This document discusses diabetes, obesity, and body mass index (BMI). It defines the different types of diabetes and risk factors for diabetes testing. Guidelines are provided for diagnosing diabetes using A1c, fasting plasma glucose, and oral glucose tolerance tests. Prediabetes criteria and monitoring are outlined. Treatment targets and medication adjustments are reviewed. Obesity definitions based on BMI and waist circumference are presented along with disease risk levels associated with overweight and obesity.

1. Diabetes,
Obesity, BMI:
What are the limits?
Iris Thiele Isip Tan MD, FPCP, FPSEM
Clinical Associate Professor, UP College of Medicine
Section of Endocrinology, Diabetes & Metabolism
Department of Medicine, Philippine General Hospital

2. Type 1 diabetes
absolute insulin deficiency
Type 2 diabetes
insulin secretory defect +
insulin resistance
Gestational diabetes
Other specific types
http://www.flickr.com/photos/
jill_a_brown/2629206224/
“Diabetes” by Jill A. Brown, 1 Jul
2008. Accessed 30 Oct 2010
http://www.flickr.com/photos/
emagineart/4655345533/
“Pills 3” by eMagine-Art.com, 31
May 2010. Accessed 30 Oct 2010

3. Overweight* or obese with one or more
risk factors
* BMI >25 kg/m2
Who should be tested for diabetes?
American Diabetes Association. Standards of Medical Care in
Diabetes - 2010. Diabetes Care 2010;33(1):S11-61

4. Physical
inactivity
First-degree
relative with
diabetes
9 lb baby
GDM
PCOS
♀ History of
CVD
Hypertension
(BP >140/90 or
on treatment)
HDL <35
mg/dL
or Trigly
>250 mg/dL
A1c >5.7%
IGT or IFG
on previous tests
Insulin
resistance
(acanthosis
nigricans, severe
obesity)
American Diabetes Association. Standards of Medical Care in
Diabetes - 2010. Diabetes Care 2010;33(1):S11-61

5. Overweight* or obese with one or more
risk factors
* BMI >25 kg/m2
Who should be tested for diabetes?
American Diabetes Association. Standards of Medical Care in
Diabetes - 2010. Diabetes Care 2010;33(1):S11-61
In those without risk factors, testing
should begin at 45 years.
FBS is part of PEME “C” for serving
seafarers >40 years old
To test for diabetes:
A1c, FPG or 2-h 75-g OGTT
Repeat testing at least q 3 years

6. Criteria for the
Diagnosis of Diabetes
In the absence of unequivocal hyperglycemia,
criteria 1-3 should be confirmed by repeat testing
A1c >6.5%
NGSP-certified
Standardized to
DCCT assay
FPG
>126 mg/dL
(7.0 mmol/L)
No caloric intake
for at least 8 h
2-h glucose
>200 mg/dL
(11.1 mmol/L)
during a
75-g OGTT
Random
plasma glucose
>200 mg/dL
(11.1 mmol/L)
with classic
symptoms of
hyperglycemia
American Diabetes Association. Standards of Medical Care in
Diabetes - 2010. Diabetes Care 2010;33(1):S11-61
1 3
2
4

7. Advantages
Fasting not required
Greater pre-analytical stability
Less perturbations during
stress and illness
HbA1c
Disadvantages
Greater cost
Limited availability
Incomplete correlation with
average glucose

8. When HbA1c can
be misleading ...
Abnormal red cell turnover
Anemias from hemolysis and iron
deficiency
Hemoglobinopathies
Sickle cell trait
Unique ethnic or geographic
distributions
American Diabetes Association. Standards of Medical Care in
Diabetes - 2010. Diabetes Care 2010;33(1):S11-61
Blood Cells by Andrew Mason, 13 June 2005. http://
www.flickr.com/photos/a_mason/19191446/
Accessed 2 Nov 2010

9. Impaired
Fasting
Glucose
Impaired
Glucose
Tolerance
Prediabetes
FPG
100-125 mg/dL
(5.6-6.9 mmol/L)
2h OGTT
140-199 mg/dL
(7.8-11.0 mmol/L)
HbA1c
5.7-6.4%
American Diabetes Association. Standards of Medical Care in
Diabetes - 2010. Diabetes Care 2010;33(1):S11-61
Toast 2, 3 & 4 by ba1969, 14 Dec 2008. http://www.sxc.hu Accessed 1 Nov 2010

10. 25%
50%
25%
Diabetes Persistent IFG/IGT NGT
Evolution of Prediabetes to Diabetes
With longer observation,
majority of individuals
develop diabetes
Observation period of 3-5 years
Nathan et al. Diabetes Care 2007,30(3):753-9

11. <180 mg/dL (10 mmol/L)
70-130 mg/dL (3.9-7.2 mmol/L)
Primary target
Individualized based on life expectancy and
comorbid conditions
Peak postprandial
capillary plasma glucose
Preprandial capillary plasma glucose
A1c <7%
American Diabetes Association. Standards of Medical Care in
Diabetes - 2010. Diabetes Care 2010;33(1):S11-61

12. Insulin secretagogues: 1-2 wk intervals
Adjusting Drug Dose
toward Glycemic Goal
Metformin: 1-2 wk intervals
α-glucosidase inhibitors:
2-4 wk intervals
TZD: maximum effect at 16-20 wks
half the glucose reduction in 4 weeks

13. HbA1c
At least twice a year
in those with stable
glycemic control
At least quarterly
for those not meeting
goals or when therapy
is changed
American Diabetes Association. Standards of Medical Care in
Diabetes - 2010. Diabetes Care 2010;33(1):S11-61

14. Diabetes &
Employment
Evaluate for
Hypoglycemia
for those on insulin secretagogues
Hyperglycemia
can cause long-term complications
American Diabetes Association. Diabetes and Employment.
Diabetes Care 2010;33(1):S82-86

15. Obesity
Body mass index (BMI)
measure of fatness
Waist circumference
measure of visceral fat
Full-figured man by Tobyotter, 15 Aug 2009. http://
www.flickr.com/photos/78428166@N00/3872155588/
Accessed 1 Nov 2010

16. Body Mass Index
= [weight (kg)/height (m) 2]
WHO Classification
Asia Pacific Classification
Underweight <18.5
<18.5
Normal 18.5-24.9
18.5-22.9
Overweight 25-29.9
23-24.9
Obese Class I 30-34.9
25-29.9
Obese Class II 35-39.9
>30
Morbid obesity >40
= (weight (lb) x 703)/height (in)2
NHLBI, The Practical Guide: Identification, Evaluation and Treatment of Overweight and Obesity in Adults (2000)

17. Measuring Tape Position for Waist Circumference
Horizontal plane around
the abdomen at the level
of the iliac crest
Tape is snug but does
not compress the skin;
is parallel to the floor
Measure at the end of
normal expiration
NHLBI, The Practical Guide: Identification, Evaluation and Treatment of Overweight and Obesity in Adults (2000)

18. Waist
Circumference
Increased risk
♂ >90 cm (35 in)
♀ >80 cm (32 in)
High risk
♂ >102 cm (40 in)
♀ >88 cm (35 in)
Free Tape Measure Woman by D. Sharon Pruitt, 18 Jan 2009.
http://www.flickr.com/photos/pinksherbet/3206805049/
Accessed 1 Nov 2010

19. BMI
(kg/m2)
Obesity
Class
Disease Risk*
(Relative to Normal Weight
and Waist Circumference)
Underweight
Normal ✝
Overweight
Obesity
Extreme
Obesity
♂<40 in (<102 cm)
♀<35 in (<88 cm)
<40 in (<102 cm)
<35 in (<88 cm)
<18.5 - -
18.5-24.9 - -
25.0-29.9 Increased High
30.0-34.9 I High Very High
35.0-39.9 II Very High Very High
>40 III Extremely High Extremely High
* Disease risk for type 2 diabetes, hypertension & CVD
✝ Increased waist circumference can also be a marker for increased risk
even in persons of normal weight
NHLBI, The Practical Guide: Identification, Evaluation and Treatment of Overweight and Obesity in Adults (2000)

20. !ank Y"
http://www.endocrine-witch.net