Diabetes in Older Adults

More than 25% of the U.S. population aged ≥65 years has diabetes, and the aging of the overall population is a significant driver of the diabetes epidemic. Although the burden of diabetes is often described in terms of its impact on working-age adults, diabetes in older adults is linked to higher mortality, reduced functional status, and increased risk of institutionalization. Older adults with diabetes are at substantial risk for both acute and chronic microvascular and cardiovascular complications of the disease.

Despite having the highest prevalence of diabetes of any age-group, older persons and/or those with multiple comorbidities have often been excluded from randomized controlled trials of treatments—and treatment targets—for diabetes and its associated conditions. Heterogeneity of health status of older adults (even within an age range) and the dearth of evidence from clinical trials present challenges to determining standard intervention strategies that fit all older adults. To address these issues, the American Diabetes Association (ADA) convened a Consensus Development Conference on Diabetes and Older Adults (defined as those aged ≥65 years) in February 2012. Following a series of scientific presentations by experts in the field, the writing group independently developed this consensus report to address the following questions:

1. What is the epidemiology and pathogenesis of diabetes in older adults?
2. What is the evidence for preventing and treating diabetes and its common comorbidities in older adults?
3. What current guidelines exist for treating diabetes in older adults?
4. What issues need to be considered in individualizing treatment recommendations for older adults?
5. What are consensus recommendations for treating older adults with or at risk for diabetes?
6. How can gaps in the evidence best be filled?

What is the epidemiology and pathogenesis of diabetes in older adults?

According to the most recent surveillance data, the prevalence of diabetes among U.S. adults aged ≥65 years varies from 22 to 33%, depending on the diagnostic criteria used. Postprandial hyperglycemia is a prominent characteristic of type 2 diabetes in older adults , contributing to observed differences in prevalence depending on which diagnostic test is used . Using the A1C or fasting plasma glucose (FPG) diagnostic criteria, as is currently done for national surveillance, one-third of older adults with diabetes are undiagnosed (1).

The epidemic of type 2 diabetes is clearly linked to increasing rates of overweight and obesity in the U.S. population, but projections by the Centers for Disease Control and Prevention (CDC) suggest that even if diabetes incidence rates level off, the prevalence of diabetes will double in the next 20 years, in part due to the aging of the population . Other projections suggest that the number of cases of diagnosed diabetes in those aged ≥65 years will increase by 4.5-fold (compared to 3-fold in the total population) between 2005 and 2050 .

The incidence of diabetes increases with age until about age 65 years, after which both incidence and prevalence seem to level off . As a result, older adults with diabetes may either have incident disease (diagnosed after age 65 years) or long-standing diabetes with onset in middle age or earlier. Demographic and clinical characteristics of these two groups differ in a number of ways, adding to the complexity of making generalized treatment recommendations for older patients with diabetes. Older-age–onset diabetes is more common in non-Hispanic whites and is characterized by lower mean A1C and lower likelihood of insulin use than is middle-age–onset diabetes. Although a history of retinopathy is significantly more common in older adults with middle-age–onset diabetes than those with older-age onset, there is, interestingly, no difference in prevalence of cardiovascular disease (CVD) or peripheral neuropathy by age of onset .

Older adults with diabetes have the highest rates of major lower-extremity amputation , myocardial infarction (MI), visual impairment, and end-stage renal disease of any age-group. Those aged ≥75 years have higher rates than those aged 65–74 years for most complications. Deaths from hyperglycemic crises also are significantly higher in older adults (although rates have declined markedly in the past 2 decades). Those aged ≥75 years also have double the rate of emergency department visits for hypoglycemia than the general population with diabetes .

Although increasing numbers of individuals with type 1 diabetes are living into old age , this discussion of pathophysiology concerns type 2 diabetes—overwhelmingly the most common incident and prevalent type in older age-groups. Older adults are at high risk for the development of type 2 diabetes due to the combined effects of increasing insulin resistance and impaired pancreatic islet function with aging. Age-related insulin resistance appears to be primarily associated with adiposity, sarcopenia, and physical inactivity, which may partially explain the disproportionate success of the intensive lifestyle intervention in older participants in the Diabetes Prevention Program (DPP) . However, age-related declines of pancreatic islet function  and islet proliferative capacity  have previously been described.

Management of Hyperglycemia in Type 2 Diabetes

In 2012, the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD) published a position statement on the management of hyperglycemia in patients with type 2 diabetes (1,2). This was needed because of an increasing array of antihyperglycemic drugs and growing uncertainty regarding their proper selection and sequence. Because of a paucity of comparative effectiveness research on long-term treatment outcomes with many of these medications, the 2012 publication was less prescriptive than prior consensus reports. We previously described the need to individualize both treatment targets and treatment strategies, with an emphasis on patient-centered care and shared decision making, and this continues to be our position, although there are now more head-to-head trials that show slight variance between agents with regard to glucose-lowering effects. Nevertheless, these differences are often small and would be unlikely to reflect any definite differential effect in an individual patient.

The ADA and EASD have requested an update to the position statement incorporating new data from recent clinical trials. Between June and September of 2014, the Writing Group reconvened, including one face-to-face meeting, to discuss the changes. An entirely new statement was felt to be unnecessary. Instead, the group focused on those areas where revisions were suggested by a changing evidence base. This briefer article should therefore be read as an addendum to the previous full account (1,2).

Glycemic Targets

Glucose control remains a major focus in the management of patients with type 2 diabetes. However, this should always be in the context of a comprehensive cardiovascular risk factor reduction program, to include smoking cessation and the adoption of other healthy lifestyle habits, blood pressure control, lipid management with priority to statin medications, and, in some circumstances, antiplatelet therapy. Studies have conclusively determined that reducing hyperglycemia decreases the onset and progression of microvascular complications (3,4). The impact of glucose control on cardiovascular complications remains uncertain; a more modest benefit is likely to be present, but probably emerges only after many years of improved control (5). Results from large trials have also suggested that overly aggressive control in older patients with more advanced disease may not have significant benefits and may indeed present some risk (6). Accordingly, instead of a one-size-fits-all approach, personalization is necessary, balancing the benefits of glycemic control with its potential risks, taking into account the adverse effects of glucose-lowering medications (particularly hypoglycemia), and the patient’s age and health status, among other concerns. Figure 1 displays those patient and disease factors that may influence the target for glucose control, as reflected by HbA1c. The main update to this figure is the separation of those factors that are potentially modifiable from those that are usually not. The patient’s attitude and expected treatment efforts and access to resources and support systems are unique in so far as they may improve (or worsen) over time. Indeed, the clinical team should encourage patient adherence to therapy through education and also try to optimize care in the context of prevailing health coverage and/or the patient’s financial means. Other features, such as age, life expectancy, comorbidities, and the risks and consequences to the patient from an adverse drug event, are more or less fixed. Finally, the usual HbA1c goal cut-off point of 7% (53.0 mmol/mol) has also been inserted at the top of the figure to provide some context to the recommendations regarding stringency of treatment efforts.

Modulation of the intensiveness of glucose lowering in type 2 diabetes. Depiction of patient and disease factors that may be used by the practitioner to determine optimal HbA1c targets in patients with type 2 diabetes. Greater concerns regarding a particular domain are represented by increasing height of the corresponding ramp. Thus, characteristics/predicaments toward the left justify more stringent efforts to lower HbA1c, whereas those toward the right suggest (indeed, sometimes mandate) less stringent efforts. Where possible, such decisions should be made with the patient, reflecting his or her preferences, needs, and values. This “scale” is not designed to be applied rigidly but to be used as a broad construct to guide clinical decision making. Based on an original figure by Ismail-Beigi et al. (59).

DIABETES AND HOME REMEDIES

Diabetes is one of the fast growing lifestyle disorder that can be effectively managed with few lifestyle modifications and eating a healthy diet. Characterized by high blood sugar levels in the body, this condition affects the body’s ability to either produce insulin or to use insulin effectively. Although there are numerous treatment options available to keep your blood sugar levels in control, home remedies can work wonders in achieving this task. Here are top 10 effective home remedies to maintain your blood sugar levels and lead a healthy life with diabetes.

#1 Holy Basil (tulsi) leaves

The leaves of holy basil are packed with antioxidants and essential oils that produce eugenol, methyl eugenol and caryophyllene. Collectively these compounds help the pancreatic beta cells (cells that store and release insulin) to function properly and increase sensitivity to insulin. An added advantage is that the antioxidants present in the leaves help beat the ill effects of oxidative stress.

Tip: Consume two to three tulsi leaves whole or about one tablespoon full of its juice on an empty stomach to lower the blood sugar levels. Here are top 10 health benefits of tulsi.

#2 Flax seeds (Alsi)

Due to their high fibre content flaxseeds help digestion and aid in the proper absorption of fats and sugars. Consuming flax seed helps reduce a diabetic’s postprandial sugar level by almost 28 per cent.

Tip: Consume one tablespoon of ground flaxseed powder every morning on an empty stomach with a glass of warm water. However, do not have more than 2 tablespoons per day, as it can be detrimental to your health. Here are 11 ways to include flaxseeds in your diet.

#3 Leaves of bilberry (neelabadari) plant

The leaves of bilberry have been used in Ayurveda for many centuries to control diabetes. Recently, the Journal of Nutrition stated that the leaves of the Bilberry plant contain high amounts of anthocyanidin, which enhance the action of various proteins involved in glucose transportation and fat metabolism. Due to this unique property, bilberry leaves are a great way to lower one’s blood sugar levels.

Tip: Crush bilberry leaves in a mortar and pestle and consume 100 milligrams of this extract everyday on an empty stomach.

#4 Cinnamon (dalchini)

Also known as dalchini, it improves insulin sensitivity and lower blood glucose levels. Having as little as ½ teaspoon of cinnamon per day can improve one’s insulin sensitivity and help controlling weight, thereby decreasing one’s risk for heart disease.

Tip: Include about 1 gram of dalchini into your daily diet for about a month to help lower blood sugar levels. Read more health benefits of cinnamon.

#5 Green Tea

Unlike other tea leaves, green tea is unfermented and is high in polyphenol content. Polyphenol is a strong antioxidant and hypo-glycaemic compound that helps control the release of blood sugars and helps the body use insulin better. Read more 10 types of flavoured green tea that have 20 health benefits.

Tip: Steep a bag of green tea in hot water for 2-3 minutes. Remove the bag and drink a cup of this tea in the morning or before your meals.

#6 Drumstick leaves

Also called moringa, the leaves of this plant are best known for their ability to boost one’s energy. In the case of diabetics, the moringa leaf increases satiety and slows the breakdown of food and lower blood pressure.

Tip: Take a few drumstick leaves, wash and crush them to extract their juice. Now take about 1/4th cup of this juice and drink it on an empty stomach, every morning to keep your sugar levels under control.

#7 Psyllium husk (Isabgol)

Also known as psyllium husk is often used as a laxative. When isabgol comes in contact with water, it swells to form a gel-like substance. This slows the breakdown and absorption of blood glucose. Isabgol also protects the stomach lining from ulcers and acidity.

Tip: Cosume isabgol after every meal, ideally with milk or water. Avoid having it with curd as it can lead to constipation. Read in detail about 8 health benefits of isabgol or psyllium husk you didn’t know.

#8 Bitter gourd (Karela)

Rich in plant insulin-polypeptide-P, a bio-chemical that mimics the insulin produced by the human pancreas and thus, reduces sugar levels in the body. You may like to read about home remedies for diabetes. It is also known to be highly beneficial for diabetics owing to the two very essential compounds called charatin and momordicin, which are the key compounds in lowering one’s blood sugar levels.

Tip: Consume karela at least once a week either as a subzi or in a curry. If you want quick results, try having a glass of karela juice on an empty stomach once in three days. Read more about 8 healthy reasons to drink bittergourd or karela juice!

#9 Neem

Found abundantly in India, the bitter leaf has a number of amazing medicinal properties. Neem enhances insulin receptor sensitivity, helps improve blood circulation by dilating the blood vessels, lowers blood glucose levels and reduces one’s dependence on hypoglycaemic drugs.  Here are more health benefits of neem.

Tip: Drink the juice of the tender shoot of neem leaves on an empty stomach for best results.

#10 Indian blackberry (Jamun)

A glycoside present in the seeds of Indian blackberry prevents the conversion of starch to sugar. It lowers blood sugar and helps prevent insulin spikes. Jambul also has properties that can protect you from heart diseases and other vascular disorders.

Tip: Eat around 5 – 6 jamuns in the morning to control your blood sugar levels. Alternatively, you can also add a spoonful of jamun seeds powder to a glass of warm water or milk and drink this daily for better control of diabetes.

DIABETES AND OBESITY

Diabetes is a group of disorders characterized by chronic high blood glucose levels (hyperglycemia) due to the body's failure to produce any or enough insulin to regulate high glucose levels. There are two main types of diabetes. Type 1 diabetes, which often occurs in children or adolescents, is caused by the body's inability to make insulin or type 2 diabetes, which occurs as a result of the body's inability to react properly to insulin (insulin resistance). Type 2 diabetes is more prevalent than type 1 diabetes and is therefore seen in roughly 90% of all diabetes cases. Type 2 diabetes is predominantly diagnosed after the age of forty, however, it is now being found in all age ranges, including children and adolescents.

The impact of diabetes goes beyond chronic hyperglycemia. Diabetes is the leading cause of blindness (diabetic retinopathy), end stage kidney diseases (diabetic nephropathy) and non-traumatic lower extremity amputations (diabetic neuropathy) in working-age adults. People with diabetes are also two to four times more likely to experience cardiovascular complications and strokes. Diabetes and its related complications result in an estimated 200,000+ deaths each year, making diabetes one of the major causes of mortality in the U.S.

In 2012, the NIH reported an estimated 29.1 million Americans (9.3% of the population) living with diabetes. Of these, an estimated 8.1 million persons were unaware that they had the disease.

How does my weight relate to type 2 diabetes?

There are many risk factors for type 2 diabetes such as age, race, pregnancy, stress, certain medications, genetics or family history, high cholesterol and obesity. However, the single best predictor of type 2 diabetes is overweight or obesity. Almost 90% of people living with type 2 diabetes are overweight or have obesity. People who are overweight or have obesity have added pressure on their body's ability to use insulin to properly control blood sugar levels, and are therefore more likely to develop diabetes. The number of diabetes cases among American adults increased by a third during the 1990s, and additional increases are expected. This rapid increase in the occurrence of diabetes is mostly attributed to the growing prevalence of obesity in the United States.

What can you do to prevent diabetes?

Type 2 diabetes is largely preventable. Studies have found that lifestyle changes and small amounts of weight loss in the range of 5-10% can prevent or delay the development of type 2 diabetes among high-risk adults. Lifestyle interventions including diet and moderate to intense physical activity (such as walking for 150 minutes per week) were used in these studies to produce small amounts of weight loss. The development of diabetes was reduced by 40% to 60% during these studies, which lasted three to six years. Preventing weight gain, increasing activity levels and working toward small amounts of weight loss if you are overweight can have a big impact on the likelihood that you will develop diabetes in the future. Thus far, weight management is the best thing you can do to prevent the development of diabetes.

What can you do if you already have diabetes?

You can have a positive influence on your blood sugar and your overall health by choosing foods wisely, exercising regularly, reducing your stress levels, making modest lifestyle changes and using medications to lower blood glucose levels. Type 1 diabetic patients must have insulin exogenously applied to maintain healthy blood glucose levels. Type 2 diabetic patients, however, can use insulin or drugs that sensitize their bodies to insulin, which work quite well in lowering blood glucose levels. Unfortunately, these drugs are not without risk as they, as well as the exogenous application of insulin, can often cause diabetic patients to suffer from low blood glucose levels (hypoglycemia) if taken improperly, which may result in seizures, unconsciousness, or death. Small amounts of weight loss (losing 10 pounds or more) can decrease the amounts of these medications needed to keep your blood sugar levels within a healthy range by lowering your blood glucose levels, which furthermore reduces the risk of diabetic complications. Ultimately, better nutrition, increased physical activity, and control of blood glucose levels can delay the progression of diabetes and help prevent the complications associated with the disease.

DIABETES AND GENETICS

A man in his 50s develops type 2 diabetes. His mother developed diabetes in her 60s. Should this man's brother and sister be concerned, too? What about his children's chances of developing diabetes?

A married couple wants to have children, but they are concerned because the husband has type 1 diabetes. They wonder what the risk is that their child would have diabetes.

A couple has three young children. One of the children develops type 1 diabetes. There's no history of diabetes anywhere in either parent's families. Is this just a fluke? What are the chances the other children will develop diabetes?

Chances are if you or a loved one have diabetes, you may wonder if you inherited it from a family member or you may be concerned that you will pass the disease on to your children.

Researchers at Joslin Diabetes Center report that, while much has been learned about what genetic factors make one more susceptible to developing diabetes than another, many questions remain to be answered. While some people are more likely to get diabetes than others, and in some ways type 2 (adult onset diabetes) is simpler to track than type 1 (juvenile onset) diabetes, the pattern is not always clear.

For more than 20 years researchers in the Epidemiology and Genetics Section at Joslin in Boston (Section Head Andrzej S. Krolewski, M.D., Ph.D., Senior Investigator James H. Warram, M.D., Sc.D., and colleagues) have been studying diabetes incidence and hereditary factors. They are continuing a scientific journey begun by Elliott P. Joslin, M.D., who in 1946 launched a 20-year study to determine the prevalence of diabetes cases in his small hometown of Oxford, MA. Over the years, Joslin researchers have studied many generations of families to determine how best to predict who is at risk for diabetes.

Diabetes affects an estimated 20.8 million Americans (about 6.2 million are undiagnosed and therefore unaware that they have the disease), with an estimated 1.5 million Americans diagnosed each year. Type 2 diabetes represents about 90 to 95 percent of the cases, and is more common in people in their 40s and beyond, in certain ethnic groups, and in those who are obese and sedentary. According to the American Diabetes Association, type 1 diabetes accounts for 5 to 10 percent of all diagnosed cases of diabetes. Each year, over 13,000 new cases of type 1 diabetes are diagnosed in children and teenagers, making it one of the most common chronic diseases in American children. People with type 1 diabetes do not produce insulin, a hormone that regulates how cells obtain energy from food; in type 2, the pancreas produces too little insulin or the body is not able to properly use insulin the body does produce. Diabetes is a major cause of heart disease, blindness, kidney disease, nerve damage and other complications.

According to Dr. Warram, several factors are central to the risk question: the person with diabetes has most likely inherited a predisposition to the disease, and secondly, something in the environment triggers the disease. For the average American, the chance of developing type 1 diabetes by age 70 years is 1 in 100 (1 percent), while the corresponding chances of getting type 2 diabetes are at 1 in 9 (11 percent). Knowing what the odds are is one thing; but one can still get the disease even if he or she is not at apparent high risk.

Type 1 Diabetes Odds

Just who is at risk for developing type 1 diabetes? Here's a sampling of what Dr. Warram, a Lecturer in Epidemiology at Harvard School of Public Health, said is known:

• If an immediate relative (parent, brother, sister, son or daughter) has type 1 diabetes, one's risk of developing type 1 diabetes is 10 to 20 times the risk of the general population; your risk can go from 1 in 100 to roughly 1 in 10 or possibly higher, depending on which family member has the diabetes and when they developed it.
• If one child in a family has type 1 diabetes, their siblings have about a 1 in 10 risk of developing it by age 50.
• The risk for a child of a parent with type 1 diabetes is lower if it is the mother — rather than the father — who has diabetes. "If the father has it, the risk is about 1 in 10 (10 percent) that his child will develop type 1 diabetes — the same as the risk to a sibling of an affected child," Dr. Warram says. On the other hand, if the mother has type 1 diabetes and is age 25 or younger when the child is born, the risk is reduced to 1 in 25 (4 percent) and if the mother is over age 25, the risk drops to 1 in 100 — virtually the same as the average American.
• If one of the parents developed type 1 diabetes before age 11, their child's risk of developing type 1 diabetes is somewhat higher than these figures and lower if the parent was diagnosed after their 11th birthday.
• About 1 in 7 people with type 1 has a condition known as type 2 polyglandular autoimmune syndrome. In addition to type 1 diabetes, these people have thyroid disease, malfunctioning adrenal glands and sometimes other immune disorders. For those with this syndrome, the child's risk of having the syndrome, including type 1 diabetes, is 1 in 2, according to the American Diabetes Association (ADA).

Caucasians (whites) have a higher risk of type 1 diabetes than any other race. Whether this is due to differences in environment or genes is unclear. Even among whites, most people who are susceptible do not develop diabetes. Therefore, scientists are studying what environmental factors may be at work. Genes influencing the function of the immune system are the most closely linked to type 1 diabetes susceptibility, regardless of race. One of those genes is HLA-DR. Most Caucasians with diabetes carry alleles (gene variants) 3 and/or 4 of the HLA-DR gene. The HLA-DR7 allele plays a role in diabetes in blacks, while HLA-DR9 allele is important in diabetes among Japanese.

Climate and Clusters

Among Caucasians, diabetes risk varies geographically. In general, the risk is higher in Northern Europeans than Southern Europeans. While climate may contribute to this, the fact that Sardinia in the Mediterranean also has a high risk goes against this theory. Generally the number of new cases over time fluctuates up and down, making it difficult to find an overall pattern. In recent decades, there has been an increase in type 1 diabetes in the United States and Europe. While Asians generally have a much lower incidence of type 1 diabetes, Japan is also experiencing an increasing incidence. "The gene pool doesn't change much within one generation, so there must be an environmental or behavioral factor involved," Dr. Warram says.

Temporal clusters of type 1 diabetes cases (i.e. those that occur around the same time — whether within families, a school or a geographical region), prompt people to suspect an environmental agent. However, no consistent explanation has come up for these clusters, and it is impossible to rule out the possibility of just coincidence. Given the fact that the development of diabetes takes many years in most cases, a clustering in time seems more likely due to chance than a common cause, Dr. Warram says. "From what we know, the autoimmune process leading to the destruction of insulin-producing beta cells in the pancreas is quite long. People can have antibodies signaling damage to the beta cells for many years without developing diabetes," Dr. Warram says. (For information about a study to identify who is at risk for type 1 diabetes and to see if this destruction can be slowed or prevented.

Take the "outbreak" at the grade school mentioned above. Chances are, the youngsters were not attending the same school or even living in the same neighborhood when the lengthy autoimmune process leading to diabetes began. (In that process, the body's disease-fighting immune system malfunctions, turning against the body's own tissues and destroying them.) While we can't be certain, it seems unlikely that we could observe a particular exposure that caused the youngsters to develop diabetes at the same time," Dr. Warram says. "Most likely it's a matter of chance. While it is not comforting to say rare events can happen by chance, rare events are happening all the time within a given population and the chances of them occurring in one place — like a school — is high."

Trauma as a Trigger

Some people have questioned whether a body trauma, like a car crash, or a viral infection like mumps, could trigger the onset of type 1 diabetes. Such events increase the body's insulin requirement and strain the insulin production system if it is being destroyed by a malfunctioning immune system. "As the demands on the body increase, it can tip the body's insulin production system over the edge," Dr. Warram says. But the trauma itself did not "cause" the diabetes, he says.

Much has been said about a possible link between Coxsackie virus, which causes human diseases such as meningitis, and the triggering of type 1 diabetes. "You can't dismiss the fact that sometimes the virus has been present, but its connection with the diabetes is unclear," Dr. Warram says. Scientists do have some significant evidence that mumps does not trigger diabetes, however. A Maryland study showed that despite a great decline in mumps cases after the mumps vaccine was introduced 30 years ago, the incidence of type 1 diabetes did not change.

Some scientists believe early diet may have a role. Prolonged breastfeeding is less common in children who developed type 1 diabetes. While some studies have pointed to exposure to cow's milk, Dr. Warram says much remains to be learned before we can assess the importance of this mechanism. To be prudent, mothers of infants at high risk of developing diabetes may want to breastfeed as long as possible and rely on cow's milk only in moderation after the baby is weaned.

Tracking Type 2 Diabetes

Patients with type 2 diabetes are more likely to know of a relative with diabetes than patients with type 1 and, therefore, suppose that diabetes “runs in the family.” To some extent the appearance of “clustering” of type 2 diabetes in families is simply the consequence of the fact that type 2 is so much more common than type 1 diabetes in the general population. Moreover, the occurrence of multiple cases in a family may reflect shared “environmental risk factors,” such as obesity and sedentary lifestyle, and does not imply necessarily the sharing of a diabetes gene. In general, the risk of diabetes for a sibling of a patient with type 2 diabetes is about the same as that in the general population. However, there are some exceptions to this general statement. If the patient developed diabetes despite being lean, then the sibling’s risk is about twice the general population risk. Or, if the patient has a parent with type 2 diabetes, the sibling’s risk is almost three times the general population risk. If both parents have type 2 diabetes, the sibling has a fourfold risk, or nearly a 50% chance of developing diabetes.

The genetics of type 2 diabetes is complex. While type 2 diabetes may have a strong genetic basis in some patients (something less than a third of them), the development of diabetes in most patients is dependent upon the effects of environmental and behavioral factors (obesity and sedentary lifestyle) on an underlying susceptibility that is poorly understood.

What about MODY?

Over Dr. Warram's desk is a chart of several generations of one family. About half of the people in the family have developed a form of type 2 diabetes called MODY (maturity-onset diabetes of the young) that typically develops in people in their teens and 20s. The family is one of about 50 families with MODY studied by the Joslin researchers. "In this family, every generation is affected and every family member with MODY had a parent with MODY," Dr. Warram says.

Joslin researchers and others have identified about six genes that produce MODY, but they only account for the diabetes in about one-third of the families. "The diabetes in the rest of the families so far is unexplained," he says.

Similar patterns can be found in studies of families with the more common form of type 2 diabetes, only the age of onset differs.

The susceptibility to certain diabetes complications also seems to be linked in some ways with genetics. For patients with susceptibility genes for complications, good blood glucose control is still an important mitigating factor.

Scientists at Joslin and elsewhere are studying genetic factors that may make some people with diabetes more susceptible to complications as well.

An Individual Decision

If there's one thing Dr. Warram feels strongly about, it's not to advise people considering having a baby or marrying someone with diabetes in the family. "I do not mind telling people what we know about diabetes risks, but I am not qualified to give an opinion about their choice. These are matters of personal choice and what's important to me may not be important to someone else," he says.

"To be told a child has a 4 percent or 10 percent risk of diabetes sounds very absolute and scientific," he says. "But a myriad other things can go wrong with a child — medically and socially — and these risks cannot be measured precisely. Also, there are a myriad other things that can go right for a child. Even if a child does develop diabetes, it needn't prevent him or her from finding success and happiness in life. "Raising children — whether they are your own or adopted — is an experience involving risks of great rewards and risks of great costs that can't really be known in advance. If a number can be attached to one of those risks, should it weigh more than the others?"

DIABETES AND BLOOD TEST

A Blood Sugar Test measures the amount of a sugar called glucose in a sample of your blood.

Glucose is a major source of energy for most cells of the body, including brain cells. Carbohydrates are found in fruit, cereal, bread, pasta, and rice. They are quickly turned into glucose in your body. This raises your blood glucose level.

Hormones made in the body help control blood glucose level.

How the Test is Performed

A blood sample is needed.

How to Prepare for the Test

The Blood Sugar Test  may be done in the following ways:

·         After you have not eaten anything for at least 8 hours (fasting)

·         At any time of the day (random)

·         Two hours after you drink a certain amount of glucose (oral glucose tolerance test)

How the Test will Feel

When the needle is inserted to draw blood, some people feel moderate pain. Others feel only a prick or stinging. Afterward, there may be some throbbing or slight bruising. This soon goes away.

Why the Test is Performed

Your doctor may order this test if you have signs of diabetes. More than likely, the doctor will order a fasting blood sugar test.

The blood glucose test is also used to monitor people who already have diabetes.

The test may also be done if you have:

·         An increase in how often you need to urinate

·         Blurred vision

·         Confusion or a change in the way you normally talk or behave

·         Fainting spells

·         Seizures (for the first time)

SCREENING FOR DIABETES

This Blood Sugar Test  may also be used to screen a person for diabetes.

High blood sugar and diabetes may not cause symptoms in the early stages. A fasting blood sugar test is almost always done to screen for diabetes.

If you are over age 45, you should be tested every 3 years.

If you have any of the risk factors below, ask your health care provider about getting tested at an earlier age and more often:

·         Overweight (body mass index, or BMI, of 25 or higher) and other risk factors

·         Blood pressure of 140/90 mm Hg or higher, or unhealthy cholesterol levels

·  

·         Woman who has delivered a baby weighing 9 pounds (lb), or 4 kilograms (kg) or more, or who had gestational diabetes

·         Polycystic ovary disease

·         Close relative with diabetes (such as a parent, brother or sister)

Children age 10 and older who are overweight and have at least 2 of the risk factors listed above should be tested for type 2 diabetes every 3 years, even if they have no symptoms.

Normal Results

If you had a fasting blood glucose test, a level between 70 and 100 mg/dL (3.9 and 5.6 mmol/L) is considered normal.

If you had a random blood glucose test, a normal result depends on when you last ate. Most of the time, the blood glucose level will be below 125 mg/dL (6.9 mmol/L).

The examples above show the common measurements for results of these tests. Normal value ranges may vary slightly among different laboratories. Some labs use different measurements or may test different specimens. Talk to your doctor about the meaning of your specific test results.

What Abnormal Results Mean

If you had a fasting blood glucose test:

·         A level of 100 to 125 mg/dL (5.6 to 6.9 mmol/L) means you have impaired fasting glucose, a type of prediabetes. This increases your risk of developing type 2 diabetes.

·         A level of 126 mg/dL (7 mmol/L) and higher usually means you have diabetes.

If you had a random blood glucose test:

·         A level of 200 mg/dL (11 mmol/L) or higher often means you have diabetes.

·         Your provider will order a fasting blood glucose, HbA1c test, or glucose tolerance test, depending on your random blood glucose test result.

·         In someone who has diabetes, an abnormal result on the random blood glucose test may mean that the diabetes is not well controlled.

Other medical problems can also cause a higher-than-normal blood glucose level, including:

·         Overactive thyroid gland

·         Pancreatic cancer

·         Swelling and inflammation of the pancreas (pancreatitis)

·         Stress due to trauma, stroke, heart attack, or surgery

·         Rare tumors, including pheochromocytoma, acromegaly, Cushing syndrome, or glucagonoma

A lower-than-normal blood glucose level (hypoglycemia) may be due to:

·         Hypopituitarism (a pituitary gland disorder)

·         Underactive thyroid gland or adrenal gland

·         Tumor in the pancreas (insulinoma) - very rare)

·         Too little food

·         Too much insulin or other diabetes medicines

·         Liver or kidney disease

·         Weight loss after weight loss surgery

·         Vigorous exercise

Some medicines can raise or lower your blood glucose level. Before having the test, tell your provider about all the medicines you are taking.

For some thin young women, a fasting blood sugar level below 70 mg/dL (3.9 mmol/L) may be normal.

Risks

Veins and arteries vary in size from one person to another and from one side of the body to the other. Obtaining a blood sample from some people may be more difficult than from others.

Other risks associated with having blood drawn are slight, but may include:

·         Excessive bleeding

·         Fainting or feeling lightheaded

·         Hematoma (blood accumulating under the skin)

·         Infection (a slight risk any time the skin is broken)

Alternative Names

Random blood sugar; Blood sugar level; Fasting blood sugar; Glucose test; Diabetic screening - blood sugar test; Diabetes - blood sugar test