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Lancet Diabetes Endocrinol. 2015 Aug;3(8):624-37. doi: 10.1016/S2213-8587(15)00129-1. Epub 2015 Jun 21.

Effects of diabetes definition on global surveillance of diabetes prevalence and diagnosis: a pooled analysis of 96 population-based studies with 331,288 participants.

Collaborators (434)

Danaei G, Fahimi S, Lu Y, Zhou B, Hajifathalian K, Di Cesare M, Lo WC, Reis-Santos B, Cowan MJ, Shaw JE, Bentham J, Lin JK, Bixby H, Magliano D, Bovet P, Miranda JJ, Khang YH, Stevens GA, Riley LM, Ali MK, Ezzati M, Abdeen ZA, Kadir KA, Abu-Rmeileh M, Acosta-Cazares B, Aekplakorn W, Aguilar-Salinas CA, Ahmadvand A, Al Nsour M, Alkerwi A, Amouyel P, Andersen LB, Anderssen SA, Andrade DS, Anjana RM, Aounallah-Skhiri H, Aris T, Arlappa N, Arveiler D, Assah FK, Avdicová M, Balakrishna N, Bandosz P, Barbagallo CM, Barceló A, Batieha AM, Baur LA, Ben Romdhane H, Bernabe-Ortiz A, Bhargava SK, Bi Y, Bjerregaard P, Björkelund C, Blake M, Blokstra A, Bo S, Boehm BO, Boissonnet CP, Bovet P, Brajkovich I, Breckenkamp J, Brewster LM, Brian GR, Bruno G, Bugge A, Cabrera de León A, Can G, Cândido AP, Capuano V, Carvalho MJ, Casanueva FF, Caserta CA, Castetbon K, Chamukuttan S, Chaturvedi N, Chen CJ, Chen F, Chen S, Cheng CY, Chetrit A, Chiou ST, Cho Y, Chudek J, Cifkova R, Claessens F, Concin H, Cooper C, Cooper R, Costanzo S, Cottel D, Cowell C, Crujeiras AB, D'Arrigo G, Dallongeville J, Dankner R, Dauchet L, de Gaetano G, De Henauw S, Deepa M, Dehghan A, Dhana K, Di Castelnuovo AF, Djalalinia S, Doua K, Drygas W, Du Y, Egbagbe EE, Eggertsen R, El Ati J, Elosua R, Erasmus RT, Erem C, Ergor G, Eriksen L, Escobedo-de la Peña J, Fall CH, Farzadfar F, Felix-Redondo FJ, Ferguson TS, Fernández-Bergés D, Ferrari M, Ferreccio C, Finn JD, Föger B, Foo LH, Fouad HM, Francis DK, Franco Mdo C, Frontera G, Furusawa T, Gaciong Z, Galbarczyk A, Garnett SP, Gaspoz JM, Gasull M, Gates L, Geleijnse JM, Ghasemain A, Giampaoli S, Gianfagna F, Giovannelli J, Gonzalez Gross M, González Rivas JP, Gorbea MB, Gottrand F, Grant JF, Grodzicki T, Grøntved A, Gruden G, Gu D, Guan OP, Guerrero R, Guessous I, Guimaraes AL, Gutierrez L, Hardy R, Hari Kumar R, Heidemann C, Hihtaniemi IT, Ho SY, Ho SC, Hofman A, Horimoto AR, Hormiga CM, Horta BL, Houti L, Hussieni AS, Huybrechts I, Hwalla N, Iacoviello L, Iannone AG, Ibrahim MM, Ikeda N, Ikram MA, Irazola VE, Islam M, Iwasaki M, Jacobs JM, Jafar T, Jasienska G, Jiang CQ, Jonas JB, Joshi P, Kafatos A, Kalter-Leibovici O, Kasaeian A, Katz J, Kaur P, Kavousi M, Kelishadi R, Kengne AP, Kersting M, Khader YS, Khang YH, Kiechl S, Kim J, Kiyohara Y, Kolsteren P, Korrovits P, Koskinen S, Kratzer W, Kromhout D, Kula K, Kurjata P, Kyobutungi C, Lachat C, Laid Y, Lam TH, Lanska V, Lappas G, Laxmaiah A, Leclercq C, Lee J, Lee J, Lehtimäki T, Lekhraj R, León-Muñoz LM, Li Y, Lim WY, Lima-Costa MF, Lin HH, Lin X, Lissner L, Lorbeer R, Lozano JE, Lundqvist A, Lytsy P, Ma G, Machado-Coelho GL, Machi S, Maggi S, Magliano D, Makdisse M, Mallikharjuna Rao K, Manios Y, Manzato E, Margozzini P, Marques-Vidal P, Martorell R, Masoodi SR, Matsha TE, Mbanya JC, McFarlane SR, McGarvey ST, McLachlan S, McNulty BA, Mediene-Benchekor S, Meirhaeghe A, Menezes AM, Merat S, Meshram II, Mi J, Miquel JF, Miranda JJ, Mohamed MK, Mohammad K, Mohan V, Mohd Yusoff MF, Møller NC, Molnar D, Mondo CK, Moreno LA, Morgan K, Moschonis G, Mossakowska M, Mostafa A, Mota J, Muiesan ML, Müller-Nurasyid M, Mursu J, Nagel G, Námešná J, Nang EE, Nangia VB, Navarrete-Muñoz EM, Ndiaye NC, Nervi F, Nguyen ND, Nieto-Martínez RE, Alvarado L, Ning G, Ninomiya T, Noale M, Noto D, Ochoa-Avilés M, Oh K, Onat A, Osmond C, Otero JA, Palmieri L, Panda-Jonas S, Panza F, Parsaeian M, Peixoto SV, Pereira AC, Peters A, Peykari N, Pilav A, Pitakaka F, Piwonska A, Piwonski J, Plans-Rubió P, Porta M, Portegies ML, Poustchi H, Pradeepa R, Price JF, Punab M, Qasrawi RF, Qorbani M, Raitakari O, Ramachandra Rao S, Ramachandran A, Ramos R, Rampal S, Rathmann W, Redon J, Reganit PF, Rigo F, Robinson SM, Robitaille C, Rodríguez LA, Rodríguez-Artalejo F, del Cristo Rodriguez-Perez M, Rojas-Martinez R, Romaguera D, Rosengren A, Rubinstein A, Rui O, Ruiz-Betancourt BS, Rutkowski M, Sabanayagam C, Sachdev HS, Saidi O, Sakarya S, Salanave B, Salonen JT, Salvetti M, Sánchez-Abanto J, Santos RN, Santos R, Sardinha LB, Scazufca M, Schargrodsky H, Scheidt-Nave C, Shaw JE, Shibuya K, Shin Y, Shiri R, Siantar R, Sibai AM, Simon M, Simons J, Simons LA, Sjostrom M, Slowikowska-Hilczer J, Slusarczyk P, Smeeth L, Snijder MB, Solfrizzi V, Sonestedt E, Soumare A, Staessen JA, Steene-Johannessen J, Stehle P, Stein AD, Stessman J, Stöckl D, Stokwiszewski J, Strufaldi MW, Sun CA, Sundström J, Suriyawongpaisal P, Sy RG, Tai ES, Tarawneh M, Tarqui-Mamani CB, Thijs L, Tolstrup JS, Topbas M, Torrent M, Traissac P, Trinh OT, Tulloch-Reid MK, Tuomainen TP, Turley ML, Tzourio C, Ueda P, Ukoli FM, Ulmer H, Valdivia G, van Valkengoed IG, Vanderschueren D, Vanuzzo D, Vega T, Velasquez-Melendez G, Veronesi G, Verschuren M, Vioque J, Virtanen J, Visvikis-Siest S, Viswanathan B, Vollenweider P, Voutilainen S, Wade AN, Wagner A, Walton J, Mohamud WN, Wang MD, Wang YX, Wannamethee SG, Weerasekera D, Whincup PH, Widhalm K, Wiecek A, Wilks RJ, Willeit J, Wojtyniak B, Wong TY, Woo J, Woodward M, Wu AG, Wu FC, Wu SL, Xu H, Yang X, Ye X, Yoshihara A, Younger-Coleman NO, Zambon S, Zargar AH, Zdrojewski T, Zhao W, Zheng Y.

Abstract

BACKGROUND:

Diabetes has been defined on the basis of different biomarkers, including fasting plasma glucose (FPG), 2-h plasma glucose in an oral glucose tolerance test (2hOGTT), and HbA1c. We assessed the effect of different diagnostic definitions on both the population prevalence of diabetes and the classification of previously undiagnosed individuals as having diabetes versus not having diabetes in a pooled analysis of data from population-based health examination surveys in different regions.

METHODS:

We used data from 96 population-based health examination surveys that had measured at least two of the biomarkers used for defining diabetes. Diabetes was defined using HbA1c (HbA1c ≥6·5% or history of diabetes diagnosis or using insulin or oral hypoglycaemic drugs) compared with either FPG only or FPG-or-2hOGTT definitions (FPG ≥7·0 mmol/L or 2hOGTT ≥11·1 mmol/L or history of diabetes or using insulin or oral hypoglycaemic drugs). We calculated diabetes prevalence, taking into account complex survey design and survey sample weights. We compared the prevalences of diabetes using different definitions graphically and by regression analyses. We calculated sensitivity and specificity of diabetes diagnosis based on HbA1c compared with diagnosis based on glucose among previously undiagnosed individuals (ie, excluding those with history of diabetes or using insulin or oral hypoglycaemic drugs). We calculated sensitivity and specificity in each survey, and then pooled results using a random-effects model. We assessed the sources of heterogeneity of sensitivity by meta-regressions for study characteristics selected a priori.

FINDINGS:

Population prevalence of diabetes based on FPG-or-2hOGTT was correlated with prevalence based on FPG alone (r=0·98), but was higher by 2-6 percentage points at different prevalence levels. Prevalence based on HbA1c was lower than prevalence based on FPG in 42·8% of age-sex-survey groups and higher in another 41·6%; in the other 15·6%, the two definitions provided similar prevalence estimates. The variation across studies in the relation between glucose-based and HbA1c-based prevalences was partly related to participants' age, followed by natural logarithm of per person gross domestic product, the year of survey, mean BMI, and whether the survey population was national, subnational, or from specific communities. Diabetes defined as HbA1c 6·5% or more had a pooled sensitivity of 52·8% (95% CI 51·3-54·3%) and a pooled specificity of 99·74% (99·71-99·78%) compared with FPG 7·0 mmol/L or more for diagnosing previously undiagnosed participants; sensitivity compared with diabetes defined based on FPG-or-2hOGTT was 30·5% (28·7-32·3%). None of the preselected study-level characteristics explained the heterogeneity in the sensitivity of HbA1c versus FPG.

INTERPRETATION:

Different biomarkers and definitions for diabetes can provide different estimates of population prevalence of diabetes, and differentially identify people without previous diagnosis as having diabetes. Using an HbA1c-based definition alone in health surveys will not identify a substantial proportion of previously undiagnosed people who would be considered as having diabetes using a glucose-based test.

FUNDING:

Wellcome Trust, US National Institutes of Health.

Comment in

PMID:
26109024
PMCID:
PMC4673089
DOI:
10.1016/S2213-8587(15)00129-1
[Indexed for MEDLINE]
Free PMC Article

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