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Exp Clin Endocrinol Diabetes 2021; 129(11): 851-852
DOI: 10.1055/a-1135-8636
Letter to the Editor

Letter to the Editor – Defining Diabetes Mellitus

Authors

  • Nevio Cimolai

    1   The University of British, Columbia and Children’s and Women’s Health Centre of British Columbia, Vancouver, Canada
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Letter to the Editor – Defining Diabetes Mellitus

The recent publication of Petersmann et al. is essential to the continued evolution of fundamentally understanding diabetes mellitus [1]. Over the last two decades, there has been a greater trend to the movement for defining diabetes mellitus categories with a predominance of purely laboratory measures. Petersmann and colleagues in their Outlook perspective have rightfully highlighted studies that will eventually refigure definition, classification, and diagnosis.

Zaharia and others as well as Ahlqvist et al. have reminded us of the lost art of diabetes determination [2] [3]. They have realized that conventional diagnostic algorithms or paradigms for classification have been either overly restrictive or overly simplified. Although Dennis and colleagues validate the latter and propose yet another application model, the overarching themes in this discussion remain [4]. The differentiation of patients into various clusters that are profiled by several genetic and pathophysiological traits reminds us that diabetes mellitus is indeed a very complex and heterogeneous group of pathologies that are largely unified in definition by the commonality of disordered carbohydrate metabolism. Popular contemporary terminologies such as ‘evident diabetes’ or ‘prediabetes’ or ‘glucose intolerance’ have been mostly and necessarily ascribed to purely laboratory parameters. Yet, diabetes can also be differentiated by natural history, pathophysiology, and prognostic variables as suggested recently by Skyler et al. [5]. That is, as the hyperglycemic state becomes manifest, or even shortly before, the risk for complications occurs at different strata and in a context of several influencing co-morbidities. The latter is very consistent as well with the recent controversy in defining prediabetes [6].

Much of this controversy stems with the need to define patients for standards that are applicable to epidemiological studies or the creation of palpable treatment guidelines in primary care [7]. What is lost, however, in such rigid parameters is that even seemingly normal patient subsets may be at risk for glycemic dysregulation [8]. The at-risk patient may move from one category to another through a life-time [9]. The more balanced view is that diabetes mellitus is a spectral diagnosis in a continuum of such dysregulation [10]. Most current guidelines have measured but yet arbitrary break-points in that continuum. Such break-points were set with the notion of probabilities for the onset of diabetic complications such as retinopathy. More wholesome and applicable medicine calls on a broader clinical assessment and mandates the recognition of any individual patient on that diagnostic spectrum [11]. The tools for that assessment may include age, metabolic parameters, family history, medication profile, past history, gestational status, and/or laboratory/genetic measures among others [12] [13] [14].

The recognition that categorization in such spectral illnesses can garner debate or realignment is evidently not new. For example, in the hypertension field, ‘Stage 1 hypertension’ has been proposed to replace ‘prehypertension’ that was formerly used [15]. As the recent studies now reaffirm, diabetes mellitus will always be a spectral illness in which a comprehensive clinical diagnosis should be individualized for a given patient. Perhaps ‘stages’ of diabetes mellitus might warrant consideration.



Publication History

Article published online:
20 April 2020

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