American Diabetes Association's New Clinical Practice Recommendations Promote A1c as Diagnostic Test for Diabetes and Pre-Diabetes

Faster, easier test could help reduce number of undiagnosed with diabetes and pre-diabetes.

The American Diabetes Association's (ADA) new Clinical Practice Recommendations being published as a supplement to the January issue of Diabetes Care call for the addition of the A1c test as a means of diagnosing diabetes and identifying pre-diabetes. The test has been recommended for years as a measure of how well people are doing to keep their blood glucose levels under control.

"We believe that use of the A1c, because it doesn't require fasting, will encourage more people to get tested for Type 2 diabetes and help further reduce the number of people who are undiagnosed but living with this chronic and potentially life-threatening disease. Additionally, early detection can make an enormous difference in a person's quality of life," said Richard M. Bergenstal, MD, President-Elect, Medicine & Science, ADA.

"Unlike many chronic diseases, Type 2 diabetes actually can be prevented, as long as lifestyle changes are made while blood glucose levels are still in the pre-diabetes range."

A1c is measured in terms of percentages. The test measures a person's average blood glucose levels over a period of up to three months and previously had been used only to determine how well people were maintaining control of their diabetes over time. A person without diabetes would have an A1c of about 5 percent.

Under the new recommendations, which are revised every year to reflect the most current available scientific research, an A1c of 5.7 -- 6.4 percent would indicate that blood glucose levels were in the pre-diabetic range, meaning higher than normal but not yet high enough for a diagnosis of diabetes. That diagnosis would occur once levels rose to an A1c of 6.5 percent or higher.

The ADA recommends that most people with diabetes maintain a goal of keeping A1c levels at or below 7 percent in order to properly manage their disease. Research shows that controlling blood glucose levels helps to prevent serious diabetes-related complications, such as kidney disease, nerve damage and problems with the eyes and gums.

The A1c would join two previous diagnostic tests for diabetes, Fasting Plasma Glucose (FPG) and the Oral Glucose Tolerance Test (OGTT), both of which require overnight fasting. Because the A1c is a simple blood test and does not require fasting, allowing patients this option could increase willingness to get tested, thereby reducing the number of people who have Type 2 diabetes but don't yet know it.

According to the Centers for Disease Control and Prevention, one-fourth of all Americans with diabetes, or 5.7 million people, don't realize they have it. Another 57 million have pre-diabetes and 1.6 million new diagnoses are made every year.

When to Test Children for Diabetes

Q: My husband is a type 1 diabetic, and we didn't know that until he went for a physical and the doctor said his body was in "ketosis" (shutting itself down). We didn't expect that since he looked healthy, and we didn't recognize any symptoms except frequent urination. At what age should we have our three children (ages 13, 15, and 16) checked? Are there more obvious signs in children? Do you recommend any particular diet as a starting point for better eating? Sorry for the many questions, I am just trying to keep my info straight. Thank you very much in advance for your time in answering this. Have a great day.
— Christina, Kansas
A:
These are all great questions. Discovering that you or a loved one has type 1 diabetes can be overwhelming — and troubling to parents who worry that their children are at risk of developing the disease. How wonderful that you are thinking about trying to prevent that from happening!

There isn't a definitive answer to your question regarding early screening. First of all, even though your husband has type 1 diabetes, it does not mean that your children will invariably develop the disease. In fact, very few children of diabetic parents do. The bad news is that we do not have a way to determine who will and who won't. Second, even when we know the specific inherited tendencies for diabetes, there are many factors in the environment that are yet undiscovered triggers. If we knew these factors, we might then be able to work on reducing their influence. Third, we do not know the rate at which a person who carries the genetic risk actually develops diabetes. They may develop the disease early or it may take many years for diabetes to establish a foothold. Fourth, we do not have an effective treatment or preventive measure to stave off type 1 diabetes among those who are at greatest risk of developing it.

In light of all these factors, the best way to move forward is to do the following:

Make sure your children get regular checkups and talk to your pediatrician about new developments in early diagnosis and prevention efforts. There are ongoing studies, the results of which will teach us more about how to proceed. There might also be research projects that your children might participate in that may give them access to genetic and immunology tests not available to the general public. These tests can give you a better idea of your children's specific odds of developing diabetes.Have your children undergo blood glucose tests starting now, biannually or annually, to prevent severe symptoms such as ketosis from being the stimulus for a diagnosis.
Watch out for the following signs and symptoms: excessive thirst, frequent urination, weight loss, fatigue, or blurred vision; and much less common signs of ketosis, including nausea and vomiting, abdominal pain, lethargy, and decreased alertness and rapid breathing. These are the same signs and symptoms as in adults.While there are no specific dietary supplements or diet recommendations, a healthy lifestyle and maintaining a healthy weight will help in general. Specific recommendations depend on your children's caloric needs, activity level, and preferences. I frequently tell my patients that their first loyalty is to nutrition — making sure they have adequate nutrients (i.e., vitamins, minerals, and protein intake) necessary for survival. In the children's case, it is important to take their growth and developmental needs into account. You might consult a dietitian for specific suggestions.

Finally, coping with a diabetic parent can be a frightening experience for children. I would advise that you and your husband normalize the daily routines of his care, which include home blood glucose testing, doctor's visits, diet and exercise regimens, insulin injections, and discussing the symptoms of high and low sugar levels. This way, you can avoid crises and show your children that diabetes is a condition that can be managed as long as you take care of yourself. This knowledge will help them a great deal in the event that they are someday diagnosed with diabetes, however small the odds may be. Best wishes to you and your husband and children. I hope all goes well.

Dinner Ideas for Type 2 Diabetes

You can create great dinners when following a diabetes diet. Substitute healthier ingredients for traditional ones and enjoy many of your favorite meals.
By Hedy Marks, MPH
Medically reviewed by Pat F. Bass III, MD, MPH

To control type 2 diabetes, you must watch what you eat to keep your weight at a healthy level and avoid complications. But eating doesn't have to be a boring chore just because you have diabetes.
You can enjoy many healthy and tasty dinner choices. In fact, by keeping a few simple tips in mind and being creative, few meals are totally off-limits, even with diabetes.
Diabetes Diet: Start With Meal Planning
The name of the game with diabetes diet management is portion control — watch your portion sizes to avoid overeating. Advance planning helps, too. Spend a few minutes every weekend deciding on your meals for the following week and keep these strategies in mind:
• Eat more whole grains and starchy vegetables. Limit fats and sweets. Eat moderate amounts of lean meats, low-fat milk and dairy products, non-starchy vegetables, and fruit.
• Be creative when cooking by making substitutions. For example, use fat-free milk instead of whole milk and trans fat-free margarine instead of butter.
• Choose whole grains and brown rice over white or enriched bread or pasta products.
• Cook with healthy oils, like canola or olive oil.
• Cut back on salt, which can raise blood pressure.
• Avoid fried foods and foods in heavy sauces.
• Limit alcohol. One drink per day for women and one to two drinks per day for men is okay, but always consume alcohol with food.
Diabetes Menu: Healthy Dinner Ideas
Here are six easy dinners that will fill your tummy and still keep your blood sugar levels in check:
• Meatloaf, mashed potatoes, and green beans. You can eat this classic "comfort food" meal, but keep it diabetes-friendly with a few smart substitutions. Use ground turkey instead of ground beef. When making the mashed potatoes, use fat-free milk instead of whole milk and trans-fat-free margarine instead of butter. You could also use fewer potatoes by folding in pureed cauliflower. Steam the green beans and season with a little salt and pepper, then top with a few almonds rather than a pat of butter.
• Chicken, brown rice, and steamed broccoli. Grill boneless, skinless chicken breasts or bake a whole chicken (don't eat the skin). Marinate the chicken in Italian dressing before grilling or season it with your favorite herbs before roasting it in the oven.
• Baked red snapper and mixed veggies. This dinner is a snap. Wrap a fish filet together with sliced vegetables — try a blend of zucchini, garlic, red peppers, onions, fennel, and tomatoes — with a drizzle of oil in parchment paper. Place in a 450 degree oven for 20 minutes or until the fish is opaque and flakes easily. Serve with a whole-grain side dish of fast-cooking couscous or quinoa
• Pasta your way. Although people with type 2 diabetes have to be careful about the amount of carbohydrates they eat, pasta can still be a safe dinner choice. As with bread, whole-grain pasta is better than enriched pasta. Avoid heavy cream sauces like Alfredo, and stick to tomato-based sauces or olive oil and garlic. You can add chicken, shrimp, or fish to your dish for protein — even lean meatballs or turkey meatballs are allowed.
• Chili. When you make it yourself, chili becomes a very healthy choice. Start with ground turkey or extra-lean ground beef, or go vegetarian with beans only ‐ black beans and kidney beans. Add lots of diced vegetables to the pot, such as garlic, onion, red, green, and yellow bell peppers, and zucchini. Use no-salt canned tomatoes and low-sodium beef broth. Instead of serving the chili topped with traditional sour cream and cheese, use low-fat yogurt or fat-free sour cream, crumbled pecans, and cilantro. Serve with a garden salad with low-fat or non-fat salad dressing and whole-grain crunchy bread.
• Asian stir-fry. Make your own version of your favorite restaurant dish. Prepare your vegetables — any combination of green beans, broccoli, carrots, onion, snow peas, red and green peppers, and baby corn — then sauté in low-sodium soy sauce and garlic. Mix in chicken, shrimp, or tofu to add protein to your meal. Serve over brown rice or whole-grain noodles.
Limiting sweets doesn't mean eliminating them. You can indulge your sweet tooth every now and then. Here are some tasty dessert ideas:
• Fresh fruit with low-fat topping
• Fat-free frozen yogurt
• Lower-fat cookies, such as ginger snaps, vanilla wafers, and graham crackers
• No sugar-added pudding or frozen fudge bars
Always keep portion size in mind so that you don't overdo the sweets. Even the most decadent desserts can be enjoyed in very small amounts on occasion.

Diet for Hypertension and Cardiovascular Disease?

Q: What's a good diet for a 45-year-old male who has hypertension, cardiovascular disease, and is overweight?

— Diane, Indiana
A:
The DASH diet is the best diet for these conditions and has been tested and proven to lower blood pressure and lipid levels. DASH stands for Dietary Approaches to Stop Hypertension and is really one of the only diets based on sound science. It calls for lean protein, low-fat dairy, lots of fruits and vegetables, and whole grains — and about 25 percent of its total daily calories come from mostly good fats, like olive and canola oils. The DASH diet is recommended by NIH (National Institutes of Health) and NHLBI (National Heart, Lung, and Blood Institute) to reduce blood pressure and maintain a good weight. So this in fact is the perfect diet for someone who is overweight and has hypertension and cardiovascular disease. It is very similar to other healthy diets that the government recommends, and is very easy to follow because it calls for making sure you give yourself a certain number of servings of lean protein, fresh fruits and vegetables, whole grains, and low-fat dairy per day. There are Web sites available that will teach you how to know how many servings of each food you need per day based on your body weight, but in general the DASH diet recommends nine servings of fruits and vegetables per day, two to three servings of low-fat dairy and protein, and five to six servings of whole grains

You Can Help Children Avoid Type 2 Diabetes

Type 2 diabetes is affecting kids in a big way, but diet and exercise can help children avoid or reverse this condition.
By Madeline Vann, MPH
Medically reviewed by Pat F. Bass III, MD, MPH

Once upon a time, type 2 diabetes was called “adult-onset diabetes.” If children had diabetes, 99 times out of 100 it was type 1 diabetes; type 2 diabetes didn’t appear until midlife. Now, studies suggest that up to 45 percent of childhood diabetes cases are type 2 diabetes.

Type 2 Diabetes: Why the Increase?
“No one is certain why, but most experts believe that it is related in part to the obesity epidemic,” explains Frank Diamond, MD, clinical director for the University of South Florida Diabetes Center and professor of pediatrics at the University of South Florida in Tampa. “We now have approximately 17 percent of the pediatric population that is overweight. Genetically at-risk children may be acquiring the disease earlier because of the increased insulin resistance associated with their early obesity. We are seeing many children with adult weights in our pediatric clinics today.”

Dr. Diamond also notes that the increase may be due to a rise in the proportion of children with ethnic minority heritage that puts them at increased risk for type 2 diabetes.

Basically, says Paul Robertson, MD, president of medicine and science at the American Diabetes Association, and professor of medicine and pharmacology at the University of Washington in Seattle, the causes of childhood type 2 diabetes boil down to genetic risk mixed with physical inactivity and poor eating habits.
“We know if the diets are corrected and they lose the weight, the diabetes becomes undetectable,” says Dr. Robertson.
The first step to preventing type 2 diabetes in childhood is to face the fact that it can happen to children, says Diamond. Then be on guard for symptoms and ask for diabetes screening.

“Symptoms include tiring easily, thirst, and increased urination. A darkening of the skin (acanthosis nigricans) on the back of the neck, under the arms, and in the groin area is associated with obesity and [is] a common finding with newly diagnosed type 2 diabetes children,” he says.

Also, bear in mind that if you had gestational diabetes during your pregnancy, your children are at increased risk of type 2 diabetes.

“Especially in families with a positive family history of type 2 diabetes, avoidance of excessive weight gain and encouragement of an active lifestyle are extremely important and the best tools to avoid the development of type 2 diabetes,” says Diamond. Some children may be candidates for a drug called metformin.

Type 2 Diabetes: Testing
Parents who are concerned that their child might have diabetes should ask for a fasting glucose screening test. That test determines how much sugar is in the blood before a person has eaten.

“A value over 99 mg/dL is abnormal and suggests ‘impending’ diabetes or glucose intolerance. A value equal to or greater than 126 mg/dL is diagnostic of diabetes,” says Diamond.

Any results above the normal range should be red flags for you and your family to:
• Eat a healthy diet rich in whole grains, lean proteins, fruits, and veggies. You can get help changing your family’s diet from a dietitian, if necessary.
• Get at least 30 minutes of exercise a day.
• Help your child lose at least 5 percent of his body weight if he is overweight.

Remember, childhood type 2 diabetes is within your family’s control.
“Lose weight, be active, eat the right foods,” says Robertson. “Lifestyle modifications can do a great deal in terms of staving off type 2 diabetes.”