200 mg/dL (11.1 mmol/L).
5. What is the A1C value that is diagnostic of diabetes?
______________________________________________________________________________________________

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___________________________________________________________________________Self-Assessment Questions

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SELF-ASSESSMENT QUESTIONSANSWERS
1. A, C, D
2. C
3. A2; B4; C3; D1
4. B
5. 6.5%

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______________________________________________________ Chapter 2: Comprehensive Management of Diabetes
CHAPTER 2: COMPREHENSIVE MANAGEMENT

OF DIABETES
INTRODUCTION
After a diagnosis of diabetes, patients and physicians face a number of issues regarding
treatment and management. The issues surrounding diabetes care are complex, and
organizations such as the ADA, AACE, and VA/DoD have developed recommendations
for the management of diabetes. This chapter begins by describing the healthcare
professionals who treat patients with diabetes. It then describes treatment standards,
as well as the key clinical trials that have established the validity of these standards.
Case studies are used to illustrate ongoing care and the importance of the team approach
to manage this disease.
LEARNING OBJECTIVES
Upon completion of this chapter, you should be able to:
1. Describe the components of a comprehensive diabetes examination.
2. List the healthcare professionals involved in the care of patients with type 2 diabetes
and describe their roles.
3. Summarize the ABCs of diabetes.
4. State the normal ranges and goals for patients with type 2 diabetes for A1C, blood
pressure, and lipids.
5. Define self-monitored blood glucose.
6. State key results from studies that emphasize the importance of glucose, blood
pressure, and lipid control.
7. Describe research that supports additional treatment considerations regarding
early diagnosis of diabetes and treatment of nephropathy.

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COMPREHENSIVE DIABETES EVALUATION

The ADA guidelines list the components that should be included in a comprehensive
diabetes evaluation (see Table 5).
Table 5. Components of the Comprehensive Diabetes Evaluation

Medical History
Patients history of diabetes (e.g., age of onset, characteristics of onset, diabetes education,
review of previous treatments and response to therapy)
Lifestyle characteristics (e.g., eating habits, physical activity)
Current treatment of diabetes (e.g., current medications, meal plan, physical activity patterns,
and readiness for behavior change)
Results of glucose monitoring and patients use of data
History of diabetic ketoacidosis, including severity and cause
Hypoglycemic episodes, including patient awareness and the frequency and cause of
severe episodes
History of diabetes-related complications (micro- and macrovascular)
Physical Examination
Height, weight, body mass index
Blood pressure test, including orthostatic measurements when indicated
Thyroid palpation
Skin examination (for acanthosis nigricans and insulin injection sites)
Annual comprehensive foot examination (i.e., visual inspection, palpitation of dorsalis pedis
and posterior tibial pulses, testing of patellar and Achilles reflexes, and evaluation of
proprioception, vibration, and monofilament sensation)
Visual inspection of the patients feet at every routine office visit
Laboratory Evaluation
A1C, if results not available from the past 2 to 3 months
If not evaluated within the past year:
Fasting lipid profile
Liver function tests
Test for urinary albumin excretion with spot urine albumin-to-creatinine ratio
Serum creatinine and calculated GFR
Thyroid-stimulating hormone in type 1 diabetes, dyslipidemia, or women over age
50 years
Referrals
Eye care professional for annual dilated eye exam (funduscopic examination)
Family planning for women of reproductive age
Registered dietitian for medical nutrition therapy
Diabetes self-management education
Dentist for comprehensive periodontal examination (evaluation for dental disease)
Mental health professional, if needed
Podiatrist

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HEALTHCARE PROFESSIONALS
Both the ADA and AACE recommend that patients receive medical treatment from
a coordinated, multidisciplinary medical team. The following case study illustrates this
team of healthcare professionals. In some cases, primary care physicians, such as
general practitioners (GPs), family practitioners (FPs), and internists, provide the bulk of
routine care for patients with diabetes, including performing eye exams and foot exams.
Edna: Patient With Diabetes for 15 years

Edna, a 68-year-old woman, has had type 2 diabetes for 15 years. She has had
difficulty controlling her glucose levels, especially after dinner. She knows that she
needs to eat on a regular schedule, but finds the schedule very difficult to maintain.
Edna has tried to exercise as her physician recommends, but finds that her legs
become painful upon exertion. In addition, she recently has had difficulty with her
vision, and as an avid reader, this has become a source of frustration for her.
At her visit, her GP decides that Edna should start seeing a diabetes educator again,
as she had soon after she was diagnosed 15 years ago. Her GP also refers Edna
to a vascular surgeonbecause he is worried about blood flow in her legsand an
ophthalmologistbecause he is worried about her vision.
The following table describes some of the primary care healthcare professionals who may
care for patients with diabetes.

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Table 6. Primary Care Professionals and Their Roles in Diabetes
Primary Care Professional Role in Diabetes Treatment
Physicians Most patients are initially seen by a nonspecialist

Family practitioners physician, who may treat them or refer them to a specialist
General practitioners These physicians may:

Perform periodic physical examinations
Internists
Provide care for non-diabetesrelated ailments
See patients who require immediate evaluation of a
medical issue
Monitor laboratory tests
Provide educational material on nutrition, exercise,
and treatment compliance
Nurse practitioners, Nurse practitioners and physicians assistants provide
physicians assistants, healthcare services, typically under the supervision of a
and/or diabetes nurse physician; may work in specialty areas, including diabetes
educators Diabetes nurse educators are registered nurses who have
special education and background caring for and teaching
individuals with diabetes
Pharmacists Experts on the pharmacologic management of diabetes;
provide diabetes medications and supplies, medication
information, health advice, and instruction on the use of
glucose monitors and insulin
In addition to primary care professionals, specialist healthcare professionals are often

involved in the management of patients with diabetes. The following table describes
some of these specialists and their roles in diabetes care.

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Table 7. Specialists and Their Roles in Diabetes
Specialist Role in Diabetes Treatment

Endocrinologists Physicians trained in diseases such as diabetes and thyroid
diseases
May be the primary physician or consultant for patients with
diabetes and difficult-to-control glucose levels or other comorbid
conditions
Cardiologists Physicians trained in diseases that affect the cardiovascular
system, including the heart, arteries, and veins
May treat patients with diabetes and diagnosed cardiovascular
disease or cardiovascular risk factors
Nephrologists Physicians trained in diseases that affect the kidneys
Patients with diabetes who need treatment for diabetic
nephropathy (nuh-FROP-uh-thee): nephropathy may be referred to a nephrologist
kidney damage that can arise
as a complication of chronic Ophthalmologists/ Healthcare professionals trained in medical care of the eye
hyperglycemia optometrists In order to screen for diabetic retinopathy, patients with diabetes
should receive a dilated eye examination annually from an
retinopathy (ret-n-OP-uh-thee):
damage to the retina of the eye; ophthalmologist or optometrist who is knowledgeable and
can lead to blindness experienced in the diagnosis and management of diabetic
retinopathy
Podiatrists Physicians trained in care of the foot, ankle, and lower leg
(chiropodists) Patients with diabetes should receive an annual comprehensive
foot examination with particular attention to high-risk foot
conditions, including bony deformities, limitation in joint mobility,
and problems with gait and balance
Registered Specialists trained in the study of nutrition
dietitians Patients with diabetes will most likely need to modify their diets,
and dietitians can help plan meals and educate patients about
eating in accordance with nutritional guidelines and needs for
glycemic control
Diabetes Healthcare professionals (may include nurses, registered dietitians,
educators/ or pharmacists) with specialized patient education skills who are
counselor certified in diabetes education
Diabetes educators teach patients about optimal diabetes care;
topics include self-monitoring of blood glucose, insulin
administration, and risk factor-modifying activities
Mental health Healthcare professionals with specialized training in the treatment
specialists with a of mental health (e.g., depression, anxiety)
focus on diabetes May be needed for some patients with diabetese.g., those
suffering from depression (with evidence of potential for self-harm)
or debilitating anxiety, those who may have an eating disorder,
and those with impaired cognitive function that significantly
impairs judgment

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ONGOING EVALUATION
After patients like Edward and Maria are diagnosed with type 2 diabetes, a lifetime of
monitoring and managing health issues begins. Type 2 diabetes is a chronic illness
that requires continual medical care and patient self-management to prevent acute
complications and to reduce the risk of long-term complications This includes:
Blood glucose monitoring: A1C and self-monitored blood glucose (SMBG); used to
determine the effectiveness of current therapy and to guide changes in medication,
diet, and other aspects of care
Blood pressure and cholesterol monitoring (cardiovascular disease [CVD] risk factors)
Screening for additional CVD risk factors (e.g., smoking, family history of premature
coronary disease, microalbuminuria or macroalbuminuria)
Monitoring for microvascular complications microalbuminuria (MAHY-kroh-al-

byoo-muh-NYOOR-ee-uh):
the leakage of a small amount
Routine screening for depression of albumin into the urine, defined
as 20 mcg/min to 200 mcg/min
Routine screening for obstructive sleep apnea, particularly in men over 50 years of macroalbuminuria (MAK-roh-al-
age; consider referral to a sleep specialist for patients with suspected sleep apnea byoo-muh-NYOOR-ee-uh):
the leakage of large amounts of
albumin into the urine; defined
The ABCs of Diabetes as >200 mcg/min
Achieving and maintaining recommended blood glucose, blood pressure, and

cholesterol levels has been shown to reduce the complications associated with diabetes.
These three treatment areas are collectively referred to as the ABCs of diabetes:
A = A1C test (generally recommended goal <7%)
B = Blood pressure (generally recommended goal <130/80 mm Hg)
C = Cholesterol (LDL-C <100 mg/dL)
Helping patients to achieve their recommended ABC goals is an important component

of ongoing evaluation of a patient with diabetes, and the general recommendations for
each of these components will be reviewed in the upcoming pages. Keep in mind that
these general recommendations need to be modified to meet the goals and needs of
the individual patient.

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A1C Testing
The standard measure used to test glucose control is the A1C test, which, as noted
previously, can provide an estimate of blood glucose control for the previous 2 to
3 months.
The A1C goal for patients with diabetes is:
ADA: <7.0%. The ADA guidelines note that, for selected individual patients, providers
might reasonably suggest even lower A1C goals than the general goal of <7%, if this
hypoglycemia can be achieved without significant hypoglycemia or other adverse effects of
(hahy-poh-glahy-SEE-mee-uh):
abnormally low concentrations of
treatment. Such patients might include those with short duration of diabetes, long life
glucose in the circulating blood expectancy, and no significant cardiovascular disease. Conversely, less stringent A1C
goals (e.g., <8%) may be appropriate for patients with a history of severe
hypoglycemia, limited life expectancy, advanced microvascular or macrovascular
complications, extensive comorbid conditions, and those with long-standing diabetes in
whom the general goal is difficult to attain.
AACE: 6.5%. The AACE notes that no randomized controlled trials have established
optimum glycemic targets and while some organizations recommend target A1C
goals of <6.5%, others recommend target A1C levels of <7%. All organizations have
recognized the risks of intensive treatment to achieve target glucose levels may
outweigh the benefits of tight glucose control in some patients, including those with
a history of frequent severe hypoglycemia; those with hypoglycemia unawareness;
and those with long-standing diabetes, particularly if they have significant
comorbidities or are of advanced age.
Self-Monitored Blood Glucose

Self-monitored blood glucose (SMBG) is a key component of diabetes management.
SMBG provides real-time information to patients regarding glucose levels, identifying
hypoglycemia, hypoglycemic episodes, and on glycemic changes during times of illness.
The most common method of SMBG involves testing a drop of blood, obtained by a finger
prick, using a glucose meter that provides an automated reading.
The frequency of SMBG in patients with type 2 diabetes depends in part on whether they
are using insulin or only oral medications. In general, less frequent SMBG testing is
needed in patients with type 2 diabetes who are treated only with oral medications
because glucose levels tend to fluctuate less. Patients should talk with their healthcare
professionals to determine the frequency and timing of SMBG, since SMBG should be
based on the needs and goals of the individual patient.

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Blood Pressure and Cholesterol Monitoring

In addition to monitoring blood glucose levels, blood pressure and cholesterol also
need to be monitored in patients with diabetes. Approximately 50% of people with
diabetes die of cardiovascular disease (primarily from heart disease and stroke).
Reducing cardiovascular risk factors is therefore a key component of diabetes
management.
Both the ADA and the AACE recommend a target blood pressure of <130/80 mm Hg. The
ADA recommends measuring blood pressure at every routine diabetes visit and notes that
based on patient characteristics and response to therapy, higher or lower systolic BP
goals may be appropriate.
The ADA also recommends that patients receive a fasting lipid profile at least annually. lipid (LIP-id): fat; found almost
exclusively in foods of animal
The following table lists the recommended lipid goals for patients with type 2 diabetes. origin and continuously synthesized
in the body
Table 8. ADA-Recommended Lipid Goals for Patients With Diabetes
ADA Lipid Goals for Patients With Diabetes

Low-density lipoprotein Individuals without overt CVD: <100 mg/dL low-density lipoprotein cholesterol
cholesterol (LDL-C) (LDL-C) (lip-oh-PROH-teen
(<2.6 mmol/L) kuh-LES-tuh-rohl): bad
Optional goal for individuals with overt CVD: cholesterol; transports most
cholesterol in the blood; when
<70 mg/dL (<1.8 mmol/L) present in high amounts, deposits
cholesterol in the walls of arteries,
High-density lipoprotein >40 mg/dL (>1.0 mmol/L) (men) forming lipid plaques
cholesterol (HDL-C) >50 mg/dL (>1.3 mmol/L) (women)
Triglycerides <150 mg/dL (<1.7 mmol/L)
Smoking Cessation
Because of the large body of evidence linking smoking to cardiovascular disease, an
additional recommendation is that all patients should be advised not to smoke. Smoking
cessation counseling and other forms of treatment should be included as a routine
component of diabetes care.

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Monitoring for Microvascular Complications

Additional tests are also necessary to monitor for microvascular complications in patients
with diabetes, as described in the following table.
Table 9. Guidelines for Monitoring Microvascular Complications
Complication Tests
Retinopathy At diagnosis and then annually:
Comprehensive eye examination
Dilated eye examination to assess retina
Nephropathy Annual measurement of:
Protein in the urine (microalbuminuria is an early
sign of kidney disease)
Potassium levels
creatinine: (kree-AT-n-in): At least annually, measure serum creatinine and
a waste product filtered from the calculate the estimated glomerular filtration rate
blood and excreted in the urine
(GFR) using either Modification in Diet of Renal
glomerular filtration rate (GFR): Disease (MDRD) or Chronic Kidney Disease
amount of fluid filtered from the
kidney per unit of time; used to
Epidemiology Collaboration (CKD EPI) equations
measure kidney function
Neuropathy Extremity (especially lower extremity) examination
Modification in Diet of Renal at least annually, including skin condition, circulation,
Disease (MDRD) equation: and nerve function (fine touch, vibration, reflexes, etc.)
estimates glomerular filtration rate
adjusted for body surface area;
variables are serum creatinine, age,
gender, and race; this equation is Summary of Ongoing Monitoring
widely used by clinical laboratories
and research studies
Chronic Kidney Disease

Maria: Ongoing Evaluation
Epidemiology Collaboration (CKD
EPI) equation: estimates glomerular Three months after confirming that Maria has type 2 diabetes, Dr. Wilkins decided
filtration rate based on the level of to test Marias A1C level to monitor her glucose control. In addition, Dr. Wilkins
serum creatinine, age, sex, and race;
is as accurate as the MDRD equation
checked Marias feet, blood pressure, lipid levels, and the amount of protein in her
in patients with GFR <60 mL/min/ urine. The results showed that Marias A1C was 7.3%, which is slightly higher than
1.73 m2 and more accurate than the recommended levels. On the other hand, Dr. Wilkins was happy to see that
the MDRD equation in patients
with GFR >60 mL/min/1.73 m2 Marias blood pressure was down to 127/77 mm Hg, which is within the recommended
range (<130/80 mm Hg). Marias lipid levels were also within the recommended
neuropathy (nyoo-ROP-uh-thee): ranges, and she did not have protein in her urine. Marias feet looked healthy, with no
nerve damage, primarily peripheral
neuropathy (in which the nerves in ulcerations or lack of sensation. In addition to these tests, Dr. Wilkins recommended
the extremities are affected); loss that Maria schedule an appointment with a diabetes educator to help her reach
of sensation may occur, which may
result in serious infection, gangrene,
her A1C goal and that Maria contact her optometrist or ophthalmologist for a
and the need for amputation comprehensive eye exam.

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SUMMARY
The following table summarizes the information presented in this chapter on the management of diabetes.
Management of Diabetes
Healthcare professionals
Primary care professionals who may treat the patient with diabetes include family practitioners, general
practitioners, internists, nurse practitioners, physician assistants, and diabetes nurse educators
Pharmacists are experts on the pharmacologic management of diabetes; they may provide medication
information, instruction, or health advice
Specialists who may treat patients with diabetes include endocrinologists, cardiologists, nephrologists,
optometrists/ophthalmologists, podiatrists, registered dietitians, diabetes educators/counselors, and mental
health specialists
ABCs of diabetes
The ABCs of diabetes are:
A = A1C (general treatment goal of <7%)
B = Blood pressure (general treatment goal of <130/80 mg Hg)
C = Cholesterol (general treatment goal of LDL-C<100 mg/dL)
Achieving and maintaining the recommended goals can help delay or prevent the complications associated
with diabetes.
Ongoing evaluation
A1C: High percentages of A1C in the blood indicate suboptimal glucose control in patients with diabetes
Testing a patients blood for the A1C level provides a record of blood glucose control for the previous 2 to
3 months
Recommendations for A1C goals in patients with diabetes are:
ADA: <7%. For selected individual patients, even lower A1C goals may be reasonable if this can be
achieved without significant hypoglycemia or other adverse effects of treatment; conversely, less stringent
A1C goals may be appropriate for other patients, including those with a history of severe hypoglycemia or
those in whom the general goal is difficult to attain
AACE: 6.5%. Notes that randomized controlled studies have not determined an optimum blood glucose
level, and some organizations recommend A1C levels <6.5% while others, such as the ADA, recommend
levels <7%
Self-monitored blood glucose (SMBG): Patients test a drop of blood in a glucose meter that provides an
automated glucose level reading; SMBG provides real-time feedback to patients regarding glucose levels
(cont.)

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Management of Diabetes (continued)

Ongoing evaluation (continued)
Blood pressure and cholesterol
Blood pressure should be measured at every routine visit
Lipid levels should be monitored at least annually
Smoking: Patients should be advised not to smoke, and smoking cessation counseling and other forms of
treatment should be included as a routine component of diabetes care
Monitoring for microvascular complications
Retinopathy: at diagnosis and then annually: visual acuity and dilated eye exam of the retina
Nephropathy: annual urine for microalbuminuria and serum creatinine, with calculation of GFR using MDRD
or CKD EPI equations
Neuropathy: lower extremity examination at least annually

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SELF-ASSESSMENT QUESTIONS
There may be more than one correct answer to each question.
1. A(n) __________ is a physician specializing in diseases such as diabetes and thyroid disease.
_____ A. nephrologist
_____ B. podiatrist
_____ C. endocrinologist
_____ D. ophthalmologist
2. The hemoglobin A1C test is used to measure:
_____ A. plasma glucose levels.
_____ B. complications of diabetes.
_____ C. blood glucose control over time.
_____ D. insulin levels over time.
3. Advantages of SMBG testing include that it:
_____ A. provides real-time information regarding glucose levels.
_____ B. is normally performed by a general practitioner.
_____ C. predicts risk of cardiovascular complications.
_____ D. allows patients to participate in their own care.
4. Which of the following statements about A1C is (are) true?
_____ A. The AACE notes that no randomized controlled trials have established optimum A1C targets.
_____ B. The ADA recommends a target A1C for patients with diabetes of 5% to 6%.
_____ C. The ADA acknowledges that the A1C target may vary for individual patients.

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SELF-ASSESSMENT QUESTIONSANSWERS
1. C
2. C
3. A, D
4. A, C

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___________________________________________________________________________________Module Summary
MODULE SUMMARY
1) Some patients who are diagnosed with type 2 diabetes initially present to their
physicians because they have symptoms. Symptoms that can lead a physician
to suspect diabetes include:
Polyuria
Polydipsia
Polyphagia
Unexplained weight loss
Patients may also present with long-term complications of diabetes.
Diagnostic tests for diabetes are:

An A1C test to assess the average glucose over the previous 2 to 3 months
Casual or random test, taken without regard to the time of the last meal
and not fasting
Fasting plasma glucose (FPG), taken >8 hours after the last meal
Oral glucose tolerance test (OGTT), taken >8 hours after the last meal
and 2 hours after drinking a standardized solution that is high in glucose
Unless a patient has clear symptoms, a second diagnostic test should be taken
to confirm a diagnosis of diabetes.
Some patients with diabetes remain asymptomatic for many years. For this reason,
in many patients, their diabetes is detected when they visit their physicians for other
reasons. Therefore, some organizations recommend routine diabetes screening,
especially in patients identified as high-risk based on:
Age
Race
Family history of diabetes
Overweight or obese
Sedentary lifestyle
History of cardiovascular disease, peripheral vascular disease, or hypertension
A1C between 5.7% and 6.4% on previous testing
Previously identified IGT, IFG, metabolic syndrome, or other clinical conditions
associated with insulin resistance

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Women with polycystic ovary syndrome and BMI 30 mg/kg2

Women with a history of gestational diabetes or who have delivered a baby
weighing >9 lb
Individuals with increased levels of triglycerides, decreased levels of HDL-C,
or both
Any of the 4 blood glucose tests may provide a diagnosis of diabetes. The levels
that are consistent with a diagnosis of diabetes for each of these tests are:
A1C: 6.5%
Casual plasma glucose: 200 mg/dL (11.1 mmol/L)
FPG: 126 mg/dL (7.0 mmol/L)
OGTT: 200 mg/dL (11.1 mmol/L)
2) Because of the extensive, ongoing treatment needed by patients with diabetes,

many kinds of healthcare specialists are often involved. These may include:
Primary care physicians (general practitioners, internists, and family
practitioners)
Nurse practitioners, physicians assistants, and diabetes nurse educators
Pharmacists
Endocrinologists
Cardiologists
Nephrologists
Ophthalmologists
Podiatrists
Registered dietitians
Patients with type 2 diabetes require continual monitoring of A1C and blood
glucose, as well as monitoring for complications of diabetes.
In particular, ongoing evaluation is important to help patients achieve and maintain

their ABC goals, because achieving and maintaining the recommended goals has
been shown to prevent or delay diabetes-related complications. The ABCs of
diabetes are: A = A1C (generally recommended goal <7%)
B = Blood pressure (generally recommended goal <130/80 mm Hg)
C = Cholesterol (generally recommended goal LDL-C <100 mg/dL)

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___________________________________________________________________________________Module Summary
High percentages of A1C in the blood indicate suboptimal glucose control in

patients with diabetes. Testing a patients blood for the A1C level provides a
record of blood glucose control for the previous 2 to 3 months. Generally, the
ADA recommends an A1C goal of <7% for patients with diabetes, although
providers may suggest lower or higher A1C goals for selected patients.
In self-monitored blood glucose (SMBG) testing, patients test a drop of blood in a

glucose meter that provides an automated glucose level reading. SMBG provides
real-time feedback to patients regarding their blood glucose levels.
Since cardiovascular disease is the major cause of death in patients with diabetes,
blood pressure should be measured at every routine diabetes visit and lipid levels
should be monitored at least annually.
Patients should be advised not to smoke, and smoking cessation counseling and
other forms of treatment should be included as a routine component of diabetes care.
Microvascular complications also require monitoring.

Retinopathy: visual acuity test and dilated eye exam of the retina should be
taken at diagnosis and then annually
Nephropathy: annual testing for protein in the urine (microalbuminuria is an early
sign of kidney disease; at least annually, measure:
Serum creatinine and calculate eGFR using either the MDRD or CKD EPI
equations
Potassium levels
Neuropathy: extremity (especially lower extremity) examination at least annually

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__________________________________________________________________________________________Glossary
GLOSSARY
body mass index (BMI): calculated value used to describe an individuals weight relative to height; calculated using
the following formula: BMI = kg/m2
Chronic Kidney Disease Epidemiology Collaboration (CKD EPI) equation: estimates glomerular filtration rate
based on the level of serum creatinine, age, sex, and race; is as accurate as the MDRD equation in patients with
GFR <60 mL/min/1.73 m2 and more accurate than the MDRD equation in patients with GFR >60 mL/min/1.73 m2
creatinine (kree-AT-n-in): a waste product filtered from the blood and excreted in the urine
fasting plasma glucose (FPG): test of blood glucose levels; measured when the patient has not eaten for at least 8 hours
glomerular filtration rate (GFR): amount of fluid filtered from the kidney per unit of time; used to measure kidney function
glycosylated hemoglobin (A1C) (glahy-KOS-uhl-ahyt-ed HEE-muh-gloh-bin): the amount of hemoglobin within

red blood cells with glucose attached; provides an estimate of blood sugar control for the previous 2 to 3 months
glycosylation (glayh-KOS-uhl-ay-shun): the chemical linkage of sugar molecules to proteins
high-density lipoprotein cholesterol (HDL-C) (lip-oh-PROH-teen kuh-LES-tuh-rohl): good cholesterol; transports

excess cholesterol to the liver for elimination
hyperglycemia (hahy-per-glahy-SEE-mee-uh): abnormally high blood glucose levels
hypertension: elevated blood pressure
hypoglycemia (hahy-poh-glahy-SEE-mee-uh): abnormally low concentrations of glucose in the circulating blood
impaired fasting glucose (IFG): fasting glucose levels higher than normal but not high enough for a diagnosis of
diabetes; defined as glucose 100 mg/dL to 125 mg/dL (5.6 mmol/L to 6.9 mmol/L)
impaired glucose tolerance (IGT): glucose levels measured during an oral glucose tolerance test that are higher than
normal but not high enough for a diagnosis of diabetes; defined as glucose 140 mg/dL to 199 mg/dL (7.8 mmol/L to
11 mmol/L)
insulin (IN-suh-lin): hormone secreted by the beta-cells of the pancreas that is the key regulator of the metabolism of
glucose and processes necessary for metabolism of fats, carbohydrates, and proteins; opposes the action of glucagon
lipid (LIP-id): fat; found almost exclusively in foods of animal origin and continuously synthesized in the body
low-density lipoprotein cholesterol (LDL-C) (lip-oh-PROH-teen kuh-LES-tuh-rohl): bad cholesterol; transports most
cholesterol in the blood; when present in high amounts, deposits cholesterol in the walls of arteries, forming lipid plaques
macroalbuminuria (MAK-roh-al-byoo-muh-NYOOR-ee-uh): the leakage of large amounts of albumin into the urine;
defined as >200 mcg/min

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microalbuminuria (MAHY-kroh-al-byoo-muh-NYOOR-ee-uh): the leakage of a small amount of albumin into the urine,
defined as 20 mcg/min to 200 mcg/min
Modification in Diet of Renal Disease (MDRD) equation: estimates glomerular filtration rate adjusted for body
surface area; variables are serum creatinine, age, gender, and race; this equation is widely used by clinical laboratories
and research studies
morbidity (mawr-BID-i-tee): sickness or disease
mortality (mawr-TAL-i-tee): death rate
nephropathy (nuh-FROP-uh-thee): kidney damage that can arise as a complication of chronic hyperglycemia
neuropathy (nyoo-ROP-uh-thee): nerve damage, primarily peripheral neuropathy (in which the peripheral nerves in the
extremities are affected); can result in loss of sensation, which may result in serious infection, gangrene, and the need for
amputation
oral glucose tolerance test (OGTT): measures the 2-hour postload glucose (PG) value; patient is tested 2 hours after
ingesting 75 g of glucose
polycystic ovary syndrome (POL-ee-sis-tik): a health problem that can affect a womans menstrual cycle, fertility,
hormones, insulin production, heart, blood vessels, and appearance; may be characterized by high levels of male
hormones (androgens), abnormal menstrual cycle, and small cysts in ovaries
polydipsia (pol-ee-DIP-see-uh): excessive thirst
polyphagia (pol-ee-FEY-jee-uh): excessive eating
polyuria (pol-ee-YOOR-ee-uh): excessive urination
postprandial (pohst-PRAN-dee-uhl): after a meal
preprandial (pree-PRAN-dee-uhl): before a meal
retinopathy (ret-n-OP-uh-thee): damage to the retina of the eye; can lead to blindness
triglyceride (trahy-GLIS-uh-rahydz): lipid molecules containing 3 fatty acids bound to glycerol; the primary fat in the diet
and the primary molecule used for fuel storage

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________________________________________________________________________________________References
REFERENCES
1. American Association of Clinical Endocrinologists. https://www.aace.com/publications. Accessed October 12, 2012.
2. American Diabetes Association. Diagnosis and classification of diabetes mellitus. Diabetes Care. 2012;35(suppl 1):
S64-S71.
3. American Diabetes Association. Standards of medical care in diabetes2012. Diabetes Care. 2012;35(suppl 1) :
S11-S63.
4. Brownlee M, Aiello LP, Cooper ME, Vinik AI, Nesto RW, Boulton AJM. Complications of diabetes mellitus. Chapter 33
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X..DOCPDF.
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12th ed. Elsevier Saunders; 2012.
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Module 2 Pathophysiology Type Diabetes

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Module 2 Pathophysiology Type Diabetes

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DIABETES LEARNING SYSTEM

MODULE 2: DIAGNOSIS OF TYPE 2 DIABETES

CONFIDENTIAL: For Training Purposes OnlyNot for Promotional Use

CONFIDENTIAL: For Training Purposes OnlyNot for Promotional Use

CHAPTER 1: DIAGNOSIS OF DIABETES ............................................................................................................................ 3

SELF-ASSESSMENT QUESTIONS .................................................................................................................................... 17

CHAPTER 2: COMPREHENSIVE MANAGEMENT OF DIABETES .................................................................................... 21

CONFIDENTIAL: For Training Purposes OnlyNot for Promotional Use m

m CONFIDENTIAL: For Training Purposes OnlyNot for Promotional Use

American Diabetes Association (ADA), which publishes a variety of clinical materials,

American Association of Clinical Endocrinologists (AACE), which publishes a variety

CONFIDENTIAL: For Training Purposes OnlyNot for Promotional Use 1

2 CONFIDENTIAL: For Training Purposes OnlyNot for Promotional Use

CHAPTER 1: DIAGNOSIS OF DIABETES

The first caseEdwardillustrates how type 2 diabetes is diagnosed in a symptomatic

CONFIDENTIAL: For Training Purposes OnlyNot for Promotional Use 3

4 CONFIDENTIAL: For Training Purposes OnlyNot for Promotional Use

DIAGNOSIS IN SYMPTOMATIC PATIENTS

Edward: Initial Assessment by Dr. Chu (Part 1)

CONFIDENTIAL: For Training Purposes OnlyNot for Promotional Use 5

DIAGNOSTIC TESTS FOR DIABETES

Casual plasma glucose (also known as random plasma glucose): measured

6 CONFIDENTIAL: For Training Purposes OnlyNot for Promotional Use

Figure 1. Formation of A1C

Figure 2. Normal Versus Elevated Levels of A1C

CONFIDENTIAL: For Training Purposes OnlyNot for Promotional Use 7

Table 1. Correlation Between A1C and Mean Plasma Glucose Levels

A1C Mean Plasma Glucose

Worldwide standardized testing (less chance for error)

Is less affected by day-to-day changes caused by stress or illness

8 CONFIDENTIAL: For Training Purposes OnlyNot for Promotional Use

Advantages to Using A1C to Diagnose Diabetes

Casual (or random) Plasma Glucose

Preprandial (pre = before, prandial = eating) preprandial (pree-PRAN-dee-uhl):

Postprandial (post = after, prandial = eating) postprandial

CONFIDENTIAL: For Training Purposes OnlyNot for Promotional Use 9

Measurement of Fasting Plasma Glucose

Normal (indicating no diabetes)

Normal (indicating no diabetes)

10 CONFIDENTIAL: For Training Purposes OnlyNot for Promotional Use

Confirmation of Test Results

Edwards Case: Follow-up Visit

Edward: Follow-up Visit

SCREENING IN ASYMPTOMATIC ADULTS

CONFIDENTIAL: For Training Purposes OnlyNot for Promotional Use 11

Maria: Initial Assessment by Dr. Wilkins (Part 1)

12 CONFIDENTIAL: For Training Purposes OnlyNot for Promotional Use

Table 3. ADA Recommendations for Testing in Asymptomatic Adults

ADA Recommendations for Testing in Asymptomatic Adults

CONFIDENTIAL: For Training Purposes OnlyNot for Promotional Use 13

DIAGNOSTIC CRITERIA FOR DIABETES

Table 4. Diagnostic Glucose Values and A1C Levels

ADA Diagnostic Glucose Values and A1C Levels

and should not be considered a diagnosis in its own right.

Maria: Initial Diagnosis of Diabetes (Part 2)

14 CONFIDENTIAL: For Training Purposes OnlyNot for Promotional Use

CONFIDENTIAL: For Training Purposes OnlyNot for Promotional Use 15

Diagnosis of Diabetes (cont.)

16 CONFIDENTIAL: For Training Purposes OnlyNot for Promotional Use

1. Symptoms that may lead a physician to suspect diabetes include:

_____ A. postprandial glucose

_____ B. oral glucose tolerance

_____ C. casual plasma glucose

_____ D. fasting plasma glucose