Glycated Hemoglobin (HbA1c) Concentrations Among Children and Adolescents With Diabetes in Middle- and Low-Income Countries, 2010-2019: A Retrospective Chart Review and Systematic Review of Literature

Abstract

Objectives: To explore the glycemic control [represented by glycated hemoglobin (HbA1c) concentrations] in children with diabetes mellitus (DM) in east China and middle- and low-income countries, from 2010 to 2019.

Methods: Retrospective data of children with DM from two hospital-based health records were reviewed. Data on HbA1c concentrations, hospitalization due to diabetic ketoacidosis, and patient demographics were collected and analyzed. A systematic review was subsequently performed to analyze publications that report HbA1c concentrations in patients aged <18 years. Patients' characteristics extracted from each publication were used to generate simulated individual data for pooled analysis. HbA1c estimates were derived from steady-state iterations.

Results: Data of 843 diabetic children (aged 11.2 ± 3.9 years) with 2,658 HbA1c measures were retrieved from the two hospitals during the period 2010-2020. The duration of diabetes in the patients was 4.4 ± 2.8 years, and their HbA1c was 8.1 ± 2.2%. Patients who were internal migrants had significantly higher HbA1c concentration than resident patients (8.4 vs. 7.9%). The literature review yielded 1,164 publications, and the majority (74.1%) of patient data were published in high-income countries. The patient data extracted from these publications generated 486,416 HbA1c concentration estimates between 2005 and 2019. The average HbA1c concentration during the 15 years was 9.07 ± 2.15%. The mean HbA1c concentrations among children were 8.23, 8.73, 9.20, and 10.11% in high-income country (HIC), upper-middle income country (UMIC), lower-middle income country (LMIC), and low-income country (LIC) respectively. The mean rate of optimized glycemic control (HbA1c <7.5%) among children was 32.4, 27.5, 21.7, and 12.7% in HIC, UMIC, LMIC, and LIC, respectively.

Conclusions: The current study indicated that there is substantial room for improvement in glycemic control in children with DM worldwide, especially in middle- and low-income countries.

Keywords: HbA1c; childhood; diabetes mellitus; glycemic control; middle- and low-income country.

Figure 1

HbA1c among pediatric DM patients in east China, HbA1c, glycated hemoglobin; N, number of subjects/number of HbA1c measures.

Figure 2

Flow diagram of literature review, * based on 2015 WHO/IMF income category, HIC, high-income country; UMIC, upper middle-income country; LMIC, lower middle-income country; LIC, low-income country; N, number.

Figure 3

The overall distribution of HbA1c in children by country income level in 2005–2019 (A); and HbA1c in childhood diabetes by year and age, and duration (B), shaded sections indicate 95% uncertainty intervals, HIC, high-income country; UMIC, upper middle-income country; LMIC, lower middle-income country; LIC, low-income country; N, number; HbA1c, glycated hemoglobin; yr, year.

Figure 4

Relative HbA1c concentrations in countries by income classification, The mean HbA1c concentration in each cell corresponds to patients’ age and diabetes duration is represented in a color scale mapping deviation (magnitude of standard deviation) from the country subgroup mean HbA1c, HIC, high-income country; UMIC, upper middle-income country; LMIC, lower middle-income country; LIC, low-income country; N, (mean) numbers of patient estimates; M, mean (of HbA1c); SD, standard deviation (of HbA1c).