Mean A1C Levels Research Articles

Serum glycated albumin predicts the progression of carotid arterial atherosclerosis

IntroductionWe investigated the association between the ratio of serum glycated albumin (GA) levels to hyperglycemic levels (GA/A1c ratio) and the progression of carotid artery atherosclerosis. MethodsFor this retrospective longitudinal study we recruited patients who had undergone carotid IMT measurement twice and been tested consecutively for both A1c and GA levels every 3 or 6 months. The subjects were classified into two groups based on non-progression (group I) and progression (group II) of carotid IMT. Mean values of A1c and GA and the GA/A1c ratio were compared between groups. ResultsOf the 218 subjects (122 men and 96 women), group II (n=77) showed significantly higher baseline systolic BP, eGFR, GA, GA/A1c ratio, and progression of carotid IMT (Δ IMT) than group I (n = 141). The mean A1c level tended to be higher in group II than in group I (p = 0.054). By Spearman's correlation test, baseline diastolic BP, total cholesterol, triglyceride, GA, and GA/A1c were significantly associated with Δ IMT in group II but not in group I. In multivariate regression analysis, serum level of GA and GA/HbA1c ratio predicted progression of IMT after adjustment for other risk factors in both models applied. ConclusionWe suggest that glycated albumin is not only a useful glycemic index but also might be an atherogenic protein in the development of diabetic atherosclerosis.

Using Health Information Technology to Prevent and Treat Diabetes

Using Health Information Technology to Prevent and Treat Diabetes

Clinical Experience with U500 Insulin: Risks and Benefits

To describe our clinical experience with U500 insulin in insulin-resistant patients, including change in glucose control, body weight, insulin dose, and hypoglycemic episodes. In September 2010, we undertook a retrospective chart review of patients who had U500 insulin in their medication list in the preceding 2 years who were treated in the endocrinology section at Dartmouth Hitchcock Medical Center. Glycosylated hemoglobin (A1C), body weight, and insulin dosage were documented before U500 insulin introduction, after 6 months of U500 insulin use, and at the last clinic visit when the patient was still taking U500 insulin. Hypoglycemic episodes and number of daily injections were recorded. Records of 53 patients were analyzed, one of the largest reports of U500 insulin use published to date. The mean A1C level decreased from 10.1% before U500 insulin was initiated to 9.1% after 6 months of U500 use to 8.6% at the last follow-up visit (mean follow-up was 36.6 ± 24 months). At the last charted visit, body weight increased by a mean of 6.8 kg and insulin dosage increased by a mean of 0.44 units/kg. We observed a significant increase in the number of nonsevere hypoglycemic episodes and a decrease in the number of daily injections. Patients with uncontrolled, severely insulin-resistant diabetes can be satisfactorily treated with U500 insulin with the potential to improve glycemic control. An increase in body weight, insulin dosage, and the number of nonsevere hypoglycemic episodes was observed.

Influence of the Duration of Diabetes on the Outcome of a Diabetes Self-Management Education Program

BackgroundDiabetes education and lifestyle modification are critical components in controlling blood glucose levels of people with type 2 diabetes. Until now, available data on the effectiveness of education with respect to the duration of diabetes are limited. We investigated whether adherence to lifestyle behavior modification prompted by diabetes education was influenced by the duration of diabetes.MethodsTwo hundred and twenty-five people with type 2 diabetes were recruited for an intensive, collaborative, group-based diabetes education program with annual reinforcement. We divided the patients into two groups based on the duration of their diabetes prior to the education program (≤1 year [≤1Y] vs. ≥3 years [≥3Y]). Dietary habits, physical activity, and the frequency of blood glucose self-monitoring were evaluated with a questionnaire prior to education and at the follow-up endpoint.ResultsThe mean follow-up period was 32.2 months. The mean hemoglobin A1c (A1C) value was significantly lower in the ≤1Y group. Self-care behaviors, measured by scores for dietary habits (P=0.004) and physical activity (P<0.001), were higher at the endpoint in the ≤1Y group than in the ≥3Y group. Logistic regression analysis revealed that a longer diabetes duration before education was significantly associated with mean A1C levels greater than or equal to 7.0% (53 mmol/mol).ConclusionDiabetes duration influenced the effectiveness of diabetes education on lifestyle behavior modification and glycemic control. More-intense, regular, and sustained reinforcement with encouragement may be required for individuals with longstanding type 2 diabetes.

Prevalence of asthma and its association with glycemic control among youth with diabetes.

To estimate the prevalence of asthma among youth with types 1 and 2 diabetes and examine associations between asthma and glycemic control. This was a cross-sectional analysis of data from the SEARCH for Diabetes in Youth study, which included youth diagnosed with type 1 (n = 1683) and type 2 (n = 311) diabetes from 2002 through 2005. Asthma status and medications were ascertained from medical records and self-administered questionnaires, and glycemic control was assessed from hemoglobin A1c measured at the study visit. Prevalence of asthma among all youth with diabetes was 10.9% (95% confidence interval [CI]: 9.6%-12.3%). The prevalence was 10.0% (95% CI: 8.6%-11.4%) among youth with type 1 and 16.1% (95% CI: 12.0%-20.2%) among youth with type 2 diabetes and differed according to race/ethnicity. Among youth with type 1 diabetes, those with asthma had higher mean A1c levels than those without asthma, after adjustment for age, gender, race/ethnicity, and BMI (7.77% vs 7.49%; P = .034). Youth with asthma were more likely to have poor glycemic control, particularly those with type 1 diabetes whose asthma was not treated with pharmacotherapy, although this association was attenuated by adjustment for race/ethnicity. Prevalence of asthma may be elevated among youth with diabetes relative to the general US population. Among youth with type 1 diabetes, asthma is associated with poor glycemic control, especially if asthma is untreated. Specific asthma medications may decrease systemic inflammation, which underlies the complex relationship between pulmonary function, BMI, and glycemic control among youth with diabetes.

Ethnic Differences in Diabetes Management in Patients With and Without Comorbid Medical Conditions

OBJECTIVETo examine ethnic disparities in diabetes management among patients with and without comorbid medical conditions after a period of sustained investment in quality improvement in the U.K.RESEARCH DESIGN AND METHODSThis cross-sectional study examined associations between ethnicity, comorbidity, and intermediate outcomes for mean A1C, total cholesterol, and blood pressure levels in 6,690 diabetes patients in South West London.RESULTSThe presence of ≥2 cardiovascular comorbidities was associated with similar blood pressure control among white and South Asian patients when compared with whites without comorbidity but with worse blood pressure control among black patients, with a mean difference in systolic blood pressure of +1.5, +1.4, and +6.2 mmHg, respectively.CONCLUSIONSDespite major reforms to improve quality, disparities in blood pressure management have persisted in the U.K., particularly among patients with cardiovascular comorbidities. Policy makers should consider the potential impacts of quality initiatives on high-risk groups.

Improved Glycemic Control Without Hypoglycemia in Elderly Diabetic Patients Using the Ubiquitous Healthcare Service, a New Medical Information System

OBJECTIVETo improve quality and efficiency of care for elderly patients with type 2 diabetes, we introduced elderly-friendly strategies to the clinical decision support system (CDSS)-based ubiquitous healthcare (u-healthcare) service, which is an individualized health management system using advanced medical information technology.RESEARCH DESIGN AND METHODSWe conducted a 6-month randomized, controlled clinical trial involving 144 patients aged >60 years. Participants were randomly assigned to receive routine care (control, n = 48), to the self-monitored blood glucose (SMBG, n = 47) group, or to the u-healthcare group (n = 49). The primary end point was the proportion of patients achieving A1C <7% without hypoglycemia at 6 months. U-healthcare system refers to an individualized medical service in which medical instructions are given through the patient’s mobile phone. Patients receive a glucometer with a public switched telephone network-connected cradle that automatically transfers test results to a hospital-based server. Once the data are transferred to the server, an automated system, the CDSS rule engine, generates and sends patient-specific messages by mobile phone.RESULTSAfter 6 months of follow-up, the mean A1C level was significantly decreased from 7.8 ± 1.3% to 7.4 ± 1.0% (P < 0.001) in the u-healthcare group and from 7.9 ± 1.0% to 7.7 ± 1.0% (P = 0.020) in the SMBG group, compared with 7.9 ± 0.8% to 7.8 ± 1.0% (P = 0.274) in the control group. The proportion of patients with A1C <7% without hypoglycemia was 30.6% in the u-healthcare group, 23.4% in the SMBG group (23.4%), and 14.0% in the control group (P < 0.05).CONCLUSIONSThe CDSS-based u-healthcare service achieved better glycemic control with less hypoglycemia than SMBG and routine care and may provide effective and safe diabetes management in the elderly diabetic patients.

Improved glycaemic control with reduced hypoglycaemic episodes and without weight gain using long-term modern premixed insulins in type 2 diabetes

The primary goal of the study was to evaluate retrospectively efficacy of long-term modern premixed insulin (MPI) administration. The secondary aims were to monitor weight gain, hypoglycaemia and compliance during MPI therapy. One hundred and fifteen outpatients with type 2 diabetes (64 male patients, 51 female patients; mean age 62.4±12.2 years; mean duration of diabetes 10±8 years; mean weight 84.3±14.8 kg) were included in this study. Patients were prescribed one of three MPIs thrice-daily: biphasic insulin lispro 25, biphasic insulin lispro 50, or biphasic insulin aspart 30. Metformin was combined with MPI in 81 patients. Data prior to and during MPI treatment were retrieved from computerised patient medical files. After a mean treatment period of 2.9±0.9 years, mean A1C levels and fasting blood glucose decreased from 8.7±1.4% and 193±59 mg/dl to 7.3±1.1% and 141±41 mg/dl (p<0.001 for both), respectively. Thirty-six per cent of the cohort achieved target A1C level of ≤7%. Serum triglycerides decreased from 183±109 mg/dl to 151±76 mg/dl (p<0.001). Weight did not change during MPI treatment. Frequency of minor hypoglycaemic episodes decreased significantly during MPI administration. No major hypoglycaemic event was reported. Number of incompliant patients decreased significantly from 39 to 25 (p=0.001) during MPI treatment. Modern premixed insulins represent an effective and safe long-term therapy for patients with type 2 diabetes. Specifically, the regimen of thrice-daily injections combined with metformin is a viable treatment option.

Differences in glycemic control and survival predict higher ESRD rates in diabetic first nations adults

Diabetic First Nations people (FN) have higher ESRD rates than other Canadians but the reasons remain unclear. We sought to better understand this disparity by comparing demographic, laboratory and survival features of diabetic FN and other Saskatchewan residents (OSK) by renal function stage. Prevalent diabetes cases in 2005/06 were identified in Saskatchewan's two largest health regions using administrative databases, and linked with centralized laboratory tests. They were sub-divided into five stages of renal function using estimated glomerular filtration rates (eGFR) that were determined in 992 of 2,321 FN (42.7%) and 14,054 of 21,886 OSK (64.2%). Age, sex, urine microalbumin (MA), glycosylated hemoglobin (A1C), low density lipoprotein cholesterol (LDL-C) and two year mortality risk was compared for all subjects. Diabetic FN were younger (mean age 52.7 vs. 64.2, p < 0.0001), more likely to be female (59.6% vs.45.4%, p < 0.001), had increased MA (56.6% vs. 48.4%, p < 0.0001) and displayed higher mean A1C levels (8.16% vs.7.36%, p < 0.0001) than OSK. Despite a larger proportion having eGFR's > 60 ml/min (87.0% vs.77.3%, p < 0.001), FN were also more likely to have ESRD (2.3% vs.0.8%, p < 0.001). Although FN with eGFR's > 30 ml/min experienced higher age/sex adjusted mortality risk than OSK, the trends for both adjusted and unadjusted mortality risks for those with advanced pre-ESRD renal failure were lower for FN than for OSK. Elevated rates of ESRD experienced by FN with diabetes are related to poorer glycemic control at all levels of renal function, and lower age-related mortality at advanced stages of chronic kidney disease.

A1C and Cardiovascular Outcomes in Type 2 Diabetes

OBJECTIVEType 2 diabetes is associated with increased cardiovascular risk. The role of aggressive glycemic control in preventing cardiovascular events is unclear. A nested case-control study design was used to evaluate the association between average A1C and cardiovascular outcomes.RESEARCH DESIGN AND METHODSAdults with type 2 diabetes were identified among members of Kaiser Permanente Southern California. Type 2 diabetes was identified based on ICD-9 diagnosis codes and either A1C >7.5% or prescriptions for hypoglycemic agents. Case subjects were defined based on nonfatal myocardial infarction, nonfatal stroke, or death attributed to cardiovascular events during a 3-year window. Four type 2 diabetes control subjects were matched to each case subject based on age, sex, and index date for the corresponding case. A conditional logistic regression model was used to estimate the odds ratio of cardiovascular events and compare three patient groups based on average A1C measured in the preindex period (≤6, >6–8, >8%).RESULTSA total of 44,628 control subjects were matched to 11,157 case subjects. Patients with an average A1C ≤6% were 20% more likely to experience a cardiovascular event than the group with an average A1C of >6–8% (P < 0.0001). Patients with an average A1C >8% experienced a 16% increase in the likelihood of a cardiovascular event (P < 0.0001). We found evidence of statistical interaction with A1C category and LDL level (P = 0.0002), use of cardiovascular medications (P = 0.02), and use of antipsychotics (P = 0.001).CONCLUSIONSHigh-risk patients with type 2 diabetes who achieved mean A1C levels of ≤6% or failed to decrease their A1C to <8% are at increased risk for cardiovascular events.

Relationship between glycemic control and diabetes-related hospital costs in patients with type 1 or type 2 diabetes mellitus.

BACKGROUND: Diabetes mellitus requires continuous medical care and patient self-management in order to prevent short-term complications and decrease the risk of long-term complications, which can result in substantial increases in the total economic burden of the disease. Findings from randomized clinical trials have shown that improved glycemic control may reduce the risk of long-term complications as long as a target for hemoglobin A1c is not set below 7% for intensive glycemic control. However, limited data from clinical practice are available regarding the relationship between glycemic control and medical costs associated with diabetes care. OBJECTIVE: To assess the potential relationships between glycemic levels, diabetes-related hospitalizations, and hospital costs among adult patients with either type 1 or type 2 diabetes mellitus who were assigned to a primary care provider (PCP) in a clinic that was affiliated with a managed care organization (MCO). METHODS: A retrospective cohort analysis was conducted using data from approximately 200,000 members of the Fallon Clinic Health Plan who were assigned to a clinic PCP at any time during a 5-year study period beginning January 1, 2002, and ending December 31, 2006. Patients aged 30 years or older with at least 2 medical claims with any listed diagnosis of diabetes mellitus (ICD-9-CM code 250.xx) during the study period and 2 or more A1c values within 1 year of each other during the study period (mean 7.6 tests over 39 months; median=6.8), were identified and stratified into 1 of 5 groups defined by 1% increments of A1c, based on their mean A1c values during the entire study period. A1c data were available only for tests ordered by a clinic provider; tests ordered by other specialists in the MCO’s network were absent from the database. The study follow-up period started with each patient’s first A1c test (index date) and continued until plan disenrollment, death, or December 31, 2006, whichever was earlier (end date), regardless of when the diagnosis of diabetes mellitus was made. Study measures included the proportion of patients with 1 or more diabetes-related hospitalizations, number of diabetes-related inpatient stays, and the associated estimated hospitalization costs over the follow-up period. Diabetes-related hospitalizations were identified based on a diagnosis, in any of 10 diagnosis fields, for 1 of 16 selected complications of diabetes identified by the authors. Hospital costs were estimated using discharge data (diagnoses and costs calculated from cost-to-charge ratios) contained in the 2004 Healthcare Cost and Utilization Project (HCUP) database and inflated to 2007 dollars using the medical care component of the Consumer Price Index. Multivariate models controlled for age, sex, number of A1c tests, diagnosis of cancer, and follow-up time. A multivariate logistic regression analysis was conducted with the occurrence of at least 1 diabetes-related hospital admission as the dependent variable. In the logistic regression analysis, follow-up time was defined as time from the index date to the date of the first diabetes-related hospitalization, plan disenrollment, death, or the study end date, whichever occurred first. A generalized linear model with a Poisson distribution and a log link was employed to estimate the rate of hospital admissions. In the Poisson regression analysis, follow-up time was defined as duration of the entire study follow-up period and was an offset variable. Costs were estimated using a 2-part model: first, we calculated the probability of having a hospitalization, as determined by the logistic regression above; second, a generalized linear model with a negative binomial distribution and a log link was used to predict the mean cost of diabetes-related hospitalizations only for patients with an inpatient stay, with the duration of the entire study followWhat is already known about this subject

Perception of the Impact of Type 1 Diabetes on Low-Income Families

The purpose of this study was to explore the psychosocial impact of type 1 diabetes (T1DM) on low-income families of various racial/ethnic backgrounds. A qualitative study using qualitative descriptive methods was conducted with a total of 21 patient-parent dyads from African American, Hispanic, and white heritage, respectively. An interview guide was developed to explore each family's attitudes and beliefs related to diabetes. Although all subjects were in excellent metabolic control (mean A1C levels were between 7.3% and 7.6%), there were a number of identifiable differences in the perception of the impact of T1DM among the 3 groups. Themes in the data demonstrated differences in the following areas: (1) view of diabetes and its effects on the family; (2) ability to successfully treat diabetes; (3) ability to cope with diabetes; and (4) experiences with the health care system. Most notable themes include a disparity across racial/ethnic groups in the preoccupation with the disease after diagnosis, cultural and financial factors identified, and differences in treatment modalities and reasons for their use. Diabetes education and care need to carefully address such differences. Although these differences are likely multifactorial, with components of socioeconomic status, family structure, and family experiences involved, it is evident that ethnicity itself is an important factor that can affect the ability of families to manage and cope with diabetes.

Differences in the prevalence of diabetes risk-factors among First Nation, Métis and non-Aboriginal adults attending screening clinics in rural Alberta, Canada

Populations that are developing (westernizing) are suffering the highest rates of increases in diabetes incidence and prevalence worldwide, with the most notable and documented increases in Canada seen among the First Nations. Less is known about the Métis (mixed blood) or the rural populations in general. To date, no studies have assessed the contributions of ethnicity to diabetes risk-factors. Our objective was to examine diabetes risk factors in First Nations, Métis and non-Aboriginal individuals residing in rural or remote locations, investigating whether ethnicity contributed to any differences. From the databases of three separate community-based diabetes screening projects in Alberta we created a unique subject pool of 3148 adults without diabetes (1790 First Nation, 867 Métis, and 491 non-Aboriginals). Age, body mass index (BMI), waist circumference, reported history of gestational diabetes (GDM) or babies over nine pounds (females only), hemoglobin A1c (A1c) fasting plasma glucose (FPG) or random plasma glucose (RPG) were assessed. Chi-square tests and logistic regression analysis were used to identify between-group differences. The highest mean values for waist circumference (104.7 cm) and BMI (31.2) were found in First Nations subjects (p<0.01). First Nations individuals had the highest prevalence of overweight/obesity (84.4%), abnormal waist circumference (76.8%) and history of GDM (9.0%) (p<0.01). The RPG was also higher in First Nations, but there were no differences between groups with respect to mean FPG and A1c levels, and there were no differences with respect to the prevalence of pre-diabetes or undiagnosed diabetes. Métis (OR 0.80; p = 0.01) and non-Aboriginal individuals (OR 0.62; p< 0.01) were less likely to be obese after age/gender adjustment, compared with First Nations. Métis (OR 0.70; p<0.01) and non-Aboriginals (OR 0.35; p<0.01) were also less likely than the First Nations group to have abnormal waist circumferences. Individuals in the non-Aboriginal group had a lower prevalence of pre-diabetes (OR 0.50; p = 0.01) compared with both the Métis and First Nations groups. First Nations individuals had more risk factors for diabetes than Métis and non-Aboriginal individuals, although Métis rates appeared intermediate. While these risk-factor differences did not translate to more undiagnosed diabetes or pre-diabetes, they are consistent with known rates of diagnosed diabetes in Alberta.

Continuity and Change in Glycemic Control Trajectories From Adolescence to Emerging Adulthood

OBJECTIVETo determine developmental classes of glycemic control in young people with type 1 diabetes throughout adolescence and emerging adulthood and assess relationships with general family climate and self-concept.RESEARCH DESIGN AND METHODSIn an eight-wave longitudinal study, 72 individuals (37 females) completed questionnaires assessing family climate (at times 1–4) and self-concept (at times 1–4 and 6). Times 1–4 covered adolescence (mean ages were 14–17 years, respectively); times 5–8 covered emerging adulthood (mean ages were 21–25 years, respectively). At each time point, patients visited their physicians to determine A1C values, and questionnaires were sent to the physicians to obtain these values. Latent class growth analysis was used to identify developmental classes of glycemic control.RESULTSLatent class growth analysis favored a three-class solution, consisting of optimal control (n = 10), moderate control (n = 51), and deteriorating control (n = 11). From time 3 on and especially during emerging adulthood, mean A1C levels were substantially different among the classes. Additional ANOVAs indicated that at times 1, 2, and 4, the optimal control class was characterized by the most optimal family climate, whereas at times 3, 4, and 6, the deteriorating control class was characterized by the lowest score on positive self-concept.CONCLUSIONSFrom late adolescence on, a multiformity of glycemic control trajectories emerged, which became more diversified throughout emerging adulthood. Family climate and self-concept in mid-to-late adolescence served as psychosocial markers of these developmental classes.

Glycemic Control in Diabetes: A Tale of Three Studies

Much of the controversy at the American Diabetes Association Scientific Sessions, held 6–10 June 2008 in San Francisco, California, pertained to questions raised about the benefits of intensive glycemic control by three large clinical studies: the Action to Control Cardiovascular Risk in Diabetes (ACCORD) trial, the Action in Diabetes and Vascular Disease (ADVANCE) trial, and the Veterans’ Administration Diabetes Trial (VADT). All three presented somewhat negative study results. David Goff (Winston-Salem, NC) discussed the ACCORD study design. The goal of ACCORD was to determine whether cardiovascular disease (CVD) event rates could be reduced by intensively treating three important risk factors (hyperglycemia, dyslipidemia, and high blood pressure) in a double 2 × 2 factorial design. For glycemia, the question of A1C <6 vs. 7–7.9% was addressed. Goff reviewed previous studies that led to the decision to aim for the low A1C target. In the UK Prospective Diabetes Study (UKPDS), insulin and sulfonylurea treatment achieved a mean A1C level of 7%, with 7.9% in a control group. The 16% CVD reduction just missed statistical significance. Metformin treatment in this study achieved a mean A1C level of 7.4% with 8% in a control group, associated with a significant 39% CVD reduction. (Goff did not mention that, compared with sulfonylureas alone, the other UKPDS metformin substudy showed that metformin with a sulfonylurea was associated with 96, 60, and 9% increases in diabetes-related and all-cause mortality and in myocardial infarction [1].) A nonsignificant CVD risk reduction of ∼50% was seen in the Kumamoto study, while there was also a nonsignificant CVD risk increase of ∼50% in the Veterans’ Affairs Cooperative Study on Glycemic Control and Complications in Type II Diabetes (VACSDM); both studies showed A1C 7.1% in the treatment group and 9.3–9.4% in the control group. Analysis of a number of observational studies …

Glycine treatment decreases proinflammatory cytokines and increases interferon-γ in patients with Type 2 diabetes

Amino acids have been shown to stimulate insulin secretion and decrease glycated hemoglobin (A1C) in patients with Type 2 diabetes. In vitro, glycine reduces tumor necrosis factor (TNF)-alpha secretion and increases interleukin-10 secretion in human monocytes stimulated with lipopolysaccharide. The aim of this study was to determine whether glycine modifies the proinflammatory profiles of patients with Type 2 diabetes. Seventy-four patients, with Type 2 diabetes were enrolled in the study. The mean age was 58.5 yr, average age of diagnosis was 5 yr, the mean body mass index was 28.5 kg/m2, the mean fasting glucose level was 175.5 mg/dl and the mean A1C level was 8%. They were allocated to one of two treatments, 5 g/d glycine or 5 g/d placebo, po tid, for 3 months. A1C levels of patients given glycine were significantly lower after 3 months of treatment than those of the placebo group. A significant reduction in TNF-receptor I levels was observed in patients given glycine compared with placebo. There was a decrease of 38% in the interferon (IFN)-gamma level of the group treated with placebo, whereas that of the group treated with glycine increased up to 43%. These data showed that patients treated with glycine had a significant decrease in A1C and in proinflammatory cytokines and also an important increase of IFN-gamma. Treatment with glycine is likely to have a beneficial effect on innate and adaptive immune responses and may help prevent tissue damage caused by chronic inflammation in patients with Type 2 diabetes.

Progression of Cardiovascular Autonomic Dysfunction in Patients With Type 2 Diabetes

OBJECTIVE—We investigated whether cardiovascular autonomic dysfunction was associated with glycemic control status over time in patients with type 2 diabetes.RESEARCH DESIGN AND METHODS—From 1999 to 2000, cardiovascular autonomic nerve function testing (AFT) was performed on patients with type 2 diabetes (n = 1,021) and was followed-up in 2006 and February 2008. Tests for cardiovascular autonomic functions measured heart rate variability parameters (expiration-to-inspiration [E/I] ratio, responses to the Valsalva maneuver, and standing). AFT scores were determined from the results of the each test as follows: 0 for normal and 1 for abnormal. We began with those who had a score of 0 and assessed the changes in total score along with biannual A1C levels.RESULTS—At follow-up, the development of cardiovascular autonomic dysfunction was 34.5% (E/I ratio 21.9%, Valsalva maneuver 77.8%, and posture 58.9%; n = 783). The development of cardiovascular autonomic dysfunction was higher in older patients (P < 0.001); in those with longer duration of diabetes (P < 0.001); of hypertension (P = 0.005), and of diabetic retinopathy (P < 0.001); and in those who had higher levels of microalbuminuria (P = 0.002). Logistic regression analysis revealed that the development of cardiovascular autonomic dysfunction was strongly associated with the mean A1C level during the follow-up period (mean A1C >9.0% vs. ≤7.0%, odds ratio 2.984, 95% CI 1.177–7.561; P = 0.021).CONCLUSIONS—The development of cardiovascular autonomic dysfunction was independently associated with microvascular complications and glycemic control status during this 7.5-year follow-up in patients with type 2 diabetes.

Continuing Stability of Center Differences in Pediatric Diabetes Care: Do Advances in Diabetes Treatment Improve Outcome? The Hvidoere Study Group on Childhood Diabetes

The Hvidoere Study Group is to be commended for their efforts to elucidate demographic, ethnic, and treatment factors associated with disparities in mean A1C that persisted between participating pediatric diabetes clinics despite similar treatment goals and management techniques (1). It was disheartening that none of the evaluated factors, with the possible exception of language difficulties, yielded an easy-to-implement way to improve mean A1C levels within clinics or reduce A1C differences between clinics. The authors mention that two clinics markedly improved their mean clinic A1C and hint that improvement may have been …

A1C in Children and Adolescents With Diabetes in Relation to Certain Clinical Parameters

We explored the relationship between A1C and insulin regimen, duration of diabetes, age, sex, and BMI as well as the differences between clinical mean A1C levels at pediatric diabetes clinics in Sweden. Data from 18,651 clinical outpatient visits (1,033 girls and 1,147 boys) at 20 pediatric clinics during 2001 and 2002 registered in the Swedish Childhood Diabetes Registry SWEDIABKIDS, a national quality registry, were analyzed. A1C was <7.0% (target value approximately 8% per Diabetes Control and Complications Trial/National Glycohemoglobin Standardization Program standards) at 35% of the visits. Girls had significantly higher mean A1C than boys during adolescence. High mean A1C was correlated with high mean insulin dose, long duration of diabetes, and older age. Mean A1C varied between clinics (6.8-8.2%). Differences between centers could not be explained by differences in diabetes duration, age, BMI, or insulin dose. Adolescents with a high insulin dose and a long duration of diabetes, especially girls, need to be focused on. Differences in mean values between centers remained inexplicable and require further investigation.

Effect of Glycemic Exposure on the Risk of Microvascular Complications in the Diabetes Control and Complications Trial—Revisited

The Diabetes Control and Complications Trial (Diabetes 44:968-983, 1995) presented statistical models suggesting that subjects with similar A1C levels had a higher risk of retinopathy progression in the conventional treatment group than in the intensive treatment group. That analysis has been cited to support the hypothesis that specific patterns of glucose variation, in particular postprandial hyperglycemia, contribute uniquely to an increased risk of microvascular complications above and beyond that explained by the A1C level. We performed statistical evaluations of these models and additional analyses to assess whether the original analyses were flawed. Statistically, we show that the original results are an artifact of the assumptions of the statistical model used. Additional analyses show that virtually all (96%) of the beneficial effect of intensive versus conventional therapy on progression of retinopathy is explained by the reductions in the mean A1C levels, similarly for other outcomes. Furthermore, subjects within the intensive and conventional treatment groups with similar A1C levels over time have similar risks of retinopathy progression, especially after adjusting for factors in which they differ. A1C explains virtually all of the difference in risk of complications between the intensive and conventional groups, and a given A1C level has similar effects within the two treatment groups. While other components of hyperglycemia, such as glucose variation, may contribute to the risk of complications, such factors can only explain a small part of the differences in risk between intensive and conventional therapy over time.