Introduction

Type 2 Diabetes Defeated

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The aim of this chapter is to describe the current treatment guidelines and goals of therapy for patients with diabetes mellitus as outlined by the American Diabetes Association (ADA) (1-3; Table 1). Each year the ADA publishes "Clinical Practice Recommendations," which are standards that have been shown to minimize the risk of both short-term (i.e., hypoglycemia) and long-term complications of diabetes. Such standards also allow objective assessment of the care provided by practitioners in managing patients with diabetes.

Over the past few years, the federal government has indicated great interest in improving diabetes care in the United States. The Diabetes Quality Improvement Project (DQEP), a collaborative effort of many groups involved with diabetes care, resulted in the development of a set of diabetes-specific performance and outcome measures—die first nationwide performance measures widely adopted by the health-care community. The National Committee for Quality Assurance (NCQA) included the DQIP measures in HEDIS 2000 (Health Employment Data Information Set), its evaluation program for accrediting health-care plans. In addition, the Heath Care Financing Administration (HCFA) now requires all health plans contracting with Medicare to report their DQIP data.

Table 1 American Diabetes Association Standards of Care

Measure

Standard

Diagnosis of diabetes Fasting blood glucose (FBG) Casual (random) BG 2-hour OGTT value Blood glucose goals Preprandial Bedtime Hemoglobin Alc Lipids LDL HDL

Triglycerides Blood pressure

Urinary microalbumin/creatinine ratio Dilated eye exam Aspirin Foot exam

Smoking

Immunizations Influenza Pneumococcal

<100 mg/dl (children: <110 mg/dl) >45 mg/dl (men), >55 mg/dl

<130/80 (children: <90th percentile for age) <30 mg/g creatinine

Yearly

Encouraged unless contraindicated Each visit (high-risk patients); yearly complete exam in all patients Document status, encourage cessation

Yearly

Once. Revaccination of those >64 years of age (see text)

DIAGNOSTIC CRITERIA FOR DIABETES

In 1997, in collaboration with the World Health Organization, the ADA revised the guidelines for the diagnosis of diabetes mellitus into three criteria. If any single criterion is met, the diagnosis of diabetes is made.

1. The presence of the typical symptoms of ongoing hyperglycemia such as polyuria, polydipsia, and weight loss and a casual (random) plasma glucose concentration >200 mg/dl (11.1 mmol/L) or

2. A fasting plasma glucose >126 mg/dl (7.0 mmol/L). Fasting is defined as no caloric intake for at least 8 hours prior to the test or

3. A blood glucose level &200 mg/dl (11.1 mmol/L) at the 2-hour point of a 75-g oral glucose tolerance test (OGTT).

It is recommended that these criteria be confirmed by repeat testing on a different day before the diagnosis is firmly established.

Defining blood glucose levels for the diagnosis of diabetes also provided an opportunity to define blood glucose levels that, while not consistent with diabetes, did not fall within the normal range. Impaired fasting glucose (IFG) is defined as 110 to 125 mg/dl (6.1-7.0 mmol/L) and impaired glucose tolerance (IGT) is a 2-hour value on the OGTT of 140 to 199 mg/dl (7.8-11.1 mmol/L).

Comment: The need to obtain a confirmatory positive test on a different day needs to be considered in the context of the individual patient. A fasting blood glucose (FBG) of 135 mg/dl (7.5 mmol/L) in the absence of any symptoms of hyperglycemia warrants repeating, whereas an FBG of 300 mg/dJ (27.7 mmol/ L) in the setting of polyuria, polydipsia, and weight loss clearly indicates clinical diabetes and need not be repeated prior to beginning treatment. The hemoglobin Alc (HbA,c) was not recommended as a diagnostic test for diabetes because it is not rigorously standardized around the world and the normal range can vary based on the assay used. Nonetheless, while a normal HbA,c does not rule out diabetes, an elevated value is highly significant and supports the diagnosis of diabetes or at least indicates a need for further testing.

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