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Every now and then I get to wonderingabout the different types of diabetes and if there is more to thediagnosis than the medical community is acknowledging. With the newguidelines from the American Diabetes Association which can be readhere (and I urge you to take time to read this), I often read thismore carefully than any other provision or discussion in theguidelines. Then I start to look for what they may not be tellingus. In any of the discussions, they seem to like to paraphrase someareas by saying that there is much to be determined at the clinicallevel.
The definition by its very natureleaves many questions, “Diabetes is agroup of metabolic diseases characterized by hyperglycemia resultingfrom defects in insulin secretion, insulin action, or both. Thechronic hyperglycemia of diabetes is associated with long-termdamage, dysfunction, and failure of different organs, especially theeyes, kidneys, nerves, heart, and blood vessels.”
I am using only the first part of thelong definition because I think this is where some defining needs tobe done. Yes, I agree that diabetes is a metabolic disease and maybea group. Why the term hyperglycemia is not defined as being acertain measurable amount or number leaves me wondering what they arelooking for in not defining this. Certainly they have a number inmind. Then they use chronic hyperglycemia to define what may happento certain organs. I can understand why some organs are missing fromthe list because of the lack of conclusive studies for hearing andcognitive decline (brain). I do question why they are not given anymention and a statement of lack of conclusive evidence. That couldthen spark studies to prove that. I suspect they are not mentionedto avoid these studies from taking place, but why?
The classification for the last severalyears has gotten more restricted and only includes fourclassifications. Table one below shows the four classes.Table 1 Etiologic classification ofdiabetes mellitus:

1. Type 1 diabetes (β-cell destruction, usually leading to absolute insulin deficiency)1. Immune mediated2. Idiopathic2. Type 2 diabetes (may range from predominantly insulin resistance with relative insulin deficiency to a predominantly secretory defect with insulin resistance) 3. Other specific types1. Genetic defects of β-cell function1. MODY 3 (Chromosome 12, HNF-1α)2. MODY 1 (Chromosome 20, HNF-4α)3. MODY 2 (Chromosome 7, glucokinase)4. Other very rare forms of MODY (e.g., MODY 4: Chromosome 13, insulin promoter factor-1; MODY 6: Chromosome 2, NeuroD1; MODY 7: Chromosome 9, carboxyl ester lipase) 5. Transient neonatal diabetes (most commonly ZAC/HYAMI imprinting defect on 6q24)6. Permanent neonatal diabetes (most commonly KCNJ11 gene encoding Kir6.2 subunit of β-cell KATP channel) 7. Mitochondrial DNA8. Others2. Genetic defects in insulin action1. Type A insulin resistance2. Leprechaunism3. Rabson-Mendenhall syndrome4. Lipoatrophic diabetes5. Others3. Diseases of the exocrine pancreas1. Pancreatitis2. Trauma/pancreatectomy3. Neoplasia4. Cystic fibrosis5. Hemochromatosis6. Fibrocalculous pancreatopathy7. Others4. Endocrinopathies1. Acromegaly2. Cushing's syndrome3. Glucagonoma4. Pheochromocytoma5. Hyperthyroidism6. Somatostatinoma7. Aldosteronoma8. Others5. Drug or chemical induced1. Vacor2. Pentamidine3. Nicotinic acid4. Glucocorticoids5. Thyroid hormone6. Diazoxide7. β-Adrenergic agonists8. Thiazides9. Dilantin10. γ-Interferon11. Others6. Infections1. Congenital rubella2. Cytomegalovirus3. Others7. Uncommon forms of immune-mediated diabetes1. “Stiff-man” syndrome2. Anti-insulin receptor antibodies3. Others8. Other genetic syndromes sometimes associated with diabetes1. Down syndrome2. Klinefelter syndrome3. Turner syndrome4. Wolfram syndrome5. Friedreich ataxia6. Huntington chorea7. Laurence-Moon-Biedl syndrome8. Myotonic dystrophy9. Porphyria10. Prader-Willi syndrome11. Others             4. Gestational diabetes mellitus

  The third item seems to be the catchallfor everything not fitting into the other three classifications. Notice that for all the things listed, prediabetes is not among them. This is only considered a risk for type 2 diabetes and nothing more. “In 1997 and 2003, the Expert Committeeon Diagnosis and Classification of Diabetes Mellitus recognized anintermediate group of individuals whose glucose levels do not meetcriteria for diabetes, yet are higher than those considered normal.”

They then define the blood glucoseimpairment range as “having impairedfasting glucose (IFG) [fasting plasma glucose (FPG) levels 100 mg/dl(5.6 mmol/l) to 125 mg/dl (6.9 mmol/l)], or impaired glucosetolerance (IGT) [2-h values in the oral glucose tolerance test (OGTT)of 140 mg/dl (7.8 mmol/l) to 199 mg/dl (11.0 mmol/l)].” Thenthey state that these have been referred to as having prediabetes,but do not go on to use any other term. This is the only use of the word.  They only use the termindividuals to describe these people with A1cs of 5.7% to 6.4%. Theyemphasize that they are to be informed of their risks for diabetesand cardiovascular disease. Like all good doctors, they want themcounseled about effective strategies to lower their risks.




So what is purpose of the ExpertCommittee on Diagnosis and Classification of Diabetes Mellitus?  Isthis the end of the use of the term prediabetes and how soon can weexpect another term?  All good questions we will have to wait for ananswer.  Is it possible we may have another term or will diabetes be expanded to include this range?  Even this discussion on prevention or delay of diabetes only uses the term prediabetes once.  Or will it take another decade or more to make the change?