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  • FYI, Revised Guidelines Lower Threshold for Impaired Fasting Glucose

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    Old 11-05-2003, 10:29 AM   #1
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    FYI, Revised Guidelines Lower Threshold for Impaired Fasting Glucose

    Oct. 24, 2003 An international expert committee on the diagnosis and classification of diabetes mellitus has published revised guidelines, which incorporate new data since the last report of 1997, in the November issue of Diabetes Care. Decreasing the cutoff for impaired fasting glucose from 110 mg/dL to 100 mg/dL could increase diagnoses of prediabetes by approximately 20%.

    "Lowering the threshold should help pick up more people who are at increased risk for developing diabetes," Committee Chair Saul Genuth, MD, from Case Western Reserve University in Cleveland, Ohio, says in a news release. "What's important about that is that we now know through studies such as the Diabetes Prevention Program (DPP) and the Finnish Diabetes Study that we can prevent or delay the progression to diabetes from impaired glucose tolerance, the original component with the term pre-diabetes, through intensive lifestyle treatment, such as exercise and diet therapy. We hope, but don't yet know, that intervening earlier might also reduce the risk of diabetic complications, including cardiovascular complications."

    Modest weight loss and regular exercise can prevent or delay the development of type 2 diabetes by up to 58%, based on results of the DPP and other studies.

    Criteria for the diagnosis of diabetes remain unchanged, and the committee recommended against using the HbA1C as a routine diagnostic test for diabetes. Although clinical evidence is currently inadequate for superiority of either the fasting plasma glucose (FPG) test or the oral glucose tolerance test (OGTT), the committee prefers the FPG because of its greater convenience and lower cost.

    The American Diabetes Association (ADA) recommends that individuals aged 45 years or older, especially those who are overweight or obese, be screened for diabetes/prediabetes and retested every three years if normal. Individuals at increased risk because of obesity, family history, gestational diabetes, or other recognized risk factors for diabetes should be considered for screening every few years, according to Dr. Genuth.

    Unanswered questions mandating further research include defining the best approach to diabetes detection, understanding the pathophysiology and risks of IPG and glucose tolerance, and determining to what extent cardiovascular risk can be lowered by starting treatment of glycemia earlier.

    "The answers to these and other questions will necessitate regular surveillance and reconsideration of new data that may lead to appropriate revisions to the diagnostic and classification criteria for diabetes over time," the authors write.

    Diabetes Care. 2003;26:3160-3167


    The 1997 International Expert Committee was convened to examine the classification and diagnostic criteria of diabetes, based on the 1979 report of the National Diabetes Data group and the World Health Organization (WHO) study group. The WHO criteria for diagnosing diabetes is FPG of 126 mg/dL or higher or two-hour plasma glucose (PG) of 200 mg/dL or higher in the OGTT after a 75 g oral glucose challenge. The criteria were adopted by the ADA in 1997. The two-hour PG has been considered the de facto "gold standard" because it is a better predictor of all-cause mortality or cardiovascular mortality than an elevated FPG value. The FPG cutoff value is based on the prediction of retinopathy beginning at approximately 126 mg/dL. Impaired glucose tolerance is defined as FPG of 110 mg/dL or higher when two-hour PG after a 75 g oral glucose challenge is 140 to 199 mg/dL. The lack of a suitable marker of diabetes has led to a reliance on metabolic abnormalities such as hyperglycemia to determine risk and diagnosis of diabetes.

    The expert committee was reconvened for this position statement to reconsider the questions of (1) cut point of the FPG and two-hour PG for diabetes diagnosis, (2) reduction of the lower limit for impaired fasting glucose from 110 mg/dL to 100 mg/dL, (3) inclusion of the HbA1C as a diagnostic criterion for diabetes, and (4) use of the two-hour PG in addition to the FPG for diagnosis of diabetes. The recommendations are based on new studies that have emerged since 1997.


    The cut point for FPG and 2-hour PG will remain unchanged from 1997. There is no consistent difference in the prevalence of diabetes across populations observed by using the 1997 criteria. Recent studies have not shown an advantage for reducing the 2-hour PG cut point to 180 mg/dL. It was noted that the 2 tests measure slightly different constructs and result in different prevalence of diabetes.

    In patients with a new diagnosis of diabetes, a confirmatory test is recommended after the initial test.

    The cut point for impaired fasting glucose was reduced from a definition of 110 mg/dL to 100 mg/dL. Impaired fasting glucose is now redefined as an FPG of 100-125 mg/dL.

    This proposed new definition for impaired fasting glucose will increase the number of individuals with prediabetes and thus increasing the number of people who may benefit from intensive lifestyle modification such as weight reduction and exercise to prevent diabetes onset.

    HbA1C is not recommended as an additional criterion for the diagnosis of diabetes. The reasons are lack of international standardization of reference ranges and the confounding effect of other conditions (such as pregnancy, uremia, hemoglobinopathies, blood transfusion, and hemolytic anemia). HbA1C is still recommended as an indicator of therapeutic response.

    Both FPG and 2-hour PG may be used for diagnosis, but the FPG has the benefits of ease of testing (no waiting and better tolerated), better reproducibility and reliability, and lower cost. There is inadequate evidence to show that either test is superior. The 2-hour PG is recommended after an abnormal FPG.
    The tragedy of science is the slaying of a beautiful hypothesis by an ugly fact. T H Huxley

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