What would be the outcome if the American Diabetes Association recommendations of 2010 had been followed in our practice in 1998-2006?

AIMS: In 2010, the American Diabetes Association has published recommendations on the population to be screened for dysglycaemia; the diagnostic criteria for intermediate hyperglycaemia and diabetes using oral glucose tolerance testing and HbA(1c); and the patients eligible for treatment with metformin. We aimed to evaluate the consequences of screening with oral glucose tolerance test or HbA(1c) in an at-risk population. METHODS: Among 1177 overweight or obese consecutive adults without known diabetes who were referred to our department for weight management, we selected 1157 individuals (83% female; 80% European) fulfilling the American Diabetes Association 2010 criteria for dysglycaemia screening. RESULTS: Mean age was 41.2 ± 13 years, BMI 37.0 ± 7.2 kg/m(2), fasting plasma glucose 4.9 ± 0.8 mmol/l and HbA(1c) (turbidimetric immunoassay) 5.7 ± 0.7% (39 mmol/mol). Based on oral glucose tolerance test and HbA(1c), respectively, 76 (6.6%) and 113 (9.8%) patients had diabetes, including 34 sharing both criteria; 307 (26.5%) and 478 (41.3%) had intermediate hyperglycaemia; and 130 (11.2%) and 255 (22.0%) would be treated with metformin. The sensitivity/specificity of HbA(1c) ≥ 6.5% (48 mmol/mol) for the diagnosis of diabetes according to the oral glucose tolerance test were 44.7/92.7%. Diabetes risk scores and UK Prospective Diabetes Study cardiovascular risk score were the highest in the 130 patients having both an abnormal oral glucose tolerance test and HbA(1c) ≥ 5.7%. CONCLUSIONS: In a population at risk for diabetes, the HbA(1c) strategy could lead to diagnosing more cases of dysglycaemia and to treating more patients with metformin than the oral glucose tolerance test strategy. The consistency of either diagnostic criteria was low. The patients with the highest a priori risk of diabetes and cardiovascular disease were those fulfilling both oral glucose tolerance test and HbA(1c) criteria.

Difficulties of smoking cessation in diabetic inpatients benefiting from a systematic consultation to help them to give up smoking.

AIM: To assess the value of systematic smoking cessation consultations for diabetic smokers admitted to hospital. METHODS: All diabetic smokers admitted to the Diabetes Department of Georges Pompidou European Hospital between February 2003 and February 2004 were systematically offered a consultation with a physician specialised in tobacco cessation. Follow-up visits at three, six and nine months were planned. RESULTS: Of the 306 diabetic patients admitted, 38 (12.4%) were smokers. There were more men than women in the group of smokers and the diabetic smokers were younger than the non-smokers. The smokers had fewer micro-angiopathic complications than the non-smokers, but there was no difference in the frequency of macro-angiopathic complications. The level of nicotine physical dependence was moderate or high for 60% of the smokers. Although all the smokers agreed to the consultation, less than half agreed to drug-based treatments to help them to give up smoking and only 15% returned for the six-month visit. Only one patient had stopped smoking at the six-month visit. CONCLUSION: This study demonstrates the difficulties in systematic interventions to help diabetic patients to stop smoking. Diabetic smokers probably constitute a specific population for which the barriers to giving up smoking should be explored.

Are Obese Individuals with no Feature of Metabolic Syndrome but Increased Waist Circumference Really Healthy? A Cross Sectional Study.

AIM: Patients displaying the metabolically healthy but obese phenotype have an intermediate cardiometabolic prognosis compared to normal weight healthy and metabolically unhealthy obese subjects. We aimed to evaluate the proportion of patients with a definite metabolically healthy obese phenotype and better characterize them. METHODS: Definite metabolically healthy obese phenotype was defined as having none of the International Diabetes Federation metabolic syndrome criteria, excluding waist circumference. We recruited 1 159 obese patients (body mass index 38.4±6.3 kg/m(2)) including 943 women, without known diabetes. Patients were characterized for cardiometabolic disorders. RESULTS: As the 202 (17.4%) metabolically healthy obese individuals were younger and had lower body mass indexes than the 957 metabolically unhealthy obese patients, they were matched for gender, age and body mass index with 404 metabolically unhealthy obese patients. In addition to the features of metabolic syndrome, when compared to unhealthy subjects, definite metabolically healthy obese patients were less frequently found with either homeostasis model assessment of insulin resistance index>3 (23.6 vs. 38.9%, p<0.001), or abnormal oral glucose tolerance test (13.9 vs. 33.9%, p<0.001), or HbA1c value≥5.7% (43.9 vs. 54.2%, p<0.05) or pulse pressure≥60 mmHg (11.7 vs. 64.9%, p<0.001). However, there were no significant differences in the prevalence of microalbuminuria (11.1 vs. 12.3%), cardiac autonomic dysfunction (45.5 vs. 35.3%) and fatty liver index ≥ 60 (5.6 vs. 10.2%). CONCLUSION: Our data do not support the characterization of metabolically healthy obesity, even definite, as really healthy, as many patients with this phenotype have abnormal cardiovascular markers and glucose or liver abnormalities. HbA1c measurement seems to be more sensitive than OGTT to detect dysglycemia in this population.

[Relationship between blood pressure, heart rate and cardiac autonomic dysfunction in non-diabetic obese patients]. / Relation entre pression artérielle, fréquence cardiaque et dysfonction autonome cardiaque chez les obèses non diabétiques.

RATIONALE: Some studies suggest that a high heart rate (HR) would be predictive of the incidence of an elevated blood pressure (BP). Cardiac autonomic dysfunction (CAD) affects a high proportion of obese patients. CAD could be involved in BP increase. Our aim was to examine the relationship between CAD, HR and BP in obese patients without known diabetes. PATIENTS AND METHODS: We included 428 overweight or obese patients. CAD was assessed by analyzing HR variations during three standard tests (Valsalva, deep breathing, lying-to-standing), which are mostly dependent on vagal control. An oral load in glucose was performed and the Matsuda index was calculated. RESULTS: The population was separated in 4 groups according to the grade of CAD (no or only one abnormal test, 2 or 3 abnormal tests) and HR (< or ≥ 75 bpm). Age was similar in the four groups. Systolic (P=0.05), diastolic (P<0.005) and mean BP (P<0.001) differed significantly between the 4 groups, and was the highest in the group of patients who had 2 or 3 abnormal tests and HR ≥ 75 bpm. Matsuda index differed across the groups (P=0.018) and was the lowest in this group. CONCLUSION: These data indicate that among overweight or obese patients with a defect in cardiac vagal activity BP is elevated only in those with a high heart rate, which is indicative of a more marked insulin resistance and probably an excess in sympathetic activity.

Haemoglobin glycation may partly explain the discordance between HbA1c measurement and oral glucose tolerance test to diagnose dysglycaemia in overweight/obese subjects.

AIM: This study assessed whether the poor correlation between HbA1c and oral glucose tolerance test (OGTT) for dysglycaemia diagnosis may be explained by haemoglobin glycation (HbG). METHODS: A total of 1033 consecutive overweight or obese patients with no known diabetes underwent OGTT and measurement of HbA1c to diagnose diabetes and dysglycaemia (American Diabetes Association criteria). For each OGTT result category, low, medium and high HbG was defined according to the mean HbA1c/fructosamine ratio and mean fructosamine. High HbG was defined as values greater than mean values in each OGTT category for both HbA1c/fructosamine ratio and fructosamine levels, and low HbG was defined as lower values of both. The remaining patients were considered medium HbG. RESULTS: Based on OGTT and HbA1c values, 267 (25.8%) and 443 (42.8%) patients had intermediate hyperglycaemia, and 66 (6.4%) and 95 (9.2%) patients had diabetes, respectively. The results were discordant for intermediate hyperglycaemia or diabetes diagnosis in 41.7% and for diabetes diagnosis in 10.0% of the patients. The proportion of patients with HbA1c≥6.5%, but without OGTT-diagnosed diabetes, was 0%, 3.8% and 32.8% in the low-HbG, medium-HbG and high-HbG groups, respectively. In contrast, the proportion of patients with HbA1c<5.7%, but with an abnormal OGTT, was 30.4%, 11.1% and 0%, respectively. The AUROC of HbA1c to detect OGTT-diagnosed diabetes was better in the medium-HbG group [0.874 (0.816-0.931)] than in those with low or high HbG [0.628 (0.489-0.768); P<0.01]. Only age was independently associated with high-HbG status [10-year OR: 1.3 (1.1-1.5); P<0.0001]. CONCLUSION: Haemoglobin glycation may explain many of the discordant results between HbA1c and OGTT when used for dysglycaemia diagnosis.

Use of clinical scores to detect dysglycaemia in overweight or obese women.

AIMS: To test if the use of either HbA(1c) level or calculated clinical scores including two published scores and a new score (the Bondy score) could help in selecting overweight or obese women who should benefit from oral glucose tolerance test (OGTT) to detect dysglycaemia. METHODS: The French Data from an Epidemiological Study on the Insulin Resistance Syndrome (DESIR) score and the Finnish Diabetes risk score (Findrisk) were calculated, whereas the Bondy score was built in a development sample of 698 women, BMI 37±7 kg/m(2), without known diabetes. External validation was performed in a validation sample of 212 women. RESULTS: A dysglycaemia (according to OGTT results, WHO criteria) was diagnosed in 161 (23.1%) patients. Sensitivity of fasting plasma glucose (FPG)≥6.1 mmol/l and HbA(1c)≥6% to identify dysglycaemia were respectively 27 and 41%. Areas under Receiver Operator Curve (AROC) of HbA(1c), DESIR score and Findrisk to detect dysglycaemia were 0.630 [95% confidence interval 0.580-0.680], 0.606 [0.561-0.652] and 0.635 [0.588-0.683], respectively. The Bondy score, based on age and waist circumference, had a better AROC (0.674 [0.626-0.721]) than the DESIR score (P<0.05). These performances were confirmed in the validation sample. Performing OGTT only in subjects with a Bondy score≥4 (41% of the sample) had a sensitivity of 61% and a better net benefit (0.128) than measuring FPG in all subjects (0.069). CONCLUSION: Performing OGTT in obese women selected on a simple clinical score is more sensitive to identify dysglycaemia than measuring FPG in all of them and may be cost-effective.

A large proportion of prediabetes and diabetes goes undiagnosed when only fasting plasma glucose and/or HbA1c are measured in overweight or obese patients.

AIMS: The purposes of the study were to determine the prevalence of unrecognized dysglycaemia in overweight (body mass index [BMI] 25-29.9 kg/m(2)) and obese (BMI ≥30 kg/m(2)) patients, to assess the extent to which measures of fasting plasma glucose (FPG) and/or HbA(1c), compared with oral glucose tolerance tests (OGTTs), misdiagnose dysglycaemia, and to determine the factors associated with an isolated abnormal post-OGTT glucose value. METHODS: OGTT was performed and HbA(1c) was measured in 1283 inpatients with BMI scores ≥ 25 kg/m(2) and no history of dysglycaemia. RESULTS: Prediabetes was found in 257 (20.0%) subjects (197 with impaired glucose tolerance, 29 with impaired fasting glucose, 31 with both) and diabetes in 77 (6.0%), including 22 with FPG ≥ 7 mmol/L (WHO definition). The sensitivity of FPG >6 mmol/L, FPG >5.5 mmol/L, HbA(1c) ≥ 6% and the recommendations of the French National Agency of Accreditation and Evaluation in Health Care (ANAES) to identify patients with abnormal OGTTs was 29.9, 41.3, 36.8 and 15.6%, respectively. The factors that were independently associated with diabetes in obese women with FPG <7 mmol/L were age (per 10 years: OR 1.54 [1.00-2.11]; P=0.049) and FPG (OR 6.1 [1.4-30.0]; P=0.014), whereas age (OR 1.26 [1.09-1.44]; P<0.01) and waist circumference (per 10 cm: OR 1.17 [1.01-1.33]; P<0.05) were independently associated with dysglycaemia in obese women with FPG <6.1 mmol/L. CONCLUSION: In overweight and obese patients: dysglycaemia is commonly seen; FPG alone, compared with OGTT, failed to diagnose 70% of dysglycaemia cases; FPG >5.5 mmol/L and HbA(1c) ≥ 6.0% are not necessarily substitutes for OGTT; and older age and larger waist circumference should be used to select those obese women with normal FPG who might further benefit from OGTTs to diagnose dysglycaemia.

Multicentre, randomised, controlled study of the impact of continuous sub-cutaneous glucose monitoring (GlucoDay) on glycaemic control in type 1 and type 2 diabetes patients.

AIM: This randomised study was designed to investigate the impact of continuous glucose monitoring (CGM) for 48h on glycaemic control with a 3-month follow-up in patients with type 1 (T1D) or type 2 (T2D) diabetes. METHODS: A total of 48 patients with poor glycaemic control (HbA(1c): 8-10.5%) underwent CGM for 48h using the GlucoDay((R)) system (A. Menarini Diagnostics), after which they were randomly assigned to treatment adjustments based on either their CGM profile (CGM group) or their usual self-monitoring of blood glucose (SMBG group). HbA(1c) measurement and 48-h CGM were repeated 3 months later. RESULTS: Altogether, 34 patients with either T1D (n=9) or T2D (n=25) completed the study; seven patients chose to leave the study, and seven patients in the CGM group were excluded because their baseline CGM graphs were not interpretable. HbA(1c) levels decreased significantly in the CGM group (n=14, -0.63+/-0.27%; P=0.023), but not in the controls (n=20, -0.28+/-0.21%; P=0.30). In T2D patients, the improvement associated with CGM vs SMBG was due to HbA(1c) decreases (mean: -0.63+/-0.34%; P=0.05 vs -0.31+/-0.29%; P=0.18, respectively). However, HbA(1c) did not change significantly with CGM in T1D patients. Comparisons of CGM data at baseline and after 3 months showed no significant changes in glucose control, glucose variability or hypoglycaemia. No major adverse events related to the GlucoDay system were reported. CONCLUSION: This is the first randomised study showing that CGM improves glycaemic control in patients with T2D.