The classification of diabetes mellitus and the tests used for its diagnosis were brought into order by the National Diabetes Data Group of the USA and the second World Health Organization Expert Committee on Diabetes Mellitus in 1979 and 1980. Apart from minor modifications by WHO in 1985, little has been changed since that time. There is however considerable new knowledge regarding the aetiology of different forms of diabetes as well as more information on the predictive value of different blood glucose values for the complications of diabetes. A WHO Consultation has therefore taken place in parallel with a report by an American Diabetes Association Expert Committee to re-examine diagnostic criteria and classification. The present document includes the conclusions of the former and is intended for wide distribution and discussion before final proposals are submitted to WHO for approval. The main changes proposed are as follows. The diagnostic fasting plasma (blood) glucose value has been lowered to > or =7.0 mmol l(-1) (6.1 mmol l(-1)). Impaired Glucose Tolerance (IGT) is changed to allow for the new fasting level. A new category of Impaired Fasting Glycaemia (IFG) is proposed to encompass values which are above normal but below the diagnostic cut-off for diabetes (plasma > or =6.1 to or =5.6 to <6.1 mmol l(-1)). Gestational Diabetes Mellitus (GDM) now includes gestational impaired glucose tolerance as well as the previous GDM. The classification defines both process and stage of the disease. The processes include Type 1, autoimmune and non-autoimmune, with beta-cell destruction; Type 2 with varying degrees of insulin resistance and insulin hyposecretion; Gestational Diabetes Mellitus; and Other Types where the cause is known (e.g. MODY, endocrinopathies). It is anticipated that this group will expand as causes of Type 2 become known. Stages range from normoglycaemia to insulin required for survival. It is hoped that the new classification will allow better classification of individuals and lead to fewer therapeutic misjudgements.

Definition, diagnosis and classification of diabetes mellitus and its complications. Part 1: diagnosis and classification of diabetes mellitus provisional report of a WHO consultation.

the growth of knowledge regarding the etiology and pathogenesis of diabetes has led many individuals and groups in the diabetes community to express the need for a revision of the nomenclature, diagnostic criteria, and classification of diabetes. As a consequence, it was deemed essential to develop an appropriate, uniform terminology and a functional, working classification of diabetes that reflects the current knowledge about the disease. (1)

Report of the expert committee on the diagnosis and classification of diabetes mellitus

A cluster of risk factors for cardiovascular disease and type 2 diabetes mellitus, which occur together more often than by chance alone, have become known as the metabolic syndrome. The risk factors include raised blood pressure, dyslipidemia (raised triglycerides and lowered high-density lipoprotein cholesterol), raised fasting glucose, and central obesity. Various diagnostic criteria have been proposed by different organizations over the past decade. Most recently, these have come from the International Diabetes Federation and the American Heart Association/National Heart, Lung, and Blood Institute. The main difference concerns the measure for central obesity, with this being an obligatory component in the International Diabetes Federation definition, lower than in the American Heart Association/National Heart, Lung, and Blood Institute criteria, and ethnic specific. The present article represents the outcome of a meeting between several major organizations in an attempt to unify criteria. It was agreed that there should not be an obligatory component, but that waist measurement would continue to be a useful preliminary screening tool. Three abnormal findings out of 5 would qualify a person for the metabolic syndrome. A single set of cut points would be used for all components except waist circumference, for which further work is required. In the interim, national or regional cut points for waist circumference can be used.

/pdf/harmonizing-the-metabolic-syndrome-a-joint-interim-statement-1vvpo24om1.pdf

Harmonizing the Metabolic Syndrome A Joint Interim Statement of the International Diabetes Federation Task Force on Epidemiology and Prevention; National Heart, Lung, and Blood Institute; American Heart Association; World Heart Federation; International Atherosclerosis Society; and International Association for the Study of Obesity

K/DOQI clinical practice guidelines for chronic kidney disease: Evaluation, classification, and stratification

The metabolic syndrome has received increased attention in the past few years. This statement from the American Heart Association (AHA) and the National Heart, Lung, and Blood Institute (NHLBI) is intended to provide up-to-date guidance for professionals on the diagnosis and management of the metabolic syndrome in adults.

The metabolic syndrome is a constellation of interrelated risk factors of metabolic origin— metabolic risk factors —that appear to directly promote the development of atherosclerotic cardiovascular disease (ASCVD).1 Patients with the metabolic syndrome also are at increased risk for developing type 2 diabetes mellitus. Another set of conditions, the underlying risk factors , give rise to the metabolic risk factors. In the past few years, several expert groups have attempted to set forth simple diagnostic criteria to be used in clinical practice to identify patients who manifest the multiple components of the metabolic syndrome. These criteria have varied somewhat in specific elements, but in general they include a combination of both underlying and metabolic risk factors.

The most widely recognized of the metabolic risk factors are atherogenic dyslipidemia, elevated blood pressure, and elevated plasma glucose. Individuals with these characteristics commonly manifest a prothrombotic state and a pro-inflammatory state as well. Atherogenic dyslipidemia consists of an aggregation of lipoprotein abnormalities including elevated serum triglyceride and apolipoprotein B (apoB), increased small LDL particles, and a reduced level of HDL cholesterol (HDL-C). The metabolic syndrome is often referred to as if it were a discrete entity with a single cause. Available data suggest that it truly is a syndrome, ie, a grouping of ASCVD risk factors, but one that probably has more than one cause. Regardless of cause, the syndrome identifies individuals at an elevated risk for ASCVD. The magnitude of the increased risk can vary according to which components of the syndrome are …

https://www.lipidcenter.com/pdf/metabolic.pdf

Diagnosis and Management of the Metabolic Syndrome An American Heart Association/National Heart, Lung, and Blood Institute Scientific Statement

Glycosylated haemoglobin (HbAl) assay is now widely used as a measure of diabetic control, but problems with sample collection and storage limit the overall usefulness of the measurement. These factors are of importance in screening programmes, and for patient care in remote areas. In hospital practice, analysis of samples is not usually possible during an out-patient clinic and prior home-blood sampling would enable a recent result to be available for the patient's visit. Sending blood samples is inconvenient, and filter paper\" spots would be preferable. However, further glycosylation of haemoglobin during the storage and transport of dried blood must be prevented. We describe here a simple and cheap method for impregnation of filter paper which inhibits further glycosylation of haemoglobin, enabling clinically suitable HbAl determination up to 4 weeks after sampling. Blood spots were taken from 16 diabetic and four non-diabetic subjects onto Blood Collection Cards (Sigma Chemical Co., St Louis, MI, USA), which were previously impregnated with citrate buffer (0,5 molar, pH 4,5) containing semicarbazide (60 mmol/L) and aniline (25 mmol/L) to trap glucose present in the sample. Filter paper blood spots were left to air dry and stored in plastic bags at room temperature until assayed. Parallel blood samples were taken into standard EDTA tubes for reference measurement. Red blood cell haemolysates (1:20 dilution in distilled water) were prepared from the reference samples and stored at 4°C for 18 h to remove the unstable aldimine fraction. HbAl was measured using the Glyco-Gel Test KitTM (Pierce Chemical Co., Rockford, IL, USA) affinity chromatography method (betweenbatch CV 3,5%). For dried blood analysis 9 mm

Prevention of excess glycosylation of haemoglobin in filter paper blood spots taken for glycosylated haemoglobin measurement.

Cimetidine fails to suppress the rise in plasma secretin during fasting.

Metabolic importance for gastro entero pancreatic hormones in obesity

The glucose clamp technique allows quantification of tissue sensitivity to insulin without modulation by the effects of hypoglycemia. The amount of glucose infused to maintain euglycemia during an insulin infusion gives a direct measure of tissue sensitivity. We have used this technique to compare the metabolic effects of highly purified porcine, highly purified bovine, and conventional insulins in diabetic subjects: (A) a group normally taking conventional bovine insulin, and (B) diabetics who had originally been treated with conventional bovine insulin and had changed to highly purified porcine insulin. Subjects were studied while attached to the Biostator with blood glucose values clamped at the basal level during a 2-h insulin infusion (0.01 U/kg/h). Both groups of diabetics received significantly more glucose in the first hour of the monocomponent porcine insulin infusion than during the same period either of conventional or of highly purified bovine insulin infusion. Highly purified porcine insulin infusion was also associated with a more rapid fall in blood ketone body concentrations. Highly purified porcine insulin infusion was accompanied by a greater and earlier increase in free insulin concentrations. All diabetics had antibodies to insulin but no differential antibody binding of beef and pork insulin was found in the two groups of patients. Thus, use of highly purified porcine insulin is associated with a more rapid onset of action and a greater initial increment in free insulin values.

Differential Response to Infusions of Highly Purified and Conventional Bovine and Porcine Insulins

Randomized crossover studies of a half-sized lunch with reduced insulin dose in 21 patients, and a delayed (by 2 h) evening meal in 22 patients, compared with normal meals, were performed in Type 1 diabetic patients. The aim was to examine whether the size and timing of meals can be varied in patients on multiple injection regimens without disturbance of blood glucose control. All patients had previously had their control optimized on multiple injection therapy using a pen-injector. The studies were carried out at home on 6 days (3 changed meals, 3 control) over 2 months, and as 8- and 7-h metabolic profiles (1 study day, 1 control) in an investigation unit. A halved calorie lunch with half the usual insulin dose resulted in equivalent blood glucose control on the study day (area under curve: changed meal 40.0 +/- 3.4 vs control meal 40.3 +/- 3.5 mmol l-1 h for the 5-h period after the meal). Ketone body levels were also unchanged. The late evening meal shifted the post-prandial blood glucose concentration accordingly, but the excursion was not different in extent from the control day (24.8 +/- 1.9 vs 21.0 +/- 1.7 mmol l-1 h). A small excursion of 3-hydroxybutyrate levels before the delayed meal (to 187 +/- 48 mumol l-1) was quickly corrected on eating. Hypoglycaemia was not different in frequency on the changed meal days. Thus no problems of clinical significance were observed when some flexibility in meal size and timing was allowed.

K. G. M. M. Alberti

Papers

Prevention of excess glycosylation of haemoglobin in filter paper blood spots taken for glycosylated haemoglobin measurement.

Cimetidine fails to suppress the rise in plasma secretin during fasting.

Metabolic importance for gastro entero pancreatic hormones in obesity

Differential Response to Infusions of Highly Purified and Conventional Bovine and Porcine Insulins

Does flexibility at mealtimes disturb blood glucose control on a multiple insulin injection regimen