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Report of the Expert Committee on the Diagnosis and Classification Of COMMITTEE REPORT Report of the Expert Committee on the Diagnosis and Classification of Diabetes Mellitus THE EXPERT COMMITTEE ON THE DIAGNOSIS AND CLASSIFICATION OF DIABETES MELLITUS* he current classification and diagno- nosis of diabetes were warranted. The in insulin secretion, insulin action, or sis of diabetes used in the U.S. was Committee met on multiple occasions both. The chronic hyperglycemia of dia- T developed by the National Diabetes and widely circulated a draft report of betes is associated with long-term dam- Data Group (NDDG) and published in their findings and preliminary recom- age, dysfunction, and failure of various 1979 (1). The impetus for the classifica- mendations to the international diabe- organs, especially the eyes, kidneys, tion and diagnosis scheme proposed then tes community. Based on the numerous nerves, heart, and blood vessels. holds true today. That is, comments and suggestions received, in- Several pathogenic processes are in- cluding the opportunity to review unpub- volved in the development of diabetes. the growth of knowledge regarding the eti- lished data in detail, the Committee These range from autoimmune destruc- ology and pathogenesis of diabetes has led discussed and revised numerous drafts of tion of the ␤-cells of the pancreas with many individuals and groups in the diabe- a manuscript that culminated in this pub- consequent insulin deficiency to abnor- tes community to express the need for a lished document. malities that result in resistance to insulin revision of the nomenclature, diagnostic This report is divided into four sec- action. The basis of the abnormalities in criteria, and classification of diabetes. As a tions: definition and description of dia- carbohydrate, fat, and protein metabo- consequence, it was deemed essential to de- velop an appropriate, uniform terminology betes, classification of the disease, lism in diabetes is deficient action of in- and a functional, working classification of diagnostic criteria, and testing for diabe- sulin on target tissues. Deficient insulin diabetes that reflects the current knowledge tes. The aim of this document is to define action results from inadequate insulin se- about the disease. (1) and describe diabetes as we know it to- cretion and/or diminished tissue re- day, present a classification scheme that sponses to insulin at one or more points in It is now considered to be particularly im- reflects its etiology and/or pathogenesis, the complex pathways of hormone action. portant to move away from a system that provide guidelines for the diagnosis of the Impairment of insulin secretion and de- appears to base the classification of the disease, develop recommendations for fects in insulin action frequently coexist disease, in large part, on the type of phar- testing that can help reduce the morbidity in the same patient, and it is often unclear macological treatment used in its manage- and mortality associated with diabetes, which abnormality, if either alone, is the ment toward a system based on disease and review the diagnosis of gestational di- primary cause of the hyperglycemia. etiology where possible. abetes. Symptoms of marked hyperglycemia An international Expert Committee, include polyuria, polydipsia, weight loss, working under the sponsorship of the DEFINITION AND sometimes with polyphagia, and blurred American Diabetes Association, was es- DESCRIPTION OF DIABETES vision. Impairment of growth and suscep- tablished in May 1995 to review the sci- MELLITUS — Diabetes mellitus is a tibility to certain infections may also ac- entific literature since 1979 and to decide group of metabolic diseases characterized company chronic hyperglycemia. Acute, if changes to the classification and diag- by hyperglycemia resulting from defects life-threatening consequences of diabetes ●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●● are hyperglycemia with ketoacidosis or From the American Diabetes Association, Alexandria, Virginia. Originally approved 1997. Modified in 1999 the nonketotic hyperosmolar syndrome. based on the Proceedings of the Fourth International Workshop-Conference on Gestational Diabetes Mel- Long-term complications of diabetes litus (Diabetes Care 21 [Suppl. 2]:B1–B167, 1998). include retinopathy with potential loss of *Members of the Expert Committee on the Diagnosis and Classification of Diabetes Mellitus: James R. Gavin vision; nephropathy leading to renal fail- III, MD, PhD (Chair), K.G.M.M. Alberti, MD, Mayer B. Davidson, MD, Ralph A. DeFronzo, MD, Allan Drash, ure; peripheral neuropathy with risk of MD, Steven G. Gabbe, MD, Saul Genuth, MD, Maureen I. Harris, PhD, MPH, Richard Kahn, PhD, Harry Keen, MD, FRCP, William C. Knowler, MD, DrPH, Harold Lebovitz, MD, Noel K. Maclaren, MD, Jerry P. foot ulcers, amputation, and Charcot Palmer, MD, Philip Raskin, MD, Robert A. Rizza, MD, and Michael P. Stern, MD. joints; and autonomic neuropathy caus- Abbreviations:ACOG, American College of Obstetricians and Gynecologists; FPG, fasting plasma glu- ing gastrointestinal, genitourinary, and cose; GCT, glucose challenge test; GDM, gestational diabetes mellitus; HNF, hepatocyte nuclear factor, IFG, cardiovascular symptoms and sexual dys- impaired fasting glucose; IGT, impaired glucose tolerance; MODY, maturity-onset diabetes of the young; NDDG, National Diabetes Data Group; NHANES III, Third National Health and Nutrition Examination function. Glycation of tissue proteins and Survey; OGTT, oral glucose tolerance test; PAI-1, plasminogen activator inhibitor-1; WHO, World Health other macromolecules and excess pro- Organization; 2-h PG, 2-h postload glucose. duction of polyol compounds from glu- DIABETES CARE, VOLUME 25, SUPPLEMENT 1, JANUARY 2002 S5 Committee Report cose are among the mechanisms thought of the NDDG (2). These groups recog- glucose tolerance (IGT), in which plasma to produce tissue damage from chronic nized two major forms of diabetes, which glucose levels during an OGTT were hyperglycemia. Patients with diabetes they termed insulin-dependent diabetes above normal but below those defined as have an increased incidence of atheroscle- mellitus (IDDM, type 1 diabetes) and diabetes. rotic cardiovascular, peripheral vascular, non-insulin-dependent diabetes mellitus The NDDG/WHO classification high- and cerebrovascular disease. Hyperten- (NIDDM, type 2 diabetes), but their clas- lighted the heterogeneity of the diabetic sion, abnormalities of lipoprotein metab- sification system went on to include evi- syndrome. Such heterogeneity has had olism, and periodontal disease are often dence that diabetes mellitus was an important implications not only for treat- found in people with diabetes. The emo- etiologically and clinically heterogeneous ment of patients with diabetes but also for tional and social impact of diabetes and group of disorders that share hyperglyce- biomedical research. This previous classi- the demands of therapy may cause signif- mia in common. The overwhelming evi- fication indicated that the disorders icant psychosocial dysfunction in patients dence in favor of this heterogeneity grouped together under the term diabetes and their families. included the following: differ markedly in pathogenesis, natural The vast majority of cases of diabetes history, response to therapy, and preven- fall into two broad etiopathogenetic cate- 1. There are several distinct disorders, tion. In addition, different genetic and en- gories (discussed in greater detail below). most of them rare, in which glucose vironmental factors can result in forms of In one category (type 1 diabetes), the intolerance is a feature. diabetes that appear phenotypically simi- cause is an absolute deficiency of insulin 2. There are large differences in the lar but may have different etiologies. secretion. Individuals at increased risk of prevalence of the major forms of di- The classification published in 1979 developing this type of diabetes can often abetes among various racial or eth- was based on knowledge of diabetes at be identified by serological evidence of an nic groups worldwide. that time and represented some compro- autoimmune pathologic process occur- 3. Patients with glucose intolerance mises among different points of view. It ring in the pancreatic islets and by genetic present with great phenotypic vari- was based on a combination of clinical markers. In the other, much more preva- ation; take, for example, the differ- manifestations or treatment requirements lent category (type 2 diabetes), the cause ences between thin, ketosis-prone, (e.g., insulin-dependent, non-insulin-de- is a combination of resistance to insulin insulin-dependent diabetes and pendent) and pathogenesis (e.g., malnu- action and an inadequate compensatory obese, nonketotic, insulin-resistant trition-related, “other types,” gestational). insulin secretory response. In the latter diabetes. It was anticipated, however, that as knowl- category, a degree of hyperglycemia suffi- 4. Evidence from genetic, immunolog- edge of diabetes continued to develop, the cient to cause pathologic and functional ical, and clinical studies shows that classification would need revision. When changes in various target tissues, but in western countries, the forms of the classification was prepared, a defini- without clinical symptoms, may be diabetes that have their onset pri- tive etiology had not been established for present for a long period of time before marily in youth are distinct from any of the diabetes subclasses, except for diabetes is detected. During this asymp- those that have their onset
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