DM: Self-Monitoring of Blood Glucose (2001)
A panel of experts in endocrinology, diabetes and metabolism was gathered by the American College of Endocrinology (ACE) in 2001 to review current research findings on the topic of glycemic control. From this conference, several questions were addressed and consensus statements documented in this paper.
None specifically mentioned.
None specifically mentioned.
Recruitment
A panel of experts in endocrinology, diabetes and metabolism heard presentations from invited speakers, who reviewed research from past and current studies on diabetes. The consensus committee statement that follows represents that panel's collective analyses, evaluations and opinions based, in part, on the conference proceedings.
Design
Consensus Report.
Blinding Used (if applicable):
Not applicable.
Intervention (if applicable):
Not applicable.
Statistical Analysis:
Statistical analysis not completed.
Timing of Measurements
Not applicable.
Dependent Variables
Not applicable.
Independent Variables
Not applicable.
Control Variables
Initial N: Number of included articles not addressed. 51 references cited.
Attrition (Final N): Not applicable.
Age: Not mentioned.
Ethnicity: Not mentioned.
Other relevant demographics:
Anthropometrics
Location: Consensus Development Conference held in Washington, DC
1. What is the goal of diabetes management?
Prevention of acute and chronic complications of diabetes mellitus.
- microvascular: retinopathy, neuropathy, nephropathy.
- macrovascular: major cause of disability and death in those with diabetes.
2. To what extent does glycemic control achieve that goal?
Large-scale, randomized, prospective trials people with type 1 and 2 diabetes have shown that reductions in hyperglycemia significantly decrease the microvascular complications of diabetes.
Primary prevention of both eye and kidney disease by intensive diabetes management in the DCCT and in the Kumamoto study reduced the incidence of these complications by 50-70%.
Intensive treatment in the UKPDS study decreased the incidence of microvascular complication by 25%.
All trials demonstrated a 30% to 35% reduction in microvascular complications per 1% absolute reduction in HbA1c.
In both DCCT and UKPDS a trend toward reduction in macrovascular complications with decreased hyperglycemia was also noted. Macrovascular complications were decreased 14% for every 1% reduction of HbA1c.
3. What factors should be used to assess glycemic control?
Primary assessment:
HbA1c is the “gold” standard for assessing and monitoring glycemic control in patients with diabetes.
All laboratories determining HbA1c should utilize methodologies certified by the National Glycohemoglobin Standardization Program.
Secondary assessment:
Assessments of both preprandial and postprandial glucose levels are important to assist with the day-to-day decision making for diabetes management. Both are necessary as part of a diabetes management program aimed at maximal reduction of HbA1c.
4. What are the guidelines for the attainment of glycemic control in patients with diabetes?
HbA1c target:
The panel recommends that HbA1c be universally adopted as the primary method of assessing glycemic control with a target of <=6.5%. This recommendation is based on data from multiple interventional studies. This test should be performed twice per year in patients at target and quarterly in patients above target.
The panel recommends that the standard name for the HbA1c test be “A1C.”
Fasting preprandial glucose targets
The panel recommends fasting target <110 mg/dL since fasting >110 is associated with increased risk of retinopathy and cardiovascular events.
Postprandial glucose target
The panel recommends postprandial target <140 mg/dL based on a small body of evidence. Studies reviewed did link postprandial hyperglycemia to macrovascular risk. Additionally two studies showed targeting postprandial blood glucose more effective in reducing the HbA1c.
Risk-to-benefit ratio
The panel recommends these guidelines may be modified for individuals in which the risk of hypoglycemia is greater than the benefit of optimal glucose control. However, new medications and technologies can improve glucose control without increasing risk of hypoglycemia.
5. What further recommendations are needed regarding glycemic control and reduction of complications?
Case finding
Current screening guidelines for diabetes have resulted in an overall 50% prevalence of complications at the time of diagnosis. Also there is a 76% increase in prevalence of diabetes in adults 30-39 years old.
The panel recommends targeted screening for populations at high risk for the development of diabetes:
- Family history of diabetes
- Cardiovascular disease
- Overweight
- Sedentary lifestyle
- Latino/Hispanic, African American, Asian American, Native American, Pacific Islander
- Previously identified impaired glucose tolerance or impaired fasting glucose
- Hypertension
- Increased levels of triglycerides and/or low concentrations of high-density lipoprotein cholesterol
- History of gestational diabetes
- Delivery of baby weighing >9 pounds
- Polycystic ovarian disease
Additional research
In the panel's review of data, there was noted differences in minority groups at which point of hyperglycemia that microvascular complications occur. There is also noted a genetic component in the develpment of these complications. This needs further research.
A large-scale, prospective, randomized interventional trial is suggested to further quantify the relationship between postchallange hyperglycemia and cardiovascular risk.
It is known from large, randomized, interventional trials that improving glucose control reduces diabetes-related complications. The recommendations of this panel are meant to encourage patients and clinicians to achieve glycemia targets that will improve health, augment longevity, and enhance quality of life.
| University/Hospital: | American Foundation of Endocrynology |
Three recommendations are included in this consensus report that are new:
1. Goal for HbA1C of <6.5%
2. 2-hr postprandial as part of regular self-blood glucose monitoring
3. Using the term "A1C" to describe HbA1C
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Quality Criteria Checklist: Review Articles
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| Relevance Questions | |||
| 1. | Will the answer if true, have a direct bearing on the health of patients? | Yes | |
| 2. | Is the outcome or topic something that patients/clients/population groups would care about? | Yes | |
| 3. | Is the problem addressed in the review one that is relevant to dietetics practice? | Yes | |
| 4. | Will the information, if true, require a change in practice? | Yes | |
| Validity Questions | |||
| 1. | Was the question for the review clearly focused and appropriate? | Yes | |
| 2. | Was the search strategy used to locate relevant studies comprehensive? Were the databases searched and the search termsused described? | ??? | |
| 3. | Were explicit methods used to select studies to include in the review? Were inclusion/exclusion criteria specified andappropriate? Wereselectionmethods unbiased? | ??? | |
| 4. | Was there an appraisal of the quality and validity of studies included in the review? Were appraisal methodsspecified,appropriate, andreproducible? | No | |
| 5. | Were specific treatments/interventions/exposures described? Were treatments similar enough to be combined? | No | |
| 6. | Was the outcome of interest clearly indicated? Were other potential harms and benefits considered? | Yes | |
| 7. | Were processes for data abstraction, synthesis, and analysis described? Were they applied consistently acrossstudies and groups? Was thereappropriate use of qualitative and/or quantitative synthesis? Was variation in findings among studies analyzed? Were heterogeneity issued considered? If data from studies were aggregated for meta-analysis, was the procedure described? | ??? | |
| 8. | Are the results clearly presented in narrative and/or quantitative terms? If summary statistics are used, are levels ofsignificance and/or confidence intervals included? | Yes | |
| 9. | Are conclusions supported by results with biases and limitations taken into consideration? Are limitations ofthe review identified anddiscussed? | No | |
| 10. | Was bias due to the review's funding or sponsorship unlikely? | Yes | |