Diabetes, Type II

What makes you think your patient has type II diabetes?

Type II diabetes is, typically, not diagnosed until health complications appear. Signs and symptoms of type II diabetes often develop slowly and include:

  • increased thirst

  • frequent urination

  • dry mouth

  • extreme hunger

  • weight loss

  • fatigue

  • headaches

  • blurred vision

Additional symptoms may include:

  • slow-healing sores or cuts

  • itching of the skin, usually around the vaginal or groin area

  • frequent yeast infections

  • recent weight gain

  • velvety dark skin changes of the neck, armpit, and groin (acanthosis nigricans)

  • numbness and tingling of the hands and feet

  • decreased vision

  • impotency

Patients who are overweight, inactive, or have a family history of diabetes are at increased risk for developing type II diabetes.

What Tests Should I Request to Confirm My Clinical Dx? In addition, what follow-up tests might be useful?

Current diagnostic criteria for diabetes include one of the four following tests: a fasting plasma glucose (FPG) level greater than or equal to 126 mg/dL (7 mmol/L), where fasting is defined as no caloric intake for more than 8 hours; an elevated 2-hour plasma glucose greater than or equal to 200 mg/dL (11.1 mmol/L) following a glucose load containing 75 g of anhydrous glucose dissolved in water during an oral glucose tolerance test (OGTT); an elevated random plasma glucose greater than or equal to 200 mg/dL in a patient exhibiting classic symptoms of hyperglycemia or hyperglycemic crisis; or a glycated hemoglobin (A1C) test of 6.5% or higher using a method certified by the National Glycohemoglobin Standardization Program (NGSP).

If any of these criteria are met, testing should be repeated on a subsequent day to establish the diagnosis, except in cases of unequivocal hyperglycemia (≥200 mg/dL accompanied by symptoms consistent with overt hyperglycemia), whereby the existence of one criteria would fulfill the diagnosis.

Diabetes-related autoantibody testing may be used to distinguish between type I and type II diabetes. The four most common autoantibody tests include Islet cell Cytoplasmic Autoantibodies (ICA), which are used to identify a variety of islet cell proteins detected in approximately 70-80% of newly diagnosed type II diabetes; Glutamic Acid Decarboxylase Autoantibodies (GADA), which test for autoantibodies directed against beta cell protein also commonly detected in 70-80% or new diagnoses; Insulinoma-Associated-2 Autoantibodies (IA-2A), which are also a nonspecific test for autoantibodies against beta cell antigens present in approximately 60% of type I diabetics; and Insulin Autoantibodies (IAA), which are present in about 50% of type I diabetic children.

Because autoantibodies detected in children differ from those detected in adults, IAA is, typically, ordered for diagnosing children, whereas ICA, GADA, and IA-2A are used for diagnosing adolescent and adult type I diabetes.(Table 1)

Table 1.
FPG ≥126 mg/dL (7 mmol/L)
2 h plasma glucose (OGTT, 75 g) ≥200 mg/dL (11.1 mmol/L)
Random plasma glucose ≥200 mg/dL (11.1 mmol/L) , accompanied by classic symptoms of hyperglycemia
A1C ≥6.5%

Are There Any Factors That Might Affect the Lab Results? In particular, does your patient take any medications – OTC drugs or Herbals – that might affect the lab results?

Given inherent variability in all laboratory testing, both preanalytical and analytical, it is possible that patients with a lab result over the threshold for diabetes have a repeated value near the margins but below the diagnostic criteria for diabetes. It is recommended that such patients be monitored closely and their testing be repeated in approximately 3-6 months.

A drop in glucose levels may occur if the specimen is not tested immediately, leading to inaccurate reporting of blood glucose levels. It is recommended that blood be drawn in a gray-top tube containing sodium fluoride, which will inhibit glycolysis within 1 hour. Blood samples drawn in a red-top tube for serum glucose or in a green-top tube for plasma glucose will demonstrate a 2-3% decrease in glucose concentration per hour. In addition, patients suffering from sepsis or conditions that result in high white blood cell counts, such as chronic lymphocytic leukemia, may have artificially low glucose concentrations because of an increased rate of glucose metabolism as a consequence of leukocytosis and activated neutrophils.

Mean FPGs tend to be higher earlier in the day, thus, it is recommended that blood for this test be drawn in the morning. In addition, plasma glucose levels, typically, vary from day to day and can be affected by other factors, such as acute stress.

Although the A1C test can overcome many of the mentioned issues, caution in interpreting results must be used, as hemoglobinopathies, age, and other medical illnesses that affect red blood cell survival make interpreting the results difficult. Thus, use of this test may result in an over-diagnosis of the elderly, African-Americans, patients with an iron deficiency, or patients genetically predisposed to increased levels of hemoglobin concentration. A correlation between decreased A1C levels and pregnancy has also been well documented. Likewise, use of the A1C test alone may not be adequate for the diagnosis of diabetes in patients with anemia, hemoglobinopathies, or kidney disease.

What Lab Results Are Absolutely Confirmatory?

Laboratory tests used for diagnosis are also used for confirmation. Typically, if a lab test results in a diagnosis of diabetes, the same test is repeated on a subsequent day for confirmation. If results are simultaneously available for two separate tests and both indicate diabetes, additional testing is not required for confirmation. If, however, the results are discordant, the test with result above the diagnostic threshold for diabetes should be repeated. Diagnosis is then based on the results of the repeated test.

Additional Issues of Clinical Importance

Following a diagnosis of diabetes, patients should seek care from a medical team comprised of physicians, nurse practitioners, physician’s assistants, nurses, dietitians, pharmacists, and mental health professionals to implement a management plan for their disease.

In nonpregnant adults, the American Diabetes Association (ADA) recommends an A1C goal greater than 7.0%, a preprandial capillary plasma glucose of 70-130 mg/dL (3.9-7.2 mmol/L), and a peak postprandial capillary plasma glucose (2 hours after eating) of less than 180 mg/dL (10 mmol/L). For women with type I or type II diabetes who become pregnant, the optimal glycemic goals set by the ADA include a premeal, bedtime, and overnight glucose of 60-99 mg/dL (3.3-5.4 mmol/L), a peak postprandial glucose of 100-129 mg/dL (5.4-7.1 mmol/L), and an A1C of 6.5%.

When establishing a treatment plan for achieving glycemic goals, it is important to consider patient age, duration of diabetes, and presence of cardiovascular disease to reduce the risk of hypoglycemic events.

Additional ADA recommendations for blood pressure, lipids, and triglycerides for patients with diabetes are listed in Table 3.

Table 3.
Parameter ADA Recommendation
Blood pressure <130/80 mmHg
Low density lipoprotein <100 mg/dL (2.6 mmol/L)
Triglycerides <150 mg/dL (<1.7 mmol/L)
High density lipoprotein >40 mg/dL (>1.1 mmol/L)

Self-monitoring of blood glucose (SMBG) should be performed by all insulin-treated patients with diabetes. Although SMBG may benefit type II diabetics treated with diet and oral agents, the data are currently insufficient to claim improved health outcomes. A1C testing is recommended biannually in all diabetic patients and quarterly for patients whose therapy has changed or who are not meeting treatment goals.(
Table 2) (Table 3)

Table 2.
Plasma glucose goal mg/dL (mmol/L)
Patient Category (years of age) Preprandial Bedtime Peak Postprandial A1C (%)
0-6 100-180 (5.6-10.0) 110-200 (6.2-11.1) <8.5
6-12 90-180 (5.0-10.0) 100-180 (5.6-10.0) <8.0
13-19 90-130 (5.0-7.2) 90-150 (5.0-8.3) <7.5
>19, non-pregnant 70-130 (3.9-7.2) 100-140 (5.6-7.8) <180 (<10.0) <7.0
>19, pregnant with pre-existing diabetes 60-99 (3.3-5.5) 100-129 (5.6-7.2) <6.0

Errors in Test Selection for Type Diabetes

Point of care testing is currently not accurate enough to be used for the diagnosis of diabetes.

A1C testing is recommended for the diagnosis of diabetes in nonpregnant adults only.

In cases of rapidly evolving diabetes, it is possible to find an A1C not significantly elevated despite overt diabetes. In these cases, the established glucose criteria should be used for diagnosis.