through mass testing of asymptomatic in-dividualshasnotbeendeﬁnitivelyproven(and rigorous trials to provide such proof are unlikely to occur), pre-diabetes anddiabetes meet established criteria for con-ditions in which early detection is appro-priate. Both conditions are common,increasing in prevalence, and impose sig-niﬁcant public health burdens. There is alongpresymptomaticphasebeforethedi-agnosisoftype2diabetesisusuallymade.Relatively simple tests are available to de-tect preclinical disease (8). Additionally,the duration of glycemic burden is astrong predictor of adverse outcomes,and effective interventions exist to pre-ventprogressionofpre-diabetestodiabe-tes (see Section IV) and to reduce risk of complications of diabetes (see Section VI).Recommendations for testing for pre-diabetes and diabetes in asymptomatic,undiagnosed adults are listed in Table 3.Testing should be considered in all adultswith BMI
and one or morerisk factors for diabetes. Because age is amajor risk factor for diabetes, testing of those without other risk factors shouldbegin no later than age 45.EitherFPGtestingorthe2-hOGTTisappropriate for testing. The 2-h OGTTidentiﬁes people with either IFG or IGTand, thus, more prediabetic people at in-creased risk for the development of dia-betes and CVD. It should be noted thatthe two tests do not necessarily detect thesame prediabetic individuals (9). The ef-ﬁcacy of interventions for primary pre-vention of type 2 diabetes (10–16) hasprimarily been demonstrated among in-dividuals with IGT, not among individu-als with IFG (who do not also have IGT). Asnotedinthediagnosissection(I.B),theFPG test is more convenient, more repro-ducible, less costly, and easier to admin-ister than the 2-h OGTT (4,5). An OGTTmay be useful in patients with IFG to bet-ter deﬁne the risk of diabetes.The appropriate interval betweentests is not known (17). The rationale forthe 3-year interval is that false negativeswill be repeated before substantial timeelapses, and there is little likelihood thatan individual will develop signiﬁcantcomplications of diabetes within 3 yearsof a negative test result.Becauseoftheneedforfollow-upanddiscussion of abnormal results, testingshould be carried out within the healthcare setting. Community screening out-side a health care setting is not recom-mended because people with positivetests may not seek appropriate follow-uptesting and care, and, conversely, theremay be failure to ensure appropriate re-peat testing for individuals who test neg-ative. Community screening may also bepoorly targeted, i.e., it may fail to reachthe groups most at risk and inappropri-ately test those at low risk (the worriedwell) or even those already diagnosed(18,19).
B. Testing for type 2 diabetes inchildren
The incidence of type 2 diabetes in ado-lescents has increased dramatically in thelast decade, especially in minority popu-lations(20),althoughthediseaseremainsrare in the general population (21). Con-sistent with recommendations for adults,children and youth at increased risk forthepresenceorthedevelopmentoftype2diabetes should be tested (22). The rec-ommendations of the ADA consensusstatement on type 2 diabetes in childrenand youth are summarized in Table 4.
C. Screening for type 1 diabetes
Generally, people with type 1 diabetespresent with acute symptoms of diabetesand markedly elevated blood glucose lev-els, and most cases are diagnosed soonafter the onset of hyperglycemia. Wide-spread clinical testing of asymptomaticindividuals for the presence of autoanti-bodies related to type 1 diabetes cannotcurrently be recommended as a means toidentifyindividualsatrisk,forseveralrea-sons:
) cutoff values for the immunemarker assays have not been completelyestablished or standardized for clinicalsettings;
) there is no consensus as towhat follow-up testing should be under-taken when a positive autoantibody testresult is obtained; and
) because the in-cidenceoftype1diabetesislow,testingof healthy individuals will identify only avery small number (
0.5%) who at thatmoment may be “prediabetic.” Finally,though clinical studies are being con-ducted to test various methods of pre-venting type 1 diabetes in high-riskindividuals, no effective intervention hasyet been identiﬁed. If studies uncover aneffective means of preventing type 1 dia-betes, targeted screening (e.g., siblings of type1children)maybeappropriateinthefuture.
Criteria for testing for pre-diabetes and diabetes in asymptomatic adult individuals
1. Testing should be considered in all adults who are overweight (BMI
*) andhave additional risk factors:
ﬁrst-degree relative with diabetes
members of a high-risk ethnic population (e.g., African American, Latino, Native American, Asian American, and Paciﬁc Islander)
women who delivered a baby weighing
9 lb or were diagnosed with GDM
140/90 mmHg or on therapy for hypertension)
HDL cholesterol level
35 mg/dl (0.90 mmol/l) and/or a triglyceride level
250mg/dl (2.82 mmol/l)
women with polycystic ovarian syndrome (PCOS)
IGT or IFG on previous testing
other clinical conditions associated with insulin resistance (e.g., severe obesityand acanthosis nigricans)
history of CVD2. In the absence of the above criteria, testing for pre-diabetes and diabetes should beginat age 45 years3. If results are normal, testing should be repeated at least at 3-year intervals, withconsideration of more frequent testing depending on initial results and risk status.
*At-risk BMI may be lower in some ethnic groups.
Testing for type 2 diabetes inasymptomatic children
85th percentile forage and sex, weight for height
85thpercentile, or weight
120% of ideal forheight)Plus any two of the following risk factors:
Family history of type 2 diabetes in ﬁrst-or second-degree relative
Race/ethnicity (e.g., Native American, African American, Latino, Asian American,and Paciﬁc Islander)
Signs of insulin resistance or conditionsassociated with insulin resistance (e.g.,acanthosis nigricans, hypertension,dyslipidemia, or PCOS)
Maternal history of diabetes or GDM Age of initiation: age 10 years or at onset of puberty, if puberty occurs at a younger ageFrequency: every 2 yearsTest: FPG preferred
Standards of Medical Care