I diabetes Mellitus ^275 ^393 ^669
Diabetes mellitus is a group of disorders that share hyperglycemia as a common feature. Diabetes results from a combination of insulin resistance, increased hepatic output of glucose, and pancreatic insufficiency.
Type 2 diabetes mellitus, which is characterized by insulin resistance, is the most common form of diabetes. Other forms include type 1 diabetes mellitus (characterized by absent or insufficient insulin production), gestational diabetes mellitus (or GDM, defined as carbohydrate intolerance that begins or is first recognized in pregnancy), and diabetes that is due to other causes (eg, genetic defects in beta-cell function or in insulin action). Approximately 30% of people with diabetes in the United States, or 6.2 million people, are undiagnosed. Even when symptoms are not present, the disease can cause long-term complications. As many as 25% of people with a new diagnosis of diabetes already have established diabetic retinopathy or microalbuminuria, which has been interpreted to mean that there is, on average, a 7-year gap between actual onset and clinical recognition. Diabetes that is due to obesity may be preventable or reversible with weight loss. Exercise increases insulin sensitivity and may forestall or prevent the development of diabetes. Management of diabetes often requires a multidisciplinary team approach and needs to take into account the goals of treatment in the multiple organ systems affected.Prevention
There is good evidence that structured programs that emphasize lifestyle changes with moderate weight loss (7% of body weight), regular physical activity (150 min/wk), and a diet of reduced calories and reduced fat intake can decrease the risk of developing type 2 diabetes in high-risk patients (Box 3-9). The oral hypoglycemic drugs metformin and acarbose are less effective than lifestyle measures in the prevention of diabetes.
NutritionBox 3-9. American Diabetes Association Criteria for Testing for Diabetes in Asymptomatic Adults ^
1. Testing should be considered in all adults who are overweight (BMI greater than or equal to 25 kg/m2[‡‡] [§§]) and have additional risk factors:
• Physical inactivity
• First-degree relative with diabetes
• High-risk race/ethnicity (eg, African American, Latino, Native American, Asian American, Pacific Islander)
• Women who gave birth to a newborn weighing more than 9 lb or were diagnosed with GDM
• Hypertension (blood pressure greater than or equal to 140/90 mm Hg or on therapy for hypertension)
• HDL cholesterol level less than 35 mg/dL (0.90 mmol/L) and/or a triglyceride level greater than 250 mg/dL (2.82 mmol/L)
• Women with polycystic ovary syndrome
• Hemoglobin Ak greater than or equal to 5.7%, IGT, or IFG on previous testing
• Other clinical conditions associated with insulin resistance (eg, severe obesity, acanthosis nigricans)
• History of cardiovascular disease
2. In the absence of the above criteria, testing for diabetes should begin at age 45 years.
3. If results are normal, testing should be repeated at least at 3-year intervals, with consideration of more frequent testing depending on initial results (eg, those with prediabetes should be tested yearly) and risk status.
control is an integral component of preventive care for women with prediabetes (ie, individuals with impaired glucose tolerance, impaired fasting glucose, or both [see Table 3-3]). These women need thorough dietary counseling and may need the services of a dietitian to help with planning their diet. Health care providers should recommend and facilitate lifestyle interventions to help prevent or delay the onset of diabetes in patients at increased risk. However, when counseling patients, clinicians should be realistic about what behavioral modifications are possible and take into consideration the patient’s readiness to change and any significant environmental factors that might impede change.
Screening and Diagnosis
It is best to identify and treat diabetes early in the disease process. The American Diabetes Association and the American College of Obstetricians and Gynecologists recommend that individuals at average risk be screened every 3 years beginning at age 45 years. Screening should begin
Table 3-3. Screening and Diagnostic Criteria for Diabetes Mellitus
| Test | Prediabetes Screening* | Diabetes Diagnosis? |
| Fasting plasma glucose | 100-125 mg/dL (impaired fasting glucose) | Greater than or equal to 126 mg/dL |
| 2-h, 75-g oral glucose tolerance test | 140-199 mg/dL (impaired glucose tolerance) | Greater than or equal to 200 mg/dL |
| Hemoglobin Ak | 5.7-6.4% | Greater than or equal to 6.5% |
| Random plasma glucose | N/A | Greater than or equal to 200 mg/dL in a patient with classic symptoms of hyperglycemia or hyperglycemic crisis |
*If screening results are negative, screen again in 3 years; if screening results are positive, repeat screening using the same method, if possible.
T∣f the results of two different tests are both above diagnostic thresholds, the diagnosis of diabetes is confirmed.
Data from Standards of medical care in diabetes-2014. American Diabetes Association. Diabetes Care 2014;37 Suppl 1:S14-80.
at a younger age and be performed more frequently in individuals with risk factors (see Box 3-9).
There has been some controversy regarding how to screen, diagnose, and treat diabetes. According to the American Diabetes Association, appropriate tests for prediabetes or diabetes include the fasting plasma glucose test; hemoglobin A1c test; or the 2-hour, 75-g oral glucose tolerance test (Table 3-3).
The hemoglobin A1c test has several advantages compared with the fasting plasma glucose test and the glucose tolerance test: it does not require patients to fast; it assesses blood glucose control over the past 2-3 months; it has standardized and reliable laboratory methods; and it results in infrequent errors caused by nonglycemic factors. However, these advantages must be balanced against the hemoglobin A1c test’s greater cost and its inaccurate assessment of glycemia in certain individuals (eg, those with certain anemias and hemoglobinopathies).Management
Women’s health care providers who wish to implement a treatment plan for women with diabetes can refer to the American Diabetes Association’s Standards of Medical Care in Diabetes (see Bibliography), which provides annually updated guidelines for management of diabetes. Ongoing treatment, however, usually requires management by a health care provider with expertise in diabetes care.
The goal of management is to ensure adequate glucose control. In asymptomatic patients, lifestyle changes (ie, dietary control, weight loss, and active exercise programs) should be instituted, and the patient should be educated about her disease. If symptoms are present, immediate drug therapy may be necessary. The patient’s condition should be assessed to detect complications of the disease, such as organ damage from vascular changes. Considerations for the use of pharmacologic agents include efficacy, cost, adverse effects, comorbidities, and patient preference. If not contraindicated and if tolerated, metformin is the recommended initial pharmacologic agent for the treatment of type 2 diabetes. Common adverse effects of metformin, such as bloating and diarrhea, may be decreased by initiating therapy at low doses and gradually increasing the amounts until therapeutic levels are attained. Metformin administration should be discontinued before radiologic procedures that use iodinated contrast material, such as intravenous pyelography.
Insulin therapy often is indicated at some point for many patients with type 2 diabetes.The American Diabetes Association recommends that nonpregnant women with diabetes lower hemoglobin A1c levels to less than 7.0% to help reduce the risk of microvascular disease. However, a more aggressive goal (such as less than 6.5%) might be considered in patients who are relatively young, such as women of reproductive age; who have short duration of disease; and who have no cardiovascular disease. Less stringent targets (such as less than 8%) might be reasonable in patients with short life expectancy or a history of hypoglycemic episodes, multiple complications, or comorbid conditions or when stricter goals are too difficult to reach.
Because of the greater risk of coronary problems in patients with diabetes, their target blood pressure (less than 140/80 mm Hg) is lower than it is for patients with uncomplicated hypertension. An even lower target level of less than 130/80 mm Hg may be appropriate if this goal can be achieved without undue treatment burden. Based on the clear synergistic risks of hypertension and diabetes, the American Diabetes Association recommends lifestyle changes for patients with diabetes with a blood pressure of more than 120/80 mm Hg and prompt pharmacologic therapy plus lifestyle changes for those with a confirmed blood pressure of more than 140/80 mm Hg.
Another consideration in the care of women with diabetes is contraceptive use. Avoidance of unintended pregnancy is particularly important until diabetes is under control, given the risks of pregnancy to the woman and her fetus. The American Diabetes Association recommends that women with diabetes achieve hemoglobin A1c levels as close to normal (less than 7%) as possible before attempting to conceive. Combined hormonal contraceptives and depot medroxyprogesterone acetate are not recommended in women with type 1 or type 2 diabetes mellitus and nephropathy, retinopathy, other vascular disease, or a history of diabetes for more than 20 years.
The risks and benefits of progesterone-only contraceptives should be weighed in this population before use is recommended. Health care providers should reference the Centers for Disease Control and Prevention’sU.S. Medical Eligibility Criteria for Contraceptive Use, 2010 (available at www.cdc.gov/mmwr/pdf/rr/rr5904.pdf) for more detailed information on the use of contraception in women with diabetes and other comorbidities (see also the “Family Planning” section later in Part 3).
Gestational Diabetes Mellitus
Gestational diabetes mellitus (GDM) affects 2-10% of pregnancies in the United States, depending on the characteristics of the population studied. Pregnancy itself impairs insulin action. Although the carbohydrate intolerance of GDM frequently resolves after delivery, up to one third of women who develop GDM will have diabetes or impaired glucose metabolism at postpartum screening and up to 50% will eventually develop diabetes. Women who develop GDM should be screened postpartum with a fasting plasma glucose test or oral glucose tolerance test. Women with normal values should be screened every 3 years thereafter (see also the “Preconception and Interconception Care” section later in Part 3).
Bibliography
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Resources
Agency for Healthcare Research and Quality. Women at high risk for diabetes: access and quality of health care, 2003-2006. Rockville (MD); 2011. Available at: http:// www.ahrq.gov/research/findings/final-reports/women-and-diabetes-2003-2006/ index.html. Retrieved September 3, 2013.
American College of Obstetricians and Gynecologists. Diabetes and women. Patient Education Pamphlet AP142. Washington, DC: American College of Obstetricians and Gynecologists; 2011.
American Diabetes Association. Women and diabetes. Available at: http://www. diabetes.org/living-with-diabetes/treatment-and-care/women. Retrieved March 28, 2014.
Department of Health and Human Services. National agenda for public health action: the national public health initiative on diabetes and women's health. Atlanta (GA): USDHHS, Centers for Disease Control and Prevention; 2003. Available at: http://stacks.cdc.gov/view/cdc/6488. Retrieved September 3, 2013.
Umpierrez GE, Hellman R, Korytkowski MT, Kosiborod M, Maynard GA, Montori VM, et al. Management of hyperglycemia in hospitalized patients in non-critical care setting: an endocrine society clinical practice guideline. Endocrine Society. J Clin Endocrinol Metab 2012;97:16-38. [PubMed]