Use of hemoglobin A1C to detect Haitian-Americans with undiagnosed Type 2 diabetes

Self-Management and Glycemic Targets in Adult Haitian Immigrants With Type 2 Diabetes: Research Protocol

BACKGROUND

Type 2 diabetes (T2D) is a chronic condition affecting more than 34.2 million U.S. adults, and people of African descent have a disproportionate burden. Haitian immigrants' unique cultural and biological factors put them at elevated risk for T2D-related complications. Despite prior research highlighting the success of multimethod approaches to T2D self-management behaviors on glycemic targets, a dearth of studies have used these methods to improve diabetes self-management in this marginalized population.

OBJECTIVES

This article describes a repeated-measures design protocol of a going study about self-management behaviors among adult Haitian immigrants with T2D and characterizing their barriers to T2D self-management.

METHODS

We will enroll 100 Haitian immigrants aged 18-64 years who have lived with T2D for at least 1 year. Using multiple recruitment methods and Research Electronic Data Capture, subjective and objective data on T2D self-management practices, glucose variability via continuous glucose monitor, and a comprehensive view of physical activity via actigraphy are collected.

RESULTS

Data analysis will follow a two-part approach mirroring the two primary study objectives.

DISCUSSION

Findings from the study will guide the development and testing of a culturally tailored diabetes self-management education program that will contribute essential information about best practices for this population and break barriers that may impede research on unique individuals and subsequent effective self-management.

HbA1c Performance in African Descent Populations in the United States With Normal Glucose Tolerance, Prediabetes, or Diabetes: A Scoping Review

Introduction

African descent populations in the United States have high rates of type 2 diabetes and are incorrectly represented as a single group. Current glycated hemoglobin A_1c (HbA_1c) cutoffs (5.7% to <6.5% for prediabetes; ≥6.5% for type 2 diabetes) may perform suboptimally in evaluating glycemic status among African descent groups. We conducted a scoping review of US-based evidence documenting HbA_1c performance to assess glycemic status among African American, Afro-Caribbean, and African people.

Methods

A PubMed, Scopus, and Cumulative Index to Nursing and Allied Health Literature (CINAHL) search (January 2020) yielded 3,238 articles published from January 2000 through January 2020. After review of titles, abstracts, and full texts, 12 met our criteria. HbA_1c results were compared with other ethnic groups or validated against the oral glucose tolerance test (OGTT), fasting plasma glucose (FPG), or previous diagnosis. We classified study results by the risk of false positives and risk of false negatives in assessing glycemic status.

Results

In 5 studies of African American people, the HbA_1c test increased risk of false positives compared with White populations, regardless of glycemic status. Three studies of African Americans found that HbA_1c of 5.7% to less than 6.5% or HbA_1c of 6.5% or higher generally increased risk of overdiagnosis compared with OGTT or previous diagnosis. In one study of Afro-Caribbean people, HbA_1c of 6.5% or higher detected fewer type 2 diabetes cases because of a greater risk of false negatives. Compared with OGTT, HbA_1c tests in 4 studies of Africans found that HbA_1c of 5.7% to less than 6.5% or HbA_1c of 6.5% or higher leads to underdiagnosis.

Conclusion

HbA_1c criteria inadequately characterizes glycemic status among heterogeneous African descent populations. Research is needed to determine optimal HbA_1c cutoffs or other test strategies that account for risk profiles unique to African American, Afro-Caribbean, and African people living in the United States.

Haitian Immigrants and Type 2 Diabetes: An Integrative Review

Type 2 diabetes (T2D) is a complex, lifelong condition that is disproportionately prevalent among minority populations. Haitian immigrants (HIs) living in the US with T2D have unique factors that influence diagnosis, treatment, and self-management. The purpose of this integrative review was to provide a synthesis of the research on T2D in the HI population. In a systematic literature search, 14 studies met the inclusion criteria. Three themes were identified: risk factors for less self-management and/or worse metabolic control; protective factors for better self-management and/or metabolic control; and mixed results. HIs had higher HbA_1c, yet better self-management, different genetic profiles, and lower levels of vitamin D and hemoglobin concentration compared to other ethnic groups. HIs also reported better dietary quality, less healthcare utilization, and higher perceived emotional/psychological stress compared to other ethnic groups. This study has implications for practice for integrating the unique cultural factors when assessing and intervening with HIs.

Diabetes Knowledge, Management, and Prevention Among Haitian Immigrants in Philadelphia

Purpose Guided by the PEN-3 Cultural Model, the purpose of this study is to generate culturally framed insight into diabetes knowledge, management, and prevention among Haitians. Despite the disproportionate distribution of type II diabetes mellitus among US minorities, limited research explores outcomes within racial ethnic groups. It is particularly important to disaggregate the large racial-ethnic groups of black given the population growth among foreign-born blacks, such as Haitians, whose population has more than quadrupled in recent decades. Methods Focus group interviews were employed to understand diabetes knowledge, management, and prevention in the Haitian immigrant population in Philadelphia. Interviews were conducted in 2 groups: (1) people living with diabetes and (2) an at-risk sample for diabetes (defined as 30 and older with self-reported family history of diabetes). Interviews were recorded and transcribed verbatim in preparation for content analysis. Results Of the 10 participants, who were recruited through a Philadelphia church-based population, ages ranged from 41 to 91, with an average of 65. Content analysis revealed 3 emergent themes across: (1) cultural identity, including person, extended family, and neighborhood; (2) relationships and expectations, including perceptions, enablers, and nurturers; and (3) cultural empowerment, including positive, existential, and negative. Conclusions Results may inform culturally appropriate diabetes interventions for Haitians. Future research should explore compliance with food recommendations as well as the cultural competency of health care professional's information delivery.

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

Background & Objectives:

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

Methods:

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

Results:

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

Interpretation & conclusions:

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

Patterns of diabetes care in Slovenia, Croatia, Serbia, Bulgaria and Romania : An observational, non-interventional, cross-sectional study

BACKGROUND

National guidelines for treating type 2 diabetes in the Balkans generally follow European guidelines. The current study was undertaken to estimate the rate of glycated hemoglobin (HbA1c) measurements and level of HbA1c control in diabetic patients treated in regular clinical practice settings in the Balkans and to evaluate if providing HbA1c measurements improves adherence to treatment guidelines.

METHODS

This cross-sectional study enrolled type 2 diabetic patients treated by 79 primary care physicians and 102 specialists. The participants were provided with HbA1c measuring devices to measure HbA1c during regular office visits and a physician survey evaluated HbA1c the results feedback. Relevant clinical, demographic, drug treatment and specialist referral data were extracted from patient charts. Descriptive statistics and stepwise multivariate regression analysis were used.

RESULTS

Among 1853 patients included (average age 63.5 ± 10.7 years, 51% male) the average diabetes duration was 8.9 ± 7.1 years, 40% of patients had HbA1c measured every 6 months and 34% every 12 months (or less frequently). The rate of 6‑month measurement was higher among specialists (43%) vs. primary care physicians (32%, p < 0.01). The average HbA1c was 7.3 ± 1.5 and 35% of patients achieved the target HbA1c level of < 6.5%. Metformin monotherapy was prescribed to 28% of patients and metformin + sulphonylurea to 23%, 55% of patients on metformin monotherapy and 32% of patients on dual therapy metformin + sulphonylurea achieved the target HbA1c < 6.5%. Treatment remained unchanged in 91% and was stepped up in only 7.2% of patients. Physicians were not surprised (in 79% of patients) or were pleasantly surprised (in 11%) by the HbA1c results at the time of visit. Average diabetes duration and patient use of home glucometers were associated with the level of disease control.

CONCLUSIONS

The rates of HbA1c measurements remain low in the Balkans, although higher among specialists. Over 60% of patients, mostly treated with traditional oral antidiabetics did not achieve disease control. Providing convenient HbA1c measurement devices was not associated with a marked change in diabetes management. Future research is needed to evaluate the impact of these treatment patterns on long-term outcomes and costs to society.

Prevalence of undiagnosed diabetes and pre-diabetes among hypertensive patients attending Kiambu district Hospital, Kenya: a cross-sectional study

INTRODUCTION

Hypertension (HTN) and diabetes mellitus (DM) are two common non-communicable diseases (NCDs) that are closely linked: one cannot be properly managed without attention to the other. The aim of this study was to determine the prevalence of undiagnosed diabetic and pre-diabetic states that is abnormal glucose regulation (AGR) and factors associated with it among hypertensive patients in Kiambu Hospital, Kenya.

METHODS

We conducted a cross-sectional study from February 2014 to April 2014. Hypertensive patients aged ≥ 18 attending the out-patient medical clinic were included in the study. Pregnant and known diabetic patients were excluded. Data was collected on socio-demographics, behavior, and anthropometrics. Diabetes status was based on a Glycated Haemoglobin (HbA1C) classification of ≥ 6.5% for diabetes, 6.0-6.4% for pre-diabetes and ≤ 6.0% for normal. AGR was the dependable variable and included two diabetic categories; diabetes and pre-diabetes.

RESULTS

We enrolled 334 patients into the study: the mean age was 59 years (Standard deviation = 14.3). Of these patients 254 (76%) were women. Thirty two percent (107/334; 32%) were found to have AGR, with 14% (46) having un-diagnosed DM and 18%(61) with pre-diabetes. Factors associated with AGR were age ≥ 45 (OR = 3.23; 95% CI 1.37 ≥ 7.62), basal metabolic index (BMI) ≥ 25 Kg/m(2) (OR = 3.13; 95% CI 1.53 - 6.41), low formal education (primary/none)(OR= 2; 95%CI 1.08 - 3.56) and family history of DM (OR = 2.19; 95%CI 1.16 - 4.15).

CONCLUSION

There was a high prevalence of undiagnosed AGR among hypertensive patients. This highlights the need to regularly screen for AGR among hypertensive patients as recommended by WHO.

Elevated HbA1c levels in individuals not diagnosed with type 2 diabetes in Qatar: a pilot study

BACKGROUND

The prevalence of type 2 diabetes (T2D) in Qatar and the Middle East is one of the highest in the world. It is estimated that about one quarter of the individuals with tbl2D are undiagnosed. Elevated HbA1c levels are an indicator of tbl2D or a pre-diabetic state. In this study we set out to examine which factors, such as anthropometric and socio-demographic risk factors, are associated with elevated HbA1c levels in a population without tbl2D.

METHODS

We examined 191 subjects with no record of tbl2D. Anthropometrics and HbA1c were measured. Socio-demographic (age, gender, ethnicity and educational level) and health information were assessed through questionnaires. Elevated HbA1c levels were defined as >6.0% (>42 mmol/mol). Individual risk factors were examined in relationship to having elevated HbA1c levels using logistic regression.

RESULTS

Thirty-eight (20%) study participants had elevated HbA1c levels. Participants from South Asian and Filipino descent were more likely to present with elevated HbA1c levels than Arab participants (adjusted odds ratios (OR): 13.30 (95% confidence interval (CI): 4.24, 41.79), p < 0.001 for South Asian and 4.54 (95% CI: 1.04, 19.83), p = 0.04 for Filipinos). A body mass index of above 30 kg/m(2) was associated with elevated HbA1c levels (adjusted OR: 2.90 (95% CI: 1.29, 6.51), p = 0.01). Neither gender nor educational level was associated with elevated HbA1c levels.

CONCLUSIONS

Elevated HbA1c levels in individuals not diagnosed with diabetes were most frequently found in the South Asian and Filipino immigrant population. Special attention should therefore be given to the early identification of tbl2D in these subjects.