Original Article

Evaluation of HbA1C and serum levels of vitamin D in

Ilam University of Medical Sciences, 3Medical Student, Ilam University of Medical Sciences, Ilam, 4Department of Pathology,
Clinical Research Development Center, Shahid Modarres Hospital, Shahid Beheshti University of Medical Science,
Tehran, Iran

A bstract
Background: Diabetes mellitus is the most common metabolic disease around the world. The present study aims at studying
hemoglobin A1C (HbA1C) and vitamin D serum levels in diabetic patients. Materials and Methods: A descriptive study was conducted
on 102 diabetic patients presenting to the diabetic clinic of a tertiary care hospital in West of Iran in 2016 (Shahid Mostafa Khomeini
Hospital of Ilam city). The data collected were inserted into the SPSS‑20 software, and it was then analyzed by using the relevant
statistical tests. For describing the quantitative variables, mean and standard deviation were used. Moreover, for describing the
qualitative variables, number and percentage were applied. The mean serum levels of HbA1C and vitamin D were compared for
different variables using the Chi‑square and ANOVA. Results: There is a positive and statistically significant relationship between the
HbA1C and fasting blood sugar (FBS). Moreover, there is a statistically significant relationship between the serum level of vitamin D
with smoking and body mass index (BMI). There is also an inverse linear relationship between vitamin D with HbA1C, FBS, BMI, and
disease duration. The relationship between HbA1C with FBS and disease duration is a linear direct one. Their relationship between
HbA1C and BMI is an inverse linear one, yet not significant. Conclusion: Given the role of this vitamin in secretion and the effect
of insulin, it seems useful to monitor the serum level of vitamin D in a diabetic patient and prescribe its supplements if necessary.

Keywords: Diabetic patients, hemoglobin A1C, Ilam, serum levels of vitamin D

Introduction in the world; 20–25% of the population suffers from the lack of
vitamin D in USA, Canada, Europe, Mexico, Asia, and Australia.[8]
Diabetes mellitus is the most common metabolic disease in the Surprisingly, the lack of vitamin D in the Persian Gulf countries
world. More than 150 million people suffer from this disease is highly prevalent, though there is enough sunshine. The
in the world, and it is predicted that this number will rise to prevalence of vitamin D (serum level of vitamin D) deficiency
300 million in 2025.[1] Iran is facing an increasing prevalence of is higher among female adolescents and young adults in Iran
diabetes, and its prevalence is currently 7% in Iran.[2] Vitamin D and >80% in Saudi Arabia.[9]
is an indispensable part of nutrition. In comparison to the other
vitamins, vitamin D has unique metabolic and physiological The lack of vitamin D and type 2 diabetes have similar risk
effects.[3–7] The shortage of vitamin D is epidemically prevalent factors including race, obesity, high age, place of residence, and
lack of physical activity. In a number of studies, it has been
Address for correspondence: Dr. Mohammad Reza Hafezi Ahmadi, observed that 25‑hydroxyvitamin D serum level is significantly
Biotechnology and Medical Plants Research Center, lower in diabetic patients than healthy individuals.[10-12] Vitamin D
Ilam University of Medical Sciences, Ilam, Iran.
E‑mail: [email protected]
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DOI: How to cite this article: Ghavam S, Ahmadi MR, Panah AD,
10.4103/jfmpc.jfmpc_73_18 Kazeminezhad B. Evaluation of HbA1C and serum levels of vitamin D in
diabetic patients. J Family Med Prim Care 2018;7:1314-8.

© 2018 Journal of Family Medicine and Primary Care | Published by Wolters Kluwer ‑ Medknow 1314
 Ghavam, et al.: HbA1C and serum levels of vitamin D

affects the production and secretion of insulin as well as insulin HbA1C and vitamin D serum levels and determining the serum
sensitivity.[13] Vitamin D is also likely to affect reduced risk[14-17] level of vitamin D in diabetic patients. Moreover, the patients’
and control type 2 diabetes.[11,14] Given the increasing prevalence demographic variables [age, gender, smoking, place of residence,
of type 2 diabetes and shortage of vitamin D, it is important to body mass index (BMI), diabetes duration, glycated hemoglobin,
study this relationship. For this reason, various studies have been fasting glucose level, and vitamin D] were determined.
conducted all over the world on this issue.
Materials and Methods
For the incidence of type 2 diabetes, there is an increased
performance of pancreatic beta cells, resistance to insulin, and The present study is a cross‑sectional descriptive one conducted
systemic inflammation. There is evidence indicating the effects of on the diabetic patients being referred to the internal clinic of
vitamin D on the abovementioned complications.[18] Vitamin D is a tertiary care hospital in Ilam. The patient’s demographic and
likely to indirectly affect insulin secretion and insulin sensitivity anthropometric information were recorded by using individual
through beta cells and environmental tissues that are the targets questionnaires. Sampling was conducted in the fasting state
of insulin. The immunomodulatory features of vitamin D in from 8 to 10 in the morning and before taking glucose‑lowering
relation to T cells activity is effective for some immune processes drugs and the serum level of vitamin D was measured by using
leading to type 1 diabetes.[19] the enzyme‑linked immunosorbent assay (ELISA) method
and applying the kit. Given the prevalence of >70%, lack of
Different studies have indicated the relationship between the vitamin D of 81 individuals was measured in diabetic patients
lack of vitamin D and concentration changes of blood glucose with the sample size error rate of 0.1. For increasing the statistical
and insulin and the sensitivity of tissues targeted for insulin.[20,21] power of the research, 102 patients were studied.
Moreover, the lack of vitamin D in patients suffering from
type 2 diabetes is likely to cause a metabolic syndrome and the Sample size was selected randomly after implementing the
replacement of vitamin D can reduce resistance to insulin.[22] inclusion and exclusion criteria. Inclusion criteria are as
Some of the studies have confirmed that vitamin D plays a key follows: diagnosed type 2 diabetes for >1 year; lack of drinking
role in insulin secretion and performance disorder.[23] A number alcohol; lack of treatment with insulin; lack of menopause or
of cross‑sectional studies have indicated the coincidence of pregnancy (for female participants); lack of taking intervention
vitamin D status and the prevalence of impaired glucose drugs or vitamin D (corticosteroids, anticonvulsants, and
tolerance (IGT) or diabetes. Two studies conducted by Kohert contraceptives); lack of history of angina, myocardial infraction,
in America and a study conducted in Finland have reported stroke, kidney or liver diseases, chronic inflammatory diseases,
the coincidence of vitamin D status and the risk of suffering and thyroid diseases during the recent year; lack of treatment
from type 2 diabetes.[24,25] In women’s health study, receiving with thiazolidinedione drugs; and lack of smoking of all kinds.
511 units of vitamin D, in comparison to 159 units, is likely The exclusion criteria are suffering from diagnosed liver or
to result in a reduced risk of suffering from type 2 diabetes. kidney diseases, having a creatinine of >2 mg/dl, malabsorption,
However, this analysis has not been modified for any other infertility, oligomenorrhea, pregnancy, breastfeeding, diagnosed
intervention factors other than age.[24] There is a significant malignancy, taking drugs affecting bone metabolism, drinking
statistical coincidence between high serum levels of vitamin D alcohol, inactivity for >1 week, taking calcium supplement in
and low incidence of diabetes in Finnish men.[25] Another study the last 2 weeks, taking vitamin D pills in the last 3 months,
conducted in New Zealand indicated that patients with type 2 injection of vitamin D in the last 6 month, obesity (BMI >40 kg/
diabetes and IGT had a lower level of vitamin D in comparison m2), severe complications of diabetes in patients suffering
to the control group.[26] There is a hypothesis indicating that there from diabetes (nephropathy, retinopathy, and so on), and
is a positive relationship between 25‑hydroxyvitamin D serum HbA1C >11%.
level and obesity. Given the effect of vitamin D on increased
lipogenesis and lipolysis control in the in vitro studies conducted, After recording the demographic and anthropometric
some researchers have reported this relationship as positive.[27] characteristics, measuring the blood pressure, and after 12 h
However, other studies conducted in this regard indicated the fasting, the qualified participants were referred to the laboratory,
negative effect.[28,29] and 10 ml of blood was taken from them. The analysis of blood
samples for measuring fasting blood sugar (FBS) was conducted
Given the contradictory findings of the existing studies, it seems by the Hitachi 917 auto analyzer. For measuring blood lipids
necessary to conduct further studies with different statistical profile Hitachi 917 machine was used by a photometric method.
populations; if it is proved that lack of vitamin D has a major 25‑hydroxyvitamin D serum level was measured by using the
role in the incidence of type 2 diabetes, the compensation of this chemiluminescence method using LIAISON machine and it was
lack will constitute the main part of the treatment for diabetic then analyzed in the DIaSorin30 kit, and 30–100 ng/mL was
patients. Thus, given the importance of the issue, variety in the determined as the natural amount. Moreover, 20 < vit D (OH)
research findings, difference in climatic conditions, the dietary <25 ng/mL was determined as vitamin D deficiency, 25 < vit D
regime of people in different areas, and the lack of conducting a <30 ng/mL was determined as inadequacy of vitamin D, and
similar study in Ilam, the present research was conducted to study vit D >30 ng/mL was defined as adequacy of vitamin D.[30]

Journal of Family Medicine and Primary Care 1315 Volume 7 : Issue 6 : November-December 2018
 Ghavam, et al.: HbA1C and serum levels of vitamin D

The data collected from the patients were inserted into the SPSS‑20 Discussion and Conclusion
and it was then analyzed by using relevant statistical tests. For
describing the quantitative variables, mean and standard deviation Based on the findings, the serum level of vitamin D was low in
were used. Moreover, for describing the qualitative variables, number diabetic individuals, and in these patients, there was no significant
and percentage were applied. The mean serum levels of HbA1C and relationship between serum level of vitamin D with diabetes
vitamin D were compared for different variables using the Chi‑square duration and HbA1C.
and analysis of variance (ANOVA). Glycated hemoglobin (HbA1C)
was used as the gold standard of blood glucose control and a The findings of this study indicated an inverse linear relationship
criterion for estimating the intensity of its complications. between vitamin D with HbA1C (P < 0.37), FBS, (P < 0.64),
BMI (P < 0.59), and disease duration (P < 0.1). There was
Findings also a direct linear relationship between HbA1C with FBS and
disease duration (P < 0.000 and P < 0.000) and an inverse linear
Frequency distribution of demographic variables and the means relationship between HbA1C and BMI (P < 0.41). Given the role
of quantitative variables are shown in Tables 1 and 2. of this vitamin in secretion and the effect of insulin, it seems
useful to monitor the serum level of vitamin D diabetic patients
The findings indicate a positive significant relationship between and prescribe its supplements if necessary.
HbA1C and FBS [Table 3].
In the present study, 53.9% of the patients suffered from
The findings indicate that there is a significant relationship between vitamin D deficiency, and this is more or less similar to the findings
the serum level of vitamin D with smoking and BMI [Table 4]. of the study conducted by Taheri et al.; vitamin D deficiency plays
an important role in the pathogenesis of type 2 diabetes.
Pearson correlation coefficient test indicates that there is an
inverse linear relationship between vitamin D with HbA1C,
Table 3: Mean and standard deviation of HbA1C in
FBS, BMI, and disease duration. Moreover, Pearson correlation
patients studied according to different variables
coefficient indicates that the relationship between HbA1C with
Variables n Mean±SD P
FBS and disease duration was a linear direct one. The relationship
Smoking Yes 24 1.95±7.39 0.74
between HbA1C and BMI was an inverse linear one and it was
No 78 1.91±7.28
not significant [Table 5].
Age <30 11 1.36±6.47 0.18
30‑60 66 1.86±7.29
Table 1: Frequency distribution of demographic variables >60 25 2.17±7.73
in the patients studied Gender Male 28 2.06±7.14 0.58
Demographic variables Frequency Percentage Female 74 86.1±37.7
Age <30 11 10.8 FBS <70 1 10.3 0.000
30‑60 66 64.7 70‑115 46 1.9±8.45
>60 25 24.5 >115 55 1.22±6.3
Gender Male 28 27.5 BMI <20 37 2.33±7.67 0.35
Female 74 72.5 20‑25 48 1.64±7.1
Smoking Yes 24 23.5 >25 17 1.56±7.11
No 78 76.5
BMI <20 37 36.3
20‑25 48 47 Table 4: Mean and standard deviation of the serum level
>25 17 16.7 of vitamin D in patients studied according to different
Place of residence City 88 86.3 variables
Village 14 13.7 Variables n Mean±SD P
Smoking Yes 24 10.79±20.27 0.04
No 78 8.15±21.44
Table 2: The mean of quantitative variables in patients Age <30 11 8.04±20.78 0.93
studied 30‑60 66 9.2±21.41
Variable n Mean±SD Min Max >60 25 8.33±20.68
Age 102 15.38±48.95 19 82 Gender Male 28 10.82±22.79 0.25
Disease duration 102 1.91±3.58 1 9 Female 74 7.9±20.55
Weight 102 9.55±71.43 50 95 FBS <70 1 15.3 0.78
Height 102 8.2±167.14 141 190 70‑115 46 8.92±21.04
FBS 102 64.15±139.48 59.3 433 >115 55 8.82±21.37
A1C 102 1.91±7.31 5.1 13.4 BMI <20 37 8.88±23.36 0.003
D3 102 8.77±19.75 1.3 46.1 20‑25 48 6.68±20.08
BMI 102 3.11±21.47 16.98 30.34 >25 17 10.12±15.89

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 Ghavam, et al.: HbA1C and serum levels of vitamin D

Table 5: The correlation coefficient between serum level of vitamin D and HbA1C with the indices studied
Age Vitamin D HbA1C FBS BMI Disease duration
Age Pearson 1 0.038 0.221 0.315 0.102 0.080
P 0.7 0.02 0.001 0.3 0.42
Vitamin D Pearson 0.038 1 −0.088 −0.047 −0.187 −0.164
P 0.703 0.378 0.643 0.059 0.1
HbA1C Pearson 0.221 −0.088 1 0.670 −0.082 **0.693
P 0.02 0.378 0.000 0.411 0.000
FBS Pearson 0.315 −0.047 0.670 1 −0.144 **0.401
P 0.001 0.643 0.000 0.149 0.000
BMI Pearson 0.102 −0.187 −0.082 −144.0 1 0.017
P 0.309 0.059 0.411 149.0 0.869
Disease duration Pearson 0.080 −0.164 0.693 0.401 0.017 1
P 0.424 0.1 0.000 0.000 0.869

The findings of the study conducted by Hidayat et al. on elderly In the present study, no significant relationship was observed
people suffering from type 2 diabetes in Indonesia revealed between serum level of vitamin D and HbA1C. However, in the
that the serum level of vitamin D is higher in men than that of study conducted by Danaei et al. (2014), a significant negative
women, and this difference is significant.[31] relationship has been reported between serum level of vitamin D
and HbA1C.[37]
The findings of the present study are similar to those of the
study conducted by Bonakdaran and Varasteh; the serum level of According to the present study as well as other studies
vitamin D reduces as the BMI increases, and there is a significant conducted in this regard, since vitamin D necessary for
statistical relationship between serum level of vitamin D and human body is supplied through receiving foods, vitamin D
BMI.[32] supplements, and sunshine, and given the high prevalence of
vitamin D deficiency in diabetic patients, it is recommended
Pearson’s correlation coefficient test indicated an inverse linear to adopt special measures to compensate the deficiency of this
relationship between vitamin D with HbA1C (P < 0.37), FBS (0.64), vitamin in diabetic patients.
BMI (P < 0.59), and disease duration (P < 0.1); the relationship
was not statistically significant. Moreover, Pearson’s correlation Ethical considerations
coefficient indicated that there was a direct linear relationship The present study was conducted after acquiring the necessary
between HbA1C with FBS and disease duration, and the relationship permit from the University Ethics Committee as well as letter
was statistically significant (P < 0.000 and P < 0.000, respectively). of consent from the patients participated.
However, the relationship between HbA1C and BMI was an inverse
linear one, and the relationship was not significant (P < 0.41). Financial support and sponsorship
Nil.
In the present study, there was an inverse relationship between
BMI and HbA1C. However, it was not statistically significant. Conflicts of interest
There was a direct and an indirect significant relationship between There are no conflicts of interest.
diabetes and HbA1C.
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