Screening diagnosis and classification of diabetes
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Screening, diagnosis and classification of diabetes. A. Prof Jonathan Shaw Associate Director Baker IDI Melbourne. Identifying people at risk of developing type 2 diabetes. Test everyone – mass screening Test people who have risk factors for diabetes

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Screening, diagnosis and classification of diabetes

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Screening diagnosis and classification of diabetes

Screening, diagnosis and classification of diabetes

A. Prof Jonathan Shaw

Associate Director Baker IDI

Melbourne


Identifying people at risk of developing type 2 diabetes

Identifying people at risk of developing type 2 diabetes

  • Test everyone – mass screening

  • Test people who have risk factors for diabetes

  • Undertake large-scale, non-invasive, self completed screening, with a validated tool, followed by blood tests for those at high-risk

    • FINDRISK

    • AUSDRISK

  • AUSDRISK

  • Self-completed risk score

  • Developed and validated on Australian data

  • Calculates 5-yr risk of developing diabetes


Screening diagnosis and classification of diabetes

1. Your age group?

Under 35 years 0 pts

35 – 44 years 2 pts

45 – 54 years 4 pts

55 – 64 years6 pts

65 years or over 8 pts

2. Your gender?

Female 0 pts

Male 3 pts


Screening diagnosis and classification of diabetes

3. Ethnicity/Country of birth:

3a. Are you of Aboriginal, Torres Strait Islander, Pacific Islander or Maori descent?

No 0 pts

Yes 2 pts

3b. Where were you born?

Australia0 pts

Asia2 pts

Mid-East, N Africa2 pts

S Europe 2 pts

Other 0 pts


Screening diagnosis and classification of diabetes

4. Have either of your parents, or any of your brothers or sisters been diagnosed with diabetes (type 1 or type 2)?

No 0 pts

Yes 3 pts

5. Have you ever been found to have high blood glucose (sugar) (e.g. in a health examination, during an illness, during pregnancy)?

No 0 pts

Yes 6 pts


Screening diagnosis and classification of diabetes

6. Are you currently taking medication for high blood pressure?

No 0 pts

Yes 2 pts

7. Do you currently smoke cigarettes or any other tobacco products on a daily basis?

No 0 pts

Yes 2 pts


Screening diagnosis and classification of diabetes

8. How often do you eat vegetables or fruit?

Everyday 0 pts

Not everyday 1 point

9. On average, would you say you do at least 2.5 hours of physical activity per week (eg 30 minutes a day on 5 or more days a week)?

Yes 0 pts

No 2 pts


Screening diagnosis and classification of diabetes

  • 10. Your waist measurement taken below the ribs (usually at the level of the navel)?

  • For those of Asian or Aboriginal or Torres Strait Islander descent:

  • Men Women

  • < 90 cm < 80 cm 0 pts

  • 90 – 100 cm 80 – 90 cm 4 pts

  • >100 cm > 90 cm 7 pts

  • For all others:

  • Men Women

  • < 102 cm < 88 cm 0 pts

  • 102 – 110 cm 88 – 100 cm 4 pts

  • > 110 cm > 100 cm 7 pts


Screening diagnosis and classification of diabetes

Your risk of developing type 2 diabetes

within 5 years:

≤ 5: Low risk

Approximately one person in every 100 will develop diabetes.

6-14: Intermediate risk

For scores of 6-8, approximately one person in every 50 will develop diabetes.

For scores of 9-14, approximately one person in every 20 will develop diabetes.

15 or more: High risk

For scores of 15-19, approximately one person in every seven will develop diabetes.

For scores of 20 and above, approximately one person in every three will develop diabetes.


Screening diagnosis and classification of diabetes

Diagnostic criteria for diabetes


Diagnostic thresholds should be defined by

Diagnostic thresholds should be defined by

  • Their association with clinically meaningful abnormalities

  • Level above which intervention is effective

  • Associations with intermediate (metabolic) disturbances

  • Normal limits of a healthy population

    • mean + 2SD

    • 9?th percentile

  • Bimodal distribution


Cut points for diabetes based on

Cut-points for diabetes based on

  • Identifying a glucose threshold for the presence of complications

  • Bi-modal distribution of blood glucose


Cut points for diabetes based on1

Cut-points for diabetes based on

  • Identifying a glucose threshold for the presence of complications

  • Bi-modal distribution of blood glucose


Relative risk of cvd mortality by 2 hr glucose decode

0

Relative risk of CVD mortality by 2-hr glucose - DECODE

6

5

4

3

2

1

0

Relative risk

>14.5

<3.0

Normal

Diabetes

IGT

0246810121416

2-hour plasma glucose (mmol/l)


Screening diagnosis and classification of diabetes

Pima

0

Range of FPG thresholds

7.6-12.5

Egypt

7.2-9.9

US - NHANES

6.7+

ADA. D Care 1997;20:1183-97


Limitations of associations with complications

0

Limitations of associations with complications

  • Thresholds have been based on micro- not macrovascular disease

  • Estimates of threshold values are imprecise (variation between populations, wide limits of deciles)

  • All data are cross-sectional – longitudinal analyses would be likely to give lower cut-points

  • ‘Diabetic retinopathy’ occurs at non-diabetic glucose levels

  • Studies need to have more cases of retinopathy, and be able to use more severe levels of retinopathy


Hba 1c for diagnosis

HbA1C for DIAGNOSIS

PROStable

Time averaged

Reproducible

Fasting not required

CONStandardisation essential

Expensive

Not freely available

Problems with anaemia, haemoglobinopathies

Poor QA schemes in many countries

Few data available

Cutpoint uncertain


Screening diagnosis and classification of diabetes

Prevalence of Sickle cell disorders


Plasma glucose for diagnosis

PLASMA GLUCOSE for DIAGNOSIS

PRODM is disorder of raised glucose

Time honoured

Much data

Allows international comparisons

Accurate assay (?)

CONBased on cross-sectional data in relatively small numbers of studies

Major pre-analytical problems

OGTT required – FPG inadequate

Often poor QA


Screening diagnosis and classification of diabetes

Recommends using HbA1c as the preferred diagnostic test for diabetes

at a cut-point of 6.5%

Diabetes Care July 2009


Screening diagnosis and classification of diabetes

Classification of diabetes


Who reports on classification 1965 1980 1985 1998 2006

WHO reports on classification 1965, 1980, 1985, 1998, 2006


Possible 2009 who classification of diabetes mellitus

POSSIBLE 2009 WHO CLASSIFICATION OF DIABETES MELLITUS

  • Type 1 diabetes (-cell destruction)

  • Type 2 diabetes

  • Other specific types

  • Gestational diabetes mellitus

  • Undefined

ADA, WHO, 1997


Screening diagnosis and classification of diabetes

Classic Onset Type 1

Age of onset

Usually under 30

Usually 30 - 60

Usually over 30 years (except for MODY)

Present-ation

Rapid onset of thirst, polyuria, weight loss

Gradual onset of milder symptoms

Often asymptomatic; may present with complications or gradual onset of symptoms. 85% obese. Part of Metabolic Syndrome.

Ketonuria

Usually present

May be absent

Absent (except with severe stress eg infection, infarction)

Anti-GAD antibodies

Present in approx 80% at diagnosis

C-peptide level

Low or absent, but may be low-normal initially (remission phase)

Normal-high

(ie hyperinsulinemia)

Treatment

Insulin required urgently to prevent ketoacidosis

Insulin required, but not urgently

Healthy eating and exercise, may require oral agents, and/or insulin later

Classic Onset Type 1

Slow Onset Type 1

(LADA)

Type 2

Absent


Summary

Summary

  • Screening

    • Begin with non-invasive score

    • Blood testing in those with a high score

  • Diagnosis

    • HbA1c may become an accepted test

    • Clinical diagnosis requires confirmation with a 2nd test

  • Classification

    • Differentiation between type 1 and 2 increasingly difficult

    • For most patients, classification, and need for insulin can be determined on simple, clinical criteria


Summary1

Summary

  • Screening

    • Begin with non-invasive score

    • Blood testing in those with a high score

  • Diagnosis

    • HbA1c may become an accepted test

    • Clinical diagnosis requires confirmation with a 2nd test

  • Classification

    • Differentiation between type 1 and 2 increasingly difficult

    • For most patients, classification, and need for insulin can be determined on simple, clinical criteria


Summary2

Summary

  • Screening

    • Begin with non-invasive score

    • Blood testing in those with a high score

  • Diagnosis

    • HbA1c may become an accepted test

    • Clinical diagnosis requires confirmation with a 2nd test

  • Classification

    • Differentiation between type 1 and 2 increasingly difficult

    • For most patients, classification, and need for insulin can be determined on simple, clinical criteria


Summary3

Summary

  • Screening

    • Begin with non-invasive score

    • Blood testing in those with a high score

  • Diagnosis

    • HbA1c may become an accepted test

    • Clinical diagnosis requires confirmation with a 2nd test

  • Classification

    • Differentiation between type 1 and 2 increasingly difficult

    • For most patients, classification, and need for insulin can be determined on simple, clinical criteria


Screening diagnosis and classification of diabetes

Some things are more complicated than screening and diagnosing diabetes!


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