Presentation of patients with diabetes depends on the type of diabetes and the stage of the type of diabetes and the stage of the pathologic process. Patients with type 1 diabetes com-monly present with the classic acute symptoms of hyperglyce-mia: polydipsia, polyuria, weight loss, and, less frequently, polyphagia, blurred vision, and pruritus. Twenty-five percent present for the first time with diabetic ketoacidosis (DKA). In patients with type 2 diabetes, the disease is often present for many years (on average, 4 to 7 years) before diagnosis. The symptoms are usually less acute than in type 1 diabetes, and they may be accompanied by lethargy and fatigue in this gener-ally older population. Chronic hyperglycemia may be associated with impairment of growth, susceptibility to infections (e. g.,balanitis, vaginitis), and show wound healing. Risk factors for type 2 diabetes are listed in Table 30 and include sedentary lifestyle and poor nutrition(Table 30).

The criteria for diagnosing diabetes have been revised and simplified. Any of the three serum glucose measurements listed in the table under diabetes mellitus may be used for diagnosis, and must be confirmed, on a subsequent day, by any one of the three. The revised diagnostic fasting plasma glucose (FPG) correlates with the 2-hour postload glucose cutoff point and causes fewer patients to have undiagnosed and misdiag-nosed diabetes. These values identify a critical level at which the prevalence of microvascular complications increases dremat-ically.

Although the oral glucose tolerance test (OGTT) remains the standard for diagnostic purposes, measurement of FPG, which is simpler, cheaper, equally accurate, faster to per-form, more reproducible, and convenient, is now recommend-ed for routine diagnostic use. Although. measurement of the glycosylatd hemoglobin (HbAlc) is a useful tool for monitoring glycemia and for making therapeutic decisions, it is not yet recommended for the diagnosis of diabetes. The OGTT is still used for diagnosing gestational diabetes.

Some people (13.4 million, or 6.9% of the United States' population) have blood glucose levels higher than nor-mal but do not fulfill the criteria for the diagnosis of diabetes. They are generally euglycemic and have an abnormal glucose response only when they are challenged with an OGTT. De-pending on the diagnostic test used, this group or stage is re-ferred to as either having imparired fasting glucose or impaired glucose tolerance. These persons are at increased risk of devel-oping type 2 diabetes (7%'per year) and its complications, particularly cardiovascular. The lower cutoff values for nor-mality previously FPGK £¼6.4 retool/L, and for the diagnosis of diabetes (previously FPG£¾7.8 mmol/L) set new levels for earlier and more aggressive diabetes therapy, in an attempt to prevent these complications(Table 31 and Table 32).

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