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Questions and Answers
Which of the following factors is NOT identified as a risk factor for gestational diabetes during screening?
What is the relative risk (RR) of developing gestational hypertension in women with gestational diabetes?
What percentage of women with a history of gestational diabetes may have persistently abnormal glucose tolerance?
What is the likelihood of developing Type 2 diabetes later in life for women with gestational diabetes?
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Which type of diabetes is characterized as maturity-onset diabetes of the young (MODY)?
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Which sign is NOT typically associated with Type 2 diabetes?
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What waist circumference measurement indicates a higher risk for Type 2 diabetes in men?
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What is the primary screening recommendation for Type 2 diabetes in adults?
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Which of the following statements about lifestyle interventions for Type 2 diabetes is true?
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Which complication should prompt doctors to consider Type 2 diabetes in postpartum women?
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In Type 2 diabetes, what is a common clinical feature during diagnosis?
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Which of these is a known risk factor for developing Type 2 diabetes?
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What long-term benefit might result from screening for Type 2 diabetes?
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What is the primary consequence of untreated diabetes regarding lifespan?
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Which of the following is NOT classified as a complication associated with diabetes?
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What percentage of U.S. adults is estimated to be diagnosed with diabetes?
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Which of the following is a significant risk factor for developing Type 2 diabetes?
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What is the primary role of HbA1c levels in diabetes management?
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In addition to diabetes, which condition is often correlated with diabetic patients?
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What diagnostic test is primarily used to assess insulin sensitivity?
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Which ethnic groups are reported to have the highest prevalence of Type 2 diabetes in youth?
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What age is recommended to start screening for Type 2 diabetes in children who are at risk?
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Which of the following conditions is NOT a risk factor for screening in Type 2 diabetes for children and adolescents?
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What is the approximate prevalence of Type 2 diabetes among youth aged 12-18 years with prediabetes?
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Which complication is NOT typically associated with Type 2 diabetes in adolescents?
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How many subtypes are there for Maturity-Onset Diabetes of the Young (MODY)?
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Which type of MODY accounts for the majority (30-50%) of cases?
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What is a common pH level indicating hyperglycemia in patients diagnosed with MODY?
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Which of the following is a significant long-term morbidity associated with Type 2 diabetes?
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Which group provides insufficient evidence to assess the benefits versus harms of screening for Type 2 diabetes in children?
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What is the primary reason for considering genetic testing in patients with Maturity-Onset Diabetes of the Young (MODY)?
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Which of the following statements is true regarding diabetes prevalence in older adults in the U.S.?
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What complicates the development of standard care guidelines for older diabetic patients?
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Which condition is NOT considered a secondary cause of diabetes?
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What is the criteria for diagnosing impaired fasting glucose tolerance?
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What is a potential benefit of fasting plasma glucose testing over other diagnostic tests?
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Which of the following statements reflects the current recommendations for screening diabetes in older adults?
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Which diabetes diagnostic test requires fasting and is recognized for identifying pre-diabetes?
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Which factor is NOT considered when making treatment decisions for older diabetic patients?
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What is the relative risk of shoulder dystocia in women with gestational diabetes?
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Which complication of gestational diabetes has the highest relative risk of developing in postpartum women?
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Which factor significantly increases the likelihood of diabetes development in women with gestational diabetes?
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What is the recommended frequency for screening women with a history of gestational diabetes for overt diabetes?
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Which of the following is NOT commonly considered a factor in high-risk populations for gestational diabetes?
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Which symptom is more commonly associated with Type 1 diabetes than with Type 2 diabetes?
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What waist circumference is indicative of a higher risk for Type 2 diabetes in women?
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Which screening recommendation is suggested for individuals with a body mass index ≥25 kg/m2?
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In terms of metabolic syndrome, which condition is primarily associated with increased risk for cardiovascular disease?
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Which of the following statements about screening for Type 2 diabetes is true?
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Which condition would most likely prompt healthcare providers to consider Type 2 diabetes in postpartum women?
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Which of the following is more strongly correlated with Type 2 diabetes compared to other conditions?
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What diagnosis feature often differentiates Type 2 diabetes from Type 1 diabetes?
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What percentage of adults aged 65 years and older in the U.S. are unaware that they have diabetes?
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Which factor should be considered when determining the necessity for diabetes screening in older adults?
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Which hormonal condition is listed as a secondary cause of diabetes?
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What method is primarily used to confirm a diabetes diagnosis in patients showing hyperglycemia?
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Which of the following statements accurately reflects the challenges related to older adults with diabetes?
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Which diabetes screening test is recognized for potentially identifying more undiagnosed cases than HbA1c?
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What is the implication of the lack of evidence from randomized trials regarding early diagnosis and therapy for MODY?
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What condition is characterized as having a significant risk of complications in older adults with diabetes?
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What role does functional status play in treatment decisions for older adults with diabetes?
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Which statement accurately describes the genetic factors involved in the development of Type 1 diabetes?
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What is the main environmental factor linked to the increasing incidence of Type 1 diabetes?
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Among individuals with Type 2 diabetes, what percentage of monozygotic twins are likely to also develop the condition if one twin is diagnosed?
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What role do genetic variants play in the development of Type 2 diabetes?
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Which age group is the peak incidence for Type 1 diabetes typically found?
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Which statement about Type 2 diabetes is true regarding its environmental risk factors?
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What is the trend in the mortality rate for individuals diagnosed with diabetes?
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How does genetic predisposition influence the risk of developing Type 1 diabetes?
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What is the age recommended for initiating screening for Type 2 diabetes in children who are at risk?
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Which ethnic groups have the highest prevalence of Type 2 diabetes among youth in the U.S.?
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What percentage of youth diagnosed with Type 2 diabetes may experience peripheral neuropathy during their teenage years?
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Which risk factor is considered least associated with the development of Type 2 diabetes in children and adolescents?
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What aspect of MODY differentiates it from Type 1 and Type 2 diabetes?
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Which of the following is a significant long-term morbidity associated with Type 2 diabetes in adolescents?
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What is a key characteristic of MODY2 compared to other types of diabetes?
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What primary issue is associated with the screening recommendations for Type 2 diabetes in children?
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Which of the following factors do NOT contribute to the risk of developing Type 2 diabetes in children according to the profile provided?
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How many subtypes of Maturity-Onset Diabetes of the Young (MODY) have been identified?
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Which of the following factors is known to falsely lower A1c levels?
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What condition is identified as falsely elevating A1c levels?
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Which condition would be expected to have no effect on A1c levels?
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Which of the following factors is likely to interfere with the accuracy of A1c measurements by lowering its value?
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Which factor contributes to variations in A1c levels but does not definitively classify them as higher or lower?
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What is the peak age range for the incidence of Type 1 diabetes?
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Which of the following factors contributes the least to the genetic risk associated with Type 1 diabetes?
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What percentage of the genetic risk for developing Type 1 diabetes is attributed to environmental factors?
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What is the primary reason diabetes is described as a metabolic disease?
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According to epidemiological studies of monozygotic twins, when one twin develops Type 2 diabetes, what is the likelihood that the second twin will develop it within a year?
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Which environmental factor is most significantly responsible for causing insulin resistance in Type 2 diabetes?
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Which of the following conditions is most closely linked to diabetes complications?
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In which region is the annual incidence of Type 1 diabetes reported to be the highest?
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What percentage reduction in lifespan is associated with diabetes?
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Which of the following antibodies is commonly found in patients diagnosed with Type 1 diabetes?
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Which of these is a common diagnostic test for monitoring diabetes but has limitations?
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What percentage of the population in Canada is diagnosed with diabetes?
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Which demographic is commonly reported to have the highest prevalence of Type 2 diabetes?
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What methodological consideration complicates diabetes management in older patients?
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Which of the following statements about the mortality rate of individuals with diabetes is accurate?
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What is the role of patient education in diabetes management?
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What is the significance of a waist circumference greater than 40 inches in men concerning Type 2 diabetes?
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Which of the following is the most appropriate screening recommendation for asymptomatic adults?
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In the context of diabetes diagnosis, which symptom is more frequently observed in Type 1 diabetes compared to Type 2 diabetes?
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What potential long-term benefit may result from screening adults for Type 2 diabetes?
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Which of the following conditions is linked to higher risk of Type 2 diabetes during pregnancy?
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What defines metabolic syndrome in the context of diabetes risk?
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How effective is screening for Type 2 diabetes at 10-year follow-up in reducing mortality?
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What is considered an initial clinical feature in the diagnosis of Type 2 diabetes?
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What is the primary method used for screening gestational diabetes during pregnancies?
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Which screening approach for gestational diabetes is associated with a higher diagnosis rate?
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What is the main conclusion regarding the benefits and harms of one-step versus two-step screening for gestational diabetes?
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What has been reported about the prevalence of gestational diabetes with respect to maternal age and BMI?
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What is the most common long-term complication associated with Type 2 diabetes in adolescents?
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Which screening criteria is recommended for children at risk of Type 2 diabetes?
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Which ethnic group has the highest prevalence of Type 2 diabetes among youth?
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What percentage of individuals diagnosed with Type 2 diabetes experience diabetic ketoacidosis at diagnosis?
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Which risk factor is least associated with the development of Type 2 diabetes in youth?
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What genetic characteristic is common in patients suspected of having Maturity-Onset Diabetes of the Young (MODY)?
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Which statement is accurate regarding the screening guidelines for Type 2 diabetes in children?
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What is the primary reason for considering genetic testing in MODY patients?
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What is the correct classification of diabetes for the majority of adolescents diagnosed with hyperglycemia?
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Which Type of MODY is most commonly associated with progressive hyperglycemia?
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Study Notes
Diabetes Mellitus
- Diabetes mellitus is a metabolic disease characterized by high blood glucose levels.
- It is one of the most common chronic diseases and a leading cause of disability and mortality.
- It reduces lifespan by 5-15 years with a mortality rate twice as high as those without diabetes.
- Globally, 1 in 11 adults between 20-79 years old is diagnosed with diabetes.
- In the U.S., an estimated 34.2 million (10.5%) adults have diabetes.
Type 2 Diabetes: Signs and Symptoms
- Weight gain, including overweight or obesity.
- Centripetal fat distribution (excess fat around the waist).
- Waist circumference greater than 40 inches for men and 35 inches for women.
- Obstetrical complications such as delivering babies over 9 lb, polyhydramnios, preeclampsia, or unexplained fetal losses.
Type 2 Diabetes: Screening Recommendations
- Screening is recommended for Type 2 diabetes.
- Lifestyle changes and medications can reduce disease progression and adverse sequelae, even in asymptomatic patients.
- Screening for asymptomatic adults with a body mass index (BMI) ≥25 kg/m2, and one or more additional risk factors:
- A1c > 5.7%
- Impaired glucose tolerance
- Impaired fasting glucose
Clinical Features of Diabetes at Diagnosis
| Feature | Type 1 Diabetes | Type 2 Diabetes |
|---|---|---|
| Polyuria and thirst | ++ | + |
| Weakness or fatigue | ++ | + |
| Polyphagia with weight loss | ++ | - |
| Recurrent blurred vision | + | ++ |
| Vulvovaginitis or pruritis | + | ++ |
| Peripheral neuropathy | + | ++ |
| Nocturnal enuresis | ++ | - |
| Often asymptomatic | - | ++ |
"Metabolic Syndrome" / Insulin Resistance Syndrome
- Identifies individuals at higher risk for developing diabetes and cardiovascular disease.
- Not clear whether it is a useful diagnostic or management tool.
- Gestational diabetes screening recommendations:
- Screen women in their first trimester if risk factors are present (obesity, advanced maternal age, history of gestational diabetes, family history of diabetes, high-risk ethnicity).
- Screen asymptomatic patients at or after 24 weeks' gestation.
Gestational Diabetes: Complications
- Increases the risk of maternal complications including gestational hypertension, preeclampsia, Cesarean delivery, shoulder dystocia, macrosomia, and birth defects.
- 7 times greater maternal risk of developing Type 2 diabetes later in life.
- 1.5 times greater risk of the child being overweight in childhood/adolescence.
- In high-risk populations, diabetes develops in up to 50% of women with gestational diabetes.
Gestational Diabetes: Management
- Short- and long-term follow-up is critical.
- Screening at 6-12 weeks postpartum with a fasting glucose measurement or a 75g 2-hour glucose tolerance test.
- Women with history of gestational diabetes should be screened every 3 years for overt diabetes.
Diabetes in Children and Adolescents
- Includes Type 1 diabetes, Type 2 diabetes, and Maturity-Onset Diabetes of the Young (MODY).
- In 2018, an estimated 210,000 children and adolescents in the U.S. had diabetes (2.5 per 1000).
- Approximately 23,000 had Type 2 diabetes (0.24 per 1000).
Type 2 Diabetes in Children and Adolescents
- Risk factors include obesity, excess adipose tissue, and family history.
- Prevalence is highest in Native American, Black, Latin American, and Atlantic/Pacific Islander youth.
- Socioeconomic position, area of residence, and environmental factors may contribute.
Type 2 Diabetes in Children and Adolescents: Complications
- Major acute complications include diabetic ketoacidosis and hyperglycemic hyperosmolar state.
- Long-term morbidity is due to macrovascular and microvascular diseases.
- Increased prevalence of associated chronic comorbid conditions: hypertension, dyslipidemia, and nonalcoholic fatty liver disease.
Type 2 Diabetes in Children and Adolescents: Screening Recommendations
- Evidence is insufficient to assess the benefits versus harms of screening for Type 2 diabetes.
- Screening is recommended for age ≤18 who are overweight and have any two of the following risk factors:
- History of Type 2 diabetes in a first- or second-degree relative
- Belonging to a high-risk ethnic group
- Acanthosis nigricans
- Hypertension
- Hyperlipidemia
- Polycystic ovarian syndrome
- Screening recommended for at-risk patients every 2 years, starting at age 10, or at onset of puberty if under age 10.
Maturity-Onset Diabetes of the Young (MODY)
- A non-insulin-dependent form of diabetes typically diagnosed at ≤25 years of age.
- 1-5% of all patients with diabetes have the MODY type, often misdiagnosed as Type 1 or 2 diabetes.
- Suspect MODY in patients who are/have:
- Non-obese and diagnosed with diabetes at a young age (< 144 mg/dL or 8.0 mmol/L, and no laboratory evidence of beta cell autoimmunity)
- Autosomal dominant disease, with 50% of offspring affected.
- Divided into 14 subtypes (MODY1 to MODY14) with MODY1 to MODY3 accounting for 95% of cases.
- Subtypes distinguished by gene mutations:
- MODY1 (HNF4A): rare
- MODY2 (GCK): less rare
- MODY3 (HNF1A): most common, 30-50% of cases
- Remaining subtypes are very rare.
- MODY1 and MODY3 have progressive hyperglycemia and vascular complication rates similar to Type 1 and 2 diabetes.
- MODY2 has mild stable fasting hyperglycemia with low risk of diabetes related complications.
Maturity-Onset Diabetes of the Young (MODY): Screening Recommendations
- Consider genetic testing and referral to an endocrinologist and/or clinical genetics consultant.
- Accurate diagnosis of MODY will determine treatment and management plan.
- Lack of evidence from randomized trials to show that early diagnosis and appropriate therapy improve patient outcomes.
Diabetes in Older Adults
- The definition of "older" varies but generally accepted as >65 years of age.
- Between 1997-2010, U.S. prevalence of diabetes in older adults increased by 62%.
- In the U.S., 21.4% of adults aged ≥65 years have a known diagnosis of diabetes and 16% are unaware.
- Most commonly affected by Type 2 diabetes.
- Older diabetic population is highly heterogeneous, complicating development of standard guidelines of care.
- Diabetes increases the risk of mortality, cardiovascular and microvascular complications, and other geriatric conditions.
Diabetes in Older Adults: Screening Recommendations
- No current recommendations for routine screening.
- Screening considerations: whether treatment would improve overall quality of life or life expectancy.
- Treatment decisions should be made based on age, life expectancy, functional status, and co-morbid diseases.
Secondary Causes of Diabetes
- Secondary causes include:
- Exocrine pancreas diseases
- Endocrinopathies
- Drug- or chemical-induced insulin resistance
- Genetic diseases
- Any disorder that damages the pancreas can result in diabetes (e.g., liver cirrhosis, hemochromatosis, hemosiderosis).
Secondary Causes of Diabetes: Examples
| Category | Examples |
|---|---|
| Exocrine Pancreas | Pancreatitis, Cystic Fibrosis |
| Endocrinopathies | Somatostatinoma, Pheochromocytoma, Acromegaly, Cushing syndrome, Glucagonomia |
| Drug- or Chemical-Induced | Corticosteroids, Sympathomimetics, Niacin, Alpelisib, Sirolimus, Thiazide diuretics, Phenytoin, Atypical antipsychotics |
| Genetic Syndromes | Down, Klinefelter, Turner, Wolfram syndrome, Type A insulin resistance, Leprechaunism, Rabson-Mendenhall syndrome, Lipoatrophic diabetes |
Diagnostic Tests
- Fasting plasma glucose levels (FPG)
- Oral glucose tolerance test (OGTT)
- Glycated hemoglobin (HbA1c)
- Additional tests (urine, self-monitoring, continuous glucose monitoring, autoantibody, genetic)
Fasting Plasma Glucose (FPG)
- 100-125 mg/dL (5.6-6.9 mmol/L) = impaired fasting glucose tolerance (increased risk of diabetes, "pre-diabetes").
- ≥126 mg/dL (7.0 mmol/L) on more than one occasion, after at least 8-hour fasting = Diagnostic.
- Diagnosis may be made with hyperglycemia signs and symptoms, PLUS >200 mg/dL (11.1 mmol/L) - and testing should be repeated to confirm.
- Pros: may identify one-third more undiagnosed cases than A1c.
- Cons: fasting is required.
Oral Glucose Tolerance Test (OGTT)
- Perform if FPG is:
- 100-125 mg/dL (5.6-6.9 mmol/L)
- Or if the patient has symptoms of hyperglycemia.
- A 2-hour post-load glucose level of >200 mg/dL (11.1 mmol/L) is diagnostic.
Glycated Hemoglobin (HbA1c)
- Reflects average blood glucose levels over the past 2-3 months.
- HbA1c of 6.5% or higher is diagnostic of diabetes.
- HbA1c of 5.7-6.4% is considered pre-diabetes.
Additional Tests
-
Urine Tests:
- Urinary glucose and ketones can be used for initial screening and monitoring.
- Proteinuria and microalbuminuria can detect kidney damage.
-
Self-Monitoring of Blood Glucose (SMBG):
- Used by patients with Type 1 and Type 2 diabetes to manage their blood glucose levels.
-
Continuous Glucose Monitoring (CGM):
- Provides real-time blood glucose readings.
- Used for tight blood glucose control and to identify patterns of hypoglycemia and hyperglycemia.
-
Autoantibody Testing:
- Can identify Type 1 diabetes by detecting autoantibodies against pancreatic beta cells.
-
Genetic Testing:
- For MODY or other genetic forms of diabetes.
### Diabetes in Canada
- 14% of Canadians have diabetes (5.7 million people)
- Since 2000, the prevalence rate has increased by an average of 3.3% each year
- Those with diabetes are living longer
Diabetes Mellitus
- Diabetes can be influenced by both genetics and environmental factors
- The two major subtypes of diabetes are type 1 and type 2
- Other subtypes include maturity-onset diabetes of the young (MODY), gestational diabetes, and secondary causes
### Type 1 Diabetes
- Results from the destruction of pancreatic islet beta cells, often due to an autoimmune reaction
- More common in children and young adults, with peak incidence between ages 4-6 and 10-14
- The global incidence of type 1 diabetes is rising by approximately 3% annually
### Type 1 Diabetes: Epidemiology
-
Genetic Factors:
- The HLA locus (HLA-DR3, -DR4, -DQ) accounts for around 40% of the genetic risk for developing type 1 diabetes
- Most patients with type 1 diabetes have circulating antibodies to islet cells, glutamic acid decarboxylase 65, insulin, tyrosine phosphatase IA2, and zinc transporter 8
-
Environmental Factors:
- The highest incidence of type 1 diabetes is found in Scandinavia and northern Europe (e.g., Finland, with an annual incidence of 40 per 100,000 children aged ≤14 years)
- The lowest incidence is observed in China and parts of South America (annual incidence is 9 per 100,000 children aged ≤14 years)
Type 2 Diabetes: Epidemiology
-
Genetic Factors:
- Epidemiological studies of monozygotic twins over 40 years of age show that if one twin develops type 2 diabetes, the other twin has a 70% chance of developing it within a year
- Genome studies have identified 143 risk variants and regulatory mechanisms for type 2 diabetes, including loci related to:
- Beta cell function/development (TCF7L2)
- Insulin secretion (e.g., CDKAL1, SLC30A8)
- Fat mass and obesity risk (FTO, MC4R)
- Insulin resistance (PPARG)
-
Environmental Factors:
- Obesity, particularly visceral obesity, is the primary environmental factor contributing to insulin resistance
Type 2 Diabetes: Signs and Symptoms
- Weight gain:
- Overweight or obese
- Centripetal fat distribution
- Waist circumference >40 inches for men, >35 inches for women
- Obstetrical complications:
- Consider type 2 diabetes in women who have delivered babies over 9 lb (4.1 kg) or have experienced polyhydramnios, preeclampsia, or unexplained fetal losses
Type 2 Diabetes: Screening Recommendations
-
The USPSTF recommends screening for type 2 diabetes
-
Reliable tests are available, and lifestyle changes and medications can reduce disease progression and adverse consequences even in asymptomatic individuals
-
Studies show that while screening may not improve mortality at 10-year follow-up, interventions like lifestyle modifications and pharmacologic treatments can delay the development of type 2 diabetes
-
Some studies suggest that screening may have mortality benefits at 23- to 30-year follow-up
-
Screen asymptomatic adults who have a body mass index (BMI) ≥25 kg/m2 and one or more of the following risk factors from previous lab results:
- A1c > 5.7%
- Impaired glucose tolerance
- Impaired fasting glucose
Clinical Features of Diabetes at Diagnosis
| Feature | Type 1 Diabetes | Type 2 Diabetes |
|---|---|---|
| Polyuria and thirst | ++ | + |
| Weakness or fatigue | ++ | + |
| Polyphagia with weight loss | ++ | - |
| Recurrent blurred vision | + | ++ |
| Vulvovaginitis or pruritis | + | ++ |
| Peripheral neuropathy | + | ++ |
| Nocturnal enuresis | ++ | - |
| Often asymptomatic | - | ++ |
“Metabolic Syndrome”
- Also known as Insulin Resistance Syndrome
- Identifies individuals at increased risk for developing diabetes and cardiovascular disease
- Its usefulness as a diagnostic or management tool is debated
- Screening recommendations for gestational diabetes:
- Screen women in their first trimester if risk factors such as obesity, advanced maternal age (>35 years), history of gestational diabetes, family history of diabetes, or high-risk ethnicity are present
- Screen asymptomatic patients at or after 24 weeks’ gestation
Gestational Diabetes: Complications
- Adverse outcomes include:
- Gestational hypertension (RR=1.6)
- Preeclampsia (RR=1.5)
- Cesarean delivery (RR=1.3)
- Shoulder dystocia (RR=2.9)
- Macrosomia (RR=1.6)
- Birth defects (RR=1.2)
- Women with gestational diabetes have a 7 times greater risk of developing type 2 diabetes later in life (RR=7.4) and a 1.5 times greater risk of their child being overweight in childhood/adolescence (RR=1.5)
- In high-risk populations (BMI >25 kg/m2 plus physical inactivity, first-degree relative with diabetes, high-risk ethnicity, previous gestational diabetes, or hypertension), diabetes develops in up to 50% of women with gestational diabetes
### Gestational Diabetes: Management
- Short- and long-term follow-up is crucial
- Screening should be done at 6-12 weeks postpartum with a fasting glucose measurement or a 75g 2-hour glucose tolerance test.
- Up to 36% of women with gestational diabetes may have persistently abnormal glucose tolerance.
- Women with a history of gestational diabetes should be screened every 3 years for overt diabetes
### Diabetes in Children and Adolescents
- Type 1 diabetes
- Type 2 diabetes
- Maturity-onset diabetes of the young (MODY)
Diabetes in Children and Adolescents
- In 2018, an estimated 210,000 children and adolescents in the U.S. (2.5 per 1000) had diabetes
- Approximately 23,000 had type 2 diabetes (0.24 per 1000)
- From 2005-2016, nearly 20% of youth aged 12-18 years had prediabetes
- Most cases occur after age 10, with peak occurrence at mid-puberty
### Type 2 Diabetes in Children and Adolescents
- Risk factors include: obesity, excess adipose tissue (especially when centrally distributed), and family history
- The prevalence is highest in Native American, Black, Latin American, and Atlantic/Pacific Islander youth (U.S.)
- Socioeconomic position, area of residence, and environmental factors may also play a role (e.g., quality of and access to health care, toxic stress, structural racism)
### Type 2 Diabetes in Children and Adolescents
- Major acute complications of type 2 diabetes in youth are diabetic ketoacidosis (10% at diagnosis) and hyperglycemic hyperosmolar state
- Long-term morbidity is due to macrovascular (atherosclerosis) and microvascular diseases (retinopathy, nephropathy, neuropathy)
- Complications like renal disease, retinopathy (13.7%), and peripheral neuropathy (17.7%) may develop during teenage and young adulthood years
- An increased prevalence of associated chronic comorbid conditions exists:
- Hypertension (11.6-33.8%)
- Dyslipidemia (4.5-10.7%)
- Nonalcoholic fatty liver disease (22.2%)
Type 2 Diabetes in Children and Adolescents: Screening
- The USPSTF considers the evidence insufficient to assess the benefits versus harms of screening for type 2 diabetes in children and adolescents
- The USPSTF concludes there is insufficient evidence to recommend for or against screening for type 2 diabetes in children and adolescents without symptoms of diabetes or prediabetes
- There is inadequate evidence to demonstrate that screening and early intervention lead to improvements in health outcomes such as preventing:
- Progression to type 2 diabetes
- Renal impairment
- Cardiovascular morbidity and mortality
- Improvement in quality of life
Type 2 Diabetes in Children and Adolescents: Screening Recommendations
- Screening is recommended for individuals aged ≤18 who are overweight and have any two of the following risk factors:
- History of type 2 diabetes in a first- or second-degree relative
- Belonging to a high-risk ethnic group
- Acanthosis nigricans
- Hypertension
- Hyperlipidemia
- Polycystic ovarian syndrome
- Screening is recommended every 2 years, starting at age 10, or at the onset of puberty if under age 10
Maturity-Onset Diabetes of the Young (MODY)
- A non-insulin-dependent form of diabetes, typically diagnosed at ≤25 years of age
- 1-5% of all patients with diabetes have MODY
- Often misdiagnosed as type 1 or 2 diabetes
### Maturity-Onset Diabetes of the Young (MODY)
- MODY should be suspected in patients who:
- Are non-obese and were diagnosed with diabetes at a young age (144 mg/dL or 8.0 mmol/L fasting glucose, with no laboratory evidence of pancreatic beta cell autoimmunity)
### Maturity-Onset Diabetes of the Young (MODY)
- Most often an autosomal dominant disease, affecting 50% of offspring
- Divided into 14 subtypes (MODY1 to MODY14), with MODY1 to MODY3 accounting for 95% of cases
- The subtypes are distinguished by their gene mutations:
- MODY1 (HNF4A): rare
- MODY2 (GCK): less rare
- MODY3 (HNF1A): most common, 30-50% of cases
- The remaining subtypes are very rare
### Maturity-Onset Diabetes of the Young (MODY)
- MODY1 and MODY3 exhibit progressive hyperglycemia and vascular complication rates similar to patients with type 1 and type 2 diabetes
- MODY2 typically presents with mild, stable fasting hyperglycemia and a low risk of diabetes-related complications. These patients generally do not require treatment, except during pregnancy.
Maturity-Onset Diabetes of the Young (MODY): Screening Recommendations
- Consider genetic testing and referral to an endocrinologist and/or clinical genetics consultant
- Accurate diagnosis of MODY is essential for determining the appropriate treatment and management plan
- However, there is a lack of evidence from randomized trials to show that early diagnosis and therapy improve patient-oriented outcomes
Diabetes in Older Adults
- The definition of "older" varies across studies; generally accepted as >65 years of age
- From 1997-2010, the U.S. prevalence of diabetes in older adults increased by 62%
- In the U.S., 21.4% of adults aged ≥65 years have a known diagnosis of diabetes; 16% are unaware they have diabetes
Diabetes in Older Adults
- Most commonly affected by type 2 diabetes
- The older diabetic population is highly heterogeneous in terms of race/ethnicity, duration of diabetes, comorbidity, and functional status, making it challenging to develop standard guidelines for care
- Diabetes increases the risk of mortality, cardiovascular and microvascular complications, and other geriatric conditions (e.g., cognitive impairment, frailty, unintentional weight loss, polypharmacy, and functional impairment)
### Diabetes in Older Adults: Screening Recommendations
- No current recommendations for routine screening
- Screening should be considered if treatment would improve overall quality of life or life expectancy
- Consider screening to prevent complications that may lead to functional impairment
- Treatment decisions should be made based on:
- Age
- Life expectancy
- Functional status
- Presence of chronic co-morbid diseases
Secondary Causes of Diabetes
- Secondary causes include:
- Exocrine pancreas diseases
- Endocrinopathies
- Drug- or chemical-induced insulin resistance
- Other genetic diseases
- Any disorder that damages the pancreas can lead to diabetes (e.g., liver cirrhosis, hemochromatosis, hemosiderosis)
### Secondary Causes of Diabetes
| Category | Examples |
|---|---|
| Exocrine Pancreas Diseases | Pancreatitis, Cystic Fibrosis |
| Endocrinopathies | Somatostatinoma, Pheochromocytoma, Acromegaly, Cushing syndrome, Glucagonomia |
| Drug- or Chemical-Induced | Corticosteroids, Sympathomimetics, Niacin, Alpelisib, Sirolimus, Thiazide diuretics, Phenytoin, Atypical antipsychotics |
| Genetic Syndromes | Down, Klinefelter, Turner, Wolfram syndrome, Type A insulin resistance, Leprechaunism, Rabson-Mendenhall syndrome, Lipoatrophic diabetes |
Diagnostic Tests
Testing for Diabetes
- Fasting plasma glucose levels (FPG)
- Oral glucose tolerance test (OGTT)
- Glycated hemoglobin (HbA1c)
- Additional tests:
- Urine
- Self-monitoring
- Continuous glucose monitoring
- Autoantibody
- Genetic
### Fasting Plasma Glucose (FPG)
- 100-125 mg/dL (5.6-6.9 mmol/L) = impaired fasting glucose tolerance - increased risk of diabetes (“pre-diabetes”)
- ≥126 mg/dL (7.0 mmol/L) on more than one occasion, after at least 8-hour fasting = Diagnostic
- Diagnosis may be made with hyperglycemia signs and symptoms, PLUS >200 mg/dL (11.1 mmol/L) – and testing should be repeated to confirm
- Pros: may identify one-third more undiagnosed cases than A1c
- Cons: fasting is required
Oral Glucose Tolerance Test (OGTT)
- Performed if FPG is:
- Normal (less than 100 mg/dL) but there is a high suspicion of diabetes
- Between 100-125 mg/dL (impaired fasting glucose)
- Involves drinking a sugary drink and having your blood sugar levels checked at intervals
Factors that Falsely Lower A1c
- Acute blood loss can cause a temporary decrease in A1c levels
- Chronic liver disease can interfere with HbA1c production and lead to inaccurate readings
- Hemolytic anemias can lower A1c by shortening the lifespan of red blood cells
- Antiretroviral treatment for HIV can affect A1c levels and sometimes cause false decreases
- Pregnancy can influence A1c levels, leading to lower readings compared to normal circumstances
- Vitamin E and C are thought to potentially reduce A1c levels
Factors that Lower or Elevate A1c
- Hemoglobinopathies or hemoglobin variants can affect A1c accuracy, sometimes lowering and sometimes elevating it
- Malnutrition can result in both increased and decreased A1c values, making interpretation challenging
Factors that Falsely Elevate A1c
- Aplastic anemias can interfere with A1c measurements, leading to falsely high readings
- Hyperbilirubinemia, high levels of bilirubin in the blood, can lead to falsely high A1c readings
- Hypertriglyceridemia, elevated levels of triglyceride in the blood, can contribute to inaccurate A1c results
- Iron deficiency anemias can cause falsely high A1c values.
- Renal failure can influence A1c levels, often leading to higher readings
- Splenectomy can cause elevation in A1c levels due to changes in red blood cell lifespan.
Diabetes Mellitus
- A metabolic disorder characterized by persistently elevated blood glucose levels.
- A leading cause of disability and mortality worldwide.
- Reduces life expectancy by 5-15 years.
- Prevalence in adults ages 20-79 is 1 in 11 globally.
- Both genetic and environmental factors contribute to its development.
- The two main types are Type 1 and Type 2.
Type 1 Diabetes
- Characterized by destruction of pancreatic beta cells, typically due to an autoimmune reaction.
- More common in children and young adults, with peak incidence at ages 4-6 & 10-14.
- Global incidence is increasing by approximately 3% each year.
- Genetic factors account for one-third of disease susceptibility, with HLA locus (HLA-DR3, -DR4, -DQ) conferring about 40% of the genetic risk.
- Environmental factors account for two-thirds of disease susceptibility, with highest incidence in Scandinavia and northern Europe.
Type 2 Diabetes
- The most prevalent type of diabetes.
- Characterized by insulin resistance and a relative deficiency of insulin secretion.
- Strongly associated with obesity, especially visceral obesity.
- Genetic factors contribute to 70% of cases when one monozygotic twin develops Type 2 diabetes after age 40.
- Environmental factors include obesity, sedentary lifestyle, and family history.
Gestational Diabetes
- Develops during pregnancy and typically resolves after delivery.
- Represents 7.8% of all pregnancies in 2020, increasing since 2016.
- Prevalence increases with advancing maternal age and higher pre-pregnancy BMI.
- Screening typically involves a 50g glucose challenge test between 24-28 weeks' gestation.
- Diagnostic criteria involve a 3-hour fasting 100g glucose challenge test with abnormal values ≥180, 155, 140 mg/dL for 1-, 2-, and 3-hour fasting glucose levels, respectively.
Diabetes in Children and Adolescents
- Represents 2-5% of all diagnosed cases of diabetes.
- Prevalence is highest in Native American, Black, Latin American, and Atlantic/Pacific Islander youth.
- Risk factors include obesity, excess adipose tissue, and family history.
- The presence of diabetic ketoacidosis (10% at diagnosis) and hyperglycemic hyperosmolar state represents major acute complications.
- Long-term morbidity is due to macrovascular and microvascular diseases.
Maturity-Onset Diabetes of the Young (MODY)
- A non-insulin-dependent form of diabetes, typically diagnosed at ≤25 years of age.
- Occurs in 1-5% of all patients with diabetes.
- Often misdiagnosed as Type 1 or 2 diabetes.
- Characterized by autosomal dominant inheritance with 50% of offspring affected.
- Divided into 14 subtypes, with MODY1 to MODY3 accounting for 95% of cases.
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Explore the key concepts related to Diabetes Mellitus, including its prevalence, signs, symptoms, and screening recommendations. This quiz covers essential information about Type 2 diabetes and its impact on health. Test your knowledge on this chronic condition that affects millions worldwide.
