Letter: Impact of HbA1c Criterion on the Detection of Subjects with Increased Risk for Diabetes among Health Check-Up Recipients in Korea (Diabetes Metab J 2012;36:151-6)

Sung Hee Choi

doi:10.4093/dmj.2012.36.3.251

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Letter Letter: Impact of HbA1c Criterion on the Detection of Subjects with Increased Risk for Diabetes among Health Check-Up Recipients in Korea (Diabetes Metab J 2012;36:151-6): Sung Hee Choi^1,2; Diabetes & Metabolism Journal 2012;36(3):251-252.
DOI: https://doi.org/10.4093/dmj.2012.36.3.251
Published online: June 14, 2012

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¹Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea.

²Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Korea.

Corresponding author: Sung Hee Choi. Department of Internal Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine, 166 Gumi-ro, Bundang-gu, Seongnam 463-707, Korea. drshchoi@snu.ac.kr

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

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Hemoglobin A1c (A1c) has been investigated as a target for treatment of diabetes. Work has been done toward the standardization of A1c measurement, and the standardized method for A1c testing produces data consistent with that of the international A1c-Derived Average Glucose (ADAG) trial and Diabetes Control and Complications Trial (DCCT) [1,2]. A1c measurement is a more convenient and reproducible method than fasting glucose, providing reliable information for chronic glycemic control for 2 to 3 months. A1c has been known to have a strong correlation with chronic complications of diabetes and mortality [3,4].

Based on this evidence, the American Diabetes Association (ADA) suggested revised criteria for the diagnosis of diabetes mellitus using A1c levels, the criteria for which was A1c ≥6.5% [5]. However, there has been some debate that the recent ADA criterion by A1c level was too high, and concern has been raised about the possible delay in detecting undiagnosed diabetes [6-8]. Furthermore, it is very important to determine the appropriate A1c cutoff value based on epidemiology data for people of different ethnic backgrounds for the diagnosis of diabetes throughout the world.

From our previous prospective Ansung-cohort study, 635 participants (6.8%) had previously undiagnosed diabetes at baseline. An A1c cutoff value of 5.8% produced the highest sensitivity (72%) and specificity (86%) for detecting undiagnosed diabetes by receiver operating characteristic curve analysis in our cohort. At 6 years, 895 (10.2%) had developed new-onset diabetes. The cutoff A1c of 5.8% was the most accurate for predicting 6-year incident diabetes. After multiple adjustments, both men and women with a baseline A1c of ≥5.8% had a more than 3-fold increase in the risk of new-onset diabetes compared with those with A1c <5.8% at baseline [8]. When we converted this value to a DCCT-aligned assay, a cutoff of ≥6.5% had only 52.3% sensitivity with 96.8% specificity. An A1c value of 6.2% as obtained from the converted value was best for detection of undiagnosed diabetes as defined by the oral glucose tolerance test criteria with 67.6% sensitivity and 90.7% specificity.

Kim et al. [9] concluded from an analysis of retrospective, routine health examination data (more than 35,000 recipients) that measurement of A1c alone could not detect undiagnosed diabetes properly in their study population (detection rate: 18.1% by A1c only vs. 31.8% by fasting blood glucose [FBS]). A diagnosis made with A1c and FBS together enhanced the accuracy of diagnosis up to 38.1%. In conclusion, A1c criteria alone identifies fewer subjects with increased risk of diabetes than does FBS criteria, and about 20% more cases could be detected by the addition of HbA1c criteria. This is an interesting and important result in terms of providing proper methods for diagnosis of diabetes in the Korean population, in spite of the retrospective data from routine health care of Kim et al. In addition, considering FBS and A1c together produced more accurate results for the detection of diabetes by reflecting both acute and chronic hyperglycemia. However, Kim et al. only mentioned that A1c was measured with high-performance liquid chromatography in their study. We wanted to know if the A1c value when converted to the the DCCT-aligned reference A1c in their study.

Furthermore, the cohort from Ansung prospective study will soon begin undergoing 10-year follow up visits. We will be able to analyze prospective cohort data and the health examination data together to provide the best cutoff value for A1c and the values for both A1c and FBS together for the detection of diabetes in Koreans.

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No potential conflict of interest relevant to this article was reported.

REFERENCES

1. UK Prospective Diabetes Study (UKPDS) Group. Effect of intensive blood-glucose control with metformin on complications in overweight patients with type 2 diabetes (UKPDS 34). Lancet 1998;352:854-865. Article PubMed
2. Rohlfing CL, Wiedmeyer HM, Little RR, England JD, Tennill A, Goldstein DE. Defining the relationship between plasma glucose and HbA(1c): analysis of glucose profiles and HbA(1c) in the Diabetes Control and Complications Trial. Diabetes Care 2002;25:275-278. PubMed
3. Khaw KT, Wareham N, Bingham S, Luben R, Welch A, Day N. Association of hemoglobin A1c with cardiovascular disease and mortality in adults: the European prospective investigation into cancer in Norfolk. Ann Intern Med 2004;141:413-420. Article PubMed
4. Tapp RJ, Tikellis G, Wong TY, Harper CA, Zimmet PZ, Shaw JE. Australian Diabetes Obesity and Lifestyle Study Group. Longitudinal association of glucose metabolism with retinopathy: results from the Australian Diabetes Obesity and Lifestyle (AusDiab) study. Diabetes Care 2008;31:1349-1354. PubMed PMC
5. American Diabetes Association. Diagnosis and classification of diabetes mellitus. Diabetes Care 2010;33(Suppl 1):S62-S69. Article PubMed PMC PDF
6. International Expert Committee. International Expert Committee report on the role of the A1C assay in the diagnosis of diabetes. Diabetes Care 2009;32:1327-1334. Article PubMed PMC PDF
7. Kramer CK, Araneta MR, Barrett-Connor E. A1C and diabetes diagnosis: The Rancho Bernardo Study. Diabetes Care 2010;33:101-103. Article PubMed PDF
8. Choi SH, Kim TH, Lim S, Park KS, Jang HC, Cho NH. Hemoglobin A1c as a diagnostic tool for diabetes screening and new-onset diabetes prediction: a 6-year community-based prospective study. Diabetes Care 2011;34:944-949. PubMed PMC
9. Kim HK, Bae SJ, Choe J. Impact of HbA1c criterion on the detection of subjects with increased risk for diabetes among health check-up recipients in Korea. Diabetes Metab J 2012;36:151-156. Article PubMed PMC

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Letter: Impact of HbA1c Criterion on the Detection of Subjects with Increased Risk for Diabetes among Health Check-Up Recipients in Korea (Diabetes Metab J 2012;36:151-6)

Diabetes Metab J. 2012;36(3):251-252. Published online June 14, 2012

DOI: https://doi.org/10.4093/dmj.2012.36.3.251

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