Paradigm shift in Diabetic care

Dr.R.V.S.N. Sarma, M.D., M.Sc.,

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 How true ?
Once there was a tiger which boasted
that it can run faster than any one.
One day he chased a rabbit and failed to
catch it.
“All right” said the tiger; “of course I
failed on my boast.
But, remember the rabbit was running
for its life and I, for my dinner.”
Now, decide who is the rabbit and who
is the tiger - among we and our patient !
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 Dr.E.P.Joslin
“The greatest burden on doctors will
be not the management of diabetes,
but the associated macro and micro-
vascular complications of it.” ..1926
“The goal of therapy in diabetes
should be to make serious efforts to
keep the blood sugar levels as close
normal as possible.” ….. 1929
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 Be serious Doctor
1. I am making India the capital of the
world shortly !
2. Already I have a big… family of 200
millions on the globe.
3. I am happily troubling 12% urban and
8.2% of rural Indians.
4. In my name I am sweet but my
effects are very hot !
5. I am not easily controlled (< 45%)
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 Haemoglobin
Structure of Hb

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 Different Hbs

1. Fetal Hemoglobin – Hb F
2. Adult Hemoglobin – Hb A
3. Sickle cell disease – Hb S
4. Hemoglobinopathies – Hb C, Hb E

Glucose in the blood reacts with the

Hemoglobin A to form Glycated Hb.

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 Glycated Hb - GHb
Different types of Glycation products
are formed from the HbA0 depending
on the carbohydrate moiety – namely
– HbA1a1 - Fr 1,6 diphos –N-term. valine
– HbA1a2 - Gl 6 phos –N-terminal valine
– HbA1b - Other CHO – N-term. valine
– HbA1c - Glucose –N-terminal valine
Normally less than 6% of Hb is HbA1c

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(Previously called glycosylated Hb.)
 Reference values of HbA1c
1. Less than 6% - Normal
2. 6 to 7.5% - Good control of DM
3. 7.6 to 9% - Unsatisfactory control
4. More than 9% - Very poor control
Values depend on the method of estimation
They vary from lab to lab.
Note if all GHb is measured instead of HbA1c

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 Factors affecting HbA1c
• Acute hyperglycemia
• Severe aneamia
• Gestational diabetes
• Life span of the RBC
• Abnormal Hb like S-Hb, Hb C
• Serum opalescence -↑TG
• On the method of estimation
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 Estimation of HbA1c
• There are many methods of estimation
• HPLC (High Performance Liquid
Chromatography) – Gold standard.
• Immuno-turbimetric meth. – HbA1cAb
• Affinity chromatography
• Electrophoretic methods
• Method based on chemical reactions.

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 HbA1c is ‘weighted’

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 How well it measures ?
Lowering Hb A1c reduces risk of complications

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 Advantages of HbA1c
• Index of long-term control over 120
days and not a snap shot like PG
• Can be done at any time of day
• Not influenced by diet, exercise,
emotional disturbances on test day
• Useful index in clinical trials
• Useful if missed drugs / default diet
• Useful in DD of stress hyperglycemia
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 Limitations of HbA1c
• Cannot be an emergency room test to
titrate Insulin or OHA dosage
• Cannot register hypoglycemia
• More sensitive to sin than repentance –
if it is elevated it confirms poor control,
if it is boarder line, it cannot assure
good control in the recent past.
• Not sensitive enough for use in GDM
•  Anaemia, Uraemia, Pregnancy
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 Correlation of MPG - HbA1c
Mean Plasma Glucose =
(33.3 x HbA1C%) - 86
(Nathan et. al. NEJM, vol. 310, No 6, Feb 9, 1994)

HbA1C % Mean BG mg %

5 80.5
7 147.1
9 213.7
11 280.3
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 Glycosylation of hair
• Hair glycosylation using thiobarbituric acid TBA
• Glycosylation of hair is  in diabetes mellitus
• Both insulin dependent , non-insulin dependent
• Glycosylation of hair is proportionate to HbA1c
• Due to the presence of hexosyl lysome in hair
• Long hair sample provides a long term record.
• May have forensic application & in population
studies.

BMJ, 1996, vol. 288 pp. 669-670

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 Blood Glucose Monitoring
Type Frequency Sample

Type 2 DM Monthly FPG / PPG

Type 1 DM 4-6 times 6th hourly

initially to 4th hourly
Stabilized Twice a week. 3 samples

Pregnancy Once a week. FPG / PPG

Peri-operative 4-6 times 6th hourly

a day to 4th hourly

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 MAGE

“Blood Glucose 80 min. after

breakfast correlates with MAGE
( Mean Amplitude of Glycaemic
Excursions ) throughout the day”

Molnar et. al.

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 SMBG
• On intensive insulin therapy
• Diabetes in pregnancy
• IDDM who lack warning symptoms
of hypoglycaemia
• Insulin - requiring diabetics
• Diabetics with unusually high/low
RTMG.
• Insulin - resistant diabetics on large
insulin doses
• Motivated diabetics for tight control.
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 New era in monitoring
control

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