SLR - May 2014 - Wendy Wu
Reference: Laiteerapong N, John PM, Nathan AG, Huang ES. Public Health Implications of Recommendations to Individualize Glycemic Targets in Adults with Diabetes. Diabetes Care. 2013 Jan;36(1):84-9.
Scientific Literature Review
Reviewed By: Wendy Wu, DPM
Residency Program: Medstar Washington Hospital Center
Podiatric Relevance: Measurement of the HbA1c in our diabetic patient population provides podiatric physicians with an overall picture of glycemic control. This number is relevant to wound healing, allows us to better risk stratify our patients, and may set up goals with our patients in terms of their long-term care. This article introduces the idea of individualizing HbA1c target goals within certain patient populations.
Methods: A population of adults with diabetes ≥20 years of age from the National Health and Nutrition Examination Survey from 2007-2008 were examined (n=757). A1C targets were assigned based on diabetes-duration, age, diabetes-related complications, and co-morbid conditions according to the ADA guideline as well as the strategy by Ismail-Beigi who has focused on setting HbA1c target ranges. Estimation was made of the number and proportion of adults with each A1C target and compared individualized targets to measured levels. In order to understand the potential impact of the individualization of glycemic targets on diabetes care quality, this study characterizes the U.S. adult diabetes population by clinical variables that have been proposed as reasons to individualize A1C targets. Further, the study operationalized the ADA and Ismail-Beigi strategies for individualization to estimate one) the distribution of the US adult diabetes population across each individualized A1C target and two) the size of the population who have measured A1C levels that are at or below their recommended individualized A1C target.
Results: Using ADA guideline recommendations, 31 percent (95 percent CI 27–34 percent) of the U.S. adult diabetes population would have recommended A1C targets of <7.0 percent, and 69 percent (95 percent CI 66–73 percent) would have A1C targets less stringent than <7.0 percent. Using the Ismail-Beigi strategy for individualizing HbA1c, 56 percent would have an A1C target of ≤7.0 percent, and 44 percent would have A1C targets less stringent than <7.0 percent. If a universal A1C <7.0 percent target were applied, 47 percent of adults with diabetes would have inadequate glycemic control. This number declined to 30 percent with the ADA guideline and 31 percent with the Ismail-Beigi strategy.
Conclusions: This is an interesting article that may provide podiatric physicians with insights into the future directions of glycemic control in our diabetic patients. The HbA1c is an important lab value that should have an effect on podiatric treatment recommendations. This article discusses realistic patient goals for this value, as well as changes that may occur in terms of medical management and reaching these goals.