CORRELATION OFLIPID PROFILE WITH GLYCATED HEMOGLOBIN (HBA1C) IN DIABETIC PATIENTS IN KING ABDULLAH HOSPITAL, BISHA, SAUDI ARABIA

1. Department of Medical Laboratory Sciences, College Of Applied Medical Sciences, University of Bisha. Bisha, 61922. P. O Box 551. Saudi Arabia. 2. Department of Medical Laboratory Sciences, Faculty Of Medical And Medical Sciences, University of Hodeidah, Yemen. 3. Department of Clinical Chemistry, Faculty of Medical Laboratory Sciences, University of El Imam El Mahdi, Kosti, 209 P.O. Box 27711. Sudan. ...................................................................................................................... Manuscript Info Abstract ......................... ........................................................................ Manuscript History Received: 10 December 2019 Final Accepted: 12 January 2020 Published: February 2020


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developing countries (Powers, et al. 2015).With an increasing incidence worldwide, DM will be a likely leading cause of morbidity and mortality in the future (Wild, et al. 2004).The international diabetes federation (IDF) has estimated the total number of persons with diabetes across the world will rise from 171millions in 2000 to 366millions by 2030 (Wild, et al. 2004).Overall prevalence of DM in adults in Kingdome of Saudi Arabia (KSA) is 23.7%. A national preventing program at community level targeting high risk groups should be implemented sooner to prevent DM (Al-Nozha, et al. 2004).Theworld health organization WHO has reported that Saudi Arabia ranks the second high in the Middle East and the seventh in the world for the rate of DM. It is estimated that a round 7millions of the population are diabetic and almost around 3millions have prediabetes. Even more worrying perhaps is the increasing pattern of DM noted in Saudi Arabia (SA) in the recent past. In facts, DM has approximately registered a tenfold increase in the past three years in SA. DM has been found to be related to lower quality of life in SA. DM is quickly reaching disturbing proportions and becoming significant cause of medical complications and even death (Mohamed, et al. 2016).
Dyslipidemia is commonly seen in DM patients. Type 2 DM is one of the most common secondary causes of hyperlipidemia. The relationship between hyperlipidemia and vascular complication of diabetes has long been of interest because both tend to occur with greater frequency in Type 2 DM. Insulin resistance and obesity combine to cause dyslipidemia and hyperglycemia and hyperlipidemia have additive cardiovascular risk. It is recommended that patients with DM should be treated as if they already have coronary artery disease.Hence identification, critical evaluation, and follow-up of serum lipid profile in Type 2 DM continue to be important (Chaturvedi, et al. 2001), (Mazzone, 2000), (Ginsberg, et al. 2001) and (Harvey, 2002).
Glycated hemoglobin (HbA 1C ) is routinely used as a marker for long-term glycemic control. Apart from functioning as an indicator for the mean blood glucose level, HbA 1C also predicts the risk for the development of diabetic complications in diabetes patients (Selvin, 2004).Glycemic control with decreased level of HbA 1C is likely to reduce the risk of complications (Irene, et al. 2000). Estimated risk of Cardio Vascular Diseases (CVD) has shown to be increased by 18% for each 1% increase in absolute HbA1c value in diabetic ). Even in nondiabetic cases with HbA 1C levels within normal range, positive relationship between HbA 1C and CVD has been demonstrated (Khaw, et al. 2004) and (Deeg, et al. 1983). A few studies have previously tried to find the correlation between HbA 1C levels and lipid profile. Some of these have shown that all the parameters of lipid profile have significant correlation with glycemic control (Gligor Ramona, et al. 2011). On the other hand, some studies do not report significant correlation between glycemic control and all parameters of lipid profile (Zhe Yan, et al. 2012). This study aimed to measure the lipid profile and to find out correlation between glycated hemoglobin (HbA 1C ) and lipid profile in diabetic patients attending the Diabetic OPD clinic, King Abdullah Hospital -Bisha.

Material and Methods:-
This study was designed as cross-sectional observationalhospital-based study.Samples of patientswho are attending the diabetic clinic in King Abdullah hospital, Bisha, Saudi Arabia, were taken during the period from November 2011 to April 2012. Samples were collected from100 patients (41 men and 59 women) with known history of DM. Permission to curry out this study was obtained from college of medical laboratory sciences, University of Bish aand King Abdulla hospital, Bisha, Saudi Arabia.
After fasting for at least 10 hours, about 5ml of blood sample were obtained from diabetic patients by venipuncture using sterile disposable syringes and needles. Collected blood was divided into two parts. The first part,(2ml) was put in EDTA container ready for use tomeasure HbA 1C . From the second part serum was obtained after blood was allowed to clot for at least 15mins at room temperature and then centrifuged at 3000 rpm for 5mins. The obtained serum was pipetted into a clean container ready for use to measure lipid profile and serum glucose.
Analyzed on the day of collection, blood HbA 1C , serum sugar and lipid profile were tested. Serum total cholesterol was determined by an enzymatic (CHOD-PAP) colorimetric method. (Allain, 1974).And triglycerides were determined by an enzymatic (GPO-PAP) method (Jacobs, et al. 1960). HDL-Cholesterol was estimated by a precipitant method (Gordon T, et al. 1977) and LDL-Cholesterol by was estimated by using Friedewald's formula (Friedewald,et al. 1972) as it has been shown below:LDL-C = TC -HDL-C -(TG/5).
Serum glucose was determined using the glucose oxidase enzymatic method (Trinder, 1969) and glycated hemoglobin (HbA 1C ) by Ion Exchange Resin method. All parameters were determined using commercially available reagent kits. The lipid profile of the subjects was classified, based on the ATP III model (NCEP).

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In the literature, diabetic patients are classified into two groups depending on their glycated hemoglobin (HbA1c); Good Glycemic Control (GGC) group having HbA 1C <7.0% and Poor Glycemic Control (PGC) group having HbA 1C >7.0%. For serum lipid reference level, National Cholesterol Education Program (NCEP) Adult Treatment Panel III (ATP III) guideline was referred. According to NCEP-ATP III guidelines, hypercholesterolemia is defined as TC >200mg/dl, high LDL when value >100 mg/dl, hypertriglyceridemia as TG >150 mg/dl and low HDL when value < 40 mg/dl. Dyslipidemia was defined by presence of one or more than one abnormal serum lipid concentration (Ram Vinod Mahato, et al. 2011).
Statistical Analysis: all results were analyzed statistically; using statistical packaged of social sciences (SPSS) for windows, version. 20. And t-test was usedto compare means. Results were considered significant when P value (<0.05). Figures were plotted using Excel program.  figure 6, illustrates glucose correlation with HDL. The correlation is considered significant when p value <0.05. Means of HbA 1C , cholesterol, HDL, LDL, and FBG were higher in females than males. However, means of triglycerides and age were lower (table; 1). In our study all parameters have positive correlation with HbA 1C . Significant correlation of HbA 1C levels were observed only with fasting blood glucose level (P<0.01).Cholesterolwas having positive correlation with all parameters except age.Triglycerides were having positive correlation with HbA 1C , and cholesteroland negative with HDL, LDL and FBG. The HDL values of all diabetic patients were negatively significantly correlated with age with P value 0.008. LDL levels were significantly correlated with cholesterol and age (P <0.01 and 0.049), respectively (table; 2).

Discussion:-
This study aimed to correlate HbA 1C with lipid profile of diabetic patients. All parameters are measured and analyzed statistically. When we compare our findings with results in the literature, the HbA 1C mean level in our study is differ than that of study done by Mohieldein In our results nearly all diabetic patients have HbA 1C >6.0% and about 81% ofthe patients have HbA 1C level of >7.0%. However, nearly half of the diabetic patients have HbA 1C >9.0%. These findings to some extent aresimilar to results done by Ahmed, et al. in 2015, whereas nearly half of the diabetic patients have HbA 1C >9.0% and 91% of the diabetic patients theirs HbA 1C level is >6.0% (Ahmed, et al. 2015).Our results are differed than results of study conducted by Khattab, et al. in 2010, in Jordanian population (Khattab, et al. 2010). As they found that diabetic patients were having HbA 1C ≥7.0% (Khattab, et al. 2010).Our results are also differed than results of study done in Pakistani, and United Kingdom populations (Khattab, et al. 2010).These studies reported that, HbA 1C level in types 2 diabetics was >7.5%. However, in a study done in Kuwaiti population HbA 1C was ≥8% (Khattab, et al. 2010). Our findings are also differed than results of study done by Ahmed, et al. in 2014. They found that >40% of diabetic patients were having HbA 1C mean value >9% (Ahmed, et al. 2014). It is reported that the level of HbA 1C ≥6.0% was associated with increased risk of diabetic complications (Edelam, et al. 2004). Development of diabetic complications was associated with the level of glycemic controlwhich it is assessed by HbA 1C level (Obot, et al. 2013).Hence, patients in this study are at high risk of diabetic complication.
Dyslipidemia is one of the major risk factors for cardiovascular disease in diabetes mellitus (Arshag, 2009).Diabetic dyslipidemia is characterized by high levels of plasma triglyceride, low HDL cholesterol concentration and increased concentration of small dense LDL-cholesterol particles (Arshag, 2009).Management of lipids plasma levels is considered as approach effective in reducing risks in diabetic patients, especially the reduced HDL (Makamto, et al. 2005). Low levels of HDL are common among diabetic patients (Drexel, 2004) and it constitutes one of the characteristics of dyslipidemia in type2 diabetic patients (Syvanne, et al. 1995 (Ahmed, et al. 2008).
In this study, 60% of the patients have HDL >46mg/dl (1.2mmol/L). Also, >70% of the patients have HDL level >30mg/dl (0.8mmol/L). Our findings are differed than results of Ahmed et al. in 2014, as they found that 42% of diabetic patients have HDL level <40mg/dl (1.06mmol/L) (Ahmed et al. 2014).Because poor glycemic control in diabetic patients can lead to decreased HDL (Imani, et al. 2006).Our findings indicate that greater than 50% of patients participated in this study may be at low risk, or in a good diabetic control or on medication. Raising plasma HDL to the level >1.2mmol/L is desirable in high-risk individuals, as it was recommended by the American Diabetes Association (ADA) guidelines (Chan, et al. 2006).
It is reported that total cholesterol concentrations were normal in diabetic patients (Valabhji, et al. 2003).However, in study done by Ahmed, et al. in 2015, the diabetic patients were having high cholesterol mean level. And 60% of the diabetic patients have cholesterol level >3.8mmol/L (Ahmed, et al. 2015).In our study, total cholesterol level of >150mg/dl (3.88mmol/L) is reported in >70% of our patients. However, only 10% of them were having cholesterol level >250mg/dl (6.47mmol/L). Thus, depending on these findings, cholesterol results may not indicate high risk to our patients.
In the literature, the desirable level of triglycerides is <1.95mmol/L (Arshag, 2009).American Diabetes Association guidelines for diabetic dyslipidemia, and the Australian guidelines recommend lowering of triglycerides to <1.5mmol/L in high risk diabetic individuals (Chan, et al. 2006).In our study nearly 50% of our diabetic patients their TGs levelsare>1.5mmol/L. Our findings were differed than findings of study done by Mohammed, et al. in 2014, they reported that triglycerides levels were increased in patients with prolonged hyperglycemia with mean concentration of 1.95mmol/L (Mohammed, et al. 2014).Patients participated in this study should be advised to lower their TGs levels.
In this study there are more than 40% of diabetic patients have LDL >100.4mg/dl (2.6mmol/L). Our results are nearly similar to results of Ahmed, et al. in 2015, they found that more than 66% of diabetic patients have LDL >2.6mmol/L (Ahmed, et al. 2015).However, it is differed than study done by Mohammed, et al. in 2014, they reported that the LDL mean value of the patients with prolonged hyperglycemia was 92.8mg/dl (Mohammed, et al. 2014).
Previous study done by Ramprasad, et al. in 2007, reported that current guideline treatment is needed to reduce LDL level in diabetic patients (Ramprasad, et al. 2007).Besides, Shen, in 2007, wrote that the abnormalities in the metabolism of LDL or HDL in diabetic patients often require pharmacological intervention (Shen, 2007).As well as, it is recommended that LDL level of diabetic patients should be kept at <1.81mmol/L to reduce coronary artery disease and cardiovascular risks (Arshag,2009).Thus, patients participated in this study were at risk of cardiovascular risk. Results in this study also indicate the need for therapeutic attention for diabetic patients. Depending on antidiabetic medications only was not enough to treat diabetic patients, lipids lowering agents were also needed (Ahmed, et al.2014).
In this study, cholesterol and LDL wereweakly positively correlated with HbA 1C, this may indicate high risk. These findings are similar to study of Karar, et al. in 2015 in Saudi population.They reported that therewas a weak positive correlation between HbA 1C and total cholesterol and LDL in diabetic patients (Karar, et al. 2015).Weakly positive correlation between HbA 1C and HDL in this study indicates good diabetic control especially for those who are at increased ages.

Conclusion:-
There was difference in the glycemic status between males and females as measured by Fasting glucose and HbA 1C . HbA 1C showed positive correlations with cholesterol, TGs, LDL and HDL. These findings suggest that HbA 1C level can be used as a good parameter for predicting the lipid profile in both male and female diabetic patients. So that, HbA 1C may be utilized for screening diabetic patient for risk of cardiovascular events and also for timely intervention with lipid lowering drugs.