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Position Statements

2. Classification and Diagnosis of Diabetes: Standards of Medical Care in Diabetes—2019

  1. American Diabetes Association
Diabetes Care 2019 Jan; 42(Supplement 1): S13-S28. https://doi.org/10.2337/dc19-S002
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    Figure 2.1

    ADA risk test (diabetes.org/socrisktest).

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  • Table 2.1

    Staging of type 1 diabetes (4,5)

    Stage 1Stage 2Stage 3
    Characteristics
    • Autoimmunity

    • Autoimmunity

    • New-onset hyperglycemia

    • Normoglycemia

    • Dysglycemia

    • Symptomatic

    • Presymptomatic

    • Presymptomatic

    Diagnostic criteria
    • Multiple autoantibodies

    • Multiple autoantibodies

    • Clinical symptoms

    • No IGT or IFG

    • Dysglycemia: IFG and/or IGT

    • Diabetes by standard criteria

    • FPG 100–125 mg/dL (5.6–6.9 mmol/L)

    • 2-h PG 140–199 mg/dL (7.8–11.0 mmol/L)

    • A1C 5.7–6.4% (39–47 mmol/mol) or ≥10% increase in A1C

  • Table 2.2

    Criteria for the diagnosis of diabetes

    FPG ≥126 mg/dL (7.0 mmol/L). Fasting is defined as no caloric intake for at least 8 h.*
    OR
    2-h PG ≥200 mg/dL (11.1 mmol/L) during OGTT. The test should be performed as described by the WHO, using a glucose load containing the equivalent of 75-g anhydrous glucose dissolved in water.*
    OR
    A1C ≥6.5% (48 mmol/mol). The test should be performed in a laboratory using a method that is NGSP certified and standardized to the DCCT assay.*
    OR
    In a patient with classic symptoms of hyperglycemia or hyperglycemic crisis, a random plasma glucose ≥200 mg/dL (11.1 mmol/L).
    • ↵* In the absence of unequivocal hyperglycemia, diagnosis requires two abnormal test results from the same sample or in two separate test samples.

  • Table 2.3

    Criteria for testing for diabetes or prediabetes in asymptomatic adults

    1. Testing should be considered in overweight or obese (BMI ≥25 kg/m2 or ≥23 kg/m2 in Asian Americans) adults who have one or more of the following risk factors:
    • • First-degree relative with diabetes

    • • High-risk race/ethnicity (e.g., African American, Latino, Native American, Asian American, Pacific Islander)

    • • History of CVD

    • • Hypertension (≥140/90 mmHg or on therapy for hypertension)

    • • HDL cholesterol level <35 mg/dL (0.90 mmol/L) and/or a triglyceride level >250 mg/dL (2.82 mmol/L)

    • • Women with polycystic ovary syndrome

    • • Physical inactivity

    • • Other clinical conditions associated with insulin resistance (e.g., severe obesity, acanthosis nigricans)

    2. Patients with prediabetes (A1C ≥5.7% [39 mmol/mol], IGT, or IFG) should be tested yearly.
    3. Women who were diagnosed with GDM should have lifelong testing at least every 3 years.
    4. For all other patients, testing should begin at age 45 years.
    5. If results are normal, testing should be repeated at a minimum of 3-year intervals, with consideration of more frequent testing depending on initial results and risk status.
  • Table 2.4

    Risk-based screening for type 2 diabetes or prediabetes in asymptomatic children and adolescents in a clinical setting

    • Testing should be considered in youth* who are overweight (≥85% percentile) or obese (≥95 percentile) A and who have one or more additional risk factors based on the strength of their association with diabetes:

    •  • Maternal history of diabetes or GDM during the child's gestation A

    •  • Family history of type 2 diabetes in first- or second-degree relative A

    •  • Race/ethnicity (Native American, African American, Latino, Asian American, Pacific Islander) A

    •  • Signs of insulin resistance or conditions associated with insulin resistance (acanthosis nigricans, hypertension, dyslipidemia, polycystic ovary syndrome, or small-for-gestational-age birth weight) B

    • ↵* After the onset of puberty or after 10 years of age, whichever occurs earlier. If tests are normal, repeat testing at a minimum of 3-year intervals, or more frequently if BMI is increasing, is recommended.

  • Table 2.5

    Criteria defining prediabetes*

    FPG 100 mg/dL (5.6 mmol/L) to 125 mg/dL (6.9 mmol/L) (IFG)
    OR
    2-h PG during 75-g OGTT 140 mg/dL (7.8 mmol/L) to 199 mg/dL (11.0 mmol/L) (IGT)
    OR
    A1C 5.7–6.4% (39–47 mmol/mol)
    • ↵* For all three tests, risk is continuous, extending below the lower limit of the range and becoming disproportionately greater at the higher end of the range.

  • Table 2.6

    Screening for and diagnosis of GDM

    One-step strategy
    Perform a 75-g OGTT, with plasma glucose measurement when patient is fasting and at 1 and 2 h, at 24–28 weeks of gestation in women not previously diagnosed with diabetes.
    The OGTT should be performed in the morning after an overnight fast of at least 8 h.
    The diagnosis of GDM is made when any of the following plasma glucose values are met or exceeded:
    • • Fasting: 92 mg/dL (5.1 mmol/L)

    • • 1 h: 180 mg/dL (10.0 mmol/L)

    • • 2 h: 153 mg/dL (8.5 mmol/L)

    Two-step strategy
    Step 1: Perform a 50-g GLT (nonfasting), with plasma glucose measurement at 1 h, at 24–28 weeks of gestation in women not previously diagnosed with diabetes.
    If the plasma glucose level measured 1 h after the load is ≥130 mg/dL, 135 mg/dL, or 140 mg/dL (7.2 mmol/L, 7.5 mmol/L, or 7.8 mmol/L, respectively), proceed to a 100-g OGTT.
    Step 2: The 100-g OGTT should be performed when the patient is fasting.
    The diagnosis of GDM is made if at least two* of the following four plasma glucose levels (measured fasting and 1 h, 2 h, 3 h during OGTT) are met or exceeded:
    Carpenter-Coustan (86)orNDDG (87)
    • • Fasting

    95 mg/dL (5.3 mmol/L)105 mg/dL (5.8 mmol/L)
    • • 1 h

    180 mg/dL (10.0 mmol/L)190 mg/dL (10.6 mmol/L)
    • • 2 h

    155 mg/dL (8.6 mmol/L)165 mg/dL (9.2 mmol/L)
    • • 3 h

    140 mg/dL (7.8 mmol/L)145 mg/dL (8.0 mmol/L)
    • NDDG, National Diabetes Data Group. *ACOG notes that one elevated value can be used for diagnosis (82).

  • Table 2.7

    Most common causes of monogenic diabetes (119)

    GeneInheritanceClinical features
    MODY
    GCKADGCK-MODY: stable, nonprogressive elevated fasting blood glucose; typically does not require treatment; microvascular complications are rare; small rise in 2-h PG level on OGTT (<54 mg/dL [3 mmol/L])
    HNF1AADHNF1A-MODY: progressive insulin secretory defect with presentation in adolescence or early adulthood; lowered renal threshold for glucosuria; large rise in 2-h PG level on OGTT (>90 mg/dL [5 mmol/L]); sensitive to sulfonylureas
    HNF4AADHNF4A-MODY: progressive insulin secretory defect with presentation in adolescence or early adulthood; may have large birth weight and transient neonatal hypoglycemia; sensitive to sulfonylureas
    HNF1BADHNF1B-MODY: developmental renal disease (typically cystic); genitourinary abnormalities; atrophy of the pancreas; hyperuricemia; gout
    Neonatal diabetes
    KCNJ11ADPermanent or transient: IUGR; possible developmental delay and seizures; responsive to sulfonylureas
    INSADPermanent: IUGR; insulin requiring
    ABCC8ADPermanent or transient: IUGR; rarely developmental delay; responsive to sulfonylureas
    6q24 (PLAGL1, HYMA1)AD for paternal duplicationsTransient: IUGR; macroglossia; umbilical hernia; mechanisms include UPD6, paternal duplication or maternal methylation defect; may be treatable with medications other than insulin
    GATA6ADPermanent: pancreatic hypoplasia; cardiac malformations; pancreatic exocrine insufficiency; insulin requiring
    EIF2AK3ARPermanent: Wolcott-Rallison syndrome: epiphyseal dysplasia; pancreatic exocrine insufficiency; insulin requiring
    FOXP3X-linkedPermanent: immunodysregulation, polyendocrinopathy, enteropathy X-linked (IPEX) syndrome: autoimmune diabetes; autoimmune thyroid disease; exfoliative dermatitis; insulin requiring
    • AD, autosomal dominant; AR, autosomal recessive; IUGR, intrauterine growth restriction.

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Diabetes Care: 42 (Supplement 1)

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2. Classification and Diagnosis of Diabetes: Standards of Medical Care in Diabetes—2019
American Diabetes Association
Diabetes Care Jan 2019, 42 (Supplement 1) S13-S28; DOI: 10.2337/dc19-S002

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2. Classification and Diagnosis of Diabetes: Standards of Medical Care in Diabetes—2019
American Diabetes Association
Diabetes Care Jan 2019, 42 (Supplement 1) S13-S28; DOI: 10.2337/dc19-S002
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  • Article
    • Abstract
    • CLASSIFICATION
    • DIAGNOSTIC TESTS FOR DIABETES
    • A1C
    • TYPE 1 DIABETES
    • PREDIABETES AND TYPE 2 DIABETES
    • GESTATIONAL DIABETES MELLITUS
    • CYSTIC FIBROSIS–RELATED DIABETES
    • POSTTRANSPLANTATION DIABETES MELLITUS
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  • 8. Obesity Management for the Treatment of Type 2 Diabetes: Standards of Medical Care in Diabetes—2020
  • 13. Children and Adolescents: Standards of Medical Care in Diabetes−2020
  • 11. Microvascular Complications and Foot Care: Standards of Medical Care in Diabetes−2020
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