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.
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Shahraz S, Pittas AG, Kent DM. Prediabetes Risk in Adult Americans According to a Risk Test. 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.
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:
How old are you (1-3 points)?
Are you a man or a woman (1 point)?
If you are a woman, have you ever been diagnosed with gestational diabetes (1 point)?
Do you have a mother, father, sister, or brother with diabetes (1 point)?
Have you ever been diagnosed with high blood pressure (1 point)?
Are you physically active (1 point)?
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.
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).
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.
Corresponding Author: Saeid Shahraz, MD, PhD, Predictive Analytics and Comparative Effectiveness Center, Tufts Medical Center, 800 Washington St, Campus Box 63, Boston, MA 02111 (email@example.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.