HbA(1c) values for defining diabetes and impaired fasting glucose in Asian Indians

Incidence of T2DM and the role of baseline glycaemic status as a determinant in a metropolitan population in northern Madrid (Spain)

AIM

To estimate the incidence of T2DM and assess the effect of pre-T2DM (isolated impaired fasting glucose [iIFG], isolated impaired glucose tolerance [iIGT] or both) on progress to T2DM in the adult population of Madrid.

METHODS

Population-based cohort comprising 1,219 participants (560 normoglycaemic and 659 preT2DM [418 iIFG, 70 iIGT or 171 IFG-IGT]). T2DM was defined based on fasting plasma glucose or HbA1c or use of glucose-lowering medication. We used a Cox model with normoglycaemia as reference category.

RESULTS

During 7.26 years of follow-up, the unadjusted incidence of T2DM was 11.21 per 1000 person-years (95 %CI, 9.09-13.68) for the whole population, 5.60 (3.55-8.41) for normoglycaemic participants and 16.28 (12.78-20.43) for pre-T2DM participants. After controlling for potential confounding factors, the baseline glycaemic status was associated with higher primary effect on developing T2DM was iIGT (HR = 3.96 [95 %CI, 1.93-8.10]) and IFG-IGT (3.42 [1.92-6.08]). The HR for iIFG was 1.67 (0.96-2.90). Obesity, as secondary effect, was strongly significantly associated (HR = 2.50 [1.30-4.86]).

CONCLUSIONS

Our incidence of T2DM is consistent with that reported elsewhere in Spain. While baseline iIGT and IFG-IGT behaved a primary effect for progression to T2DM, iIFG showed a trend in this direction.

Hyperinsulinemia: an early biomarker of metabolic dysfunction

Introduction

Hyperinsulinemia in the absence of impaired glucose tolerance and normal HbA1c is considered indicative of pre-diabetes. Very few Indian studies have focused on hyperinsulinemia particularly in young adults. The present study aimed to determine whether hyperinsulinemia may be present despite HbA1c being normal.

Methods

This was a cross-sectional study conducted on adolescents and young adults aged 16-25 years living in Mumbai, India. The participants attended various academic institutions and were those who underwent screening as the first step of a clinical trial for studying the efficacy of almond intake in prediabetes.

Results

Among this young population (n=1313), 4.2% (n=55) of the participants were found to be prediabetic (ADA criteria) and 19.7% of them had HbA1c levels between 5.7%-6.4%. However, almost, 30.5% had hyperinsulinemia inspite of normal blood glucose levels and normal HbA1c. Among those with HbA1c<5.7 (n=533), 10.5% (n=56) participants had fasting insulin>15 mIU/L and a higher percentage (39.4%, n=260) had stimulated insulin above 80 mIU/L. These participants had higher mean anthropometric markers than those with normal fasting and/or stimulated insulin.

Conclusion

Hyperinsulinaemia in the absence of impaired glucose tolerance and normal HbA1c may provide a much earlier indicator of detection for risk of metabolic disease and progression to metabolic syndrome and diabetes mellitus.

Comparison of triglyceride glucose index and HbA1C as a marker of prediabetes - A preliminary study

BACKGROUND AND AIMS

HbA₁C and HOMA-IR (Homeostatic model assessment for assessing insulin resistance) are established diagnostic markers of diabetes and insulin resistance respectively, but are relatively expensive. Triglyceride glucose (TyG) index is calculated based on fasting plasma glucose and fasting triglyceride levels which are available as routine laboratory parameters and is inexpensive. This is a preliminary study which aims to compare Triglyceride glucose (TyG) index with HbA₁C as a marker of prediabetes and also with HOMA-IR (Homeostatic model assessment for assessing insulin resistance) as a marker of insulin resistance.

METHODS

100 diagnosed cases of prediabetes and 100 age and sex-matched normoglycemic controls were recruited in the study. Fasting plasma glucose, 2-hour OGTT, fasting triglycerides, fasting plasma insulin and HbA₁C were measured. Triglyceride glucose (TyG) index and HOMA-IR (Homeostatic model assessment for assessing insulin resistance) were calculated. Receiver operator curve was plotted and analysed between HbA₁C and Triglyceride glucose (TyG) index.

RESULTS

Out of 100 subjects with prediabetes; 53 were female and 47 were male. In this study, there was higher mean Triglyceride glucose (TyG) index (4.942 ± 0.137 vs 4.661 ± 0.173) and HOMA-IR (Homeostatic model assessment for assessing insulin resistance) (2.424 ± 1.045 vs 1.03 ± 0.594) in individuals with prediabetes compared to normoglycemic individuals. The area under curve (AUC) for HbA1C (0.942) was more than Triglyceride glucose (TyG) index (0.898) for the diagnosis of prediabetes. But the difference was not statistically significant with p = 0.06.

CONCLUSIONS

Triglyceride glucose (TyG) index is comparable to HbA1C as a marker for the diagnosis of prediabetes.

Burden of Type 2 Diabetes and Associated Cardiometabolic Traits and Their Heritability Estimates in Endogamous Ethnic Groups of India: Findings From the INDIGENIUS Consortium

To assess the burden of type 2 diabetes (T2D) and its genetic profile in endogamous populations of India given the paucity of data, we aimed to determine the prevalence of T2D and estimate its heritability using family-based cohorts from three distinct Endogamous Ethnic Groups (EEGs) representing Northern (Rajasthan [Agarwals: AG]) and Southern (Tamil Nadu [Chettiars: CH] and Andhra Pradesh [Reddys: RE]) states of India. For comparison, family-based data collected previously from another North Indian Punjabi Sikh (SI) EEG was used. In addition, we examined various T2D-related cardiometabolic traits and determined their heritabilities. These studies were conducted as part of the Indian Diabetes Genetic Studies in collaboration with US (INDIGENIUS) Consortium. The pedigree, demographic, phenotypic, covariate data and samples were collected from the CH, AG, and RE EEGs. The status of T2D was defined by ADA guidelines (fasting glucose ≥ 126 mg/dl or HbA1c ≥ 6.5% and/or use of diabetes medication/history). The prevalence of T2D in CH (N = 517, families = 21, mean age = 47y, mean BMI = 27), AG (N = 530, Families = 25, mean age = 43y, mean BMI = 27), and RE (N = 500, Families = 22, mean age = 46y, mean BMI = 27) was found to be 33%, 37%, and 36%, respectively, Also, the study participants from these EEGs were found to be at increased cardiometabolic risk (e.g., obesity and prediabetes). Similar characteristics for the SI EEG (N = 1,260, Families = 324, Age = 51y, BMI = 27, T2D = 75%) were obtained previously. We used the variance components approach to carry out genetic analyses after adjusting for covariate effects. The heritability (h²) estimates of T2D in the CH, RE, SI, and AG were found to be 30%, 46%, 54%, and 82% respectively, and statistically significant (P ≤ 0.05). Other T2D related traits (e.g., BMI, lipids, blood pressure) in AG, CH, and RE EEGs exhibited strong additive genetic influences (h² range: 17% [triglycerides/AG and hs-CRP/RE] - 86% [glucose/non-T2D/AG]). Our findings highlight the high burden of T2D in Indian EEGs with significant and differential additive genetic influences on T2D and related traits.

Effect of Correction of Hyperthyroidism with Anti-thyroid Drugs on the Glycated Hemoglobin in Non-diabetic Patients with Primary Hyperthyroidism

BACKGROUND

Glycated hemoglobin (HbA1c) levels are dependent not only on the average blood glucose levels over the preceding 2 - 3 months but also on the turnover of erythrocytes. Hyperthyroidism is known to be associated with an increase in erythrocyte turnover that may falsely lower the HbA1c in relation to the level of glycemia.

OBJECTIVES

To assess the impact of medical correction of hyperthyroidism on HbA1c, independent of changes in the fasting plasma glucose and 2-hour post-oral glucose tolerance test plasma glucose.

METHODS

Adult patients with overt hyperthyroidism (n = 36) were tested for their hemoglobin, reticulocyte percentage, HbA1c and fasting and post-oral glucose tolerance test (OGTT) 2-hour plasma glucose, both at baseline and following at least three months of near normalization of serum thyroxin on Carbimazole treatment.

RESULTS

Correction of hyperthyroidism in 36 patients was associated with an increase in the hemoglobin (P = 0.004) and a rise in HbA1c (P = 0.025), even though no significant change was observed in both the fasting (P = 0.28) and post OGTT two-hour plasma glucose (P = 0.54). Also, the proportion of patients with HbA1c ≥ 5.7% rose from 3/36 to 10/36; P = 0.016, while the proportion of patients with either abnormal fasting or abnormal post OGTT 2-hour plasma glucose or both did not show any significant change (P = 0.5). The sensitivity of HbA1c to diagnose prediabetes increased from 20% to 50% post- treatment.

CONCLUSIONS

Glycated hemoglobin is falsely low in relation to glycemia in patients with untreated hyperthyroidism.

Optimizing the treatment of newly diagnosed type 2 diabetes mellitus with combination of dipeptidyl peptidase-4 inhibitors and metformin: An expert opinion

The expanding burden of Type 2 Diabetes Mellitus (T2DM) in today's world, with respect to incidence, prevalence, and cost incurred, is an existential risk to society. Various guidelines recommend individualization of treatment. This expert opinion aims to review the recent evidences and reach a consensus on the preferable combination therapy for use in newly diagnosed Indian T2DM patients with HbA_1C >7.5%. The core committee included seventeen diabetes specialists. Three statements were developed, discussed, and rated by specialists and recommendations were noted. Specialists were requested to rate the statements using a 9-point Likert's scale with score of 1 being “Strongly Disagree” and 9 being “Strongly Agree”. Statement-specific scores of all the specialists were added and mean score of ≥7.00 was considered to have achieved a consensus. Statements used to meet the consensus were: Statement 1. Majority of newly-diagnosed Indian diabetics have HbA_1C >7.5%; Statement 2. Patients with HbA_1C >7.5% may be initiated with dual therapy of dipeptidyl peptidase-4 inhibitors (DPP4Is) + Metformin; and Statement 3. In Indian patients with HbA_1C >7.5% at diagnosis, DPP4Is + Metformin may be considered as a first-line therapy. Literature review revealed that HbA_1C level at the time of diagnosis in majority of Indian T2DM patients is >7.5%. Consensus was reached that dual anti-diabetic therapy should be initiated in patients with HbA_1C >7.5%. DPP4Is + Metformin is the preferred cost-effective option and may be considered as a first-line therapy in Indian T2DM patients with HbA_1C >7.5% at diagnosis.

Pitfalls of HbA1c in the Diagnosis of Diabetes

Many health care providers screen high-risk individuals exclusively with an HbA1c despite its insensitivity for detecting dysglycemia. The 2 cases presented describe the inherent caveats of interpreting HbA1c without performing an oral glucose tolerance test (OGTT). The first case reflects the risk of overdiagnosing type 2 diabetes (T2D) in an older African American male in whom HbA1c levels, although variable, were primarily in the mid-prediabetes range (5.7-6.4% [39-46 mmol/mol]) for many years although the initial OGTT demonstrated borderline impaired fasting glucose with a fasting plasma glucose of 102 mg/dL [5.7 mmol/L]) without evidence for impaired glucose tolerance (2-hour glucose ≥140-199 mg/dl ([7.8-11.1 mmol/L]). Because subsequent HbA1c levels were diagnostic of T2D (6.5%-6.6% [48-49 mmol/mol]), a second OGTT performed was normal. The second case illustrates the risk of underdiagnosing T2D in a male with HIV having normal HbA1c levels over many years who underwent an OGTT when mild prediabetes (HbA1c = 5.7% [39 mmol/mol]) developed that was diagnostic of T2D. To avoid inadvertent mistreatment, it is therefore essential to perform an OGTT, despite its limitations, in high-risk individuals, particularly when glucose or fructosamine and HbA1c values are discordant. Innate differences in the relationship between fructosamine or fasting glucose to HbA1c are demonstrated by the glycation gap or hemoglobin glycation index.

Review of methods for detecting glycemic disorders

Prediabetes (intermediate hyperglycemia) consists of two abnormalities, impaired fasting glucose (IFG) and impaired glucose tolerance (IGT) detected by a standardized 75-gram oral glucose tolerance test (OGTT). Individuals with isolated IGT or combined IFG and IGT have increased risk for developing type 2 diabetes (T2D) and cardiovascular disease (CVD). Diagnosing prediabetes early and accurately is critical in order to refer high-risk individuals for intensive lifestyle modification. However, there is currently no international consensus for diagnosing prediabetes with HbA1c or glucose measurements based upon American Diabetes Association (ADA) and the World Health Organization (WHO) criteria that identify different populations at risk for progressing to diabetes. Various caveats affecting the accuracy of interpreting the HbA1c including genetics complicate this further. This review describes established methods for detecting glucose disorders based upon glucose and HbA1c parameters as well as novel approaches including the 1-hour plasma glucose (1-h PG), glucose challenge test (GCT), shape of the glucose curve, genetics, continuous glucose monitoring (CGM), measures of insulin secretion and sensitivity, metabolomics, and ancillary tools such as fructosamine, glycated albumin (GA), 1,5- anhydroglucitol (1,5-AG). Of the approaches considered, the 1-h PG has considerable potential as a biomarker for detecting glucose disorders if confirmed by additional data including health economic analysis. Whether the 1-h OGTT is superior to genetics and omics in providing greater precision for individualized treatment requires further investigation. These methods will need to demonstrate substantially superiority to simpler tools for detecting glucose disorders to justify their cost and complexity.

Glycated hemoglobin (HbA1c) as diagnostic criteria for diabetes: the optimal cut-off points values for the Pakistani population; a study from second National Diabetes Survey of Pakistan (NDSP) 2016-2017

AIM

Glycated hemoglobin (HbA1c) cut-off values as diagnostic tool in diabetes and prediabetes with its concordance to oral glucose tolerance test (OGTT) in Pakistani population.

METHODOLOGY

Data for this substudy was obtained from second National Diabetes Survey of Pakistan (NDSP) 2016-2017. With this survey, 10 834 individuals were recruited and after excluding known subjects with diabetes, 6836 participants fulfilled inclusion criteria for this study. Demographic, anthropometric and biochemical parameters were obtained. OGTT was used as standard diagnostic tool to screen population and HbA1c for optimal cut-off values. Participants were categorized into normal glucose tolerance (NGT), newly diagnosed diabetes (NDD) and prediabetes.

RESULTS

Out of 6836 participants, 4690 (68.6%) had NGT, 1333 (19.5%) had prediabetes and 813 (11.9%) had NDD by OGTT criteria with median (IQR) age of 40 (31-50) years. Optimal HbA1c cut-off point for identification of diabetes and prediabetes was observed as 5.7% ((AUC (95% CI)=0.776 (0.757 to 0.795), p<0.0001)) and 5.1% ((AUC (95% CI)=0.607 (0.590 to 0.624), p<0.0001)), respectively. However, out of 68.6% NGT subjects identified through OGTT, 24.1% and 9.3% participants were found to have prediabetes and NDD, respectively by using HbA1c criteria. By using both OGTT and HbA1c criteria, only 7.9% and 7.3% were observed as prediabetes and diabetes, respectively.

CONCLUSION

Findings from second NDSP demonstrated disagreement between findings of OGTT and HbA1c as diagnostic tool for Pakistani population. As compared with international guidelines, HbA1c threshold for prediabetes and NDD were lower in this part of world. HbA1c as diagnostic tool might require ethnic or regional-based modification in cut-off points, validated by relevant community-based epidemiological surveys.

Metabolic syndrome is a predictor of decreased renal function among community-dwelling middle-aged and elderly Japanese

PURPOSE

Metabolic syndrome (MetS) is increasing worldwide with the continuous increase in obesity prevalence. Chronic kidney disease (CKD) is also a major public health problem, but there is controversy over whether baseline MetS is a predictor of decreased renal function among Japanese community-dwelling middle-aged and elderly Japanese.

METHODS

We conducted a prospective cohort study designed as part of the Nomura study. We recruited a random sample of 410 men aged 68 ± 8 (mean ± standard deviation; range, 50-95) years and 549 women aged 69 ± 7 (50-84) years during their annual health examination in a single community. We examined the relationship between baseline MetS and renal dysfunction after a 3-year evaluation based on estimated glomerular filtration rate (eGFR_CKDEPI) using the CKD-EPI equations modified by the Japan coefficient. CKD was defined as dipstick-positive proteinuria (> or = 1 +) or a low eGFR_CKDEPI (< 60 mL/min/1.73 m²).

RESULTS

Of the 959 participants, 413 (43.1%) had MetS at baseline. Annual eGFR decline rate was significantly greater in those with MetS than in those without MetS, and the annual eGFR decline rate of < - 1.2 mL/min/1.73 m²/year increased significantly in relation to presence of baseline MetS, especially low HDL cholesterol (HDL-C). Moreover, the incidence rate of CKD after 3 years was 13.5% and increased significantly in relation to presence of baseline MetS, especially its components such as elevated HbA1c. The multivariate-adjusted odd ratio (OR) for CKD in participants with MetS versus those without MetS was 1.55 (0.99-2.43). The multivariate-adjusted ORs for rapid annual eGFR decline rate were significantly high in patients aged ≥ 65 years and presence of medication, regardless of gender and eGFR value.

CONCLUSIONS

Low HDL-C and elevated HbA1c levels correlated significantly with eGFR decline in a short period of 3 years. MetS also showed a significant association with eGFR decline. This study suggests the importance of low HDL-C and elevated HbA1c in the effect of MetS on eGFR decline rather than obesity among Japanese community-dwelling middle-aged and elderly Japanese without CKD.

Comparison of Hemoglobin A1c with Fasting and 2-h Plasma Glucose Tests for Diagnosis of Diabetes and Prediabetes among High-risk South Indians

BACKGROUND

Glycosylated hemoglobin (HbA1c) has not been evaluated extensively for diabetes and prediabetes diagnosis and short-term variability of fasting plasma glucose (FPG), 2-h PG post-75 g glucose load (2 hPG) and HbA1c has not been studied among Indians.

OBJECTIVES

The study aimed to compare the sensitivity of HbA1c, FPG and 2 hPG for diabetes and prediabetes diagnosis as per the American Diabetes Association criteria, assess short-term variability of three tests and determine optimal HbA1c cutoffs for diabetes and prediabetes diagnosis among high-risk south Indians.

METHODS

This diagnostic accuracy study, conducted at a tertiary care teaching hospital located in South India, enrolled 332 adults at high risk for diabetes and subjected them to testing (FPG, 2 hPG, and HbA1c) twice at 2-3 weeks interval. Sensitivity of three tests for diagnosing diabetes and prediabetes was determined based on the final diagnosis of normoglycemia/prediabetes/diabetes made with six test results for each participant. Optimal HbA1c cutoffs for diabetes and prediabetes were determined based on the final diagnosis of glycemic status made with four test results of FPG and 2 hPG.

RESULTS

FPG, 2 hPG, and HbA1c, at American Diabetes Association recommended values, had sensitivity of 84.4%, 97%, and 93.8% respectively for diabetes diagnosis. HbA1c had lowest short-term variability (CVw = 1.6%). Receiver operating characteristic curve plotted with mean (of two values) HbA1c for each participant showed optimal HbA1c cutoffs of 6.5% for diabetes (area under curve [AUC] =0.990, sensitivity = 95.8%, specificity = 96.2%, accuracy = 95.2%) and 5.9% for prediabetes (AUC = 0.893, sensitivity = 84.3%, specificity = 80%, accuracy = 75.6%) diagnosis respectively. HbA1c <5.6% had 100% negative predictive value to exclude prediabetes/diabetes.

CONCLUSIONS

HbA1c ≥6.5% is a convenient and reliable alternative to plasma glucose tests to diagnose diabetes among high-risk South Indians. HbA1c ≥5.9% is optimal for prediabetes diagnosis and value <5.6% excludes prediabetes/diabetes.Abbreviations used in the manuscript: ADA: American Diabetes Association, AUC: Area under curve, CVw: Within-person coefficient of variation, FPG: Fasting plasma glucose, 2 hPG: Two-hour plasma glucose post-75 g oral glucose load, HbA1c: Glycosylated haemoglobin, IFG: Impaired fasting glucose, IGT: Impaired glucose tolerance, NPV: Negative predictive value, PPV: Positive predictive value; PG: Plasma glucose, ROC: Receiver operating characteristic.

Derivation & validation of glycosylated haemoglobin (HbA 1c ) cut-off value as a diagnostic test for type 2 diabetes in south Indian population

Background & Objectives:

Glycosylated haemoglobin (HbA_1c) has been in use for more than a decade, as a diagnostic test for type 2 diabetes. Validity of HbA_1c needs to be established in the ethnic population in which it is intended to be used. The objective of this study was to derive and validate a HbA_1c cut-off value for the diagnosis of type 2 diabetes in the ethnic population of Rayalaseema area of south India.

Methods:

In this cross-sectional study, consecutive patients suspected to have type 2 diabetes underwent fasting plasma glucose (FPG) and 2 h post-load plasma glucose (2 h-PG) measurements after a 75 g glucose load and HbA_1c estimation. They were classified as having diabetes as per the American Diabetes Association criteria [(FPG ≥7 mmol/l (≥126 mg/dl) and/or 2 h-PG ≥11.1 mmol/l (≥200 mg/dl)]. In the training data set (n = 342), optimum cut-off value of HbA_1c for defining type 2 diabetes was derived by receiver-operator characteristic (ROC) curve method using oral glucose tolerance test results as gold standard. This cut-off was validated in a validation data set (n = 341).

Results:

On applying HbA_1c cut-off value of >6.3 per cent (45 mmol/mol) to the training data set, sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) for diagnosing type 2 diabetes were calculated to be 90.6, 85.2, 80.8 and 93.0 per cent, respectively. When the same cut-off value was applied to the validation data set, sensitivity, specificity, PPV and NPV were 88.8, 81.9, 74.0 and 92.7 per cent, respectively, although the latter were consistently smaller than the proportions for the training data set, the differences being not significant.

Interpretation & conclusions:

HbA_1c >6.3 per cent (45 mmol/mol) appears to be the optimal cut-off value for the diagnosis of type 2 diabetes applicable to the ethnic population of Rayalaseema area of Andhra Pradesh state in south India.

The changing relationship between HbA1c and FPG according to different FPG ranges

PURPOSE

Since the American Diabetes Association included hemoglobin A1c (HbA1c) in the diagnostic criteria for diabetes in 2010, the clinical use of HbA1c has remained controversial. We explored the use of HbA1c for diagnosing diabetes and intermediate hyperglycemia in comparison with fasting plasma glucose (FPG).

METHODS

We screened 3710 adult subjects (mean age = 55.24 years) comprising 1704 males and 2006 females. We drew an receiver operating characteristic (ROC) curve to evaluate the ability of HbA1c to diagnose diabetes and intermediate hyperglycemia according to FPG. We used Kappa coefficient and Pearson's correlation coefficient to evaluate the relationship between HbA1c and FPG in different FPG ranges.

RESULTS

The areas under ROC curve to diagnose diabetes and intermediate hyperglycemia were 0.859 (95 % CI 0.827-0.892) and 0.633 (95 % CI 0.615-0.651). The kappa coefficients between FPG and HbA1c for diagnosis of diabetes and intermediate hyperglycemia were 0.601 (P < 0.001) and 0.104 (P < 0.001). The Pearson's correlation coefficient of FPG and HbA1c was 0.640 (P < 0.001), but when we classified FPG as normal, intermediate hyperglycemia and diabetes, the coefficients became 0.07 (P = 0.002), 0.185 (P < 0.001) and 0.760 (P < 0.001), respectively.

CONCLUSIONS

The relationship between HbA1c and FPG changed according to the different FPG ranges. When FPG was higher, the relationship was stronger. HbA1c and FPG were highly consistent in diagnosing diabetes, but they were not in predicting intermediate hyperglycemia.

Predictive Value of Glycated Hemoglobin and Body Mass Index for Pretreatment Neuropathy in Patients With Multiple Myeloma

BACKGROUND

Peripheral neuropathy (PN) is detected in up to 62% patients with multiple myeloma (MM) at diagnosis. No specific risk factor for pretreatment neuropathy has been identified.

PATIENTS AND METHODS

We evaluated 29 sequential patients with MM attending our tertiary care center for peripheral neuropathy at diagnosis using symptoms, clinical examination, and nerve conduction studies (NCSs). Total Neuropathy Score, reduced (TNSr) and Total Neuropathy Score, clinical (TNSc) were calculated, and a score of ≥ 2 in each scale was considered diagnostic of PN. The study was approved by our institutional review board.

RESULTS

We found that 51.7% (n = 15) and 17.2% (n = 5) of patients had pretreatment neuropathy by TNSr and TNSc scales, respectively. Higher glycated hemoglobin (HbA1C) (P = .022), higher body mass index (BMI) (P = .008), higher serum creatinine levels (P = .023), and higher blood urea levels (P = .006) were associated with neuropathy by TNSr in univariate analysis. Higher blood urea levels (P = .023), higher serum creatinine levels (P = .003), and higher serum β2-microglobulin levels (P = .013) were associated with neuropathy by TNSc in univariate analysis. Higher HbA1c levels (P = .036; odds ratio [OR], 9.46) and BMI (P = .028; OR, 1.78) were associated with neuropathy by TNSr on binomial logistic regression analysis. Cutoffs of 5.6% (sensitivity, 60%; specificity, 71.4%) and 23.7 kg/m(2) (sensitivity, 80%; specificity, 71.4%) were obtained for HbA1c (area under the curve [AUC], 0.75) and BMI (AUC, 0.79), respectively, on receiver operating characteristic (ROC) curve analysis to predict neuropathy. The combination of HbA1c ≥ 5.6% and BMI ≥ 23.7 kg/m(2) had higher odds of neuropathy by TNSr (OR, 27.0; 95% confidence interval [CI], 2.0-368.4) when compared with either factor alone.

CONCLUSION

Use of TNSr, which incorporates electrophysiological abnormalities in addition to clinical manifestations, improves the detection rate of neuropathy. We found that high HbA1c and high BMI together are risk factors for neuropathy at diagnosis in patients with MM.

Management of NCD in low- and middle-income countries

Noncommunicable disease (NCD), comprising cardiovascular disease, stroke, diabetes, and chronic obstructive pulmonary disease, are increasing in incidence rapidly in low- and middle-income countries (LMICs). Some patients have access to the same treatments available in high-income countries, but most do not, and different strategies are needed. Most research on noncommunicable diseases has been conducted in high-income countries, but the need for research in LMICs has been recognized. LMICs can learn from high-income countries, but they need to devise their own systems that emphasize primary care, the use of community health workers, and sometimes the use of mobile technology. The World Health Organization has identified "best buys" it advocates as interventions in LMICs. Non-laboratory-based risk scores can be used to identify those at high risk. Targeting interventions to those at high risk for developing diabetes has been shown to work in LMICs. Indoor cooking with biomass fuels is an important cause of chronic obstructive pulmonary disease in LMICs, and improved cookstoves with chimneys may be effective in the prevention of chronic diseases.

HbA(1c) as a diagnostic tool for diabetes and pre-diabetes: the Bangladesh experience

AIMS

To evaluate HbA(1c) as a tool for the diagnosis of diabetes and pre-diabetes (impaired glucose tolerance and/or impaired fasting glucose) and to identify the optimal cut-off values suitable for a Bangladeshi population.

METHODS

In this cross-sectional survey in a rural community, 2293 randomly selected individuals aged ≥ 20 years without prior history of diabetes were included. HbA(1c) and other clinical covariates necessary for the diagnosis of diabetes were recorded. Diabetes and pre-diabetes were defined according to the World Health Organization 1999 criteria. The receiver operating characteristic curve was used to determine the performance of HbA(1c).

RESULTS

The prevalences of diabetes and pre-diabetes were 7.9 and 8.6%, respectively. Based on receiver operating characteristic curve analysis, an HbA(1c) cut-off value of ≥ 42 mmol/mol (≥ 6.0%) gave an optimal sensitivity of 86.2% and specificity of 93.3%, with an area under the curve of 0.949 to predict diabetes using the oral glucose tolerance test as the gold standard; a cut-off value of ≥ 38 mmol/mol (≥ 5.6%) gave an optimal sensitivity of 68.0% and specificity of 66.4%, with an area under the curve of 0.714 to predict pre-diabetes. In subjects at high risk of diabetes, HbA(1c) ≥ 42 mmol/mol (≥ 6.0%) showed higher sensitivity than fasting plasma glucose ≥ 7.0 mmol/l, 2-h plasma glucose ≥ 11.1 mmol/l and HbA(1c) ≥ 48 mmol/mol (≥ 6.5%).

CONCLUSIONS

An HbA(1c) cut-off value of ≥ 42 mmol/mol (≥ 6.0%) was highly sensitive and specific in diagnosing diabetes mellitus. This optimal cut-off level may be suitable as a diagnostic criterion for diabetes in a Bangladeshi population.

Association between serum endogenous secretory receptor for advanced glycation end products and risk of type 2 diabetes mellitus with combined depression in the Chinese population

OBJECTIVE

The role of the endogenous secretory receptor for advanced glycation end products (esRAGE) in depression of diabetes patients and its clinical significance are unclear. This study investigated the role of serum esRAGE in patients with type 2 diabetes mellitus with depression in the Chinese population.

PATIENTS AND METHODS

One hundred nineteen hospitalized patients with type 2 diabetes were recruited at Fujian Provincial Hospital (Fuzhou, China) from February 2010 to January 2011. All selected subjects were assessed with the Hamilton Rating Scale for Depression (HAMD). Among them, 71 patients with both type 2 diabetes and depression were included. All selected subjects were examined for the following: esRAGE concentration, glycosylated hemoglobin (HbA1c), blood lipids, C-reactive protein, trace of albumin in urine, and carotid artery intima-media thickness (IMT). Association between serum esRAGE levels and risk of type 2 diabetes mellitus with depression was also analyzed.

RESULTS

There were statistically significant differences in gender, age, body mass index, waist circumference, and treatment methods between the group with depression and the group without depression (P<0.05). Multiple linear regression analysis showed that HAMD scores were negatively correlated with esRAGE levels (standard regression coefficient -0.270, P<0.01). HAMD-17 scores were positively correlated with IMT (standard regression coefficient 0.183, P<0.05) and with HbA1c (standard regression coefficient 0.314, P<0.01).

CONCLUSIONS

Female gender, younger age, obesity, poor glycemic control, complications, and insulin therapy are all risk factors of type 2 diabetes mellitus with combined depression in the Chinese population. Inflammation and atherosclerosis play an important role in the pathogenesis of depression. esRAGE is a protective factor of depression among patients who have type 2 diabetes.

Multi-center feasibility study evaluating recruitment, variability in risk factors and biomarkers for a diet and cancer cohort in India

BACKGROUND

India's population exhibits diverse dietary habits and chronic disease patterns. Nutritional epidemiologic studies in India are primarily of cross-sectional or case-control design and subject to biases, including differential recall of past diet. The aim of this feasibility study was to evaluate whether a diet-focused cohort study of cancer could be established in India, providing insight into potentially unique diet and lifestyle exposures.

METHODS

Field staff contacted 7,064 households within three regions of India (New Delhi, Mumbai, and Trivandrum) and found 4,671 eligible adults aged 35-69 years. Participants completed interviewer-administered questionnaires (demographic, diet history, physical activity, medical/reproductive history, tobacco/alcohol use, and occupational history), and staff collected biological samples (blood, urine, and toenail clippings), anthropometric measurements (weight, standing and sitting height; waist, hip, and thigh circumference; triceps, sub-scapula and supra-patella skin fold), and blood pressure measurements.

RESULTS

Eighty-eight percent of eligible subjects completed all questionnaires and 67% provided biological samples. Unique protein sources by region were fish in Trivandrum, dairy in New Delhi, and pulses (legumes) in Mumbai. Consumption of meat, alcohol, fast food, and soft drinks was scarce in all three regions. A large percentage of the participants were centrally obese and had elevated blood glucose levels. New Delhi participants were also the least physically active and had elevated lipids levels, suggesting a high prevalence of metabolic syndrome.

CONCLUSIONS

A high percentage of participants complied with study procedures including biological sample collection. Epidemiologic expertise and sufficient infrastructure exists at these three sites in India to successfully carry out a modest sized population-based study; however, we identified some potential problems in conducting a cohort study, such as limited number of facilities to handle biological samples.