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Secular Changes in U.S. Prediabetes Prevalence Defined by Hemoglobin

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Secular Changes in U.S. Prediabetes Prevalence Defined by Hemoglobin Epidemiology/Health Services Research ORIGINAL ARTICLE Secular Changes in U.S. Prediabetes fi Prevalence De ned by Hemoglobin A1c and Fasting Plasma Glucose National Health and Nutrition Examination Surveys, 1999–2010 1 1 KAI MCKEEVER BULLARD, PHD LINDA S. GEISS, MA 199 mg/dL (impaired glucose tolerance 1 1 SHARON H. SAYDAH, PHD YILING J. CHENG, PHD 1 1 [IGT]), or hemoglobin A1c (A1C) 5.7 to GIUSEPPINA IMPERATORE, MD, PHD DEBORAH B. ROLKA, MS , , 2 1 6.5% (39 to 48 mmol/mol) (2). In CATHERINE C. COWIE, PHD DESMOND E. WILLIAMS, MD, PHD 1 1 2010, 79 million U.S. adults had predia- EDWARD W. GREGG, PHD CARL J. CASPERSEN, PHD, MPH betesbasedonIFGorelevatedA1Ccrite- ria (1). Fortunately, the Diabetes Prevention Program of the National Institutes of OBJECTIVEdUsing a nationally representative sample of the civilian noninstitutionalized U.S. population, we estimated prediabetes prevalence and its changes during 1999–2010. Health and other studies have shown that among adults with elevated glucose RESEARCH DESIGN AND METHODSdData were from 19,182 nonpregnant individ- levels, type 2 diabetes can be delayed or uals aged $12 years who participated in the 1999–2010 National Health and Nutrition Exam- prevented (3–6). Further, recent studies fi , , ination Surveys. We de ned prediabetes as hemoglobin A1c 5.7 to 6.5% (39 to 48 mmol/mol, have shown that effective lifestyle-based , A1C5.7) or fasting plasma glucose (FPG) 100 to 126 mg/dL (impaired fasting glucose [IFG]). interventions can be successfully imple- We estimated the prevalence of prediabetes, A1C5.7, and IFG for 1999–2002, 2003–2006, and – mented in community-based settings 2007 2010. We calculated estimates age-standardized to the 2000 U.S. census population and (7–9), potentially reaching disparate pop- used logistic regression to compute estimates adjusted for age, sex, race/ethnicity, poverty-to- – income ratio, and BMI. Participants with self-reported diabetes, A1C $6.5% ($48 mmol/mol), ulations (10 13). As the public health or FPG $126 mg/dL were included. community seeks to address the urgent problem of diabetes prevention with RESULTSdAmong those aged $12 years, age-adjusted prediabetes prevalence increased from broadimplementationofprovenmea- 27.4% (95% CI 25.1–29.7) in 1999–2002 to 34.1% (32.5–35.8) in 2007–2010. Among adults sures, there is a strong need for reliable $ – – aged 18 years, the prevalence increased from 29.2% (26.8 31.8) to 36.2% (34.5 38.0). As surveillance data to identify, measure, single measures among individuals aged $12 years, A1C5.7 prevalence increased from 9.5% – – and characterize populations who could (8.4 10.8) to 17.8% (16.6 19.0), a relative increase of 87%, whereas IFG remained stable. These fi prevalence changes were similar among the total population, across subgroups, and after con- bene t from such interventions and help trolling for covariates. assess the effectiveness of prevention efforts. CONCLUSIONSdDuring 1999–2010, U.S. prediabetes prevalence increased because of Prediabetes prevalence estimates vary increases in A1C5.7. Continuous monitoring of prediabetes is needed to identify, quantify, according to the type and combination of and characterize the population of high-risk individuals targeted for ongoing diabetes primary glycemic tests in use, the demographic prevention efforts. characteristics of the population being measured, and other factors (14). Al- though increases in diagnosed and total diabetes in the U.S. are well documented, iabetesisamajorpublichealth convened by the America Diabetes Asso- no increases in the prevalence of predia- fi Dproblem in the U.S., affecting 25.8 ciation de ned prediabetes as a fasting betes have been detected (15). However, million people in 2011 (1). In plasma glucose (FPG) level of 100 to there have been several changes in the addition, a condition known as prediabe- 125 mg/dL (impaired fasting glucose measurement of prediabetes since 2003, tes is associated with an increased risk of [IFG]), a 2-h plasma glucose level after a including changes in FPG criteria from developing diabetes. An expert committee 75-g oral glucose tolerance test of 140 to 110 to 100 mg/dL and the introduction ccccccccccccccccccccccccccccccccccccccccccccccccc of A1C prediabetes cut points (16,17). 1 Changes have also occurred in the demo- From the Division of Diabetes Translation, Centers for Disease Control and Prevention, Atlanta, Georgia; and the 2National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Be- graphic distribution of the U.S. popula- thesda, Maryland. tion (18). To examine whether these Corresponding author: Kai McKeever Bullard, [email protected]. changes may have been accompanied by Received 9 December 2012 and accepted 25 February 2013. corresponding changes in the prevalence DOI: 10.2337/dc12-2563 This article contains Supplementary Data online at http://care.diabetesjournals.org/lookup/suppl/doi:10 of prediabetes, we estimated the preva- .2337/dc12-2563/-/DC1. lence of prediabetes in the U.S. for three The findings and conclusions in this report are those of the authors and do not necessarily represent the official time periods: 1999–2002, 2003–2006, position of the Centers for Disease Control and Prevention or the National Institute of Diabetes and Di- and 2007–2010. We compared preva- gestive and Kidney Diseases. © 2013 by the American Diabetes Association. Readers may use this article as long as the work is properly lence estimates obtained using two differ- cited, the use is educational and not for profit, and the work is not altered. See http://creativecommons.org/ ent measures of glycemic statusdalone licenses/by-nc-nd/3.0/ for details. and combineddand obtained estimates care.diabetesjournals.org DIABETES CARE 1 Diabetes Care Publish Ahead of Print, published online April 19, 2013 Prediabetes prevalence in the U.S. for a range of subpopulations defined by Measures sex, race/ethnicity (non-Hispanic white, sociodemographic and obesity status. The A1C assays used high-performance non-Hispanic black, Mexican American, liquid chromatography (HPLC) methods other race/ethnicity), and poverty-to- RESEARCH DESIGN AND performed on instruments certified by the income ratio (PIR; ratio of family income METHODS National Glycohemoglobin Standardiza- to federal poverty thresholds, specificto tion Program (19). Final reportable A1C family size, year, and state). Data source and population results were standardized to the reference We used data from the 1999–2010 National method used for the Diabetes Control and Statistical analysis Health and Nutrition Examination Surveys Complications Trial (22). During 1999– We imputed missing data for PIR (n = (NHANES), a repeated cross-sectional 2010, three types of changes occurred in 1,544) and BMI (n = 376) using the survey representative of the civilian, non- the A1C measurement methods used in PROC MI procedure in SAS 9.2 software institutionalized U.S. population, conduc- NHANES: 1) two instrument changes (SAS Institute, Inc., Cary, NC). All depen- ted by the National Center for Health (Primus I, Model CLC330 [1999–2004] dent, independent, and design variables Statistics (NCHS) (19–21) of the Centers to Tosoh A1C 2.2 Plus [2005–2006] to were included in the imputation model. for Disease Control and Prevention Tosoh A1C G7 [2007–2010], Primus We reported combined estimates using (CDC). NHANES is conducted in inde- Corporation, Kansas City, MO and Tosoh five imputed datasets. To examine how pendent, 2-year cycles. To produce reli- Bioscience, Inc., South San Francisco, CA), characteristics of the U.S. population dif- able estimates, NCHS recommends that 2) a laboratory site change (Missouri [1999– fered during the study period 1999– data from two or more cycles be combined 2004] to Minnesota [2005–2010]), and 3) 2010, we reported selected descriptive for analysis (21). Response rates were sim- an HPLC method change (boronate-affinity statistics for consecutive 2-year survey pe- ilar across the six cycles conducted from [1999–2004] to nonporous ion-exchange riods. After excluding participants with 1999 through 2010, ranging from 75 to [2005–2010]). However, per NCHS rec- diagnosed or undiagnosed diabetes, we 80% (19). The survey protocol was ap- ommendation, we analyzed the A1C data examined the distributions of A1C and proved by the NCHS Institutional Review without any correction for these labora- FPG values during 12 years using empir- Board. Written informed consent was ob- tory changes (23). ically estimated cumulative distribution tained from all participants aged $18 FPG measurements were performed functions for each 2-year period. Includ- years; written parental consent was ob- using a hexokinase enzymatic method ing participants with diagnosed or undi- tained for those aged ,18 years. (19). During 2005–2010, there were two agnosed diabetes in the denominator, we From 1999 through 2006, NHANES changes in instruments used to measure estimated the prevalence of prediabetes, used a stratified, multistage design with glucose levels (Roche Cobas Mira [1999– A1C5.7, and IFG for three periods: 1999– oversampling of adolescents, older adults, 2004] to Roche/Hitachi 911 [2005–2006] 2002, 2003–2006, and 2007–2010. African Americans, Mexican Americans, to Roche/Hitachi Modular P [2007–2010]; For each measure, we compared age- low-income non-Hispanic whites, and Roche Diagnostics, Inc., Indianapolis, IN). adjusted prevalences for the three periods pregnant women (20). Beginning in 2007, We applied Deming regression equations, using an overall F test for equal propor- the sampling methodology was modified as recommended by NCHS, to data from tions and t tests for the following con- to provide estimates for specificageranges, 2005–2006 (FPG 3 0.9835) and 2007– trasts: 1999–2002 versus 2003–2006, oversample Hispanics, and discontinue the 2010 (0.9835 3 [FPG 2 1.139]) to ensure 2003–2006 versus 2007–2010, and oversampling of adolescents and preg- comparability to earlier years of NHANES 1999–2002 versus 2007–2010. Age- nant women (21). NHANES participants glucose data (24,25).
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