The Correlation of Fasting and 2-Hours Postprandial Plasma Glucose

with Glycated Hemoglobin as Glycemic Control

Mutiara Indah Sari

, Milahayati Daulay

, Dian Dwi Wahyuni

and Zaimah Z. Tala

Department of Biochemistry, Faculty of Medicine, Universitas Sumatera Utara, Jl.Dr. Mansur No.5 Medan, Indonesia

Department of Physiology, Faculty of Medicine, Universitas Sumatera Utara, Jl.Dr. Mansur No.5 Medan, Indonesia

Department of Microbiology, Faculty of Medicine, Universitas Sumatera Utara, Jl.Dr. Mansur No.5 Medan, Indonesia

Department of Clinical Nutrition, Faculty of Medicine, Universitas Sumatera Utara, Jl.Dr. Mansur No.5 Medan, Indonesia

Keywords: Fasting Plasma Glucose, Postprandial Plasma Glucose, Glycated Hemoglobin, Glycemic Control.

Abstract: Diabetes Mellitus (DM) is one of the non-communicable diseases that are currently increasing in number.

One of the indicators that used to describe the longer period of glycemic control in patients with DM is the

level of glycated hemoglobin or HbA1c. The purpose of this study was to determine whether in fasting or 2-

hours postprandial plasma glucose (PPG) level correlated with HbA1c level. So it can be used as the glycemic

control when measurement of the HbA1c is not available. This study is a cross-sectional study, on 60 type 2

diabetes mellitus patients at the University of Sumatera Utara Hospital. Before the examination, respondents

are required to fast for 10-12 hours. Examination of fasting plasma glucose (FPG) and 2-hours PPG were

performed using a cobas 6000 analyzer with hexokinase and immunoturbidimetry method. HbA1c was

measured using high-performance liquid chromatography (HPLC) method. The correlation between FPG with

HbA1c and 2-hours PPG with HbA1c was analyzed with the Spearman bivariate correlation test by SPSS 22

version. We found that the mean and SD values of FPG, 2-hours PPG, and HbA1c were 186.31 ± 71.27,

284.88 ± 92.06 and 8.85 ± 1.73, respectively. The Spearman bivariate correlation indicated a significant

association (p = 0.005, r = 0.357) between FPG with HbA1c. In this study found that no correlation between

2-hours PPG with HbA1c (p = 0.780, r = 0.036). We conclusions, FPG indicated as glycemic control better

than 2-hours PPG on type 2 diabetic if the HbA1c examination is not available.

1 INTRODUCTION

Diabetes mellitus (DM) is a metabolic disorder

marked with elevated chronic blood sugar levels

(hyperglycemic/ BGLs). This hyperglycemia

condition can be affected by insulin resistance

syndrome, insulin deficiency, or a combination of

both. It leads to impaired metabolism (Rodwell,

2015). DM is a non-communicable disease that every

year the incidence of this disease is increases. In year

2015 data by WHO shows that about 415 million

people suffer DM and it will be continued to increase

in over the last three decades. WHO estimate in year

2040 incidence rate of DM will be 642 million people

(WHO, 2016). Oxidative stress is a complications that

happen in DM. Oxidative stress will increase lipid

peroxide as malondialdehyde (MDA) (Sari, 2018).

Increase of lipid peroxide will increase of cell death.

Achieving a good glycemic control is an attempt to

prevent complications.

Glycemic control in DM patients can be

schematically described as the 'glucose triad', with

hemoglobin glycate or HbA1c, fasting plasma

glucose (FPG), and 2-hours postprandial plasma

glucose (PPG) levels (Monnier and Collete, 2009).

Among these three components, the HbA1c level

examination as a glycemic control is more

advantages. The advantage of the HbA1c test is any

diet does not influence it, before HbA1c level

examination, the patients no need to fasting, (it is so

simple for the patients), the results of HbA1c level is

stable to monitor hyperglycemic conditions for three

months ago and stress conditions not affect the

HbA1c levelz (ADA, 2014; Schteingart, 2002). The

rate of hemoglobin glycate formation is equivalent to

the average amount of blood glucose concentration.

When glucose levels rise above normal, the amount

of hemoglobin glycate will also increase. The

direct association between HbA1c and the average

amount of glucose occurs because the erythrocytes

Sari, M., Daulay, M., Wahyuni, D. and Tala, Z.

The Correlation of Fasting and 2-Hours Postprandial Plasma Glucose with Glycated Hemoglobin as Glycemic Control.

DOI: 10.5220/0010080206050609

In Proceedings of the International Conference of Science, Technology, Engineering, Environmental and Ramiﬁcation Researches (ICOSTEERR 2018) - Research in Industry 4.0, pages

605-609

ISBN: 978-989-758-449-7

605

are continuously binding of glucose (Glycosylated)

for 120 days of life (Schteingart, 2002).

There is no perfect clinical diagnostic test. HbA1c

examination techniques and tools are not available in

every hospital or community health center. One of the

other limitations is that the cost of HbA1c

examination is quite expensive. It is, therefore,

necessary to identify whether the HbA1c values are

more closely correlated with the fasting plasma

glucose or to the 2-hours postprandial plasma glucose

levels. This condition is important to know so it can

be determined which of the two is preferred as the

glycemic control if the HbA1c examination is not

possible. Patel .'s research (2016) found that HbA1c

contributed more to fasting plasma glucose so that

FPG and HbA1c were closer to describing glycemic

control (Patel ., 2016). The (Ya'cub, 2014) study

showed a strong correlation between the 2-hours

postprandial plasma glucose and HbA1c values.

(Ketema and Kibret, 2015) state that FPG and 2-hours

PPG are similarly correlated with HbA1c levels, but

the 2-hours postprandial plasma glucose has a closer

association with HbA1c than FPG (Ya’cub, 2014;

Ketema and Kibret, 2015). Thus, the purpose of the

present study was to determine whether HbA1c

correlates with fasting plasma glucose or 2-hours

postprandial plasma glucose as a glycemic control of

type 2 diabetes mellitus (T2DM) in Universitas

Sumatera Utara, Hospital, Medan.

2 METHOD

This research used an analytical cross-sectional

design. The study were approved by the Ethics

Committee of the Faculty of Medicine of the

Universitas Sumatera Utara with No. 227/FK USU.

The population in this research was type 2 diabetes

mellitus patients who were diagnosed by an

endocrine specialist based on the criteria

established by PERKENI (PERKENI, 2015)

in Universitas Sumatera Utara hospital.

The research population consisted of 60 diabetic,

and the inclusion criteria were 1) had experienced

T2DM for more than six months 2) willing to

participate in the research by signing on the

presentation sheet after explanation. The exclusion

criteria were 1) anemia, hemoglobinopathy 2) had a

history of blood transfusion in the last 2-3 months 3)

had a disease affecting erythrocyte age and 4)

impaired renal function.

Data collection of characteristics such as age,

gender and duration of disease were done through

interviews using questionnaires. FPG, 2-hours PPG,

and HbA1c levels were measured from the blood

plasma of the type 2 DM patients obtained from vena

mediana cubiti after fasting for at least 8-12 hours.

FPG, 2-hours PPG, and HbA1c were measured at the

Integrated Laboratory in the Universitas Sumatera

Utara Hospital on the same day. The FPG and 2-hours

PPG measurements used the cobas 6000 analyzer

with hexokinase and immunoturbidimetry method

(Roche Diagnostics, Switzerland). HbA1c was

measured using high-performance liquid

chromatography (HPLC) method. Then the data

was analyzed using the Spearman bivariate

correlation test with p-values of < 0.05 were

considered significant by SPSS version 22.

3 RESULT AND DISCUSSION

In this study, the characteristics of 60 type 2 DM

patients can be seen in Table 1

Table 1: Distribution of respondent characteristics

Variables N (%) Mean, SD

Age (years) - 57.53±9.09

Gender (male/

female)

39(65)/

21(35)

Duration of disease

(years)

- 7.52±2.80

Fasting blood

glucose (mg/dl)

- 186.31±71.

2-hours postprandial

blood glucose

(mg/dl)

- 284.88±92.

HbA1c (%) - 8.85±1.73

Table 1 shows the mean values of the age of

respondents was 57.53 years (SD = 9.09). Age is one

of the risk factors for diabetes mellitus. This condition

is probably caused by some changes in body

composition which is created by the aging process.

Aging causes a decline in the pancreatic function that

synthesizes insulin (Rochmah, 2009).

In the present research, based on gender found that

male respondents group more than female (65% VS

35%). The males are more likely to suffer from DM

in this population. The results of this research are not

the same as the research conducted by Mihardja

which showed that females are two times more likely

to have hyperglycemia than males (Mihardja, 2009).

Females control the excess energy as fat deposits

while male use their excess energy to synthesize

proteins. In the female, central obesity and increased

body fat will result in a decrease in the action of

ICOSTEERR 2018 - International Conference of Science, Technology, Engineering, Environmental and Ramiﬁcation Researches

606

insulin in the target tissue, leading to an increase in

blood glucose levels (Flier and Maratos-Flier, 2010).

In the present, the mean value of the duration of

DM disease is 7.52 years. This value can be

seen by reflecting on the mean of FPG, 2-hours PPG

and HbA1c levels of the research subjects. On the

uncontrolled of DM, the length of the duration of DM

will cause the parameters of BGLs will get worse

(Sari

, ., 2018). The mean of the three glycemic

parameters were above normal (186.31 mg/dl,

284.88, and 8.85%) with poor HbA1c glycemic

control (glycemic controls of either if HbA1c levels

<7%, poor, if HbA1c levels >7%) (PERKENI, 2015)

HbA1c is a substance formed from a chemical

reaction between glucose and hemoglobin. In HbA1c,

the glucose molecules will bind to the N-terminal

group on the HbA0 chain of HbA1c, so then the

glucose will fuse with the free amino group on valine

N-terminal of β hemoglobin (Rodwell, 2015). This

binding is called glycosylation. In DM patients,

glycosylation of hemoglobin increases

proportionately with blood glucose levels during the

previous two-three months. In 1976, the HbA1c level

was first proposed as an indicator of glucose

regulation in diabetic patients. The HbA1c level is

mainly determined by two factors which are blood

glucose level and erythrocyte age. Since 1980 the

measurement of HbA1c levels as a determination of

the DM glycemia index has been widely accepted.

HbA1c measurement is important for long-term

control of glycemic status in diabetic patients to

predict a decrease or increase in DM complications

(International Expert Committee, 2009)

There is no perfect clinical diagnostic test. HbA1c

as a glycemic control does not reflect glycemic

changes in a relatively short period, and its accuracy

is said to decrease if accompanied by abnormalities

of hemoglobin metabolism such as anemia and in

patients with thalasemia (Monnier and Collete,

2009). Another problem is it is expensive and not

available in most hospitals or health centers.

In addition to the HbA1c test, glycemic control in

patients with DM can be done by measuring the FPG

and 2-hours PPG levels. These three examinations

can schematically be described as 'glucose triads'

(Monnier and Collete, 2009). The significance and

strength of FPG correlations with HbA1c levels and

PPG with HbA1c levels shown in Table 2.

In this study, the Spearman bivariate correlation

test showed a significant correlation between FPG

and HbA1c levels with weak correlation strength (p =

0.005, r = 0.357), The FPG level is the BGLs

measured after a person undergoes an 8-12 hours fast

on the night before the test. The

objective of fasting on this test is to reduce the

variability of glucose metabolites resulting from the

metabolism of nutrients after meals. Fasting ensures

that BGLs are not affected by carbohydrate

metabolites from the last intake of nutrients (Rodwell,

2015). Whether there is a correlation between FPG

and HbA1c levels so that it can be used to replace

HbA1c examination is still debatable. The objective

of the FPG examination is as a substitute for the

HbA1c examination if the HbA1c test is not available.

Table 2: Correlations between FPG and PPG with HbA1c

Variable Mean±SD

mg/dl

p Correlatio

n (r) with

HBA1C

FPG

2-hours

PPG

186.31±71.2

284.88±92.0

0.005*

0.780

0.357**

0.036**

*p< 0.01 level (2-tailed)

Figure 1. Scatter-plot of FPG with HbA1C levels

The results of the present research are similar to

the study by (Akinloye, 2007) who found a significant

correlation between FPG and 2-hours PPG levels in

patients with type 2 DM with a strong correlation, but

no significant in the healthy group (Akinloye, 2017).

Similar results were also found in the research by

(Suprihartini, 2016) and (Kan, 2015) (Suprihartini,

2016; Khan, 2015). In the study of (Kan, 2015)

found a significant correlation between FPG and

HbA1c level with regression analysis on both

variables showed significance. The significant

correlation between the two variables were obtained

by cut-off point criteria of HbA1c ≥ 6.5 (Khan,

2015).

Another research of DM patients in Japan shows

that FPG is significantly correlated with HbA1c if the

cut-off point of HbA1c> 8 (Kikuchi, 2010). The study

The Correlation of Fasting and 2-Hours Postprandial Plasma Glucose with Glycated Hemoglobin as Glycemic Control

607

by Khatab show there was no significant correlation

between FPG and 2-hours PPG in the cut-off

point HbA1c < 8. FPG appears to be a major

contributor to BGLs in uncontrolled diabetes patients

(HbA1C> 8.4%) (Khatab, 2010). Research by (Patel,

2016) suggests FPG correlates to HBA1c with levels

above> 7%, not below 7%. FPG was also conferred

to be the key contributor for glycation of hemoglobin

and can assess the shift of glycemic status in diabetics

(Patel, 2016).

As well as the debate over the correlation of FPG

with HbA1c, the debate over the 2-

hours PPG correlation with HbA1c is also much of a

basis for research. In the present study, the Spearman

correlation between PPG and HbA1c levels show no

significant correlation with p = 0.780, r = 0.036. The

results of this study are different from the research

conducted by (Sikaris, 2009) which states that there

is a significant correlation between PPG with HbA1c

and no significant correlation between FPG and

HbA1c (Sikaris, 2009). Research by (Ketema and

Kibret, 2015) and research by (Shrestha, 2012) found

significant correlations between PPG with HbA1c

levels and also FPG with HbA1c levels, but PPG

found a stronger correlation with HbA1c than FPG

(Ketema and Kibret, 2015; Shrestha, 2012). Research

by Swetha (2014) also shows a correlation between

HbA1c with PPG and FPG, where the r value is PPG>

FPG. Sensitivity test results show that the specificity

obtained by PPG showed better sensitivity (79% vs.

74%) than FPG whereas FPG showed higher

specificity (84% vs. 74%) and positive predictive

value (87% vs. 80%) compared to PPG (Swetha,

2014).

The 2-hours PPG test is a BGLs examination

which is done 2-hours postprandial after fasting for at

least 8-12 hours. The 2-hours PPG test was done to

see how much of the pancreas or insulin function is

made out of the pancreas to regulate the distribution

of glucose levels from the blood circulation into the

cells. Diabetic patients will experience an increase in

BGLs after eating, and because of the insulin, these

BGLs will decline within two hours after eating

(Rodwell, 2015).

The previous research has found that there is a racial

and ethnic variation play a role of HbA1c as a

diagnostic test for diabetes. The role of racial and

ethnic differences in HbA1c values has been

recognized for many years, but so far these

differences have generally been associated with

differences in care patterns or quality of care

(Herman, 2009). Data analysis from the National

Health and Nutrition of 1999-2000 showed a

difference in mean values of HbA1c levels in the

white race compared to black and Hispanic race. This

analysis was done on a population of diabetic and

non-diabetic patients. The study reported an average

HbA1c value in the white race compared to black, and

the Hispanic race was 7.6% VS 8.1% VS 8.2%. This

ethnic and racial role in this HbA1c value may affect

the correlation between HbA1c and the mean value of

either FPG or PPG. The correlation between mean

blood glucose and HbA1c may not be the same in all

people depending on the ethnicity and race (Herman,

2012)

4 CONCLUSIONS

In this study, HbA1c levels show a significant

correlation with FPG levels, not with PPG levels.

Hence, as glycemic control, FPG examination may be

used instead of HbA1c if the HbA1c test is not

available. It should be noted that HbA1c remains the

gold standard in the assessment of glycemic control

with the availability of the HbA1c method.

ACKNOWLEDGEMENT

The present study is supported by the Ministry of

Research and Technology and the Higher Education

Republic of Indonesia, under the research grant

PDUPT USU of the Year 2018 with Contract Number

84/UN5.2.3.1/PPM/KP-DRPM/2018. The authors be

thankful to the Director of the Universitas Sumatera

Utara Hospital, Dr. dr. Syah Mirsya Warli, Sp.U and

the Head of the Integrated Laboratory, Faculty of

Medicine, USU, dr. Dewi Indah Sari Siregar, Sp.PK,

for providing the place for this research.

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