Discordance in the diagnosis of diabetes: Comparison between HbA1c and fasting plasma glucose

Integrating Bayesian Approaches and Expert Knowledge for Forecasting Continuous Glucose Monitoring Values in Type 2 Diabetes Mellitus

Precise and timely forecasting of blood glucose levels is essential for effective diabetes management. While extensive research has been conducted on Type 1 diabetes mellitus, Type 2 diabetes mellitus (T2DM) presents unique challenges due to its heterogeneity, underscoring the need for specialized blood glucose forecasting systems. This study introduces a novel blood glucose forecasting system, applied to a dataset of 100 patients from the ShanghaiT2DM study. Our study uniquely integrates knowledge-driven and data-driven approaches, leveraging expert knowledge to validate and interpret the relationships among diabetes-related variables and deploying the data-driven approach to provide accurate forecast blood glucose levels. The Bayesian network approach facilitates the analysis of dependencies among various diabetes-related variables, thus enabling the inference of continuous glucose monitoring (CGM) trajectories in similar individuals with T2DM. By incorporating past CGM data including inference CGM trajectories, dietary records, and individual-specific information, the Bayesian structural time series (BSTS) model effectively forecasts glucose levels across time intervals ranging from 15 to 60 minutes. Forecast results show a mean absolute error of mg/dL, a root mean square error of mg/dL, and a mean absolute percentage error of , for a 15-minute prediction horizon. This study makes the first application of the ShanghaiT2DM dataset for glucose level forecasting, considering the influences of diabetes-related variables. Its findings establish a foundational framework for developing personalized diabetes management strategies, potentially enhancing diabetes care through more accurate and timely interventions.

The effect of sarpogrelate compared to aspirin in high- or very-high-risk diabetes for primary prevention

The benefit of aspirin in primary prevention for atherosclerotic cardiovascular diseases (ASCVD) is questionable due to bleeding complications. We analyzed the Korean National Health Insurance data to compare the efficacy and overall bleeding of sarpogrelate, an antiplatelet agent with lower bleeding risk, versus aspirin in high-/very-high-risk diabetic populations without prior ASCVD. The primary endpoint was net adverse clinical events (NACE), defined as a composite of efficacy and overall bleeding. The efficacy was a composite of all-cause death, myocardial infarction (MI) and stroke, whereas overall bleeding included intracranial hemorrhage (ICH) and gastrointestinal (GI) bleeding. A total of 10,778 high-/very-high-risk diabetic patients (9550 on aspirin, 1228 on sarpogrelate) were analyzed. After propensity score matching, sarpogrelate was linked to a lower incidence of NACE (HR:0.71; 95% CI 0.57-0.88), mainly driven by 62% reductions in overall bleeding (0.38; 0.17-0.81), a composite of 64% and 72% lower rate of GI bleeding and ICH, respectively. Additionally, there was no significant differences in MI or stroke between groups. In high- or very-high-risk diabetic patients without ASCVD, sarpogrelate use was associated with net clinical benefit mainly due to the reduction of significant reduction in overall bleeding events.

Screening for Type 2 Diabetes Mellitus: A Systematic Review of Recent Economic Evaluations

OBJECTIVES

To examine recent economic evaluations and understand whether any type 2 diabetes mellitus (T2DM) screening designs may represent better value for money and to rate their methodological qualities.

METHODS

We systematically searched 3 concepts (economic evaluations [EEs], T2DM, screening) in 5 databases (Medline, Embase, EconLit, Web of Science, and Cochrane) for EEs published between 2010 and 2023. Two independent reviewers screened for and rated their methodological quality (using the Consensus on Health Economics Criteria Checklist-Extended).

RESULTS

Of 32 EEs, a majority were from high-income countries (69%). Half used single biomarkers (50%) to screen adults ≥30 to <60 years old (60%) but did not report locations (69%), treatments for those diagnosed (66%), diagnostic methods (57%), or screening intervals (54%). Compared with no screening, T2DM screening using single biomarkers was found to be not cost-effective (23/54 comparisons), inconclusive (16/54), dominant (11/54), or cost-effective (4/54). Compared with no screening, screening with a risk score and single biomarkers was found to be cost-effective (21/40) or dominant (19/40). The risk score alone was mostly dominant (6/10). Compared with universal screening, targeted screening among obese, overweight, or older people may be cost-effective or dominant. Compared with fasting plasma glucose or fasting capillary glucose, screening using risk scores was found to be mostly dominant or cost-effective. Expanding screening locations or lowering HbA1c or fasting plasma glucose thresholds was found to be dominant or cost-effective. Each EE had 4 to 17 items (median 13/20) on Consensus on Health Economics Criteria Checklist-Extended rated "Yes/Rather Yes."

CONCLUSIONS

EE findings varied based on screening tools, intervals, locations, minimum screening age, diagnostic methods, and treatment. Future EEs should more comprehensively report screening designs and evaluate T2DM screening in low-income countries.

Evidence-based screening, clinical care and health education recommendations for Alaska Native peoples with prediabetes living in southcentral Alaska: findings from the Alaska EARTH follow-up study

Pre-diabetes (pre-DM) is a strong predictor of diabetes (DM) over time. This study investigated how much of the recent increase in pre-DM identified among Alaska Native (AN) peoples living in urban southcentral Alaska may be due to changes in diagnostic methods. We used clinical and demographic data collected at baseline between 2004 and 2006 and at follow-up collected between 2015 and 2017 from the urban southcentral Alaska Education and Research Towards Health (EARTH) cohort. We used descriptive statistics and logistic regression to explore differences in demographic and clinical variables among the identified pre-DM groups. Of 388 participants in the follow-up study, 243 had A1c levels indicating pre-DM with only 20 demonstrating pre-DM also by fasting blood glucose (FBG). Current smoking was the sole predictor for pre-DM by A1c alone while abdominal obesity and elevated FBG-predicted pre-DM by A1c+FBG. No participants had an elevated FBG without an A1c elevation. A substantial portion of the rise in pre-DM found among urban southcentral AN peoples in the EARTH follow-up study was due to the addition of A1c testing. Pre-DM by A1c alone should be used to motivate behavioural changes that address modifiable risk factors, including smoking cessation, physical activity and weight management.

Routine measurement of cardiometabolic disease risk factors in primary care in England before, during, and after the COVID-19 pandemic: A population-based cohort study

BACKGROUND

This study estimated to what extent the number of measurements of cardiometabolic risk factors (e.g., blood pressure, cholesterol, glycated haemoglobin) were impacted by the COVID-19 pandemic and whether these have recovered to expected levels.

METHODS AND FINDINGS

A cohort of individuals aged ≥18 years in England with records in the primary care-COVID-19 General Practice Extraction Service Data for Pandemic Planning and Research (GDPPR) were identified. Their records of 12 risk factor measurements were extracted between November 2018 and March 2024. Number of measurements per 1,000 individuals were calculated by age group, sex, ethnicity, and area deprivation quintile. The observed number of measurements were compared to a composite expectation band, derived as the union of the 95% confidence intervals of 2 estimates: (1) a projected trend based on data prior to the COVID-19 pandemic; and (2) an assumed stable trend from before pandemic. Point estimates were calculated as the mid-point of the expectation band. A cohort of 49,303,410 individuals aged ≥18 years were included. There was sharp drop in all measurements in March 2020 to February 2022, but overall recovered to the expected levels during March 2022 to February 2023 except for blood pressure, which had prolonged recovery. In March 2023 to March 2024, blood pressure measurements were below expectation by 16% (-19 per 1,000) overall, in people aged 18 to 39 (-23%; -18 per 1,000), 60 to 79 (-17%; -27 per 1,000), and ≥80 (-31%; -57 per 1,000). There was suggestion that recovery in blood pressure measurements was socioeconomically patterned. The second most deprived quintile had the highest deviation (-20%; -23 per 1,000) from expectation compared to least deprived quintile (-13%; -15 per 1,000).

CONCLUSIONS

There was a substantial reduction in routine measurements of cardiometabolic risk factors following the COVID-19 pandemic, with variable recovery. The implications for missed diagnoses, worse prognosis, and health inequality are a concern.

Risk of new-onset diabetes and efficacy of pharmacological weight loss therapy

AIMS

To develop a clinical risk model to identify individuals at higher risk of developing new-onset diabetes and who might benefit more from weight loss pharmacotherapy.

MATERIALS AND METHODS

A total of 21 143 patients without type 2 diabetes at baseline from two TIMI clinical trials of stable cardiovascular patients were divided into a derivation (~2/3) and validation (~1/3) cohort. The primary outcome was new-onset diabetes. Twenty-seven candidate risk variables were considered, and variable selection was performed using multivariable Cox regression. The final model was evaluated for discrimination and calibration, and for its ability to identify patients who experienced a larger benefit from the weight loss medication lorcaserin in terms of risk of new-onset diabetes.

RESULTS

During a median (interquartile range) follow-up of 2.3 (1.8-2.7) years, new-onset diabetes occurred in 1013 patients (7.7%). The final model included five independent predictors (glycated haemoglobin, fasting glucose, age, body mass index, and triglycerides/high-density lipoprotein). The clinical risk model showed good discrimination (Harrell's C-indices 0.802, 95% confidence interval [CI] 0.788-0.817 and 0.807, 95% CI 0.788-0.826) in the derivation and validation cohorts. The calibration plot demonstrated adequate calibration (2.5-year area under the curve was 81.2 [79.1-83.5]). While hazard ratios for new-onset diabetes with a weight-loss therapy were comparable across risk groups (annual risks of <1%, 1%-5%, and >5%), there was a sixfold gradient in absolute risk reduction from lowest to highest risk group (p = 0.027).

CONCLUSIONS

The developed clinical risk model effectively predicts new-onset diabetes, with potential implications for personalized patient care and therapeutic decision making.

Associations of fasting plasma glucose and glycosylated hemoglobin levels at less than 24 weeks of gestation with hypertensive disorders of pregnancy: the BOSHI study

This study aimed to evaluate the associations of fasting plasma glucose (FPG) and glycosylated hemoglobin (HbA1c) levels at <24 weeks of gestation with hypertensive disorders of pregnancy (HDP) and compare the strengths of the associations of HDP with FPG and HbA1c levels. Totally, 1,178 participants were included in this prospective cohort study. HDP, FPG, HbA1c, and potential confounding factors were included in multiple logistic regression models. The number of HDP cases was 136 (11.5%). When FPG and HbA1c were included in the model separately, quartile 4 (Q4) of FPG (87-125 mg/dL) and HbA1c (5.2-6.3% [33-45 mmol/mol]) levels had higher odds of HDP than quartile 1. The odds ratios (ORs) were 1.334 (95% confidence interval [CI]: 1.002-1.775) for Q4 of FPG and 1.405 (95% CI: 1.051-1.878) for Q4 of HbA1c. When the participants were divided into two categories based on the cut-off value with the maximum Youden Index of FPG or HbA1c, the ORs for high FPG (≥84 mg/dL) or high HbA1c (≥5.2% [33 mmol/mol]) were 1.223 (95% CI: 1.000-1.496) and 1.392 (95% CI: 1.122-1.728), respectively. When both FPG and HbA1c were included in the model simultaneously, the statistical significance of Q4 of FPG disappeared, whereas that of HbA1c remained. In two-category models, the same results were obtained. High FPG and HbA1c levels at <24 weeks of gestation were risk factors for HDP in pregnant Japanese women. In addition, high HbA1c levels were more strongly associated with HDP than high FPG levels.

Objective Analysis of Traditional Chinese Medicine Syndrome Differentiation of Patients With Diabetes and Prediabetes: Protocol for a Nonrandomized, Exploratory, Observational Case-Control Study Using Digitalized Traditional Chinese Medicine Diagnostic Tools

BACKGROUND

Diabetes and prediabetes are diagnosed differentially by Western and Chinese medicine. While Western medicine uses objective laboratory analysis of biochemical parameters to define the severity of diabetes and prediabetes, Chinese medicine uses a comprehensive approach that integrates observation, inquiry, pulse palpation, and tongue diagnosis. The medical information collected is then categorized into different syndromes. However, traditional methods of pulse and tongue diagnoses used to determine syndrome differentiation are highly subjective and skill dependent.

OBJECTIVE

This study aims to identify the gap in conventional traditional Chinese medicine (TCM) diagnostic techniques for syndrome differentiation analysis using contemporary diagnostic devices. We devised a protocol for a nonrandomized, exploratory, observational case-control study with equal allocations in 5 arms to investigate the syndrome differentiation of diabetes and prediabetes. We hypothesize that the TCM syndrome differentiation of diabetes and prediabetes in the tropical climate may differ from that defined based on the Chinese demographic. We also speculate that the high-frequency spectral energy may reflect a difference in pulse wave intensity and density between the healthy and diabetes groups.

METHODS

A total of 250 eligible participants will be equally assigned to 1 of 5 arms (healthy or subhealthy, prediabetes, diabetes, prediabetes with hypertension and dyslipidemia, and diabetes with hypertension and dyslipidemia). Participants aged 21-75 years, of any sex or race, and have been diagnosed with diabetes (fasting plasma glucose [FPG] of 7 mmol/L, or 2-hour plasma glucose [2hPG] of 11.1 mmol/L) or prediabetes (impaired FPG of 6.1-6.9 mmol/L, or impaired glucose tolerance with an 2hPG of 7.8-11 mmol/L) will be included. The Health Evaluation Questionnaire, Physical Activity Questionnaire, sugar intake assessment, Constitution in Chinese Medicine Questionnaire, radial pulse diagnosis, and tongue diagnosis will be performed in a single visit. ANOVA for continuous data and chi-square tests of independence will be used for categorical data assessments, with a level of P<.05 considered significant.

RESULTS

The recruitment is in progress. We anticipate that the study will conclude in June 2025. As of July 15, 2024, we have enrolled 140 individuals.

CONCLUSIONS

To the best of our knowledge, this is the first study to use contemporary TCM diagnostic instruments to map expert and empirical knowledge of TCM to its scientific equivalents for the purpose of evaluating the syndrome differentiation of diabetes. We designed this protocol with the exploratory goal to examine objectively the syndrome differentiation of patients with diabetes and those with prediabetes using TCM diagnostic technologies. The data collected and evaluated under standardized conditions using these contemporary diagnostic devices will exhibit a higher degree of stability, hence yielding dependable and unbiased results for syndrome differentiation. Thus, our findings may potentially increase the accuracy of identification, diagnosis, treatment, and prevention of diabetes and prediabetes through a system of targeted treatment.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05563090; https://clinicaltrials.gov/ct2/show/NCT05563090.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/56024.

Nonrestorative Sleep and Type 2 Diabetes Incidence: The Aichi Workers' Cohort Study

BACKGROUND

The term "nonrestorative sleep (NRS)" refers to an unrefreshed feeling at wake-up and is a domain of poor sleep quality. Previous research has demonstrated that NRS is linked to a number of diseases and adverse health outcomes, but less is known regarding the link between NRS and diabetes, particularly in Japanese.

METHODS

We studied 3,665 middle-aged male participants of the Aichi Workers' Cohort Study who were followed-up from 2002 through 2019. Cox proportional hazards models estimated hazard ratios (HRs) and 95% confidence intervals (CIs) of incident type 2 diabetes mellitus (T2DM) in relation to NRS adjusted for potential confounding variables.

RESULTS

During a median follow-up of 14.6 years, 421 type 2 diabetes cases were identified. Participants with NRS had a higher crude incidence rate of T2DM (11.2/1,000 person-years), compared to participants without NRS (9.3/1,000 person-years). In the fully adjusted model, individuals who reported having NRS had a significantly higher risk of developing T2DM (HR1.36; 95% CI, 1.10-1.67). The association was observed only in participants under 50 years old (HR 1.82; 95% CI, 1.36-2.43), not in the older (50 years or older) participants (P for interaction = 0.025). In contrast, stratified analyses by the presence of shift work, obesity, or sleep duration showed similar associations in all the strata.

CONCLUSION

NRS was associated with higher risk of T2DM in middle-aged Japanese male workers independent of a variety of lifestyle factors and other sleep problems.

Mitochondrial Biomarkers and Metabolic Syndrome in Bipolar Disorder

The object of this study is test whether mitochondrial blood-based biomarkers are associated with markers of metabolic syndrome in bipolar disorder, hypothesizing higher lactate but unchanged cell-free circulating mitochondrial DNA levels in bipolar disorder patients with metabolic syndrome. In a cohort study, primary testing from the FondaMental Advanced Centers of Expertise for bipolar disorder (FACE-BD) was conducted, including 837 stable bipolar disorder patients. The I-GIVE validation cohort consists of 237 participants: stable and acute bipolar patients, non-psychiatric controls, and acute schizophrenia patients. Multivariable regression analyses show significant lactate association with triglycerides, fasting glucose and systolic and diastolic blood pressure. Significantly higher levels of lactate were associated with presence of metabolic syndrome after adjusting for potential confounding factors. Mitochondrial-targeted metabolomics identified distinct metabolite profiles in patients with lactate presence and metabolic syndrome, differing from those without lactate changes but with metabolic syndrome. Circulating cell-free mitochondrial DNA was not associated with metabolic syndrome. This thorough analysis mitochondrial biomarkers indicate the associations with lactate and metabolic syndrome, while showing the mitochondrial metabolites can further stratify metabolic profiles in patients with BD. This study is relevant to improve the identification and stratification of bipolar patients with metabolic syndrome and provide potential personalized-therapeutic opportunities.

Oral Semaglutide in Type 2 Diabetes: Clinical-Metabolic Outcomes and Quality of Life in Real-World Practice

Background: Glucagon-like peptide-1 receptor agonists (GLP-1 RAs) are a novel class of incretin mimetics for treating type 2 diabetes (T2D). This study evaluated the impact of semaglutide, the first oral GLP-1RA, on glycated hemoglobin (HbA1c), fasting plasma glucose (FPG), and body composition and anthropometric parameters. Additionally, the effects on cardiovascular risk factors and quality of life (QoL) in T2D patients were assessed. Methods: A prospective observational study with a six-month follow-up was conducted. Clinical parameters, including HbA1c, FPG, anthropometric measurements, blood pressure, cardiovascular risk factors, Diabetes Treatment Satisfaction Questionnaire (DTSQ) responses, and Short Form (36) Health Survey (SF-36) responses, were collected at baseline (T0) and at six months (T1). Results: Sixty-one subjects were enrolled, with there being an average T2D duration of 4.67 ± 3.93 years. Significant decreases were observed in HbA1c (µ = -1.24; SD = 1.33; p < 0.05), FPG (µ = -31.01 mg/dL; SD = 41.71; p < 0.05), body composition and anthropometric parameters (p < 0.05), and cardiovascular risk factors (p < 0.05), with an increase in DTSQ scores (p < 0.05). Conclusions: The administration of 14 mg/day oral semaglutide improved several clinical parameters after six months of treatment. These findings suggest semaglutide is effective in improving glycemic control, weight management, and some cardiovascular risk factors in T2D patients.

Continuous Glucose Monitoring for Prediabetes: What Are the Best Metrics?

BACKGROUND

Continuous glucose monitoring (CGM) has transformed the care of type 1 and type 2 diabetes, and there is potential for CGM to also become influential in prediabetes identification and management. However, to date, we do not have any consensus guidelines or high-quality evidence to guide CGM goals and metrics for use in prediabetes.

METHODS

We searched PubMed for all English-language articles on CGM use in nonpregnant adults with prediabetes published by November 1, 2023. We excluded any articles that included subjects with type 1 diabetes or who were known to be at risk for type 1 diabetes due to positive islet autoantibodies.

RESULTS

Based on the limited data available, we suggest possible CGM metrics to be used for individuals with prediabetes. We also explore the role that glycemic variability (GV) plays in the transition from normoglycemia to prediabetes.

CONCLUSIONS

Glycemic variability indices beyond the standard deviation and coefficient of variation are emerging as prominent identifiers of early dysglycemia. One GV index in particular, the mean amplitude of glycemic excursion (MAGE), may play a key future role in CGM metrics for prediabetes and is highlighted in this review.

Possible Causal Association between Type 2 Diabetes and Glycaemic Traits in Primary Open-Angle Glaucoma: A Two-Sample Mendelian Randomisation Study

Existing literature suggests a controversial relationship between type 2 diabetes mellitus (T2D) and glaucoma. This study aimed to examine the potential causal connection between T2D and glycaemic traits (fasting glucose [FG] and glycated haemoglobin [HbA1c] levels) as exposures to primary open-angle glaucoma (POAG) in multi-ethnic populations. Single-nucleotide polymorphisms associated with exposure to T2D, FG, and HbA1c were selected as instrumental variables with significance (p < 5.0 × 10-8) from the genome-wide association study (GWAS)-based meta-analysis data available from the BioBank Japan and the UK Biobank (UKB). The GWAS for POAG was obtained from the meta-analyses of Genetic Epidemiology Research in Adult Health and Aging and the UKB. A two-sample Mendelian randomisation (MR) study was performed to assess the causal estimates using the inverse-variance weighted (IVW) method, and MR-Pleiotropy Residual Sum and Outlier test (MR-PRESSO). Significant causal associations of T2D (odds ratio [OR] = 1.05, 95% confidence interval [CI] = [1.00-1.10], p = 0.031 in IVW; OR = 1.06, 95% CI = [1.01-1.11], p = 0.017 in MR-PRESSO) and FG levels (OR = 1.19, 95% CI = [1.02-1.38], p = 0.026 in IVW; OR = 1.17, 95% CI = [1.01-1.35], p = 0.041 in MR-PRESSO) with POAG were observed, but not in HbA1c (all p > 0.05). The potential causal relationship between T2D or FG and POAG highlights its role in the prevention of POAG. Further investigation is necessary to authenticate these findings.

Metabolic syndrome, its components, and gastrointestinal cancer risk: a meta-analysis of 31 prospective cohorts and Mendelian randomization study

BACKGROUND AND AIM

Cohort studies have linked metabolic syndrome (MetS) to gastrointestinal (GI) cancer risk. We aimed to evaluate the associations between MetS, its components, and combinations of MetS components with eight GI cancers risk.

METHODS

We conducted a systematic search of prospective cohort studies and performed a meta-analysis. Subgroup analyses regarding diagnostic criteria, sex, cancer sites, histological subtypes, ethnic groups, and studies adjusted for alcohol consumption were carried out. Mendelian randomization (MR) was employed to evaluate the causality between 17 MetS-related traits and eight GI cancers among Europeans and Asians separately.

RESULTS

Meta-analyses of 31 prospective studies indicated that MetS was significantly associated with an increased risk of colorectal cancer (CRC) (RR [95% CI] = 1.13 [1.12-1.15]), esophageal cancer (EC) (RR [95% CI] = 1.17 [1.03-1.32]), gallbladder cancer (GBC) (RR [95% CI] = 1.37[1.10-1.71]), liver cancer (LC) (RR [95% CI] = 1.46 [1.29-1.64]), and pancreatic cancer (PaC) (RR [95% CI] = 1.25 [1.20-1.30]), but not gastric cancer (GC) (RR [95% CI] = 1.11 [0.96-1.28]). Regarding the associations between MetS components and GI cancers risk, the following associations showed statistical significance: obesity-CRC/LC/EC/, hypertriglyceridemia-LC/PaC, reduced high-density lipoprotein (HDL)-CRC/LC/GC/PaC, hyperglycemia-CRC/LC/PaC, and hypertension-CRC/LC/EC/PaC. Sex-specific associations were observed between individual MetS components on GI cancers risk. Among the top three common combinations in both sexes, obesity + HTN + hyperglycemia had the strongest association with CRC risk (RR [95% CI] = 1.54 [1.49-1.61] for males and 1.27 [1.21-1.33] for females). MR analyses revealed causality in 16 exposure-outcome pairs: waist-to-hip ratio/BMI/HbA1c-CRC; BMI/childhood obesity/waist circumference/T2DM/glucose-EC; BMI/waist circumference/cholesterol-LC; cholesterol/childhood obesity/waist circumference/HbA1c-PaC; and HbA1c-GBC. These results were robust against sensitivity analyses.

CONCLUSIONS

Since MetS is reversible, lifestyle changes or medical interventions targeting MetS patients might be potential prevention strategies for GI cancers.

Early detection of type 2 diabetes risk: limitations of current diagnostic criteria

Type 2 diabetes (T2D) is the leading cause of diabetes worldwide and is increasing rapidly, especially in youth. It accounts for most diabetes deaths in adults ≥20 years old in the Americas, with type 2 diabetes responsible for most of the disease burden. The incidence and burden of type 2 diabetes in adolescents and young adults have risen in recent decades globally. Countries with lower socioeconomic status had the highest incidence and burden, and females generally had higher mortality and disease burden than males at ages <30 years. Early diagnosis and management are crucial to delaying progression, but current diagnostic criteria based on glucose thresholds and glycated hemoglobin have limitations. Recent analyses show that prediabetes increases cancer risk. Better diagnostic criteria are urgently needed to identify high-risk individuals earlier. This article discusses the limitations of current criteria and explores alternative approaches and future research directions.

Causal relationships between type 2 diabetes, glycemic traits and keratoconus

Purpose

The relationship between diabetes mellitus and keratoconus remains controversial. This study aimed to assess the potential causal relationships among type 2 diabetes, glycemic traits, and the risk of keratoconus.

Methods

We used a two-sample Mendelian randomization (MR) design based on genome-wide association summary statistics. Fasting glucose, proinsulin levels, adiponectin, hemoglobin A1c (HbA1c) and type 2 diabetes with and without body mass index (BMI) adjustment were used as exposures and keratoconus was used as the outcome. MR analysis was performed using the inverse-variance weighted method, MR-Egger regression method, weighted-mode method, weighted median method and the MR-pleiotropy residual sum and outlier test (PRESSO).

Results

Results showed that genetically predicted lower fasting glucose were significantly associated with a higher risk of keratoconus [IVW: odds ratio (OR) = 0.382; 95% confidence interval (CI) = 0.261-0.560; p = 8.162 × 10-7]. Genetically predicted lower proinsulin levels were potentially linked to a higher risk of keratoconus (IVW: OR = 0.739; 95% CI = 0.568-0.963; p = 0.025). In addition, genetically predicted type 2 diabetes negatively correlated with keratoconus (IVW: BMI-unadjusted: OR = 0.869; 95% CI = 0.775-0.974, p = 0.016; BMI-adjusted: OR = 0.880, 95% CI = 0.789-0.982, p = 0.022). These associations were further corroborated by the evidence from all sensitivity analyses.

Conclusion

These findings provide genetic evidence that higher fasting glucose levels are associated with a lower risk of keratoconus. However, further studies are required to confirmed this hypothesis and to understand the mechanisms underlying this putative causative relationship.

Global variation in diabetes diagnosis and prevalence based on fasting glucose and hemoglobin A1c

Fasting plasma glucose (FPG) and hemoglobin A1c (HbA1c) are both used to diagnose diabetes, but these measurements can identify different people as having diabetes. We used data from 117 population-based studies and quantified, in different world regions, the prevalence of diagnosed diabetes, and whether those who were previously undiagnosed and detected as having diabetes in survey screening, had elevated FPG, HbA1c or both. We developed prediction equations for estimating the probability that a person without previously diagnosed diabetes, and at a specific level of FPG, had elevated HbA1c, and vice versa. The age-standardized proportion of diabetes that was previously undiagnosed and detected in survey screening ranged from 30% in the high-income western region to 66% in south Asia. Among those with screen-detected diabetes with either test, the age-standardized proportion who had elevated levels of both FPG and HbA1c was 29-39% across regions; the remainder had discordant elevation of FPG or HbA1c. In most low- and middle-income regions, isolated elevated HbA1c was more common than isolated elevated FPG. In these regions, the use of FPG alone may delay diabetes diagnosis and underestimate diabetes prevalence. Our prediction equations help allocate finite resources for measuring HbA1c to reduce the global shortfall in diabetes diagnosis and surveillance.

Strikes and Gutters: Biomarkers and anthropometric measures for predicting diagnosed diabetes mellitus in adults in low- and middle-income countries

The management of diabetes necessitates the requirement of reliable health indices, specifically biomarkers and anthropometric measures, to detect the presence or absence of the disease. Nevertheless, limited robust empirical evidence exists regarding the optimal metrics for predicting diabetes in adults, particularly within low- and middle-income countries. This study investigates objective and subjective indices for screening diabetes in these countries.

METHODS

Data for this study was sourced from surveys conducted among adults (aged 18 years and above) in seventeen (17) countries. Self-reported diabetes status, fifty-four biomarkers, and twenty-six core and twenty-eight estimated anthropometric indices, including weight, waist circumference, body mass index, glycaemic triglycerides, and fasting blood glucose, were utilised to construct lasso regression models.

RESULTS

The study revealed variances in diabetes prediction outcomes across different countries. Central adiposity measures, fasting plasma glucose and glycaemic triglycerides demonstrated superior predictive capabilities for diabetes when compared to body mass index. Furthermore, fasting plasma or blood glucose, serving as a biomarker, emerged as the most accurate predictor of diabetes.

CONCLUSIONS

These findings offer critical insights into both general and context-specific tools for diabetes screening. The study proposes that fasting plasma glucose and central adiposity indices should be considered as routine screening tools for diabetes, both in policy interventions and clinical practice. By identifying adults with or at higher risk of developing diabetes and implementing appropriate interventions, these screening tools possess the potential to mitigate diabetes-related complications in low- and middle-income countries.

Sick and depressed? The causal impact of a diabetes diagnosis on depression

BACKGROUND

There is sparse evidence on the impact of health information on mental health as well as on the mechanisms governing this relationship. We estimate the causal impact of health information on mental health via the effect of a diabetes diagnosis on depression.

METHODS

We employ a fuzzy regression discontinuity design (RDD) exploiting the exogenous cut-off value of a biomarker used to diagnose type-2 diabetes (glycated haemoglobin, HbA1c) and information on psycometrically validated measures of diagnosed clinical depression drawn from rich administrative longitudinal individual-level data from a large municipality in Spain. This approach allows estimating the causal impact of a type-2 diabetes diagnosis on clinica ldepression.

RESULTS

We find that overall a type-2 diabetes diagnosis increases the probability of becoming depressed, however this effect appears to be driven mostly by women, and in particular those who are relatively younger and obese. Results also appear to differ by changes in lifestyle induced by the diabetes diagnosis: while women who did not lose weight are more likely to develop depression, men who did lose weight present a reduced probability of being depressed. Results are robust to alternative parametric and non-parametric specifications and placebo tests.

CONCLUSIONS

The study provides novel empirical evidence on the causal impact of health information on mental health, shedding light on gender-based differences in such effects and potential mechanisms through changes in lifestyle behaviours.

The triglyceride glucose-waist-to-height ratio outperforms obesity and other triglyceride-related parameters in detecting prediabetes in normal-weight Qatari adults: A cross-sectional study

INTRODUCTION

The triglyceride-glucose (TyG)-driven indices, incorporating obesity indices, have been proposed as reliable markers of insulin resistance and related comorbidities such as diabetes. This study evaluated the effectiveness of these indices in detecting prediabetes in normal-weight individuals from a Middle Eastern population.

METHODS

Using the data of 5,996 adult Qatari participants from the Qatar Biobank cohort, we employed adjusted logistic regression to assess the ability of various obesity and triglyceride-related indices to detect prediabetes in normal-weight (18.5 ≤ BMI <25 kg/m2) adults (≥18 years).

RESULTS

Of the normal-weight adults, 13.62% had prediabetes. TyG-waist-to-height ratio (TyG-WHTR) was significantly associated with prediabetes among normal-weight men [OR per 1-SD 2.68; 95% CI (1.67-4.32)] and women [OR per 1-SD 2.82; 95% CI (1.61-4.94)]. Compared with other indices, TyG-WHTR had the highest area under the curve (AUC) value for prediabetes in men [AUC: 0.76, 95% CI (0.70-0.81)] and women [AUC: 0.73, 95% CI (0.66-0.80)], and performed significantly higher than other indices (p < 0.05) in detecting prediabetes in men. Tyg-WHTR shared similar diagnostic values as fasting plasma glucose (FPG).

DISCUSSION

Our findings suggest that the TyG-WHTR index could be a better indicator of prediabetes for general clinical usage in normal weight Qatari adult men than other obesity and TyG-related indices. TyG-WHTR can help identify a person's risk for developing prediabetes in both men and women when combined with FPG results.

Discordance Between Glucose Management Indicator and Glycated Hemoglobin in People Without Diabetes

Background: In recent years, continuous glucose monitor (CGM) use is increasing in people without diabetes to promote healthy lifestyle. CGM metrics such as glucose management indicator (GMI), a statistical formula to estimate glycated hemoglobin (HbA1c) from sensor glucose, is commonly used to approximate HbA1c. This study was aimed to evaluate discordance between GMI and HbA1c in people without diabetes. Methods: Children and nonpregnant adults (age ≥6 years) without diabetes (laboratory HbA1c <5.7% and negative islet antibodies) were invited to participate in a multicenter prospective study aimed to evaluate glycemic profiles in nondiabetic individuals. Each participant wore a blinded Dexcom G6 for up to 10 days. GMI was calculated from mean sensor glucose and discordance between GMI and HbA1c was analyzed. Results: Of 201 screened participants, 153 participants (mean age 31.2 ± 21.0 years, 66.0% female, HbA1c 5.1% ± 0.3%) were included in the analysis. Mean GMI was 0.59% higher than laboratory HbA1c in participants without diabetes. The discordance between GMI and HbA1c of 0.4% or greater was 71% in participants without diabetes compared with 39% in the original GMI development cohort. Conclusion: GMI does not accurately estimate HbA1c in healthy people without diabetes. Clinical trial registration number is: NCT00717977.

Causal Relationships Between Glycemic Traits and Myopia

Purpose

Little is known about whether sugar intake is a risk factor for myopia, and the influence of glycemic control remains unclear, with inconsistent results reported. This study aimed to clarify this uncertainty by evaluating the link between multiple glycemic traits and myopia.

Methods

We employed a two-sample Mendelian randomization (MR) design using summary statistics from independent genome-wide association studies. A total of six glycemic traits, including adiponectin, body mass index, fasting blood glucose, fasting insulin, hemoglobin A1c (HbA1c), and proinsulin levels, were used as exposures, and myopia was used as the outcome. The inverse-variance-weighted (IVW) method was the main applied analytic tool and was complemented with comprehensive sensitivity analyses.

Results

Out of the six glycemic traits studied, we found that adiponectin was significantly associated with myopia. The genetically predicted level of adiponectin was consistently negatively associated with myopia incidence: IVW (odds ratio [OR] = 0.990; P = 2.66 × 10-3), MR Egger (OR = 0.983; P = 3.47 × 10-3), weighted median method (OR = 0.989; P = 0.01), and weighted mode method (OR = 0.987; P = 0.01). Evidence from all sensitivity analyses further supported these associations. In addition, a higher HbA1c level was associated with a greater risk of myopia: IVW (OR = 1.022; P = 3.06 × 10-5).

Conclusions

Genetic evidence shows that low adiponectin levels and high HbA1c are associated with an increased risk of myopia. Given that physical activity and sugar intake are controllable variables in blood glycemia treatment, these findings provide new insights into potential strategies to delay myopia onset.

Causal Effect of Higher Glycated Hemoglobin (HbA1c) Levels on Knee Osteoarthritis Risk: A Mendelian Randomization Study

INTRODUCTION

The association between diabetes mellitus (DM) and risk of osteoarthritis (OA) is inconsistent based on published observational studies. This study aimed to conduct a two-sample Mendelian randomization (MR) analysis to explore the causal link between glycated hemoglobin (HbA1c) level and OA risk.

METHODS

Genome-wide association studies (GWAS) summary statistics were obtained from the publicly available Integrative Epidemiology Unit (IEU) OpenGWAS database. A series of screening processes were performed to select qualified instrumental single-nucleotide polymorphisms (SNPs) strongly related to exposure. The inverse-variance-weighted method, weighted-median method, and MR-Egger method were performed to ensure robust and reliable results. The MR-Egger intercept test, Cochran's Q test, and the leave-one-out sensitivity analysis were utilized to assess the horizontal pleiotropy, heterogeneities, and stability of these genetic variants for OA. Odds ratio (OR) and 95% confidence interval (CI) were calculated.

RESULTS

MR analyses found a robust causal association of genetically determined HbA1c with knee OA (OR = 1.561; 95% CI 1.110-2.197; P = 0.011), but not with hip OA (OR = 1.073; 95% CI 0.674-1.710; P = 0.766) or overall OA (OR = 1.141; 95% CI 0.904-1.441; P = 0.804). Sensitivity analyses showed that there was a strong association between SNPs and HbA1c (F = 21.138), no evidence of heterogeneity (Q = 150.625, P = 0.402), and no potential SNPs affecting the causal link.

CONCLUSION

Our MR study supported a causal effect of genetically increased HbA1c on knee OA risk.

Longitudinal trends in glycated hemoglobin during and after tuberculosis treatment

AIMS

To investigate the impact of pulmonary TB on glycemic status during and after TB treatment, and associations of glycemic trends with antidiabetic therapy and TB outcomes.

METHODS

Data from two prospective cohort studies of adults in Chennai, India, with pulmonary TB were combined for this analysis. Participants were classified by baseline hemoglobin A1_c (A1C) as having normoglycemia (NG; n = 74), prediabetes (pre-DM; n = 110), or diabetes (DM; n = 244). Repeat A1C measurements were performed at TB treatment months 3 and 6, and then 6 and 12 months after TB treatment completion.

RESULTS

Median A1C at baseline declined after TB treatment initiation in all groups. No baseline NG or pre-DM participants progressed to DM by end of study, while 16.7% of baseline DM participants shifted to pre-DM or NG levels of A1C. In the baseline DM group, rising A1C after the intensive phase of TB treatment was significantly associated with adverse TB outcomes.

CONCLUSIONS

Incident TB promotes transient glucose elevation but was not conclusively shown to promote chronic dysglycemia. Rising A1C during and after TB treatment may predict unfavorable treatment response in persons presenting with A1C ≥ 6.5 % at the time of TB diagnosis.

Does health information affect lifestyle behaviours? The impact of a diabetes diagnosis

Despite an increasing interest in the effect of health information on health-behaviours, evidence on the causal impact of a diagnosis on lifestyle factors is still mixed and does not often account for long-term effects. We explore the role of health information in individual health-related decisions by identifying the causal impact of a type-2 diabetes diagnosis on body mass index (BMI) and lifestyle behaviours. We employ a fuzzy regression discontinuity design (RDD) exploiting the exogenous cut-off value in the diagnosis of type-2 diabetes provided by a biomarker (glycated haemoglobin) drawn from unique administrative longitudinal data from Spain. We find that following a type-2 diabetes diagnosis individuals appear to reduce their weight in the short-term. Differently from previous studies, we also provide evidence of statistically significant long-term impacts of a type-2 diabetes diagnosis on BMI up to three years from the diagnosis. We do not find perceivable effects of a type-2 diabetes diagnosis on quitting smoking or drinking. Overall, health information appears to have a sustained causal impact on weight reduction, a key lifestyle and risk factor among individuals with type-2 diabetes.

Diabetes Prevalence and Associated Risk Factors among Women in a Rural District of Nepal Using HbA1c as a Diagnostic Tool: A Population-Based Study

Given the scarcity of data on diabetes prevalence and associated risk factors among women in rural Nepal, we aimed to examine this, using glycated hemoglobin (HbA1c) as a diagnostic tool. A cross-sectional survey addressing reproductive health and non-communicable diseases was conducted in 2012–2013 among non-pregnant, married women in Bolde, a rural district of Nepal. HbA1c ≥ 6.5% (48 mmol/mol) was used as diagnostic criterion for diabetes, a cut-off of 7.0% (53 mmol/mol) was used to increase the specificity. HbA1c was measured in 757 women (17–86 years). The prevalence of diabetes and prediabetes was 13.5% and 38.5%, respectively. When using 7.0% as a cut-off, the prevalence of diabetes was 5.8%. Aging, intake of instant noodles and milk and vegetarian food (ns) were associated with increased risk for diabetes. Waist circumference was higher among women with diabetes, although not significant. The women were uneducated (87.6%), and only 12% had heard about diabetes. In conclusion, we observed a higher prevalence of diabetes and prediabetes than anticipated among rural, Nepalese women. The increased risk was mainly attributed to dietary factors. In contrast to most previous studies in Nepal, we used HbA1c as diagnostic criterion.

Metabolic Reprogramming of Innate Immune Cells as a Possible Source of New Therapeutic Approaches in Autoimmunity

Immune cells undergo different metabolic pathways or immunometabolisms to interact with various antigens. Immunometabolism links immunological and metabolic processes and is critical for innate and adaptive immunity. Although metabolic reprogramming is necessary for cell differentiation and proliferation, it may mediate the imbalance of immune homeostasis, leading to the pathogenesis and development of some diseases, such as autoimmune diseases. Here, we discuss the effects of metabolic changes in autoimmune diseases, exerted by the leading actors of innate immunity, and their role in autoimmunity pathogenesis, suggesting many immunotherapeutic approaches.

Discordance between Fasting Plasma Glucose (FPG) and HbA1c in Diagnosing Diabetes and Pre-diabetes in The Malaysian Cohort

OBJECTIVE

In this present study, we aim to evaluate the accuracy of the HbA1c relative to fasting plasma glucose (FPG) in the diagnosis of diabetes and pre-diabetes among The Malaysian Cohort (TMC) participants.

METHODOLOGY

FPG and HbA1c were taken from 40,667 eligible TMC participants that have no previous history of diabetes, aged between 35-70 years and were recruited from 2006 - 2012. Participants were classified as normal, diabetes and pre-diabetes based on the 2006 World Health Organization (WHO) criteria. Statistical analyses were performed using ANOVA and Chi-square test, while Pearson correlation and Cohen's kappa were used to examine the concordance rate between FPG and HbA1c.

RESULTS

The study samples consisted of 16,224 men and 24,443 women. The prevalence of diabetes among the participants was 5.7% and 7.5% according to the FPG and HbA1c level, respectively. Based on FPG, 10.6% of the participants had pre-diabetes but this increased to 14.2% based on HbA1c (r=0.86; P<0.001). HbA1c had a sensitivity of 58.20 (95% CI: 56.43, 59.96) and a specificity of 98.59 (95% CI: 98.46, 98.70).

CONCLUSION

A higher prevalence of pre-diabetes and diabetes was observed when using HbA1c as a diagnosis tool, suggesting that it could possibly be more useful for early detection. However, given that HbA1c may also have lower sensitivity and higher false positive rate, several diagnostic criteria should be used to diagnose diabetes accurately.

The effects of short term hyperglycemia on human red blood cells studied using Raman spectroscopy and optical trap

Management of postprandial hyperglycemia is important for preventing severe complications like cardiovascular disease in diabetes patients. The associated glycemic instability in postprandial hyperglycemia may also cause disorders in circulating red blood cells (RBCs). Therefore, effects of short-term hyperglycemic stress on RBCs such as occur in the postprandial condition, have been studied here ex vivo using single-cell Raman spectroscopy and optical trapping. RBCs incubated in high glucose containing media relevant to postprandial hyperglycemia were studied for changes with respect to controls by analyzing the single-cell Raman spectra acquired with Raman optical tweezers with 532 nm excitation light. Use of 532 nm light for exciting Raman spectra also results in simultaneous photoreduction of intracellular hemoglobin (Hb). The level of photoreduction was noticed to be limited in hyperglycemia-exposed cells in comparison to the control. Since this suggests formation of permanently oxidized Hb in hyperglycemia-exposed RBCs, a fluorescence study was performed which showed elevated levels of oxidative stress in these cells. The changes in the RBC membrane, which may result due to higher levels of oxidative stress, were investigated using optical stretching experiments under the laser trap. The results indicated a loss of elasticity for the RBC membrane due to hyperglycemic exposure.

Investigating Health-Related Features and Their Impact on the Prediction of Diabetes Using Machine Learning

Diabetes Mellitus (DM) is one of the most common chronic diseases leading to severe health complications that may cause death. The disease influences individuals, community, and the government due to the continuous monitoring, lifelong commitment, and the cost of treatment. The World Health Organization (WHO) considers Saudi Arabia as one of the top 10 countries in diabetes prevalence across the world. Since most of its medical services are provided by the government, the cost of the treatment in terms of hospitals and clinical visits and lab tests represents a real burden due to the large scale of the disease. The ability to predict the diabetic status of a patient with only a handful of features can allow cost-effective, rapid, and widely-available screening of diabetes, thereby lessening the health and economic burden caused by diabetes alone. The goal of this paper is to investigate the prediction of diabetic patients and compare the role of HbA1c and FPG as input features. By using five different machine learning classifiers, and using feature elimination through feature permutation and hierarchical clustering, we established good performance for accuracy, precision, recall, and F1-score of the models on the dataset implying that our data or features are not bound to specific models. In addition, the consistent performance across all the evaluation metrics indicate that there was no trade-off or penalty among the evaluation metrics. Further analysis was performed on the data to identify the risk factors and their indirect impact on diabetes classification. Our analysis presented great agreement with the risk factors of diabetes and prediabetes stated by the American Diabetes Association (ADA) and other health institutions worldwide. We conclude that by performing analysis of the disease using selected features, important factors specific to the Saudi population can be identified, whose management can result in controlling the disease. We also provide some recommendations learned from this research.

Does autonomic nervous system dysfunction influence cardiovascular disease risk in young adults with intellectual disability?

People with intellectual disability (ID) experience cardiometabolic-related morbidity and mortality. However, it has been suggested that this population presents and lives with underestimated cardiovascular risk factors at a younger age, hence affecting their overall health and quality of life and contributing to early mortality. We assessed autonomic nervous system function in subjects with ID (n = 39), aged 18-45 yr, through measures of sudomotor function, heart rate and systolic blood pressure variability, and cardiac baroreflex function. Traditional clinical cardiovascular measurements and a biochemical analysis were also undertaken. We found that young adults with ID presented with sudomotor dysfunction, impaired cardiac baroreflex sensitivity, and systolic blood pressure variability, when compared with age-matched control subjects (n = 38). Reduced hand and feet electrochemical skin conductance and asymmetry were significantly associated with having a moderate-profound ID. Autonomic dysfunction in individuals with ID persisted after controlling for age, sex, and other metabolic parameters. Subjects in the ID group also showed significantly increased blood pressure, body mass index, and waist/hip circumference ratio, as well as increased plasma hemoglobin A1c and high-sensitivity C-reactive protein levels. We conclude that autonomic dysfunction is present in young adults with ID and is more marked in those with more severe disability. These finding have important implications in developing preventative strategies to reduce the risk of cardiovascular disease in people with ID.NEW & NOTEWORTHY Adults with intellectual disability experience higher risk of premature death than the general population. Our investigation highlights increased cardiovascular risk markers and autonomic dysfunction in young adults with intellectual disability compared with control adults. Autonomic dysfunction was more marked in those with a more severe disability but independent of cardiovascular parameters. Assessment of autonomic nervous system (ANS) function may provide insight into the mechanisms of cardiometabolic disease development and progression in young adults with intellectual disability.

Glycated hemoglobin (HbA1c) as diagnostic criteria for diabetes: the optimal cut-off points values for the Pakistani population; a study from second National Diabetes Survey of Pakistan (NDSP) 2016-2017

AIM

Glycated hemoglobin (HbA1c) cut-off values as diagnostic tool in diabetes and prediabetes with its concordance to oral glucose tolerance test (OGTT) in Pakistani population.

METHODOLOGY

Data for this substudy was obtained from second National Diabetes Survey of Pakistan (NDSP) 2016-2017. With this survey, 10 834 individuals were recruited and after excluding known subjects with diabetes, 6836 participants fulfilled inclusion criteria for this study. Demographic, anthropometric and biochemical parameters were obtained. OGTT was used as standard diagnostic tool to screen population and HbA1c for optimal cut-off values. Participants were categorized into normal glucose tolerance (NGT), newly diagnosed diabetes (NDD) and prediabetes.

RESULTS

Out of 6836 participants, 4690 (68.6%) had NGT, 1333 (19.5%) had prediabetes and 813 (11.9%) had NDD by OGTT criteria with median (IQR) age of 40 (31-50) years. Optimal HbA1c cut-off point for identification of diabetes and prediabetes was observed as 5.7% ((AUC (95% CI)=0.776 (0.757 to 0.795), p<0.0001)) and 5.1% ((AUC (95% CI)=0.607 (0.590 to 0.624), p<0.0001)), respectively. However, out of 68.6% NGT subjects identified through OGTT, 24.1% and 9.3% participants were found to have prediabetes and NDD, respectively by using HbA1c criteria. By using both OGTT and HbA1c criteria, only 7.9% and 7.3% were observed as prediabetes and diabetes, respectively.

CONCLUSION

Findings from second NDSP demonstrated disagreement between findings of OGTT and HbA1c as diagnostic tool for Pakistani population. As compared with international guidelines, HbA1c threshold for prediabetes and NDD were lower in this part of world. HbA1c as diagnostic tool might require ethnic or regional-based modification in cut-off points, validated by relevant community-based epidemiological surveys.

Plasma HbA1c in the investigation of suspected heart failure in general practice: An audit of the 2018 NICE guidelines update

Introduction:

Diabetes mellitus is a known risk factor for heart failure (HF); nevertheless, many HF patients remain undiagnosed. The National Institute for Health and Care Excellence in England updated their HF guidelines in 2018, replacing the use of fasting plasma glucose with glycated hemoglobin (HbA1c), in suspected HF investigation. This audit aimed to assess this update's uptake at a general practice partnership in Colchester, England.

Materials and Methods:

The audit cycle consisted of a two-round electronic record search, for approximately 29,000 patients registered at the partnership. From November 1, 2017 to November 1, 2018 for the first round and from November 1, 2018 to March 6, 2019 for the second round, patients who had their NT pro-brain natriuretic peptide levels measured for the initial investigation of suspected HF were included in the study. Interventions put in place after the first round included an oral presentation and an illustrated guide for the general practitioners (GPs).

Results:

One hundred and ten patients, 19 in cycle 1 and 91 in cycle 2, were identified and included in the analysis. At the first round, only 31.6% of the patients had their HbA1c level measured, while 36.8% had no diabetic investigation done. At the second round, the percentage of patients who had their HbA1c level assessed increased to 59.3%. A decrease from 36.8% of patients without diabetic status assessment to 20% was observed.

Conclusions:

Lack of awareness among GPs regarding this guideline update was identified and simple interventions achieved an increase in the guideline's uptake. Regular and complete audit cycles can help GPs adhere to up-to-date guidelines. Primary care can help other organizations such as pathology laboratories keep up to date with guidelines, while primary care technology can be amended in-house to help adherence to new guidelines. We recommend the National UK Heart Failure Audit considers auditing the use of HbA1c testing in inpatients investigated for new HF.

The ratio of fasting plasma glucose to hemoglobin A1c as a predictor of all-cause mortality in individuals with normal glucose levels: The Jichi Medical School cohort study

OBJECTIVES

The fasting plasma glucose/hemoglobin A1c ratio is considered a marker associated with glucose metabolism disorders, including fasting hyperglycemia. However, it remains unclear whether this ratio can be used for the prevention of deaths in individuals with normal fasting plasma glucose levels. This study aimed to see the predictive value of the fasting plasma glucose/hemoglobin A1c ratio for all-cause mortality in a general population with normal fasting plasma glucose levels.

METHODS

The study investigated prospectively a cohort of 1087 multi-regional, community-dwelling Japanese participants (women, 69.2%) for a follow-up period of 11.3 years. We included individuals with fasting plasma glucose levels <6.11 mmol/L and excluded those meeting the diabetes criteria. All-cause mortality was the primary outcome and hazard ratios were calculated using the Cox proportional hazard model after dividing the fasting plasma glucose/hemoglobin A1c ratios into tertiles.

RESULTS

There were 54 deaths (25 women) during the follow-up period. The high tertile group had a significantly higher hazard ratio for all-cause mortality than the low tertile group in women (multivariate-adjusted hazard ratio = 4.45; 95% confidence interval = 1.26-15.72), but not clearly in men.

CONCLUSION

The data of the population-based cohort study suggest that a high fasting plasma glucose/hemoglobin A1c ratio can predict all-cause mortality in women with normal fasting plasma glucose levels.

Prevalence of diabetes and pre-diabetes in rural Tehri Garhwal, India: influence of diagnostic method

Background

There are few available data regarding the prevalence of diabetes in the sub-Himalayan region of India. The aim of this study was to determine the prevalence of pre-diabetes and diabetes in rural Garhwal based on glycosylated hemoglobin.

Methods

In a cross-sectional survey of 500 adults from five randomly selected villages in Chamba, a mountainous Tehri Garhwal district in Uttarakhand in north-west India, we determined the prevalence of diabetes (hemoglobin (Hb) A_1c ≥ 6.5%) and pre-diabetes (5.7% ≤ HbA_1c ≤ 6.4%). In a sub-sample of those diagnosed with diabetes or pre-diabetes (n = 140), fasting blood glucose (FBG, n = 117) or postprandial blood glucose (PBG, n = 23), and blood hemoglobin concentration, was measured at follow-up.

Results

Based on HbA_1c, 10.0% had diabetes and 56.4% pre-diabetes. Of those diagnosed as diabetic by HbA_1c, 10 of 16 (62.5%) were diagnosed as diabetic by FBG (> 125 mg/dL) or PBG (≥200 mg/dL). In those diagnosed as pre-diabetic by HbA_1c, only 55 of 124 (44.4%) were diagnosed as pre-diabetic by FBG (100–125 mg/dL) or PBG (140–199 mg/dL). A large proportion of these 140 individuals (67.1%) were moderately to severely anemic (Hb < 11.4 mg/dL). The diagnostic gap for pre-diabetes between HbA_1c and FBG/PBG was similar for the groups with and without moderate to severe anemia.

Conclusions

HbA_1c and FBG/PBG have similar diagnostic performance for diabetes in this population. However, many individuals were diagnosed with pre-diabetes by HbA_1c but not FBG/PBG. The relative excess diagnosis of pre-diabetes with HbA_1c does not appear to be explained by anemia, an endemic condition in India. The prognostic significance of diagnosis of pre-diabetes by HbA_1c but not FBG/PBG remains unknown, but merits investigation.

Electronic supplementary material

The online version of this article (10.1186/s12889-019-7184-4) contains supplementary material, which is available to authorized users.

Does reviewing fasting plasma glucose results patterns before glycosylated hemoglobin testing in type-2 diabetic patients lead to better testing decision?

AIMS

Glycosylated hemoglobin (HbA_1c) test for blood glucose control in type-2 diabetic patients is recommended at least once annually under the guidelines of the Thai National Health Security Office (NHSO) benefits coverage. With limited resources and capability for HbA_1c testing in most primary-care providers, this study explored patterns of fasting plasma glucose (FPG) tests for proper timing of HbA_1c test would increase value of the money spent.

METHODS

A retrospective review of laboratory findings of 4906 type-2 diabetic outpatients in two university hospitals in Thailand was conducted. Percentages of discordant results between the indexed FPG and HbA_1c tests were compared between the patient groups with different FPG patterns before HbA_1c testing and the control group of randomly selected cases.

RESULTS

Having HbA_1c tested after two and three consecutively normal FPG tests (OO and OOO patterns) were found to have significantly less discordance than the control group (-9.6% and -15.7%). HbA_1c testing after two abnormal and one normal consecutive FPG tests (XXO pattern) gained the discordant results by 24.8%.

CONCLUSIONS

Some FPG patterns were more predictive of HbA_1c findings than focusing on one-time FPG results. Reviewing and recognizing certain patterns of FPGs prior to taking HbA_1c tests can lead to better HbA_1c testing decision than randomly prescribing the tests.

The association between fasting plasma glucose and glycated hemoglobin in the prediabetes range and future development of hypertension

Background

Prediabetes is a well-established risk factor for progression to overt diabetes mellitus (DM), which is in turn associated with development of hypertension (HTN) and vice versa. However, the role of prediabetes and HbA1c in particular as an independent risk factor for the development of hypertension is unclear.

Aim

In this current study, we aimed to evaluate the association between both fasting plasma glucose (FPG) and hemoglobin A1c (HbA1c) levels in the prediabetes range and development of HTN among a large cohort of normotensive subjects.

Design and methods

We investigated 5016 normotensive participants without DM and other cardiovascular risk factors who were annually screened in a tertiary medical center. Subjects were divided into normoglycemic and prediabetic groups. Normoglycemia was defined as HbA1c < 5.7% and FPG < 100 mg/dl. Prediabetes was defined according to the ADA criteria, i.e., 6.5% > HbA1c ≥ 5.7% or impaired fasting glucose (IFG):126 mg/dl > FPG ≥ 100 mg/dl. Subgroup analysis was made by dividing participants into four groups according to FPG and HbA1C levels, i.e., normoglycemia, impaired HbA1c only, IFG only, and both parameters impaired.

Results

During a follow-up of 3.7 ± 2.9 years, 318 (6.3%) subjects developed HTN. A cumulative hazard function for the development of hypertension showed a 2.89-fold ([95% CI 2.19–3.83], p < .0001) increased risk for HTN in the prediabetic population. In a multivariable Cox proportional hazard regression model adjusted to common confounding risk factors for HTN, prediabetes was found to be independently associated with a 1.95-fold ([95%, CI 1.43–2.52] p < .0001) increased risk for hypertension. Impaired HbA1C only was not found to be independently associated with HTN, while IFG only showed a 2.13-fold (95%, [CI 1.46–3.11] p < .0001) increased risk for HTN compared to normoglycemic, and a 2.55-fold ([95% CI 1.85–3.51] p < .0001) increased risk for HTN when both parameters impaired.

Conclusion

Our study demonstrates that FPG in the prediabetes range, albeit not glycated hemoglobin, is independently and significantly associated with future development of HTN. Therefore, our findings further highlight the pivotal predictive role of IFG for HTN development as opposed to the limited independent role of abnormal HbA1c levels.

Electronic supplementary material

The online version of this article (10.1186/s12933-019-0859-4) contains supplementary material, which is available to authorized users.

Postprandial Glucose Levels Are Better Associated with the Risk Factors for Diabetes Compared to Fasting Glucose and Glycosylated Hemoglobin (HbA1c) Levels in Elderly Prediabetics: Beneficial Effects of Polyherbal Supplements-A Randomized, Double-Blind, Placebo Controlled Trial

BACKGROUNDS

Prediabetes is a condition in which a person's blood glucose levels are higher than normal physiological levels but lower compared to patients with diabetes. Up to 70% of individuals with prediabetes will eventually develop diabetes. To date, there have been no pharmaceutical drugs to treat diabetes. It is believed that early diagnosis and nonpharmacological intervention for prediabetes are critical for effective prevention of diabetes. Most individuals with prediabetes remain undiagnosed even after being evaluated using the standard tests for fasting glucose (FG) and HbA1c. We investigated if postprandial glucose levels (2h-PG) were associated with pre/diabetes and if polyherbal supplements could be beneficial for individuals with prediabetes.

MATERIALS AND METHODS

100 elderly individuals with impaired 2h-PG or fasting glucose levels were recruited to receive either a 12-week supplement of GlucoVita (an antioxidative polyherbal formulation) (n=50) or placebo (n=50).

RESULTS

No baseline differences were observed for FG, HbA1c, or 2h-PG. Individuals who received a twelve-week administration of GlucoVita supplements had significantly reduced 2h-PG (8.15±1.67 versus 7.35±2.06 mmol/l, P<0.05) levels compared to individuals in the placebo group. In addition, HbA1c levels were lower in individuals who received GlucoVita (5.81±0.49 %) compared to the individuals in the placebo group (6.00±0.51%) (P=0.08) after 12-weeks. Stratified analysis, based on impaired fasting glucose (IFG), 2h-PG, metabolic symptom, and age, demonstrated that, after the 12-week intervention, HbA1c levels were significantly lower in the GlucoVita administered group compared to the placebo group (IFG subgroup; 5.85±0.46%, n= 27 versus 6.14±0.50, n=33, P<0.05) and the metabolic symptom-free subgroup (5.73±0.45%, n=23 versus 6.04±0.52%, n=24, P<0.05). GlucoVita also reduced FG in individuals with normal 2h-PG (6.37±0.27 versus 6.08±0.38 mmol/l, P<0.05). Baseline 2h-PG levels, but not HbA1c or FG levels, were significantly correlated with body weight, waist circumference, and BMI (r=0.25, P<0.05; r=0.31, P<0.01; r=0.22, P<0.05, respectively).

CONCLUSION

2h-PG levels were better associated with body weight, waist circumference, and BMI risk factors compared to FG and HbA1c levels in elderly individuals with prediabetes. Polyherbal formulation GlucoVita supplements improved 2h-PG and HbA1c levels only in elderly individuals who were overweight but were symptom-free and under 65 years of age. Due to the small cohort size of this pilot study, future studies are required to validate our findings.

The Irreplaceable Value of Laboratory Diagnostics: Four Recent Tests that have Revolutionized Clinical Practice

There is a common perception that laboratory medicine may be occasionally perceived as neglected discipline by clinicians, and that laboratory tests may be considered ordinary commodities. Although there is still debate on the real contribution of diagnostic testing in care pathways, many clinical diagnoses cannot be made without laboratory data. In support of evidence-based added value of laboratory diagnostics, this article aims to discuss the over-reaching contribution of some recent tests to the clinical decision making, and the unquestionable role they have played in revolutionizing clinical practice. These paradigmatic tests include highly-sensitive cardiac troponin immunoassays for diagnosing non-ST elevation myocardial infarction, hemoglobin A1c for diagnosis and therapeutic management of diabetes, procalcitonin for diagnosing severe bacterial infections and improving antibiotic stewardship, along with natriuretic peptides for early diagnosing and managing heart failure. It is advisable that altogether these paradigms will help reaffirming the vital role of laboratory medicine in modern healthcare.

Reactive oxygen species (ROS) in macrophage activation and function in diabetes

In a diabetic milieu high levels of reactive oxygen species (ROS) are induced. This contributes to the vascular complications of diabetes. Recent studies have shown that ROS formation is exacerbated in diabetic monocytes and macrophages due to a glycolytic metabolic shift. Macrophages are important players in the progression of diabetes and promote inflammation through the release of pro-inflammatory cytokines and proteases. Because ROS is an important mediator for the activation of pro-inflammatory signaling pathways, obesity and hyperglycemia-induced ROS production may favor induction of M1-like pro-inflammatory macrophages during diabetes onset and progression. ROS induces MAPK, STAT1, STAT6 and NFκB signaling, and interferes with macrophage differentiation via epigenetic (re)programming. Therefore, a comprehensive understanding of the impact of ROS on macrophage phenotype and function is needed in order to improve treatment of diabetes and its vascular complications. In the current comprehensive review, we dissect the role of ROS in macrophage polarization, and analyze how ROS production links metabolism and inflammation in diabetes and its complications. Finally, we discuss the contribution of ROS to the crosstalk between macrophages and endothelial cells in diabetic complications.