International Recommendations as on 2009 on Diabetes??

What were  the Recommendations and conclusion of International Committee, 2009 ?? :

1) At present  there is no single gold standard test for the diagnosis of diabetes .

2) The measure  to capture chronic exposure to glucose is more likely to be informative  presence of diabetes than single measure of glucose

3) HbA1c is a reliable measure  of  chronic hyperglycaemia  and has  a better co relationship  with  chronic micro vascular complications

4) HbA1c  estimation   done by  the method certified by  NSGP has several advantages  over blood glucose estimaton

5) Properly performed HbA1c  is a better test for diagnosis of diabetes than blood glucose estimation

6) Diagnosis of diabetes is made if HbA1c  is equal to or greater than 6.5%

7) Diagnosis of diabetes should be confirmed by repeat  HbA1c  estimation unless there are gross symptoms of diabetes and random blood glucose is above  200 mg%

8) In those  suffering from  haemoglobinopathies dn anemia interfering with HbA1c  estimation and interpretation and if HbA1c  estimation is not available current conventional tests should be used for the diagnosis of diabetes

9) In pregnancy blood glucose estimation should be  continued to be used for  the diagnosis of diabetes   as changes accruing in red cell turnover rate during the pregnancy can affect HbA1c  estimation

10)      Individuals with HbA1c  values between 6.0 to 6.5% are  likely to have higher risk for progression to  diabetes  and thus should be kept on follow up ans screened for other risk  factors.

11)      Subsequently  in January 2010 Americna Diabees  Association ratified the recommendations of the  International  committed as regards the use of HbA1c  for eh diagnosis of diabetes mellitus in its position statement issued in supplement to Diabetes Care .

Are we in India  ready for adaptation of HbA1x  as a diagnostics est for diabetes in non pregnant  persons? In  many places and situations we are not yet ready  because  of the following  reasons

1) Proplerly done HbA1c  test is available  at very limited laboratories in big cities.

2) The cost  of doing HbA1c is eight  times more than that  of blood glucose test thus it  would be  out of reach of majority of Indians.

3) Many  doctors re not conversant with the interpretation of HbA1c  report.

4)   Many doctors  are not conversant with the  interpretation  of HbA1c  report

5) However clinicians should be aware of this latest addition to the  diagnostic criteria   for diabetes and wherever possible  this new  criterion can be used.

Fructosamine Test

Like HbA1c  it is a blood  test in which glycated plasma proteins are measured and expressed as percentage of total plasma proteins. It gives  information  on average metabolic control  over the previous  two weeks it is not yet regularly  done in our country. It  is more  useful than HbA1c  to access metabolic  control during  pregnancy.

HJbA1c  derived average  glucose  a new patient  friendly concept  of expressing metabolic  control

Glycosylated haemolglobin HbA1c   a gold standard in assessing metabolic control   is expressed in % value Even though it is an indicator of average  blood glucose control since  the unit  of expression is to in mg%   and since the values are at variance with blood glucose    values the expression is not patient  friendly but is confusing  to the  patient 

In order in express average  blood glucose  in patient  friendly and meaningful manner a large multi centric multi national work was carried out in 700 persons . 300 each had type 1 and 2 diabetes and 100 were normal controls Originally 11  centers  spread across North America Europe Africa  and Asia  were included . One centre dropped out   due to technical reasons. Those  having conditions such as anemia haemoglobinopathies and renal impairment  were  excluded from eh study  A large amount   of data on glycemic control was generated in these people by studying  was generated in these  people by studing theem for 4 months  in thins period   all were subjected in continuous interstitial fluid  glucose  monitoring for 48  hours every months for 4  months In addition they were subjected to HbA1c   estimation 3 times at a central laboratory in Europe Participants also  underwent self capillary glucose monitoring  seven times a day three  times a week for 4 months. From this data average  glucose value was calculated and it’s  correlation with HbA1c  was worked out and a mathematical formula to convert HbA1c  in to average glucose  value  was developed Interstitial fluid values  were scaled up by 5% to derive capillary glucose values 507  participants  completed the entire study.

  The  entire work was a joint  effort oa ADA EASD  IDF and IFCC