Screening for diabetes and pre-diabetes with proposed A1C-based diagnostic criteria

Short-term structured dietary and exercise interventions delay diabetes onset in prediabetic patients: a prospective quasi-experimental study

Hypothesis

Prediabetes indicates an increased risk of developing diabetes mellitus. We hypothesized that structured anti-inflammatory and antioxidant dietary and exercise interventions (SAIDEs) can reduce the onset of diabetes in prediabetic patients.

Methods

This study included 542 prediabetic patients who met at least one of the three common criteria for prediabetes: fasting blood glucose (FBG), 2-h oral glucose tolerance (2h OGTT), or hemoglobin A1c (HbA1C). Patients were randomly assigned to one of four groups using the block randomization method: routine community intervention, dietary intervention, exercise intervention, or SAIDEs for 6 months. Follow-up assessments were conducted at 6 months and 7.5 years, monitoring diabetes-related outcomes, inflammatory markers, and diabetes progression.

Results

At baseline, most tested variables, including age, gender, body weight, blood lipids, blood sugar, β-cell function, blood inflammatory and immunological markers, and energy intake, did not differ among the groups. After 6 months of short-term interventions (diet, exercise, and SAIDEs) and 6 months of follow-up, all intervention groups exhibited reduced total energy intake, body weight, blood pressure, blood cholesterol, and glucose levels, along with improved β-cell functions (all p < 0.001). Regardless of time considerations, intervention consistently increased total physical activity (p < 0.001). Short-term interventions also reduced blood IgE, high-sensitivity C-reactive protein, IL-6, and TNF-α, while increasing blood IL-4 and IL-10 (all p < 0.001). The prevalence of abnormal blood glucose markers-FBG, 2h OGTT, and HbA1C-significantly decreased within each intervention group after short-term intervention and 6 months of follow-up. The time-dependent Cox regression test did not indicate a significant effect of dietary or exercise intervention on diabetes incidence over the 8-year follow-up period. However, the log-rank test revealed significant differences in "survival" distribution among the four intervention groups (χ 2 = 15.63, p = 0.001). The mean survival time before diabetes onset was significantly longer in prediabetic patients who received SAIDEs than in those in other groups.

Conclusions

Short-term intervention with SAIDEs exhibited significant anti-inflammatory activity and reduced the prevalence of abnormal blood glucose markers. These benefits persisted even after 6 months of follow-up. However, over the 8-year follow-up period, intensive SAIDEs did not reduce diabetes incidence among prediabetic patients but did delay its onset.

Clinical trial registration

https://www.chictr.org.cn/searchproj.html, identifier ChiCTR-IOR-16008445.

Understanding the link between ALDH2 genotypes and diabetes

Introduction

The association between aldehyde dehydrogenase-2 (ALDH2) rs671 and diabetes remains controversial, with uncertainty about whether alcohol consumption or other factors mediate or modify this relationship. This study aimed to examine the ALDH2-diabetes association using standardized clinical criteria while systematically investigating potential confounding, mediating, and interacting factors in a community-based cohort.

Method

We analyzed baseline data from 4,535 participants in the China Cardiometabolic Disease and Cancer Cohort Study (4C study). Diabetes was diagnosed based on standardized clinical criteria, including fasting plasma glucose, 2-h postprandial glucose, glycosylated hemoglobin A1c (HbA1c), or documented prior diagnosis. We evaluated the association between ALDH2 rs671 and diabetes risk using both logistic and Cox regression models, with age as the time scale and adjustment for potential confounders. Comprehensive mediation and interaction analyses were performed to elucidate the underlying mechanisms.

Result

Among male participants, the ALDH2 rs671 GA/AA genotype was associated with a lower diabetes risk compared to the GG genotype after adjusting for alcohol consumption and other potential confounders (OR = 0.751, 95% CI: 0.567-0.995). Subgroup analyses revealed that this protective effect was most pronounced in individuals with BMI < 24 (OR = 0.651, 95% CI: 0.448-0.947), with significant interaction p-values of 0.024. In mediation analysis, abdominal adiposity accounted for 30.4% (95% CI: 10.0%-127.0%) of the ALDH2-diabetes association and BMI mediated 18.9% (95% CI: 4.8%-75.4%) of this relationship, while alcohol consumption showed no significant mediating effect (p = 0.56).

Conclusion

Our findings revealed that East Asian men with the ALDH2 GG genotype had an increased risk of diabetes compared to those with the GA/AA genotype, particularly among individuals with a BMI < 24. Interestingly, increased adiposity, especially abdominal fat, emerged as a potential mediator rather than alcohol consumption. Thus, individuals with the GG genotype, even with a relatively normal BMI, may benefit from regular moderate-intensity exercise and dietary interventions aimed at managing waist circumference.

Association between the haemoglobin glycation index (HGI) and clinical outcomes in patients with acute decompensated heart failure

BACKGROUND

A growing number of studies show that people with similar blood glucose levels have different levels of glycosylated haemoglobin (HbA1c), and relying only on HbA1c may lead to clinical decision-making errors. The haemoglobin glycation index (HGI) quantifies the difference in HbA1c among individuals and is strongly linked to the risk of cardiovascular disease. However, the connection between this phenomenon and the poor outcomes of patients with acute decompensated heart failure (ADHF) is currently unknown.

PATIENTS AND METHODS

This retrospective, single-centre-based cohort study included 1531 hospitalized patients with ADHF from September 2010 to January 2020. The HGI is calculated from the difference between the observed and predicted HbA1c values [predicted HbA1c = 0.024 × fasting plasma glucose (FPG) (mg/dL)+3.1]. The endpoints examined in the study included all-cause death, cardiovascular (CV) death, and major adverse cardiac events (MACE). We fitted multivariable-adjusted Cox proportional hazard models to investigate the association between the HGI and clinical outcomes.

RESULTS

During the five-year follow-up, 427 (27.9%) patients died from all causes, 232 (15.6%) from CV death, and 848 (55.4%) from MACE. The restricted cubic spline analysis also showed that the cumulative risk of all-cause and CV deaths decreased linearly with increasing HGI. According to multivariate Cox proportional hazard models, the highest tertile of the HGI was associated with a lower incidence of all-cause and cardiovascular deaths [all-cause death, adjusted hazard ratio (HR): 0.720, 95% confidence interval (CI): 0.563-0.921, p = 0.009; CV death, adjusted HR: 0.619, 95% CI: 0.445-0.861, p = 0.004]. A 1% increase in the HGI was associated with a 12.5% reduction in the risk of all-cause death and a 20.8% reduction in the risk of CV death.

CONCLUSIONS

A high HGI was directly associated with a reduction in all-cause and CV deaths but was not associated with MACE. These findings may be helpful in the management of patients with ADHF.

Impact of Dietary Niacin on Metabolic Dysfunction-Associated Steatotic Liver Disease in Mediterranean Subjects: A Population-Based Study

BACKGROUND

The impact of dietary niacin on metabolic dysfunction-associated steatotic liver disease (MASLD) is elusive. This sub-study aimed to investigate the relationship between dietary niacin intake and the presence of MASLD in participants from two Catalonian cohorts.

METHODS

A total of 222 subjects with MASLD were age- and sex-matched to 222 non-MASLD subjects. Dietary nutrients were analyzed using a validated food frequency questionnaire (FFQ). Dietary niacin and other nutrients were adjusted for total energy intake. MASLD was defined by a Fatty Liver Index (FLI) of >60 and by having at least one component of metabolic syndrome. The association between niacin intake (distributed into tertiles) and the presence of MASLD was assessed using multivariate logistic regression. Potential non-linear relationships were also analyzed through restricted cubic spline regression (RCS).

RESULTS

Our data revealed that subjects with MASLD had worse metabolic profiles. The dietary intake of niacin did not differ between subjects with and without MASLD. Even after adjusting for different confounding variables, i.e., sociodemographic variables, smoking status, physical activity, and cardiometabolic comorbidities, no significant associations were observed between higher intakes of niacin (tertiles 2 and 3) and the presence of MASLD: odds ratio (95% confidence) second tertile: 0.99 (0.89-1.09); third tertile: 0.98 (0.89-1.10). However, RCS analysis uncovered a significant non-linear dose-response association between dietary niacin intake and odds of MASLD. Specifically, such analysis revealed that MASLD risk was decreased in subjects with niacin intake values of <35 mg/day.

CONCLUSIONS

Our data showed that dietary niacin intake was associated with lower odds of MASLD in a Mediterranean population; however, our logistic regression analysis failed to reveal significant associations between the intake of niacin and the risk of MASLD. Further research is warranted to establish a causal relationship between dietary niacin interventions and MASLD.

Serum L C3-II levels in type 2 diabetic patients with impaired renal functions

This study was designed to evaluate serum LC3-II, BCL-2, IL-1β, TGF-β1, and podocin levels in. type 2 diabetes (T2DM) patients with renal dysfunction.

MATERIALS

176 Turkish subjects were enrolled, of whom 26 were healthy, and 150 had T2DM.

PATIENTS

were classified according to albumin urea ratio: 88 patients had macroalbuminuria, 20. patients had microalbuminuria, and 42 had normoalbuminuria. T2DM patients were also. classified into three groups according to proteinuria and eGFR stages.

RESULTS

Increased serum LC3-II levels in patients with T2DM with increased urinary albumin. extraction and impaired renal functions. There was a strong relationship between serum. LC3-II levels and serum BCL-2, IL-1β, TGF-β1, and Podocin levels. The efficiency of LC3- II as a diagnostic biomarker in the differential diagnosis of DM patients with. macroproteinuria from DM patients with normoproteinuria was 75.4%.

CONCLUSIONS

It was thought that increased serum LC3-II levels in T2DM patients with impaired renal. functions may cause renal podocyte damage. In these patients, serum LC3-II levels can be. evaluated as a new biomarker to follow the development of renal damage.

Integrating point-of-care diabetes detection with lifestyle counselling in community settings: outcomes from Western Sydney, Australia

INTRODUCTION

Early detection and prevention of type 2 diabetes and its complications are global health priorities. Optimal outcomes depend on individual awareness and proactive self-management of health risks. This study evaluates the effectiveness of a community-based diabetes detection and intervention program in a high-risk area in western Sydney, Australia.

RESEARCH DESIGN AND METHODS

We collaborated with the Workers Lifestyle Group, Tamil Association Arts and Culture Association, and the National Aboriginal and Islanders Day Observance Committee to implement our program. Participants underwent HbA1C testing via point-of-care blood spot testing. They received personalized feedback, education on diabetes management, and were offered opportunities to enrol in lifestyle modification programs. Participants identified with pre-diabetes (HbA1C 5.7-6.4%) or diabetes (HbA1C > 6.4%) were advised to consult their General Practitioners (GPs). A follow-up questionnaire was distributed 3-8 months post-intervention to evaluate the programs usefulness and relevance and lifestyle changes implemented by the participants.

RESULTS

Over eight months, 510 individuals participated. Of these, 19% had an HbA1C > 6.4%, and 38% had levels between 5.7 and 6.4%. Among those with diabetes, HbA1C levels ranged as follows: 56% <7%; 20% 7-7.9%; 18% 8-8.9%; and 5% >9%. Post intervention survey indicated that the program was well-received, with 62.5% of responses reporting lifestyle changes and 36.3% seeking further advice from their local healthcare providers.

CONCLUSION

The study demonstrates a significant prevalence of pre-diabetes and diabetes in the community, similar to findings from larger-scale hospital and general practice studies. Point-of-care testing combined with personalized education effectively motivated participants toward healthier lifestyle choices and medical consultations. The paper discusses the scalability of this approach for broader population.

At an appointment with a patient with diarrhea: the doctor’s algorithm of actions

Diarrhoea is one of the most common gastroenterological complaints made by patients who seek medical attention. It can be a manifestation of the whole range of different diseases, although not exclusively of the digestive tract, which requires a thorough examination of the patient and often is a challenge for the clinician, especially in the limited time settings during an outpatient visit. The cause of diarrhoea should be identified early to begin treatment of the patient in a timely and rational manner. In managing a patient with diarrhoea, a diagnostic search must begin with the following actions: working out complaints in detail, identification of symptoms of anxiety and taking a medical history, including epidemiological, pharmaceutical, hereditary, allergic, as well as analysis of dietary preferences. A physical examination is an integral part of the patient management; it allows to assess the general health condition, identify signs of dehydration and clinical stigmas of the underlying condition, which may manifest itself as diarrhoea. After an initial examination and exclusion of anxiety symptoms, a number of laboratory and instrumental examination methods is prescribed to determine the cause of diarrhoea. Given the polyetiology of diarrhoea syndrome, the range of methods for examining the patient can be quite wide, therefore the choice of area for the diagnostic search and the scope of the necessary diagnostic procedures is carried out on an individual basis, taking into account the features of the clinical picture, history data and physical examination findings. Treatment of a patient with diarrhoea at the pre-examination stage must include rehydration, timely detection and correction of electrolyte disturbances and other possible complications. Once the cause of diarrhoea has been established, the patient is treated due to the identified etiological factor in accordance with the current clinical guidelines. The article presents a step-by-step algorithm for making a differential diagnosis in a patient with diarrhoea, and also presents our own clinical observations.

Incidence of T2DM and the role of baseline glycaemic status as a determinant in a metropolitan population in northern Madrid (Spain)

AIM

To estimate the incidence of T2DM and assess the effect of pre-T2DM (isolated impaired fasting glucose [iIFG], isolated impaired glucose tolerance [iIGT] or both) on progress to T2DM in the adult population of Madrid.

METHODS

Population-based cohort comprising 1,219 participants (560 normoglycaemic and 659 preT2DM [418 iIFG, 70 iIGT or 171 IFG-IGT]). T2DM was defined based on fasting plasma glucose or HbA1c or use of glucose-lowering medication. We used a Cox model with normoglycaemia as reference category.

RESULTS

During 7.26 years of follow-up, the unadjusted incidence of T2DM was 11.21 per 1000 person-years (95 %CI, 9.09-13.68) for the whole population, 5.60 (3.55-8.41) for normoglycaemic participants and 16.28 (12.78-20.43) for pre-T2DM participants. After controlling for potential confounding factors, the baseline glycaemic status was associated with higher primary effect on developing T2DM was iIGT (HR = 3.96 [95 %CI, 1.93-8.10]) and IFG-IGT (3.42 [1.92-6.08]). The HR for iIFG was 1.67 (0.96-2.90). Obesity, as secondary effect, was strongly significantly associated (HR = 2.50 [1.30-4.86]).

CONCLUSIONS

Our incidence of T2DM is consistent with that reported elsewhere in Spain. While baseline iIGT and IFG-IGT behaved a primary effect for progression to T2DM, iIFG showed a trend in this direction.

Metabolic syndrome prevalence and impact on outcomes in patients with chronic graft-versus-host disease

Patients with chronic graft-versus-host disease (cGVHD) are at heightened risk for components of metabolic syndrome (MetS), yet the prevalence and impact of MetS in the cGVHD patient population remain unknown. Adult patients (n = 229) with cGVHD enrolled in the cross-sectional NIH cGVHD Natural History Study (NCT00092235) were evaluated for MetS at enrollment and for variables associated with MetS. A majority (54.1%, 124/229) of the cohort met the diagnostic criteria for MetS. Patients with higher body mass index and lower performance status scores were more likely to have MetS (P < 0.0001; P = 0.026; respectively). Higher circulating erythrocyte sedimentation rate, C-reactive protein, and creatinine concentrations, along with lower estimated glomerular filtration rate, were associated with MetS (P < 0.001; P < 0.004; P = 0.02; P = 0.002; respectively). Patients with MetS compared to patients without MetS had no statistical differences in survival or NRM (5-year OS: 64% [95% CI: 54.8-71.8%] vs. 75.1% [95% CI: 65.6-82.3%]; respectively; overall P = 0.20; 5-year NRM: 21.7% [95% CI: 13.6-30.9%] vs. 10.1% [95% CI: 4.4-18.7%]; respectively; overall P = 0.12). Additionally, there was no difference in cGVHD severity between the two groups. Given the high prevalence of MetS in this cohort, clinicians should screen for its presence before it develops into comorbidities that complicate the course of cGVHD treatment.

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.

From pre-COPD to COPD: a Simple, Low cost and easy to IMplement (SLIM) risk calculator

BACKGROUND

The lifetime risk of developing clinical COPD among smokers ranges from 13% to 22%. Identifying at-risk individuals who will develop overt disease in a reasonable timeframe may allow for early intervention. We hypothesised that readily available clinical and physiological variables could help identify ever-smokers at higher risk of developing chronic airflow limitation (CAL).

METHODS

Among 2273 Lovelace Smokers' Cohort (LSC) participants, we included 677 (mean age 54 years) with normal spirometry at baseline and a minimum of three spirometries, each 1 year apart. Repeated spirometric measurements were used to determine incident CAL. Using logistic regression, demographics, anthropometrics, smoking history, modified Medical Research Council dyspnoea scale, St George's Respiratory Questionnaire, comorbidities and spirometry, we related variables obtained at baseline to incident CAL as defined by the Global Initiative for Chronic Obstructive Lung Disease and lower limit of normal criteria. The predictive model derived from the LSC was validated in subjects from the COPDGene study.

RESULTS

Over 6.3 years, the incidence of CAL was 26 cases per 1000 person-years. The strongest independent predictors were forced expiratory volume in 1 s (FEV1)/forced vital capacity (FVC) <0.75, having smoked ≥30 pack-years, body mass index (BMI) ≤25 kg·m2 and symptoms of chronic bronchitis. Having all four predictors increased the risk of developing CAL over 6 years to 85% (area under the receiver operating characteristic curve (AUC ROC) 0.84, 95% CI 0.81-0.89). The prediction model showed similar results when applied to subjects in the COPDGene study with a follow-up period of 10 years (AUC ROC 0.77, 95% CI 0.72-0.81).

CONCLUSION

In middle-aged ever-smokers, a simple predictive model with FEV1/FVC, smoking history, BMI and chronic bronchitis helps identify subjects at high risk of developing CAL.

DMF scores in patients with diabetes mellitus: A systematic review and meta-analysis of observational studies

OBJECTIVE

The aim of this systematic review(SR) is to comprehensively and critically summarise and synthesise the available scientific evidence from observational studies that use the decayed-missed-filled(DMF) index to determine caries experiences among adult patients with diabetes mellitus  (DM) as compared to individuals without DM(non-DM).

DATA

Indices that present examinations of decayed-filled-surfaces(DFS), decayed-missed-filled-surfaces(DMFS), and decayed-missed-filled-teeth(DMFT) established from observational studies were considered.

SOURCES

MEDLINE-PubMed and Cochrane Central databases were searched through 1 February 2023 to identify studies that evaluate DMF indices for adult patients with DM compared to non-DM. The reference lists of the selected studies were reviewed to identify additional potentially relevant studies.

STUDY SELECTION

All studies were independently screened by two reviewers. Included papers were critically appraised using pre-designed forms, and the risk of bias was assessed. Data as means and standard deviations were extracted. A descriptive data presentation was used for all studies. If quantitative methods were feasible, then a meta-analysis was performed. It was decided 'a priori' to perform a sub-analysis on type of DM(I or II). The quality of the studies was assessed.

RESULTS

Initially 932 studies were found, and screening resulted in 13 eligible observational studies. The total number of subjects included in this SR is 21,220. A descriptive analysis of the comparisons demonstrated that eight studies provided data and demonstrated higher DFS (1/2), DMFS (2/3) and DMFT (5/8). This was confirmed by the meta-analysis difference of means(DiffM), which was 3.01([95%CI:1.47,4.54],p=0.0001) for DMFT and 10.30([95% CI:8.50,12.11],p<0.00001) for DMFS. Subgroup analysis showed that this difference is irrespective to the type of DM(DiffM=3.09;[95%CI:2.09,4.09],p<0.00001).

CONCLUSION

There is moderate certainty for a higher DMF index score in DM patients as compared to those without DM disease.

CLINICAL SIGNIFICANCE

This SR indicates a higher DMF index in DM patients. Oral disease prevention should be the focus of the dental care practitioner in this patient category.

Role of Chlorhexidine and Herbal Oral Rinses in Managing Periodontitis

OBJECTIVE

The aim of this research was to assess the effect of 0.12% chlorhexidine (CHX) and a Salvadora persica-based mouthwash on whole salivary tumour necrosis factor-alpha (TNF-α) levels and periodontal inflammation in patients with type 2 diabetes mellitus (T2DM).

METHODS

Patients with and without medically diagnosed T2DM were included. Patients' medical records were evaluated to confirm the diagnosis of T2DM. All patients underwent nonsurgical periodontal therapy (NSPT). Patients were divided into 2 subgroups. In the test and control group, patients were advised to rinse with an S persica-based mouthwash and a non-alcoholic 0.12% CHX after NSPT twice daily for 2 weeks, respectively. Demographic data were collected. Full-mouth plaque index (PI), gingival index (GI), probing depth (PD), and clinical attachment loss (AL) were measured, and whole salivary TNF-α levels were gauged at baseline and at 3-month follow-up. Haemoglobin A1c (HbA1c) levels were measured in all patients at baseline and at 3-month follow-up. Sample size estimation was done, and group comparison was performed. Level of significance was set at P < .01.

RESULTS

Twenty-one nondiabetic individuals and 21 patients with T2DM were included. At baseline, there was no significant difference in clinical and radiographic periodontal parameters amongst in patients with and without T2DM. At 3-month follow-up, HbA1c, TNF-α, PI, PD, and clinical AL were comparable with their respective baseline values in the test and control groups amongst patients with T2DM. In nondiabetic individuals, there was a significant reduction in PI (P < .01), GI (P < .01), and PD (P < .01), and TNF-α (P < .01) at 3-month follow-up in the test and control groups compared with their respective baseline scores.

CONCLUSIONS

In the short term, NSPT with 0.12% CHX or S persica-based mouthwashes is more effective in reducing periodontal inflammation and whole salivary TNF-α levels in nondiabetic individuals than in patients with T2DM with periodontal inflammation.

The clinical significance of serum HbA1c to diagnose diabetes mellitus during acute pancreatitis

AIMS

To investigate the prevalence of diabetes mellitus (DM) in acute pancreatitis (AP) patients and to explore the extent to which inflammatory stress affects plasma glucose (PG) levels in AP patients.

METHODS

A retrospective analysis of 2163 AP patients was performed. The PG differences among AP patients under differing pancreatic necrosis conditions and inflammation severity were compared. Receiver operating characteristic curves were used to assess whether fasting PG in the inflammatory stage of AP might be used for DM screening.

RESULTS

The overall DM prevalence was 19.97% in AP patients, 32.41% of whom had newly diagnosed DM (based on HbA1c levels in patients who self-reported no DM). The DM prevalence was 46.93% in hyperlipidemic AP patients, 44.14% of whom had newly diagnosed DM. In patients with and without pancreatic necrosis, the optimal PG thresholds for the screening of newly diagnosed DM were 10.40 mmol/L and 8.21 mmol/L, respectively, with an AUC of 0.959 ± 0.034 (P < 0.001) and 0.972 ± 0.006 (P < 0.001), respectively.

CONCLUSIONS

For hospitalized AP patients and fasting PG levels exceeding 10 mmol/L (with necrosis) or 8 mmol/L (without necrosis) (P < 0.001), HbA1c testing is recommended to investigate the presence of comorbid undiagnosed DM.

Data assimilation on mechanistic models of glucose metabolism predicts glycemic states in adolescents following bariatric surgery

Type 2 diabetes mellitus is a complex and under-treated disorder closely intertwined with obesity. Adolescents with severe obesity and type 2 diabetes have a more aggressive disease compared to adults, with a rapid decline in pancreatic β cell function and increased incidence of comorbidities. Given the relative paucity of pharmacotherapies, bariatric surgery has become increasingly used as a therapeutic option. However, subsets of this population have sub-optimal outcomes with either inadequate weight loss or little improvement in disease. Predicting which patients will benefit from surgery is a difficult task and detailed physiological characteristics of patients who do not respond to treatment are generally unknown. Identifying physiological predictors of surgical response therefore has the potential to reveal both novel phenotypes of disease as well as therapeutic targets. We leverage data assimilation paired with mechanistic models of glucose metabolism to estimate pre-operative physiological states of bariatric surgery patients, thereby identifying latent phenotypes of impaired glucose metabolism. Specifically, maximal insulin secretion capacity, σ, and insulin sensitivity, SI, differentiate aberrations in glucose metabolism underlying an individual's disease. Using multivariable logistic regression, we combine clinical data with data assimilation to predict post-operative glycemic outcomes at 12 months. Models using data assimilation sans insulin had comparable performance to models using oral glucose tolerance test glucose and insulin. Our best performing models used data assimilation and had an area under the receiver operating characteristic curve of 0.77 (95% confidence interval 0.7665, 0.7734) and mean average precision of 0.6258 (0.6206, 0.6311). We show that data assimilation extracts knowledge from mechanistic models of glucose metabolism to infer future glycemic states from limited clinical data. This method can provide a pathway to predict long-term, post-surgical glycemic states by estimating the contributions of insulin resistance and limitations of insulin secretion to pre-operative glucose metabolism.

Cardiometabolic risk factors and cardiovascular disease predictions in older African and European Americans

Cardiometabolic (CMO) risks factors do not provide similar cardiovascular disease (CVD) predictions in young African (AA) and European Americans (EA) adults. Whether CMO risk predictions contribute to this disparity in older adults is unclear. We hypothesize that older AA CMO clustering pattern will be different from EA clustering patterns when determine with non-fasting lipid and lipoproteins. The participants were 106 older adults (66 AA and 40 EA) from a working/middle class neighborhood (income $46,364 – $80,904) in an urban North Carolina community. The participants were evaluated for CMO risk factors (total cholesterol, high- (HDL) and low-density lipoproteins (LDL), triglyceride (TG), glycosylated hemoglobin (HbA1c), systolic –SBP- and diastolic blood pressures -DBP), body mass index (BMI), body fat % (BF%) and timed up and go test (assessed falls risk and physical function). The AA participants were heavier, had higher BMI, BF%, and timed up and go values (p < 0.01). The data were evaluated for differences (t-test) and Pearson correlations for relationships. If data differ by p < 0.05 the data were significantly different. The AA had a 17.6 % higher HDL (64.7 vs 55.1 mg/dL – p < 0.05) and 7.6 % higher HbA1c (5.8 vs 5.4 % – p < 0.01) than EA. Higher HDL values in EA indicate lower CVD risks. The HDL paradox for AA (AA had higher HDL values, but greater CVD risks) was observed and the HbA1c difference may be misleading, as similar glucose values in AA tend to have higher HbA1c values. Lipid, lipoprotein, and blood pressure was not different between the races. AA had higher body composition and HDL values. Although future research on this topic with larger samples, dietary data and detailed descriptions of participations medications is warranted to validate findings from this study. These data suggest older AA and EA adults with similar environmental conditions have similar CMO risks when measures with none fasting blood samples. Since AA have a greater prevalence of CVD, these finding suggests that population specific CMO risk factor clustering may be more effective predictors of CVD for AA.

One-hour plasma glucose as a long-term predictor of cardiovascular events and all-cause mortality in a Chinese older male population without diabetes: A 20-year retrospective and prospective study

Introduction

Elevated one-hour plasma glucose (1 h-PG) during oral glucose tolerance test predicts the development of type 2 diabetes mellitus and its complications. However, to date, there have been no studies investigating the predictive values of 1 h-PG for the risk of cardiovascular diseases (CVDs) and all-cause mortality in the elderly population in China. This study aimed to evaluate and compare the effectiveness of 1 h-PG and two-hour plasma glucose (2 h-PG) to predict the risk of CVD and all-cause mortality in the Chinese elderly population.

Materials and methods

This retrospective and prospective cohort study was conducted using data obtained from the Chinese People’s Liberation Army General Hospital. All the non-diabetic elderly participants, who had plasma glucose measured at 0, 1, and 2 h during an OGTT (75 g glucose), were followed for 20 years. The primary outcomes were all-cause mortality, myocardial infarction, unstable angina, and stroke. Multivariate-adjusted Cox proportional hazard regression models were performed to examine the association between risk factors and outcomes and to estimate the risk of CVD and all-cause mortality based on 1 h-PG levels.

Results

A total of 862 non-diabetic male individuals were included. The median age was 74.0 (25th–75th percentile: 68.0–79.0) years. There were 480 CVD events and 191 deaths during 15,527 person-years of follow-up. The adjusted hazard ratio (HR) of 1 h-PG as a continuous variable was 1.097 (95% CI 1.027–1.172; P = 0.006) for CVD events and 1.196 (95% CI 1.115–1.281; P < 0.001) for higher risk of mortality. When compared with the lowest 1 h-PG tertile, the other tertiles were associated with CVD events (HR 1.464, 95% CI 1.031–2.080; P = 0.033 and HR 1.538, 95% CI 1.092–2.166; P = 0.014, for tertile 2 and tertile 3 compared with tertile 1, respectively), and the highest 1 h-PG tertile had a significantly higher risk of mortality (HR 2.384, 95% CI 1.631–3.485; P < 0.001) after full adjustment. Compared with 1 h-PG, 2 h-PG had similar abilities to predict all-cause mortality. However, 2 h-PG was less closely associated with CVD when examined in the fully adjusted model, neither as a continuous variable nor as a categorical variable. Conversely, 1 h-PG remained an independent predictor of CVD and all-cause mortality after adjusting for various traditional risk factors.

Conclusion

Patients with higher 1 h-PG had a significantly increased risk of CVD and all-cause mortality regardless of prediabetes status or development of diabetes at follow-up. The 1 h-PG level might be a better predictor of cardiovascular risk than the 2 h-PG level for the Chinese elderly population.

Prevalent Morphometrically Assessed Vertebral Fractures in Individuals With Type 2 Diabetes, Prediabetes and Normal Glucose Metabolism: The Maastricht Study

BACKGROUND

Type 2 diabetes (T2D) is frequently reported to be associated with an increased fracture risk. Epidemiological data on prevalent morphometric vertebral fractures (VFs) in T2D are sparse and even less is known in the prediabetic state.

PURPOSE

To determine the association between prevalence and severity of morphometric VFs and glucose metabolism state: normal glucose metabolism (NGM), impaired glucose metabolism (prediabetes) or T2D.

METHODS

This study included cross-sectional data from 3625 participants of the Maastricht Study who had a vertebral fracture assessment on lateral Dual Energy X-Ray Absorptiometry images. VFs were classified based on morphometric assessment into mild, moderate and severe VFs (respectively 20-24%, 25-39% or ≥40% reduction in expected vertebral body height). Logistic regression models were used to investigate the association between glucose metabolism status and the prevalence and severity of VFs. Analyses were adjusted for subject characteristics and life-style factors.

RESULTS

T2D individuals were older (62.8 ± 7.5 years old) and less often female (30.5%) compared to the NGM group (57.7 ± 8.5 years old, and 58.8% female, respectively). At least one mild, moderate or severe prevalent VF was found in 8.6% of the men and 2.2% of the women in the T2D group, in 9.4% and 8.4% in the prediabetes group and in 9.1% and 4.8% in the NGM group, respectively. After adjustment T2D in women was associated with a lower probability of having a prevalent VF compared to NGM [adjusted OR 0.25 (95% CI 0.09-0.65)], while this was not the case for prediabetes. Furthermore, women with T2D had a significantly lower probability of a prevalent moderate or severe VF [adjusted OR 0.32 (95% CI 0.11-0.96)]. In men there was no significant association between T2D or prediabetes and prevalent VFs.

CONCLUSION

Women with T2D had a lower probability of prevalent VFs compared to women with a normal glucose metabolism, while this was not the case for men with T2D and participants with prediabetes.

Effects of the hemoglobin glycation index on hyperglycemia diagnosis: Results from the REACTION study

AIMS

This study aimed to assess the effects of the hemoglobin glycation index (HGI) on hyperglycemia diagnosis and summarize the general characteristics of patients with a high-HGI phenotype.

METHODS

The fasting plasma glucose and glycated hemoglobin (HbA1c) levels of participants (n = 47,648) were used to estimate a linear regression equation and determine the baseline HGI. Overall, 42,317 participants without a history of diabetes were included in the final analysis. The participants were divided into three groups according to the tertiles (low, moderate, and high) of baseline HGI. Proportions and variables were compared among the three HGI groups. A multivariate ordered logistic regression model was used to explore associations between related variables and the high-HGI phenotype.

RESULTS

Regression analysis indicated that the high-HGI phenotype was positively associated with female sex, advanced age, obesity, increased low-density lipoprotein and triglyceride levels, decreased high-density lipoprotein cholesterol, and postprandial glycemic excursion levels (all P < 0.05). The prevalence of hyperglycemia increased from the low- to the high-HGI groups when using HbA1c for diagnosis.

CONCLUSIONS

Individuals with high HGI have similar clinical characteristics. Measuring HbA1c alone for diagnosis could lead to inappropriate diabetes management decisions in people with low or high HGI.

Assessment of diabetes knowledge, screening and uptake of community diabetes programs in a peri-urban region in Australia

AIMS

The Wollondilly Diabetes Program (WDP) is testing ways to improve uptake of diabetes prevention services. This project evaluated the reach of WDP in diabetes promotion while assessing diabetes knowledge and risk among residents.

METHODS

A WDP member travelled in the DW weekly to community events including outreach programs between October 2016 and June 2019. Data from diabetes knowledge questionnaire (DKQ), the Australian Type 2 Diabetes Risk Assessment Tool (AUSDRISK), HbA1c and Random Blood Glucose (RBG) measurements obtained from participants who attended community events and road shows.

RESULTS

Over the 32 months period, WDP attended 32 community events reaching 1415 people (∼3% of the Wollondilly adult population). DKQ was completed by 154 people (52.9% females, 78% Australian born, median age 69 years), 39% had diabetes and their mean score (25.0 ± 3.1, maximum possible score = 31) was similar to those without diabetes (24.0 ± 4.6, p = 0.093). AUSDRISK assessment was completed by 166 people with 85% at intermediate or high risk of diabetes. There were 65% results above range for RBG (≥5.5 mmol/l) and/or HbA1c (≥5.7%,39 mmol/mol).

CONCLUSION

A community outreach team set up in partnership with local stakeholders that offers opportunistic diabetes screening, is an effective way of engaging with the community to increase diabetes awareness and knowledge.

Significance of Neutrophil Gelatinase-Associated Lipocalin as a Biomarker for the Diagnosis of Diabetic Kidney Disease: A Systematic Review and Meta-Analysis

BACKGROUND

Neutrophil gelatinase-associated lipocalin (NGAL) is a promising marker for the diagnosis of diabetic kidney disease (DKD), but its utility is currently debated. This meta-analysis aims to evaluate the diagnostic value of NGAL for DKD.

METHOD

MEDLINE, Embase, -Cochrane Library, CNKI, and CBM databases were searched up to April 13, 2019. In bivariate random-effect models, the diagnostic performance of NGAL for DKD was assessed using pooled estimates of sensitivity, specificity, likelihood ratio, diagnostic odds ratio, and hierarchical summary receiver-operating characteristic analysis.

RESULTS

Nineteen studies were eligible for the meta-analysis. Serum NGAL had a pooled sensitivity and specificity of 0.79 (95% confidence intervals [CI] 0.60-0.91) and 0.87 (0.75-0.93) (7 studies, 1,238 patients). The pooled positive likelihood ratio (LR+) and negative likelihood ratio (LR-) were 5.97 (3.03-11.76) and 0.24 (0.11-0.51). For urine NGAL, the pooled sensitivity, specificity, LR+, and LR- were 0.85 (0.74-0.91), 0.74 (0.57-0.86), 3.26 (1.87-5.67), and 0.21 (0.12-0.35), respectively (10 studies, 1,369 patients). The pooled sensitivity and specificity for kidney disease in normoalbuminuric patients with diabetes was 0.90 (0.82-0.95) and 0.97 (0.90-0.99) for both serum NGAL and 0.94 (0.87-0.98) and 0.90 (0.81-0.96) for urine NGAL (4 studies, 221 patients). NGAL appeared to perform similarly in subgroup analysis.

CONCLUSION

The meta-analysis has shown that NGAL may be useful for DKD classification and also has a potential diagnostic value for normoalbuminuric kidney disease. Large-scale prospective studies are required to clarify its role in the diagnosis and risk stratification of patients with DKD.

Emerging Diabetic Novel Biomarkers of the 21st Century

Diabetes is a growing epidemic with estimated prevalence of infected to reach ~592 million by the year 2035. An effective way to approach is to detect the disease at a very early stage to reduce the complications and improve lifestyle management. Although several traditional biomarkers including glucated hemoglobin, glucated albumin, fructosamine, and 1,5-anhydroglucitol have helped in ease of diagnosis, there is lack of sensitivity and specificity and are inaccurate in certain clinical settings. Thus, search for new and effective biomarkers is a continuous process with an aim of accurate and timely diagnosis. Several novel biomarkers have surged in the present century that are helpful in timely detection of the disease condition. Although it is accepted that a single biomarker will have its inherent limitations, combining several markers will help to identify individuals at high risk of developing prediabetes and eventually its progression to frank diabetes. This review describes the novel biomarkers of the 21st century, both in type 1 and type 2 diabetes mellitus, and their present potential for assessing risk stratification due to insulin resistance that will pave the way for improved clinical outcome.

A Review of Chronic Comorbidities in Adults Living With HIV: State of the Science

ABSTRACT

People living with HIV are living longer, high-quality lives; however, as they age, this population is at increased risk for developing chronic comorbidities, including cardiovascular disease, certain types of cancer (e.g., lung, anal, and liver), and diabetes mellitus. The purpose of this state-of-the-science review is to provide an evidence-based summary on common physical comorbidities experienced by people living and aging with HIV. We focus on those chronic conditions that are prevalent and growing and share behavioral risk factors that are common in people living with HIV. We will discuss the current evidence on the epidemiology, physiology, prevention strategies, screening, and treatment options for people living with HIV across resource settings.

Time trends in the incidence of clinically diagnosed type 2 diabetes and pre-diabetes in the UK 2009-2018: a retrospective cohort study

INTRODUCTION

To describe recent trends in the incidence of clinically diagnosed type 2 diabetes and pre-diabetes in people seen in UK general practice.

RESEARCH DESIGN AND METHODS

A retrospective cohort study using IQVIA Medical Research Data looking at people newly diagnosed with type 2 diabetes and pre-diabetes through primary care registers in the UK between 1 January 2009 and 31 December 2018.

RESULTS

A cohort of 426 717 people were clinically diagnosed with type 2 diabetes and 418 656 people met the criteria for a diagnosis of pre-diabetes in that time period. The incidence of clinically diagnosed type 2 diabetes per 1000 person years at risk (PYAR) in men decreased from a peak of 5.06 per 1000 PYAR (95% CI 4.97 to 5.15) in 2013 to 3.56 per 1000 PYAR (95% CI 3.46 to 3.66) by 2018. For women, the incidence of clinically diagnosed type 2 diabetes per 1000 PYAR decreased from 4.45 (95% CI 4.37 to 4.54) in 2013 to 2.85 (2.76 to 2.93) in 2018. The incidence rate of pre-diabetes tripled by the end of the same study period in men and women.

CONCLUSIONS

Between 2009 and 2018, the incidence rate of new clinical diagnoses of type 2 diabetes recorded in a UK primary care database decreased by a third from its peak in 2013-2014, while the incidence of pre-diabetes has tripled. The implications of this on timely treatment, complication rates and mortality need further longer term exploration.

Prevalence of diabetes and pre-diabetes in Greece. Results of the First National Survey of Morbidity and Risk Factors (EMENO) study

AIMS

To report the results of the first national Health Examination Survey (HES) on the prevalence of diabetes, its pharmacologic treatment and level of control, as well as pre-diabetes in Greece.

METHODS

Data were derived from the National Survey of Morbidity and Risk Factors (EMENO), in a randomly selected, representative sample of the adult Greek population. Sampling weights were applied to adjust for study design and post-stratification weights to match sample age/sex distribution to the population. Non-response was adjusted by inverse probability weighting. Weighted prevalence estimates are provided.

RESULTS

A total of 4393 persons with HbA1c and/or fasting plasma glucose measurements were included. Total diabetes prevalence was 11.9% (95% CI: 10.9-12.9), known diabetes 10.4% (9.5-11.4), and unknown 1.5% (1.1-1.9), with considerable increase in older age groups and no difference between genders. Pre-diabetes prevalence was 12.4% (11.4-13.6). The majority of persons with known diabetes were receiving metformin. Of those with known diabetes (and measured HbA1c), 70.9% were well controlled (HbA1c <7.0%).

CONCLUSIONS

This first representative national HES showed high prevalence of diabetes in Greece, with low prevalence of unknown diabetes. Pre-diabetes prevalence is also substantial. These results will hopefully enable national authorities develop tailored and efficient strategies for disease prevention and management.

The Oral Glucose Tolerance Test: 100 Years Later

For over 100 years, the oral glucose tolerance test (OGTT) has been the cornerstone for detecting prediabetes and type 2 diabetes (T2DM). In recent decades, controversies have arisen identifying internationally acceptable cut points using fasting plasma glucose (FPG), 2-h post-load glucose (2-h PG), and/or HbA1c for defining intermediate hyperglycemia (prediabetes). Despite this, there has been a steadfast global consensus of the 2-h PG for defining dysglycemic states during the OGTT. This article reviews the history of the OGTT and recent advances in its application, including the glucose challenge test and mathematical modeling for determining the shape of the glucose curve. Pitfalls of the FPG, 2-h PG during the OGTT, and HbA1c are considered as well. Finally, the associations between the 30-minute and 1-hour plasma glucose (1-h PG) levels derived from the OGTT and incidence of diabetes and its complications will be reviewed. The considerable evidence base supports modifying current screening and diagnostic recommendations with the use of the 1-h PG. Measurement of the 1-h PG level could increase the likelihood of identifying high-risk individuals when the pancreatic ß-cell function is substantially more intact with the added practical advantage of potentially replacing the conventional 2-h OGTT making it more acceptable in the clinical setting.

Comparison of peri-implant soft tissue and crestal bone status of dental implants placed in prediabetic, type 2 diabetic, and non-diabetic individuals: a retrospective cohort study

Background

Clinicoradiographic status of narrow-diameter implants (NDIs) among patients with prediabetes and type 2 diabetes mellitus (DM) is scarce. The aim was to address the clinicoradiographic status of NDIs placed prediabetic, type 2 diabetic, and non-diabetic individuals. In this retrospective cohort study, patients having undergone oral rehabilitation with NDI were included. The participants were divided into the following: (a) patients with prediabetes; (b) patients with poorly controlled type 2 DM; (c) patients with well-controlled type 2 DM; and (d) normoglycemic individuals. Demographic data was collected. In all groups, peri-implant plaque index (PI), gingival index (GI), probing depth (PD), and mesiodistal CBL were measured in all groups. Information related to implant dimensions, surface characteristics, insertion torque, implant geometry, duration of NDI in function, and jaw location of NDI was also recorded. Data normality was assessed and group comparisons were performed. A probability value under 0.01 was considered statistically significant.

Results

Eighty-three patients (20 patients had prediabetes, 22 with poorly controlled type 2 DM, 20 with well-controlled type 2 DM, and 20 self-reported non-diabetic individuals) were included. The mean HbA1c levels were significantly higher among patients with prediabetes (P < 0.01) and poorly controlled type 2 DM (P < 0.01) than patients with well-controlled type 2 DM and non-diabetic controls. Peri-implant PI, GI, PD, and mesiodistal CBL levels were significantly higher among patients with pre-diabetes (P < 0.01) and poorly controlled type 2 DM (P < 0.01) than patients with well-controlled type 2 DM and non-diabetic controls. Peri-implant PI, GI, PD, and mesiodistal CBL levels were significantly higher among patients with poorly controlled type 2 DM (P < 0.01) than patients with prediabetes.

Conclusion

Chronic hyperglycemia increases the risk of peri-implant diseases around NDIs.

Improved Detection of Abnormal Glucose Tolerance in Africans: The Value of Combining Hemoglobin A1c With Glycated Albumin

OBJECTIVE

In African-born Blacks living in America, we determined by BMI category 1) prevalence of abnormal glucose tolerance (Abnl-GT) and 2) diagnostic value and reproducibility of hemoglobin A1c (HbA1c), fructosamine, and glycated albumin (GA).

RESEARCH DESIGN AND METHODS

Participants (n = 416; male, 66%; BMI 27.7 ± 4.5 kg/m2 [mean ± SD]) had an oral glucose tolerance test with HbA1c, GA, and fructosamine assayed. These glycemic markers were repeated 11 ± 7 days later. Abnl-GT diagnosis required 0 h ≥5.6 mmol/L (≥100 mg/dL) and/or 2 h ≥7.8 mmol/L (≥140 mg/dL). Thresholds for HbA1c, GA, and fructosamine were the values at the 75th percentile for the population (39 mmol/mol [5.7%], 14.2%, and 234 μmol/L, respectively).

RESULTS

Abnl-GT prevalence in the nonobese was 34% versus 42% in the obese (P = 0.124). Reproducibility was excellent for HbA1c and GA (both κ ≥ 0.8), but moderate for fructosamine (κ = 0.6). Focusing on HbA1c and GA in the nonobese, we found as single tests the sensitivities of HbA1c and GA were 36% versus 37% (P = 0.529). Combining HbA1c and GA, sensitivity increased to 58% because GA identified 37% of Africans with Abnl-GT not detected by HbA1c (P value for both tests vs. HbA1c alone was <0.001). For the obese, sensitivities for HbA1c, GA, and the combined tests were 60%, 27%, and 67%, respectively. Combined test sensitivity did not differ from HbA1c alone (P = 0.25) because GA detected only 10% of obese Africans with Abnl-GT not detected by HbA1c.

CONCLUSIONS

Adding GA to HbA1c improves detection of Abnl-GT in nonobese Africans.

Optimal fasting plasma glucose and haemoglobin A1c levels for screening of prediabetes and diabetes according to 2-hour plasma glucose in a high-risk population: The Korean Diabetes Prevention Study

BACKGROUND

The primary aim of this study was to assess the utility of fasting plasma glucose (FPG) and HbA1c to identify diabetes by the 2-hour plasma glucose (PG) criterion in the Korean population at high risk for diabetes.

METHODS

A total of 1646 participants with a body mass index of ≥23 kg/m2 without having a history of diabetes were recruited in this study. The cut-off values of FPG and HbA1c for detecting diabetes were identified using the Youden index using receiver operating characteristic (ROC) analysis. The gold standard for diabetes prediction was defined by the 2-hour PG level of ≥200 mg/dL.

RESULTS

The participants comprised 54.0% women, and the mean age of all participants was 55.0 ± 8.1 years. At baseline, FPG was 104.1 ± 14.2 mg/dL, the 2-hour PG value was 162.9 ± 55.3 mg/dL, and HbA1c was 5.9% ± 0.5%. Four hundred and forty-six subjects (27.1%) were diagnosed with diabetes and 976 subjects (59.3%) were determined to be at prediabetes. The area under the ROC curve (AUC) of FPG and HbA1c for diabetes were 0.776 and 0.802, while the AUC of FPG and HbA1c for prediabetes were 0.515 and 0.477. The optimal cut-off value for diagnosing diabetes of FPG and HbA1c were 104.5 mg/dL (sensitivity 75.8%, specificity 67.5%) and 5.9% (sensitivity 80.6%, specificity 63.8%), respectively.

CONCLUSIONS

FPG of 104.5 mg/dL and HbA1c value of 5.9% (41 mmol/mol) can be used as an optimal screening value for diabetes by 2-hour PG criterion in the Korean population at high risk for diabetes.

The Growing Epidemic of Diabetes Mellitus

BACKGROUND

During the past decades, the prevalence of diabetes (DM) has increased significantly, mainly as a result of continuous rise in the incidence of type 2 DM. According to World Health Organization statistics, >422 million adults globally were suffering from DM in 2014 and a continuous rise in DM prevalence is expected.

OBJECTIVE

The present review considers recent epidemiological data providing worldwide estimates regarding the incidence of DM.

METHODS

A comprehensive literature search was conducted to identify available data from epidemiological studies evaluating the current burden of DM.

RESULTS

Over the past few decades the prevalence of DM has risen significantly in nearly all countries and may be considered as a growing epidemic. Urbanization and income status are major factors which influence current rates in the prevalence studies introducing interesting differences between several population groups.

CONCLUSION

Having recognized the global burden of DM, we now realize the urgent need for effective interventions. In order to monitor the public-health strategies and design effective future interventions we need reliable global estimates regarding the prevalence of DM.

Pitfalls of HbA1c in the Diagnosis of Diabetes

Many health care providers screen high-risk individuals exclusively with an HbA1c despite its insensitivity for detecting dysglycemia. The 2 cases presented describe the inherent caveats of interpreting HbA1c without performing an oral glucose tolerance test (OGTT). The first case reflects the risk of overdiagnosing type 2 diabetes (T2D) in an older African American male in whom HbA1c levels, although variable, were primarily in the mid-prediabetes range (5.7-6.4% [39-46 mmol/mol]) for many years although the initial OGTT demonstrated borderline impaired fasting glucose with a fasting plasma glucose of 102 mg/dL [5.7 mmol/L]) without evidence for impaired glucose tolerance (2-hour glucose ≥140-199 mg/dl ([7.8-11.1 mmol/L]). Because subsequent HbA1c levels were diagnostic of T2D (6.5%-6.6% [48-49 mmol/mol]), a second OGTT performed was normal. The second case illustrates the risk of underdiagnosing T2D in a male with HIV having normal HbA1c levels over many years who underwent an OGTT when mild prediabetes (HbA1c = 5.7% [39 mmol/mol]) developed that was diagnostic of T2D. To avoid inadvertent mistreatment, it is therefore essential to perform an OGTT, despite its limitations, in high-risk individuals, particularly when glucose or fructosamine and HbA1c values are discordant. Innate differences in the relationship between fructosamine or fasting glucose to HbA1c are demonstrated by the glycation gap or hemoglobin glycation index.

Review of methods for detecting glycemic disorders

Prediabetes (intermediate hyperglycemia) consists of two abnormalities, impaired fasting glucose (IFG) and impaired glucose tolerance (IGT) detected by a standardized 75-gram oral glucose tolerance test (OGTT). Individuals with isolated IGT or combined IFG and IGT have increased risk for developing type 2 diabetes (T2D) and cardiovascular disease (CVD). Diagnosing prediabetes early and accurately is critical in order to refer high-risk individuals for intensive lifestyle modification. However, there is currently no international consensus for diagnosing prediabetes with HbA1c or glucose measurements based upon American Diabetes Association (ADA) and the World Health Organization (WHO) criteria that identify different populations at risk for progressing to diabetes. Various caveats affecting the accuracy of interpreting the HbA1c including genetics complicate this further. This review describes established methods for detecting glucose disorders based upon glucose and HbA1c parameters as well as novel approaches including the 1-hour plasma glucose (1-h PG), glucose challenge test (GCT), shape of the glucose curve, genetics, continuous glucose monitoring (CGM), measures of insulin secretion and sensitivity, metabolomics, and ancillary tools such as fructosamine, glycated albumin (GA), 1,5- anhydroglucitol (1,5-AG). Of the approaches considered, the 1-h PG has considerable potential as a biomarker for detecting glucose disorders if confirmed by additional data including health economic analysis. Whether the 1-h OGTT is superior to genetics and omics in providing greater precision for individualized treatment requires further investigation. These methods will need to demonstrate substantially superiority to simpler tools for detecting glucose disorders to justify their cost and complexity.

Diagnosis of Diabetes Mellitus in Older Adults

In the United States, 4 out of 10 adults with diabetes are ≥65 years of age. The older adult with diabetes is very likely to be asymptomatic and also at higher risk of vascular disease. New concerns include new diagnosis of diabetes for older adults admitted to hospital and older adults in long-term care facilities. The pathophysiology for increased incidence of diabetes in older adults is multifactorial, but dominant features are increased likelihood of metabolic syndrome, dysfunctional insulin secretion, and peripheral insulin resistance. Society in general benefits from more cost-effective care of older adults with diabetes.

Impact of mismatches in HbA1c vs glucose values on the diagnostic classification of diabetes and prediabetes

AIMS

To determine whether HbA_1c mismatches (HbA_1c levels that are higher or lower than expected for the average glucose levels in different individuals) could lead to errors if diagnostic classification is based only on HbA_1c levels.

METHODS

In a cross-sectional study, 3106 participants without known diabetes underwent a 75-g oral glucose tolerance test (fasting glucose and 2-h glucose) and a 50-g glucose challenge test (1-h glucose) on separate days. They were classified by oral glucose tolerance test results as having: normal glucose metabolism; prediabetes; or diabetes. Predicted HbA_1c was determined from the linear regression modelling the relationship between observed HbA_1c and average glucose (mean of fasting glucose and 2-h glucose from the oral glucose tolerance test, and 1-h glucose from the glucose challenge test) within oral glucose tolerance test groups. The haemoglobin glycation index was calculated as [observed - predicted HbA_1c ], and divided into low, intermediate and high haemoglobin glycation index mismatch tertiles.

RESULTS

Those participants with higher mismatches were more likely to be black, to be men, to be older, and to have higher BMI (all P<0.001). Using oral glucose tolerance test criteria, the distribution of normal glucose metabolism, prediabetes and diabetes was similar across mismatch tertiles; however, using HbA_1c criteria, the participants with low mismatches were classified as 97% normal glucose metabolism, 3% prediabetes and 0% diabetes, i.e. mostly normal, while those with high mismatches were classified as 13% normal glucose metabolism, 77% prediabetes and 10% diabetes, i.e. mostly abnormal (P<0.001).

CONCLUSIONS

Measuring only HbA_1c could lead to under-diagnosis in people with low mismatches and over-diagnosis in those with high mismatches. Additional oral glucose tolerance tests and/or fasting glucose testing to complement HbA_1c in diagnostic classification should be performed in most individuals.

Reproducibility of a prediabetes classification in a contemporary population

Aims

To assess whether meeting both fasting plasma glucose (FPG) and HbA1c criteria for prediabetes in people at high risk indicates with near certainty the presence of dysglycemia on repeat testing.

Methods

Observational study using data from Vitamin D and Type 2 Diabetes (D2d) study. HbA1c, FPG were measured at screening visit 1; FPG, HbA1c and 2 h plasma glucose (2hPG) measured at screening visit 2 (a median of 21 days later); participants classified as having normal glucose regulation (all 3 tests in normal range), prediabetes or diabetes (at least 1 of 3 tests in diabetes range). A predictive model was developed to estimate the probability of confirming dysglycemia and for detecting diabetes at screening visit 2 based on values of FPG and HbA1c at screening visit 1.

Results

Of 1271 participants who met both FPG and HbA1c criteria for prediabetes at screening visit 1, 98.6% exhibited dysglycemia (defined as prediabetes or diabetes) on repeat testing (84.5% were classified as having prediabetes, 14.1% were reclassified as having diabetes). Of those with diabetes, 62.6% were identified by 2hPG alone.

Conclusions

Combined measurement of FPG and HbA1c is a reliable and reproducible measure to identify presence of dysglycemia among people at high risk. A prediction model is provided to help clinicians decide whether an oral glucose tolerance test will provide value in detecting diabetes based on the 2hPG criterion.

Prevalence of pre-diabetes and undiagnosed diabetes in the Mollerussa prospective observational cohort study in a semi-rural area of Catalonia

OBJECTIVES

To assess the prevalence of undiagnosed diabetes and pre-diabetes in the healthy population in the Mollerussa cohort. As a secondary objective, to identify the variables associated with these conditions and to describe the changes in glycaemic status after 1 year of follow-up in subjects with pre-diabetes.

DESIGN

Prospective observational cohort study.

SETTING

General population from a semi-rural area.

PARTICIPANTS

The study included 583 participants without a diagnosis of diabetes recruited between March 2011 and July 2014.

RESULTS

The prevalence of undiagnosed diabetes was 20, 3.4% (95% CI 2.6 to 4.2) and that of pre-diabetes was 229, 39.3% (37.3 to 41.3). Among those with pre-diabetes, 18.3% had isolated impaired fasting plasma glucose (FPG) (FPG: 100 to <126 mg/dL), 58.1% had isolated impaired glycated haemoglobin (HbA1c) (HbA1c 5.7 to <6.5) and 23.6% fulfilled both criteria. Follow-up data were available for 166 subjects; 41.6%(37.8 to 45.4) returned to normoglycaemia, 57.6% (57.8 to 61.4) persisted in pre-diabetes and 0.6% (0 to 1.2) progressed to diabetes. Individuals with pre-diabetes had worse cardiometabolic risk profiles and sociodemographic features than normoglycaemic subjects. In the logistic regression model, variables significantly associated with pre-diabetes were older age (OR; 95% CI) (1.033; 1.011 to 1.056), higher physical activity (0.546; 0.360 to 0.827), body mass index (1.121; 1.029 to 1.222) and a family history of diabetes (1.543; 1.025 to 2.323). The variables significantly associated with glycaemic normalisation were older age (0.948; 0.916 to 0.982) and body mass index (0.779; 0.651 to 0.931).

CONCLUSIONS

Among adults in our region, the estimated prevalence of undiagnosed diabetes was 3.4% and that of pre-diabetes was 39.3%. After a 1-year follow-up, a small proportion of subjects (0.6%) with pre-diabetes progressed to diabetes, while a high proportion (41.6%) returned to normoglycaemia. Individuals with pre-diabetes who returned to normoglycaemia were younger and had a lower body mass index.

Association of neutrophil-gelatinase-associated lipocalin with microvascular complications in patients with type 2 diabetes: a cross-sectional study

Diabetic nephropathy and diabetic retinopathy are serious microvascular complications of diabetes mellitus. Recent studies have demonstrated that neutrophil-gelatinase-associated lipocalin (NGAL) may be accompanied by these complications during and before the appearance of microalbuminuria. In this study, we set out to research the role of NGAL in patients with diabetic nephropathy and diabetic retinopathy.

Material and methods

Eighty-two patients with type 2 diabetes were enrolled in our study. Urinary microalbumine and NGAL levels were measured in urine samples over 24 hours. We also studied NGAL levels in serum. All patients went through an ophthalmologic examination. The results were evaluated based on the presence of microalbuminuria and retinopathy.

Results

There were no significant differences in serum and urine NGAL levels between normoalbuminuric (n = 66) and microalbuminuric (n = 16) patients. We also did not find any significant difference in patients with retinopathy (n = 16) or without retinopathy (n = 66).

Conclusion

There are controversial findings about the role of NGAL in diabetic patients in medical literature. Standard values of urine and serum NGAL levels have yet to be determined. Our study suggests that NGAL is not a useful marker to differentiate microalbuminuric patients from normoalbuminuric subjects. We also did not find a relationship between NGAL levels and the presence of retinopathy. Additional studies with larger sample sizes will be required to confirm or refute these findings.

Comparing the Frequency of Some Oral Lesions in Prediabetic and Healthy Individuals: Is There Any Difference?

BACKGROUND

Diagnosis of prediabetic stage is very important for prevention of diabetes and complications. This stage may be associated with some oral lesions. Only a few studies are available on the oral status of prediabetic patients and incidence of oral lesions in this population. This study aimed to compare some oral complications between prediabetic and healthy control groups.

METHODS

The present two-group cross-sectional study was carried out on 302 prediabetic and non-diabetic (healthy) 20- to 60-year-old subjects. In this study, data on age, gender, educational level, medications use, smoking, and some other variables were extracted through history taking. In addition, orodental examination was carried out by an oral medicine specialist to diagnose oral lesions including candidiasis, lichen planus, periodontitis, gingivitis, xerostomia, delayed wound healing, geographic tongue, fissured tongue, and burning mouth sensation. Data entry and analysis was performed by SPSS version 22 software, and P value and odds ratio (OR) were calculated to show statistical relationship between variables.

RESULTS

The most common oral lesion in prediabetic subjects was periodontitis (27.2%), followed by gingivitis (14.7%) and xerostomia (11.3%). In the control group, gingivitis (20.5%) followed by periodontitis (11.3%) are common oral lesions. Candidiasis (P = 0.036), periodontitis (P < 0.001), and xerostomia (P < 0.001) in prediabetic subjects were higher than control group that is statistically significant. Regression analysis showed that in the prediabetic group, periodontitis [OR = 2.91, confidence interval (CI): 1.54-5.49] and xerostomia (OR = 18.51, CI = 2.42-141.45) were significantly more prevalent than healthy subjects.

CONCLUSION

Based on the results, glucose intolerance stage exhibited a significantly higher oral problems such as periodontitis and xerostomia than healthy euglycemic stage.

Racial differences in performance of HbA1c for the classification of diabetes and prediabetes among US adults of non-Hispanic black and white race

AIM

To characterize differences between black and white people in optimal HbA_1c thresholds for diagnoses of diabetes and prediabetes.

METHODS

Data were included from the National Health and Nutrition Examination Survey, 2005-2014. Black and white adults (age 18-70 years) who underwent an oral glucose tolerance test and had available fasting plasma glucose, 2-h plasma glucose and HbA_1c measurements were eligible for inclusion. Diabetes or prediabetes status was defined by fasting plasma glucose and 2-h plasma glucose using American Diabetes Association criteria. Classification of diabetes, prediabetes and dysglycaemia by HbA_1c was evaluated for a range of HbA_1c thresholds, with optimal thresholds defined as those values that maximized the sum of sensitivity and specificity (Youden's index).

RESULTS

In 5324 black (32.3%) and white (67.7%) individuals, Youden's index (optimal) thresholds for HbA_1c were ≥42 mmol/mol (6.0%) and ≥39 mmol/mol (5.7%) for discriminating diabetes vs non-diabetes, ≥ 44 mmol/mol (6.2%) and ≥39 mmol/mol (5.7%) for discriminating diabetes vs prediabetes (excluding normoglycaemia), ≥39 mmol/mol (5.7%) and ≥37 mmol/mol (5.5%) for discriminating dysglycaemia vs normoglycaemia, and ≥39 mmol/mol (5.7%) and ≥37 mmol/mol (5.5%) for discriminating prediabetes vs normoglycaemia (excluding diabetes), in black and white people, respectively.

CONCLUSIONS

Consistently higher optimal HbA_1c thresholds in black people than in white people suggest a need to individualize HbA_1c relative to glucose levels if HbA_1c is used to diagnose diabetes and prediabetes.

Prediabetes defined by HbA1c and by fasting glucose: differences in risk factors and prevalence

AIMS

To investigate, in a sample of nondiabetic adults from a Spanish community, the differences between prediabetes as defined by HbA_1c ("H-prediabetes") and by fasting plasma glucose (FPG) ("F-prediabetes") in regard to prevalence and the influence of potential risk factors, adjusting the latter for confounders.

METHODS

A total of 1328 nondiabetic participants aged ≥ 18 years were classified as normoglycemic, H-prediabetic [HbA_1c 5.7-6.4% (39-47 mmol/mol)] or F-prediabetic (FPG 5.6-6.9 mmol/L). Multivariable analyses were used to compare the impacts of risk factors on the prevalence of H-prediabetes, F-prediabetes and their conjunctive and disjunctive combinations ("HaF-prediabetes" and "HoF-prediabetes," respectively).

RESULTS

Some 29.9% of participants were HoF-prediabetic, 21.7% H-prediabetic, 16.3% F-prediabetic and only 8.1% HaF-prediabetic. Whatever the definition of prediabetes, increasing age, fasting insulin and LDL cholesterol were each a risk factor after adjustment for all other variables. Increasing BMI and decreasing mean corpuscular hemoglobin (MCH) were additional risk factors for H-prediabetes; male sex and increasing uric acid for F-prediabetes and increasing BMI for HaF-prediabetes. The participants satisfying the compound condition "hypertension or hyperlipidemia or obesity or hyperuricemia" (59.9% of the whole study group) included 83.1% of all subjects with HoF-prediabetes.

CONCLUSIONS

In this population, the most sensitive risk factor for detection of prediabetes was age, followed by fasting insulin, LDL cholesterol, BMI, MCH, male sex and uric acid, with differences depending on the definition of prediabetes. MCH, an indirect measure of erythrocyte survival, significantly influences the prevalence of HbA_1c-defined prediabetes. This study suggests that screening of individuals with selected risk factors may identify a high proportion of prediabetic persons.

The Legacy Effect in Type 2 Diabetes: Impact of Early Glycemic Control on Future Complications (The Diabetes & Aging Study)

OBJECTIVE

To examine for a legacy effect of early glycemic control on diabetic complications and death.

RESEARCH DESIGN AND METHODS

This cohort study of managed care patients with newly diagnosed type 2 diabetes and 10 years of survival (1997-2013, average follow-up 13.0 years, N = 34,737) examined associations between HbA1c <6.5% (<48 mmol/mol), 6.5% to <7.0% (48 to <53 mmol/mol), 7.0% to <8.0% (53 to <64 mmol/mol), 8.0% to <9.0% (64 to <75 mmol/mol), or ≥9.0% (≥75 mmol/mol) for various periods of early exposure (0-1, 0-2, 0-3, 0-4, 0-5, 0-6, and 0-7 years) and incident future microvascular (end-stage renal disease, advanced eye disease, amputation) and macrovascular (stroke, heart disease/failure, vascular disease) events and death, adjusting for demographics, risk factors, comorbidities, and later HbA1c.

RESULTS

Compared with HbA1c <6.5% (<48 mmol/mol) for the 0-to-1-year early exposure period, HbA1c levels ≥6.5% (≥48 mmol/mol) were associated with increased microvascular and macrovascular events (e.g., HbA1c 6.5% to <7.0% [48 to <53 mmol/mol] microvascular: hazard ratio 1.204 [95% CI 1.063-1.365]), and HbA1c levels ≥7.0% (≥53 mmol/mol) were associated with increased mortality (e.g., HbA1c 7.0% to <8.0% [53 to <64 mmol/mol]: 1.290 [1.104-1.507]). Longer periods of exposure to HbA1c levels ≥8.0% (≥64 mmol/mol) were associated with increasing microvascular event and mortality risk.

CONCLUSIONS

Among patients with newly diagnosed diabetes and 10 years of survival, HbA1c levels ≥6.5% (≥48 mmol/mol) for the 1st year after diagnosis were associated with worse outcomes. Immediate, intensive treatment for newly diagnosed patients may be necessary to avoid irremediable long-term risk for diabetic complications and mortality.

Alcohol consumption and diabetes risk in a Chinese population: a Mendelian randomization analysis

AIM

To assess the causality between alcohol intake, diabetes risk and related traits.

DESIGN

Mendelian randomization (MR) study. Subgroup analysis, standard instrumental variable analysis and local average treatment effect (LATE) methods were applied to assess linear and non-linear causality.

SETTING

China.

PARTICIPANTS

A total of 4536 participants, including 721 diabetes cases.

FINDINGS

Carriage of an ALDH2 rs671 A allele reduced alcohol consumption by 44.63% [95% confidence interval (CI) = -49.44%, -39.37%]. In males, additional carriage of an A allele was significantly connected to decreased diabetes risk for the overall population [odds ratio (OR) = 0.716, 95% CI = 0.567-0.904, P = 0.005] or moderate drinkers (OR = 0.564, 95% CI = 0.355-0.894, P = 0.015). In instrumental variable (IV) analysis, increasing alcohol consumption by 1.7-fold was associated with an incidence-rate ratio of 1.32 (95% CI = 1.06-1.67, P = 0.014) for diabetes risk, and elevated alcohol intake was causally connected to natural log-transformed fasting, 2-hour post-load plasma glucose (β = 0.036, 95% CI = 0.018-0.054; β = 0.072, 95% CI = 0.035-0.108) and insulin resistance [homeostatic model assessment for IR (HOMA-IR] (β = 0.104, 95% CI = 0.039-0.169), but was not associated with beta-cell function (HOMA-beta). In addition, the LATE method did not identify significant U-shaped causality between alcohol consumption and diabetes-related traits. In females, the effects of alcohol intake on all the outcomes were non-significant.

CONCLUSION

Among men in China, higher alcohol intake appears to be causally associated with increased diabetes risk and worsened related traits, even for moderate drinkers. This study found no significant U-shaped causality between alcohol consumption and diabetes-related traits.

Senescent T Cells Predict the Development of Hyperglycemia in Humans

Senescent T cells have been implicated in chronic inflammatory and cardiovascular diseases. In this study, we explored the relationship between senescent T cells and glycemic status in a cohort of 805 participants by investigating the frequency of CD57⁺ or CD28^null senescent T cells in peripheral blood. Participants with normal glucose tolerance (NGT) with follow-up data (N = 149) were included to determine whether hyperglycemia (prediabetes or type 2 diabetes) developed during follow-up (mean 2.3 years). CD8⁺CD57⁺ and CD8⁺CD28^null T-cell frequencies were significantly higher in prediabetes and type 2 diabetes compared with NGT. Increased CD57⁺ or CD28^null cells in the CD8⁺ T-cell subset were independently associated with hyperglycemia. Furthermore, among participants with baseline NGT, the frequency of CD8⁺CD57⁺ T cells was an independent predictor of hyperglycemia development. Immunofluorescent analyses confirmed that CD8⁺CD57⁺ T-cell infiltration was increased in visceral adipose tissue of patients with prediabetes or type 2 diabetes compared with those with NGT. Our data suggest that increased frequency of senescent CD8⁺ T cells in the peripheral blood is associated with development of hyperglycemia.

Not performing an OGTT results in underdiagnosis, inadequate risk assessment and probable cost increases of (pre)diabetes in Han Chinese over 40 years: a population-based prospective cohort study

OBJECTIVE

To explore the influence by not performing an oral glucose tolerance test (OGTT) in Han Chinese over 40 years.

DESIGN

Overall, 6682 participants were included in the prospective cohort study and were followed up for 3 years.

METHODS

Fasting plasma glucose (FPG), 2-h post-load plasma glucose (2h-PG), FPG and 2h-PG (OGTT), and HbA1c testing using World Health Organization (WHO) or American Diabetes Association (ADA) criteria were employed for strategy analysis.

RESULTS

The prevalence of diabetes is 12.4% (95% CI: 11.6-13.3), while the prevalence of prediabetes is 34.1% (95% CI: 32.9-35.3) and 56.5% (95% CI: 55.2-57.8) using WHO and ADA criteria, respectively. 2h-PG determined more diabetes individuals than FPG and HbA1c. The testing cost per true positive case of OGTT is close to FPG and less than 2h-PG or HbA1c. FPG, 2h-PG and HbA1c strategies would increase costs from complications for false-positive (FP) or false-negative (FN) results compared with OGTT. Moreover, the least individuals identified as normal by OGTT at baseline developed (pre)diabetes, and the most prediabetes individuals identified by HbA1c or FPG using ADA criteria developed diabetes.

CONCLUSIONS

The prevalence of isolated impaired glucose tolerance and isolated 2-h post-load diabetes were high, and the majority of individuals with (pre)diabetes were undetected in Chinese Han population. Not performing an OGTT results in underdiagnosis, inadequate developing risk assessment and probable cost increases of (pre)diabetes in Han Chinese over 40 years and great consideration should be given to OGTT in detecting (pre)diabetes in this population. Further population-based prospective cohort study of longer-term effects is necessary to investigate the risk assessment and cost of (pre)diabetes.

Trends in the prevalence of type 2 diabetes and prediabetes in a Japanese community, 1988-2012: the Hisayama Study

Objective

We estimated secular trends in the prevalence of type 2 diabetes (T2DM) and prediabetes, and examined potential explanatory factors for these trends in a Japanese community.

Methods

4 cross-sectional examinations were conducted among subjects aged 40-79 years in 1988 (n = 2,490), 2002 (n = 2,856), 2007 (n = 2,761), and 2012 (n = 2,644). Glucose tolerance status was defined by a 75g oral glucose tolerance test.

Results

The age-standardized prevalence of T2DM increased significantly in both sexes from 1988 to 2002, and thereafter it remained stable in men, and decreased nonsignificantly in women from 2002 to 2012. The age-standardized prevalence of prediabetes in men increased significantly between 1988 and 2002, but then decreased significantly. A similar trend was observed in women. The age-specific prevalence of T2DM increased greatly in men aged 60-79 years and women aged 70-79 years from 1988 to 2002, and then plateaued at a high level, while a significant decreasing trend was observed in women aged 40-49 years. The mean values of body mass index (BMI) increased steeply in these elderly subjects from 1988 to 2002, and remained at a high level, whereas those in middle-aged women decreased appreciably over the study period.

Conclusions

Our findings suggest that in Japanese, there was no further increase in the prevalence of T2DM or prediabetes in either men or women in the 2000s. Secular change in the BMI level was likely to contribute to trends in the prevalence of T2DM, and thus the management of obesity may be important to reduce the prevalence of T2DM.

Prevalence of moderately increased albuminuria among individuals with normal HbA1c level but impaired glucose tolerance: Results from the LIFE-Adult-Study

AIMS

Diabetes screening strategies using glycated haemoglobin (HbA1c) as first-instance diagnostic parameter may cause failure to detect individuals with abnormal glucose regulation and possible signs of microvascular complications despite "rule-out" HbA1c levels. This cross-sectional study examined the diagnostic performance of HbA1c in relation to fasting and two-hour postload plasma glucose (FPG/2 h-PG), and investigated whether individuals with normal HbA1c but abnormal FPG/2 h-PG have a higher prevalence of moderately increased albuminuria as possible sign of early stage kidney damage.

METHODS

A total of 2695 individuals (age 40-79 years, 48% men) without prior diagnosis of diabetes and complete measurement of HbA1c, FPG, 2 h-PG and urine albumin-creatinine ratio (UACR) were taken from a large population-based epidemiological study in the City of Leipzig, Germany.

RESULTS

A total of 2439 individuals (90.5%, 95% CI: 89.4-91.6) had normal HbA1c levels, <39 mmol/mol (<5.7%), while 234 (8.7%, 95% CI: 7.7-9.8) had prediabetes, HbA1c ≥39 and <48 mmol/mol (≥5.7 and <6.5%), and 22 (0.8%, 95% CI: 0.5-1.2) had diabetes, HbA1c ≥48 mmol/mol (≥6.5%), according to HbA1c. Among individuals with normal HbA1c, 35.6% (95% CI: 33.7-37.5) had impaired fasting glucose or impaired glucose tolerance and 1.8% (95% CI: 1.4-2.4) had diabetes according to FPG/2 h-PG. Individuals with normal HbA1c but prediabetic or diabetic FPG/2 h-PG had a significantly higher prevalence of moderately increased albuminuria (9.4%, 95% CI: 7.6-11.5 and 13.3%, 95% CI: 5.8-25.4, respectively) than individuals with normal HbA1c and normal FPG/2 h-PG (3.9%, 95% CI: 3.0-5.0).

CONCLUSIONS

The prevalence of prediabetes according to FPG/2 h-PG among individuals with normal HbA1c is considerably high, and the prevalence of moderately increased albuminuria in this group is significantly elevated. Risk factors for diabetes such as age, gender and BMI may help to better identify this at-risk group.

Evidence for the utility of antenatal HbA1c to predict early postpartum diabetes after gestational diabetes in South Africa

Aim To evaluate antenatal HbA1c at diagnosis and in the 4 weeks preceding delivery to predict early postpartum diabetes mellitus (DM) in women with Gestational Diabetes Mellitus (GDM). Methods Seventy-eight women with GDM were prospectively assessed. The ability of HbA1c at GDM diagnosis (t1) and in the 4 weeks preceding delivery (t2) to predict DM 6-12 weeks after delivery was investigated. Glucose assessment was performed between November 1, 2015, and November 1, 2016 at Tygerberg Hospital (TH), Cape Town, South Africa (SA). Individuals with known pre-existing diabetes were excluded. Results HbA1c of 6.2% (44 mmol/mol) and 6.5% (48 mmol/mol) at t1 predicted DM with sensitivities of 95% and 90% and specificities of 62% and 70% respectively. At t2 the best cut-off for HbA1c, in accordance with t1, was also 6.2% (44 mmol/mol; sensitivity 92%, specificity 56%). Nineteen of the 29 women with suspected pre-gestational DM had HbA1c levels ≥ 6.5% (48 mmol/mol) at t1. The increased risk for postpartum DM with HbA1c ≥ 6.2% (44 mmol/mol) was four-fold (OR 3.97 CI 2.08-7.59p < 0.001) at t1 and five-fold (OR 5.08 CI 1.60-16.25 p = 0.006) at t2. Conclusion HbA1c lower than 6.5% (48 mmol/mol) predicts postpartum DM in women with GDM. HbA1c can serve as instrument to improve postpartum follow-up.