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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

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
slide4

1. Your age group?

Under 35 years 0 pts

35 – 44 years 2 pts

45 – 54 years 4 pts

55 – 64 years 6 pts

65 years or over 8 pts

2. Your gender?

Female 0 pts

Male 3 pts

slide5

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?

Australia 0 pts

Asia 2 pts

Mid-East, N Africa 2 pts

S Europe 2 pts

Other 0 pts

slide6

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

slide7

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

slide8

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

slide9

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
slide10

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.

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

0 2 4 6 8 10 12 14 16

2-hour plasma glucose (mmol/l)

slide16

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

PRO Stable

Time averaged

Reproducible

Fasting not required

CON Standardisation essential

Expensive

Not freely available

Problems with anaemia, haemoglobinopathies

Poor QA schemes in many countries

Few data available

Cutpoint uncertain

plasma glucose for diagnosis
PLASMA GLUCOSE for DIAGNOSIS

PRO DM is disorder of raised glucose

Time honoured

Much data

Allows international comparisons

Accurate assay (?)

CON Based on cross-sectional data in relatively small numbers of studies

Major pre-analytical problems

OGTT required – FPG inadequate

Often poor QA

slide21

Recommends using HbA1c as the preferred diagnostic test for diabetes

at a cut-point of 6.5%

Diabetes Care July 2009

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

slide25

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
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