Comparison of The World Health Organization (WHO) two-step strategy and OGTT for diabetes mellitus screening

The new diagnostic criteria recommended by the American Diabetes Association (ADA) will only detect diabetic patients with fasting hyperglycemia, and leave patients with isolated post-challenge hyperglycemia (IPCH) and imparied glucose tolerance (IGT) unidentified. The WHO recommends that all those with abnormal fasting glucose should undergo the oral glucose tolerance test (OGTT) to exclude the diagnosis of diabetes (two-step strategy). This two-step strategy will leave out subjects with normal fasting glucose (<109 mg/dl). The aim of this study is to compare the WHO two-step strategy and the gold standard OGTT for all subjects. We re-analyzed the results of 907 high-risk patients who have been screened for diabetes mellitus and impaired glucose tolerance. All subjects were screened with an OGTT containing a 75-gram glucose load after fasting for 12 hours. The results were classified into three categories: the ADA criteria, the two-step strategy, and the OGTT. Using the ADA criteria, these 907 subjects can be classified has having normal fasting glucose (fasting plasma glucose - FPG < 109 mg/dl) in 715 subjects (78.9%), abnormal fasting glucose (FPG 110 - 125 mg/dl) in 107 subjects (11.8%), and diabetes mellitus (FPG > 126 mg/dl) in 85 subjects (9.4%). The WHO two-step strategy performed in 107 IFG subjects identified another 30 diabetic patients (FPG < 109 mg/dl and 2 hour post load > 200 mg/dl = IPCH) or 3.3%, and 49 patients with IGT, or 5.4% from all subjects. If the OGTT was performed on the 715 normal fasting glucose, it could identify another 40 diabetic patients or 4.4%, and another 178 IGT patients, or 19.6% of all subjects. This means that without OGTT to all subjects, 40 diabetic patients or 25.8% of all diabetic patients and 178 patients or 78.4% from all IGT subjects would have remained unidentified. From this study we can conclude that applying the WHO two-step strategy in subjects with IFG would fail to detect 25.8% of diabetic patients and 78.4% of IGT subjects. It is recommended that the old strategy of screening--the gold standard OGTT--should be used instead of the two-step strategy, at least in high-risk groups.     

Clinical screening examination for impaired glucose tolerance: is it possible to diagnose impaired glucose tolerance without a 75g oral glucose tolerance test?

It is well known that diabetes mellitus is one of the most crucial risk factors in the pathogenesis of atherosclerosis, including cardiovascular diseases (CVD). Considerable epidemiological and clinical studies, such as the Funagata study and the Diabetes Epidemiology Collaborative analysis of Diagnostic criteria in Europe (DECODE) study, have established that even a prediabetic state, including impaired glucose tolerance (IGT), is strongly associated with the occurrence of CVD. For the diagnosis of IGT, the 75g oral glucose tolerance test (75g OGTT) is required clinically, but the test takes at least 2 hours, at considerable cost. Therefore, for the prevention of atherosclerosis and subsequent CVD, another methods and/or beneficial parameters are anticipated to diagnose IGT without 75g OGTT. Recent studies have suggested that subjects beyond approximately 100 mg/dl fasting plasma glucose (FPG) might be classified into IGT by using receiver operating characteristic (ROC) analyses, and that the FPG 100 mg/dl is a suitable cut-off level between IGT and normal glucose tolerance (NGT). In contrast, although it is difficult to distinguish IGT from NGT by the HbAlc level alone, the combination of FPG with HbAlc is more beneficial for the diagnosis of IGT.     

Laboratory diagnosis and monitoring of diabetes mellitus.

The American Diabetes Association emphasizes fasting plasma glucose (FPG) levels, rather than the oral glucose tolerance test (OGTT), to diagnose diabetes mellitus. The diagnostic cutoff for FPG is 126 mg/dL (7.0 mmol/L). A 2-hour plasma glucose level of 200 mg/dL (11.1 mmol/L) or more during an OGTT or a random plasma glucose level of 200 mg/dL (11.1 mmol/L) or more also is diagnostic of diabetes. The 100-g, 3-hour OGTT remains the "gold standard" for gestational diabetes mellitus (GDM). Two of 4 samples exceeding cutoffs (fasting, > or = 105 mg/dL [5.8 mmol/L]; 1 hour, > or = 190 mg/dL [10.5 mmol/L]; 2 hours, > or = 165 mg/dL [9.2 mmol/L]; 3 hours, > or = 145 mg/dL [8.0 mmol/L]) indicate GDM. An effective GDM screening test is plasma glucose 1 hour after a 50-g oral glucose load. Tight control, which requires self-monitoring of blood glucose, reduces microvascular complications for patients with type 1 or type 2 diabetes. Patients with well-controlled diabetes have glycohemoglobin concentrations of 7% AIc (0.07 AIc/A) or less. Microalbuminuria indicates early, reversible, diabetic nephropathy. The random urine albumin-creatinine ratio is a convenient effective screening test. Albumin-creatinine ratios in the 0.03 to 0.30 (g/g) range indicate microalbuminuria.     

Comparative performance of HbA1c 6.5% for FPG ≥7.0 vs 2hr PG≥11.1 criteria for diagnosis of type 2 diabetes

Background

International expert committee on the use of HbA1c to diagnose diabetes mellitus in 2009 and World Health Organization (WHO) in 2011 has advocated the use of HbA1c to diagnose diabetes mellitus.

Objective

To determine and compare the relationship between the new cut off value of HbA1c with established criteria.

Methods

Thirty-one hypertensive subjects attending Lagos University Teaching Hospital were recruited for HbA1c and standard oral glucose tolerance test. Fasting plasma glucose (FPG) and two-hour plasma glucose (2hrpp) value of e”126mg/ dl and ≥200mg/dl were used as standard respectively for diagnosis of diabetes. The HbA1c of e”6.5% was used to diagnose diabetes. The performance and correlation of HbA1c with FPG and 2hrpp were calculated and results were compared.

Results

Mean age of the subjects was 53.97±6.27years. The sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), efficiency and correlation of FPG is 50%, 68%, 27%, 85%, 64% and 0.5 respectively while the sensitivity, specificity, PPV, NPV, efficiency and correlation of 2hrpp is 73.91%, 62.5%,85%, 41.66%, 70.97% and 0.73% respectively. There was a significant difference between FPG and 2hrpp interms of sensitivity, PPV and NPV.

Conclusion

The results of HbA1c with 2hrpp has better correlation, sensitivity, and PPV compared to HbA1c with FPG.     

Should we consider performing oral glucose tolerance tests more frequently in postmenopausal women for optimal screening of impaired glucose tolerance?

OBJECTIVE: To investigate an optimal screening protocol for impaired glucose tolerance (IGT) and type II or non-insulin-dependent diabetes mellitus (DM) by using fasting plasma glucose (FPG) and oral glucose tolerance test (OGTT) in postmenopausal women. DESIGN: One hundred consecutive postmenopausal women were screened with FPG determination, and then all underwent an OGTT. Basal serum lipid and insulin levels of these women were also determined. Insulin sensitivity was determined by using the homeostasis model assessment. Receiver operating characteristic analysis was performed to determine the efficacy of these variables in detecting women with IGT and DM, and optimal cutoff values were determined. RESULTS: FPG with a cutoff value of 98 mg/dL had the best combination of sensitivity (71%) and specificity (76%) for the detection of IGT and DM. Combined FPG and body mass index screening (with the optimal cutoff value of 26.5 kg/m2) improved the sensitivity to 96% but decreased the specificity to 47%. This combined screening protocol detected 94% of the women with IGT and all diabetic women. CONCLUSIONS: Given that IGT and DM are common among postmenopausal women and DM can be prevented by nonpharmacologic interventions in women with IGT, OGTT may be used more frequently among these women. Our data indicate that for optimal screening of non-insulin-dependent DM and IGT, OGTT should be considered in postmenopausal women, especially when risk factors in addition to age are present. This model may detect most of the women with IGT and almost all diabetic women.     

Gestational diabetes mellitus

Gestational diabetes (GDM) is defined as any degree of glucose intolerance with onset or first recognition during pregnancy and is associated with increased feto-maternal morbidity as well as long-term complications in mothers and offspring. GDM is diagnosed by an oral glucose tolerance test (OGTT) or fasting glucose concentrations in the diabetic range. In case of a high risk for GDM/type 2 diabetes (history of GDM or prediabetes [impaired fasting glucose or impaired glucose tolerance]; malformation, stillbirth, successive abortions or birth-weight > 4500 g in previous pregnancies) performance of the OGTT (120 min; 75 g glucose) is recommended already in the first trimester and--if normal--the OGTT should be repeated in the second/third trimester. In case of clinical symptoms of diabetes (glucosuria, macrosomia) the test has to be performed immediately. All other women should undergo a diagnostic test between 24 and 28 gestational weeks. If fasting plasma glucose exceeds 95 mg/dl, 1 h 180 mg/dl and 2 hrs 155 mg/dl after glucose loading (OGTT) the woman is classified as GDM (one pathological value is sufficient). In this case a strict metabolic control is mandatory. All women should receive nutritional counseling and be instructed in blood glucose self-monitoring. If blood glucose levels cannot be maintained in the normal range (fasting < 95 mg/dl and 1 h after meals < 130 mg/dl) insulin therapy should be initiated. Maternal and fetal monitoring is required in order to minimize maternal and fetal/neonatal morbidity and perinatal mortality. After delivery all women with GDM have to be reevaluated as to their glucose tolerance by a 75 g OGTT (WHO criteria).     

Decision levels of diabetes mellitus and hyperlipidemia in elderly Japanese subjects

Decision levels of diabetes mellitus and hyperlipidemia in elderly subjects as well as younger subjects should be determined to prevent complications of these diseases such as microvascular and macrovascular diseases. Therefore, prospective follow-up study is necessary to decide the decision levels. In the case of diabetes mellitus, there are some useful studies such as KUMAMOTO STUDY show that strict glycemic control can prevent microvascular diseases, but there are few studies in elderly subjects. However, hypoglycemia causes macrovascular events, and chronic hypoglycemia leads to dementia and apathy. It is generally accepted that the glycemic control level can be milder than that in younger subjects. We suggest that the following decision levels are reasonable for elderly diabetic subjects, 1. FPG > 140-160 mg/dl, 2. PG(2 h) > 200-250 mg/dl, 3. HbA1c > 7-8%. Decision level of hyperlipidemia in elderly subjects should also be determined to prevent cardiovascular disease. It is demonstrated that anti-hyperlipidemic treatment can prevent CHD even in elderly subjects by many prospective studies. Japan Atherosclerosis Society recommend that the decision levels of hyperlipidemia in elderly subjects can be the same as younger subjects. The decision levels indicating diet therapy and medication for risk factor free subjects(category A) are LDL-C > or = 140 and 160 mg/dl, respectively. Those for subjects without CHD but have some risk factors(category B) are LDL-C > or = 120 and 140 mg/dl, respectively. Those for subjects with CHD(category C) are LDL-C > or = 100 and 120 mg/dl, respectively.     

The impaired hyperglycemic peak as an additional indicator of Type 2 diabetes development is misdetected

Because there is not an optimal control for Type 2 diabetes mellitus (DM2), which encompasses about 90% of diagnosed diabetic patients, its prevention is key. Early detection of DM2 development can be made through impaired fasting glucose and/or impaired glucose tolerance diagnosis. However, cases exist when oral glucose tolerance test (OGTT) results show an hyperglycemic peak >or =200 mg/dl as a unique alteration. This alteration is defined as impaired hyperglycemic peak (IHP) and should be considered as an additional early indicator of DM2 development. Because IHP is commonly misdetected by the standard OGTT, it is proposed that this misdetection can be solved using a closer sampled OGTT. The objective of this research was to detect IHP on 225 volunteers using a 10 min sampled OGTT during 2 h. Results show the existence of IHP in 25 cases, making it the most frequent and the less detected OGTT alteration. In eight of these cases, IHP could not have been detected using a standard OGTT, because at 30, 60 and 90 min, plasma glucose concentrations were <200 200 mg/dl, however, at 40, 50, 70, and/or 80 min, IHP exists.     

糖化血红蛋白在糖代谢异常患者中的改变及其与血糖的关系

目的探讨糖化血红蛋白（HbAlc）检测在不同糖代谢异常状态的临床价值。方法选取254名受试者（其中男149人,女105人）进行口服糖耐量试验（OGYr）和HbAlc检测。根据OGTY结果分为正常糖耐量（NGT）、单纯空腹血糖受损（I-IFG））、单纯糖耐量受损（I-IGT）、IFG合并IGT（IFG／IGT）和糖尿病（DM）5组,通过单因素方差分析比较各组HbAlc值,对各组HbAlc与空腹血糖（FPG）和OGTr2h血糖（2hPG）进行线性相关和回归分析。结果①HbAlc水平（％,下同）DM组（7．41±1．94）明显高于其余4组（以上P均〈0．01）,I-IFG组（6．06±0．37）、I-IGT组（5．91±0．39）、IFG／IGT组（6．12±0．38）3组间差异无统计学意义（P〉0．05）,但分别明显高于NGT组（P〈0．05）。②DM组HbAlc分别与FPG（r=0．934,P〈0．01）和2hPG（r=0．760,P〈0．01）存在着明显的正相关,回归方程为：HbAlc=2．957＋0．458（FPG）＋0．05（2hPG）;IFG／IGT组（r=0．326,P〈0．01）、I-IGT组（r=0．254,P〈0．05）HbAlc只与2hPG存在正相关;I-IFG组HbAlc只与FPG存在正相关（r=0．404,P〈0．01）;NGT组HbAlc与FPG（r=0．157）和2hPG（r=-0．006）均不存在相关性。结论糖化血红蛋白水平能够正确地反映正常糖代谢、糖调节受损和糖尿病3种不同糖代谢状态的血糖水平,是区分3种糖代谢状态的有用指标。     

Diabetes mellitus in a young man with Bloom''s syndrome

Bloom's syndrome (BS) is a rare autosomal recessive genetic disorder in which diabetes mellitus unusually frequently develops as a complication. We report on a 21-year-old Japanese male patient with BS who exhibited impaired glucose tolerance (IGT) in the initial oral glucose tolerance test (OGTT) and had developed patterns of diabetes mellitus by the second OGTT at the 2-years-and-2-months follow-up. German and Passarge reported that the onset of diabetes in patients with BS was in late adolescence or early adulthood. Our results support the findings of German and Passarge. Therefore, when a person with BS reaches late adolescence or early adulthood, an OGTT is necessary to ascertain whether the patient has IGT or diabetes mellitus as a complication, regardless of whether or not diabetic signs such as glucosuria are present.     

The usefulness of glycated hemoglobin A1c (HbA1c) for identifying dysglycemic states in individuals without previously diagnosed diabetes

PurposeWe investigated HbA1c's validity as a screening parameter for excluding dysglycemic states in the studied population.Material/MethodsSensitivity and specificity of HbA1c in some cut-off points were compared with diagnoses based on the oral glucose tolerance test (OGTT) in individuals diagnosed between 2009–2010. Receiver operating characteristic (ROC) analysis for HbA1c was conducted. HbA1c and OGGT measures were done in 441 people (253 women, 187 men, average age 40.1 years (18–79 years)). Based on the OGGT test 37 individuals were diagnosed as diabetic, 28 as impaired glucose tolerant (IGT) and 63 as having impaired fasting glycemia (IFG).ResultsA cut-off value of 6.5% HbA1c classifies diabetic subjects with a sensitivity of 45.9% and specificity of 97.5%. In the investigated population the best cut-off point (the highest sum of the sensitivity and specificity) was 5.9% HbA1c (sensitivity 86.6%, specificity 73%). HbA1c values excluding the risk of dysglycemic states have shown false negative rate in 31.9% when HbA1c was 5.5% and 10.6% when HbA1c was 5.0%.ConclusionsOur results indicate that in the investigated population the evaluation of the prevalence of type 2 diabetes using HbA1c values proposed by the American Diabetes Association (ADA) has unsatisfactory sensitivity and detects less than a half of cases of diabetes based on the OGTT diagnoses. HbA1c 5.7% does not have sufficient specificity to identify individuals not being at risk of any disorder of glucose metabolism.     

Diabetes mellitus and HbA1c

Since the Japan Diabetes Association(JDS) began to distribute Lot 1 as the primary calibrator for measuring Hemoglobin A1c(HbA1c) to manufactures of reagents and devices in 1995, the standardization of the measurement of HbA1c has been achieved throughout Japan. In 1999, JDS proposed a new diagnostic criterion for diabetes mellitus, and HbA1c was adopted firstly as an assistant index for diagnosis of diabetes mellitus, after HbA1c measurement was standardized by JDS. Furthermore, JDS published a clinical guideline for treatment of diabetes mellitus in 1999, in which it was stated that HbA1c below 6.5% should be one of the goals. This statement was made based on the results of the Kumamoto Study. Because Lot 1 was made mainly in order to minimize the difference among measurements by HPLC devices, Lot 1 is a freeze-dried material. Since some faults of Lot 1 were pointed out after its distribution, in 2001 JDS approved Lot 2 as the new standard material, a deeply frozen material. Currently in Japan, the standardization of HbA1c is maintained with Lot 2.     

Differences in metabolic parameters and cardiovascular risk between American Diabetes Association and World Health Organization definition of impaired fasting glucose in European Caucasian subjects: a cross-sectional study

Introduction

The American Diabetes Association (ADA) defines impaired fasting glucose (IFG) as fasting plasma glucose concentration of 100–125 mg/dl, whereas the World Health Organization (WHO) and the International Diabetes Federation (IDF) define IFG as fasting plasma glucose levels of 110–125 mg/dl. We identified differences in metabolic parameters and cardiovascular disease (CVD) risk according to the ADA or WHO/IDF definition of IFG.

Material and methods

Healthy drug-naive Caucasian (Greek) subjects (n = 396; age 55 ±12 years) participated in this cross-sectional study.

Results

Diastolic blood pressure (DBP) and uric acid levels were higher in the subjects with glucose 100–109 mg/dl compared with those with glucose < 100 mg/dl (87 ±9 mm Hg vs. 84 ±11 mm Hg, p = 0.004 for DBP, 5.6 ±1.5 mg/dl vs. 5.0 ±1.0 mg/dl, p = 0.002 for uric acid), whereas triglyceride levels were lower in subjects with glucose 100–109 mg/dl compared with those with glucose ≥ 110 mg/dl (169 mg/dl (interquartile range (IQR) = 102–186) vs. 186 mg/dl (IQR = 115–242), p = 0.002). Only the ADA definition recognized subjects with significantly increased 10-year CVD risk estimation (SCORE risk calculation) compared with their respective controls (5.4% (IQR = 0.9–7.3) vs. 4.1% (IQR = 0.7–5.8), p = 0.002).

Conclusions

The ADA IFG definition recognized more subjects with significantly increased CVD risk (SCORE model) compared with the WHO/IDF definition.     

Effects of dietary pattern and education on glycemic control in patients with type 2 diabetes mellitus at Dr. Sardjito Central General Hospital, Yogyakarta

Aim: to recognize the effect of education and diet on glycemic control in patients with type 2 diabetes mellitus at Dr. Sardjito Central General Hospital, Jogjakarta. Methods: a cross-sectional study was conducted in 88 patients with type 2 DM who had routine visit to the outpatient clinic in Endocrinology Division of Dr. Sardjito Central General Hospital, Jogjakarta. As inclusion criteria, patients who had routine visit in 3 month continuously with fasting plasma glucose (GDN) < 126 mg/dl was participated as a well glycemic control group, and the one with GDN > 126 mg/dl as poor glycemic control group. Data were recorded which included age, sex, period of DM, daily diet pattern, and education received. Results: we found that glycemic control was not affected by sex (p=0.52) and age (p=0.38), but it was affected by period of DM (p=0.02). Glycemic control in the present study was affected by dietary pattern (p=0.01), but not by education (p=1.00). Conclusion: the present study has found significant correlation between regulation of dietary pattern and glycemic control (p=0.01).     

Body mass index and waist circumference according to glucose tolerance status in Korea: the 2005 Korean Health and Nutrition Examination Survey

The purpose of this study was to investigate the stage of glucose intolerance in which persons showed a maximum obesity in Korea. A total of 4,479 participants, who were involved in the 2005 Korean National Health and Nutrition Examination Survey, was examined. The participants were divided into 5 groups by fasting plasma glucose (FPG); normal fasting glucose (NFG)1, FPG < 90 mg/dL; NFG2, FPG 90-99 mg/dL; impaired fasting glucose (IFG)1, FPG 100-109 mg/dL; IFG2, FPG 110-125 mg/dL; and diabetes mellitus, FPG ≥ 126 mg/dL or with anti-diabetes drugs. In those with FPG < 110 mg/dL, body mass index (BMI) and waist circumference (WC) were increased with increase of FPG (BMI in men; NFG1, 23.3 ± 0.1; NFG2, 24.4 ± 0.1; IFG1, 25.0 ± 0.2 kg/m(2), in women; NFG1, 23.0 ± 0.1; NFG2, 24.0 ± 0.1; IFG1, 24.8 ± 0.2 kg/m(2), WC in men; NFG1, 82.1 ± 0.3; NFG2, 85.3 ± 0.3; IFG1, 86.7 ± 0.5 cm, in women; NFG1, 77.1 ± 0.2; NFG2, 79.4 ± 0.3; IFG1, 81.8 ± 0.6 cm). In IFG2 and diabetes range, there was no more increase of BMI and WC with increase of FPG in each sex. The data suggest that degree of obesity increases with an increase of FPG in range of FPG < 100 mg/dL, peaked in FPG of 100-109 mg/dL, and then plateaus in higher FPG range in general Korean population.     

Implications of the new definition of diabetes for health disparities

In July 2009, an international committee announced a new diagnostic criterion for diabetes based on hemoglobin Alc (HbA1c) values. Our objective was to estimate how the new diabetes diagnostic criterion will affect the prevalence of diabetes among different race, age, and gender subpopulations, compared to the previously used fasting plasma glucose (FPG) criterion. We analyzed nationally representative data from The National Health and Nutrition Examination Survey (NHANES), aggregated from 1999 to 2006. We estimated the prevalence of known diabetes (prevalence static across either diagnostic criterion), unknown, and no diabetes (prevalence variable by criterion). We tested statistical significance of prevalence differences for unknown diabetes between the prior diagnostic criterion--FPG of at least 126 mg/dL--and the new diagnostic criterion--HbA1c of at least 6.5%--using conditional logistic regression. We further tested the association of these differences with demographic factors. The new HbA1c diagnostic criterion differentially affects different racial/ethnic groups. For non-Hispanic whites, the prevalence of undiagnosed diabetes was more than halved from 2.6% (95% confidence interval [CI], 2.2-3.1) with FPG diagnosis to 1.3% (95% CI, 1.0-1.7), P<.001 with HbAic diagnosis. For Hispanics and non-Hispanic blacks, the differences in prevalence by the 2 criteria were smaller and nonsignificant. Racial differences by diagnostic criteria were most pronounced among people aged over 55 years. Overall, the new definition of diabetes differentially affects ethnic groups, especially for older people. If the new criterion is widely adopted, over time, we may see an apparent widening of racial/ethnic disparities in diabetes prevalence.     

Insulin secretion and sensitivity during oral glucose tolerance test in Korean lean elderly women

Impaired glucose tolerance (IGT) and type 2 diabetes including undiagnosed isolated postchallenge hyperglycemia (IPH) are common in the elderly. The aim of this study was to investigate the insulin secretion and sensitivity in Korean elderly lean diabetic women. Forty-one lean women aged 65-88 years took 2 hr oral glucose tolerance test (OGTT) and were stratified according to the WHO criteria (normal glucose tolerance [NGT], n=20; IGT, n=6; and type 2 diabetics, n=15 including seven IPH). HbA1c and fructosamine progressively increased from the NGT to the diabetic subjects (p=0.006 and p=0.001, respectively). Compared with subjects with NGT, the insulinogenic index, a marker of early insulin secretion and the AUC(ins), a marker of total insulin secretion, decreased significantly in diabetic group [0.53 (-0.44 -1.45) vs. 0.18 (0.00 -1.11), p=0.03 and 306+/-165 vs. 199+/-78 pmol/L, p=0.02 respectively]. A significant difference was found in the AUC(c-peptide) among each group (221+/-59 vs. 206+/-34 vs. 149+/-51 pmol/L, p=0.001 for each). The homeostasis model assessment of insulin resistance (HOMA-IR), a marker of insulin resistance, was not different among the groups. We conclude that compared with NGT subjects, elderly lean women with diabetes have impaired oral glucose-induced insulin secretion but have relatively preserved insulin sensitivity. This suggests that insulin resistance is not necessarily an essential component of Korean elderly lean diabetic women.     

Impaired glucose tolerance and pregnancy outcome in Chinese women with high body mass index

To determine if impaired glucose tolerance (IGT) impacts on the outcome of singleton pregnancies in Chinese women with a high (>26 kg/m(2)) body mass index (BMI), a retrospective case-control study was performed on 128 women with IGT and 128 controls with normal oral glucose tolerance test results, who were matched for pre-pregnancy BMI (within 0.1 kg/m(2)) and delivered within the same 3 year period. The IGT group was older, with more multiparae, a higher incidence of previous gestational diabetes mellitus, higher booking haemoglobin and fasting glucose concentrations, but no difference in the pre-pregnancy weight, gestational weight gain, or weight or BMI at delivery. There was no difference in the obstetric complications, mode of delivery, or the gestational age or mean infant birthweight. However, the birthweight ratio (relative to mean birthweight for gestation), incidence of large-for-gestational-age (birthweight >90th percentile) and macrosomic (birthweight > or =4000 g) infants, and treatment for neonatal jaundice, were significantly higher in the IGT group. The results suggest that some of the complications attributed to gestational diabetes mellitus are probably related to maternal weight excess/obesity in the affected subjects, but IGT could still affect infant birthweight outcome despite diet treatment which has normalized gestational weight gain.     

Conduite à tenir devant une glycémie « limite supérieure »

Type 2 diabetes is preceded by a long preclinical period with progressively glucose tolerance abnormalities. Beside diabetes defined by a venous fasting glucose superior to 7 mmol/l (1.26 g/l), American Diabetes Association identified two others abnormalities of glucose tolerance: the impaired glucose tolerance (IGT) defined by a two hours glycaemia between 7.8 and 11 mmol/l (1.4 and 1.9 g/l) at the oral glucose tolerance test (OGTT) and the impaired fasting glycaemia (IFG) with a fasting glycaemia between 6.1 and 6.9 mmol/L (1.1 and 1.25 g/l). Prevalence of IGF is between 2 and 10% in non diabetic adult subjects. IFG concerns mainly subjects aged 40–50 years and is 1.5 to 3 fold more frequent in man. Most of the well-known risk factors for developing type 2 such us overweight, abdominal obesity, familial history of diabetes, over –consumption of fat and alcohol are present in subjects having IFG. Hypertension is present in more than 50% of the subjects with IFG. Fifty percents of subjects with IFG are also an impaired glucose tolerance. IFG is associated with a high diabetes risk because 10 to 30% of subjects with IFG will develop type 2 diabetes after five years. Both IFG and IGT are associated with an increase of risk of cardiovascular mortality while the two hours glycaemia of OGTT is more predictive than IFG. Microalbuminuria and carotid intima media-thickness are significantly increased in subjects having both IGT and IFG compared to subjects with only IGT. Subjects with IFG are associated with an increase risk of developing diabetes and cardiovascular disease. IFG requires the realization of an OGTT to search IGT or diabetes.     

Can fasting plasma glucose and glycated hemoglobin levels predict oral complications following invasive dental procedures in patients with type 2 diabetes mellitus? A preliminary case-control study

OBJECTIVE:

To evaluate the effects of the levels of glycemic control on the frequency of clinical complications following invasive dental treatments in type 2 diabetic patients and suggest appropriate levels of fasting blood glucose and glycated hemoglobin considered to be safe to avoid these complications.

METHOD:

Type 2 diabetic patients and non-diabetic patients were selected and divided into three groups. Group I consisted of 13 type 2 diabetic patients with adequate glycemic control (fasting blood glucose levels <140 mg/dl and glycated hemoglobin (HbA1c) levels <7%). Group II consisted of 15 type 2 diabetic patients with inadequate glycemic control (fasting blood glucose levels >140 mg/dl and HbA1c levels >7%). Group III consisted of 18 non-diabetic patients (no symptoms and fasting blood glucose levels <100 mg/dl). The levels of fasting blood glucose, glycated HbA1c, and fingerstick capillary glycemia were evaluated in diabetic patients prior to performing dental procedures. Seven days after the dental procedure, the frequency of clinical complications (surgery site infections and systemic infections) was examined and compared between the three study groups. In addition, correlations between the occurrence of these outcomes and the glycemic control of diabetes mellitus were evaluated.

RESULTS:

The frequency of clinical outcomes was low (4/43; 8.6%), and no significant differences between the outcome frequencies of the various study groups were observed (p>0.05). However, a significant association was observed between clinical complications and dental extractions (p = 0.02).

CONCLUSIONS:

Because of the low frequency of clinical outcomes, it was not possible to determine whether fasting blood glucose or glycated HbA1c levels are important for these clinical outcomes.