한국 성인에서 제2형 당뇨병의 예측인자로서 공복 혈장 혈당과 당화혈색소의 조합 = Original Articles : The Combination of Fasting Plasma Glucose and Glycosylated Hemoglobin as a Predictor for Type 2 Diabetes in Korean Adults

국문 초록 (Abstract)

연구배경: 당뇨병의 선별 검사로서 경구당부하검사는 재현성이 낮으면서 시행하기 어려운 단점이 있어, 좀 더 쉬운 검사가 요구된다. 본 연구에서는 공복 혈장 혈당과 당화혈색소의 조합이 한국 성인의 당뇨병을 예측하는데 있어서 유용한지 알아보고자 하였다. 방법: 2002년 1월부터 2003년 12월까지 영남대학교병원 건강 증진 센터를 방문한 환자 2,045명(남자 1,276명, 평균 연령 47.8±9.0세)를 대상으로 공복 혈장 혈당과 당화혈색소, 다른 생화학적 검사를 시행하였고 4년 후 추적 검사를 시행하였다. 기저시점 검사에서 AST, ALT, 총 빌리루빈치가 높은 환자와 당뇨병이 있는 환자는 제외되었다. 결과: 4년 후 새롭게 당뇨병으로 진단 받은 사람은 2,045명 중 32명(1.6%)이었다. 당뇨 발생군은 비발생군에 비해 나이가 많았으며 혈압, 공복 혈장 혈당, 당화혈색소, 중성지방, 고밀도 지단백 콜레스테롤, GGT, LDH가 높았다(P<0.05). 다중 회귀분석에서 공복 혈장 혈당(OR 1.124)과 당화혈색소(OR 4.794)는 당뇨병의 발병과 유의한 상관관계가 있었다(P<0.05). 공복 혈장 혈당과 당화혈색소의 교호작용에 대한 OR은 1 이상으로, 두 가지의 조합은 당뇨병의 발병을 예측하는데 있어 상승 작용을 나타내었다. 당뇨병 예측을 위한 두 인자의 ROC curve에서 당화혈색소와 공복 혈장 혈당의 기준치는 각각 5.35% (AUC=0.944), 102.5 mg/dL (AUC=0.930)였다. 결론: 한국 성인에서 5.35% 이상의 당화혈색소와 102.5 mg/dL 이상의 공복 혈장 혈당을 가진 경우에 각각의 경우보다 당뇨병의 발생을 더 잘 예측할 수 있었다. 이 결과로 한국 성인에서 제2형 당뇨병의 예측 인자로서 공복 혈장 혈당과 당화혈색소의 조합이 유용할 것으로 생각된다.

다국어 초록 (Multilingual Abstract)

Background: The oral glucose tolerance test (OGTT) for detection of diabetes is difficult to perform in clinical settings. The aim of this study is to evaluate the performance of a more practical detection test, combined fasting plasma glucose (FPG) and glycosylated hemoglobin (HbA1c), as a predictor of diabetes mellitus (DM) in a Korean sample. Methods: We examined 2,045 (M=1,276, mean age=47.8±9.0 yrs) medical check-up program participants between January 2002 to December 2003. FPG, HbA1c and a number of other biochemical tests were performed at baseline and four after years after initial screening. Patients who originally presented with diabetes were excluded. The characteristics of newly-diagnosed DM patients and non-diabetic patients were compared. Results: The incidence of newly diagnosed diabetes was 1.6% (32/2,045) after four years of follow up. The subjects in the DM group were older, had higher levels of SBP, DBP, FPG, HbA1c, triglyceride, HDL cholesterol, GGT and LDH (P<0.05). In multivariate logistic regression analysis, FPG (odds ratio [OR] 1.124) and HbA1c (OR 4.794) were significantly correlated with onset of diabetes (P<0.05). The interaction parameter between FPG and HbA1c was more than 1.0, indicating that the two effects are synergistic. The predictive cut-off values of HbA1c and FPG were 5.35% (area under curve [AUC]=0.944) and 102.5 mg/dL (AUC=0.930), respectively. Conclusion: The combination of HbA1c above 5.35% and FPG above 102.5 mg/dL predicted the onset of diabetes in a Korean sample. These results suggest that the combination of FPG and HbA1c may be useful for predicting progression to type 2 diabetes in east Asians. (Korean Diabetes J 33:306-314, 2009)

참고문헌 (Reference)

1 Peterson KP, "What is hemoglobin A1c? An analysis of glycated hemoglobins by electrospray ionization mass spectrometry" 44 : 1951-1958, 1998

2 Wang W, "Using HbA1c to improve efficacy of the American Diabetes Association fasting plasma glucose criterion in screening for new type 2 diabetes in American Indians" 25 : 1365-1370, 2002

3 Masaki T, "Usefulness of paired estimation of fasting plasma glucose and HbA1c: a long-term follow-up study of screened nondiabetic subjects" 44 : 745-750, 2001

4 Korean Diabetes Association, "Treatment guideline for diabetes. 1st ed. p.9-12" MMK communications 2007

5 Inoue M, "The combination of fasting plasma glucose and glycosylated hemoglobin predicts type 2 diabetes in Japanese workers" 77 : 451-458, 2007

6 Barr RG, "Tests of glycemia for the diagnosis of type 2 diabetes mellitus" 137 : 263-272, 2002

7 American Diabetes Association, "Standards of medical care in diabetes--2009" 32 (32): S13-S61, 2009

8 Engelgau MM, "Screening for type 2 diabetes" 23 : 1563-1580, 2000

9 American Diabetes Association, "Screening for type 2 diabetes" 27 (27): S11-S14, 2004

10 Engelgau MM, "Screening for NIDDM in nonpregnant adults: a review of principles, screening tests, and recommendations" 18 : 1606-1618, 1995

11 Davidson MB, "Relationship between fasting plasma glucose and glycosylated hemoglobin: potential for false-positive diagnoses of type 2 diabetes using new diagnostic criteria" 281 : 1203-1210, 1999

12 Finke A, "Preparation of a candidate primary reference material for the international standardisation of HbA1c determinations" 36 : 299-308, 1998

13 Harris MI, "Onset of NIDDM occurs at least 4-7 yr before clinical diagnosis" 15 : 815-819, 1992

14 Jesudason DR, "Macrovascular risk and diagnostic criteria for type 2 diabetes: implications for the use of FPG and HbA(1c) for cost-effective screening" 26 : 485-490, 2003

15 Chobanian AV, "Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. National Heart, Lung, and Blood Institute; National high blood pressure education program coordinating committee: Seventh report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure" 42 : 1206-1252, 2003

16 American Diabetes Association, "International expert committee report on the role of the A1c assay in the diagnosis of diabetes" 32 : 1327-1334, 2009

17 de Vegt F, "Hyperglycemia is associated with all-cause and cardiovascular mortality in the Hoorn population: the Hoorn Study" 42 : 926-931, 1999

18 Bennett CM, "HbA(1c) as a screening tool for detection of type 2 diabetes: a systematic review" 24 : 333-343, 2007

19 Khaw KT, "Glycated hemoglobin, diabetes, and mortality in men in Norfolk cohort of European prospective investigation of cancer and nutrition (EPIC-Norfolk)" 322 : 15-18, 2001

20 Sung KC, "Glycated hemoglobin as a predictor for metabolic syndrome in non-diabetic Korean adults" 24 : 848-854, 2007

21 King H, "Global estimates for prevalence of diabetes mellitus and impaired glucose tolerance in adults" 16 : 157-177, 1993

22 Park S, "GHb is a better predictor of cardiovascular disease than fasting or postchallenge plasma glucose in women without diabetes: the Rancho Bernardo Study" 19 : 450-456, 1996

23 Kirkwood BR, "Essential medical statistics. 2nd ed. p.322-30" Blackwell science 2003

24 Pauker SG, "Deciding about screening" 118 : 901-902, 1993

25 McCance DR, "Comparison of tests for glycated hemoglobin and fasting and two hour plasma glucose concentrations as diagnostic methods for diabetes" 308 : 1323-1328, 1994

26 Ko GT, "Combined use of fasting plasma glucose and HbA1c predicts the progression to diabetes in Chinese subjects" 23 : 1770-1773, 2000

27 Ko GT, "Combined use of a fasting plasma glucose concentration and HbA1c or fructosamine predicts the likelihood of having diabetes in high-risk subjects" 21 : 1221-1225, 1998

28 Sato KK, "Combined measurement of fasting plasma glucose and A1c is effective for the prediction of type 2 diabetes" 32 : 644-646, 2009

29 Manley SE, "Calibration of HbA1c and its measurement in the presence of variant hemoglobins: report on questionnaire to manufacturers" 43 : 135-145, 006

30 Saudek CD, "A new look at screening and diagnosing diabetes mellitus" 93 : 2447-2453, 2008

31 Peters AL, "A clinical approach for the diagnosis of diabetes mellitus: an analysis using glycosylated hemoglobin levels" 276 : 1246-1252, 1996