692296

research-article2017
TAE0010.1177/2042018817692296Therapeutic Advances in Endocrinology and MetabolismA Hussain, I Ali

Therapeutic Advances in Endocrinology and Metabolism Original Research

Correlation between hemoglobin A1c and

Ther Adv Endocrinol
Metab

serum lipid profile in Afghani patients

2017, Vol. 8(4) 51­–57

DOI: 10.1177/
https://doi.org/10.1177/2042018817692296
https://doi.org/10.1177/2042018817692296
2042018817692296

with type 2 diabetes: hemoglobin A1c © The Author(s), 2017.

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Arshad Hussain, Iftikhar Ali, Muhammad Ijaz and Afaq Rahim

Abstract
Background: Patients with type 2 diabetes (T2DM) have an increased prevalence of
dyslipidemia, which contributes to their high risk of cardiovascular diseases (CVDs). This study
is an attempt to determine the correlation between hemoglobin A1c (HbA1c) and serum lipid
profile and to evaluate the importance of HbA1c as an indicator of dyslipidemia in Afghani
patients with T2DM.
Methods: A total of 401 Afghani patients with T2DM (men, 175; women, 226; mean age,
51.29 years) were included in this study. The whole blood and sera were analyzed for fasting
blood sugar (FBS), HbA1c, total cholesterol (TC), triglycerides (TGs), high-density lipoprotein
cholesterol (HDL-C) and low-density lipoprotein cholesterol (LDL-C). Dyslipidemia was
defined according to the National Cholesterol Education Program Adult Treatment Panel III
(NCEP ATP III) guidelines. Diabetes was defined as per American Diabetes Association criteria.
The correlation of FBS, HbA1c with lipid ratios and individual lipid indexes were analyzed. The
statistical analysis was done by SPSS statistical package version 16.0.
Results: The mean age ± standard deviation of male and female patients were 51.71 ± 11.70
and 50.97 ± 10.23 years respectively. There was a significant positive correlation between
HbA1c, TC, TG, LDL-C and LDL-C/HDL-C ratio. The correlation between HbA1c and HDL-C
was negative and was statistically nonsignificant. Furthermore, HbA1c was found to be a
predictor of hypercholesterolemia, LDL-C and TG via a linear regression analysis. Patients
with HbA1c value greater than 7.0% had significantly higher value of cholesterol, LDL-C, and
LDL-C/HDL-C ratio compared with patients with an HbA1c value up to 7.0%.
Conclusions: Apart from a reliable glycemic index, HbA1c can also be used as a predictor of
dyslipidemia and thus early diagnosis of dyslipidemia can be used as a preventive measure for
the development of CVD in patients with T2DM.
Correspondence to:
Keywords:  Afghanistan, cardiovascular diseases, diabetes mellitus, dyslipidemia, HbA1c, Iftikhar Ali
Department of Pharmacy,
serum lipids University of Swabi, 23430,
Khyber Pakhtunkhwa,
Pakistan
Received: 3 November 2016; accepted in revised form: 13 January 2017. Department of Pharmacy
Services, Northwest
General Hospital &
Research Center,
Peshawar 25100, Khyber
Introduction T2DM is a rapidly growing public health Pakhtunkhwa, Pakistan
iftikharalijan@gmail.com
Diabetes mellitus (DM) is a chronic metabolic problem worldwide, with a significant impact on
Arshad Hussain,
disorder that occurs as a result of a complex inter- health, quality of life and the healthcare system of Muhammad Ijaz,
action of genetic, environmental factors, and life- the countries. According to current statistics from Afaq Rahim
Department of Medicine &
style choices. Morbidity and mortality due to DM the International Diabetes Federation (IDF), 415 Allied, Northwest General
are increasing because of changes in behavior million adults have DM worldwide; this figure is Hospital & Research
Center, Peshawar 25100,
such as an unhealthy diet, physical inactivity, expected to reach the 642 million mark by 2040, Khyber Pakhtunkhwa,
being overweight, obesity and tobacco use.1,2 which means every 11th individual will be Pakistan

journals.sagepub.com/home/tae 51
Therapeutic Advances in Endocrinology and Metabolism 8(4)
diagnosed as having T2DM.3 The proportion of
people with T2DM is increasing in most coun-
tries.3 Nearly 80% of people with the disease live
in low- and middle-income countries.4
Pakistan and Afghanistan have been included in
the Middle East and North African region by the
IDF; this region is approximately 9.7% of the
total regional population, which means around
37 million people in the region are living with
T2DM.5
Due to the political instability in Afghanistan, very
limited data are available regarding the prevalence
of DM in the country, its complications and mor-
tality rates. The prevalence of DM in the adult
population after the world population adjustment
has been estimated to be 8.6% and 9.9% in 2010
and 2030 respectively.1,6
Annually, 5% of all deaths globally are related to
DM and its complications.7 DM was responsible
for 342,000 deaths in 2015 in this part of the
world.5 Over half (51.3%) of all deaths from DM
in the region occurred in people under 60 years of
age. These early deaths may be the result of a
combination of factors: the rapidly changing envi-
ronments and lifestyles in the region, late diagno-
ses, and healthcare systems that are not equipped
to provide optimal management of the increasing
numbers of people with DM.8
DM is a metabolic disorder that has a long-term
impact on different body systems, contributing to
the huge burden of morbidity associated with it.
Cardiovascular disease (CVD) is one group
among the spectrum of diseases; altered lipid
metabolism in DM contributes to atherosclero-
sis.9 This greatly increases the risk of CVD com-
pared with people without DM. The prevalence
of CVD is higher in people with T2DM and is
also the top killer in this population.4
DM is an independent risk factor for CVD and
it potentiates the effects of other common risk
factors such as smoking, hypertension and
dyslipidemia.10
HbA1c predicts the risk of developing diabetic
complications in patients with DM.7 Apart from
classical risk factors like dyslipidemia, elevated
HbA1c is an independent risk factor for CVD. It
is estimated that there is an 18% increased risk of
CVD for each 1% rise in absolute HbA1c levels in
52 journals.sagepub.com/home/tae
the diabetic population. This positive correlation
between HbA1c and CVD has been demon-
strated in nondiabetic cases, even within the nor-
mal range of HbA1c.7,11
The aim of this study was to assess the relationship
between glycemic control (HbA1c) and serum
lipid profile as well as to evaluate the importance of
HbA1c as an indicator of dyslipidemia in patients
with T2DM in an Afghani population.
Material and methods
Study design and location
A cross-sectional study was conducted from April
2015 to August 2015. Afghani patients with
T2DM visiting an outpatient department (dia-
betic clinic) in the Northwest General Hospital &
Research Center, Hayatabad Peshawar, Khyber
Pakhtunkhwa, Pakistan were included in the
study. This is a 220-bed tertiary care hospital, a
Venture of Alliance Healthcare (PVT) Ltd,
located in the historic city of Peshawar. Its catch-
ment area is all over the province of Khyber
Pakhtunkhwa and nearby border areas of
Afghanistan. The study protocol was approved by
the ethics committee of the Hospital. Informed
written consent was obtained from all the patients
after explaining the study objectives.
Patients and methods
Venous blood samples were collected from a total
of 401 Afghani patients with T2DM, of which
there were 175 men and 226 women. The serum
was used for analyzing fasting blood sugar (FBS),
total cholesterol (TC), high-density lipoprotein
cholesterol (HDL-C), triglycerides (TGs), and
low-density lipoprotein cholesterol (LDL-C)
using an auto analyzer (Roche/Hitachi 912/
Modular Analyzers: CAN 435, Germany).
HbA1c was estimated using an ARCHITECT
c4000 analyzer (Abbott Diagnostics, USA).
For the serum lipid reference level, the National
Cholesterol Education Program Adult Treatment
Panel III (NCEP ATP III) guideline was referred.
According to these guidelines, hypercholester-
olemia is defined as TC greater than 200 mg/dl,
high LDL-C when the value is over 100 mg/dl,
hypertriglyceridemia when TG is greater than
150 mg/dl and low HDL-C as a value less than 40
mg/dl. Dyslipidemia was defined as the presence
 A Hussain, I Ali et al.

Table 1.  Serum lipid profile parameter results for male and female patients with T2DM.

Parameters Male patients (n = 175) Female patients (n = 226) p value

  Mean SD Range Mean SD Range

Age (years) 51.71 11.70 22–92 50.97 10.23 17–81 0.49
FBS (mg/dl) 219.64 96.52 95–580 239.15 103.18 95–500 0.07
HbA1c (%) 9.79 2.66 5.50–16.80 9.94 2.36 5.50–16.50 0.53
Cholesterol (mg/dl) 204.08 54.46 88–365 208.04 52.96 96–321 0.46
TG (mg/dl) 266.03 156.72 51–1046 249.53 131.79 45–779 0.25
HDL-C (mg/dl) 39.68 14.25 13–98 41.75 13.08 18–98 0.13
LDL-C (mg/dl) 115.10 55.35 20–295 121.67 48.77 23–256 0.20
TC/HDL-C 5.64 2.21 1.70–15.38 5.40 2.03 1.59–15.45 0.27
FBS, fasting blood sugar; HbA1c, hemoglobin A1c; HDL-C, high-density lipoprotein cholesterol; LDL-C, low-density
lipoprotein cholesterol SD, standard deviation; T2DM, type 2 diabetes mellitus; TC, total cholesterol; TG, triglyceride.

of one or more abnormal serum lipid concentra-
tions.12 DM was defined as per American Diabetes
Association criteria.13
All patients were categorized into two groups
according to their HbA1c levels. The data were
evaluated via the SPSS statistical package version
16.0. Pearson’s correlation test was performed to
examine various correlations. Independent sam-
ple Student’s t test (two tailed) was used to com-
pare means of different parameters. All p values
less than 0.05 were considered statistically signifi-
cant. The value of HbA1c was given as a percent-
age of the total hemoglobin and values of all other
parameters were given in mg/dl. All values are
expressed as mean ± standard deviation (SD) or
standard error of the mean.
less than 40 mg/dl in 51.9% of the study sample.
Of the 401 patients, 48 (11.97%) had only one
abnormal lipid profile parameter, 44 (10.97%) had
two abnormal lipid parameters, and 208 (51.87%)
had more than two abnormal lipid profile param-
eters. According to the NCEP ATP III guideline,
118 of 226 women (52.21%) and 83 of 175 men
(47.42 %) were found to have dyslipidemia.
The mean value of FBS, HbA1c, TC, HDL-C
and LDL-C were slightly higher in female com-
pared with male patients, but the differences
were not statistically significant. Although the
mean levels of TC and the TC/HDL-C ratio
were slightly lower in women than in men, these
differences were statistically nonsignificant, as
shown in Table 1.

The age and FBS of patients did not show any

Results
A total of 401 Afghani patients with T2DM
(men, 175; Women; 226; mean age, 51.29 years)
were included in this study. The mean age ± SD
of male and female patients were 51.71 ± 11.70
and 50.97 ± 10.23 years respectively. The mean
± SD of FBS, HbA1c, TC, TG, HDL-C and
LDL-C were 230.54 ± 100.58, 9.84 ± 2.47, 206
± 53.51, 256 ± 143.2, 40.85 ± 13.62, and 118.81
± 51.78 respectively.
Hypercholesterolemia was found in 50.1% of
patients; similarly hypertriglyceridemia was found
in 74.8% of patients. Abnormal LDL-C levels
were found in 62.8% of patients and HDL-C was
significant correlation with HbA1c (r = 0.063, p
= 0.206; r = 0.098, p = 0.072 respectively).
There was a significant positive correlation
between HbA1c and TC (r = 0.257, p = 0.000).
HbA1c also demonstrated a significant correla-
tion with TG (r = 0.235, p = 0.000). The corre-
lation between HbA1c and HDL-C was negative
and was found to be statistically nonsignificant (r
= −0.024, p = 0.625). Furthermore, it was found
that HbA1c was positively and significantly
related to LDL-C (r = 0.153, p = 0.002) and
LDL-C/HDL-C ratio (r = 0.150, p = 0.003).
HbA1c was also found to be a predictor of hyper-
cholesterolemia (p = 0.000, R2 = 0.078), LDL-C
(p = 0.002, R2 = 0.002), and TG (p = 0.000,

journals.sagepub.com/home/tae 53
Therapeutic Advances in Endocrinology and Metabolism 8(4)

Figure 1.  Correlations between hemoglobin A1c, FBS and lipid profile panel. FBS, fasting blood sugar;
HDL, high-density lipoprotein; LDL, low-density lipoprotein; TC, total cholesterol; TG, triglyceride.

R2 = 0.055) validated by a linear regression
analysis as shown in Figure 1. However, HDL-C
(p = 0.625, R2 = 0.001) and FBS (p = 0.963,
R2 = 0.000) did not show any significant associa-
tion with HbA1c in the regression analysis.
Patients were divided into two groups as per
their glycemic index (HbA1c); the first group
consisted of patients with HbA1c values up to
7.0% and the second group consisted of patients
with HbA1c values greater than 7.0%. Patients
with HbA1c values greater than 7.0% had
significantly higher values of cholesterol
(p = 0.004), LDL-C (p = 0.002), LDL-C/
HDL-C ratio (p = 0.024), FBS (p = 0.64), TG
(p = 0.097), HDL-C (p = 0.334), and risk ratio
(p = 0.58), compared with the first group, as
shown in Table 2.

54 journals.sagepub.com/home/tae
 A Hussain, I Ali et al.

Table 2.  Biochemical parameters categorized by patient’s hemoglobin A1c.

Parameters HbA1c ⩽ 7.0(n = 66) HbA1c > 7.0 (n = 335) p value

  Mean SD Range SEM Mean Range SD SEM

Age (years) 49.39 13.18 17–81 1.62 51.67 19–92 10.36 0.57 0.12
FBS (mg/dl) 224.4 88.77 95–400 12.31 231.35 95–560 102.62 6.05 0.64
Cholesterol (mg/dl) 189.03 46.12 102–318 5.68 209.72 88–365 54.36 2.97 0.004*
TG (mg/dl) 229.97 144.04 69–654 17.73 262.00 45–1046 142.72 7.79 0.097
HDL-C (mg/dl) 39.36 15.25 13–93 1.85 41.14 18–98 13.34 0.73 0.334
LDL-C (mg/dl) 101.08 47.19 35–240 5.81 122.30 20–295 51.99 2.84 0.002*
TC/HDL- C (risk ratio) 5.37 2.32 1.59–15.38 0.29 5.53 1.65–15.45 2.07 0.11 0.58
LDL-C/HDL-C 2.76 1.23 0.39–4.70 0.15 3.21 0.33–9.90 1.53 0.08 0.024*
*Statistically significant.
FBS, fasting blood sugar; HbA1c, hemoglobin A1c; HDL-C, high-density lipoprotein cholesterol; LDL-C, low-density lipoprotein cholesterol SD,
standard deviation; SEM, standard error of the mean; TC, total cholesterol; TG, triglyceride.

Discussion In one Pakistani study by Firdous and colleagues,

The association of DM and CVD is well known
and this relationship has been much discussed over
the past few decades.14 Both lipid profile and DM
have been shown to be important predictors of
metabolic disturbances, including dyslipidemia,
hypertension, CVD, and hyperinsulinemia.15
People with T2DM have a higher cardiovascular
morbidity and mortality, and are disproportion-
ately affected by CVD compared with subjects
without DM. Early detection and treatment of
dyslipidemia associated with DM may be one
step in reducing the CVD risk.16
In our study, the correlation of HbA1c and lipid
profile in T2DM was evaluated. Interestingly,
52.21% of women and 47.42% of men were found
to have dyslipidemia according to the NCEP ATP
III guideline. These findings are consistent with
some previous studies.7,12,13,17 Hyperlipidemia in
women may be attributed to the effects of sex hor-
mones on body fat distribution, which leads to dif-
ferences in changed lipoproteins.18
We observed that the correlation between HbA1c
and HDL-C was negative, however there was a
positive, significant correlation between HbA1c
and TC, LDL-C, and TGs. Various studies have
described this before.7,19–21
A rather interesting finding was that HbA1c was
found to be a predictor of hypercholesterolemia
by linear regression analysis.
38% of people with DM were found to have high
TG levels. In our study, women with DM were
found to have slightly higher LDL levels com-
pared with men, which is consistent with previous
studies.7,12,22
It is suggested that insulin resistance has a cen-
tral role in the development of diabetic dyslipi-
demia. One of the causes is increased free fatty
acid release from insulin-resistant fat cells.23
If the glycogen stores are adequate, these free
fatty acids promote TG production which
further stimulates Apolipoprotein (Apo-B) and
very low density lipoprotein.24
According to the Diabetes Complications and
Control Trial, HbA1c is the gold standard of gly-
cemic control.25 Various studies have shown an
HbA1c of up to 7.0% may reduce the risk of car-
diovascular complications.7,11
In our study, we divided patients into two groups
as per the HbA1c values. Those with HbA1c
greater than 7.0% exhibited a significant increase
in TC, LDL-C, TG, and LDL-C/HDL-C ratio
compared with those with HbA1c up to 7.0%.
Improving glycemic control may substantially
reduce the risk of cardiovascular events. It has
been projected that a decrease in the HbA1c value
by 0.2% could lower the mortality by 10%.26
The results of our study suggest the importance
of glycemic control in managing dyslipidemia and

journals.sagepub.com/home/tae 55
Therapeutic Advances in Endocrinology and Metabolism 8(4)
further reducing the risk for CVD in patients with
T2DM, as shown by the significant association of
HbA1c with various lipid parameters.
Data from the Afghani population are lacking due
to political unrest in the form of war and a paucity
of structured health care. At the Northwest
General Hospital & Research Center, Peshawar
we treat some of the patients from across the bor-
der. We hope that by doing this study the world
will get some insight into the diabetic status of the
Afghani population.
Conclusion
In our study we have seen a significant correlation
between HbA1c and various circulating lipid
parameters. We noted a significant difference in
lipid parameters in two groups (⩽7.0% and
>7.0%) of HBA1c. This may indicate that
HbA1c can be used as a potential biomarker for
predicting dyslipidemia in patients with T2DM
in addition to glycemic control. Hence, early
diagnosis can be accomplished through relatively
inexpensive blood testing and may be utilized for
screening high-risk patients with DM for timely
intervention with lipid-lowering drugs.
Acknowledgements
We are thankful to Northwest General Hospital &
Research Centre, Peshawar, Pakistan for provid-
ing ethical approval of data collection and pub-
lishing this article. We would also like to thank
Waheed Iqbal and Muhammad Nasir from the
Department of Pharmacy Services for data entry
and cleaning.
Authors Contribution
Substantial contributions to the conception or
design of the work, or the acquisition, analysis, or
interpretation of data for the work: Iftikhar Ali,
Arshad Hussain, Muhammad Ijaz; drafting the
work and revising it critically for important intel-
lectual content: Arshad Hussain, Iftikhar Ali,
Muhammad Ijaz, Afaq Rahim; final approval of
the version to be published: Arshad Hussain,
Iftikhar Ali, Afaq Rahim. This article has not
been presented or published in any conference/
journal.
Funding
This research received no specific grant from any
funding agency in the public, commercial, or not-
for-profit sectors.
56 journals.sagepub.com/home/tae
Conflict of interest statement
The authors declare that there is no conflict of
interest.
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