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RD,CDE
Using A1c to diagnose prediabetes
Section:  General Diabetes

I'm really interested in prevention, and this article caught my eye: 

Zhuo X, et al "Alternative HbA1c cutoffs to identify high-risk adults for diabetes prevention: a cost-effectiveness perspective" Am J Prev Med 2012; DOI: 10.1016/j.amepre.2012.01.003.

http://www.diabetesincontrol.com/index.php?option=com_content&view=article&id=12418&catid=1&Itemid=17

"The author's group ran simulations using a nationally-representative sample of the nondiabetic adult population in the National Health and Nutritional Examination Survey (NHANES 1999 to 2006), modeling the impact of each 0.1% increment in the threshold for prediabetes from 6.4% to 5.5%.

Each lower threshold progressively improved health of the population considered over a lifetime from the healthcare system perspective but also increased costs.

Assuming that prediabetes found in that population was treated with a higher-cost approach similar to that seen in the Diabetes Prevention Program study averaging about $1,000 a year, moving the cutoff for prediabetes diagnosis as low as 5.7% was cost-effective.

The cost per quality life-year gained was:

  • $27,000 to go from 6.0% to 5.9%
  • $34,000 to further drop from 5.9% to 5.8%
  • $45,000 to go from 5.8% to 5.7%

But bringing the threshold for diagnosis down further exceeded the $50,000 mark per quality life-year gained, at $58,000 to go from 5.7% to 5.6% and $96,000 to go from 5.6% to 5.5%.

The numbers were better assuming use of lower cost interventions averaging about $300 per year to treat prediabetes as in the Promoting a Lifestyle of Activity and Nutrition for Working to Alter the Risk of Diabetes (PLAN4WARD) study.

The cost per quality life-year gained in that analysis was just $24,000 to lower the HbA1c cutoff from 6.0% to 5.9% and $34,000 to get down to 5.7%.

Even going from 5.7% to 5.6% would be considered cost-effective in that less expensive scenario, costing $43,000 per quality life year gained, although the next increment to 5.6% wasn't at $70,000.

The group cautioned that use of hemoglobin A1c for diagnosis isn't universally agreed upon and does have some limitations."

It seems to me that we need to keep finding and implementing lower cost, community based interventions designed to treat prediabetes, not just for cost savings, but for the overall health of our population.

MEMBER COMMENTS
Re: Using A1c to diagnose prediabetes

 Hi Lynn,


Yes, more local programs on diabetes prevention is one of the keys to tackle the onset of T2 diabetes!


Here is some information on the National Diabetes Prevention Program, created just for this purpose:


The CDC-led National Diabetes Prevention Program (NDPP) is designed to bring to communities evidence-based lifestyle change programs for preventing type 2 diabetes.

The NDPP is a public--private partnership of community organizations, private insurers, employers, health care organizations, and government agencies. These partners work in individual states to establish local evidence-based lifestyle change programs for people at high risk for type 2 diabetes (people with prediabetes) to prevent or delay the onset of the disease.

It is based on the Diabetes Prevention Program lifestyle research study led by the National Institutes of Health and supported by Centers for Disease Control and Prevention.


The lifestyle program in this study showed that making modest behavior changes, such as improving food choices and increasing physical activity to at least 150 minutes per week, helped participants lose 5 to 7 percent of their body weight. These lifestyle changes reduced the risk of developing type 2 diabetes by 58 percent in people at high risk for diabetes. People with prediabetes are more likely to develop heart disease and stroke.


Participants work with a lifestyle coach in a group setting to receive a 1-year lifestyle change program that includes 16 core sessions (usually 1 per week) and 6 post-core sessions (1 per month).


The National Diabetes Prevention Program encourages collaboration among federal agencies, community-based organizations, employers, insurers, health care professionals, academia, and other stakeholders to prevent or delay the onset of type 2 diabetes among people with prediabetes in the United States.


See below components pdf
              States with Diabetes Prevention and Control Programs

              On this website:   http://www.cdc.gov/diabetes/states/

        users click on the state name to obtain contact information and a

                                  program review of that state:
 


Mary Ann Hodorowicz, RD, CDE, MBA, Certified Endocrinology Coder
PresentDiabetes Author of MNT and DSMT Reimbursement Audio Lectures

Eat Well, Laugh Often, Love Much


Re: Using A1c to diagnose prediabetes

There is a good deal of confusion, even among medical professionals, about the use of the A1c to "screen" and to "diagnose."  It turns out that the A1c is lousy for both, all steming from the same basic problem.  The A1c is a lagging indicator.  In fact, the fasting blood sugar (FBS) isn't the best screening tool either, but it is better than the A1c.  A better screening would be to check FBS and perform a simplified OGTT, having the patient down a banana split and then roughly sampling their blood sugar afterwards.  Those having a FBS > 126 mg/dl or a random BS > 200 mg/dl after the ice cream are caught by the screen and those patients are diabetes candidates and then are "diagnosed."  A huge number of patients would be caught by such a screen who would pass the A1c with flying colors.  Numerous studies have found that glucose intolerance is not picked up by the FBS and only when the intolerance has gotten "very bad" will it affect the A1c enough to drift the average up to 6.5%.

I actually think that a proper "diagnosis" of diabetes should involve a full BS panel, including an OGTT as well as antibodies (GAD, ICA and IA-2) and c-peptide.  In the future, it will also be important to perform testing for monogenic diabetes.  Instead, the situation we have today is that patients are screened with only the FBS and today often with A1c.  They are told they are ok (possibly for years) as they have high blood sugars and then they are actually not diagnosed.  It is just "assumed" they are T2 and they are treated.  Only if the treatment doesnt work (possibly after more years) does anyone bother with an actual diagnosis.

Just the random thought from a "diagnosed T2" who has never actually been diagnosed in all my years (although my endo now marks me with ICD 250.01).

Re: Using A1c to diagnose prediabetes

Diagnosis issues aside, I've had the fortunate ability to become a lifestyle coach, for the Diabetes Prevention Programs.  There are only a few people in MA, that are being trained by the Emery staff.  What a great opportunity.  Now as they say in MA:  well, we've built it, let's see if they will come!

 

Re: Using A1c to diagnose prediabetes

I'm so glad my hubby's doctor decided to do a HBA1c when his HDL went down and triglycerides went up. Once told he was prediabetic, he started eating low-carb with me and 3 months later he no longer has elevated BG. The Prevention Program is sorely needed here in KY where a large portion of our population is diabetic.

Re: Re: Using A1c to diagnose prediabetes
Quote:

I'm so glad my hubby's doctor decided to do a HBA1c when his HDL went down and triglycerides went up. Once told he was prediabetic, he started eating low-carb with me and 3 months later he no longer has elevated BG. The Prevention Program is sorely needed here in KY where a large portion of our population is diabetic.


Ummm, actually the Diabetes Prevention Program (DPP) tells people to eat low fat.  And most surprising the DPP education materials make no mention that carbs raise blood sugars

Unfortunately, in seemingly obvious defiance of reality, the mainstream medical advice still does not recommend low carb diets as appropriate for people with diabetes.

I am happy for you and your husband.  The lipid abnormalities you mention are a classic metabolic disturbance that occurs with high blood sugars.  It is often the case that LDL cholesterol also increases and shifts towards smaller particles (the dangerous kind).

Re: Using A1c to diagnose prediabetes

Brian:

I have to disagree with you re: the main stream and the low carb approach.  If you look at the 2012 clinical guidelines from ADA you will find the following:

 

E. Medical nutrition therapy (MNT)

General recommendations.

  • Individuals who have prediabetes or diabetes should receive individualized MNT as needed to achieve treatment goals, preferably provided by a registered dietitian familiar with the components of diabetes MNT. (A)

  • Because MNT can result in cost-savings and improved outcomes (B), MNT should be adequately covered by insurance and other payers. (E)

Energy balance, overweight, and obesity.

  • Weight loss is recommended for all overweight or obese individuals who have or are at risk for diabetes. (A)

  • For weight loss, either low-carbohydrate, low-fat calorie-restricted, or Mediterranean diets may be effective in the short-term (up to 2 years). (A)

Re: Re: Using A1c to diagnose prediabetes
Quote:

Brian:

I have to disagree with you re: the main stream and the low carb approach.  If you look at the 2012 clinical guidelines from ADA you will find the following:

 

E. Medical nutrition therapy (MNT)

General recommendations.

  • Individuals who have prediabetes or diabetes should receive individualized MNT as needed to achieve treatment goals, preferably provided by a registered dietitian familiar with the components of diabetes MNT. (A)

  • Because MNT can result in cost-savings and improved outcomes (B), MNT should be adequately covered by insurance and other payers. (E)

Energy balance, overweight, and obesity.

  • Weight loss is recommended for all overweight or obese individuals who have or are at risk for diabetes. (A)

  • For weight loss, either low-carbohydrate, low-fat calorie-restricted, or Mediterranean diets may be effective in the short-term (up to 2 years). (A)

"For weight loss, either low-carbohydrate, low-fat calorie-restricted, or Mediterranean diets may be effective in the short-term (up to 2 years). (A)"

Yes, the ADA does finally recognize that low carb diets are effective for weight loss.  But they do not recommend them as an appropriate nutritional therapy for ongoing management of diabetes.  I stand by my statement.

Re: Using A1c to diagnose prediabetes

Brian:

Ok, I see your point re: short vs. long term.  Is there long term data that you can provide that supports this ( for longer than 2 years?)  I have to assume that when there is the science to show longer term effectivness, then they will adjust their recommendations. 

I'd love to read more if you have the data.

 

 

Re: Using A1c to diagnose prediabetes

Brian, et al,

Actually, the American Diabetes Association's 2012 Standards of Medical Care in Diabetes do recommend specific MNT guidelines with regard to carb, fat, etc. (below is only part of the nutrition section):

Recommendations for management of diabetes

Macronutrients in diabetes management.

  • The mix of carbohydrate, protein, and fat may be adjusted to meet the metabolic goals and individual preferences of the person with diabetes. 

  • Monitoring carbohydrate, whether by carbohydrate counting, choices, or experience-based estimation, remains a key strategy in achieving glycemic control. 

  • Saturated fat intake should be

  • Reducing intake of trans fat lowers LDL cholesterol and increases HDL cholesterol (A), therefore intake of trans fat should be minimized. 

  • It is recommended that individualized meal planning include optimization of food choices to meet recommended daily allowance (RDA)/dietary reference intake (DRI) for all micronutrients.  


    Clinical trials/outcome studies of MNT have reported decreases in A1C at 3–6 months ranging from 0.25 to 2.9% with higher reductions seen in type 2 diabetes of shorter duration. 


    Multiple studies have demonstrated sustained improvements in A1C at 12 months and longer when an registered dietitian provided follow-up visits ranging from monthly to three sessions per year (101108). Studies in nondiabetic suggest that MNT reduces LDL cholesterol by 15–25 mg/dL up to 16% (109) and support a role for lifestyle modification in treating hypertension (109,110).  


    Although numerous studies have attempted to identify the optimal mix of macronutrients for meal plans of people with diabetes, it is unlikely that one such combination of macronutrients exists. The best mix of carbohydrate, protein, and fat appears to vary depending on individual circumstances. It must be clearly recognized that regardless of the macronutrient mix, total caloric intake must be appropriate to weight management goal. 

    Further, individualization of the macronutrient composition will depend on the metabolic status of the patient (e.g., lipid profile, renal function) and/or food 

    preferences. A variety of dietary meal patterns are likely effective in managing diabetes including Mediterranean-style, plant-based (vegan or vegetarian), low-fat and lower-carbohydrate eating patterns (113,126128).


    It should be noted that the RDA for digestible carbohydrate is 130 g/day and is based on providing adequate glucose as the required fuel for the central nervous system without reliance on glucose production from ingested protein or fat. Although brain fuel needs can be met on lower-carbohydrate diets, long-term metabolic effects of very-low-carbohydrate diets are unclear, and such diets eliminate many foods that are important sources of energy, fiber, vitamins, and minerals and that are important in dietary palatability (129).

    Saturated and trans fatty acids are the principal dietary determinants of plasma LDL cholesterol. There is a lack of evidence on the effects of specific fatty acids on people with diabetes; the recommended goals are therefore consistent with those for individuals with CVD (109,130).                        

                                                       

    Mary Ann Hodorowicz, RD, CDE, MBA, Certified Endocrinology Coder
    PresentDiabetes Author of MNT and DSMT Reimbursement Audio Lectures

    Eat Well, Laugh Often, Love Much

Re: Using A1c to diagnose prediabetes

I think it is unfare to suggest that the ADA recommends a low carb diet as appropriate for management of diabetes.  While the clinical care guidelines may accept that the RDA is 130 g/day, the guidance to patients is clear, you should eat 45-65% of calories from carbs.  This is embodied in the main ADA tool, the "MyFoodAdvisor" which deeply embeds the 45-65% of calories from carbs.  MyFoodAdvisor does have an ability to suggest "lower carb" recipe options, but this only achieves 40% of calories from carbs, hardly low carb in my book.  If I ate 45% of my calories from carbs, I would have to eat more than 300g/day.