Differences in A1C by race and ethnicity among patients with impaired glucose tolerance in the Diabetes Prevention Program

Association between hemoglobin glycation index and non-alcoholic fatty liver disease

OBJECTIVE

The hemoglobin glycation index (HGI) reflects biological variability in hemoglobin A1c. Even so, studies on the relationship between HGI and non-alcoholic fatty liver disease (NAFLD) are limited. Therefore, this study aimed to explore the relationship between HGI and NAFLD. In addition, the study also aimed to provide new methods to identify patients with a high risk for the development of NAFLD.

METHODS

This was a retrospective study based on physical examination data from Japan. Patients were divided into quartiles (Q1-Q4) according to their HGI level; the lowest quartile (Q1) was used as the reference group. Patents were also classified into two subgroups based on the presence or absence of NAFLD. Baseline characteristics between the groups were compared. Multivariate logistic regression analysis was used to investigate the association between the HGI and NAFLD. A mediation analysis examined the mediation relationship between HGI and NAFLD. Subgroup analyses were performed to the reliability of the results.

RESULTS

A total of 14280 patients were eligible for inclusion in this study; 2515 had NAFLD. Patients in the NAFLD group had higher levels of HGI than patients in the non-NAFLD group. Increases in HGI correlated with an increased risk of NAFLD. After adjusting for confounding factors, the multivariate logistic regression analysis revealed that HGI was positively related to the prevalence of NAFLD. In addition, mediation analysis showed that body mass index (BMI) partly mediated the indirect impact of HGI on NAFLD preference. Subgroup analyses were performed according to age, sex, smoking status, and waist circumference. Our results indicated that HGI significantly correlated with NAFLD in patients with one of the following factors: age ≤60 years, BMI >28 kg/m², female sex, a history of smoking, and abdominal obesity.

CONCLUSIONS

HGI was an independent risk factor for NAFLD, and BMI partly mediated the association between HGI and NAFLD.

Impact of haemoglobin variants on the use of haemoglobin A1c for the diagnosis and monitoring of diabetes: a contextualised review

HbA1c is the established test for monitoring glycaemic control in diabetes, and intervention trials studying the impact of treatment on glycaemic control and risk of complications focus predominantly on this parameter in terms of evaluating the glycaemic outcomes. It is also the main parameter used when targets for control are being individualised, and more recently, it has been used for the diagnosis of type 2 diabetes. For laboratories performing this test and clinicians utilising it in their decision-making process, a thorough understanding of factors that can impact on the accuracy, and appropriate interpretation of the test is essential. The changing demographic in the Irish population over the last two decades has brought this issue sharply into focus. It is therefore timely to review the utility, performance and interpretation of the HbA1c test to highlight factors impacting on the results, specifically the impact of haemoglobin variants, and the impact of these factors on its utilisation in clinical practice.

Pros and Cons of Current Diagnostic Tools for Risk-Based Screening of Prediabetes and Type 2 Diabetes in Children and Adolescents with Overweight or Obesity

It is still a matter of debate which is the most suitable diagnostic test for risk-based screening of prediabetes and type 2 diabetes (T2D) in children and adolescents with overweight or obesity. This review highlighted benefits and pitfalls of currently recommended screening tools (fasting plasma glucose [FPG], oral glucose tolerance test [OGTT], glycated hemoglobin A1c [HbA1c]). The greatest advantage of OGTT is the ability to detect people with impaired glucose tolerance, a subcategory at high risk of developing both T2D and cardiovascular disease. Important disadvantages are low reproducibility and inconvenience. FPG measurement is more practical, as it needs only one blood draw, although both OGTT and FPG require fasting. The reliability of HbA1c as a screening tool has been questioned, especially in children and adolescents, but its undeniable convenience can lead to increased adherence to screening. In contrast, it can be altered by several nonglycemic factors. Importantly, none of these tests have been validated in the pediatric population. Alternative tests have been recently proposed, including new OGTT-derived biomarkers and additional nonfasting glycemic markers. In conclusion, when choosing the most suitable test in clinical practice, advantages and disadvantages should be considered, as well as the possibility of performing different tests at once.

The hemoglobin glycation index predicts the risk of adverse cardiovascular events in coronary heart disease patients with type 2 diabetes mellitus

Background

Previous studies have shown that the hemoglobin glycation index (HGI) can be used as a predictor of diabetic complications. However, limited information is currently available to indicate the correlation between HGI and comorbidity of coronary heart disease (CHD) and diabetes. This study aimed to evaluate the potential of HGI to predict major adverse cardiovascular events (MACEs) in CHD patients with type 2 diabetes mellitus (T2DM) undergoing percutaneous coronary intervention (PCI).

Materials and methods

A total of 918 CHD patients with T2DM were enrolled in a 3-year retrospective cohort study, from December 2017 to December 2020 at the First Affiliated Hospital of Zhengzhou University. Data including fasting blood glucose (FPG/FBG) and glycated hemoglobin A1c (HbA1c) were collected. HGI was calculated as actual measured HbA1c minus predicted HbA1c. Three groups were further divided based on the levels of HGI, including low, medium, and high levels.

Result

Kaplan Meier analysis indicated that elevated HGI was strongly associated with the occurence of MACE (log-rank P < 0.001). Multivariate Cox regression analysis revealed that elevated HGI was an independent risk factor for incident MACE in CHD patients with T2DM [adjusted hazard ratio (HR): 1.473; 95% confidence interval (CI): 1.365-1.589, P < 0.001].

Conclusions

Hemoglobin glycation index is an independent predictor of MACE events in CHD patients with T2DM. High HGI indicates a higher risk of MACE occurrence.

Differences in Weight Loss by Race and Ethnicity in the PRIDE Trial: a Qualitative Analysis of Participant Perspectives

BACKGROUND

Many Diabetes Prevention Program (DPP) translation efforts have been less effective for underresourced populations. In the cluster-randomized Prediabetes Informed Decision and Education (PRIDE) trial, which evaluated a shared decision-making (SDM) intervention for diabetes prevention, Hispanic and non-Hispanic Black participants lost less weight than non-Hispanic White participants at 12-month follow-up.

OBJECTIVE

To explore perspectives about weight loss from PRIDE participants of different racial and ethnic groups.

PARTICIPANTS

Sample of participants with prediabetes who were randomized to the PRIDE intervention arm (n=24).

APPROACH

We conducted semi-structured interviews within three groups stratified by DPP participation and % weight loss at 12 months: (DPP+/WL+, enrolled in DPP and lost >5% weight; DPP+/WL-, enrolled in DPP and lost <3% weight; DPP-/WL-, did not enroll in DPP and lost <3% weight). Each group was further subdivided on race and ethnicity (non-Hispanic Black (NHB), non-Hispanic White (NHW), Hispanic). Interviews were conducted on Zoom and transcripts were coded and analyzed with Dedoose.

KEY RESULTS

Compared to NHW participants, Hispanic and NHB participants more often endorsed weight loss barriers of limited time to make lifestyle changes due to long work and commute hours, inconvenient DPP class locations and offerings, and limited disposable income for extra weight loss activities. Conversely, facilitators of weight loss regardless of race and ethnicity included retirement or having flexible work schedules; being able to identify convenient DPP classes; having a strong, positive support system; and purchasing supplementary resources to support lifestyle change (e.g., gym memberships, one-on-one activity classes).

CONCLUSIONS

We found that NHB and Hispanic SDM participants report certain barriers to weight loss more commonly than NHW participants, particularly barriers related to limited disposable income and/or time constraints. Our findings suggest that increased lifestyle change support and flexible program delivery options may be needed to ensure equity in DPP reach, participant engagement, and outcomes.

Cardiometabolic risk factors and cardiovascular disease predictions in older African and European Americans

Cardiometabolic (CMO) risks factors do not provide similar cardiovascular disease (CVD) predictions in young African (AA) and European Americans (EA) adults. Whether CMO risk predictions contribute to this disparity in older adults is unclear. We hypothesize that older AA CMO clustering pattern will be different from EA clustering patterns when determine with non-fasting lipid and lipoproteins. The participants were 106 older adults (66 AA and 40 EA) from a working/middle class neighborhood (income $46,364 – $80,904) in an urban North Carolina community. The participants were evaluated for CMO risk factors (total cholesterol, high- (HDL) and low-density lipoproteins (LDL), triglyceride (TG), glycosylated hemoglobin (HbA1c), systolic –SBP- and diastolic blood pressures -DBP), body mass index (BMI), body fat % (BF%) and timed up and go test (assessed falls risk and physical function). The AA participants were heavier, had higher BMI, BF%, and timed up and go values (p < 0.01). The data were evaluated for differences (t-test) and Pearson correlations for relationships. If data differ by p < 0.05 the data were significantly different. The AA had a 17.6 % higher HDL (64.7 vs 55.1 mg/dL – p < 0.05) and 7.6 % higher HbA1c (5.8 vs 5.4 % – p < 0.01) than EA. Higher HDL values in EA indicate lower CVD risks. The HDL paradox for AA (AA had higher HDL values, but greater CVD risks) was observed and the HbA1c difference may be misleading, as similar glucose values in AA tend to have higher HbA1c values. Lipid, lipoprotein, and blood pressure was not different between the races. AA had higher body composition and HDL values. Although future research on this topic with larger samples, dietary data and detailed descriptions of participations medications is warranted to validate findings from this study. These data suggest older AA and EA adults with similar environmental conditions have similar CMO risks when measures with none fasting blood samples. Since AA have a greater prevalence of CVD, these finding suggests that population specific CMO risk factor clustering may be more effective predictors of CVD for AA.

Effects of a Low-Carbohydrate Dietary Intervention on Hemoglobin A1c: A Randomized Clinical Trial

IMPORTANCE

Low-carbohydrate diets decrease hemoglobin A1c (HbA1c) among patients with type 2 diabetes at least as much as low-fat diets. However, evidence on the effects of low-carbohydrate diets on HbA1c among individuals with HbA1c in the range of prediabetes to diabetes not treated by diabetes medications is limited.

OBJECTIVE

To study the effect of a behavioral intervention promoting a low-carbohydrate diet compared with usual diet on 6-month changes in HbA1c among individuals with elevated untreated HbA1c.

DESIGN, SETTING, AND PARTICIPANTS

This 6-month randomized clinical trial with 2 parallel groups was conducted from September 2018 to June 2021 at an academic medical center in New Orleans, Louisiana. Laboratory analysts were blinded to assignment. Participants were aged 40 to 70 years with untreated HbA1c of 6.0% to 6.9% (42-52 mmol/mol). Data analysis was performed from November 2021 to September 2022.

INTERVENTIONS

Participants were randomized to a low-carbohydrate diet intervention (target <40 net grams of carbohydrates during the first 3 months; <60 net grams for months 3 to 6) or usual diet. The low-carbohydrate diet group received dietary counseling.

MAIN OUTCOMES AND MEASURES

Six-month change in HbA1c was the primary outcome. Outcomes were measured at 0, 3, and 6 months.

RESULTS

Of 2722 prescreened participants, 962 underwent screening, and 150 were enrolled (mean [SD] age, 58.9 [7.9] years; 108 women [72%]; 88 Black participants [59%]) and randomized to either the low-carbohydrate diet intervention (75 participants) or usual diet (75 participants) group. Six-month data were collected on 142 participants (95%). Mean (SD) HbA1c was 6.16% (0.30%) at baseline. Compared with the usual diet group, the low-carbohydrate diet intervention group had significantly greater 6-month reductions in HbA1c (net difference, -0.23%; 95% CI, -0.32% to -0.14%; P < .001), fasting plasma glucose (-10.3 mg/dL; 95% CI, -15.6 to -4.9 mg/dL; P < .001), and body weight (-5.9 kg; 95% CI, -7.4 to -4.4 kg; P < .001).

CONCLUSIONS AND RELEVANCE

In this randomized clinical trial, a low-carbohydrate dietary intervention led to improvements in glycemia in individuals with elevated HbA1c not taking glucose-lowering medication, but the study was unable to evaluate its effects independently of weight loss. This diet, if sustained, might be a useful dietary approach for preventing and treating type 2 diabetes, but more research is needed.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT03675360.

Effectiveness and Acceptability of a Nutrition Intervention Targeting Chinese Adult Immigrants With Type 2 Diabetes in Canada: A Study Using Mixed-Methods Analysis

OBJECTIVES

Although culturally tailored diabetes treatment is recommended, there is a lack of relevant dietary resources for the Chinese population in Canada. In this study, we assessed the feasibility and efficacy of a culturally tailored menu plan combined with nutrition education on clinical outcomes, diet quality and qualitative outcomes among Chinese immigrants with type 2 diabetes.

METHODS

Participants were 17 Chinese immigrants living with type 2 diabetes in Edmonton, Alberta, Canada. The design was a 12-week, single-arm intervention that included weekly nutrition education supported by a culturally tailored menu plan with mixed-methods evaluation. Diet quality, clinical and other outcomes were assessed pre- and postintervention. One-on-one interviews were conducted postintervention to identify program feasibility and obstacles to adherence.

RESULTS

Waist circumference (mean ± standard deviation: -2.0±2.5 cm; p=0.004), total cholesterol (-21.4±28.2 mg/dL; p=0.007) and low-density lipoprotein cholesterol (-18.4±24.6 mg/dL; p=0.007) were decreased when compared with baseline. No significant change was detected in glycated hemoglobin. Postintervention, the Healthy Eating Index (p=0.01) and diabetes knowledge score (p=0.009) also increased. Participants reported that the program was culturally acceptable, easily understood and feasible to implement. Participants indicated the program helped them to improve their diabetes knowledge, adhere to the dietary guidelines, choose low glycemic index food and read food labels when shopping.

CONCLUSIONS

A flexible, culturally tailored menu plan was a feasible and effective tool for improving diabetes knowledge, diet quality and metabolic outcomes among Chinese immigrants with type 2 diabetes.

Factors Associated With Discordant A1C-Estimated and Measured Average Glucose Among Hospitalized Patients With Diabetes

In this retrospective analysis, we explored the correlation between measured average glucose (mAG) and A1C-estimated average glucose (eAG) in hospitalized patients with diabetes and identified factors associated with discordant mAG and eAG at the transition from home to hospital. Having mAG lower than eAG was associated with Black race, other race, increasing length of stay, community hospital setting, surgery, fever, metformin use, certain inpatient diets, home antihyperglycemic treatment, and coded type 1 or type 2 diabetes. Having mAG higher than eAG was associated with certain discharge services (e.g., intensive care unit), higher BMI, hypertension, tachycardia, higher albumin, higher potassium, anemia, inpatient glucocorticoid use, and treatment with home insulin, secretagogues, and glucocorticoids. These factors should be considered when using patients' A1C as an indicator of outpatient glycemic control to determine the inpatient antihyperglycemic regimens.

High prevalence and significant ethnic differences in actionable HbA1C after gestational diabetes mellitus in women living in Norway

BACKGROUND

The type 2 diabetes risk after gestational diabetes mellitus (GDM) is twice as high in South Asian compared to European women. Current guidelines differ regarding which test to use as a screening-tool post-GDM. We aimed to identify ethnic differences in the prevalence rates and early predictors for actionable HbA_1c (defined as prediabetes and diabetes) short time after GDM.

METHODS

This cross-sectional study, enrolling South Asian and Nordic women 1-3 years after a diagnosis of GDM, was undertaken at three hospitals in Norway. We performed a clinical and laboratory evaluation including an oral glucose tolerance test (OGTT). Medical records were used to retrieve data during pregnancy. Prediabetes was classified with HbA_1c alone or combined with OGTT glucose measurements according to the WHO, WHO-IEC, and ADA criteria (fasting plasma glucose (FPG) 6.1-6.9 mmol/L, FPG 6.1-6.9 mmol/L and/or HbA_1c 42-47 mmol/mol (6.0-6.4%), and FPG 5.6-6.9 mmol/L and/or HbA_1c 39-47 mmol/mol (5.7-6.4%)). Ethnic differences in prevalence and predictors of glucose deterioration were assed by χ² (Pearson) tests and logistic regression models.

RESULTS

We included 163 South Asian and 108 Nordic women. Actionable HbA_1c levels were highly prevalent and more so among South Asian than Nordic women (WHO-IEC-HbA_1c: 25.8% vs. 6.5% (p ≤ 0.001), ADA-HbA_1c: 58.3% vs. 22.2% (p ≤ 0.001)). Although adding OGTT-data gave higher combined prevalence rates of prediabetes and diabetes (WHO: 65.6% vs. 47.2% (p ≤ 0.05), WHO-IEC: 70.6% vs. 47.2% (p ≤ 0.001), ADA: 87.8% vs. 65.7% (p ≤ 0.001)), the excess risk in the South Asian women was best captured by the HbA_1c. Important predictors for glucose deterioration after GDM were: South Asian ethnicity, GDM before the index pregnancy, use of glucose-lowering drugs in pregnancy, higher age, and higher in-pregnancy fasting glucose levels.

CONCLUSIONS

In women with GDM 1-3 year previously, we found high prevalence and significant ethnic differences in actionable ADA-HbA_1c levels, with South Asian ethnicity, GDM before the index pregnancy, and the use of glucose-lowering drugs in pregnancy as the most important risk factors. This study reinforces the importance of annual screening-preferably with HbA_1c measurements-to facilitate early intervention after GDM.

Glucometabolic State Transitions: The Jackson Heart Study

Background

Diabetes and prediabetes are common among African Americans (AA), but the frequency and predictors of transition between normal, impaired glucose metabolism, and diabetes are not well-described. The aim of this study was to examine glucometabolic transitions and their association with the development of type 2 diabetes (T2D).

Methods

AA participants of the Jackson Heart Study who attended baseline exam (2000-2004) and at least one of two subsequent exams (2005-2008 and 2009-2013, ~8 years) were classified according to glycemic status. Transitions were defined as progression (deterioration) or remission (improvement) of glycemic status. Multinomial logistic regression models with repeated measures were used to estimate the odds ratios (OR) for remission and progression with adjustment for demographic, anthropometric, behavioral, and biochemical factors.

Results

Among 3353 participants, (mean age 54.6±12.3 years), 43% were normoglycemic, 32% were prediabetes, and 25% had diabetes at baseline. For those with normal glucose at a visit, the probability at the next visit (~4years) of having prediabetes or diabetes was 38.5% and 1.8%, respectively. For those with prediabetes, the probability was 9.9% to improve to normal and 19.9% to progress to diabetes. Progression was associated with baseline BMI, diabetes status, triglycerides, family history of diabetes, and weight gain (OR 1.04 kg, 95% CI:1.03-1.06, P=<.0001). Remission was strongly associated with weight loss (OR .97 kg, 95%CI: .95-.98, P<.001).

Conclusions

In AAs, glucometabolic transitions were frequent and most involved deterioration. From a public health perspective additional emphasis should be placed on weight control to preserve glucometabolic status and prevent progression to T2D.

Newly diagnosed diabetes based on an oral glucose tolerance test predicts cardiovascular outcomes in patients with coronary artery disease: An observational study

Diabetes is prevalent in patients with coronary artery disease (CAD). Using the oral glucose tolerance test (OGTT), abnormal glucose regulation can be detected early in CAD patients without known diabetes. In the present study, we assessed the impact of abnormal glucose regulation on the long-term cardiovascular outcomes of patients with established CAD. Patients hospitalized for a scheduled angiography due to angina were enrolled in Taichung Veterans General Hospital. Fasting plasma glucose (FPG) and 2-hour postload glucose (2hPG) were assessed using the OGTT. Hemoglobin A1c (HbA1c) and other biochemical analyses were assessed using fasting blood samples. During a median follow-up period of 4.6 years, a composite of all-cause mortality, nonfatal myocardial infarction, and nonfatal stroke was recorded as the primary endpoint. In 682 enrolled patients who completed the follow-up, there were 16 myocardial infarction events, 12 stroke events, and 58 deaths as composite endpoints. According to FPG and 2hPG, patients with newly diagnosed diabetes had a 2-fold higher risk for the composite endpoint than those in the normal glucose group (hazard ratio [HR], 2.011; 95% confidence interval (CI), 1.101-3.673; P = .023); however, prediabetes was not significantly associated with the composite endpoint (HR, 1.452; 95% CI, 0.788-2.675; P = .232). On the other hand, patients with diabetes diagnosed by FPG and HbA1c did not have a significantly higher risk for the composite endpoint than those in the normal glucose group (HR, 1.321; 95% CI, 0.686-2.545; P = .405). A 2hPG ≥7.8 mmol/L was a significant predictor for the composite endpoint (odds ratio, 1.743; 95% CI, 1.060-2.863; P = .028) after adjusting for age, sex, and estimated glomerular filtration rate. Diabetes, but not prediabetes, detected via OGTT is associated with a significantly increased risk for the composite endpoint in patients with established CAD. The 2hPG provided a greater predictive power for the composite endpoint than fasting glucose and HbA1c.

Association between haemoglobin A1c and all-cause and cause-specific mortality in middle-aged and older Koreans: a prospective cohort study

Background

This study aimed to examine associations between haemoglobin A1c (HbA1c) levels over time and all-cause and cause-specific mortality in middle-aged and older Koreans.

Methods

Using 16 years of follow-up data from the Korean Genome and Epidemiology Study, we analysed 9294 individuals aged 40–69 years with no history of cardiovascular disease (CVD) or cancer. Participants were divided into a known diabetes group and five groups categorized by HbA1c levels (< 5.0%, 5.0–5.4%, 5.5–5.9%, 6.0–6.4%, and ≥ 6.5%). Hazard ratios (HRs) for all-cause and cause-specific mortality associated with HbA1c levels were calculated using a conventional and a time-dependent Cox proportional hazards model. Restricted cubic spline models were fitted to investigate the relationship between continuous HbA1c levels and mortality among people without known diabetes. Subgroup analyses were performed for age, sex, smoking, hypertension, liver diseases, and red blood cell counts.

Results

During a median follow-up period of 15.7 years, there were 944 deaths, including 185 deaths from CVD, 359 from cancer, and 125 from all external causes. Compared with participants with HbA1c levels of 5.5–5.9%, multivariate-adjusted HRs and 95% confidence intervals for all-cause death of participants with levels < 5.0%, 5.0–5.4%, 6.0–6.4%, and ≥ 6.5% and participants with known diabetes were 1.84 (1.35–2.51), 1.13 (0.95–1.34), 1.30 (1.04–1.62), 1.37 (0.97–1.93), and 2.03 (1.70–2.44), respectively. The risk of cancer mortality was significantly increased in HbA1c < 5.0% (HR, 2.21; 95% CI 1.42–3.44) and known diabetes (HR, 1.60; 95% CI 1.18–2.15). When we performed diverse subgroup analyses, low HbA1c levels at baseline were strongly associated with mortality in participants with liver diseases.

Conclusions

We found U-shaped associations between HbA1c levels at baseline and over time and all-cause mortality in middle-aged and older Koreans. Additionally, the risk of cancer mortality increased both in low and high HbA1c groups, but CVD mortality increased only in high HbA1c group. In particular, people with liver diseases and low HbA1c levels had a high risk of all-cause mortality. Therefore, more careful management of these groups is suggested to identify any deteriorating health conditions.

Graphical abstract

Supplementary Information

The online version contains supplementary material available at 10.1186/s12986-022-00682-4.

Potential misclassification of diabetes and prediabetes in the U.S.: Mismatched HbA1c and glucose in NHANES 2005-2016

AIMS

To assess the prevalence and clinical implications of "mismatches" between HbA1c and glucose levels in the United States across the life course.

METHODS

Participants ages 12-79 years from U.S. National Health and Nutrition Examination Survey (NHANES) 2005-2016 without known diagnosis of diabetes and who had a 75 g oral glucose tolerance test were included. Previously undiagnosed diabetes (DM), prediabetes, and normal glucose metabolism (NGM) were defined using American Diabetes Association cut-points. Mismatches were defined by the hemoglobin glycation index (HGI).

RESULTS

In 10,361 participants, 5% and 41% had diabetes and prediabetes, respectively, by fasting or 2-hour glucose criteria. By HbA1c criteria, the high HGI tertile consisted of mostly abnormal classification (3% DM, 52% prediabetes) and the low HGI tertile contained mostly normal classification (78% NGM). Across all ages, 15% (weighted: 30 million individuals) had clinically significant mismatches of HGI magnitude ≥+0.5% (i.e., high mismatch) or ≤-0.5% (low mismatch). Mismatch was most common in older adults and non-Hispanic Black participants.

CONCLUSIONS

Mismatches of clinically significant magnitude could lead to HbA1c-related misdiagnosis or inappropriate management in up to 30 million Americans. Older adults, non-Hispanic Black individuals, and others with high mismatches may benefit from complementing HbA1c with additional diagnostic and management strategies.

Hyperglycemia First Detected in Pregnancy in South Africa: Facts, Gaps, and Opportunities

This review contextualizes hyperglycemia in pregnancy from a South-African perspective. It aims to create awareness of the importance of hyperglycemia in pregnancy in low-middle-income countries. We address unanswered questions to guide future research on sub-Saharan African women with hyperglycemia first detected in pregnancy (HFDP). South African women of childbearing age have the highest prevalence of obesity in sub-Saharan Africa. They are predisposed to Type 2 diabetes (T2DM), the leading cause of death in South African women. T2DM remains undiagnosed in many African countries, with two-thirds of people living with diabetes unaware. With the South African health policy's increased focus on improving antenatal care, women often gain access to screening for non-communicable diseases for the first time in pregnancy. While screening practices and diagnostic criteria for gestational diabetes mellitus (GDM) differ amongst geographical areas in South Africa (SA), hyperglycemia of varying degrees is often first detected in pregnancy. This is often erroneously ascribed to GDM, irrespective of the degree of hyperglycemia and not overt diabetes. T2DM and GDM convey a graded increased risk for the mother and fetus during and after pregnancy, with cardiometabolic risk accumulating across the lifespan. Resource limitations and high patient burden have hampered the opportunity to implement accessible preventative care in young women at increased risk of developing T2DM in the broader public health system in SA. All women with HFDP, including those with true GDM, should be followed and undergo glucose assessment postpartum. In SA, studies conducted early postpartum have noted persistent hyperglycemia in a third of women after GDM. Interpregnancy care is advantageous and may attain a favourable metabolic legacy in these young women, but the yield of return following delivery is suboptimal. We review the current best evidence regarding HFDP and contextualize the applicability in SA and other African or low-middle-income countries. The review identifies gaps and shares pragmatic solutions regarding clinical factors that may improve awareness, identification, diagnosis, and management of women with HFDP.

Association of Hemoglobin Glycation Index With Contrast-Induced Acute Kidney Injury in Patients Undergoing Coronary Angiography: A Retrospective Study

Background: The hemoglobin glycation index (HGI) quantifies interindividual variation in glycation and is positively associated with cardiovascular diseases. However, the association between HGI and contrast-induced acute kidney injury (CI-AKI) remains unclear. Therefore, this study aimed to assess the association of HGI with CI-AKI.

Methods: In this observational study, a total of 3,142 patients undergoing coronary angiography (CAG) or percutaneous coronary intervention (PCI) were included. The HGI was calculated as the difference between the measured glycated hemoglobin (HbA1c) and predicted HbA1c. CI-AKI was defined as an increase of either 25% or 0.5 mg/dl (44.2 μmol/L) in the serum creatinine (SCr) level within 72 h following the exposure to contrast medium. Piecewise linear regression analysis was conducted to testify the association of HGI with the proportion of SCr elevation. Modified Poisson’s regression analysis was performed to determine the association between HGI and CI-AKI. Exploratory analysis was also performed according to the stratification of HbA1c levels.

Results: Among 3,142 patients, the average age was 66.9 years and 483 of them (15.4%) suffered CI-AKI. Piecewise linear regression analysis demonstrated the linear association of HGI with the proportion of SCr elevation on both positive and negative sides of HGI [HGI <0: β = −9.537, 95% CI (−12.057 to −7.017), p < 0.001; HGI ≥0: β = 1.655, 95% CI (0.125 to 3.186), p = 0.034]. Modified Poisson’s regression analysis showed that the higher absolute value of HGI was strongly associated with higher incidence of CI-AKI [(<−1.0 vs. −0.2 to 0.2): aRR = 1.897, 95% CI [1.467 to 2.452], p < 0.001 (≥1.0 vs. −0.2 to 0.2): aRR = 1.545, 95% CI (1.171 to 2.037), p = 0.002]. Furthermore, the results in exploratory analysis showed that such association still remained irrespective of HbA1c levels.

Conclusion: The higher absolute value of HGI was strongly associated with higher incidence of CI-AKI in patients undergoing CAG and PCI.

What is the optimal anthropometric index/ratio associated with two key measures of cardio-metabolic risk associated with hypertension and diabetes?

BACKGROUND

Few studies have investigated the optimal anthropometric index associated with potential cardio-metabolic risk. Using direct measures of standing height, body mass, and waist circumference, we sought to identify the optimal index for detecting cardio-metabolic risk associated with diabetes and hypertension in a nationally representative sample of US adults.

METHODS

Complete (non-missing) cross-sectional data from 8375 US adults aged 18-80+ years were obtained from the 2015-16 and 2017-March 2020 (pre-pandemic) cycles of the National Health and Nutrition Examination Survey. The cardio-metabolic risk was identified using blood pressure and glycohemoglobin (A1c). Allometric models were used to identify the optimal anthropometric indices associated with cardio-metabolic risk. Receiver operating characteristics curves were used to verify the discriminatory ability of the identified index in comparison with other anthropometric measures.

RESULTS

The optimal anthropometric index associated with cardio-metabolic risk was waist circumference divided by body mass to the power of 0.333 (WC/M^0.333). The ability for this new index to discriminate those with diabetes (area under the ROC curve: 0.73 [95%CI: 0.71-0.74]) and hypertension (area under the curve: 0.70 [95%CI: 0.69-0.72]) was superior to all other anthropometric measure/indices investigated in this study (body mass index, waist circumference, waist-to-height ratio, and waist/height^0.5).

CONCLUSIONS

We identified WC/M^0.333 as the optimal anthropometric index for identifying US adults with hypertension and diabetes. Instead of using body mass index (kg/m²), we recommend using WC/M^0.333 in clinical and public health practice to better identify US adults at potential cardio-metabolic risk associated with hypertension and diabetes.

Novel use of menstrual blood for monitoring glycaemic control in patients with diabetes: a proof-of-concept study

BACKGROUND

Glycated haemoglobin (HbA1c) is the diagnostic and prognostic standard for clinical management of diabetes mellitus (DM). Unfortunately, patient adherence to guidelines for routine testing can be poor and there are significant gender-based disparities in DM management and outcomes. Recent evidence suggests that menstrual blood may be comparable to systemic blood for monitoring of common biomarkers. The objective of the present study was to assess the concordance of HbA1c levels between menstrual and systemic blood in healthy women and women with diabetes of reproductive age.

METHODS

In this prospective, observational cohort study, we enrolled healthy and diabetic (type 1 and type 2 DM) reproductive-age women (aged ≥18 and ≤45 years). Menstrual blood and venous systemic blood specimens were simultaneously obtained at time of menstruation, and analysed for HbA1c levels. Participants self-collected menstrual blood using a QPad, a novel, modified menstrual pad with an embedded dried blood spot strip.

RESULTS

Among 172 participants, 57.6% were healthy and 42.4% had a diagnosis of either type 1 or type 2 DM. There were no significant differences in mean HbA1c values in menstrual and systemic blood across the overall cohort or within the diabetic subgroup. Furthermore, HbA1c levels between blood sources were robustly correlated and demonstrated a significant linear relationship.

CONCLUSIONS

There is a strong concordance in HbA1c levels between menstrual and systemic blood. Empowered by self-collection technologies, these findings suggest that menstrual blood may serve as a reliable, non-invasive and potentially cost-effective alternative to serum for HbA1c monitoring among reproductive-age women with DM.

Risk Adjustment in Home and Community Based Services Outcome Measurement

The purpose of this study was to review and evaluate existing research that used risk adjusters in disability research. Risk adjustment controls for individual characteristics of persons when examining outcomes. We have conducted a systematic review and an evaluation of existing studies that included risk adjusters for outcomes of people with disabilities receiving services (home or community based). The process included coding each study according to the type(s) of risk adjusters employed and their relation to the specific population and outcomes within a framework. Panels were utilized to prioritize the risk adjusters. Findings indicate that four risk adjusters can be tentatively recommended as potential candidate risk adjusters: chronic conditions, functional disability, mental health status, and cognitive functioning. Holistic Health and Functioning far outweighed other outcomes studied to date. Further, there is a need for testing recommended risk adjusters across multiple outcomes and different populations of people with disabilities.

The Potential Diagnostic and Predictive Role of HbA1c in Diabetic, Septic Patients: A Retrospective Single-Center Study

Background

As diabetes mellitus is a major risk factor of sepsis, we aimed to evaluate the possible effects of diabetes mellitus and poor glycemic control on the diagnosis of sepsis.

Methods

In our retrospective study, we included diabetic, septic patients-in whom the diagnosis of sepsis was based on the systemic inflammatory response syndrome (SIRS) criteria (n = 112, SIRS group)-who had HbA1c levels measured either in the previous 30 days (n = 39, SIRS 30 d subgroup) or within 24 hours after their emergency department admission (n = 73, SIRS 24 h subgroup). We later selected those patients from the SIRS group, whose sequential organ failure assessment (SOFA) score was ≥2 (n = 55, SOFA group), and these patients were also divided based on the time of HbA1c measurement (n = 21, SOFA 30 d subgroup and n = 34, SOFA 24 h subgroup). We analyzed the relationship between laboratory parameters, length of hospital stay, and HbA1c.

Results

We found a significant positive correlation between glucose and HbA1c (p < 0.001, p < 0.001, respectively), significant negative correlations between white blood cell count (WBC) and glucose (p=0.01, p=0.02, respectively), WBC and HbA1c levels (p=0.001, p=0.02, respectively) in the SIRS 24 h and SOFA 24 h subgroups. Furthermore, there was a significant positive correlation between length of hospital stay and HbA1c in the SOFA 24 h subgroup (p=0.01). No significant correlations were found in the SIRS 30 d and SOFA 30 d subgroups.

Conclusion

Based on our results, normal WBC with elevated HbA1c might be considered a positive SIRS criterium in diabetic, SIRS 24 h patients. Besides this potential diagnostic role, HbA1c might also be an additional prognostic biomarker in diabetic, SOFA 24 h patients.

Correlation between the Variability of Glycosylated Hemoglobin and Cardiovascular Risk in New-Onset T2DM Patients

Objective

To investigate the relationship between glycosylated hemoglobin variant index and cardiovascular disease in patients with type 2 diabetes.

Methods

A total of 120 patients with type 2 diabetes who were admitted to the Department of Endocrinology in Chun'an Branch of Zhejiang Provincial People's Hospital from January 2014 to January 2017 were enrolled. The clinical data, fasting blood glucose, and glycosylated hemoglobin levels of the patients were collected, and HGI was obtained by calculating the FPG level into the formula. Follow-up for three years was performed to observe the cardiovascular disease (including coronary heart disease and ischemic stroke) in patients. The occurrence of CVD was analyzed in patients with different levels of HGI. Multivariate logistics regression analysis was used to analyze the risk factors of CVD in patients with T2DM.

Results

After three years of follow-up, 8 cases of 120 patients were lost to follow-up. In the end, 24 cases of CVD occurred in 112 patients, with an incidence rate of 21.43%. Comparing the clinical data of CVD patients and non-CVD patients, it was found that the proportion of age, FPG, HbA1c, HGI, and insulin control in the CVD group was higher than that of the non-CVD group, and the difference was statistically significant (P < 0.05). After grouping according to different HGI levels, it was found that with the increase of HGI level, the proportion of HbA1c, FPG, TC, CVD, and insulin use showed an upward trend (P < 0.05). Multivariate logistic regression analysis showed that high HGI level (OR = 4.660), older age (OR = 4.815), and higher FPG level (OR = 1.717) are independent risk factors that affect T2DM patients with cardiovascular disease (P < 0.05).

Conclusion

High HGI is independently associated with CVD events in patients with type 2 diabetes. HGI testing is helpful for clinical assessment of personalized assessment and prediction of cardiovascular risk in patients with diabetes.

Assessment of Glycemic Control at St. Luke's Free Medical Clinic: Retrospective Chart Review

Background

A free clinic is a health care delivery model that provides primary care and pharmaceutical services exclusively to uninsured patients. With a multidisciplinary volunteer clinical staff, which includes physicians, social workers, dieticians, and osteopathic medical students, St. Luke’s Free Medical Clinic (SLFMC) cares for over 1700 patients annually in Spartanburg, South Carolina.

Objective

This study aims to measure the change, over time, in patient hemoglobin A_1c measurements at the SLFMC to quantify the success of the clinic’s diabetes treatment program.

Methods

A prospective-retrospective chart review of patients (n=140) enrolled at the SLFMC between January 1, 2018, and January 1, 2021, was performed. Patients were stratified as having controlled (hemoglobin A_1c<7.0, n=53) or uncontrolled (hemoglobin A_1c≥7.0, n=87) diabetes relative to a therapeutic hemoglobin A_1c target of 7.0, which is recommended by the American Diabetes Association. For both controlled and uncontrolled groups, baseline hemoglobin A_1c values were compared to subsequent readings using a Wilcoxon matched-pairs signed rank test. Results from the SLFMC population were compared to the published literature on hemoglobin A_1c from other free clinics.

Results

Patients with uncontrolled diabetes experienced significant reductions in median hemoglobin A_1c at both 6 months (P=.006) and 1 year (P=.002) from baseline. Patients with controlled diabetes showed no significant changes. Black and Hispanic patients with uncontrolled diabetes experienced a 1.0% mean improvement in hemoglobin A_1c over the study window. The SLFMC’s wholly uninsured patient population showed a population rate of controlled diabetes (42%), which was similar to recent nationwide averages for adults with diabetes (51% to 56%), as reported by the National Health and Nutrition Examination Survey. The clinic’s Hispanic population (n=47) showed the greatest average improvement in hemoglobin A_1c of any ethnic group from baseline. Additionally, 61% of the SLFMC’s Black population (n=33) achieved a hemoglobin A_1c of <7.0 by the end of the study window, which surpassed the nationwide averages for glycemic control.

Conclusions

We present free clinic hemoglobin A_1c outcomes obtained through a retrospective chart review. Uninsured patients treated for diabetes at the SLFMC show a reduction in hemoglobin A_1c, which is comparable to nationwide standards, although average hemoglobin A_1c levels in this study were higher than nationwide averages. Black and Hispanic patients with uncontrolled diabetes showed a mean 1% improvement in hemoglobin A_1c levels. These results represent some of the first in the literature emerging from a free clinic that is not affiliated with a major medical school.

The relationship between HbA1C levels and clinical outcome in patients with traumatic train injury: A prospective study

Introduction/Aim: Recently, hemoglobin A1c (HbA1c) has been suggested as a predictor of mortality and poor clinical outcome in patients with trauma. The aim of this study was to evaluate the relationship between HbA1c values and clinical outcome in patients with traumatic brain injury (TBI). Methods: In a cross-sectional study, a total of 133 TBI patients referred to the emergency department of Imam Khomeini Hospital in Sari, Mazandaran, Iran were evaluated. After transferring the patients to the neurosurgery ward, their HbA1c, fasting blood glucose (FBG) and postprandial glucose (PPG) were measured. Also, patients' Glasgow Coma Scale (GCS) score was recorded at the time of admission, 24 hours after admission and at the time of discharge from the hospital. Results: The mean of GCS score of patients at the time of admission, 24 hours after admission, and at the time of discharge were 9.02 (2.09), 10.07 (2.16), and 12.98 (1.82), respectively. The mean GCS score of patients with HbA1c < 5.7% was significantly lower than of patients with HbA1c = 5.7 - 6.5% at the time of admission (p < 0.05). At 24 hours after admission, the mean GCS score of patients with HbA1c < 5.7% was significantly lower than in other groups (p < 0.05). However, at the time of discharge, the mean GCS score of patients with HbA1c > 6.5% was significantly lower than in patients with HbA1c = 5.7 - 6.5% (p < 0.05). Over time, the mean of GCS scores in all patients significantly increased (p < 0.001). Conclusion: According to the results of this study it seems that HbA1c measurements cannot provide clear information about the clinical outcome of patients with TBI.

American Diabetes Association Professional Practice Committee. 2. Classification and Diagnosis of Diabetes: Standards of Medical Care in Diabetes-2022

The American Diabetes Association (ADA) "Standards of Medical Care in Diabetes" includes the ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, a multidisciplinary expert committee (https://doi.org/10.2337/dc22-SPPC), are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations, please refer to the Standards of Care Introduction (https://doi.org/10.2337/dc22-SINT). Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.

Prediabetes Burden in Nigeria: A Systematic Review and Meta-Analysis

Prediabetes is a borderline glycemic status associated with both higher incidence of cardiovascular disease as well as higher risk of progression to diabetes. There is a rising burden of diabetes and prediabetes globally. This study aims to estimate the burden of prediabetes in Nigeria. Online searches of Google Scholar, PubMed, and Scopus were conducted and studies were selected based on predefined criteria. A total of 15 studies consisting of 14,206 individuals conducted between 2000 and 2019 were included in the meta-analysis with studies using American Diabetic Association (ADA) and World Health Organization (WHO) criteria pooled separately. The pooled prevalence of prediabetes in Nigeria was found to be 13.2% (95% CI: 5.6-23.2%, I2 = 98.4%) using the ADA criteria and 10.4% (95% CI: 4.3-18.9%, I2 = 99.2%) using the WHO criteria. According to the latest data by the United Nations, this translates to an estimated 15.8 and 12.5 million adult prediabetic individuals in Nigeria using the ADA and WHO criteria, respectively. The prevalence rates for women and men were similar at 12.1% (95% CI: 5-21%). The pooled prevalence rates for urban and rural settlements were also similar at 9% (95% CI: 2-22%). In conclusion, the prevalence of prediabetes in Nigeria was almost two times higher than the 7.3% estimate by the International Diabetes Federation in 2003. The similar rates of prediabetes between men and women and between urban and rural settlements points toward narrowing of cardiovascular risk burden between the two sexes and the two settlements. This represents higher future cardiovascular disease burden in the country further pressurizing the overstretched healthcare system.

Definition and Classification of Diabetes and Prediabetes and Emerging Data on Phenotypes

Diabetes diagnosis has important implications for individuals. Diagnostic criteria for fasting and 2-hour plasma glucose and HbA1c are universally agreed. Intermediate hyperglycemia/prediabetes is a risk factor for diabetes and cardiovascular disease. Because risk is a continuum, determining cut-point is problematic and reflected in significant differences in recommended fasting glucose and HbA1c criteria. Many types of diabetes are recognized. Diabetes classification systems are limited by a lack of understanding of etiopathogenetic pathways leading to diminished β-cell function. The World Health Organization classification system is designed to assist clinical care decisions. Newly recognized phenotypic clusters of diabetes might inform future classification systems.

Implementation of a community-based low-calorie dietary intervention for the induction of type-2 diabetes and pre-diabetes remission: a feasibility study utilising a type 2 hybrid design

Objectives

The aims of this feasibility study were to (1) examine the implementation of a community-based health advocate (CHA) training programme to develop the clinical skills needed to support a diabetes remission protocol based on a low-calorie diet (LCD) and (2) investigate if participant weight loss can be achieved and diabetes remission induced under these conditions.

Methods

This tripartite study followed a type 2 implementation-effectiveness design. Three faith-based organisations (FBOs) were purposively selected as study sites. Implementation outcomes were guided by the Consolidated Framework for Implementation Research. During the pre-implementation phase, site ‘readiness’ to facilitate the intervention was determined from a site visit and an interview with the FBOs’ leadership. During the implementation phase, congregants could volunteer for the 10-week CHA training which included practical exercises in weight, glucose and blood pressure (BP) measurement, and a summative practical assessment. Acceptability and implementation effectiveness were assessed via survey. During the intervention phase, other congregants and community members with T2DM or pre-diabetes and overweight were invited to participate in the 12-week LCD. Anti-diabetic medication was discontinued on day 1 of the intervention. Clinical effectiveness was determined from the change in weight, fasting blood glucose (FBG) and BP which were monitored weekly at the FBO by the CHA. HbA1C was performed at weeks 1 and 12.

Results

The FBOs were found to be ready as determined by their adequate resources and engagement in health-related matters. Twenty-nine CHAs completed the training; all attained a passing grade at ≥1 clinical station, indicating implementation effectiveness. CHA feedback indicated that the programme structure was acceptable and provided sufficient access to intervention-related material. Thirty-one persons participated in the LCD (11 T2DM:20 pre-diabetes). Mean (95%CI) weight loss was 6.0 kg (3.7 to 8.2), 7.9 kg in males vs 5.7 kg in females; A1C (%) decreased from 6.6 to 6.1, with a greater reduction in those with T2DM when compared to pre-diabetes. FBG decreased from 6.4 to 6.0mmol/L. T2DM remission rates were 60% and 90% by A1C<6.5% and FBG<7mmol/L respectively. Pre-diabetes remission was 18% and 40% by A1C<5.7% and FBG<5.6 respectively.

Conclusion

Implementation of a community-based diabetes remission protocol is both feasible and clinically effective. Its sustainability is to be determined. Adaptability to other disorders or other settings should be investigated.

Trial registration

NCT03536377 registered on 24 May 2018.

Who should return for an oral glucose tolerance test? A proposed clinical pathway based on retrospective analysis of 332 children

OBJECTIVES

Fasting plasma glucose or oral glucose tolerance test (OGTT) is the traditional diagnostic tool for type 2 diabetes (T2DM). However, fasting is required and implementation in all overweight/obese subjects is not practical. This study aimed to formulate a clinical pathway to stratify subjects according to their risk of abnormal OGTT.

METHODS

This retrospective study included patients with overweight or obesity who had undergone OGTT in a tertiary paediatric unit from 2012 to 2018. The optimal haemoglobin A1c (HbA1c) cutoff that predicts abnormal OGTT was evaluated. Other non-fasting parameters, in combination with this HbA1c cutoff, were also explored as predictors of abnormal OGTT.

RESULTS

Three hundred and thirty-two patients (boys: 54.2%, Chinese: 97.3%) were included for analysis, of which, 272 (81.9%) patients had normal OGTT while 60 (18.0%) patients had abnormal OGTT (prediabetes or T2DM). Optimal HbA1c predicting abnormal OGTT was 5.5% (AUC 0.71; sensitivity of 66.7% and specificity of 71%). When HbA1c≥5.5% was combined with positive family history and abnormal alanine transaminase (ALT) level, the positive predictive value for abnormal OGTT was increased from 33.6 to 61.6%.

CONCLUSIONS

HbA1c, family history of T2DM and ALT level could be used to derive a clinical pathway to stratify children who have high risk of abnormal OGTT.

Emerging Diabetic Novel Biomarkers of the 21st Century

Diabetes is a growing epidemic with estimated prevalence of infected to reach ~592 million by the year 2035. An effective way to approach is to detect the disease at a very early stage to reduce the complications and improve lifestyle management. Although several traditional biomarkers including glucated hemoglobin, glucated albumin, fructosamine, and 1,5-anhydroglucitol have helped in ease of diagnosis, there is lack of sensitivity and specificity and are inaccurate in certain clinical settings. Thus, search for new and effective biomarkers is a continuous process with an aim of accurate and timely diagnosis. Several novel biomarkers have surged in the present century that are helpful in timely detection of the disease condition. Although it is accepted that a single biomarker will have its inherent limitations, combining several markers will help to identify individuals at high risk of developing prediabetes and eventually its progression to frank diabetes. This review describes the novel biomarkers of the 21st century, both in type 1 and type 2 diabetes mellitus, and their present potential for assessing risk stratification due to insulin resistance that will pave the way for improved clinical outcome.

A Review on Research Progress in the Application of Glycosylated Hemoglobin and Glycated Albumin in the Screening and Monitoring of Gestational Diabetes

Glycosylated hemoglobin (HbA1C) and glycated albumin (GA) can be used for blood glucose management of a person with diabetes as a result of their convenience and stability. However, there is no corresponding standard for the application of glycosylated hemoglobin and glycosylated albumin in gestational diabetes mellitus (GDM). In this review, we summarize the published research and discuss three aspects of the significance of HBA1C and GA in GDM patients: screening of gestational diabetes mellitus, blood glucose monitoring and the relationship with pregnancy outcome. At present, studies suggest that HBA1C can be used as a screening indicator for pregnant women, but it cannot completely replace OGTT. HbA1C and GA can be used for blood glucose management in patients with GDM to reduce the incidence of GDM complications. However, the application of HBA1C and GA in GDM still needs more research and clinical practice support.

Evaluation of Hemoglobin A1c before and after initiation of continuous glucose monitoring in children with type 1 diabetes mellitus

OBJECTIVES

The development of continuous glucose monitoring (CGM) systems has allowed for identification of blood sugar variations and trends in real-time that is not feasible with conventional self-monitoring of blood glucose. However, there is inconsistent data to show that the use of CGM leads to better glycemic control as measured by Hemoglobin A1c (HbA1c) in pediatric patients with type 1 diabetes mellitus. Our study aimed to compare the average HbA1c level in the 1-2 years prior to starting a CGM to the average HbA1c level in the 1-2 years immediately following CGM initiation in a sample of 1-20 year olds with type 1 diabetes mellitus.

METHODS

Participants were 90 youth (ages 1-20) followed for type 1 diabetes care at our institution who used a CGM for at least a 6 month time period. We performed a retrospective chart review to obtain up to four HbA1c values pre and post-CGM initiation each. We evaluated pre- and post-CGM initiation changes in mean HbA1c via dependent samples t-tests using IBM SPSS 24.0.

RESULTS

The mean HbA1c was 8.7% pre-CGM and decreased to 8.27% 9-12 months after CGM initiation in the overall sample. A statistically significant decrease in HbA1c was seen in patients who used multiple daily injections (p=0.02), those with a pre-CGM HbA1c greater than 9% (p=0.01), and those with a diabetes duration of 5-10 years (p=0.02).

CONCLUSION

CGM use was associated with a decrease in HbA1c over time which was statistically significant in some subgroups.

Knowledge of Hemoglobin A1c and Glycemic Control in an Urban Population

AIM

Our study aims to assess the knowledge of hemoglobin A1c (HbA1c) and glycemic control in patients with diabetes mellitus (DM) at an urban academic institution.

METHODS

This was a retrospective cross-sectional study that included a survey of 100 adult patients with DM. Our patient cohort was divided into those with recent HbA1c < 8.0% and those with HbA1c ≥ 8.0% for subgroup analysis.

RESULTS

The majority (71%) of patients correctly defined HbA1c and half were aware of their HbA1c target, but they were unable to correlate the correct average blood glucose for an HbA1c level of 7%. Worse control, defined as an HbA1c level of ≥ 8%, was associated with co-morbid disease, but was not associated with understanding HbA1c definition, target or socioeconomic disparities. Perceived glycemic control was congruent with the actual control in 46% of our patients. Ninety percent of those with HbA1c ≥ 8% perceived their control to be better than it actually was, and 97% of those with HbA1c < 8% perceived their control worse than it actually was (P < 0.00001).

CONCLUSION

Although most patients knew the definition of HbA1c, they were unable to correlate HbA1c with average blood sugar. There remain opportunities to increase education for this vulnerable population with co-morbid disease on the use of the HbA1c disease marker as an education tool.

The utility of diagnostic tests in the detection and prediction of glucose intolerance in the early and late postpartum period in women after gestational diabetes: a longitudinal cohort study

BACKGROUND

Due to diverging international recommendations, the unclear role of HbA1c and the lack of longitudinal data, we investigated the accuracy of diagnostic tests in the early and late postpartum in women with gestational diabetes (GDM) especially to predict future glucose-intolerance.

METHODS

This longitudinal cohort included 967 women with GDM from 2011 to 2020. A 75-g oGTT and HbA1c were performed at 4-12 weeks (early) postpartum. FPG and HbA1c were measured at 1 and 3-year (late) postpartum. ADA criteria were used as gold standards. At all time-points (4-12 weeks, 1-year and 3-year postpartum) women with diabetes and prediabetes were grouped together and referred to as glucose-intolerant, because at most 3% of the entire cohort population had diabetes at any time-point.

RESULTS

The prevalence of glucose-intolerance in the early postpartum was higher using FPG and HbA1c (27.5%) than oGTT criteria (18.2%). Only 48-80% of women diagnosed with glucose-intolerance in the early postpartum actually remained intolerant. This was especially low when FPG or oGTT were combined with HbA1c (1-year: ≤ 62% and 3-years: ≤ 50%). Regardless of the test used, 1/3 of women with initially normal glucose-tolerance became glucose-intolerant in the late postpartum. HbA1c was unrelated to iron status/intake, remained stable throughout, but poorly predicted future glucose-intolerance. In the longitudinal analyses, all diagnostic tests in the early postpartum showed acceptable specificities (74-96%) but poor sensitivities (all < 38%) to predict glucose-intolerance after only 10-months. At 1-year postpartum however, the combination of FPG and HbA1c could best predict glucose-intolerance 2-years later.

CONCLUSIONS

Combining FPG with HbA1c at 1-year postpartum represents a reliable choice to predict future glucose-intolerance. Given the poor prediction of tests including oGTT in the early postpartum, focus should rather be on continuous long-term screening.

Postchallenge glucose increment was associated with hemoglobin glycation index in subjects with no history of diabetes

We investigated the association between postchallenge glucose increment and hemoglobin glycation index (HGI), the difference between observed and predicted glycated hemoglobin (HbA1c), in subjects with no history of diabetes. We enrolled 1381 subjects who attended our outpatient clinic for an oral glucose tolerance test (OGTT) to screen for diabetes. HGI was defined as observed HbA1c minus predicted HbA1c. The predicted HbA1c was calculated by entering fasting plasma glucose (FPG) level into an equation [HbA1c(%)=FPG(mg/dL)*0.029+2.9686] determined from an HbA1c versus FPG regression analysis using data from an independent cohort of 2734 subjects with no history of diabetes. The association between 2-hour glucose increment and HGI was analyzed using linear regression analyses with adjustment of relevant parameters. Overall, the proportions of subjects with normal glucose tolerance, pre-diabetes, and newly diagnosed diabetes were 42.3%, 41.3%, and 16.4%, respectively. Compared with subjects who had an HGI≤0, subjects with an HGI>0 had a lower FPG (95.0±13.3 vs 98.5±15.3 mg/dL, p<0.001) but a higher 2-hour plasma glucose (151.1±52.8 vs 144.6±51.4 mg/dL, p=0.027) and 2-hour glucose increment (56.1±46.1 vs 46.1±45.0 mg/dL, p<0.001). The 2-hour glucose increment after an OGTT was independently associated with HGI (β coefficient 0.003, 95% CI 0.002 to 0.003, p<0.001). Our findings suggested that postchallenge glucose increment was independently associated with HGI in subjects with no history of diabetes.

The Impact of Race on Short-term Treatment Response to Bevacizumab in Diabetic Macular Edema

PURPOSE

To determine the impact of race and ethnicity on efficacy of intravitreal bevacizumab for diabetic macular edema in anti-vascular endothelial growth factor (VEGF) treatment-naive patients.

DESIGN

Retrospective cohort study.

METHODS

Setting: Urban-based academic institution with affiliated private offices.

STUDY POPULATION

Intravitreal anti-VEGF naïve patients seen between 2010 and 2019 of White (W) race, Black (B) race, or Hispanic (H) ethnicity aged 18 years and older with diabetic macular edema who received intravitreal injections of bevacizumab. Exclusion criteria were prior intravitreal anti-VEGF treatment, invasive ophthalmologic interventions, and laser treatments within 3 months prior to first injection through the duration of the study. Exposures: Intravitreal bevacizumab.

MAIN OUTCOMES MEASURES

Percentage of patients with visual acuity (VA) improvement and mean percentage reduction in central macular thickness (CMT).

RESULTS

Percentage with VA improvement was 27% vs 39% vs 50% after 1 injection (n = 314), and 34% vs 55% vs 59% after 3 injections (n = 150) for B, H, and W cohorts, respectively. Black patients experienced lower odds of VA improvement compared with White and Hispanic patients after 1 injection (odds of 0.480, CI 0.284-0.814, P = .006) and 3 injections (odds of 0.342, CI 0.149-0.782, P = .008) while controlling for age, sex, baseline glycated hemoglobin (HbA_1c), baseline CMT, baseline VA, laser history, injection time course, and follow-up delay.

CONCLUSIONS

Black patients had a significantly lower likelihood of visual acuity improvement following intravitreal bevacizumab treatment compared with White and Hispanic patients. Further research is warranted to understand the effect of race and ethnicity on anti-VEGF efficacy to ensure optimal treatment for each individual.

COVID-19 pandemic: Can fasting plasma glucose and HbA1c replace the oral glucose tolerance test to screen for hyperglycaemia in pregnancy?

AIMS

To evaluate proposals considering HbA1c and fasting plasma glucose (FPG) measurement as a substitute for oral glucose tolerance test (OGTT) to diagnose hyperglycaemia in pregnancy (HIP) during COVID-19 pandemic.

METHODS

Of the 7,334 women who underwent the OGTT between 22 and 30 weeks gestation, 966 had HIP (WHO diagnostic criteria, reference standard). The 467 women who had an available HbA1c were used for analysis. French-speaking Society of Diabetes (SFD) proposal to diagnose HIP during COVID-19 pandemic was retrospectively applied: HbA1c ≥5.7% (39 mmol/mol) and/or FPG level ≥5.1 mmol/l. SFD proposal sensitivity for HIP diagnosis and the occurrence of HIP-related events (preeclampsia, large for gestational age infant, shoulder dystocia or neonatal hypoglycaemia) in women with false negative (FN) and true positive (TP) HIP-diagnoses were evaluated.

RESULTS

The sensitivity was 57% [95% confidence interval 52-62]. FN women had globally lower plasma glucose levels during OGTT, lower HbA1c and body mass index than those TP. The percentage of HIP-related events was similar in FN (who were cared) and TP cases, respectively 19.5 and 16.9% (p = 0.48). We observed similar results when women at high risk for HIP only were considered.

CONCLUSION

The SFD proposal has a poor sensitivity to detect HIP. Furthermore, it fails to have any advantages in predicting adverse outcomes.

Association of Baseline Characteristics With Insulin Sensitivity and β-Cell Function in the Glycemia Reduction Approaches in Diabetes: A Comparative Effectiveness (GRADE) Study Cohort

OBJECTIVE

We investigated sex and racial differences in insulin sensitivity, β-cell function, and glycated hemoglobin (HbA1c) and the associations with selected phenotypic characteristics.

RESEARCH DESIGN AND METHODS

This is a cross-sectional analysis of baseline data from 3,108 GRADE (Glycemia Reduction Approaches in Diabetes: A Comparative Effectiveness Study) participants. All had type 2 diabetes diagnosed <10 years earlier and were on metformin monotherapy. Insulin sensitivity and β-cell function were evaluated using the HOMA of insulin sensitivity and estimates from oral glucose tolerance tests, including the Matsuda Index, insulinogenic index, C-peptide index, and oral disposition index (DI).

RESULTS

The cohort was 56.6 ± 10 years of age (mean ± SD), 63.8% male, with BMI 34.2 ± 6.7 kg/m2, HbA1c 7.5 ± 0.5%, and type 2 diabetes duration 4.0 ± 2.8 years. Women had higher DI than men but similar insulin sensitivity. DI was the highest in Black/African Americans, followed by American Indians/Alaska Natives, Asians, and Whites in descending order. Compared with Whites, American Indians/Alaska Natives had significantly higher HbA1c, but Black/African Americans and Asians had lower HbA1c. However, when adjusted for glucose levels, Black/African Americans had higher HbA1c than Whites. Insulin sensitivity correlated inversely with BMI, waist-to-hip ratio, triglyceride-to-HDL-cholesterol ratio (TG/HDL-C), and the presence of metabolic syndrome, whereas DI was associated directly with age and inversely with BMI, HbA1c, and TG/HDL-C.

CONCLUSIONS

In the GRADE cohort, β-cell function differed by sex and race and was associated with the concurrent level of HbA1c. HbA1c also differed among the races, but not by sex. Age, BMI, and TG/HDL-C were associated with multiple measures of β-cell function and insulin sensitivity.

Prevalence and impact of chronic dysglycemia in intensive care unit patients-A retrospective cohort study

BACKGROUND

The prevalence of chronic dysglycemia (diabetes and prediabetes) in patients admitted to Swedish intensive care units (ICUs) is unknown. We aimed to determine the prevalence of such chronic dysglycemia and asses its impact on blood glucose control and patient-centered outcomes in critically ill patients.

METHODS

In this retrospective observational cohort study, we obtained glycated hemoglobin A1c (HbA1c) in patients admitted to four tertiary ICUs in Sweden between March and August 2016. Based on previous diabetes history and HbA1c we determined the prevalence of chronic dysglycemia. We used multivariable regression analyses to study the association of chronic dysglycemia with the time-weighted average blood glucose concentration, glycemic lability index (GLI), and development of hypoglycemia (co-primary outcomes), and with ICU length of stay, mechanical ventilation duration, renal replacement therapy (RRT) use, vasopressor use, ICU-acquired infections, and mortality (exploratory clinical outcomes).

RESULTS

Of 943 patients, 312 (33%) had chronic dysglycemia. Of these 312 patients, 84 (27%) had prediabetes, 43 (14%) had undiagnosed diabetes and 185 (59%) had known diabetes. Chronic dysglycemia was independently associated with higher time-weighted average blood glucose concentration (P < .001), higher GLI (P < .001), and hypoglycemia (P < .001). Chronic dysglycemia was independently associated with RRT use (adjusted odds ratio 1.97, 95% CI 1.24-3.13, P = .004) but not with other exploratory clinical outcomes.

CONCLUSIONS

In four tertiary Swedish ICUs, measurement of HbA1c showed that one-third of patients had chronic dysglycemia. Chronic dysglycemia was associated with marked derangements in glycemic control, and a greater need for renal replacement therapy.

2. Classification and Diagnosis of Diabetes: Standards of Medical Care in Diabetes-2021

The American Diabetes Association (ADA) "Standards of Medical Care in Diabetes" includes the ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, a multidisciplinary expert committee (https://doi.org/10.2337/dc21-SPPC), are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations, please refer to the Standards of Care Introduction (https://doi.org/10.2337/dc21-SINT). Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.

The Compatibility of Hemoglobin A1c with Oral Glucose Tolerance Test and Fasting Plasma Glucose

Objectives:

Diabetes mellitus (DM) is a chronic metabolic disease requiring lifelong medical care, and its prevalence is increasing worldwide. Early diagnosis of prediabetes and diabetes is significant in view of the mortality, morbidity and cost associated with them. Because of the difficulties in application and reproducibility of oral glucose tolerance test (OGTT), which is considered to be the gold standard in the diagnosis of DM, more feasible diagnostic tests are needed. This study aims to evaluate the validity of hemoglobin A1c (HbA1c) in predicting prediabetes and diabetes in the Turkish population and to evaluate the compatibility of HbA1c with other diagnostic tests.

Methods:

The patients who were admitted to Health Sciences University Sisli Hamidiye Etfal Training and Research Hospital internal diseases and endocrinology outpatient clinics between 01.01.2013 and 30.06.2014 enrolled in this study. The participants were >18 years of age and were not diagnosed with prediabetes or DM earlier. The results of OGTT, fasting plasma glucose (FPG) and HbA1c tests were retrospectively screened, and the correlation of them was analyzed.

Results:

In this study, 201 participants enrolled. Of these cases, 127 were women and 74 were men. Mean age of the group was 49.3±10.4 years. HbA1c was observed <5.7% in the 15%, 5.7-6.4% in the 60%, and ≥ 6.5% in the 25% of the cases. While FPG was <100 mg/dL in 24% of the participants, it was found to be between 100-126 mg/dL in 71% and ≥126 mg/dL in 5% of the participants. According to the OGTT data, 23% of the cases were healthy, 59% were prediabetic and 18% were diabetic. The sensitivity and specificity of HbA1c were calculated as 50% and 80%, respectively. While the sensitivity of FPG was 17% and specificity was 97%.

Conclusion:

The data obtained from our study show that HbA1c is a more sensitive test compared to FPG in the diagnosis of DM. Prospective studies with broad participation at national and international levels are needed to redefine HbA1c cut-off points for the diagnosis of DM and prediabetes. Thus, it will be possible to revise the diagnostic guidelines accordingly.

The trials and tribulations of determining HbA1c targets for diabetes mellitus

Glycated haemoglobin (HbA1c) is considered the gold standard for predicting glycaemia-associated risks for the microvascular and macrovascular complications of diabetes mellitus over 5-10 years. The value of HbA1c in the care of patients with type 1 diabetes mellitus (T1DM) and type 2 diabetes mellitus (T2DM) is unassailable, yet HbA1c targets remain contentious. Guidelines from diabetes care organizations recommend conflicting HbA1c targets - generally between 6.5% and 8%. However, all such organizations advocate for individualization of HbA1c targets, leaving both health-care providers and their patients confused about what HbA1c target is appropriate in an individual patient. In this Review, we outline the landmark T1DM and T2DM trials that informed the current guidelines, we discuss the evidence that drives individualized HbA1c targets, we examine the limitations of HbA1c, and we consider alternatives for monitoring glycaemic control. Ultimately, in synthesizing this literature, we argue for an HbA1c target of <7% for most individuals, but emphasize the importance of helping patients determine their own personal goals and determinants of quality of life that are independent of a particular glycaemic target. We also recognize that as newer technologies and anti-hyperglycaemic therapies emerge, glycaemic targets will continue to evolve.

Association of Adipose Tissue Distribution With Type 2 Diabetes in Breast Cancer Patients

PURPOSE

We examined the association of adipose tissue distribution with type 2 diabetes (T2D) in breast cancer patients.

METHODS

Participants (N = 238) diagnosed with breast cancer at 20-75 years old who received breast cancer treatment at a major hospital from January 1, 2012, to December 31, 2017, with at least one completed and identifiable abdominal or pelvic computed tomography (CT) scan and data regarding race and ethnicity were included. Thirty-two breast cancer patients were identified as T2D patients after their breast cancer diagnoses. The adipose tissue distribution (visceral fat area [VFA], subcutaneous fat area [SFA], and the ratio of VFA to SFA [VFA/SFA]) was quantified on CT images of the third lumbar vertebra. T2D status was retrieved from patients' electronic medical records. The association of adipose tissue distribution with T2D in women with breast cancer was examined using multivariable logistic regression.

RESULTS

Participants with T2D had significantly smaller SFA compared to those without T2D (odds ratio [OR] = 0.88, 95% confidence interval [95% CI] = 0.81-0.96, per 10 cm2 SFA). A positive association of VFA/SFA ratio with T2D was observed (OR = 19.57, 95% CI = 3.26-117.42, per unit VFA/SFA), although the estimate was imprecise.

CONCLUSIONS

The amount of subcutaneous adipose tissue was inversely associated with T2D, and the ratio of the amount of visceral adipose tissue to the amount of subcutaneous adipose tissue was positively associated with T2D in breast cancer patients.

Association of hemoglobin glycation index and its interaction with obesity/family history of hypertension on hypertension risk: a community-based cross-sectional survey

Background

Hemoglobin glycation index (HGI) is considered to be a convenient measurable indicator to assess the inter-individual variation of HbA1c. In the present study, we tested the relationship between HGI and risk of hypertension, and further explored the possible interacting influences of HGI with other such factors on hypertension risk among Chinese individuals.

Methods

The eligible subjects were chosen from a community-based cross-sectional survey in China. We collected relevant data and clinical indicators for each participant. HGI was calculated as “measured HbA1c-predicted HbA1c” and divided into four categories according to quartile. The following indicators were used to assess interactive effects: (1) relative excess risk due to interaction (RERI); (2) attributable proportion due to interaction (AP); and (3) synergy index (SI). Statistical analysis was performed using R software.

Results

Specifically, 1777 eligible participants were selected in this cross-sectional survey. There were 433 subjects who were identified to have hypertension (24.4%). A significant increase in the prevalence of hypertension from Q1 to Q4 of HGI was observed (p < 0.001). Multivariable logistic model demonstrated that subjects at the highest HGI group had a substantially increased risk of being hypertensive than subjects in the first quartile of HGI, as indicated by the OR value of 1.87 (95% CI 1.26–2.78). Moreover, a significant interaction between family history of hypertension and HGI on hypertension risk was detected (RERI: 1.36, 95% CI 0.11–2.63; AP: 0.43, 95% CI 0.17–0.69; and SI:2.68, 95% CI 1.10–6.48). The interactive effect between HGI and abdominal obesity was also found to be significant, as estimated by the value of RERI (1.04, 95% CI 0.24–1.85), AP (0.33, 95% CI 0.11–0.56) and SI (1.96, 95% CI 1.01–3.79). However, in the analysis of the interaction between HGI and general obesity, only the AP value (0.28, 95% CI 0.01–0.54) was observed to be significant.

Conclusion

High HGI was independently associated with the risk of hypertension. Moreover, HGI significantly shared interactions with obesity and family history of hypertension that influenced the risk of hypertension.

Inducing remission of Type 2 diabetes in the Caribbean: findings from a mixed methods feasibility study of a low-calorie liquid diet-based intervention in Barbados

AIM

In a high proportion of people with recently diagnosed Type 2 diabetes, a short (2-3-month) low-calorie diet is able to restore normal glucose and insulin metabolism. The aim of this study was to determine the feasibility of this approach in Barbados.

METHODS

Twenty-five individuals with Type 2 diabetes diagnosed within past 6 years, not on insulin, BMI ≥ 27 kg/m² were recruited. Hypoglycaemic medication was stopped on commencement of the 8-week liquid (760 calorie) diet. Insulin response was assessed in meal tests at baseline, 8 weeks and 8 months. Semi-structured interviews, analysed thematically, explored participants' experiences. 'Responders' were those with fasting plasma glucose (FPG) < 7 mmol/l at 8 weeks.

RESULTS

Ten men and 15 women (mean age 48, range 26-68 years) participated. Mean (sd) BMI was 34.2 kg/m² (6.0); FPG 9.2 mmol/l (2.2). Mean weight loss at 8 weeks and 8 months was 10.1 kg [95% confidence interval (CI) 8.1, 12.0] and 8.2 kg (95% CI 5.8, 10.6); FPG was lower by 2.2 mmol/l (95% CI 1.2, 3.2) and 1.7 mmol/l (95% CI 0.8, 2.7) respectively. Nine of 11 (82%) of those who lost ≥ 10 kg were 'responders' compared with 6 of 14 (43%) who lost < 10 kg (P = 0.048). The 30-min insulin increment was higher in responders at baseline and follow-up (P ≤ 0.01). A food culture based on starchy foods and pressures to eat large amounts at social events were among the challenges identified by participants.

CONCLUSIONS

The feasibility of this approach to weight loss and diabetes remission in a predominantly black population in Barbados was demonstrated.

Racial differences in prediabetes prevalence by test type for the US pediatric and adult population: NHANES 1999-2016

BACKGROUND

Previous studies have shown that US estimates of prediabetes or diabetes differ depending on test type, fasting plasma glucose (FPG) vs hemoglobin A1c (HbA1c). Given age, race, and test differences reported in the literature, we sought to further examine these differences in prediabetes detection using a nationally representative sample.

METHODS

Using the National Health and Nutrition Examination Survey (NHANES) 1999-2016, individuals were identified as having prediabetes with an HbA1c of 5.7% to 6.4% or a FPG of 100 to 125 mg/dL. We excluded individuals with measurements in the diabetic range. We ran generalized estimating equation logistic regressions to examine the relationship between age, race, and test type with interactions, controlling for sex and body mass index. We compared the difference in predicted prediabetes prevalence detected by impaired fasting glycemia (IFG) vs HbA1c by race/ethnicity among children and adults separately using adjusted Wald tests.

RESULTS

The absolute difference in predicted prediabetes detected by IFG vs HbA1c was 19.9% for white adolescents, 0% for black adolescents, and 20.1% for Hispanic adolescents; 21.4% for white adults, -1.2% for black adults, and 19.2% for Hispanic adults. Using adjusted Wald tests, we found the absolute differences between black vs white and black vs Hispanic individuals to be significant, but, not between Hispanic and white individuals among children and adults separately.

CONCLUSIONS

These observations highlight differences in test performance among racial/ethnic groups. Our findings corroborate the need for further studies to determine appropriate HbA1c cutoff levels for diagnosis of prediabetes by age group and race.

High concordance between chart review adjudication and electronic medical record data to identify prevalent and incident diabetes mellitus among persons with and without HIV

BACKGROUND

Electronic medical records (EMR) represent a rich source of data, but the value of EMR for health research relies on accurate ascertainment of clinical diagnoses. Identifying diabetes in EMR is complicated by the variety of accepted diagnostic criteria, some of which can be confounded by conditions such as HIV infection. We compared EMR-based criteria for estimating diabetes prevalence and incidence in the Veterans Health Administration (VHA), overall and by HIV status, against physician chart review and adjudication.

RESEARCH DESIGN AND METHODS

We used laboratory values (serum glucose and hemoglobin A1c% [HbA1c]), ICD-9 codes, and medication records from the United States Veterans Aging Cohort Study Biomarker Cohort to identify veterans with any indication of diabetes in the EMR for subsequent physician adjudication. Sensitivity, specificity, PPV, NPV, and kappa statistics were used to evaluate agreement of EMR-based diabetes diagnoses with chart review adjudicated diagnoses.

RESULTS

EMR entries were reviewed for 1546 persons with HIV (PWH) and 843 HIV-negative participants through 2015. Agreement was at least moderate overall (kappa ≥ 0.42) for all pre-specified measures and among PWH vs HIV-negative, and African-American vs white sub-groups. Having at least one HbA1c ≥6.5% provided substantial agreement with chart adjudication for prevalent and incident diabetes (kappa = 0.89 and 0.73).

CONCLUSIONS

Identification of those with diabetes nationally within the VHA can be used in future studies to evaluate treatments, health outcomes, and adjust for diabetes in epidemiologic studies. Our methodology may provide insights for other organizations seeking to use EMR data for accurate determination of diabetes.

Geographic and Racial/Ethnic Variation in Glycemic Control and Treatment in a National Sample of Veterans With Diabetes

OBJECTIVE

Geographic and racial/ethnic disparities related to diabetes control and treatment have not previously been examined at the national level.

RESEARCH DESIGN AND METHODS

A retrospective cohort study was conducted in a national cohort of 1,140,634 veterans with diabetes, defined as two or more diabetes ICD-9 codes (250.xx) across inpatient and outpatient records. Main exposures of interest included 125 Veterans Administration Medical Center (VAMC) catchment areas as well as racial/ethnic group. The main outcome measure was HbA1c level dichotomized at ≥8.0% (≥64 mmol/mol).

RESULTS

After adjustment for age, sex, racial/ethnic group, service-connected disability, marital status, and the van Walraven Elixhauser comorbidity score, the prevalence of uncontrolled diabetes varied by VAMC catchment area, with values ranging from 19.1% to 29.2%. Moreover, these differences largely persisted after further adjusting for medication use and adherence as well as utilization and access metrics. Racial/ethnic differences in diabetes control were also noted. In our final models, compared with non-Hispanic Whites, non-Hispanic Blacks (odds ratio 1.11 [95% credible interval 1.09-1.14]) and Hispanics (1.36 [1.09-1.14]) had a higher odds of uncontrolled HBA1c level.

CONCLUSIONS

In a national cohort of veterans with diabetes, we found geographic as well as racial/ethnic differences in diabetes control rates that were not explained by adjustment for demographics, comorbidity burden, use or type of diabetes medication, health care utilization, access metrics, or medication adherence. Moreover, disparities in suboptimal control appeared consistent across most, but not all, VAMC catchment areas, with non-Hispanic Black and Hispanic veterans having a higher odds of suboptimal diabetes control than non-Hispanic White veterans.

The Sickle Effect: The Silent Titan Affecting Glycated Hemoglobin Reliability

Hemoglobin A1c (HbA1c) is a popular invaluable tool in the diagnosis of Type 2 diabetes for red blood cells (RBCs) with a lifespan of 120 days; however, many factors, including hemoglobinopathies, affect its accuracy. Sickle cell trait, primarily a benign medical condition, is a point mutation in only one of two beta-globin genes on chromosome 11. We performed a traditional review to identify how the sickle cell trait (SCT) affects the interpretation of HbA1c and the further implications it may have on the diagnosis and management of Type 2 diabetes. A literature search was performed using PubMed®/MEDLINE® and Google Scholar with formulated keywords (sickle cell trait, HbAS, HbA1c, glycosylated hemoglobin, diabetes, RBC lifespan, race, and genetics), with the majority of results being mainly observational studies. The National Glycohemoglobin Standardization Program (NGSP) is responsible for standardizing HbA1c results and also highlights factors that can interfere with HbA1c, including hemoglobin variants. Studies that utilize only an NGSP-certified method with no clinically significant interference by HbS in patients with and without SCT showed contrasting results. Additional studies showed that persons of African ancestry, the group to which the majority of SCT patients belong, have a higher HbA1c than non-Hispanic whites (NHWs), just based on race, and a greater probability of having glucose-6-phosphate dehydrogenase (G6PD) deficiency, which lowers HbA1c. The most extensive study investigating the RBC lifespan in SCT patients showed a reduction in the cell lifespan compared to normal patients; however, other smaller studies were contradictory. Our study highlights the need for hemoglobinopathy detection before or during HbA1c measurement in populations with a high degree of African ancestry and the importance of patient notification. It also shows that SCT affects the accuracy of HbA1c, through its likely reduction of RBC lifespan and its increased association with African ancestry and G6PD deficiency. This review recommends that for SCT patients with potential Type 2 diabetes, HbA1c should be used in combination with another diagnostic tool such as fasting blood glucose, fructosamine, or glycated albumin to decrease the chances of a missed diagnosis.