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Lado-Baleato Ó, Roca-Pardiñas J, Cadarso-Suárez C, Gude F. Modeling conditional reference regions: Application to glycemic markers. Stat Med 2021; 40:5926-5946. [PMID: 34396576 DOI: 10.1002/sim.9163] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2020] [Revised: 07/07/2021] [Accepted: 07/29/2021] [Indexed: 12/31/2022]
Abstract
Many clinical decisions are taken based on the results of continuous diagnostic tests. Usually, only the results of one single test is taken into consideration, the interpretation of which requires a reference range for the healthy population. However, the use of two different tests, can be necessary in the diagnosis of certain diseases. This obliges a bivariate reference region be available for their interpretation. It should also be remembered that reference regions may depend on patient variables (eg, age and sex) independent of the suspected disease. However, few proposals have been made regarding the statistical modeling of such reference regions, and those put forward have always assumed a Gaussian distribution, which can be rather restrictive. The present work describes a new statistical method that allows such reference regions to be estimated with no insistence on the results being normally distributed. The proposed method is based on a bivariate location-scale model that provides probabilistic regions covering a specific percentage of the bivariate data, dependent on certain covariates. The reference region is estimated nonparametrically and the nonlinear effects of continuous covariates via polynomial kernel smoothers in additive models. The bivariate model is estimated using a backfitting algorithm, and the optimal smoothing parameters of the kernel smoothers selected by cross-validation. The model performed satisfactorily in simulation studies under the assumption of non-Gaussian conditions. Finally, the proposed methodology was found to be useful in estimating a reference region for two continuous diagnostic tests for diabetes (fasting plasma glucose and glycated hemoglobin), taking into account the age of the patient.
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Affiliation(s)
- Óscar Lado-Baleato
- Department of Statistics, Mathematical Analysis, and Optimization, Universidade de Santiago de Compostela, Galicia, Spain
| | - Javier Roca-Pardiñas
- Statistical Inference, Decision and Operations Research, Universidade de Vigo, Galicia, Spain
| | - Carmen Cadarso-Suárez
- Department of Statistics, Mathematical Analysis, and Optimization, Universidade de Santiago de Compostela, Galicia, Spain
| | - Francisco Gude
- Clinical Epidemiology Unit, Complexo Hospitalario de Santiago de Compostela, Galicia, Spain
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2
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Runge CR, Ng M, Herman WH, Gebremariam A, Hirschfeld E, Lee JM. Racial differences in prediabetes prevalence by test type for the US pediatric and adult population: NHANES 1999-2016. Pediatr Diabetes 2020; 21:1110-1115. [PMID: 32681534 PMCID: PMC10771709 DOI: 10.1111/pedi.13083] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Revised: 06/29/2020] [Accepted: 07/13/2020] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Previous studies have shown that US estimates of prediabetes or diabetes differ depending on test type, fasting plasma glucose (FPG) vs hemoglobin A1c (HbA1c). Given age, race, and test differences reported in the literature, we sought to further examine these differences in prediabetes detection using a nationally representative sample. METHODS Using the National Health and Nutrition Examination Survey (NHANES) 1999-2016, individuals were identified as having prediabetes with an HbA1c of 5.7% to 6.4% or a FPG of 100 to 125 mg/dL. We excluded individuals with measurements in the diabetic range. We ran generalized estimating equation logistic regressions to examine the relationship between age, race, and test type with interactions, controlling for sex and body mass index. We compared the difference in predicted prediabetes prevalence detected by impaired fasting glycemia (IFG) vs HbA1c by race/ethnicity among children and adults separately using adjusted Wald tests. RESULTS The absolute difference in predicted prediabetes detected by IFG vs HbA1c was 19.9% for white adolescents, 0% for black adolescents, and 20.1% for Hispanic adolescents; 21.4% for white adults, -1.2% for black adults, and 19.2% for Hispanic adults. Using adjusted Wald tests, we found the absolute differences between black vs white and black vs Hispanic individuals to be significant, but, not between Hispanic and white individuals among children and adults separately. CONCLUSIONS These observations highlight differences in test performance among racial/ethnic groups. Our findings corroborate the need for further studies to determine appropriate HbA1c cutoff levels for diagnosis of prediabetes by age group and race.
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Affiliation(s)
- Carly R. Runge
- Department of Nutritional Sciences, School of Public Health, University of Michigan
- Susan B. Meister Child Health Evaluation and Research Center (CHEAR), Division of General Pediatrics, University of Michigan
| | - Michelle Ng
- Susan B. Meister Child Health Evaluation and Research Center (CHEAR), Division of General Pediatrics, University of Michigan
| | - William H. Herman
- Department of Internal Medicine, University of Michigan
- Department of Epidemiology, University of Michigan
| | - Acham Gebremariam
- Susan B. Meister Child Health Evaluation and Research Center (CHEAR), Division of General Pediatrics, University of Michigan
| | - Emily Hirschfeld
- Susan B. Meister Child Health Evaluation and Research Center (CHEAR), Division of General Pediatrics, University of Michigan
| | - Joyce M. Lee
- Department of Nutritional Sciences, School of Public Health, University of Michigan
- Susan B. Meister Child Health Evaluation and Research Center (CHEAR), Division of General Pediatrics, University of Michigan
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3
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Jagannathan R, Neves JS, Dorcely B, Chung ST, Tamura K, Rhee M, Bergman M. The Oral Glucose Tolerance Test: 100 Years Later. Diabetes Metab Syndr Obes 2020; 13:3787-3805. [PMID: 33116727 PMCID: PMC7585270 DOI: 10.2147/dmso.s246062] [Citation(s) in RCA: 49] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2020] [Accepted: 09/24/2020] [Indexed: 12/15/2022] Open
Abstract
For over 100 years, the oral glucose tolerance test (OGTT) has been the cornerstone for detecting prediabetes and type 2 diabetes (T2DM). In recent decades, controversies have arisen identifying internationally acceptable cut points using fasting plasma glucose (FPG), 2-h post-load glucose (2-h PG), and/or HbA1c for defining intermediate hyperglycemia (prediabetes). Despite this, there has been a steadfast global consensus of the 2-h PG for defining dysglycemic states during the OGTT. This article reviews the history of the OGTT and recent advances in its application, including the glucose challenge test and mathematical modeling for determining the shape of the glucose curve. Pitfalls of the FPG, 2-h PG during the OGTT, and HbA1c are considered as well. Finally, the associations between the 30-minute and 1-hour plasma glucose (1-h PG) levels derived from the OGTT and incidence of diabetes and its complications will be reviewed. The considerable evidence base supports modifying current screening and diagnostic recommendations with the use of the 1-h PG. Measurement of the 1-h PG level could increase the likelihood of identifying high-risk individuals when the pancreatic ß-cell function is substantially more intact with the added practical advantage of potentially replacing the conventional 2-h OGTT making it more acceptable in the clinical setting.
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Affiliation(s)
- Ram Jagannathan
- Division of Hospital Medicine, Emory University School of Medicine, Atlanta, GA, USA
| | - João Sérgio Neves
- Department of Surgery and Physiology, Cardiovascular Research and Development Center, Faculty of Medicine, University of Porto, Porto, Portugal
- Department of Endocrinology, Diabetes and Metabolism, Sa˜o Joa˜ o University Hospital Center, Porto, Portugal
| | - Brenda Dorcely
- NYU Grossman School of Medicine, Division of Endocrinology, Diabetes, Metabolism, New York, NY10016, USA
| | - Stephanie T Chung
- Diabetes, Obesity, and Endocrinology Branch, National Institute of Diabetes & Digestive & Kidney Diseases, National Institutes of Health, Bethesda, MD, USA
| | - Kosuke Tamura
- Social Determinants of Obesity and Cardiovascular Risk Laboratory, Cardiovascular Branch, Division of Intramural Research, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD20892, USA
| | - Mary Rhee
- Emory University School of Medicine, Department of Medicine, Division of Endocrinology, Metabolism, and Lipids, Atlanta VA Health Care System, Atlanta, GA30322, USA
| | - Michael Bergman
- NYU Grossman School of Medicine, NYU Diabetes Prevention Program, Endocrinology, Diabetes, Metabolism, VA New York Harbor Healthcare System, Manhattan Campus, New York, NY10010, USA
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4
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Bergman M, Abdul-Ghani M, Neves JS, Monteiro MP, Medina JL, Dorcely B, Buysschaert M. Pitfalls of HbA1c in the Diagnosis of Diabetes. J Clin Endocrinol Metab 2020; 105:dgaa372. [PMID: 32525987 PMCID: PMC7335015 DOI: 10.1210/clinem/dgaa372] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2020] [Accepted: 06/08/2020] [Indexed: 02/06/2023]
Abstract
Many health care providers screen high-risk individuals exclusively with an HbA1c despite its insensitivity for detecting dysglycemia. The 2 cases presented describe the inherent caveats of interpreting HbA1c without performing an oral glucose tolerance test (OGTT). The first case reflects the risk of overdiagnosing type 2 diabetes (T2D) in an older African American male in whom HbA1c levels, although variable, were primarily in the mid-prediabetes range (5.7-6.4% [39-46 mmol/mol]) for many years although the initial OGTT demonstrated borderline impaired fasting glucose with a fasting plasma glucose of 102 mg/dL [5.7 mmol/L]) without evidence for impaired glucose tolerance (2-hour glucose ≥140-199 mg/dl ([7.8-11.1 mmol/L]). Because subsequent HbA1c levels were diagnostic of T2D (6.5%-6.6% [48-49 mmol/mol]), a second OGTT performed was normal. The second case illustrates the risk of underdiagnosing T2D in a male with HIV having normal HbA1c levels over many years who underwent an OGTT when mild prediabetes (HbA1c = 5.7% [39 mmol/mol]) developed that was diagnostic of T2D. To avoid inadvertent mistreatment, it is therefore essential to perform an OGTT, despite its limitations, in high-risk individuals, particularly when glucose or fructosamine and HbA1c values are discordant. Innate differences in the relationship between fructosamine or fasting glucose to HbA1c are demonstrated by the glycation gap or hemoglobin glycation index.
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Affiliation(s)
- Michael Bergman
- NYU School of Medicine, Director, NYU Diabetes Prevention Program, Section Chief, Endocrinology, Diabetes, Metabolism, VA New York Harbor Healthcare System, Manhattan Campus, New York, New York
| | - Muhammad Abdul-Ghani
- Division of Diabetes, University of Texas Health Science Center at San Antonio, San Antonio, Texas
| | - João Sérgio Neves
- Department of Surgery and Physiology, Cardiovascular Research Center, Faculty of Medicine, University of Porto, Porto, Portugal
- Department of Endocrinology, Diabetes and Metabolism, São João University Hospital Center, Porto, Portugal
| | - Mariana P Monteiro
- Endocrine, Cardiovascular & Metabolic Research, Unit for Multidisciplinary Research in Biomedicine (UMIB), University of Porto, Porto, Portugal
- Institute of Biomedical Sciences Abel Salazar (ICBAS), University of Porto, Porto, Portugal
| | | | - Brenda Dorcely
- NYU Grossman School of Medicine, Division of Endocrinology, Diabetes, Metabolism, New York, New York
| | - Martin Buysschaert
- Department of Endocrinology and Diabetology, Université Catholique de Louvain, University Clinic Saint-Luc, Brussels, Belgium
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5
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Ghosh S, Manley SE, Nightingale PG, Williams JA, Susarla R, Alonso‐Perez I, Stratton IM, Gkoutos GV, Webber J, Luzio SD, Hanif W, Roberts GA. Prevalence of admission plasma glucose in 'diabetes' or 'at risk' ranges in hospital emergencies with no prior diagnosis of diabetes by gender, age and ethnicity. Endocrinol Diabetes Metab 2020; 3:e00140. [PMID: 32704561 PMCID: PMC7375073 DOI: 10.1002/edm2.140] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2020] [Accepted: 04/04/2020] [Indexed: 01/29/2023] Open
Abstract
AIMS To establish the prevalence of admission plasma glucose in 'diabetes' and 'at risk' ranges in emergency hospital admissions with no prior diagnosis of diabetes; characteristics of people with hyperglycaemia; and factors influencing glucose measurement. METHODS Electronic patient records for 113 097 hospital admissions over 1 year from 2014 to 2015 included 43 201 emergencies with glucose available for 31 927 (74%) admissions, comprising 22 045 people. Data are presented for 18 965 people with no prior diagnosis of diabetes and glucose available on first attendance. RESULTS Three quarters (14 214) were White Europeans aged 62 (43-78) years, median (IQ range); 12% (2241) South Asians 46 (32-64) years; 9% (1726) Unknown/Other ethnicities 43 (29-61) years; and 4% (784) Afro-Caribbeans 49 (33-63) years, P < .001. Overall, 5% (1003) had glucose in the 'diabetes' range (≥11.1 mmol/L) higher at 8% (175) for South Asians; 16% (3042) were 'at risk' (7.8-11.0 mmol/L), that is 17% (2379) White Europeans, 15% (338) South Asians, 14% (236) Unknown/Others and 11% (89) Afro-Caribbeans, P < .001. The prevalence for South Asians aged <30 years was 2.1% and 5.2%, respectively, 2.6% and 8.6% for Afro-Caribbeans <30 years, and 2.0% and 8.4% for White Europeans <40 years. Glucose increased with age and was more often in the 'diabetes' range for South Asians than White Europeans with South Asian men particularly affected. One third of all emergency admissions were for <24 hours with 58% of these having glucose measured compared to 82% with duration >24 hours. CONCLUSIONS Hyperglycaemia was evident in 21% of adults admitted as an emergency; various aspects related to follow-up and initial testing, age and ethnicity need to be considered by professional bodies addressing undiagnosed diabetes in hospital admissions.
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Affiliation(s)
- Sandip Ghosh
- Diabetes Translational Research GroupDiabetes CentreNuffield HouseQueen Elizabeth Hospital BirminghamBirminghamUK
- Institute of Translational MedicineHeritage Building (Queen Elizabeth Hospital)BirminghamUK
| | - Susan E. Manley
- Diabetes Translational Research GroupDiabetes CentreNuffield HouseQueen Elizabeth Hospital BirminghamBirminghamUK
- Institute of Translational MedicineHeritage Building (Queen Elizabeth Hospital)BirminghamUK
- Institute of Metabolism and Systems ResearchCollege of Medical and Dental SciencesUniversity of BirminghamBirminghamUK
| | - Peter G. Nightingale
- Institute of Translational MedicineHeritage Building (Queen Elizabeth Hospital)BirminghamUK
| | - John A. Williams
- Institute of Translational MedicineHeritage Building (Queen Elizabeth Hospital)BirminghamUK
- Institute of Cancer and Genomic SciencesCollege of Medical and Dental SciencesUniversity of BirminghamBirminghamUK
- Mammalian Genetics UnitMedical Research Council Harwell InstituteOxfordshireUK
| | - Radhika Susarla
- Diabetes Translational Research GroupDiabetes CentreNuffield HouseQueen Elizabeth Hospital BirminghamBirminghamUK
- Institute of Translational MedicineHeritage Building (Queen Elizabeth Hospital)BirminghamUK
| | - Irene Alonso‐Perez
- Health Informatics DepartmentQueen Elizabeth Hospital BirminghamBirminghamUK
| | - Irene M. Stratton
- Gloucestershire Retinal Research GroupCheltenham General HospitalCheltenhamUK
| | - Georgios V. Gkoutos
- Institute of Translational MedicineHeritage Building (Queen Elizabeth Hospital)BirminghamUK
- Institute of Cancer and Genomic SciencesCollege of Medical and Dental SciencesUniversity of BirminghamBirminghamUK
- MRC Health Data Research UK (Central Office)Gibbs BuildingLondonUK
- NIHR Biomedical Research CentreBirminghamUK
| | - Jonathan Webber
- Diabetes Translational Research GroupDiabetes CentreNuffield HouseQueen Elizabeth Hospital BirminghamBirminghamUK
| | - Stephen D. Luzio
- Diabetes Translational Research GroupDiabetes CentreNuffield HouseQueen Elizabeth Hospital BirminghamBirminghamUK
- Diabetes Research Unit (Cymru)Grove BuildingSwansea UniversitySwanseaUK
| | - Wasim Hanif
- Diabetes Translational Research GroupDiabetes CentreNuffield HouseQueen Elizabeth Hospital BirminghamBirminghamUK
- Institute of Translational MedicineHeritage Building (Queen Elizabeth Hospital)BirminghamUK
| | - Graham A. Roberts
- Diabetes Translational Research GroupDiabetes CentreNuffield HouseQueen Elizabeth Hospital BirminghamBirminghamUK
- Diabetes Research Unit (Cymru)Grove BuildingSwansea UniversitySwanseaUK
- HRB‐Clinical Research Facility – CorkMercy University HospitalCorkIreland
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6
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Yamada M, Okada S, Oda H, Nakajima Y, C Bastie C, Kasai Y, Osaki A, Shimoda Y, Shibusawa R, Uehara R, Saito T, Ozawa A, Yamada E. Evaluation of the relationship between glycated hemoglobin A1c and mean glucose levels derived from the professional continuous flash glucose monitoring system. Endocr J 2020; 67:531-536. [PMID: 32023560 DOI: 10.1507/endocrj.ej19-0502] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Previously, we reported that short-term continuous glucose monitoring (CGM) with the professional iPro2© CGM device is a good clinical indicator of glycated hemoglobin (HbA1c) levels. However, there was no significant correlation between CGM and HbA1c levels when HbA1c levels were >8.0%. To further investigate this issue, we performed a similar study using the FreeStyle Libre Pro©, a newer device that does not require glucose calibration and allows patients to be examined for up to 14 days. Fifty-nine patients (68% women, 32% men) were examined. Twenty-eight and 31 patients presented with type 1 and type 2 diabetes, respectively. Clinically assessed HbA1c levels were compared to blood glucose levels determined by the FreeStyle Libre Pro© for up to 14 days (10.7 ± 3.7 days). We found a significant correlation between HbA1c and CGM levels even when HbA1c levels were >8.0%. Additionally, the correlation between HbA1c and average glucose was identified with the modern CGM and was found to deviate substantially from the new suggested formula. More importantly, we found a more robust correlation between HbA1c and CGM levels in patients with type 2 diabetes. Overestimation or underestimation of blood glucose levels through CGM might increase the risks of inappropriate clinical treatment of diabetes patients. Our results indicate the need for proper CGM data interpretation individualized for each patient to better assist the determination of customized treatments for patients.
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Affiliation(s)
- Masanobu Yamada
- Department of Medicine and Molecular Science, Gunma University Graduate School of Medicine, Maebashi, Gunma 371-8511, Japan
| | - Shuichi Okada
- Department of Medicine and Molecular Science, Gunma University Graduate School of Medicine, Maebashi, Gunma 371-8511, Japan
| | - Hiroki Oda
- Faculty of Medicine, Gunma University School of Medicine, Maebashi, Gunma 371-8511, Japan
| | - Yasuyo Nakajima
- Department of Medicine and Molecular Science, Gunma University Graduate School of Medicine, Maebashi, Gunma 371-8511, Japan
| | - Claire C Bastie
- Division of Biomedical Sciences, Warwick Medical School, Coventry CV4 7AL, United Kingdom
| | - Yuko Kasai
- Department of Medicine and Molecular Science, Gunma University Graduate School of Medicine, Maebashi, Gunma 371-8511, Japan
| | - Aya Osaki
- Department of Medicine and Molecular Science, Gunma University Graduate School of Medicine, Maebashi, Gunma 371-8511, Japan
| | - Yoko Shimoda
- Department of Medicine and Molecular Science, Gunma University Graduate School of Medicine, Maebashi, Gunma 371-8511, Japan
| | - Ryo Shibusawa
- Department of Medicine and Molecular Science, Gunma University Graduate School of Medicine, Maebashi, Gunma 371-8511, Japan
| | - Ryota Uehara
- Department of Medicine and Molecular Science, Gunma University Graduate School of Medicine, Maebashi, Gunma 371-8511, Japan
| | - Tsugumichi Saito
- Department of Medicine and Molecular Science, Gunma University Graduate School of Medicine, Maebashi, Gunma 371-8511, Japan
| | - Atsushi Ozawa
- Department of Medicine and Molecular Science, Gunma University Graduate School of Medicine, Maebashi, Gunma 371-8511, Japan
| | - Eijiro Yamada
- Department of Medicine and Molecular Science, Gunma University Graduate School of Medicine, Maebashi, Gunma 371-8511, Japan
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7
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Shimazawa R, Ikeda M. Imbalance in glycemic control between the treatment and placebo groups in cardiovascular outcome trials in type 2 diabetes. J Pharm Policy Pract 2019; 12:30. [PMID: 31832207 PMCID: PMC6859615 DOI: 10.1186/s40545-019-0193-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2019] [Accepted: 08/23/2019] [Indexed: 02/13/2023] Open
Abstract
Background Glycated hemoglobin (HbA1c) is accepted as the most reliable marker for assessing chronic glycemia. The present study aimed to investigate glycemic control in cardiovascular outcome trials (CVOTs) performed by pharmaceutical sponsors, at the request of the United States Food and Drug Administration (FDA) to ensure that newer hypoglycemic agents do not increase cardiovascular risk for patients with type 2 diabetes. Methods We chose ClinicalTrials.gov as a data source to identify randomized, double-blind, placebo-controlled non-inferiority trials of newer hypoglycemic agents for which the FDA 2008 guidance required a CVOT involving patients with type 2 diabetes. Results We identified 12 CVOTs, all of which were performed in accordance with the FDA guidance and published as of December 2018. Participants received either active treatment or placebo in addition to their existing therapy. On the assumption that HbA1c concentrations would be higher in the placebo group than in the treatment group, the use of open-label glucose lowering agents was encouraged as required to help all patients reach appropriate HbA1c targets according to local guidelines. As a result, the number of patients who received additional hypoglycemic agents during the trial was greater in the placebo group than in the treatment group in 10 of the CVOTs. Although the CVOTs were designed to avoid any imbalance in glycemic control between the groups, HbA1c concentrations were substantially higher in the placebo group than in the treatment group in all CVOTs throughout the observational period. The inferior glycemic control in the placebo groups was not considered in analyzing the outcomes in any of the CVOTs. Conclusions The safety and efficacy of new hypoglycemic agents are potentially inflated because the participants in the placebo groups unexpectedly exhibited inferior glycemic control throughout the trial compared with the outcomes in the treatment groups. This imbalance may distort data interpretation and mask potential risks of the drugs. Re-analysis with adjustment for HbA1c concentrations would determine whether the results of these CVOTs were biased by the difference in glycemic control between the treatment and placebo groups and reveal potential effects of the test drugs independent of glycemic control.
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Affiliation(s)
- Rumiko Shimazawa
- 1Department of Clinical Pharmacology, Tokai University School of Medicine, Isehara, Kanagawa 259-1193 Japan
| | - Masayuki Ikeda
- 2Department of Medical Informatics, Kagawa University Hospital, Miki-cho, Kagawa 761-0793 Japan
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8
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Ikeda M, Shimazawa R. Challenges to hemoglobin A1c as a therapeutic target for type 2 diabetes mellitus. J Gen Fam Med 2019; 20:129-138. [PMID: 31312579 PMCID: PMC6612881 DOI: 10.1002/jgf2.244] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2019] [Revised: 02/26/2019] [Accepted: 03/04/2019] [Indexed: 12/21/2022] Open
Abstract
Glycated hemoglobin (HbA1c) is widely accepted as the most reliable measure of long-term glycemia. However, there is disagreement among professional medical societies on a proper glycemic target for long-term benefits in type 2 diabetes (T2D). The use of some glucose-lowering drugs was associated with heart failure despite substantial lowering of HbA1c. The failure of intensive glycemic control to reduce cardiovascular risk in some trials again brought into question the usefulness of HbA1c as a therapeutic target in T2D. In large cardiovascular outcome trials, some newer glucose-lowering drugs were associated with higher risks of heart failure or amputation despite comparable glycemic control between the test and placebo groups. Here, we provide evidence that variation in hemoglobin glycation between individuals is responsible for these inconsistencies. We suggest that further research be conducted in this area and that the findings be applied to clinical trials and practice.
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Affiliation(s)
- Masayuki Ikeda
- Department of Medical InformaticsKagawa University HospitalKagawaJapan
| | - Rumiko Shimazawa
- Department of Clinical PharmacologyTokai University School of MedicineKanagawaJapan
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9
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Vajravelu ME, Lee JM. Identifying Prediabetes and Type 2 Diabetes in Asymptomatic Youth: Should HbA1c Be Used as a Diagnostic Approach? Curr Diab Rep 2018; 18:43. [PMID: 29868987 PMCID: PMC7799173 DOI: 10.1007/s11892-018-1012-6] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
PURPOSE OF REVIEW Because the incidence of type 2 diabetes and prediabetes in children is rising, routine screening of those at risk is recommended. In 2010, the ADA made the recommendation to include hemoglobin A1c (HbA1c) as a diagnostic test for diabetes, in addition to the oral glucose tolerance test or fasting plasma glucose. Our objective was to assess the pediatric literature with regard to HbA1c test performance and discuss advantages and disadvantages of use of the test for diagnostic purposes. RECENT FINDINGS HbA1c has a number of advantages, including elimination of the need for fasting, lower variability, assay standardization, and long-term association with future development of diabetes. It also has many drawbacks. It can be affected by a number of non-glycemic factors, including red blood cell turnover, hemoglobinopathies, medications, race, and age. In particular, it performs differently in children compared with adults, generally with lower sensitivity for prediabetes (as low as 0-5% in children vs 23-27% in adults) and lower area under the receiver operating characteristic curve (AUC) (0.53 vs 0.73 for prediabetes), and it has lower efficacy at a higher cost, compared with other tests of glycemia. Finally, HbA1c may perform very differently across diverse populations according to race/ethnicity; in Chinese populations, the proportion of individuals classified with prediabetes based on HbA1c predominates compared with IFG (77% for HbA1c vs 27.7% for IFG), whereas in US populations, it is the opposite (24.8% for HbA1c vs 80.1% for FPG). HbA1c is controversial because although it is convenient, it is not a true measure of glycemia. The interpretation of HbA1c results requires a nuanced understanding that many primary care physicians who are ordering the test in greater numbers do not possess. Alternative markers of glycemia may hold promise for the future but are not yet endorsed for use in practice. Further studies are needed to determine appropriate thresholds for screening tests and the long-term impact of screening and identification.
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Affiliation(s)
- Mary Ellen Vajravelu
- Division of Endocrinology and Diabetes, The Children's Hospital of Philadelphia, 11NW30, 3401 Civic Center Blvd, Philadelphia, PA, 19104, USA
| | - Joyce M Lee
- University of Michigan, 300 NIB, Room 6E14, Campus Box 5456, Ann Arbor, MI, 48109, USA.
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10
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Shu H, Lu J, Zhang P, Zhu D, Li X, Ji J, Zhao F, Ji L. Clinical characteristics of type 2 diabetes patients with discordance between HbA 1c and fasting plasma glucose in the real world: An analysis of the ORBIT study. Diabetes Metab Res Rev 2018; 34:e2977. [PMID: 29314667 DOI: 10.1002/dmrr.2977] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2017] [Revised: 11/27/2017] [Accepted: 12/12/2017] [Indexed: 12/16/2022]
Abstract
BACKGROUND We aimed to determine the clinical characteristics of type 2 diabetes patients on basal insulin therapy with inadequate glucose control due to discordance between glycated haemoglobin (HbA1c ) and fasting plasma glucose (FPG) in the real world. METHODS This was a retrospective analysis of data from the ORBIT study in China. Clinical characteristics of patients with discordance between HbA1c and FPG at baseline and at the end of 6 months of follow-up were analysed using multinomial logistic regression in 4 study groups divided by HbA1c and FPG. RESULTS Overall, of 6721 patients initiated on basal insulin, 853 achieved HbA1c < 7% but FPG ≥ 7 mmol/L (group 2), while 997 had FPG < 7 mmol/L but HbA1c ≥ 7% (group 3) at the end of follow-up. Patients in group 3 had a longer duration of type 2 diabetes compared with those in group 2 (7.22 ± 5.30 vs 6.00 ± 4.80 y, P < .05). Patients on glargine (32.90%) or detemir (36.88%) treatment accounted for a higher proportion of patients with both HbA1c and FPG controlled than those on neutral protamine Hagedorn therapy (23.45%; P < .05). Per the multinomial logistic analysis, higher frequency of self-monitoring of blood glucose (SMBG) and use of glargine or detemir therapy were significantly inversely associated with risk of discordance between HbA1c and FPG, while dose of insulin was a risk factor for discordance at the end of follow-up (all P < .05). CONCLUSIONS Patients treated with insulin analogues (glargine or detemir), instead of neutral protamine Hagedorn, and with more frequent SMBG are more likely to exhibit concordance between HbA1c and FPG.
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Affiliation(s)
- Hua Shu
- Department of Endocrinology, Chinese PLA General Hospital, Beijing, China
- Department of Endocrinology and Metabolism, Tianjin Medical University General Hospital, Tianjin, China
| | - Juming Lu
- Department of Endocrinology, Chinese PLA General Hospital, Beijing, China
| | - Puhong Zhang
- The George Institute for Global Health at Peking University Health Science Center, Beijing, China
| | - Dongshan Zhu
- The George Institute for Global Health at Peking University Health Science Center, Beijing, China
| | - Xian Li
- The George Institute for Global Health at Peking University Health Science Center, Beijing, China
| | - Jiachao Ji
- The George Institute for Global Health at Peking University Health Science Center, Beijing, China
| | - Fang Zhao
- The George Institute for Global Health at Peking University Health Science Center, Beijing, China
| | - Linong Ji
- Department of Endocrinology, Peking University People's Hospital, Beijing, China
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11
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van Steen SC, Schrieks IC, Hoekstra JB, Lincoff AM, Tardif JC, Mellbin LG, Rydén L, Grobbee DE, DeVries JH. The haemoglobin glycation index as predictor of diabetes-related complications in the AleCardio trial. Eur J Prev Cardiol 2017; 24:858-866. [PMID: 28186441 DOI: 10.1177/2047487317692664] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
The haemoglobin glycation index (HGI) quantifies the interindividual variation in the propensity for glycation and is a predictor of diabetes complications and adverse effects of intensive glucose lowering. We investigated the relevance of HGI as independent predictor of complications by using data of the AleCardio trial. The AleCardio trial randomized 7226 type 2 diabetes patients with an acute coronary syndrome to aleglitazar or placebo. From 6458 patients with baseline glycated haemoglobin (HbA1c) and fasting plasma glucose (FPG), a linear regression equation, HbA1c (%) = 5.45 + 0.0158 * FPG (mg/dl), was used to calculate predicted HbA1c and derive HGI (= observed - predicted HbA1c). With multivariate Cox regression we examined the association with major adverse cardiac events, cardiovascular mortality, total mortality and hypoglycaemia, irrespective of treatment allocation, using HGI subgroups (low, intermediate and high) and HGI as continuous variable. Patients with high HGI were younger, more often non-Caucasian, had a longer duration of diabetes, showed more retinopathy and used insulin more often. Hypoglycaemia occurred less often in the low HGI subgroup, but this difference disappeared after adjustment for duration of diabetes, insulin and sulphonylurea use. Low HGI patients were at lower risk for cardiovascular mortality (hazard ratio 0.64; 95% confidence interval 0.44-0.93, p = 0.020) and total mortality (hazard ratio 0.69; 95% confidence interval 0.50-0.95, p = 0.025), as compared with high HGI patients. Every percentage increase in HGI was associated with a 16% increase in the risk for cardiovascular mortality ( p = 0.005). The association between HGI and mortality disappeared with additional adjustment for HbA1c. HGI predicts mortality in diabetes patients with acute coronary syndromes, but no better than HbA1c.
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Affiliation(s)
- Sigrid Cj van Steen
- 1 Department of Endocrinology, Academic Medical Centre, University of Amsterdam, The Netherlands
| | - Ilse C Schrieks
- 2 Julius Clinical, Zeist, The Netherlands.,3 Julius Centre for Health Sciences and Primary Care, University Medical Centre Utrecht, The Netherlands
| | - Joost Bl Hoekstra
- 1 Department of Endocrinology, Academic Medical Centre, University of Amsterdam, The Netherlands.,2 Julius Clinical, Zeist, The Netherlands
| | - A Michael Lincoff
- 4 Department of Cardiovascular Medicine, Cleveland Clinic Coordinating Center for Clinical Research, USA
| | - Jean-Claude Tardif
- 5 Montreal Heart Institute Coordinating Center, Université de Montréal, Canada
| | - Linda G Mellbin
- 6 Department of Medicine, Cardiology Unit, Karolinska Institutet, Sweden
| | - Lars Rydén
- 6 Department of Medicine, Cardiology Unit, Karolinska Institutet, Sweden
| | - Diederick E Grobbee
- 2 Julius Clinical, Zeist, The Netherlands.,3 Julius Centre for Health Sciences and Primary Care, University Medical Centre Utrecht, The Netherlands
| | - J Hans DeVries
- 1 Department of Endocrinology, Academic Medical Centre, University of Amsterdam, The Netherlands
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12
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Mohan A, Reddy SA, Sachan A, Sarma K, Kumar DP, Panchagnula MV, Rao PS, Kumar BS, Krishnaprasanthi P. Derivation & validation of glycosylated haemoglobin (HbA 1c ) cut-off value as a diagnostic test for type 2 diabetes in south Indian population. Indian J Med Res 2016; 144:220-228. [PMID: 27934801 PMCID: PMC5206873 DOI: 10.4103/0971-5916.195035] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Background & Objectives: Glycosylated haemoglobin (HbA1c) has been in use for more than a decade, as a diagnostic test for type 2 diabetes. Validity of HbA1c 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 HbA1c 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 HbA1c 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 HbA1c 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 HbA1c 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: HbA1c >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.
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Affiliation(s)
- Alladi Mohan
- Department of Medicine, Sri Venkateswara Institute of Medical Sciences, Tirupati, India
| | - S Aparna Reddy
- Department of Medicine, Sri Venkateswara Institute of Medical Sciences, Tirupati, India
| | - Alok Sachan
- Department of Endocrinology and Metabolism, Sri Venkateswara Institute of Medical Sciences, Tirupati, India
| | - Kvs Sarma
- Department of Statistics, Sri Venkateswara University, Tirupati, India
| | - D Prabath Kumar
- Department of Medicine, Sri Venkateswara Institute of Medical Sciences, Tirupati, India
| | - Mahesh V Panchagnula
- Department of Applied Mechanics, Indian Institute of Technology Madras, Chennai, India
| | - Pvln Srinivasa Rao
- Department of Biochemistry, Sri Venkateswara Institute of Medical Sciences, Tirupati, India
| | - B Siddhartha Kumar
- Department of Medicine, Sri Venkateswara Institute of Medical Sciences, Tirupati, India
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13
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Yamada E, Okada S, Nakajima Y, Bastie CC, Vatish M, Tagaya Y, Osaki A, Shimoda Y, Shibusawa R, Saito T, Okamura T, Ozawa A, Yamada M. HBA1C AND MEAN GLUCOSE DERIVED FROM SHORT-TERM CONTINUOUS GLUCOSE MONITORING ASSESSMENT DO NOT CORRELATE IN PATIENTS WITH HBA1C >8. Endocr Pract 2016; 23:10-16. [PMID: 27631849 DOI: 10.4158/ep161363.or] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE Optimum therapy for patients with diabetes depends on both acute and long-term changes in plasma glucose, generally assessed by glycated hemoglobin (HbA1c) levels. However, the correlation between HbA1c and circulating glucose has not been fully determined. Therefore, we carefully examined this correlation when glucose levels were assessed by continuous glucose monitoring (CGM). METHODS Fifty-one patients (70% female, 30% male) were examined; among them were 28 with type 1 diabetes and 23 with type 2 diabetes. Clinically determined HbA1c levels were compared with blood glucose determined by CGM during a short time period. RESULTS Changes in HbA1c levels up to 8.0% showed a clear and statistically strong correlation (R = 0.6713; P<.0001) with mean blood glucose levels measured by CGM, similar to that observed in the A1c-derived Average Glucose study in which patients were monitored for a longer period. However, we found no statistical correlation (R = 0.0498; P = .83) between HbA1c and CGM-assessed glucose levels in our patient population when HbA1c was >8.0%. CONCLUSION Short-term CGM appears to be a good clinical indicator of long-term glucose control (HbA1c levels); however, cautions should be taken while interpreting CGM data from patients with HbA1c levels >8.0%. Over- or underestimation of the actual mean glucose from CGM data could potentially increase the risks of inappropriate treatment. As such, our results indicate that a more accurate analysis of CGM data might be useful to adequately tailor clinical treatments. ABBREVIATIONS ADAG = A1c-Derived Average Glucose CGM = continuous glucose monitoring %CV = percent coefficient of variation HbA1c = glycated hemoglobin.
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14
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Hitt JM, Velasquez-Mieyer P, Neira C, Cowan P. Factors Affecting Hemoglobin A1C in the Diagnosis of Diabetes and Prediabetes in Youth. J Pediatr Nurs 2016; 31:511-8. [PMID: 27132801 DOI: 10.1016/j.pedn.2016.03.020] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2016] [Revised: 03/30/2016] [Accepted: 03/31/2016] [Indexed: 10/21/2022]
Abstract
UNLABELLED We sought to examine the correlation between variables and A1C levels to determine if prediction modeling could be used in the screening and diagnosis of diabetes and prediabetes in youth. We also sought to test relationships between A1C levels to insulin sensitivity indices and β-cell function indices. DESIGN AND METHODS We performed a retrospective review of 904 medical records from youth deemed at-risk for the disease. We performed Pearson correlation, multiple regression, and simple regression testing to determine the relationship between variables and A1C levels. In addition, we performed Pearson correlation testing on insulin sensitivity indices and β-cell function indices to determine the strength of correlation to A1C levels. RESULTS Statistical analysis did not show a strong relationship between the variables tested and the A1C. When racial and ethnic groups were tested together, the results from African American participants resulted in bias estimates, and as a result, a statistical model for the entire sample could not be performed. Results indicate that A1C is correlated with all β-cell function proxy measurements and correlated to the corrected insulin level at 30minutes, but not the fasting insulin or insulinogenic index. DISCUSSION The results from this study underline the multi-dimensional causes of diabetes and prediabetes and further stress the difficulties in predicting the diseases. The causes of diabetes and prediabetes are multifaceted, often individualized, and often difficult to ascertain. PRACTICE IMPLICATIONS Clinicians should continue to examine a variety of variables prior to determining the need for diabetes diagnostic testing.
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Affiliation(s)
| | | | | | - Patricia Cowan
- University of Tennessee Health Science Center, Memphis, TN
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15
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Munshi MN, Segal AR, Slyne C, Samur AA, Brooks KM, Horton ES. Shortfalls of the use of HbA1C-derived eAG in older adults with diabetes. Diabetes Res Clin Pract 2015; 110:60-65. [PMID: 26272739 DOI: 10.1016/j.diabres.2015.07.012] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2015] [Revised: 06/18/2015] [Accepted: 07/27/2015] [Indexed: 12/26/2022]
Abstract
AIMS The hemoglobin HbA1C (HbA1C) value, translated into estimated average glucose concentration (eAG), is commonly used to assess glycaemic control and manage treatment regimens in people with diabetes. However, the relationships among HbA1C-derived eAG, and mean glucose concentration derived from continuous glucose monitoring (CGM) in different populations have not been well studied. We examined this relationship in older people with diabetes and compared the results to those currently used in clinical practice. METHODS Data from three studies evaluating CGM in older adults (≥70 years of age), with stable glycaemic control were analyzed retrospectively. Mean glucose and mean amplitude of glucose excursion (MAGE) were calculated from CGM data and correlated with HbA1C and HbA1C-derived eAG using the ADAG study formula. RESULTS HbA1C and CGM data were analyzed from 90 patients with mean age 76±5 years, HbA1C 7.9±1.2% (63±13 mmol/mol) and 77% with Type 2 diabetes. The HbA1C and HbA1C-derived eAG correlated significantly with CGM-measured mean glucose (r(2)=0.30, p<0.0001) and MAGE (r(2)=0.16, p=0.00013) in this population and all its subgroups, but the slopes of the relationship between HbA1C and eAG or CGM-measured mean glucose were significantly different. CONCLUSIONS HbA1C-derived eAG values may not accurately reflect CGM-measured mean glucose or MAGE in older adults with diabetes. Wide glucose excursions should be considered and HbA1C should be interpreted cautiously when making treatment changes based on HbA1C.
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Affiliation(s)
- M N Munshi
- Joslin Diabetes Center, United States; Beth Israel Deaconess Medical Center, United States; Harvard Medical School, United States.
| | - A R Segal
- Joslin Diabetes Center, United States; MCPHS University, United States
| | - C Slyne
- Joslin Diabetes Center, United States
| | | | - K M Brooks
- Tufts University School of Medicine, United States
| | - E S Horton
- Joslin Diabetes Center, United States; Harvard Medical School, United States
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16
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Hempe JM, Liu S, Myers L, McCarter RJ, Buse JB, Fonseca V. The hemoglobin glycation index identifies subpopulations with harms or benefits from intensive treatment in the ACCORD trial. Diabetes Care 2015; 38:1067-74. [PMID: 25887355 PMCID: PMC4439529 DOI: 10.2337/dc14-1844] [Citation(s) in RCA: 121] [Impact Index Per Article: 13.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2014] [Accepted: 02/15/2015] [Indexed: 02/06/2023]
Abstract
OBJECTIVE This study tested the hypothesis that intensive treatment in the Action to Control Cardiovascular Risk in Diabetes (ACCORD) trial disproportionately produced adverse outcomes in patients with diabetes with a high hemoglobin glycation index (HGI = observed HbA1c - predicted HbA1c). RESEARCH DESIGN AND METHODS ACCORD was a randomized controlled trial of 10,251 patients with type 2 diabetes assigned to standard or intensive treatment with HbA1c goals of 7.0% to 7.9% (53 to 63 mmol/mol) and less than 6% (42 mmol/mol), respectively. In this ancillary study, a linear regression equation (HbA1c = 0.009 × fasting plasma glucose [FPG] [mg/dL] + 6.8) was derived from 1,000 randomly extracted participants at baseline. Baseline FPG values were used to calculate predicted HbA1c and HGI for the remaining 9,125 participants. Kaplan-Meier and Cox regression were used to assess the effects of intensive treatment on outcomes in patients with a low, moderate, or high HGI. RESULTS Intensive treatment was associated with improved primary outcomes (composite of cardiovascular events) in the low (hazard ratio [HR] 0.75 [95% CI 0.59-0.95]) and moderate (HR 0.77 [95% CI 0.61-0.97]) HGI subgroups but not in the high HGI subgroup (HR 1.14 [95% CI 0.93-1.40]). Higher total mortality in intensively treated patients was confined to the high HGI subgroup (HR 1.41 [95% CI 1.10-1.80]). A high HGI was associated with a greater risk for hypoglycemia in the standard and intensive treatment groups. CONCLUSIONS HGI calculated at baseline identified subpopulations in ACCORD with harms or benefits from intensive glycemic control. HbA1c is not a one-size-fits-all indicator of blood glucose control, and taking this into account when making management decisions could improve diabetes care.
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Affiliation(s)
- James M Hempe
- Department of Pediatrics, Louisiana State University Health Sciences Center and Children's Hospital Research Institute for Children, New Orleans, LA
| | - Shuqian Liu
- Department of Medicine, Tulane University Health Sciences Center, New Orleans, LA
| | - Leann Myers
- Department of Biostatistics and Bioinformatics, School of Public Health and Tropical Medicine, Tulane University, New Orleans, LA
| | - Robert J McCarter
- Research Division of Biostatistics and Study Methodology, Children's National Medical Center, Washington, DC
| | - John B Buse
- Department of Medicine, University of North Carolina School of Medicine, Chapel Hill, NC
| | - Vivian Fonseca
- Department of Medicine, Tulane University Health Sciences Center, New Orleans, LA
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17
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Lai YJ, Lee ST, Kuo SC, Chou P. Comparison of fasting plasma glucose and glycated hemoglobin for diagnosing diabetes in a Taiwanese population. Metab Syndr Relat Disord 2015; 13:203-7. [PMID: 25734884 DOI: 10.1089/met.2014.0108] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND The purposes of this study were to examine the impact of using glycated hemoglobin (HbA1c) as a diagnostic criterion for (pre)diabetes and to determine the appropriate HbA1c cutoff value in a Taiwanese population. METHODS We used a dataset from the Clinical Informatics Research & Development Center of Taichung Veteran General Hospital. Fasting plasma glucose (FPG) and HbA1c test results were obtained from outpatient laboratory reports produced from January 1, 2011, to April 30, 2012. A total of 4920 blood tests were analyzed. For each potential HbA1c cutoff value, the sensitivity, specificity, positive and negative predictive values, and area under the receiver operator characteristic curve (AUC) were calculated at FPG levels of 100 and 126 mg/dL. Two-sample t- and chi-sqaured tests were used to compare differences in characteristics between individuals matching the definitions of diabetes set by the American Diabetes Association (ADA) in 2009 and 2010. RESULTS Among the 4920 study subjects, 580 people had an FPG value < 126 mg/dL and an HbA1c ≥ 6.5%. After the diagnostic criterion of HbA1c percentage was applied, the numbers of patients with normoglycemia and prediabetes decreased, whereas the number of diabetic patients increased. For FPG levels of 100 and 126 mg/dL, the HbA1c cutoff points were 5.95% and 6.35%, respectively. CONCLUSIONS More patients were diagnosed with diabetes when HbA1c was added as a diagnostic criterion. HbA1c thresholds of 5.95% and 6.35% were highly specific for prediabetes and diabetes, respectively, in Taiwanese adults.
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Affiliation(s)
- Yun-ju Lai
- 1 Division of Endocrinology and Metabolism, Department of Internal Medicine, Puli Branch of Taichung Veterans General Hospital , Nantou, Taiwan
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18
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Kohnert KD, Heinke P, Vogt L, Salzsieder E. Utility of different glycemic control metrics for optimizing management of diabetes. World J Diabetes 2015; 6:17-29. [PMID: 25685275 PMCID: PMC4317309 DOI: 10.4239/wjd.v6.i1.17] [Citation(s) in RCA: 62] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2014] [Revised: 09/26/2014] [Accepted: 12/01/2014] [Indexed: 02/05/2023] Open
Abstract
The benchmark for assessing quality of long-term glycemic control and adjustment of therapy is currently glycated hemoglobin (HbA1c). Despite its importance as an indicator for the development of diabetic complications, recent studies have revealed that this metric has some limitations; it conveys a rather complex message, which has to be taken into consideration for diabetes screening and treatment. On the basis of recent clinical trials, the relationship between HbA1c and cardiovascular outcomes in long-standing diabetes has been called into question. It becomes obvious that other surrogate and biomarkers are needed to better predict cardiovascular diabetes complications and assess efficiency of therapy. Glycated albumin, fructosamin, and 1,5-anhydroglucitol have received growing interest as alternative markers of glycemic control. In addition to measures of hyperglycemia, advanced glucose monitoring methods became available. An indispensible adjunct to HbA1c in routine diabetes care is self-monitoring of blood glucose. This monitoring method is now widely used, as it provides immediate feedback to patients on short-term changes, involving fasting, preprandial, and postprandial glucose levels. Beyond the traditional metrics, glycemic variability has been identified as a predictor of hypoglycemia, and it might also be implicated in the pathogenesis of vascular diabetes complications. Assessment of glycemic variability is thus important, but exact quantification requires frequently sampled glucose measurements. In order to optimize diabetes treatment, there is a need for both key metrics of glycemic control on a day-to-day basis and for more advanced, user-friendly monitoring methods. In addition to traditional discontinuous glucose testing, continuous glucose sensing has become a useful tool to reveal insufficient glycemic management. This new technology is particularly effective in patients with complicated diabetes and provides the opportunity to characterize glucose dynamics. Several continuous glucose monitoring (CGM) systems, which have shown usefulness in clinical practice, are presently on the market. They can broadly be divided into systems providing retrospective or real-time information on glucose patterns. The widespread clinical application of CGM is still hampered by the lack of generally accepted measures for assessment of glucose profiles and standardized reporting of glucose data. In this article, we will discuss advantages and limitations of various metrics for glycemic control as well as possibilities for evaluation of glucose data with the special focus on glycemic variability and application of CGM to improve individual diabetes management.
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Selvin E, Rawlings AM, Bergenstal RM, Coresh J, Brancati FL. No racial differences in the association of glycated hemoglobin with kidney disease and cardiovascular outcomes. Diabetes Care 2013; 36:2995-3001. [PMID: 23723353 PMCID: PMC3781554 DOI: 10.2337/dc12-2715] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVE There is debate regarding the clinical significance of well-established racial differences in HbA1c. We compared the associations of diabetes diagnostic categories for HbA1c and fasting glucose with clinical outcomes in black and white persons in the community. RESEARCH DESIGN AND METHODS We conducted a prospective cohort analysis of participants without diabetes or cardiovascular disease from the Atherosclerosis Risk in Communities study. We examined the associations of clinical categories of HbA1c (<5.7%, 5.7-6.4%, ≥6.5%) and fasting glucose (<100, 100-125, ≥126 mg/dL) with outcomes separately among 2,484 black and 8,593 white participants and tested for race interactions. RESULTS Baseline characteristics differed significantly in blacks compared with whites, including HbA1c (5.8 vs. 5.4%; P<0.001). During 18 years of follow-up, there were trends of increased risk of kidney disease, fatal and nonfatal coronary heart disease, and stroke across categories of HbA1c in both blacks and whites. The adjusted hazard ratios for each outcome across categories of HbA1c were similar in blacks and whites (P for interaction>0.05) except for all-cause mortality. Patterns of association were similar, but weaker, for fasting glucose. HbA1c and fasting glucose both were more strongly associated with all-cause mortality in whites compared with blacks, largely explained by racial differences in the rate of cardiovascular deaths. CONCLUSIONS HbA1c is a risk factor for vascular outcomes and mortality in both black and white adults. Patterns of association for HbA1c were similar to or stronger than those for fasting glucose. With respect to long-term outcomes, our findings support a similar interpretation of HbA1c in blacks and whites for diagnosis and treatment of diabetes mellitus.
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20
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Affiliation(s)
- Tobin M Abraham
- Department of Endocrinology, Hypertension and Diabetes, Brighamand Women’s Hospital and Harvard Medical School, Boston, Massachusetts, USA
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21
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Zafon C, Ciudin A, Valladares S, Mesa J, Simó R. Variables involved in the discordance between HbA1c and fructosamine: the glycation gap revisited. PLoS One 2013; 8:e66696. [PMID: 23776693 PMCID: PMC3680426 DOI: 10.1371/journal.pone.0066696] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2013] [Accepted: 05/13/2013] [Indexed: 01/09/2023] Open
Abstract
AIMS Glycation gap (GG) is defined as the difference between the measured level of HbA1c and the level that would be predicted from its regression on the fructosamine level. The aims of the study were: 1) To determine the reproducibility and consistency of GC; 2) To discover factors related to GG value. Given that metformin might increase glucose transport through the erythrocyte membrane, this treatment was also considered in the analyses of the results. METHODS GG was calculated in two blood samples separated 30.6 (SD 7.3) weeks, obtained in 508 type 2 diabetic patients. The following variables were considered: HbA1c, fructosamine, glucose, creatinine, hematological parameters and treatment with metformin. Multivariate and logistic regression analyses were performed to explore the variables independently related to CG. RESULTS GG was reproducible and consistent over time. Creatinine, mean corpuscular hemoglobin concentration (MCHC), and glycemia (inverse relationship); and HbA1c and treatment with metformin (direct relationship) were independently related to GG. Patients treated with metformin showed higher HbA1c values, despite similar fructosamine concentrations, than patients not treated with the drug. CONCLUSIONS GG is independently related to serum levels of creatinine, MCHC and treatment with metformin. The spurious effect of metformin on Hb glycation could have serious clinical implications and should be considered when interpreting the results of clinical trials.
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Affiliation(s)
- Carles Zafon
- Diabetes and Metabolism Research Unit (VHIR) and Department of Endocrinology, Hospital Vall d'Hebron and Universitat Autònoma de Barcelona, Barcelona, Spain.
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Abstract
HbA1c has become the gold standard for monitoring glycemic control in patients with diabetes mellitus. The use of this test has been expanded to diagnose and screen for diabetes mellitus with the endorsement of influential diabetes societies and the World Health Organization. The literature on the use of HbA1c for the diagnosis and screening of diabetes mellitus was critically examined. There is substantial recent literature on this topic with strong advocates for the use of HbA1c to diagnose and screen for diabetes and equally strong detractors for its use. Advocates of the use of HbA1c cite challenges in respect of patient compliance and the analysis of glucose and inconsistency of diagnosis with glucose-based diabetes diagnosis with the elimination or reduction in these challenges in HbA1c-based diagnosis. Detractors of its use cite increased cost, concerns about the availability of HbA1c testing, and the influence of demographic and clinical factors on HbA1c results that make the use of a single-threshold values questionable for different ethnic and age groups. Despite the recommendation of many international diabetes societies that HbA1c be used for screening and diagnosis of diabetes mellitus, there is a wide divergence of opinion on this use.
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Affiliation(s)
- Trefor Higgins
- DynaLIFEDx, #200, 10150 102 St, Edmonton, AB, T6L 1X2, Canada.
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23
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Bower JK, Brancati FL, Selvin E. No ethnic differences in the association of glycated hemoglobin with retinopathy: the national health and nutrition examination survey 2005-2008. Diabetes Care 2013; 36:569-73. [PMID: 23069841 PMCID: PMC3579340 DOI: 10.2337/dc12-0404] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVE Current recommendations for the use of hemoglobin A(1c) (HbA(1c)) in diabetes screening and diagnosis aim to identify those at greatest risk for diabetic microvascular complications. However, there is current controversy regarding the clinical implications of ethnic differences in HbA(1c) values. The objective of this study was to determine whether the association between HbA(1c) and retinopathy differs by ethnic group in a representative sample of U.S. adults. RESEARCH DESIGN AND METHODS The study was a cross-sectional analysis of 2,945 non-Hispanic white, 1,046 non-Hispanic black, and 1,231 Hispanic American participants aged ≥40 years from the 2005-2008 National Health and Nutrition Examination Survey. RESULTS Among nondiabetic adults, the mean HbA(1c) was 5.5% in non-Hispanic whites, 5.7% in non-Hispanic blacks, and 5.6% in Hispanic Americans. Among those with diagnosed diabetes, mean HbA(1c) was 6.9% in non-Hispanic whites, 7.5% in non-Hispanic Blacks, and 7.7% in Hispanic Americans. Overall, non-Hispanic blacks had the highest prevalence of retinopathy. In multivariable logistic models, HbA(1c) clinical categories were strongly associated with prevalent retinopathy. However, the magnitude of the association did not differ by ethnic group (all P values for interaction ≥ 0.7). Similar results were observed with HbA(1c) modeled continuously (per one percentage point) and stratified by diabetes status (all P for interactions > 0.3). CONCLUSIONS We observed no ethnic differences in the association of HbA(1c) with retinopathy. These data do not support ethnic-specific cut points for HbA(1c) for diagnosis or screening of diabetes mellitus.
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Affiliation(s)
- Julie K Bower
- Department of Epidemiology and the Welch Center for Prevention, Epidemiology and Clinical Research, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
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Mostafa SA, Khunti K, Kilpatrick ES, Webb D, Srinivasan BT, Gray LJ, Davies MJ. Diagnostic performance of using one- or two-HbA1c cut-point strategies to detect undiagnosed type 2 diabetes and impaired glucose regulation within a multi-ethnic population. Diab Vasc Dis Res 2013; 10:84-92. [PMID: 22773521 DOI: 10.1177/1479164112451473] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
INTRODUCTION We compared test performance and cost per case for strategies detecting diabetes on the oral glucose tolerance test (OGTT) using either (a) glycated haemoglobin (HbA1c) ≥ 6.5% (48 mmol/mol) or (b) two HbA1c thresholds where the first cut-point 'rules out' and the second 'rules in' diabetes. HbA1c values in between the thresholds require confirmatory glucose testing for diagnosis. MATERIALS AND METHODS We conducted an analysis of adults aged 40-75 years from the Leicester Ethnic Atherosclerosis and Diabetes Risk (LEADER) cohort (Leicester, UK), from 2002 to 2008, who underwent oral glucose tolerance testing (OGTT) and HbA1c testing. RESULTS From 8696 individuals (mean age 57.3 years, 73% white Europeans (WE) and 27% South Asians (SA)), HbA1c ≥ 6.5% produced sensitivity of 62.1% for detecting diabetes in WE and 78.9% in SA. Using two selected thresholds, HbA1c ≤ 5.8% (rule-in, 40 mmol/mol) and HbA1c ≥ 6.8% (rule-out, 51 mmol/mol) produced high sensitivity/specificity (> 91.0%) for detecting diabetes, however, 28.8% of the cohort with HbA1c 5.9%-6.7% required a subsequent glucose test. The two cut-point threshold produced a lower cost per case of diabetes detected in WE, compared to HbA1c ≥ 6.5% of £38.53 (1.89 to 86.81) per case, but was more expensive in SA by £84.50 (69.72 to 100.92) per case. Using a risk score to determine HbA1c testing, the same costs per case became £63.33 (23.33 to 113.26) in WE and £69.21 (55.60 to 82.41) in SA. CONCLUSION Using a two-threshold strategy may have some benefits over a single cut-point; however, 28.8% of individuals required two blood tests.
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Affiliation(s)
- S A Mostafa
- Division of Diabetes and Endocrinology, Department of Cardiovascular Sciences, Level 0, Victoria Building, Leicester Royal Infirmary, Leicester, LE1 5WW, UK.
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Cohen RM, Lindsell CJ. When the blood glucose and the HbA(1c) don't match: turning uncertainty into opportunity. Diabetes Care 2012; 35:2421-3. [PMID: 23173128 PMCID: PMC3507598 DOI: 10.2337/dc12-1479] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Affiliation(s)
- Robert M Cohen
- Department of Medicine, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA.
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Hirsch IB, Amiel SA, Blumer IR, Bode BW, Edelman SV, Seley JJ, Verderese CA, Kilpatrick ES. Using multiple measures of glycemia to support individualized diabetes management: recommendations for clinicians, patients, and payers. Diabetes Technol Ther 2012; 14:973-83; quiz 983. [PMID: 23066850 DOI: 10.1089/dia.2012.0132] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
By the year 2030, the diabetes pandemic will likely affect more than 10% of the world's population. The personal, public health, and economic crises implicit in this trend call for decisive action. Yet, escalating dilemmas thwart full realization of current therapies. First, controversial studies, such as the Action to Control Cardiovascular Risk in Diabetes (ACCORD) Trial, have amplified calls to individualize glycated hemoglobin (A1C) targets in the absence of adequate infrastructures for supporting personalized care. Second, costlier medications and technologies addressing more nuanced aspects of metabolic dysfunction are expanding options for diabetes management amidst growing disparities between "affordable" and "best" care. Third, common clinical quandaries, such as discrepancies between A1C and self-monitoring of blood glucose data, as well as misconceptions about long-term glycemic assessment, compound entrenched cycles of inadequate self-care, delayed intervention, and suboptimal glycemic outcomes. Because individual, clinical, and public policy responses to these conflicting forces are based largely on methodologies for glucose measurement, a panel of clinical experts from Europe and North America was convened to reexamine our glucose measuring tools and determine ways in which they can be better applied toward more purposeful processes of glycemic management. Among the main issues addressed were the need for caution in interpreting A1C for individual patients, the role of alternative biomarkers in identifying aspects of glycemic dysregulation not captured by A1C, and the value of using patients' own glucose data to consolidate therapeutic, educational, and behavior-change objectives.
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Affiliation(s)
- Irl B Hirsch
- University of Washington School of Medicine, Seattle, Washington 98105, USA.
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Chapp-Jumbo E, Edeoga C, Wan J, Dagogo-Jack S. Ethnic disparity in hemoglobin A1c levels among normoglycemic offspring of parents with type 2 diabetes mellitus. Endocr Pract 2012; 18:356-62. [PMID: 22138077 DOI: 10.4158/ep11245.or] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
OBJECTIVE To investigate the racial/ethnic disparities in hemoglobin A1c levels among nondiabetic persons with similar parental history of type 2 diabetes mellitus. METHODS We studied a community-based sample of adult offspring of parents with type 2 diabetes mellitus. Measurements included anthropometry, hematology assessments, serial fasting plasma glucose, oral glucose tolerance testing, plasma insulin, hemoglobin A1c, insulin sensitivity, and β-cell function, using a homeostasis model assessment. RESULTS The study included 302 participants (135 white, 167 black). Compared with white participants, black participants had lower fasting plasma glucose levels (91.9 ± 0.51 mg/dL vs 93.6 ± 0.50 mg/dL, P = .015), lower area under the curve of plasma glucose during oral glucose tolerance testing (P = <.001), higher body mass index (31.1 ± 0.61 kg/m² vs 28.5 ± 0.57 kg/m², P = <.001), and similar insulin sensitivity and β-cell function. Hemoglobin A1c was higher in black participants than in white participants (5.68 ± 0.033% vs 5.45 ± 0.028%, P<.001). The absolute black-white difference in hemoglobin A1c level of approximately 0.22% persisted after adjusting for age, hemoglobin, hematocrit, body mass index, waist circumference, fasting plasma glucose, glucose area under the curve, and other covariates. CONCLUSIONS Among healthy offspring of parents with type 2 diabetes mellitus in this study, African American participants had higher hemoglobin A1c levels than white participants after adjusting for age, adiposity, blood glucose, and known variables. Thus, plasma glucose level is more valid than hemoglobin A1c for diagnosing prediabetes or diabetes in black persons.
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Affiliation(s)
- Emmanuel Chapp-Jumbo
- Division of Endocrinology, Diabetes, and Metabolism, University of Tennessee Health Science Center, Memphis, Tennessee 38163, USA
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Higgins T. HbA1c — An analyte of increasing importance. Clin Biochem 2012; 45:1038-45. [DOI: 10.1016/j.clinbiochem.2012.06.006] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2012] [Revised: 06/04/2012] [Accepted: 06/06/2012] [Indexed: 11/29/2022]
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Tsugawa Y, Mukamal KJ, Davis RB, Taylor WC, Wee CC. Should the hemoglobin A1c diagnostic cutoff differ between blacks and whites? A cross-sectional study. Ann Intern Med 2012; 157:153-9. [PMID: 22868832 PMCID: PMC3655723 DOI: 10.7326/0003-4819-157-3-201208070-00004] [Citation(s) in RCA: 61] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Hemoglobin A1c (HbA1c) levels are known to be consistently higher in black persons than in white persons at any given glycemic level. Whether the optimal diagnostic threshold of HbA1c should differ between blacks and whites is unclear. OBJECTIVE To compare the relationships between HbA1c level and the prevalence of retinopathy in black and white U.S. adults. DESIGN Cross-sectional study. SETTING A nationally representative sample of the National Health and Nutrition Examination Survey from 2005 through 2008. PATIENTS 2804 white persons and 1008 black persons aged 40 years or older in the United States. MEASUREMENTS Prevalence of retinopathy. Logistic regression models and restricted cubic spline models were constructed separately for white and black populations to test the HbA1c levels at which risk for retinopathy begins to increase. RESULTS After adjustment for age, sex, hypertension, body mass index, family history of diabetes, and use of antidiabetes medications or insulin, the lowest HbA1c category for which the prevalence of retinopathy was significantly higher than the reference category (<5.5%) was 6.0% to 6.4% for white persons (risk difference, 4.8% [95% CI, 0.5% to 9.1%]) and 5.5% to 5.9% for black persons (risk difference, 5.3% [CI, 1.0% to 9.5%]). The restricted cubic spline models indicated that the risk for retinopathy increased at lower HbA1c levels in black persons than in white persons. LIMITATION The cross-sectional design of the study precluded examining the effect of the duration at each HbA1c level. CONCLUSION The prevalence of retinopathy begins to increase at a lower HbA1c level in black Americans than in white Americans. The findings do not support increasing the diagnostic threshold of HbA1c in black persons. PRIMARY FUNDING SOURCE None.
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Affiliation(s)
- Yusuke Tsugawa
- Beth Israel Deaconess Medical Center, 330 Brookline Avenue, Boston, MA 02215, USA.
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Hempe JM, McGehee AM, Hsia D, Chalew SA. Characterization of unstable hemoglobin A1c complexes by dynamic capillary isoelectric focusing. Anal Biochem 2012; 424:149-55. [DOI: 10.1016/j.ab.2012.02.011] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2011] [Revised: 02/07/2012] [Accepted: 02/08/2012] [Indexed: 12/16/2022]
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Ramachandran A, Riddle MC, Kabali C, Gerstein HC. Relationship between A1C and fasting plasma glucose in dysglycemia or type 2 diabetes: an analysis of baseline data from the ORIGIN trial. Diabetes Care 2012; 35:749-53. [PMID: 22323416 PMCID: PMC3308289 DOI: 10.2337/dc11-1918] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVE A1C measurement has advantages over measures of plasma glucose. Few studies have evaluated the A1C-fasting plasma glucose (FPG) relationship and whether oral antidiabetes drugs (OADs) and ethnic or geographic variations affect the relationship. Baseline A1C and FPG data from the Outcome Reduction with Initial Glargine Intervention (ORIGIN) trial participants were analyzed to 1) elucidate the relationship between A1C and FPG in people with moderate dysglycemia (A1C 5.6-9.0% [38-75 mmol/mol]) and additional risk factors for cardiovascular disease, 2) determine whether this relationship is altered by use of an OAD, and 3) study whether geographic and ethnic differences exist. RESEARCH DESIGN AND METHODS Analysis was performed of 12,527 participants with dysglycemia or early type 2 diabetes recruited in North America, South America, Europe, Australia, and Asia who comprised white, Latin American, Asian, black, and other ethnicities. The A1C-FPG relationships were analyzed using cubic B spline curves in all participants and in subgroups not using an OAD or using an OAD and comprising persons of different ethnic or geographic origin. RESULTS A strong relationship between FPG in the range of 5.6-9.0 mmol/L and the corresponding A1C was seen across different geographic regions and ethnic groups. A smaller increase in A1C per unit increase in FPG occurred for persons taking an OAD versus those not taking an OAD. CONCLUSIONS The strong relationship between A1C and FPG in moderate dysglycemia is not significantly affected by ethnic or geographic differences. Use of an OAD alters the relationship and should be considered when interpreting A1C level.
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Affiliation(s)
- Ambady Ramachandran
- India Diabetes Research Foundation and Dr. A. Ramachandran’s Diabetes Hospitals, Chennai, India.
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Dagogo-Jack S. Comment on: Maruthur et al. Does genetic ancestry explain higher values of glycated hemoglobin in African Americans? Diabetes 2011;60:2434-2438. Diabetes 2012; 61:e1; author reply e2. [PMID: 22187382 PMCID: PMC3237668 DOI: 10.2337/db11-1277] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Zemlin AE, Matsha TE, Hassan MS, Erasmus RT. HbA1c of 6.5% to diagnose diabetes mellitus -- does it work for us? -- the Bellville South Africa study. PLoS One 2011; 6:e22558. [PMID: 21857932 PMCID: PMC3155525 DOI: 10.1371/journal.pone.0022558] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2011] [Accepted: 06/27/2011] [Indexed: 12/03/2022] Open
Abstract
Background HbA1c has been the gold standard for glycaemic control follow-up for decades. In 2009, a level of 6.5% (48 mmol/mol) was proposed as diagnostic for diabetes. We test this cut-off in our community. Methods Participants (946) from a community-based study were screened for diabetes using either a fasting blood glucose or oral glucose tolerance test (OFTT). The HbA1c cut-off of 6.5% was tested for each group. A receiver operator characteristic (ROC) curve for both groups was generated to establish an optimal cut-off. Results Our study included 224 (23.7%) males and 722 (76.3%) females. Using fasting blood glucose alone, 117 (14%) were diagnosed with diabetes −50% had an HbA1c value of ≥6.5% (48 mmol/mol). Using an OGTT, 147 (18%) were diagnosed with diabetes −46% had an HbA1c value of ≥6.5% (48 mmol/mol). ROC curves found a level of 6.1% (43 mmol/mol) to be optimal in both groups (AUC 0.85 and 0.82 respectively). The sensitivities were 80% and 75% and the specificities 77% and 78% respectively. Conclusions A cut off of 6.5% (48 mmol/mol) is a good diagnostic tool with its high specificity; however the low sensitivity limits its use. We found a level of 6.1% (43 mmol/mol) to be optimal. This emphasizes the need for evidenced based values to be established in various population groups.
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Affiliation(s)
- Annalise E. Zemlin
- Division of Chemical Pathology, Faculty of Health Sciences, National Health Laboratory Service and University of Stellenbosch, Cape Town, South Africa
| | - Tandi E. Matsha
- Department of Biomedical Sciences, Faculty of Health and Wellness Science, Cape Peninsula University of Technology, Cape Town, South Africa
| | - Mogamat S. Hassan
- Department of Nursing and Radiography, Faculty of Health and Wellness Science, Cape Peninsula University of Technology, Cape Town, South Africa
| | - Rajiv T. Erasmus
- Division of Chemical Pathology, Faculty of Health Sciences, National Health Laboratory Service and University of Stellenbosch, Cape Town, South Africa
- * E-mail:
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Kehl KG, Findeisen HM, Fardo DW, Bruemmer D, Mannino DM, Sanderson WT. Race-ethnicity as an effect modifier of the association between HbAlc and mortality in U.S. adults without diagnosed diabetes. Eur J Endocrinol 2011; 165:275-81. [PMID: 21622476 DOI: 10.1530/eje-11-0171] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
OBJECTIVE HbAlc is increasingly appreciated as a risk factor for all-cause and cardiovascular disease (CVD) mortality in the non-diabetic population. In this study, we investigated the association between HbAlc and mortality with a particular focus on the impact of race-ethnicity. Design Cohort study. METHODS We analyzed the association between HbAlc and all-cause and CVD mortality in 12 698 non-diabetic adults 20 years or older from the Third National Health and Nutrition Examination Survey using separate models for people of different race-ethnicity. RESULTS In our stratified analyses, higher non-diabetic HbAlc levels were associated with all-cause and CVD mortality in non-Hispanic whites only. In this group, compared with HbAlc values of 5.0-<5.35%, the multivariable-adjusted estimated hazard ratios (est. HR) with 95% confidence interval (CI) for all-cause mortality were 1.21 (0.92, 1.58), 1.22 (1.03, 1.45), 1.29 (1.14, 1.47), and 1.4 (1.02, 1.87) for HbAlc levels of <5.0, 5.35-<5.7, 5.7-<6.5, and 6.5% or greater respectively. The association did not reach significance in Mexican-Americans (est. HR (95% CI): 1.77 (1.08, 2.91), 0.81 (0.56, 1.19), 1.16 (0.86, 1.57), and 1.4 (0.83, 2.36)). No association was observed in non-Hispanic blacks: 1.13 (0.91, 1.39), 0.81 (0.61, 1.08), 0.84 (0.69, 1.03), and 0.94 (0.67, 1.33). Results were similar for CVD mortality. CONCLUSIONS Our data suggest limitations of HbAlc as a risk factor for all-cause and cardiovascular mortality across race-ethnic populations.
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Affiliation(s)
- Katharina G Kehl
- Department of Epidemiology, College of Public Health, University of Kentucky, Suite 213, 121 Washington Avenue, Lexington, Kentucky 40536-0003, USA
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Zhang Q, Monroe ME, Schepmoes AA, Clauss TRW, Gritsenko MA, Meng D, Petyuk VA, Smith RD, Metz TO. Comprehensive identification of glycated peptides and their glycation motifs in plasma and erythrocytes of control and diabetic subjects. J Proteome Res 2011; 10:3076-88. [PMID: 21612289 DOI: 10.1021/pr200040j] [Citation(s) in RCA: 78] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Nonenzymatic glycation of proteins sets the stage for formation of advanced glycation end-products and development of chronic complications of diabetes. In this report, we extended our previous methods on proteomics analysis of glycated proteins to comprehensively identify glycated proteins in control and diabetic human plasma and erythrocytes. Using immunodepletion, enrichment, and fractionation strategies, we identified 7749 unique glycated peptides, corresponding to 3742 unique glycated proteins. Semiquantitative comparisons showed that glycation levels of a number of proteins were significantly increased in diabetes and that erythrocyte proteins were more extensively glycated than plasma proteins. A glycation motif analysis revealed that some amino acids were favored more than others in the protein primary structures in the vicinity of the glycation sites in both sample types. The glycated peptides and corresponding proteins reported here provide a foundation for potential identification of novel markers for diabetes, hyperglycemia, and diabetic complications in future studies.
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Affiliation(s)
- Qibin Zhang
- Biological Sciences Division, Pacific Northwest National Laboratory, Richland, Washington 99352, USA
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Selvin E, Steffes MW, Ballantyne CM, Hoogeveen RC, Coresh J, Brancati FL. Racial differences in glycemic markers: a cross-sectional analysis of community-based data. Ann Intern Med 2011; 154:303-9. [PMID: 21357907 PMCID: PMC3131743 DOI: 10.7326/0003-4819-154-5-201103010-00004] [Citation(s) in RCA: 145] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Although differences between black and white persons in hemoglobin A(1c) (HbA(1c)) values are well established, recent studies suggest that this might not reflect differences in glycemia. OBJECTIVE To investigate racial disparities in glycemic markers, including those that reflect biological processes independent of hemoglobin glycation and erythrocyte turnover. DESIGN Cross-sectional. SETTING Community-based. PARTICIPANTS 1376 nondiabetic and 343 diabetic adults in a substudy of the Atherosclerosis Risk in Communities Study. MEASUREMENTS Hemoglobin A(1c), fasting glucose, glycated albumin, fructosamine, and 1,5-anhydroglucitol levels. RESULTS Among persons with and without diabetes, black persons had significantly higher HbA(1c), glycated albumin, and fructosamine levels than white persons before and after adjustment for covariates and fasting glucose concentration. Serum 1,5-anhydroglucitol levels, which are reduced in the setting of hyperglycemia-induced glycosuria, were lower in black persons than in white persons, although this difference was statistically significant only in nondiabetic adults. LIMITATION The design was cross-sectional, a limited number of participants with a history of diabetes was included, and the study did not include integrated measures of circulating nonfasting glycemia. CONCLUSION Differences between black and white persons in glycated albumin, fructosamine, and 1,5-anhydroglucitol levels parallel differences between these groups in HbA(1c) values. Racial differences in hemoglobin glycation and erythrocyte turnover cannot explain racial disparities in these serum markers. The possibility that black persons have systematically higher levels of nonfasting glycemia warrants further study. PRIMARY FUNDING SOURCE National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases.
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Affiliation(s)
- Elizabeth Selvin
- Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, USA.
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Lipska KJ, De Rekeneire N, Van Ness PH, Johnson KC, Kanaya A, Koster A, Strotmeyer ES, Goodpaster BH, Harris T, Gill TM, Inzucchi SE. Identifying dysglycemic states in older adults: implications of the emerging use of hemoglobin A1c. J Clin Endocrinol Metab 2010; 95:5289-95. [PMID: 20861123 PMCID: PMC2999974 DOI: 10.1210/jc.2010-1171] [Citation(s) in RCA: 89] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2010] [Accepted: 08/25/2010] [Indexed: 12/11/2022]
Abstract
CONTEXT Hemoglobin A1c (A1c) was recently added to the diagnostic criteria for diabetes and prediabetes. OBJECTIVE Our objective was to examine performance of A1c in comparison with fasting plasma glucose (FPG) in diagnosing dysglycemia in older adults. DESIGN AND SETTING We conducted a cross-sectional analysis of data from the Health, Aging, and Body Composition study at yr 4 (2000-2001) when FPG and standardized A1c measurements were available. PARTICIPANTS Of 3075 persons (aged 70-79 yr, 48% men, 42% Black) at study entry, 1865 participants without known diabetes who had appropriate measures were included. MAIN OUTCOME MEASURES Sensitivity and specificity of A1c-based diagnoses were compared with those based on FPG and the proportion of participants identified with dysglycemia by each measure. RESULTS Of all participants, 2.7 and 3.1% had undiagnosed diabetes by FPG≥126 mg/dl and A1c≥6.5%, respectively. Among the remaining participants, 21.1% had prediabetes by impaired fasting glucose (≥100 mg/dl) and 22.2% by A1c≥5.7%. Roughly one third of individuals with diabetes and prediabetes were identified by either FPG or A1c alone and by both tests simultaneously. Sensitivities and specificities of A1c compared with FPG were 56.9 and 98.4% for diabetes and 47.0 and 84.5% for prediabetes, respectively. Blacks and women were more likely to be identified with dysglycemia by A1c than FPG. CONCLUSIONS In this older population, we found considerable discordance between FPG- and A1c-based diagnosis of diabetes and prediabetes, with differences accentuated by race and gender. Broad implementation of A1c to diagnose dysglycemic states may substantially alter the epidemiology of these conditions in older Americans.
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Affiliation(s)
- Kasia J Lipska
- Robert Wood Johnson Clinical Scholars Program, Yale University School of Medicine, P.O. Box 208088, 333 Cedar Street, SHM IE-61, New Haven, Connecticut 06520-8088, USA.
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Cohen RM, Haggerty S, Herman WH. HbA1c for the diagnosis of diabetes and prediabetes: is it time for a mid-course correction? J Clin Endocrinol Metab 2010; 95:5203-6. [PMID: 21131541 PMCID: PMC2999978 DOI: 10.1210/jc.2010-2352] [Citation(s) in RCA: 66] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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Mogensen CE. Mistakes, misunderstandings and controversies in diabetes: A review and personal account. J Diabetes Investig 2010; 1:97-100. [PMID: 24843414 PMCID: PMC4008022 DOI: 10.1111/j.2040-1124.2010.00012.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
A number of controversies in diabetes have had too little attention. I discuss the following issues: (i) drug therapy; (ii) genetics; (iii) antihypertensive treatment in patients with normoalbuminuria and with abnormal albuminuria; (iv) insulin analogs; (v) cancer in diabetes; (vi) hypophysectomy; (vii) renal biopsy; (viii) low protein diet; and (ix) glycated hemoglobin. A closer look at these items is required in order to have a more realistic picture of diabetes research. A scheme of other controversies is also provided. (J Diabetes Invest, doi: 10.1111/j.2040‐1124.2010.00012.x, 2010)
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Affiliation(s)
- Carl Erik Mogensen
- Medical Department M, Aarhus Sygehus and University of Aarhus, Aarhus, Denmark
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Christensen DL, Witte DR, Kaduka L, Jørgensen ME, Borch-Johnsen K, Mohan V, Shaw JE, Tabák AG, Vistisen D. Moving to an A1C-based diagnosis of diabetes has a different impact on prevalence in different ethnic groups. Diabetes Care 2010; 33:580-2. [PMID: 20009099 PMCID: PMC2827511 DOI: 10.2337/dc09-1843] [Citation(s) in RCA: 126] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVE To compare screen-detected diabetes prevalence and the degree of diagnostic agreement by ethnicity with the current oral glucose tolerance test (OGTT)-based and newly proposed A1C-based diagnostic criteria. RESEARCH DESIGN AND METHODS Six studies (1999-2009) from Denmark, the U.K., Australia, Greenland, Kenya, and India were tested for the probability of an A1C > or =6.5% among diabetic case subjects based on an OGTT. The difference in probability between centers was analyzed by logistic regression adjusting for relevant confounders. RESULTS Diabetes prevalence was lower with the A1C-based diagnostic criteria in four of six studies. The probability of an A1C > or =6.5% among OGTT-diagnosed case subjects ranged widely (17.0-78.0%) by study center. Differences in diagnostic agreement between ethnic subgroups in the U.K. study were of the same magnitude as between-country comparisons. CONCLUSIONS A shift to an A1C-based diagnosis for diabetes will have substantially different consequences for diabetes prevalence across ethnic groups and populations.
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Affiliation(s)
- Dirk L Christensen
- Department of International Health, Immunology and Microbiology, University of Copenhagen, Copenhagen, Denmark
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Mohan V, Vijayachandrika V, Gokulakrishnan K, Anjana RM, Ganesan A, Weber MB, Narayan KMV. A1C cut points to define various glucose intolerance groups in Asian Indians. Diabetes Care 2010; 33:515-9. [PMID: 19903752 PMCID: PMC2827500 DOI: 10.2337/dc09-1694] [Citation(s) in RCA: 89] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVE To determine A1C cut points for glucose intolerance in Asian Indians. RESEARCH DESIGN AND METHODS A total of 2,188 participants without known diabetes were randomly selected from the Chennai Urban Rural Epidemiology Study. All had fasting plasma glucose (FPG) and 2-h postload plasma glucose measurements after a 75-g load and were classified as having impaired fasting glucose (IFG) (American Diabetes Association [ADA] criteria, FPG > or =5.5 and <7 mmol/l, and World Health Organization [WHO] criteria, FPG > or =6.1 and <7 mmol/l), impaired glucose tolerance (IGT) (2-h postload plasma glucose > or =7.8 and <11.1 mmol/l), or diabetes (FPG > or =7 mmol/l and/or 2-h postload plasma glucose > or =11.1 mmol/l). A1C was measured using the Bio-Rad Variant machine. Based on receiver operating characteristic curves, optimum sensitivity and specificity were derived for defining A1C cut points for diabetes, IGT, and IFG. RESULTS Mean +/- SD values of A1C among subjects with normal glucose tolerance, IGT, and diabetes were 5.5 +/- 0.4, 5.9 +/- 0.6, and 8.3 +/- 2.0%, respectively (P(trend) < 0.001) with considerable overlap. To identify diabetes based on 2-h postload plasma glucose, the A1C cut point of 6.1% had an area under the curve (AUC) of 0.941 with 88.0% sensitivity and 87.9% specificity. When diabetes was defined as FPG > or =7.0 mmol/l, the A1C cut point was 6.4% (AUC = 0.966, sensitivity 93.3%, and specificity 92.3%). For IGT, AUC = 0.708; for IFG, AUC = 0.632 (WHO criteria) and 0.708 (ADA criteria), and the A1C cut point was 5.6%. CONCLUSIONS In Asian Indians, A1C cut points of 6.1 and 6.4% defined diabetes by 2-h postload plasma glucose or FPG criteria, respectively. A value of 5.6% optimally identified IGT or IFG but was <70% accurate.
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Affiliation(s)
- Viswanathan Mohan
- Madras Diabetes Research Foundation and Dr. Mohan's Diabetes Specialities Centre, World Health Organization Collaborating Centre for Non-Communicable Diseases Prevention and Control, and International Diabetes Federation Centre for Education, Chennai, India.
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Herman WH, Dungan KM, Wolffenbuttel BHR, Buse JB, Fahrbach JL, Jiang H, Martin S. Racial and ethnic differences in mean plasma glucose, hemoglobin A1c, and 1,5-anhydroglucitol in over 2000 patients with type 2 diabetes. J Clin Endocrinol Metab 2009; 94:1689-94. [PMID: 19276235 DOI: 10.1210/jc.2008-1940] [Citation(s) in RCA: 160] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
CONTENT Recent studies have reported hemoglobin A(1c) (A1c) differences across racial/ethnic groups. Our diverse population allows for further investigation of potential differences in measurements of glycemia. OBJECTIVES Our objectives were to describe and explore baseline racial/ethnic differences in self-monitored plasma glucose profiles, A1c, and 1,5-anhydroglucitol (1,5-AG) in patients with type 2 diabetes enrolled in the Assessing DURAbility of Basal vs. Lispro Mix 75/25 Insulin Efficacy trial. DESIGN, SETTING, PATIENTS The trial enrolled 2094 patients with type 2 diabetes, ages 30-80 yr, from 11 countries. MAIN OUTCOME MEASURES Estimated mean plasma glucose (MPG), A1c, and 1,5-AG were compared among racial/ethnic groups before and after adjusting for factors affecting glycemia: age, sex, duration of diabetes, body mass index, and MPG. RESULTS Baseline estimated MPG +/- sd was 220.0 +/- 82.0 mg/dl, mean A1c was 9.0 +/- 1.3%, and 1,5-AG was 5.0 +/- 4.1microg/ml. Estimated MPG did not differ between Caucasian and non-Caucasian groups. A1c was higher in Hispanics (9.4 +/- 1.4%; P < 0.001), Asians (9.2 +/- 1.4%; P < 0.01), and patients of other racial/ethnic groups (9.7 +/- 1.5%; P < 0.001) compared with Caucasians (8.9 +/- 1.2%). Paradoxically, 1,5-AG was higher for Asian (5.7 +/- 4.6 microg/ml) and African patients (6.2 +/- 5.4 microg/ml) vs. Caucasians (4.9 +/- 3.9 microg/ml) (P < 0.01). After adjusting for factors affecting glycemia, A1c was higher (all P <or= 0.002) in Hispanics, Asians, Africans, and patients of other racial/ethnic groups, and 1,5-AG was higher in Asian and African patients (P < 0.001) vs. Caucasians. CONCLUSIONS There were differences in A1c and 1,5-AG, but not MPG, among racial/ethnic groups. Comparisons of glycemia across racial/ethnic groups using these parameters may be problematic due to inherent biological variability and methodological issues.
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Affiliation(s)
- William H Herman
- Internal Medicine and Epidemiology, University of Michigan, Ann Arbor, Michigan 48109, USA.
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Leslie RDG, Kilpatrick ES. Translating the A1C assay into estimated average glucose values: response to Nathan et al. Diabetes Care 2009; 32:e11; author reply e12. [PMID: 19114620 DOI: 10.2337/dc08-1524] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Affiliation(s)
- R. David G. Leslie
- Centre for Diabetes and Metabolic Medicine, Institute of Cell and Molecular Science, London, U.K
| | - Eric S. Kilpatrick
- Department of Clinical Biochemistry Hull Royal Infirmary and Hull York Medical School, Hull, U.K
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Macdonald DR, Hanson AM, Holland MR, Singh BM. Clinical impact of variability in HbA1c as assessed by simultaneously measuring fructosamine and use of error grid analysis. Ann Clin Biochem 2008; 45:421-5. [PMID: 18583630 DOI: 10.1258/acb.2008.007259] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
BACKGROUND Haemoglobin A1c (HbA1c) is the only measure of glycaemic control used for many patients with diabetes, but it has limitations and might sometimes be misleading. HbA(1c) concentrations are influenced by conditions that alter red-cell life and there is evidence that biochemical variation in intracellular glycation rates also influence HbA1c concentrations. This paper is the first to propose a method of using simultaneously measured HbA1c and fructosamine, and error grid analysis, in the clinical setting, to gain a better understanding of glycaemic control. METHODS Cross-sectional analytical study using HbA1c and fructosamine measures on the same blood sample from 1744 patients having blood taken for hospital diabetes clinic appointments. No other selection or exclusion criteria were applied. RESULTS The fructosamine results were converted to a HbA1c equivalent which was then compared with the HbA1c. In an Altman-Bland plot, the paired result differences ranged between -6.9% and +5.5% HbA1c with 1139 (65%), 438 (25%), 130 (8%) and 37 (2%) being < or =1%, 1-2%, 2-3% or >3% of HbA1c difference, respectively. In clinical error grid analysis, 864 (50%) results had tight concordance for clinical interpretation, 761 (43%) had one block disunity of probably little clinical significance, but 105 (6%) were two blocks and 14 (1%) were three blocks discordant. CONCLUSION HbA1c may not accurately reflect glucose control. Our method, utilizing co-assessment with serum fructosamine, evaluates the possible clinical impact of this. We suggest the analysis used in this paper should be used routinely in diabetes practice.
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Affiliation(s)
- David R Macdonald
- Albrighton Medical Practice, Shaw Lane, Albrighton, Wolverhampton, West Midlands WV7 3DT, UK.
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Khera PK, Joiner CH, Carruthers A, Lindsell CJ, Smith EP, Franco RS, Holmes YR, Cohen RM. Evidence for interindividual heterogeneity in the glucose gradient across the human red blood cell membrane and its relationship to hemoglobin glycation. Diabetes 2008; 57:2445-52. [PMID: 18591386 PMCID: PMC2518496 DOI: 10.2337/db07-1820] [Citation(s) in RCA: 93] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVE To determine whether interindividual heterogeneity in the erythrocyte (red blood cell [RBC]) transmembrane glucose gradient might explain discordances between A1C and glycemic control based on measured fructosamine. RESEARCH DESIGN AND METHODS We modeled the relationship between plasma glucose and RBC glucose as the concentration distribution (C(i)-to-C(o) ratio) of a nonmetabolizable glucose analog (14)C-3-O-methyl glucose ((14)C-3OMG) inside (C(i)) and outside (C(o)) RBCs in vitro. We examined the relationship between that distribution and the degree of glycation of hemoglobin in comparison with glycation of serum proteins (fructosamine), the glycation gap. A1C, fructosamine, and in vitro determination of the (14)C-3OMG distribution in glucose-depleted RBCs were measured in 26 fasted subjects. RESULTS The C(i)-to-C(o) ratio 0.89 +/- 0.07 for 3-O-methyl-d-glucopyranose (3OMG) ranged widely (0.72-1.04, n = 26). In contrast, urea C(i)-to-C(o) (1.015 +/- 0.022 [range 0.98-1.07], P < 0.0001) did not. Concerning mechanism, in a representative subset of subjects, the C(i)-to-C(o) ratio was retained in RBC ghosts, was not dependent on ATP or external cations, and was reestablished after reversal of the glucose gradient. The 3OMG C(i)-to-C(o) ratio was not correlated with serum fructosamine, suggesting that it was independent of mean plasma glucose. However, C(i)-to-C(o) did correlate with A1C (R(2) = 0.19) and with the glycation gap (R(2) = 0.20), consistent with a model in which differences in internal glucose concentration at a given mean plasma glucose contribute to differences in A1C for given level of glycemic control. CONCLUSIONS The data demonstrate interindividual heterogeneity in glucose gradients across RBC membranes that may affect hemoglobin glycation and have implications for diabetes complications risk and risk assessment.
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Affiliation(s)
- Paramjit K Khera
- Division of Endocrinology, Diabetes, and Metabolism, Department of Medicine, University of Cincinnati Medical Center, Cincinnati, Ohio, USA
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Red cell life span heterogeneity in hematologically normal people is sufficient to alter HbA1c. Blood 2008; 112:4284-91. [PMID: 18694998 DOI: 10.1182/blood-2008-04-154112] [Citation(s) in RCA: 308] [Impact Index Per Article: 19.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Although red blood cell (RBC) life span is a known determinant of percentage hemoglobin A1c (HbA1c), its variation has been considered insufficient to affect clinical decisions in hematologically normal persons. However, an unexplained discordance between HbA1c and other measures of glycemic control can be observed that could be, in part, the result of differences in RBC life span. To explore the hypothesis that variation in RBC life span could alter measured HbA1c sufficiently to explain some of this discordance, we determined RBC life span using a biotin label in 6 people with diabetes and 6 nondiabetic controls. Mean RBC age was calculated from the RBC survival curve for all circulating RBCs and for labeled RBCs at multiple time points as they aged. In addition, HbA1c in magnetically isolated labeled RBCs and in isolated transferrin receptor-positivereticulocytes was used to determine the in vivo synthetic rate of HbA1c. The mean age of circulating RBCs ranged from 39 to 56 days in diabetic subjects and 38 to 60 days in nondiabetic controls. HbA1c synthesis was linear and correlated with mean whole blood HbA1c (R(2) = 0.91). The observed variation in RBC survival was large enough to cause clinically important differences in HbA1c for a given mean blood glucose.
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Bloomgarden ZT, Inzucchi SE, Karnieli E, Le Roith D. The proposed terminology 'A(1c)-derived average glucose' is inherently imprecise and should not be adopted. Diabetologia 2008; 51:1111-4. [PMID: 18449525 DOI: 10.1007/s00125-008-1027-7] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2008] [Accepted: 03/20/2008] [Indexed: 12/18/2022]
Abstract
The proposed use of a more precise standard for glycated (A(1c)) and non-glycated haemoglobin would lead to an A(1c) value, when expressed as a percentage, that is lower than that currently in use. One approach advocated to address the potential confusion that would ensue is to replace 'HbA(1c)' with a new term, 'A(1c)-derived average glucose.' We review evidence from several sources suggesting that A(1c) is, in fact, inherently imprecise as a measure of average glucose, so that the proposed terminology should not be adopted.
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Abstract
PURPOSE OF REVIEW HbA1c is a trusted standard for monitoring glycemic control and predicting complications. However, there are emerging issues complicating the interpretation of HbA1c that the clinician caring for patients with diabetes needs to consider. RECENT FINDINGS There is increasing evidence of the potential for mismatches between HbA1c and other measures of glycemia which require some caution in HbA1c interpretation. We have attempted to characterize the nature of these discordances by developing the concept of the 'glycation gap' in which differences in protein glycation occurring in the intracellular space (HbA1c) versus in the extracellular space (measured as fructosamine) are compared. We have evidence that HbA1c results discordant from other measures of glycemic control may be secondary to previously unappreciated physiological variables, including erythrocyte lifespan, in hematologically normal individuals. We relate these findings to a number of HbA1c interpretation issues important for diabetes care: factors affecting hemoglobin glycation, relationship of HbA1c to glycemia, standardization of the HbA1c assay, and HbA1c relation to complications. SUMMARY There are an increasing number of clinical circumstances in which there are nuances to HbA1c interpretation such that standard norms for assessment of glycemic control or complication risk may need to be modified.
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Affiliation(s)
- Robert M Cohen
- Division of Endocrinology, Diabetes and Metabolism, Department of Medicine, University of Cincinnati College of Medicine, Cincinnati, Ohio 45267-0547, USA.
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