Glycated haemoglobin predicts progression to diabetes mellitus in Pima Indians with impaired glucose tolerance

Summary Glycated haemoglobin could offer several practical advantages over the OGTT for assessing glucose metabolism. Initial cross-sectional studies (1983–1985) on 381 subjects (mostly Pima Indians) described the relationship between HbA_1c (a specific glycated Hb) and the OGTT. We performed follow-up OGTTs and HbA_1c measurements on 257 of these same subjects 1.6–6.1 years later. Subjects were again grouped according to both the result of the OGTT (normal, IGT or diabetes, by WHO criteria) and HbA_1c result (normal or elevated based on mean ± 1.96 SD of normal). Of 66 subjects with IGT at baseline, 47 (71%) had normal HbA_1c and 19 (29%) had elevated HbA_1c. Twentysix (39%) of these subjects had diabetes at follow-up. Of these subjects with IGT, a significantly greater percentage of subjects with elevated HbA_1c at baseline (68%) showed worsening to diabetes than those with a normal HbA_1c (28%); (chi-square=7.8, df=1, p<0.01). Thus, in subjects with IGT, glycated Hb may be a useful predictor of progression to diabetes.Abbreviations OGTT Oral glucose tolerance test - WHO World Health Organisation - IGT impaired glucose tolerance     

High-performance liquid chromatographic assay of serum glycated albumin

Summary A method for determination of serum glycated albumin by high-performance liquid chromatography is presented. The system involves anion exchange chromatography to separate albumin and consecutive boronate affinity chromatography to separate glycated and nonglycated albumin. The method is rapid (20 min), precise (coefficient of variation, 0.7–4.9%), requires only a small sample (5 l), and can be automated. Assay of glycated albumin by this method is not influenced by the protein concentration of the sample or the presence of glucose. The variation in glycated albumin values in consecutive samples obtained within a day from diabetic patients (coefficient of variation, 2.02±0.65%) was significantly smaller (p<0.001) than that of values for fructosamine (coefficient of variation, 4.33±2.0%). The values of glycated albumin in normal subjects (20.2±1.6%) were clearly less than those in diabetic patients [39,6±5.4% in 40 Type 1 (insulin-dependent) and 39.4±5.9% in 25 Type 2 (non-insulin-dependent) patients]. The serum glycated albumin level was well correlated with HbA_1c in 65 diabetic patients (r=0.60). Because the life span of albumin in the circulation is short, measurement of glycated albumin should be useful as a short-term index of glycaemic control.     

d-Lysine reduces the non-enzymatic glycation of proteins in experimental diabetes mellitus in rats

Summary d-Lysine, the non-physiological isomer of l-lysine, can competitively reduce protein non-enzymatic glycation in vitro. To study the effect of d-lysine in vivo, 6–8-week old Sprague-Dawley rats with streptozotocin-induced diabetes mellitus were treated from diagnosis for 45 days with two daily subcutaneous injections of d-lysine (0.5 g·ml^–1·day^–1). Another group of diabetic rats was only injected with equal volumes of physiological saline (0.9% NaCl). Glycated haemoglobin was measured by ion exchange chromatography, and glycated serum and lens proteins by boronate affinity gel chromatography. Serum and urinary creatinine concentrations were evaluated by the alkaline-picrate reaction. Urinary lysine concentrations at mid- and end-study were evaluated by cation exchange chromatography. Blood glucose concentrations, serum creatinine levels and creatinine clearances, measured at the end of the study, were similar in both diabetic groups (> 22.0 mmol/l, 106 mol/l and 0.02 ml/s, respectively). Urinary lysine concentration in d-lysine-treated diabetic animals was more than 50-fold higher than in placebo-treated diabetic rats. In d-lysine-treated vs placebo-treated diabetic animals, a statistically significant reduction was found in the levels of glycated haemoglobin (stable HbA₁; mean ± SD=3.00±0.74% vs 4.02±0.46%, p<0.05; labile HbA₁=3.92±0.89% vs 5.84±0.61%, p<0.005), glycated serum proteins (1.40±0.47% vs 2.52±1.15%, p<0.05) and glycated lens proteins (4.90±0.96% vs 5.98±0.65 %,p<0.05). Thus, d-lysine (i) is not nephrotoxic and (ii) causes a significant reduction of the early glycation products at the protein level. Therefore, the d-amino acid could be useful in attempting to control damaging phenomena associated with or due to an enhanced protein non-enzymatic glycation.     

Both acute and chronic near-normoglycaemia are required to improve insulin resistance in Type 1 (insulin-dependent) diabetes mellitus

Summary To determine the impact of both short- and longterm near-normoglycaemia on insulin resistance in Type 1 (insulin-dependent) diabetes hepatic glucose production (mg · kg^–1 · min^–1) and peripheral glucose utilisation (M-value, mg · kg^–1 · min^–1) were estimated during an euglycaemic hyperinsulinaemic clamp (10 mU · kg · min) in patients with either good (HbA_1c<5.8%, groups A and B) or poor (HbA_1c>7.5%, groups C and D) long-term metabolic control (time > 12 months) and in healthy subjects (HbA_1c: 5.08±0.20%; n=8). To this end blood glucose was stabilized at 6.7 mmol/l by overnight (t=12 h) i.v. regular insulin in groups (n=8 each) A (HbA_1c: 5.49±0.46%) and C (HbA_1c: 8.83±1.20%),while groups B (HbA_1c:5.55±0.19%) andD (HbA_1c: 8.51±1.09%) were kept overnight on long-acting insulin without feed-back control of blood glucose before euglycaemic clamping. Thereby, pre-equilibration of blood glucose at 6.7 mmol/l was shown to normalize basal hepatic glucose production (A: 2.27±0.48; C 2.50±0.57 mg · kg^–1 · min^–1) despite different HbA_1c values, whereas basal hepatic glucose production stayed elevated in groups B (3.09±0.38 mg · kg^–1 · min^–1) and D (3.21±0.58 mg · kg^–1 · min^–1) with poor actual glycaemia (B: 10.9±4.6; D: 12.1±4.6 mmol/l). To restitute peripheral glucose utilisation close to normal (healthy subjects: 13.99±2.13; A: 12.12±2.67; B: 8.72±3.0; C: 10.27±1.69; D: 7.10±2.31 mg · kg^–1 · min^–1; healthy subjects vs A: NS; healthy subjects vs B, C, D: p<0.05) both long-term (HbA_1c<5.8%) and acute nearnormoglycaemia by 12-h i. v. insulin pre-treatment were required (group A). We conclude that good long-term glucose control per se is unable to normalize hepatic and peripheral glucose metabolism in Type 1 diabetic patients unless actual near-normoglycaemia is provided consistently, e.g. by i.v. overnight infusion of regular insulin.     

Radioimmunoassay for the determination of glycated haemoglobin

Summary A competitive radioimmunoassay for the quantitative determination of glycated haemoglobin was developed. The antiserum, obtained by immunizing guinea pigs with reduced glycated human albumin, was capable of identifying and quantitating the glucitollysine residues of glycated Hb after reduction with sodium borohydride. To simplify the sample preparation we introduced trichloroacetic acid precipitation to remove unreacted sodium borohydride instead of using dialysis or gel filtration. Using this procedure, our radioimmunoassay became relatively simple and provided satisfactory within- and between-run (1.3–2.8% and 1.9–5.4% coefficient of variation, respectively). The radioimmunoassay method was compared to the measurement of HbA _1c by high performance liquid chromatography which is the most widely used method for quantitating glycated Hb. For this purpose glycated Hb was measured in normal glucose tolerance, impaired glucose tolerance, and diabetes mellitus groups based on WHO criteria. Both assays were able to discriminate between the normal and diabetic groups. In addition, while the determination of glycated Hb by the radioimmunoassay method was able to clearly discriminate between the normal and impaired glucose tolerance groups, the determination of HbA _1c by the high performance liquid chromatography method failed to discriminate between these two groups. Moreover, 15 of the 20 impaired glucose tolerance patients exceeded the upper normal range (mean normal values + 2 SD) in radioimmunoassay. But all 20 patients with impaired glucose tolerance were within the upper normal range in HbA _1c values.These results demonstrate that the measurement of glycated Hb by radioimmunoassay is more sensitive than the measurement of HbA _1c by high performance liquid chromatography since it can discriminate between the normal and impaired glucose tolerance groups.     

Glycated serum proteins and glucose tolerance

Summary Glycated serum proteins (GSP), stable glycated hemoglobin (HbA_1c) together with some metabolic parameters were evaluated in 120 subjects, 30 with normal glucose tolerance (NGT), 30 with impaired glucose tolerance (IGT), 30 with non-insulin-dependent diabetes mellitus (NIDD), and 30 with insulin-dependent diabetes mellitus (IDD). GSP levels were significantly higher in IGT, NIDD and IDD than in NGT. HbA_1c levels were not significantly higher in IGT in comparison with NGT, but were significantly higher in NIDD and in IDD than in NGT and IGT. GSP correlated better than HbA_1c with all metabolic parameters considered. Taking into account the distribution of the values, GSP showed a smaller overlap than HbA_1c in all four groups studied. Moreover, only 9 subjects (30%) with IGT showed GSP levels above the normal range. Therefore, GSP assay is able to distinguish between normal and diabetic subjects but is unable by itself to discriminate subjects with normal from those with reduced glucose tolerance. This study was supported by a grant fromConsiglio Nazionale delle Ricerche (Rome, Italy)Progetto Finalizzato ‘Medicina Preventiva e Riabilitativa’, Sottoprogetto ‘Malattie Degenerative’, Ob. 46.     

Does ethanol intake interfere with the evaluation of glycated hemoglobins?

Summary Ethanol and/or its metabolites interfere with the chromatographic assay of glycated hemoglobins. Fasting plasma glucose, blood ethanol, HbA₁, HbA_a1+b, MCV and GGT were determined in 22 control subjects, 22 alcoholics, 22 diabetic patients and 22 alcoholic diabetic patients. Fasting plasma glucose and all hemoglobin fractions were lower in alcoholic subjects and, except for HbA_1a+b, higher in diabetic patients and in alcoholic diabetic patients. HbA₁ and HbA_1c correlated well with plasma glucose but not with blood ethanol, MCV and GGT. Glycated hemoglobin was not found to be a useful marker for alcohol abuse. With the chromatographic method we used, the evaluation of glycated hemoglobin fractions, chiefly HbA_1c, confirms its usefulness in monitoring the metabolic control of diabetic subjects, even in case of ethanol abuse.     

Glycosylated haemoglobin in renal failure

Summary The level of the glycosylated haemoglobin HbA_1c was measured in (1) subjects with normal renal function, (2) patients with renal failure and (3) patients on intermittent haemodialysis. In 60 subjects with normal renal function but with a varying degree of glucose tolerance, there was a significant correlation between HbA_1c and fasting blood-glucose. In 20 patients with renal failure the mean value of HbA_1c was 6.6±1.3% (mean ± SD) whereas in 17 subjects with normal renal function, but with the same degree of glucose tolerance, this value was 4.7±0.9%. In 30 patients on intermittent dialysis the mean level of HbA_1c was 6.3±1.5%. This level did not fall after 3 months of dialysis with a glucose-free fluid. In both groups of patients with renal failure there was no correlation between HbA_1c and fasting blood-glucose. — It is concluded that renal failure itself causes an increase in HbA_1c.     

Pharmacokinetics of intravenous glibenclamide investigated by a high performance liquid Chromatographic assay

Summary The relationship between blood glucose and glycosylated haemoglobin (HbA_1c) has been investigated during an 8 week period in 53 Type 1 (insulin-dependent) diabetic women studied during the third trimester of pregnancy. Blood glucose estimations (fasting and 2 h post-prandially) were made an average of 41 times in each patient during this period and HbA_1c was determined once at the end of the study. There was a significant correlation between both the mean blood glucose over the preceding 8 weeks and the standard deviation of the fasting blood glucose with HbA_1c (r=0.69, p<0.001; r=0.46, p<0.001, respectively). A glycosylation index was calculated for each patient (HbA_1c divided by the mean blood glucose value). There was a significant correlation between the glycosylation index and duration of diabetes (r=0.68, p<0.001). In contrast, there was no correlation between red cell 2,3-diphosphoglycerate and HbA_1c or glycosylation index. These findings suggest that increasing duration of diabetes influences the post-translational formation of HbA_1c and that isolated HbA_1c values need to be interpreted with caution in the pregnant diabetic.     

Islet cell antibodies are associated withβ-cell failure also in obese adult onset diabetic patients

To clarify the utility of islet cell antibodies (ICA) to correctly classify and predict insulin treatment in newly diagnosed diabetic subjects, ICA, body mass index (BMI), glycated hemoglobin (HbA_1c), and fasting plasma C-peptide values were evaluated at and 3 years after diagnosis in 233 new, consecutively diagnosed, adult diabetic patients classified as obese or nonobese (National Diabetes Data Group, NDDG criteria). Among the 233 patients, 31 were nonobese ICA-positive (mean age at diagnosis 43±3 years), 55 nonobese ICA-negative (mean age at diagnosis 58±2 years), 7 obese ICA-positive (mean age at diagnosis 57±5 years), and 139 obese ICA-negative (mean age at diagnosis 58±1 years). Fasting C-peptide decreased (P<0.05) in nonobese ICA-positive patients who after 3 years showed lower BMI (22.6±0.6 versus 24.5±0.4;P<0.05), lower fasting C-peptide (0.14±0.06 nmol/l versus 0.71±0.07 nmol/l;P<0.001), and higher frequency of insulin treatment [28/31 (90%) versus 6/45 (13%);P<0.001] than nonobese ICA-negative patients. In obese ICA-positive patients, fasting C-peptide also decreased ( C-peptide 0.17±0.04 nmol/l;P<0.05) after diagnosis, and 3 years after diagnosis, obese ICA-positive patients showed lower BMI (25.7±1.2 versus 29.8±0.4;P<0.01) and fasting C-peptide (0.08±0.04 nmol/l versus 1.06±0.05 nmol/l;P<0.001) and higher HbA_1c values (9.92%±0.68% versus 7.39%±0.21%;P<0.01) and a higher frequency of insulin treatment [7/7 (100%) versus 5/121 (4%);P<0.001] than obese ICA-negative patients. Therefore, ICA detected at diagnosis of diabetes in both obese and nonobese adult patients indicate -cell dysfunction, high HbA_1c levels, and progression to insulin dependency.     

Adherence to a Mediterranean diet and glycaemic control in Type 2 diabetes mellitus

Aims Mediterranean‐type diets reduce the risk of Type 2 diabetes. Whether a Mediterranean‐type diet improves glycaemic control in diabetes remains unknown. Methods We conducted a cross‐sectional analysis in 901 outpatients with Type 2 diabetes attending diabetes clinics located in Campania County, South Italy. We explored the relation between glycated haemoglobin (HbA_1c), measured centrally, self‐measured pre‐ and postprandial glucose levels and consumption of a Mediterranean‐type diet. Adherence to a Mediterranean‐type diet was assessed by a 9‐point scale that incorporated the salient characteristics of this diet (range of scores, 0–9, with higher scores indicating greater adherence). The study was conducted from 2001 to 2007. Results Diabetic patients with the highest scores (6–9) had lower body mass index and waist circumferences, a lower prevalence of the metabolic syndrome and lower HbA_1c and post‐meal glucose levels than diabetic patients with the lowest scores (0–3). In multivariate analysis, mean HbA_1c and 2‐h post‐meal glucose concentrations were significantly lower in diabetic patients with high adherence to a Mediterranean‐type diet than those with low adherence [difference: HbA_1c 0.9%, 95% confidence intervals (CI) 0.5–1.2%, P < 0.001; 2‐h glucose 2.2 mmol/l, 95% CI 0.8–2.9 mmol/l, P < 0.001]. Conclusions In Type 2 diabetes, greater adherence to a Mediterranean‐type diet is associated with lower HbA_1c and postprandial glucose levels.     

Glycated Haemoglobin Levels in Patients with Diabetes in One General Practice over a 10-year Period

The aim of the study was to evaluate the level of control, as reflected by HbA_1c, in patients with diabetes attending one general practice over a 10-year period. The study was based in one general practice in South Tyneside, UK and consisted of an analysis of HbA_1c values of all patients with diabetes attending the practice between 1983 and 1992. HbA_1c levels were analysed and are presented as multiples of the standard deviation above the mean. In the practice 256 patients with non-insulin-dependent diabetes mellitus (NIDDM) and 76 with insulin-dependent diabetes mellitus (IDDM), attended for a total of 1596 doctor/patient contacts in the diabetic clinic over 10 years. The prevalence of diabetes was 1.9%. Over the course of the clinic, in any one year, 25% of patients with NIDDM and 55% with IDDM had levels of HbA_1c above those thought to be associated with increased risk of microvascular complications. Significant reduction in glycated haemoglobin (HbA_1c) occurred in the first year after diagnosis (p < 0.01) and after changing treatment from diet alone to diet and oral hypoglycaemic agents (p < 0.001). We conclude that a large proportion of patients within this population had levels of glycaemic control that put them ‘at increased risk’.     

Clinical significance of HbA<Subscript>1c</Subscript> as a marker of circulating lipids in male and female type 2 diabetic patients

Diabetic patients with accompanied (but often unnoticed) dyslipidemia are soft targets of cardiovascular deaths. An early intervention to normalize circulating lipids has been shown to reduce cardiovascular complications and mortality. Glycated hemoglobin (HbA_1c) is a routinely used marker for long-term glycemic control. This investigation is an attempt to evaluate the diagnostic value of HbA_1c in predicting diabetic dyslipidemia. Venous blood samples were collected from 2,220 type 2 diabetic patients (ages, 35–91 years; male/female ratio, 1.07). The sera were analyzed for HbA_1c, fasting blood glucose (FBG), total cholesterol, triglycerides, high-density lipoprotein cholesterol (HDL) and low-density lipoprotein cholesterol (LDL). The levels of HbA_1c did not differ significantly between males (8.33 ± 0.06%) and females (8.47 ± 0.07%), whereas female patients had significantly higher FBG (10.01 ± 0.13 mmol/l) than males (9.31 ± 0.11 mmol/l). HbA_1c showed direct and significant correlations with cholesterol, triglycerides and LDL and inverse correlation with HDL. Female diabetic patients had significantly higher levels of serum cholesterol (5.42 ± 0.03 vs. 5.18 ± 0.03 mmol/l) and HDL (1.32 ± 0.01 vs. 1.12 ± 0.01 mmol/l) as compared to males. There was no significant difference in triglycerides and LDL between the two genders. Older patients (>70 years) had significantly lower FBG, cholesterol, triglycerides and LDL. There was a linear and significant increase in triglycerides in the patients of both genders with impaired glycemic control. Both male and female patients with worse glycemic control (HbA_1c > 9%) had significantly high cholesterol and LDL levels. Serum HDL showed a significant and inverse relationship with uncontrolled hyperglycemia in females but not in males. These findings clearly suggest that HbA_1c can provide valuable supplementary information about the extent of circulating lipids besides its primary role in monitoring long-term glycemic control. Further studies are warranted to reinforce the potential of HbA_1c as a biomarker for screening of high-risk diabetic patients.     

Study of the effect of altitude on the measurement of glycated haemoglobin using point-of-care instruments

We measured the glycated haemoglobin (HbA_1c) levels of a total of 24 non-diabetic volunteers and diabetic patients using a point-of-care (POC) analyser in three Cameroonian cities at different altitudes. Although 12 to 25% of duplicates had more than 0.5% (8 mmol/mol) difference across the sites, HbA_1c values correlated significantly (r = 0.89–0.96). Further calibration studies against gold-standard measures are warranted.     

HbA1c levels in non‐diabetic Dutch children aged 8–9 years: the PIAMA birth cohort study

Aim Glycated haemoglobin (HbA_1c) is considered the best index of glycaemic control in established diabetes. It may also be useful in the diagnosis of diabetes and as a screening tool. Little is known about the distribution of HbA_1c in healthy children and its predictors. The aim of this study is to describe the distribution of HbA_1c in non‐diabetic Dutch children aged 8–9 years and to investigate potential associations of HbA_1c in this group. Methods HbA_1c was measured in 788 non‐diabetic children aged 8–9 years participating in the PIAMA birth cohort study. Data on parents and children were collected prospectively by questionnaires. Weight, height and waist and hip circumference of the children were measured when blood samples were taken. Results Mean (sd ) HbA_1c was 4.9 ± 0.33%, range 3.5–6.0%. HbA_1c was significantly higher in boys (4.9 ± 0.31 vs. 4.9 ± 0.33%) and in children of mothers with gestational diabetes (5.0 ± 0.37 vs. 4.9 ± 0.32%). We found a significant inverse association between HbA_1c and haemoglobin (regression coefficient: ?0.169 (95% CI ?0.221 to ?0.118), P < 0.001). HbA_1c was not significantly associated with age, body mass index, waist circumference, parental diabetes or maternal body mass index. Conclusions We found no significant relation between known risk factors for Type 2 diabetes and HbA_1c at age 8–9 years. Moreover, there was a significant inverse association between haemoglobin and HbA_1c. These results suggest that HbA_1c may not only reflect the preceding blood glucose levels, but seems to be determined by other factors as well.     

Beneficial effects of flexible insulin therapy in children and adolescents with type 1 diabetes mellitus

Abstract. The purpose of this study was to determine the feasibility of a flexible multiple daily insulin (FMDI) regimen in routine pediatric diabetes care by comparing HbA_1c, body mass index (BMI), and episodes of severe hypoglycemia (SH) before and after initiation of FMDI therapy. Data from 44 patients (2–16 years old), on a conventional insulin (CI) regimen, were collected during quarterly diabetes clinic visits. These patients were transitioned from CI to FMDI regimen: pre-meal lispro (bolus) and once or twice daily Humulin Ultralente with or without bedtime Humulin NPH as the basal insulin. There was a significant improvement in HbA_1c in prepubertal (9.3%±1.3% vs. 8.0%±1.1%, p<0.002) and pubertal subjects (9.2%±1.0% vs. 8.2%±0.9%, p<0.001). Pubertal subgroup demonstrated an increase in BMI (21.3±3.1 vs. 22.7±3.2 kg/m², p<0.0001) after one year. The rate of SH was decreased in both prepubertal (p<0.01) and pubertal (p<0.05) groups of patients on FMDI therapy. The use of FMDI in a general pediatric diabetic population is a feasible therapeutic option for maintenance and possible improvement of glycemic control. It may effectively decrease the HbA_1c, and reduce hypoglycemic episodes, without producing an abnormal increase in BMI.     

Good Blood Glucose Control Characterizes Patients Without Retinopathy After Long Diabetes Duration

The importance of blood glucose control for the avoidance of retinopathy was assessed by monitoring glycated haemoglobin for 5 years or more in Type 1 (insulin-dependent) diabetic patients diagnosed before an age of 31 years, and with a diabetes duration of 20 years or more. They were followed up for an average of 9.4 years with 3.3 measurements per year. Of the 213 included patients, 16 had no retinopathy, 126 had background retinopathy (including 8 with macula oedema) and 71 had proliferative retinopathy. Patients without retinopathy had a mean HbA_1c ± SEM for the whole follow-up period of 6.3 ± 0.19 %, the 117 patients with background retinopathy but not macula oedema 7.0 ± 0.08%; Mann-Whitney test vs group without retinopathy p = 0.003, macula oedema 7.9 ± 0.31%; p = 0.001, and proliferative retinopathy 7.4 ± 0.09; p < 0.001. The mean duration was 31 years, without significant differences between the groups. In conclusion, these results suggests that good blood glucose control is of major importance to prevent or postpone diabetic retinopathy also after long duration of diabetes, and that no patient with high HbA_1c levels for several years is protected from retinopathic lesions.     

Cognitive behavioural therapy (CBT) compared with blood glucose awareness training (BGAT) in poorly controlled Type 1 diabetic patients: long‐term effects on HbA1c moderated by depression. A randomized controlled trial

Objective To test the effectiveness at 6 and 12 months’ follow‐up of group cognitive behavioural therapy (CBT) compared with blood glucose awareness training (BGAT) in poorly controlled Type 1 diabetic patients and to explore the moderating effect of baseline depression. Research design and methods Adults with Type 1 diabetes (n = 86) with glycated haemoglobin (HbA_1c) ≥ 8% were randomized to CBT or BGAT. Primary outcome was HbA_1c control. Secondary outcomes were: self‐care, diabetes‐related distress (Problem Areas in Diabetes scale; PAID), diabetes self‐efficacy (Confidence in Diabetes Self‐care scale; CIDS) and depressive symptoms (Centre for Epidemiological Studies – Depression scale; CES‐D). Measurements were scheduled before CBT and BGAT, and at 3, 6 and 12 months after. Differential effects were analysed for the subgroup of patients reporting low vs. high baseline levels of depression. Results Neither CBT nor BGAT had a significant impact on HbA_1c at 6 and 12 months’ follow‐up. Both interventions resulted in lower depressive symptoms (CES‐D 15.7–13.3, P = 0.01) up to 12 months, but only CBT was effective in lowering HbA_1c in patients with high baseline depression scores (HbA_1c 9.5–8.8%) up to 1 year of follow‐up (P = 0.03). Conclusions Our findings suggest that group CBT can effectively help Type 1 diabetic patients with co‐morbid depression achieve and maintain better glycaemic outcomes.     

Audit of a shared-care program for persons with diabetes: baseline and 3 annual follow-ups

Abstract. In Italy, data on shared-care programs for diabetes are lacking. We described the characteristics of type 2 diabetic population assisted in general practice and evaluated 3 years of follow-up outcomes and performance indicators in a shared-care program in Modena, Italy (1998–2001); only well-controlled diabetic patients were considered. Forty-nine percent of territorial GPs adhered to the project (257 out of 521) and 77% of them sent 6409 paired baseline and follow-up datasheets. Altogether, 97.8% patients had type 2 diabetes, mean age 68.6±11.7 years, disease duration 9.6±7.5 years, BMI 28.6±4.8 kg/m2, HbA_1c 7.6%±1.6%, 16.1% of them were disabled. Among the non-disabled patients, 23.6% had optimal glycemic control (HbA_1c 6.5%); at baseline the prevalence of micro- and macrovascular diabetic complications was: 8.2% microalbuminuria and 2.4% macroalbuminuria plus nephropathy, 11.0% nonproliferative and 3.0% preproliferative retinopathy, 7.0% neuropathy, 1.8% diabetic foot; 8.5% angina, 6.9% TIA or stroke, 6.3% infarction, 5.2% intermittent claudication, 4.1% heart failure. Among the disabled patients 27.9% had optimal glycemic control, but they had more diabetic complications. The performance indicators significantly improved over the 3-year study period: glycemic control indicators increased from 66%–75% to 83%–90% and micro- and macrovascular indicators from 59%–65% to 75%–81%. The outcome indicators also improved: mean HbA_1c value changed from 7.6%±1.6% to 7.3%±1.3% and the percentage of people with HbA_1c6.5% significantly improved over time. Similar trends were observed in both disabled and non-disabled diabetic patients.     

Hemoglobin A(1c) proportion, mortality rate, and risk factors for death in diabetic patients with severe hypoglycemia: a multicenter retrospective survey over ten years

Objective

To investigate the HbA_1c proportion and mortality rate across diabetic patients with severe hypoglycemia and the risk factors for death.

Methods

All the diabetic patients with severe hypoglycemia were divided into HbA_1c < 6.5% group and HbA_1c ≥ 6.5% group. The proportion of HbA_1c, mortality rate and the risk factors for death were analyzed. Common causes for severe hypoglycemia were also analyzed.

Results

The percentages of HbA_1c in the HbA_1c < 6.5% and HbA_1c ≥ 6.5% groups were 51.2% and 48.8%, respectively. The mortality rates were not significantly different between the 2 groups (5.3% vs. 5.1%, χ² = 0.01, p = 0.17). Binary logistic regression analysis revealed that in both groups, creatinine, aspartate aminotransferase, and uric acid levels were the risk factors for death. In the HbA_1c < 6.5% and HbA_1c ≥ 6.5% groups, 65.0% and 64.2% showed common causes of severe hypoglycemia, respectively.

Conclusions

With respect to severe hypoglycemia, equal attention should be paid to patients with an HbA_1c level of ≥6.5% and those with an HbA_1c level of <6.5%. The mortality rate is approximately 5% in severe hypoglycemia no matter how the HbA_1c level is. Creatinine, aspartate aminotransferase, and uric acid are the main risk factors in both groups. Two-thirds of severe hypoglycemia cases could be prevented.