A prospective, randomized, multicentered controlled trial to compare the annual outcomes of patients with diabetes mellitus monitored with weekly fructosamine testing versus usual care: a 3-month interim analysis

A review of glycated albumin as an intermediate glycation index for controlling diabetes

INTRODUCTION

This article reviews glycated albumin (GA) as a potential intermediate-term glycation index to fill the gap between self-monitoring of blood glucose (SMBG) and hemoglobin A1c testing in diabetes management. The introduction gives an assessment of available short-, medium-, and long-term glycemic indicators. METHODOLOGIES AND UTILITY: Methods of GA measurement are summarized, and the variance of normal and diabetic GA values are discussed. Greatest uniformity in GA measurement is generally associated with immunoassay and the newer affinity chromatography methodologies utilized by reference laboratories. Utility of GA measurement includes its value as a marker for glycation, its substantial relationship to diabetes complications such as nephropathy and coronary artery disease, and as an unambiguous indicator of glycemic control in diabetes patients undergoing hemodialysis. Studies support the utility of GA in detecting short-term changes in glycemic control, and GA testing has been strongly recommended for gestational diabetes.

RESULTS AND DISCUSSION

The results of a survey with mailings to over 3500 diabetes care professionals primarily in the United States are outlined and analyzed (margin of error: +/-6.5%, 95% confidence). Respondents strongly supported the need for a test for intermediate glycemic control as well as the utility of a rapid GA test as a monthly glycemic indicator.

CONCLUSIONS

Such a test, as yet unavailable, could increase compliance and enhance empowerment among diabetes patients. It also has the potential to reduce the number of recommended SMBG tests, which may result in significant health care cost savings.

Meta-analysis of the health effects of using the glycaemic index in meal-planning

Diabetes mellitus and CVD are some of the leading causes of mortality and morbidity. Accumulating data indicate that a diet characterised by low-glycaemic index (GI) foods may improve the management of diabetes or lipid profiles. The objective of the present meta-analysis was to critically analyse the scientific evidence that low-GI diets have beneficial effects on carbohydrate and lipid metabolism compared with high-GI diets. We searched for randomised controlled trials with a crossover or parallel design published in English between 1981 and 2003, investigating the effect of low-GI v. high-GI diets on markers for carbohydrate and lipid metabolism. Unstandardised differences in mean values were examined using the random effects model. The main outcomes were fructosamine, glycated Hb (HbA1c), HDL-cholesterol, LDL-cholesterol, total cholesterol and triacylglycerol. Literature searches identified sixteen studies that met the strict inclusion criteria. Low-GI diets significantly reduced fructosamine by –0·1 (95 % CI –0·20, 0·00) mmol/l (P=0·05), HbA1c by 0·27 (95 % CI –0·5, –0·03) % (P=0·03), total cholesterol by –0·33 (95 % CI –0·47, –0·18) mmol/l (P>0·0001) and tended to reduce LDL-cholesterol in type 2 diabetic subjects by –0·15 (95 % CI –0·31, –0·00) mmol/l (P=0·06) compared with high-GI diets. No changes were observed in HDL-cholesterol and triacylglycerol concentrations. No substantial heterogeneity was detected, suggesting that the effects of low-GI diets in these studies were uniform. Results of the present meta-analysis support the use of the GI as a scientifically based tool to enable selection of carbohydrate-containing foods to reduce total cholesterol and to improve overall metabolic control of diabetes.

Diagnostic accuracy of glycohemoglobin A1c (HbA1c) for postprandial hyperglycemia was equivalent to that of fasting blood glucose

OBJECTIVES

To compare the sensitivity, specificity, and total accuracy of an HbA1c of > or =6.5% in the detection of hyperglycemia (PPHG) relative to those of a fasting blood glucose (FBG) of > or =7.0 mmol/L.

METHODS

A total of 6,010 subjects (2,987 men and 3,023 women) living or working in Kasugai, Japan, underwent a medical checkup at Kasugai City Medical Care Center between April 2001 and March 2002. For the 91 subjects who had either a FBG of > or =7.0 mmol/L or an HbA1c of > or =6.5%, a 75-g oral glucose tolerance test was performed to confirm or exclude PPHG. We calculated the true- and false-positive odds ratios to evaluate the sensitivity and specificity of HbA1c relative to FBG, and compared the overall accuracy by calculating the conditional relative odds ratio (CROR).

RESULTS

Among the 91 subjects, the true- and false-positive odds ratios were 0.43 (95% CI 0.26-0.69) and 0.40 (0.13-1.27) (Fisher's exact test, P < .090), respectively; the CROR was 1.07 (95% CI 0.30-3.75).

CONCLUSIONS

Although the HbA1c test was marginally more specific but less sensitive than the FBG test, at the given cutoff points the accuracies of two tests were equivalent.

Pharmacogenomic assessment of treatment options in gestational diabetes

Gene expression profiles offer a multidimensional view of metabolic diseases, typically characterized by a single parameter, and can provide a basis for choosing between therapies yielding a common clinical end point. We applied such an approach in gestational diabetes mellitus (GDM). Gene expression was examined in four maternal tissues and placentas from normal patients and euglycemic GDM patients, undergoing elective Cesarean sections at term, treated either by diet or diet plus insulin. Deviations from normal were 11-fold greater for the patients treated by diet, alone, than for patients treated by diet plus insulin. Assuming the achievement of a "normal" gene expression profile, in addition to euglycemia, is a desirable outcome of treatment, insulin treatment appears to have a beneficial effect in the treatment of GDM. Subsequently, we utilized the expression data to identify serum biomarkers that provide ways to monitor the benefits of insulin treatment in GDM.

A prospective, randomized, multicentered controlled trial to compare the annual glycemic and quality outcomes of patients with diabetes mellitus monitored with weekly fructosamine testing versus usual care

Fructosamine is an indicator of overall glycemic control for a 10-14-day time frame, medium-term marker, versus the 90-day average indicated by the hemoglobin A1c (A1C) test. The utility of the home fructosamine test for management of persons with diabetes remains undefined. The primary objectives of this study were (1) to compare the annual A1C results of subjects monitoring weekly fructosamine with those receiving usual care, (2) to identify the number of subjects achieving goal A1C, and (3) to determine if the addition of a weekly fructosamine test changed a subject's quality of life. This was a prospective, randomized, multicenter, controlled trial. Subjects were recruited from three sites and randomly assigned to collect weekly fructosamine in addition to daily glucose (Group 1) or to receive usual care of daily glucose collection (Group 2). Follow-up occurred at 3-month intervals for a year. Baseline and quarterly A1C tests were collected. Quality of life assessment was conducted at baseline and at the final study visit. Seventy-two subjects were randomized. Demographic and whole blood assessments were similar between the two groups at baseline. The mean percent change of A1C from baseline to final study visit in Group 1 (-0.52 +/- 1.5) was not statistically different than Group 2 (-0.86 +/- 1.4) (P = 0.320). Seven subjects in each group achieved A1C of less than 7% (P = 0.532). No change in quality of life between or within the two groups was observed (P > 0.05) for each area of concern. Blood glucose monitoring alone was shown to be superior to the additional fructosamine testing after 1 year of treatment; however, weekly fructosamine testing demonstrated a decrease in A1C earlier and more consistently throughout the study. Despite glycemic improvement, the number of subjects attaining American Diabetes Association-defined A1C goals was not different between the treatment groups. Quality of life did not change with the addition of a weekly fructosamine test.