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Prevalence of Prediabetes and Abdominal Obesity Among Healthy-Weight Adults: 18-Year Trend

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Prevalence of Prediabetes and Abdominal Obesity Among Healthy-Weight Adults: 18-Year Trend Prevalence of Prediabetes and Abdominal Obesity Among Healthy-Weight Adults: 18-Year Trend 1,2 Arch G. Mainous III, PhD ABSTRACT 1 Rebecca J. Tanner, MA PURPOSE Trends in sedentary lifestyle may have influenced adult body composi- Ara Jo, MS1 tion and metabolic health among individuals at presumably healthy weights. This study examines the nationally representative prevalence of prediabetes and 3 Stephen D. Anton, PhD abdominal obesity among healthy-weight adults in 1988 through 2012. 1Department of Health Services Research, METHODS We analyzed the National Health and Nutrition Examination Survey Management, and Policy, University of Florida, Gainesville, Florida (NHANES) III (1988-1994) and NHANES for the years 1999 to 2012, focusing on adults aged 20 years and older who have a body mass index (BMI) of 18.5 to 2 Department of Community Health and 24.99 and do not have diabetes, either diagnosed or undiagnosed. We defined Family Medicine, University of Florida, prediabetes using glycated hemoglobin (HbA ) level ranges from 5.7% to 6.4%, Gainesville, Florida 1c as specified by the American Diabetes Association. Abdominal obesity was mea- 3Department of Aging and Geriatric sured by waist circumference and waist-to-height ratio. Research, University of Florida, Gainesville, Florida RESULTS The prevalence of prediabetes among healthy-weight adults, aged 20 years and older and without diagnosed or undiagnosed diabetes, increased from 10.2% in 1988-1994 to 18.5% in 2012. Among individuals aged 45 years and older, the prevalence of prediabetes increased from 22.0% to 33.1%. The per- centage of adults aged 20 years and older with an unhealthy waist circumference increased from 5.6% in 1988-1994 to 7.6% in 2012. The percentage of individu- als with an unhealthy waist-to-height ratio increased from 27.2% in 1988-1994 to 33.7% in 2012. Adjusted models found that measures of abdominal obesity were not independent predictors of prediabetes among adults with a healthy BMI. CONCLUSIONS Among individuals within a healthy BMI range, the prevalence of prediabetes and abdominal obesity has substantially increased. Abdominal obe- sity does not appear to be the primary cause of the increase. Ann Fam Med 2016;14:304-310. doi: 10.1370/afm.1946. INTRODUCTION rediabetes is a high-risk state for the development of diabetes and its associated complications.1-3 Recent data have shown that in devel- Poped countries, such as the Unites States and the United Kingdom, more than one-third of adults have prediabetes, but most of these indi- viduals are unaware they have the condition.4-6 Once detected, prediabe- tes needs to be acknowledged with a treatment plan to prevent or slow the transition to diabetes.7,8 Treatment of prediabetes is associated with delay of the onset of diabetes.9 Detection and treatment of prediabetes is therefore a fundamental strategy in diabetes prevention.1 Moreover, pre- diabetes-aware adults are more likely than those with prediabetes who are Conflicts of interest: authors report none. unaware of their condition to engage in diabetes risk-reducing behaviors.10 Historical trends in the United States have indicated a substantial rise CORRESPONDING AUTHOR in sedentary lifestyle among adults in recent years.11 Comparing findings Arch G. Mainous III, PhD from the National Health and Nutrition Examination Survey (NHANES) Department of Health Services Research, 1988-1994 with NHANES 2009-2010, the proportion of adults who Management and Policy reported no leisure-time physical activity increased from 19.1% to 51.7%. Health Sciences Center, PO Box 100195 University of Florida Although these leisure-time activity findings have been criticized as a Gainesville, FL 32610 USA result of methodological changes in the NHANES, findings from other [email protected] national surveys have shown decreasing trends in leisure-time physi- ANNALS OF FAMILY MEDICINE ✦ WWW.ANNFAMMED.ORG ✦ VOL. 14, NO. 4 ✦ JULY/AUGUST 2016 304 PREVALENCE OF PREDIABETES cal activity from the 1990s into the 2000s.12,13 As Normoglycemia and Prediabetes trends in sedentary lifestyle increased, so did trends Individuals participating in the NHANES undergo a in the prevalence of obesity.11 In addition to the rise physical examination that includes laboratory analysis in obesity, this population-level increase in sedentary of blood. We defined normoglycemia as an HbA1c level lifestyle may have influenced adult body composition between 4.0% and 5.6% (20-38 mmol/mol). To control and metabolic health among individuals at presumably for any potential effect of low HbA1c levels, we also healthy weights. removed individuals with an HbA1c level of less than Current recommendations for prediabetes screen- 4.0% (20 mmol/mol), a level associated with increased ing by the American Diabetes Association focus nearly all-cause mortality in adults without diabetes.15 exclusively on adults who are overweight or obese as We defined prediabetes among individuals without defined by body mass index (BMI; kg/m2) until the previously diagnosed or undiagnosed diabetes using 1 patient meets the age-oriented screening at 45 years. HbA1c level ranges as specified by the American Dia- Further, the recently released recommendation from the betes Association, 5.7% to 6.4% (39-46 mmol/mol).1 US Preventive Services Task Force regarding screening This range has been shown in a meta-analysis to be for abnormal glucose levels and type 2 diabetes limits predictive of progression to diabetes.16 We excluded screening to individuals who are overweight or obese.14 individuals with previously diagnosed diabetes because This focus on obese or overweight individuals, how- the current glycemic status of those patients may sim- ever, may lead to missed opportunities for investigation ply represent diabetes control. of undetected disease in healthy-weight individuals. Although obesity and prediabetes have shown Abdominal Obesity trends of increasing prevalence, it is unclear whether Abdominal obesity was measured by waist circumfer- prediabetes has also increased among healthy-weight ence and waist-to-height ratio. Waist circumference adults. Moreover, it is unclear whether abdominal obe- measured a horizontal line just above the uppermost sity has increased among healthy-weight adults. Thus, lateral border of the right ilium for participants the purpose of this study was to examine the nationally at standing position by using measuring tape. An representative prevalence of prediabetes and abdomi- unhealthy waist circumference was defined as a waist nal obesity among healthy-weight adults reported in circumference of greater than 102 cm for men and the 1988-1994 and 1999-2012 NHANES findings. greater than 88 cm for women. These measures are consistent with the levels for characterizing metabolic syndrome. An unhealthy waist-to-height ratio was METHODS defined as .53 or greater in men and .49 and greater in We analyzed the NHANES III and NHANES data for women, levels that are indicative of increased cardio- the years 1999-2012. NHANES III was conducted in metabolic health risk.17-19 1988-1994. The NHANES is a large, nationally rep- resentative survey that samples the noninstitutional- First-Degree Relative With Diabetes ized population of the United States using a stratified In NHANES III, respondents were asked whether multistage probability sample design. The application any of their living or deceased blood relatives (includ- of weights and variables accounting for the complex ing grandparents, parents, brothers, and sisters) were survey design allows the study to provide nationally ever told by a physician that they had diabetes. In representative population estimates for the United NHANES 1999-2012, respondents were asked whether States. The current study focused on adults aged 20 any close biological or blood relatives (including father, years and older who have a BMI of 18.5 to 24.99, mother, sisters, or brothers) were ever told by a health the range considered healthy, and who have not had professional that they had diabetes. diabetes diagnosed or a glycated hemoglobin (HbA1c) level of 6.5% or greater. This study was approved by Demographic Characteristics the Institutional Review Board at the University of Age was self-reported and categorized as 20 to 44 Florida as exempt. years, 45 to 64 years, and 65 years and older. Sex was self-reported. Race was self-reported and is categorized Previously Diagnosed Diabetes as non-Hispanic white, non-Hispanic black, Mexican Individuals were considered to have diabetes if they American, and other. Education was categorized as less reported ever being told by a health care provider that than high school (<12 years of education), high school they had diabetes, excluding gestational diabetes. We (12 years of education), and some college/degree (>12 also removed individuals with an HbA1c of 6.5% or years of education). Poverty-to-income ratio is based greater to account for undiagnosed diabetes. on self-report and categorized as less than 1.0 (pov- ANNALS OF FAMILY MEDICINE ✦ WWW.ANNFAMMED.ORG ✦ VOL. 14, NO. 4 ✦ JULY/AUGUST 2016 ANNALS OF FAMILY MEDICINE ✦ WWW.ANNFAMMED.ORG ✦ VOL. 14, NO. 4 ✦ JULY/AUGUST 2016 304 305 PREVALENCE OF PREDIABETES erty) and 1.0 or greater (not in poverty).20 Health ratio for all adults, as well as for adults aged 45 years insurance status was self-reported and categorized as and older. Time is modeled as a continuous variable. private, public, and none. t Tests were used to calculate the mean difference in BMI, waist circumference, and waist-to-height ratio Analysis between individuals with and without prediabetes for The NHANES uses a stratified multistage probability 2011-2012 data. Forced inclusion logistic regressions design. To account for the complex sample design of were conducted using 2011-2012 data to assess the the NHANES, SAS 9.4 (SAS Institute, Cary, NC) and impact of waist circumference and waist-to-height ratio SUDAAN 11.0.1 (RTI International, Research Triangle on prediabetes.
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