Controlling the diabetes epidemic: how should we screen for undiagnosed diabetes and dysglycaemia?

Diagnosing Gestational Diabetes by a Single-Test Procedure Is a Propitious Step Towards Containing the Epidemic of Diabetes

In recent years, diabetes has evolved into a non-communicable disease pandemic with data showing that one out of ten adults in the world have diabetes. Among various factors that contribute to this rising trend in diabetes, one factor that is of paramount importance is gestational diabetes mellitus (GDM). Maternal hyperglycemia sets off a vicious cycle that affects not only the mother and her child but also the generations to come. There are many criteria that are used for the diagnosis of GDM. Almost all of these criteria require the pregnant woman to be in the fasting state in order to perform an oral glucose tolerance test (OGTT). In many parts of the world, especially in low- and middle-income countries, OGTT is a resource-intensive and technically demanding procedure. More often than not, pregnant women do not attend the antenatal clinic fasting. If they are asked to come fasting again for the OGTT, the drop-out rate is increased. Thus, for practical purposes, a test that is feasible on the ground is essential. In this paper, we emphasize a "single-test" procedure wherein a 75-gram oral glucose load is administered to the pregnant woman irrespective of whether she is in the fasting state or not, and plasma glucose is measured at two hours. A plasma glucose value ≥ 140 mg/dL (7.8 mmol/L) at two hours is considered diagnostic of GDM. The single-test procedure was found to be a sustainable, cost-effective, evidence-based, and affordable test procedure for any society. It serves both as a screening test and a diagnostic test for GDM. Furthermore, we emphasize the need for universal screening of all pregnant women who attend the antenatal clinics to detect dysglycemia, especially in the early weeks of pregnancy when the impact on the growing fetus would be significant.

Diagnosis and principles of management of gestational diabetes mellitus in the prevailing COVID-19 pandemic

BACKGROUND

Limited medical facilities are available due to Covid-19 pandemic. Nevertheless, all efforts should be made in planning judicial and possible methods of delivering health care, particularly to pregnant woman with GDM. GDM may play a crucial role in the increasing prevalence of diabetes and obesity and also may be the origin of cardiometabolic diseases.

METHODS

It is mandatary to diagnose and care pregnant woman with GDM. The test suggested to diagnose GDM has to be evidence based and in this regard "a single test procedure" evaluated meets this requirement. This doable test has been accepted by the Diabetes in Pregnancy Study Group India (DIPSI) and approved by MHFW-GOI, WHO, International Diabetes Federation, and International Federation of Obstetricians and Gynecologists. MHFW-GOI also recommends testing at first antenatal visit and then at 24-28 weeks of gestation. This opportunity can also be utilized for performing ultrasonography for assessing fetal development.

RESULT

The first-line management is MNT and life style modifications. Non-responders may require insulin or OHA. The target glycemic control is FPG ~ 5.0 mmol/dl (90 mg/dl) and 2 h PPPG ~ 6.7 mmol/dl (120 mg/dl). The goal is to obtain newborns birth weight appropriate for gestational age between 2.5 and 3.5 kg, a step to prevent offspring developing diabetes.

CONCLUSION

The essential precaution required during COVID pandemic is to wear face mask, avoid crowded places, and maintain social distancing. Finally, the economical and evidence based "single test procedure" of DIPSI is most appropriate for screening during the COVID pandemic.

Strategies for implementing the WHO diagnostic criteria and classification of hyperglycaemia first detected in pregnancy

The World Health Organization (WHO) has recently released updated recommendations on Diagnostic Criteria and Classification of Hyperglycaemia First Detected in Pregnancy which are likely to increase the prevalence of gestational diabetes mellitus (GDM). Any increase in the number of women with GDM has implications for health services since these women will require treatment and regular surveillance during the pregnancy. Some health services throughout the world may have difficulty meeting these demands since country resources for addressing the diabetes burden are finite and resource allocation must be prioritised by balancing the need to improve care of people with diabetes and finding those with undiagnosed diabetes, including GDM. Consequently each health service will need to assess their burden of hyperglycaemia in pregnancy and decide if and how it will implement programmes to test for and treat such women. This paper discusses some considerations and options to assist countries, health services and health professionals in these deliberations.

Global estimates of the prevalence of hyperglycaemia in pregnancy

AIMS

We estimated the number of live births worldwide and by IDF Region who developed hyperglycaemia in pregnancy in 2013, including total diabetes in pregnancy (known and previously undiagnosed diabetes) and gestational diabetes.

METHODS

Studies reporting prevalence of hyperglycaemia first-detected in pregnancy (formerly termed gestational diabetes) were identified using PubMed and through a review of cited literature. A simple scoring system was developed to characterise studies on diagnostic criteria, year study was conducted, study design, and representation. The highest scoring studies by country with sufficient detail on methodology for characterisation and reporting at least three age-groups were selected for inclusion. Forty-seven studies from 34 countries were used to calculate age-specific prevalence of hyperglycaemia first-detected in pregnancy in women 20-49 years. Adjustments were then made to account for heterogeneity in screening method and blood glucose diagnostic threshold in studies and also to align with recently published diagnostic criteria as defined by the WHO for hyperglycaemia first detected in pregnancy. Prevalence rates were applied to fertility and population estimates to determine regional and global prevalence of hyperglycaemia in pregnancy for 2013. An estimate of the proportion of cases of hyperglycaemia in pregnancy due to total diabetes in pregnancy was calculated using age- and sex-specific estimates of diabetes from the IDF Diabetes Atlas and applied to age-specific fertility rates.

RESULTS

The global prevalence of hyperglycaemia in pregnancy in women (20-49 years) is 16.9%, or 21.4 million live births in 2013. An estimated 16.0% of those cases may be due to total diabetes in pregnancy. The highest prevalence was found in the South-East Asia Region at 25.0% compared with 10.4% in the North America and Caribbean Region. More than 90% of cases of hyperglycaemia in pregnancy are estimated to occur in low- and middle-income countries.

CONCLUSION

These are the first global estimates of hyperglycaemia in pregnancy and conform to the new WHO recommendations regarding diagnosis and also include estimates of live births in women with known diabetes. They indicate the importance of the disease from a public health and maternal and child health perspective, particularly in developing countries.

Identifying undiagnosed diabetes: cross-sectional survey of 3.6 million patients' electronic records

BACKGROUND

Around 1% of the UK population has diabetes that is either undiagnosed or unrecorded on practice disease registers.

AIM

To estimate the number of people in UK primary care databases with biochemical evidence of undiagnosed diabetes. To develop simple practice-based search techniques to support early recognition of diabetes.

DESIGN OF STUDY

Cross-sectional survey of 3 630 296 electronic records.

SETTING

Four hundred and eighty UK practices contributing to the QRESEARCH database.

METHOD

Electronic searches to identify people with no diabetes diagnosis in one of two categories (A and B), using the most recently recorded blood glucose measurement: random blood glucose level >or=11.1 mmol/l or fasting blood glucose level >or=7.0 mmol/l (A); either a random or a fasting blood glucose level >or=7.0 mmol/l (B). An additional outcome measure was the proportion of the population with at least one blood glucose measurement in the record.

RESULTS

The number (percentage) identified in category A was 3758 (0.10% of the total population); the number in category B was 32 785 (0.90%). Projected to a practice of 7000 patients, around eight patients have biochemical evidence of undiagnosed diabetes, and 68 have results suggesting the need for further follow-up. One-third of people aged over 40 years without diabetes have a blood glucose measurement in the past 2 years in their record.

CONCLUSION

People with possible undiagnosed diabetes are readily identifiable in UK primary care databases through electronic searches using blood glucose data. People with borderline levels, who may benefit from interventions to reduce their risk of progression to diabetes, can also be identified using practice-based software.

Development and piloting of a community health worker-based intervention for the prevention of diabetes among New Zealand Maori in Te Wai o Rona: Diabetes Prevention Strategy

OBJECTIVE

The progression from impaired glucose tolerance (IGT)/impaired fasting glucose (IFG) to type 2 diabetes can be prevented or delayed through intensive lifestyle changes. How to translate this to implementation across whole communities remains unclear. We now describe the results to a pilot of a personal trainer (Maori Community Health Worker, MCHW) approach among Maori in New Zealand.

DESIGN, SETTING AND SUBJECTS

A randomised cluster-controlled trial of intensive lifestyle change was commenced among 5,240 non-pregnant Maori family members without diabetes from 106 rural and 106 urban geographical clusters. Baseline assessments included lifestyle questionnaires, anthropometric measurements and venesection. A pilot study (Vanguard Study) cohort of 160 participants were weighed before and during MCHW intervention, and compared with fifty-two participants weighed immediately before intervention and with 1,143 participants from the same geographical area. Interactions between participants and the MCHW were reported using personal digital assistants with a programmed detailed structured approach to each interview.

RESULTS

During the Vanguard Study, participants and MCHW found the messages, toolkit and delivery approach acceptable. Those with IGT/IFG diagnosed (n 27) experienced significant weight loss after screening and during the Vanguard Study (5.2 (sd 6.6) kg, paired t test P < 0.01). Significant weight loss occurred during the Vanguard Study among all participants (-1.3 (sd 3.6) kg, P < 0.001).

CONCLUSIONS

Comparable initial weight loss was shown among those with IGT/IFG and those from existing trials. Community-wide prevention programmes are feasible among Maori and are likely to result in significant reductions in the incidence of diabetes.

Prevention of Type 2 diabetes: fact or fiction?

The growing prevalence of Type 2 diabetes with its high morbidity and excess mortality is imposing a heavy burden on healthcare systems. Because of the magnitude of the problem, obviating diabetes has been a long-standing dream. In the last decade, a number of intervention strategies have been shown to be effective for the prevention of diabetes in high-risk populations with prediabetes. Seven studies have now confirmed that lifestyle modifications, including weight-reducing diets and exercise programs, are very effective in precluding or delaying Type 2 diabetes in high-risk populations with impaired glucose tolerance (IGT). Two major trials are the Diabetes Prevention Study (n = 522) from Finland and the Diabetes Prevention Program (n = 3234) from the US. Both studies have shown that intensive lifestyle intervention could reduce the progression of IGT to diabetes by 58%. Furthermore, four currently-available drugs have been established as being effective in preventing diabetes in subjects with prediabetes. The Diabetes Prevention Program revealed that metformin 850 mg b.i.d. reduced the risk of diabetes by 31%. The STOP-NIDDM (Study To Prevent Non-Insulin-Dependent Diabetes Mellitus) trial (n = 1429) showed that acarbose 100 mg t.i.d. with meals decreased the incidence of diabetes by 36% when the diagnosis was based on 2 oral glucose tolerance tests. The XENDOS (Xenical in the Prevention of Diabetes in Obese Subjects) study examined the use of orlistat, an antiobesity drug, as an adjunct to an intensive lifestyle modification program in obese non-diabetic subjects. Orlistat treatment resulted in a 37% decline in the development of diabetes. More recently, the DREAM (Diabetes Reduction Assessment with Ramipril and Rosiglitazone Medication) study (n = 5269) demonstrated that rosiglitazone at 8 mg once/day in subjects with prediabetes (IGT and/or impaired fasting glucose) was effective in reducing the risk of diabetes by 60%. It can be concluded that Type 2 diabetes can be prevented or delayed through lifestyle modifications and/or pharmacologic interventions. This is a fact.

The effect of borderline diabetes on the risk of dementia and Alzheimer's disease

To verify the hypothesis that borderline diabetes may increase the risk of dementia and Alzheimer's disease, a community-based cohort of 1,173 dementia- and diabetes-free individuals aged >or=75 years was longitudinally examined three times to detect patients with dementia and Alzheimer's disease (Diagnostic and Statistical Manual of Mental Disorders, Revised Third Edition criteria). Borderline diabetes was defined as a random plasma glucose level of 7.8-11.0 mmol/l. Data were analyzed using Cox proportional hazards models. During the 9-year follow-up, 397 subjects developed dementia, including 307 Alzheimer's cases. At baseline, 47 subjects were identified with borderline diabetes. Borderline diabetes was associated with adjusted hazard ratios (95% CIs) of 1.67 (1.04-2.67) for dementia and 1.77 (1.06-2.97) for Alzheimer's disease; the significant associations were present after additional adjustment for future development of diabetes. Stratified analysis suggested a significant association between borderline diabetes and Alzheimer's disease only among noncarriers of APOE epsilon4 allele. There was an interaction between borderline diabetes and severe systolic hypertension on the risk of Alzheimer's disease (P = 0.04). We conclude that borderline diabetes is associated with increased risks of dementia and Alzheimer's disease; the risk effect is independent of the future development of diabetes. Borderline diabetes may interact with severe systolic hypertension to multiply the risk of Alzheimer's disease.

Erectile Dysfunction—An Observable Marker of Diabetes Mellitus? A Large National Epidemiological Study

PURPOSE

We examined whether men with erectile dysfunction are more likely to have diabetes mellitus than men without erectile dysfunction, and whether erectile dysfunction can be used as an observable early marker of diabetes mellitus.

MATERIALS AND METHODS

Using a nationally representative managed care claims database from 51 health plans and 28 million members in the United States, we conducted a retrospective cohort study to compare the prevalence rates of diabetes mellitus between men with erectile dysfunction (285,436) and men without erectile dysfunction (1,584,230) during 1995 to 2001. Logistic regression models were used to isolate the effect of erectile dysfunction on the likelihood of having diabetes mellitus with adjustment for age, region and 7 concurrent diseases.

RESULTS

The diabetes mellitus prevalence rates were 20.0% in men with erectile dysfunction and 7.5% in men without erectile dysfunction. With adjustment for age, region and concurrent diseases, the odds ratio of having diabetes mellitus between men with erectile dysfunction and without erectile dysfunction was 1.60 (p <0.0001). With adjustment for regions and concurrent diseases, the age specific odds ratios ranged from 2.94 (p <0.0001, age 26 to 35) to 1.05 (p = 0.1717, age 76 to 85).

CONCLUSIONS

Men with erectile dysfunction were more than twice as likely to have diabetes mellitus as men without erectile dysfunction. Erectile dysfunction is an observable marker of diabetes mellitus, strongly so for men 45 years old or younger and likely for men 46 to 65 years old, but it is not a marker for men older than 66 years.

Should an oral glucose tolerance test be performed routinely in all renal transplant recipients?

Posttransplantation diabetes (PTD) contributes to cardiovascular disease and graft loss in renal transplant recipients (RTR). Current recommendations advise fasting blood glucose (FBG) as the screening and diagnostic test of choice for PTD. This study sought to determine (1) the predictive power of FBG with respect to 2-h blood glucose (2HBG) and (2) the prevalence of PTD using FBG and 2HBG compared with that using FBG alone, in prevalent RTR. A total of 200 RTR (mean age 52 yr; 59% male; median transplant duration 6.6 yr) who were > 6 mo posttransplantation and had no known history of diabetes were studied. Patients with FBG < 126 mg/dl (7.0 mmol/L; n = 188) underwent an oral glucose tolerance test (OGTT). Receiver operating characteristic analyses evaluated the optimal level of FBG predictive of PTD (2HBG > or = 200 mg/dl [11.1 mmol/L]) and impaired glucose tolerance (IGT; 2HBG 140 to 200 mg/dl [7.8 to 11.0 mmol/L]). An abnormal OGTT was reported in 79 (42%) nondiabetic RTR: PTD (n = 22) and IGT (n = 57). The optimal FBG that was predictive of PTD was 101 mg/dl (5.6 mmol/L; area under the curve 0.70; sensitivity 64%, specificity 67%, positive predictive value 20%, negative predictive value 93%). The optimal FBG that was predictive of IGT was less well defined (area under the curve 0.54). The prevalence of PTD was higher by OGTT than by FBG alone (17 versus 6%; P < 0.001). FBG may not be the optimal screening or diagnostic tool for PTD or IGT in RTR. Consideration should be given to introducing the OGTT as a routine posttransplantation investigation, although the implications of a pathologic OGTT are still to be determined in this population.