March 1, 2013

Classification and Diagnosis of Diabetes

It is interesting how the American Diabetes Association dodges the classifications for diabetes. So there is no doubt, I will quote what they have in print.
The classification of diabetes includes four clinical classes:
1. Type 1 diabetes (results from β-cell destruction, usually leading to absolute insulin deficiency)
2. Type 2 diabetes (results from a progressive insulin secretory defect on the background of insulin resistance)
3. Other specific types of diabetes due to other causes, e.g., genetic defects in β-cell function, genetic defects in insulin action, diseases of the exocrine pancreas (such as cystic fibrosis), and drug- or chemical-induced (such as in the treatment of HIV/AIDS or after organ transplantation)
4. Gestational diabetes mellitus (GDM) (diabetes diagnosed during pregnancy that is not clearly overt diabetes)”

At least for two years is a row they have been consistent, if that counts for anything. I do find it absurd that they lump genetic defects together with other diseases of the pancreas and drug- or chemical-induced diabetes. Yet again, prediabetes is only listed as a risk for diabetes. It is no wonder physicians do not take prediabetes seriously and in general ignore it. With research showing that diabetes can be stopped during this stage and full diabetes prevented, one would think this should receive more attention – maybe even rating it as diabetes so that insurance would cover treatment as a preventive measure since it has been proven that prediabetes intervention does help in the prevention of full onset of diabetes.

This means that the ADA only looks to something they can diagnose as a disease and treat as being important. Again, there is no incentive to diagnosis and treat prediabetes because without ADA making this a classification, medical insurance will have no incentive to reimburse for treatment or medications to stop diabetes. Even with the Centers for Medicare and Medicaid Services (CMS) expanding into many prevention services, the ADA does not see this as a value. Their mantra seems to be: “let them get diabetes and then we will treat them.”

Even if they did not change anything from last year in their statement after the classifications. They continue to give doctors a blanket to hide under when a patient is incorrectly diagnosed. They have stated, “Some patients cannot be clearly classified as type 1 or type 2 diabetic. Clinical presentation and disease progression vary considerably in both types of diabetes. Occasionally, patients who otherwise have type 2 diabetes may present with ketoacidosis. Similarly, patients with type 1 diabetes may have a late onset and slow (but relentless) progression of disease despite having features of autoimmune disease. Such difficulties in diagnosis may occur in children, adolescents, and adults. The true diagnosis may become more obvious over time.”

Then in the diagnosis area, they also repeat the information from 2012. In one short paragraph, they throw out the oral glucose tolerance test (OGTT) and then bring it back later – at their convenience. They cite costs and later use the OGTT when it suits their needs. They recognize that African Americans may have higher rates of glycation and then dismiss this as controversial. They cite epidemiological studies for their dismissal and then leave out other studies that show that Asians may also have higher glycation rates.

It seems that the people in charge do what suits them and ignore what they don't want to consider. With the increase of Americans from other countries, more consideration needs to be paid to their ethnic heritage and variances from the European and Scandinavian heritage of most of them.

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