Article    Table of Contents                    Full Text of this article    PDF of this article (PDFs free after 6 months)    Figures/Tables List    Related articles in Annals  Services    Send comment/rapid response letter    Notify a friend about this article    Alert me when this article is cited    Add to Personal Archive    Download to Citation Manager    ACP Search                            Get Permissions  Google Scholar    Search for Related Content  PubMed Articles in PubMed by Author:    Barr, R G.    Singer, D. E.    Related Articles in PubMed    PubMed Citation    PubMed

ACADEMIA AND CLINIC

COMMON DIAGNOSTIC TESTS

Series Editors: Allan Garber, MD, PhD, and Harold Sox, MD

Tests of Glycemia for the Diagnosis of Type 2 Diabetes Mellitus

R Graham Barr, MD, MPH; David M. Nathan, MD; James B. Meigs, MD, MPH; and Daniel E. Singer, MD

20 August 2002 | Volume 137 Issue 4 | Pages 263-272

This paper discusses tests of glycemia for the diagnosis of type 2 diabetes mellitus, with particular reference to the 1997 diagnostic criteria of the American Diabetes Association. The potential benefits of the lower diagnostic threshold for fasting plasma glucose are not well defined. However, the change in the diagnostic cut-off for diabetes mellitus affects as many as 1.9 million persons in the United States; therefore, the medical and social costs of the lower threshold may be considerable.

Type 2 diabetes mellitus is defined by a threshold imposed on the continuous distribution of glycemic levels, typically with respect to risk for microvascular complications. However, the burden of type 2 diabetes relates more to macrovascular than microvascular complications. Because no clear threshold exists for macrovascular complications, a formal balancing of direct and indirect costs with both microvascular and macrovascular complications may be appropriate to establish glycemic thresholds.

Because fasting plasma glucose, hemoglobin A_1c, and the oral glucose tolerance test all predict diabetic complications yet test reliability is better for fasting plasma glucose and hemoglobin A_1c than for the oral glucose tolerance test, we suggest an alternative diagnostic approach: If random plasma glucose is elevated ( 11.1 mmol/L [200 mg/dL]) and the hemoglobin A_1c level is more than 2 SDs above the laboratory mean, then diabetes mellitus should be diagnosed, and management should be based on the hemoglobin A_1c level. If the result of only one of these tests is positive, then fasting plasma glucose should be tested to evaluate the patient for impaired fasting glucose and diabetes mellitus.

The glycemic threshold for type 2 diabetes should be established by cost-effectiveness analysis. The clinical diagnosis of diabetes mellitus could be streamlined by incorporation of hemoglobin A_1c into established criteria.

Author and Article Information

From Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts; and College of Physicians and Surgeons, Columbia University, New York, New York.

Grant Support: Dr. Barr performed this work while supported by a grant from the U.S. National Institutes of Health (NRSA grant PE-11001).

Requests for Single Reprints: R. Graham Barr, MD, MPH, Division of General Medicine, Columbia–Presbyterian Medical Center, PH-9 East 105, 622 West 168th Street, New York, NY 10032; e-mail, rgb9{at}columbia.edu.

Current Author Addresses: Dr. Barr: Division of General Medicine, Columbia–Presbyterian Medical Center, PH-9 East 105, 622 West 168th Street, New York, NY 10032.

Dr. Nathan: Diabetes Center, Massachusetts General Hospital, 50 Staniford Street, 3rd floor, Boston, MA 02114.

Drs. Meigs and Singer: General Medicine Division, Massachusetts General Hospital, 50 Staniford Street, 9th Floor, Boston, MA 02114.

Related articles in Annals:

Editorials
Articles on Diagnostic Tests: A New Series and an Invitation to Authors
Alan M. Garber, Cynthia Mulrow, AND Harold C. Sox

Annals 2002 137: 288-289. [Full Text]  

Letters
Tests of Glycemia
Mayer B. Davidson

Annals 2003 138: 517. [Full Text]  

Letters
Tests of Glycemia
R Graham Barr, James B. Meigs, AND Daniel E. Singer

Annals 2003 138: 517. [Full Text]  

This article has been cited by other articles:

				J. Dai, D. P Jones, J. Goldberg, T. R Ziegler, R. M Bostick, P. W Wilson, A. K Manatunga, L. Shallenberger, L. Jones, and V. Vaccarino Association between adherence to the Mediterranean diet and oxidative stress Am. J. Clinical Nutrition, November 1, 2008; 88(5): 1364 - 1370. [Abstract] [Full Text] [PDF]

				F. A. Sloan, D. Belsky, D. Ruiz Jr, and P. Lee Changes in Incidence of Diabetes Mellitus-Related Eye Disease Among US Elderly Persons, 1994-2005 Arch Ophthalmol, November 1, 2008; 126(11): 1548 - 1553. [Abstract] [Full Text] [PDF]

				C. D. Saudek, W. H. Herman, D. B. Sacks, R. M. Bergenstal, D. Edelman, and M. B. Davidson A New Look at Screening and Diagnosing Diabetes Mellitus J. Clin. Endocrinol. Metab., July 1, 2008; 93(7): 2447 - 2453. [Abstract] [Full Text] [PDF]

				C. Thomas, E. Hypponen, and C. Power Obesity and Type 2 Diabetes Risk in Midadult Life: The Role of Childhood Adversity Pediatrics, May 1, 2008; 121(5): e1240 - e1249. [Abstract] [Full Text] [PDF]

				F. A. Sloan, M. A. Bethel, D. Ruiz Jr, A. H. Shea, and M. N. Feinglos The Growing Burden of Diabetes Mellitus in the US Elderly Population Arch Intern Med, January 28, 2008; 168(2): 192 - 199. [Abstract] [Full Text] [PDF]

				J. Dai, A. H. Miller, J. D. Bremner, J. Goldberg, L. Jones, L. Shallenberger, R. Buckham, N. V. Murrah, E. Veledar, P. W. Wilson, et al. Adherence to the Mediterranean Diet Is Inversely Associated With Circulating Interleukin-6 Among Middle-Aged Men: A Twin Study Circulation, January 15, 2008; 117(2): 169 - 175. [Abstract] [Full Text] [PDF]

				V. H. Srihari, C. Tek, L. A. Chwastiak, S. W. Woods, and J. L. Steiner Best Practices: Surveillance and Management of Diabetes in a CMHC Population Psychiatr Serv, September 1, 2007; 58(9): 1151 - 1153. [Abstract] [Full Text] [PDF]

				C. Thomas, E. Hypponen, and C. Power Prenatal Exposures and Glucose Metabolism in Adulthood: Are effects mediated through birth weight and adiposity? Diabetes Care, April 1, 2007; 30(4): 918 - 924. [Abstract] [Full Text] [PDF]

				C. Droumaguet, B. Balkau, D. Simon, E. Caces, J. Tichet, M. A. Charles, E. Eschwege, and the DESIR Study Group Use of HbA1c in Predicting Progression to Diabetes in French Men and Women: Data from an Epidemiological Study on the Insulin Resistance Syndrome (DESIR) Diabetes Care, July 1, 2006; 29(7): 1619 - 1625. [Abstract] [Full Text] [PDF]

				T. F. Slaughter Hemostasis and glycemic control in the cardiac surgical patient. Seminars in Cardiothoracic and Vascular Anesthesia, June 1, 2006; 10(2): 176 - 179. [Abstract] [PDF]

				C. D. Saudek, R. L. Derr, and R. R. Kalyani Assessing Glycemia in Diabetes Using Self-monitoring Blood Glucose and Hemoglobin A1c JAMA, April 12, 2006; 295(14): 1688 - 1697. [Abstract] [Full Text] [PDF]

				C. Thomas, E. Hypponen, and C. Power Type 2 diabetes mellitus in midlife estimated from the cambridge risk score and body mass index. Arch Intern Med, March 27, 2006; 166(6): 682 - 688. [Abstract] [Full Text] [PDF]

				J. D. Sorkin, D. C. Muller, J. L. Fleg, and R. Andres The Relation of Fasting and 2-h Postchallenge Plasma Glucose Concentrations to Mortality: Data from the Baltimore Longitudinal Study of Aging with a critical review of the literature Diabetes Care, November 1, 2005; 28(11): 2626 - 2632. [Abstract] [Full Text] [PDF]

				R. K. Danish and B. B. West Rapid Progression From Pre-diabetes to Severely Ill Diabetes While Under "Expert Care": Suggestions for Improved Screening for Disease Progression Diabetes Spectr, October 1, 2005; 18(4): 229 - 239. [Abstract] [Full Text] [PDF]

				W. Rathmann, S. Martin, B. Haastert, A. Icks, R. Holle, H. Lowel, G. Giani, and for the KORA Study Group Performance of Screening Questionnaires and Risk Scores for Undiagnosed Diabetes: The KORA Survey 2000 Arch Intern Med, February 28, 2005; 165(4): 436 - 441. [Abstract] [Full Text] [PDF]

				R. J. Schrot Targeting Plasma Glucose: Preprandial Versus Postprandial Clin. Diabetes, October 1, 2004; 22(4): 169 - 172. [Abstract] [Full Text] [PDF]

				S. R. Marder, S. M. Essock, A. L. Miller, R. W. Buchanan, D. E. Casey, J. M. Davis, J. M. Kane, J. A. Lieberman, N. R. Schooler, N. Covell, et al. Physical Health Monitoring of Patients With Schizophrenia Am J Psychiatry, August 1, 2004; 161(8): 1334 - 1349. [Abstract] [Full Text] [PDF]

				Expert Committee on the Diagnosis and Classificati Follow-up Report on the Diagnosis of Diabetes Mellitus Clin. Diabetes, April 1, 2004; 22(2): 71 - 79. [Full Text] [PDF]

				Follow-up Report on the Diagnosis of Diabetes Mellitus Diabetes Spectr, January 1, 2004; 17(1): 51 - 59. [Full Text] [PDF]

				The Expert Committee on the Diagnosis and Classifi Follow-up Report on the Diagnosis of Diabetes Mellitus Diabetes Care, November 1, 2003; 26(11): 3160 - 3167. [Full Text] [PDF]

				M. B. Davidson Tests of Glycemia Ann Intern Med, March 18, 2003; 138(6): 517 - 517. [Full Text] [PDF]

				R. Harris, K. Donahue, S. S. Rathore, P. Frame, S. H. Woolf, and K. N. Lohr Screening Adults for Type 2 Diabetes: A Review of the Evidence for the U.S. Preventive Services Task Force Ann Intern Med, February 4, 2003; 138(3): 215 - 229. [Abstract] [Full Text] [PDF]

				A. M. Garber, C. Mulrow, and H. C. Sox Articles on Diagnostic Tests: A New Series and an Invitation to Authors Ann Intern Med, August 20, 2002; 137(4): 288 - 289. [Full Text] [PDF]