LY

2018 Clinical Practice Guidelines

O N
S E
L U
Screening for Diabetes
N A in
Adults SO
R
PE
Chapter 4
Jean-Marie Ekoe MD CSPQ PD,
Ronald Goldenberg MD FRCPC FACE,
Pamela Katz MD FRCPC
 Disclaimer

All Content contained on this slide deck is the property of Diabetes

Canada, its content suppliers or its licensors as the case may be, and
is protected by Canadian and international copyright, trademark, and
other applicable laws. Diabetes Canada grants personal, limited,
revocable, non-transferable and non-exclusive license to access and
read content in this slide deck for personal, non-commercial and
not-for-profit use only. The slide deck is made available for lawful,
personal use only and not for commercial use.

The unauthorized reproduction, distribution of this copyrighted

work is not permitted.

For permission to use this slide deck for commercial or any use
other than personal, please contact guidelines@diabetes.ca
2018 Diabetes Canada CPG – Chapter 4. Screening for Diabetes in Adults

Key Changes 2018

• Reinforcement of the importance of screening for

diabetes using FPG and/or A1C every 3 years in
LY
O N
individuals ≥40 years of age or at high risk using a
risk calculator S E
• New information on L U
A
ONfor screening with the 75 g
• De-emphasized Srole
ER
oral glucosePtolerance test
• Arab population added as high-risk for type 2
diabetes

PERSONAL USE ONLY

2018 Diabetes Canada CPG – Chapter 4. Screening for Diabetes in Adults

Screening Checklist
 ASSESS all adults clinically every year for risk of
type 2 diabetes
LY
 SCREEN every 3 years if ≥ 40 yrsOor high risk on risk N
calculator S E
LU
 SCREEN earlier andOmore A
N frequently if very high
R S or additional risk factors
PE
risk on risk calculator
present
 USE FPG and/or A1C as initial screening tests

A1C, glycated hemoglobin; FPG, fasting plasma glucose

PERSONAL USE ONLY
DIASCAN: Canadian Screening for
Type 2 diabetes in those age >40 yrs
in Primary Care

LY
O N 5.7%
S E undiagnosed
L U glucose
N A abnormalities
SO
R
PE

Leiter LA et al. Diabetes Care 2001;24:1038-43.

DM; diabetes mellitus; IFG, impaired fasting glucose; IGT, impaired glucose tolerance
PERSONAL USE ONLY
ADDITION-Cambridge:
No Mortality Benefit of Screening for Type
2 diabetes in United Kingdom

LY
O N
S E
L U
N A
SO
R
PE

Simmons RK et al. Lancet 2012;380:1741-48.

PERSONAL USE ONLY
ADDITION-Cambridge:
Prevalence of Diabetes
• Prevalence of diabetes only 3.0-3.3% in this study
LY
N
E O 6.8%
• Prevalence of diabetes in Canada
S
L U
N A
Can the results O
S of ADDITION-Cambridge
E R
P
be applied to Canada?

Public Health Agency of Canada. Diabetes in Canada: Facts and figures from a public health
perspective. Ottawa, 2011.
Simmons RK et al. Lancet 2012;380:1741-48. PERSONAL USE ONLY
Diabetes in Canada: Prevalence by
Province and Territory
Age-standardized† prevalence of diagnosed DM among individuals ≥ 1 year, 2008/09

< 5.0

LY 5.0 < 5.5

O N 5.5 < 6.0

6.0 < 6.5
YT
S E
U
≥ 6.5
L
5.4%
NT
5.5%
NU
N A
O
4.4% NL

RS
6.5%

PE
BC
AB
5.4% MB
4.9%
5.9%
SK QC PE
5.4% 5.1% 5.6%
ON
6.0% NS
NB 6.1%
† Age-standardized to the 1991 Canadian population. 5.9%
NL, NS and ON had the highest prevalence, while
NU, AB and QC had the lowest.

Public Health Agency of Canada. Diabetes in Canada: Facts and figures from a public health perspective. Ottawa, 2011.
PERSONAL USE ONLY
2018 Diabetes Canada CPG – Chapter 4. Screening for Diabetes in Adults

Risk factors for type 2 diabetes

• Age ≥40 years
• First-degree relative with type 2 diabetes
LY
•
O N Arab, Asian,
Member of high-risk population (e.g., African,
S
Hispanic, Indigenous or South Asian Edescent, low
socioeconomic status) L U
N A
•
S O lFG or A1C 6.0%-6.4%)*
History of prediabetes (lGT,
• History of GDM PE
R
• History of delivery of a macrosomic infant
• Presence of end organ damage associated with diabetes:
• Microvascular (retinopathy, neuropathy, nephropathy)
• CV (coronary, cerebrovascular, peripheral)

A1C, glycated hemoglobin; CV, cardiovascular; GDM, gestational diabetes mellitus; IFG, impaired
fasting glucose; IGT, impaired glucose tolerance
PERSONAL USE ONLY
2018 Diabetes Canada CPG – Chapter 4. Screening for Diabetes in Adults

Risk factors for type 2 diabetes

(cont’d)
• Presence of vascular risk factors:
LY in females
• HDL-C <1.0 mmol/L in males, <1.3 mmol/L
O N
• TG ≥1.7 mmol/L E
U S
• Hypertension
AL
• Overweight O N
R S
P E
• Abdominal obesity
• Smoking

HDL-C, high density lipoprotein cholesterol; TG, triglycerides

PERSONAL USE ONLY
2018 Diabetes Canada CPG – Chapter 4. Screening for Diabetes in Adults

Risk factors for type 2 diabetes

(cont’d)
• Presence of associated diseases:
• History of pancreatitis
LY
• Polycystic ovary syndrome O N
S E
• Acanthosis nigricans
L U
Hyperuricemia/gout A
•
O N
•
R S
Non-alcoholic steatohepatitis
• PE
Psychiatric disorders (bipolar disorder, depression,
schizophrenia)
• HlV infection
• Obstructive sleep apnea
• Cystic fibrosis

HIV, human immunodeficiency virus-1

PERSONAL USE ONLY
2018 Diabetes Canada CPG – Chapter 4. Screening for Diabetes in Adults

Risk factors for type 2 diabetes

(cont’d)
• Use of drugs associated with diabetes:
• Glucocorticoids LY
O N
• Atypical antipsychotics E
US
• Statins
AL
O N
• Highly active antiretroviral therapy
R S
P
• Anti-rejection Edrugs
• Other
• Other secondary causes

PERSONAL USE ONLY

2018 Diabetes Canada CPG – Chapter 4. Screening for Diabetes in Adults

If you choose to use a

diabetes risk calculator …
• Public Health Agency of Canada CANRISK
calculator For people 40 - 74 yrsNLY
E O
• Components
U S
L
• Age, sex, BMI, waistAcircumference
O N
S level, eating veg and fruits
• Physical activity
R
P E
• Hypertension, history of dysglycemia (GDM, acute
illness etc.) macrosomia
• Family history, ethnicity, level of education
• Calculates low, moderate or high risk groups

BMI, body mass index; GDM, gestational diabetes

PERSONAL USE ONLY
 LY
O N
S E
L U
N A
SO
R
PE

PERSONAL USE ONLY

FINRISK calculator
• Similar to CANRISK
• Does not include:
• Macrosomia LY
O N
• Ethnicity
S E
• Level of education
L U
• Risk categories differ: N A
• Low-moderate RSO
• High PE
• Very high
• http://canadiantaskforce.ca/g
uidelines/2012-diabetes/

PERSONAL USE ONLY

2018 Diabetes Canada CPG – Chapter 4. Screening for Diabetes in Adults
2018
Screening for type 2 diabetes in
adults
Screen every 3 years in individuals ≥40 years of age or in individuals at
high risk using a risk calculator.

LY
Screen earlier and/or more frequently (every 6 to 12 months) in people

O
a risk calculator N
with additional risk factors for diabetes or for those at very high risk using

S E
L U
N A
FPG <5.6 mmol/L
SO
FPG 5.6-6.0 mmol/L FPG 6.1-6.9 mmol/L FPG ≥7.0 mmol/L
R
PE
and/or A1C <5.5% and/or A1C 5.5-5.9%* and/or A1C 6.0- and/or A1C ≥6.5%
6.4%**

Normal
At Risk Prediabetes Diabetes
Recreen as
Rescreen more often Rescreen more often
recommended

If both FPG and A1C are available, but discordant, use the test that appears furthest to
the right side of the algorithm.

*Consider 75-g OGTT if 1 risk factors; ** Consider 75-g OGTT

PERSONAL USE ONLY
2018 Diabetes Canada CPG – Chapter 4. Screening for Diabetes in Adults

Do we need to screen for

Type 1 diabetes (T1DM)?
LY
O N
S E
L U
N A
SO
R NO
PE
There is insufficient evidence for interventions to
prevent or delay type 1 diabetes

PERSONAL USE ONLY

2018 Diabetes Canada CPG – Chapter 4. Screening for Diabetes in Adults

Recommendation 1
1. All individuals should be evaluated annually for
type 2 diabetes risk on the basisLof Y demographic
ON
and clinical criteria [Grade D, Consensus]
E
US
L
O NA
R S
PE

PERSONAL USE ONLY

2018 Diabetes Canada CPG – Chapter 4. Screening for Diabetes in Adults

Recommendation 2
2. Screening for diabetes using FPG and/or A1C
should be performed every 3 years LY in individuals
≥40 years of age or at high risk O Nusing a risk
S
calculator [Grade D, Consensus].
E Earlier testing
L U
and/or more frequent N A follow-up (every 6 to 12
months) with eitherSO FPG and/or A1C should be
E R
considered inPthose at very high risk using a risk
calculator or in people with additional risk factors
for diabetes [Grade D, Consensus]

PERSONAL USE ONLY

2018 Diabetes Canada CPG – Chapter 4. Screening for Diabetes in Adults

Key Messages

• In the absence of evidence for interventions to

Y
prevent or delay type 1 diabetes,Lroutine
screening for type 1 diabetes O
is
Nnot recommended
E S
L U
N A
SO
R
PE

PERSONAL USE ONLY

2018 Diabetes Canada CPG – Chapter 4. Screening for Diabetes in Adults

Key Messages
• Screen for type 2 diabetes using a FPG and/or A1C
every 3 years in individuals ≥40 yrs or in
LY
individuals at high risk on a riskNcalculator (33%
E O
chance of developing diabetes
S over 10 years)
L U
A absence of symptomatic
• Diagnose diabetes inNthe
SO
hyperglycemia EifRA1C is ≥6.5% on two tests, FPG
P
≥7.0 mmol/L on two tests, or A1C ≥6.5% and FPG
≥7.0 mmol/L

A1C, glycated hemoglobin; FPG, fasting plasma glucose

PERSONAL USE ONLY
2018 Diabetes Canada CPG – Chapter 4. Screening for Diabetes in Adults

Key Messages for People with

Diabetes
• If you are age 40 years or over, you are at risk for type
LY every 3 years
2 diabetes and should be tested at least
N
E O
S
• If you have risk factors thatUincrease the likelihood of
A
developing type 2 diabetes,
L you should be tested more
O N
S
frequently or startRregular screening earlier. Some of
E
the risk factorsPinclude family history of diabetes;
being a member of a high-risk population; history of
prediabetes or gestational diabetes; and being
overweight

PERSONAL USE ONLY

2018 Diabetes Canada CPG – Chapter 4. Screening for Diabetes in Adults

Key Messages for People with

Diabetes
• You can use the Canadian Diabetes Risk (CANRISK)
LY
calculator to assess your risk for diabetes
N
E O
U
• Several methods for screeningS for diabetes are
AL
available. Usually two N
abnormal blood tests are
SO
needed to makeEaRdiagnosis of diabetes
P
• The earlier you are diagnosed, the sooner you can take
action to stay well

PERSONAL USE ONLY

Visit guidelines.diabetes.ca

LY
O N
S E
L U
N A
SO
R
PE

PERSONAL USE ONLY

Or download the App

LY
O N
S E
L U
N A
SO
R
PE

PERSONAL USE ONLY

Diabetes Canada Clinical
Practice Guidelines

LY
http://guidelines.diabete
s.caE O
N
U– Sfor health-care
AL providers
O N
R S
PE
1-800-BANTING (226-
8464)

http://diabetes.ca – for
people with diabetes

PERSONAL USE ONLY