Diabetes and the role of HbA1c

Primer

Simply put, diabetes is a condition characterized by high blood sugar levels in the body. The hormone called insulin, produced by our pancreas, regulates the levels of blood sugar to an optimum standard under normal conditions. However, under a diabetic state, this mechanism of blood sugar regulation fails to work correctly and can give rise to an unregulated escalation of blood sugar. This generally occurs due to two pathways. Firstly, it can be due to a deficiency of insulin on our body. In this case, there could be a problem with the pancreas per se or a defect in the functioning of certain specialized cells of the pancreas called the beta cells of the islets of Langerhans, which are chief insulin producers in the human body. A problem related to the pancreas or to the beta cells of the islets can lead to lesser than normal level of insulin being produced. Hence, insulin deficiency sets in. This is known as type 1 diabetes. In the second case, though the pancreas is normal and the beta cells produce adequate amount of insulin, the tissues of the body are unable to utilize the available insulin effectively for regulating blood sugar. Hence, a diabetic state sets in spite of the presence of adequate insulin; a condition often referred to as insulin resistance or lowered insulin sensitivity. This is called as type 2 diabetes. While type 1 diabetes is more frequently seen in children and teens and is often referred to as childhood or adolescent onset diabetes; type 2 is the more common form of the disease affecting the young productive age group and the elderly.

 

Global and Indian statistics

Latest statistics put forth by the International Diabetes Federation, reveal an alarming global situation.

■387 million people have diabetes; by 2035 this will rise to 592 million

■The number of people with type 2 diabetes is increasing in every country

■77% of people with diabetes live in low- and middle-income countries

■Most cases of diabetes are between 40 and 59 years of age

■179 million people with diabetes are undiagnosed

■Diabetes caused 4.9 million deaths in 2014; every seven seconds a person dies from diabetes

■Diabetes caused at least USD 612 billion dollars in health expenditure in 2014 – 11% of total spending on adults

■More than 79,000 children developed type 1 diabetes in 2013

■More than 21 million live births were affected by diabetes during pregnancy in 2013

■In South-East Asia, almost half of people with diabetes are undiagnosed

The situation is equally grim back home. Diabetes is growing alarmingly in India, home to more than 65.1 million people with the disease, compared to 50.8 million in 2010. Until the latter half of the last decade, the number of people with diabetes in India was estimated to be around 40.9 million and has been projected to rise to 69.9 million by 2025. Infact, it has been predicted that if urgent remedial measures are not taken, India could be home to 80 million diabetics by 2030.

Diabetes: Why are Indians more vulnerable than people of other phenotypes?

Clinical evidence has proven that Indians are genetically at a greater risk of diabetes. This is because the Indian ethnicity has what is known as a “diabetogenic phenotype”; simply put; a set of clinical and biochemical features that increase one’s susceptibility to type II diabetes. These include central abdominal obesity, high quantum of abdominal and visceral fat, higher waist circumference in spite of lower body mass index, higher waist to hip ratios, lower levels of protective adipokines like adiponectin, greater insulin resistance, tendency to develop higher hs-CRP and adipose metabolites. This is what researchers have frequently referred to as the vulnerable diabetogenic “Asian Indian phenotype”. Add to this other predisposing factors like old age, male gender and a positive family history, poor diet, high stress levels, alcohol or tobacco use and a sedentary lifestyle; and the conundrum looks even more complex.

Accurate and timely diagnosis: A key to tackling the overwhelming burden of diabetes

The growing burden of diabetes presents a grave public concern. The most effective method to prevent the growing burden of this disease is to detect it correctly and as early as possible. Effective community surveillance measures need to be established for diabetes screening. Early stage cases need to be monitored regularly so as to prevent plan and tailor therapy. This will prevent the development of complications and reduce overall morbidity and mortality associated with the disease.

Individuals belonging to the high risk category should be tested for diabetes. In case if their test results reveal a normal status, these individuals should be re-tested yearly least once in 2 years. Children and adolescents also need to be tested in the following cases:

1. Overweight with body weight exceeding 120% of the ideal weight
2. Positive family history among first and second degree relatives
3. Signs of insulin resistance
4. Conditions known to predispose to insulin resistance (For example; acanthosis nigricans, dyslipidemia, PCOS, hypertension)

Glycated hemoglobin (HbA1C): A gold standard for measuring glycemic status

Measuring glycated hemoglobin (HbA1C) is the current gold standard for measuring chronic glycemia. HbA1C levels are indicative of microvascular complications of diabetes. Monitoring these levels aids therapy decision making. This assay has become the most pivotal tool in the diagnosis and monitoring of diabetes.

The American Diabetes Association currently recommends a glycated hemoglobin goal of less than 7%. Clinical studies have shown that for every 1% reduction in glycated hemoglobin amounts to a 10% relative risk reduction in microvascular complications of diabetes. Measuring glycated hemoglobin levels mirrors the patient’s glycemic status over a period of 3 months. Though, whether or not HbA1C values correlate perfectly with a 3-month average glucose level, has been an issue of considerable debate, clinicians all over the world use glycated hemoglobin measurements for successfully determining glycemic status and therapy goals.

 

Why is HbA1c done?

This test is done to:

• Diagnose prediabetes and diabetes.
• To check and monitor your response to diabetes therapy

How to prepare for this test?

You do not need to stop eating before you have an A1C test. This test can be done any time during the day, even after a meal.

How is the test performed?

The blood sample is taken from a vein in your arm. An elastic band is wrapped around your upper arm. It may feel tight. You may feel nothing at all from the needle, or you may feel a quick sting or pinch.

Other tests performed along with HbA1c?

Fasting blood sugar and post prandial blood sugar tests are also performed in conjunction

 

SRL in-house pan India data for 2012—14; for Hba1C tests

At SRL labs across India, a total of 1108742 HbA1c tests were performed during 2012—14. The samples tested belonged to different zones of the country as illustrated below. The highest number of samples was received from the western parts of India followed by the zone followed by the northern zone.

Out of the total samples tested for HbA1c, 70.27% samples had a value higher than normal whereas 29.73% samples showed a normal level.

We further analyzed the samples that showed up abnormal results; as per their age groups, geographic zones and gender.

The highest number of abnormal samples was received from the XX zone followed by the XX zone.

The highest number of abnormal samples belonged to the age group of 46—60 years followed by the 61—85 year age group.

The male population in our analysis sample showed a notably higher number of samples with abnormal HbA1c values. Out of the total samples with elevated HbA1c values, 59.03% were from male patients.

Diabetes prevention – Needs a concerted effort

Diet – Avoid trans fats and saturated fats, simple sugars, aerated drinks, tobacco based products, excess alcohol, excess hot beverages like tea and coffee. Include more of green leafy vegetables, plenty of water, fruits, complex carbohydrates with a high glycemic index like oatmeal, include plenty of fibrous food, limit the intake of dietary cholesterol, limit salt intake and consume healthy meats, legumes and grains

Exercise – Regular moderate physical exercise, yoga, and meditation is recommended and avoid a sedentary lifestyle as far as possible. Reduction in weight can also help you in reducing your risk of diabetes.

Stress is a known aggravating trigger in diabetes. Keeping your stress levels under control can be a major physical, emotional and psychological relief and can help you lower your risk of diabetes

Regular medical Check ups – Consult your family physician at regular intervals and keep checking your blood sugar. This assumes more importance for people who have a strong family history of diabetes. A combination of symptoms like excessive thirst, excessive hunger and very frequent urination; should ring an alarm for you to consult your doctor for a diabetes check up.

DISCLAIMER: This analysis presented in this report is based on results of patients’ samples tested at SRL labs. Its findings cannot be construed as a representation of HbA1c levels in the general population; it cannot be extrapolated to a real setting.