Contributions of 2‐h post‐load glucose, fasting blood glucose and glycosylated haemoglobin elevations to the prevalence of diabetes and pre‐diabetes in adults: A systematic analysis of global data

Early pregnancy glycaemia predicts postpartum diabetes mellitus

Objective To determine the association of an elevated hemoglobin A1c (HbA1c) as part of an early pregnancy universal screening protocol and postpartum (PP) weight retention in the absence of a diagnosis of diabetes. Methods This is a retrospective cohort study of patients who underwent universal HbA1c screening with initial prenatal labs (≤16 weeks) over a 2-year period (2016–2018) at a single urban tertiary care center. An elevated HbA1c was defined as 5.7–6.4%. All patients who delivered ≥32 weeks with documented weights at first prenatal visit, delivery, and PP visit were included. Patients with preexisting or gestational diabetes, multiple gestation, fetal demise, or no glucose tolerance screening were excluded. Body mass index (BMI) was calculated and gestational weight gain was assessed by National Academy of Medicine (NAM) guidelines. The primary outcome was PP weight retention among patients with normal versus elevated HbA1c. Results 2,284 patients met inclusion criteria, of whom 2015 (88.2%) had a normal HbA1c and 269 (11.8%) had an elevated HbA1c. Compared to patients with a normal HbA1c, patients with an elevated HbA1c were more likely to be non-Hispanic black, multiparous, or publicly insured. They were also more likely to enter pregnancy obese. Patients with an elevated HbA1c gained less weight during pregnancy compared to those with normal HbA1c; however, this was no longer significant after adjusting for pre-pregnancy BMI. In both groups, almost half of patients exceeded NAM guidelines for gestational weight gain during the pregnancy. Patients with an elevated HbA1c had significantly less PP weight retention (2.2 vs. 4.5 kg, p < .001) compared to patients with a normal HbA1c. After adjusting for differences in baseline characteristics, the association between HbA1c and PP weight retention remained significant (B = −0.86, p < .003). More patients in the elevated HbA1c group returned to their pre-pregnancy weight or less by the PP visit. In all BMI categories, those who exceeded NAM guidelines had greater postpartum weight retention compared to those that met guidelines Conclusion Among patients not diagnosed with diabetes, elevated HbA1c in early pregnancy is associated with similar gestational weight gain but significantly less postpartum weight retention compared to those with normal HbA1c.

Diabetes mellitus (DM) is a major public health problem in Oman. We evaluated the impact of the revised diagnostic criteria for DM adopted by the American Diabetes Association (ADA) on the prevalence of diabetes and impaired glucose tolerance (IGT), and on the classification of individuals among the Omani population. We used the dataset of the National Diabetes Survey, conducted in 1991 and involving 4682 subjects who did not have any missing data on fasting and 2-hour glucose. The subjects comprised 2002 males and 2680 females aged 20 years or above. Data were analyzed using the ADA criteria (diabetes as fasting plasma glucose [FPG] > or =7 mmol/L, impaired fasting glucose [IFG] as FPG > or =6.1 mmol/L and <7 mmol/L), and compared these with the World Health Organization (WHO) criteria (diabetes as FPG > or =7.8 mmol/L and/or 2-hour post-glucose load > or =11.1 mmol/L, IGT as FPG <7.8 mmol/L, and 2-hour post-load 7.8-11.1 mmol/L). Applying the ADA criteria on the Omani population resulted in an overall reduction of diabetes prevalence by 2.2% (95% confidence interval [CI] 1.6% to 2.8%), and a 4.8% reduction of IGT (95% CI 3.8% to 5.8%). Over 29% of diabetics classified by the WHO criteria were reclassified as being normal or having IFG by the ADA criteria. Around 3.6% of those who were normoglycemic by the WHO criteria were classified as having diabetes or IFG by the ADA criteria. In all but one region of Oman, the prevalence of diabetes and IFG using the ADA criteria was lower compared to the prevalence using the WHO criteria. Gender, age and body mass index did not seem to pose an increased risk to the probability of being diagnosed by one criteria or the other or both together. The adoption of the ADA criteria in Oman will significantly reduce the prevalence of diabetes and IGT. In addition, the glycemic status of a substantial number of individuals will be changed from normal to either being diabetic or having IGT.

HbA1c testing provides average blood glucose control, an elevated result may be associated with adverse post-operative outcomes. Our objective was to evaluate the association between elevated pre-operative HbA1c and post-operative complications in patients undergoing major gynaecological oncology surgery. HbA1c was measured pre-operatively in 364 patients. We identified 65 (16%) patients at risk of developing diabetes with borderline HbA1c measurements. Patients with borderline HbA1c (42–47 mmol/mol) had almost double the incidence of infections compared to patients with normal HbA1c (15.8% vs. 6.5%, p=.038). There were significantly less infections between patients with a normal HbA1c (<42 mmol/mol) and those with an HbA1c of over 42 mmol/mol (6.5% vs. 22.8%, p<.05). There was an association between elevated HbA1c and infective complications especially in patients with a borderline HbA1c. It is suggested that knowing HbA1c status, intervention can be made to prevent post-operative infective complications and improve outcomes. Impact statement What is already known on this subject? Obesity is a common risk factor for gynaecological cancer and elevated HbA1c. Chronically elevated HbA1c may lower immunity. An association has been shown previously between elevated HbA1c and post-operative complications. What the results of this study add? This study examined infective complications in patients undergoing gynaecological surgery; showing that patients with a borderline HbA1c (42–47 mmol/mol), especially those with a diagnosis of diabetes to be most at risk. This suggests that pre-operative HbA1c should be used routinely to guide care rather than diabetic status alone to prevent post-operative infections. What the implications are of these findings for clinical practice and/or further research? More research needs to be carried out to find the optimal pre-operative HbA1c targets to reduce post-operative infection rates. Work needs to be done in conjunction with general practitioners to help patients to reduce their HbA1c prior to treatment.

Introduction. Fasting glucose (FG) is part of the Adult Treatment Panel III (ATP III) criteria for defining the metabolic syndrome (MetS). Glycated hemoglobin (HbA1c) is a measure of 2-3 month endogenous glucose exposure and is now recommended for diabetes diagnosis and screening for high-risk individuals. The aim of this study was to evaluate if replacing FG with HbA1c to define MetS improves prediction of incident coronary heart disease (CHD) in the Atherosclerosis Risk in Communities (ARIC) cohort. Methods. We included 11,194 ARIC participants without diabetes (based on diagnosis, medication use, FG ≥126 mg/dL, or HbA1c ≥6.5%) or prevalent CHD at baseline (1990-92). Cox proportional hazards models (adjusted for age, race, and study center) were used to compare the association between MetS defined using HbA1c (5.7-6.4%) or FG (100-125 mg/dL, based on ATP III guidelines) and risk of CHD (defined by myocardial infarction or fatal CHD, event data available through 2009). Results. Study participants had a mean age at baseline of 57 years, 43% were male, and 79% were white; median follow-up time was 16 years. Thirty-four percent of the study population had both normal FG (&lt;100 mg/dL) and HbA1c (&lt;5.7%), 37% had elevated FG and normal HbA1c, 4% had normal FG and elevated HbA1c, and 25% had both elevated FG (100-125 mg/dL) and HbA1c (5.7-6.4%). The association of combined FG and HbA1c categories with incident CHD are shown in the Figure. The adjusted hazard ratio predicting for incident CHD from MetS status was 1.43 (95% CI: 1.25-1.63, c-statistic: 0.61) using FG in the definition of MetS and 1.69 (95% CI: 1.48-1.93, c-statistic: 0.62) in the model replacing FG with HbA1c. Conclusions. Incorporating HbA1c into the definition of the MetS may help in identifying individuals who should be targeted for aggressive CHD risk factor reduction. Additionally, HbA1c may be useful clinically and in research settings for identifying individuals with MetS in cases where FG measures are not available.

Background The glycated haemoglobin (HbA1c) test is a venous blood test used as a diagnostic test for diabetes mellitus and to monitor glucose control in patients known to have diabetes. The test has been recommended by National Institute for Health Care Excellence (NICE) clinical guidelines in the pre-operative setting since 2016. The purpose of testing is to reduce perioperative morbidity and mortality by optimising management of blood glucose levels in the perioperative period. The aim of this study was to assess the prognostic value of HbA1c in pancreatic cancer patients treated with pancreaticoduodenectomy. Methods This is a retrospective analysis of a prospectively managed database of pancreatic resections at a single institution from January 2016 to December 2020. Included patients had confirmed pancreatic adenocarcinoma and underwent a pancreaticoduodenectomy with preoperative measurement of their HbA1c. Patients who were already prescribed insulin were excluded. Demographic data, survival, operative and perioperative details were collected. Included patient records were assessed for the incidence of postoperative complications in accordance with International Study Group of Pancreatic Surgery guidelines for pancreatic fistula, delayed gastric emptying and post pancreatectomy haemorrhage. An HbA1c greater than 41 was deemed elevated. Results There were 145 patients who met the inclusion criteria. The HbA1c level was normal in 101/145 (70%) and elevated in 44/45 (30%). The postoperative pancreatic fistula rate was 18% in the patients with a normal HbA1c and 23% in those with elevated HbA1c (p = 0.499). The rate of delayed gastric emptying was 21 and 23% in the patients with normal and elevated HbA1c respectively. There were five relaparotomies overall, one of these patients had an elevated preoperative HbA1c. There were no perioperative deaths. Overall survival was 31months (95%CI 27-35) with a normal preoperative HbAlc and 32months (95%CI 27-38) if elevated. Conclusions There is little doubt that the preoperative HbA1c is helpful in the package of preoperative assessment tests to optimise patients for surgery. However, the preoperative HbA1c level in patients planned for pancreaticoduodenectomy is not predictive of pancreaticoduodenectomy specific complications such as postoperative pancreatic fistula, delayed gastric emptying, relaparotomy or mortality. In addition, long-term overall survival is not influenced by an elevated preoperative HbAlc.

BackgroundTo investigate the influence of HbA1c level and GWG on pregnancy outcomes in pregnant women with GDM.MethodsA total of 2,171 pregnant women with GDM were retrospectively included and categorized as follows: (1) normal (HbA1c <6%) and elevated (HbA1c ≥6%) HbA1c groups according to the HbA1c level in the second trimester, and (2) inadequate, appropriate, and excessive GWG groups according to the IOM guidelines.ResultsIn pregnant women with GDM, advanced age and high pre-pregnancy BMI were high-risk factors for elevated HbA1c. Pregnant women with elevated HbA1c had higher OGTT levels than those with normal HbA1c, and the risks of adverse pregnancy outcomes were higher (P < 0.05). The risks of primary cesarean section, hypertensive disorders during pregnancy, and macrosomia in pregnant women with excessive GWG were significantly higher than those with inadequate and appropriate GWG (P < 0.05). When GWG was appropriate, the risk of hypertensive disorders during pregnancy in the elevated HbA1c group was higher than that in the normal HbA1c group. When GWG was excessive, the risks of postpartum hemorrhage, macrosomia, and neonatal asphyxia in the elevated HbA1c group were significantly higher than in the normal HbA1c group (P < 0.05).ConclusionMonitoring and controlling blood glucose levels have shown effectiveness in reducing the adverse pregnancy outcomes in women with GDM, particularly for those who had excessive GWG.

165 Elevated hemoglobin A1c and postpartum weight retention

In 1997 the American Diabetes Association (ADA) published new categories for diabetes based on fasting plasma glucose that classified diabetes as a plasma glucose of 7.0 mmol/l, or more, rather than one of 7.8 mmol/l or more, as published previously by the National Diabetes Data Group (NDDG) in 1979. We compared the cardiovascular disease risk factors of subjects classified as having Type II (non-insulin-dependent) diabetes mellitus under the NDDG and ADA criteria. We examined a database of approximately 3,700 men (40.4 +/- 11.5 years old) and distributed them into four categories: normal fasting plasma glucose (NFG) of less than 6.1 mmol/l, impaired (IFG) 6.1 to 7.0 mmol/l, ADA diabetic 7.0 to 7.8 mmol/l and NDDG diabetic of 7.8 mmol/l or more. Fasting glucose was 5.2 +/- 0.5, 6.4 +/- 0.2, 7.3 +/- 0.2 and 11.2 +/- 2.9 mmol/l for the subjects of the NFG, IFG, ADA and NDDG groups, respectively. Estimated treadmill VO2max was 41.4 +/- 8.0, 36.0 +/- 7.8, 32.2 +/- 7.6, 30.6 +/- 7.0 ml x kg(-1) x min(-1) in the NFG, IFG, ADA, and NDDG groups, respectively (NFG and IFG > ADA and NDDG: p < 0.05). The ADA and NDDG groups were also similar for resting and exercise blood pressure and body composition. Triglycerides and total: HDL cholesterol ratios were higher and LDL cholesterol concentration was lower, in the NDDG group than in all other groups (p < 0.05). Total and LDL cholesterol in the ADA and NDDG groups were similar. The similarities in the aerobic capacities, blood pressure and body composition of the ADA and NDDG groups indicate that the decision to lower the cut-off from 7.8 mmol/l to 7.0 mmol/l blood glucose for the clinical classification of diabetes was appropriate. The ADA and NDDG groups, however, might not have identical risks for cardiovascular disease because of differences between total:HDL cholesterol ratios, circulating HDL cholesterol and triglyceride concentrations.

OBJECTIVETo determine which measures—impaired fasting glucose (IFG), elevated HbA1c, or both—best predict incident diabetes in older adults.RESEARCH DESIGN AND METHODSFrom the Health, Aging, and Body Composition study, we selected individuals without diabetes, and we defined IFG (100–125 mg/dL) and elevated HbA1c (5.7–6.4%) per American Diabetes Association guidelines. Incident diabetes was based on self-report, use of antihyperglycemic medicines, or HbA1c ≥6.5% during 7 years of follow-up. Logistic regression analyses were adjusted for age, sex, race, site, BMI, smoking, blood pressure, and physical activity. Discrimination and calibration were assessed for models with IFG and with both IFG and elevated HbA1c.RESULTSAmong 1,690 adults (mean age 76.5, 46% men, 32% black), 183 (10.8%) developed diabetes over 7 years. Adjusted odds ratios of diabetes were 6.2 (95% CI 4.4–8.8) in those with IFG (versus those with fasting plasma glucose [FPG] <100 mg/dL) and 11.3 (7.8–16.4) in those with elevated HbA1c (versus those with HbA1c <5.7%). When FPG and HbA1c were considered together, odds ratios were 3.5 (1.9–6.3) in those with IFG only, 8.0 (4.8–13.2) in those with elevated HbA1c only, and 26.2 (16.3–42.1) in those with both IFG and elevated HbA1c (versus those with normal FPG and HbA1c). Addition of elevated HbA1c to the model with IFG resulted in improved discrimination and calibration.CONCLUSIONSOlder adults with both IFG and elevated HbA1c have a substantially increased odds of developing diabetes over 7 years. Combined screening with FPG and HbA1c may identify older adults at very high risk for diabetes.

To examine the implications for epidemiological studies of the American Diabetes Association (ADA) recommendation that the fasting blood glucose at a lowered level becomes the main diagnostic test for diabetes on cross-sectional-based data from sub-Saharan Africa. Data from 11 surveys conducted in rural, peri-urban and urban Cameroon (n = 1804), South Africa (n = 3799) and Tanzania (n = 10013) which measured fasting (ADA criteria) and 2-h blood glucose concentrations during a standard 75 g OGTT (old WHO criteria) were analysed. The prevalence of diabetes was higher in eight of the 11 surveys when applying the new ADA compared to the old WHO criteria. With the exception of one population (Mara, Tanzania) the absolute difference in prevalence between the two classifications tended to be small (< 2%). There was considerable variation in the categorization of individuals using the ADA and old WHO criteria. The level of agreement between the two ranged from fair to good (Kappa statistic 0.17-0.86). The prevalence of impaired fasting glycaemia (IFG) was lower than that of impaired glucose tolerance (IGT) in 10 of the surveys and the agreement between the two was fair, < or = 0.26 in all the surveys. Although the use of the new ADA fasting criteria for prevalence surveys is an attractive and practical option, particularly in Africa, further information is required on the characteristics and prognosis of individuals classified as IFG or diabetic by the fasting criteria, prior to wide adoption of the ADA criteria. Ideally measurement of both fasting and two low glucose concentrations should remain the standard for epidemiological studies.

3. The impact of elevated HbA1c on Surgical Site Infection and other infectious morbidities after isolated coronary artery bypass surgery

BackgroundAlthough an elevated hemoglobin A1c (HbAc1) level is an independent predictor of worse survival in patients with both digestive cancer and diabetes mellitus, its relationship to short-term prognosis in these patients has not been addressed. This study assessed this relationship in gastrointestinal cancer (GIC) patients with type 2 diabetes mellitus (T2DM).MethodsA retrospective review of patients with GIC with or without T2DM from 2004 to 2014 was performed. Patients with T2DM were grouped according to HbA1c level, either normal (mean < 7.0%) or elevated (mean ≥ 7.0%). Age- and sex-matched GIC patients without T2DM served as controls.ResultsOne hundred and eighteen patients aged 33 - 81 years with T2DM met the study eligibility criteria; 51 were in the normal HbA1c group, and 67 were in the elevated HbA1c group. The 91 patients in the non-T2DM group were randomly selected and matched to the T2DM group in terms of admittance date, age, and sex. There was a trend toward a higher 180-day mortality rate in the T2DM group compared with the non-T2DM group (15.3% vs. 7.7%, P = 0.095) and in the elevated HbA1c group compared with the normal HbA1c group (19.4% vs. 9.8%, P = 0.151); however, the differences were not significant. The duration of the hospital stay was longer in patients with T2DM than in those without T2DM (13.2 vs. 8.9 days, P < 0.05) and in patients with elevated versus normal HbA1c levels (14.5 vs. 11.4 days, P < 0.05). Diabetic GIC patients with elevated HbA1c levels had significantly more total postoperative complications than those with normal HbA1c levels (25.4% vs. 9.8%, P < 0.05). In multivariate regression analyses, short-term adverse outcomes were strongly associated with elevated HbA1c levels (odds ratio (OR): 5.276; 95% confidence level (CI): 1.73 - 16.095; P < 0.05) and no strict antidiabetic treatment (OR: 7.65; 95% CI: 2.49 - 23.54; P < 0.001).ConclusionAn elevated level of HbA1c significantly correlated with and was an independent predictor of short-term adverse outcomes in GIC patients with T2DM.

To determine the prevalence of diabetes, impaired glucose metabolism, and related risk factors in Tonga. A randomly selected representative national sample of 1,024 people aged >15 years was surveyed. Each participant had fasting blood glucose and HbA(1c) measured. Subjects with a fasting blood glucose >5.0 mmol/l (90 mg/dl) and <11.1 mmol/l (200 mg/dl) or a fasting blood glucose < or =5.0 mmol/l and an HbA(1c) >6.0% and every fifth subject with a fasting blood glucose < or =5.0 mmol/l and a normal HbA(1c) had a 75-g oral glucose tolerance test (OGTT). A total of 472 individuals had an OGTT based on these criteria. Subjects with a fasting blood glucose > or =11.1 mmol/l and an elevated HbA(1c) were diagnosed as having diabetes. The mean age was 41.3 years, and the mean BMI was 32.3 kg/m(2). The age-standardized prevalence of diabetes was 15.1% (CI 12.5-17.6), 12.2% (8.7-15.8) in men and 17.6% (14.0-21.1) in women (NS), of which only 2.1% was previously diagnosed. A total of 75% of people with newly diagnosed diabetes had a fasting plasma glucose > or =7.0 mmol/l (126 mg/dl). The prevalence of impaired glucose tolerance was 9.4% (7.3-11.5) and of impaired fasting glycemia 1.6% (0.7-2.6). Undiagnosed diabetes was significantly associated with increasing age, obesity, hypertension, and a family history of diabetes. The current prevalence of diabetes in Tonga is 15.1%, of which 80% is undiagnosed. A similar survey in 1973 reported a 7.5% diabetes prevalence, indicating a doubling of diabetes over the past 25 years. In addition, lesser degrees of glucose intolerance are common, and much of the community is overweight

BackgroundThere is still controversy surrounding the precise characterization of prediabetic population. We aim to identify and examine factors of demographic, behavioral, clinical, and biochemical characteristics, and obesity indicators (anthropometric characteristics and anthropometric prediction equation) for prediabetes according to different definition criteria of the American Diabetes Association (ADA) in the Chinese population.MethodsA longitudinal study consisted of baseline survey and two follow-ups was conducted, and a pooled data were analyzed. Prediabetes was defined as either impaired fasting glucose (IFG), impaired glucose tolerance (IGT), or elevated glycosylated hemoglobin (HbA1c) according to the ADA criteria. Robust generalized estimating equation models were used.ResultsA total of 5,713 (58.42%) observations were prediabetes (IGT, 38.07%; IGT, 26.51%; elevated HbA1c, 23.45%); 9.66% prediabetes fulfilled all the three ADA criteria. Among demographic characteristics, higher age was more evident in elevated HbA1c [adjusted OR (aOR)=2.85]. Female individuals were less likely to have IFG (aOR=0.70) and more likely to suffer from IGT than male individuals (aOR=1.41). Several inconsistency correlations of biochemical characteristics and obesity indicators were detected by prediabetes criteria. Body adiposity estimator exhibited strong association with prediabetes (D10: aOR=4.05). For IFG and elevated HbA1c, the odds of predicted lean body mass exceed other indicators (D10: aOR=3.34; aOR=3.64). For IGT, predicted percent fat presented the highest odds (D10: aOR=6.58).ConclusionSome correlated factors of prediabetes under different criteria differed, and obesity indicators were easily measured for target identification. Our findings could be used for targeted intervention to optimize preventions to mitigate the obviously increased prevalence of diabetes.