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A New Look at Screening and Diagnosing Diabetes Mellitus

Department of Medicine (C.D.S.), Division of Endocrinology and Metabolism, Johns Hopkins University School of Medicine, Baltimore, Maryland 21287; Departments of Medicine and Epidemiology (W.H.H.), University of Michigan School of Medicine, Ann Arbor, Michigan 48109; Department of Pathology (D.B.S.), Brigham & Women’s Hospital, Harvard Medical School, Boston, Massachusetts 02115; International Diabetes Center (R.M.B.), Minneapolis, Minnesota 55416; Department of Medicine (D.E.), Division of General Internal Medicine, Durham Veterans Administration Medical Center, Duke University, Durham, North Carolina 27705; and Department of Internal Medicine (M.B.D.), Charles R. Drew University, Los Angeles, California 90059

Address all correspondence and requests for reprints to: Dr. Saudek, Osler Building, Room 575, Johns Hopkins University School of Medicine, Baltimore, Maryland 21287. E-mail: csaudek{at}jhu.edu.

Objective: Diabetes is underdiagnosed. About one third of people with diabetes do not know they have it, and the average lag between onset and diagnosis is 7 yr. This report reconsiders the criteria for diagnosing diabetes and recommends screening criteria to make case finding easier for clinicians and patients.

Participants: R.M.B. invited experts in the area of diagnosis, monitoring, and management of diabetes to form a panel to review the literature and develop consensus regarding the screening and diagnosis of diabetes with particular reference to the use of hemoglobin A1c (HbA1c). Participants met in open session and by E-mail thereafter. Metrika, Inc. sponsored the meeting.

Evidence: A literature search was performed using standard search engines.

Consensus Process: The panel heard each member’s discussion of the issues, reviewing evidence prior to drafting conclusions. Principal conclusions were agreed on, and then specific cut points were discussed in an iterative consensus process.

Conclusions: The main factors in support of using HbA1c as a screening and diagnostic test include: 1) HbA1c does not require patients to be fasting; 2) HbA1c reflects longer-term glycemia than does plasma glucose; 3) HbA1c laboratory methods are now well standardized and reliable; and 4) errors caused by nonglycemic factors affecting HbA1c such as hemoglobinopathies are infrequent and can be minimized by confirming the diagnosis of diabetes with a plasma glucose (PG)-specific test. Specific recommendations include: 1) screening standards should be established that prompt further testing and closer follow-up, including fasting PG of 100 mg/dl or greater, random PG of 130 mg/dl or greater, or HbA1c greater than 6.0%; 2) HbA1c of 6.5–6.9% or greater, confirmed by a PG-specific test (fasting plasma glucose or oral glucose tolerance test), should establish the diagnosis of diabetes; and 3) HbA1c of 7% or greater, confirmed by another HbA1c- or a PG-specific test (fasting plasma glucose or oral glucose tolerance test) should establish the diagnosis of diabetes. The recommendations are offered for consideration of the clinical community and interested associations and societies.

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