Review of hemoglobin A(1c) in the management of diabetes

Trajectory of haemoglobin A1c and incidence of cardiovascular disease in patients with type 2 diabetes mellitus

AIM

To evaluate the association between changes in haemoglobin A1c (HbA1c) and the concurrent incidence of cardiovascular disease (CVD) in type 2 diabetes mellitus (T2DM) patients.

METHOD

We conducted a retrospective cohort study among T2DM patients with HbA1c measurement after T2DM diagnosis between August 2009 and September 2010. The patients were classified into six subgroups based on baseline HbA1c (<7%; 7%-7.9%; ≥8%) and age (<65; ≥65 years), and then clustered into classes by HbA1c trajectory and CVD incidence over the 12-year follow-up period using joint latent class mixture models. We explored the HbA1c trajectories and CVD incidences in each latent class. Multinomial logistic regression was used to compare the baseline characteristics among different latent classes.

RESULTS

A total of 128 843 T2DM patients were included with a median follow-up period of 11.7 years. Ten latent classes were identified in patients with baseline HbA1c ≥ 8% and age <65 years, while seven classes were identified in the other five groups. Among all the identified latent classes, patients with fluctuating HbA1c trajectories, characterized by alternating periods of increase and decrease, had higher CVD incidences. Male patients, and patients with higher baseline HbA1c and use of antidiabetic drugs were more likely to have a fluctuating HbA1c trajectory. More specifically, patients aged < 65 years with younger age or a smoking habit, and patients aged ≥ 65 years with a longer duration of T2DM were more likely to have a fluctuating HbA1c trajectory.

CONCLUSION

We found that T2DM patients with fluctuating HbA1c trajectories could have a higher CVD risk. Different trajectory-associated characteristics in age subgroups highlight the need for individualized management of T2DM patients.

Longitudinal metabolite and protein trajectories prior to diabetes mellitus diagnosis in Danish blood donors: a nested case-control study

AIMS/HYPOTHESIS

Metabolic risk factors and plasma biomarkers for diabetes have previously been shown to change prior to a clinical diabetes diagnosis. However, these markers only cover a small subset of molecular biomarkers linked to the disease. In this study, we aimed to profile a more comprehensive set of molecular biomarkers and explore their temporal association with incident diabetes.

METHODS

We performed a targeted analysis of 54 proteins and 171 metabolites and lipoprotein particles measured in three sequential samples spanning up to 11 years of follow-up in 324 individuals with incident diabetes and 359 individuals without diabetes in the Danish Blood Donor Study (DBDS) matched for sex and birth year distribution. We used linear mixed-effects models to identify temporal changes before a diabetes diagnosis, either for any incident diabetes diagnosis or for type 1 and type 2 diabetes mellitus diagnoses specifically. We further performed linear and non-linear feature selection, adding 28 polygenic risk scores to the biomarker pool. We tested the time-to-event prediction gain of the biomarkers with the highest variable importance, compared with selected clinical covariates and plasma glucose.

RESULTS

We identified two proteins and 16 metabolites and lipoprotein particles whose levels changed temporally before diabetes diagnosis and for which the estimated marginal means were significant after FDR adjustment. Sixteen of these have not previously been described. Additionally, 75 biomarkers were consistently higher or lower in the years before a diabetes diagnosis. We identified a single temporal biomarker for type 1 diabetes, IL-17A/F, a cytokine that is associated with multiple other autoimmune diseases. Inclusion of 12 biomarkers improved the 10-year prediction of a diabetes diagnosis (i.e. the area under the receiver operating curve increased from 0.79 to 0.84), compared with clinical information and plasma glucose alone.

CONCLUSIONS/INTERPRETATION

Systemic molecular changes manifest in plasma several years before a diabetes diagnosis. A particular subset of biomarkers shows distinct, time-dependent patterns, offering potential as predictive markers for diabetes onset. Notably, these biomarkers show shared and distinct patterns between type 1 diabetes and type 2 diabetes. After independent replication, our findings may be used to develop new clinical prediction models.

Perspective of Continuous Glucose Monitoring-Based Interventions at the Various Stages of Type 2 Diabetes

Continuous glucose monitoring (CGM) is now advocated for the clinical management of individuals with type 1 diabetes (T1D). However, this glucose monitoring strategy is not routinely used in type 2 diabetes (T2D), given the large population, significant cost implications and relatively limited supporting evidence. T2D is a more heterogenous condition compared with T1D with various glucose lowering therapies that do not necessarily require CGM to ensure within target glucose levels. While all individuals with T2D may benefit from CGM at certain time points, the whole T2D population does not necessarily require this technology continuously, which should be prioritized based on patient benefit and cost effectiveness. In this pragmatic opinion piece, we describe the rationale and evidence for CGM use in different subgroups of individuals with T2d, divided according to the stage of the condition, glycemic therapies, presence of diabetes complications, or associated co-morbidities. We discuss a total of 16 T2D subgroups and provide a clinical view on CGM use in each, based on current evidence while also highlighting areas of knowledge gaps. This work provides health care professionals with a simple guide to CGM use in different T2D groups and gives suggestion for future studies to justify expansion of this technology.

Sustained metabolic dysregulation and the emergence of diabetes: associations between HbA1c and metabolic syndrome components in Tunisian diabetic and nondiabetic groups

INTRODUCTION

Metabolic Syndrome (MetS), diabetes, and other noncommunicable diseases (NCDs) have been a major focus of research in recent decades as the prevalence of these conditions continues to rapidly increase globally. However, the timing and patterns of development from metabolic risk factors to disease states are less well understood and are especially critical to understand in low- and middle-income countries (LMICs) and populations undergoing epidemiological transitions.

METHODS

Nationally representative sociodemographic, anthropometric, and point-of-care biomarker data from the 2016 Tunisian Health Examination Survey (n = 8170) were used to determine the prevalence of diabetes and MetS components in Tunisia and to investigate associations between glycated hemoglobin (HbA1c) and MetS components (blood pressure [BP], HDL cholesterol [HDL], triglycerides [TG], and waist circumference [WC]) in participants aged 15-97 years old. To better understand how sustained metabolic dysregulation and disease states impact these associations, diabetic and nondiabetic groups were analyzed separately.

RESULTS

The overall prevalence of diabetes based on measured HbA1c was 18.2%. The diabetic groups had a higher prevalence of each individual MetS component, and significantly higher (BP, TG, WC, and HbA1c) and lower (HDL) values than the nondiabetic groups. Yet, there were a higher number of significant associations between HbA1c and MetS components found in nondiabetic women and men when compared to diabetic women and men. HbA1c was positively associated with the cumulative number of MetS components, irrespective of diabetes status in men and women.

CONCLUSIONS

The prevalence of both diabetes and MetS components (particularly low HDL cholesterol and elevated TG) is high among the Tunisian population. More MetS components were associated with HbA1c in nondiabetic individuals, showing a strong connection between the development of MetS components and diabetes. However, once the diabetes disease state manifests, there is more variability in the relationships. These results show the potential for HbA1c to be an indicator of metabolic health below clinical disease cutoffs, which may allow insights into the physiological changes that precipitate the emergence of diabetes.

Sex- and age-specific associations of serum essential elements with diabetes among the Chinese adults: a community-based cross-sectional study

BACKGROUND

Although several studies have found the relationship between essential elements and diabetes, the studies about the association of essential elements with diabetes diagnosed according to an oral glucose tolerance test (OGTT) and glycated hemoglobin (HbA1c) in a sex- and age-specific manner were limited. To investigate the linear and nonlinear relationship of five essential elements including iron (Fe), copper (Cu), Zinc (Zn), magnesium (Mg), and calcium (Ca) with diabetes, fasting plasma glucose (FPG), 2-h postprandial plasma glucose (PPG), and HbA1c and to evaluate the sex- and age-specific heterogeneities in these relationships.

METHODS

A total of 8392 community-dwelling adults were recruited to complete a questionnaire and undergo checkups of anthropometric parameters and serum levels of five metals (Fe, Cu, Zn, Mg, and Ca). The multivariable logistic and linear regression, the restricted cubic spline (RCS) analysis, and subgroup analysis were applied to find the associations between the essential elements and the prevalence of diabetes as well as FPG, PPG, and HbA1c.

RESULTS

In the multivariable logistic regression and multivariable linear regression, serum Cu was positively associated with FPG, PPG, and HbA1c while serum Mg was significantly inversely correlated with FPG, PPG, HbA1c, and diabetes (all P < 0.001). In the RCS analysis, the non-linear relationship of Cu and diabetes (P < 0.001) was found. In the subgroup analysis, stronger positive associations of Cu with diabetes (P for interaction = 0.027) and PPG (P for interaction = 0.002) were found in younger women.

CONCLUSIONS

These findings may lead to more appropriate approaches to essential elements supplementation in people with diabetes of different ages and sexes. However, more prospective cohort and experimental studies are needed to probe the possible mechanism of sex- and age-specific associations between serum essential elements and diabetes.

Association between the stress-hyperglycemia ratio and all-cause mortality in community-dwelling populations: An analysis of the National Health and Nutrition Examination Survey (NHANES) 1999-2014

BACKGROUND

Reportedly, the stress-hyperglycemia ratio (SHR) is closely associated with poor prognosis in patients with severe acute disease. However, the community-dwelling may also be in a state of stress due to environmental exposure. Our study aimed to explore the association between SHR and all-cause mortality in the community-dwelling population.

METHODS

A total of 18 480 participants were included out of 82 091 from the NHANES 1999-2014 survey. The Kaplan-Meier survival analyses were used to assess the disparities in survival rates based on SHR, and the log-rank test was employed to investigate the distinctions between groups. The multivariate Cox regression analysis and restricted cubic spline (RCS) analysis were performed to assess the association of SHR with all-cause mortality. A subgroup analysis was also conducted.

RESULTS

A total of 3188 deaths occurred during a median follow-up period of 11.0 (7.7; 15.4) years. The highest risk for all-cause mortality was observed when SHR≤ 0.843 or SHR ≥0.986 (log-rank p < .001). After adjusting for the confounding factors, compared with subjects in the second SHR quartile (Q2), participants in the highest (Q4, adjusted hazard ratio [HR] 1.49, 95% confidence interval [CI] 1.28-1.73) and lowest quartiles (Q1, adjusted HR 1.37, 95% CI 1.16-1.60) have a higher probability of all-cause death. The RCS observed a dose-response U-shaped association between SHR and all-cause mortality. The U-shaped association between SHR and all-cause mortality was similar across subgroup analysis.

CONCLUSIONS

The SHR was significantly associated with all-cause mortality in the community-dwelling population, and the relationship was U-shaped.

Baseline glycated albumin level and risk of type 2 diabetes mellitus in Healthy individuals: a retrospective longitudinal observation in Korea

Glycated albumin (GA) reflects glycemic status for the past three weeks. GA level demonstrates a strong correlation with HbA1c level and is used as an adjunctive biomarker for diagnosis and monitoring of type 2 diabetes mellitus (T2DM). In this study, we validated the predictive performance of baseline GA for development of T2DM in healthy individuals in Korea. From August 2013 to September 2014, the medical records of 3,771 healthy Koreans were retrospectively reviewed. Each participant was categorized into tertiles based on initial GA level. During the follow-up period through May 2020, study participants were evaluated for T2DM using HbA1c, fasting glucose level, and a self-reported diagnosis history. Baseline GA level by tertile (T1 to T3) was 10.4 ± 0.8% (mean ± SD), 12.1 ± 0.3%, and 13.7 ± 0.9%, respectively. The median follow-up was 5.97 years, during which 4.9% (186 of 3,771) of the participants developed T2DM. After adjusting for confounding factors, the hazard ratio for the development of T2DM in the highest GA level group (T3) compared to the reference group (T1) was 2.46 (95% CI, 1.7 to 3.58, p < 0.001 for trend) with a Harrell's C index of 0.80 (95% CI, 0.76 to 0.83). Also, within highest group of baseline HbA1c and FG levels, higher GA levels were associated with an increased HRs for T2DM. In conclusion, Our study confirms that the risk of T2DM increases with baseline GA level. Additional follow-up of the cohort is warranted to investigate the correlations between GA and other clinical indicators including diabetic complications.

The Effect of Iron Replacement Therapy on HbA1c Levels in Diabetic and Nondiabetic Patients: A Systematic Review and Meta-Analysis

BACKGROUND

Several studies have reported that iron-deficiency anemia (IDA) and its treatment might lead to a distorted reading of glycated hemoglobin (HbA1c) value. Hence, this review aims to systematically investigate the effect of iron replacement therapy (IRT) on HbA1c levels, as the literature is deficient in assessing this clinical phenomenon.

METHODS

An electronic search of the Cochrane, MEDLINE, and Embase databases was conducted by four independent authors.

RESULTS

Among the 8332 articles identified using the search strategy, 10 records (with a total of 2113 participants) met the inclusion criteria and were analyzed. In nine of the studies, IRT was found to decrease HbA1c levels; in the remaining study, IRT was found to increase HbA1c levels. The effect size of the pooled standardized mean difference in HbA1c levels between the treatment and control groups with IDA was 1.8 (95% CI = -0.5, 2.31). Heterogeneity was assessed using the I2 and χ2 tests, and the resultant values were 98.46% and p = 0.09, respectively. Additionally, the mean difference between the HbA1c levels (pre-IRT and post-IRT) showed a drop in the HbA1c levels which ranged from 1.20 to 0.43 mg/dL.

CONCLUSIONS

The results suggest that IRT decreases HbA1c levels, and it is helpful in treating IDA patients with poor glycemic control. Accordingly, the results provide an added perspective on antidiabetic medication dosing and physicians' interpretation of initially elevated HbA1c values.

Glycated Hemoglobin Is Suboptimal for the Screening of Prediabetes and Type 2 Diabetes in Adults With Nonalcoholic Fatty Liver Disease

OBJECTIVES

Nonalcoholic fatty liver disease (NAFLD) is a risk factor for type 2 diabetes (T2D), but T2D screening tests are not well validated in this population. In this study, we assessed performance of glycated hemoglobin (A1C) and fasting plasma glucose (FPG) in glucose dysmetabolism screening and aimed to optimize detection thresholds for individuals with NAFLD.

METHODS

We retrospectively included oral glucose tolerance tests (OGTTs) from consecutive patients undergoing a specialized clinic for NAFLD, if A1C and/or fasting glucose was available within 3 months of OGTT. We compared performances of A1C and fasting glucose with the "gold standard" of OGTT using thresholds from the 2018 Diabetes Canada guidelines. A1C and FPG thresholds were optimized for detection of glucose dysmetabolism using receiver operating characteristic curves.

RESULTS

We included 63 OGTTs from individuals with NAFLD (52% female, age 48 [interquartile range 35 to 63] years, body mass index 34 [interquartile range 29 to 40] kg/m2). A1C had 16% (95% confidence interval [CI] 6% to 38%) sensitivity (Se) and 97% (95% CI 85% to 100%) specificity (Sp) for T2D detection, and 45% (95% CI 30% to 62%) Se and 100% (95% CI 83% to 100%) Sp for abnormal blood glucose detection. FPG had 67% (95% CI 45% to 83%) Se and 100% (95% CI 92% to 100%) Sp for T2D detection, and 74% (95% CI 59% to 85%) Se and 92% (95% CI 74% to 99%) Sp for abnormal blood glucose detection. Optimal A1C and FPG thresholds were 5.6% and 6.3 mmol/L for T2D detection, which are lower than current recommendations.

CONCLUSIONS

A1C is less sensitive than FPG and is suboptimal for T2D detection, suggesting that OGTT may be obtained if A1C is ≥5.6% or FPG is ≥6.3 mmol/L in individuals with NAFLD, to avoid underdiagnosis and treatment inertia.

Effects of curcumin/turmeric supplementation on glycemic indices in adults: A grade-assessed systematic review and dose-response meta-analysis of randomized controlled trials

INTRODUCTION

Glycemic control is of utmost importance both as a preventive measure in individuals at risk of diabetes and in the management of patients with disturbed glycemia. Turmeric/curcumin has been extensively studied in this field. In the present systematic review and meta-analysis, we aimed at investigating the impact of turmeric/curcumin supplementation on glycemic control.

METHODS

Major online databases (PubMed, Scopus, Web of Science, Cochrane Library and Google Scholar) were systematically searched from inception up to October 2022. Relevant randomized controlled trials (RCTs) meeting our eligible criteria were included. Weighted mean differences (WMDs) with confidence intervals (CIs) were expressed using a random-effect model. Subgroup analyses were conducted to find the sources of heterogeneities. To detect risk of bias in the included studies, we used the Cochrane risk-of-bias tool. The registration number was CRD42022374874.

RESULTS

Out of 4182 articles retrieved from the initial search, 59 RCTs were included. Our findings suggested that turmeric/curcumin supplementation was significantly effective in improving fasting blood sugar (WMD: 4.60 mg/dl; 95% CI: 5.55, -3.66), fasting insulin levels (WMD: 0.87 μIU/ml; 95% CI: 1.46, -0.27), hemoglobin A1c (HbA1c) (WMD: 0.32%; 95% CI: 0.45, -0.19), and homeostatic model assessment of insulin resistance (HOMA-IR) (WMD: 0.33; 95% CI: 0.43, -0.22).

CONCLUSION

Our results indicate that turmeric/curcumin supplementation can be considered as a complementary method in the management of disturbed glycemia.

Analytical evaluation and quality assessment of the ARKRAY ADAMS A1c Lite HA-8380V for HbA1c

INTRODUCTION

ARKRAY ADAMS A1c Lite HA-8380V is a fully automated high- performance liquid chromatography system for the measurement of HbA1c. We aimed to evaluate its analytical performance using the Variant Mode.

METHODS

Carry-over, linearity, imprecision, trueness, interferences and comparison against ARKRAY ADAMS A1c HA-8180V and HA-8180T analyzers were studied.

RESULTS

Total CVs 0.93% (IFCC units), 0.63% (NGSP units) at low concentration and 1.01% (IFCC) 0.74% (NGSP), at high concentration. Mean difference with the target values was -0.44 mmol/mol (IFCC) -0.04% (NGSP). Carry-over, linearity and method comparison were excellent.The results were not affected in the range of total Hb 39-199 g/L, labile fraction 5.7%, carbamylated Hb 9.1% nor acetylated Hb 7.8%, effect of common variants was negligible.

CONCLUSIONS

the analyzer demonstrated very good analytical performances, according to the consensus criteria established for HbA1c; it is adequate for laboratories with medium-low workloads.

Factors affecting Hemoglobin A1c in the longitudinal study of the Iranian population using mixed quantile regression

Diabetes, a major non-communicable disease, presents challenges for healthcare systems worldwide. Traditional regression models focus on mean effects, but factors can impact the entire distribution of responses over time. Linear mixed quantile regression models (LQMMs) address this issue. A study involving 2791 diabetic patients in Iran explored the relationship between Hemoglobin A1c (HbA1c) levels and factors such as age, sex, body mass index (BMI), disease duration, cholesterol, triglycerides, ischemic heart disease, and treatments (insulin, oral anti-diabetic drugs, and combination). LQMM analysis examined the association between HbA1c and the explanatory variables. Associations between cholesterol, triglycerides, ischemic heart disease (IHD), insulin, oral anti-diabetic drugs (OADs), a combination of OADs and insulin, and HbA1c levels exhibited varying degrees of correlation across all quantiles (p < 0.05), demonstrating a positive effect. While BMI did not display significant effects in the lower quantiles (p > 0.05), it was found to be significant in the higher quantiles (p < 0.05). The impact of disease duration differed between the low and high quantiles (specifically at the quantiles of 5, 50, and 75; p < 0.05). Age was discovered to have an association with HbA1c in the higher quantiles (specifically at the quantiles of 50, 75, and 95; p < 0.05). The findings reveal important associations and shed light on how these relationships may vary across different quantiles and over time. These insights can serve as guidance for devising effective strategies to manage and monitor HbA1c levels.

The Association between Neutrophil-to-Lymphocyte Ratio and Glycemic Control in Type 2 Diabetes Mellitus: A Systematic Review and Meta-Analysis

Background

Glycated hemoglobin (HbA1c) is a commonly used clinical marker to monitor the control of type 2 diabetes mellitus patients (T2DM). However, it is unable to identify the ongoing inflammatory changes in the body. These factors could be easily identified and monitored by the neutrophil-to-lymphocyte ratio (NLR). Therefore, this study is aimed at investigating the relationship between NLR and glycemic control in T2DM.

Method

A comprehensive search of eligible studies was performed in various databases published until July 2021. A random effect model was used to estimate the standardized mean difference (SMD). A metaregression, subgroup, and sensitivity analysis were conducted to search for potential sources of heterogeneity.

Result

A total of 13 studies were included in this study. Accordingly, the SMD of the NLR values between the poor and good glycemic control groups was 0.79 (95% CI, 0.46-1.12). Our study also showed that high NLR was significantly associated with poor glycemic control in T2DM patients (OR = 1.50, 95% CI: 1.30-1.93).

Conclusion

The results of this study suggest an association between high NLR values and an elevated HbA1C in T2DM patients. Therefore, NLR should be considered a marker of glycemic control in addition to HbA1c in T2DM patients.

Rubrometabolic Syndrome

Metabolic syndrome (MS), a conglomeration of several conditions including obesity, type 2 diabetes mellitus (T2DM), insulin resistance, elevated blood pressure, and dyslipidemia is reaching epidemic proportions. Anemia is caused by iron deficiency or dysregulation of iron homeostasis, leading to tissue hypoxia. Coexistence of anemia and MS or its components has been reported in the literature. The term "rubrometabolic syndrome" acts as a unifying entity linking the importance of blood in health and anemia in MS; it justifies two principles - redness of blood and low-grade inflammation. Chronic low-grade inflammation in MS affects iron metabolism leading to anemia. Tissue hypoxia that results from the anemic condition seems to be a major causative factor for the exacerbation of several microvascular and macrovascular components of T2DM, which include diabetic neuropathy, nephropathy, retinopathy, and cardiovascular complications. In obesity, anemia leads to malabsorption of micronutrients and can complicate the management of the condition by bariatric surgery. Anemia interferes with the diagnosis and management of T2DM, obesity, dyslipidemia, or hypertension due to its effect on pathological tests as well as medications. Since anemia in MS is multifaceted, the management of anemia is challenging as overcorrection of anemia with erythropoietin-stimulating agents can cause detrimental effects. These limitations necessitate availability of an effective and safe therapy that can maintain and elevate the hemoglobin levels along with maintaining the physiological balance of other systems. This review discusses the physiological links between anemia and MS along with diagnosis and management strategies in patients with coexistence of anemia and MS.

Association of community walkability and glycemic control among pregnant individuals with pregestational diabetes mellitus

BACKGROUND

Neighborhood walkability is a community-level social determinant of health that measures whether people who live in a neighborhood walk as a mode of transportation. Whether neighborhood walkability is associated with glycemic control among pregnant individuals with pregestational diabetes remains to be defined.

OBJECTIVE

This study aimed to evaluate the association between community-level neighborhood walkability and glycemic control as measured by hemoglobin A1c (A1C) among pregnant individuals with pregestational diabetes.

STUDY DESIGN

This was a retrospective analysis of pregnant individuals with pregestational diabetes enrolled in an integrated prenatal and diabetes care program from 2012 to 2016. Participant addresses were geocoded and linked at the census-tract level. The exposure was community walkability, defined by the US Environmental Protection Agency National Walkability Index (score range 1-20), which incorporates intersection density (design), proximity to transit stops (distance), and a mix of employment and household types (diversity). Individuals from neighborhoods that were the most walkable (score, 15.26-20.0) were compared with those from neighborhoods that were less walkable (score <15.26), as defined per national Environmental Protection Agency recommendations. The outcomes were glycemic control, including A1C <6.0% and <6.5%, measured both in early and late pregnancy, and mean change in A1C across pregnancy. Modified Poisson regression and linear regression were used, respectively, and adjusted for maternal age, body mass index at delivery, parity, race and ethnicity as a social determinant of health, insurance status, baseline A1C, gestational age at A1C measurement in early and late pregnancy, and diabetes type.

RESULTS

Among 417 pregnant individuals (33% type 1, 67% type 2 diabetes mellitus), 10% were living in the most walkable communities. All 417 individuals underwent A1C assessment in early pregnancy (median gestational age, 9.7 weeks; interquartile range, 7.4-14.1), and 376 underwent another A1C assessment in late pregnancy (median gestational age, 30.4 weeks; interquartile range, 27.8-33.6). Pregnant individuals living in the most walkable communities were more likely to have an A1C <6.0% in early pregnancy (15% vs 8%; adjusted relative risk, 1.46; 95% confidence interval, 1.00-2.16), and an A1C <6.5% in late pregnancy compared with those living in less walkable communities (13% vs 9%; adjusted relative risk, 1.33; 95% confidence interval, 1.08-1.63). For individuals living in the most walkable communities, the median A1C was 7.5 (interquartile range, 6.0-9.4) in early pregnancy and 5.9 (interquartile range, 5.4-6.4) in late pregnancy. For those living in less walkable communities, the median A1C was 7.3 (interquartile range, 6.2-9.2) in early pregnancy and 6.2 (interquartile range, 5.6-7.1) in late pregnancy. Change in A1C across pregnancy was not associated with walkability.

CONCLUSION

Pregnant individuals with pregestational diabetes mellitus living in more walkable communities had better glycemic control in both early and late pregnancy. Whether community-level interventions to enhance neighborhood walkability can improve glycemic control in pregnancy requires further study.

Trends in Quantification of HbA1c Using Electrochemical and Point-of-Care Analyzers

Glycated hemoglobin (HbA1c), one of the many variants of hemoglobin (Hb), serves as a standard biomarker of diabetes, as it assesses the long-term glycemic status of the individual for the previous 90-120 days. HbA1c levels in blood are stable and do not fluctuate when compared to the random blood glucose levels. The normal level of HbA1c is 4-6.0%, while concentrations > 6.5% denote diabetes. Conventionally, HbA1c is measured using techniques such as chromatography, spectroscopy, immunoassays, capillary electrophoresis, fluorometry, etc., that are time-consuming, expensive, and involve complex procedures and skilled personnel. These limitations have spurred development of sensors incorporating nanostructured materials that can aid in specific and accurate quantification of HbA1c. Various chemical and biological sensing elements with and without nanoparticle interfaces have been explored for HbA1c detection. Attempts are underway to improve the detection speed, increase accuracy, and reduce sample volumes and detection costs through different combinations of nanomaterials, interfaces, capture elements, and measurement techniques. This review elaborates on the recent advances in the realm of electrochemical detection for HbA1c detection. It also discusses the emerging trends and challenges in the fabrication of effective, accurate, and cost-effective point-of-care (PoC) devices for HbA1c and the potential way forward.

Significant increase of serum extracellular vesicle-packaged growth differentiation factor 15 in type 2 diabetes mellitus: a cross-sectional study

BACKGROUND

Growth differentiation factor 15 (GDF15) is a stress-inducible factor involved in the inflammatory progression of many complications, including type 2 diabetes mellitus (T2DM). Growing evidence suggests that molecules in extracellular vesicles (EVs) are associated with diabetes or diabetes-related complications. However, the correlation between serum extracellular vesicle-derived growth differentiation factor15 (EV-GDF15) and T2DM is unknown. The aim of this cross-sectional study is to investigate whether serum EV-GDF15 is associated with T2DM incidence.

METHODS

116 individuals, including 78 T2DM and 38 non-T2DM, were recruited as participants. The concentrations of serum EV-GDF15 and serum GDF15 were determined by Luminex assay. Serum EVs were obtained by ultracentrifugation. Multivariate stepwise regression analysis was used to determine the association between serum GDF15 levels and fasting plasma glucose (FPG) as well as glycated hemoglobin (HbA1c). The association of serum EV-GDF15 levels with T2DM was determined by multivariate logistic regression analysis.

RESULTS

Our data showed that the levels of serum EV-GDF15 and serum GDF15 were significantly increased in T2DM patients compared with non-T2DM subjects (EV-GDF15 levels, 13.68 (6.61-23.44) pg/mL vs. 5.56 (3.44-12.09) pg/mL, P < 0.001; and serum GDF15 levels, 1025.49 (677.87-1626.36) pg/mL vs. 675.46 (469.53-919.98) pg/mL, P < 0.001). There was a linear correlation between EV-GDF15 levels and fasting plasma glucose (FPG) and Hemoglobin A1C (HbA1c) levels (normalized β = 0.357, P < 0.001; normalized β = 0.409, P < 0.001, respectively). Elevated levels of EV-GDF15 were accompanied by an increase in the proportion of patients with T2DM (from 47.5 to 78.9%) and a progressive independent association with the incidence of T2DM (from OR = 3.06, 95% CI 1.02-9.19, P = 0.047 to OR = 3.75, 95% CI 1.14-12.26, P = 0.029). Notably, high levels of serum GDF15 plus high levels of serum EV-GDF15 were significantly associated with T2DM more than either alone.

CONCLUSION

This study elucidated that increased levels of GDF15 in serum EVs were independently associated with T2DM.

Analytical evaluation and quality assessment of the ARKRAY ADAMS A1c HA-8190V for Hb A1c

ARKRAY ADAMS A1c HA-8190V is a fully automated high-pressure liquid chromatography (HPLC) system for the measurement of HbA1c. The runtime is 58 s per sample in the Variant mode and 24 s per sample in the Fast mode. We evaluated the analytical performance of this analyzer in the Variant mode, to verify the quality of analysis, according to the consensus criteria established for this measurand. Reproducibility, trueness, carry-over, linearity, interferences and comparison with ARKRAY ADAMS A1c HA-8180V and HA-8180T analyzers were evaluated. Total CVs were 0.76% (IFCC units) 0.55 (NGSP units) at low HbA1c concentration and 0.85% (IFCC units) 0.68 (NGSP units) at high HbA1c concentration. Mean difference with the target values was -1.25 mmol/mol (-0.119%) and total error at medium level was 2.83% (IFCC units), 2.46% (NGSP units) Carry-over was 0%. Linearity was shown in the range 27-122 mmol/mol (4.6-13.3%). The results were not affected in the range of total Hb 59-199 g/L, labile fraction up to 5.5%, carbamylated up to Hb 6.3% nor acetylated Hb up to 5.3%. Method comparison demonstrated good concordance between the methods. The analyzer demonstrated a high analytical performance adequate for routine clinical use in laboratories with high workloads.

Using Reminder Letters to Improve Adherence to Routine Hemoglobin A1C Testing in Adults with Diabetes

The American Diabetes Association (ADA) recommends hemoglobin A1C (A1C) goals of < 7% for most non-pregnant adults and < 8% for adult patients with extensive or life-limiting comorbidities. A1C testing is indicated every 3-months for patients not meeting goals to assess glycemic control, adjust medications, suggest lifestyle changes, and offer counseling. However, many patients do not adhere to routine testing. A clinic-wide quality improvement (QI) pilot project was implemented using mailed reminder letters to improve patient adherence to routine A1C testing in patients with hemoglobin A1C . 8%. Sixty-eight patients were identified for this letter intervention. Of these, 14 patients (20%) were historically adherent to 3-month interval testing, 31 patients (46%) were historically non-adherent, and 23 (34%) had historical A1C test intervals of less than 3-months because of provider orders. The primary outcome was improvement in A1C testing adherence rates of those who were previously non-adherent. There was a 58% increase overall and a 103% increase in testing rates among women. Statistical significance was not observed at the P = .05 level. However, improvement in adherence rates among women reached the P = .10 significance level. Mailed reminder letters may be useful in improving adherence to routine A1C testing in patients with diabetes. Further study of this intervention in larger groups is needed to provide timely data for the management of diabetes care.

Criteria for prediabetes and posttransplant diabetes mellitus after kidney transplantation: A 2-year diagnostic accuracy study of participants from a randomized controlled trial

Posttransplant diabetes mellitus (PTDM) and prediabetes (impaired glucose tolerance [IGT] and impaired fasting glucose [IFG]) are associated with cardiovascular events. We assessed the diagnostic performance of fasting plasma glucose (FPG) and HbA1c as alternatives to oral glucose tolerance test (OGTT)-derived 2-hour plasma glucose (2hPG) using sensitivity and specificity in 263 kidney transplant recipients (KTRs) from a clinical trial. Between visits at 6, 12, and 24 months after transplantation, 28%-31% of patients switched glycemic category (normal glucose tolerance [NGT], IGT/IFG, PTDM). Correlations of FPG and HbA1c against 2hPG were lower at 6 months (r = 0.59 [FPG against 2hPG]; r = 0.45 [HbA1c against 2hPG]) vs. 24 months (r = 0.73 [FPG against 2hPG]; r = 0.74 [HbA1c against 2hPG]). Up to 69% of 2hPG-defined PTDM cases were missed by conventional HbA1c and FPG thresholds. For prediabetes, concordance of FPG and HbA1c with 2hPG ranged from 6%-9%. In conclusion, in our well-defined randomized trial cohort, one-third of KTRs switched glycemic category over 2 years and although the correlations of FPG and HbA1c with 2hPG improved with time, their diagnostic concordance was poor for PTDM and, especially, prediabetes. Considering posttransplant metabolic instability, FPG's and HbA1c 's diagnostic performance, the OGTT remains indispensable to diagnose PTDM and prediabetes after kidney transplantation.

Assessment of Glycemic Control in Patients With Diabetes in Northern Sudan Using Calculated HbA1c

BACKGROUND

Diabetes mellitus (DM) significantly burdens health services worldwide. As a simple and cost-effective method, the mathematical calculation of HbA1c is coming to be of value in areas with scarce resources. This study aimed to use calculated HbA1c to ascertain the prevalence of uncontrolled DM and correlate it with the risk factors for DM.

METHODS

In the River Nile State of northern Sudan, a cross-sectional study was conducted in five leading cities from May to August 2021. Patients diagnosed and recorded as having type 2 or type 1 DM were included in this study. Enzymatic methods were used to assess fasting blood glucose (FBG). We used the mean of three FBG readings for three months to calculate HbA1c using the equation {HbA1c = (FBG mg/dl) x 0.03+2.6}, which was used to compute the estimated mediocre blood sugar over the course of three months.

RESULTS

A total of 2047 diabetic patients from northern Sudan were studied for their DM control. Nearly two-thirds (65.2%) had uncontrolled DM. Of the patients studied, uncontrolled DM was significantly positively associated with older age, history of ischemic heart disease, and being a housewife. Multivariate regression analysis showed significant correlations between uncontrolled DM, an inactive lifestyle, and obesity.

CONCLUSION

The prevalence of uncontrolled DM among known patients with diabetic in northern Sudan is high (65.2%). The inactive lifestyles of housewives and freelance workers, having type 1 DM, and being hypertensive and obese are risk factors significantly associated with uncontrolled DM and its related complications.

Metabolic disorders and post-acute hospitalization in black/mixed-race patients with long COVID in Brazil: A cross-sectional analysis

BACKGROUND

Although low-middle income countries have been disproportionately affected by the COVID-19 pandemic, there is scarce information about the impact of long COVID on their population. This study aimed to evaluate long COVID symptomatology, complications (hospital readmission and metabolic disorders), and main clinical features that impact Quality of Life (QoL).

METHODS

This cross-sectional study provides a detailed clinical and laboratory picture of individuals who presented residual symptoms after mild to severe acute COVID-19. Between Aug-2020 to Sep-2021, long COVID patients were evaluated in a reference center for long COVID in Bahia State, Brazil. The EQ-5D-5L questionnaire accessed QoL.

RESULTS

A total of 1164 (52 ±13.4 years, 57% female, 88% black/mixed-race) were evaluated 2.3 [IQR = 1.6-3.7] months after mild (n = 351, 30.2%), moderate (338, 29.0%) or severe (475, 40.8%) acute illness. Dyspnea (790, 67.9%), fatigue (738, 63.5%), and chest pain (525, 42.9%) were the most frequent residual symptoms regardless of acute severity, affecting the QoL of 88.9% of patients (n/N-826/925), mainly the domains of anxiety/depression and pain/discomfort. High levels of HbA1c were detected for 175 out of 664 patients (26.6%), 40% of them without a previous diagnosis of diabetes mellitus. Of note, hospital admission one-to-three months after the acute phase of disease was required for 51 (4.4%) patients.

CONCLUSION

In this majority-black/mixed-race population, long COVID was associated with post-acute hospitalization, newly diagnosed diabetes mellitus, and decreased QoL, particularly in women and regardless of disease severity of acute infection, suggesting important implications for health care system.

Effect of Iron Deficiency Anemia on Glycated Albumin Levels: A Comparative Study in Nondiabetic Subjects with Iron Deficiency Anemia

Objective Glycated hemoglobin A1c (HbA1c), used for monitoring glycemia control, is altered in iron deficiency anemia (IDA). Glycated albumin (GA) is considered an alternate biomarker to HbA1c. However, effect of IDA on GA needs to be studied.

Materials and Methods Thirty nondiabetic cases with IDA and 30 healthy controls were included. Fasting plasma glucose (FPG), creatinine, urea, albumin, total protein, ferritin, iron, unsaturated iron binding capacity, hemoglobin (Hb), HbA1c, complete hemogram, and GA were estimated. Transferrin saturation and total iron binding capacity (TIBC) were calculated. Statistical analysis was done using unpaired two-tailed t-test/Mann–Whitney U-test and Pearson's correlation/Spearman-rank correlation, as appropriate.

Results Total protein, albumin, Hb, iron, ferritin, and transferrin saturation were significantly lower while FPG, GA, TIBC, and HbA1c were significantly higher in cases compared to controls. HbA1C and GA have a significant negative correlation with iron, transferrin saturation, and ferritin. Significant negative correlations of GA with albumin (r = –0.754; p < 0.001) and Hb (r = –0.435; p = 0.001) and that of HbA1c with albumin (r = –0.271; p = 0.03) and Hb (r = –0.629; p  < 0.001) while significant positive correlation of Hb with albumin (r = 0.395; p = 0.002) and HbA1c with FPG (r = 0.415; p = 0.001) were observed.

Conclusion Low albumin levels increase plasma protein glycation, including albumin. Hence, elevated GA levels indicate false elevation of GA in scenario of lowered albumin observed in IDA, similar to HbA1c. Thus, using GA in diabetes mellitus with IDA should be avoided or used with caution to prevent potentially inappropriate treatment intensification and risk of hypoglycemia.

Missed Opportunities for Screening and Management of Dysglycemia among Patients Presenting with Acute Myocardial Infarction in North India: The Prospective NORIN STEMI Registry

Background

Dysglycemia is a major and increasingly prevalent cardiometabolic risk factor worldwide, but is often undiagnosed even in high-risk patients. We evaluated the impact of protocolized screening for dysglycemia on the prevalence of prediabetes and diabetes among patients presenting with ST-segment elevation myocardial infarction (STEMI) in North India.

Methods

We conducted a prospective NORIN STEMI registry-based study of patients presenting with STEMI to two government-funded tertiary care medical centers in New Delhi, India, from January to November 2019. Hemoglobin A1c (HbA1c) was collected at presentation as part of the study protocol, irrespective of baseline glycemic status.

Results

Among 3,523 participants (median age 55 years), 855 (24%) had known diabetes. In this group, baseline treatment with statins, sodium-glucose cotransporter 2 inhibitors, or glucagon-like peptide-1 receptor agonists was observed in 14%, <1%, and 1% of patients, respectively. For patients without known diabetes, protocolized inpatient screening identified 737 (28%) to have prediabetes (HbA1c 5.7-6.4%) and 339 (13%) to have newly detected diabetes (HbA1c ≥ 6.5%). Patients with prediabetes (49%), newly detected diabetes (53%), and established diabetes (48%) experienced higher rates of post-MI LV dysfunction as compared to euglycemic patients (42%). In-hospital mortality (5.6% for prediabetes, 5.1% for newly detected diabetes, 10.3% for established diabetes, 4.3% for euglycemia) and 30-day mortality (8.1%, 7.6%, 14.4%, 6.6%) were higher in patients with dysglycemia. Compared with euglycemia, prediabetes (adjusted odds ratio (aOR) 1.44 [1.12-1.85]), newly detected diabetes (aOR 1.57 [1.13-2.18]), and established diabetes (aOR 1.51 [1.19-1.94]) were independently associated with higher odds of composite 30-day all-cause mortality or readmission.

Conclusions

Among patients presenting with STEMI in North India, protocolized HbA1c screening doubled the proportion of patients with known dysglycemia. Dysglycemia was associated with worse clinical outcomes at 30 days, and use of established pharmacotherapeutic risk-reduction strategies among patients with known diabetes was rare, highlighting missed opportunities for screening and management of dysglycemia among high-risk patients in North India.

Association of change in haemoglobin A1c with adverse perinatal outcomes in women with pregestational diabetes

AIMS

To determine whether a net decline in glycosylated haemoglobin (HbA_1c ) from early to late pregnancy is associated with lower risk of adverse perinatal outcomes at delivery among women with pregestational diabetes.

METHODS

A retrospective analysis from 2012 to 2016 at a tertiary care centre. The exposure was the net change in HbA_1c from early (<20 weeks gestation) to late pregnancy (≥20 weeks gestation). Primary outcomes were large for gestational age (LGA) and neonatal hypoglycaemia. The association between outcomes per 6 mmol/mol (0.5%) absolute decrease in HbA_1c was evaluated using modified Poisson regression, and adjusted for age, body mass index, White Class, early HbA_1c and haemoglobin and gestational age at HbA_1c measurement and delivery.

RESULTS

Among 347 women with pregestational diabetes, HbA_1c was assessed in early (9 weeks [IQR 7,13]) and late pregnancy (31 weeks [IQR 29,34]). Mean HbA_1c decreased from early (59 mmol/mol [7.5%]) to late (47 mmol/mol [6.5%]) pregnancy. Each 6 mmol/mol (0.5%) absolute decrease in HbA_1c was associated with a 12% reduced risk of LGA infant (30%, aRR:0.88; 95% CI:0.81,0.95), and a 7% reduced risk of neonatal hypoglycaemia (35%, aRR:0.93; 95% CI:0.87,0.99). Preterm birth (36%, aRR:0.93; 95% CI:0.89,0.98) and neonatal intensive care unit admission (55%, aRR:0.95; 95% CI:0.91,0.98) decreased with a net decline in HbA_1c , but not caesarean delivery, pre-eclampsia, shoulder dystocia and respiratory distress syndrome.

CONCLUSIONS

Women with pregestational diabetes with a reduction in HbA_1c may have fewer infants born LGA or with neonatal hypoglycaemia. Repeated assessment of HbA_1c may provide an additional measure of glycaemic control.

The relative contribution of diurnal and nocturnal glucose exposures to HbA1c in type 1 diabetes males: a pooled analysis

Purpose

The exact contribution of daily glucose exposure to HbA1c in people with type 1 diabetes (T1D) remains controversial. We examined the contribution of pre- and postprandial glycaemia, nocturnal and early-morning glycaemia, and glycaemic variability to HbA1c levels in T1D. In this analysis, we used clinical data, namely age, BMI and HbA1c, as well as glycaemic metrics (24-h glycaemia, postprandial, nocturnal, early-morning glycaemia, wake-up glucose, and glycaemic variability) obtained over a four-week period of continuous glucose monitoring (CGM) wear in thirty-two males with T1D.

Methods

The trapezoid method was used estimate the incremental area under the glucose curve (iAUC) for 24-h, postprandial (3-h period following breakfast, lunch, and dinner, respectively), nocturnal (between 24:00–04:00 AM), and early-morning (2-h period 2-h prior to wake-up) glycaemia. Linear regression analysis was employed whereby CGM-derived glycaemic metrics were explanatory variables and HbA1c was the outcome.

Results

Thirty-two T1D males (mean ± SD: age 29 ± 4 years; HbA1c 7.3 ± 0.9% [56 ± 13 mmol/mol]; BMI 25.80 ± 5.01 kg/m²) were included in this analysis. In linear models adjusted for age and BMI, HbA1c was associated with 24-h mean glucose (r² = 0.735, p < 0.001), SD (r² = 0.643, p = 0.039), and dinner iAUC (r² = 0.711, p = 0.001). CGM-derived metrics and non-glycaemic factors explained 77% of the variance in HbA1c, in which postprandial glucose accounted for 32% of the variance explained. The single greatest contributor to HbA1c was dinner iAUC resulting in 0.6%-point (~7 mmol/mol) increase in HbA1c per SD increase in dinner iAUC.

Conclusions

Using comprehensive CGM profiling, we show that postprandial glucose, specifically evening-time postprandial glucose, is the single largest contributing factor to HbA1c in T1D.

Trial registration number

NCT02204839 (July 30th 2014); NCT02595658 (November 3rd 2015).

Expected or unexpected clinical findings in liver glycogen storage disease type IX: distinct clinical and molecular variability

OBJECTIVES

To reveal the different clinical presentations of liver glycogen storage disease type IX (GSD IX), which is a clinically and genetically heterogeneous type of glycogenosis.

METHODS

The data from the electronic hospital records of 25 patients diagnosed with liver GSD IX was reviewed. Symptoms, clinical findings, and laboratory and molecular analysis were assessed.

RESULTS

Of the patients, 10 had complaints of short stature in the initial presentation additionally other clinical findings. Elevated serum transaminases were found in 20 patients, and hepatomegaly was found in 22 patients. Interestingly, three patients were referred due to neurodevelopmental delay and hypotonia, while one was referred for only autism. One patient who presented with neurodevelopmental delay developed hepatomegaly and elevated transaminases during the disease later on. Three of the patients had low hemoglobin A1C and fructosamine values that were near the lowest reference range. Two patients had left ventricular hypertrophy. Three patients developed osteopenia during follow-up, and one patient had osteoporosis after puberty. The most common gene variant, PHKA2, was observed in 16 patients, 10 variants were novel and six variants were defined before. Six patients had variants in PHKG2, two variants were not defined before and four variants were defined before. PHKB variants were found in three patients. One patient had two novel splice site mutations in trans position. It was revealed that one novel homozygous variant and one defined homozygous variant were found in PHKB.

CONCLUSIONS

This study revealed that GSD IX may present with only hypotonia and neurodevelopmental delay without liver involvement in the early infantile period. It should be emphasized that although liver GSDIX is thought of as a benign disease, it might present with multisystemic involvement and patients should be screened with echocardiography, bone mineral densitometry, and psychometric evaluation.

Association between liver and chronic kidney disease on hemoglobin A1c concentrations

INTRODUCTION

HbA1c is the gold standard for measuring long-range glycemic control in patients with type-2 diabetes mellitus. Conditions such as CKD or LD can lead to spurious HbA1c test results. There is conflicting literature about the relationship between HbA1c, LD, and CKD.

METHODS

Results for HbA1c concentrations were retrieved from 2015- to 2019. We evaluated over 2,500 test results with LD and 20,000 results with CKD compared to over 21,000 test results without LD, iron deficiency anemia, or CKD. Patients were classified as having LD if they had high ALT and AST concentrations. If they have abnormal serum creatinine and BUN or low eGFR based on age-based reference ranges for CKD. Kruskal-Wallis statistical analyses method was used to test whether the two samples followed the same distribution and significance. Results The median HbA1c concentration was 5.8% (40 mmol/l) among LD classified patients in both males and females vs. 5.4% (36 mmol/l) (P<0.001) for females and 5.6% (38 mmol/l) (P<0.001) for males without LD. A significant difference in median HbA1c concentrations were also observed between CKD samples (female: 5.7% (39 mmol/l), male: 6.0% (42 mmol/l)) and non-CKD samples (female: 5.4% (36 mmol/l), male: 5.6% (38 mmol/l)) (P<0.001). Depending on the population's CKD stage, median concentrations of % HbA1c are increased from stage-1 through stage-4 and fell in Stage-5. Conclusion Patients with high AST and ALT concentrations or CKD can have increased HbA1c concentrations compared to normal patients. When using HbA1c concentrations to monitor diabetes, healthcare professionals should consider LD or CKD status before making any therapeutic decisions.

Report from the CVOT Summit 2021: new cardiovascular, renal, and glycemic outcomes

The 7th Cardiovascular Outcome Trial (CVOT) Summit on Cardiovascular, Renal, and Glycemic Outcomes, was held virtually on November 18-19, 2021. Pursuing the tradition of the previous summits, this reference congress served as a platform for in-depth discussion and exchange on recently completed CVOTs. This year's focus was placed on the outcomes of EMPEROR-Preserved, FIGARO-DKD, AMPLITUDE-O, SURPASS 1-5, and STEP 1-5. Trial implications for diabetes and obesity management and the impact on new treatment algorithms were highlighted for endocrinologists, diabetologists, cardiologists, nephrologists, and general practitioners. Discussions evolved from outcome trials using SGLT2 inhibitors as therapy for heart failure, to CVOTs with nonsteroidal mineralocorticoid receptor antagonists and GLP-1 receptor agonists. Furthermore, trials for glycemic and overweight/obesity management, challenges in diabetes management in COVID-19, and novel guidelines and treatment strategies were discussed.Trial registration The 8th Cardiovascular Outcome Trial Summit will be held virtually on November 10-11, 2022 ( http://www.cvot.org ).

Consumption of home-prepared meal at workplace as a predictor of glycated haemoglobin among people with type 2 diabetes in Hong Kong: a mixed-methods study

OBJECTIVES

There is increasing attention on association between eating patterns and diabetes control following global changes in eating patterns. There had been very limited research on the eating patterns of diabetic patients with employment, although working age population has seen the highest increase in diabetes incidence. This study aimed to identify workplace eating patterns in relation to glycaemic control among type 2 diabetic patients with employment.

METHODS

This is a sequential mixed-methods study. The exploratory qualitative study involved focus group interviews with 31 type 2 diabetic patients with employment, which guided the design of a subsequent cross-sectional investigation involving 185 patients with employment. Thematic analysis was conducted on the qualitative data to identify workplace eating patterns most relevant to glycaemic control. Hierarchical multiple linear regression was performed to examine association between workplace eating pattern and glycaemic control, proxied by HbA1c.

RESULTS

The focus group interviews identified frequency in the consumption of home-prepared meals (HPM) and meal hours as the major workplace eating patterns that affected glycaemic control. The cross-sectional study confirmed that regular consumption of HPM at workplace could explain variance of HbA1c, independent of socio-demographic factors, lifestyle factors and disease condition, with R² = 0.146, F(14, 170) = 2.075, p = 0.015; adjusted R² = 0.076. Patients who were female, in non-skilled occupation, on shift, with fixed work location and had break during work were more likely to consume HPM.

CONCLUSIONS

Consumption of HPM at workplace should be promoted to facilitate better glycaemic control by type 2 diabetic patients with employment, possibly through more practical dietary advice, and workplace accommodation in terms of space and facilities. In the context of COVID-19 pandemic, consumption of HPM also meant additional protection for diabetic patients through reducing close contact exposures in restaurants.

HbA1c Is Disproportionately Higher in Women and Older People With Type 1 Diabetes Compared With Flash Glucose Monitoring Metrics of Glycemic Control

AIMS

Discrepancy between HbA1c and glucose exposure may have significant clinical implications. We sought to assess predictors of disparity between HbA1c and flash monitoring metrics and how these relate to microvascular complications.

METHODS

We conducted a cross-sectional study of adults with type 1 diabetes (n = 518). We assessed the relationship between clinic HbA1c and flash monitoring metrics, predictors of discrepancy between these measurements, and whether discrepancy was associated with microvascular complications.

RESULTS

Actual HbA1c and estimated HbA1c were strongly correlated (r = .779, P < .001). The likelihood of having a higher actual HbA1c than estimated HbA1c was greater with increasing age (OR = 1.055 per year, P < .001) and lower in men (OR = .208, P < .001). HbA1c was significantly lower in men (58 mmol/mol [51-67]) (7.5% [6.8-8.3]) compared to women (61 mmol/mol [54-70], P = .021) (7.7% [7.1-8.6]), despite no significant differences in any flash monitoring metrics. Whereas HbA1c was not different between younger (≤39 years) and older individuals (>39 years) despite significantly higher glucose exposure, in younger people, based on multiple flash monitoring metrics. Having a lower estimated than actual HbA1c was independently associated with a lower prevalence of retinopathy (OR = .55, P = .004).

CONCLUSIONS

HbA1c appears to overestimate glucose exposure in women and older people with type 1 diabetes. This has potentially important clinical implications, as is hinted at by the independent relationship with retinopathy prevalence. It may also be of relevance when considering the use of HbA1c for the diagnosis of diabetes.

The Impact of Racial and Ethnic Health Disparities in Diabetes Management on Clinical Outcomes: A Reinforcement Learning Analysis of Health Inequity Among Youth and Young Adults in the SEARCH for Diabetes in Youth Study

OBJECTIVE

To estimate difference in population-level glycemic control and the emergence of diabetes complications given a theoretical scenario in which non-White youth and young adults (YYA) with type 1 diabetes (T1D) receive and follow an equivalent distribution of diabetes treatment regimens as non-Hispanic White YYA.

RESEARCH DESIGN AND METHODS

Longitudinal data from YYA diagnosed 2002-2005 in the SEARCH for Diabetes in Youth Study were analyzed. Based on self-reported race/ethnicity, YYA were classified as non-White race or Hispanic ethnicity (non-White subgroup) versus non-Hispanic White race (White subgroup). In the White versus non-White subgroups, the propensity score models estimated treatment regimens, including patterns of insulin modality, self-monitored glucose frequency, and continuous glucose monitoring use. An analysis based on policy evaluation techniques in reinforcement learning estimated the effect of each treatment regimen on mean hemoglobin A1c (HbA1c) and the prevalence of diabetes complications for non-White YYA.

RESULTS

The study included 978 YYA. The sample was 47.5% female and 77.5% non-Hispanic White, with a mean age of 12.8 ± 2.4 years at diagnosis. The estimated population mean of longitudinal average HbA1c over visits was 9.2% and 8.2% for the non-White and White subgroup, respectively (difference of 0.9%). Within the non-White subgroup, mean HbA1c across visits was estimated to decrease by 0.33% (95% CI -0.45, -0.21) if these YYA received the distribution of diabetes treatment regimens of the White subgroup, explaining ∼35% of the estimated difference between the two subgroups. The non-White subgroup was also estimated to have a lower risk of developing diabetic retinopathy, diabetic kidney disease, and peripheral neuropathy with the White youth treatment regimen distribution (P < 0.05), although the low proportion of YYA who developed complications limited statistical power for risk estimations.

CONCLUSIONS

Mathematically modeling an equalized distribution of T1D self-management tools and technology accounted for part of but not all disparities in glycemic control between non-White and White YYA, underscoring the complexity of race and ethnicity-based health inequity.

Glycemic Control and Risk of Sepsis and Subsequent Mortality in Type 2 Diabetes

OBJECTIVE

To investigate the nature of the relationship between HbA1c and sepsis among individuals with type 2 diabetes, and to assess the association between sepsis and all-cause mortality in such patients.

RESEARCH DESIGN AND METHODS

We included 502,871 individuals with type 2 diabetes recorded in the Swedish National Diabetes Register and used multivariable Cox regression and restricted cubic spline analyses to assess the association between time-updated HbA1c values and sepsis occurrence between 1 January 2005 and 31 December 2015. The association between sepsis and death was examined using multivariable Cox regression analysis.

RESULTS

Overall, 14,534 (2.9%) patients developed sepsis during the study period. On multivariable Cox regression analysis, compared with an HbA1c of 48-52 mmol/mol (6.5-6.9%), the adjusted hazard ratio for sepsis was 1.15 (95% CI 1.07-1.24) for HbA1c <43 mmol/mol (6.1%), 0.93 (0.87-0.99) for HbA1c 53-62 mmol/mol (7.0-7.8%), 1.05 (0.97-1.13) for HbA1c 63-72 mmol/mol (7.9-8.7%), 1.14 (1.04-1.25) for HbA1c 73-82 mmol/mol (8.8-9.7%), and 1.52 (1.37-1.68) for HbA1c >82 mmol/mol (9.7%). In the cubic spline model, a reduction of the adjusted risk was observed within the lower HbA1c range until 53 mmol/mol (7.0%), with a hazard ratio of 0.78 (0.73-0.82) per SD; it increased thereafter (P for nonlinearity <0.001). As compared with patients without sepsis, the adjusted hazard ratio for death among patients with sepsis was 4.16 (4.03-4.30).

CONCLUSIONS

In a nationwide cohort of individuals with type 2 diabetes, we found a U-shaped association between HbA1c and sepsis and a fourfold increased risk of death among those developing sepsis.

Photoacoustic Spectroscopy and Hyperglycemia in Experimental Type 1 Diabetes

According to the World Health Organization, diabetes was the seventh leading cause of death in 2016. Long-term diabetes complications are associated with hyperglycemia. It is difficult to predict the beginning and evolution of those complications. The goal of the study was to evaluate the relationship between glycemia and blood spectroscopic variables in an experimental model of type 1 diabetes (streptozotocin model). Blood samples were taken weekly (10 weeks) from the tail of male Wistar rats with or without diabetes. Blood optical absorption spectra were obtained by means of photoacoustic spectroscopy. It was possible to estimate the time-course of blood characteristic peak ratios. The area under the curve of those peaks correlated with hyperglycemia. The evolution of the optical absorption at 450 nm, related to cytochrome p450, was obtained by using the phase-resolved method. The area under the curve of p450 correlated also with hyperglycemia. It is concluded that photoacoustic spectroscopy is a reliable technology to detect the effects of hyperglycemia on blood with possible applications in the study of long-term diabetes complications.

Associations between Grip Strength and Glycemic Control in Type 2 Diabetes Mellitus: the 2014-2019 Korea National Health and Nutrition Examination Survey

OBJECTIVES

Glycemic control is essential for preventing severe complications in patients with diabetes mellitus. This study investigated the association between grip strength and glycemic control in Korean adults with type 2 diabetes mellitus.

METHODS

From the Korea National Health and Nutrition Examination Survey, 2,498 participants aged over 19 years that patients with diabetes mellitus who did not have a history of cardiovascular disease or cancer were selected for analysis. Grip strength was assessed using a handheld dynamometer and was represented as age-specific and sex-specific tertiles. Multivariable logistic regression was performed to calculate the odds ratio (OR) and 95% confidence interval (CI) of glycemic control according to the grip strength tertiles.

RESULTS

A significantly lower probability (OR, 0.67; 95% CI, 0.47 to 0.97) for glycemic control was found in the lowest tertile of grip strength compared to the highest tertile. Furthermore, a subgroup analysis by sex only found significant associations between grip strength and glycemic control in males.

CONCLUSIONS

Lower grip strength was associated with poor glycemic control in patients with diabetes mellitus, especially in males. However, further studies are needed to confirm the causal relationship between grip strength and glycemic control.

HbA1c Below the Reportable Range

This case report concerns a 71 year old female patient who had a very low glycosylated hemoglobin (HbA1c) despite having a high level of fasting blood glucose. The patient had a decreased erythrocyte count, elevated red blood cell indices, and a reticulocyte count with no evidence of hemoglobinopathy. She reported receiving hydroxychloroquine treatment for systemic lupus erythematosus. Subsequent laboratory investigations revealed hemolysis with formation of cold agglutinin. Because cold agglutinins can interfere with HbA1c assays, the specimens were reanalyzed after warming. The complete blood count results improved, but the HbA1c result did not change. In patients in whom medications and/or medical conditions may interfere with HbA1c levels, alternative measures of glycemic control, such as fructosamine, could be beneficial.

Effect of inflammatory bowel disease treatments on patients with diabetes mellitus

As medical care progresses and the number of patients with chronic conditions increases there is the inevitable challenge of managing patients with multiple co-morbidities. Inflammatory bowel disease (IBD) is an umbrella term for are inflammatory conditions affecting the gastrointestinal tract, the two most common forms being Ulcerative Colitis and Crohn’s disease. These diseases, usually diagnosed in young adults, exhibit a relapsing and remitting course and usually require long-term treatment. IBD can be treated with a number of topical and systemic treatments. We conducted a review of the current published evidence for the effects these medications can have on diabetes mellitus (DM) and glycaemic control. Searches were conducted on medline and embase with a timeframe from 1947 (the date from which studies on embase are recorded) to November 2020. Suitable publications were selected and reviewed. Current evidence of the impact of aminosalicylates, corticosteroids, thiopurines, and biologic agents was reviewed. Though there was limited evidence for certain agents, IBD medications have been shown to have an effect of DM and these effects should be considered in managing patients with dual pathologies. The effects of steroids on blood sugar control is well documented, but consideration of other agents is also important. In patients requiring steroids for Ulcerative Colitis, locally acting steroid agents delivered rectally may be preferred to minimise side effects in those with distal bowel Ulcerative Colitis. A switch to other agents should be considered as soon as possible in people with diabetes to limit the impact on glycaemic control. 5-aminosalicylates appear to play a role in the reduction of hemoglobin A1c (HbA1c), although the literature suggests these may be falsely low readings. Consequently, monitoring of people with diabetes on these agents may require daily monitoring of capillary blood sugars rather than relying simply on HbA1c; for example fructosamine performed 3-6 monthly, although this risks missing the rise in readings. There is only limited evidence of the effects of thiopurines on diabetes and further investigation is needed into the possible relationship between them. However, given the current available evidence it may be preferable to commence patients with diabetes on thiopurines as soon as possible, whilst also monitoring for side effects such as pancreatitis. There appears to be more evidence supporting a link between tumor necrosis factor-α inhibitors and DM. Both infliximab and adalimumab have evidence suggesting that both can cause reduced blood sugar levels. Further studies on the effects of the various biological agents mentioned are required alongside any novel biologic therapy and the impact of dual biologic therapy in the future.

Discordance between Fasting Plasma Glucose (FPG) and HbA1c in Diagnosing Diabetes and Pre-diabetes in The Malaysian Cohort

OBJECTIVE

In this present study, we aim to evaluate the accuracy of the HbA1c relative to fasting plasma glucose (FPG) in the diagnosis of diabetes and pre-diabetes among The Malaysian Cohort (TMC) participants.

METHODOLOGY

FPG and HbA1c were taken from 40,667 eligible TMC participants that have no previous history of diabetes, aged between 35-70 years and were recruited from 2006 - 2012. Participants were classified as normal, diabetes and pre-diabetes based on the 2006 World Health Organization (WHO) criteria. Statistical analyses were performed using ANOVA and Chi-square test, while Pearson correlation and Cohen's kappa were used to examine the concordance rate between FPG and HbA1c.

RESULTS

The study samples consisted of 16,224 men and 24,443 women. The prevalence of diabetes among the participants was 5.7% and 7.5% according to the FPG and HbA1c level, respectively. Based on FPG, 10.6% of the participants had pre-diabetes but this increased to 14.2% based on HbA1c (r=0.86; P<0.001). HbA1c had a sensitivity of 58.20 (95% CI: 56.43, 59.96) and a specificity of 98.59 (95% CI: 98.46, 98.70).

CONCLUSION

A higher prevalence of pre-diabetes and diabetes was observed when using HbA1c as a diagnosis tool, suggesting that it could possibly be more useful for early detection. However, given that HbA1c may also have lower sensitivity and higher false positive rate, several diagnostic criteria should be used to diagnose diabetes accurately.

Should HbA1C be used to screen pregnant women for undiagnosed diabetes in the first trimester? A review of the evidence

BACKGROUND

Diabetes in pregnancy is associated with miscarriage, stillbirth, congenital abnormalities, macrosomia and perinatal mortality. The demographics of the population becoming pregnant has changed (more obese and older women). More women are therefore entering pregnancy with undiagnosed diabetes.

AIM

To review the literature on HbA1c as a screening tool to identify undiagnosed diabetes in the first trimester of pregnancy.

METHODS

A systematic search of the evidence was undertaken using specific search criteria from Cochrane Library, EMBASE, Medline, NICE Guidance, PROSPERO and PubMed. The initial search identified 319 papers, based on the inclusion and exclusion criteria eight papers were critically appraised.

RESULTS

There is limited evidence on the use of HbA1c as a screening tool for undiagnosed diabetes in the literature during the first trimester of pregnancy. Although HbA1c is considered a useful test for diabetes in the non-pregnant population the hormonal and metabolic changes that occur in pregnancy mean that there are many limitations in pregnancy. Furthermore, HbA1c levels are affected by iron deficiency which is common in pregnancy.

CONCLUSIONS AND RECOMMENDATIONS

There is insufficient evidence to suggest a change in practice to include offering HbA1c screening for undiagnosed diabetes in the first trimester.

HbA mutation causing false-normal HbA1c results determined by HPLC in a patient with type 2 diabetes mellitus: A case report

Glycated hemoglobin A1c (HbA1c) is a convenient measure of long-term blood glucose concentrations and it is an accepted diagnostic test for type 2 diabetes mellitus (T2DM). The present study reported on a female patient with T2DM, whose fasting blood glucose and glycated albumin levels were elevated, while the HbA1c levels were in the normal range, which was inconsistent with the patient's clinical diagnosis. In the subsequent analysis, genomic DNA was extracted from the patient's blood and the HbA genes were analyzed by Sanger sequencing. The results indicated that the patient's HbA α1/2-chain genes had no mutations, while two HbA β-chain gene mutations were present, including an HBB:c.9T>C variant and a Hb G-Coushatta variant. The HBB:c.9T>C variant is a silent mutation that has no effect on HbA1c levels when detected by ion-exchange high-performance liquid chromatography (HPLC), while the Hb G-Coushatta variant may cause a discrepancy between blood glucose control and HbA1c levels when detected by ion-exchange HPLC. These results suggested that the Hb G-Coushatta variant gave rise to the false-normal result regarding HbA1c levels when detected by ion-exchange HPLC that was inconsistent with the clinical manifestations in this patient.

The impact of ferritin on the disassociation of HbA1c and mean plasma glucose

OBJECTIVE

To explore the impact of ferritin level on the disassociation of glycated hemoglobin A1c (HbA1c) and mean plasma glucose (MPG).

RESEACH DESIGN AND METHODS

We used a 2012-2013 cross-sectional survey conducted in Pinggu district, Beijing including 3095 Chinese participants aged 25-75 years. We categorized their glycemic status by interviewing for diagnosed diabetes and by measuring HbA1c, fasting plasma glucose (FPG), and 2-hours post-load plasma glucose (2-hours PPG). We fitted a multivariable regression model to explore the impact of ferritin on the association of HbA1c or glycated albumin (GA) and mean plasma glucose.

RESULTS

A total of 5.65% of participants were diagnosed as diabetes using HbA1c criteria, and 9.79% using oral glucose tolerance test criteria. Compared with males, females had significantly lower hemoglobin levels (159.82 ± 11.56 vs 135.93 ± 12.62) and lower ferritin levels (113.00 [68.55, 185.50] vs 33.40 [12.40, 70.13]). Linear regression analysis performed in different groups classified by different diagnose criterion indicated that the correlation between MPG and HbA1c differs in different tertiles of ferritin (lowest vs middle vs highest: R² = 0.507 vs 0.645 vs 0.687 in female; R² = 0.415 vs 0.715 vs 0.615 in male), and the association between MPG and HbA1c diminished in the lowest tertile of ferritin.

CONCLUSIONS

Ferritin level might affect the association between glucose and HbA1c, which should be taken into account when using HbA1c as a diagnosis criterion for diabetes and prediabetes.

Influence of Serum Albumin on HbA1c and HbA1c-Defined Glycemic Status: A Retrospective Study

Background: Glycated hemoglobin (HbA1c) is commonly used in the diagnosis and evaluation of glycemic control in diabetes, and it may be influenced by several non-glycemic and glycemic factors, including albumin. This retrospective study investigated the influence of albumin on HbA1c and HbA1c-defined glycemic status. Methods: The demographic, hematological, and biochemical data were collected for 11,922 patients undergoing routine physical examination. Univariate and multivariate linear regression analyses, stratified analyses and interaction analyses, and multiple logistic regression were conducted to identify the association between albumin and HbA1c in people with different glycemic status. Results: HbA1c levels were inversely associated with serum albumin level (P < 0.0001) in all participants. Risk factors leading to the association included age > 45 years, high fasting plasma glucose (≥7.0 mmol/L), and anemia. The negative association between HbA1c and albumin was curved (P < 0.0001) and had a threshold effect in the HbA1c-defined diabetic population; the association was significantly stronger when the albumin level fell below 41.4 g/L (β: -0.31, 95% CI: -0.45 to -0.17, P < 0.0001). A 2 g/L increase in albumin reduced the odds of HbA1c-defined dysglycemia, diabetes, and poor glycemia control by 12% to 36%, after adjustment for all possible confounders. Conclusions: HbA1c was inversely associated with albumin level in all participants, and the association was significantly stronger in people with diabetes (defined by HbA1c criteria). For diabetic patients with lower albumin level, there was an increased risk of an erroneous HbA1c-based identification and management of glycemic status.

Thanatochemical Study of Glycated Hemoglobin in Diabetic Status Assessment

Background and objectives. In forensic medicine, the postmortem determination of glycated hemoglobin (HbA1c) helps identify undiagnosed cases of diabetes or cases with uncontrolled glycemic status. In order to contribute to the solidification of thanatochemistry, both globally and especially nationally, we aimed to determine this biomarker postmortem, for the first time in our institution, in order to identify undiagnosed pre-mortem diabetics, as well as those with inadequate glycemic control. Materials and Methods. Our research consisted of analyzing a total number of 180 HbA1c values, 90 determinations from the peripheral blood and 90 from the central blood. The determination of HbA1c was performed by means of a fully automatic analyzer (HemoCue HbA1c 501), certified by the National Glycohemoglobin Standardization Program (NGSP)/Diabetes Control and Complications Trial (DCCT) and calibrated according to the standards developed by the International Federation of Clinical Chemistry (IFCC). According to ADA criteria, HbA1c values can provide us with the following information about the diagnosis of diabetes: normal 4.8-5.6%; prediabetes 5.7-6.4%; diabetes ≥ 6.5%. Results. A considerable number of cases with an altered glycemic status (cases that had HbA1c values equal to or greater than 5.7%) were identified-51% demonstrable by peripheral blood determinations and 41% by central blood determinations. Notably, 23 people with diabetes (25%) were identified by analyzing the peripheral blood; 18 other people with diabetes (20%) were identified by analyzing the central blood. Conclusions. Our study managed to confirm the antemortem diagnosis of DM using a simple point-of-care analyzer and applying standardized and certified criteria on HbA1c levels measured postmortem. We also identified a considerable number of cases with DM in patients with no antemortem history of glucose imbalance-at least 20% more cases. Although the two different sites used for blood collection showed a strong statistical correlation, it seems that the peripheral site could have a higher sensibility in detecting postmortem altered glycemic status.

Erroneous reduction of HbA1c levels in patients with type 2 diabetes mellitus on dapsone treatment for Hansen's disease - a single-center retrospective cohort study

BACKGROUND

Dapsone treatment may reduce HbA1c levels in patients with diabetes.

AIMS

To assess the prevalence and characteristics of dapsone associated reduction of HbA1c in patients with Hansen's disease.

METHODS

A retrospective data review of outpatient and inpatient charts of consecutive patients with Hansen's disease and type 2 diabetes mellitus was conducted over two years from January 2014 to January 2016 at the Department of Dermatology, CMC Vellore, India.

RESULTS

Of the 245 patients with a confirmed diagnosis of Hansen's disease who were on oral dapsone 100 mg/day as part of their treatment regimen, 49 patients had diabetes and were eligible for the study as per predetermined inclusion criteria. Of these, 35 subjects (71%) had an HbA1c discordantly lower than the corresponding mean plasma glucose levels. Patients with discordant HbA1c levels were more likely to be male and to have a higher RBC mean corpuscular volume (MCV). A greater reduction in HbA1c levels was seen during the initial 3 months of therapy of dapsone treatment.

LIMITATIONS

The small sample size and retrospective design were limitations of this study. Also, we did not analyze the role of methemoglobinemia or the utility of alternative measures of glycemic control in these patients.

CONCLUSION

We describe a high prevalence of dapsone associated inappropriate HbA1c lowering in type 2 diabetes mellitus patients. This may have serious implications for the management of diabetes in patients on therapy with dapsone.

Correlation between glycosylated serum albumin and glycosylated haemoglobin in the southwest Chinese population: Establishment of a regression model

AIMS

To correlate glycated albumin (GA) and glycosylated haemoglobin (HbA1c) and establish a novel formula for estimating HbA1c from GA.

METHODS

We retrospectively enrolled 20,381 cases and excluded HbA1c and GA outliers by residual analysis. HbA1c ranged from 4.0-12.0% and GA from 7.5-45%. The HbA1c range of 4.0-8.0% in both sexes was stratified into eight groups with an increase of 0.5%, and the means of GA and HbA1c were compared. HbA1c was divided into 38 groups with increments of 0.1% (range, 4.3-8.0%), and the correlation between HbA1c and GA was investigated.

RESULTS

There was no significant sex-based difference between HbA1c and GA. The analysis showed that when HbA1c was 6.2% or GA was 12.28%, the linear relationship between the two parameters was not continuous. When HbA1c was <6.2% or GA < 12.28%, we devised the formula: HbA1c = 1.136 × GA - 7.289 (R² = 0.824). For HbA1c ≥ 6.2% or GA ≥ 12.28%, the equation was: HbA1c = 0.252 × GA + 3.163 (R² = 0.948).

CONCLUSION

A discontinuous linear relationship exists between HbA1c and GA when HbA1c is 6.2% or GA is 12.28%, although with a significant turning point. The GA value can be used to estimate the HbA1c value with the two regression equations to accurately estimate the long-term average blood glucose level of patients.

Obesity is associated with lower bacterial vaginosis prevalence in menopausal but not pre-menopausal women in a retrospective analysis of the Women's Interagency HIV Study

The vaginal microbiota is known to impact women's health, but the biological factors that influence the composition of the microbiota are not fully understood. We previously observed that levels of glycogen in the lumen of the vagina were higher in women that had a high body mass index (BMI). Vaginal glycogen is thought to impact the composition of the vaginal microbiota. We therefore sought to determine if BMI was associated having or not having bacterial vaginosis (BV), as determined by the Amsel criteria. We also hypothesized that increased blood glucose levels could lead to the previously-observed higher vaginal glycogen levels and therefore investigated if hemoglobin A1c levels were associated with BV. We analyzed data from the Women's Interagency HIV Study using multiple multivariable (GEE) logistic regression models to assess the relationship between BMI, BV and blood glucose. Women with a BMI >30 kg/m2 (obese) had a lower rate (multivariable adjusted OR 0.87 (0.79-0.97), p = 0.009) of BV compared to the reference group (BMI 18.5-24.9 kg/m2). There was a significantly lower rate of BV in post-menopausal obese women compared to the post-menopausal reference group, but not in pre-menopausal women. HIV- post-menopausal obese women had a significantly lower rate of BV, but this was not seen in HIV+ post-menopausal obese women. Pre-menopausal women with a higher hemoglobin A1c (≥6.5%) had a significantly lower rate (multivariable adjusted OR 0.66 (0.49-0.91), p = 0.010) of BV compared to pre-menopausal women with normal hemoglobin A1c levels (<5.7%), but there was no difference in post-menopausal women. This study shows an inverse association of BMI with BV in post-menopausal women and hemoglobin A1c with BV in pre-menopausal women. Further studies are needed to confirm these relationships in other cohorts across different reproductive stages and to identify underlying mechanisms for these observed associations.

Association of Improved Periconception Hemoglobin A1c With Pregnancy Outcomes in Women With Diabetes

IMPORTANCE

Prepregnancy diabetes is associated with higher perinatal and maternal morbidity, especially if periconception glycemic control is suboptimal. It is not known whether improved glycemic control from preconception to early pregnancy and midpregnancy periods can reduce the risk of adverse perinatal and maternal outcomes.

OBJECTIVE

To determine whether a net decline in glycated hemoglobin A1c (HbA1c) from preconception to the first half of pregnancy is associated with a lower risk of adverse outcomes for mother and child.

DESIGN, SETTING, AND PARTICIPANTS

This population-based cohort study was completed in all of Ontario, Canada, from 2007 to 2018. Included were births among women with prepregnancy diabetes whose HbA1c was measured within 90 days preconception and again from conception through 21 weeks completed gestation (early pregnancy to midpregnancy). Statistical analysis was performed from July to September 2020.

EXPOSURES

Net decrease in HbA1c from preconception to early pregnancy and midpregnancy.

MAIN OUTCOMES AND MEASURES

The main outcome was a congenital anomaly from birth to age 1 year. Other outcomes included preterm birth or perinatal mortality among offspring as well as severe maternal morbidity (SMM) or death among mothers. Adjusted relative risks (aRRs) were calculated per 0.5% absolute net decline in HbA1c from preconception up to early pregnancy and midpregnancy, adjusting for maternal age at conception, preconception HbA1c and hemoglobin concentration, and gestational age at HbA1c measurement.

RESULTS

A total of 3459 births were included, with a mean (SD) maternal age of 32.6 (5.0) years at conception. Overall, the mean (SD) HbA1c decreased from 7.2% (1.6%) preconception to 6.4% (1.1%) in early pregnancy to midpregnancy. There were 497 pregnancies (14.4%) with a congenital anomaly, with an aRR of 0.94 (95% CI, 0.89-0.98) per 0.5% net decrease in HbA1c, including for cardiac anomalies (237 infants; aRR, 0.89; 95% CI, 0.84-0.95). The risk was also reduced for preterm birth (847 events; aRR, 0.89; 95% CI, 0.86-0.91). SMM or death occurred among 191 women (5.5%), with an aRR of 0.90 (95% CI, 0.84-0.96) per 0.5% net decrease in HbA1c.

CONCLUSIONS AND RELEVANCE

These findings suggest that women with prepregnancy diabetes who achieve a reduction in HbA1c may have improved perinatal and maternal outcomes. Further study is recommended to determine the best combination of factors, such as lifestyle changes and/or glucose-lowering medications, that can influence periconception HbA1c reduction.