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Int J Pharm Biomed Res 2010, 1(2), 53-56

International Journal of
PHARMACEUTICAL AND BIOMEDICAL RESEARCH ISSN No: 0976-0350

Research article

Glycated haemoglobin (HbA1c) as a stable indicator of type 2 diabetes

CRISTAL Diagnostic & Research Laboratory (CDRL), Sri Sugam Hospital Campus, Omalur, Salem-636 455, Tamil Nadu, India Department of General Medicine & Diabetologe, Sri Sugam Hospital, Omalur, Salem-636 455, Tamil Nadu, India 3 Department of Gynecology, Sri Sugam Hospital, Omalur, Salem-636 455, Tamil Nadu, India

Received: 05 Apr 2010 / Revised: 26 Apr 2010 / Accepted: 28 Apr 2010 / Online publication: 05 May 2010

ABSTRACT HbA1c expressed, as the percentage of adult haemoglobin that is glycated, is the most widely used measure of chronic glycaemia. Achieving near normal HbA1c levels have been shown to reduce long term complications and the HbA1c assay is recommended to determine whether treatment is adequate and to guide adjustments. However, daily adjustments of therapy are guided by glucose levels. We determined the relationship between an accurate measure of mean glucose levels over time and the HbA1c level, and whether HbA1c can be expressed in the same units as self monitoring results. The aim of the study was to assess whether HbA1c levels reflected mean blood glucose (MBG) levels in Type 2 diabetes. Despite the good correlation between HbA1c and MBG, the use of HbA1c alone for glycemic control monitoring in these patients could be insufficient to clearly trace their risk of complications. The study population consisted of 100 subjects divided into two groups viz. participants with diabetes (n=50) and non-diabetic (n=50). Changes in the levels of MBG and HbA1c were determined in diabetic and non-diabetic subjects. The level of blood glucose, HbA1c, MBG, microalbuminurea, urea and creatnine was significantly increased in diabetics than non diabetic subjects. There was a statistically significant relationship between MBG and HbA1c. The mathematical relationship established between HbA1c and MBG in this study should allow the expression of HbA1c as an equivalent for mean glucose level. This is likely to be beneficial to patients and care providers alike as the assay of chronic glucose control would be in the same units as the patients self-monitoring. However, before this transformation can take place, the mathematical relationship between HbA1c and MBG levels should be confirmed in a larger study with a more diverse population to ensure that the relationship applies for all diabetes patients. Key words: Glycated haemoglobin, Mean blood glucose, Type 2 diabetes, Glycation.

1. INTRODUCTION The HbA1c assay has become the most commonly used measure of chronic glycaemia in epidemiological studies, clinical trials and the management of diabetes since its introduction more than 25 years ago [1]. The concentration of HbA1c, formed through the non-enzymatic attachment of glucose to haemoglobin, is commonly considered to reflect the integrated mean glucose level over the previous 812 weeks, the time period being dictated by the 120-day lifespan of the erythrocyte. The relationship between mean blood glucose and HbA1c has been suggested by old studies that used a variety of measures of outpatient and inpatient plasma
*Corresponding Author. Tel: +91 4290 220355, Fax: +91 4290 222953 Email: drppasupathi@gmail.com

and capillary glucose concentrations, all of which suffered from relatively infrequent sampling of glucose levels, infrequent sampling of HbA1c [2,3]. The clinical role of the assay was subsequently established by demonstrating that it provided information regarding mean blood glucose (MBG) that could not be provided by any other available measures. The pre-eminent role of the assay was cemented by the Diabetes Control and Complications Trial (DCCT) and others, which used the assay to measure chronic glycaemia and demonstrated its central role in the pathogenesis of long term complications [4]. The recommended goals for metabolic control of diabetes are based on the HbA1c assay [2,3], the vast majority of methods now being standardized to the DCCT assay

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P. Pasupathi et al., Int J Pharm Biomed Res 2010, 1(2), 53-56

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through an international programme [5]. Self monitoring of blood glucose (SMBG) is an important component of diabetes care, and MBG and HbA1c are considered interchangeable estimates of glycemic control. In particular, the DCCT allowed correlating HbA1c levels to MBG to enable patients and physicians to set glucose targets to achieve HbA1c goals [6]. However, several studies have reported that these two parameters are not necessarily identical estimates of glycemic control, suggesting that haemoglobin glycation phenotype may explain the observed individual differences in the relationship between MBG and HbA1c [7]. Given the uncertainty about these aspects, and since all the available data refer to Type 1 diabetes, we assessed whether HbA1c levels reflected MBG levels in Type 2 diabetes mellitus. We used continuous MBG monitoring in patients with diabetes with relatively stable glycaemia, and in non-diabetic individuals, to determine true mean glycaemia. HbA1c assays were measured monthly and best fit correlations were determined over time. 2. MATERIALS AND METHODS 2.1. Study population The study population consisted of 100 subjects (age matched male subjects) divided in to two groups viz., diabetic patients (type 2 diabetic subjects; n=50) and nondiabetic participants (n=50). The prospective study was carried out at Sri Sugam Hospital, Salem, Tamil Nadu, India, during November 2008 to January 2010. General health characteristics such as age, sex, smoking status, menopausal status, alcohol consumption and dietary habits, particularly as related to preference were investigated by a self administered questionnaire. Three non-diabetic volunteers were also recruited. The diabetic participants were required to have relatively stable glycaemic control, manifest by at least two HbA1c assay results in the previous 6 months that were no more than 1% different. We tried to recruit approximately similar numbers of diabetic participants with HbA1c <7, 78.5 and >8.5%. The non-diabetic participants had no history of diabetes and had HbA1c levels in the non-diabetic range (<6.1%) in the assays used for the study. Exclusion criteria included any condition that would probably cause a change in glucose control during the three month period of study or that would change erythrocyte turnover. Potential participants with known haemoglobinopathies were excluded to avoid any possible interference with the HbA1c assays [8]. All participants signed an informed consent form approved by the human research committee. 2.2. Determination of blood glucose, HbA1c, serum lipids and proteins Biochemical investigation including blood glucose, urea, creatnine, total protein and albumin were determined using

fully automated clinical chemistry analyzer (Hitachi 912, Boehringer Mannheim, Germany). Estimated HbA1c values were calculated according to the conversion formula established by Rohlfing et al. [9], which was constructed on the basis of the DCCT database about MPG and HbA1c levels, shown below:

Estimated HbA1C % =
2.3. Statistical analysis

MPG (mg/dL) + 1.87 35.6

(Eq.1)

All data were expressed as mean SD. The statistical significance was evaluated by Students t test using SPSS version 10.0 (Cary, NC, USA). 3. RESULTS Table 1 shows the information about the investigated characteristics of study population. The mean age limit was 65 15 years in diabetic patients and 62 10 years in nondiabetic subjects. A significant increase in body mass index (BMI) was observed in diabetic patients (30 6.2 kg/m2) when compared to non-diabetic subjects (33 6.0 kg/m2). Diabetic participants were defined as those with a fasting blood glucose concentration minimum >120 mg/dL. Table 2 shows the levels of blood glucose, HbA1c, microalbuminuria, urea, creatinine, and proteins in nondiabetic and diabetic subjects. The level of blood glucose, HbA1c, MBG, microalbuminuria, urea and creatinine was significantly increased in diabetics than non-diabetic subjects. On the other hand, the levels of serum total protein and albumin were significantly decreased in diabetic patients when compared to non-diabetic subjects. 4. DISCUSSION The HbA1c assay is widely accepted as the best means of retrospectively capturing mean glycaemia. It is the basis of treatment guidelines and is used universally to adjust therapy [2,10]. In order for patients to achieve HbA1c goals, they adjust their day-to-day therapies based on plasma glucose levels, measured with meters that are adjusted to provide values comparable to venous plasma levels [11]. However, the relationship between HbA1c values and mean glucose levels has never been carefully explored, owing in great part to the absence of means to measure glucose levels frequently enough to reveal a complete description of mean glucose levels over time. Previous studies that have been performed have used relatively infrequent glucose testing and have not been able to measure MBG levels with confidence because of potential sampling errors [12]. For example, the DCCT data set included a seven point glucose profile performed every 3 months [13]. The limited number of HbA1c assay results in the higher range limits our ability to choose between the linear and exponential models. Although the choice of research

P. Pasupathi et al., Int J Pharm Biomed Res 2010, 1(2), 53-56 Table 1 Demographic characteristics of control (non-diabetic) and diabetic patients Parameter Control (n=50) Diabetic (n=50) Age (year) Diabetes duration (years) Smokers Alcohols Hypertension Body mass index (kg/m2) 62 10 10% 10% 4% 30 6.2 65 15NS 15 10 25% 15% 20 % 33 6.0NS

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Values are given as mean S.D. Diabetic group compared with control group (NS-Not significant) Table 2 Comparison of biochemical changes in control (non-diabetic) and diabetic patients Parameter Control (n=50) Diabetic (n=50) Blood glucose (mg/dL) Fasting 90.0 12.0 225.0 35.0*** Postprandial 121.0 23.0 378.0 31.0*** HbA1C (%) 3.1 1.7 13.1 3.1*** MBG (mg/dL) 58.0 17.0 271.0 51.0*** Microalbuminuria (mg/L) 8.0 2.1 38.0 12.3*** Urea (mg/dL) 21.1 9.0 31.5 11.0** Creatinine (mg/dL) 0.7 0.2 1.1 0.3** Total protein (g/dL) 7.5 1.0 5.9 1.3*** Albumin (g/dL) 4.2 1.2 3.3 0.6*** Values are given as mean S.D. Diabetic group compared with control group (**p<0.01, ***p<0.001).

imposable MBG levels could in theory be attributed to the different contribution of FBG and PPG in determining HbA1c levels in individuals with good and poor metabolic control [21,22]. Nevertheless, in our study we were unable to document significant differences in FBG and PPG between individuals with low and high HGI. Another implication is that in some patients HbA1c levels at target are associated with FBG and PPG levels largely above the desired values. The sole use of HbA1c to monitor metabolic control in these patients could thus be insufficient to clearly delineate their risk of complications. A limitation of the current study is that these indices were not derived from repeated measurements over time. Furthermore, the phenomenon could represent an artifact of measurement or analytical bias in the determination of HbA1c. 5. CONCLUSIONS In conclusion, the relationship between plasma glucose and HbA1c is complex and still not fully understood. The mathematical relationship established between HbA1c and MBG in this study should allow the expression of HbA1c as an equivalent mean glucose level. This is likely to be beneficial to patients and care providers alike as the assay of chronic glucose control would be in the same units as the patients self-monitoring. However, before this transformation can take place, the mathematical relationship between HbA1c and MBG levels should be confirmed in a larger study with a more diverse population to ensure that the relationship applies for all diabetes patients. REFERENCES
[1] Nathan, D.M., Turgeon, H., Regan, S., Diabetologia 2007, 50, 22392244. [2] American Diabetes Association, Diabetes Care 2007, 30, S4-S41. [3] Saudek, C.D., Derr, R.L., Kalyani, R.R., JAMA 2006, 295, 1688-1697. [4] DCCT Research Group, Diabetes 1995, 44, 968-983. [5] Little, R.R., Rohlfing, C.L., Wiedmeyer, H.M., Myers, G.L., Sacks, D.B., Clin Chem 2001, 47, 1985-1992. [6] Rohlfing, C.L., Wiedmeyer, H.M., Little, R.R., England, J.D., Tennill, A., Goldstein, D.E., Diabetes Care 2002, 25, 275-278. [7] Hempe, J.M., Gomez, R., McCarter Jr, R.J., Chalew, S.A., J Diabetes Complications 2002, 16, 313-320. [8] Bry, L., Chen, P.C., Sacks, D.B., Clin Chem 2001, 47, 153-163. [9] Mannucci, E., Ognibene, A., Sposato, I., Brogi, M., Gallori, G., Bardini, G., Cremasco, F., Messeri, G., Rotella, C.M., Acta Diabetol 2003, 40, 181-186. [10] Nathan, D.M., Buse, J.B., Davidson, M.B., Heine, R.J., Holman, R.R., Sherwin, R., Zinman, B., Diabetelogia 2006, 49, 1711-1721. [11] Goldstein, D.E., Little, R., Lorenz, R.A., Malone, J.I., Nathan, D., Diabetes Care 2004, 27, 1761-1773. [12] Murata, G.H., Hoffman, R.M., Duckworth, W.C., Wendel, C.S., Shah, J.H., Am J Med Sci 2004, 327, 319-323. [13] Svendsen, P.A., Lauritzen, T., Soegaard, U., Nerup, J., Diabetologia 1982, 23, 403-405. [14] Virtue, M.A., Furne, J.K., Nuttall, F.Q., Levitt, M.D., Diabetes Care 2004, 27, 931-935. [15] Tahara, Y., Shima, K., Diabetes Care 1993, 9, 1313-1314. [16] Koga, M., Matsumoto, S., Saito, H., Kasayama, S., Endocrine J 2006, 53, 387-391. [17] Shahbazkia, H.R., Nazifi, S., Comp Clin Pathol 2008, 17, 9-12. [18] Merino-Torres, J.F., Fajardo-Montanana, C., Ferrer-Garcia, J.C., PinonSelles, F., J Diabetes Complications 2003, 17, 249-253.

participants with stable HbA1c levels and the decision not to adjust therapy during the study limited our ability to examine the dynamics of glucose change and HbA1c levels, the strongest correlations between HbA1c and MBG levels appeared to be over the preceding 12 weeks, consistent with prior studies [1]. Of note, although there was less than a perfect correlation between the measured MBG and the HbA1c levels, the relatively high r values, especially given the limited sample size and range of values, suggests that there are probably no extraneous factors that affect the relationship between MBG and HbA1c in a substantive way. Some studies have suggested that variable red cell turnover, which may be affected by hyperglycemia, may alter the relationship between MBG and HbA1c values [14,15]. We found in Type 2 diabetes mellitus a good correlation between HbA1c and MBG, as previously described in other studies [16-20]. However, in our study one third of the patients had consistently higher HbA1c levels or consistently lower HbA1c levels than that expected under the hypothesis that HbA1c is solely determined by MBG. In particular, we identified two subgroups of patients characterized by a striking difference in HbA1c levels, despite identical MBG and non-significant differences in FBG and PBG mean values. This suggests the existence, even in Type 2 diabetes mellitus, of different haemoglobin glycation phenotypes that could explain the observation of individuals who develop major complications despite adequate HbA1c levels, or, vice versa, the presence of individuals who do not develop complications despite poor metabolic control. The presence of marked differences in HbA1c levels even with super

P. Pasupathi et al., Int J Pharm Biomed Res 2010, 1(2), 53-56 [19] Chalew, S.A., McCarter, R.J., Thomas, J., Thomson, J.L., Hempe, J.M., J Diabetes Complications 2005, 19, 218-222. [20] Ozmen, S., Cil, T., Atay, A.E., Tuzcu, A.K., Bahceci, M., Diabet Med 2006, 23, 1151-1154.

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[21] Monnier, L., Lapinski, H., Colette, C., Diabetes Care 2003, 26, 881885. [22] Nathan, D.M., Buse, J.B., Davidson, M.B., Diabetelogia 2006, 49, 1711-1721.