Hemoglobin A1c in diabetes: panacea or pointless?

Effects of ADHD and ADHD treatment on glycemic management in type 1 diabetes: A systematic review and meta-analysis of observational studies

AIMS

Studies suggested a higher prevalence of Attention-deficit/hyperactivity disorder (ADHD) in individuals with Type 1 Diabetes Mellitus (T1D). However, it is unclear how ADHD impacts glycemia and diabetes-related complications. This systematic review and meta-analysis aimed to investigate the effect of ADHD and ADHD medications on HbA1c and acute complications in T1D.

METHODS

A literature search was conducted in PubMed, EMBASE, CINAHL, Scopus, PsycINFO, CENTRAL, and Web of Science collections up to November 22, 2023. Seventeen studies were selected for the systematic review by independent reviewers, with twelve included in the meta-analysis.

RESULTS

Mean HbA1c levels were significantly higher in T1D individuals with ADHD compared to those without ADHD (MD = 0.60; 95 % CI: 0.41, 0.79; I2 = 90.1 %; p-value < 0.001). The rates of suboptimal HbA1c levels, hospitalization, diabetic ketoacidosis, and hypoglycemia were all substantially higher in T1D individuals with ADHD than those without ADHD. No difference was found in mean HbA1c between those who received ADHD treatment and those who did not (mean difference = -0.52; 95 % confidence interval: -1.16, 0.13; I2 = 78.6 %; p-value = 0.12).

CONCLUSIONS

ADHD is associated with higher HbA1c and increased acute diabetes-related complications. More research is needed to assess the effects of ADHD treatments on T1D management.

Dried Blood Spot Test for Glycated Hemoglobin Measurement in Pediatric Diabetes Care

BACKGROUND

The dried blood spot (DBS) card is a novel collection method for measuring glycated hemoglobin (A1C) in individuals with diabetes mellitus. The potential benefits of DBS specimens compared with traditional phlebotomy include a reduction in required total blood volume, reduced procedural pain, and an ability for self-initiated collection. DBS cards for A1C measurement have been validated in the adult population, but there is a paucity of pediatric data.

METHODS

The aim of this study was to validate the use of A1C measurement by DBS cards in comparison to venous A1C and to identify potential barriers to implementing this novel approach. Venous and DBS card A1C samples were collected simultaneously from 62 patients at their local laboratory and transported to the central provincial lab for analysis. Correlation analyses compared venous and DBS A1C with data rescaling performed to account for the DBS-venous interassay difference.

RESULTS

Mean venous A1C was 7.49% and DBS A1C was 7.26%, with an interassay difference of 0.23%. Data showed a strong, positive correlation between A1C collection methods (r=0.86, p<0.001); this was further strengthened at lower A1C values (A1C <7.5%, r=0.87, p<0.0001). A stronger relationship emerged when the data were rescaled to account for the DBS-venous interassay difference (r=0.8935, p<0.0001).

CONCLUSIONS

Given the potential feasibility, practicality, accessibility, cost-effectiveness, and performance characteristics of the DBS A1C, especially at lower A1C values hovering around the diagnostic threshold for diabetes, this study provides supporting evidence for consideration of the use of DBS A1C testing in pediatric diabetes care.

Relationship between electrolytes and glycated hemoglobin among diabetic patients with poor adherence to antidiabetic medications: a cross-sectional study

Introduction

type 2 Diabetes mellitus is a chronic metabolic disease with devastating effects on patients and results in numerous healthcare challenges in terms of its management and the cost burden among the affected. Successful management involves maintaining optimal glycemic control to prevent complications, with adherence to antidiabetic medications playing a crucial role in achieving this objective. Additionally, maintaining a healthy electrolyte balance is key for overall well-being and physiological function. However, the correlation between glycated hemoglobin and electrolyte balance remains under investigated, particularly in patients with suboptimal adherence. The aim of this research was to study the relationship between glycated hemoglobin and electrolytes among diabetic patients with poor adherence to antidiabetic medications.

Methods

this study was conducted at Samburu County Referral Hospital in Samburu County, Kenya. We employed a descriptive cross-sectional design focusing on adult diabetic patients aged 18 years and above who had visited the diabetic clinic over a three-month period. To evaluate their adherence levels, we employed a Morisky Medication Adherence Scale-8. Seventy-two diabetic patients who got adherence level scores of < 6 were categorized as having low adherence and their blood samples were collected for measuring glycated hemoglobin levels and electrolytes levels particularly potassium, sodium, calcium, magnesium, phosphorus and chloride. Relationship between electrolytes and glycated hemoglobin among diabetic patients with poor adherence to antidiabetics was determined using Karl Pearson correlation.

Results

among the study participants, the lowest hemoglobin A1C (HbA1c) level recorded was 5.1% while the highest was 15.0% and the majority (41.7%) fell within the HbA1c range of 5-7%. A high proportion of individuals (58.3%) with poor adherence to antidiabetics had elevated HbA1c levels, indicating poor glycemic control. The correlations observed between glycated hemoglobin and electrolytes which included magnesium, sodium, chloride, calcium and phosphorus was r= -0.07, -0.32, -0.05 -0.24 and -0.04 respectively.

Conclusion

this study concluded that there is a relationship between electrolytes and glycated hemoglobin among diabetic patients with poor adherence to antidiabetics. A statistically significant negative correlation was observed between glycated hemoglobin and calcium level (r=-0.2398 P ≤0.05) and also sodium (r=-0.31369 P≤0.05). A negative correlation (P≥0.05) was observed between phosphorus, magnesium, chloride and potassium with HbA1c levels though not statistically significant.

Correlation between time on target and glycated hemoglobin in people with diabetes mellitus: systematic review

to analyze the correlation between time on target and glycated hemoglobin in people living with diabetes mellitus and carrying out continuous blood glucose monitoring or self-monitoring of capillary blood glucose.

systematic review of etiology and risk based on JBI guidelines and reported according to Preferred Reporting Items for Systematic Reviews and Meta- Analyses, covering six databases and grey literature. The sample included 16 studies and methodological quality was assessed using JBI tools. Protocol registered in the Open Science Framework, available at https://doi.org/10.17605/OSF.IO/NKMZB.

time on target (70-180 mg/dl) showed a negative correlation with glycated hemoglobin, while time above target (>180 mg/dl) showed a positive correlation. Correlation coefficients ranged between -0.310 and -0.869 for time on target, and between 0.66 and 0.934 for time above target. A study was carried out on a population that performed self-monitoring.

there is a statistically significant correlation between time on target and time above target with glycated hemoglobin. The higher the proportion in the adequate glycemic range, the closer to or less than 7% the glycated hemoglobin will be. More studies are needed to evaluate this metric with data from self-monitoring of blood glucose.

The influence of periodontitis case definition on the association between periodontal disease and glycaemic status

OBJECTIVE

The association between periodontitis and glycaemic control is complex, and often described as 'bidirectional'. Although epidemiological studies have examined this relationship extensively, a disagreement on periodontitis case definition still exists. This study aimed to assess the influence of case definition on the association between periodontal disease and glycaemic status.

METHODS

The study is a secondary analysis of data from the United States National Health and Nutrition Examination Survey (NHANES), 2009-2014 cycles. The association between periodontitis and glycated haemoglobin (HbA1c) was assessed using different periodontitis case definitions: the definition by the Centers for Disease Control and Prevention and the American Academy of Periodontology (CDC/AAP), Community Periodontal Index (CPI), ≥1 site with ≥3 mm clinical attachment loss (CAL) and ≥4 mm probing depth (PD), ≥1 site with ≥4 mm CAL and ≥4 mm PD, the 5th European Workshop definitions, Machtei et al. 'established periodontitis', the 2017 World Workshop classification, and self-reported periodontitis. The associations between periodontitis and HbA1c were compared across the case definitions.

RESULTS

There was substantial variability in prevalence estimates of periodontitis, and in the strength of association between periodontitis and HbA1c when different case definitions were applied. The CDC/AAP and stage III/IV periodontitis were consistently significantly associated with elevated HbA1c. For stage III/IV, the adjusted odds ratios of prediabetes and diabetes HbA1c were 1.19 and 1.76, respectively.

CONCLUSION

Comprehensive periodontitis case definitions that account for CAL and PD, such as the CDC/AAP and the 2017 classification, seem to better detect the association between periodontal disease and HbA1c.

Autoimmune liver diseases and diabetes

Autoimmune liver diseases include autoimmune hepatitis, primary biliary cholangitis, and primary sclerosing cholangitis. They are chronic, heterogenous diseases affecting the liver which is a key metabolic organ that ensures glucose homeostasis. It is well known that patients with other chronic liver diseases such as cirrhosis and nonalcoholic fatty liver disease (NAFLD) display glucose disturbances like insulin resistance and have an increased risk of diabetes. Previous evidence on glucose disturbances in patients with autoimmune liver disease is scarce but does point towards a potentially increased risk of type 1 diabetes and type 2 diabetes. The underlying mechanisms are unknown but may reflect genetic predisposition, concurrent NAFLD and or cirrhosis development, and treatment (steroid) related impairment of glucose homeostasis. Therefore, increased awareness and surveillance of diabetes development in patients with autoimmune liver disease may be important. Overall, detection and treatment of diabetes generally follow the usual diabetes guidelines; however, in patients with advanced liver cirrhosis, HbA1c may not be a reliable marker of average glucose levels, and treatment with insulin is generally recommended. In addition, it has recently been suggested that sodium-glucose cotransporter 2 inhibitors may be beneficial in treating refractory ascites. Further research on diabetes risk in autoimmune liver disease is warranted.

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 HbA_1c 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 HbA_1c against 2hPG were lower at 6 months (r = 0.59 [FPG against 2hPG]; r = 0.45 [HbA_1c against 2hPG]) vs. 24 months (r = 0.73 [FPG against 2hPG]; r = 0.74 [HbA_1c against 2hPG]). Up to 69% of 2hPG-defined PTDM cases were missed by conventional HbA_1c and FPG thresholds. For prediabetes, concordance of FPG and HbA_1c 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 HbA_1c with 2hPG improved with time, their diagnostic concordance was poor for PTDM and, especially, prediabetes. Considering posttransplant metabolic instability, FPG's and HbA_1c 's diagnostic performance, the OGTT remains indispensable to diagnose PTDM and prediabetes after kidney transplantation.

Disparities in HbA1c testing between aging US Latino and non-Latino white primary care patients

US Latinos disproportionately face diabetes-related disparities compared to non-Latino Whites. A number of barriers, including linguistic and cultural discordance, have been consistently linked to these disparities. Glycated hemoglobin (HbA1c) testing is used to assess glycemic control among individuals living with diabetes. This study aimed to compare HbA1c levels and corresponding testing rates among non-Latino Whites and Latinos with both English and Spanish preference from a national cohort of primary care patients within community health centers. We analyzed electronic health records from patients who turned 50 years of age (n = 66,921) and were diagnosed with diabetes during or prior to the study period. They also must have been under observation for at least one year from January 1, 2013 to December 31, 2017. We calculated the rates of HbA1c tests each person received over the number of years observed and used covariate-adjusted negative binomial regression to estimate incidence rate ratios for Spanish preferring Latinos and English preferring Latinos compared to non-Latino Whites. Spanish preferring Latinos (rate ratio = 1.23, 95% CI = 1.16-1.30), regardless of HbA1c level, had higher testing rates than non-Latino Whites and English preferring Latinos. English preferring Latinos with controlled HbA1c levels had higher rates of HbA1c testing compared to non-Latino whites. Overall, the Latinos with Spanish preference maintained higher HbA1c testing rates and had disproportionately higher rates of uncontrolled HbA1c levels compared to non-Latino whites. Future efforts should focus on understanding effective approaches to increasing engagement among Spanish preferring Latinos and addressing organizational-level barriers, given HbA1c disparities.

Association of time in range with postoperative wound healing in patients with diabetic foot ulcers

Time in range (TIR) is a novel indicator of glycaemic control that has been reported to have an association with diabetic complications. The objective of the study was to explore the association of TIR with postoperative wound healing in patients with diabetic foot ulcers (DFUs). We retrospectively analysed the data of DFU patients who had undergone surgical treatment from 2015 to 2019. A 1:1 ratio in propensity score matching (PSM) was adopted to compare patients with TIR ≥50% with those <50%. Data were summarised using chi-squared, Fisher's exact, and Mann-Whitney U tests. Patients with TIR <50% underwent a higher rate of secondary surgery within a month (P = .032) and had a longer hospital stay (P = .045) with greater hospital charges (P < .001) than the TIR ≥50% group. Multivariate analysis revealed that TIR (P = .034), Wagner score (P = .009), diabetes treatment (P = .006), and type of surgery (P = .013) were independent risk factors for secondary surgery. Additionally, patient subgroups with TIR <50% and baseline HbA1c < 7.5% (P = .025), albumin level ≥ 30 g/L (P = .039), HDL < 1.16 (P = .021), or Wagner score ≥ 3 (P = .048) also experienced a higher incidence of secondary surgery. TIR was correlated with postoperative wound healing in patients with DFUs. Strict glycaemic targets should be established for surgical patients.

Ion Mobility Mass Spectrometry Analysis of Oxygen Affinity-Associated Structural Changes in Hemoglobin

Hemoglobin (Hb) is a major oxygen-transporting protein with allosteric properties reflected in the structural changes that accompany binding of O₂. Glycated hemoglobin (GHb), which is a minor component of human red cell hemolysate, is generated by a nonenzymatic reaction between glucose and hemoglobin. Due to the long lifetime of human erythrocytes (∼120 days), GHb is widely used as a reliable biomarker for monitoring long-term glucose control in diabetic patients. Although the structure of GHb differs from that of Hb, structural changes relating to the oxygen affinity of these proteins remain incompletely understood. In this study, the oxygen-binding kinetics of Hb and GHb are evaluated, and their structural dynamics are investigated using solution small-angle X-ray scattering (SAXS), electrospray ionization mass spectrometry equipped with ion mobility spectrometry (ESI-IM-MS), and molecular dynamic (MD) simulations to understand the impact of structural alteration on their oxygen-binding properties. Our results show that the oxygen-binding kinetics of GHb are diminished relative to those of Hb. ESI-IM-MS reveals structural differences between Hb and GHb, which indicate the preference of GHb for a more compact structure in the gas phase relative to Hb. MD simulations also reveal an enhancement of intramolecular interactions upon glycation of Hb. Therefore, the more rigid structure of GHb makes the conformational changes that facilitate oxygen capture more difficult creating a delay in the oxygen-binding process. Our multiple biophysical approaches provide a better understanding of the allosteric properties of hemoglobin that are reflected in the structural alterations accompanying oxygen binding.

Early pregnancy essential and non-essential metal mixtures and gestational glucose concentrations in the 2nd trimester: Results from project viva

Metals are involved in glucose metabolism, and some may alter glycemic regulation. However, joint effects of essential and non-essential metals on glucose concentrations during pregnancy are unclear. This study explored the joint associations of pregnancy exposures to essential (copper, magnesium, manganese, selenium, zinc) and non-essential (arsenic, barium, cadmium, cesium, lead, mercury) metals with gestational glucose concentrations using 1,311 women enrolled 1999-2002 in Project Viva, a Boston, MA-area pregnancy cohort. The study measured erythrocyte metal concentrations from 1st trimester blood samples and used glucose concentrations measured 1 h after non-fasting 50-gram glucose challenge tests (GCT) from clinical gestational diabetes screening at 26-28 weeks gestation. Bayesian Kernel Machine Regression (BKMR) and quantile-based g-computation were applied to model the associations of metal mixtures-including their interactions-with glucose concentrations post-GCT. We tested for reproducibility of BKMR results using generalized additive models. The BKMR model showed an inverse U-shaped association for barium and a linear inverse association for mercury. Specifically, estimated mean glucose concentrations were highest around 75th percentile of barium concentrations [2.1 (95% confidence interval: -0.2, 4.4) mg/dL higher comparing to the 25th percentile], and each interquartile range increase of erythrocyte mercury was associated with 1.9 mg/dL lower mean glucose concentrations (95% credible interval: -4.2, 0.4). Quantile g-computation showed joint associations of all metals, essential-metals, and non-essential metals on gestational glucose concentrations were all null, however, we observed evidences of interaction for barium and lead. Overall, we found early pregnancy barium and mercury erythrocytic concentrations were associated with altered post-load glucose concentrations in later pregnancy, with potential interactions between barium and lead.

Glycated Albumin for Glycemic Control in T2DM Population: A Multi-Dimensional Evaluation

Purpose

To investigate the glycated albumin (GA) introduction implications, as an add-on strategy to traditional glycemic control (Hb1Ac and fasting plasma glucose – FPG) instruments, considering insulin-naïve individuals with type 2 diabetes mellitus (T2DM), treated with oral therapies.

Methods

A Health Technology Assessment was conducted in Italy, as a multi-dimensional approach useful to validate any innovative technology. The HTA dimensions, derived from the EUnetHTA Core Model, were deployed by means of literature evidence, health economics tools and qualitative questionnaires, filled-in by 15 professionals.

Results

Literature stated that the GA introduction could lead to a higher number of individuals achieving therapeutic success after 3 months of therapy (97.0% vs 71.6% without GA). From an economic point of view, considering a projection of 1,955,447 T2DM insulin-naïve individuals, potentially treated with oral therapy, GA introduction would imply fewer individuals requiring a therapy switch (−89.44%), with a 1.06% in costs reduction, on annual basis, thus being also the preferable solution from a cost-effectiveness perspective (cost-effectiveness value: 237.74 vs 325.53). According to experts opinions, lower perceptions on GA emerged with regard to equity aspects (0.13 vs 0.72, p-value>0.05), whereas it would improve both individuals (2.17 vs 1.33, p-value=0.000) and caregivers quality of life (1.50 vs 0.83, p-value=0.000). Even if in the short term, GA required additional investments in training courses (−0.80 vs 0.10, p-value = 0.036), in the long run, GA could become the preferable technology (0.30 vs 0.01, p-value=0.018) from an organisational perspective.

Conclusion

Adding GA to traditional glycaemic control instruments could improve the clinical pathway of individuals with T2DM, leading to economic and organisational advantages for both hospitals and National Healthcare Systems.

Evaluation of Hemoglobin A1c before and after initiation of continuous glucose monitoring in children with type 1 diabetes mellitus

OBJECTIVES

The development of continuous glucose monitoring (CGM) systems has allowed for identification of blood sugar variations and trends in real-time that is not feasible with conventional self-monitoring of blood glucose. However, there is inconsistent data to show that the use of CGM leads to better glycemic control as measured by Hemoglobin A1c (HbA1c) in pediatric patients with type 1 diabetes mellitus. Our study aimed to compare the average HbA1c level in the 1-2 years prior to starting a CGM to the average HbA1c level in the 1-2 years immediately following CGM initiation in a sample of 1-20 year olds with type 1 diabetes mellitus.

METHODS

Participants were 90 youth (ages 1-20) followed for type 1 diabetes care at our institution who used a CGM for at least a 6 month time period. We performed a retrospective chart review to obtain up to four HbA1c values pre and post-CGM initiation each. We evaluated pre- and post-CGM initiation changes in mean HbA1c via dependent samples t-tests using IBM SPSS 24.0.

RESULTS

The mean HbA1c was 8.7% pre-CGM and decreased to 8.27% 9-12 months after CGM initiation in the overall sample. A statistically significant decrease in HbA1c was seen in patients who used multiple daily injections (p=0.02), those with a pre-CGM HbA1c greater than 9% (p=0.01), and those with a diabetes duration of 5-10 years (p=0.02).

CONCLUSION

CGM use was associated with a decrease in HbA1c over time which was statistically significant in some subgroups.

What Next After Metformin in Type 2 Diabetes? Selecting the Right Drug for the Right Patient

INTRODUCTION

Metformin is the recommended initial treatment in type 2 diabetes mellitus (T2DM), but when this does not give adequate glucose control the choice of which second-line drug to use is uncertain as none have been found to have a better overall glycaemic response. In this real-world study dipeptidyl peptidase 4 inhibitors (DPP4i), sulphonylureas (SU), thiazolidinediones (TZD) and sodium glucose co-transporter 2 inhibitors (SGLT2i) were compared for their effectiveness in lowering glycated haemoglobin (HbA1c) levels for a particular individual based on their clinical characteristics.

METHODS

A retrospective analysis was undertaken of electronic health records of people with T2DM prescribed metformin alongside a DPP4i, SU, TZD or SGLT2i at second-line. Regression modelling was used to model the changes in HbA1c from baseline at month 6 and month 12 for the individual therapies, adjusting for demographic and clinical characteristics.

RESULTS

There were 7170 people included in the study. Treatment at second-line with SUs, DPP4i, TZDs and SGLT2i resulted in similar percentages of people achieving the recommended HbA1c target of < 7.5% (58 mmol/mol) at both 6 and 12 months. For those receiving SGLT2i and SUs, the greatest improvement in HbA1c was observed in relatively younger and older people, respectively. Trends were detected between other baseline characteristics and HbA1c improvement by drug class, but they were not statistically significant. Non-adherence rates were low for all drug classes. People with a higher medication possession ratio (≥ 80%) also had greater improvements in HbA1c at 12 months.

CONCLUSION

This study identified patients' phenotypic characteristics that may have the potential to influence individual treatment response. Accounting for these characteristics in clinical treatment decisions may facilitate individualised prescribing by being able to select the right drug for the right patient.

Short term optimization of glycaemic control using insulin improves sympatho-vagal tone activities in patients with type 2 diabetes

INTRODUCTION

Diabetic cardiac autonomic neuropathy (CAN) is potentially life threatening and its severity might further be aggravated by poor glycaemic control. A decrease in Heart rate variability (HRV) is the earliest finding of CAN even at the sub clinical stage. While intensive glycaemic control prevents the development of CAN in patients with type 1 diabetes, it is not known whether the intensification of glycaemic control using insulin would improve cardiovascular autonomic functions in type 2 diabetes patients. This study aimed to determine the short term effects of optimizing glycaemic control using insulin on the HRV in type 2 diabetes patients.

METHODS

We conducted a single arm open label clinical trial. Participants were poorly controlled non-insulin treated type 2 diabetes mellitus patients (HbA1c ≥ 7%). The intervention lasted 60 days and consisted in the intensification of glycaemic control through the initiation of a basal plus insulin regimen with titration of insulin to protocol defined glycaemic targets which were; fasting glycaemia: 0.70-1.30 g/L and post prandial glycaemia <1.80 g/L. Long term HRV measurement was done using a 24-h ambulatory electrocardiographic (ECG) recording on day 0 and day 60. Wilcoxon signed rank test was used to compare differences in HRV parameters before and after the intervention.

RESULTS

A total of 29 (14 males and 15 females) consenting type 2 diabetes mellitus patients without clinical signs of CAN were enrolled and allocated to intervention (14 males and 15 females). The median age was 52 [43-59] years, and duration of diabetes 3.0 [0.6-6.7] years. The intervention induced a reduction in HbA1c from 10.1 [9.1-11.9]% to 6.7 [5.9-6.9]% (p < 0.001) without severe hypoglycaemic events. Concerning HRV parameters, there was a significant improvement in markers of the parasympathetic tone (PNN50: 5.7 [3.6-10.3]% to 8.1 [3.1-16.9]%, p = 0.008) and sympathetic tone (SDNN: 102.01 [90.45-111.05] ms to 122.40 [91.70-135.95] ms, p = 0.01).

CONCLUSION

The optimization of glycaemic control using a basal plus insulin regimen while inducing a significant reduction in glycated hemoglobin, significantly improves 24-h ambulatory ECG derived sympathetic and parasympathetic activities. This suggests that tight glycaemic control using insulin may revert cardiac autonomic neuropathy in type 2 diabetes mellitus patients.

The relationship between plasma lipids, oxidant-antioxidant status, and glycated proteins in individuals at risk for atherosclerosis

Objective: Ageing is one of the major risks for atherosclerosis. The age-related changes of interactions between plasma lipids, oxidative stress, antioxidant defense, and glycation processes are still not established while we age. Thus, the aim of the study was to analyze such relationships in individuals at risk for atherosclerosis due to their age.

Methods: Elderly and middle-aged persons with no acute disease or severe chronic disorder were assessed. Fasting plasma lipids (total cholesterol (T-C), high-density lipoprotein-cholesterol (HDL-C), low-density lipoprotein-cholesterol, and triacylglycerols), thiobarbituric acid reacting substances (TBARS), plasma total antioxidant status (TAS), and glucose and glycated proteins (fructosamine (FA) and glycated hemoglobin (HbA_1c)) were determined. An oral glucose tolerance test allowed exclusion of persons with type 2 diabetes.

Results: Lipid profiles were significantly profitable, increased HDL-C especially (p<0.0001), in the elderly versus middle-aged group. Decreased TBARS and TAS were found in the elderly versus middle-aged group (p=0.0001 and p=0.00002, respectively). Increased fructosamine was found in the elderly (255±30 μmol/L) versus middle-aged (236±33 μmol/L) group (p=0.006). Multiple regression analysis showed that in the middle-aged group TBARS correlated with T-C and HDL-C, and in the elderly group with HbA_1c and FA independently of other factors.

Conclusion: The factors which have an impact on oxidant–antioxidant status are crucial to understanding the pathomechanisms of senescence as well as the development of chronic diseases. Healthy aging may be maintained throughout proper lipid control. Moreover, data support the premise that the balance between lipid metabolism and oxidative stress may play a role in the initial phases of glycation plasma proteins particularly among elderly persons.

Label-free quantitation of glycated hemoglobin in single red blood cells by transient absorption microscopy and phasor analysis

As a stable and accurate biomarker, glycated hemoglobin (HbA1c) is clinically used to diagnose diabetes with a threshold of 6.5% among total hemoglobin (Hb). Current methods such as boronate affinity chromatography involve complex processing of large-volume blood samples. Moreover, these methods cannot measure HbA1c fraction at single-red blood cell (RBC) level, thus unable to separate the contribution from other factors such as RBC lifetime. Here, we demonstrate a spectroscopic transient absorption imaging approach that is able to differentiate HbA1c from Hb on the basis of their distinct excited-state dynamics. HbA1c fraction inside a single RBC is derived quantitatively through phasor analysis. HbA1c fraction distribution of diabetic blood is apparently different from that of healthy blood. A mathematical model is developed to derive the long-term blood glucose concentration. Our technology provides a unique way to study heme modification and to derive clinically important information void of bloodstream glucose fluctuation.

Update on biomarkers of glycemic control

Attaining and maintaining good glycemic control is a cornerstone of diabetes care. The monitoring of glycemic control is currently based on the self-monitoring of blood glucose (SMBG) and laboratory testing for hemoglobin A1c (HbA1c), which is a surrogate biochemical marker of the average glycemia level over the previous 2-3 mo period. Although hyperglycemia is a key biochemical feature of diabetes, both the level of and exposure to high glucose, as well as glycemic variability, contribute to the pathogenesis of diabetic complications and follow different patterns in type 1 and type 2 diabetes. HbA1c provides a valuable, standardized and evidence-based parameter that is relevant for clinical decision making, but several biological and analytical confounders limit its accuracy in reflecting true glycemia. It has become apparent in recent years that other glycated proteins such as fructosamine, glycated albumin, and the nutritional monosaccharide 1,5-anhydroglucitol, as well as integrated measures from direct glucose testing by an SMBG/continuous glucose monitoring system, may provide valuable complementary data, particularly in circumstances when HbA1c results may be unreliable or are insufficient to assess the risk of adverse outcomes. Long-term associations of these alternative biomarkers of glycemia with the risk of complications need to be investigated in order to provide clinically relevant cut-off values and to validate their utility in diverse populations of diabetes patients.

A1C Underperforms as a Diagnostic Test in Africans Even in the Absence of Nutritional Deficiencies, Anemia and Hemoglobinopathies: Insight From the Africans in America Study

Introduction: To improve detection of undiagnosed diabetes in Africa, there is movement to replace the OGTT with A1C. The performance of A1C in the absence of hemoglobin-related micronutrient deficiencies, anemia and heterozygous hemoglobinopathies is unknown. Therefore, we determined in 441 African-born blacks living in America [male: 65% (281/441), age: 38 ± 10 y (mean ± SD), BMI: 27.5 ± 4.4 kg/m²] (1) nutritional and hematologic profiles and (2) glucose tolerance categorization by OGTT and A1C. Methods: Hematologic and nutritional status were assessed. Hemoglobin <11 g/dL occurred in 3% (11/441) of patients and led to exclusion. A1C and OGTT were performed in the remaining 430 participants. ADA thresholds for A1C and OGTT were used. Diagnosis by A1C required meeting either A1C-alone or A1C&OGTT criteria. Diagnosis by OGTT-alone required detection by OGTT and not A1C. Results: Hemoglobin, mean corpuscular volume and red blood cell distribution width were 14.0 ± 1.3 g/dL, 85.5 ± 5.3 fL, and 13.2 ± 1.2% respectively. B12, folate, and iron deficiency occurred in 1% (5/430), 0% (0/430), and 4% (12/310), respectively. Heterozygous hemoglobinopathy prevalence was 18% (78/430). Overall, diabetes prevalence was 7% (32/430). A1C detected diabetes in 32% (10/32) but OGTT-alone detected 68% (22/32). Overall prediabetes prevalence was 41% (178/430). A1C detected 57% (102/178) but OGTT-alone identified 43% (76/178). After excluding individuals with heterozygous hemoglobinopathies, the rate of missed diagnosis by A1C of abnormal glucose tolerance did not change (OR: 0.99, 95% CI: 0.61, 1.62). Conclusions: In nutritionally replete Africans without anemia or heterozygous hemoglobinopathy, if only A1C is used, ~60% with diabetes and ~40% with prediabetes would be undiagnosed. Clinical Trial Registration:: www.ClinicalTrials.gov, Identifier: NCT00001853.

Interactive effect of acute and chronic glycemic indexes for severity in acute ischemic stroke patients

Background

Diabetes mellitus is a well-established risk factor for ischemic stroke and is known to increase stroke risk by 2–6 fold. Numerous studies have reported the relationship between parameters for glycemic status and stroke-related outcomes; however, studies focusing on the interaction between acute and chronic glycemic status indexes with stroke phenotype are lacking.

Methods

Acute ischemic stroke patients who were admitted to a tertiary hospital stroke center from 2002 to 2015 were consecutively enrolled in this study. Fasting blood sugar (FBS) and serum glycated hemoglobin (HbA1c) levels were recorded as acute and chronic glycemic indexes, respectively. The associations between initial stroke severity and both glycemic indexes were evaluated with consideration of the interaction between the glycemic indexes. Moreover, the distinct effects of stroke subtypes were evaluated.

Results

A total of 2595 patients were included in the final analysis. After adjustment for covariates, FBS was associated with initial stroke severity (P < 0.001), while HbA1c was not (P = 0.16). However, an interaction between FBS and HbA1c in association with initial stroke severity was observed (P < 0.001). The association between FBS and initial stroke severity was stronger, with a relatively normal HbA1c level. Among stroke subtypes, the interactions were significant for the large artery disease and cardioembolism subtypes (all, P < 0.001), but for the small vessel occlusion subtype (P = 0.63).

Conclusions

This study shows that HbA1c is an effect modifier for the association between FBS and initial stroke severity, and the interactive effect differs among stroke subtypes.

Electronic supplementary material

The online version of this article (10.1186/s12883-018-1109-1) contains supplementary material, which is available to authorized users.

Labile haemoglobin as a glycaemic biomarker for patient-specific monitoring of diabetes: mathematical modelling approach

Diabetes mellitus constitutes a major health problem and its clinical presentation and progression may vary considerably. A number of standardized diagnostic and monitoring tests are currently used for diabetes. They are based on measuring either plasma glucose, glycated haemoglobin or both. Their main goal is to assess the average blood glucose concentration. There are several sources of interference that can lead to discordances between measured plasma glucose and glycated haemoglobin levels. These include haemoglobinopathies, conditions associated with increased red blood cell turnover or the administration of some therapies, to name a few. Therefore, there is a need to provide new diagnostic tools for diabetes that employ clinically accessible biomarkers which, at the same time, can offer additional information allowing us to detect possible conflicting cases and to yield more reliable evaluations of the average blood glucose level concentration. We put forward a biomathematical model to describe the kinetics of two patient-specific glycaemic biomarkers to track the emergence and evolution of diabetes: glycated haemoglobin and its labile fraction. Our method incorporates erythrocyte age distribution and utilizes a large cohort of clinical data from blood tests to support its usefulness for diabetes monitoring.

Average glucose from hemoglobin A1c for altered red blood cell lifetimes: Predictions based on a model for hemoglobin A1c formation

BACKGROUND

A model for hemoglobin A_1c (HbA_1c) formation was used to predict the relationship between average glucose (AG) and %HbA_1c under conditions of altered red blood cell lifetime (RCL).

METHODS

Using a kinetic mass balance model for formation of HbA_1c in red blood cells as a function of age (time in circulation), whole blood %HbA_1c vs. glucose was calculated based on the nonlinear distribution of red blood cells as a function of age across RCL.

RESULTS

Model calculations provided a close fit to the standard relationship of estimated average glucose to %HbA_1c for normal RCL (r>0.999). Results for altered RCL were calculated assuming simple time-scale compression or expansion of the distribution of red blood cells as a function of RCL. For a given %HbA_1c, the operative average glucose needed to have achieved a given %HbA_1c was predicted to be altered by RCL according to average glucose×RCL=constant.

CONCLUSIONS

Model calculations estimate the extent to which standard reporting of AG vs. HbA_1c underestimates or overestimates AG under conditions of altered RCL. Conditions of altered RCL may often be operative in patients with certain hemoglobin variants.

Metrics Beyond Hemoglobin A1C in Diabetes Management: Time in Range, Hypoglycemia, and Other Parameters

We review clinical instances in which A1C should not be used and reflect on the use of other glucose metrics that can be used, in substitution of or in combination with A1C and SMBG, to tailor an individualized approach that will result in better outcomes and patient empowerment.

Mechanistic modeling of hemoglobin glycation and red blood cell kinetics enables personalized diabetes monitoring

The amount of glycated hemoglobin (HbA1c) in diabetic patients' blood provides the best estimate of the average blood glucose concentration over the preceding 2 to 3 months. It is therefore essential for disease management and is the best predictor of disease complications. Nevertheless, substantial unexplained glucose-independent variation in HbA1c makes its reflection of average glucose inaccurate and limits the precision of medical care for diabetics. The true average glucose concentration of a nondiabetic and a poorly controlled diabetic may differ by less than 15 mg/dl, but patients with identical HbA1c values may have true average glucose concentrations that differ by more than 60 mg/dl. We combined a mechanistic mathematical model of hemoglobin glycation and red blood cell kinetics with large sets of within-patient glucose measurements to derive patient-specific estimates of nonglycemic determinants of HbA1c, including mean red blood cell age. We found that between-patient variation in derived mean red blood cell age explains all glucose-independent variation in HbA1c. We then used our model to personalize prospective estimates of average glucose and reduced errors by more than 50% in four independent groups of greater than 200 patients. The current standard of care provided average glucose estimates with errors >15 mg/dl for one in three patients. Our patient-specific method reduced this error rate to 1 in 10. Our personalized approach should improve medical care for diabetes using existing clinical measurements.

Are There Clinical Implications of Racial Differences in HbA1c? A Difference, to Be a Difference, Must Make a Difference

Studies that have compared HbA1c levels by race have consistently demonstrated higher HbA1c levels in African Americans than in whites. These racial differences in HbA1c have not been explained by measured differences in glycemia, sociodemographic factors, clinical factors, access to care, or quality of care. Recently, a number of nonglycemic factors and several genetic polymorphisms that operate through nonglycemic mechanisms have been associated with HbA1c Their distributions across racial groups and their impact on hemoglobin glycation need to be systematically explored. Thus, on the basis of evidence for racial differences in HbA1c, current clinical guidelines from the American Diabetes Association state: "It is important to take…race/ethnicity…into consideration when using the A1C to diagnose diabetes." However, it is not clear from the guidelines how this recommendation might be actualized. So, the critical question is not whether racial differences in HbA1c exist between African Americans and whites; the important question is whether the observed differences in HbA1c level are clinically meaningful. Therefore, given the current controversy, we provide a Point-Counterpoint debate on this issue. In the preceding point narrative, Dr. Herman provides his argument that the failure to acknowledge that HbA1c might be a biased measure of average glycemia and an unwillingness to rigorously investigate this hypothesis will slow scientific progress and has the potential to do great harm. In the counterpoint narrative below, Dr. Selvin argues that there is no compelling evidence for racial differences in the validity of HbA1c as a measure of hyperglycemia and that race is a poor surrogate for differences in underlying causes of disease risk.-William T. CefaluEditor in Chief, Diabetes Care.

Epigenome-wide association study identifies TXNIP gene associated with type 2 diabetes mellitus and sustained hyperglycemia

Type 2 diabetes mellitus (DM) is an established risk factor for a wide range of vascular diseases, including ischemic stroke (IS). Glycated hemoglobin A1c (HbA1c), a marker for average blood glucose levels over the previous 12 weeks, is used as a measure of glycemic control and also as a diagnostic criterion for diabetes (HbA1c levels ≥ 6.5%). Epigenetic mechanisms, such as DNA methylation, may be associated with aging processes and with modulation of the risk of various pathologies, such as DM. Specifically, DNA methylation could be one of the mechanisms mediating the relation between DM and environmental exposures. Our goal was to identify new CpG methylation sites associated with DM. We performed a genome-wide methylation study in whole-blood DNA from an IS patient cohorts. Illumina HumanMethylation450 BeadChip array was used to measure DNA methylation in CpG sites. All statistical analyses were adjusted for sex, age, hyperlipidemia, body mass index (BMI), smoking habit and cell count. Findings were replicated in two independent cohorts, an IS cohort and a population-based cohort, using the same array. In the discovery phase (N = 355), we identified a CpG site, cg19693031 (located in the TXNIP gene) that was associated with DM (P = 1.17 × 10(-12)); this CpG was replicated in two independent cohorts (N = 167 and N = 645). Methylation of TXNIP was inversely and intensely associated with HbA1c levels (P = 7.3 × 10(-16)), specifically related to diabetic patients with poor control of glucose levels. We identified an association between the TXNIP gene and DM through epigenetic mechanisms, related to sustained hyperglycemia levels (HbA1c ≥ 7%).

Effects of Glucocorticoid Treatment on β- and α-Cell Mass in Japanese Adults With and Without Diabetes

The aim of this study was 1) to clarify β-cell regenerative capacity in the face of glucocorticoid (GC)-induced insulin resistance and 2) to clarify the change in β- and α-cell mass in GC-induced diabetes in humans. We obtained the pancreases from 100 Japanese autopsy case subjects. The case subjects were classified according to whether or not they had received GC therapy before death and the presence or absence of diabetes. Fractional β-cell area (%BCA) and α-cell area (%ACA) were quantified, and the relationship with GC therapy was evaluated. As a result, in case subjects without diabetes, there was no significant difference in %BCA between case subjects with and without GC therapy (1.66 ± 1.05% vs. 1.21 ± 0.59%, P = 0.13). %ACA was also not significantly different between the two groups. In case subjects with type 2 diabetes, %BCA and %ACA were both significantly reduced compared with control subjects without diabetes; however, neither %BCA nor %ACA was significantly decreased in case subjects with GC-induced diabetes. There was a significant negative correlation between %BCA and HbA1c measured before death; however, this relationship was attenuated in case subjects with GC therapy. In conclusion, the current study suggests that β- and α-cell mass remain largely unchanged in the face of GC-induced insulin resistance in Japanese individuals, implying limited capacity of β-cell regeneration in adult humans. The absence of apparent β-cell deficit in case subjects with GC-induced diabetes suggests that GC-induced diabetes is mainly caused by insulin resistance and/or β-cell dysfunction, but not necessarily a deficit of β-cell mass.

Quality of HbA1c Measurement in the Practice: The German Perspective

Hemoglobin A1c (HbA1c) measurement has come to be a cornerstone in modern diabetes therapy. However, the methodological aspects of this type of measurement have been given little attention lately due to its position as an established method of choice. Nevertheless, quite a number of issues face practical application, such as clinically relevant differences between different measurement methods--both lab-based and point-of-care (POCT) systems will show better or worse diabetes management results after switching methods; and there are a number of possible reasons that need to be known and observed in practice. The aim of this review is to draw attention to these problems from a German point of view and provide suggestions for appropriate measures to improve the situation.

Dysglycaemia in the critically ill and the interaction of chronic and acute glycaemia with mortality

PURPOSE

Hyperglycaemia is common in the critically ill. The objectives of this study were to determine the prevalence of critical illness-associated hyperglycaemia (CIAH) and recognised and unrecognised diabetes in the critically ill as well as to evaluate the impact of premorbid glycaemia on the association between acute hyperglycaemia and mortality.

METHODS

In 1,000 consecutively admitted patients we prospectively measured glycated haemoglobin (HbA1c) on admission, and blood glucose concentrations during the 48 h after admission, to the intensive care unit. Patients with blood glucose ≥7.0 mmol/l when fasting or ≥11.1 mmol/l during feeding were deemed hyperglycaemic. Patients with acute hyperglycaemia and HbA1c <6.5% (48 mmol/mol) were categorised as 'CIAH', those with known diabetes as 'recognised diabetes', and those with HbA1c ≥6.5% but no previous diagnosis of diabetes as 'unrecognised diabetes'. The remainder were classified as 'normoglycaemic'. Hospital mortality, HbA1c and acute peak glycaemia were assessed using a logistic regression model.

RESULTS

Of 1,000 patients, 498 (49.8%) had CIAH, 220 (22%) had recognised diabetes, 55 (5.5%) had unrecognised diabetes and 227 (22.7%) were normoglycaemic. The risk of death increased by approximately 20% for each increase in acute glycaemia of 1 mmol/l in patients with CIAH and those with diabetes and HbA1c levels <7% (53 mmol/mol), but not in patients with diabetes and HbA1c ≥7%. This association was lost when adjusted for severity of illness.

CONCLUSIONS

Critical illness-associated hyperglycaemia is the most frequent cause of hyperglycaemia in the critically ill. Peak glucose concentrations during critical illness are associated with increased mortality in patients with adequate premorbid glycaemic control, but not in patients with premorbid hyperglycaemia. Optimal glucose thresholds in the critically ill may, therefore, be affected by premorbid glycaemia.

Islet number rather than islet size is a major determinant of β- and α-cell mass in humans

OBJECTIVE

The objective of the study was to clarify the relative contribution of islet number and islet size to β- and α-cell mass in humans.

RESEARCH DESIGN AND METHODS

We obtained the pancreas at autopsy from 72 Japanese adults with no history of diabetes or pancreatitis (aged 47 ± 12 years, body mass index 24.1 ± 5.0 kg/m(2)). Pancreatic sections were stained for insulin or glucagon, and fractional β-cell area (%BCA) and α-cell area (%ACA) were measured. Islet number and islet size as well as β-cell turnover were also quantified. Glycosylated hemoglobin measured within 1 year prior to death was obtained in 38 individuals.

RESULTS

There was considerable interindividual variation in islet density and mean islet size, with a significant negative correlation between the two (r = -0.25, P = .03). There were significant positive correlations between islet density and %BCA or %ACA (r = 0.63, P < .001, and r = 0.41, P = .001), whereas mean islet size correlated with neither of them. Islet density as well as %BCA, but not mean islet size, was negatively correlated with glycosylated hemoglobin (r = -0.37, P = .02, and r = -0.36, P = .03).

CONCLUSION

The present study suggests that islet number rather than islet size is a major determinant of β- and α-cell mass in humans. Interindividual difference in islet number may contribute to susceptibility to development of glucose intolerance.

Fructosamine and glycated albumin for risk stratification and prediction of incident diabetes and microvascular complications: a prospective cohort analysis of the Atherosclerosis Risk in Communities (ARIC) study

BACKGROUND

HbA1c is the standard measure by which to monitor long-term (2-3 months) glucose control in people with diabetes and is now used for diagnosis of diabetes. Fructosamine and glycated albumin are markers of short-term (2-4 weeks) glycaemic control that might add complementary prognostic information to HbA1c. Our aim was to clarify the performance of fructosamine and glycated albumin measurements for identifying people at risk of incident diabetes or diabetic complications.

METHODS

We measured glycated albumin and fructosamine in blood samples from 11 348 adults without diabetes and 958 adults diagnosed with diabetes mellitus (both type 1 and 2) who attended the second examination of the Atherosclerosis Risk in Communities (ARIC) study in 1990-92 (baseline). We assessed the associations of fructosamine and glycated albumin with risk of incident diabetes, retinopathy, and risk of incident chronic kidney disease (CKD), during two decades of follow-up. We compared these associations with those of HbA1c with incident diabetes, retinopathy, and CKD. For analyses of associations with incident diabetes and CKD, adjusted hazard ratios (HRs) and their corresponding 95% CIs were estimated using Cox proportional hazards models. Model discrimination was assessed using Harrell's C statistic.

FINDINGS

The HRs for incident diabetes were 4·96 (4·36-5·64) for fructosamine above the 95th percentile and 6·17 (5·45-6·99) for glycated albumin above the 95th percentile. Associations were attenuated but persisted after adjustment for HbA1c. Fructosamine and glycated albumin were strongly associated with retinopathy (p<0·0001 for trend). The multivariable-adjusted HRs for CKD for people with fructosamine and glycated albumin above the 95th percentile were 1·50 (95% CI 1·22-1·85) and 1·48 (1·20-1·83), respectively, when compared with people with no diabetes and fructosamine or glycated albumin below the 75th percentile. Prediction of incident CKD by fructosamine (C statistic 0·717) and glycated albumin (0·717) were nearly as strong as by HbA1c (0·726), but HbA1c outperformed fructosamine and glycated albumin for prediction of incident diabetes with C statistics of 0·760, 0·706, and 0·703, respectively.

INTERPRETATION

Fructosamine and glycated albumin were strongly associated with incident diabetes and its microvascular complications, with prognostic value comparable to HbA1c.

FUNDING

National Heart, Lung, and Blood Institute.

Beyond HbA1c and glucose: the role of nontraditional glycemic markers in diabetes diagnosis, prognosis, and management

Fasting glucose and hemoglobin A1c (HbA1c) are the standard measures for diagnosis and monitoring of diabetes. There has been recent interest in nontraditional markers of hyperglycemia, including fructosamine, glycated albumin, and 1,5-anhydroglucitol (1,5-AG), as alternatives or adjuncts to standard measures. There is a growing literature linking these nontraditional markers with microvascular and macrovascular complications. Fructosamine and glycated albumin have also been shown to improve identification of persons with diabetes. However, long-term prospective studies with clinical outcomes are lacking. Some modern laboratory assays for fructosamine, glycated albumin, and 1,5-AG have excellent performance. Expanded use of these tests has the potential to improve diabetes care as these measures may overcome limitations of HbA1c in certain patients, complement traditional measures by providing additional information on shorter-term glycemic control, and improve risk stratification for diabetes and its complications. Nonetheless, studies are needed to demonstrate if their routine use will benefit patients and improve outcomes.

Recommendations for standardizing glucose reporting and analysis to optimize clinical decision making in diabetes: the Ambulatory Glucose Profile (AGP)

Abstract Underutilization of glucose data and lack of easy and standardized glucose data collection, analysis, visualization, and guided clinical decision making are key contributors to poor glycemic control among individuals with type 1 diabetes. An expert panel of diabetes specialists, facilitated by the International Diabetes Center and sponsored by the Helmsley Charitable Trust, met in 2012 to discuss recommendations for standardization of analysis and presentation of glucose monitoring data, with the initial focus on data derived from CGM systems. The panel members were introduced to a universal software report, the Ambulatory Glucose Profile (AGP), and asked to provide feedback on its content and functionality, both as a research tool and in clinical settings. This paper provides a summary of the topics and issues discussed during the meeting and presents recommendations from the expert panel regarding the need to standardize glucose profile summary metrics and the value of a uniform glucose report to aid clinicians, researchers, and patients.

Recommendations for standardizing glucose reporting and analysis to optimize clinical decision making in diabetes: the ambulatory glucose profile

Underutilization of glucose data and lack of easy and standardized glucose data collection, analysis, visualization, and guided clinical decision making are key contributors to poor glycemic control among individuals with type 1 diabetes mellitus. An expert panel of diabetes specialists, facilitated by the International Diabetes Center and sponsored by the Helmsley Charitable Trust, met in 2012 to discuss recommendations for standardizing the analysis and presentation of glucose monitoring data, with the initial focus on data derived from continuous glucose monitoring systems. The panel members were introduced to a universal software report, the Ambulatory Glucose Profile, and asked to provide feedback on its content and functionality, both as a research tool and in clinical settings. This article provides a summary of the topics and issues discussed during the meeting and presents recommendations from the expert panel regarding the need to standardize glucose profile summary metrics and the value of a uniform glucose report to aid clinicians, researchers, and patients.