Diagnosis and Classification of Diabetes Mellitus

D iabetes mellitus is a chronic illness that requires continuing medical care and ongoing patient self-management education 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. A large body of evidence exists that supports a range of interventions to improve diabetes outcomes. These standards of care are intended to provide clinicians, patients, researchers, payers, and other interested individuals with the components of diabetes care, general treatment goals, and tools to evaluate the quality of care. While individual preferences, comorbidities, and other patient factors may require modification of goals, targets that are desirable for most patients with diabetes are provided. Specifically titled sections of the standards address children with diabetes, pregnant women, and people with prediabetes. These standards are not intended to preclude clinical judgment or more extensive evaluation and management of the patient by other specialists as needed. For more detailed information about management of diabetes, refer to references 1–3. The recommendations included are screening, diagnostic, and therapeutic actions that are known or believed to favorably affect health outcomes of patients with diabetes. A large number of these interventions have been shown to be cost-effective (4). A grading system (Table 1), developed by the American Diabetes Association (ADA) andmodeled after existingmethods, was utilized to clarify and codify the evidence that forms the basis for the recommendations. The level of evidence that supports each recommendation is listed after each recommendation using the letters A, B, C, or E. These standards of care are revised annually by the ADA’s multidisciplinary Professional Practice Committee, incorporating new evidence. For the current revision, committee members systematically searched Medline for human studies related to each subsection and published since 1 January 2010. Recommendations (bulleted at the beginning of each subsection and also listed in the “Executive Summary: Standards of Medical Care in Diabetesd2012”) were revised based on new evidence or, in some cases, to clarify the prior recommendation or match the strength of the wording to the strength of the evidence. A table linking the changes in recommendations to new evidence can be reviewed at http:// professional.diabetes.org/CPR_Search. aspx. Subsequently, as is the case for all Position Statements, the standards of care were reviewed and approved by the ExecutiveCommittee of ADA’s Board ofDirectors, which includes health care professionals, scientists, and lay people. Feedback from the larger clinical community was valuable for the 2012 revision of the standards. Readers who wish to comment on the “Standards of Medical Care in Diabetesd2012” are invited to do so at http://professional.diabetes.org/ CPR_Search.aspx. Members of the Professional Practice Committee disclose all potential financial conflicts of interest with industry. These disclosures were discussed at the onset of the standards revisionmeeting. Members of the committee, their employer, and their disclosed conflicts of interest are listed in the “Professional PracticeCommitteeMembers” table (see pg. S109). The AmericanDiabetes Association funds development of the standards and all its position statements out of its general revenues and does not utilize industry support for these purposes.

https://www.science-open.com/document_file/bb04d9d0-b3df-4133-9494-e71e300f4279/PubMedCentral/bb04d9d0-b3df-4133-9494-e71e300f4279.pdf

Standards of Medical Care in Diabetes—2012

In the accompanying comment letter (1), Weinert summarizes published data from the Brazilian Gestational Diabetes Study (2) and comments on applying International Association of Diabetes and Pregnancy Study Groups (IADPSG) Consensus Panel recommendations (3) for the diagnosis of gestational diabetes mellitus (GDM) to that cohort

The Brazilian study provided evidence that adverse perinatal outcomes are associated with levels of maternal glycemia below those diagnostic of GDM by American Diabetes Association or World Health Organization criteria However, the results were potentially confounded by the treatment of GDM It did find that women with GDM were at increased risk for some …

/pdf/international-association-of-diabetes-and-pregnancy-study-zxp9yhda0w.pdf

International association of diabetes and pregnancy study groups recommendations on the diagnosis and classification of hyperglycemia in pregnancy.

D iabetes is a chronic illness that requires continuing medical care and ongoing patient self-management education 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. A large body of evidence exists that supports a range of interventions to improve diabetes outcomes. These standards of care are intended to provide clinicians, patients, researchers, payors, and other interested individuals with the components of diabetes care, general treatment goals, and tools to evaluate the quality of care. While individual preferences, comorbidities, and other patient factors may require modification of goals, targets that are desirable for most patients with diabetes are provided. These standards are not intended to preclude clinical judgment or more extensive evaluation and management of the patient by other specialists as needed. For more detailed information about management of diabetes, refer to references 1–3. The recommendations included are screening, diagnostic, and therapeutic actions that are known or believed to favorably affect health outcomes of patients with diabetes. A grading system (Table 1), developed by the American Diabetes Association (ADA) and modeled after existing methods, was used to clarify and codify the evidence that forms the basis for the recommendations. The level of evidence that supports each recommendation is listed after each recommendation using the letters A, B, C, or E. These standards of care are revised annually by the ADA multidisciplinary Professional Practice Committee, and new evidence is incorporated. Members of the Professional Practice Committee and their disclosed conflicts of interest are listed in the Introduction. Subsequently, as with all position statements, the standards of care are reviewed and approved by the Executive Committee of ADA’s Board of Directors.

Standards of Medical Care in Diabetes—2010

How to screen and treat gestational diabetes mellitus (GDM) has always been controversial for clinicians and decision makers. The problem is complex, and the evidence is limited. The new standards set by the American Diabetes Association (ADA) in 2011 (1) recommend 1 ) universal screening at 24–28 weeks of gestation (2010 ADA standards recommended selective screening based on risk factors) and 2 ) an oral glucose tolerance test with a diagnostic fasting plasma glucose of ≥92 mg/dL (4.5 mmol/L) (much lower than the World Health Organization [WHO] criteria of ≥126 mg/dL [7.0 mmol/L] commonly used in clinical practice in Europe). Furthermore, diabetes is diagnosed when only one abnormal value is detected (whereas in the 2010 standards two …

https://care.diabetesjournals.org/content/diacare/34/5/e53.full.pdf

Comment on: American Diabetes Association. Standards of Medical Care in Diabetes—2011. Diabetes Care 2011;34(Suppl. 1):S11–S61

Background It is uncertain whether treatment of mild gestational diabetes mellitus improves pregnancy outcomes. Methods Women who were in the 24th to 31st week of gestation and who met the criteria for mild gestational diabetes mellitus (i.e., an abnormal result on an oral glucose-tolerance test but a fasting glucose level below 95 mg per deciliter [5.3 mmol per liter]) were randomly assigned to usual prenatal care (control group) or dietary intervention, self-monitoring of blood glucose, and insulin therapy, if necessary (treatment group). The primary outcome was a composite of stillbirth or perinatal death and neonatal complications, including hyperbilirubinemia, hypoglycemia, hyperinsulinemia, and birth trauma. Results A total of 958 women were randomly assigned to a study group — 485 to the treatment group and 473 to the control group. We observed no significant difference between groups in the frequency of the composite outcome (32.4% and 37.0% in the treatment and control groups, respectively; P=0.1...

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A Multicenter, Randomized Trial of Treatment for Mild Gestational Diabetes

Although there is little evidence that the screening, identification, and treatment of mild gestational diabetes during pregnancy is beneficial, a number of professional organizations have recommended screening for this disorder in most pregnant women. The aim of this multicenter randomized trial was to determine whether treatment of women with mild gestational diabetes mellitus reduces perinatal and obstetrical complications. The participants were 958 women between 24 and 31 weeks of gestation who met criteria for mild gestational diabetes mellitus. They were randomly assigned to receive either formal nutritional counseling, diet therapy, and self-monitoring of blood glucose, together with insulin if required (treatment group, n = 485) or usual prenatal care (control group, n = 473). The primary study outcome was a composite outcome that included perinatal mortality (stillbirth or neonatal death) and neonatal complications that have been associated with maternal hyperglycemia: hypoglycemia, hyperbilirubinemia, neonatal hyperinsulinemia, and birth trauma.
There was no significant difference between the 2 groups in the frequency of the composite primary perinatal outcomes of mortality and neonatal complications (treatment group: 32.4% and control group: 37.0%, respectively; the relative risk was 0.87, with a 97% confidence interval of 0.72–1.07; P = 0.14). However, compared with usual care, treatment was associated with significant reductions in several prespecified secondary neonatal or maternal outcomes including mean birth weight (3408 vs. 3302 g), neonatal fat mass (464 vs. 427 g), the frequency of large-for-gestational age infants (14.5% vs. 7.1%), birth weight greater than 4000 g (14.3% vs. 5.9%), shoulder dystocia (4.0% vs. 1.5%), and cesarean delivery (33.8% vs. 26.9%) (P < 0.02 for all comparisons). In addition, the frequency of the combined rates of preeclampsia and gestational hypertension was significantly lower in the treatment group (P < 0.01).
These findings show that treatment of mild gestational diabetes mellitus is associated with a reduced risk of several secondary complications including fetal overgrowth, shoulder dystocia, cesarean delivery, and hypertensive disorders (preeclampsia and gestational hypertension).

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Kristine Y. Lain

Papers

A Multicenter, Randomized Trial of Treatment for Mild Gestational Diabetes

A Multicenter, Randomized Trial of Treatment for Mild Gestational Diabetes