Diabetes Mellitus Overview
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Questions and Answers

Which of the following factors is NOT identified as a risk factor for gestational diabetes during screening?

  • Obesity
  • Advanced maternal age (>35 years)
  • History of gestational hypertension (correct)
  • Family history of diabetes

    • What is the relative risk (RR) of developing gestational hypertension in women with gestational diabetes?

  • 1.2
  • 1.6 (correct)
  • 1.5
  • 2.9

    • What percentage of women with a history of gestational diabetes may have persistently abnormal glucose tolerance?

  • 50%
  • 36% (correct)
  • 24%
  • 15%

    • What is the likelihood of developing Type 2 diabetes later in life for women with gestational diabetes?

    <p>7 times greater</p> Signup and view all the answers

    Which type of diabetes is characterized as maturity-onset diabetes of the young (MODY)?

    <p>Genetic defects in insulin secretion</p> Signup and view all the answers

    Which sign is NOT typically associated with Type 2 diabetes?

    <p>Polyphagia with weight loss</p> Signup and view all the answers

    What waist circumference measurement indicates a higher risk for Type 2 diabetes in men?

    <p>Greater than 40 inches</p> Signup and view all the answers

    What is the primary screening recommendation for Type 2 diabetes in adults?

    <p>Screen asymptomatic adults with BMI ≥25 and additional risk factors</p> Signup and view all the answers

    Which of the following statements about lifestyle interventions for Type 2 diabetes is true?

    <p>They can reduce disease progression and adverse effects</p> Signup and view all the answers

    Which complication should prompt doctors to consider Type 2 diabetes in postpartum women?

    <p>Delivery of a baby over 9 lb</p> Signup and view all the answers

    In Type 2 diabetes, what is a common clinical feature during diagnosis?

    <p>Often asymptomatic</p> Signup and view all the answers

    Which of these is a known risk factor for developing Type 2 diabetes?

    <p>Impaired fasting glucose</p> Signup and view all the answers

    What long-term benefit might result from screening for Type 2 diabetes?

    <p>Delay in the development of Type 2 diabetes</p> Signup and view all the answers

    What is the primary consequence of untreated diabetes regarding lifespan?

    <p>Reduces lifespan by 5-15 years</p> Signup and view all the answers

    Which of the following is NOT classified as a complication associated with diabetes?

    <p>Osteoporosis</p> Signup and view all the answers

    What percentage of U.S. adults is estimated to be diagnosed with diabetes?

    <p>10.5%</p> Signup and view all the answers

    Which of the following is a significant risk factor for developing Type 2 diabetes?

    <p>Obesity</p> Signup and view all the answers

    What is the primary role of HbA1c levels in diabetes management?

    <p>To monitor long-term glucose control</p> Signup and view all the answers

    In addition to diabetes, which condition is often correlated with diabetic patients?

    <p>Cancer</p> Signup and view all the answers

    What diagnostic test is primarily used to assess insulin sensitivity?

    <p>Fasting blood sugar</p> Signup and view all the answers

    Which ethnic groups are reported to have the highest prevalence of Type 2 diabetes in youth?

    <p>Native American, Black, Latin American, and Atlantic/Pacific Islander</p> Signup and view all the answers

    What age is recommended to start screening for Type 2 diabetes in children who are at risk?

    <p>At age 10 or at onset of puberty if under age 10</p> Signup and view all the answers

    Which of the following conditions is NOT a risk factor for screening in Type 2 diabetes for children and adolescents?

    <p>Asthma</p> Signup and view all the answers

    What is the approximate prevalence of Type 2 diabetes among youth aged 12-18 years with prediabetes?

    <p>Approximately 20%</p> Signup and view all the answers

    Which complication is NOT typically associated with Type 2 diabetes in adolescents?

    <p>Thyroid dysfunction</p> Signup and view all the answers

    How many subtypes are there for Maturity-Onset Diabetes of the Young (MODY)?

    <p>14</p> Signup and view all the answers

    Which type of MODY accounts for the majority (30-50%) of cases?

    <p>MODY3</p> Signup and view all the answers

    What is a common pH level indicating hyperglycemia in patients diagnosed with MODY?

    <p>144 mg/dL or 8.0 mmol/L</p> Signup and view all the answers

    Which of the following is a significant long-term morbidity associated with Type 2 diabetes?

    <p>Microvascular diseases</p> Signup and view all the answers

    Which group provides insufficient evidence to assess the benefits versus harms of screening for Type 2 diabetes in children?

    <p>United States Preventive Services Task Force</p> Signup and view all the answers

    What is the primary reason for considering genetic testing in patients with Maturity-Onset Diabetes of the Young (MODY)?

    <p>To accurately diagnose MODY for treatment and management</p> Signup and view all the answers

    Which of the following statements is true regarding diabetes prevalence in older adults in the U.S.?

    <p>21.4% of adults aged ≥65 years are diagnosed with diabetes.</p> Signup and view all the answers

    What complicates the development of standard care guidelines for older diabetic patients?

    <p>There is a lack of homogeneity in the older diabetic population.</p> Signup and view all the answers

    Which condition is NOT considered a secondary cause of diabetes?

    <p>Type 2 diabetes</p> Signup and view all the answers

    What is the criteria for diagnosing impaired fasting glucose tolerance?

    <p>Fasting plasma glucose between 100-125 mg/dL</p> Signup and view all the answers

    What is a potential benefit of fasting plasma glucose testing over other diagnostic tests?

    <p>It can identify undiagnosed cases that other tests might miss.</p> Signup and view all the answers

    Which of the following statements reflects the current recommendations for screening diabetes in older adults?

    <p>Decisions regarding screening depend on potential treatment benefits.</p> Signup and view all the answers

    Which diabetes diagnostic test requires fasting and is recognized for identifying pre-diabetes?

    <p>Fasting plasma glucose (FPG)</p> Signup and view all the answers

    Which factor is NOT considered when making treatment decisions for older diabetic patients?

    <p>Ethnic background of the patient</p> Signup and view all the answers

    What is the relative risk of shoulder dystocia in women with gestational diabetes?

    <p>2.9</p> Signup and view all the answers

    Which complication of gestational diabetes has the highest relative risk of developing in postpartum women?

    <p>Type 2 diabetes</p> Signup and view all the answers

    Which factor significantly increases the likelihood of diabetes development in women with gestational diabetes?

    <p>All of the above</p> Signup and view all the answers

    What is the recommended frequency for screening women with a history of gestational diabetes for overt diabetes?

    <p>Every 3 years</p> Signup and view all the answers

    Which of the following is NOT commonly considered a factor in high-risk populations for gestational diabetes?

    <p>Previous high birth weight infants</p> Signup and view all the answers

    Which symptom is more commonly associated with Type 1 diabetes than with Type 2 diabetes?

    <p>Polyphagia with weight loss</p> Signup and view all the answers

    What waist circumference is indicative of a higher risk for Type 2 diabetes in women?

    <p>35 inches</p> Signup and view all the answers

    Which screening recommendation is suggested for individuals with a body mass index ≥25 kg/m2?

    <p>Screen for diabetes if one or more risk factors are present</p> Signup and view all the answers

    In terms of metabolic syndrome, which condition is primarily associated with increased risk for cardiovascular disease?

    <p>Insulin Resistance Syndrome</p> Signup and view all the answers

    Which of the following statements about screening for Type 2 diabetes is true?

    <p>Lifestyle and pharmacologic interventions can delay disease progression.</p> Signup and view all the answers

    Which condition would most likely prompt healthcare providers to consider Type 2 diabetes in postpartum women?

    <p>Delivering a baby weighing over 9 lbs</p> Signup and view all the answers

    Which of the following is more strongly correlated with Type 2 diabetes compared to other conditions?

    <p>Metabolic Syndrome</p> Signup and view all the answers

    What diagnosis feature often differentiates Type 2 diabetes from Type 1 diabetes?

    <p>Commonly asymptomatic upon diagnosis</p> Signup and view all the answers

    What percentage of adults aged 65 years and older in the U.S. are unaware that they have diabetes?

    <p>16%</p> Signup and view all the answers

    Which factor should be considered when determining the necessity for diabetes screening in older adults?

    <p>Quality of life or life expectancy improvements</p> Signup and view all the answers

    Which hormonal condition is listed as a secondary cause of diabetes?

    <p>Acromegaly</p> Signup and view all the answers

    What method is primarily used to confirm a diabetes diagnosis in patients showing hyperglycemia?

    <p>Repeat blood glucose testing</p> Signup and view all the answers

    Which of the following statements accurately reflects the challenges related to older adults with diabetes?

    <p>Heterogeneous factors complicate care standardization.</p> Signup and view all the answers

    Which diabetes screening test is recognized for potentially identifying more undiagnosed cases than HbA1c?

    <p>Fasting plasma glucose (FPG)</p> Signup and view all the answers

    What is the implication of the lack of evidence from randomized trials regarding early diagnosis and therapy for MODY?

    <p>Early diagnosis may have no significant benefits.</p> Signup and view all the answers

    What condition is characterized as having a significant risk of complications in older adults with diabetes?

    <p>Multiple geriatric conditions</p> Signup and view all the answers

    What role does functional status play in treatment decisions for older adults with diabetes?

    <p>It influences treatment decisions based on life expectancy.</p> Signup and view all the answers

    Which statement accurately describes the genetic factors involved in the development of Type 1 diabetes?

    <p>About 40% of genetic risk is attributed to the HLA locus.</p> Signup and view all the answers

    What is the main environmental factor linked to the increasing incidence of Type 1 diabetes?

    <p>High incidence rates found in northern Europe.</p> Signup and view all the answers

    Among individuals with Type 2 diabetes, what percentage of monozygotic twins are likely to also develop the condition if one twin is diagnosed?

    <p>70%</p> Signup and view all the answers

    What role do genetic variants play in the development of Type 2 diabetes?

    <p>143 risk variants have been identified, influencing various metabolic processes.</p> Signup and view all the answers

    Which age group is the peak incidence for Type 1 diabetes typically found?

    <p>Children aged 4-6.</p> Signup and view all the answers

    Which statement about Type 2 diabetes is true regarding its environmental risk factors?

    <p>Visceral obesity is the most critical environmental factor for insulin resistance.</p> Signup and view all the answers

    What is the trend in the mortality rate for individuals diagnosed with diabetes?

    <p>The mortality rate has decreased, indicating longer life expectancy for patients.</p> Signup and view all the answers

    How does genetic predisposition influence the risk of developing Type 1 diabetes?

    <p>Roughly one-third of the risk is attributed to genetic factors.</p> Signup and view all the answers

    What is the age recommended for initiating screening for Type 2 diabetes in children who are at risk?

    <p>At age 10</p> Signup and view all the answers

    Which ethnic groups have the highest prevalence of Type 2 diabetes among youth in the U.S.?

    <p>Native American, Black, and Latin American</p> Signup and view all the answers

    What percentage of youth diagnosed with Type 2 diabetes may experience peripheral neuropathy during their teenage years?

    <p>17.7%</p> Signup and view all the answers

    Which risk factor is considered least associated with the development of Type 2 diabetes in children and adolescents?

    <p>High physical activity levels</p> Signup and view all the answers

    What aspect of MODY differentiates it from Type 1 and Type 2 diabetes?

    <p>It is often misdiagnosed as Type 1 or Type 2 diabetes.</p> Signup and view all the answers

    Which of the following is a significant long-term morbidity associated with Type 2 diabetes in adolescents?

    <p>Cardiovascular disease</p> Signup and view all the answers

    What is a key characteristic of MODY2 compared to other types of diabetes?

    <p>Results in mild stable fasting hyperglycemia.</p> Signup and view all the answers

    What primary issue is associated with the screening recommendations for Type 2 diabetes in children?

    <p>Insufficient evidence about benefits versus harms.</p> Signup and view all the answers

    Which of the following factors do NOT contribute to the risk of developing Type 2 diabetes in children according to the profile provided?

    <p>Daily sugary drink consumption</p> Signup and view all the answers

    How many subtypes of Maturity-Onset Diabetes of the Young (MODY) have been identified?

    <p>14 subtypes</p> Signup and view all the answers

    Which of the following factors is known to falsely lower A1c levels?

    <p>Chronic liver disease</p> Signup and view all the answers

    What condition is identified as falsely elevating A1c levels?

    <p>Aplastic anemias</p> Signup and view all the answers

    Which condition would be expected to have no effect on A1c levels?

    <p>Hemoglobinopathies</p> Signup and view all the answers

    Which of the following factors is likely to interfere with the accuracy of A1c measurements by lowering its value?

    <p>Vitamin E and C supplementation</p> Signup and view all the answers

    Which factor contributes to variations in A1c levels but does not definitively classify them as higher or lower?

    <p>Hemoglobin variants</p> Signup and view all the answers

    What is the peak age range for the incidence of Type 1 diabetes?

    <p>4-6 years</p> Signup and view all the answers

    Which of the following factors contributes the least to the genetic risk associated with Type 1 diabetes?

    <p>Environmental triggers</p> Signup and view all the answers

    What percentage of the genetic risk for developing Type 1 diabetes is attributed to environmental factors?

    <p>66%</p> Signup and view all the answers

    What is the primary reason diabetes is described as a metabolic disease?

    <p>It results in elevated blood glucose levels.</p> Signup and view all the answers

    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?

    <p>70%</p> Signup and view all the answers

    Which environmental factor is most significantly responsible for causing insulin resistance in Type 2 diabetes?

    <p>Visceral obesity</p> Signup and view all the answers

    Which of the following conditions is most closely linked to diabetes complications?

    <p>Chronic kidney disease</p> Signup and view all the answers

    In which region is the annual incidence of Type 1 diabetes reported to be the highest?

    <p>Northern Europe</p> Signup and view all the answers

    What percentage reduction in lifespan is associated with diabetes?

    <p>5-15 years</p> Signup and view all the answers

    Which of the following antibodies is commonly found in patients diagnosed with Type 1 diabetes?

    <p>Glutamic acid decarboxylase 65</p> Signup and view all the answers

    Which of these is a common diagnostic test for monitoring diabetes but has limitations?

    <p>HbA1c levels</p> Signup and view all the answers

    What percentage of the population in Canada is diagnosed with diabetes?

    <p>14%</p> Signup and view all the answers

    Which demographic is commonly reported to have the highest prevalence of Type 2 diabetes?

    <p>Adults aged 20-79</p> Signup and view all the answers

    What methodological consideration complicates diabetes management in older patients?

    <p>Insufficient evidence for standard care guidelines</p> Signup and view all the answers

    Which of the following statements about the mortality rate of individuals with diabetes is accurate?

    <p>It is twice as high as for those without diabetes.</p> Signup and view all the answers

    What is the role of patient education in diabetes management?

    <p>It is pivotal for preventing complications.</p> Signup and view all the answers

    What is the significance of a waist circumference greater than 40 inches in men concerning Type 2 diabetes?

    <p>It identifies individuals at a higher risk for developing Type 2 diabetes.</p> Signup and view all the answers

    Which of the following is the most appropriate screening recommendation for asymptomatic adults?

    <p>Screen individuals with a BMI ≥25 kg/m2 and one or more additional risk factors.</p> Signup and view all the answers

    In the context of diabetes diagnosis, which symptom is more frequently observed in Type 1 diabetes compared to Type 2 diabetes?

    <p>Polyphagia with weight loss</p> Signup and view all the answers

    What potential long-term benefit may result from screening adults for Type 2 diabetes?

    <p>Delay in the development of Type 2 diabetes.</p> Signup and view all the answers

    Which of the following conditions is linked to higher risk of Type 2 diabetes during pregnancy?

    <p>Preeclampsia and polyhydramnios</p> Signup and view all the answers

    What defines metabolic syndrome in the context of diabetes risk?

    <p>A disorder that identifies individuals at higher risk for diabetes and cardiovascular disease due to insulin resistance.</p> Signup and view all the answers

    How effective is screening for Type 2 diabetes at 10-year follow-up in reducing mortality?

    <p>Has no measurable impact on mortality rates.</p> Signup and view all the answers

    What is considered an initial clinical feature in the diagnosis of Type 2 diabetes?

    <p>Often asymptomatic presentations.</p> Signup and view all the answers

    What is the primary method used for screening gestational diabetes during pregnancies?

    <p>Non-fasting 50g glucose challenge test</p> Signup and view all the answers

    Which screening approach for gestational diabetes is associated with a higher diagnosis rate?

    <p>One-step testing method</p> Signup and view all the answers

    What is the main conclusion regarding the benefits and harms of one-step versus two-step screening for gestational diabetes?

    <p>Both approaches produce equivalent benefits and fewer harms</p> Signup and view all the answers

    What has been reported about the prevalence of gestational diabetes with respect to maternal age and BMI?

    <p>Increases with age and higher pre-pregnancy BMI</p> Signup and view all the answers

    What is the most common long-term complication associated with Type 2 diabetes in adolescents?

    <p>Peripheral neuropathy</p> Signup and view all the answers

    Which screening criteria is recommended for children at risk of Type 2 diabetes?

    <p>Acanthosis nigricans and obesity</p> Signup and view all the answers

    Which ethnic group has the highest prevalence of Type 2 diabetes among youth?

    <p>Black</p> Signup and view all the answers

    What percentage of individuals diagnosed with Type 2 diabetes experience diabetic ketoacidosis at diagnosis?

    <p>10%</p> Signup and view all the answers

    Which risk factor is least associated with the development of Type 2 diabetes in youth?

    <p>Regular physical activity</p> Signup and view all the answers

    What genetic characteristic is common in patients suspected of having Maturity-Onset Diabetes of the Young (MODY)?

    <p>Non-obesity</p> Signup and view all the answers

    Which statement is accurate regarding the screening guidelines for Type 2 diabetes in children?

    <p>Screening should begin at age 10 in at-risk children.</p> Signup and view all the answers

    What is the primary reason for considering genetic testing in MODY patients?

    <p>To confirm the specific subtype of MODY</p> Signup and view all the answers

    What is the correct classification of diabetes for the majority of adolescents diagnosed with hyperglycemia?

    <p>Type 2 diabetes only</p> Signup and view all the answers

    Which Type of MODY is most commonly associated with progressive hyperglycemia?

    <p>MODY3</p> Signup and view all the answers

    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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