November 28, 2018
3 min read

Position statement identifies 4 distinct stages of type 2 diabetes

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A new complications-centric model identifies four distinct, evidence-based disease stages along the type 2 diabetes spectrum, emphasizing preventive care that begins at the first signs of insulin resistance, according to a joint position statement from the American Association of Clinical Endocrinologists and the American College of Endocrinology.

The model, labeled by the statement authors as “dysglycemia-based chronic disease,” or DBCD, includes recommendations for comprehensive risk-reduction strategies, including lifestyle changes and weight-loss therapy, to mitigate the progression to diabetes or limit the effect of established type 2 diabetes.

Jeffrey I. Mechanick

“We’re not getting rid of the term type 2 diabetes,” Jeffrey I. Mechanick, MD, FACP, FACE, FACN, ECNU, professor of medicine at the Icahn School of Medicine at Mount Sinai and a past president of AACE and the American College of Endocrinology (ACE), told Endocrine Today. “We’re viewing type 2 diabetes, cardiovascular disease and also prediabetes and insulin resistance, all as one framework, which we’re calling dysglycemia-based chronic disease.”

The available data, Mechanick said, suggest that many people with prediabetes “leapfrog” over type 2 diabetes without complications and progress to type 2 diabetes with CVD.

“So, really, it’s not just primary prevention, there is a secondary prevention component,” Mechanick said. “It brings into question a lot of the older models just following glycemic status, rather than following a comprehensive approach. The earlier you intervene, the better. Not only from a cost-savings standpoint, but also for the individual patient’s quality of life, welfare and overall health.”

The position statement identifies four stages of dysglycemia-based chronic disease:

  • stage 1: defined as DCBD insulin resistance;
  • stage 2: defined as DCBD prediabetes;
  • stage 3: defined as DCBD type 2 diabetes; and
  • stage 4: defined as DCBD vascular complications, including retinopathy, nephropathy or neuropathy, and/or type 2 diabetes-related microvascular events.

In examining the problem of prediabetes, Mechanick said, the position statement authors sought to defend the importance from a public health standpoint of diagnosing — and managing — prediabetes, which is often thought to be associated with low risk for complications.

“What we did was we reframed the problem,” Mechanick said in an interview. “We viewed prediabetes not in isolation, but rather in terms of a continuum, expanding the framework for type 2 diabetes.”

Type 2 diabetes, Mechanick said, is a disease that “migrates” from a state of normoglycemia with insulin resistance, to mild glycemic abnormalities typically diagnosed as prediabetes, to overt type 2 diabetes that can be asymptomatic, to more morbid forms of the disease with vascular complications. The statement notes that future researchers may eventually reclassify what the authors term “stage 2 DCBD prediabetes” from a “predisease” to a true disease state.

“When you view prediabetes in that kind of continuum, then it has a lot of importance,” Mechanick said. “The context for the importance is a preventive care model. Rather than waiting for a patient to evolve through this continuum, all the way to morbid forms of type 2 diabetes where tertiary prevention would be implemented, which is costly, wouldn’t it make sense to intervene earlier?”

The position statement features a DBCD care model table that outlines each stage, clinical context, pragmatic relevance and evidence base for each of the four stages. The care model follows a similar format for adiposity-based chronic disease, or ABCD, published by AACE and ACE in December 2016 and reported by Endocrine Today. In that position statement, the authors focused on the characteristic pathophysiologic effects of abnormal fat mass, distribution and function, rather than just increased body weight, and provided standardized protocols for weight loss and complications management. – by Regina Schaffer

For more information:

Jeffrey I. Mechanick, MD, can be reached at 1190 Fifth Ave., Guggenheim Pavilion 1-West, New York, NY 10029; email:

Disclosures: Mechanick reports he has received honoraria for lectures and program development from Abbott Nutrition. Please see the position statement for the other authors’ relevant financial disclosures.