All about Diabetes > Comprehensive Tutorial > Detection & Evaluation


Detection and evaluation:

A simplified Indian Diabetes Risk Score for screening for undiagnosed Diabetic Subjects1

A Diabetes Risk Score was developed by Dr. Mohan V et al based on multiple logistic regression model using four simple parameters namely age, abdominal obesity, family history of diabetes and leisure time physical activity.
The information for these risk factors can be obtained based on four simple questions and one anthropometric measurement namely waist circumference. The four question are:

  • What is your age?
  • Do you have a family history of diabetes? If yes, does your father or mother or both have diabetes?
  • Do you exercise regularly?
  • How physically demanding is your work (occupation)?

Indian Diabetes Risk Score (IDRS) developed based on multiple logistic regression analysis derived from CURES

Particulars

Score

Age (years)

<35 (reference)

0

35-49

20

> 50

30

Abdominal obesity

Waist <80 cm (female), <90 (male)(reference)

0

Waist > 80 - 90 cm (female), > 90 - 99 cm (male)

10

Waist > 90 cm (female), > 100 cm (male)

20

Physical activity

Exercise (regular) + strenuous workout (reference)

0

Exercise (regular) & strenuous work

20

No exercise and sedentary work

30

Family history

No family history (reference)

0

Either parent

10

Both parents

20

Minimum score

0

Maximum score

100

Example for deriving risk scores (IDRS)

Parameter

Score

IDRS Score

Gender

Male

-

Age

60

30

Waist circumtence

101 cm

20

Occupation
+
Exercise

Retired
+
Regular exercise

20

Family history

Both panels

20

Total score

 

90

For eg: male 60 years, waist Circumference of 101, retired but engaging in regular exercise with history of both parents with Diabetes.

Reference:
1 Mohan V, Deepa R, Shanthirani CS, Farooq S, Ganesan A.M. Datta. A Diabetes Risk Score for identifying undiagnosed diabetes - The Chennai Urban Rural Epidemiology Study (CURES - 23), 2005, Metabolism (Submitted).

Criteria for testing for pre-diabetes and diabetes in asymptomatic adult individuals2

  1. Testing should be considered in all adults who are overweight (BMI>/25 kg/m2*) and have additional risk factors:
    • Physical inactivity
    • First-degree relative with diabetes
    • Members of a high-risk ethnic population (e.g., Africian American, Latino, Native American, Asian American, Pacific Islander)
    • Women who delivered a baby weighing >9 lb or were diagnosed with GDM
    • Hypertension (>140/90 mmHg or on therapy for hypertension)
    • HDL cholesterol level <35 mg/dl (0.90 mmol/l) and/or a triglyceride level>250 mg/dl (2.82 mmol/l)
    • Women with polycystic ovarian syndrome (PCOS)
    • IGT or IFG on previous testing
    • Other clinical conditions associated with insulin resistance (e.g., severe obesity, acanthosis nigricans)
    • History of CVD
  2. In the absence of the above criteria, testing for pre-diabetes and diabetes should begin at age 45 years.
  3. If results are normal, testing should be repeated at least at 3 year intervals, with consideration of more frequent testing depending on initial results and risk status.

Reference
*At-risk BMI may be lower in some ethnic groups.
2. Diabetes care; volume 32, supplement 1, January 2009

Components of the comprehensive diabetes evaluation3

Medical history

  • Age and characteristics of onset of diabetes (e.g., DKA, asymptomatic laboratory finding)
  • Eating patterns, physical activity habits, nutritional status, and weight history; growth and development in children and adolescents
  • Diabetes education history
  • Review of previous treatment regimens and response to therapy (A1C records)
  • Current treatment of diabetes, including medications, meal plan, physical activity patterns, and results of glucose monitoring and patient's use of data
  • DKA frequency, severity, and cause
  • Hypoglycemic episodes
  • Hypoglycemia awareness
  • Any severe hypoglycemia: frequency and cause
  • History of diabetes-related complications
  • Microvascular: retinopathy, nephropathy, neuropathy (sensory, including history of foot lesions; autonomic, including sexual dysfunction and gastroparesis)
  • Macrovascular: CHD, cerebrovascular disease, PAD
  • Other: psychosocial problems,* dental disease*

Physical examination*

  • Height, weight, BMI
  • Blood pressure determination, including orthostatic measurements when indicated
  • Fundoscopic examination*
  • Thyroid palpation
  • Skin examination (for acanthosis nigricans and insulin injection sites)
  • Comprehensive foot examination:
  • Inspection
  • Palpation of dorsalis pedis and posterior tibial pulses
  • Presence/absence of patellar and Achilles reflexes
  • Determination of proprioception, vibration, and monofilament sensation

Laboratory evaluation

  • A1C, if results not available within past 2-3 months

If not performed/available within past year:

  • Fasting lipid profile, including total, LDL-and HDL-cholesterol and triglycerides
  • Liver function tests
  • Test for urine albumin excretion with spot urine albumin/creatinine ration
  • Serum creatinine and calculated GFR
  • Thyroid-stimulating hormone in type 1 diabetes, dyslipidemia or women over age 50

Referrals

  • Annual dilated eye exam
  • Family planning for women of reproductive age
  • Registered dietitian for MNT
  • Diabetes self-management education
  • Dental examination
  • Mental Health professional, if needed

Reference:
*See appropriate referrals for these categories.
3. Diabetes care, volume 32, supplement 1, January 2009

Oral glucose tolerance test in nonpregnant adult 4

Overview:

The oral glucose tolerance test can be useful in diagnosing patients, by monitoring glucose levels following an oral glucose challenge. (Note: This data reflects recommendations prior to the 1997 American Diabetes Association revised criteria)

Test preparation:

  • Starting 3 days prior to test, the patient receives a diet containing 150g of carbohydrate per day.
  • The patient must not be stressed by illness prior or during the test.
  • All nonessential medications should be discontinued at least 3 days prior to testing; many medications can impair glucose tolerance.
  • A 10-16 hour fast is recommended.
  • Undue exercise before or during the test is to be avoided.
  • No coffee or smoking is allowed once the fast has started or during the test.

Dose of glucose for test:

  • 75 g orally (1.75 grams of glucose per kilogram of ideal body weight, up to 75 grams)
  • Oral glucose solutions come in 10 US fluid ounces (296 mL) bottles containing 50, 75 or 100 grams of glucose (5, 7.5 and 10g per fluid ounce)

Initial evaluation:

  • If the fasting glucose is < 115 mg/dL, then diabetes is excluded
  • If the fasting glucose is 115-140 mg/dL, then an oral glucose tolerance test should be done
  • If the fasting glucose is >140 mg/dL, then the diagnosis of diabetes is supported.

Nonpregnant adult tolerance

Normal

Diabetes

Impaired glucose

Fasting

70-105 (70-115 if 60 y.o)

>=140 mg/dL

<140 mg/dL

30 minute (0.5 hour)

110-170

**

**

60 minute (1 hour)

120-170

**

**

90 minute (1.5 hour)

100-140

**

**

120 minute (2 hour)

70-120

>200 mg/dL

140-200 mg/dL

** atleast one of these results must be > = 200 mg/dL


The abnormalities in glucose tolerance test must be present on at least 2 occasions before the diagnosis of diabetes mellitus is made. An oral tolerance test need not be done.

  • If a fasting glucose is > = 140 mg/dL at least twice
  • A random glucose level is > 200 mg/dL and classis symptoms (polyuria, polydipsia, ketonuria, weight loss) are found

Drugs may cause decreased glucose tolerance: beta-adrenergic blocking agents, catecholamines, corticosteroids, diuretics, estrogens, oral contraceptives, phenothiazines, phenytoin, thyroid hormones and several others.

References:
4. Nelson RL. Oral glucose tolerance test: Indications and limitations, May Clin Proc. 1988; 63: 263-269

Oral glucose tolerance test in pregnant adult female5-7

Pregnant women should be screened for diabetes mellitus sometime between the 26th and 28th week of gestation. (Note: This data reflects recommendations prior to the 1997 American Diabetes Association revised criteria)

Test preparation:

  • Starting 3 days prior to test, the patient receives a diet containing 150 g of carbohydrate per day.
  • The patient must not be stressed by illness prior or during the test.
  • All nonessential medications should be discontinued at least 3 days prior to testing; many medications can impair glucose tolerance.
  • A 10-16 hour fast is recommended.
  • Undue exercise before or during the test is to be avoided.
  • No coffee or smoking is allowed once the fast has started or during the test.

Dose of glucose for test:

  • Screening test: 50 grams orally
  • Diagnostic test: 100 grams orally
  • Oral glucose solutions come in 10 US fluids ounces (296 mL) bottles containing 50, 75 or 100 grams of glucose (5, 7.5 and 10 g per fluid ounce).

Screening test: If 1 hour after the 50 gram dose the serum glucose is >=150 mg/dL, then the full dose test should be performed.

Gestational diabetes: at least 2 glucose values must exceed the following after the 100 gram loading dose:

Specimen

Serum

Whole blood or capillary

Fasting

105 mg/dL

90 mg/dL

1 hour

190 mg/dL

170 mg/dL

2 hour

165 mg/dL

145 mg/dL

3 hour

145 mg/dL

125 mg/dL

References:
5 O' Sullivan JB, Mahan CM, Criteria for the oral glucose tolerance test in pregnancy. Diabetes, 19654:13:278-285.
6 Roche Biomedical Laboratories. The Comprehensive Clinical References Interpretive Guide. 1995. Pages 464-465
7 Tietz NW (editor), Clinical Guide to Laboratory Tests, Third Edition, W.B. Saunders Co. 1995. Page 274-277.

Oral glucose tolerance test in pediatric population8-9

The oral glucose tolerance test can be useful in the diagnosis of diabetes mellitus, by following glucose levels following an oral glucose challenge. (Note: This data reflects recommendations prior to the 1997 American Diabetes Association revised criteria)

Test preparation:

  • Starting 3 days prior to test, the patient receives a diet containing 150g of carbohydrate per day.
  • The patient must not be stressed by illness prior or during the test.
  • All nonessential medications should be discontinued at least 3 days prior to testing; many medications can impair glucose tolerance.
  • A10-16 hour fast is recommended.
  • Undue exercise before or during the test is to be avoided.

Dose of glucose for test:

  • 1.75 gram per kilogram of ideal body weight, up to a maximum 75 grams.
  • Oral glucose solutions come in 10 US fluid ounces (296 mL) bottles containing 50, 75 or 100 grams of glucose (5, 7.5 and 10g per fluid ounce).

Interpretation:

  • Both an elevated fasting glucose and a sustained elevated glucose during the oral tolerance test need to be present on at least 2 occasions to make the diagnosis of diabetes mellitus.
  • The oral tolerance test is not needed if classic symptoms are present (polyuria, polydipsia, ketonuria, weight loss) and if a random glucose exceeds 200 mg/dL.

Pediatric Patient

Diabetes

impaired glucose
tolerance

Fasting

<140 mg/dL

<140 mg/dL

30 minute (0.5 hour)

**

N/A

60 minute (1 hour)

**

N/A

90 minute (1.5 hour)

**

N/A

120 minute (hour)

>200 mg/dL

140-00 mg/dL


** atleast one of these results must be > = 200 mg/Dl

References:
8 Guthrie RA, Gutherie DW, et al. Standardization of the oral glucose tolerance test and the criteria for diagnosis of chemical diabetes in children. Metabolism. 197322:275-282
9 Tietz NW (editor), Clinical Guide to Laboratory Tests, Third Edition, W.B. Saunders Co. 1995. Page 274-277.

Glucose tolerance test, intravenous10-11

This test is indicated if the patient cannot tolerate a large oral carbohydrate load or if the patient has a gastrointestinal condition (disease, surgery) that could affect the rate of glucose absorption from the GI tract. The test is done only infrequently and shows a poor correlation with the oral GTT (Note: This data reflects recommendations prior to the 1997 American Diabetes Association revised criteria.)

Test preparation:

  • Starting 3 days prior to test, the patient receives a diet containing 150g of carbohydrate per day.
  • The patient must not be stressed by illness prior or during the test.
  • All nonessential medications should be discontinued at least 3 days prior to testing; many medications can impair glucose tolerance.
  • A10-16 hour fast is recommended.
  • Undue exercise before or during the test is to be avoided.

Dose of glucose for test: 0.5 gram per kilogram body weight up to a maximum of 35 grams, given IV as 5 g glucose per 100 mL solution within 1-2 minutes.

Specimen collection:

Glucose levels are drawn fasting, and then 3, 5, 10, 20, 30, 45 and 60 minutes after the infustion is complete.
Occasionally plasma insulin levels are drawn at 2, 3 and 5 minutes after the infusion is complete.

Shortly after the infusion, transient glucose concentrations up to 250 mg/dL can be seen in normal individuals, but fasting glucose levels will be achieved by 90 minutes, with subfasting levels at 120 minutes and return to fasting levels at 180 minutes. Transient glucosuria can be seen right after the infusion since the renal threshold for glucose will be exceeded.

The rate in decrease in glucose levels is then determined. Blood glucose levels tend to decrease exponentially.

  • Normal adults under 50 years of age show a mean rate of glucose disappearance of 1.5% per minute
  • Normal adults over 50 years of age will show a mean rate of glucose disappearance which declines with the age over 50 (about 0.09% per decade)
  • Diabetics show a mean rate of glucose disappearance of <1% per minute.

 

The rate of decrease can be measured is several ways. Methods include:

  • The rate of disappearance of glucose expressed as a percent per minute of the 10 minute level (take 10 minute level as 100%, and then the subsequent levels as percentages).
  • A semilogarithmic rate of decline of glucose from 10 to 30 minutes.

A common example of the first method is the equation:
rate of disappearance of glucose in % per minute = 70 / (number of minutes required for the blood glucose level to half of the 10 minute level)

References:
10 Sacks DB, Chapter 22: Carbohydrates, pages 928-1001 (951-952). IN: Burtis C, Ashwood E. Tietz Textbook of Clinical Chemistry, Second edition, W.B. Saunders Company 1994.
11 Tietz NW (editor). Clinical guide to Laboratory Tests, Third Edition. W.B. Saunders Co. 1995. Pages 274-275.

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