HbA1c platforms studied for lipemia interference

A forgotten creditor. A poor relation. An envious rival. In the theater, one of these characters often emerges from the woodwork, ready to supply a plot twist just when the protagonist is riding highest. In the health care world, a new study shows, laboratories may be finding that the very popularity of hemoglobin A1c has magnified the underappreciated effect of fats known to interfere with this centrally important diabetes diagnostic. Enter, stage left: Lipemia.

Interferences in general are an interest of Paul M. Yip, PhD, D(ABCC)—in particular interferences that affect front-line chemistry testing. “Many times users are unaware when there may be an interference present that can affect the final result, especially when serum indices are not checked,” says Dr. Yip, division head of biochemistry at Sunnybrook Health Sciences Centre and associate professor in the Department of Laboratory Medicine and Pathobiology, University of Toronto.

Reporting on results of a study he conducted with colleague Michelle L. Parker, PhD, Dr. Yip said in a poster presentation at the AACC annual meeting last July that lipemia interferes differently with HbA1c results depending on the assay method used and the extent of the lipemia (Parker ML, et al. Abstract 288).

To conduct the study, which received funding support from Bio-Rad Laboratories Canada, Drs. Yip and Parker used samples spiked with saline and/or Intralipid to generate triglyceride levels of 0, 5, and 20 g/L to investigate the concentration of Intralipid-sourced triglycerides that may cause significant interference on four commonly used HbA1c analytical methods, and they used clinically lipemic specimens to assess the performance of nine routine HbA1c platforms. “We included essentially all the major manufacturers’ platforms available in North America,” Dr. Yip says.

The platforms studied were: Bio-Rad D-100, Bio-Rad Variant II Turbo 2.0, and Bio-Rad VII HbA2/HbA1c Dual Program; Sebia Capillarys; Beckman Coulter AU; Siemens Dimension Vista; Roche Cobas c501 Tina-quant; Ortho Vitros; and Abbott Architect.

Most immunoassays and the enzymatic method for HbA1c, the study found, are susceptible to negative interference from elevated triglycerides, while chromatographic and electrophoretic methods are resistant. For the Intralipid-spiked specimens, similar results were obtained; the findings are consistent with an earlier study that also used triglyceride/cholesterol-spiked specimens but assessed fewer assays (Wu X, et al. Biochem Med [Zagreb]. 2016;26[3]:353–364).

The assays that involved more of the traditional separation of the specimens were ones that were less affected by lipemia, Dr. Yip says. “Meanwhile, the other methods that used large chemical auto-analyzers that do multiple tests and have non-separation–based assays and any photometric or optical method that uses light” were also thrown off by lipemia. “In the presence of cloudiness or turbidity, the lipids in the sample are obviously going to have an impact on the light,” he says.
To avoid reporting falsely low HbA1c measurements, the study concluded, laboratories should consider evaluating their assay performance for significant interference from clinical lipemia. In addition, the authors said, “Although further investigations are needed, our data suggest that a serum triglyceride threshold of approximately 10 mmol/L may warrant a cautionary note when reporting HbA1c or reflexive testing to a lipemia-resistant platform.”

Hemolysis, hyperbilirubinemia, and lipemia are serum indices, Dr. Yip notes, a general class of interferences that occur in serum or plasma samples and may arise because of the patient’s physiological state or the handling of the samples. While considerable attention has been paid to the ways that hemoglobin variants can interfere with HbA1c, matrix-related interferences like lipemia have been investigated less, he says.

Lipemia’s interference with HbA1c is an under-recognized problem, in his view. “HbA1c is available on many different automated platforms, but not much has been reported in terms of how lipemia can affect results,” Dr. Yip says. “No one has really encountered, at least to my knowledge, a result that was so discrepant that through their troubleshooting and investigation they determined it was due specifically to a lipid interference.”

Lipids in a patient specimen can vary considerably. “They can be produced within the body, they may arise from diet if you have had a fatty meal, and they are heterogeneous in composition, in terms of the size of the lipid particles and the different concentrations of individual lipids. All of those things together can have a very different impact on the analysis.”

When laboratories are reporting on the presence of lipemia, often they are dealing with a serum or a plasma sample, Dr. Yip notes. “Because the plasma and the cells in the blood have been separated, you can see whether or not the sample is clear or if it is cloudy or murky. HbA1c analysis, though, is using a whole blood sample in which everything appears red. It’s difficult if not impossible to tell whether or not lipemia is there.” Adding to that difficulty, “When users are putting a sample into an automated analyzer, they may not even think to look at the specimen. It’s just a matter of loading it on and letting the machine do the testing.”

Major diagnostics manufacturers generally document common interferences well, he says. “Pretty much all of them we found did make a claim in their package inserts as to the kind of interference and whether it was a robust interference.” It’s difficult to replicate lipemia in a manufacturer’s environment, he says. But it can be simulated through Intralipid, a nutritional supplement that is essentially an emulsion of oil and other lipid material. “You can do an artificial setup by adding specified amounts of Intralipid and checking to see if it has any interference on what you are analyzing.” He and Dr. Parker used that technique in their study.

Says Dr. Yip: “HbA1c has taken on such a primary role as a diagnostic test and we’ve been caught up in improving accuracy, reducing imprecision, standardizing the results, and doing a lot of important work to make the assay available and accessible.” Now that those improvements appear to be in place, “we can start setting our sights on some of the less appreciated issues that can have an impact on results.”

In the traditional HbA1c context of diagnosing diabetes, patients would probably see a primary care physician or address the disease on an ambulatory basis, he notes. “Now we see patients going into the ER and ER doctors ordering HbA1c because they want to diagnose diabetes or see what sort of diabetic state the patient is in. In an emergency, you are probably in an acute situation and there are other bodily changes happening at the same time, so you are testing in less than ideal conditions.”

HbA1c is highlighted as the go-to test for diabetes because it doesn’t require a fasting specimen. But in these emergency circumstances, a nonfasting specimen is even more likely and the potential for lipemia is going to increase along with that, Dr. Yip says. “For diabetics there is a greater incidence of dyslipidemia as well. If dyslipidemia is present at a sufficiently high level, that can also have an impact on the test result.”

Each laboratory needs to determine for itself what its risk of encountering an interference is, he says, and how it is going to mitigate that risk. At University Health Network in Toronto, where Dr. Yip worked previously and where the lipemia study was conducted, he estimated that about 0.2 percent of, or one in 500, samples were significantly lipemic. The method that the UHN laboratory used was not affected by lipemia. “But for any laboratory using a routine auto-analyzer, many if not all of the major chemistry auto-analyzers can do a serum indices check, which could give a crude estimate of how much lipemia might be present.”

Dr. Yip sees immediate clinical implications for this study. “That’s because we appreciate now that A1c has to perform so tightly, so well, the total allowable error is constantly getting smaller and smaller, and my feeling is that it will continue to tighten. We have various guidelines that specify diagnosis of diabetes at an A1c of 6.5 percent. Now we have to be very sure that that 6.5 percent is as accurate as possible. If you have significant lipemic interference with one of the methods and an error that can falsely lower results, you could be missing that diagnosis of diabetes.”

It’s not surprising that the chemistry analyzers that use a spectrophotometer, except for one of the immunoassays, showed a significant interference by lipemia in samples in the study, says James Nichols, PhD, D(ABCC), medical director of clinical chemistry and point-of-care testing at Vanderbilt University Medical Center and professor of pathology, microbiology, and immunology, Vanderbilt University School of Medicine.

“Any of the spectrophometric methods that we use in chemistry can be interfered with by lipids, by bilirubin, or by hemolysis. The HbA1c analyzed by HPLC or capillary electrophoresis did not show this problem because there you are separating hemoglobin from the constituents of plasma and you separate the different types of hemoglobin on those columns or the capillary. If you have high triglycerides or high lipids, those interferences are going to wash out in the solvent front at the beginning of the run, and then later you’ll see the separation of the hemoglobins.”

“With the chemistry analyzers, you are mixing the patient’s whole blood with the reagent from the manufacturer, and the reaction is occurring in that same cuvette where the detection occurs. Everything is in the same cuvette, and you’re shining light through it, so if you have an interfering substance like lipids, it is going to interfere with that detection if it is the right wavelength.” The one method may be using a different wavelength than the other analyzers, he says, and thus there may be less interference for that reason.

Can results from different platforms be comparable then? That is the issue, in Dr. Nichols’ view. “If you are seeing a negative effect or impact, as Dr. Yip was showing with the triglycerides, it is significant for diabetics because most diabetics have problems with glucose metabolism. Because they are not metabolizing glucose, they need to metabolize protein and triglycerides or lipids for energy sources.”

Many people with diabetes have high cholesterol or high triglycerides. “Because of that, they are going to show, with these particular methods, a decrease in HbA1c. The HbA1c will make them look more compliant or better than they actually are,” Dr. Nichols says. “Their estimated average glucose over the past couple of months is going to look a little better than their actual average glucose. And they would be undertreated, in essence.”

If a laboratory is monitoring a patient over time with a chemistry platform that is falsely showing a decrease in HbA1c with triglycerides, he says, that is one thing. “But if you are monitoring a patient over time you are probably going to see a trend of increase or decrease overlaid with this interference. If you don’t switch methods, you can probably trend a patient over time because their lipids are not going to significantly change, unless there’s treatment with lipid-lowering drugs. And we’ve been managing patients currently pretty well based on these different methods.”

A visual inspection for lipemia in the laboratory is common with the automated platforms and chemistry analyzers, Dr. Nichols says. “We used to look at every sample visually and give an assessment of lipemia. Now, a visual inspection is either automated or it is ordered as a part of the chemistry panels. And we append comments on interferences at different levels.”
He suspects laboratories that are using the chemistry platforms studied by Drs. Yip and Parker can do a similar type of commenting. “If it was above a particular level that was significant, they would run a lipemia index and append a comment or note that the result may be falsely decreased because of the increase in lipids.”

Whether clinicians will notice is a different matter. “It depends on the electronic medical record system. A lot of times we append comments. Up front on the first EMR screen, you’ll see a number with an asterisk or a little arrow, but unless the clinicians click on the results on this EMR screen, they don’t see the comment. So, there can be issues with missing an important interference comment—and with a magnitude that is clinically significant.”

In addition, since the benefit of HbA1c is that the patient does not have to fast before the test, patients may have eaten just before the test and may have higher triglycerides, creating an even larger decrease in their HbA1c results.

High patient triglycerides are common enough to be a concern, Dr. Nichols says. “The study showed a pretty significant difference. The results were negatively biased by 10 percent and 25 percent at 5 g/L and 20 g/L of triglycerides.

“If you are looking at a 10 percent to 25 percent decrease in a result and you are sitting just above abnormal at an HbA1c of seven or eight, a 25 percent decrease will take you down to six, which would be considered intermediary, or even lower into the normal range. That could lead to incorrect treatment or a missed diagnosis.” This is more important for less serious cases of diabetes and maybe type 2 diabetes, for which clinicians screen patients in their physical exams, he adds, because if a person is widely out of range with their glucose, they will have HbA1cs of 10, 11, or in the teens. “A 10 percent decrease there is not going to be missed.”

Separately, there is already concern about using the chemistry methods for HbA1c because of the risk of missing hemoglobinopathies. “In other words, if you have a patient with sickle cells or high prevalence of hemoglobin variants in your patient population, you should be cautiously using a chemistry analyzer in the first place because the number you get won’t tell you that you have a hemoglobin variant, unless the patient knows they have a variant. So that chemistry analyzer number is going to be misleading for HbA1c to start with, depending on the type of hemoglobin variant and the specific method.” Independent of a direct interference, the presence of some hemoglobin variants can increase red cell turnover, affecting HbA1c levels.

Most of the chemistry methods’ package inserts list the common interferences, including hemolysis and triglycerides. “That factors in when they are developing the reagents and validation studies as part of the FDA submission data,” Dr. Nichols says, although, he adds, apparently the study showed that some of the manufacturers don’t have this data in their inserts.
The study results do not mean that laboratories should think right away about switching methods if they are showing a bias, Dr. Nichols says. Instead, “Laboratories should take note of this and discuss it with their clinicians and determine what the impact is on their patient population.”

In response to the study, Jeannine Holden, MD, Beckman Coulter’s chief medical officer, says lipemia is potentially an issue for any assay with a turbidimetric readout, not just HbA1c, and the study results Dr. Yip and colleague obtained are consistent with Beckman Coulter’s instructions for use for its HbA1c assay.

HbA1c assays are challenging in many respects, she says, and each of the common assay types has its benefits and drawbacks. “Immunoassays are generally more resistant to variant hemoglobins, so they may be preferable in areas with higher prevalence, and they don’t require a separate, dedicated instrument.”

Lipemia is underappreciated as a source of interference, Dr. Holden says. “In general, clinician awareness of lipemia as a potential interfering substance for assays is low, so laboratorians need to consider it when reporting any turbidimetric assay, not just HbA1c. Clinicians may also be unaware of the impact of red cell turnover on HbA1c results regardless of the assay type,” she adds, “and unlike lipemia, accelerated red blood cell turnover may be difficult to detect.”

Does Roche recommend the cautionary note suggested in the study? Günter Trefz, PhD, head of homogeneous immunoassay development, R&D Germany, Roche Diagnostics, points to the cautionary note on the Cobas c501Tina-quant package insert and notes that the limitations section clearly states: “Lipemia (Intralipid): No significant interference up to an Intralipid concentration of 600 mg/dL. There is poor correlation between triglycerides concentration and turbidity.”

“According to internal statistical data, the number of samples with an L-index greater than 200 mg/dL is less than 0.1 percent,” Dr. Trefz tells CAP TODAY. The number of samples with L-index greater than 500 mg/dL has been shown to be less than 0.02 percent in another study (Mainali S, et al. Pract Lab Med. 2017;8:1–9). “Therefore, it is rare to have samples with an L-index at or above 600 mg/dL.”

The company refers users to the NGSP website (ngsp.org/factors.asp) for full details, but says, “High-performance liquid chromatography methods for determination of HbA1c may be resistant to lipemia, but HPLC users must be aware of potential hemoglobin variant interference which exists at a higher prevalence and leads to inaccurate % HbA1c values.”

Roche also raises a question about the difference between the study’s methodology and CAP Surveys. “In this study, there appears to be a problem with how zero lipemia samples were measured. The baseline for zero lipemia samples appears to have been measured with an HPLC or CE method, resulting in bias with the Roche Tina-quant method. This finding is not seen in CAP Surveys, where the Roche Tina-quant method shows no significant bias. The correct procedure to detect lipemia interference would be to baseline each assay individually with the zero lipemia sample.”

Dr. Yip is continuing his research on lipemia interference by studying larger numbers of HbA1c samples on the various platforms. In the meantime, he says, “Laboratories need to be aware that this interference may occur, especially if they’re using a photometric-based method. And they should talk to the manufacturers about how they can approach the potential interference.”

SGLT2 Inhibitors: Is This the Start of a New Era?

Sodium-glucose cotransporter 2 (SGLT2) inhibitors are a relatively new class of antihyperglycemic agents that lower blood glucose by enhancing urinary excretion of glucose.[1] This mechanism of action, along with the relatively modest HbA1c reduction when used as a second-line agent, left some clinicians underwhelmed.

Beginning in 2015, however, cardiovascular outcomes trials designed to demonstrate safety began reporting cardiovascular benefits—especially in heart failure—as well as reductions in albuminuria and increases in estimated glomerular filtration rate (eGFR).[2]

The American Heart Association (AHA) 2018 Scientific Sessions included reviews of existing data and exciting new clinical trial results on the benefits of SGLT2 inhibitors.

The Metabolic Face of Heart Failure

The Sunday afternoon symposium, “The Metabolic Face of Heart Failure,” was presented by experts who reviewed what is currently known about SGLT2 inhibitors as well as the other newer classes of antihypeglycemics—dipeptidyl peptidase 4 (DPP-4) inhibitors and glucagon-like peptide 1 (GLP-1) receptor agonists.

Dr Eugene Braunwald led with an overview of the positive effects of SGLT2 inhibitors on diabetes, heart failure, and renal dysfunction. The EMPA-REG OUTCOME trial was the first to report cardiovascular benefits, achieving a 14% risk reduction in the primary composite outcome with empagliflozin.[3] The result was driven by a 38% reduction in death from cardiovascular causes, with no significant differences in nonfatal myocardial infarction or stroke. The other key finding was a 35% reduction in risk for hospitalization for heart failure.

A subsequent pooled analysis of phase 3 trials of empagliflozin demonstrated a significant reduction in urine albumin-to-creatinine ratio (UACR).[4] Two years later, the CANVAS Program reported a 14% reduction in the same primary outcome with canagliflozin, along with a 33% reduction in hospitalization for heart failure and a 27% lower risk for progression of albuminuria. Risk for the composite outcome of a 40% reduction in eGFR, renal replacement therapy, or death from renal causes was reduced by 40%.[5]

A later report from CANVAS suggested a slowing of eGFR decline among those who were randomly assigned to canagliflozin.[6] Both EMPA-REG and CANVAS were conducted among patients with diabetes who had established atherosclerotic disease or were otherwise at high risk for cardiovascular disease.

Dr Subodh Verma further reviewed cardiovascular outcomes trials of SGLT2 inhibitors, as well as those for DPP-4 inhibitors and GLP-1 receptor agonists. Overall, DPP-4 inhibitors did not provide a cardiovascular benefit and produced mixed results on heart failure.

GLP-1 receptor agonists may provide some cardiovascular benefit, although Verma pointed out that the benefit may be limited to analogues of human GLP-1 rather than exendin-based or DPP-4–resistant analogues. He also noted that the reduction in major cardiovascular events with SGLT2 inhibitors was limited to patients with diabetes who had established cardiovascular disease.

Indeed, the DECLARE-TIMI 58 cardiovascular outcomes trial of dapagliflozin, which included patients who were at risk but did not have established cardiovascular disease, reported no benefit (or harm) in the risk for major cardiovascular events.[7] However, like EMPA-REG and CANVAS, DECLARE-TIMI 58 demonstrated a significant reduction in risk for hospitalization for heart failure (27%) and risk for the renal composite (24%). A meta-analysis of these three trials was published simultaneously with the 2018 AHA Scientific Sessions.[2]

EMPA-HEART Explains the Benefits

Although blood-pressure lowering and weight loss were seen in the treatment arms of the three SGLT2 inhibitor outcomes trials, they were not enough to account for the results. Thus, the mechanism by which these studies achieved their heart failure and mortality benefits has not been clear.

In a late-breaking clinical trials session, the EMPA-HEART study[8] was presented to a packed house. The goal of the randomized controlled trial was to examine the effects of empagliflozin (n = 49) versus placebo (n = 48) on left ventricular remodeling over 6 months among patients with type 2 diabetes, with or without prior heart failure. All participants had established cardiovascular disease (ie, prior coronary revascularization or history of myocardial infarction), normal kidney function (eGFR ≥ 60 mL/min/1.73 m2), and left ventricular (LV) ejection fraction (EF) of at least 30%. Most of the participants were men (93%).

The primary outcome was change in LV mass index from baseline. After statistical adjustment, the empagliflozin group attained a 2.6 g/m2 reduction in LV mass index versus -0.01 g/m2 with placebo (P = .01), with the greatest improvement occurring among those with baseline LV mass index > 60 g/m2.

In addition, the treatment group had a change in systolic blood pressure of -7.9 mm Hg versus -0.7 mm Hg (P = .003), an increase in hematocrit (2.4% vs 0.4%, P = .006), and an improvement in LVEF, though not significant (2.2% vs -0.01%, P = .07).

It is remarkable that these effects were observed over a follow-up of only 6 months. On the other hand, the short follow-up begs the question of whether the effects could be sustained or whether they would continue to separate over longer periods.

In any case, the study provided the first mechanistic explanation for the favorable heart failure and cardiovascular death benefits seen in the EMPA-REG OUTCOME, CANVAS Program, and DECLARE-TIMI 58 cardiovascular outcomes trials.

Other important studies of SGLT2 inhibitors are underway. In particular, whether these agents can reduce heart failure hospitalizations and cardiovascular deaths in patients without diabetes with preserved or reduced ejection fraction will be reported in 2020. Another large trial studying the renal benefits of SGLT2 inhibitors in patients both with and without diabetes has also been announced. The era of SGLT2 inhibitors may indeed be upon us.

Obscure Asthma Drug Shows Promise for Treating Diabetes

A little-used asthma drug called amlexanox may potentially be repurposed to treat type 2 diabetes, according to findings from a small proof-of-concept study published in the July issue of Cell Metabolism.

Results showed that using the drug for 12 weeks was linked to significantly reduced HbA1c in some patients with obesity, type 2 diabetes, and nonalcoholic fatty-liver disease (NAFLD).

“The overall significant reduction in HbA1c over this relatively short trial indicates that amlexanox can benefit some patients with type 2 diabetes. The reduction in HbA1c is on the order of a [dipeptidyl peptidase-4] DPP-4 inhibitor when given alone over the same time period,” commented first author Elif Oral, MD, director of the MEND Obesity and Metabolic Disorder Program at the University of Michigan, Ann Arbor.

Researchers also looked at baseline inflammation, which revealed an interesting finding: people with higher levels of inflammation responded better.

“Among drug-treated patients, there seemed to be a greater degree of inflammation in responders compared with nonresponders. This is interesting, since we know that inflammatory pathways drive up expression of the targets of amlexanox,” Dr Oral said.

Amlexanox inhibits two enzymes: IKKƐ and TBK1. Studies in mice have shown that inhibiting these enzymes improves weight, insulin resistance, fatty liver, and inflammation.

Another intriguing result: responders showed over 1100 gene changes, and these changes were found only in this group.

“The drug response was characterized by a unique and dramatic molecular signature of gene-expression changes, consistent with what was seen in mouse models, in which expression of energy-expenditure genes were increased. We’re still investigating the importance and significance of these gene-expression changes,” Dr Oral added.

Amlexanox Developed in Japan to Treat Allergies and Asthma

Amlexanox was developed in Japan in the 1980s to treat asthma and allergic rhinitis. However, it requires thrice-daily dosing and was never introduced to the United States, because of heavy competition from more popular medications like montelukast, which can be taken once a day. Even in Japan, the prescription rate was very low, and therefore amlexanox was discontinued this year for commercial reasons.

However, its exact mechanism of action has never been fully investigated. It was not until Dr Oral and colleagues screened 150,000 chemicals, looking for inhibitors of IKKƐ and TBK1, that they hit upon amlexanox as a potential antidiabetes drug.

They first tested amlexanox in mice and did an open-label safety study in humans. Both the animal and human trials pointed to fat tissue as an important target for amlexanox.

So researchers next tested amlexanox in a randomized double-blind placebo controlled study that included 42 obese individuals with type 2 diabetes and NAFLD. Participants were randomized to 12 weeks of 50-mg amlexanox three times daily or placebo.

About one-third of participants showed a robust response to amlexanox, with reductions in HbA1c of ≥ 0.5% percentage points or more, which was significantly different from placebo (= .05). Responders also showed significant decreases in fructosamine, a marker for shorter-term glucose control (= .024).

Similar to results in mice, at 2 to 4 weeks responders showed a transient increase in IL-6, followed by decreased fasting glucose and improved insulin sensitivity. A subgroup of responders with NAFLD showed improvement in fatty liver.

Responders also had higher levels of baseline inflammation than nonresponders or placebo patients, including higher levels of CRP, which correlated with the amount of reduction in HbA1c. And analyses of fat biopsies showed they also had higher baseline activation of genes involved in inflammation.

Fat biopsies also replicated findings from the open-label study in humans, showing responders treated with amlexanox had higher expression of genes involved in energy expenditure and “browning” of fat.

Seven patients in the amlexanox group developed a rash at 4 weeks, which resolved within 2 weeks using local treatment. No other adverse events attributable to amlexanox occurred. This is consistent with the long-term safety profile in Japan, in which about 5% of patients developed rash, Dr Oral pointed out.

“We don’t understand the mechanism for why participants with more underlying inflammation responded better. However, previous work has shown that TBKI and IKKƐ are upregulated in the setting of more inflammation. So it is possible that inflammation oversensitizes the pathway that the drug targets,” she explained.

More Studies Planned

The team is now planning a longer 6-month prospective, randomized study in humans that will test whether individuals with elevated CRP and higher levels of fat inflammation at baseline have better responses to amlexanox.

They also plan another trial in humans that will test amlexanox in combination with mirabegron (Myrbetriq, Astellas Pharma), a pure beta agonist used to treat overactive bladder. The idea is to see whether amlexanox can restore catecholamine sensitivity.

Future studies will also determine the optimal safe dose and dosing regimen for amlexanox.

“If we can really prove that those patients with higher inflammation will respond better with this drug, it will be the first time that such an observation will be made, which is exciting. It’s another way of customizing therapy for patients,” Dr Oral stressed.

The group is currently looking for ways to partner with companies and investors, but currently none are involved.

Overweight Individuals with T2DM | Keto Diet vs Plate Method Diet

Recently a study was conducted by Saslow LR and colleagues to study whether a very low carbohydrate ketogenic diet with lifestyle factors (intervention) or a “Create Your Plate” diet (control) recommended by the American Diabetes Association (ADA) would improve glycemic control and other health outcomes among overweight individuals with type 2 diabetes mellitus (T2DM).

This article was published in February 2017 in a very reputed journal ‘Journal of Medical Internet Research’. In 2017, the impact factor of this journal was 4.671. For those of you who don’t know what an impact factor is or have never heard of, it simply means the number of times recent articles published in that journal in a year was cited by others. If the impact factor is high, it is considered to be a highly ranked journal.

Now coming back to the study, it was a parallel-group, balanced randomization (1:1) trial. This trial was approved by the University of California, San Francisco, Institutional Review Board and registered with ClinicalTrials.gov (NCT01967992).

In this study, glycemic control, operationalized as the change in glycated hemoglobin (HbA1c) was the primary outcome.

They also assessed body weight, cholesterol, triglycerides, diabetes-related distress, subjective experiences of the diet, and physical side effects.

During the study, the participants were asked to measure urinary acetoacetate (one type of ketone bodies that can be measured in urine) test kits (KetoStix). Basically, there are three types of ketone bodies. Other two types of ketone bodies are acetone and beta-hydroxybutyrate.

The other group i.e. the control group were asked to follow “Create Your Plate” diet recommended by ADA. What does this ADA diet consist of? Well, ADA recommends a low-fat diet which includes green vegetables, lean protein sources, and limited starchy and sweet foods. Most of the doctors worldwide follow ADA guidelines and recommend this particular diet to their patients.

As mentioned earlier the investigators divided the eligible participants into two groups (intervention group and control group).

In fact, when I was diagnosed with T2DM my diabetologist also recommended a low-fat diet with a caloric restriction of 1800 calories. But he never advised me how to restrict my calories to 1800 or what should I eat.  I was totally confused.

Also, he prescribed a couple of oral antidiabetic drugs and a statin. I followed his instructions for a couple of weeks and the result was that within 2 weeks I developed side effects of the drugs. I immediately STOPPED all my medications and started following a keto diet. Finally, I was able to reverse my T2DM. Anyway, that’s a separate story.

Coming back to the study, all the parameters were measured at baseline before randomization in both the groups. Again, all the parameters were measured after 16 and 32 weeks of intervention.

So what conclusions were drawn from this study. Let me list the results of this study in bullet points for better understanding.

  • The investigators observed that there were significantly greater reductions in HbA1cthose who followed the ketogenic diet after 16 as well as 32 weeks
  • Similarly, those who were on keto diet lost more weight than those who followed conventional ADA diet (12.7 kg versus 3 kg)
  • Also, triglycerides level was much lower in the ketogenic group compared to ADA diet followers

This study showed that those who followed a ketogenic diet had several health benefits including lower HbA1c, body weight, and triglyceride levels.

There were few limitations in this study. The number of participants was very less (25 participants) and the follow-up duration of the study was not long.

Despite all limitations, the conclusion we can draw from this study is that low-carbohydrate ketogenic diet and lifestyle changes are beneficial in individuals who are overweight with T2DM.

If you have any queries or any experience to share please type in the comment box. I will try to reply to all your queries.

If you have enjoyed reading this article, I would request you to share with your friends and colleagues who are diagnosed with T2DM. I am sure by reading this article, they will be motivated that it’s not the end of the world if they are diagnosed with T2DM.

With dietary and lifestyle modifications, it is possible to reverse your T2DM.

Dapagliflozin drives HbA1c, SBP, and weight down in DERIVE

Dr Siew-Pheng Chan.

The use of the sodium/glucose cotransporter 2 (SGLT-2) inhibitor dapagliflozin in patients with type 2 diabetes (T2D) and moderate renal impairment provides benefits beyond glucose lowering, with no new safety signals, in the phase III DERIVE* study.

At 6 months, the primary endpoint of mean reduction in HbA1c level was greater by 0.34 percent in patients treated with dapagliflozin vs placebo (p< 0.001). There were also greater reductions in systolic blood pressure (SBP, 3.1 mm Hg; p<0.05) and mean body weight (1.25 percent, p< 0.001) with dapagliflozin. (APSC 2018, abstract S105-01)

“Dapagliflozin induces glycosuria and lowers blood glucose. However, the glycaemic efficacy of dapagliflozin is attenuated in patients with moderate renal impairment, for example in stage 3 CKD, because less glucose is cleared in the kidney in this group,” said Dr Siew-Pheng Chan, consultant endocrinologist at Subang Jaya Medical Centre in Subang Jaya, Malaysia, who is unaffiliated with the study.

Researchers led by Dr Paola Fioretto of the University of Padova in Padua, Italy conducted the DERIVE study to compare the efficacy and safety of dapagliflozin vs placebo in 321 patients with T2D (HbA1c of 7 –11 percent) and moderate renal impairment (stage 3A chronic kidney disease (CKD), estimated glomerular filtration rate (eGFR), 45 to <60 mL/min/1.73m2). Patients were randomized to either dapagliflozin 10 mg (n=160) or placebo (n=161) over 6 months. Randomization was stratified by background glucose-lowering medication. Both groups had similar baseline characteristics.

At 6 months, treatment with dapagliflozin resulted in a significant reduction in mean HbA1c (-0.37 percent vs -0.03 percent for placebo) and mean body weight (-3.17 vs -1.92 kg, respectively) from baseline. The mean fasting plasma glucose was also significantly reduced with dapagliflozin (-21.46 vs -4.87 mg/dL for placebo) as was mean SBP (-4.8 vs -1.7 mm Hg, respectively) from baseline to 6 months.

In terms of safety, mean eGFR was reduced with dapagliflozin (-3.23 mL/min/1.73m2) vs placebo (-0.63 mL/min/1.73m2). Urinary tract infection and genital infection were the most common adverse events of interest reported. Overall, the safety profile of dapagliflozin was consistent with previous reports seen for T2D. No bone fractures or amputations were reported.

Dapagliflozin is currently indicated as an adjunct to diet and exercise to improve glycaemic control in adults with T2D. Dapagliflozin remains contraindicated in patients with an eGFR <30 mL/min/1.73 m².


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How to Use Average Blood Glucose to Estimate HbA1c

Checking blood glucose

By John Pemberton, Head Coach at Diabetic Muscle and Fitness and Diabetes Specialist Dietitian/Educator 

Do you have this essential diabetes management skill?

Most adults only get their HbA1c checked once a year, sound familiar?

This means you have an idea how things have been going for the previous 90 days, but what about the other 275 days?

The most effective way of keeping on top of your diabetes control is by regularly checking your average blood glucose (BG).

How Often Do You Check Yours?

Do you know how to use the results to predict HbA1c?

This table shows where your HbA1c will be very close to, depending on what level your average BG has been at for 90 days. The table also shows the benefits and consequences of having different levels of control for long periods of time.

What has your average BG been for the:

  • Last 90 days?
  • Last 30 days?
  • Last 14 days?

If you are currently in the red zone – don’t freak out!

This article is your wake up call. It’s time to take action. You can change this around very quickly, that is the beauty of using average BG to guide you.

How Do I Achieve Better Average Blood Glucose Levels?

Make small incremental changes to your daily diabetes habits and regimen. You can evaluate your progress by tracking the change in average BG every two weeks.

Top Diabetes Management Tips Based on 1000s of Hours Spent in Clinical Practice

  • Test BG at least five times per day – this allows you to correct high glucose levels more often.
  • Aim to be in target before bed; this means 8 hours per day of in target levels.
  • Bolus 15-30 minutes before food to prevent high glucose levels after, remember BIFF:
    • Blood test,
    • Insulin dose,
    • Fifteen minutes wait,
    • Food, eat it.
  • Keep to 3-4 meals per day, spread equally with 3-4 hours in-between.
  • This matches with the action of quick acting insulin (Apidra, NovoRpaid, Fiasp, Humalog) perfectly.
  • Frequent snacking makes in target glucose control very difficult.
  • Eat mixed macronutrient meals. Avoid carb only snacks, unless using for exercise management.
  • Review the patterns of your glucose trends every 14 days to identify where you need to change your habits and diabetes regimen.
  • Use a written log; there is a lot to be said for writing it down. Why? You process and identify patterns as you write.
  • Use an online platform where you can upload your meter, pump, and CGM devices:
    • Diasend & Glooko
    • They are both the same platform – they have just merged.

I personally use this platform and love it. I have even made guides and videos of how to set up an account, how to review control, and how to make changes in my day job as a Diabetes Specialist Dietitian. You can access these guides and videos here.

  • Use APPS such as MySugar and Diabetes:M
  • If you are struggling to identify solutions and find it hard to make changes, get professional help.

Your diabetes team or a professional with the requisite skills and qualifications should be able to guide and empower you.

If they just tell you what to do without teaching you how to do it, they are not setting you up for long-term success!

I work on the premise that as long as my average BG is less than 8.0 mmol/L (145mg/dL), I am all good.

If it’s above there, I need to focus on improving my control.

A special note: it’s no good having an average BG of 6.0 mmol/L (110mg/dL) if it means you are hypo all the time.

Research suggests having 3-4 mild hypos a week that you can treat yourself is usual for people with good control. But if more than this you are at risk of becoming hypo unaware. This research is from people on MDI and pumps who adjust their doses based on food intake and activity.

Being hypo unaware will mean you will not be able to drive (in the UK and most places if your physician knows or you call out an ambulance), and you will be at much higher risk of having a severe hypo. This is not a worthwhile trade-off for a HbA1c of 5.0%!

It’s all about balance.

Everyone is different, so set your target according to your circumstances.

As a general rule these are two good markers to aim for:

  1. Average BG less than 8.0 mmol/L (145 mg/dL).
  2. Less than 3-4 mild hypos per week, but no severe hypos and you can detect your hypos.

Checking average BG every 14 days will mean you stay in control and catch issues early! A Wiseman one told me: “If you’re not assessing, you’re guessing!”

Hope that helps!


  1. DAFNE Research Database Study

HbA1c, diabetes and cognitive decline: the English Longitudinal Study of Ageing



The aim of the study was to evaluate longitudinal associations between HbA1c levels, diabetes status and subsequent cognitive decline over a 10 year follow-up period.


Data from wave 2 (2004–2005) to wave 7 (2014–2015) of the English Longitudinal Study of Ageing (ELSA) were analysed. Cognitive function was assessed at baseline (wave 2) and reassessed every 2 years at waves 3–7. Linear mixed models were used to evaluate longitudinal associations.


The study comprised 5189 participants (55.1% women, mean age 65.6 ± 9.4 years) with baseline HbA1c levels ranging from 15.9 to 126.3 mmol/mol (3.6–13.7%). The mean follow-up duration was 8.1 ± 2.8 years and the mean number of cognitive assessments was 4.9 ± 1.5. A 1 mmol/mol increment in HbA1c was significantly associated with an increased rate of decline in global cognitive z scores (−0.0009 SD/year, 95% CI −0.0014, −0.0003), memory z scores (−0.0005 SD/year, 95% CI −0.0009, −0.0001) and executive function z scores (−0.0008 SD/year, 95% CI −0.0013, −0.0004) after adjustment for baseline age, sex, total cholesterol, HDL-cholesterol, triacylglycerol, high-sensitivity C-reactive protein, BMI, education, marital status, depressive symptoms, current smoking, alcohol consumption, hypertension, CHD, stroke, chronic lung disease and cancer. Compared with participants with normoglycaemia, the multivariable-adjusted rate of global cognitive decline associated with prediabetes and diabetes was increased by −0.012 SD/year (95% CI −0.022, −0.002) and −0.031 SD/year (95% CI −0.046, −0.015), respectively (p for trend <0.001). Similarly, memory, executive function and orientation z scores showed an increased rate of cognitive decline with diabetes.


Significant longitudinal associations between HbA1c levels, diabetes status and long-term cognitive decline were observed in this study. Future studies are required to determine the effects of maintaining optimal glucose control on the rate of cognitive decline in people with diabetes.

Air pollution exposure linked to heart disease risk factors

Blood glucose levels, cholesterol and other risk factors for heart disease may be worsened with exposure to air pollution, especially among those with diabetes, according to study findings.

“While air pollution is linked with relatively small changes in cardiometabolic risk factors, the continuous nature of exposure and the number of people affected give us cause for concern,” Victor Novack, MD, PhD, of Soroka University Medical Center and Ben-Gurion University in Israel, said in a press release. “Even small changes in glucose levels and glycemic control can contribute to increased risk of cardiovascular disease.”

In the 10-year population-based retrospective cohort study, Novack and colleagues evaluated data from 73,117 adults living in southern Israel from 2003 to 2012 to determine the effects of both short- and intermediate-term exposure to particulate matter on serum glucose, HbA1c, triglyceride, HDL and LDL levels. Thirty-six percent of participants had diabetes.

Acute exposure to particulate matter less than 10 µm in diameter was not linked to glucose, triglyceride, or LDL or HDL levels. However, intermediate exposures (3 months) to particulate matter less than 10 µm in diameter and less than 2.5 µm in diameter were linked to increases in glucose (0.3% and 0.02%, respectively), LDL (2.32% and 1.42%, respectively) and triglyceride (0.23% and 0.37%, respectively) levels and decreases in HDL (1.13% and 1.3%, respectively).

Participants with diabetes had the strongest links between particulate matter and increases in HbA1c (3.58% for particulate matter < 10 µm in diameter and 2.93% for < 2.5 µm in diameter) and LDL (2.37% for particulate matter < 10 µm in diameter and 1.54% for < 2.5 µm in diameter).

“We found an association between air pollution exposure in the intermediate term and undesirable changes in cholesterol,” study researcher Maayan Yitshak Sade, MPH, also of Soroka University Medication Center and Ben-Gurion University, said in the release. “This suggests that cumulative exposure to air pollution over the course of a lifetime could lead to elevated risk of [CVD].” – by Amber Cox

HbA1c increasing among adults with obesity

Adults with obesity have experienced a steady increase in mean HbA1c during the past 3 decades, which indicates a rising risk for type 2 diabetes, despite an overall reduction in blood pressure and cholesterol levels, according to an analysis of National Health and Nutrition Examination Survey data.

“The adverse impact of obesity on blood sugar status appears to develop over a longer period of time, and the population is still experiencing progressive worsening of glycemic status,” Fangjian Guo, MD, PhD, assistant professor of obstetrics and gynecology at the University of Texas in Galveston, said in a press release. “If blood sugar goes high too often, it can overwork the body’s ability to keep blood sugar in healthy ranges, increasing the risk for developing diabetes complications.”

Fangjian Guo

Fangjian Guo

Guo and W. Timothy Garvey, MD, professor of medicine and chair of the department of nutrition sciences at the University of Alabama in Birmingham, analyzed data from 18,626 adults with obesity (BMI at least 30 kg/m²) participating in NHANES III and NHANES 1999-2014. Researchers measured BP, blood glucose and lipid profiles, and used data to determine secular trends in the prevalence of cardiovascular disease risk factors and CV health status in the United States during the past 3 decades.

Within the cohort, mean systolic BP decreased from 126.1 mm Hg in 1988-1992 to 124.4 mm Hg in 2011-2014 (P < .001 for trend); diastolic BP also decreased, from a mean of 76.6 mm Hg to 72.5 mm Hg from 1988 to 2014. The reductions were observed across age and racial and ethnic groups and in both sexes.

Timothy Garvey

W. Timothy Garvey

Mean total cholesterol also decreased among all subgroups from a mean of 214.5 mg/dL in 1988-1992 to 193.7 mg/dL in 2011-2014, for a mean decrease of 20.8 mg/dL (P < .001); mean HDL increased from 45.4 mg/dL to 47.4 mg/dL between 1988 and 2014 (P < .001).

Mean HbA1c increased from 5.7% in 1988-1992 to 5.9% in 2011-2014 (P < .001 for trend). Researchers observed increases across all age, sex and racial groups except among black adults. The researchers noted that an increase in the prevalence of self-reported diabetes contributed to declining glycemic health; diabetes prevalence increased from 11.3% to 19% from 1988 to 2014 across all subgroups except among young adults.

The number of adults with obesity who had all three CVD risk factors increased by 37% across all subgroups during the study period, from 16.4% to 22.4%.

“The increase occurred in parallel with a decline in the prevalence of healthy blood glucose, which is the predominant explanation accounting for the rise in the prevalence of presence of all three risk factors,” the researchers wrote.

The prevalence of adults free from all three risk factors remained stable at about 15% during the study period, with adults aged 20 to 39 years most likely to fall into this category. Very few adults with obesity met the criteria for ideal CV health; prevalence remained stable at about 2% during the study period, according to researchers.

“Diabetes places patients at very high risk for heart attack and coronary death,” Garvey said in the release. “Obese adults at high risk for diabetes and heart disease may require more intense approaches to control blood sugar and achieve weight loss, such as healthy meal plans and physical activity.” – by Regina Schaffer

HbA1c testing in ED targets undiagnosed diabetes, prediabetes

People with undiagnosed diabetes and prediabetes may be identified with routine HbA1c testing in the ED, according to findings of a pilot study in Australia.

Routine HbA1c testing may provide opportunities for these patients to improve their care, according to the researchers.

“Diabetes case finding in the ED is justified as there is a significant population with known and undiagnosed diabetes,” the researchers wrote. “Following the findings of this pilot, it is intended that routine HbA1c testing will be the norm in the ED at Blacktown Hospital.”

Tien-Ming Hng, MBBS, PhD, FRACP, of Western Sydney University and Blacktown Hospital in Australia, and colleagues evaluated all patients undergoing blood sampling in the ED and random blood glucose measuresover 6 weeks. HbA1c was measured on the same sample if blood glucose was at least 5.5 mmol/L. Diabetes was defined as HbA1c levels of at least 6.5%, and prediabetes was defined as HbA1c levels of 5.7% to 6.4%. Researchers identified patients with previously undiagnosed diabetes by reviewing hospital records.

Tien-Ming Hng

Tien-Ming Hng

Overall, there were 4,580 presentations to the ED and 1,267HbA1c measurements (47.3% women); 38% of participants were identified as having diabetes. Of those with diabetes, 45% were women and 32.2% were newly diagnosed.

Of participants with newly diagnosed diabetes, 61.8% had mild diabetes. Twenty-seven percent of participants with HbA1c sampled had evidence of prediabetes. The diagnosis of diabetes was not coded in 28% of participants who were known to have diabetes; 11% were previously known to have diabetes, 81% were newly diagnosed and 8% were coded as impaired glucose regulation.

“In areas of high diabetes prevalence, HbA1c screening is an effective means of findings cases of diabetes and prediabetes,” Hng told Endocrine Today. “The findings of this study provides a better understanding of the diabetes burden in our local population and its potential impact on our health resources. This allows us to plan service delivery within our local health district and the wider community; to identify individuals at risk for diabetes thus providing an opportunity for intervention to prevent them from progressing to diabetes; to identify undiagnosed patients thus resulting in earlier intervention; to recognize the population and improve management of diabetes within the hospital; and to ensure that patients admitted to the hospital are appropriately coded for the complexity of their admission.” – by Amber Cox

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