Relationship between glycated haemoglobin and microvascular complications: is there a natural cut-off point for the diagnosis of diabetes?

Association between Hemoglobin A1c and Renal Arteriolar Sclerosis in Subjects Presenting without any Apparent Kidney Dysfunction

AIMS

Diabetic kidney disease is a major vascular complication in patients with diabetes mellitus (DM). However, the association between the hemoglobin (Hb)A1c levels, notably the prediabetic levels, and renal pathological changes remains unclear. We investigated the association between the HbA1c levels and renal arteriolar lesions in subjects without any apparent kidney dysfunction using a living kidney donor cohort.

METHODS

Between January 2006 and May 2016, 393 living kidney donors underwent a "zero-time" biopsy at Kyushu University Hospital. The patients were divided into four groups (HbA1c levels ＜5.6%, 5.6%-5.7%, 5.8%-6.4%, and ≥ 6.5%, or diagnosed with DM [DM group]). Renal arteriolar hyalinization and wall thickening were assessed using semi-quantitative grading. We then investigated the association between the HbA1c levels and renal pathological changes.

RESULTS

158 (40.2%) patients had arteriolar hyalinization and 148 (37.6%) showed wall thickening. A significant correlation was observed between the HbA1c levels and wall thickening (p for trend ＜0.001). An elevated HbA1c level was significantly associated with wall thickening according to a multivariable logistic analysis in subjects with HbA1c levels of 5.6%-5.7% and 5.8%-6.4%, and the DM group, compared with those with HbA1c levels of ＜5.6% (odds ratio [OR], 1.91; 95% confidence interval [CI]: [1.03-3.54] for 5.6%-5.7%, OR, 1.96; 95% CI: [1.09-3.53] for 5.8%-6.4%, and OR, 2.86; 95% CI: [0.91-9.01] for the DM group), whereas arteriolar hyalinization did not increase within the nondiabetic HbA1c levels.

CONCLUSIONS

Elevated high-normal HbA1c levels are considered to be independent risk factors for arteriolar wall thickening. Subclinical renal arteriolar sclerosis may develop in patients with prediabetic HbA1c levels.

Anti-inflammatory effect of luteoloside against methylglyoxal induced human dental pulp cells

PURPOSE

The aim of this study was to investigate whether luteoloside, a flavonoid, could protect human dental pulp cells (HDPCs) against inflammation and oxidative stress induced by methylglyoxal (MGO), one of the advanced glycated end products (AGE) substances.

METHODS

HDPCs were stimulated with MGO and treated with luteoloside. MTT assay was used to determine cell viability. Protein expression was measured via western blotting. Reactive oxygen species (ROS) were measured with a Muse Cell Analyzer. Alkaline phosphatase activity (ALP) and Alizarin red staining were used for mineralization assay.

RESULTS

Luteoloside down-regulated the expression of inflammatory molecules such as ICAM-1, VCAM-1, TNF-α, IL-1β, MMP-2, MMP-9, and COX-2 in MGO-induced HDPCs without showing any cytotoxicity. It attenuated ROS formation and enhanced osteogenic differentiation such as ALP activity and Alizarin red staining in MGO-induced HDPCs. Overall, luteoloside showed protective actions against inflammation and oxidative stress in HDPCs induced by MGO through its anti-inflammatory, anti-oxidative, and osteogenic activities by down-regulating p-JNK in the MAPK pathway.

CONCLUSION

These results suggest that luteoloside might be a potential adjunctive therapeutic agent for treating pulpal pathological conditions in patients with diabetes mellitus.

Screening for Turner syndrome-associated hyperglycemia: Evaluating hemoglobin A1c and fasting blood glucose

INTRODUCTION

Individuals with Turner syndrome (TS) are at increased risk of developing diabetes mellitus (DM). Currently, annual DM screening with hemoglobin A1c (HbA1c) with or without fasting blood glucose (FBG) is recommended starting at age 10. However, the optimal DM screening for individuals with TS is not known. The purpose of this study was to evaluate the correlation between HbA1c, FBG, and the 2-hour oral glucose tolerance test (OGTT). A second goal was to query whether optimal HbA1c and fasting (FBG) cut points for TS-associated DM and impaired glucose tolerance (IGT), as defined by the OGTT 2-hour blood glucose (BG), might differ from those for the general population.

METHODS

Individuals with TS ≥ age 10 from the TS: Genotype Phenotype study in the National Institute of Child Health and Human Development's Data and Specimen Hub (DASH) who had 2-hour OGTT BG, HbA1c, and FBG were included. Correlations between HbA1c, FBG, and 2-hour OGTT BG were evaluated. Areas under the receiver operative characteristic (ROC-AUC) curves were generated. Optimal cut points for predicting TS-associated IGT (2-hour BG ≥ 7.77 mmol/L ) and DM 2-hour BG ≥11.10 mmol/L) were determined.

RESULTS

348 individuals had complete data (2-hour OGTT BG < 7.77 mmol/L, n = 239; TS-associated IGT, n = 79; DM, n = 30). ROC-AUC was poor for HbA1c to predict IGT (0.57, 0.49-0.65) but better for DM (0.81, 0.71-0.90). ROC-AUC was also poor for FBG to predict IGT (0.63, 0.56-0.70) but better for DM (0.85, 0.77-0.93). At a cut point of 38 mmol/mol (5.6%), HbA1c had 67% sensitivity (95% CI: 47-83%) and 86% specificity (95% CI: 82-90%) for identifying TS-associated DM defined by 2-hour OGTT BG.

DISCUSSION/CONCLUSIONS

The correlation of HbA1c and 2-hour OGTT BG are lower in TS than other published studies regarding type 2 DM. HbA1c is fairly specific for DM in TS but lacks sensitivity especially at currently utilized levels. Future research should focus on characterizing individuals with TS whose glycemic status is discordant, as this may provide additional insights into the pathophysiology of glucose metabolism in TS. Longitudinal assessement of glycemia as it relates to micro- and macrovascular complications in individuals with TS will further inform DM screening in this population.

The pathophysiology of diabetic foot: a narrative review

An aging population and changes in dietary habits have increased the incidence of diabetes, resulting in complications such as diabetic foot ulcers (DFUs). DFUs can lead to serious disabilities, substantial reductions in patient quality of life, and high financial costs for society. By understanding the etiology and pathophysiology of DFUs, their occurrence can be prevented and managed more effectively. The pathophysiology of DFUs involves metabolic dysfunction, diabetic immunopathy, diabetic neuropathy, and angiopathy. The processes by which hyperglycemia causes peripheral nerve damage are related to adenosine triphosphate deficiency, the polyol pathway, oxidative stress, protein kinase C activity, and proinflammatory processes. In the context of hyperglycemia, the suppression of endothelial nitric oxide production leads to microcirculation atherosclerosis, heightened inflammation, and abnormal intimal growth. Diabetic neuropathy involves sensory, motor, and autonomic neuropathies. The interaction between these neuropathies forms a callus that leads to subcutaneous hemorrhage and skin ulcers. Hyperglycemia causes peripheral vascular changes that result in endothelial cell dysfunction and decreased vasodilator secretion, leading to ischemia. The interplay among these four preceding pathophysiological factors fosters the development and progression of infections in individuals with diabetes. Charcot neuroarthropathy is a chronic and progressive degenerative arthropathy characterized by heightened blood flow, increased calcium dissolution, and repeated minor trauma to insensate joints. Directly and comprehensively addressing the pathogenesis of DFUs could pave the way for the development of innovative treatment approaches with the potential to avoid the most serious complications, including major amputations.

"Knowing It Before Blocking It," the ABCD of the Peripheral Nerves: Part B (Nerve Injury Types, Mechanisms, and Pathogenesis)

Selander emphatically said, "Handle these nerves with care," and those words still echo, conveying a loud and clear message that, however rare, peripheral nerve injury (PNI) remains a perturbing possibility that cannot be ignored. The unprecedented nerve injuries associated with peripheral nerve blocks (PNBs) can be most tormenting for the unfortunate patient and a nightmare for the anesthetist. Possible justifications for the seemingly infrequent occurrences of PNB-related PNIs include a lack of documentation/reporting, improper aftercare, or associated legal implications. Although they make up only a small portion of medicolegal claims, they are sometimes difficult to defend. The most common allegations are attributed to insufficient informed consent; preventable damage to a nerve(s); delay in diagnosis, referral, or treatment; misdiagnosis, and inappropriate treatment and follow-up care. Also, sufficient prospective studies or randomized trials have not been conducted, as exploring such nerve injuries (PNB-related) in living patients or volunteers may be impractical or unethical. Understanding the pathophysiology of various types of nerve injury is vital to dealing with them further. Processes like degeneration, regeneration, remyelination, and reinnervation can influence the findings of electrophysiological studies. Events occurring in such a process and their impact during the assessment determine the prognosis and the need for further interventions. This educational review describes various types of PNB-related nerve injuries and their associated pathophysiology.

Traditional and disease-related cardiovascular risk factors in ANCA-associated vasculitis: A prospective, two-centre cohort study

OBJECTIVES

ANCA-associated vasculitis (AAV) has been associated with increased risk of cardiovascular (CV) events. The aim was to assess traditional and disease-related CV risk determinants in a two-centre prospective cohort of AAV patients.

METHODS

Patients were recruited from centres in the Netherlands and Canada. A comprehensive CV risk assessment was performed at inclusion. Subjects were followed up yearly for 3-5 years until the first CV event, death or end of follow-up. Cox proportional hazards analyses were performed to relate baseline characteristics to the first CV event.

RESULTS

A total of 144 patients were included (mean age 62 years, female sex 44%, median Framingham risk score 14.3%). Insulin resistance was present in 73% of patients tested at inclusion, independent of concurrent prednisone therapy. After a median follow-up of 2.90 years, 16 patients (11%) experienced a CV event (14 non-fatal and 2 fatal). The incidence of CV events was 5.45 per 100 patient-years. Age, Framingham risk score, HbA1c level, Diabetes Mellitus (DM), and previous CV event were significantly associated with CV events. Other factors, such as sex, impaired renal function, dyslipidemia, hypertension, smoking history and microalbuminuria, or disease-specific variables, like ANCA serotype or disease activity, were not significantly related to CV events in univariable or age-adjusted cox regression analysis.

CONCLUSIONS

Determinants of an increased CV risk were identified. Disease-related factors and treatments can further modify individual risk factors, such as for steroids causing chronic insulin resistance and DM. Treatment of risk factors is essential to optimize long-term outcomes in AAV patients.

The Potential of Glucose Treatment to Reduce Reactive Oxygen Species Production and Apoptosis of Inflamed Neural Cells In Vitro

Neuroinflammation is a key feature in the pathogenesis of entrapment neuropathies. Clinical trial evidence suggests that perineural injection of glucose in water at entrapment sites has therapeutic benefits beyond a mere mechanical effect. We previously demonstrated that 12.5-25 mM glucose restored normal metabolism in human SH-SYFY neuronal cells rendered metabolically inactive from TNF-α exposure, a common initiator of neuroinflammation, and reduced secondary elevation of inflammatory cytokines. In the present study, we measured the effects of glucose treatment on cell survival, ROS activity, gene-related inflammation, and cell cycle regulation in the presence of neurogenic inflammation. We exposed SH-SY5Y cells to 10 ng/mL of TNF-α for 24 h to generate an inflammatory environment, followed by 24 h of exposure to 3.125, 6.25, 12.5, and 25 mM glucose. Glucose exposure, particularly at 12.5 mM, preserved apoptotic SH-SY5Y cell survival following a neuroinflammatory insult. ROS production was substantially reduced, suggesting a ROS scavenging effect. Glucose treatment significantly increased levels of CREB, JNK, and p70S6K (p < 0.01), pointing to antioxidative and anti-inflammatory actions through components of the MAPK family and Akt pathways but appeared underpowered (n = 6) to reach significance for NF-κB, p38, ERK1/2, Akt, and STAT5 (p < 0.05). Cell regulation analysis indicated that glucose treatment recovered/restored function in cells arrested in the S or G2/M-phases. In summary, glucose exposure in vitro restores function in apoptotic nerves after TNF-α exposure via several mechanisms, including ROS scavenging and enhancement of MAPK family and Akt pathways. These findings suggest that glucose injection about entrapped peripheral nerves may have several favorable biochemical actions that enhance neuronal cell function.

Association between hemoglobin glycation index and diabetic kidney disease in type 2 diabetes mellitus in China: A cross- sectional inpatient study

Objective

To investigate the association between Hemoglobin Glycation Index (HGI) and Diabetic Kidney Disease (DKD) in Chinese type 2 diabetic individuals and to construct a risk score based on HGI to predict a person's risk of DKD.

Methods

We retrospectively analyzed 1622 patients with type 2 diabetes mellitus (T2DM). HGI was obtained by calculating the fasting plasma glucose (FPG) level into the formula, and they were grouped into low HGI group (L-HGI), medium HGI group (H-HGI) and high HGI group (H-HGI) according to tri-sectional quantile of HGI. The occurrence of DKD was analyzed in patients with different levels of HGI. Multivariate logistics regression analysis was used to analyze the risk factors of DKD in patients with T2DM.

Results

A total of 1622 patients with T2DM were enrolled in the study. Among them, 390 cases were DKD. The prevalence of DKD among the three groups was 16.6%, 24.2% and 31.3%. The difference was statistically significant (P = 0.000). There were significant differences in age (P=0.033), T2DM duration (P=0.005), systolic blood pressure (SBP) (P=0.003), glycosylated hemoglobin (HbA1c) (P=0.000), FPG (P=0.032), 2-hour postprandial plasma glucose (2h-PPG) (P=0.000), fasting C-peptide FCP (P=0.000), 2-hour postprandial C-peptide (2h-CP) (P=0.000), total cholesterol (TC) (P=0.003), low density lipoprotein cholesterol (LDL-C) (P=0.000), serum creatinine (sCr) (P=0.001), estimated glomerular filtration rate (eGFR) (P=0.000) among the three groups. Mantel-Haenszel chi-square test showed that there was a linear relationship between HGI and DKD (x2=177.469, p < 0.001). Pearson correlation analysis showed that with the increase of HGI level the prevalence of DKD was increasing (R= 0.445, P=0.000). It was indicated by univariate logistic regression analysis that individuals in H-HGI was more likely to develop DKD (OR: 2.283, 95% CI: 1.708~ 3.052) when compared with L-HGI. Adjusted to multiple factors, this trend still remained significant (OR: 2.660, 95% CI: 1.935~ 3.657). The combined DKD risk score based on HGI resulted in an area under the receiver operator characteristic curve (AUROC) of 0.702.

Conclusions

High HGI is associated with an increased risk of DKD. DKD risk score may be used as one of the risk predictors of DKD in type 2 diabetic population.

Italian Ketogenic Mediterranean Diet in Overweight and Obese Patients with Prediabetes or Type 2 Diabetes

Obesity is a multifactorial disease strongly associated with insulin resistance and/or type 2 diabetes mellitus. Correct nutrition represents a valid strategy to fight these dysmetabolic pathologies responsible for numerous diseases, including inflammatory and cardiovascular ones. Medical nutrition therapy, including a Mediterranean diet (MD) and a very low-calorie ketogenic diet (VLKCD), is the first-line treatment for prediabetes/diabetes and overweight/obesity. Eighty patients (forty women and forty men) affected by overweight/obesity and type 2 diabetes mellitus or impaired glucose tolerance or impaired fasting glucose (51 (ys) ± 1.75; BMI (kg/m2) 33.08 ± 1.93; HA1c (%): 6.8% ± 0.25) were enrolled at the University Service of Diet Therapy, Diabetology and Metabolic Diseases, Policlinico Riuniti Hospital of Foggia, and subjected to a very-low-calorie Mediterranean diet and a very-low-calorie ketogenic Mediterranean diet for thirty days. Both diets result in a marked decrease in body weight (kg) and BMI (kg/m2). At the same time, only the very-low-calories ketogenic Mediterranean diet reduced waist and hip circumferences. Both diets helped reduce fat mass, but a major loss was achieved in a very low-calorie ketogenic Mediterranean diet. Among gluco-metabolic parameters, only the very-low-calorie ketogenic Mediterranean diet group showed a significant decrease in fasting blood glucose and HbA1c, insulin, C-peptide total cholesterol, LDL, and triglycerides. The results of our study seem to show that the very-low-calorie ketogenic Mediterranean diet is a good strategy to improve rapidly metabolic, anthropometric, and body composition parameters in patients with prediabetes or diabetes and overweight/obesity.

Risk of Macrovascular and Microvascular Disease in Diabetes Diagnosed Using Oral Glucose Tolerance Test With and Without Confirmation by Hemoglobin A1c: The Whitehall II Cohort Study

BACKGROUND

It is unclear whether replacing oral glucose tolerance test (OGTT) with hemoglobin A1c (HbA1c) measurement for diagnosing diabetes is justified. We aimed to assess the proportion of OGTT-diagnosed diabetes cases that can be confirmed by HbA1c and to examine whether individuals with OGTT diagnosis but nondiagnostic HbA1c are at higher risk of macrovascular and microvascular disease.

METHODS

Participants were 5773 men and women from the population-based Whitehall II prospective cohort study in the United Kingdom. New OGTT diabetes cases diagnosed in clinical examinations in 2002 to 2004 and 2007 to 2009 were assessed for HbA1c confirmation (≥6.5%) in these and subsequent clinical examinations in 2012 to 2013 and 2015 to 2016. All participants were followed up for major cardiovascular events through linkage to electronic health records until 2017 and for incident chronic kidney disease (estimated glomerular filtration rate <60 mL·min^-1·1.73 m^-2) until the last clinical examination. In analysis of vascular disease risk, new OGTT-diagnosed diabetes cases with and without diagnostic HbA1c and preexisting diabetes cases were compared with diabetes-free participants.

RESULTS

Of the 378 (59.3%) participants with OGTT-diagnosed diabetes, 224 were confirmed by HbA1c during 4.1 years (SD, 4.1 years) of follow-up. We recorded 942 cardiovascular events over 12.1 years. After adjustment for nonmodifiable risk factors and compared with the 4997 diabetes-free participants, 371 participants with new HbA1c-confirmed diabetes and 405 participants with preexisting diabetes had increased risk of cardiovascular disease (hazard ratio, 1.53 [95% CI, 1.12-2.10] and 1.85 [95% CI, 1.50-2.28], respectively). The corresponding hazard ratios in the analysis of incident chronic kidney disease (487 cases; follow-up, 6.6 years) were 1.69 (95% CI, 1.09-2.62) for 282 participants with new HbA1c-confirmed diabetes and 1.67 (95% CI, 1.22-2.28) for 276 participants with preexisting diabetes. In both analyses, OGTT cases with nondiagnostic HbA1c (n=149 and 107) had a risk (hazard ratio, 0.99-1.07) similar to that of the diabetes-free population.

CONCLUSIONS

More than 40% of OGTT-diagnosed diabetes cases were not confirmed by HbA1c during an extended follow-up. However, because these individuals have a risk of cardiovascular disease and chronic kidney disease similar to that of the diabetes-free population, replacement of OGTT with HbA1c-based diagnosis appears justified.

A Cross-Sectional Study of Electrophysiological Changes Occurring in Type II Diabetes Mellitus

Background

Diabetes is a long-term metabolic condition that results in high blood sugar levels from either reduced insulin production or diminished tissue sensitivity to insulin. Peripheral neuropathy is the most frequent consequence of diabetes. In this research project, with the aid of neurophysiological measures, we conducted a cross-sectional study to examine the impact of glycemic management on the physiological functioning of nerves, regardless of the duration of diabetes.

Objectives

The main objective of the study was to investigate the association between the degree of glycemic control and the severity of neurological changes. The study also aimed to clarify whether glycemic management, independent of the duration of diabetes, acts as an independent risk factor for the emergence of diabetic neuropathy.

Methodology

A total of 150 type 2 diabetic patients visiting the diabetic outpatient department were included in the study. The patients were divided into two groups: group A consisted of 90 subjects with HbA1c levels <10 and group B comprised 60 subjects with HbA1c levels >10. In the neurophysiology lab, an electrodiagnostic exam was conducted on the sensory (sural nerve) and motor (tibial nerve) parameters. Data on the neurophysiological parameters of the two groups were analyzed and compared.

Results

When the neurophysiological parameters of the two groups (group A having HbA1c <10 and group B having HbA1c >10) were analyzed, it was observed that group B had lower conduction velocity (CV) and amplitude potential than group A, with a significant statistical difference (p<0.05). It was also observed that sensory parameters were more affected than motor parameters.

Conclusion

Based on our findings, glycemic control is related to the severity of neuropathic changes.

Effects of Feedback From Self-Monitoring Devices on Lifestyle Changes in Workers with Diabetes: 3-Month Randomized Controlled Pilot Trial

Background

Although lifestyle interventions are useful in the prevention and management of diabetes, they can be expensive and time-consuming. There is some evidence on the effectiveness of automated mobile technology for health self-monitoring; however, few studies have used such devices in the occupational health field.

Objective

We aimed to examine the effectiveness of a digital self-monitoring device on glucose levels and activity of workers with diabetes in Japan. The primary outcomes were changes in blood glucose levels, and the secondary outcomes were changes in weight and BMI.

Methods

A 2-arm randomized controlled pilot trial was conducted with workers from 23 organizations. The intervention group (n=50) wore an armband activity monitor, a body composition monitor, and a blood pressure monitor for 3 months and received semiautomated weekly email messages tailored to their device data. The control group (n=53) engaged in no self-monitoring. Messages were developed by a physician and a dietician. Postintervention changes in blood glucose levels, weight, and BMI were compared between the intervention and control groups, using blood tests and questionnaires.

Results

At the end of 3 months, the intervention group showed significantly lower blood glucose levels (HbA1c: intervention group mean 6.4% (SD 0.3%) vs control group mean 6.6% (SD 0.3%); Cohen d=0.7, 95% CI 0.2-1.1; P=.009). There were no significant between-group differences in weight and BMI.

Conclusions

Mobile digital self-monitoring was effective in improving blood glucose levels in workers with diabetes. The use of digital health devices is a cost-effective way of implementing health self-monitoring for large numbers of individuals in the workplace. However, due to the large volume of missing values in this study, we need to be careful in interpreting the results, and well-designed intervention studies need to be conducted.

Trial Registration

University Hospital Medical Information Network UMIN000023651; https://upload.umin.ac.jp/cgi-open-bin/icdr/ctr_view_cb.cgi?recptno=R000027244&flwp_key=1008PYbOcXKmk7CAg4Th1FWS

Revised Glycemic Index for Diagnosing and Monitoring of Diabetes Mellitus in South Indian Population

Aim: To find the optimal threshold of fasting plasma glucose (FPG) and glycated hemoglobin (HbA1c) for diagnosis of diabetes mellitus (DM) and to evaluate the association with diabetic retinopathy (DR) in the South Indian population.

Settings and Design: A retrospective population-based study.

Methods and Materials: A total of 909 newly detected type 2 DM patients were selected from our two previously conducted studies, which include an urban and a rural population of South India. All underwent estimation of fasting, postprandial plasma glucose (PPG), and other biochemical tests. A comprehensive and detailed ophthalmic examination was carried out. The fundi of patients were photographed using 45°, four-field stereoscopic photography. Based on receiver operating characteristic (ROC) curves, sensitivity and specificity were derived.

Results: The optimal cut-off values determined by maximizing the sensitivity and specificity of FPG and HbA1c using the Youden index were ≥ 6.17 mmol/L and ≥ 6.3%, respectively. By distributing the cut-off points into deciles and comparing them to the WHO criteria, we found that our HbA1c level of 6.60% was more than the WHO threshold (6.5%), with higher sensitivity (81.6%) and lower specificity (48.3%). The FPG level of 6.80 mmol/L was lower to the WHO criteria (7 mmol/L) with increased sensitivity (77.0%) and lower specificity (45.7%). Prevalence of DR by HbA1c levels between 6.5% and 6.9% was 15.3%. The prevalence of DR was more in the FPG category between 6.4 and 6.9 mmol/L and ≥ 7.5 mmol/L.

Conclusion: Our population-based data indicate that for the South Indian population HbA1c value of ≥63 % and FPG value of ≥6.17 mmol/L may be optimal for diagnosing DM with a high level of accuracy and will be useful for the identification of mild and moderate DR.

Comparison of ETDRS 7-Field to 4-Widefield Digital Imaging in the Evaluation of Diabetic Retinopathy Severity

Purpose

To compare Early Treatment Diabetic Retinopathy Study (ETDRS) severity levels between two digital fundus imaging protocols for research studies of diabetic retinopathy: the gold standard 7-field (7F) imaging and the more recent 4-widefield (4W) imaging.

Methods

Two hundred twenty-two participants enrolled in the Diabetes Prevention Program Outcomes Study underwent concurrent 7F and 4W imaging. The ETDRS levels from 220 paired gradable images were determined by masked graders. Each image was graded by two independent graders with adjudication by a senior grader, if necessary. Percent agreement between graders and between imaging protocols was evaluated with kappa statistics and weighted kappa statistics.

Results

Of 220 gradable eyes, diabetic retinopathy was seen in 11.8%; this was mild in 10.4% and more than mild in 1.4% using 7F imaging. The ETDRS levels showed exact agreement of 95% between 7F and 4W imaging (weighted kappa 0.86). Intergrader agreement for each modality had exact agreement of 89% (weighted kappa of 0.73) for 7F and 91% (weighted kappa 0.77) for 4W.

Conclusions

There is substantial agreement in the ETDRS severity level between the 7F and 4W digital imaging protocols, demonstrating that the two imaging protocols are interchangeable. Both 4W and 7F digital imaging protocols can be used for assessing ETDRS levels, even in populations with minimal diabetic retinopathy.

Translational Relevance

The 4W protocol requires fewer images than the 7F, is more comfortable for the patients, is easier for photographic capture, and provides diabetic retinopathy data that is equivalent to the 7F imaging protocol.

Influence of Glucose Fluctuation on Peripheral Nerve Damage in Streptozotocin-Induced Diabetic Rats

BACKGROUND

It is unclear whether glycemic variability (GV) is a risk factor for diabetic peripheral neuropathy (DPN), and whether control of GV is beneficial for DPN. The purpose of this study was to investigate the effect of GV on peripheral nerve damage by inducing glucose fluctuation in streptozotocin-induced diabetic rats.

METHODS

Rats were divided into four groups: normal (normal glucose group [NOR]), diabetes without treatment (sustained severe hyperglycemia group; diabetes mellitus [DM]), diabetes+once daily insulin glargine (stable hyperglycemia group; DM+LAN), and diabetes+once daily insulin glargine with twice daily insulin glulisine (unstable glucose fluctuation group; DM+Lantus [LAN]+Apidra [API]). We measured anti-oxidant enzyme levels and behavioral responses against tactile, thermal, and pressure stimuli in the plasma of rats. We also performed a quantitative comparison of cutaneous and sciatic nerves according to glucose fluctuation.

RESULTS

At week 24, intraepidermal nerve fiber density was less reduced in the insulin-administered groups compared to the DM group (P<0.05); however, a significant difference was not observed between the DM+LAN and DM+LAN+API groups irrespective of glucose fluctuation (P>0.05; 16.2±1.6, 12.4±2.0, 14.3±0.9, and 13.9±0.6 for NOR, DM, DM+LAN, and DM+LAN+API, respectively). The DM group exhibited significantly decreased glutathione levels compared to the insulin-administered groups (2.64±0.10 μmol/mL, DM+LAN; 1.93±0.0 μmol/mL, DM+LAN+API vs. 1.25±0.04 μmol/mL, DM; P<0.05).

CONCLUSION

Our study suggests that glucose control itself is more important than glucose fluctuation in the prevention of peripheral nerve damage, and intra-day glucose fluctuation has a limited effect on the progression of peripheral neuropathy in rats with diabetes.

Predictive model and risk analysis for diabetic retinopathy using machine learning: a retrospective cohort study in China

OBJECTIVE

Aiming to investigate diabetic retinopathy (DR) risk factors and predictive models by machine learning using a large sample dataset.

DESIGN

Retrospective study based on a large sample and a high dimensional database.

SETTING

A Chinese central tertiary hospital in Beijing.

PARTICIPANTS

Information on 32 452 inpatients with type-2 diabetes mellitus (T2DM) were retrieved from the electronic medical record system from 1 January 2013 to 31 December 2017.

METHODS

Sixty variables (including demography information, physical and laboratory measurements, system diseases and insulin treatments) were retained for baseline analysis. The optimal 17 variables were selected by recursive feature elimination. The prediction model was built based on XGBoost algorithm, and it was compared with three other popular machine learning techniques: logistic regression, random forest and support vector machine. In order to explain the results of XGBoost model more visually, the Shapley Additive exPlanation (SHAP) method was used.

RESULTS

DR occurred in 2038 (6.28%) T2DM patients. The XGBoost model was identified as the best prediction model with the highest AUC (area under the curve value, 0.90) and showed that an HbA1c value greater than 8%, nephropathy, a serum creatinine value greater than 100 µmol/L, insulin treatment and diabetic lower extremity arterial disease were associated with an increased risk of DR. A patient's age over 65 was associated with a decreased risk of DR.

CONCLUSIONS

With better comprehensive performance, XGBoost model had high reliability to assess risk indicators of DR. The most critical risk factors of DR and the cut-off of risk factors can be found by SHAP method to render the output of the XGBoost model clinically interpretable.

The hypertriglyceridemic-waist phenotype as a valuable and integrative mirror of metabolic syndrome traits

Rates of non-communicable diseases (NCDs), such as obesity, diabetes, cardiovascular events and cancer, continue to rise worldwide, which require objective instruments for preventive and management actions. Diverse anthropometric and biochemical markers have been used to qualitatively evaluate degrees of disease, metabolic traits and evolution of nutritional status. The aim of this study was to integrate and assess the interactions between an anthropometric measurement, such as waist circumference (WC), and biochemical data, such as the triglyceride glucose index (TyG), in order to individually characterize metabolic syndrome (MetS) features considering the hypertriglyceridemic waist phenotype as a marker. An ancillary cross-sectional study was conducted using anthropometric measurements, such as weight, height, waist and hip circumferences, as well as fasting biochemical data of 314 participants. Different indices based on WC (WC, WC*TG and WC*TyG) were estimated to compute MetS components and accompanying comorbidities. ROC curves were fitted to define the strength of the analyses and the validity of the relationships. Associations were confirmed between anthropometric, biochemical and combined indices with some chronic disease manifestations, including hyperglycemia, hypertension and dyslipidemia. Both WC*TG and WC*TyG indices showed similar performance in diagnosing MetS (area under the ROC curve = 0.81). Interestingly, when participants were categorized according to a reference value of the WC*TyG index (842.7 cm*mg/dl), our results evidenced that subjects classified over this limit presented statistically higher prevalence of MetS and accompanying individual components with clinical relevance for interventions. These results revealed that WC*TyG mirrors the hypertriglyceridemic phenotype, which suggests may serve as a good indicator to define the metabolic syndrome phenotype and a suitable, sensitive, and simple proxy to complement others. A reference point was proposed with a good clinical performance and maximized sensitivity and specificity values.

Understanding the place for GLP-1RA therapy: Translating guidelines for treatment of type 2 diabetes into everyday clinical practice and patient selection

Since the first glucagon-like peptide 1 (GLP-1) receptor agonist (GLP-1RA) was approved in 2005 (exenatide twice daily) for type 2 diabetes (T2D), the class has developed with newer compounds having more pronounced effects on glycaemic control and body weight. Also, administration regimes have become more convenient with once weekly injections, and recently an oral administration has become available. Large-scale randomized controlled cardiovascular (CV) outcome trials (CVOTs) have shown that GLP-1RA therapy can reduce the risk of CV disease (CVD) in high-risk individuals with T2D. In addition, GLP-1RAs may have renal benefits driven by new-onset macroalbuminuria, although no effect on hard renal endpoints has been found. Subsequently, the place for GLP-1RA therapy has changed over recent years, with most societies endorsing GLP-1RA therapy in patients with established or high risk of CVD independently of glycaemia. Initiation of GLP-1RA therapy can be complex due to differences in efficacy, side effects and safety profiles as well as administration forms within the class. Implementing guideline recommendations into ideal patient selection may be challenging both in specialty and non-specialty settings. To ensure adequate and proactive use of modern glucose-lowering medications in the treatment of T2D, it is essential to recognize patients with high risk or documented CVD. The present review provides an overview of the efficacy and benefits of the currently available GLP-1RA compounds. Furthermore, we review the results from recent large-scale CVOTs in a clinical context and suggest improving the implementation of GLP-1RA therapy across specialties to improve overall patient selection.

Deep Learning Algorithm for Management of Diabetes Mellitus via Electrocardiogram-Based Glycated Hemoglobin (ECG-HbA1c): A Retrospective Cohort Study

BACKGROUND

glycated hemoglobin (HbA1c) provides information on diabetes mellitus (DM) management. Electrocardiography (ECG) is a noninvasive test of cardiac activity that has been determined to be related to DM and its complications. This study developed a deep learning model (DLM) to estimate HbA1c via ECG.

METHODS

there were 104,823 ECGs with corresponding HbA1c or fasting glucose which were utilized to train a DLM for calculating ECG-HbA1c. Next, 1539 cases from outpatient departments and health examination centers provided 2190 ECGs for initial validation, and another 3293 cases with their first ECGs were employed to analyze its contributions to DM management. The primary analysis was used to distinguish patients with and without mild to severe DM, and the secondary analysis was to explore the predictive value of ECG-HbA1c for future complications, which included all-cause mortality, new-onset chronic kidney disease (CKD), and new-onset heart failure (HF).

RESULTS

we used a gender/age-matching strategy to train a DLM to achieve the best AUCs of 0.8255 with a sensitivity of 71.9% and specificity of 77.7% in a follow-up cohort with correlation of 0.496 and mean absolute errors of 1.230. The stratified analysis shows that DM presented in patients with fewer comorbidities was significantly more likely to be detected by ECG-HbA1c. Patients with higher ECG-HbA1c under the same Lab-HbA1c exhibited worse physical conditions. Of interest, ECG-HbA1c may contribute to the mortality (gender/age adjusted hazard ratio (HR): 1.53, 95% conference interval (CI): 1.08-2.17), new-onset CKD (HR: 1.56, 95% CI: 1.30-1.87), and new-onset HF (HR: 1.51, 95% CI: 1.13-2.01) independently of Lab-HbA1c. An additional impact of ECG-HbA1c on the risk of all-cause mortality (C-index: 0.831 to 0.835, p < 0.05), new-onset CKD (C-index: 0.735 to 0.745, p < 0.01), and new-onset HF (C-index: 0.793 to 0.796, p < 0.05) were observed in full adjustment models.

CONCLUSION

the ECG-HbA1c could be considered as a novel biomarker for screening DM and predicting the progression of DM and its complications.

Diagnosing type 2 diabetes using Hemoglobin A1c: a systematic review and meta-analysis of the diagnostic cutpoint based on microvascular complications

AIMS

Diabetic microvascular complications of retinopathy, nephropathy and neuropathy may occur at hemoglobin A1c levels (HbA1c) below the 6.5% (48 mmol/mol) diagnostic threshold. Our objective was to assess the validity of the HbA1c diagnostic cutpoint of 6.5% based upon published evidence of the prevalence of retinopathy, nephropathy and neuropathy as markers of diabetes.

METHODS

Data Sources PubMed, Embase, Cochrane, Scopus and CINAHL from 1990-March 2019, grey literature sources. Study Selection All studies reported after 1990 (to ensure standardized HbA1c values) where HbA1c levels were presented in relation to prevalence of retinopathy, nephropathy or neuropathy in subjects not known to have diabetes. Data Extraction Studies were screened independently, data abstracted, and risk of bias appraised. Data Synthesis Data were synthesized using HbA1c categories of < 6.0% (< 42 mmol/mol), 6.0-6.4% (42-47 mmol/mol) and ≥ 6.5% (≥ 48 mmol/mol). Random-effects meta-analyses were conducted for retinopathy, nephropathy and neuropathy prevalence stratified by HbA1c categories. Random-effects multivariable meta-regression was conducted to identify predictors of retinopathy prevalence and sources of between-study heterogeneity.

RESULTS

Pooled mean prevalence was: 4.0%(95% CI: 3.2-5.0%) for retinopathy, 10.5% (95% CI: 4.0-19.5%) for nephropathy, 2.5% (95% CI: 1.1-4.3%) for neuropathy. Mean prevalence when stratified for HbA1c < 6.0%, 6.0-6.4% and ≥ 6.5% was: retinopathy: 3.4% (95% CI: 1.8-5.4%), 2.3% (95% CI: 1.6-3.2%) and 7.8%(95% CI: 5.7-10.3%); nephropathy: 7.1% (95% CI: 1.7-15.9%), 9.6% (95% CI: 0.8-26.4%) and 17.1% (95% CI: 1.0-46.9%); neuropathy: 2.1% (95% CI: 0.0-6.8%), 3.4% (95% CI: 0.0-11.6%) and 2.8% (95% CI: 0.0-12.8%). Multivariable meta-regression showed HbA1c ≥ 6.5% (OR: 4.05; 95% CI: 1.92-8.57%), age > 55 (OR: 3.23; 95% CI 1.81-5.77), and African-American race (OR: 10.73; 95% CI: 4.34-26.55), to be associated with higher retinopathy prevalence. Marked heterogeneity in prevalence estimates was found across all meta-analyses (Cochran's Q-statistic p < 0.0001).

CONCLUSIONS

The prevalence of nephropathy and moderate retinopathy was increased in subjects with HbA1c values ≥ 6.5% confirming the high specificity of this value for diagnosing T2DM; however, at HbA1c < 6.5% retinopathy increased at age > 55 years and, most strikingly, in African-Americans, suggesting there may be excess microvascular complication prevalence (particularly nephropathy) in individuals below the diabetes diagnostic threshold.

Efficacy and safety of a herbal drug of Coccinia grandis (Linn.) Voigt in patients with type 2 diabetes mellitus: A double blind randomized placebo controlled clinical trial

BACKGROUND

Several lines of preclinical studies have shown promising antidiabetic effects of the aqueous leaves extract of Coccinia grandis (Linn.) Voigt (Cucurbitaceae) in vivo and in vitro.

PURPOSE

The present study was conducted to evaluate the efficacy and safety of a newly developed herbal formulation of C. grandis in newly diagnosed patients with type 2 diabetes mellitus (T2DM).

STUDY DESIGN

A three months long, randomized, double blind, placebo controlled clinical trial in patients with newly diagnosed T2DM.

METHOD

Based on fasting plasma glucose (FPG) concentration, a total number of 158 newly diagnosed patients with T2DM (45 ± 15 years age) were recruited for the present trial from the University Medical Clinic, Teaching Hospital, Karapitiya, Galle, Sri Lanka. They were randomly assigned to the test or placebo group to receive 500 mg of herbal drug (n = 79) or placebo drug (n = 79) once daily for three months. Patients and investigators were blinded for the treatment. Percentage of glycated hemoglobin (HbA_1C %), insulin and lipid profile parameters were estimated at the base line and at the end of the intervention. Serum concentration of fructosamine was assessed at every other visit of the trial. The homeostatic model assessment for insulin resistance (HOMA-IR), atherogenic index (AI), cardio-protective index (CPI) and coronary risk index (CRI) were calculated. Furthermore, fasting plasma glucose concentration, renal and liver toxicity parameters, hematological parameters, blood pressure (BP) were assessed throughout the study in two weekly intervals till the end of three months.

RESULTS

Out of 158, a total number of 145 patients completed the entire clinical trial period successfully. Mean (SD) changes of variables from the baseline to the end of the intervention in test and placebo groups were 0.65 (0.54) and 0.08 (0.66) for HbA_1C % (p < 0.001), 1.91 (3.07) and -1.28 (9.77) for insulin (p < 0.001), 0.02 (0.03) and -0.01 (0.04) for frucosamine (p < 0.001), 1.51 (0.49) and 0.05 (0.50) for FPG (p < 0.001), 1.73 (1.36) and -0.37 (3.38) for HOMA-IR (p < 0.001), 0.16 (0.18) and -0.04 (0.42) for TG (p < 0.001), 0.07 (0.08) and -0.02 (0.19) for VLDL-C (p < 0.001), respectively. However, the herbal drug of C. grandis was unable to change other outcome variables significantly when compared to the placebo (p > 0.05). All the renal, liver and toxicity parameters, hematological parameters and BP were within the normal physiological reference ranges at each visit.

CONCLUSION

Treatment with herbal drug of C. grandis (500 mg per day) for three months for patients with newly diagnosed T2DM significantly improved their glycemic and selected lipid profile parameters with well tolerated safety.

Carbamazepine conquers spinal GAP43 deficiency and sciatic Nav1.5 upregulation in diabetic mice: novel mechanisms in alleviating allodynia and hyperalgesia

This work tested the role of carbamazepine in alleviating alloxan-induced diabetic neuropathy and the enhancement of spinal plasticity. Mice were randomized into four groups: normal, control, carbamazepine (25-mg/kg) and carbamazepine (50-mg/kg). Nine weeks after induction of diabetes, symptoms of neuropathy were confirmed and carbamazepine (or vehicle) was given every other day for five weeks. After completing the treatment period, mice were sacrificed and the pathologic features in the spinal cord and the sciatic nerves were determined. The spinal cords were evaluated for synaptic plasticity (growth associated protein-43, GAP43), microglia cell expression (by CD11b) and astrocyte expression (glial fibrillary acidic protein, GFAP). Further, sciatic nerve expression of Nav1.5 was measured. Results revealed that carbamazepine 50 mg/kg prolonged the withdrawal threshold of von-Frey filaments and increased the hot plate jumping time. Carbamazepine improved the histopathologic pictures of the sciatic nerves and spinal cords. Spinal cord of carbamazepine-treated groups had enhanced expression of GAP43 but lower content of CD11b and GFAP. Furthermore, specimens from the sciatic nerve indicated low expression of Nav1.5. In conclusion, this work provided evidence, for the first time, that the preventive effect of carbamazepine against diabetic neuropathy involves correction of spinal neuronal plasticity and glia cell expression.

The Correlation between Hemoglobin A1c (HbA1c) and Hyperreflective Dots (HRD) in Diabetic Patients

Hyperreflective dots (HRD) are activated retinal microglial cells induced by retinal inflammation in diabetic patients. This study was conducted to compare the HRD count of normal and diabetic subjects; to determine the correlation between hemoglobin A1c (HbA1c) levels and HRD count; to determine HbA1c cut-off levels for the appearance of HRD in diabetic patients. A cross-sectional study was conducted among normal and diabetic patients. Fundus photos, SD-OCT images and HbA1c levels were taken. A total of 25 normal subjects, 32 diabetics without retinopathy and 26 mild-to-moderate nonproliferative diabetic retinopathy (NPDR) diabetics were recruited. There was a statistically significant difference between the mean count of HRD among the normal group, the diabetic without retinopathy group and the mild-to-moderate NPRD group. The mean HRD count in the inner retina layer was significantly higher compared to the outer retina layer. There was a significant linear relationship between the HbA1c levels and HRD count. Using the receiver operating curve, the HbA1c level of 5.4% was chosen as the cut-off point for the appearance of HRD. The positive linear correlation between the HbA1c levels and the appearance of HRD may indicate that hyperglycemia could activate retina microglial cells in diabetic patients.

A Clinic-based Approach to Diagnosis and Management of Prediabetes in High-risk Children and Adolescents

Background

Type 2 diabetes (T2D) in youth is increasing in prevalence. Diabetes screening is recommended for at-risk youth but best-practice strategies for management of pediatric prediabetes are unknown. This study leverages a pediatric prediabetes clinic to assess identification of high-risk patients, the rate of clinic follow-up and progression to T2D in youth over time.

Methods

Retrospective chart review of children referred to a single center for evaluation of prediabetes over a 3-year period. Measurements included hemoglobin A1c (HbA1C) and oral glucose tolerance testing. Patients were classified as normal glucose tolerance (NGT), impaired glucose tolerance (IGT) or T2D based on 2019 American Diabetes Association criteria. Patients classified as IGT/T2D were prescribed metformin.

Results

Of the 254 patients included; 25.6% had IGT and 6.7% had T2D. The IGT/T2D groups were older and more obese than the NGT group. There was a moderate correlation between HbA1C and fasting glucose (r = 0.59, P < 0.001); HbA1C and 2-hour glucose (r = 0.63, P < 0.001). Over the 3-year study, 52 of 82 patients with IGT/T2D (63%) returned for follow-up. Four patients regained NGT; 3 of those had isolated impaired fasting glucose (100 to 102 mg/dL). Three patients (4.6%) progressed from IGT to T2D over an average of 13 ± 6.2 months. In those patients, body mass index had increased 1.7 ± 2.3 kg/m² from baseline.

Conclusions

A pediatric prediabetes clinic may allow for identification of high-risk youth but lost to follow-up rates are high. Continued weight gain is a risk factor for progression to T2D and effective weight management programs are needed.

A Comparison of the Association of Fasting Plasma Glucose and HbA1c Levels with Diabetic Retinopathy in Japanese Men

INTRODUCTION

The relationship between HbA1c and diabetic retinopathy is expected to differ between different races. This study was designed to verify whether HbA1c or fasting plasma glucose (FPG) is more effective in detecting diabetic retinopathy in a Japanese population.

MATERIALS AND METHODS

The study subjects underwent health examinations between 2008 and 2009 with fasting. Of these participants, we analyzed the data for 2,921 Japanese men who had undergone an ophthalmologic examination. Retinopathy was classified into 7 categories according to a simplified diabetic retinopathy scale. The odds ratios of retinopathy according to the eight groups of FPG and HbA1c were estimated using multiple logistic regression analysis adjusted for age. Receiver operator characteristic analysis was used to evaluate each value associated with the presence or absence of retinopathy. Results and Discussion. The odds ratios (95% CI) of retinopathy for HbA1c level categories, in ascending order, were 1.0 (ref.), 0.88 (0.28-2.75), 1.27 (0.44-3.69), 1.52 (0.48-4.79), 1.89 (0.52-6.85), 2.70 (0.66-11.10), 4.10 (0.80-21.00), and 6.34 (2.37-16.97) where the odds ratios significantly increased with HbA1c ≥ 6.8%. The area under the curve (SE) for FPG and HbA1c was almost the same, at 0.668 (0.043) and 0.680 (0.043), respectively.

CONCLUSIONS

It was clarified that the higher the level of HbA1c, the higher the prevalence of retinopathy, and there was no clear threshold. The detection ability of retinopathy was almost the same, suggesting that it is possible to detect the risk of retinopathy by HbA1c only.

Strong correlation and high comparability of capillary electrophoresis and three different methods for HbA1c measurement in a population without hemoglobinopathy

The present study aimed to investigate the comparability of capillary electrophoresis (CE) and three different methods for HbA1c measurement. The 270 whole blood samples with normal hemoglobin profiles were analyzed for HbA1c values by the Roche turbidimetric inhibition immunoassay (TINIA), the Mindray enzymatic assay (EA), the Arkray high-performance liquid chromatography (HPLC) in comparison with the Sebia CE. The within-laboratory coefficient of variation of all four methods was within the accepted goal (<2%), showing good performance of all of these methods. Pairwise comparisons of HbA1c values obtained by CE and other methods were determined in both total group and subgroups (HbA1c levels of <6.5%, 6.5-8% and >8%). Mean differences of HbA1c values in all groups were very small in which the mean HbA1c value measured by EA was lower while those by TINIA and HPLC were higher than that of CE. The majority of different values were within the limits of agreement in Bland-Altman analysis, indicating good agreement between CE and the others. Less than 5% of percentage differences were out of the total allowable error limit in all groups, showing that differences of HbA1c values between CE and other methods were not clinically significant. Pairwise comparisons of HbA1c values of CE and the others in Passing-Bablok regression and Spearman rank correlation studies displayed high concordance and strong correlation in all groups. In conclusion, the present study showed strong correlation, high comparability and consistent results for HbA1c measurement between capillary electrophoresis and the other three different methods.

Association of pancreatic fat content with type II diabetes mellitus. Clin Radiol. 2020;75:51-56. [PMID: 31711639 DOI: 10.1016/j.crad.2019.05.027]

AIM

To determine the association between regional fat content in the pancreas and the presence or absence of type II diabetes mellitus (T2DM), the value of regional pancreatic fat quantification in identifying patients at risk of T2DM, and whether pancreatic fat content is associated with glycaemic control in T2DM.

MATERIALS AND METHODS

A retrospective survey of a radiology database identified 45 patients with T2DM, and 81 "at risk for T2DM" patients who developed diabetes, between 0.6 and 3.7 years after magnetic resonance imaging (MRI). A control group who did not develop diabetes during a 5-year follow-up and without known metabolic syndrome, liver, or pancreatic diseases were also identified. Fat content was measured by placing regions of interest (ROIs) on in-phase and out-of-phase chemical shift MRI images. Multiple clinical parameters including body mass index, cholesterol levels, blood pressure, glycated haemoglobin (HbA1c; in T2DM group) were collected.

RESULTS

There was a significant difference between the T2DM and control groups for fat fraction in the pancreatic head (p=0.043), body (p=0.015), and tail (p=0.001), but not liver (p=0.107). On regression analysis, only the fat fraction within the pancreatic tail was significantly different between control group and "at risk" for T2DM group (p=0.007). A pancreatic tail fat content of >10% had a sensitivity of 45.5% and specificity of 81.3% for predicting development of T2DM within 4 years. Pancreatic fat content was not associated with glycaemic control.

CONCLUSIONS

Increased fat in the pancreatic tail may identify patients at risk for T2DM.

Sleeve Gastrectomy Reversed Obesity-Induced Hypogonadism in a Rat Model by Regulating Inflammatory Responses in the Hypothalamus and Testis

BACKGROUND

Obesity is a metabolic disease with a serious health burden in children and adults, and it induces a variety of conditions including subfecundity. Sleeve gastrectomy showed encouraging results in terms of weight loss and improve quality of life, and this study aimed to determine whether sleeve gastrectomy could reverse obesity-induced impaired fertility in male Sprague-Dawley rats.

METHODS

After 16 weeks of a chow diet (CD) or a high-fat diet (HFD) challenge, rats on the HFD were given a sleeve gastrectomy or sham operation and then fed an HFD for another 8 weeks. Serum glucose, insulin, lipids, sex hormone, sperm quality, inflammatory profile of the testis, and hypothalamic Kiss1 expression in the three study groups were compared.

RESULTS

Sleeve gastrectomy significantly decreased HFD-induced obesity and serum glucose and insulin levels. It also reversed the HFD-induced increase in teratozoospermia and decreases in sperm motility and progressive motility. Testicular morphological abnormalities were also improved after sleeve gastrectomy. Enzyme-linked immunosorbent assay showed that the expression of sex hormones increased after sleeve gastrectomy and that expression of inflammatory factors decreased. The HFD induced a hypothalamic inflammatory response that inhibited Kiss1 expression, which in turn mediated sex hormone expression. Sleeve gastrectomy treatment improved the hypothalamic response.

CONCLUSIONS

The results consistently showed that sleeve gastrectomy reversed obesity-induced male fertility impairment by decreasing the inflammatory responses of the testis and hypothalamus.

HbA1c and retinal sensitivity in diabetics using microperimetry

PURPOSE

The purpose of this study was to determine the relationship between HbA1c values and retinal sensitivity at central 10° using the MP-1 microperimeter.

METHODS

A prospective study was carried out on 32 healthy subjects (control group) and 60 diabetic patients. The diabetic patients were divided into 2 groups. Group 1 comprised of 30 patients without diabetic retinopathy (DR) and group 2 had 30 patients with mild non-proliferative DR. A full-threshold microperimetry of the central 10° of retina (the macula) was performed on all subjects, utilizing 32 points with the MP-1. The relationship between light sensitivity and HbA1c value was calculated using linear regression analysis.

RESULTS

Total mean sensitivity at 10° for group 1 without DR, group 2 with mild NPDR and control group were 18.67±0.83, 17.98±1.42 and 19.45±0.34 (dB), respectively. There was a significant difference in total mean retinal sensitivity at 10° between the 3 groups (F(2,89)=18.14, p=0.001). A simple linear regression was calculated to predict HbA1c based on retinal sensitivity. A significant regression equation was found (F(1,90)=107.61, p=0.0001, with an R² of 0.545). The linear regression analysis revealed that there was a 0.64dB decline in mean retinal sensitivity within the central 10° diameter with an increase of 1mmHg of HbA1c.

CONCLUSION

Retinal sensitivity at the central 10° of the macula is affected by changes in HbA1c values.

Hypertriglyceridemia and Its Association with HbA1c Test: A Prospective In Vivo Controlled Study

BACKGROUND

Hypertriglyceridemia and hyperglycemia coexist in 30-60% of patients with diabetes. The impact of hypertriglyceridemia regarding HbA1c assay reliability remains uncertain. Therefore, we conducted a prospective in vivo controlled study with the aim of defining the association between triglyceride levels and HbA1c.

METHODS

A total of 44 patients with an index-hospital admission diagnosis of diabetic ketoacidosis or hypertriglyceridemia-induced pancreatitis, as a model for acute elevation of triglycerides, were recruited. Blood samples were drawn for the measurement of HbA1c, triglycerides, glucose, and hemoglobin at baseline and subsequently 24 and 48 hours after admission. HbA1c analysis was performed with high-performance liquid chromatography Bio-Rad D10 (NGSP approved).

RESULTS

All patients completed the study protocol. A difference between mean triglycerides from day 0 (baseline) to day 2 of 1567.2 mg/dL was observed. We found a difference between mean serum HbA1c from days 0 to 2 of 0.09% [1 mmol/mol] (p = 0.004). Moreover, a weak correlation between the mean difference of HbA1c and triglycerides from baseline to day 2 was found to be statistically significant (r = 0.256, p = 0.015). None of these findings, however, are clinically significant.

CONCLUSION

Triglycerides do not impair the interpretation of HbA1c assay. Patients and clinicians can now be confident that hypertriglyceridemia is not an important factor when interpreting HbA1c results.

Managing patients with prediabetes and type 2 diabetes after coronary events: individual tailoring needed - a cross-sectional study

BACKGROUND

Understanding the determinants associated with prediabetes and type 2 diabetes in coronary patients may help to individualize treatment and modelling interventions. We sought to identify sociodemographic, medical and psychosocial factors associated with normal blood glucose (HbA1c < 5.7%), prediabetes (HbA1c 5.7-6.4%), and type 2 diabetes.

METHODS

A cross-sectional explorative study applied regression analyses to investigate the factors associated with glycaemic status and control (HbA_1c level) in 1083 patients with myocardial infarction and/or a coronary revascularization procedure. Data were collected from hospital records at the index event and from a self-report questionnaire and clinical examination with blood samples at 2-36 months follow-up.

RESULTS

In all, 23% had type 2 diabetes, 44% had prediabetes, and 33% had normal blood glucose at follow-up. In adjusted analyses, type 2 diabetes was associated with larger waist circumference (Odds Ratio 1.03 per 1.0 cm, p = 0.001), hypertension (Odds Ratio 2.7, p < 0.001), lower high-density lipoprotein cholesterol (Odds Ratio 0.3 per1.0 mmol/L, p = 0.002) and insomnia (Odds Ratio 2.0, p = 0.002). In adjusted analyses, prediabetes was associated with smoking (Odds Ratio 3.3, p = 0.001), hypertension (Odds Ratio 1.5, p = 0.03), and non-participation in cardiac rehabilitation (Odds Ratio 1.7, p = 0.003). In patients with type 2 diabetes, a higher HbA_1c level was associated with ethnic minority background (standardized beta [β] 0.19, p = 0.005) and low drug adherence (β 0.17, p = 0.01). In patients with prediabetes or normal blood glucose, a higher HbA_1c was associated with larger waist circumference (β 0.13, p < 0.001), smoking (β 0.18, p < 0.001), hypertension (β 0.08, p = 0.04), older age (β 0.16, p < 0.001), and non-participation in cardiac rehabilitation (β 0.11, p = 0.005).

CONCLUSIONS

Along with obesity and hypertension, insomnia and low drug adherence were the major modifiable factors associated with type 2 diabetes, whereas smoking and non-participation in cardiac rehabilitation were the factors associated with prediabetes. Further research on the effect of individual tailoring, addressing the reported significant predictors of failure, is needed to improve glycaemic control.

TRIAL REGISTRATION

Retrospectively registered at ClinicalTrials.gov: NCT02309255 , December 5th 2014.

Optimal cutoff values of fasting plasma glucose (FPG) variability for detecting retinopathy and the threshold of FPG levels for predicting the risk of retinopathy in type 2 diabetes: A longitudinal study over 27 years

AIMS

To determine the cutoff values of fasting plasma glucose (FPG) variability for detecting retinopathy and examine the threshold of FPG levels for predicting retinopathy incidence in type 2 diabetes.

METHODS

Subjects comprised 170 patients with type 2 diabetes who had no retinopathy at their first visit, and continuously visited thereafter for 27 years. Retinopathy was evaluated by ophthalmologists at least annually.

RESULTS

114 patients developed retinopathy. 46 of them had advanced retinopathy. The optimal cutoff values of intrapersonal mean and standard deviation (SD) of FPG over 27 years and intrapersonal mean HbA1c from the initial measurement to the last visit for detecting retinopathy were 7.4 mmol/L, 1.4 mmol/L, and 7.2% (56 mmol/mol), respectively. Similarly, for advanced retinopathy, 7.7 mmol/L, 1.9 mmol/L, and 7.5% (59 mmol/mol), respectively. Hazard ratios of deciles of intrapersonal mean FPG (mmol/L) during the initial 2 years for retinopathy incidence significantly increased from eighth-decile (6.9-7.4), and were sharply elevated from ninth-decile (7.4-8.7).

CONCLUSIONS

Our study provides new cutoff values for FPG variability. Cutoff values of FPG and HbA1c were slightly higher than recommended targets of the current guideline. The threshold of FPG levels (6.9 mmol/L) is proposed to predict retinopathy incidence during the subsequent 25 years.

Hemoglobin A1c and diagnosis of diabetes

The prevalence of diabetes is increasing markedly worldwide, especially in China. Hemoglobin A1c is an indicator of mean blood glucose concentrations and plays an important role in the assessment of glucose control and cardiovascular risk. In 2010, the American Diabetes Association included HbA1c ≥6.5% into the revised criteria for the diagnosis of diabetes. However, the debate as to whether HbA1c should be used to diagnose diabetes is far from being settled and there are still unanswered questions regarding the cut-off value of HbA1c for diabetes diagnosis in different populations and ethnicities. This review briefly introduces the history of HbA1c from discovery to diabetes diagnosis, key steps towards using HbA1c to diagnose diabetes, such as standardization of HbA1c measurements and controversies regarding HbA1c cut-off points, and the performance of HbA1c compared with glucose measurements in the diagnosis of diabetes.

Ethnic dependent differences in diagnostic accuracy of glycated hemoglobin (HbA1c) in Canadian adults

AIM

Previous studies have shown varying sensitivity and specificity of hemoglobin A1c (HbA1c) to identify diabetes and prediabetes, compared to 2-h oral glucose tolerance testing (OGTT) and fasting plasma glucose (FPG), in different ethnic groups. Within the Canadian population, the ability of HbA1c to identify prediabetes and diabetes in First Nations, Métis and Inuit, East and South Asian ethnic groups has yet to be determined.

METHODS

We collected demographic, lifestyle information, biochemical results of glycemic status (FPG, OGTT, and HbA1c) from an ethnically diverse Canadian population sample, which included a purposeful sampling of First Nations, Métis, Inuit, South Asian and East Asian participants.

RESULTS

Sensitivity and specificity using Canadian Diabetes Association (CDA) recommended cut-points varied between ethnic groups, with greater variability for identification of prediabetes than diabetes. Dysglycemia (prediabetes and diabetes) was identified with a sensitivity and specificity ranging from 47.1% to 87.5%, respectively in Caucasians to 24.1% and 88.8% in Inuit. Optimal HbA1c ethnic-specific cut-points for dysglycemia and diabetes were determined by receiver operating characteristic (ROC) curve analysis.

CONCLUSIONS

Our sample showed broad differences in the ability of HbA1c to identify dysglycemia or diabetes in different ethnic groups. Optimal cut-points for dysglycemia or diabetes in all ethnic groups were substantially lower than CDA recommendations. Utilization of HbA1c as the sole biochemical diagnostic marker may produce varying degrees of false negative results depending on the ethnicity of screened individuals. Further research is necessary to identify and validate optimal ethnic specific cut-points used for diabetic screening in the Canadian population.

The accuracy of a non-invasive glucose monitoring device does not depend on clinical characteristics of people with type 2 diabetes mellitus

Objective: GlucoTrack is a non-invasive device that indirectly measures glucose fluctuation in the earlobe tissue. Thus, its accuracy may be subjected to a time lag between glucose concentration in blood and tissue. This time lag was shown to depend on individual characteristics related to microvascular complications, such as diabetes duration, HbA1c level, and smoking history. Therefore, the current study investigated the effects of these factors on GlucoTrack performance. Research design and methods: Clinical trials were conducted on 114 people with type 2 diabetes. Device performance was clinically evaluated using Clarke error grid (CEG) analysis and numerically evaluated using the distribution of absolute relative difference (ARD) values. Results: CEG analysis revealed that 98.0% of glucose readings were within the clinically acceptable CEG A + B zones. Total mean ARD was 22.7%. Clinical and numerical accuracies were comparable between never smokers and former/current smokers, but slightly reduced in the HbA1c ≥ 7.5% group and in the diabetes duration ≥15 years group. Yet, likelihood ratio and parametric bootstrap tests statistically demonstrated that ARD values did not depend on diabetes duration, HbA1c level, or smoking history. Conclusions: GlucoTrack performance does not depend on diabetes duration, HbA1c level, and smoking history, indicating the device is suitable for various people with type 2 diabetes.

Low association between fasting and OGTT stimulated glucose levels with HbA1c in overweight children and adolescents

BACKGROUND

Diabetes and prediabetes are defined based on different methods such as fasting glucose, glucose at 2-hour in oral glucose tolerance test (OGTT), and glycated hemoglobin A1c (HbA1c). These parameters probably describe different deteriorations in glucose metabolism limiting the exchange between each other in definitions of diabetes.

OBJECTIVE

To investigate the relationship between OGTT and HbA1c in overweight and obese children and adolescents living in Germany.

METHODS

Study population: Overweight and obese children and adolescents (n = 4848; 2668 female) aged 7 to 17 years without known diabetes. The study population was stratified into the following subgroups: normal glucose tolerance, prediabetes, diabetes according to OGTT and/or HbA1c categories, confirmed diagnosis of diabetes.

RESULTS

In the entire study group fasting plasma glucose (FPG) correlated weakly to 2-hour glucose (r = 0.26), FPG correlated weakly to HbA1c (r = 0.18), and 2-hour glucose correlated weakly to HbA1c (r = 0.17, all P < .001). Patients with confirmed diabetes showed a very high correlation between FPG and 2-hour glucose (r = 0.73, n = 50). Moderate correlations could be found for patients with impaired fasting glucose (2-hour glucose vs HbA1c: r = 0.30, n = 436), for patients with diabetes according to OGTT and/or HbA1c (FPG vs 2-hour glucose: r = 0.43; 2-hour glucose vs HbA1c: r = -0.30, n = 115) and for patients with confirmed diabetes (2-hour glucose vs HbA1c: r = -0.47, all P < .001).

CONCLUSIONS

Because FPG, 2-hour glucose, and HbA1c correlated only weakly we propose that these parameters, particularly in the normal range, might reflect distinct aspects of carbohydrate metabolism.

Neuropathy-specific alterations in a Mexican population of diabetic patients

Background

Neuropathy is one of the major complications of type 2 diabetes mellitus. Our first aim was to determine the clinical characteristics of a population of diabetic patients with different types of neuropathy. Our next goal was to characterize the cytokine profile (IL-6 and IL-10), nerve growth factor (NGF) and circulating cell-adhesion molecules in these patients. Finally, we aimed to compare the renal function among the groups of neuropathic patients.

Methods

In a cross-sectional study, we included 217 diabetic patients classified in three groups: sensory polyneuropathy with hypoesthesia (DS_hP) or hyperesthesia (DS_HP), and motor neuropathy (DMN). Two control groups were included: one of 26 diabetic non-neuropathic patients (DNN), and the other of 375 non-diabetic (ND) healthy subjects. The participants were attending to the Mexican Institute of Social Security.

Results

The circulating levels of NGF were significantly lower in diabetic patients, compared to healthy subjects. The range of IL-6 and IL-10 levels in neuropathic patients was higher than the control groups; however, several samples yielded null measurements. Neuropathic patients also showed increased circulating levels of the adhesion molecules ICAM, VCAM, and E-Selectin, compared to the ND group. Moreover, neuropathic patients showed reduced glomerular filtration rates compared to healthy subjects (82–103 ml/min per 1.73 m², data as range from 25th–75th percentiles), especially in the group with DMN (45–76 ml/min per 1.73 m²).

Conclusions

Some particular alterations in neuropathic patients included -but were not limited to- changes in circulating NGF, cell adhesion molecules, inflammation, and the worsening of the renal function. This study supports the need for further clinical surveillance and interventions considering a neuropathy-related basis.

Electronic supplementary material

The online version of this article (doi:10.1186/s12883-017-0939-6) contains supplementary material, which is available to authorized users.

Glycated Hemoglobin, Albuminuria and Surrogate Markers of Macrovascular Disease in Adults Without Diabetes: The Guangzhou Biobank Cohort Study, Cardiovascular Disease Subcohort

OBJECTIVES

To explore the clinical utility of glycated hemoglobin (A1C) levels as an early marker of albuminuria, macrovascular disease and subclinical cardiovascular disease in comparison to fasting and postprandial glucose levels in a well-characterized Chinese population with no history of diabetes.

METHODS

The study population consisted of 1223 individuals who were enrolled in the Guangzhou Biobank Cohort Study, Cardiovascular Disease Subcohort, and who had undergone oral glucose tolerance tests. The associations between each glycemic measure and albuminuria, carotid intima-media thickness (CIMT) and CIMT-based presence of carotid plaques and aortic arch calcification were assessed by chest radiographs.

RESULTS

The overall prevalence of albuminuria, carotid plaque and any aortic arch calcification was 20.6%, 22.8% and 25.8%, respectively. All 3 glycemia indices were significantly associated with albuminuria, but only 1 (fasting glucose) was associated with carotid plaques. No significant difference was detected among them in the area under the curve for albuminuria (chi-square test; p=0.84), carotid plaques (p=0.28) or calcifications (p=0.29). In sensitivity analysis, adjusted for age and sex, the above findings remained unchanged.

CONCLUSIONS

Although there was evidence suggesting differential associations, the performance of the glycemic indices was similar, and their association with macrovascular disease and albuminuria was modest.

Does Baseline Hemoglobin A1c Level Predict Diabetic Foot Ulcer Outcome or Wound Healing Time?

BACKGROUND

We sought to evaluate the relationship between baseline hemoglobin A_1c (HbA_1c) level and clinical outcomes, including foot ulcer outcome (resolved versus unresolved) and wound-healing time, in individuals with type 2 diabetes.

METHODS

A prospective observational study was conducted on 99 patients presenting with a diabetic foot ulceration. Patient and ulcer characteristics were recorded. Patients were followed up for a maximum of 1 year.

RESULTS

After 1 year of follow-up, 77% of ulcers healed and 23% did not heal. Although this study demonstrated that the baseline HbA_1c reading was not a significant predictor of foot ulcer outcome (P = .603, resolved versus amputated), on further statistical analyses, when HbA_1c was compared with the time taken for complete ulcer healing in the resolved group (n = 77), it proved to be significant (P = .009).

CONCLUSIONS

These findings have important implications for clinical practice, especially in an outpatient setting. Improving glycemic control may improve ulcer outcomes. Prediction of outcome may be helpful for health-care professionals in individualizing and optimizing clinical assessment and management of patients. Identification of determinants of outcome could result in improved health outcomes, improved quality of life, and fewer diabetes-related foot complications.

HbA1c in relation to incident diabetes and diabetes-related complications in non-diabetic adults at baseline

AIMS

We compared the utility of glycated hemoglobin (HbA_1c) and oral glucose tolerance (oGTT) in non-diabetic patients for identifying incident diabetes; all-cause mortality; cardiovascular disease (CVD) mortality; CVD, coronary heart disease (CHD), and ischemic stroke events; and diabetes microvascular complications.

METHODS

Data from a New Zealand community setting were prospectively linked to hospitalization, mortality, pharmaceutical and laboratory test results data. After applying exclusion criteria (prior laboratory diagnosis or history of drug treatment for diabetes or hospitalization for diabetes or CVD event), there were 31,148 adults who had an HbA_1c and 2-h 75g oGTT. HbA_1c was measured by ion-exchange high-performance liquid chromatography, and glucose using a commercial enzymatic method. We compared glycemic measures and outcomes using multivariable Cox proportional hazards regression.

RESULTS

The median follow-up time was 4years (range 0 to 13). The mean age was 57·6years and 53·0% were male. After adjusting for other glycemic measures (fasting glucose, 2-h glucose and/or HbA_1c where relevant) in addition to age, sex, ethnicity and smoking habit, the hazard ratios for incident diabetes and diabetes complications of retinopathy and nephropathy were highest for 2-h glucose levels, followed by HbA_1c and lastly by fasting glucose. However, all-cause mortality and CHD were significantly associated with HbA_1c concentrations only, and ischemic stroke and CVD events with 2-h glucose only. Circulatory complications showed a stronger association with HbA_1c.

CONCLUSION

Apart from neuropathy, HbA_1c showed stronger associations with outcomes compared to fasting glucose and provides a convenient alternative to an oGTT.

Diabetes diagnostic thresholds of the glycated hemoglobin A1c and fasting plasma glucose levels considering the 5-year incidence of retinopathy

AIMS

As retinopathy is used as a defining threshold of diabetes, we assessed the glycated hemoglobin A1c (HbA1c) and fasting plasma glucose (FPG) values associated with an increased risk of 5-year incidence of retinopathy.

METHODS

We studied HbA1c, FPG, and optic fundus findings of 2605 individuals without previously diagnosed diabetes annually during a 5-year period. Retinopathy was examined using non-mydriatic, 45° digital fundus photography. Baseline levels were stratified as <5.3 [34], 5.3-5.6 [34-38], 5.7-6.0 [39-42], 6.1-6.4 [43-47], and ⩾6.5% [48mmol/mol] for HbA1c and <5.0, 5.0-5.5, 5.6-6.0, 6.1-6.9, and ⩾7.0mmol/L for FPG. Cox proportional hazard models were used to analyze hazard ratios (HRs) associated with HbA1c or FPG for incident retinopathy.

RESULTS

During a total of 11845 person-years, we identified 50 (1.9%) cases of incident retinopathy. The adjusted HRs for incident retinopathy associated with a one-standard deviation increase in HbA1c and FPG were 1.2 (95% confidence intervals: 1.1-1.4) and 1.2 (1.1-1.4), respectively. These HRs were significantly higher for a HbA1c level ⩾6.5% (48mmol/mol) (3.4 [1.1-10.2]) or FPG level ⩾7.0mmol/L (3.6 [1.1-11.6]) than for a HbA1c level <5.3% (34mmol/mol) or FPG level <5.0mmol/L.

CONCLUSIONS

A HbA1c value of 6.5% (48mmol/mol) and FPG value of 7.0mmol/L might be proper as diabetes diagnostic thresholds that indicate a high risk of future retinopathy.

Evidence for current diagnostic criteria of diabetes mellitus

Diabetes mellitus is a non-communicable metabolic derangement afflicting several millions of individuals globally. It is associated with several micro and macrovascular complications and is also a leading cause of mortality. The unresolved issue is that of definition of the diagnostic threshold for diabetes. The World Health Organization and the American Diabetes Association (ADA) have laid down several diagnostic criteria for diagnosing diabetes and prediabetes based on the accumulating body of evidence.This review has attempted to analyse the scientific evidence supporting the justification of these differing criteria. The evidence for diagnosing diabetes is strong, and there is a concordance between the two professional bodies. The controversy arises when describing the normal lower limit of fasting plasma glucose (FPG) with little evidence favouring the reduction of the FPG by the ADA. Several studies have also shown the development of complications specific for diabetes in patients with prediabetes as defined by the current criteria though there is a significant overlap of such prevalence in individuals with normoglycemia. Large multinational longitudinal prospective studies involving subjects without diabetes and retinopathy at baseline will ideally help identify the threshold of glycemic measurements for future development of diabetes and its complications.

Prevalence of diabetic retinopathy in screening-detected diabetes mellitus: results from the Gutenberg Health Study (GHS)

AIMS/HYPOTHESIS

Individuals with type 2 diabetes mellitus may experience an asymptomatic period of hyperglycaemia, and complications may already be present at the time of diagnosis. We aimed to determine the prevalence of diabetic retinopathy in patients with newly diagnosed (screening-detected) type 2 diabetes.

METHODS

The Gutenberg Health Study is a population-based study with 15,010 participants aged between 35 and 74 years. We determined the weighted prevalence of diabetic retinopathy by assessing fundus photographs. Screening-detected type 2 diabetes was defined as an HbA1c concentration of 6.5% (47.5 mmol/mol) or more, no medical diagnosis of diabetes and no intake of insulin or oral glucose-lowering agents.

RESULTS

Of 14,948 participants, 1377 (9.2%) had diabetes mellitus. Of these, 347 (25.2%) had newly diagnosed type 2 diabetes detected by the screening. Overall, the weighted prevalence of screening-detected type 2 diabetes was 2.1%. Fundus photos were evaluable for 285 (82.1%) participants with newly diagnosed diabetes. The weighted prevalence of diabetic retinopathy in screening-detected type 2 diabetes was 13.0%; 12% of participants had a mild non-proliferative diabetic retinopathy and 0.6% had a moderate non-proliferative diabetic retinopathy. Diabetic retinopathy was proliferative in 0.3%. No cases of severe non-proliferative diabetic retinopathy or diabetic maculopathy were found. Thirty (14.9%) of 202 and six (7.2%) of 83 individuals with and without concomitant arterial hypertension, respectively, had diabetic retinopathy (OR 2.54, 95% CI 1.06, 7.14). Visual acuity did not differ between individuals with and without diabetic retinopathy .

CONCLUSIONS/INTERPRETATION

In this large European study, the prevalence of diabetic retinopathy in screening-detected type 2 diabetes was 13%. Only a very small proportion of participants with detected diabetic retinopathy needed treatment.

Glycosylated Hemoglobin Threshold for Predicting Diabetes and Prediabetes from the Fifth Korea National Health and Nutrition Examination Survey

We aimed to estimate the threshold level of glycosylated hemoglobin (HbA1c) for the fasting plasma glucose of 100 and 126 mg/dL in the Korean adult population, using the 2011 Korea National Health and Nutrition Examination Survey. A total of 4,481 participants over 19 years of age without diabetic medications and conditions to influence the interpretation of HbA1c levels, such as anemia, renal insufficiency, liver cirrhosis, and cancers, were analyzed. A point-wise area under the receiver operating characteristic curve was used to estimate the optimal HbA1c cutoff value. A HbA1c threshold of 6.35% was optimal for predicting diabetes with a sensitivity of 86.9% and a specificity of 99.1%. Furthermore, the threshold of HbA1c was 5.65% for prediabetes, with a sensitivity of 69.3% and a specificity of 71%. Further prospective studies are needed to evaluate the HbA1c cutoff point for diagnosing prediabetes and diabetes in the Korean population.

Glycaemic control status among type 2 diabetic patients and the role of their diabetes coping behaviours: a clinic-based study in Tripoli, Libya

BACKGROUND

Achieving good glycaemic control is important in diabetes management. However, poor glycaemic control is widely reported. This article assessed the prevalence of uncontrolled and poor glycaemic control among Libyans with type 2 diabetes and examined the relative contribution of diabetes coping behaviours to their glycaemic control status.

METHODS

A cross-sectional study was undertaken in 2013 in a large diabetes centre in Tripoli. The study included 523 respondents. Diabetes coping behaviours were measured using the revised version of the Summary of Diabetes Self-Care Activities measure (SDSCA) and the eight-item Morisky Medication Adherence Scale (MMAS-8(©)), while glycaemic control status was based on the HbA1c level.

RESULTS

Mean HbA1c was 8.9 (±2.1), and of the 523 patients, only 114 (21.8%) attained the glycaemic control target of HbAc1 of less than 7.0%. Females (OR=1.74, 95% CI=1.03-2.91), patients on insulin and oral hypoglycaemic agents (OR=1.92, 95% CI=1.05-3.54), patients on insulin (OR=3.14, 95% CI=1.66-6.03), and low-medication adherents (OR=2.25, 95% CI=1.36-3.73) were more likely to have uncontrolled and poor glycaemic control, while exercise contributed to glycaemic control status as a protective factor (OR=0.85, 95% CI=0.77-0.94).

CONCLUSION

The findings from this study showed the considerable burden of uncontrolled and poor glycaemic control in one of the largest diabetes care settings in Libya. Medication adherence as well as exercise promotion programs would help in reducing the magnitude of poor glycaemic control.

Obesity and glycemic control in patients with diabetes mellitus: Analysis of physician electronic health records in the US from 2009-2011

AIMS

Examine the association between obesity and glycemic control among patients with type 1 (T1DM) or type 2 diabetes mellitus (T2DM).

METHODS

Data from US physician electronic health records (Humedica®) from 2009-2011 were utilized. Patients were defined as having above-target glycemic control if they had an HbA1c ≥7% at any time during the study period. Multinomial logistic regressions were conducted separately for T1DM and T2DM patients, and examined associations between BMI categories and probability of having above-target glycemic control (≥7% and <8%, ≥8% and <9%, or ≥9%) while controlling for patient demographics, general health, comorbid conditions, and antihyperglycemic medication use.

RESULTS

There were 14,028 T1DM and 248,567 T2DM patients; 47.8% of T1DM and 63.4% of T2DM were obese (BMI ≥30kg/m(2)). For T1DM, being overweight (BMI 25-<30), obese class I (30-<35), II (35-<40), or III (≥40) was associated with a significantly higher probability of having HbA1c≥8% and <9% or ≥9%, while being overweight was associated with a significantly higher probability of having HbA1c ≥7% and <8% compared to normal BMI (BMI≥18.5 and<25). For T2DM patients, being overweight, obese class I, II, or III was associated with a significantly higher probability of having HbA1c ≥7% and <8%, ≥8% and <9%, or ≥9%.

CONCLUSIONS

For both T1DM and T2DM patients, there were positive and statistically significant associations between being overweight or obese and having suboptimal glycemic control. These findings quantify the associations between obesity and glycemic control, and highlight the potential importance of individual characteristics on glycemic control.