Diagnosis of Diabetes

What is diabetes?

Diabetes is a disease in which levels of blood glucose, also called blood sugar, are above normal. People with diabetes have problems converting food to energy. Normally, after a meal, the body breaks food down into glucose, which the blood carries to cells throughout the body. Cells use insulin, a hormone made in the pancreas, to help them convert blood glucose into energy.

People develop diabetes because the pancreas does not make enough insulin or because the cells in the muscles, liver, and fat do not use insulin properly, or both. As a result, the amount of glucose in the blood increases while the cells are starved of energy. Over the years, high blood glucose, also called hyperglycemia, damages nerves and blood vessels, which can lead to complications such as heart disease, stroke, kidney disease, blindness, nerve problems, gum infections, and amputation.

Main types of Diabetes

The two main types of diabetes are called type 1 and type 2. A third form of diabetes is called gestational diabetes.

• Type 1 diabetes, formerly called juvenile diabetes, is usually first diagnosed in children, teenagers, and young adults. In this form of diabetes, the pancreas no longer makes insulin because the body’s immune system has attacked and destroyed the pancreatic cells specialized to make insulin. These insulin-producing cells are called beta cells.
• Type 2 diabetes, formerly called adult-onset diabetes, is the most common form. People can develop type 2 diabetes at any age, even during childhood. This form of diabetes usually begins with insulin resistance, a condition in which muscle, liver, and fat cells do not use insulin properly. As a result, the body needs more insulin to help glucose enter cells to be used for energy. At first, the pancreas keeps up with the added demand by producing more insulin. In time, however, the pancreas loses its ability to secrete enough insulin in response to meals.
• Gestational diabetes is diabetes that first occurs during pregnancy. When women are pregnant, their need for insulin appears to increase, and many can develop gestational diabetes during the late stages of pregnancy. Although this form of diabetes usually goes away after the baby is born, a woman who has had it is more likely to develop type 2 diabetes later in life.

Other types of Diabetes

A number of other types of diabetes exist. A person may exhibit characteristics of more than one type. For example, in latent autoimmune diabetes in adults (LADA), also called type 1.5 diabetes or double diabetes, people show signs of both type 1 and type 2 diabetes. Diagnosis usually occurs after age 30.

Most people with LADA still produce their own insulin when first diagnosed, like those with type 2 diabetes, but within a few years, they must take insulin to control blood glucose levels. In LADA, as in type 1 diabetes, the beta cells of the pancreas stop making insulin because the body’s immune system attacks and destroys them. Some experts believe that LADA is a slowly developing kind of type 1 diabetes.

Other types of diabetes include those caused by

• Genetic defects of the beta cell, such as maturity-onset diabetes of the young (MODY) and neonatal diabetes mellitus
• Genetic defects in insulin action, resulting in the body’s inability to control blood glucose levels, as seen in leprechaunism and the Rabson-Mendenhall syndrome
• Diseases of the pancreas or conditions that damage the pancreas, such as pancreatitis and cystic fibrosis
• Excess amounts of certain hormones resulting from some medical conditions—such as cortisol in Cushing’s syndrome—that work against the action of insulin
• Medications that reduce insulin action, such as glucocorticoids, or chemicals that destroy beta cells
• Infections, such as congenital rubella and cytomegalovirus
• Rare autoimmune disorders, such as stiff-man syndrome, an autoimmune disease of the central nervous system
• Genetic syndromes associated with diabetes, such as Down syndrome and Prader-Willi syndrome

More information about MODY and neonatal diabetes mellitus is in the National Diabetes Information Clearinghouse’s fact sheet Monogenic Forms of Diabetes: Neonatal Diabetes Mellitus and Maturity-onset Diabetes of the Young. The fact sheet is available at diabetes.niddk.nih.gov/dm/pubs/mody/index.htm or by calling 800.860.8747.

Type 1 and type 2 diabetes

In 1997, to move away from naming the two main types of diabetes based on treatment or the age at onset, an American Diabetes Association expert committee recommended universal adoption of simplified terminology. The National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) agrees.

Former names for Type 1 diabetes

• Type 1
• Juvenile diabetes
• Insulin-dependent diabetes mellitus
• IDDM

Preferred name for Type 1 diabetes

Type 1 diabetes

Former names for Type 2 diabetes

• Type 2
• Adult-onset diabetes
• Noninsulin-dependent diabetes mellitus
• NIDDM

Preferred name for Type 2 diabetes

Type 2 diabetes

What is pre-diabetes?

In pre-diabetes, blood glucose levels are higher than normal but not high enough for a diagnosis of diabetes. However, many people with pre-diabetes develop type 2 diabetes within 10 years. Experts disagree about the specific blood glucose level they should use to diagnose diabetes, and through the years, that number has changed. Individuals with pre-diabetes have an increased risk of heart disease and stroke. With modest weight loss and moderate physical activity, people with pre-diabetes can delay or prevent type 2 diabetes.

How are diabetes and pre-diabetes diagnosed?

The following tests are used for diagnosis:

• A fasting plasma glucose (FPG) test measures blood glucose in a person who has not eaten anything for at least 8 hours. This test is used to detect diabetes and pre-diabetes.
• An oral glucose tolerance test (OGTT) measures blood glucose after a person fasts at least 8 hours and 2 hours after the person drinks a glucose-containing beverage. This test can be used to diagnose diabetes and pre-diabetes.
• A random plasma glucose test, also called a casual plasma glucose test, measures blood glucose without regard to when the person being tested last ate. This test, along with an assessment of symptoms, is used to diagnose diabetes but not pre-diabetes.

Test results indicating that a person has diabetes should be confirmed with a second test on a different day.

FPG Test

The FPG test is the preferred test for diagnosing diabetes because of its convenience and low cost. However, it will miss some diabetes or pre-diabetes that can be found with the OGTT. The FPG test is most reliable when done in the morning. Results and their meaning are shown in Table 1. People with a fasting glucose level of 100 to 125 milligrams per deciliter (mg/dL) have a form of pre-diabetes called impaired fasting glucose (IFG). Having IFG means a person has an increased risk of developing type 2 diabetes but does not have it yet. A level of 126 mg/dL or above, confirmed by repeating the test on another day, means a person has diabetes.

OGTT

Research has shown that the OGTT is more sensitive than the FPG test for diagnosing pre-diabetes, but it is less convenient to administer. The OGTT requires fasting for at least 8 hours before the test. The plasma glucose level is measured immediately before and 2 hours after a person drinks a liquid containing 75 grams of glucose dissolved in water. Results and their meaning are shown in Table 2. If the blood glucose level is between 140 and 199 mg/dL 2 hours after drinking the liquid, the person has a form of pre-diabetes called impaired glucose tolerance (IGT). Having IGT, like having IFG, means a person has an increased risk of developing type 2 diabetes but does not have it yet. A 2-hour glucose level of 200 mg/dL or above, confirmed by repeating the test on another day, means a person has diabetes.

Gestational diabetes is also diagnosed based on plasma glucose values measured during the OGTT, preferably by using 100 grams of glucose in liquid for the test. Blood glucose levels are checked four times during the test. If blood glucose levels are above normal at least twice during the test, the woman has gestational diabetes. Table 3 shows the above-normal results for the OGTT for gestational diabetes.

Gestational diabetes: Above-normal results for the OGTT*

Additional information about the diagnosis and treatment of gestational diabetes is in the publication What I need to know about Gestational Diabetes. This publication is available at diabetes.niddk.nih.gov/dm/pubs/gestational/index.htm or by calling 800.860.8747.

Random Plasma Glucose Test

A random, or casual, blood glucose level of 200 mg/dL or higher, plus the presence of the following symptoms, can mean a person has diabetes:

• increased urination
• increased thirst
• unexplained weight loss

Other symptoms can include fatigue, blurred vision, increased hunger, and sores that do not heal. The doctor will check the person’s blood glucose level on another day using the FPG test or the OGTT to confirm the diagnosis.

Who should be tested for diabetes and pre-diabetes?

The American Diabetes Association recommends that testing to detect pre-diabetes and type 2 diabetes be considered in adults without symptoms who are overweight or obese and have one or more additional risk factors for diabetes. In those without these risk factors, testing should begin at age 45. The Body Mass Index Table can be used to find out whether someone is normal weight, overweight, obese, or extremely obese.

People ages 45 or older should consider getting tested for pre-diabetes or diabetes. People younger than 45 should consider testing if they are overweight, obese, or extremely obese and have one or more of the following risk factors:

• being physically inactive
• having a parent, brother, or sister with diabetes
• having a family background that is African American, Alaska Native, American Indian, Asian American, Hispanic/Latino, or Pacific Islander
• giving birth to a baby weighing more than 9 pounds or being diagnosed with gestational diabetes
• having high blood pressure—140/90 mmHg or above—or being treated for high blood pressure
• having an HDL, or "good," cholesterol level below 35 mg/dL or a triglyceride level above 250 mg/dL
• having polycystic ovary syndrome, also called PCOS
• having IFG or IGT on previous testing
• having a condition called acanthosis nigricans, characterized by a dark, velvety rash around the neck or armpits
• having a history of cardiovascular disease—disease affecting the heart and blood vessels

If results of testing are normal, testing should be repeated at least every 3 years. Doctors may recommend more frequent testing depending on initial results and risk status. People whose test results indicate they have pre-diabetes should have their blood glucose checked again in 1 to 2 years and take steps to prevent type 2 diabetes.

When a woman is pregnant, the doctor will assess her risk for developing gestational diabetes at her first prenatal visit and order testing as needed during the pregnancy. Women who develop gestational diabetes should also have follow-up testing 6 to 12 weeks after the baby is born.

Type 2 diabetes has become more common in children and teens than in the past, and those at high risk for developing diabetes should be tested every 2 years. Testing should begin at age 10 or at puberty, whichever occurs first. Children and teens who are overweight or obese and have other risk factors, such as a family history of diabetes, are at high risk for developing diabetes.

Body Mass Index (BMI)

BMI is a measurement of body weight relative to height. Adults aged 20 or older can use the BMI Table to find out whether they are normal weight, overweight, obese, or extremely obese. To use the table

• find the adult’s height in the left-hand column
• move across the row to the number closest to that person’s weight
• find the number at the top of that column

The number at the top of the column is the person’s BMI. The words above the BMI number indicate whether the person is normal weight, overweight, obese, or extremely obese. People who are overweight, obese, or extremely obese should consider talking with a doctor about ways to lose weight to reduce the risk of diabetes.

The BMI has certain limitations. It may overestimate body fat in athletes and others who have a muscular build and underestimate body fat in older adults and others who have lost muscle.

BMI for children and teens must be determined based on age, height, weight, and sex. The Centers for Disease Control and Prevention (CDC) has information about BMI in children and teens, including a BMI calculator. The CDC website also has a BMI calculator for adults.

Body Mass Index Table 1 of 3

Body Mass Index Table 2 of 3

Body Mass Index Table 3 of 3

In addition to weight, the location of excess fat on the body can be important. A waist measurement of 40 inches or more for men or 35 inches or more for women is linked to insulin resistance and increases a person’s risk for type 2 diabetes.

What steps can delay or prevent type 2 diabetes?

A major research study, the Diabetes Prevention Program (DPP), confirmed that people with IGT—pre-diabetes—were able to sharply reduce their risk of developing diabetes during the study by losing 5 to 7 percent of their body weight through dietary changes and increased physical activity. Study participants followed a low-fat, low-calorie diet and engaged in regular physical activity, such as walking briskly for 30 minutes, five times a week. These strategies worked well for both men and women and were especially effective for participants aged 60 and older.

How is diabetes managed?

People with diabetes can manage it with meal planning, physical activity, and, if needed, medications. Additional information about taking care of type 1 or type 2 diabetes is available in the publication Your Guide to Diabetes: Type 1 and Type 2. This publication is available at diabetes.niddk.nih.gov/dm/pubs/type1and2/index.htm or by calling 800.860.8747.

Points to remember

• Diabetes, pre-diabetes, and gestational diabetes are diagnosed by checking blood glucose levels.
• Tests used for diagnosing diabetes and pre-diabetes include the fasting plasma glucose (FPG) test and the oral glucose tolerance test (OGTT).
• People aged 45 or older should consider getting tested for pre-diabetes or diabetes. People younger than 45 who are overweight, obese, or extremely obese and have one or more additional risk factors for diabetes should consider testing.
• Many people with pre-diabetes develop type 2 diabetes within 10 years.
• People with pre-diabetes can delay or prevent type 2 diabetes by losing a modest amount of weight through regular physical activity and a diet low in fat and calories.

For more information

American Association of Diabetes Educators
200 West Madison Street, Suite 800
Chicago, IL 60606
Phone: 800.338.3633
Diabetes Educator Access Line: 800.TEAMUP4 (832.6874)
Fax: 312.424.2427
diabeteseducator.org

American Diabetes Association
1701 North Beauregard Street
Alexandria, VA 22311
Phone: 800.DIABETES (342.2383)
Fax: 703.549.6995
diabetes.org/home.jsp

Juvenile Diabetes Research Foundation International
26 Broadway, 14th Floor
New York, NY 10004–4001
Phone: 800.533.CURE (2873)
Fax: 212.785.9595
jdrf.org

National Diabetes Education Program
1 Diabetes Way
Bethesda, MD 20814–9692
Phone: 888.693.NDEP (6337)
TTY: 866.569.1162
Fax: 703.738.4929
ndep.nih.gov

National Cancer Institute's Public Inquiries Office
6116 Executive Boulevard, Suite 3036A
MSC8322
Bethesda, MD 20892-8322
Phone: 888.693.NDEP (6337)
Phone: 301.435.3848

U.S. residents may call the National Cancer Institute's (NCI's) Cancer Information Service toll-free at 800.4.CANCER (800.422.6237) Monday through Friday from 9:00 a.m. to 4:30 p.m. Deaf and hard-of-hearing callers with TTY equipment may call 800.332.8615.

Information about ongoing clinical trials is available from the NCI Web site cancer.gov/clinicaltrials

Source: National Institutes of Health; The National Diabetes Information Clearinghouse (NDIC) is a service of the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK).