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

Goodarz Danaei, Saman Fahimi, Yuan Lu, Bin Zhou, Kaveh Hajifathalian, Mariachiara Di Cesare, Wei Cheng Lo, Barbara Reis-Santos, Melanie J. Cowan, Jonathan E. Shaw, James Bentham, John K. Lin, Honor Bixby, Dianna Magliano, Pascal Bovet, J. Jaime Miranda, Young Ho Khang, Gretchen A. Stevens, Leanne M. Riley, Mohammed K. AliMajid Ezzati, Khalid Abdul Kadir, Niveen M. Abu-Rmeileh, Benjamin Acosta-Cazares, Wichai Aekplakorn, Carlos A. Aguilar-Salinas, Alireza Ahmadvand, Mohannad Al Nsour, Ala'a Alkerwi, Philippe Amouyel, Lars Bo Andersen, Sigmund A. Anderssen, Dolores S. Andrade, Ranjit Mohan Anjana, Hajer Aounallah-Skhiri, Tahir Aris, Nimmathota Arlappa, Dominique Arveiler, Felix K. Assah, Mária Avdicová, Nagalla Balakrishna, Piotr Bandosz, Carlo M. Barbagallo, Barceló Alberto Barceló, Anwar M. Batieha, Louise A. Baur, Habiba Ben Romdhane, Antonio Bernabe-Ortiz, Santosh K. Bhargava, Yufang Bi, Peter Bjerregaard, Cecilia Björkelund, Margaret Blake, Anneke Blokstra, Simona Bo, Bernhard O. Boehm, Carlos P. Boissonnet, Imperia Brajkovich, Juergen Breckenkamp, Lizzy M. Brewster, Garry R. Brian, Graziella Bruno, Anna Bugge, Antonio Cabrera de León, Gunay Can, Ana Paula C. Cândido, Vincenzo Capuano, Maria J. Carvalho, Felipe F. Casanueva, Carmelo A. Caserta, Katia Castetbon, Snehalatha Chamukuttan, Nishi Chaturvedi, Chien Jen Chen, Fangfang Chen, Shuohua Chen, Ching Yu Cheng, Angela Chetrit, Shu Ti Chiou, Yumi Cho, Jerzy Chudek, Renata Cifkova, Frank Claessens, Hans Concin, Cyrus Cooper, Rachel Cooper, Simona Costanzo, Dominique Cottel, Chris Cowell, Ana B. Crujeiras, Graziella D'Arrigo, Jean Dallongeville, Rachel Dankner, Luc Dauchet, Giovanni de Gaetano, Stefaan de Henauw, Mohan Deepa, Abbas Dehghan, Klodian Dhana, Augusto F. Di Castelnuovo, Shirin Djalalinia, Kouamelan Doua, Wojciech Drygas, Yong Du, Eruke E. Egbagbe, Robert Eggertsen, Jalila El Ati, Roberto Elosua, Rajiv T. Erasmus, Cihangir Erem, Gul Ergor, Louise Eriksen, Jorge Escobedo-de la Peña, Caroline H. Fall, Farshad Farzadfar, Francisco J. Felix-Redondo, Trevor S. Ferguson, Daniel Fernández-Bergés, Marika Ferrari, Catterina Ferreccio, Joseph D. Finn, Bernhard Föger, Leng Huat Foo, Heba M. Fouad, Damian K. Francis, Maria do Carmo Franco, Oscar H. Franco, Guillermo Frontera, Takuro Furusawa, Zbigniew Gaciong, Andrzej Galbarczyk, Sarah P. Garnett, Jean Michel Gaspoz, Magda Gasull, Louise Gates, Johanna M. Geleijnse, Anoosheh Ghasemain, Simona Giampaoli, Francesco Gianfagna, Jonathan Giovannelli, Marcela Gonzalez Gross, Juan P. González Rivas, Mariano Bonet Gorbea, Frederic Gottrand, Janet F. Grant, Tomasz Grodzicki, Anders Grøntved, Grabriella Gruden, Dongfeng Gu, Ong Peng Guan, Ramiro Guerrero, Idris Guessous, Andre L. Guimaraes, Laura Gutierrez, Rebecca Hardy, Rachakulla Hari Kumar, Jiang He, Christin Heidemann, Ilpo Tapani Hihtaniemi, Sai Yin Ho, Suzanne C. Ho, Albert Hofman, Andrea R.V. Russo Horimoto, Claudia M. Hormiga, Bernardo L. Horta, Leila Houti, Abdullatif S. Hussieni, Inge Huybrechts, Nahla Hwalla, Licia Iacoviello, Anna G. Iannone, Mohsen M. Ibrahim, Nayu Ikeda, Arfan M. Ikram, Vilma E. Irazola, Muhammad Islam, Masanori Iwasaki, Jeremy M. Jacobs, Tazeen Jafar, Grazyna Jasienska, Chao Qiang Jiang, Jost B. Jonas, Pradeep Joshi, Anthony Kafatos, Ofra Kalter-Leibovici, Amir Kasaeian, Joanne Katz, Prabhdeep Kaur, Maryam Kavousi, Roya Kelishadi, Andre P. Kengne, Mathilde Kersting, Yousef Saleh Khader, Stefan Kiechl, Jeongseon Kim, Yutaka Kiyohara, Patrick Kolsteren, Paul Korrovits, Seppo Koskinen, Wolfgang Kratzer, Daan Kromhout, Krzysztof Kula, Pawel Kurjata, Catherine Kyobutungi, Carl Lachat, Youcef Laid, Tai Hing Lam, Orlando Landrove, Vera Lanska, Georg Lappas, Avula Laxmaiah, Catherine Leclercq, Jeannette Lee, Jeonghee Lee, Terho Lehtimäki, Lekhraj Rampal, Luz M. León-Muñoz, Yanping Li, Wei Yen Lim, M. Fernanda Lima-Costa, Hsien Ho Lin, Xu Lin, Lauren Lissner, Roberto Lorbeer, José Eugenio Lozano, Annamari Lundqvist, Per Lytsy, Guansheng Ma, George L.L. Machado-Coelho, Suka Machi, Stefania Maggi, Marcia Makdisse, Kodavanti Mallikharjuna Rao, Yannis Manios, Enzo Manzato, Paula Margozzini, Pedro Marques-Vidal, Reynaldo Martorell, Shariq R. Masoodi, Tandi E. Matsha, Jean Claude N. Mbanya, Shelly R. McFarlane, Stephen T. McGarvey, Stela McLachlan, Breige A. McNulty, Sounnia Mediene-Benchekor, Aline Meirhaeghe, Ana Maria B. Menezes, Shahin Merat, Indrapal I. Meshram, Jie Mi, Juan Francisco Miquel, Mostafa K. Mohamed, Kazem Mohammad, Viswanathan Mohan, Muhammad Fadhli Mohd Yusoff, Niels C. Moller, Denes Molnar, Charles K. Mondo, Luis A. Moreno, Karen Morgan, George Moschonis, Malgorzata Mossakowska, Aya Mostafa, Jorge Mota, Maria L. Muiesan, Martina Müller-Nurasyid, Jaakko Mursu, Gabriele Nagel, Jana Namesna, Ei Ei K. Nang, Vinay B. Nangia, Eva Maria Navarrete-Muñoz, Ndeye Coumba Ndiaye, Flavio Nervi, Nguyen D. Nguyen, Ramfis E. Nieto-Martínez, Guang Ning, Toshiharu Ninomiya, Marianna Noale, Davide Noto, Angélica M. Ochoa-Avilés, Kyungwon Oh, Altan Onat, Clive Osmond, Johanna A. Otero, Luigi Palmieri, Songhomitra Panda-Jonas, Francesco Panza, Mahboubeh Parsaeian, Sergio Viana Peixoto, Alexandre C. Pereira, Annette Peters, Niloofar Peykari, Aida Pilav, Freda Pitakaka, Aleksandra Piwonska, Jerzy Piwonski, Pedro Plans-Rubió, Miquel Porta, Marileen L.P. Portegies, Hossein Poustchi, Rajendra Pradeepa, Jacqueline F. Price, Margus Punab, Radwan F. Qasrawi, Mostafa Qorbani, Olli Raitakari, Sudha Ramachandra Rao, Ambady Ramachandran, Rafel Ramos, Sanjay Rampal, Wolfgang Rathmann, Josep Redon, Paul Ferdinand M. Reganit, Fernando Rigo, Sian M. Robinson, Cynthia Robitaille, Laura A. Rodríguez, Fernando Rodríguez-Artalejo, María del Cristo Rodriguez-Perez, Rosalba Rojas-Martinez, Dora Romaguera, Annika Rosengren, Adolfo Rubinstein, Ornelas Rui, Blanca Sandra Ruiz-Betancourt, Marcin Rutkowski, Charumathi Sabanayagam, Harshpal S. Sachdev, Olfa Saidi, Sibel Sakarya, Benoit Salanave, Jukka T. Salonen, Massimo Salvetti, Jose Sánchez-Abanto, Renata Nunes dos Santos, Rute Santos, Luis B. Sardinha, Marcia Scazufca, Herman Schargrodsky, Christa Scheidt-Nave, Kenji Shibuya, Youchan Shin, Rahman Shiri, Rosalynn Siantar, Abla M. Sibai, Mary Simon, Judith Simons, Leon A. Simons, Michael Sjostrom, Jolanta Slowikowska-Hilczer, Przemyslaw Slusarczyk, Liam Smeeth, Marieke B. Snijder, Vincenzo Solfrizzi, Emily Sonestedt, Aicha Soumare, Jan A. Staessen, Jostein Steene-Johannessen, Peter Stehle, Aryeh D. Stein, Jochanan Stessman, Doris Stöckl, Jakub Stokwiszewski, Maria Wany Strufaldi, Chien An Sun, Johan Sundström, Paibul Suriyawongpaisal, Rody G. Sy, E. Shyong Tai, Mohammed Tarawneh, Carolina B. Tarqui-Mamani, Lutgarde Thijs, Janne S. Tolstrup, Murat Topbas, Maties Torrent, Pierre Traissac, Oanh T.H. Trinh, Marshall K. Tulloch-Reid, Tomi Pekka Tuomainen, Maria L. Turley, Christophe Tzourio, Peter Ueda, Flora M. Ukoli, Hanno Ulmer, Gonzalo Valdivia, Irene G.M. van Valkengoed, Dirk Vanderschueren, Diego Vanuzzo, Tomas Vega, Gustavo Velasquez-Melendez, Giovanni Veronesi, Monique Verschuren, Jesus Vioque, Jyrki Virtanen, Sophie Visvikis-Siest, Bharathi Viswanathan, Peter Vollenweider, Sari Voutilainen, Alisha N. Wade, Aline Wagner, Janette Walton, Wan Nazaimoon Wan Mohamud, Ming Dong Wang, Ya Xing Wang, S. Goya Wannamethee, Deepa Weerasekera, Peter H. Whincup, Kurt Widhalm, Andrzej Wiecek, Rainford J. Wilks, Johann Willeit, Bogdan Wojtyniak, Tien Yin Wong, Jean Woo, Mark Woodward, Aleksander Giwercman Wu, Frederick C. Wu, Shou Ling Wu, Haiquan Xu, Xiaoguang Yang, Xingwang Ye, Akihiro Yoshihara, Novie O. Younger-Coleman, Sabina Zambon, Abdul Hamid Zargar, Tomasz Zdrojewski, Wenhua Zhao, Yingfeng Zheng

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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.

Original languageEnglish
Pages (from-to)624-637
Number of pages14
JournalThe Lancet Diabetes and Endocrinology
Volume3
Issue number8
DOIs
Publication statusPublished - Aug 1 2015

ASJC Scopus subject areas

  • Internal Medicine
  • Endocrinology, Diabetes and Metabolism
  • Endocrinology

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    Danaei, G., Fahimi, S., Lu, Y., Zhou, B., Hajifathalian, K., Cesare, M. D., Lo, W. C., Reis-Santos, B., Cowan, M. J., Shaw, J. E., Bentham, J., Lin, J. K., Bixby, H., Magliano, D., Bovet, P., Miranda, J. J., Khang, Y. H., Stevens, G. A., Riley, L. M., ... Zheng, Y. (2015). Effects of diabetes definition on global surveillance of diabetes prevalence and diagnosis: A pooled analysis of 96 population-based studies with 331 288 participants. The Lancet Diabetes and Endocrinology, 3(8), 624-637. https://doi.org/10.1016/S2213-8587(15)00129-1