Standardising HbA1c-based diabetes diagnosis: opportunities and challenges

Continuous Glucose Monitoring and Time in Range: Association with Adverse Outcomes among People with Type 2 or Gestational Diabetes Mellitus

OBJECTIVE

 Continuous glucose monitoring (CGM) has become available for women with type 2 diabetes mellitus (T2DM) or gestational diabetes mellitus (GDM) during pregnancy. The recommended time in range (TIR, blood glucose 70-140 mg/dL) and its correlation with adverse pregnancy outcomes in this group is unknown. Our aim was to compare maternal and neonatal outcomes in pregnant people with T2DM or GDM with average CGM TIR values >70 versus ≤70%.

STUDY DESIGN

 We conducted a retrospective cohort study of all individuals using CGM during pregnancy from January 2017 to June 2022. Individuals with type 1 diabetes mellitus, or those missing CGM or delivery data were excluded. Primary composite neonatal outcome included any of the following: large for gestational age, NICU admission, need for intravenous glucose, respiratory support, or neonatal death. Secondary outcomes included other maternal and neonatal outcomes. Regression models were used to estimate adjusted odds ratio (aOR) and 95% confidence interval (CI).

RESULTS

 During the study period, 141 individuals with diabetes utilized CGM during pregnancy, with 65 (46%) meeting inclusion criteria. Of the study population, 28 (43%) had TIR ≤70% and 37 (57%) had TIR > 70%. Compared with those with TIR > 70%, the primary composite outcome occurred more frequently in neonates of individuals TIR ≤70% (71.4 vs. 37.8%, aOR: 4.8, 95% CI: 1.6, 15.7). Furthermore, individuals with TIR ≤70% were more likely to have hypertensive disorders (42.9 vs. 16.2%, OR: 3.9, 95% CI: 1.3, 13.0), preterm delivery (54 vs. 27%, OR: 3.1, 95% CI: 1.1, 9.1): , and cesarean delivery (96.4 vs. 51.4%, OR: 4.6, 95% CI: 2.2, 15.1) compared with those with TIR >70%.

CONCLUSION

 Among people with T2DM or GDM who utilized CGM during pregnancy, 4 out 10 individuals had TIR ≤70% and, compared with those with TIR > 70%, they had a higher likelihood of adverse neonatal and maternal outcomes.

KEY POINTS

· Time in range can be utilized as a metric for pregnant patients using continuous glucose monitor.. · Time in range >70% is achievable by 6 out of 10 patients.. · Time in range below goal is associated with adverse neonatal and maternal outcomes..

Serum-based ATR-FTIR spectroscopy combined with multivariate analysis for the diagnosis of pre-diabetes and diabetes

Diabetes mellitus (DM) is a metabolic disease with an increasing prevalence that is causing worldwide concern. The pre-diabetes stage is the only reversible stage in the patho-physiological process towards DM. Due to the limitations of traditional methods, the diagnosis and detection of DM and pre-diabetes are complicated, expensive, and time-consuming. Therefore, it would be of great benefit to develop a simple, rapid and inexpensive diagnostic test. Herein, the infrared (IR) spectra of serum samples from 111 DM patients, 111 pre-diabetes patients and 333 healthy volunteers were collected using attenuated total reflection Fourier-transform IR (ATR-FTIR) spectroscopy and this was combined with the multivariate analysis of principal component analysis linear discriminant analysis (PCA-LDA) to develop a discriminant model to verify the diagnostic potential of this approach. The study found that the accuracy of the test model established by ATR-FTIR spectroscopy combined with PCA-LDA was 97%, and the sensitivity and specificity were 100% and 100% in the control group, 94% and 98% in the pre-diabetes group, and 91% and 98% in the DM group, respectively. This indicates that this method can effectively diagnose DM and pre-diabetes, which has far-reaching clinical significance.

Vibrational Spectroscopy for Detection of Diabetes: A Review

Type II diabetes mellitus (T2DM) is a metabolic disorder that is characterized by chronically elevated glucose caused by insulin resistance. Although T2DM is manageable through insulin therapy, the disorder itself is a risk factor for much more dangerous diseases including cardiovascular disease, kidney disease, retinopathy, Alzheimer's disease, and more. T2DM affects 450 million people worldwide and is attributed to causing over four million deaths each year. Current methods for detecting diabetes typically involve testing a person's glycated hemoglobin levels as well as blood sugar levels randomly or after fasting. However, these methods can be problematic due to an individual's levels differing on a day-to-day basis or being affected by diet or environment, and due to the lack of sensitivity and reliability within the tests themselves. Vibrational spectroscopic methods have been pursued as a novel method for detecting diabetes accurately and early in a minimally invasive manner. This review summarizes recent research, since 2015, which has used infrared or Raman spectroscopy for the purpose of developing a fast and accurate method for diagnosing diabetes. Based on critical evaluation of the reviewed work, vibrational spectroscopy has the potential to improve and revolutionize the way diabetes is diagnosed, thereby allowing for faster and more effective treatment of the disorder.

Hemoglobin Fukuoka caused unexpected hemoglobin A1c results: A case report

BACKGROUND

Glycated hemoglobin (Hb) (HbA_1c) is an indicator that is used to diagnose and monitor the treatment of diabetes. Many factors can affect the detection of HbA_1c. One of the most important of these factors is the Hb variant. Here, we report a rare Hb variant and evaluate its effect on HbA_1c.

CASE SUMMARY

A 35-year-old man was suspected of harboring an Hb variant following the measurement of HbA_1c with the Variant II Turbo 2.0 Hb detection system during a routine examination. Subsequently, we used the Arkray HA-8160 and ARCHITECT c4000 system to reanalyze HbA_1c. Finally, the Hb variant was detected with a Capillary2FP analyzer that operates on the principle of capillary electrophoresis. We also used gene sequencing to investigate the mutation site. The value of HbA_1c detected with the Variant II Turbo 2.0 system was 52.7%. However, the Arkray HA-8160 system did not display a result while the ARCHITECT c16000 system showed a result of 5.4%. The Capillary2FP analyzer did not reveal any abnormal Hb zones. However, gene sequencing identified the presence of a mutation in the Hb β2 chain [CD2(CAC>TAC), His>Tyr, HBB: c.7C>T]; the genotype was Hb Fukuoka.

CONCLUSION

Hb variants could cause abnormal HbA_1c results. For patients with Hb variants, different methods should be used to detect HbA_1c.

A Prediction Model Based on Noninvasive Indicators to Predict the 8-Year Incidence of Type 2 Diabetes in Patients with Nonalcoholic Fatty Liver Disease: A Population-Based Retrospective Cohort Study

Background

The prevention of type 2 diabetes (T2D) and its associated complications has become a major priority of global public health. In addition, there is growing evidence that nonalcoholic fatty liver disease (NAFLD) is associated with an increased risk of diabetes. Therefore, the purpose of this study was to develop and validate a nomogram based on independent predictors to better assess the 8-year risk of T2D in Japanese patients with NAFLD.

Methods

This is a historical cohort study from a collection of databases that included 2741 Japanese participants with NAFLD without T2D at baseline. All participants were randomized to a training cohort (n = 2058) and a validation cohort (n = 683). The data of the training cohort were analyzed using the least absolute shrinkage and selection operator method to screen the suitable and effective risk factors for Japanese patients with NAFLD. A cox regression analysis was applied to build a nomogram incorporating the selected features. The C-index, receiver operating characteristic curve (ROC), calibration plot, decision curve analysis, and Kaplan-Meier analysis were used to validate the discrimination, calibration, and clinical usefulness of the model. The results were reevaluated by internal validation in the validation cohort.

Results

We developed a simple nomogram that predicts the risk of T2D for Japanese patients with NAFLD by using the parameters of smoking status, waist circumference, hemoglobin A1c, and fasting blood glucose. For the prediction model, the C-index of training cohort and validation cohort was 0.839 (95% confidence interval (CI), 0.804-0.874) and 0.822 (95% CI, 0.777-0.868), respectively. The pooled area under the ROC of 8-year T2D risk in the training cohort and validation cohort was 0.811 and 0.805, respectively. The calibration curve indicated a good agreement between the probability predicted by the nomogram and the actual probability. The decision curve analysis demonstrated that the nomogram was clinically useful.

Conclusions

We developed and validated a nomogram for the 8-year risk of incident T2D among Japanese patients with NAFLD. Our nomogram can effectively predict the 8-year incidence of T2D in Japanese patients with NAFLD and helps to identify people at high risk of T2D early, thus contributing to effective prevention programs for T2D.

Performance of diabetes screening tests: an evaluation study of Iranian diabetes screening program

BACKGROUND

Type 2 diabetes is a common non-communicable disease that is responsible for about 9% of all deaths and a 25% reduction in life expectancy. However, nearly half of the diabetic patients are not aware of their disease. In this regard, to identify un-known diabetic patients, diabetes screening is of great importance. This study was conducted to evaluate the performance of two commonly used diabetes screening tests that are currently recommended by the Iranian diabetes screening program for (DSP).

METHODS

The validity of the two diabetes screening tests were measured among 1057 participants who were older than 30 years of age. The studied screening tests included capillary fasting blood glucose (CBG) and glycated hemoglobin (HbA1c). The golden standard for measuring the validity of the tests was venous fasting plasma glucose (VPG).

RESULTS

According to the results, the sensitivity of CBG and HbA1c tests was 69.01% and 84.5%, and the specificity of the tests were 95.7% and 79.3%, respectively. Positive and negative predictive values were 53.84% and 97.72% for CBG and 22.72% and 98.61% for HbA1c, respectively. The recommended cut points for CBG and HbA1c were 116.5 mg/dl and 7.15%, respectively. Using these values as the new cut points, sensitivity and specificity of CBG and HbA1c changed to 80.30% and 89.10%, and 77.50% and 94.20%, respectively.

CONCLUSIONS

Compared to several other countries, the performance of Iranian DSP is relatively better. The Receiver Operating Characteristic Curve suggested new cut points for significantly better performance of DSP.

Time in Range: How to Measure It, How to Report It, and Its Practical Application in Clinical Decision-Making

The A1C metric has been the gold standard for assessing glycemia for decades. This biologic assay, based on averaging, is fraught with limitations and may be giving way to more holistic approaches. This article reviews glycemic time in range as the new standard for assessing patients with continuous glucose monitoring data. Information from the International Consensus Group on Time in Range will be summarized.

Arachidyl amido cholanoic acid improves liver glucose and lipid homeostasis in nonalcoholic steatohepatitis via AMPK and mTOR regulation

BACKGROUND

Arachidyl amido cholanoic acid (Aramchol) is a potent downregulator of hepatic stearoyl-CoA desaturase 1 (SCD1) protein expression that reduces liver triglycerides and fibrosis in animal models of steatohepatitis. In a phase IIb clinical trial in patients with nonalcoholic steatohepatitis (NASH), 52 wk of treatment with Aramchol reduced blood levels of glycated hemoglobin A1c, an indicator of glycemic control.

AIM

To assess lipid and glucose metabolism in mouse hepatocytes and in a NASH mouse model [induced with a 0.1% methionine and choline deficient diet (0.1MCD)] after treatment with Aramchol.

METHODS

Isolated primary mouse hepatocytes were incubated with 20 μmol/L Aramchol or vehicle for 48 h. Subsequently, analyses were performed including Western blot, proteomics by mass spectrometry, and fluxomic analysis with ¹³C-uniformly labeled glucose. For the in vivo part of the study, male C57BL/6J mice were randomly fed a control or 0.1MCD for 4 wk and received 1 or 5 mg/kg/d Aramchol or vehicle by intragastric gavage for the last 2 wk. Liver metabolomics were assessed using ultra-high-performance liquid chromatography-time of flight-MS for the determination of glucose metabolism-related metabolites.

RESULTS

Combination of proteomics and Western blot analyses showed increased AMPK activity while the activity of nutrient sensor mTORC1 was decreased by Aramchol in hepatocytes. This translated into changes in the content of their downstream targets including proteins involved in fatty acid (FA) synthesis and oxidation [P-ACCα/β(S79), SCD1, CPT1A/B, HADHA, and HADHB], oxidative phosphorylation (NDUFA9, NDUFB11, NDUFS1, NDUFV1, ETFDH, and UQCRC2), tricarboxylic acid (TCA) cycle (MDH2, SUCLA2, and SUCLG2), and ribosome (P-p70S6K[T389] and P-S6[S235/S236]). Flux experiments with ¹³C-uniformely labeled glucose showed that TCA cycle cataplerosis was reduced by Aramchol in hepatocytes, as indicated by the increase in the number of rounds that malate remained in the TCA cycle. Finally, liver metabolomic analysis showed that glucose homeostasis was improved by Aramchol in 0.1MCD fed mice in a dose-dependent manner, showing normalization of glucose, G6P, F6P, UDP-glucose, and Rbl5P/Xyl5P.

CONCLUSION

Aramchol exerts its effect on glucose and lipid metabolism in NASH through activation of AMPK and inhibition of mTORC1, which in turn activate FA β-oxidation and oxidative phosphorylation.

Hemoglobin A1c and Early Gestational Diabetes

Background: Screening for diabetes in early pregnancy is recommended for high-risk women, however, the optimal test for the diagnosis of early gestational diabetes mellitus (GDM) is unknown. Thus, the objective of this study was to evaluate hemoglobin A_1c (HbA_1c) as a diagnostic test for early GDM compared with two-step testing. Materials and Methods: Retrospective cohort of women with prior GDM or obesity who had HbA_1c and two-step testing <21 weeks' gestation. Early GDM was diagnosed by 1 hour, 50 g oral glucose challenge test (GCT) ≥135 mg/dL and ≥2 abnormal values on 3 hour, 100 g oral glucose tolerance test or GCT >200 mg/dL. The area under the receiver operating characteristic curve (AUC) evaluated HbA_1c for diagnosis of early GDM. Results: Of 243 women, 14 (5.8%) had early GDM by two-step testing. Median HbA_1c levels were higher among women with GDM versus those without GDM (5.8% vs. 5.3%, p < 0.001). The AUC for HbA_1c compared with two-step testing was 0.80 (95% CI 0.69-0.91). The optimal HbA_1c threshold was 5.6% (64% sensitivity, 84% specificity). Conclusions: HbA_1c is moderately predictive of early GDM compared with two-step testing, and a threshold lower than that used for diabetes diagnosis among nonpregnant adults is justified.

Recent Trends in Electrochemical Sensors for Vital Biomedical Markers Using Hybrid Nanostructured Materials

This work provides a succinct insight into the recent developments in electrochemical quantification of vital biomedical markers using hybrid metallic composite nanostructures. After a brief introduction to the biomarkers, five types of crucial biomarkers, which require timely and periodical monitoring, are shortlisted, namely, cancer, cardiac, inflammatory, diabetic and renal biomarkers. This review emphasizes the usage and advantages of hybrid nanostructured materials as the recognition matrices toward the detection of vital biomarkers. Different transduction methods (fluorescence, electrophoresis, chemiluminescence, electrochemiluminescence, surface plasmon resonance, surface-enhanced Raman spectroscopy) reported for the biomarkers are discussed comprehensively to present an overview of the current research works. Recent advancements in the electrochemical (amperometric, voltammetric, and impedimetric) sensor systems constructed with metal nanoparticle-derived hybrid composite nanostructures toward the selective detection of chosen vital biomarkers are specifically analyzed. It describes the challenges involved and the strategies reported for the development of selective, sensitive, and disposable electrochemical biosensors with the details of fabrication, functionalization, and applications of hybrid metallic composite nanostructures.

Design and Rationale of the Biomarker Center of the Household Air Pollution Intervention Network (HAPIN) Trial

BACKGROUND

Biomarkers of exposure, susceptibility, and effect are fundamental for understanding environmental exposures, mechanistic pathways of effect, and monitoring early adverse outcomes. To date, no study has comprehensively evaluated a large suite and variety of biomarkers in household air pollution (HAP) studies in concert with exposure and outcome data. The Household Air Pollution Intervention Network (HAPIN) trial is a liquified petroleum gas (LPG) fuel/stove randomized intervention trial enrolling 800 pregnant women in each of four countries (i.e., Peru, Guatemala, Rwanda, and India). Their offspring will be followed from birth through 12 months of age to evaluate the role of pre- and postnatal exposure to HAP from biomass burning cookstoves in the control arm and LPG stoves in the intervention arm on growth and respiratory outcomes. In addition, up to 200 older adult women per site are being recruited in the same households to evaluate indicators of cardiopulmonary, metabolic, and cancer outcomes.

OBJECTIVES

Here we describe the rationale and ultimate design of a comprehensive biomarker plan to enable us to explore more fully how exposure is related to disease outcome.

METHODS

HAPIN enrollment and data collection began in May 2018 and will continue through August 2021. As a part of data collection, dried blood spot (DBS) and urine samples are being collected three times during pregnancy in pregnant women and older adult women. DBS are collected at birth for the child. DBS and urine samples are being collected from the older adult women and children three times throughout the child's first year of life. Exposure biomarkers that will be longitudinally measured in all participants include urinary hydroxy-polycyclic aromatic hydrocarbons, volatile organic chemical metabolites, metals/metalloids, levoglucosan, and cotinine. Biomarkers of effect, including inflammation, endothelial and oxidative stress biomarkers, lung cancer markers, and other clinically relevant measures will be analyzed in urine, DBS, or blood products from the older adult women. Similarly, genomic/epigenetic markers, microbiome, and metabolomics will be measured in older adult women samples.

DISCUSSION

Our study design will yield a wealth of biomarker data to evaluate, in great detail, the link between exposures and health outcomes. In addition, our design is comprehensive and innovative by including cutting-edge measures such as metabolomics and epigenetics. https://doi.org/10.1289/EHP5751.

An evaluation of randomized controlled trials on nutraceuticals containing traditional Chinese medicines for diabetes management: a systematic review

BACKGROUND

Nutraceuticals containing traditional Chinese medicine (TCM) are promoted for use in the management of diabetes. The evidence to support such use is largely unknown. This study aimed to summarise and evaluate the literature reporting the results of randomized controlled trials (RCTs) investigating the effects of nutraceuticals in people living with diabetes.

METHODS

Literature from four electronic databases (PubMed, Scopus, CINAHL and Web of Science) was searched following PRISMA guidelines to yield RCT publications on nutraceutical for diabetes management published since 2009. The quality of reporting was assessed using the CONSORT 2010 checklist statement. Risk-of-bias for each study was assessed using the Cochrane risk of bias tool.

RESULTS

Out of 1978 records identified in the initial search, 24 randomized, double/triple-blinded, controlled trials that investigated the effect of nutraceuticals covering 17 different TCM herbs for diabetes management were selected. Participants included people who were diabetic (n = 16), pre-diabetic (n = 3) or predisposed to diabetes (n = 5). Sample sizes ranged between 23 and 117 for 2 arms, or 99-165 for 3 arms. Comparisons were made against placebo (n = 22), conventional medicine (n = 1), or regular diet (n = 1) for a duration between 4 and 24 weeks. All but one study tested the effect on fasting blood glucose levels (n = 23) or glycated haemoglobin levels (n = 18), and/or postprandial 2-h blood glucose levels (n = 4) as the primary outcomes. Nineteen studies reported some statistically significant reductions in the respective measures while 5 studies showed no effect on primary or secondary outcomes. None of the included studies met all the criteria for the CONSORT guidelines. Incomplete reporting about randomization and blinding, and a lack of ancillary analyses to explore other influential factors and potential harms associated with the use were repeatedly noted. Based on the Cochrane risk-of-bias tool, 19 studies were deemed to have a high risk of bias mainly attributed to sponsor bias.

CONCLUSIONS

There is some evidence to suggest positive clinical outcomes in response to the administration of a range of nutraceuticals containing TCM in the management of diabetes. However, these results must be interpreted with caution due to the overall low quality of the trials.

Understanding the adoption and use of point-of-care tests in Dutch general practices using multi-criteria decision analysis

BACKGROUND

The increasing number of available point-of-care (POC) tests challenges clinicians regarding decisions on which tests to use, how to efficiently use them, and how to interpret the results. Although POC tests may offer benefits in terms of low turn-around-time, improved patient's satisfaction, and health outcomes, only few are actually used in clinical practice. Therefore, this study aims to identify which criteria are, in general, important in the decision to implement a POC test, and to determine their weight. Two POC tests available for use in Dutch general practices (i.e. the C-reactive protein (CRP) test and the glycated haemoglobin (HbA_1c) test) serve as case studies. The information obtained from this study can be used to guide POC test development and their introduction in clinical practice.

METHODS

Relevant criteria were identified based on a literature review and semi-structured interviews with twelve experts in the field. Subsequently, the criteria were clustered in four groups (i.e. user, organization, clinical value, and socio-political context) and the relative importance of each criterion was determined by calculating geometric means as implemented in the Analytic Hierarchy Process. Of these twelve experts, ten participated in a facilitated group session, in which their priorities regarding both POC tests (compared to central laboratory testing) were elicited.

RESULTS

Of 20 criteria in four clusters, the test's clinical utility, its technical performance, and risks (associated with the treatment decision based on the test result) were considered most important for using a POC test, with relative weights of 22.2, 12.6 and 8.5%, respectively. Overall, the experts preferred the POC CRP test over its laboratory equivalent, whereas they did not prefer the POC HbA_1c test. This difference was mainly explained by their strong preference for the POC CRP test with regard to the subcriterion 'clinical utility'.

CONCLUSIONS

The list of identified criteria, and the insights in their relative impact on successful implementation of POC tests, may facilitate implementation and use of existing POC tests in clinical practice. In addition, having experts score new POC tests on these criteria, provides developers with specific recommendations on how to increase the probability of successful implementation and use.

Sulfonylurea for the treatment of neonatal diabetes owing to KATP-channel mutations: a systematic review and meta-analysis

The effect of sulfonylurea for the treatment of neonatal diabetes (NDM) is remain uncertain. We conducted this systematic review and meta-analysis to investigate the effect of sulfonylurea for NDM and to provide the latest and most convincing evidence for developing clinical practice guidelines of NDM. A literature review was performed to identify all published studies reporting the sulfonylurea on the treatment of neonatal diabetes. The search included the following databases: PUBMED, EMBASE and the Cochrane Library. The primary outcome was the success rates of treatment, change of glycosylated hemoglobin (HbA1c) and C-peptide. Data results were pooled by using MetaAnalyst with a random-effects model. Ten studies (6 cohort studies and 4 cross-sectional studies) involving 285 participants were included in the analysis. The pooled estimated success rate by the random-effects model was 90.1%(95% CI: 85.1%-93.5%). HbA1c had a significantly lower compared with before treatment. The pooled estimate of MD was -2.289, and the 95% CI was -2.790 to -1.789 (P < 0.001). The subgroup analysis showed a similar result for cohort studies and in cross-sectional studies. The common mild side effect is gastrointestinal reaction. The present meta-analysis suggested that sulfonylurea had a positive effect for treatment NDM due to K_ATP channel mutations. In addition, sulfonylurea also displayed sound safety except the mild gastrointestinal reaction. However, the findings rely chiefly on data from observational studies. Further well-conducted trials are required to assess sulfonylurea for NDM.

Are Ethnic Disparities in HbA1c Levels Explained by Mental Wellbeing? Analysis of Population-Based Data from the Health Survey for England

Aims

It is unclear how ethnic differences in HbA_1c levels are affected by individual variations in mental wellbeing. Thus, the aim of this study was to assess the extent to which HbA_1c disparities between Caucasian and South Asian adults are mediated by various aspects of positive psychological functioning.

Methods

Data from the 2014 Health Survey for England was analysed using bootstrapping methods. A total of 3894 UK residents with HbA_1c data were eligible to participate. Mental wellbeing was assessed using the Warwick-Edinburgh Mental Well-being Scale. To reduce bias BMI, blood pressure, diabetes status, and other factors were treated as covariates.

Results

Ethnicity directly predicted blood sugar control (unadjusted coefficient −2.15; 95% CI −3.64, −0.67), with Caucasians generating lower average HbA_1c levels (37.68 mmol/mol (5.6%)) compared to South Asians (39.87 mmol/mol (5.8%)). This association was mediated by positive mental wellbeing, specifically concerning perceived vigour (unadjusted effect 0.30; 95% CI 0.13, 0.58): South Asians felt more energetic than Caucasians (unadjusted coefficient −0.32; 95% CI −0.49, −0.16), and greater perceived energy predicted lower HbA_1c levels (unadjusted coefficient −0.92; 95% CI −1.29, −0.55). This mediator effect accounted for just over 14% of the HbA_1c variance and was negated after adjusting for BMI.

Conclusions

Caucasian experience better HbA_1c levels compared with their South Asian counterparts. However, this association is partly confounded by individual differences in perceived energy levels, which is implicated in better glycaemic control, and appears to serve a protective function in South Asians.