It is generally accepted that diabetes is a major health problem all over the world, and especially so in the developing countries. India has the dubious distinction of being home to one in five persons with diabetes worldwide. The World Health Organisation (WHO) predicts that the number of people with diabetes is to double in the next couple of decades and that the major brunt of this will be borne by the developing countries. In fact, diabetes has long passed the stage of being an epidemic in India, but can be said to have reached "pandemic" proportions.
But when one talks of numbers of people with diabetes, it presumes that the diagnosis of diabetes is based on criteria and methods which have evolved based on the scientific data which is presently available, and not on abstract assumptions. One must feel confident that the diagnosis is correct, fully established and reproducible. After all, the diagnosis of diabetes is something which will "stick" with a person throughout one's life. As it has been so aptly said,"once a diabetic, always a diabetic!"
India has the dubious distinction of having the largest number of people with diabetes. Recent studies have shown that for every person known to have diabetes, there are more than 2 people who have diabetes but are unaware of it.
In fact, many persons with Type II diabetes already show the presence of the long term complications associated with diabetes at the time of diagnosis. It is now widely accepted that if diabetes is detected early and adequate steps are taken, it may be possible to significantly delay the onset and progression of these complications. Thus, this is all the more reason to try and diagnose the onset of diabetes at the earliest.
Although diabetes does have its typical signs and symptoms, many people do not exhibit these "typical" signs and symptoms even though they have diabetes.
All those who complain of symptoms or show signs commonly associated with diabetes must have a test for diabetes, if feasible, all persons over the age of 30 years should undergo an annual test to rule out the presence of diabetes.
A negative test for diabetes does NOT mean that the person will never get diabetes. It only means that the person does not have diabetes at the time of testing.
Persons at high risk MUST undergo testing when they present for medical attention for whatever reason, and if negative, must have a regular annual check, thereafter.
a) All persons manifesting any of the following signs and symptoms: polyuria, polydipsia, polyphagia, weight loss inspite of adequate food intake, undue tiredness and fatigue, tingling or numbness in the extremities, burning feet, generalised pruritus, pruritus vulvae, balanitis, delayed wound healing, impotency, premature cataracts, visual disturbances.
b) All persons with a family history of diabetes.
c) All obese patients, especially those with central obesity, waist-hip (W-H) ratio, approx. >0.95 in men and >0.85 in women, and/or a Body Mass Index (BMI) >25.
d) All adult patients with tuberculosis, including atypical presentations, recurrent infections, non- healing ulcers.
e) Patients with atherosclerosis and its complications, especially those with premature macrovascular disease.
f) All patients with high blood pressure and lipid abnormalities.
g) All women with a bad obstetric history, recurrent fetal wastage, and those who give birth to large weight babies.
h) Persons who were large weight babies; very low birth weight babies may also be predisposed to diabetes.
i) Persons who show an acute rise in the blood glucose levels at time of physical (myocardial infarction, cerebrovascular accidents, acute infections, trauma, etc.) or mental stress.
j) Persons taking drugs which are known to increase blood glucose levels like steroids, thiazide diuretics, oral contraceptives, beta-blockers, phenytoin sodium, etc. Ideally,
All persons over the age of 30 years should undergo an annual test for the presence of diabetes.
|Glucose Concentration (mg/100ml)|
|2 hours post Glucose Load or both||>180||>200||>200|
|Impaired Glucose Tolerance|
|2 hours post Glucose Load||>/=120 & </=180||>/=140 & </=200||>/=140 & </=200|
|Impaired Fasting Glycemia|
|Fasting||>/=100 & </=110||>/=100 & </=110||>/=110 & </=126|
|2 hours PG (If measured)||<120||<140||<140|
Impaired Glucose Tolerance. Many patients in this category will go on to have diabetes; many I.G.T. patients show associated problems like hypertension, lipid disorders, high uric acid, obesity, etc. which merit treatment; I.G.T. is risk factor for the development of macrovascular disease.
Impaired fasting glycemia is an entity which has recently been introduced to delineate persons in whom only the fasting blood glucose has been done, but who do not come in the normal or diabetic category. It has been proposed that the diagnosis of diabetes can be made from a fasting blood glucose level only and that it may not be necessary to do a complete GTT. There is still some controversy about this, but the general consensus is that whilst doing only the fasting blood glucose may be sufficient to pinpoint those with diabetes in prevalence studies, it may be better to confirm this with a complete GT, if feasible.
IFG is felt to reflect a higher average glycemic burden than IGT. It is considered a marker for the development of diabetes and its long term complications.
Values not falling within any of the above categories signifies a normal tolerance to glucose.
"A NEGATIVE TEST RESULT ONLY SHOWS THAT THE PATIENT IS NOT A DIABETIC AT THE TIME OF TESTING; IT DOES NOT MEAN THAT HE WILL NEVER DEVELOP DIABETES; SUCH PERSONS MUST HAVE AN ANNUAL CHECK UP".
Thus, it is important for gestational diabetes to be ruled out in all pregnancies.
Ideally, all pregnant women should be tested to rule out gestational diabetes, but if this is not feasible, all high risk patients must undergo the test.
The test should be carried out at the time of initial visit and at the start of every trimester; high risk patients may require more frequent testing.
Initial screening produce may be done by estimating the fasting glucose levels and the levels 1 hour after an oral dose of 50 gms. of glucose.
This test can be carried out in the fasting stage or at any time; in the latter case, only the one hour blood glucose value is taken into consideration for diagnosis.
Patients with a fasting venous whole blood glucose level of more than 80 mg% (venous plasma glucose more than 90 mg%).
a 1 hour post 50 gms. glucose load venous whole blood glucose value greater than 120 mg/% (venous plasma glucose more than 140 mg%_ require a more comprehensive test.
A "random" venous blood glucose level exceeding 105 mg% (plasma glucose >120 mg%) also merits a more comprehensive test.
The comprehensive test is the same as described for the diagnosis of diabetes in non pregnant persons. BUT, the criteria differ. In addition to blood glucose levels in the diabetic range, values suggestive of IGT, in a pregnant female, should be taken to be diagnostic of gestational diabetes.
Many centres still utilise the O'Sullivan Criteria.
In this test, blood is collected in the fasting stage and then at 1, 2 and 3 hours intervals after an oral load of 100 gms of glucose.
The presence of gestational diabetes is diagnosed according to the following criteria: Plasma Glucose (mg/100ml)
|Two of the four values must be met to diagnose GDM|
Women with GDM may go on to have diabetes in later life. They must be considered as having high risk for the development of diabetes and must undergo annual testing.