The Korean Journal of Medicine

The Korean Association of Internal Medicine (대한내과학회)
권호 표지

The Use of $HbA_{1c}$ for Diagnosis of Type 2 Diabetes in Korea

한국인 당뇨병의 진단을 위한 당화혈색소 측정의 유용성

  • Lee, Young-Sil (Department of Internal Medicine, Dongguk University Gyeongju Hospital, Dongguk University College of Medicine) ;
  • Moon, Seong-Su (Department of Internal Medicine, Dongguk University Gyeongju Hospital, Dongguk University College of Medicine)
  • 이영실 (동국대학교 의과대학 경주병원 내분비내과) ;
  • 문성수 (동국대학교 의과대학 경주병원 내분비내과)
  • Published : 2011.03.01
⟨ Previous Next ⟩

Abstract

Background/Aims: An $HbA_{1c}$ test result ${\geq}$ 6.5% has recently been recommended as the defining criterion for diabetes by the American Diabetes Association. We compared the detection of diabetes using oral glucose tolerance test (OGTT)-based and $HbA_{1c}$-based diagnostic criteria. Additionally, we identified the optimal $HbA_{1c}$ threshold for diabetes in Korea. Methods: This study was a cross-sectional retrospective design using data from 405 subjects without known diabetes who underwent OGTT and $HbA_{1c}$ tests for the diagnosis of diabetes between January, 2005, and June, 2010, at Dongguk University Gyeongju Hospital, Korea. The OGTT is considered to be the gold standard for diagnosing diabetes. Based on a receiver operating characteristics (ROC) curve, optimal sensitivity and specificity were derived for identifying the $HbA_{1c}$ threshold. Results: For diabetes, $HbA_{1c}$ at 6.5% gave a sensitivity of 52.9%, specificity of 95.1%, positive predictive value of 92.9%, and a negative predictive value of 62.7%. A total of 47.1% of subjects with newly diagnosed diabetes had $HbA_{1c}$ levels <6.5%. Results were similar in sex- and age-stratified analyses. To identify diabetes based on OGTT, the $HbA_{1c}$ threshold of 6.1% had an area under the curve (AUC) of 0.849 with 77.8% sensitivity and 71.7% specificity. Conclusions: In a Korean population, diabetes prevalence was lower using the $HbA_{1c}$-based diagnostic criteria. An $HbA_{1c}$ threshold of 6.1% optimally identified diabetes by OGTT-based diagnostic criteria in Korea. Further large-scale, population-based studies are needed to evaluate the $HbA_{1c}$ threshold for diagnosing diabetes in Korea.

목적: 최근 미국당뇨병학회에서는 당뇨병의 진단기준으로 당화혈색소 ${\geq}$ 6.5%를 추가하였다. 저자들은 한국인에서 경구 당 부하검사와 당화혈색소를 통한 당뇨병의 진단 정도를 비교하여, 당뇨병의 진단에 있어 당화혈색소 적용의 유용성 및 적절한 진단적 역치를 알아보고자 하였다. 방법: 이 연구는 의무기록을 토대로 한 단면적 후향적 연구로서, 2005년 1월부터 2010년 6월까지 본원에 내원하여 경구당 부하검사와 당화혈색소를 동시에 측정하였던, 당뇨병의 과거력이 없는 405명을 대상으로 하였다. 경구 당 부하검사를 당뇨병의 표준 진단법으로 하여 ROC curve분석을 통해 적절한 민감도와 특이도를 갖는 당화혈색소의 역치를 구하였다. 결과: 당뇨병 환자에서 당화혈색소 ${\geq}$ 6.5%은 민감도 52.9%, 특이도 95.1%, 양성예측도 92.9% 및 음성예측도 62.7%를 보였다. 당뇨병으로 진단된 환자의 47.1%에서는 당화혈색소가 < 6.5%였고, 성별 및 연령에 따라 차이는 없었다. 경구 당 부하검사를 표준검사로 하여 시행된 ROC curve분석에서 당화 혈색소의 AUC는 0.849였고, 당화혈색소 6.1%에서 민감도 77.8%, 특이도 71.7%를 보였다. 결론: 한국인에서 당뇨병의 진단에 당화혈색소의 적용은 경구 당 부하검사에 비해 당뇨병의 진단율을 떨어뜨릴 수 있으므로, 공복혈당 및 경구 당부하 검사에 보조적인 진단 수단으로 사용되어야 한다. 당화혈색소 6.1% 이상이 당뇨병을 진단하는데 적절한 역치임을 알 수 있으나, 한국인에서 당뇨병의 진단에 당화혈색소를 적용하기 위해서는 보다 대규모의 일반 인구 대상의 연구가 필요하리라 생각된다.

Keywords

References

  1. 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. https://doi.org/10.2337/dc09-9033
  2. American Diabetes Association. Standards of medical care in diabetes- 2010. Diabetes Care 2010;33(Suppl 1):S11-S61.
  3. Bennett CM, Guo M, Dharmage SC. HbA(1c) as a screening tool for detection of Type 2 diabetes: a systematic review. Diabet Med 2007;24:333-343. https://doi.org/10.1111/j.1464-5491.2007.02106.x
  4. Christensen DL, Witte DR, Kaduka L, et al. Moving to an A1C-based diagnosis of diabetes has a different impact on prevalence in different ethnic groups. Diabetes Care 2010;33:580-582. https://doi.org/10.2337/dc09-1843
  5. Bao Y, Ma X, Li H, et al. Glycated haemoglobin A1c for diagnosing diabetes in Chinese population: cross sectional epidemiological survey. BMJ 2010;340:c2249. https://doi.org/10.1136/bmj.c2249
  6. van't Riet E, Alssema M, Rijkelijkhuizen JM, Kostense PJ, Nijpels G, Dekker JM. Relationship between A1C and glucose levels in the general Dutch population: the new Hoorn study. Diabetes Care 2010;33:61-66. https://doi.org/10.2337/dc09-0677
  7. Lu ZX, Walker KZ, O'Dea K, Sikaris KA, Shaw JE. A1C for screening and diagnosis of type 2 diabetes in routine clinical practice. Diabetes Care 2010;33:817-819. https://doi.org/10.2337/dc09-1763
  8. Mohan V, Vijayachandrika V, Gokulakrishnan K, et al. A1C cut points to define various glucose intolerance groups in Asian Indians. Diabetes Care 2010;33:515-519. https://doi.org/10.2337/dc09-1694
  9. The Expert Committee on the Diagnosis and Classification of Diabetes Mellitus. Report of the expert committee on the diagnosis and classification of diabetes mellitus. Diabetes Care 1997; 20:1183-1197.
  10. DECODE Study Group on behalf of the European Diabetes Epidemiology Study Group. Will new diagnostic criteria for diabetes mellitus change phenotype of patients with diabetes? Reanalysis of European epidemiological data. BMJ 1998;317: 371-375. https://doi.org/10.1136/bmj.317.7155.371
  11. Qiao Q, Nakagami T, Tuomilehto J, et al. Comparison of the fasting and the 2-h glucose criteria for diabetes in different Asian cohorts. Diabetologia 2000;43:1470-1475. https://doi.org/10.1007/s001250051557
  12. Amquist H, Wallensteen M, Jeppsson JO. Standardization of long-term glucose measurements established. Lakartidningen 1997;50:4789-4790.
  13. Sacks DB. Global harmonization of hemoglobin A1c. Clin Chem 2005;51:681-683. https://doi.org/10.1373/clinchem.2004.047431
  14. Vistisen D, Colagiuri S, Borch-Johnsen K. Bimodal distribution of glucose is not universally useful for diagnosing diabetes. Diabetes Care 2009;32:397-403. https://doi.org/10.2337/dc08-0867
  15. Sabanayagam C, Liew G, Tai ES, et al. Relationship between glycated haemoglobin and microvascular complications: is there a natural cut-off point for the diagnosis of diabetes? Diabetologia 2009;52:1279-1289. https://doi.org/10.1007/s00125-009-1360-5
  16. Watanabe M, Kokubo Y, Higashiyama A, Ono Y, Okayama A, Okamura T. New diagnosis criteria for diabetes with hemoglobin A1c and risks of macro-vascular complications in an urban Japanese cohort: the Suita study. Diabetes Res Clin Pract 2010; 88:e20-e23. https://doi.org/10.1016/j.diabres.2010.01.019
  17. Selvin E, Steffes MW, Zhu H, et al. Glycated hemoglobin, diabetes, and cardiovascular risk in nondiabetic adults. N Engl J Med 2010;362:800-811. https://doi.org/10.1056/NEJMoa0908359
  18. Rohlfing CL, Little RR, Wiedmeyer HM, et al. Use of GHb (HbA1c) in screening for undiagnosed diabetes in the U.S. population. Diabetes Care 2000;23:187-191. https://doi.org/10.2337/diacare.23.2.187
  19. Anand SS, Razak F, Vuksan V, et al. Diagnostic strategies to detect glucose intolerance in a multiethnic population. Diabetes Care 2003;26:290-296. https://doi.org/10.2337/diacare.26.2.290
  20. Ko GT, Chan JC, Yeung VT, et al. Combined use of a fasting plasma glucose concentration and HbA1c or fructosamine predicts the likelihood of having diabetes in high-risk subjects. Diabetes Care 1998;21:1221-1225. https://doi.org/10.2337/diacare.21.8.1221
  21. Nakagami T, Tominaga M, Nishimura R, et al. Is the measurement of glycated hemoglobin A1c alone an efficient screening test for undiagnosed diabetes? Japan national diabetes survey. Diabetes Res Clin Pract 2007;76:251-256. https://doi.org/10.1016/j.diabres.2006.09.015
  22. Gomez-Perez FJ, Aguilar-Salinas CA, Almeda-Valdes P, Cuevas- Ramos D, Lerman Garber I, Rull JA. HbA1c for the diagnosis of diabetes mellitus in a developing country: a position article. Arch Med Res 2010;41:302-308. https://doi.org/10.1016/j.arcmed.2010.05.007
  23. Pani LN, Korenda L, Meigs JB, et al. Effect of aging on A1C levels in individuals without diabetes: evidence from the framingham offspring study and the national health and nutrition examination survey 2001-2004. Diabetes Care 2008;31:1991-1996. https://doi.org/10.2337/dc08-0577
  24. Cowie CC, Rust KF, Byrd-Holt DD, et al. Prevalence of diabetes and high risk for diabetes using A1C criteria in the U.S. population in 1988-2006. Diabetes Care 2010;33:562-568. https://doi.org/10.2337/dc09-1524