[Skip to Content]
[Skip to Content Landing]
Figure.
Risk Scores of Prediabetes Among the Nondiabetic Population in the United States According to Age
Risk Scores of Prediabetes Among the Nondiabetic Population in the United States According to Age

Distribution of scores for risk for prediabetes among the nondiabetic population in the United States 40 years or older (A) or older than 60 years (B). Shaded area identifies at-risk population.

1.
Knowler  WC, Barrett-Connor  E, Fowler  SE,  et al; Diabetes Prevention Program Research Group.  Reduction in the incidence of type 2 diabetes with lifestyle intervention or metformin.  N Engl J Med. 2002;346(6):393-403.PubMedGoogle ScholarCrossref
2.
Balk  EM, Earley  A, Raman  G, Avendano  EA, Pittas  AG, Remington  PL.  Combined diet and physical activity promotion programs to prevent type 2 diabetes among persons at increased risk: a systematic review for the Community Preventive Services Task Force.  Ann Intern Med. 2015;163(6):437-451.PubMedGoogle ScholarCrossref
3.
Yudkin  JS, Montori  VM.  The epidemic of pre-diabetes: the medicine and the politics.  BMJ. 2014;349:g4485.PubMedGoogle ScholarCrossref
4.
Do you have prediabetes? Prediabetes Risk Test. https://doihaveprediabetes.org/pdf/Prediabetes_PrintableRiskTest(English).pdf. Accessed May 15, 2016.
5.
Sussman  JB, Kent  DM, Nelson  JP, Hayward  RA.  Improving diabetes prevention with benefit based tailored treatment: risk based reanalysis of Diabetes Prevention Program.  BMJ. 2015;350:h454.PubMedGoogle ScholarCrossref
6.
U.S. Preventive Services Task Force.  Screening for type 2 diabetes mellitus in adults: U.S. Preventive Services Task Force recommendation statement [published correction appears in Ann Intern Med. 2008;149(2):147].  Ann Intern Med. 2008;148(11):846-854.PubMedGoogle ScholarCrossref
Limit 200 characters
Limit 25 characters
Conflicts of Interest Disclosure

Identify all potential conflicts of interest that might be relevant to your comment.

Conflicts of interest comprise financial interests, activities, and relationships within the past 3 years including but not limited to employment, affiliation, grants or funding, consultancies, honoraria or payment, speaker's bureaus, stock ownership or options, expert testimony, royalties, donation of medical equipment, or patents planned, pending, or issued.

Err on the side of full disclosure.

If you have no conflicts of interest, check "No potential conflicts of interest" in the box below. The information will be posted with your response.

Not all submitted comments are published. Please see our commenting policy for details.

Limit 140 characters
Limit 3600 characters or approximately 600 words
    1 Comment for this article
    Physical activity profile included in the risk assessment
    Claudio Gil Araujo, MD, PhD | CLINIMEX - Exercise Medicine Clinic
    For long time several major health indicators - risk assessment and prognostic indexes -, including Framingham and European SCORE have not considered physical activity, despite strong scientific evidences for its relevance. In this context, the authors should be valued for having included physical activity in their risk assessment proposal.
    CONFLICT OF INTEREST: Recipient of research grants from Brazilian agencies (CNPq/FAPERJ)
    Research Letter
    Less Is More
    December 2016

    Prediabetes Risk in Adult Americans According to a Risk Test

    Author Affiliations
    • 1Predictive Analytics and Comparative Effectiveness Center, Tufts Medical Center, Boston, Massachusetts
    • 2Division of Endocrinology, Tufts Medical Center, Boston, Massachusetts
    JAMA Intern Med. 2016;176(12):1861-1863. doi:10.1001/jamainternmed.2016.5919

    The Diabetes Prevention Program and other studies found that individuals with impaired glucose tolerance (based on a 75-g oral glucose tolerance test) can decrease their risk of type 2 diabetes developing either by an intensive supervised lifestyle intervention, including diet and exercise modification, or by metformin hydrochloride treatment.1,2 Subsequently, the glycemic criteria for prediabetes were expanded to include hemoglobin A1c and a decreased level for fasting glucose.3 Although the benefit of type 2 diabetes prevention is unclear in this broader group, the Centers for Disease Control and Prevention, American Diabetes Association, and American Medical Association have promoted a web-based risk test to evaluate people at high risk for prediabetes for whom they recommend practice-based laboratory testing.4 We estimated the proportion of the adult, nondiabetic US population that would be classified as being at high risk for prediabetes according to this widely endorsed risk instrument.

    Methods

    Using data from the 2013-2014 National Health and Nutrition Examination Survey population older than 18 years without type 2 diabetes, we calculated risk scores for prediabetes based on 7 questions4:

    1. How old are you (1-3 points)?

    2. Are you a man or a woman (1 point)?

    3. If you are a woman, have you ever been diagnosed with gestational diabetes (1 point)?

    4. Do you have a mother, father, sister, or brother with diabetes (1 point)?

    5. Have you ever been diagnosed with high blood pressure (1 point)?

    6. Are you physically active (1 point)?

    7. What is your weight status (1-3 points)?

    We selected the questions from the National Health and Nutrition Examination Survey that closely matched those in the instrument. Physical inactivity was defined by a negative answer to a set of 5 questions regarding activity level. We inferred results of the weighted proportions to the US adult population after a complete case analysis. The study was considered exempt from the institutional review board approval by Tufts Medical Center. The National Health and Nutrition Examination Survey obtained patient consent in a written form. Patients receiving a score of 5 or more are at high risk for prediabetes and are advised to visit their physician for a blood glucose test.

    Results

    Of 10 175 participants, 96.5% provided complete information for all questions. The Figure shows the distribution of the risk scores. Among people 40 years or older, the estimated number evaluated as being at high risk for prediabetes was 73.3 million, corresponding to 58.7% (sample size for the age group, 3815; 95% CI, 56%-62%) of the population (Figure, A). Among those participants older than 60 years, the weighted proportion of the population at high risk for prediabetes was 80.8% (sample size for the age group, 1841; 95% CI, 78%-84%) (Figure, B).

    Discussion

    When applied to the US population, the Centers for Disease Control and Prevention, American Diabetes Association, and American Medical Association risk instrument categorizes 3 of 5 people 40 years or older and 8 of 10 individuals 60 years or older as being at high risk for prediabetes, requiring a medical visit and a blood glucose test for confirmation. Given the expanded criteria, many of these high-risk individuals will have prediabetes when tested.3 However, such a widespread process may be premature for many reasons. First, intensive lifestyle methods—even for those participants with impaired glucose tolerance—are most beneficial for those at the highest risk.5 Second, according to the US Preventive Services Task Force, there is no direct evidence that type 2 diabetes prevention alters the risk for diabetes-related complications.1,6 Third, to our knowledge, the natural history of prediabetes based on the latest American Diabetes Association criteria has not been prospectively assessed, but it is likely that progression to type 2 diabetes will be slower with the expanded criteria compared with impaired glucose tolerance. Finally, medicalization of prediabetes may have the unintended consequence of reducing health care access to patients with type 2 diabetes and other chronic conditions. A valid method to examine for prediabetes should avoid unnecessary medicalization by labeling a disease predecessor as a medical condition and seek to concentrate on people at highest risk to allow for efficient distribution of limited health care resources.

    Back to top
    Article Information

    Corresponding Author: Saeid Shahraz, MD, PhD, Predictive Analytics and Comparative Effectiveness Center, Tufts Medical Center, 800 Washington St, Campus Box 63, Boston, MA 02111 (shahraz@gmail.com).

    Published Online: October 3, 2016. doi:10.1001/jamainternmed.2016.5919

    Author Contributions: Drs Shahraz and Kent had full access to all the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

    Study concept and design: All authors.

    Acquisition, analysis, or interpretation of data: Shahraz, Kent.

    Critical revision of the manuscript for important intellectual content: All authors.

    Administrative, technical, or material support: Shahraz, Kent.

    Study supervision: All authors.

    Conflict of Interest Disclosures: None reported.

    Funding/Support: This study was supported by research grants DK076092 and DK098245 from the National Institute of Diabetes and Digestive and Kidney Diseases and the National Institutes of Health Office of Dietary Supplements (Dr Pittas).

    Role of the Funder/Sponsor: The funding sources had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

    References
    1.
    Knowler  WC, Barrett-Connor  E, Fowler  SE,  et al; Diabetes Prevention Program Research Group.  Reduction in the incidence of type 2 diabetes with lifestyle intervention or metformin.  N Engl J Med. 2002;346(6):393-403.PubMedGoogle ScholarCrossref
    2.
    Balk  EM, Earley  A, Raman  G, Avendano  EA, Pittas  AG, Remington  PL.  Combined diet and physical activity promotion programs to prevent type 2 diabetes among persons at increased risk: a systematic review for the Community Preventive Services Task Force.  Ann Intern Med. 2015;163(6):437-451.PubMedGoogle ScholarCrossref
    3.
    Yudkin  JS, Montori  VM.  The epidemic of pre-diabetes: the medicine and the politics.  BMJ. 2014;349:g4485.PubMedGoogle ScholarCrossref
    4.
    Do you have prediabetes? Prediabetes Risk Test. https://doihaveprediabetes.org/pdf/Prediabetes_PrintableRiskTest(English).pdf. Accessed May 15, 2016.
    5.
    Sussman  JB, Kent  DM, Nelson  JP, Hayward  RA.  Improving diabetes prevention with benefit based tailored treatment: risk based reanalysis of Diabetes Prevention Program.  BMJ. 2015;350:h454.PubMedGoogle ScholarCrossref
    6.
    U.S. Preventive Services Task Force.  Screening for type 2 diabetes mellitus in adults: U.S. Preventive Services Task Force recommendation statement [published correction appears in Ann Intern Med. 2008;149(2):147].  Ann Intern Med. 2008;148(11):846-854.PubMedGoogle ScholarCrossref
    ×